Delirium within the emergency care setting, occurrence and detection: a systematic review

Abstract

Recent recommendations from the Society for Academic Emergency Medicine and the American College of Emergency Physicians identified the detection of delirium in the emergency department (ED) as a 'high yield' research objective. This review aimed to determine the occurrence rate, and physician detection rates, of delirium within the ED. A systematic literature review was conducted and identified using online databases. Prospective cohort and cross-sectional studies from hospital EDs were interrogated. Systematic data extraction and assessments of quality were carried out. Searching yielded 723 publications, and 13 papers met inclusion criteria. Occurrence of delirium at admission to the ED ranged from 7% to 20% of patients. Physician diagnosis rates of preconfirmed delirium (using a specified tool) within the ED varied between 11.1% and 46.0%. Many studies used non-validated assessment tools to gather data. Four delirium outcome studies were conducted in the ED setting. Results vary, with several being of poor quality; however, delirium at ED presentation may have a significant effect on long-term outcomes. Delirium is a significant concern in the ED, with many delirious patients not identified by physicians. Given the scale, addressing delirium should be a priority for clinicians and researchers. To improve delirium outcomes and hospital management, measures must include mechanisms to improve detection. Finding a single validated assessment method and facilitating research in this difficult patient population would be an important progress.

Prognostic Value and Risk Factors of Delirium in Emergency Patients With Decompensated Heart Failure

“…23 Dementia and functional dependency are predisposing factors of delirium clearly identified in ED and hospitalized patients, regardless of whether the delirium is prevalent or incident. 4,7 These findings are widely described in prior studies. 8,23,24 Several studies have shown that a high proportion of elderly patients admitted for cardiac decompensation (in particular HF) concomitantly have some geriatric syndrome that worsens their prognosis.…”

“…10 In studies conducted in ED populations similar to our study cohort, the prevalence delirium ranges from 7% to 15% at admission, although most studies show a prevalence of approximately 10%. 4,5,22 These data suggest the prevalence of delirium could be somewhat higher in patients with decompensated HF than in patients who present to the ED for other reasons. Although studies focusing on this aspect are lacking, the prevalence of delirium in HF is not negligible.…”

Is delirium being detected in emergency?

“…This incidence rate of delirium (14%) reflected international hospital data 14 . It is of concern that delirium was not formally documented in the medical records of the majority of the patients who presented with a delirium (27 of the 31 patients -87%).…”

Cancer patients with delirium in the emergency department: A frequent and distressing problem that calls for better assessment

“…(7) Other studies of elderly patients attending the ED reported an even higher frequency of missing the diagnosis of delirium, ranging from 65-84%. (5,8,9) The lower frequency of missed diagnosis found by Elsayem et al could relate to many factors: the delivery of two lectures to their ED physicians on delirium; priming the ED physician in assessing whether the patient could be approached for study recruitment; and exclusion of patients with dementia and those attending between 6pm and 10am. Regardless, missing the diagnosis of delirium in 41% of cases is a serious concern.…”

“…(5,(8)(9)(10) However, given the higher prevalence figures for delirium in hospitalized cancer patients, (1) the 9% prevalence seems low. Of the study eligible patients (n=624), 47% (n=291) were noted to be unapproachable for a variety of reasons, including the fact that they were "sleeping/tired".…”