Due to time constraints and surging patient volumes, elderly emergency department patients are not routinely screened for delirium. A Cleveland Clinic geriatrician is making a case for why that should change, however, showing that even a 60-second test can accurately detect confused patients who may otherwise slip through the cracks.
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Although delirium screenings are routine for older patients being admitted to the hospital or ICU, they are not yet commonplace in emergency departments, explains Saket Saxena, MD, Codirector of the geriatric emergency department at Cleveland Clinic. “Unfortunately, elderly patients who present with acute conditions often wait hours or days to be fully screened for delirium,” he says, “However, we know that recognizing the disorder early can significantly improve patient care.”
Dr. Saxena is the principal author of a recent study that evaluated 4AT, a bedside screening tool for delirium in emergency department patients. The study found that 4AT, which takes around one minute to complete, can detect delirium with a positivity rate of 14%, a number that is consistent with the general population. Interestingly, about 7% of those determined to have delirium did not initially present with a complaint of altered mental status.
When people imagine delirium, he notes, they often think of patients who are agitated or even aggressive – getting out of bed, struggling or pulling out their lines. However, a significant number of these patients have hypoactive delirium, a condition that prompts a quiet, docile demeanor. Although these patients may not appear obviously confused, they will sleep a lot, eat little and decline to actively participate in conversations or therapies.
“That is the type of delirium that often gets missed when patients are transitioned from emergency to inpatient care,” explains Dr. Saxena.
Although hypoactive delirium can be particularly difficult to identify because it can easily be explained away by simple fatigue or “not being hungry,” the disorder can have a significant impact on patient outcomes.
“Nutritional status cannot be maintained if the patient isn’t eating,” explains Dr. Saxena. “And if the patient isn’t getting out of bed, the chances of debilitation rise; muscular strength is lost, and the risk of blood clots in the legs increases. All of these factors play a role in how these patients perform during hospitalization and beyond.” In fact, studies have found that patients with delirium have a length of stay that’s twice as long as those without, he notes.
Historically, Cleveland Clinic has used the Confusion Assessment Method to screen patients for delirium in the hospital or ICU; however, no method has been used to formally assess delirium in the emergency department. In preparation for the study, Dr. Saxena worked with triage nurses to identify the delirium screening tool they were most comfortable using in an emergency setting. The 4AT method, which was deemed easy to learn and administer, was chosen as the preferred rapid delirium test. Patients were flagged for screening if they were over 65 years old and medically complex, and all patients over age 80 were screened.
The rapid test begins by asking the person accompanying the patient if they are concerned about or have noticed any changes in the patient’s mental status. If the caregiver answers yes, the assessment is completed by asking the patient “orientation” questions that evaluate their ability to understand today’s date, where they are, and their date of birth and age. Their attention span is measured by asking the patient to name the months of the year backwards.
Any patient who receives a score of four or more is flagged for delirium.
Dr. Saxena said the study demonstrates that while detecting delirium in the acute setting is challenging, it can be done quickly and accurately using a rapid test like the 4AT method. Among Dr. Saxena’s future goals are improving interdepartmental communication about high-risk geriatric patients. “This approach helps ensure continuity of care throughout the hospital stay by making subsequent caregivers aware of any diagnoses – including delirium – that were made in the emergency department.”