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Screening for Delirium in EDs: Seeking Validation

Screening for Delirium in EDs: Seeking Validation

About 10% of older adults who seek care in EDs throughout the United States experience delirium. The condition can foretell other health issues and causes distress to patients and caregivers. Delirium also puts patients at increased risk for poor outcomes. Studies indicate that the condition adds between $38 billion and $152 billion annually to healthcare expenditures in the U.S. Patients who are discharged home from the ED with unidentified delirium have 6-month mortality rates that are nearly three-fold higher than those of counterparts whose delirium is detected in the ED. However, studies show that emergency providers identify delirium in only 16% to 35% of cases. The Heart of the Issue Unrecognized delirium in older adults presents a major health challenge and increases the burden placed on the healthcare system. Several screening instruments have been developed to identify delirium in various settings, but the ED is a unique environment because of intense time demands and high patient volume. Caring for adults with delirium in the ED setting is challenging and requires a separately evaluated screening instrument for the condition. For a study published in Annals of Emergency Medicine, Michael A. LaMantia, MD, MPH, and colleagues conducted a systematic review of existing studies on delirium in EDs to determine why the condition is so frequently undiagnosed in older adults. “We sought to determine whether any standardized instruments had been well studied for identifying delirium in the ED,” says Dr. LaMantia. Information was collected on a range of studies performed using seven delirium screening tools in the ED environment. These included the: 1. Confusion Assessment Method (CAM). 2. CAM-ICU. 3. CAM-ED. 4....
Using Restraints to Manage Agitated Patients

Using Restraints to Manage Agitated Patients

Most emergency physicians think of agitation as relatively simple to treat, with sedation being the most common course of action. However, sedating even just a few agitated patients in precious ED beds can increase waiting times for the entire ED. Further complicating matters is that all agitation is not the same. Use of restraints is sometimes necessary, but decisions to use them are often made without thinking of the ramifications. “Use of restraints is sometimes necessary, but decisions to use them are often made without thinking of the ramifications.” The key advantages to restraining agitated patients are that it protects staff from violence from patients and facilitates intramuscular (IM) delivery of calming medications. On the other hand, improperly applied restraints may injure patients. In addition, most injuries to staff probably occur during the restraint process. Physicians should be mindful that restraints don’t allow patients to participate fully in their care. Appropriate Use of Restraints Among Agitated Patients Restraints should be applied either in the upper extremities only or on the upper and lower extremities with minimal force,which usually requires assistance from others in the ED. Every attempt should be made to avoid standing or sitting on patients during application. If weight force is needed, it should be applied as briefly as possible with careful monitoring of ventilatory status. Although many physicians wish to stand aside during the forceful takedown of patients, physician presence during takedowns may reassure staff and patients that these procedures will be done as gently as possible. Emergency physicians, however, should only partake in takedowns if they’ve been trained to do so.   In most cases,...
Delirium Among Hospitalized AD Patients: The Long-Term Impact

Delirium Among Hospitalized AD Patients: The Long-Term Impact

Recent studies show that patients with Alzheimer’s Disease (AD) who are hospitalized are at increased risk for further cognitive decline, institutionalization, and death in the year following their hospital stay. These risks are highest among those who develop delirium while being hospitalized. Little attention has been paid to the consequences of delirium on cognitive deterioration among patients with AD. Most studies have focused on short-term cognitive outcomes, but few have addressed whether these changes result in enduring problems in cognitive function. Examining Long-Term Changes Following Delirium In the August 20, 2012 online issue of the Archives of Internal Medicine, a study by senior investigator Sharon K. Inouye, MD, MPH, myself, and other colleagues explored the long-term trajectory of cognitive decline among older adults with AD who experienced delirium while they were hospitalized. The rate of cognitive deterioration was monitored for up to 5 years before and 5 years after hospitalization. Delirium in patients with AD was independently associated with cognitive deterioration for up to 5 years after hospitalization; the rate was roughly twice that of patients with AD who did not develop delirium while hospitalized. Delirium is a Medical Emergency In our analysis, delirium developed in 56% of the study group. Unfortunately, research suggests that delirium is recognized by physicians in fewer than 30% of hospital patients. Our study serves as an alarm to the long-term dangers of delirium on the development and progression of long-term cognitive impairment. Physicians should handle delirium cases among AD patients as they would a true medical emergency. Strategies to Prevent Delirium Efforts are needed to incorporate delirium prevention routinely into standard practices for...
Managing Delirium Among Elderly Patients in the ED

Managing Delirium Among Elderly Patients in the ED

National estimates demonstrate that elderly patients are increasingly presenting for care at EDs throughout the United States each year, and by current projections, this trend is expected to increase significantly as Americans are living longer than ever. Between 10% and 30% of the elderly who are evaluated in the ED will present with delirium, but the prevalence may be higher. “The causes of delirium in elderly patients presenting to EDs are multifactorial,” explains Medley O’Keefe Gatewood, MD (Table 1). “While it’s difficult to discern exactly what’s going on clinically, delirium is oftentimes the only sign of underlying serious and potentially life-threatening illnesses. Much like myocardial infarction and sepsis, delirium is a high-stakes entity.” Research has suggested that emergency physicians are inconsistent in recognizing mental status impairment and the signs and symptoms indicative of a delirium diagnosis in the elderly. Recent analyses have shown that emergency physicians correctly diagnose delirium in only about 24% to 35% of elderly patients, and many of these individuals are discharged with little consideration of delirium as an indicator of more serious medical conditions. Diagnosing Delirium Among the Elderly “Failing to detect delirium among the elderly in the ED and then discharging them can increase mortality within the first few months of discharge and up to a year,” says Dr. Gatewood, who coauthored an article in the May 2012 Western Journal of Emergency Medicine on the topic. “Even when delirium is diagnosed, some patients are still inappropriately discharged. Considering the high prevalence of impaired mental status and the increasing number of elderly patients who have delirium and are still discharged, emergency physicians must make greater...

Guidelines for Managing Agitated Patients in the ED

Proper management of agitated patients presenting to the ED is essential to keeping staff safe and ensuring appropriate care. In many cases, agitation cases can be managed with non-pharmacologic methods, but medications are becoming increasingly important in acute agitation in EDs. In the February 2012 Western Journal of Emergency Medicine, my colleagues and I at the American Association for Emergency Psychiatry published consensus recommendations on best practices for using medication to manage agitated patients in emergency settings. Rationale & Goals When Calming Patients Non-pharmacologic approaches—verbal de-escalation, quieting the room, and dimming the lighting—should be attempted before medications are administered. When initial verbal methods fail to calm patients, medication may be necessary. Clinicians should make a provisional diagnosis on the likely cause of the agitation because this can help guide medication choices. In many cases, agitation increases over time during ED treatment. By intervening early, to preempt the potential escalation of agitation to severe and dangerous levels, it may be possible to include patients in the medication decision process and use lower doses. The goal of using medication in agitated patients is to calm them without inducing sleep. Excessive sedation may interfere with assessment and treatment of underlying conditions. To the extent possible, medications should be used that specifically target the cause of agitation based on the provisional diagnosis. “The goal of using medication in agitated patients is to calm them without inducing sleep.” No class of medication is considered “best” in all cases of agitation, but three drug classes have been studied and used most frequently, including first- and second-generation antipsychotics and benzodiazepines. Although these drugs may manage acute...
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