The Importance of Early Delirium Detection Among Geriatric Emergency Patients

The crisis is nationwide: Emergency department (ED) patients slated for hospital admission can wait hours – or even days – for a bed assignment. Often termed boarders, these patients can experience a variety of negative consequences when a diagnosis or treatment is delayed. For older adults, the effects – including a higher risk of mortality – can be especially dire.

Chief among the risks for geriatric emergency patients is delirium, a mental state of confusion and disorientation that can develop suddenly over hours or days. Older adults are especially vulnerable to the condition, which can arise when the combined strain of illness, environmental circumstances and other factors leads to a widespread disruption of brain activity. Although delirium is often preventable, it can lead to permanent, long-term problems when treatment is delayed.

In an ongoing effort to better detect and manage the disorder, Cleveland Clinic researchers are conducting an ongoing study to evaluate the prevalence of delirium in geriatric emergency patients. The investigation is designed to assess the mental status of older patients’ (aged ≥65) in relationship to the time they spend boarding in the ED.

“Regrettably, long boarding times aren’t a new problem,” says Cleveland Clinic geriatrician Saket Saxena, MD, noting that the issue was exacerbated by the COVID-19 pandemic. “Unfortunately, long ED stays affect older and more medically complex individuals more dramatically than younger, healthier patients. Our newest study aims to answer one fundamental question: Do longer ED stays negatively affect the mental capacity of geriatric patients?”

Mitigating environmental challenges

Finding the answer presents several challenges, he notes. “To reliably say that a patient’s delirium was developed in the ED, a solid delirium screening must be performed at the time of ED entry,” says Dr. Saxena, codirector of Cleveland Clinic’s geriatric ED. “However, the fast-paced nature of the ED, exacerbated by time constraints and staffing shortages, can make these assessments difficult to do.”

Furthermore, older patients often require more nursing support and can present significant diagnostic challenges – even under the best of circumstances, he explains. Compounding matters, the level of support geriatric patients require is often unavailable in traditional ED settings.

“Mobility assistance, fall prevention protocols, proper lighting and access to appropriate food and drink may be harder to find in the ED, and – despite staff members’ best efforts – those shortcomings can precipitate changes in a patient’s mental status,” he says. “The result is that patients may not arrive with delirium, but they can certainly develop it during a prolonged ED stay. To prevent any downstream effects, changes in mental status should be detected early – ideally, at the time of triage.”

The utility of screening

For this reason, Dr. Saxena and his team have turned to the 4AT, a quick delirium assessment tool designed for use in clinical settings. Short; easy to learn, administer and score; and usable by health professionals from a range of disciplines, the 4AT has become a vital component of geriatric emergency care at Cleveland Clinic.

A previous study coauthored by Dr. Saxena and published in The Journal of Geriatric Emergency Medicine evaluated more than 100 high-risk geriatric ED patients who were randomly selected to undergo 4AT screening. The incidence of delirium and cognitive impairment was then calculated and contrasted with the ED’s traditional approach to delirium, in which patients were only screened if changes in mental status were noted by caregivers or healthcare providers.

“Our results confirmed that traditional screening approaches underestimated the prevalence of delirium,” Dr. Saxena says. “It’s incumbent on hospitals to develop a reliable process like the 4AT that enables them to systematically screen highest-risk older adults for the disorder and intervene in a timely manner.”

Mounting evidence

Although Dr. Saxena’s latest study is still in its early stages, initial results point to a high prevalence of delirium among the research cohort: 24 geriatric patients who boarded for an average of 20.4 hours. Although the study wasn’t specifically designed to distinguish between older patients who arrived with altered mental status and those who developed it during their stay in the ED, approximately 17% of those screened at triage with the 4AT were found to be delirious. An abstract of the work was presented at the 2024 Annual Scientific Meeting of the American Geriatric Society.

“There’s still much work to do, but it’s clear that we must continue to improve how we evaluate and manage older emergency patients,” he says. “Perhaps most importantly, we need to understand how to reduce the risks that can plague those experiencing delirium in the ED – and that includes doing all we can to reduce boarding times.”

As one of the nation’s largest healthcare organizations to have earned accreditation from the American College of Emergency Physicians, Cleveland Clinic is dedicated to improving geriatric emergency care throughout the health system, says Dr. Saxena.

“And what we’re talking about here – improving delirium detection and care in the ED – is an essential part of that overall goal,” he concludes.