Emergency Care and Dementia
Geriatric emergency medicine developed as a subspecialty of emergency medicine, yet persons living with dementia (PLWD) are at greater risk for adverse events, safety risks, and worse outcomes, Christopher R. Carpenter, MD, MSc, and colleagues wrote in an editorial. At the same time, there is a lack of dementia-focused research in emergency departments.
Dr. Carpenter, of Washington University in St. Louis School of Medicine, is a co-investigator with the Geriatric Emergency Care Applied Research 2.0-Alzheimer’s Dementia Care Network, or GEAR 2.0-ADC.
“Our multidisciplinary consensus conference (that included emergency medicine and geriatric physicians, emergency medicine nurses, social work, pharmacists, and most importantly persons living with dementia and their care partners) identified the many knowledge gaps when delivering emergency care for PLWD,” Dr. Carpenter told Caring. “As emergency medicine updates the Geriatric Emergency Department Guidelines and accredits hospitals around the world based on their quality improvement efforts for delivering age-friendly emergency care, high-quality research is required to provide the foundation for effective, patient-oriented, and cost-effective bedside care.”
The August issue of JAMDA includes four studies from GEAR 2.0-ADC. These four studies, Dr. Carpenter said, “provide a compass to guide researchers and funders toward the highest priority questions surrounding emergency department care of PLWD and their care partners.”
Research priorities involve dementia detection, communication/decision -making between emergency department health care teams and PLWD/care partners, best practices for emergency department care of PLWD, and care transitions from home or nursing home to emergency department and from the emergency department to inpatient or outpatient settings.
“This work is inclusive of the nursing home population as they interface with the emergency department in an increasingly complex medical world,” Dr. Carpenter said. “This is particularly relevant in the care transitions that nursing home patients face when referred to an emergency department or returning from an episode of emergency care.”
Besides a lack of dementia-focused research, Dr. Carpenter and his colleagues also found other challenges, including diversity and inclusivity.
“Surprisingly, despite a concerted effort to identify opportunities for improving the conduct and reporting of research around diversity, equity, and inclusivity, we found very little transparency around these issues in the individual studies identified for our scoping review,” Dr. Carpenter said. “So much work remains to unravel the opportunities to improve health equity for PLWD in emergency department settings. Finally, a tension between immediate action without evidence of benefit versus a more pragmatic approach to balance inspiration with real-world constraints is palpable in our work.”
Future research, the authors said, should investigate real-world settings and be more transparent about inclusivity. Further information is available at https://gearnetwork.org/
Source: Carpenter CR, et al. Adapting Emergency Care for Persons Living With Dementia: Results of the Geriatric Emergency Care Applied Research Network Scoping Review and Consensus Conference. J Am Med Dir Assoc. Manuscript number: JAMDA-D-22-00367.
Emergency Care Components and Needs
Some 57% of persons living with dementia have at least one visit to the emergency department every year, research has shown. These patients have complex needs, yet a lack of in-depth research with reproduceable results exists to aid in developing specific guidelines for them, a scoping review found.
As part of GEAR 2.0-ADC, Scott M. Dresden, MD, MS, of Northwestern University’s Feinberg School of Medicine, and colleagues searched several databases to determine priority areas for future research.
After identifying 6,348 potentially relevant articles, they chose 23 articles that looked at components of emergency department care that might improve patient-centered outcomes for persons living with dementia and 26 articles that addressed how emergency care needs for these individuals differ from those of other patients.
Four studies found that a comprehensive geriatric assessment and dedicated emergency department for older adults, a hospital-at-home program, a low-stimulation bed shade and contract-free monitor, and staff members serving as dementia companions all led to improved patient outcomes. “These successful interventions should be considered for future multi-centered studies,” the researchers wrote.
This review, the authors said, suggested that future research should address behavioral and psychological symptoms of dementia, functional ability, and pain as common needs leading to emergency department visits. They also said that research should look at decreasing stimulation and improving communication between clinicians, persons living with dementia, and care partners in the emergency department.
Source: Dresden SM, et al. Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review. J Am Med Dir Assoc. Manuscript number: JAMDA-D-22-00158R2.
Delirium and Hospital Discharge
Hospitalized individuals who have delirium are more likely to require additional medical care after discharge rather than return home and have a much greater risk of mortality, according to a study in Switzerland.
Led by Carl M. Zipser, MD, of University Hospital Zurich and University of Zurich, the researchers conducted a pragmatic prospective cohort study of adults admitted to a tertiary care center. Delirium was diagnosed according to the Delirium Observation Screening Scale (DOS), the Intensive Care Delirium Screening Checklist (ICDSC), or the Diagnostic and Statistical Manual 5 (DSM-5) relevant parameters of the electronic Patients’ Assessment-Acute Care questionnaire.
Out of 27,026 individuals included, 5,313 (19.7%) had delirium at least once while in the hospital. These individuals were nearly 90% less likely to return home and were more than four times as likely to be transferred to an acute rehabilitation facility, nursing home, or outside hospital. The adjusted risk of mortality was 30 times higher in these individuals.
“These findings support further research on the adverse consequences of delirium and call for implementation of prevention and management strategies,” the researchers said.
Source: Zipser CM, et al. Discharge Destinations of Delirious Patients: Findings From a Prospective Cohort Study of 27,026 Patients From a Large Health Care System [published online: February 13, 2022]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2022.01.051.
Jeffrey S. Eisenberg, a freelance writer in the Philadelphia area, compiled this report.