Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments

INTRODUCTION

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening.

METHODS

We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds.

RESULTS

Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%.

CONCLUSIONS

The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

Reduction and prevention of agitation in persons with neurocognitive disorders: an international psychogeriatric association consensus algorithm

OBJECTIVES

To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA).

DESIGN

Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion.

SETTING

IPA Agitation Workgroup.

PARTICIPANTS

IPA panel of international experts on agitation.

INTERVENTION

Integration of available information into a comprehensive algorithm.

MEASUREMENTS

None.

RESULTS

The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues-home, nursing home, emergency department, hospice-and adjustments to the therapeutic approach are presented.

CONCLUSIONS

The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.

Agitation in cognitive disorders: Progress in the International Psychogeriatric Association consensus clinical and research definition

BACKGROUND

The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove "provisional" from the definition.

METHODS

This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition.

RESULTS

We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions.

CONCLUSION

The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.

Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients

STUDY OBJECTIVE

Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients.

METHODS

We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3).

RESULTS

For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill.

CONCLUSION

We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

Spanish transcultural adaptation of the 4AT score for the evaluation of delirium in the emergency department: a prospective diagnostic test accuracy study

BACKGROUND

Delirium is one of the most common adverse events in older people during hospitalization, especially in the emergency department. Reliable, easy-to-use instruments are necessary to properly manage delirium in this setting. This study aims to evaluate the diagnostic validity of the Spanish version of the 4 'A's Test (4AT) in the ED.

METHODS

A diagnostic accuracy study was conducted in patients over 65 years old admitted to the Emergency Department who did not have a formal diagnosis of dementia or a severe mental health disorder. Face and content validity were evaluated by an expert panel. Emergency nurses performed the evaluation with 4AT, whilst blinded and trained researchers assessed patients with the Revised Delirium Rating Scale as the gold standard. The content validity index, sensitivity, specificity, positive and negative predictive values, likelihood ratios, Youden's Index and ROC curves were calculated to evaluate the diagnostic accuracy of the instrument.

RESULTS

Of 393 eligible patients, 380 were finally analyzed. Content validity yielded a median content validity index of 4 (interquartile range: 0). The Spanish 4AT sensitivity (95.83%; 95% ECI: 78.9-99.9%), specificity (92.98%; 95% CI: 89.8-95.4%), positive predictive value (47.92%) and negative predictive value (99.7%) were satisfactory. Youden's index was 0.89. Positive likelihood ratio was 13.65, and negative likelihood ratio 0.045. The area under the curve was 0.97.

CONCLUSIONS

The Spanish version of the 4AT for use in the Emergency Departments is easy-to-use and applicable. The validation results indicate that it is a valid instrument with sufficient predictive validity to identify patients at risk of delirium in the Emergency Departments. Moreover, it is a tool that facilitates the management of an adverse event that is associated with increased mortality and morbidity.

Management of the Agitated Patient

The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.

Geriatric Psychiatric Emergencies

Geriatric patients, those 65 years of age and older, often experience psychiatric symptoms or changes in mentation as a manifestation of an organic illness. It is crucial to recognize and treat delirium in these patients as it is often under-recognized and associated with significant morbidity. Iatrogenic causes of altered mentation or delirium due to medication adverse reactions are common. Treatment of the underlying cause, creating an environment conducive to orientation, and minimizing agitation and discomfort are first-line interventions. Antipsychotics are first-line pharmacologic interventions if needed to preserve patient safety.

Delirium risk screening and assessment among older patients in general wards and the emergency department: a best practice implementation project

OBJECTIVES

The aim of this project was to improve compliance with evidence-based criteria regarding risk of delirium and the assessment of delirium among older patients in the general hospitalization wards and the emergency department.

INTRODUCTION

More than 50% of older hospitalized patients experience delirium. Some studies have highlighted the need to implement an orientation protocol in the emergency department and to continue this in the general wards, with the aim of decreasing the delirium rate among older patients admitted to hospital.

METHODS

The project followed the JBI evidence implementation framework. We conducted a baseline audit, a half-way audit, and final audit of 50 patients at risk of delirium admitted to the emergency department and the general wards, respectively. The audits measured compliance with eight criteria informed by the available evidence.

RESULTS

In the final audit, three of the eight criteria achieved more than 50% compliance in the general wards: pressure injury screening (96%); monitoring changes (74%); and performing interventions (76%). In the emergency department, worse results were reported because of the service conditions. The exception was the criterion on the training of nurses on the topic, with 98%. The integration of a tool to screen for delirium in older patients in the hospital's electronic clinical history records increased the percentage of compliance with audit criteria regarding the use of the scale and delirium detection (rising from 0% to 32% in the final audit in the general wards).

CONCLUSION

Through the implementation of this project, validated and evidence-based evaluation will ensure that nurses are supported through appropriate measures to reduce patient confusion and aggression resulting from delirium.

Optimizing the Care of Persons Living with Dementia in the Emergency Department

Emergency department (ED) care for persons living with dementia (PLWD) involves the identification of dementia or cognitive impairment, ED care which is sensitive to the specific needs of PLWD, effective communication with PLWD, their care partners, and outpatient clinicians who the patient and care-partner know and trust, and care-transitions from the emergency department to other health care settings. The recommendations in this article made based on wide-ranging heterogeneous studies of various interventions which have been studied primarily in single-site studies. Future research should work to incorporate promising findings from interventions such as hospital at home, or ED to home Care Transitions Intervention.

Delirium and Delirium Prevention in the Emergency Department

This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.

A Lethal Combination of Delirium and Overcrowding in the Emergency Department

Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.

Thirty-day mortality among patients with acute delirium in the emergency department

Purpose

The number of visits to the emergency department (ED) is growing among older patients. Older people are at risk of acute delirium, which is associated with mortality. Our primary objective was to determine the 30-day mortality outcome between older patients with and without acute delirium.

Methods

From August 2018 to October 2019, we conducted a prospective cohort study in the ED of a tertiary care and university hospital. Patients over the age of 65 years who presented to the ED were included in the study. Within the first 12 h after the ED visit, delirium was assessed by using the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected data on 30-day mortality, ED LOS, hospital length of stay (LOS), and the 30-day ED revisit rate.

Results

We enrolled 173 patients in this study; 49 (28%) patients had acute delirium according to the CAM-ICU. The overall 30-day mortality was 4% (7/173). Delirium had no effect on 30-day mortality (adjusted odds ratio [OR], 2.15; 95% confidence interval [CI], 0.37-12.55; P = 0.40). Delirium was not associated with hospital LOS (adjusted mean difference -18.83 h; 95% CI, -71.94-34.28; P = 0.49) and the 30-day ED revisit rate (adjusted OR, 1.55; 95% CI, 0.59-4.11; P = 0.37). However, an increasing trend in ED LOS was observed (adjusted mean difference 16.39 h; 95% CI, -0.160-32.96; P = 0.05).

Conclusions

We found insufficient evidence to establish an association between delirium and 30-day mortality, hospital LOS, or 30-day emergency department revisits.

Trial registration

The trial was retrospectively registered in the Thai Clinical Trial Registry, identification number TCTR2021082700 on August 27, 2021.

Current Trends for Delirium Screening within the Emergency Department

Delirium is an acute neurological disorder that involves attention and cognition. It is associated with a high risk of morbidity and mortality among older people (>65 years old). In the context of the Emergency Department (ED), it is frequently experienced by patients but often not recognized. Literature studies have identified some screening instruments for an initial evaluation of delirium. Most of these tools have not been validated yet in the context of emergencies, but, in other settings, they were very useful for assessing and maximizing the recognition of this condition among older patients. We conducted a review of the literature, including randomized control trials, clinical and observational studies, and research studies published in recent years, confirming that most of the screening tools for delirium used in the intensive care unit (ICU) or the geriatric department have not been tested in the ED, and the ideal timing and form of the delirium assessment process for older adults have not been defined yet. The aim of our review is to summarize the updated evidence about the screening tools for delirium in the context of the ED, due to the fact that overcrowding of the ED and the stressful condition of emergency situations (that contribute to the onset of delirium) could expose older patients to a high risk of complications and mortality if delirium is not promptly recognized. In conclusion, we support the evidence that delirium is a current and real condition that emergency physicians have to face daily, and we are aware that more research is needed to explore this field in order to improve the overall outcomes of older patients admitted to the ED.

Six-item cognitive impairment test (6-CIT)'s accuracy as a cognitive screening tool: best cut-off levels in emergency department setting

Background

Nowadays, elderly patients represent a significant number of accesses to the Emergency Department (ED). Working rhythms do not allow to perform complete cognitive analysis, which would, however, be useful for the health care. This study aims to define the optimal cut-off values of the six-item Cognitive Impairment Test (6-CIT) as a cognitive screening tool in ED.

Methods

This study included 215 subjects, evaluated at the Emergency Department of the University Hospital of Monserrato, Cagliari, Italy, from July to December 2021. The accuracy of 6-CIT as a cognitive screening tool was assessed by comparison with Mini Mental State Examination (MMSE).

Results

The correlation coefficient between the two tests was -0.836 (CI: -0.87 to -0.79; p < 0.0001), and 6-CIT showed AUC = 0.947 (CI: 0.908-0.973; p < 0.0001). The 8/9 6-CIT cut-off score presented 86.76% sensitivity (CI: 76.4-93.8) and 91.84% specificity (CI: 86.2-95.7), and Youden index for this score was 0.786.

Conclusion

Our study demonstrates that 6-CIT is a reliable cognitive screening tool in ED, offering excellent sensitivity and specificity with a 8/9 points cut-off score.

Delirium, confusion, or altered mental status as a risk for abnormal head computed tomogram findings in older adults in the emergency department: A Geriatric Emergency Department Guidelines 2.0 systematic review and meta-analysis

BACKGROUND

Altered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT).

METHODS

A systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status.

RESULTS

The search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status.

CONCLUSION

We did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.

Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian Long-Term Care Residents with Dementia Before and During COVID-19

Background

Agitation is a disabling neuropsychiatric symptom of dementia. Pro re nata (PRN) injections of psychotropics can be administered for severe acute agitation, but little is known about the frequency of their actual use.

Objective

Characterize actual use of injectable PRN psychotropics for severe acute agitation in Canadian long-term care (LTC) residents with dementia and compare use before and during the COVID-19 pandemic.

Methods

Residents from two Canadian LTC facilities with orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018- May 1, 2019 (i.e., pre-COVID-19) and January 1, 2020- May 1, 2021 (i.e., COVID-19) were identified. Electronic medical records were reviewed to document PRN injections of psychotropic medications and collect data on reason and demographic characteristics. Descriptive statistics were used to characterize frequency, dose, and indications of use, and multivariate regression models were used to compare use between time periods.

Results

Of the 250 residents, 45 of 103 (44%) people in the pre-COVID-19 period and 85 of 147 (58%) people in the COVID-19 period with standing orders for PRN psychotropics received ≥1 injections. Haloperidol was the most frequently used agent in both time periods (74% (155/209 injections) pre-COVID-19; 81% (323/398 injections) during COVID-19). Residents in the COVID-19 period were almost two times more likely to receive injections compared with those in the pre-COVID-19 period (odds ratio = 1.96; 95% CI = 1.15-3.34; p = 0.01).

Conclusion

Our results suggest that use of PRN injections increased in LTC during the pandemic and contribute to the mounting evidence that agitation worsened during that time.

Leveraging the Electronic Health Record to Implement Emergency Department Delirium Screening

OBJECTIVE

The aim of this study is to understand how emergency departments (EDs) use health information technology (HIT), and specifically the electronic health record (EHR), to support implementation of delirium screening.

METHODS

We conducted semi-structured interviews with 23 ED clinician-administrators, representing 20 EDs, about how they used HIT resources to implement delirium screening. Interviews focused on challenges participants experienced when implementing ED delirium screening and EHR-based strategies they used to overcome them. We coded interview transcripts using dimensions from the Singh and Sittig sociotechnical model, which addresses use of HIT in complex adaptive health care systems. Subsequently, we analyzed data for common themes across dimensions of the sociotechnical model.

RESULTS

Three themes emerged about how the EHR could be used to address challenges in implementation of delirium screening: (1) staff adherence to screening, (2) communication among ED team members about a positive screen, and (3) linking positive screening to delirium management. Participants described several HIT-based strategies including visual nudges, icons, hard stop alerts, order sets, and automated communications that facilitated implementation of delirium screening. An additional theme emerged about challenges related to the availability of HIT resources.

CONCLUSION

Our findings provide practical HIT-based strategies for health care institutions planning to adopt geriatric screenings. Building delirium screening tools and reminders to perform screening into the EHR may prompt adherence to screening. Automating related workflows, team communication, and management of patients who screen positive for delirium may help save staff members' time. Staff education, engagement, and access to HIT resources may support successful screening implementation.

Agitated Geriatric Patients and Violence in the Workplace

Older adults may suddenly exhibit behaviors that are viewed as noncompliant, noncooperative, and threatening. They may even lash out verbally and physically causing injury to health care staff. In addition to taking actions that prevent harm to the staff and the patient, determining what caused this behavior (dementia vs delirium or other cases) will be critical, as well as debriefing the staff after the incident.

Contemporary Practices for Medical Evaluation of the Psychiatric Patient in the Emergency Department

Although emergency department (ED) visits for patients with mental illness are frequent, medical evaluation (i.e., "medical screening") of patients presenting with psychiatric complaints is inconsistent. This may largely be related to differing goals for medical screening, which often vary according to specialty. Although emergency physicians typically focus on stabilization of life-threatening diseases, psychiatrists tend to believe that care in the ED is more comprehensive, which often places the two fields at odds. The authors discuss the concept of medical screening, review the literature on this topic, and offer a clinically oriented update to the 2017 American Association for Emergency Psychiatry consensus guidelines on medical evaluation of the adult psychiatric patient in the ED.

Head computed tomography for elderly patients with acute altered mental status in the emergency setting: value for decision-making and predictors of abnormal findings

OBJECTIVE

This study evaluated the impact of head computed tomography (CT) on clinical decision-making about older adults with acute altered mental status (AMS) in the emergency department in terms of CT's diagnostic yield, emergency department length of stay, and changes in medical strategy. It also attempted to find predictors of an acute imaging abnormality.

METHODS

This was a 1-year, retrospective, single-center observational study of patients aged ≥75 years who underwent noncontrast head CT because of an isolated episode of AMS. The acute positive CT findings were ischemic strokes, hemorrhages, tumors, demyelinating lesions, hydrocephalus, and intracranial infections.

RESULTS

A total of 594 CTs were performed, of which 38 (6.4%) were positive. The main etiology of AMS was sepsis (29.1%). Changes in medical strategy were more common in patients with a positive CT, and the major changes were ordering additional neuro exams (odds ratio [OR], 95.3; 95% confidence interval [CI], 38.4-233.8; P<0.001), adjusting treatments (OR, 12.2; 95% CI, 5.0-29.5; P<0.001), and referral to a neurologic unit (OR, 7.3; 95% CI, 3.0-17.5; P<0.01). Three factors were significantly associated with a positive outcome: Glasgow Coma Scale <13 (OR, 8.5; 95% CI, 2.3-28.9; P<0.001), head wound (OR, 3.1; 95% CI, 1.1-8.2; P=0.025), and dehydration (OR, 0.3; 95% CI, 0.1-0.4; P=0.021). For elderly patients with a Glasgow Coma Scale ≥13 and no head wound or clinical dehydration, the probability of a positive CT was 0.02 (95% CI, 0.01-0.04). Considering only those patients, the diagnostic yield fell to 1.7%.

CONCLUSION

In elderly patients, the causes of AMS are primarily extracerebral. Randomized clinical trials are needed to validate a clinical pathway for selecting patients who require emergent neuroimaging.

Optimal Injectable Haloperidol Dose Assessment in the Older Hospitalized Inpatient

Background:

Haloperidol can be used off-label for agitation and/or delirium in older individuals. The recommended initial intramuscular or intravenous dose is 0.5 to 1 mg. However, the evidence to support these doses is nominal.

Objectives:

The primary outcome was to determine whether low-dose injectable haloperidol (≤0.5 mg) was similar in effect to higher doses by assessing the need for repeat doses within 4 hours as a surrogate marker. Secondary outcomes include comparison of length of stay, utilization of restraints, and discharge outcomes between dosage groups.

Methods:

This was a retrospective, single-center, cohort study. Patients aged ≥65 years who received haloperidol injectable who were not on antipsychotics prior to admission were reviewed.

Results:

In the low-dose group (n = 15), no patients required additional haloperidol doses within 4 hours compared with 1 patient each in the medium-dose (n = 23) and high-dose (n = 19) groups ( P = 0.94). There was a difference regarding length of stay, utilization of restraints, and discharge to facility when admitted from home favoring low-dose haloperidol.

Conclusions and Relevance:

While limited by sample size and retrospective design, patients who received low-dose haloperidol demonstrated similar efficacy to those who received higher doses of haloperidol. In addition, secondary outcomes mentioned above favored the use of low-dose haloperidol as well. Based on these findings, low-dose haloperidol is a reasonable initial dose for the agitated older patient.

Melatonin Receptor Agonists for the Prevention of Delirium: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Although a previous review illustrated the efficacy of melatonin receptor agonists (MRAs) in preventing delirium, some recent randomized controlled trials (RCTs) did not confirm these effects.

OBJECTIVES

This study systematically reviewed the efficacy, acceptability, and tolerability of MRAs for delirium prevention.

MATERIALS AND METHODS

We searched electronic databases, including Scopus, PubMed, CINAHL, and Controlled Trials Register, from their inception to February 20, 2022. The primary efficacy outcome was delirium incidence rate after MRA administration; relative risks (RRs), overall discontinuation, and discontinuation due to adverse events are also presented.

RESULTS

The overall pooled incidence rates of delirium in MRA-treated and placebo-treated groups were significantly different with RR (95% CI)=0.66(0.52, 0.84, ), I2=59%. Similarly, the incidence rate was significantly lower in the melatonin-treated group than in the placebo-treated group [RR (95% CI) =0.65 (0.49, 0.88), I2=65%]. Unfortunately, incidence rates were not significantly different between ramelteon-treated and placebo-treated groups [RR (95% CI) =0.67 (0.42, 1.08), I2=50%]. The pooled incidence rate of delirium in either melatonin or ramelteon-treated groups was not significantly different from the placebo-treated group in elderly patients. The pooled incidence rate of delirium was significantly lower in the melatonin-treated group than in the benzodiazepinetreated group.

CONCLUSION

Based on this review, melatonin could prevent delirium with a small effect size. However, ramelteon did not show efficacy in preventing delirium. Additionally, neither melatonin nor ramelteon individually showed effectiveness in preventing delirium in elderly patients. Therefore, using MRAs to prevent delirium in clinical practice should be cautious. However, future welldefined and large sample size studies could verify these findings.

Challenges in the Detection of Clinically Useful Biomarkers for the Diagnosis of Delirium in Older People in the Emergency Department-A Case-Control Study

Background: The identification of biomarkers associated with delirium in the emergency department could contribute to the understanding, prediction and diagnosis of this disorder. The present study was carried out to identify biomarkers included in easily and quickly obtained standard blood examinations in older patients with delirium in the emergency department. Methods: A case–control study was carried out in the emergency department of Francesc de Borja Hospital (Gandía, Valencia, Spain). Older adults (≥65 years of age) diagnosed with delirium (n = 128) were included. Cases due to alcohol or substance abuse were excluded. Controls were selected on a randomized basis from the remaining patients (n = 128). All laboratory test parameters included in the routine blood and urine tests of the emergency department were collected. Results: The mean age of the patients was 81.24 ± 7.51 years, and 56.2% were males, while the mean age of the controls was 78.97 ± 7.99 years, and 45.3% were males. Significant differences were found between the cases and controls in relation to the following parameters: urea 43 (32–58) mg/dL versus 50 (37–66) mg/dL, respectively; neutrophils 69.6 (62.05–78.75)% versus 75.5 (65.1–83.2)%; monocytes 8.7 (7–10.4)% versus 7.6 (5.5–9.2)%; platelets 213 (159–266) × 10⁹/L versus 224 (182–289) × 10⁹/L; neutrophil–lymphocyte ratio 3.88 (2.45–7.07) versus 5 (2.75–8.83); platelet–lymphocyte ratio 281.4 (210–360) versus 357.1 (257.8–457.1); and mean platelet volume 10.6 (10–11.5) fl versus 10.4 (9.67–10.9) fl. Although the mean values were above desirable levels in both groups, they were higher for most parameters in the control group. No significant differences were observed in C-reactive protein concentration (9.99 (1.69–51) mg/L versus 12.3 (3.09–65.97) mg/L). Conclusions: The identification of delirium biomarkers poses difficulties due to the urgent nature of the disorders found in older people admitted to the emergency department. Research in this field is needed, since it would allow early identification and treatment of delirium.

Frailty Network in an Acute Care Setting: The New Perspective for Frail Older People

The incidence of elderly patients who come to the emergency room is progressively increasing. The specialization of the physician units might not be adequate for the evaluation of this complexity. The present study aimed to present a standard procedure, called ‘The Geriatric Frailty Network’, operating at the Policlinico Gemelli IRCCS Foundation, which is configured specifically for the level II assessment of frail elderly patients. This was a retrospective study in 1191 patients aged over 65, who were evaluated by the Geriatric Frailty Unit directly after emergency department admission for one year. All patients underwent multidimensional geriatric evaluation. Data were collected on demographics, co-morbidity, disease severity, and Clinical Frailty Scale. Among all patients, 723 were discharged directly from the emergency room with early identification of continuity of care path. Globally, 468 patients were hospitalized with an early assessment of frailty that facilitated the discharge process. The geriatric frailty network model aims to assist the emergency room and ward doctor in the prevention of the most common geriatric syndromes and reduce the number of incongruous hospitalizations.

Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine

BACKGROUND

In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service.

DISCUSSION

At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions.

CONCLUSIONS

In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.

An Emergency Department Delirium Screening and Management Initiative: The Development and Refinement of the SCREENED-ED Intervention

The current article describes an intervention aimed at emergency department (ED) nurses and physicians that was designed to address the challenges of managing delirium in the ED environment. The intervention development process followed the Medical Research Council principles paired with a user-centered design perspective. Expert clinicians and nursing staff were involved in the development process. As a result, the SCREENED-ED intervention includes four major components: screening for delirium, informing providers, an acronym (ALTERED), and documentation in the electronic health record. The acronym "ALTERED" includes seven key elements of delirium management that were considered the most evidence-based, relevant, and practical for the ED. Nurses are at the frontline of delirium recognition and management and the SCREENED-ED intervention with the ALTERED acronym holds the potential to improve nursing care in this complex clinical setting. [Journal of Gerontological Nursing, 47(12), 13-17.].

Use of antipsychotic and sedative medications in older patients in the emergency department

BACKGROUND

Antipsychotics and sedatives are used to treat agitation in the emergency department (ED) but carry significant risk in older adults. Our objective was to determine factors associated with their administration to older ED patients.

METHODS

This was an observational study using data from the 2014-2017 National Hospital Ambulatory Medical Care Survey. We identified ED visits for patients aged ≥65 years and determined whether an antipsychotic or sedative was administered. Visits related to substance use/withdrawal, other psychiatric complaints, and intubation were excluded. We performed multivariable logistic regression to identify risk factors for antipsychotic or sedative administration.

RESULTS

Of the 78.7 million ED visits that met inclusion criteria, 3.5% involved at least one dose of antipsychotic or sedative medication; 13% involved an antipsychotic and 92% a sedative. Factors associated with antipsychotic administration included nursing home residence (adjusted odds ratio [aOR]: 2.67; 95% CI: 1.05-6.80), dementia (aOR: 5.62; 95% CI: 2.44-12.94), and delirium (aOR: 7.33; 95% CI: 2.21-24.32). Sedative administration was positively associated with CT or MR imaging (aOR: 1.86; 95% CI: 1.42-2.43), urbanicity of ED (aOR: 1.46; 95% CI: 1.02-2.08), and female gender (aOR: 1.47; 95% CI: 1.08-1.99) and negatively associated with older age (age: 75-84; aOR: 0.67; 95% CI: 0.49-0.91; age: 85+; aOR: 0.63; 95% CI: 0.45-0.88; reference age: 65-74 years). Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.

CONCLUSION

We identified patient- and facility-level factors associated with sedative and antipsychotic administration in older ED patients. Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.

Evaluating older adults with cognitive dysfunction: A qualitative study with emergency clinicians

BACKGROUND

Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic.

METHODS

From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10-20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive-inductive approach. Responses regarding experiences before and during the pandemic were compared.

RESULTS

Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic.

CONCLUSION

Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.

[Pharmacological and multimodal care of the adult patient with psychiatric presentation in the emergency department]

The pharmacological management of patients with psychiatric presentations, on prescription, and by nurses in emergency medicine structures is based on knowledge of a limited number of molecules and their methods of administration. This is accompanied by a relational approach and techniques to ensure the safety of the teams in the case of an agitated or very resistant patient.

[The elderly with a psychiatric prognosis in the emergency room]

In the emergency department, the diagnosis of an acute psychiatric condition in an elderly patient should only be made after rigorous clinical and paraclinical examinations to rule out any somatic pathology. In addition, the management and treatment of acute agitation must be adapted.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders

STUDY OBJECTIVE

We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts.

METHODS

We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach.

RESULTS

Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients.

CONCLUSION

Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

Recommandations de pratique clinique sur la prise en charge du patient adulte à présentation psychiatrique dans les structures d’urgences

De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.

Chronic Brain Failure

Chronic brain failure, also known as dementia or major neurocognitive disorder, is a syndrome of progressive functional decline characterized by both cognitive and neuropsychiatric symptoms. It can be conceptualized like other organ failure syndromes and its impact on quality of life can be mitigated with proper treatment. Dementia is a risk factor for delirium, and their symptoms can be similar. Patients with dementia can present with agitation that can lead to injury. Logic and reason are rarely successful when attempting to redirect someone with advanced dementia. Interactions that offer a sense of choice are more likely to succeed.

Increased Emergency Department Hallway Length of Stay is Associated with Development of Delirium

Introduction

Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development.

Methods

This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway.

Results

A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P<0.001); had longer ED LOS (median 11.94 vs 8.12 hours, P<0.001); had more ED room transfers (median 5 vs 4, P<0.001); and had longer hospital LOS (median 5.0 vs 4.6 days, P<0.001). Patients more frequently developed delirium in the ED (77.5%) than on inpatient units (22.5%). The relative odds of a patient developing delirium increased by 3.31 times for each percent increase in ED hallway time (95% confidence interval, 2.85, 3.83).

Conclusion

Patients with delirium had more ED hallway exposure, longer ED LOS, and more ED room transfers. Understanding delirium in the ED has substantial implications for improving patient safety.

Succinct Approach to Delirium in the Emergency Department

Purpose of Review

This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework.

Recent Findings

Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers' primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort.

Summary

Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.

Rapid Fire: Acute Brain Failure in Older Emergency Department Patients

Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement

BACKGROUND

Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions.

METHODS

GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci.

RESULTS

In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research.

CONCLUSIONS

Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

Neurologic Emergencies at the Extremes of Age

The diagnosis and management of neurologic conditions are more complex at the extremes of age than in the average adult. In the pediatric population, neurologic emergencies are somewhat rare and some may require emergent consultation. In older adults, geriatric physiologic changes with increased comorbidities leads to atypical presentations and worsened outcomes. The unique considerations regarding emergency department presentation and management of stroke and altered mental status in both age groups is discussed, in addition to seizures and intracranial hemorrhage in pediatrics, and Parkinson's disease and meningitis in the geriatric population.

Top 20 drug - drug interactions, polypharmacy and analysis of the nature of risk factors due to QT interval prolonging drug use in elderly psychiatry outpatients

INTRODUCTION AND OBJECTIVES

Psychotropic medications extend the corrected QT (QTc) period in the ECG. Psychiatric patients exposed to ≥ 1 psychotropic medication (s) represent a group with a marked probability of drug-activated QTc-prolongation. Prolonged QTc interval in elderly patients (age > 60 years) is connected to a greater risk of all-cause and coronary heart disease deaths. We investigated the pattern of utilization of QTc-interval prolonging medications, QT-extending interactions between drugs, and prevalence of QTc-interval prolonging risk factors in elderly patients.

METHODS

This was a cross-sectional, prospective study at the Psychiatry OPD at All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India from October 1, 2017 to December 31, 2018 employing the pertinent prescriptions.

RESULTS

A total of 208 elderly patients (age 60 years or more) visiting the Psychiatry OPD during the aforementioned study period were investigated. 105 (50.5%) patients were males whereas 103 (49.5%) were females in our study. 147 out of 208 patients (70.7%) were using interacting agents with the capacity to produce TdP. 288 interacting torsadogenic medication pairs were unraveled. As per AzCERT/CredibleMeds Classification, 254 (48.8%), 181 (34.8%), and 62 (12%) interacting medications were identified with known, possible, and conditional risk of TdP, respectively. The common interacting medications belonged to antidepressant (144), proton pump inhibitor (91), antipsychotic (85), anti-nausea (46), antimicrobial (39), and H₂ receptor antagonist (15) therapeutic categories.

CONCLUSIONS

Many geriatric patients were administered drugs and drug combinations with heightened proclivity towards QT-interval prolongation. Therefore, we need to exigently embrace precautionary safety interventions, to be vigilant, and forestall QT-prolongation and TdP in clinical settings. Online evidence-based drug information resources can aid clinicians in choosing drugs for psychiatric patients.

Delirium prevention and treatment in the emergency department (ED): a systematic review protocol

INTRODUCTION

Delirium is a dangerous syndrome of acute brain dysfunction that is common in the emergency department (ED), especially among the geriatric population. Most systematic reviews of interventions for delirium prevention and treatment have focused on inpatient settings. Best practices of effective delirium care in ED settings have not been established. The primary objective of this study is to identify pharmacologic and non-pharmacologic interventions as applied by physicians, nursing staff, pharmacists and other ED personnel to prevent incident delirium and to shorten the severity and duration of prevalent delirium in a geriatric population within the ED.

METHODS AND ANALYSIS

Searches using subject headings and keywords will be conducted from database inception through June 2020 in MEDLINE, EMBASE, Web of Science, PsychINFO, CINAHL, ProQuest Dissertations and Theses Global and Cochrane CENTRAL as well as grey literature. Database searches will not be limited by date or language. Two reviewers will identify studies describing any interventions for delirium prevention and/or treatment in the ED. Disagreements will be settled by a third reviewer. Pooled data analysis will be performed where possible using Review Manager. Risk ratios and weighted difference of means will be used for incidence of delirium and other binary outcomes related to delirium, delirium severity or duration of symptoms, along with 95% CIs. Heterogeneity will be measured by calculating I², and a forest plot will be created. If significant heterogeneity is identified, metaregression is planned using OpenMeta to identify possible sources of heterogeneity.

ETHICS AND DISSEMINATION

This is a systematic review of previously conducted research; accordingly, it does not constitute human subjects research needing ethics review. This review will be prepared as a manuscript and submitted for publication to a peer-reviewed journal, and the results will be presented at conferences.

PROSPERO TRIAL REGISTRATION NUMBER

CRD42020169654.