The effect of mental status screening on the care of elderly emergency department patients.

Department of Emergency Medicine, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Annals of Emergency Medicine (Impact Factor: 4.33). 06/2003; 41(5):678-84. DOI: 10.1067/mem.2003.152
Source: PubMed

ABSTRACT We determine the effect of screening examinations for mental status impairment on the care of elderly patients in the emergency department and prospectively assess recognition of mental status impairment by emergency physicians.
We performed a prospective cross-sectional study. Patients were 70 years of age or older and presented to an urban teaching hospital ED over a 17-month period. Mental status impairment screening comprised the Orientation Memory Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Emergency physicians who were blinded to the patient's screening results were interviewed to assess recognition of mental status impairment, dispositions, and referrals. Results of mental status impairment screens were then given to emergency physicians, and emergency physicians were reinterviewed regarding any change in care.
Two hundred seventy-one of the 327 eligible patients were enrolled. Seventy-four (27%; 95% confidence interval [CI] 22% to 33%) patients had impaired mental status. Nineteen (7%; 95% CI 4% to 11%) had delirium, and 55 (20%; 95% CI 16% to 25%) had cognitive impairment without delirium. Mental status impairment was recognized in only 28 (38%; 95% CI 27% to 50%) of 74 patients: 3 (16%; 95% CI 3% to 40%) of 19 with delirium and 25 (46%; 95% CI 32% to 59%) of 55 with cognitive impairment without delirium. Emergency physicians altered management in none of the study patients on the basis of survey results. Five (26%; 95% CI 9% to 51%) of the 19 patients with delirium were discharged to home. Of these 5 patients discharged to home with unrecognized delirium, 1 presented with fall, 2 returned 3 days later and required hospitalization, and 1 with a history of colon cancer was given a new diagnosis of metastatic disease 4 days after the initial ED visit.
Mental status impairment is highly prevalent in older ED patients. There is a lack of recognition by emergency physicians of mental status impairment in this group. Screening tools for mental status impairment in the ED did not substantially alter the care of elderly patients with mental status impairment.

1 Follower
  • [Show abstract] [Hide abstract]
    ABSTRACT: To examine associations between polypharmacy and delirium diagnosed in elderly patients hospitalized in geriatric acute care unit after emergency hospital admission. Study design was an observational cohort study in the acute geriatric care unit of a university hospital. We included 410 consecutive patients admitted to the acute geriatric ward during 9 months. Within 72 hours of each patient's hospitalization, a clinically trained geriatrician collected the following data: sociodemographic details (age, sex, type of residence), predisposing factors for delirium, main cause of hospitalization, and current medications. Polypharmacy was defined as 6 or more drugs a day. Delirium was assessed by a geriatrician using the Confusion Assessment Method and was diagnosed on the basis of clinical history with an acute change in usual functional status, behavioral observation, and clinical and cognitive assessment. Nearly 25% of hospitalized patients had delirium. The Confusion Assessment Method was positive in 69% of patients receiving polypharmacy and in 30% of those not receiving polypharmacy, a relative risk of 2.33. The proportion of elderly patients receiving polypharmacy was 58.53%. In our study, polypharmacy is an independent risk factor for delirium in a population of elderly patients after emergency admission. In the geriatric population, delirium is an underestimated scourge and because of its medicosocial and economic consequences and its impact on morbidity and mortality, we need to give increased attention to the prevention and control of polypharmacy, which is a predisposing factor for delirium.
    Journal of the American Medical Directors Association 11/2014; 15(11):850.e11-5. DOI:10.1016/j.jamda.2014.08.012 · 4.78 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They expe- rience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people’s assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and man- aged appropriately. Identifying patients with specific frailty syndromes can be critical to iden- tifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoid- ance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.
    Clinical Interventions in Aging 01/2014; 9:2033-2043. DOI:10.2147/CIA.S29662 · 1.82 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: The Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients. Methods: We surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand. Results: We had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium. Conclusions: Basic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED. Keywords: Delirium; Elderly; Emergency department; Emergency physician; knowledge
    International Journal of Emergency Medicine 09/2014; 7(38). DOI:10.1186/s12245-014-0038-z


1 Download
Available from