The Missed and Misdiagnosed: Geriatric Delirium in the Emergency Department

Introduction: Older patients with delirium are at increased risk for prolonged hospitalization, poor outcomes, higher costs and a greater risk for institutionalization. By identifying those at risk early, interventions can be implemented to prevent or minimize the severity of the delirium. Per hospital policy, our geriatric emergency department (ED) screens for delirium by performing a 4AT only if changes in mental status are noted by caregivers or healthcare providers familiar with the patient. We hypothesize this approach underestimates the prevalence of delirium on presentation to the ED, particularly among high-risk older patients. The aim of this study is to determine how many cases of delirium that are present on admission are missed using this traditional approach. Methods: High risk older patients presenting to the ED were identified using an internally devised Electronic Medical Record (EMR) based risk stratification algorithm with known risk factors for delirium including age (>65 years old), polypharmacy (>10 medications), dementia history, sensory impairment and repeat ED visits or hospitalizations (>5 over the preceding year). Of these high-risk patients, 100 patients were randomly selected to undergo a 4AT delirium screen in the ED on presentation, regardless of whether mental status changes were noted in triage. Incidence of delirium and cognitive impairment on presentation using the 4AT score was calculated and contrasted with the traditional approach using the McNemer test to detect any statistical difference. Results: The average age was 74 years old (65–95 years old), outpatient medication count was 15 (0–40) and average prior ED visits/hospitalizations over the preceding year was 3 (1–68). Seven had a known prior history of dementia, 56 were male and 44 were female. Of the 100 patients screened, 14 scored 4 or above on the 4AT; indicating delirium on arrival. Of these 14, only 3 were detected using the traditional approach. The difference between the number of cases detected by the traditional approach and the EMR based risk stratification method was noted to be significant (p<0.05). 27 of those screened scored 1–3; indicating likely underlying cognitive impairment not meeting criteria for delirium. None of these patients were detected by the traditional method. Conclusion: All high-risk older patients, as identified by the EMR, should be screened for delirium on presentation to the ED at the time of triage using the 4AT screen or comparable screening test. This screening should not be dependent only on report of acute mental status changes by patient or caregivers. Patients with underlying cognitive impairment who do not screen positive for delirium but score 1–3 on 4AT are likely to benefit from the early implementation of delirium prevention strategies

The Missed and the Misdiagnosed: Geriatric Delirium in the Emergency Department

Background: Older patients with delirium are at increased risk for prolonged hospitalization, poor outcomes, higher costs and a greater risk for institutionalization. By identifying those at risk early, interventions can be implemented to prevent or minimize the severity of the delirium. Per hospital policy, our geriatric emergency department (ED) screens for delirium by performing a 4AT only if changes in mental status are noted by caregivers or healthcare providers familiar with the patient. We hypothesize this approach underestimates the prevalence of delirium on presentation to the ED, particularly among high-risk older patients. The aim of this study is to determine how many cases of delirium that are present on admission are missed using this traditional approach. Methodology: High risk older patients presenting to the ED were identified using an internally devised Electronic Medical Record (EMR) based risk stratification algorithm with known risk factors for delirium including age (\u3e65 years old), polypharmacy (\u3e10 medications), dementia history, sensory impairment and repeat ED visits or hospitalizations (\u3e5 over the preceding year). Of these high-risk patients, 100 patients were randomly selected to undergo a 4AT delirium screen in the ED on presentation, regardless of whether mental status changes were noted in triage. Incidence of delirium and cognitive impairment on presentation using the 4AT score was calculated and contrasted with the traditional approach using the McNemer test to detect any statistical difference. Results:The average age was 74 years old (65-95 years old), outpatient medication count was 15 (0-40) and average prior ED visits/hospitalizations over the preceding year was 3 (1-68). Seven had a known prior history of dementia, 56 were male and 44 were female. Of the 100 patients screened, 14 scored 4 or above on the 4AT; indicating delirium on arrival. Of these 14, only 3 were detected using the traditional approach. The difference between the number of cases detected by the traditional approach and the EMR based risk stratification method was noted to be significant (p Conclusion: All high-risk older patients, as identified by the EMR, should be screened for delirium on presentation to the ED at the time of triage using the 4AT screen or comparable screening test. This screening should not be dependent only on report of acute mental status changes by patient or caregivers. Patients with underlying cognitive impairment who do not screen positive for delirium but score 1-3 on 4AT are likely to benefit from the early implementation of delirium prevention strategies

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults

Introduction: We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients.Methods: We performed a retrospective case control study from June 1–August 31, 2019 (pre-program) to September 24, 2019–January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables.Results: A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P &lt; 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P &lt; 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41–0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14–0.50).Conclusion: Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients

Percutaneous Coronary Intervention Outcomes Based on Decision-Making Capacity.

Background Long-term outcomes of percutaneous coronary intervention (PCI) based on patients\u27 decision-making ability have not been studied. Our objective was to assess long-term outcomes after PCI in patients who provided individual versus surrogate consent. Methods and Results Data were collected retrospectively for patients who underwent PCI at Cleveland Clinic between January 1, 2015 and December 31, 2016. Inclusion criteria consisted of hospitalized patients aged ≥20 years who had PCI. Patients with outpatient PCI, or major surgery 30 days before or 90 days after PCI, were excluded. Patients who underwent PCI with surrogate consent versus individual consent were matched using the propensity analysis. Kaplan-Meier, log rank