Geriatrics/review article
Screening for Delirium in the Emergency Department: A Systematic Review

Presented as a poster at the American Geriatrics Society annual scientific meeting, May 2012, Seattle, WA.
https://doi.org/10.1016/j.annemergmed.2013.11.010Get rights and content

Older adults who visit emergency departments (EDs) often experience delirium, but it is infrequently recognized. A systematic review was therefore conducted to identify what delirium screening tools have been used in ED-based epidemiologic studies of delirium, whether there is a validated set of screening instruments to identify delirium among older adults in the ED or prehospital environments, and an ideal schedule during an older adult's visit to perform a delirium evaluation. MEDLINE/EMBASE, Cochrane, PsycINFO, and CINAHL databases were searched from inception through February 2013 for original, English-language research articles reporting on the assessment of older adults' mental status for delirium. Twenty-two articles met all study inclusion criteria. Overall, 7 screening instruments were identified, though only 1 has undergone initial validation for use in the ED environment and a second instrument is currently undergoing such validation. Minimal information was identified to suggest the ideal scheduling of a delirium assessment process to maximize the recognition of this condition in the ED. Study results indicate that several delirium screening tools have been used in investigations in the ED, though validation of these instruments for this particular environment has been minimal to date. The ideal interval(s) during which a delirium screening process should take place has yet to be determined. Research will be needed both to validate delirium screening instruments to be used for investigation and clinical care in the ED and to define the ideal timing and form of the delirium assessment process for older adults.

Introduction

Delirium is a syndrome of acute change in mental status accompanied by inattention and marked by a fluctuating course.1 The condition is estimated to occur in 11% to 42% of hospitalizations,2 is believed to add between $38 billion and $152 billion to health care expenditures annually in the United States,3 and is a common complication of the care of acutely ill older adults. Delirium causes distress to caregivers and places patients at higher risk for institutionalization, readmission to the hospital, and death.4, 5 Because patients discharged home from the emergency department (ED) with unidentified delirium have 6-month mortality rates almost 3-fold greater (30.8% versus 11.8%) than their counterparts in whom delirium is detected,6 unrecognized delirium in the acute care setting presents a major health challenge to older adults.

Editor's Capsule Summary

What is already known on this topic

Although delirium is estimated to be present in 7% to 10% of older patients in the emergency department (ED), it frequently goes undetected.

What question this study addressed

What is the evidence that delirium screening instruments are feasible and valid in the ED and when should they be used?

What this study adds to our knowledge

Data about delirium screening are scarce.

How this is relevant to clinical practice

Despite there being a need to identify delirium in ED geriatric patients, there are no validated instruments and there is a paucity of data on this topic.

On average, delirium has been estimated to be present in approximately 7% to 10% of older ED visitors during their ED stay7, 8, 9 but often goes undetected. Studies consistently show that emergency providers identify delirious patients in only 16% to 35% of cases.7, 8, 10, 11 Consequently, the Society for Academic Emergency Medicine's Geriatric Task Force has called for mental status screening to be a standard component of the evaluation of every senior in the ED.12 Members of the Geriatric Task Force have also articulated a need for further investigation into delirium assessment,13 including the identification of an optimal screening tool and window during which patient evaluations should be performed.14

During the last several decades, several screening instruments have been developed to identify delirious patients in a variety of venues for either research, clinical care, or both.15, 16 The ED, however, represents a unique environment with intense time demands on providers and high volumes of patients that can make caring for older adults more challenging17 and where it will be necessary as a result to separately evaluate screening instruments for delirium.14 Therefore, in this systematic review, we sought to answer the following questions: what delirium assessment tools have been used in epidemiologic studies of delirium in the ED and out-of-hospital environment, is there a set of validated screening instruments that should be used to identify delirium among elderly ED patients, and is there evidence for when delirium screening should be performed during the course of a patient's ED encounter?

Section snippets

Materials and Methods

We conducted a search through February 2013 of MEDLINE/EMBASE from 1946, the Cochrane Library from inception, the PsycINFO database from 1941, and the CINAHL database from 1965. Search terms included the words “delirium” or “acute confusional state” AND “emergency,” “emergency room,” or “emergency department.” We limited the results of the CINAHL and PsycINFO searches to those articles that were peer reviewed. The reference lists of included articles were reviewed by 2 people (M.A.L., a

Results

In our initial search of the databases, we identified 2,666 titles (Figure). In this process, we found that the same titles emerged from different sources, suggesting saturation of all available articles. After full review, 22 articles ultimately met all of the inclusion criteria and were included in this systematic review. All of these articles described studies that provided information that addressed the use of screening instruments for delirium identification within the ED, whereas 3 of

Limitations

Our study may be limited by its search strategy, its inclusion of articles printed only in English, and publication bias. Additionally, our review was conducted without the involvement of a research librarian, though a member of our research team has conducted previous systematic reviews. To limit these potential biases, we hand-searched reference lists for potential additional articles and searched multiple scientific databases. Our review deviated from the Preferred Reporting Items for

Discussion

This review provides a comprehensive outline of the use of delirium screening instruments in studies conducted in EDs and the out-of-hospital environment, both nationally and internationally, during the last several decades. Furthermore, it identifies those screening tools that have been used in epidemiologic studies of delirium, those delirium screening instruments that have been validated for use in the ED, and the body of evidence that exists to support when a delirium screening process

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      More than twenty delirium screening tools have been developed; however, not all are suitable for the ED.62 Several tools have been validated in the ED and are summarized in Table 4.63,64 The Geriatric Emergency Department Guidelines, a research-based and consensus-based best practices report, advocates the use of the Delirium Triage Screen (DTS) and Brief Confusion Assessment Method (bCAM) for mental status evaluation.58

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    Please see page 552 for the Editor's Capsule Summary of this article.

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    Supervising editor: Rita K. Cydulka, MD, MS

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: This research was funded by the Indiana University Center for Aging Research, Regenstrief Institute, Inc., and the Indiana University Department of Emergency Medicine.

    Sponsor's Role: The sponsors played no role in the design, methods, data collection, analysis, or writing of this article.

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