Review finds lack of delirium screening in the emergency department

An estimated one in 10 older adults seen in hospital emergency departments in the United States experiences delirium, but this acute change in mental status is often not recognized. Researchers from the Regenstrief Institute and Indiana University conducted a systematic review of existing studies on delirium in emergency departments and found that neither completely validated delirium screening instruments nor an ideal schedule to perform delirium assessments exist there.

The emergency department is a unique environment with significant time pressure challenges. Emergency department physicians typically don't have long-term relationships with patients; they are often unaware of patients' baseline mental status as the health care team tends to the emergency.

"Fewer than a third of older adults with delirium in the ED are being recognized, and we need to improve that detection rate," said Regenstrief Institute investigator Michael A. LaMantia, M.D., MPH, who led the systemic review of delirium screening. "Patients sent home from the ED with undetected delirium have six-month mortality rates almost three times greater than their counterparts in whom delirium is detected. Unrecognized delirium presents a major health challenge to older adults and an increased burden on the health care system.

"Patients with delirium will have hospital stays that are more than twice as long -- 21 versus nine days," said Dr. LaMantia, who is also an IU Center for Aging Research scientist and assistant professor of medicine at IU School of Medicine. "They will also have a greater probability of being discharged from the hospital to a long-term-care facility and a much higher probability of developing dementia than individuals who do not experience delirium."

Delirium is a state of confusion that can develop suddenly and usually goes away in days to weeks if treated properly, according to the American Delirium Society. The society estimates that more than 7 million hospitalized Americans experience delirium annually.

Dr. LaMantia, who is a geriatrician, said further work is needed to develop and validate emergency department-specific screening instruments and to determine how often to administer screenings in the rapid-paced environment. He also encourages those accompanying an older adult to the emergency department to serve as patient advocates by passing along baseline mental status information.

"The ED doctor is unaware of what the person looks like in daily life," he said. "They aren't seeing a complete set of colors. A family member or friend can help fill in the colors and gradations of colors. Nothing can replace having someone who knows the patient telling you that person's baseline."