Functional and cognitive decline in older delirious adults after an emergency department visit.

BACKGROUND: the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient's functional and cognitive status at 60 days post ED visit. METHODS: this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m. RESULTS: a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of -2.9/28 [95%CI: -3.9, -2.0] points on the OARS scale compared to non-delirious patients who lost -1.6 [95%CI: -1.9, -1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by -1.6 [95%CI: -3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: -0.1, 1.1] (P = 0.03). CONCLUSION: seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers.

BACKGROUND: delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. OBJECTIVES: to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. DESIGN: a prospective observational multicenter cohort study. SETTING: four Quebec EDs. PARTICIPANTS: independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation. MEASUREMENTS: eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. RESULTS: we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%). CONCLUSION: serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Validation of the O3DY French Version (O3DY-F) for the Screening of Cognitive Impairment in Community Seniors in the Emergency Department.

BACKGROUND: It is recommended that older patients undergo systematic mental status screening when presenting to the emergency department (ED). However, the tools available are not necessarily adapted to the ED environment, therefore, quicker and easier tools are needed. OBJECTIVES: The purpose of this study is to validate the Ottawa 3DY-French (O3DY-F) Scale as a screening tool for delirium and cognitive impairment in a French-speaking cohort. METHOD: This multicenter prospective study was conducted in four hospitals across the province of Quebec. Inclusion criteria were: age ≥ 65 years, ED stay ≥ 8 h, awaiting admission to a care unit, and independent or semi-independent in their daily living activities. Cognitive status was assessed during the initial interview using the Telephone Interview for Cognitive Screening-modified (TICS-m) and the O3DY-F scale. Comparisons were made between the O3DY-F and the TICS-m and Confusion Assessment Method (CAM) to assess the sensitivity and specificity of the O3DY-F for the detection of cognitive impairment and delirium. RESULTS: A total of 313 patients were included in this study, 139 of which had a positive O3DY-F. When compared with the CAM, the O3DY-F had a sensitivity of 84.2% (95% confidence interval [CI] 60.4-96.6) and a specificity of 58.2% (95% CI 52.3-63.9) for the detection of prevalent delirium. The O3DY-F had a sensitivity of 76.2% (95% CI 66.7-84.8) and a specificity of 67.6% (95% CI 61.0-73.6) for cognitive impairment (defined as a TICS-m < 27). CONCLUSION: The O3DY-F is a useful and effective tool to screen for delirium and undetected cognitive impairment among a French-speaking cohort in the ED.

Unrecognized Incident Delirium in Older Emergency Department Patients.

BACKGROUND: It is documented that health professionals from various settings fail to detect > 50% of delirium cases. OBJECTIVE: This study aimed to describe the proportion of unrecognized incident delirium in five emergency departments (EDs). Secondary objectives were to compare the two groups (recognized/unrecognized) and assess the impact of unrecognized delirium at 60 days regarding 1) unplanned consultations and 2) functional and cognitive decline. METHOD: This is a sub-analysis of a multicenter prospective cohort study. Independent patients aged ≥ 65 years who tested negative for delirium on the initial interview with an ED stay ≥ 8 h were enrolled. Patients were assessed twice daily using the Confusion Assessment Method (CAM) and the Delirium Index up to 24 h into hospital admission. Medical records were reviewed to assess whether delirium was recognized or not. RESULTS: The main study reported a positive CAM in 68 patients. Three patients' medical files were incomplete, leaving a sample of 65 patients. Delirium was recognized in 15.4% of our participants. These patients were older (p = 0.03) and female (p = 0.01) but were otherwise similar to those with unrecognized delirium. Delirium Index scores were higher in patients with recognized delirium (p = 0.01) and they experienced a more important functional decline at 60 days (p = 0.02). No association was found between delirium recognition and health care services utilization or decline in cognitive function. CONCLUSIONS: This study confirms reports of high rates of missed or unrecognized delirium (84.6%) in ED patients compared to routine structured screening using the CAM performed by a research assistant. Patients with recognized delirium were older women with a greater severity of symptoms and experienced a more significant functional decline at 60 days.

Frailty Assessment to Help Predict Patients at Risk of Delirium When Consulting the Emergency Department.

BACKGROUND: Delirium is underdiagnosed in seniors at emergency departments (EDs) even though it is a frequent complication and is associated with functional and cognitive decline. As frailty is an independent predictor of adverse events in seniors, screening for frailty in EDs may help identify those at risk of delirium. OBJECTIVES: To assess if screening older patients for frailty in EDs could help identify those at risk of delirium. METHODOLOGY: This study was part of the multicenter prospective cohort INDEED study. Patients aged ≥ 65 years, initially free of delirium, with an ED stay ≥ 8 h were followed up to 24 h after ward admission. Frailty was assessed at baseline using the Clinical Frailty Scale; seniors with a score ≥ 5/7 were considered frail. Their delirium status was assessed twice daily using the Confusion Assessment Method. RESULTS: Among the 335 included patients, delirium occurred in 20/70 frail (28.6%) patients and in 20/265 (7.6%) robust ones. After adjusting for age and sex, the risk of delirium during ED stay was 3.13 (95% confidence interval 1.60-6.21) times higher in frail than in robust patients. Time between arrival to the ED and the incidence of delirium was also shorter for frail patients than for the robust ones (adjusted hazard ratio 2.44, 95% confidence interval 1.26-4.74). CONCLUSION: Increased frailty is associated with increased delirium during ED stays. Screening for frailty at emergency triage could help ED professionals identify seniors at higher risk of delirium.

Predictors of delirium in older patients at the emergency department: a prospective multicentre derivation study.

OBJECTIVE: The objective of this study was to identify the predictors of incident delirium in this high-risk population. METHODS: This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium. RESULTS: Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p < 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p < 0.001). CONCLUSION: More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.

RéSUMé: OBJECTIF: L'objectif de cette étude était d'identifier les prédicteurs du délirium incident dans cette population à hautrisque. MéTHODES: Cette étude était une sous-analyse planifiée de l'étude de cohorte multicentrique INDEED. Nous avons recruté des patients âgés de ≥ 65 ans, indépendants/semi-indépendants, ayant une durée de séjour au département d'urgence (DU) ≥ 8 h et admis dans n'importe quel service. Les patients ont été suivis pendant leur séjour aux urgences jusqu'à 24 h après leur admission. Les caractéristiques sociodémographiques, les comorbidités, l'état fonctionnel (OARS), la gravité de la maladie, le niveau de fragilité, l'état cognitif (TICS-m) et l'évaluation de l'environnement des urgences/patients ont été recueillis lors de l'entretien initial. Les patients ont été soumis à un dépistage du délirium deux fois par jour à l'aide de la méthode d'évaluation de la confusion. Une régression logistique multivariée a été effectuée pour identifier les prédicteurs de délirium. RéSULTATS: Le délirium incident a été détecté chez 68 des 612 patients inclus (11%). Au départ, sept prédicteurs candidats ont été inclus dans un modèle de régression, dont quatre ont été retenus par une procédure de sélection par étapes. La présence d'un déficit cognitif initial (RC 3,6, p < 0,001), l'absence de mobilisation pendant toute la durée du séjour à l'urgence (RC 3,3, p = 0,002), une durée de séjour plus longue à l'urgence (RC 1,02, p = 0,006) étaient associées à un risque plus élevé de délirium incident, tandis qu'un état fonctionnel plus élevé était associé à un risque plus faible (RC 0,8, p < 0,001). CONCLUSIONS: Des travaux supplémentaires sont nécessaires pour déterminer quel(s) outil(s) sont les plus appropriés au DU afin d'accroître le dépistage du délirium par les professionnels de santé travaillant dans ce service. C'est vraiment la première étape pour pouvoir proposer des interventions visant à diminuer l'incidence du délirium.

Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients.

OBJECTIVES: Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients. METHODS: A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged ≥ 65 years old, waiting for hospital admission between March and July 2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8 hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24 hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS = 0-100) during the initial interview, and all opioid treatments were documented. RESULTS: A total of 338 patients were included; 51% were female, and mean (±SD) age was 77 (±8) years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47 (±19) hours after ED admission. Among patients with pain intensity ≥ 65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain < 65 (p < 0.01), and no significant association was found between opioid consumption and delirium (p = 0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity ≥ 65 are 3.3 (95% confidence interval = 1.4 to 7.9) times more likely to develop delirium than patients who had pain intensity of <65. CONCLUSIONS: Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.

Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study.

OBJECTIVE: We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment. DESIGN: This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward. SETTING: The study took place in four Canadian EDs. PARTICIPANTS: 338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent. MAIN OUTCOMES AND MEASURES: The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes. RESULTS: Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient. CONCLUSIONS: An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department.

OBJECTIVES: Delirium is very frequent in older patients presenting to the emergency department (ED), but is often undetected. The purpose of this study was to evaluate the performance of the French version of the 4 A's Test (4AT-F) for the detection of delirium and cognitive impairment in older patients. METHODS: The study was conducted in four Canadian ED. Participants (n= 320) were independent or semi-independent patients (able to perform ≥5 activities of daily living) aged 65 and older and had an 8-hour exposure to the ED environment. The Telephone Interview for Cognitive Status (TICS-m), the Confusion Assessment Method (CAM) as well as the 4AT-F were administered to patients at the initial interview. The CAM and 4AT-F were then administered twice a day during the patients' ED or hospital stay. The 4AT-F's sensitivity and specificity were compared to those of the CAM (for delirium), and to that of the TICS (for cognitive impairment). RESULTS: Our results suggest that the 4AT-F has a sensitivity of 84% (95% CI: [76, 93]) and a specificity of 74% (95% CI: [70, 78]) for delirium, as well as a sensitivity of 49% (95% CI: [34, 64]) and a specificity of 87% (95% CI: [82, 92]) for cognitive impairment. CONCLUSION: The 4AT-F is a fast and reliable screening tool for delirium and cognitive impairment in ED. Due to its quick administration time, it allows a systematic screening of patients at risk of delirium, without significantly increasing the workload of the ED staff.

Using the Bergman-Paris Question to screen seniors in the emergency department.

OBJECTIVES: In the fast pace of the Emergency Department (ED), clinicians are in need of tailored screening tools to detect seniors who are at risk of adverse outcomes. We aimed to explore the usefulness of the Bergman-Paris Question (BPQ) to expose potential undetected geriatric syndromes in community-living seniors presenting to the ED. METHODS: This is a planned sub-study of the INDEED multicentre prospective cohort study, including independent or semi-independent seniors (≥65 years old) admitted to hospital after an ED stay ≥8 hours and who were not delirious. Patients were assessed using validated screening tests for 3 geriatric syndromes: cognitive and functional impairment, and frailty. The BPQ was asked upon availability of a relative at enrolment. BPQ's sensitivity and specificity analyses were used to ascertain outcomes. RESULTS: A response to the BPQ was available for 171 patients (47% of the main study's cohort). Of this number, 75.4% were positive (suggesting impairment), and 24.6% were negative. To detect one of the three geriatric syndromes, the BPQ had a sensitivity of 85.4% (95% CI [76.3, 92.0]) and a specificity of 35.4% (95% CI [25.1, 46.7]). Similar results were obtained for each separate outcome. Odds ratio demonstrated a higher risk of presence of geriatric syndromes. CONCLUSION: The Bergman-Paris Question could be an ED screening tool for possible geriatric syndrome. A positive BPQ should prompt the need of further investigations and a negative BPQ possibly warrants no further action. More research is needed to validate the usefulness of the BPQ for day-to-day geriatric screening by ED professionals or geriatricians.