Assessment and Management of Delirium in Older Adults in the Emergency Department

Rosen, Tony; Connors, Scott; Clark, Sunday; Halpern, A.; Stern, Michael E.; DeWald, Jennifer; Lachs, Mark S.; Flomenbaum, Neal

doi:10.1097/tme.0000000000000066

Cited by 38 publications

(22 citation statements)

References 70 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Protocols for reducing delirium among older ED patients have been suggested in nursing66 and EM literature 67. However, there have not been sufficient studies in the ED to determine and quantify what measures may reduce the rates of development of delirium among high-risk patients, improve the symptom severity of delirium, reduce the length of delirium, or reduce hospital LOS.…”

Section: Discussionmentioning

confidence: 99%

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients

Shenvi¹,

Wilson²,

Aldai³

et al. 2019

WestJEM

View full text Add to dashboard Cite

Introduction Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on “Special Populations: Agitation in the Elderly” from the 2016 Coalition on Psychiatric Emergencies’ first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. Results Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. Conclusion It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.

show abstract

Section: Discussionmentioning

confidence: 99%

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients

Shenvi¹,

Wilson²,

Aldai³

et al. 2019

WestJEM

View full text Add to dashboard Cite

show abstract

“… 14 Common causes include drugs (eg, steroids, opiates, benzodiazepines, anticholinergics), infections, postoperative or painful states, alcohol withdrawal, metabolic disturbances, myocardial infarction, constipation and urinary retention. 15 In up to 20% of cases, the cause is never identified. 16 Sensory deprivation can contribute to disorientation and delirium as, for example, rates of postoperative delirium have been noted to be higher in units without windows.…”

Section: Introductionmentioning

confidence: 99%

TIME to think about delirium: improving detection and management on the acute medical unit

et al. 2018

View full text Add to dashboard Cite

Delirium affects 18%–35% patients in the acute hospital setting, yet is often neither detected nor managed appropriately. It is associated with increased risk of falls, longer hospital stay and increased morbidity and mortality rates. It is a frightening and unpleasant experience for both patients and their families. We used quality improvement tools and a multicomponent intervention to promote detection and improve management of delirium on the acute medical unit (AMU). We reviewed whether a delirium screening tool (4AT) had been completed for all patients aged over 65 years admitted to the AMU over 1 week. If delirium was detected, we assessed whether investigation and management was adequate as per national guidance. After baseline data collection, we delivered focused sessions of delirium education for doctors and nursing staff, including training on use of the 4AT tool and the TIME (Triggers, Investigate, Manage, Engage) management bundle. We introduced TIME checklists, an online delirium order set and created a bedside orientation tool. We collected data following the interventions and identified areas for further improvement. Following our first PDSA (Plan, Do, Study, Act) cycle, use of the 4AT screening tool improved from 40% to 61%. Adequate assessment for the causes of and exacerbating factors for delirium increased from 73% to 94% of cases. Use of personal orientation tools improved from 0% to 38%. In summary, a targeted staff education programme and practical aids for the ward have improved the screening and management of delirium on the AMU. This may be improved further through more frequent training sessions to account for regular change-over of junior doctors and through implementing a nursing champion for delirium.

show abstract

“…Dehydration is an independent predictor of inpatient mortality following a diagnosis of delirium [157]. The mechanism by which dehydration effects cognitive function is not entirely understood, but cerebral hypoperfusion and hormonal changes may be contributing factors [154,158]. Dehydration and delirium are synergistic, with many factors, such as advanced age and reduced mobility common to both; it is difficult to differentiate how much hydration status contributes to confusion (and vice versa).…”

Section: V) Deliriummentioning

confidence: 99%

A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications

et al. 2019

View full text Add to dashboard Cite

Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and Methods: A modified Delphi process combined expert opinion and evidence appraisal. 12 relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally-accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; 'dehydration' and 'hypovolaemia' are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognised and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours.

show abstract

Assessment and Management of Delirium in Older Adults in the Emergency Department

Cited by 38 publications

References 70 publications

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients

TIME to think about delirium: improving detection and management on the acute medical unit

A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications

Contact Info

Product

Resources

About