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Vallath AL, Sivasubramanian BP, Ravikumar DB, Lalendran A, Krishnan S, Samanta S, Banerjee S, Das T, Kundu R, Richharia V, More R, Khithani M, Nazimudeen S, Gunturu S, Dasgupta I. The importance of rapid assessment tools in evaluating mental health in emergency departments among patients with chronic diseases. Front Public Health 2024; 12:1258749. [PMID: 38496389 PMCID: PMC10940474 DOI: 10.3389/fpubh.2024.1258749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/30/2024] [Indexed: 03/19/2024] Open
Abstract
Background Rapid screening tools such as the WHO well-being Index (WWBI), Six-item screener (SIS), and the CLOX-1 test can be used to assess overall mental health and cognition, respectively. We sought to evaluate mental health with cognition in individuals with chronic diseases and stable vital signs presenting to the Emergency Department (ED). Methods An observational study in the ED with 279 participants was conducted. Results Chronic diseases were more prevalent among 51-70 years (43.4%) and diabetes was most common (58.8%). Fever (22.6%) and GI bleeding (32.6%) presentation were high. Participants with low WWBI had low SIS compared to the ones with higher scores (83.3% vs. 17.7%, p < 0.001) and also had low CLOX-1 compared to ones with high CLOX-1 (67.3% vs. 5%, <0.001). A positive correlation between WWBI with SIS (correlation coefficient = 0.305, p < 0.001) and CLOX-1 (0.441, <0.001). Regression analysis indicates a positive association between WWBI and the SIS (standardized regression coefficient = 0.187, 95%CI = 0.236-1.426, and p = 0.006) and CLOX 1 (0.338, 0.2-0.463, <0.001). Conclusion In the ED, the evaluation of mental health even among cognitive impaired is feasible and crucial.
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Affiliation(s)
- Aditya Lal Vallath
- Department of Emergency Medicine, Peerless Hospital and BK Roy Research Center, Kolkata, India
| | | | | | - Akshita Lalendran
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Sudeshna Samanta
- BBA Hospital Management, George Group of Colleges, Kolkata, India
| | - Snigda Banerjee
- Clinical Pharmacology and Research, Peerless Hospital and BK Roy Research Center, Kolkata, India
| | - Tania Das
- Department of Orthopedics and Trauma, Peerless Hospital and BK Roy Research Center, Kolkata, India
| | - Ritwick Kundu
- Department of Emergency Medicine, Peerless Hospital and BK Roy Research Center, Kolkata, India
| | - Vyom Richharia
- Department of Public Health, Bharati Vidyapeeth Deemed University Medical College, Pune, India
| | - Ravisha More
- National AIDS Research Center, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | | | - Sahana Nazimudeen
- Department of Emergency Medicine, Peerless Hospital and BK Roy Research Center, Kolkata, India
| | - Sasidhar Gunturu
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Indraneel Dasgupta
- Department of Emergency Medicine, Peerless Hospital and BK Roy Research Center, Kolkata, India
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Cohn-Schwartz E, Joshi R, McClure LA. The Associations of Loneliness and Social Support with Cognitive Impairment among Middle-Aged and Older Individuals with Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1885. [PMID: 36767249 PMCID: PMC9914689 DOI: 10.3390/ijerph20031885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 06/18/2023]
Abstract
Diabetes mellitus is a chronic disease with significant morbidity and mortality and it is associated with poor cognitive performance in later life. This study seeks to determine the relationship between social support and cognitive function among participants with type 2 diabetes mellitus (T2DM). We used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including participants with T2DM aged 45 and older (n = 4821). We examined different aspects of perceived social support, measured as structural social support (e.g., marital status), functional social support (having a caregiver in case of sickness or disability), and loneliness. We examined cognitive functioning using a six-item screener. Our results indicate that adults who felt lonely for 5-7 days per week had almost double the odds of cognitive impairment compared to those who didn't feel lonely. These results suggest that among middle-aged and older individuals with T2DM, interventions targeting lonely adults and which aim to reduce loneliness may combat some of the risks of cognitive decline.
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Affiliation(s)
- Ella Cohn-Schwartz
- Department of Epidemiology, Biostatistics, and Community Health Sciences, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva 8410501, Israel
| | - Rennie Joshi
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
| | - Leslie A. McClure
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
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Gootee E, Stein C, Walker A, Daneshvari NO, Blaha MJ, Lima JAC, Gottesman RF, Johansen MC. Normal left atrial diameter is associated with better performance on a cognitive screener among a cohort of ischemic stroke patients. Front Neurol 2022; 13:1028296. [PMID: 36504665 PMCID: PMC9729539 DOI: 10.3389/fneur.2022.1028296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/04/2022] [Indexed: 11/26/2022] Open
Abstract
Background Cardiac structure is an important determinant of ischemic stroke (IS) etiology; however, whether an association between cardiac structural markers and cognition post-IS exists is not yet established. The aim of this study is to examine the association between LAD and LVEF with cognitive performance among IS patients. Methods IS patients admitted to the Johns Hopkins Hospital (2017-2019) underwent transthoracic echocardiography. IS was classified (TOAST) by a masked reviewer. Left atrial diameter (LAD) was evaluated as a non-linear continuous variable with one spline knot at 4 cm; left ventricle ejection fraction (LVEF) was dichotomized, then further evaluated as a non-linear continuous variable with spline knots at 50% and 70%. Patients were contacted by telephone on average 422 days post-stroke and administered the Six-Item Screener (SIS) to assess for dementia. SIS scores were dichotomized into low and high, imputing low scores for non-answerers. Multivariable logistic regression determined the association of SIS category with LAD or LVEF. A sensitivity analysis re-evaluated the association between SIS category and LAD, excluding participants with atrial fibrillation (AF). Results Participants (N = 108) were on average 61 years old (range = 18-89 years), 55% male, and 63% Black. Among patients considered to have a normal LAD (≤ 4 cm), a 1 mm larger LAD was associated with 1.20 greater odds (95%CI = 1.05-1.38) of scoring in the high SIS category in the final adjustment model. This association remained significant when excluding participants with prevalent AF. There was no association between a 1 mm larger LAD and SIS category among patients with a LAD >4 cm in both the primary analysis and the sensitivity analysis. There was no association between LVEF and SIS category. Conclusions In this prospective study, among ischemic stroke patients with a LAD within the normal range, a 1 mm increase in LAD was associated with higher scores on a telephone cognitive battery, without an association found among those with a LAD >4 cm.
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Affiliation(s)
- Emma Gootee
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Colin Stein
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alex Walker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Michael J. Blaha
- Department of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Joao A. C. Lima
- Department of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Rebecca F. Gottesman
- National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, MD, United States
| | - Michelle C. Johansen
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States,*Correspondence: Michelle C. Johansen
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Nowroozpoor A, Dussetschleger J, Perry W, Sano M, Aloysi A, Belleville M, Brackett A, Hirshon JM, Hung W, Moccia JM, Ohuabunwa U, Shah MN, Hwang U. Detecting Cognitive Impairment and Dementia in the Emergency Department: A Scoping Review. J Am Med Dir Assoc 2022; 23:1314.e31-1314.e88. [PMID: 35940682 PMCID: PMC10804640 DOI: 10.1016/j.jamda.2022.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/23/2022] [Accepted: 03/30/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To identify research and practice gaps to establish future research priorities to advance the detection of cognitive impairment and dementia in the emergency department (ED). DESIGN Literature review and consensus-based rankings by a transdisciplinary, stakeholder task force of experts, persons living with dementia, and care partners. SETTING AND PARTICIPANTS Scoping reviews focused on adult ED patients. METHODS Two systematic scoping reviews of 7 medical research databases focusing on best tools and approaches for detecting cognitive impairment and dementia in the ED in terms of (1) most accurate and (2) most pragmatic to implement. The results were screened, reviewed, and abstracted for relevant information and presented at the stakeholder consensus conference for discussion and ranked prioritization. RESULTS We identified a total of 1464 publications and included 45 to review for accurate tools and approaches for detecting cognitive impairment and dementia. Twenty-seven different assessments and instruments have been studied in the ED setting to evaluate cognitive impairment and dementia, with many focusing on sensitivity and specificity of instruments to screen for cognitive impairment. For pragmatic tools, we identified a total of 2166 publications and included 66 in the review. Most extensively studied tools included the Ottawa 3DY and Six-Item Screener (SIS). The SIS was the shortest to administer (1 minute). Instruments with the highest negative predictive value were the SIS (vs MMSE) and the 4 A's Test (vs expert diagnosis). The GEAR 2.0 Advancing Dementia Care Consensus conference ranked research priorities that included the need for more approaches to recognize more effectively and efficiently persons who may be at risk for cognitive impairment and dementia, while balancing the importance of equitable screening, purpose, and consequences of differentiating various forms of cognitive impairment. CONCLUSIONS AND IMPLICATIONS The scoping review and consensus process identified gaps in clinical care that should be prioritized for research efforts to detect cognitive impairment and dementia in the ED setting. These gaps will be addressed as future GEAR 2.0 research funding priorities.
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Affiliation(s)
- Armin Nowroozpoor
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jeff Dussetschleger
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - William Perry
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Mary Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Research and Development, James J. Peters VAMC, Bronx, NY, USA
| | - Amy Aloysi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William Hung
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | | | - Ugochi Ohuabunwa
- Division of General Medicine and Geriatrics, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Manish N Shah
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, WI, USA; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.
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Rapid cognitive assessment tools for screening of mild cognitive impairment in the preoperative setting: A systematic review and meta-analysis. J Clin Anesth 2022; 78:110682. [DOI: 10.1016/j.jclinane.2022.110682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/21/2022] [Accepted: 02/07/2022] [Indexed: 12/29/2022]
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Calf AH, Pouw MA, van Munster BC, Burgerhof JGM, de Rooij SE, Smidt N. Screening instruments for cognitive impairment in older patients in the Emergency Department: a systematic review and meta-analysis. Age Ageing 2021; 50:105-112. [PMID: 33009909 PMCID: PMC7793600 DOI: 10.1093/ageing/afaa183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background cognitive impairment is highly prevalent among older patients attending the Emergency Department (ED) and is associated with adverse outcomes. Methods we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of cognitive screening instruments to rule out cognitive impairment in older patients in the ED. A comprehensive literature search was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. A risk of bias assessment using QUADAS-2 was performed. Results 23 articles, examining 18 different index tests were included. Only seven index tests could be included in the meta-analysis. For ruling out cognitive impairment irrespective of aetiology, Ottawa 3 Day Year (O3DY) (pooled sensitivity 0.90; (95% CI) 0.71–0.97) had the highest sensitivity. Fourteen articles focused on screening for cognitive impairment specifically caused by delirium. For ruling out delirium, the 4 A’s Test (4AT) showed highest sensitivity (pooled sensitivity 0.87, 95% confidence interval (95% CI) 0.74–0.94). Conclusions high clinical and methodological heterogeneity was found between included studies. Therefore, it is a challenge to recommend one diagnostic test for use as a screening instrument for cognitive impairment in the ED. The 4AT and O3DY seem most promising for ruling out cognitive impairment in older patients attending the ED. The review protocol was registered in PROSPERO (CRD42018082509).
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Affiliation(s)
- Agneta H Calf
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
| | - Maaike A Pouw
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Martini Hospital, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Geriatrics, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Medical Spectrum Twente, Medical School Twente, Enschede, The Netherlands
| | - Nynke Smidt
- Department of Geriatrics, University Medical Center Groningen, Groningen, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Center for Quality Aging, Vanderbilt University Medical Center, 311 Oxford House, Nashville, TN 37232, USA.
| | - Joe Suyama
- Department of Emergency Medicine, Magee-Womens Hospital of UPMC, University of Pittsburgh School of Medicine, 3600 Forbes Tower, Pittsburgh, PA 15213, USA
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Geschke K, Weyer-Elberich V, Mueller AK, Binder H, Fellgiebel A. Feasibility and utility of a cognitive screening for risk stratification in hospitalized older patients. Int J Geriatr Psychiatry 2019; 34:588-593. [PMID: 30588672 DOI: 10.1002/gps.5056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/29/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To determine whether the Mini-Cog can be applied by nursing staff to hospitalized elderly patients for cognitive impairment associated risk stratification. METHODS This explorative prospective multicenter cohort study was carried out among 2522 patients aged 70 and older, hospitalized due to physical illness in eight hospitals in Rhineland-Palatinate, Germany. All patients were asked to conduct the Mini-Cog at the day of admission and were clustered into low-performance, intermediate-performance, and good-performance categories by trained nursing staff and two experienced geronto-psychiatrists as gold standard. Complications in the course of the treatment were monitored. RESULTS The Mini-Cog was conducted in 1398 (54%) out of 2522 eligible patients. Mini-Cog scores assessed by nursing staff differed from the gold standard in 327 cases (23.9%). According to the area under the curve (AUC), nursing staff identified cognitively low-performing patients almost as well as the geronto-psychiatrists (AUC = 0.862; 95% CI, 0.83-0.89; P < 0.001, accuracy 89.6%). Overall, 241 (17.6%) patients were classified as low performing. These patients had a significantly higher probability of suffering from at least one complication (odds ratio [OR] = 3.13; 95% CI, 2.09-4.70; calculated by a logistic regression model, adjusted for age), and they had a higher probability to show behavioral symptoms. CONCLUSION Even under naturalistic conditions, nursing staff detected cognitively low-performing inpatients with the Mini-Cog. Using this short screening instrument should enable to predict complications of hospitalized older patients associated with cognitive impairment, a precondition to implement targeted care for this vulnerable patient group.
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Affiliation(s)
- Katharina Geschke
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Veronika Weyer-Elberich
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Mainz, Germany
| | - Anne-Kristin Mueller
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Harald Binder
- Institute for Medical Biometry and Statistics, Alberts-Ludwig University Freiburg, Freiburg, Germany
| | - Andreas Fellgiebel
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
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Yamamoto H, Ogawa K, Huaman Battifora H, Yamamuro K, Ishitake T. Assessment and clinical implications of cognitive impairment in acutely ill geriatric patients using a revised simplified short-term memory recall test (STMT-R). Aging Clin Exp Res 2019; 31:345-351. [PMID: 29797228 DOI: 10.1007/s40520-018-0969-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/09/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Cognitive dysfunction due to delirium or dementia is a common finding in acutely ill geriatric patients, but often remains undetected. A brief and sensitive clinical identification method could prevent errors or complications while evaluating the mental status of elderly patients. AIMS To evaluate the usefulness and clinical implications of the revised simplified short-term memory recall test (STMT-R) in geriatric patients admitted in the emergency department; with age, gender, dementia history, serum albumin, underlying diseases and clinical outcome used as comparative factors. METHODS Mini-mental state examination and STMT-R scores were initially compared and a positive correlation was observed (r = 0.66, p < 0.001). Subsequently, 885 inpatients aged over 50 years underwent STMT-R evaluation between October 2014 and September 2015. We considered as cognitive dysfunction STMT-R scores ≤ 4 of a maximum score of 8. RESULTS Among enrolled patients, 52.2% were female and the mean age was 78.9 years. There were 159 patients who were unable to complete the test (incomplete testing group). We observed cognitive dysfunction in 460 patients, while 266 did not have cognitive dysfunction. There were significant differences between those with and without cognitive dysfunction in terms of age, dementia history, underlying respiratory diseases, and hospital outcome. CONCLUSION Cognitive dysfunction at admission can have a negative effect on the hospital outcomes of elderly patients. Age, a history of dementia and underlying respiratory diseases may also influence cognitive functional decline.
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Fry M, Elliott R. Pragmatic evaluation of an observational pain assessment scale in the emergency department: The Pain Assessment in Advanced Dementia (PAINAD) scale. Australas Emerg Care 2018; 21:131-136. [DOI: 10.1016/j.auec.2018.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/11/2018] [Accepted: 09/03/2018] [Indexed: 02/04/2023]
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Hullick C, Conway J, Higgins I, Hewitt J, Stewart B, Dilworth S, Attia J. An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study. BMC Geriatr 2018; 18:126. [PMID: 29843623 PMCID: PMC5975558 DOI: 10.1186/s12877-018-0811-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/08/2018] [Indexed: 11/10/2022] Open
Abstract
Background Older people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium. This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium. Methods Using a pre-post design, data was collected before and after the introduction of Older Person Technical Assistants (OPTAs) in the ED. OPTA activity was recorded during the intervention period and a medical record audit undertaken prior to and 9 months after implementation. Data were analysed using descriptive statistics for OPTA activities. Weighted Kappa scores were calculated comparing concordance in screening scores between OPTAs and Aged Services Emergency Team Registered Nurses. Changes in the rates of documented screening and supportive care were analysed using Chi-square tests. Focus groups were conducted to explore clinicians’ experiences of the OPTA role. Results Three thousand five hundred fourty two people were seen by OPTAs in 4563 ED Presentations between 1st July 2011 and 2012. The reproducibility of all screening tools were found to be high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9. The medical record audit showed significant improvement in the rates of documented screening, including cognition from 1.5 to 38% (p < 0.001) and review of pain from 29 to 75% (p < 0.001). Supportive care such as being given fluids or food also improved from 13 to 49% (p < 0.001) and pressure care from 4.8 to 30% (p < 0.001). This was accomplished with no increase in ED length of stay among this age group. Focus group interviews described mixed responses and support for the OPTA role. Conclusions An assistant workforce in an ED setting was found to provide comparable screening results and improve the rates of documented screening and supportive care provided to older people with or at risk of developing delirium in the ED. There is a need for a shared philosophy to the care of older people in the ED. Trial registration Australian New Zealand Clinical Trials Registration number is ACTRN12617000742370. It was retrospectively registered on 22nd May 2017.
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Affiliation(s)
- Carolyn Hullick
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.
| | - Jane Conway
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,School of Health, University of New England and Conjoint Professor of Nursing, University of Newcastle, Newcastle, Australia
| | - Isabel Higgins
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia.,School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
| | - Jacqueline Hewitt
- Aged Care Emergency Service, Clinical Nurse Consultant, Patient Flow Unit, Hunter New England Local Health District, Newcastle, Australia
| | - Bernadette Stewart
- John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, Armidale, NSW, 2310, Australia
| | - Sophie Dilworth
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia
| | - John Attia
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW, 2305, Australia
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Xue J, Chiu HFK, Liang J, Zhu T, Jiang Y, Chen S. Validation of the Six-Item Screener to screen for cognitive impairment in primary care settings in China. Aging Ment Health 2018; 22:453-457. [PMID: 28145741 DOI: 10.1080/13607863.2017.1280768] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to examine the reliability and validity of the Six-Item Screener (SIS) in screening cognitive impairment (CI) compared to the Mini-Mental State Examination (MMSE) in primary care settings in China. METHODS Participants (n = 2556, aged 60 years or older) from 30 primary care settings in Hangzhou, China, were recruited and screened using the SIS. They had a mean age of 71.6 ± 8.7 years, 50% were females, and 73% had education fewer than 5 years. A number of 373 screened participants received the MMSE assessment after the screening. RESULTS The correlation coefficients between the six items of the SIS and its total score ranged from 0.17 to 0.78. The correlation between the total score of SIS and MMSE was 0.70. The Cronbach's α coefficient of the SIS was 0.70. The receiver operating characteristic analysis using MMSE as the golden standard had the optimal cut-off score of 3, with sensitivity of 0.86 and specificity of 0.87, and the area under the curve (AUC) was 0.93. CONCLUSION The SIS performs well compared with the MMSE for screening of individuals with CI in primary care settings in China.
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Affiliation(s)
- Jiang Xue
- a Department of Psychology , Zhejiang University , Hangzhou , China
| | - Helen F K Chiu
- b Department of Psychiatry , The Chinese University of Hong Kong , Hong Kong
| | - Jiaming Liang
- a Department of Psychology , Zhejiang University , Hangzhou , China
| | - Tingfei Zhu
- a Department of Psychology , Zhejiang University , Hangzhou , China
| | - Yuxing Jiang
- a Department of Psychology , Zhejiang University , Hangzhou , China
| | - Shulin Chen
- a Department of Psychology , Zhejiang University , Hangzhou , China
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Preston L, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06160] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BackgroundEmergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.ObjectivesTo systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.DesignA systematic mapping review.SettingEvidence from developed countries on interventions delivered in the ED.ParticipantsFrail and high-risk older people and general populations of older people (aged > 65 years).InterventionsInterventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.Main outcome measuresPatient outcomes (direct and indirect) and health service outcomes.Data sourcesEvidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.Review methodsA review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.ResultsOf the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.LimitationsThis review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.ConclusionsA substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.Future workFuture work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.Study registrationThis study is registered as PROSPERO CRD42016043260.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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14
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Abstract
Older patients who present to the emergency department frequently have acute or chronic alterations of their mental status, including their level of consciousness and cognition. Recognizing both acute and chronic changes in cognition are important for emergency physicians. Delirium is an acute change in attention, awareness, and cognition. Numerous life-threatening conditions can cause delirium; therefore, prompt recognition and treatment are critical. The authors discuss an organized approach that can lead to a prompt diagnosis within the time constraints of the emergency department.
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Affiliation(s)
- Scott T Wilber
- Department of Emergency Medicine, Summa Health System-Akron City Hospital, Northeastern Ohio Medical University, 525 East Market Street, Akron, OH 44309, USA.
| | - Jason E Ondrejka
- Department of Emergency Medicine, Summa Health System-Akron City Hospital, Northeastern Ohio Medical University, 525 East Market Street, Akron, OH 44309, USA
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15
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Krupp S, Seebens A, Kasper J, Willkomm M, Balck F. [Validation of the German version of the 6‑item screener : Brief cognitive test with broad application possibilities]. Z Gerontol Geriatr 2017; 51:275-281. [PMID: 28093627 DOI: 10.1007/s00391-016-1177-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 09/29/2016] [Accepted: 12/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Especially during admission the detection of cognitive deficits relevant to everyday life should burden patient and examiner as little as possible. The 6‑item screener (SIS) takes approximately 1 min, is easy to learn, does not require any material and is independent of the patient's visual and fine motor skills. The test was first published in 2002 by Callahan who approved the present German translation. OBJECTIVE We checked the convergent and discriminant validity, reliability and sensitivity to change of the German translation among geriatric patients. MATERIAL AND METHODS A total of 165 patients in an acute geriatric department performed the SIS (4 times), the mini mental state examination (MMSE, 2 times), clock-drawing test according to Shulman (2 times), the Regensburg verbal fluency test (2 times) and the Montgomery-Åsberg depression rating scale within a period of 16 days. The overall judgment of a physician blinded to the test results served as the reference standard. RESULTS The SIS closely correlated with the medical judgment (-0.729). The retest reliability was 0.705 and the internal consistency 0.821 (Cronbach's alpha). The sensitivity to detect cognitive deficits relevant to activities of daily living was 100% if a threshold of 5 points was chosen. The achievement of maximum points largely rules out even mild cognitive impairment. CONCLUSION The SIS is a valid, reliable short cognitive test. Using a threshold of 5 points the SIS detects cognitive deficits relevant to daily living with a higher sensitivity than the MMSE with a threshold of 25. When the maximum score is achieved there are no medical indications for further cognitive assessment of clinically unremarkable geriatric patients. The brevity and simple application of the SIS also enable its application outside geriatric wards.
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Affiliation(s)
- S Krupp
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland.
| | - A Seebens
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland.,Psychosoziale Medizin und Entwicklungsneurowissenschaften, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland.,Universität zu Lübeck, Lübeck, Deutschland
| | - J Kasper
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland
| | - M Willkomm
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland
| | - F Balck
- Forschungsgruppe Geriatrie Lübeck, Krankenhaus Rotes Kreuz Lübeck - Geriatriezentrum, Marlistr. 10, 23566, Lübeck, Deutschland.,Psychosoziale Medizin und Entwicklungsneurowissenschaften, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
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Kaldirim U, Eroglu M, Durusu M, Yildirim AO, Tuncer SK, Eyi YE, Arziman I, Kaya C, Acikel C, Yamanel L. The Evaluation of Mental Status of Elderly Patients Presenting to Emergency Services and the Comparison Between the Last Diagnosis and Their Complaints. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140515122830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Umit Kaldirim
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara - Turkey
| | - Murat Eroglu
- Gulhane Military Medical Academy, Haydarpasa Training Hospital Department of Emergency Medicine, Istanbul - Turkey
| | - Murat Durusu
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara - Turkey
| | - Ali Osman Yildirim
- Gulhane Military Medical Academy, Haydarpasa Training Hospital Department of Emergency Medicine, Istanbul - Turkey
| | - Salim Kemal Tuncer
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara - Turkey
| | - Yusuf Emrah Eyi
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara - Turkey
| | - Ibrahim Arziman
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara - Turkey
| | - Cengiz Kaya
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara - Turkey
| | - Cengizhan Acikel
- Department of Public Health, Gulhane Military Medical Academy, Ankara - Turkey
| | - Levent Yamanel
- Department of Intensive Care, Gulhane Military Medical Academy, Ankara - Turkey
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17
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Rosted E, Poulsen I, Hendriksen C, Wagner L. The Importance of Risk and Subgroup Analysis of Nonparticipants in a Geriatric Intervention Study. SCIENTIFICA 2016; 2016:2787282. [PMID: 27446634 PMCID: PMC4944059 DOI: 10.1155/2016/2787282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 05/12/2016] [Accepted: 06/01/2016] [Indexed: 06/06/2023]
Abstract
Background. A major concern in intervention studies is the generalizability of the findings due to refusal of intended participants to actually take part. In studies including ill older people the number of those declining to participate may be large and the concern is therefore relevant. Objectives. To compare patients characteristics, rates of acute readmission, and mortality after one and six months among older persons who agreed and those who declined to participate in a randomized controlled trial and to describe subgroups of nonparticipants. Design. Comparative study based on a randomized controlled trial. Setting. University hospital in the Capital Region of Denmark. Participants. Patients ≥70 years discharged home after a short Emergency Department stay. 399 were requested to participate; 271 consented, whereas 128 refused. Results. Refusers were more likely to be readmitted (p < 0.001) or die (p = 0.006). The largest subgroup of refusers described as "too ill" had the highest risk of readmission (OR = 3.00, 95% CI = 1.61-5.47, p = 0.001) and of mortality within six months (OR = 3.50, 95% CI = 1.64-7.49, p = 0.002). However, this seems not to have affected the results of our randomized study. Conclusion. We recommend that intervention studies among older people or other fragile patient groups include analysis of relevant risk and subgroup analyses of refusers.
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Affiliation(s)
- Elizabeth Rosted
- Copenhagen University Hospital, Amager-Hvidovre, 2300 Copenhagen S, Denmark
| | - Ingrid Poulsen
- RUBRIC, Clinic of Neurorehabilitation, TBI Unit, Rigshospitalet, 2100 Copenhagen Ø, Denmark
| | - Carsten Hendriksen
- Institute of Public Health, University of Copenhagen and Copenhagen University Hospital, Bispebjerg, 2400 Copenhagen NV, Denmark
| | - Lis Wagner
- Research Unit of Nursing, Institute of Clinical Research, Faculty of Health Research, University of Southern Denmark, 5230 Odense M, Denmark
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18
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Wilding L, Eagles D, Molnar F, O'Brien JA, Dalziel WB, Moors J, Stiell I. Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients. Ann Emerg Med 2015; 67:157-63. [PMID: 26607333 DOI: 10.1016/j.annemergmed.2015.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/19/2015] [Accepted: 09/02/2015] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVE Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test. METHODS We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment. RESULTS Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%). CONCLUSION Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.
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Affiliation(s)
- Laura Wilding
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Molnar
- Regional Geriatric Program of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada; Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jo-Anne O'Brien
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - William B Dalziel
- Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joy Moors
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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19
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McCabe JJ, Kennelly SP. Acute care of older patients in the emergency department: strategies to improve patient outcomes. Open Access Emerg Med 2015; 7:45-54. [PMID: 27147890 PMCID: PMC4806806 DOI: 10.2147/oaem.s69974] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Older patients in the emergency department (ED) are a vulnerable population who are at a higher risk of functional decline and hospital reattendance subsequent to an ED visit, and have a high mortality rate in the months following an ED attendance. The delivery of acute care in a busy environment to this population presents its own unique challenge. The purpose of this review is to detail the common geriatric syndromes encountered in the ED as well as the appropriate strategies and instruments, which can be utilized to support the clinical decision matrix and improve outcomes.
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Affiliation(s)
- John J McCabe
- Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
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20
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Paddick SM, Gray WK, Ogunjimi L, Lwezuala B, Olakehinde O, Kisoli A, Kissima J, Mbowe G, Mkenda S, Dotchin CL, Walker RW, Mushi D, Collingwood C, Ogunniyi A. Validation of the Identification and Intervention for Dementia in Elderly Africans (IDEA) cognitive screen in Nigeria and Tanzania. BMC Geriatr 2015; 15:53. [PMID: 25908439 PMCID: PMC4455989 DOI: 10.1186/s12877-015-0040-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/25/2015] [Indexed: 11/17/2022] Open
Abstract
Background We have previously described the development of the Identification and Intervention for Dementia in Elderly Africans (IDEA) cognitive screen for use in populations with low levels of formal education. The IDEA cognitive screen was developed and field-tested in an elderly, community-based population in rural Tanzania with a relatively high prevalence of cognitive impairment. The aim of this study was to validate the IDEA cognitive screen as an assessment of major cognitive impairment in hospital settings in Nigeria and Tanzania. Methods In Nigeria, 121 consecutive elderly medical clinic outpatients reviewed at the University College Hospital, Ibadan were screened using the IDEA cognitive screen. In Tanzania, 97 consecutive inpatients admitted to Mawenzi Regional Hospital (MRH), Moshi, and 108 consecutive medical clinic outpatients attending the geriatric medicine clinic at MRH were screened. Inter-rater reliability was assessed in Tanzanian outpatients attending St Joseph’s Hospital in Moshi using three raters. A diagnosis of dementia or delirium (DSM-IV criteria) was classified as major cognitive impairment and was provided independently by a physician blinded to the results of the screening assessment. Results The area under the receiver operating characteristic (AUROC) curve in Nigerian outpatients, Tanzanian outpatients and Tanzanian inpatients was 0.990, 0.919 and 0.917 respectively. Inter-rater reliability was good (intra-class correlation coefficient 0.742 to 0.791). In regression models, the cognitive screen did not appear to be educationally biased. Conclusions The IDEA cognitive screen performed well in these populations and should prove useful in screening for dementia and delirium in other areas of sub-Saharan Africa.
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Affiliation(s)
- Stella-Maria Paddick
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK. .,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.
| | - William K Gray
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK.
| | - Luqman Ogunjimi
- University College Hospital, University of Ibadan, Ibadan, Nigeria.
| | | | | | - Aloyce Kisoli
- Hai District Hospital, Boman'gombe, Kilimanjaro, Tanzania.
| | - John Kissima
- Hai District Hospital, Boman'gombe, Kilimanjaro, Tanzania.
| | - Godfrey Mbowe
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Sarah Mkenda
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Catherine L Dotchin
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK. .,Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK.
| | - Richard W Walker
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK. .,Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
| | - Declare Mushi
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | | | - Adesola Ogunniyi
- University College Hospital, University of Ibadan, Ibadan, Nigeria.
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Sangha S, George J, Winthrop C, Panchal S. Confusion: delirium and dementia - a smartphone app to improve cognitive assessment. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:bmjquality_uu202580.w1592. [PMID: 26732085 PMCID: PMC4645948 DOI: 10.1136/bmjquality.u202580.w1592] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 01/05/2015] [Indexed: 12/03/2022]
Abstract
Older patients with dementia and delirium are more prone to adverse events in hospital, but formal cognitive assessment to identify these vulnerable patients on admission is often not carried out by junior doctors. A smartphone app was created and provided on hospital wards to facilitate the use of standard cognitive assessments for delirium and dementia. Before the introduction of the app, 36% of patients over 75 years old were assessed cognitively. After the app, the percentage of cognitive assessments improved to 63%. Improvements in cognitive assessments were most marked after individual teaching of the doctors on the wards in the use of the app and on making the app available on the ward tablets. The results of the study suggest that the introduction of a smartphone app for junior doctors can improve performance in cognitive assessment of older people.
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Affiliation(s)
| | - J George
- North Cumbria University Hospitals Trust
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22
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Abstract
OVERVIEW Although it increases the risk of poor outcomes and raises the costs of care, cognitive impairment in hospitalized older adults is often neither accurately identified nor well managed. In conducting a two-phase, comparative-effectiveness clinical trial of the effects of three nursing interventions-augmented standard care, resource nurse care, and the transitional care model-on hospitalized older adults with cognitive deficits, a team of researchers encountered several challenges. For example, in assessing potential subjects for the study, they found that nearly half of those assessed had cognitive impairment, yet many family caregivers could not be identified or had no interest in participating in the study. One lesson the researchers learned was that research involving cognitively impaired older adults must actively engage clinicians, patients, and family caregivers, as well as address the complex process of managing postdischarge care.
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24
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Fry M, Arendts G, Chenoweth L, MacGregor C. Cognitive impairment is a risk factor for delayed analgesia in older people with long bone fracture: a multicenter exploratory study. Int Psychogeriatr 2014; 27:1-6. [PMID: 25162158 DOI: 10.1017/s1041610214001732] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT Background: Older people who present to the emergency department (ED) often experience a significant delay to analgesia. This study compares the time to analgesia for cognitively impaired and cognitively intact older people diagnosed with a long bone fracture. Methods: The aim of the study was to determine if cognitive impairment is associated with a delayed analgesic response. A 12-month exploratory study, using patient data, was conducted across four EDs. Medical records of 264 patients with long bone fractures were randomly selected. Results: The majority of patients waited longer than 60 minutes for analgesia. The median time to analgesia was longer for the cognitively impaired (149 minutes) compared with cognitively intact (72 minutes; Mann-Whitney U test: p < 0.001). Conclusions: This study suggests that cognitive impairment is a significant risk factor for delayed analgesia response in the ED.
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Affiliation(s)
- Margaret Fry
- Research and Practice Development,Northern Sydney Local Health District,St Leonards,NSW,Australia
| | - Glenn Arendts
- School of Primary,Aboriginal and Rural Health Care,University of Western Australia,Crawley,WA,Australia
| | - Lynn Chenoweth
- Aged and Extended Care Nursing,University of Technology,Sydney,NSW,Australia
| | - Casimir MacGregor
- Research and Practice Development,Northern Sydney Local Health District,St Leonards,NSW,Australia
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What is the evidence to guide best practice for the management of older people with cognitive impairment presenting to emergency departments? A systematic review. Adv Emerg Nurs J 2013; 35:154-69. [PMID: 23636047 DOI: 10.1097/tme.0b013e31828c7f4a] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The aim of this study was to conduct a systematic literature review of research-based studies to identify practices designed to meet the specific care needs of older cognitively impaired patients in emergency departments (ED). A systematic literature review of studies was completed using PRIMSA methodology. The search criteria included articles from both emergency and acute care settings. A total of 944 articles were screened, and a total of 43 articles were identified as eligible. The review found a number of intervention studies to improve quality of care for older persons with cognitive impairment carried out or commenced in emergency settings, including interventions to improve cognitive impairment recognition (n = 9) and clinical approaches to reduce falls (n = 1) and both delirium incidence and prevalence (n = 2). Relevant studies carried out in acute care settings regarding cognitive impairment recognition (n = 4) and primary and secondary prevention of delirium (n = 18) and intervention studies that reduced the prescription of deliriogenic drugs (n = 1), reduced behavioral symptoms and discomfort (n = 7), and improved nutritional intake (n = 1) in hospitalized older persons with dementia were also identified. There is limited research available that reports interventions that improve the quality of care of older ED patients with cognitive impairment. Although this review found evidence obtained from the acute care setting, additional research is needed to identify whether these interventions are beneficial in fast-paced emergency settings.
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Schnitker LM, Martin-Khan M, Burkett E, Beattie ERA, Gray LC. Appraisal of the quality of care of older adults with cognitive impairment in the emergency department. J Gerontol Nurs 2013; 39:34-40. [PMID: 23394489 DOI: 10.3928/00989134-20130131-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 07/18/2012] [Indexed: 11/20/2022]
Abstract
The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.
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Affiliation(s)
- Linda M Schnitker
- University of Queenland, The Centre for Research in Geriatric Medicine, Brisbane, Australia.
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Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and "inpatient" management models for geriatric emergencies. Clin Geriatr Med 2013; 29:31-47. [PMID: 23177599 PMCID: PMC3875836 DOI: 10.1016/j.cger.2012.09.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care.
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Abstract
Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
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Affiliation(s)
- Jin H. Han
- Center for Quality Aging, Assistant Professor of Emergency Medicine, Vanderbilt University School of Medicine, Department of Emergency Medicine, 703 Oxford House, Nashville, TN 37232-4700, Phone: 615-936-1434, Fax: 615-936-1316
| | - Scott T. Wilber
- Emergency Medicine Research Center, Associate Professor of Emergency Medicine, Summa Akron City Hospital, Northeastern Ohio Medical University, 525 East Market Street, Akron, Ohio 44309, Phone: 330-375-7530, Fax: 330-375-7564
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Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study. Int J Nurs Stud 2012; 50:1206-18. [PMID: 23219329 DOI: 10.1016/j.ijnurstu.2012.11.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 11/03/2012] [Accepted: 11/06/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting. METHOD Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis. RESULTS Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs. CONCLUSIONS In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.
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Betz ME, Schwartz R, Haukoos JS, DiGuiseppi C, Valley M, Johnson R, Lowenstein SR. A pilot study to develop a brief question-based screening tool to identify higher-risk older drivers. J Am Geriatr Soc 2012; 60:1791-4. [PMID: 22985161 DOI: 10.1111/j.1532-5415.2012.04131.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, School of Medicine, University of Colorado Aurora, Colorado, USA
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Steis MR, Evans L, Hirschman KB, Hanlon A, Fick DM, Flanagan N, Inouye SK. Screening for delirium using family caregivers: convergent validity of the Family Confusion Assessment Method and interviewer-rated Confusion Assessment Method. J Am Geriatr Soc 2012; 60:2121-6. [PMID: 23039310 PMCID: PMC3498543 DOI: 10.1111/j.1532-5415.2012.04200.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To explore agreement between the Family Confusion Assessment Method (FAM-CAM) for delirium identification and interviewer-rated CAM delirium ratings. DESIGN Exploratory analysis of agreement. SETTING Community. PARTICIPANTS Fifty-two family caregivers and 52 elderly adults with preexisting impairment according to standardized cognitive testing. MEASUREMENTS The interviewer-rating for delirium was determined by fulfillment of the CAM algorithm RESULTS The total sample included 52 paired CAM:FAM-CAM assessments completed across 52 dyads of elderly adults with preexisting cognitive impairment and family caregivers. The point prevalence of delirium was 13% (7/52). Characteristics did not differ significantly between the groups with and without delirium. The FAM-CAM questions that mapped directly to the original four-item CAM algorithm had the best overall agreement with the interviewer-rated CAM (kappa = 0.85, 95% confidence interval (CI) = 0.65-1.0), sensitivity of 88% (95% CI = 47-99%), and specificity of 98% (95% CI = 86-100%). CONCLUSION The FAM-CAM is a sensitive screening tool for detection of delirium in elderly adults with cognitive impairment using family caregivers, with relevance for research and clinical practice.
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Affiliation(s)
| | - Lois Evans
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Karen B. Hirschman
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Alexandra Hanlon
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Donna M. Fick
- School of Nursing, The Pennsylvania State University, University Park, Pennsylvania
| | - Nina Flanagan
- Decker School of Nursing, Binghamton University, Binghamton, New York
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and the Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
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Clevenger CK, Chu TA, Yang Z, Hepburn KW. Clinical Care of Persons with Dementia in the Emergency Department: A Review of the Literature and Agenda for Research. J Am Geriatr Soc 2012; 60:1742-8. [DOI: 10.1111/j.1532-5415.2012.04108.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Thasha A. Chu
- Nell Hodgson Woodruff School of Nursing; Emory University; Atlanta; Georgia
| | - Zhou Yang
- Rollins School of Public Health; Emory University; Atlanta; Georgia
| | - Kenneth W. Hepburn
- Nell Hodgson Woodruff School of Nursing; Emory University; Atlanta; Georgia
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Bradway C, Trotta R, Bixby MB, McPartland E, Wollman MC, Kapustka H, McCauley K, Naylor MD. A qualitative analysis of an advanced practice nurse-directed transitional care model intervention. THE GERONTOLOGIST 2012; 52:394-407. [PMID: 21908805 PMCID: PMC3342512 DOI: 10.1093/geront/gnr078] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 07/08/2011] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs). DESIGN AND METHODS APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences. RESULTS Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond. IMPLICATIONS APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.
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Dementia=(MC)2: a 4-item screening test for mild cognitive impairment and dementia. Alzheimer Dis Assoc Disord 2011; 25:220-4. [PMID: 21566510 DOI: 10.1097/wad.0b013e31820bd36e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To develop a practical informant-based screening tool that reliably identifies patients with mild cognitive impairment (MCI) and dementia, we analyzed data from a sample of patients and normal controls seen in a memory clinic. All patients were evaluated with the Clinical Dementia Rating scale. Individual Clinical Dementia Rating responses were dichotomized and entered into a forward stepwise multivariable logistic regression model. Four independent predictors of MCI and dementia thus identified were combined into a prediction rule that was validated in a separate cohort drawn from the same clinic. Using a cut point of 2 or more positive responses to the 4 questions, the final prediction rule had sensitivity of 95% (95% confidence interval (CI): 92-97%) for MCI or dementia, and a specificity of 91% (95% CI: 86-95%). When applied to the validation cohort, the sensitivity for MCI or dementia was 96% (95% CI: 94-98%), and the specificity was 96% (95% CI: 92-98%). Using both cohorts, the positive likelihood ratio for MCI or dementia was 15.6 (95% CI: 14.0-17.3) and the negative likelihood ratio was 0.05 (95% CI: 0.04-0.07). This tool has the potential to identify patients who warrant further cognitive evaluation in busy outpatient or emergency department settings.
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Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and nurse acceptance of technicians to screen for geriatric syndromes in the emergency department. West J Emerg Med 2011; 12:489-95. [PMID: 22224145 PMCID: PMC3236152 DOI: 10.5811/westjem.2011.1.1962] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 09/09/2010] [Accepted: 01/15/2011] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The objective of this study was to evaluate emergency medicine physician and nurse acceptance of nonnurse, nonphysician screening for geriatric syndromes. METHODS This was a single-center emergency department (ED) survey of physicians and nurses after an 8-month project. Geriatric technicians were paid medical student research assistants evaluating consenting ED patients older than 65 years for cognitive dysfunction, fall risk, or functional decline. The primary objective of this anonymous survey was to evaluate ED nurse and physician perceptions about the geriatric screener feasibility and barriers to implementation. In addition, as a secondary objective, respondents reported ongoing geriatric screening efforts independent of the research screeners. RESULTS The survey was completed by 72% of physicians and 33% of nurses. Most nurses and physicians identified geriatric technicians as beneficial to patients without impeding ED throughput. Fewer than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluated for fall risk significantly more often than physicians, but no other significant differences were noted in ongoing screening efforts. CONCLUSION Dedicated geriatric technicians are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. Most nurses and physicians are not currently screening for any geriatric syndromes.
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Affiliation(s)
- Christopher R Carpenter
- Washington University School of Medicine, Division of Emergency Medicine, St Louis, Missouri
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Boyle LL, Richardson TM, He H, Xia Y, Tu X, Boustani M, Conwell Y. How do the PHQ-2, the PHQ-9 perform in aging services clients with cognitive impairment? Int J Geriatr Psychiatry 2011; 26:952-60. [PMID: 21845598 PMCID: PMC3930057 DOI: 10.1002/gps.2632] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 08/06/2010] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the performance of the Patient Health Questionnaire-2 (PHQ-2) and the PHQ-9 in detecting current major depressive episode (MDE) in aging services care management clients who screen positive for cognitive impairment (CI). METHODS Cross-sectional observational study of 236 care management clients ages ≥60 years recruited from an Upstate NY aging services agency. The test characteristics of the PHQ-2 and PHQ-9 to screen for depression were calculated using the Structured Clinical Interview for DSM-IV (SCID) to identify MDE (gold standard). CI was identified with the Six-Item Screen (SIS). RESULTS Participants had a mean age of 77 years, 68% female, 16% non-white, and 26% had less than a high school education. 16% of participants had CI identified by ≥2 errors on SIS. Of these, 41% had positive PHQ-2 (scores ≥3), 43% had positive PHQ-9 (scores ≥10), while 24% met criteria for MDE. In the sample with CI, the PHQ-2, using a cutoff of 3, had sensitivity = 0.78, specificity = 0.71, and receiver operating characteristic (ROC) area under the curve (AUC) = 0.81, compared with 0.79, 0.82, and 0.88, respectively, for those without CI. In the sample with CI, the PHQ-9, using a cutoff of 10, had sensitivity = 0.89, specificity = 0.71, and AUC = 0.85, compared with 0.85, 0.89, and 0.91, respectively, for those without CI. CONCLUSIONS Cognitive status should be considered when using the PHQ as a depression screener due to poorer specificity in seniors with CI.
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Affiliation(s)
- Lisa L. Boyle
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Thomas M. Richardson
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Hua He
- Department of Biostatistics, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Yinglin Xia
- Department of Biostatistics, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Xin Tu
- Department of Biostatistics, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Malaz Boustani
- Indiana University Center for Aging Research and Regenstrief Institute, Inc, Indiana, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, New York, USA
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Carpenter CR, DesPain B, Keeling TN, Shah M, Rothenberger M. The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med 2011; 57:653-61. [PMID: 20855129 PMCID: PMC3213856 DOI: 10.1016/j.annemergmed.2010.06.560] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 05/25/2010] [Accepted: 06/24/2010] [Indexed: 01/10/2023]
Abstract
STUDY OBJECTIVE We evaluate the diagnostic test characteristics of the Six-Item Screener and the AD8 to detect cognitive dysfunction in adults older than 65 years and using the emergency department (ED) for any reason. METHODS We conducted an observational cross-sectional cohort study at a single academic urban university-affiliated hospital. Subjects were consenting, non--critically ill, English-speaking adults older than 65 years and receiving care in the ED. We quantitatively assessed the diagnostic test characteristics of the Six-Item Screener and AD8 by using the Mini-Mental State Examination score less than 24 as the criterion standard for cognitive dysfunction. RESULTS The prevalence of cognitive dysfunction was 35%, but only 6% of charts noted a pre-existing deficit. The Six-Item Screener was superior to either the caregiver-administered AD8 or the patient-administered AD8 for the detection of cognitive dysfunction. CONCLUSION The Six-Item Screener was superior to the caregiver- or patient-administered AD8 to identify older adults at increased risk for occult cognitive dysfunction.
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Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
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Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 2011; 18:374-84. [PMID: 21496140 DOI: 10.1111/j.1553-2712.2011.01040.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use. OBJECTIVES The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer's Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools. METHODS In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients' responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non-critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments. RESULTS The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE. CONCLUSIONS The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.
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Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, MO, USA.
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Parke B, Beaith A, Slater L, Clarke AM. Contextual factors influencing success or failure of emergency department interventions for cognitively impaired older people: a scoping and integrative review. J Adv Nurs 2011; 67:1426-48. [PMID: 21382076 DOI: 10.1111/j.1365-2648.2011.05611.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM This paper is a report of a scoping review of research on cognitive impairment in older adults who visit Emergency Departments of acute care hospitals, followed by an integrative review that included a quality assessment to determine the effectiveness of interventions for this population. BACKGROUND Being old and cognitively impaired in the Emergency Department--a fast-paced intervention system--is a complex phenomenon that challenges many healthcare professionals. The rise in the incidence and prevalence of dementia will have a large impact on healthcare systems. DATA SOURCES MEDLINE, EMBASE, CINAHL, PsycInfo, AgeLine, Abstracts in Social Gerontology, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and Google Scholar between 1990 and 2008, for qualitative or quantitative studies reporting extractable data on delirium or dementia in non-institutionalized older people (65+ years) in the Emergency Department. REVIEW METHODS Titles screened by a project researcher and checked against inclusion criteria by another researcher. Two reviewers completed independent data extraction and synthesis of included studies. Quality assessment occurred using the Critical Appraisal Skills Programme Tools. RESULTS Fifteen studies met the inclusion criteria for integrative review. Analysis of these studies indicates that the prevalence of cognitive impairment is high and improvements are needed. Contextual details and relevant features of an appropriate intervention are poorly explained. CONCLUSION Although the prevalence and incidence of cognitive impairment is recognized, appropriate interventions and programmatic responses remain elusive. Quality improvements require more thorough examination of emergency department context to identify modifiable influencing factors that are transferable across settings.
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Affiliation(s)
- Belinda Parke
- Faculty of Nursing, University of Alberta, Edmonton, Canada.
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Shah MN, Richardson TM, Jones CMC, Swanson PA, Schneider SM, Katz P, Conwell Y. Depression and cognitive impairment in older adult emergency department patients: changes over 2 weeks. J Am Geriatr Soc 2011; 59:321-6. [PMID: 21275931 DOI: 10.1111/j.1532-5415.2010.03268.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To evaluate older adult emergency department (ED) patients for depression and cognitive impairment and to re-evaluate those findings 2 weeks later. DESIGN Prospective cohort study. SETTING ED. PARTICIPANTS One thousand two hundred six older community-dwelling ED patients consented to participate; 811 (67%) completed the 2-week follow-up. MEASUREMENTS Screening for depression (9-item Patient Health Questionnaire) and cognitive impairment (Six-Item Screener) was performed. Changes were evaluated through paired comparisons. RESULTS At 2-week follow-up, for depression, 27 of 97 (28%) with baseline positive tests remained positive, and 22 of 706 (3%) with baseline negative tests were positive. At 2-week follow-up, for cognitive impairment, five of 43 (12%) with baseline positive tests remained positive, and 11 of 765 (1%) with baseline negative tests were positive. CONCLUSION Significant variability exists for depression and cognitive impairment testing completed during and after the ED visit, with markedly fewer subjects testing positive at follow-up. The variability may reflect changes in clinical state, confounding from other conditions, or poor validity of the instruments in the ED setting. Further studies are needed to explain these findings before case-finding for these conditions is implemented in the ED setting.
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Affiliation(s)
- Manish N Shah
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA.
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Han JH, Bryce SN, Ely EW, Kripalani S, Morandi A, Shintani A, Jackson JC, Storrow AB, Dittus RS, Schnelle J. The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Ann Emerg Med 2011; 57:662-671.e2. [PMID: 21272958 DOI: 10.1016/j.annemergmed.2010.12.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 11/17/2010] [Accepted: 12/01/2010] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE We seek to determine how delirium and dementia affect the accuracy of the presenting illness and discharge instruction comprehension in older emergency department (ED) patients. METHODS This cross-sectional study was conducted at an academic ED from May 2008 to July 2008 and included non-nursing home patients aged 65 years and older. Two open-ended interviews were performed to assess patients' ability to accurately provide their presenting illness and comprehension of their ED discharge instructions. The surrogates' version of the presenting illness and printed discharge instructions were the reference standards. Concordance between the patient and the reference standards was determined by 2 reviewers using a 5-point scale ranging from 1 (no concordance) to 5 (complete concordance). Proportional odds logistic regression was performed to determine whether cognitive impairment was associated with presenting complaint accuracy and discharge instruction comprehension. All models were adjusted for age, health literacy, education, nonwhite race, and hearing impairment. RESULTS For the presenting illness analysis, 202 patients participated. Compared with patients without cognitive impairment, those with delirium superimposed on dementia (DSD) had lower odds of agreeing with their surrogates with regard to why they were in the ED (adjusted proportional odds ratio=0.20; 95% confidence interval [CI] 0.09 to 0.43). For the discharge instruction comprehension analysis, 115 patients participated. Patients with DSD had significantly lower odds of comprehending their discharge diagnosis (adjusted proportional odds ratio=0.13; 95% CI 0.04 to 0.47), return to the ED instructions (adjusted proportional odds ratio=0.18; 95% CI 0.04 to 0.82), and follow-up instructions (adjusted proportional odds ratio=0.09; 95% CI 0.02 to 0.35) compared with patients without cognitive impairment. CONCLUSION DSD is associated with decreased accuracy of the older patient's presenting illness and decreased comprehension of ED discharge instructions.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-4700, USA.
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Chen MR, Guo QH, Cao XY, Hong Z, Liu XH. A preliminary study of the Six-Item Screener in detecting cognitive impairment. Neurosci Bull 2010; 26:317-21. [PMID: 20651813 DOI: 10.1007/s12264-010-0106-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The present retrospective study was to explore the clinical value of Six-Item Screener (SIS), which is constituted by 6 items from mini-mental status examination (MMSE), to identify cognitive impairment. METHODS A total number of 1976 patients aged over 50 years, from the Memory Clinic of Huashan Hospital were employed in a battery of neuropsychological tests including MMSE. Subjects with severe conditions, unable to cooperate, or having been previously enrolled, were excluded from this study. The employed subjects were divided into 3 groups: subjective memory complaints (SMCs) (475 cases), patients with mild cognitive impairment (MCI) (440 cases), and patients with Alzheimer's disease (AD) (1061 cases, including 555 mild, 339 moderate, and 167 severe). A total score of MMSE and a score of SIS composed of date, month, year, three-word delayed recall from MMSE were calculated. Data were analyzed based on educational background. RESULTS The cut-off of SIS score was <2 for illiterate, <3 for elementary, and <4 for junior high school or above. The sensitivity and specificity of SIS for detecting mild AD were 88.5% and 78.3%, respectively, with an overall accuracy of 83.8%, while for detecting MCI, the sensitivity and specificity were 34.3% and 90.1%, respectively, with an overall accuracy of 63.2%. CONCLUSION SIS is an effective and reliable instrument for dementia detection in outpatient department. However, it has limited value for MCI identification.
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Affiliation(s)
- Mei-Rong Chen
- Department of Neurology, People's Hospital of Putuo District, Shanghai, China
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Abstract
Multidisciplinary orthogeriatric care can enhance prompt ED diagnosis, optimal pre- and postoperative care, and functional recovery in older adults with bony injuries. Emergency care providers should be cognizant of prevalent geriatric syndromes including delirium and standing level falls to minimize fracture-related morbidity. Recognizing the implications of aging physiology, acute care physicians should be aware of effective alternatives to analgesia, procedural sedation, and definitive imaging to promote early surgical management and postoperative recovery.
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Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Barnes Jewish Hospital, Washington University in St Louis, Campus Box 8072, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Glasser SP, Wadley V, Judd S, Kana B, Prince V, Jenny N, Kissela B, Safford M, Prineas R, Howard G. The association of statin use and statin type and cognitive performance: analysis of the reasons for geographic and racial differences in stroke (REGARDS) study. Clin Cardiol 2010; 33:280-8. [PMID: 20513066 DOI: 10.1002/clc.20758] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Statin use and type have been variably associated with impaired or improved cognitive performance. HYPOTHESIS To assess the association of statin use and type (lipophilic vs hydrophilic) and cognitive impairment. METHODS Cross-sectional analysis of 24 595 participants (7191 statin users and 17 404 nonusers) age > or = 45 years, from a population-based national cohort study (Reasons for Geographic And Racial Differences in Stroke) enrolled between January 2003 and October 2008, with oversampling from the southeastern Stroke Belt and African Americans. Statin use and type were documented in participants' homes by a trained health professional. Cognitive performance was assessed with a prior validated instrument of global cognitive status (Six-Item Screener). Cognitive impairment was defined as a score of < 4. RESULTS Overall, an association of cognitive impairment and statin use was observed (8.6% of users vs 7.7% of nonusers had cognitive impairment, P = 0.014); but, after adjusting for variables known to be associated with cognition (age, gender, race, income, education level, and cardiovascular disease), the association was attenuated (odds ratio [OR]: 0.98, confidence interval [CI]: 0.87-1.10). No association was observed between statin type (lipophilic vs hydrophilic) and cognition (OR: 1.03, CI: 0.86-1.24), and there were no regional differences in cognitive impairment in statin users (8% in the Stroke Belt and 7.9% in other regions, P = 0.63). CONCLUSIONS Statin use and type were marginally associated with cognitive impairment. After adjusting for known variables that affect cognition, no association was observed. No regional differences were observed. This large study found no evidence to support an association between statins and cognitive performance.
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Affiliation(s)
- Stephen P Glasser
- University of Alabama at Birmingham, Division of Preventive Medicine, Birmingham, Alabama 35205, USA.
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Koita J, Riggio S, Jagoda A. The Mental Status Examination in Emergency Practice. Emerg Med Clin North Am 2010; 28:439-51. [DOI: 10.1016/j.emc.2010.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wilber ST, Blanda M, Gerson LW, Allen KR. Short-term functional decline and service use in older emergency department patients with blunt injuries. Acad Emerg Med 2010; 17:679-86. [PMID: 20653580 DOI: 10.1111/j.1553-2712.2010.00799.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Injuries are a common reason for emergency department (ED) visits by older patients. Although injuries in older patients can be serious, 75% of these patients are discharged home after their ED visit. These patients may be at risk for short-term functional decline related to their injuries or treatment. OBJECTIVES The objectives were to determine the incidence of functional decline in older ED patients with blunt injuries not requiring hospital admission for treatment, to describe their care needs, and to determine the predictors of short-term functional decline in these patients. METHODS This institutional review board-approved, prospective, longitudinal study was conducted in two community teaching hospital EDs with a combined census of 97,000 adult visits. Eligible patients were > or = 65 years old, with blunt injuries <48 hours old, who could answer questions or had a proxy. We excluded those too ill to participate; skilled nursing home patients; those admitted for surgery, major trauma, or acute medical conditions; patients with poor baseline function; and previously enrolled patients. Interviewers collected baseline data and the used the Older Americans Resources and Services (OARS) questionnaire to assess function and service use. Potential predictors of functional decline were derived from prior studies of functional decline after an ED visit and clinical experience. Follow-up occurred at 1 and 4 weeks, when the OARS questions were repeated. A three-point drop in activities of the daily living (ADL) score defined functional decline. Data are presented as means and proportions with 95% confidence intervals (CIs). Logistic regression was used to model potential predictors with functional decline at 1 week as the dependent variable. RESULTS A total of 1,186 patients were evaluated for eligibility, 814 were excluded, 129 refused, and 13 were missed, leaving 230 enrolled patients. The mean (+/-SD) age was 77 (+/-7.5) years, and 70% were female. In the first week, 92 of 230 patients (40%, 95% CI = 34% to 47%) had functional decline, 114 of 230 (49%, 95% CI = 43% to 56%) had new services initiated, and 76 of 230 had an unscheduled medical contact (33%, 95% CI = 27% to 39%). At 4 weeks, 77 of 219 had functional decline (35%, 95% CI = 29% to 42%), 141 of 219 had new services (65%, 95% CI = 58% to 71%), and 123 of 219 had an unscheduled medical contact (56%, 95% CI = 49% to 63%), including 15% with a repeated ED visit and 11% with a hospital admission. Family members provided the majority of new services at both time periods. Significant predictors of functional decline at 1 week were female sex (odds ratio [OR] = 2.2, 95% CI = 1.1 to 4.5), instrumental ADL dependence (IADL; OR = 2.5, 95% CI = 1.3 to 4.8), upper extremity fracture or dislocation (OR = 5.5, 95% CI = 2.5 to 11.8), lower extremity fracture or dislocation (OR = 4.6, 95% CI = 1.4 to 15.4), trunk injury (OR = 2.4, 95% CI = 1.1 to 5.3), and head injury (OR = 0.48, 95% CI = 0.23 to 1.0). CONCLUSIONS Older patients have a significant risk of short-term functional decline and other adverse outcomes after ED visits for injuries not requiring hospitalization for treatment. The most significant predictors of functional decline are upper and lower extremity fractures.
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Affiliation(s)
- Scott T Wilber
- Department of Emergency Medicine, Summa Akron City Hospital, Northeastern Ohio Universities College of Medicine, USA.
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Betz ME, Fisher J. The Trail-making Test B and driver screening in the emergency department. TRAFFIC INJURY PREVENTION 2009; 10:415-420. [PMID: 19746304 DOI: 10.1080/15389580903132819] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Emergency departments (EDs) rarely screen for older driving safety. The Trail-Making Test B (TMT-B) is a neuropsychological test that may predict ability to drive. We sought to examine the driving patterns of older ED patients and the feasibility of screening patients in the ED using the TMT-B. METHODS At a single ED at a tertiary care center, we administered the TMT-B and a survey of health status and driving habits to a convenience sample of adult (age 18 and older) ED patients. We excluded those with altered mentation, critical illness, or language barriers. The TMT-B, scored by the time of first attempt, requires connection of letters and numbers in sequence on paper, and a time > or = 180 s may suggest elevated driving risk. We compared time to complete the TMT-B among ED patients to published norms. RESULTS Of 144 patients ages 18 to 95, 95 (72.2%) were current drivers, and 91.4 percent of drivers were able to complete the TMT-B; 47.1 percent of drivers were older (65+), and 88.8 percent of older drivers rated their ability as good or excellent. In multivariate logistic regression, neither TMT-B performance nor being older predicted a recent collision. The mean TMT-B completion time was 66.1 (SD = 36.3, median = 56) s among drivers under age 65 and 117.5 (SD = 79.2, median = 95) s among those 65 or older. Approximately 1.9 percent (95% CI: 0.04-10.2) of drivers under 65 and 14.0 percent (95% CI: 5.3-27.9%) of drivers 65 or older required 180 s or more for the TMT-B. Using unpaired T-tests, study TMT-B times were not significantly different from previously published norms except among 25- to 34-year-olds (79.2 versus 50.7 s; p < 0.05) and 80- to 84-year-olds (223.9 versus 146.8 s; p < 0.01). CONCLUSIONS Many older ED patients drive, and relatively healthy ED patients are able to complete the TMT-B with results similar to standard nomograms. The TMT-B may prove useful as part of targeted driver screening programs in EDs.
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Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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