Missed delirium in older emergency department patients: A quality-of-care problem

doi:10.1067/mem.2002.122273

Annals of Emergency Medicine

Volume 39, Issue 3, March 2002, Pages 338-341

https://doi.org/10.1067/mem.2002.122273 Get rights and content

Abstract

Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. March 2002;39:338-341.

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Cited by (59)

Delirium and Delirium Prevention in the Emergency Department
2023, Clinics in Geriatric Medicine
Increased short-term mortality among patients presenting with altered mental status to the emergency department: A cohort study
2022, American Journal of Emergency Medicine
To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints.
Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7 and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities.
A total of 9850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p < .001). Similarly, we found that patients presenting with AMS had a significantly higher risk of dying within 30 days compared to patients with chest pain (HR 3.65, 95% CI 2.49 to 5.37, p < .001), and headache (HR 2.09, 95% CI 1.09 to 4.01, p = .026). Differences were not statistically significant for comparisons with abdominal pain and generalized weakness, but confidence intervals were wide.
Patients presenting with AMS have worse short-term prognosis than patients presenting to the ED with chest pain or headache. AMS may indicate an underlying brain dysfunction (delirium), which is associated with adverse outcomes and increased mortality.
Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis
2021, Annals of Emergency Medicine
We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age ≥ 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study’s protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions.
Impact of emergency department length of stay on anxiety and comfort in older people
2021, International Emergency Nursing
Citation Excerpt :
Older ED users are a vulnerable population with complex healthcare needs and they are highly reliant on ED clinicians to ensure their emergency care is safe [28]. Older ED users are more likely to have cognitive impairment, anxiety, depression [29], and are at risk of unrecognised functional decline, cognitive impairment and delirium [11,30]. There is also evidence of lower quality of care and less likelihood of evidence-based care for older ED users when compared to younger patients [31–33].
Older people are frequent emergency department (ED) users, a vulnerable population and often have long stays in the ED. The aim of this study was to determine whether ED length of stay (LOS) had an impact on older people’s (aged ≥65 years) anxiety, comfort and adverse events.
This prospective observational study was conducted in Melbourne, Australia. Patients (n = 301) from three EDs were classified by ED LOS: ≤4-hours (n = 89), 4–8 h (n = 136) and >8-hours (n = 76). Current state and trait anxiety and comfort were measured in ED. Adverse event data were collected from medical records. LOS groups were compared using Chi-Square and Kruskal-Wallis test.
There was no significant difference in Trait Anxiety Scores. Patients with ED LOS ≤ 4-hours had lower median State Anxiety Scores (p = 0.003), were less likely to require ward admission (p < 0.001), and more likely to require short stay unit admission (p < 0.001). There were no significant differences between groups in comfort or adverse events during ED care or hospitalisation (for admitted patients).
The impact of ED LOS on the anxiety of older ED users appears limited. There was no association identified between ED LOS and comfort during ED care or adverse events during ED care or hospitalisation.
Cognitive outcomes following coronary artery bypass grafting: A systematic review and meta-analysis of 91,829 patients
2019, International Journal of Cardiology
Cognitive impairments, including delirium, are common after coronary artery bypass grafting (CABG) surgery, as described in over three decades of research. Our aim was to pool estimates across the literature for the first-time, relative to time (from pre- to post-CABG) and diagnosis (cognitive impairment, delirium and dementia).
A systematic search of four databases was undertaken. 215 studies incorporating data from 91,829 patients were used to estimate the prevalence of cognitive impairments pre- and post-CABG, including delirium and dementia post-CABG, using random effects meta-analyses.
Pre-surgical cognitive impairment was seen in 19% of patients. Post-operatively, cognitive impairment was seen in around 43% of patients acutely; this resolved to 19% at 4–6 months and then increased to 25% of patients between 6-months to 1-year post-operatively. In the long term, between 1 and 5-years post-operatively, cognitive impairment increased and was seen in nearly 40% of patients. Post-operative delirium was apparent in 18% of CABG patients which increased to 24% when a diagnostic instrument was utilized alongside clinical criteria. Dementia was present in 7% of patients 5–7 years post-surgery.
The results of this meta-analysis demonstrate that cognitive impairment and delirium are major issues in CABG patients which require specific attention. It is imperative that appropriate methods for investigating cognitive impairment, and screening for delirium using a diagnostic instrument, occur in both pre-and post-CABG settings.
Delirium and Dementia
2018, Clinics in Geriatric Medicine
Citation Excerpt :
Although the presence of altered mental status as a chief complaint is 99% specific for delirium, it is only 38% sensitive, making it unreliable as a delirium screen.95 Missing delirium may have several important downstream implications for clinical care.96 Delirious patients are frequently unable to provide an accurate reason of why they are in the ED, which may lead to inadequate diagnostic workups.97

View all citing articles on Scopus

^*: Reprints not available from the author. Address for correspondence: Arthur B. Sanders, MD, MHA, Department of Emergency Medicine, University of Arizona College of Medicine, PO Box 245057, Tucson, AZ 87524-5057; 520-626-5032; E-mail: [email protected].

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EditorialsMissed delirium in older emergency department patients: A quality-of-care problem*

Abstract

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Editorials
Missed delirium in older emergency department patients: A quality-of-care problem*