Missed delirium in older emergency department patients: A quality-of-care problem☆
Article Outline
Abstract
Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. March 2002;39:338-341.
See related article, p. 248 .
In this issue of Annals, Hustey and Meldon1 report on a prospective study of 297 patients aged 70 years or older who presented with a variety of chief complaints and were assessed for mental status impairments by trained research assistants. The researchers used standardized tools to assess patients for cognitive deficits and delirium. The tools included the Confusion Assessment Method (CAM) for evaluation of delirium and the Orientation Memory Concentration (OMC) test for evaluation of cognitive impairment; both of these tests have been previously used in emergency departments for mental status assessment in older patients.2, 3, 4, 5 The mental status assessments were performed independent of the ED evaluation of these patients and on all patients, regardless of chief complaint, unless they were critically ill or were unable or unwilling to participate. The researchers also reviewed the patients' charts, including discharge instructions, to determine whether the mental status abnormalities were recognized in the clinical course of treating these patients in the ED.
Using standardized testing, the researchers discovered that 26% (78/297) of older ED patients had mental status impairment. This included 10% of older ED patients who met the criteria for delirium, whereas an additional 16% met criteria for cognitive impairment without delirium. The researchers found that 81% of patients with cognitive impairment had no prior history of dementia or cognitive impairment and thus were newly diagnosed in the ED. Remarkably, less than 30% of the 78 patients with mental status impairment had any documentation of mental status evaluation in the ED record. Forty-four percent (34/78) of patients with mental status impairment were sent home. Of the 30 patients who met the criteria for delirium, 37% were discharged home from the ED.1
The data from this study indicate a problem of emergency health care professionals not recognizing or addressing mental status impairment in older ED patients. These findings are remarkably consistent with previous studies in the medical literature. Lewis et al2 studied the prevalence of delirium in 385 ED patients aged 65 and older using the CAM scale administered by a research nurse. They found that 10% of the older ED patients met the criteria for probable or definite delirium. The ED record included delirium or a synonym in only 17% of patients who tested positive for delirium. Thirty-eight percent of patients who met criteria for delirium were discharged from the ED. The most common discharge diagnosis for patients with delirium was “status post fall.” The 3-month mortality rate for patients with delirium was 14%, compared with 8% for patients without delirium.2
Naughton et al3 studied the prevalence of impaired mental status in 188 ED patients aged 70 years and older. The researchers used the CAM scale for delirium, the Mini-Mental State Exam to assess cognitive impairment, and the Glasgow Coma Scale to assess impaired consciousness. Forty percent of patients tested had mental status impairment, with 22% having cognitive impairment, 9.6% delirium, and 8.5% impaired consciousness. The authors concluded that cognitive impairment was common among older ED patients.3
Elie et al4 used the CAM and Mini-Mental State Exam to assess the prevalence of delirium in 447 ED patients aged 65 years and older. They found that 9.6% of patients met criteria for delirium and that the sensitivity for detection of delirium by the emergency physician was 35.5%.4
Gerson et al5 used the OMC test to assess cognitive impairment in ED patients aged 65 years and older who had no prior history of dementia. The OMC test was administered in less than 2 minutes. The authors found that 33.5% (183/547) of patients had moderate or severe cognitive impairment, with a greater prevalence in patients older than 80 years.5
The data presented in these studies have been remarkably consistent and carry important implications for the practice of emergency medicine and the assessment of the quality of care for older patients in EDs.
When does this consistent data on the high prevalence of mental status impairment in older ED patients become convincing enough to change our clinical practice? Should we be screening older ED patients for delirium and cognitive impairments? As the volume and severity of ED patients continues to rise, it is easy to understand why emergency health care providers must focus on chief complaints and the efficient use of emergency medical resources. One can argue that screening and case finding for cognitive impairment may not be practical in many ED settings and is best left to the primary care system. On the other hand, when data are repeatedly presented from multiple studies in different institutions that we are missing delirium and acute cognitive impairment in 25% to 40% of older ED patients, one questions whether cognitive testing must be performed to assure quality care for older ED patients. When does “screening” or “case finding” change from a preventive medicine/public health issue to a quality-of-care issue indicating the possibility of an acute medical condition? When does missing delirium in 10% of older ED patients become a medical error? One can reason that some assessment for cognitive function in older ED patients does not represent screening but is part of the basic assessment of the older patient's chief complaint.
Clinically, an awareness of the older patient's cognitive status is important for the ED evaluation. If the patient has a known history of dementia, emergency physicians will attempt to get the history from other sources. If, however, emergency health care providers are unaware of the mental status impairment, it can lead to serious errors. The history may not be accurate. Patients may be placed on inappropriate medications or be discharged from the ED and unable to comply with instructions. Patients with delirium may have a medical emergency with a differential diagnosis that includes sepsis, acute coronary syndromes, adverse drug events, metabolic abnormalities, acute cerebral vascular events, and other symptoms. Patients with delirium generally receive comprehensive ED evaluations. If a clear etiology is not found, admission for observation and further assessment is appropriate. It is our opinion that most emergency physicians will appropriately evaluate delirium and acute cognitive impairments if they recognize that such impairments exist. The key is an awareness that many older patients presenting with diverse complaints such as falls, weakness, not feeling well, and so on will have mental status impairments that may be indicative of significant diseases.
In 1996, the Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force concluded that emergency health care professionals need to modify the model of medical care that is used for older persons.6 A set of principles for geriatric emergency medicine was defined and a more comprehensive medical model was recommended. This model of care includes evaluating the presenting complaint in the context of cognitive status, functional assessment, and psychosocial considerations.6 Unless we change the model of care that we use for older patients, we risk the danger of compromising our quality of care by missing important and even life-threatening conditions such as delirium. The SAEM Geriatric Emergency Medicine Task Force recommended that all older ED patients receive some assessment for delirium and cognitive impairment. Cognitive assessment may be performed with the use of screening questions for orientation and 3-item recall. The use of formal mental status tools, such as the CAM scale for delirium, the OMC test, or the Mini-Mental State Exam for cognitive assessment, can be used for patients with negative results on the initial orientation and 3-item recall questions. These tools can be used by any member of the emergency health care team and often take less than 2 minutes to complete.
If we come to a reasonable consensus that missed delirium and unrecognized acute cognitive abnormalities in some patients are medical errors, how do we correct the situation? The demographic projections in the United States indicate that older persons are the fastest-growing segment of the population. Thus, this quality-of-care concern will get worse during the next 30 years. It is our opinion that, like most quality issues, it should be approached as a systems problem. Educational efforts have only limited impact on the clinical practice of medicine. The more effective solution is to develop systems that increase awareness and the detection of cognitive impairments. This might be approached by including simple cognitive screening tests administered by the triage nurse, patient care technician, paramedic, or physician as part of the ED intake procedure for older patients. The use of charts that are specific for older patients can be a tool for reminding emergency physicians that older patients need a more comprehensive assessment, including cognitive and functional assessment. Clinical decision support systems have been used successfully to improve and standardize the quality of care. Quality improvement projects in which feedback is given to emergency health care professionals may also address this issue. Once the assessment is made that a specific patient meets the criteria for delirium or acute cognitive decline, emergency physicians will take appropriate action in evaluating the complaint and make the appropriate disposition and follow-up arrangements. The main considerations in improving care for older patients, with regard to cognitive impairment, are raising the awareness of its prevalence, giving health care practitioners the tools to easily assess cognitive impairment, and putting in place systems in which this is readily done.
The issue of cognitive impairment in older ED patients deserves further research from the academic community. What is the long-term follow-up and outcome for patients with cognitive impairment that is detected in the ED? It can be speculated that many of these patients will have cognitive impairment resulting from temporary medical conditions that led to their ED visits. We must perform further assessments to sort out what are the causes and long-term outcomes for the 25% to 40% of older ED patients who have negative results on standardized cognitive tests. What is the best ED evaluation and management for these patients? Are there high-risk criteria that emergency physicians can use to better sort out which patients need to have formal cognitive testing? For example, it has been consistently demonstrated that patients with cognitive impairment are older than patients without impairment. What should be the age cut-off for cognitive screening—60 years, 65, 70, 75, 80? Are there specific patient complaints or profiles that put patients at higher risk for cognitive impairment and may allow us to focus our efforts for performing mental status examinations? What is the most appropriate cognitive assessment tool for use in the ED? If we systematically perform cognitive assessment for older ED patients and detect those with delirium and cognitive impairments, does it result in better long-term outcomes?
In conclusion, cognitive impairment is common among older ED patients. A knowledge of the patient's mental status is key for appropriate ED management of patient complaints. Delirium or acute cognitive impairment in ED patients may be a manifestation of serious medical conditions that should be addressed in the ED visit. Unfortunately, the data from several studies indicate that only a minority of older patients with mental status impairment will have this impairment recognized by the treating emergency physician. This situation can lead to medical errors, missed diagnoses, and quality-of-care concerns. It is recommended that systems be put in place in EDs that allow for mental status assessments for older ED patients. In addition, further research needs to be done to better define the meaning of cognitive impairment in older ED patients.
References
- . The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39:248–253
- Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13:142–145
- Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. 1995;25:751–755
- Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163:877–881
- Case finding for cognitive impairment in elderly emergency department patients. Ann Emerg Med. 1994;23:813–817
- In: Sanders AB editors. Emergency Care of the Elder Person. St. Louis, MO: Beverly Cracom Publications; 1996;
☆ 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: art@aemrc.arizona.edu.
PII: S0196-0644(02)18515-5
doi:10.1067/mem.2002.122273
© 2002 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Refers to article:
- The prevalence and documentation of impaired mental status in elderly emergency department patients
