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 efforts to recognize delirium, even if subtle, as a medical emergency.” He adds that early diagnosis, treatment, and appropriate discharge may lead to faster recoveries and better longer-term outcomes.
Attempts must be made to parse out acute delirium from underlying dementia. Delirium can be distinguished from dementia by examining several domains, but the hallmark of delirium is the acute onset—manifesting in hours or a few days—of changes in attention and cognition. “Diagnosing delirium among elderly patients in the ED requires recognizing the condition and taking a systematic approach to manage it,” Dr. Gatewood says. “While some patients are obviously delirious, others are more difficult to assess for delirium because of subtle presentation of symptoms.” The Confusion Assessment Method described in Table 2 is one of the best validated tools available to facilitate the diagnosis of delirium for emergency physicians.
Conducting Examinations for Delirium
To improve recognition of delirium in the elderly, emergency physicians are encouraged to take a detailed patient history, conduct a thorough physical examination, and order ancillary testing if mental status is unconfirmed. “Similar to immunocompromised patients, the presentation can be subtle,” says Dr. Gatewood. “Patients may be described as being ‘just not right.’ In highly vulnerable elderly patients with multiple comorbidities, seemingly innocuous issues can spark an episode of delirium.”
Detailed history-taking may require interviewing multiple people, including the pre-hospital providers who evaluate and transport patients to the ED, family members, and other caregivers. “Medical history and comorbid conditions should be confirmed during patient exams,” notes Dr. Gatewood. “A thorough physical examination is essential, especially if the cause of delirium is not obvious.” Further testing—such as blood work, urinalysis, radiologic studies, and electrocardiograms— may be warranted, depending on the characteristics of each individual patient.
Managing Delirious Patients
When managing delirious patients, Dr. Gatewood says initial care should start with the standard assessments of airway, breathing, and circulation, and, if indicated, cervical spine precautions. “While screening for readily reversible causes of delirium, it’s important to consider acute stroke and other neurologic conditions as the possible underlying diagnosis.” For elderly patients with hyperactive delirium, several drug classes can be considered to calm the patient, to perform vital tests or procedures, or for safety reasons, but such medications should be used cautiously and judiciously. In addition, simple practices like having a family member, friend, or caregiver monitor patients, ensuring a quiet environment to decrease sensory overload, and addressing patients by name can help.
According to Dr. Gatewood, it is important that emergency physicians be cognizant that many delirious elderly patients warrant and benefit from admission to the hospital from the ED. “As the number of elderly patients presenting to EDs continues to rise, emergency physicians must strive to better appreciate, identify, and manage this problem. Delirium among elderly patients is not a normal process of aging and should be managed like other potentially dangerous medical emergencies. Research has documented 12-month mortality rates ranging between 10% and 26% for elderly patients diagnosed with delirium in the ED. Most causes of delirium are usually readily reversible, but the key is to diagnose it and treat it promptly so that we can reduce morbidity and mortality rates in these patients.”
Readings & Resources (click to view)
Gower LE, O’Keefe Gatewood M, Kang CS. Emergency department management of delirium in the elderly. Western J Emerg Med. 2012;13:194-201. Available at: http://www.medscape.com/viewarticle/766762_print.
Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39:248–253.
Hustey FM, Meldon SW, Smith MD, et al. The effect of mental status screening on the care of the elderly emergency department patients. Ann Emerg Med. 2003;41:678–684.
Lewis LM, Miller DK, Morley JE, et al. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13:142–145.
Han JH, Zimmerman BA, Cutler N, et al. Delirium in older emergency department patients: recognition, risk, factors, and psychomotor subtypes. Acad Emerg Med. 2009;16:193–200.
Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51:443–450.
Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med. 2010;56:244–252,e1.
Witlox J, Eurelings LSM, de Jonghe JFM, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304:443–451.
Pisani MA, Kong SYJ, Kasl SV, et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med. 2009;180:1092–1097.
Currier GW, Allen MH, Bunney B, et al. Updated treatment algorithm: algorithm for patients who present to the ED with acute psychotic agitation and require physical or pharmacological restraint. J Emerg Med. 2004;27:S25–26.