Challenges of Delirium Detection in Older Adults in the Emergency Department

By Sondra Forsyth

An estimated one to two million older adults with delirium visit hospital emergency departments in the United States annually. Yet about two-thirds of the cases of this sudden and potentially lethal change in mental status are unrecognized by emergency department clinicians who are under time pressure and almost always managing multiple patients at once. Half a year later, those with undetected delirium who were discharged from the emergency department have significantly higher mortality rates than those whose delirium was recognized.

Researchers from the Indiana University Center for Aging Research and the Regenstrief Institute have conducted what is believed to be the first study to interview providers to identify the barriers and possible catalysts to delirium detection in emergency care situations.

A release from the university quotes Michael LaMantia, M.D., MPH, an Indiana University Center for Aging Research scientist, Regenstrief Institute investigator and assistant professor of medicine at IU School of Medicine, as saying, “Delirium is a serious condition that is too often missed in the ambulance and emergency department and we need to improve its detection. Patients sent home from the emergency department with undetected delirium have six-month mortality rates almost three times greater than their counterparts in whom delirium is detected. Unrecognized delirium presents a major health challenge to older adults and an increased burden on caregivers and the health care system.”

The researchers, led by Dr. LaMantia, report that the hectic emergency department environment, typically focusing on accident victims and acutely ill individuals rather than older adults with multiple chronic illnesses who are experiencing a sudden need for emergency care, is the largest challenge to delirium recognition and treatment. They also found that emergency department medical staffers were more likely to think of delirium in older adults when patients exhibit agitation, rather than in those who are more withdrawn.

“Emergency Medical Service, Nursing, and Physician Providers’ Perspectives on Delirium Identification and Management” was published online ahead of print in July 2015 in Dementia: The International Journal of Social Research and Practice, a peer-reviewed journal.

In focus groups convened by the researchers, emergency physicians, emergency department nurses, and emergency medical service personnel indicated that delirium recognition is hampered by not having a sense of the baseline cognitive state of the patient, particularly among those with pre-existing cognitive impairment such as Alzheimer’s disease.

Doctors indicated a need for a delirium screening test that could be rapidly administered. One physician volunteered. “We’re comfortable with obvious delirium. 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 thirty second test that is pretty good at screening for delirium.”

Other physicians added that an emergency department dementia screening tool had to be “physician proof,” simple to document, not open to interpretation, brief to administer, and “better than our judgment.”

Some nurses admitted to more discomfort with treating delirium. Other nurses admitted to feeling overwhelmed by the burden of caring for an older adult with delirium in the busy emergency department environment.

“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,” Dr. 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.”

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Co-authors of the study, in addition to Dr. LaMantia are Frank C. Messina, M.D., and Cherri D. Hobgood, M.D., and Arif Nazir, M.D., of the IU School of Medicine; Shola Jhanji, M.A., of Indiana University-Purdue University Indianapolis; Mungai Maina and Siobhan McGuire, MPhil, of the IU Center for Aging Research and Regenstrief Institute and Douglas K. Miller, M.D., formerly with the Indiana University Center for Aging Research, Regenstrief Institute and IU School of Medicine.

Emergency department personnel from Eskenzai Health and IU Health were surveyed for the study.

This work was supported by the John A. Hartford Foundation and National Institute on Aging. The content of the study is solely the responsibility of the authors and does not necessarily represent the official views of the funders.