Geriatrics/Original Research
The effect of mental status screening on the care of elderly emergency department patients,☆☆

This article was presented in part at the Society for Academic Emergency Medicine Scientific Assembly, St. Louis, MO, May 2002.
https://doi.org/10.1067/mem.2003.152Get rights and content

Abstract

Study objectives: We determine the effect of screening examinations for mental status impairment on the care of elderly patients in the emergency department and prospectively assess recognition of mental status impairment by emergency physicians. Methods: We performed a prospective cross-sectional study. Patients were 70 years of age or older and presented to an urban teaching hospital ED over a 17-month period. Mental status impairment screening comprised the Orientation Memory Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Emergency physicians who were blinded to the patient's screening results were interviewed to assess recognition of mental status impairment, dispositions, and referrals. Results of mental status impairment screens were then given to emergency physicians, and emergency physicians were reinterviewed regarding any change in care. Results: Two hundred seventy-one of the 327 eligible patients were enrolled. Seventy-four (27%; 95% confidence interval [CI] 22% to 33%) patients had impaired mental status. Nineteen (7%; 95% CI 4% to 11%) had delirium, and 55 (20%; 95% CI 16% to 25%) had cognitive impairment without delirium. Mental status impairment was recognized in only 28 (38%; 95% CI 27% to 50%) of 74 patients: 3 (16%; 95% CI 3% to 40%) of 19 with delirium and 25 (46%; 95% CI 32% to 59%) of 55 with cognitive impairment without delirium. Emergency physicians altered management in none of the study patients on the basis of survey results. Five (26%; 95% CI 9% to 51%) of the 19 patients with delirium were discharged to home. Of these 5 patients discharged to home with unrecognized delirium, 1 presented with fall, 2 returned 3 days later and required hospitalization, and 1 with a history of colon cancer was given a new diagnosis of metastatic disease 4 days after the initial ED visit. Conclusion: Mental status impairment is highly prevalent in older ED patients. There is a lack of recognition by emergency physicians of mental status impairment in this group. Screening tools for mental status impairment in the ED did not substantially alter the care of elderly patients with mental status impairment. [Ann Emerg Med. 2003;41:678-684.]

Introduction

Mental status impairment is highly prevalent among elderly emergency department patients.1, 2, 3, 4 These patients might carry an increased risk for adverse outcome after ED discharge.3 Patients with delirium often have acute underlying illnesses and have been shown to have higher morbidity and mortality rates than their counterparts without delirium.5, 6, 7, 8 Patients with dementia might have difficulty with medication and discharge instruction compliance, which can also result in increased morbidity and mortality. In addition, the presentation of impaired mental status in the elderly might be subtle, making it difficult for the unsuspecting emergency physician to detect.

Prior studies have suggested poor recognition of mental status impairment by emergency physicians.1, 2, 3 However, although these studies prospectively screened for mental status impairment, they addressed recognition by using retrospective methodologies and ED chart reviews. The findings were supported by a lack of specific referrals by emergency physicians to address mental status impairment and by the significant number of patients with delirium who were discharged to home.1 In response to these findings, a recent editorial suggested that if emergency physicians were made aware of mental status impairment, they would take appropriate action in evaluating the complaint and make the appropriate disposition and follow-up arrangements.9 We designed this prospective interventional study with 2 major objectives. The first was to determine the effect of screening examination results for mental status impairment, when presented to the emergency physician, on the care plans of older ED patients. The second was to prospectively assess emergency physician recognition of mental status impairment in this group of ED patients.

Section snippets

Materials and methods

This was a prospective interventional study involving a convenience sample of older patients presenting to an ED between July 2000 and November 2001. Sampling periods were varied to include day, night, weekday, and weekend shifts, with frequencies based on the usual ED presentation times of older patients. This study was reviewed and approved by the hospital institutional review board.

The study was conducted at an urban teaching hospital with approximately 55,000 ED visits per year and an

Results

Three hundred twenty-seven eligible patients were screened, of whom 56 were subsequently excluded (Table 1).

. Patient participation.

ParticipationNo. (%)
Ineligible56/327 (17)
Prior enrollment5
Incomplete data6
Refused21
Unable to cooperate with survey15
Non-English speaking5
Critically ill4
Completed interview271/327 (83)
Of the remaining 271 patients, 126 (46%) were black, 143 (53%) were white, and 2 (1%) were Hispanic. One hundred fifty-two (56%) patients were female. Age ranged from 70 to 102 years,

Discussion

Our study, which is one of the first to prospectively assess the recognition of mental status impairment by emergency physicians, reveals that mental status impairment in older persons is both highly prevalent and poorly recognized. The substantial prevalence rate of mental status impairment in this group is in concordance with previous studies.1, 2, 3, 4 Three prior studies1, 4, 12 reported that between 26% and 40% of all ED elders have some form of mental status impairment. Delirium alone has

References (19)

There are more references available in the full text version of this article.

Cited by (183)

  • Neurological Emergencies in Geriatric Patients

    2022, Emergency Imaging of At-Risk Patients: General Principles
View all citing articles on Scopus

Dr. Meldon was supported in part by an American Geriatrics Society/Hartford Foundation Jahnigen Career Development Scholars Award.

☆☆

Address for reprints: Fredric M. Hustey, MD, Department of Emergency Medicine-E-19, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; 216-445-4558, fax 216-444-1703; E-mail [email protected] .

View full text