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Cognitive Impairment in Older People Presenting to ED

  • Chris Miller
  • Elizabeth Teale
  • Jay Banerjee
Chapter

Abstract

An increasing number of frail older people are attending emergency departments. Many of these have existing cognitive impairment (e.g. a dementia), whilst for others, there may be an acute confusional state (e.g. delirium). Cognitive impairment is commonly missed in the ED, and this has been associated with poor outcomes. People with frailty and dementia are particularly susceptible to delirium, and this is typically precipitated by additional stressor (e.g. acute illness or a recent change in medications). Cognitive impairment may or may not be the cause of the presentation, but in all cases, it is imperative to consider and screen for the possibility of new (delirium) or existing (dementia) cognitive impairment, paying particular attention to the possibility of coexistence of these conditions. A collateral history from people who know the patient well is imperative and should form part of the routine assessment for frail older people. Screening for cognitive impairment in the ED should use evidence-based tools to identify potential precipitating factors, some of which may be modifiable. The diagnosis of delirium is clinical, and there are no specific investigations although routine investigations may point to potential contributing factors or help to exclude other causes of cognitive impairment. Delirium management is focused on addressing the modifiable contributing factors, and we should refrain from pharmacological interventions unless behaviour poses a significant risk of harm. A calm environment for people with both dementia and delirium is key, and as far as possible, sensory stimuli should be minimised. Reorientation (time, place and person) is a simple, yet important intervention.

References

  1. 1.
    Fong T, Tulebaev S, Inouye S (2009) Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol 5:210–220CrossRefGoogle Scholar
  2. 2.
    Han J, Shintani A, Eden S, Morandi A, Solberg L, Schnelle J, Dittus R, Storrow A, Ely E (2010) Delirium in the emergency department: an independent predictor of death within six months. Ann Emerg Med 56:244–252CrossRefGoogle Scholar
  3. 3.
    Barron E, Holmes J (2013) Delirium within the emergency care setting, occurrence and detection: a systematic review. Emerg Med J 30:263–268CrossRefGoogle Scholar
  4. 4.
    Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A, Dittus RS, Storrow AB, Ely EW (2009) Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 16:193–200CrossRefGoogle Scholar
  5. 5.
    Mccusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E (2002) Delirium predicts 12-month mortality. Arch Intern Med 162:457–463CrossRefGoogle Scholar
  6. 6.
    Kakuma R, du Fort G, Arsenault L, Perrault A, Platt R, Monette J, Moride Y, Wolfson C (2003) Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 51:443–450CrossRefGoogle Scholar
  7. 7.
    Cole M, Ciampi A, Belzile E, Zhong L (2009) Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing 38:19–26CrossRefGoogle Scholar
  8. 8.
    Hendry K, Quinn TJ, Evans JJ, Stott DJ (2015) Informant single screening questions for delirium and dementia in acute care—a cross-sectional test accuracy pilot study. BMC Geriatr 15:17CrossRefGoogle Scholar
  9. 9.
    Maclullich A, Ryan T, Cash H (2014) 4AT-Rapid assessment test for delirium [online]. www.the4at.com. Accessed Oct 2014
  10. 10.
    Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW (2013) Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 62:457–465CrossRefGoogle Scholar
  11. 11.
    Inouye SK, Westendorp RGJ, Saczynski JS (2014) Delirium in elderly people. Lancet 383:911–922CrossRefGoogle Scholar
  12. 12.
    Dyer C, Ashton C, Teasdale T (1995) Postoperative delirium. A review of 80 primary data-collection studies. Arch Intern Med 155:461–465CrossRefGoogle Scholar
  13. 13.
    Han JH, Wilson A, Ely EW (2010b) Delirium in the older emergency department patient—a quiet epidemic. Emerg Med Clin North Am 28:611–631CrossRefGoogle Scholar
  14. 14.
    Fox C, Richardson K, Maidment ID, Savva GM, Matthews FE, Smithard D, Coulton S, Katona C, Boustani MA, Brayne C (2011) Anticholinergic medication use and cognitive impairment in the older population: The Medical Research Council Cognitive Function and Ageing Study. J Am Geriatr Soc 59:1477–1483CrossRefGoogle Scholar
  15. 15.
    Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM (1999) A Multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676CrossRefGoogle Scholar
  16. 16.
    Schnitker L, Martin-Khan M, Beattie E, Gray L (2013) What is the evidence to guide best practice for the management of older people with cognitive impairment presenting to emergency departments? A systematic review. Adv Emerg Nurs J 35:154–169CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2018

Authors and Affiliations

  1. 1.Department of Geriatric MedicineUniversity Hospitals of Leicester NHS TrustLeicesterUK
  2. 2.Emergency MedicineUniversity Hospitals of Leicester NHS TrustLeicesterUK
  3. 3.Department of Health SciencesUniversity of LeicesterLeicesterUK

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