- Email: [email protected]
The prevalence and documentation of impaired mental status in elderly emergency department patients
ORIGINAL CONTRIBUTION
The Prevalence and Documentation of Impaired Mental Status in Elderly Emergency Department Patients
From the Department of Emergency Medicine, The Cleveland Clinic Foundation,* and the Department of Emergency Medicine, Metro Health Medical Center,‡ Cleveland, OH. Author contributions are provided at the end of this article. Received for publication February 28, 2001. Revisions received July 27, 2001, and October 3, 2001. Accepted for publication October 30, 2001. Presented in part at the Society for Academic Emergency Medicine annual meeting, Atlanta, GA, May 2001. Address for reprints: Fredric M. Hustey, MD, Department of Emergency Medicine, E-19, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; 216-445-4558; E-mail [email protected]. Copyright © 2002 by the American College of Emergency Physicians. 0196-0644/2002/$35.00 + 0 47/1/122057 doi:10.1067/mem.2002.122057
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Fredric M. Hustey, MD* Stephen W. Meldon, MD‡
See editorial, p. 338. Study objective: We sought to determine the prevalence of mental status impairment in elderly emergency department patients and to assess documentation of and referrals by emergency physicians for mental status impairment after discharge from the ED. Methods: We performed a prospective, observational study of a convenience sample of 297 patients 70 years or older presenting to an urban teaching hospital ED over a 12-month period. Patients were screened with the Orientation-MemoryConcentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Documentation, dispositions, and referrals were abstracted from chart review. Results: Two hundred ninety-seven of the 337 eligible patients were enrolled. Seventy-eight of the 297 (26%; 95% confidence interval [CI] 21% to 31%) patients had mental status impairment; 30 (10%; 95% CI 7% to 14%) had delirium; 48 (16%; 95% CI 12% to 20%) had cognitive impairment without delirium; 17 (6%; 95% CI 3% to 9%) screened positive on both examinations. Only 22 (28%; 95% CI 19% to 40%) of the 78 patients had any documentation of mental status impairment by the emergency physician. Specific mention of delirium, cognitive impairment, or an acceptable synonym was noted in 13 (17%; 95% CI 9% to 27%). Of 34 (44%; 95% CI 32% to 55%) patients with mental status impairment discharged home, only 6 (18%; 95% CI 7% to 35%) had plans documented by the emergency physician to address impairment. Eleven (37%; 95% CI 20% to 56%) of the 30 patients with delirium were discharged home. Sixteen (70%; 95% CI 47% to 87%) of the 23 patients with cognitive impairment who were discharged home had no prior history of dementia; these patients were less likely to have specialized assistance with care (13%; 95% CI 4% to 27%) than those with known dementia (58%; 95% CI 28% to 85%).
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Conclusion: Impaired mental status is common among older ED patients. Lack of documentation, admission, or referral by emergency physicians suggests a lack of recognition of this important problem. [Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. March 2002;39:248-253.] INTRODUCTION
Mental status impairment, including delirium and cognitive dysfunction, is highly prevalent among elderly emergency department patients.1-3 Patients affected with these conditions carry an increased risk for adverse outcome after ED evaluation. The presence of dementia in the elderly patient can affect medication and discharge instruction compliance, resulting in increased morbidity and mortality. In addition, lack of early recognition and referral may also contribute to poor long-term outcomes.4 ED patients with delirium also carry a special risk. These patients often suffer from serious underlying illness and have worse outcomes than patients without delirium.5,6 In addition, the presentation of delirium may be subtle, making it even more difficult for the unsuspecting physician to detect.7 Few studies have attempted to address prevalence and physician recognition of impaired mental status in elderly ED patients.1-3 To our knowledge, none have addressed physician documentation of cognitive dysfunction other than delirium, and few have studied physician management of these problems in the ED. We designed a prospective, observational study with 2 major objectives. The first was to determine the prevalence of mental status impairment in elderly ED patients. The second was to assess for documentation of these problems by emergency physicians. A secondary objective was to evaluate the use of referrals recommended by the emergency physician to address mental status impairment on discharge of these patients from the ED. M AT E R I A L S A N D M E T H O D S
The study was conducted at an urban teaching hospital with approximately 50,000 ED visits per year and an affiliated ED residency program. This was a convenience sampling of ED patients obtained during a 12-month period between July 1999 and July 2000. Sampling included day, night, weekday, and weekend shifts. All patients aged 70
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years or older admitted to the ED during the study period were eligible for enrollment. Patients were excluded if they refused to participate, were critically ill, were unable to communicate or cooperate with data acquisition, or did not speak English in the absence of an acceptable translator. Only the initial visit was included for patients presenting to the ED more than once. Patients were evaluated using the Confusion Assessment Method (CAM) (Appendix 1)8 and OrientationMemory-Concentration (OMC) (Appendix 2)9 tests, which were administered by research assistants trained in the use of these surveys. Initial screens were observed by the primary investigator to ensure reliability. Standardized scores on the CAM for the detection of delirium were used (delirium was scored if patients exhibited features 1, 2a, and 2b from the CAM, in addition to abnormalities in either 3 or 4).8 Weighted scores of 11 or more on the OMC test were indicative of at least moderate cognitive impairment, whereas scores of 21 or more were indicative of severe impairment.9 Patients who scored positive on the CAM were classified as having delirium. Patients who scored positive on the OMC but negative on the CAM were categorized as having cognitive impairment without delirium. Patients who scored positive on both surveys were categorized as having delirium but excluded from the “cognitive impairment without delirium” category. This was to account for difficulties in the accuracy of cognitive assessment and dementia in the presence of delirium.10 To account for the fluctuating nature of delirium, patients, proxies, and family members (when available) were interviewed regarding CAM elements. Patients and families were also interviewed regarding past history of cognitive impairment, current living arrangements, availability of home health care, and mode of ED arrival. Demographic data, physician documentation of mental status impairment, disposition, and referrals were abstracted from chart review. A standardized medical record abstraction sheet was used. Acceptable synonyms for delirium included the mention of a new or acute confusional state, acute organic brain syndrome, encephalopathy, or acute mental status change. Acceptable synonyms for cognitive impairment included notation of dementia or any of its specific subtypes. Physician recognition of impaired mental status was accepted if terms suggestive of impairment were noted in any portion of the chart, such as an abnormal orientation, impaired memory, or inappropriate behavior. Past history of cognitive dysfunction and/or dementia was established at the time of the patient interview. Discharge referrals that were accepted as efforts to address mental status impairment included
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social work, home health aide, geriatrics, geriatric nurse specialist, or any other action on discharge specifically noted by the physician to address mental status impairment. All chart abstractions were reviewed a second time by the primary investigator for accuracy and missing data. Prevalence rates and proportions are reported with 95% confidence intervals (CI). Relative risks (RR) were calculated to compare admission rates between patients with and without mental status impairment. This study was approved by the hospital Institutional Review Board. The requirement for written informed consent was waived. Verbal informed consent was obtained for all participants. R E S U LT S
Three hundred thirty-seven eligible patients were screened, 40 of whom were subsequently excluded (Table 1). Of the remaining 297 patients, 127 (43%) were black, 168 (57%) were white, 1 was Asian, and 1 was Arabic. One hundred sixty-four (55%) patients were women, and 133 (45%) were men. Age ranged from 70 to 97 years, and the mean age was 77.9 years (±5.96). Seven patients resided in extended care facilities, 8 in assisted living centers, 2 in rehabilitation centers, and the remainder lived at home either alone or with family. The prevalence of mental status impairment is summarized in Table 2. Seventeen (6%) patients scored positive on both the OMC and the CAM surveys. Three of these patients had a known history of dementia. The mean age of patients without mental status impairment was 77 years. The mean age of patients with delirium or cognitive impairment was 81 years. Documentation of mental status impairment is summarized in Table 3. For patients with cognitive impair-
Table 1.
Ineligible Prior enrollment Incomplete data Refused Unable to complete survey Patients of primary investigator Non–English-speaking Completed interview
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Table 2.
Prevalence of mental status impairment in the ED. Population
Prevalence (%; 95% CI)
All patients with mental status impairment Cognitive impairment without delirium Delirium* *Includes
78/297 (26; 21–31) 48/297 (16; 12–20) 30/297 (10; 7–14)
17 (6%) patients with positive scores on both the OMC and CAM surveys.
Table 3.
Patient participation. Participation
ment without delirium, physicians were much more likely to document an abnormality in mental status if the patient was known to have a past medical history of dementia (6/9 patients with past history of dementia, 67%; 95% CI 30% to 93%; compared with 3/39 patients with no past history of dementia, 8%; 95% CI 16% to 21%). There was no statistically significant difference of documentation of impaired mental status between patients with severe cognitive impairment (1/6 patients, 17%; 95% CI 0.4% to 64%) and moderate cognitive impairment (8/42 patients, 19%; 95% CI 9% to 34%). The overall hospital admission rate was 36% (106/297 patients). The presence of impaired mental status affected the chance of admission. Overall, 36/78 (46%) patients with mental status impairment were admitted, compared with 70/219 (32%) for those with no impairment (RR 1.44; 95% CI 1.06 to 1.96). There was no statistical difference in the admission rate of patients with cognitive impairment without delirium (17/48, 35%; versus 35% of patients without impairment; RR 0.99; 95% CI 0.65 to 1.50). However, patients with delirium (19/30; 63%) were twice as likely to be admitted to the hospital than those without delirium (87/267, 33%; RR 1.94; 95% CI
Documentation of mental status impairment. No. (%) 40/337 (11.9) 11 11 7 7 3 1 297/337 (88.1)
Nature of Impairment All patients with mental status impairment Delirium Cognitive impairment without delirium
Any Documentation (%; 95% CI)
Delirium, Cognitive Impairment, or Acceptable Synonym (%; 95% CI)
22/78 (28; 19–40)
13/78 (17; 9–27)
13/30 (43; 26–63) 9/48 (19; 9–33)
4/30 (13; 4–31) 9/48 (19; 9–33)
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1.41 to 2.68). In addition, 50 (17%) of 297 patients were admitted to the ED observation unit. These included 8 of the 48 patients with cognitive impairment, and none with delirium. Referrals and instructions provided to address mental status impairment on discharge from the ED are summarized in Table 4. Of the 4 patients with cognitive impairment without delirium who were discharged to home with instructions specific to address mental status impairment, 2 had a known history of dementia, and 2 were considered new cases. Of the 23 patients discharged home with cognitive impairment, 16 had no known history of dementia, and 4 were already institutionalized or in assisted living centers. A total of 39 (81%) of the 48 cases of cognitive impairment were considered newly discovered in the ED during this study (patients with no prior history of cognitive impairment). These patients were less likely to have specialized assistance with care including home health aides, skilled care facility personnel, or assisted living centers (5/39 patients, 13%; 95% CI 4% to 27%) than the patients with a prior history of cognitive impairment (58%; 95% CI 28% to 85%). DISCUSSION
Our study is in agreement to prior data suggesting that mental status impairment is common in elderly ED patients. The 10% prevalence of delirium in our ED population is nearly identical to that found in several prior studies.2,3,11 The prevalence of cognitive impairment in our population of 16% is also similar to prior findings.1,3 Some studies suggest that the prevalence may be even higher.1,3,12 Gerson et al1 found one third of geriatric ED patients to be at least moderately cognitively impaired. Naughton et al3 noted that some form of mental status impairment existed in nearly 40% of geriatric ED patients.
Table 4.
Referrals and special instructions provided on discharge to address mental status impairment. No. Receiving Referrals/Instructions (%; 95% CI)
Population All patients with mental status impairment Cognitive impairment without delirium Delirium
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6/34 (18; 7–35) 4/23 (17; 5–39) 2/11 (18; 2–52)
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Given the high prevalence of impaired mental status in older ED patients, this age group might benefit from targeted screening. Our data also suggest that emergency physicians may not be recognizing mental status impairment in the elderly patient. A lack of documentation of impairment in the patient’s medical record and the absence of referrals given to address these problems are supportive of such an assumption. With the potential for increased morbidity and mortality in these patients, it seems prudent for physicians to include such information in discharge planning. Only 18% of these patients in our study were given these instructions during ED discharge. This lack of recognition may be widespread among emergency physicians and not just institutionally specific. In a recent study by Elie et al,11 the sensitivity of the detection of delirium by emergency physicians was only 35%. Lewis et al2 found a similar lack of recognition of delirium by emergency physicians. The large proportion of patients with delirium in our study who were discharged to home (37%) also reflects the underrecognition of mental status impairment in this population. These patients are often seriously ill and may have nearly twice the short-term mortality rate than their nondelirious counterparts.2 Strong consideration should be given to hospitalizing these patients, unless the cause of the delirium is known and easily reversible and there is adequate home supervision and support for the patient. There may be misconceptions among physicians regarding mental status impairment that contribute in part to these findings. Emergency physicians might assume that dementia has already been addressed by the patient’s primary care physician, thus reducing the need for documentation or referral. However, in our study, nearly 70% of all patients who were discharged home with cognitive impairment had no prior history of dementia and were potentially new cases discovered in the ED. These newly discovered cases were also much less likely to have access to resources to assist with impairment than counterparts with known dementia. Further support for the importance of recognition of impairment comes from recent data that suggest that, among hospitalized patients, early recognition of delirium may contribute to improved outcomes.7 The potential for serious clinical consequences in patients with mental status impairment is high. The presence of dementia in the elderly patient can effect medication and discharge instruction compliance,1 potentially resulting in an increased morbidity and mortality. Because most forms of dementia are now treatable (and in some progression may be halted or reversed),13,14 a lack
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of recognition and delay in treatment can also contribute to poor long-term outcome. These patients are also at increased risk for falls.15 Recognizing these patients could lead to interventions16 (eg, medication reviews, home safety assessments) that may reduce this risk and possibly prevent further injury. Patients with delirium are also at risk.17,18 These patients often have an acute underlying illness necessitating hospitalization and have worse outcomes than patients without delirium.5,6 Confusion may contribute to difficulty with medication and discharge instruction compliance. In addition, patients with delirium may be prone to ED recidivism.19 However, screening evaluations for mental status impairment in the ED present a special challenge. Structured psychiatric interviews are not applicable in this setting. The CAM survey for delirium by Inouye et al8 is an alternative screening method that has been validated against structured psychiatric interviews with a sensitivity of 94% to 100% and specificity of 90% to 95% for the detection of delirium. It has also been shown to have a high interobserver reliability.8 The CAM evaluates the presence of 4 criteria to differentiate delirium from dementia: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of alertness.8 The OMC test for cognitive dysfunction has also been previously validated,9 and can be easily administered in the ED in less than 2 minutes.1 It is reliable, valid, and has a better sensitivity for milder levels of impairment than the Short Portable Mental Status Questionnaire.20,21 This test is also unique in that scores have been shown to correlate with neuropathologic findings of dementia at autopsy.9 The brevity and ease of use of these screening tools make targeted screening for mental status impairment feasible in the ED. Combined with educational programs to enhance physician awareness, such targeted screening may have the potential to improve the care of these patients. Our study has several limitations. The actual prevalence of mental status impairment in this population may be significantly underestimated. Patients who could not be interviewed because of critical illness or inability to cooperate with data acquisition were excluded from the study. This group may have had a much higher prevalence of mental status impairment than the general study population. The actual number of patients with cognitive impairment other than delirium may also be underestimated. Seventeen patients in our study scored positive on both surveys but were excluded from the “cognitive impairment without delirium” category because of the
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presence of delirium. Some of these patients may have scored poorly on both tests partly because of a coexisting dementia. To accurately determine whether the positive OMC test was reflective of this (or solely caused by the presence of delirium), these patients would have to be tested again once the delirium has resolved.10 In addition, the lack of physician recognition of mental status impairment in this study can only be implied on the basis of the evidence obtained from retrospective chart review. A future prospective study addressing emergency physician recognition might prove to be more conclusive. Finally, because our population was a convenience sampling, a sampling bias cannot be excluded. Our relatively small sample population also contributed to limited statistical significance in some subgroup analyses. Mental status impairment is common in elderly ED patients. Lack of documentation, admission, or referrals by emergency physicians is suggestive of a lack of recognition of these problems. Further interventions, such as targeted screening and education of physicians, may be helpful in improving care in these areas. Author contributions: FMH and SWM conceived the study and designed the protocol. FMH supervised the conduct of the study and data collection. FMH managed the data, including quality control. SWM provided statistical advice and assisted FMH with data analysis. FMH drafted the manuscript. SWM contributed substantially to its revision. FMH takes responsibility for the paper as a whole.
REFERENCES 1. Gerson LW, Counsell SR, Fontanarosa PB, et al. Case finding of cognitive impairment in elderly emergency department patients. Ann Emerg Med. 1994;23:813-817. 2. Lewis LM, Miller DK, Morely JE, et al. Unrecognized delirium in geriatric patients. Am J Emerg Med. 1995;13:142-145. 3. Naughton BJ, Moran MB, Kadah H, et al. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. 1995;25:751-755. 4. Hustey FM. Dementia in the elderly: avoiding the pitfalls. Geriatr Emerg Med Rep. 2000;1:13-20. 5. O’Keefe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc. 1997;45:174-178. 6. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156:1-20. 7. Rockwood K, Cosway S, Stolee P, et al. Increasing the recognition of delirium in elderly patients. J Am Geriatr Soc. 1994;42:252-256. 8. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113:941-948. 9. Katzman R, Brown T, Fuld P, et al. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983;140:734-739. 10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Revised (DSM-IV). Washington, DC: American Psychiatric Association; 1994. 11. Elie M, Rouseau F, Cole M, et al. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163:977-981. 12. Gerson LW, Rousseau EW, Hogan TM, et al. Multicenter study of case finding in elderly emergency department patients. Acad Emerg Med. 1995;2:729-734.
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13. Geldmacher DS, Whitehouse PJ. Current concepts: evaluation of dementia. N Engl J Med. 1996;335:330-336. 14. Johnson JC, Sims R, Gottlieb G. Differential diagnosis of dementia, delirium and depression. Drugs Aging. 1994;5:431-445. 15. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701-1707. 16. Baraff LJ, Della Penna R, Williams N, et al. Practice guideline for the ED management of falls in community-dwelling elderly persons. Ann Emerg Med. 1997;30:480-489. 17. Bedford PD. General medical aspects of confusional states in elderly people. BMJ. 1959;2:185-188. 18. Levkoff SE, Besdine RW, Wetle T. Acute confusional states in the hospitalized elderly. Annu Rev Gerontol Geriatr. 1986;6:1-26. 19. Bernstein E. Repeat visits by elder emergency department patients: sentinel events. Acad Emerg Med. 1997;4:538-539. 20. Fillenbaum GG, Landerman LR, Simonsick EM. Equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire and the Orientation-MemoryConcentration Test. J Am Geriatr Soc. 1998;46:1512-1518. 21. Davis PB, Morris JC, Grant E. Brief screening tests versus clinical staging in senile dementia of the Alzheimer type. J Am Geriatr Soc. 1990;38:129-135.
APPENDIX 1. The CAM survey for delirium.* 1. Is there evidence of an acute change in mental status from the patient’s baseline? Yes No 2a. Did the patient have difficulty focusing attention, that is, being easily distractable or having difficulty keeping track of what was being said? Yes No 2b. If present or abnormal, did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity? Yes No 3. Was the patient’s thinking disorganized or incoherent, such as, rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Yes No 4. Overall, how would you rate this patient’s level of consciousness? Alert (normal) Vigilant (hyperalert, easily startled) Lethargic (drowsy, easily aroused) Stupor (difficult to arouse) Coma (unarousable) Delirium Presence of delirium (presence of features 1 and 2 with either 3 or 4 from CAM) Absence of delirium (not meeting above criteria) *From Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113:941-948. Reprinted with permission.
APPENDIX 2. The OMC examination for cognitive impairment.* Maximum Error Score What year is it now? What month is it now? Repeat this phrase after me: John Brown, 42 Market Street, Chicago About what time is it? Count backwards from 20 to 1 Say the months in reverse order Repeat the memory phrase TOTAL WEIGHTED SCORE
Weight
Total Score
1 1
× ×
4 3
1 2 2 5
× × × ×
3 2 2 2
0–10=minimal to no impairment 11–20=moderate impairment ≥21=severe impairment *
American Journal of Psychiatry, vol. 140, pp. 734-739, (1983). Copyright 1983, the American Psychiatric Association. Reprinted with permission.
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The Prevalence and Documentation of Impaired Mental Status in Elderly Emergency Department Patients
From the Department of Emergency Medicine, The Cleveland Clinic Foundation,* and the Department of Emergency Medicine, Metro Health Medical Center,‡ Cleveland, OH. Author contributions are provided at the end of this article. Received for publication February 28, 2001. Revisions received July 27, 2001, and October 3, 2001. Accepted for publication October 30, 2001. Presented in part at the Society for Academic Emergency Medicine annual meeting, Atlanta, GA, May 2001. Address for reprints: Fredric M. Hustey, MD, Department of Emergency Medicine, E-19, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; 216-445-4558; E-mail [email protected]. Copyright © 2002 by the American College of Emergency Physicians. 0196-0644/2002/$35.00 + 0 47/1/122057 doi:10.1067/mem.2002.122057
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Fredric M. Hustey, MD* Stephen W. Meldon, MD‡
See editorial, p. 338. Study objective: We sought to determine the prevalence of mental status impairment in elderly emergency department patients and to assess documentation of and referrals by emergency physicians for mental status impairment after discharge from the ED. Methods: We performed a prospective, observational study of a convenience sample of 297 patients 70 years or older presenting to an urban teaching hospital ED over a 12-month period. Patients were screened with the Orientation-MemoryConcentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Documentation, dispositions, and referrals were abstracted from chart review. Results: Two hundred ninety-seven of the 337 eligible patients were enrolled. Seventy-eight of the 297 (26%; 95% confidence interval [CI] 21% to 31%) patients had mental status impairment; 30 (10%; 95% CI 7% to 14%) had delirium; 48 (16%; 95% CI 12% to 20%) had cognitive impairment without delirium; 17 (6%; 95% CI 3% to 9%) screened positive on both examinations. Only 22 (28%; 95% CI 19% to 40%) of the 78 patients had any documentation of mental status impairment by the emergency physician. Specific mention of delirium, cognitive impairment, or an acceptable synonym was noted in 13 (17%; 95% CI 9% to 27%). Of 34 (44%; 95% CI 32% to 55%) patients with mental status impairment discharged home, only 6 (18%; 95% CI 7% to 35%) had plans documented by the emergency physician to address impairment. Eleven (37%; 95% CI 20% to 56%) of the 30 patients with delirium were discharged home. Sixteen (70%; 95% CI 47% to 87%) of the 23 patients with cognitive impairment who were discharged home had no prior history of dementia; these patients were less likely to have specialized assistance with care (13%; 95% CI 4% to 27%) than those with known dementia (58%; 95% CI 28% to 85%).
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Conclusion: Impaired mental status is common among older ED patients. Lack of documentation, admission, or referral by emergency physicians suggests a lack of recognition of this important problem. [Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. March 2002;39:248-253.] INTRODUCTION
Mental status impairment, including delirium and cognitive dysfunction, is highly prevalent among elderly emergency department patients.1-3 Patients affected with these conditions carry an increased risk for adverse outcome after ED evaluation. The presence of dementia in the elderly patient can affect medication and discharge instruction compliance, resulting in increased morbidity and mortality. In addition, lack of early recognition and referral may also contribute to poor long-term outcomes.4 ED patients with delirium also carry a special risk. These patients often suffer from serious underlying illness and have worse outcomes than patients without delirium.5,6 In addition, the presentation of delirium may be subtle, making it even more difficult for the unsuspecting physician to detect.7 Few studies have attempted to address prevalence and physician recognition of impaired mental status in elderly ED patients.1-3 To our knowledge, none have addressed physician documentation of cognitive dysfunction other than delirium, and few have studied physician management of these problems in the ED. We designed a prospective, observational study with 2 major objectives. The first was to determine the prevalence of mental status impairment in elderly ED patients. The second was to assess for documentation of these problems by emergency physicians. A secondary objective was to evaluate the use of referrals recommended by the emergency physician to address mental status impairment on discharge of these patients from the ED. M AT E R I A L S A N D M E T H O D S
The study was conducted at an urban teaching hospital with approximately 50,000 ED visits per year and an affiliated ED residency program. This was a convenience sampling of ED patients obtained during a 12-month period between July 1999 and July 2000. Sampling included day, night, weekday, and weekend shifts. All patients aged 70
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years or older admitted to the ED during the study period were eligible for enrollment. Patients were excluded if they refused to participate, were critically ill, were unable to communicate or cooperate with data acquisition, or did not speak English in the absence of an acceptable translator. Only the initial visit was included for patients presenting to the ED more than once. Patients were evaluated using the Confusion Assessment Method (CAM) (Appendix 1)8 and OrientationMemory-Concentration (OMC) (Appendix 2)9 tests, which were administered by research assistants trained in the use of these surveys. Initial screens were observed by the primary investigator to ensure reliability. Standardized scores on the CAM for the detection of delirium were used (delirium was scored if patients exhibited features 1, 2a, and 2b from the CAM, in addition to abnormalities in either 3 or 4).8 Weighted scores of 11 or more on the OMC test were indicative of at least moderate cognitive impairment, whereas scores of 21 or more were indicative of severe impairment.9 Patients who scored positive on the CAM were classified as having delirium. Patients who scored positive on the OMC but negative on the CAM were categorized as having cognitive impairment without delirium. Patients who scored positive on both surveys were categorized as having delirium but excluded from the “cognitive impairment without delirium” category. This was to account for difficulties in the accuracy of cognitive assessment and dementia in the presence of delirium.10 To account for the fluctuating nature of delirium, patients, proxies, and family members (when available) were interviewed regarding CAM elements. Patients and families were also interviewed regarding past history of cognitive impairment, current living arrangements, availability of home health care, and mode of ED arrival. Demographic data, physician documentation of mental status impairment, disposition, and referrals were abstracted from chart review. A standardized medical record abstraction sheet was used. Acceptable synonyms for delirium included the mention of a new or acute confusional state, acute organic brain syndrome, encephalopathy, or acute mental status change. Acceptable synonyms for cognitive impairment included notation of dementia or any of its specific subtypes. Physician recognition of impaired mental status was accepted if terms suggestive of impairment were noted in any portion of the chart, such as an abnormal orientation, impaired memory, or inappropriate behavior. Past history of cognitive dysfunction and/or dementia was established at the time of the patient interview. Discharge referrals that were accepted as efforts to address mental status impairment included
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social work, home health aide, geriatrics, geriatric nurse specialist, or any other action on discharge specifically noted by the physician to address mental status impairment. All chart abstractions were reviewed a second time by the primary investigator for accuracy and missing data. Prevalence rates and proportions are reported with 95% confidence intervals (CI). Relative risks (RR) were calculated to compare admission rates between patients with and without mental status impairment. This study was approved by the hospital Institutional Review Board. The requirement for written informed consent was waived. Verbal informed consent was obtained for all participants. R E S U LT S
Three hundred thirty-seven eligible patients were screened, 40 of whom were subsequently excluded (Table 1). Of the remaining 297 patients, 127 (43%) were black, 168 (57%) were white, 1 was Asian, and 1 was Arabic. One hundred sixty-four (55%) patients were women, and 133 (45%) were men. Age ranged from 70 to 97 years, and the mean age was 77.9 years (±5.96). Seven patients resided in extended care facilities, 8 in assisted living centers, 2 in rehabilitation centers, and the remainder lived at home either alone or with family. The prevalence of mental status impairment is summarized in Table 2. Seventeen (6%) patients scored positive on both the OMC and the CAM surveys. Three of these patients had a known history of dementia. The mean age of patients without mental status impairment was 77 years. The mean age of patients with delirium or cognitive impairment was 81 years. Documentation of mental status impairment is summarized in Table 3. For patients with cognitive impair-
Table 1.
Ineligible Prior enrollment Incomplete data Refused Unable to complete survey Patients of primary investigator Non–English-speaking Completed interview
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Table 2.
Prevalence of mental status impairment in the ED. Population
Prevalence (%; 95% CI)
All patients with mental status impairment Cognitive impairment without delirium Delirium* *Includes
78/297 (26; 21–31) 48/297 (16; 12–20) 30/297 (10; 7–14)
17 (6%) patients with positive scores on both the OMC and CAM surveys.
Table 3.
Patient participation. Participation
ment without delirium, physicians were much more likely to document an abnormality in mental status if the patient was known to have a past medical history of dementia (6/9 patients with past history of dementia, 67%; 95% CI 30% to 93%; compared with 3/39 patients with no past history of dementia, 8%; 95% CI 16% to 21%). There was no statistically significant difference of documentation of impaired mental status between patients with severe cognitive impairment (1/6 patients, 17%; 95% CI 0.4% to 64%) and moderate cognitive impairment (8/42 patients, 19%; 95% CI 9% to 34%). The overall hospital admission rate was 36% (106/297 patients). The presence of impaired mental status affected the chance of admission. Overall, 36/78 (46%) patients with mental status impairment were admitted, compared with 70/219 (32%) for those with no impairment (RR 1.44; 95% CI 1.06 to 1.96). There was no statistical difference in the admission rate of patients with cognitive impairment without delirium (17/48, 35%; versus 35% of patients without impairment; RR 0.99; 95% CI 0.65 to 1.50). However, patients with delirium (19/30; 63%) were twice as likely to be admitted to the hospital than those without delirium (87/267, 33%; RR 1.94; 95% CI
Documentation of mental status impairment. No. (%) 40/337 (11.9) 11 11 7 7 3 1 297/337 (88.1)
Nature of Impairment All patients with mental status impairment Delirium Cognitive impairment without delirium
Any Documentation (%; 95% CI)
Delirium, Cognitive Impairment, or Acceptable Synonym (%; 95% CI)
22/78 (28; 19–40)
13/78 (17; 9–27)
13/30 (43; 26–63) 9/48 (19; 9–33)
4/30 (13; 4–31) 9/48 (19; 9–33)
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1.41 to 2.68). In addition, 50 (17%) of 297 patients were admitted to the ED observation unit. These included 8 of the 48 patients with cognitive impairment, and none with delirium. Referrals and instructions provided to address mental status impairment on discharge from the ED are summarized in Table 4. Of the 4 patients with cognitive impairment without delirium who were discharged to home with instructions specific to address mental status impairment, 2 had a known history of dementia, and 2 were considered new cases. Of the 23 patients discharged home with cognitive impairment, 16 had no known history of dementia, and 4 were already institutionalized or in assisted living centers. A total of 39 (81%) of the 48 cases of cognitive impairment were considered newly discovered in the ED during this study (patients with no prior history of cognitive impairment). These patients were less likely to have specialized assistance with care including home health aides, skilled care facility personnel, or assisted living centers (5/39 patients, 13%; 95% CI 4% to 27%) than the patients with a prior history of cognitive impairment (58%; 95% CI 28% to 85%). DISCUSSION
Our study is in agreement to prior data suggesting that mental status impairment is common in elderly ED patients. The 10% prevalence of delirium in our ED population is nearly identical to that found in several prior studies.2,3,11 The prevalence of cognitive impairment in our population of 16% is also similar to prior findings.1,3 Some studies suggest that the prevalence may be even higher.1,3,12 Gerson et al1 found one third of geriatric ED patients to be at least moderately cognitively impaired. Naughton et al3 noted that some form of mental status impairment existed in nearly 40% of geriatric ED patients.
Table 4.
Referrals and special instructions provided on discharge to address mental status impairment. No. Receiving Referrals/Instructions (%; 95% CI)
Population All patients with mental status impairment Cognitive impairment without delirium Delirium
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6/34 (18; 7–35) 4/23 (17; 5–39) 2/11 (18; 2–52)
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Given the high prevalence of impaired mental status in older ED patients, this age group might benefit from targeted screening. Our data also suggest that emergency physicians may not be recognizing mental status impairment in the elderly patient. A lack of documentation of impairment in the patient’s medical record and the absence of referrals given to address these problems are supportive of such an assumption. With the potential for increased morbidity and mortality in these patients, it seems prudent for physicians to include such information in discharge planning. Only 18% of these patients in our study were given these instructions during ED discharge. This lack of recognition may be widespread among emergency physicians and not just institutionally specific. In a recent study by Elie et al,11 the sensitivity of the detection of delirium by emergency physicians was only 35%. Lewis et al2 found a similar lack of recognition of delirium by emergency physicians. The large proportion of patients with delirium in our study who were discharged to home (37%) also reflects the underrecognition of mental status impairment in this population. These patients are often seriously ill and may have nearly twice the short-term mortality rate than their nondelirious counterparts.2 Strong consideration should be given to hospitalizing these patients, unless the cause of the delirium is known and easily reversible and there is adequate home supervision and support for the patient. There may be misconceptions among physicians regarding mental status impairment that contribute in part to these findings. Emergency physicians might assume that dementia has already been addressed by the patient’s primary care physician, thus reducing the need for documentation or referral. However, in our study, nearly 70% of all patients who were discharged home with cognitive impairment had no prior history of dementia and were potentially new cases discovered in the ED. These newly discovered cases were also much less likely to have access to resources to assist with impairment than counterparts with known dementia. Further support for the importance of recognition of impairment comes from recent data that suggest that, among hospitalized patients, early recognition of delirium may contribute to improved outcomes.7 The potential for serious clinical consequences in patients with mental status impairment is high. The presence of dementia in the elderly patient can effect medication and discharge instruction compliance,1 potentially resulting in an increased morbidity and mortality. Because most forms of dementia are now treatable (and in some progression may be halted or reversed),13,14 a lack
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of recognition and delay in treatment can also contribute to poor long-term outcome. These patients are also at increased risk for falls.15 Recognizing these patients could lead to interventions16 (eg, medication reviews, home safety assessments) that may reduce this risk and possibly prevent further injury. Patients with delirium are also at risk.17,18 These patients often have an acute underlying illness necessitating hospitalization and have worse outcomes than patients without delirium.5,6 Confusion may contribute to difficulty with medication and discharge instruction compliance. In addition, patients with delirium may be prone to ED recidivism.19 However, screening evaluations for mental status impairment in the ED present a special challenge. Structured psychiatric interviews are not applicable in this setting. The CAM survey for delirium by Inouye et al8 is an alternative screening method that has been validated against structured psychiatric interviews with a sensitivity of 94% to 100% and specificity of 90% to 95% for the detection of delirium. It has also been shown to have a high interobserver reliability.8 The CAM evaluates the presence of 4 criteria to differentiate delirium from dementia: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of alertness.8 The OMC test for cognitive dysfunction has also been previously validated,9 and can be easily administered in the ED in less than 2 minutes.1 It is reliable, valid, and has a better sensitivity for milder levels of impairment than the Short Portable Mental Status Questionnaire.20,21 This test is also unique in that scores have been shown to correlate with neuropathologic findings of dementia at autopsy.9 The brevity and ease of use of these screening tools make targeted screening for mental status impairment feasible in the ED. Combined with educational programs to enhance physician awareness, such targeted screening may have the potential to improve the care of these patients. Our study has several limitations. The actual prevalence of mental status impairment in this population may be significantly underestimated. Patients who could not be interviewed because of critical illness or inability to cooperate with data acquisition were excluded from the study. This group may have had a much higher prevalence of mental status impairment than the general study population. The actual number of patients with cognitive impairment other than delirium may also be underestimated. Seventeen patients in our study scored positive on both surveys but were excluded from the “cognitive impairment without delirium” category because of the
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presence of delirium. Some of these patients may have scored poorly on both tests partly because of a coexisting dementia. To accurately determine whether the positive OMC test was reflective of this (or solely caused by the presence of delirium), these patients would have to be tested again once the delirium has resolved.10 In addition, the lack of physician recognition of mental status impairment in this study can only be implied on the basis of the evidence obtained from retrospective chart review. A future prospective study addressing emergency physician recognition might prove to be more conclusive. Finally, because our population was a convenience sampling, a sampling bias cannot be excluded. Our relatively small sample population also contributed to limited statistical significance in some subgroup analyses. Mental status impairment is common in elderly ED patients. Lack of documentation, admission, or referrals by emergency physicians is suggestive of a lack of recognition of these problems. Further interventions, such as targeted screening and education of physicians, may be helpful in improving care in these areas. Author contributions: FMH and SWM conceived the study and designed the protocol. FMH supervised the conduct of the study and data collection. FMH managed the data, including quality control. SWM provided statistical advice and assisted FMH with data analysis. FMH drafted the manuscript. SWM contributed substantially to its revision. FMH takes responsibility for the paper as a whole.
REFERENCES 1. Gerson LW, Counsell SR, Fontanarosa PB, et al. Case finding of cognitive impairment in elderly emergency department patients. Ann Emerg Med. 1994;23:813-817. 2. Lewis LM, Miller DK, Morely JE, et al. Unrecognized delirium in geriatric patients. Am J Emerg Med. 1995;13:142-145. 3. Naughton BJ, Moran MB, Kadah H, et al. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med. 1995;25:751-755. 4. Hustey FM. Dementia in the elderly: avoiding the pitfalls. Geriatr Emerg Med Rep. 2000;1:13-20. 5. O’Keefe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc. 1997;45:174-178. 6. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156:1-20. 7. Rockwood K, Cosway S, Stolee P, et al. Increasing the recognition of delirium in elderly patients. J Am Geriatr Soc. 1994;42:252-256. 8. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113:941-948. 9. Katzman R, Brown T, Fuld P, et al. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983;140:734-739. 10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Revised (DSM-IV). Washington, DC: American Psychiatric Association; 1994. 11. Elie M, Rouseau F, Cole M, et al. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163:977-981. 12. Gerson LW, Rousseau EW, Hogan TM, et al. Multicenter study of case finding in elderly emergency department patients. Acad Emerg Med. 1995;2:729-734.
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13. Geldmacher DS, Whitehouse PJ. Current concepts: evaluation of dementia. N Engl J Med. 1996;335:330-336. 14. Johnson JC, Sims R, Gottlieb G. Differential diagnosis of dementia, delirium and depression. Drugs Aging. 1994;5:431-445. 15. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701-1707. 16. Baraff LJ, Della Penna R, Williams N, et al. Practice guideline for the ED management of falls in community-dwelling elderly persons. Ann Emerg Med. 1997;30:480-489. 17. Bedford PD. General medical aspects of confusional states in elderly people. BMJ. 1959;2:185-188. 18. Levkoff SE, Besdine RW, Wetle T. Acute confusional states in the hospitalized elderly. Annu Rev Gerontol Geriatr. 1986;6:1-26. 19. Bernstein E. Repeat visits by elder emergency department patients: sentinel events. Acad Emerg Med. 1997;4:538-539. 20. Fillenbaum GG, Landerman LR, Simonsick EM. Equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire and the Orientation-MemoryConcentration Test. J Am Geriatr Soc. 1998;46:1512-1518. 21. Davis PB, Morris JC, Grant E. Brief screening tests versus clinical staging in senile dementia of the Alzheimer type. J Am Geriatr Soc. 1990;38:129-135.
APPENDIX 1. The CAM survey for delirium.* 1. Is there evidence of an acute change in mental status from the patient’s baseline? Yes No 2a. Did the patient have difficulty focusing attention, that is, being easily distractable or having difficulty keeping track of what was being said? Yes No 2b. If present or abnormal, did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity? Yes No 3. Was the patient’s thinking disorganized or incoherent, such as, rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Yes No 4. Overall, how would you rate this patient’s level of consciousness? Alert (normal) Vigilant (hyperalert, easily startled) Lethargic (drowsy, easily aroused) Stupor (difficult to arouse) Coma (unarousable) Delirium Presence of delirium (presence of features 1 and 2 with either 3 or 4 from CAM) Absence of delirium (not meeting above criteria) *From Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113:941-948. Reprinted with permission.
APPENDIX 2. The OMC examination for cognitive impairment.* Maximum Error Score What year is it now? What month is it now? Repeat this phrase after me: John Brown, 42 Market Street, Chicago About what time is it? Count backwards from 20 to 1 Say the months in reverse order Repeat the memory phrase TOTAL WEIGHTED SCORE
Weight
Total Score
1 1
× ×
4 3
1 2 2 5
× × × ×
3 2 2 2
0–10=minimal to no impairment 11–20=moderate impairment ≥21=severe impairment *
American Journal of Psychiatry, vol. 140, pp. 734-739, (1983). Copyright 1983, the American Psychiatric Association. Reprinted with permission.
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