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Most ED Patients With Delirium Unrecognized; Study Seeks Solutions

INDIANAPOLIS – With time pressure and managing multiple patients, emergency clinicians often fail to recognize delirium in older adults visiting their facilities.

In fact, about two-thirds of the cases of the sudden and potentially lethal change in mental status go undiagnosed in EDs, although, within six months, patients with undetected delirium who were discharged from the ED have significantly higher mortality rates than those whose delirium was recognized, according to a study published online by Dementia: The International Journal of Social Research and Practice.

To identify the barriers to detecting delirium during emergency care, researchers from the Indiana University Center for Aging Research and the Regenstrief Institute conducted focus groups with ED staff.

"Delirium is a serious condition that is too often missed in the ambulance and emergency department and we need to improve its detection," said lead author Michael LaMantia, MD, MPH, an Indiana University Center for Aging Research scientist, Regenstrief Institute investigator and assistant professor of medicine at IU School of Medicine, who added, “Unrecognized delirium presents a major health challenge to older adults and an increased burden on caregivers and the healthcare system."

In focus groups convened by the researchers, emergency physicians, ED nurses, and emergency medical service personnel suggested that delirium recognition is hampered by unawareness of the baseline cognitive state of the patient, particularly among those with pre-existing cognitive impairment such as Alzheimer's disease.

That’s why, for example, ED staffers were more likely to suspect delirium in older adults when patients exhibited agitation, not those who were withdrawn. Focus group participants, drawn from Eskenazi Health and IU Health, expressed the need for a delirium screening test that could be rapidly administered.

"We're comfortable with obvious delirium,” said one physician participating in a focus group. “We're all petrified, and we, at least I know my own limitations is that I guarantee you I'm missing patients who have it. And so what would make me comfortable is that when you come back to me and you said, hey we've got a 30-second test that is pretty good at screening for delirium."

Other physicians said that any ED dementia screening tool needs to be "physician proof," simple to document, not open to interpretation, brief to administer, and "better than our judgment."

Nurses also said they were often uncomfortable dealing with patients with delirium, especially when the ED was busy.

"Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms by which the medical staff can easily learn about the patient's mental status from family or friends, the adoption of a systematized approach to recognizing delirium, and the institution of protocols to treat the condition when it's identified," LaMantia said. "The efforts of emergency providers, geriatricians, brain scientists, and implementation experts will be needed to further develop and test these responses to this challenging clinical condition."