It's time to mobilize: Moving mobility interventions for delirium from inpatient units to the emergency department

Abstract

Delirium occurs in 10%-15% of all older emergency department (ED) patients and accounts for 1.5 million ED visits annually, yet emergency clinicians miss this diagnosis one third of the time. [1][2][3] For this reason, ED-based delirium research has predominantly focused on improving delirium identification. However, delirium identification alone without a concerted effort to improve management is insufficient to ameliorate the detrimental effects of delirium. One third of hospitalized older adults and up to 80% of critically ill patients have delirium. 4,5 Delirium is associated with higher mortality, future cognitive decline, greater institutionalization, longer hospital lengths of stay, and greater costs of care. 5,6 Accordingly, it is critical that we implement evidence-based interventions to decrease incident delirium and delirium duration. Non-pharmacologic delirium prevention programs in inpatient wards, which include early mobility, have been shownto prevent approximately half of incident delirium and may decrease inpatient falls, hospital lengths of stay, and costs of care. 7,8 Delirium prevention bundles in inpatient wards and ICUs, which also address mobility, have been demonstrated to reduce mortality and decrease delirium duration. 9,10 However, there is limited research investigating delirium prevention and no research into delirium treatment initiated in the ED. 11 In this issue of JACEP Open, Jordano et al examined the impact of physical therapy (PT) and/or occupational therapy (OT) on delirium duration among ED patients admitted to the hospital. This was a secondary analysis of the prospective cohort study by Han et al funded by the National Institute on Aging, which enrolled a total of 228 patients, of which 105 had delirium, 47 had subsyndrome delirium, and 76 were not delirious in the ED. 12 This secondary analysis was restricted to 130 patients who received PT/OT during their hospitalization. The authors report that the time spent with PT/OT relative to hospital length of stay, termed "PT/OT intensity," was associated with a significant reduction in delirium duration (adjusted odds ratio [OR] = 0.39; 95% confidence interval [CI]: 0.21, 0.73). However, time to initiation of PT/OT was not associated with delirium duration (adjusted OR = 1.02; 95% CI: 0.82, 1.27). What makes this study particularly noteworthy is the inclusion of patients diagnosed with delirium in the ED-to the best of our knowledge presently, this is the only study to examine the effect of PT/OT as a treatment for delirium in ED patients who were hospitalized.Several key limitations of the Jordano et al study merit scrutiny. The