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

Case Western Reserve University, Cleveland, Ohio, United States
Annals of Emergency Medicine (Impact Factor: 4.68). 06/2003; 41(5):678-84. DOI: 10.1067/mem.2003.152
Source: PubMed


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
10 Reads
  • Source
    • "Delirium, characterized by acute changes in cognitive status, particularly attention and executive function [1], is common in older ED patients and makes them prone to adverse outcomes such as impaired functional status [2], prolonged hospital stay [3], cognitive decline [4], and increased mortality [5]. Delirium prevalence in older ED patients has been estimated to be between 7% and 10% [6,7]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Delirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED. This was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses' assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined. In total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians' informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729). Informal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 03/2014; 22(1):19. DOI:10.1186/1757-7241-22-19 · 2.03 Impact Factor
  • Source
    • "By the mid-21st century, this number will increase to 82 million, or 20% of the population,1,2 It is estimated that 10% to 30% of the elderly evaluated in the emergency department (ED) will present with delirium.3–5 The prevalence might be even higher, as patients who are unable to communicate due to critical illness or are unable to cooperate are excluded from many studies.6 Several other studies have suggested that emergency physicians are “suboptimal” at recognizing mental status impairment in the elderly as well as eliciting signs and symptoms necessary to diagnose delirium.6–8 "
    [Show abstract] [Hide abstract]
    ABSTRACT: An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.
    The western journal of emergency medicine 05/2012; 13(2):194-201. DOI:10.5811/westjem.2011.10.6654
  • Source
    • "Third, the survey used was not validated and the reported results may not reflect actual practice. For example, cognitive dysfunction is often underrecognized by EM physicians, suggesting that dementia and/or delirium screening efforts are not routinely conducted.14,15 In addition, question 2 offered several general reasons why geriatric technician screening might be impractical, with the option to free text additional barriers not foreseen by the investigators, but additional obstacles undoubtedly exist. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The objective of this study was to evaluate emergency medicine physician and nurse acceptance of nonnurse, nonphysician screening for geriatric syndromes. This was a single-center emergency department (ED) survey of physicians and nurses after an 8-month project. Geriatric technicians were paid medical student research assistants evaluating consenting ED patients older than 65 years for cognitive dysfunction, fall risk, or functional decline. The primary objective of this anonymous survey was to evaluate ED nurse and physician perceptions about the geriatric screener feasibility and barriers to implementation. In addition, as a secondary objective, respondents reported ongoing geriatric screening efforts independent of the research screeners. The survey was completed by 72% of physicians and 33% of nurses. Most nurses and physicians identified geriatric technicians as beneficial to patients without impeding ED throughput. Fewer than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluated for fall risk significantly more often than physicians, but no other significant differences were noted in ongoing screening efforts. Dedicated geriatric technicians are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. Most nurses and physicians are not currently screening for any geriatric syndromes.
    The western journal of emergency medicine 11/2011; 12(4):489-95. DOI:10.5811/westjem.2011.1.1962
Show more


10 Reads
Available from