Improved awareness, better screening needed to identify delirium patients who present to the ED
October 1, 2014
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Improved awareness, better screening needed to identify delirium patients who present to the ED
Executive Summary
While many older patients experience symptoms of delirium while in the emergency setting, the condition often is not recognized by emergency providers. Further, a missed diagnosis can lead to enhanced caregiver stress as well as a higher risk of institutionalization, readmission, and death. Experts suggest that providers need to be better educated on the subtle clues that a patient may be delirious so that steps can be taken to find and address the inciting cause.
• Research shows that delirium is present in 7% to 10% of older patients who present to the ED, but it is unrecognized about 75% of the time.
• Most cases of delirium involve what is called the hypoactive subtype in which patients appear to be sedate or depressed, and they have difficulty paying attention. Many patients with hypoactive delirium are mistaken as being depressed, and as a result, this is a subtype that is frequently missed by clinicians.
• While no screening tool is 100% effective, researchers have had the best success with a two-step process that involves use of a rapid Delirium Triage Screen (DTS) to rule out delirium.
• Patients who are not ruled out by the DTS then undergo a more formal Brief Confusion Assessment Method or B-CAM, a tool that is a modified form of the CAM-ICU.
Researchers: Two-step screening process shows promise for improving diagnosis
Delirium is a common geriatric syndrome, but the diagnosis is often missed by emergency providers. Experts estimate that while the syndrome is present in 7-10% of older patients who present to the ED, it is only identified in a small percentage of these cases,1 and the consequences of a missed diagnosis can be severe.
"Delirium frequently goes unrecognized, and it is a condition that is costly, it causes caregivers to stress, and, ultimately, from a wealth of resources we have seen that delirium places patients at higher risk of institutionalization, readmission, and death," explains Michael LaMantia, MD, MPH, a geriatrician at Indiana University’s Center for Aging Research in Indianapolis, IN, and the lead author of a recent review of instruments used to screen for delirium in the ED.2 "We are looking at a three-fold change in the risk of mortality at six months if delirium is unrecognized in a patient who is discharged home, so that is one of the large reasons why I think this issue bears further attention."
Improve knowledge, awareness
Part of the problem is that there is a lack of provider awareness about how delirium typically presents, according to Jin Han, MD, MSc, an associate professor in the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville, TN, who has conducted numerous studies on delirium in the emergency setting. "Many clinicians and health care providers, not just those in the ED, think of delirium as this agitated state where patients are ripping out their IVs, blood pressure cuffs, and whatnot, but [these symptoms] actually only occur in the minority of cases," explains Han.
In fact, most cases of delirium involve what is called the hypoactive subtype, says Han. "These are patients who are more sedated, maybe somnambulant, even depressed looking," he explains. "A lot of times, patients with hypoactive delirium can be mistaken as being depressed, and, as a result, this is a subtype that is frequently missed by clinicians."
In research he has conducted, Han has found that emergency providers miss the diagnosis as often as 76% of the time, resulting in a lost opportunity for treatment of the delirium and potentially the wrong approach in resolving the patient’s urgent or acute medical problems.3 "For us, history is so crucial in determining the direction to go as far as the diagnostic workup, and what we have found is that patients who have delirium are unable to provide an accurate history as to why they are in the ED, and this can lead us in a different direction," observes Han.
For instance, Han recalls one recent case involving a patient who presented to the ED with leg pain after a fall. Han ordered an X-ray, but he noticed that something was a little off about the patient, so he re-examined him. "Finally a family member came, and what I gathered from the family member was that the patient was more confused than normal, and it turned out that the patient was delirious," explains Han. "What the patient was telling me was just a portion of his history, but he had actually been confused and falling frequently over the past couple of days."
Han moved from the X-ray to a more comprehensive workup, and it was discovered that the patient had a urinary tract infection (UTI) that was causing his symptoms. "I could have very easily missed the UTI, which then could have turned into sepsis or something more life-threatening down the line," he explains.
There are some studies that have shown that if you miss delirium, the diagnosis of underlying illnesses gets delayed, adds Han. "That is a danger as well to the patient," he says. "As diagnosticians, our job is to diagnose underlying illnesses." (Also see "Researchers: Consider malnutrition in older adults who present to the ED," p. 116.)
Get input from family, caregivers
Given the hectic nature of the emergency setting, it can be difficult to pick up on the often subtle signs that a patient may be delirious, explains LaMantia. "It’s an environment that is very busy, and an environment that requires physicians to interact with numerous patients very quickly," he observes. "Then there is the fact that to detect delirium you frequently need to have a baseline knowledge of what the patient was like previously, so this makes it more challenging for a physician who is meeting a patient for the first time to arrive at that diagnosis."
Consequently, when family or caregivers are present in the ED with the patient, clinicians should take advantage of the opportunity to discern whether a patient’s mental status or behavior is different from the norm. "Family and caregivers can be a great source of information for emergency providers when they are evaluating vulnerable patients," advises LaMantia. "They can provide context for the patient and point out any changes the patient may be experiencing."
Han agrees, noting that when family members or a caregiver is present with an older patient, he will typically ask them if the patient is acting normally or more confused. "That is a nice starting point. Then I delve into how confused they are," he explains. "So if 100% is what the patient is normally in terms of no confusion, then [I will ask family members] what percent of that normal baseline mental status the patient is now."
Typically, family members or caregivers will provide answers in terms of percentages, saying the patient’s mental status is 70% or 80% of normal, for example. "That is a nice, quick way of telling the clinician how confused a patient is and whether or not we need to do a delirium workup," says Han.
Another cardinal tip off for delirium is inattention, so it is important to observe whether or not the patient is paying attention to you, explains Han. "A lot of times, patients who are delirious will be easily distractible. They will look off and you will have to repeat your questions a couple of times. That should raise a light bulb that the patient may be delirious," says Han. "Unfortunately, assessing attention takes a lot of clinical judgment. It is not something people readily pick up, especially early on [in their medical careers]."
Spend time with the patient
Getting to a diagnosis of delirium is particularly challenging in the emergency environment because it requires a lengthy assessment process. However, with awareness of the condition, providers can pick up on the subtle clues that an added workup is needed. "A lot of my residents know at least that something is off with the patient, and that should be a signal that perhaps the patient is delirious," notes Han. "That sense that something is not quite right should prompt you to spend a little bit more time with the patient and try to uncover whether the patient is delirious or not."
Han advises clinicians to visit with the patient multiple times throughout the ED course; this can reveal changes either in the patient’s consciousness or the way he or she is acting. Further, verifying a diagnosis of delirium requires a screening assessment, and this is where many providers fall short, he explains. "Unfortunately, most health care providers in all settings, including the ED, do not routinely use a screening assessment for delirium," says Han.
While no screening tool is 100% effective, Han and his research colleagues have seen the best success with a two-step process they created that first involves use of a rapid delirium triage screen (DTS) to rule out delirium. Patients who are not ruled out by the DTS then undergo a more formal brief confusion assessment method (B-CAM), a tool Han and colleagues developed by modifying the CAM-ICU (confusion assessment method for the ICU).4
"[The B-CAM] is also not a perfect tool because it is still only 80% sensitive, so you miss 20% of patients with delirium," explains Han. "But keep in mind that we now miss about 75% of delirium at baseline, so just using this tool would improve recognition significantly."
For emergency providers, it is always a matter of balancing diagnostic accuracy with how long it takes to use the diagnostic tool, explains Han. "The only way to accurately diagnose delirium is to spend a lot of time with the patient," he says. "That is not something that emergency physicians have ... because we see so many patients in a short period of time."
Patients with dementia or mild cognitive impairment are more susceptible to delirium, but delirium can impact other patients as well. Typically, there is a cause or "insult" that prompts the patient to become delirious, explains LaMantia. For example, infections such as UTIs or pneumonia can precipitate delirium.In addition, the introduction of new drugs or drug-drug interactions can bring on the condition.
"If you take an older patient, who at baseline has mild cognitive impairment, and you give him a new pain medication that he has never taken before, that could tip him over into becoming delirious," says LaMantia. "It is very important to do a very thorough investigation into understanding what is the inciting cause, and then look to remedy that."
Review the care process
Han would like to see more work done at the residency level to make proficiency in the care of patients with geriatric syndromes more of a core competency for emergency providers. He has seen some movement in this direction, as well as an increasing number of geriatric emergency medicine fellowships become available. "As our aging population exponentially grows, I think seeing more geriatric patients is going to be part of our clinical practice," notes Han. "So knowing the different types of geriatric syndromes, like delirium, is going to be something that is bread and butter for all emergency physicians."
There is also room for improvement in the way ED administrators manage the process of care for older patients, observes LaMantia. "We’re talking about vulnerable older adults who are incredibly sensitive to the environment and to the interventions that we provide to them," he says. "I would encourage administrators to think about whether there are certain areas of the ED that could be made more geriatric-friendly, and that are staffed by people who have been given extra training in geriatric principles so that they are more attuned to the needs of older adults."
References
- Lewis LM, Miller DK, Morley JE, et al. Unrecognized delirium in ED geriatric patients. American Journal of Emergency Medicine 1995;13:
142-145. - LaMantia M, Messina F, Hobgood C, Miller D. Screening for delirium in the emergency department: A systematic review. Annals of Emergency Medicine 2014;63:551-560.
- Han J, Zimmerman E, Cutler N, et al. Delirium in older emergency department patients: Recognition, risk factors, and psychomotor subtypes. Academic Emergency Medicine 2009;15:193-200.
- Han J, Wilson A, Vasilevskis E, et al. Diagnosing delirium in older emergency department patients: Validity and reliability of the delirium triage screen and the brief confusion assessment method. Annals of Emergency Medicine 2013;62:
457-465.
SOURCES
• Jin Han, MD, MSc, Associate Professor, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN. E-mail: [email protected].
• Michael LaMantia, MD, MPH, Geriatrician, Indiana University Center for Aging Research, Indianapolis, IN. E-mail: [email protected].
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