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Cognitive Impairment in the Emergency Department. Jin H. Han, MD, MSc Assistant Professor Department of Emergency Medicine Research Division Center for Quality Aging Vanderbilt University School of Medicine. What We Will Cover…. Define cognitive impairment Delirium Dementia

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cognitive impairment in the emergency department

Cognitive Impairment in the Emergency Department

Jin H. Han, MD, MSc

Assistant Professor

Department of Emergency Medicine

Research Division

Center for Quality Aging

Vanderbilt University School of Medicine

what we will cover
What We Will Cover…
  • Define cognitive impairment
    • Delirium
    • Dementia
  • Screening for cognitive impairment in the emergency department
cognitive impairment in the ed
Cognitive Impairment in the ED

Up to 25% of older emergency department (ED) patients will have cognitive impairment

Hustey et al. Ann Emerg Med. 2002;39:248-53

two main flavors
Two Main Flavors

Hustey et al. Ann Emerg Med. 2002;39:248-53

Han et al. Ann Emerg Med. 2011:57:662-71

Carpenter et al. AcadEmerg Med 2011: 18: 374–84

Elie et al. CMAJ. 2000:163:977-81

  • Delirium – acute loss of cognition
    • Affects 5 - 18% of older ED patients1,2,3
    • Recognized 20 - 50% of the time1,4
  • Dementia – chronic loss of cognition
    • Affects 15 - 40% of older ED patients1,2,3
    • Documented in medical record in 3 – 13% of cases.2,3
  • Delirium and dementia often occur concurrently
what is delirium
What is delirium?

A disturbance of consciousness (i.e. inattention) that is accompanied by a acute change (hours to days) in cognition that cannot be better accounted for by a preexisting or evolving dementia. This disturbance tends to fluctuate throughout the course of the day.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

what is dementia
What is dementia?
  • Gradual (months to years) loss of cognition that causes significant impairment in social or occupational functioning. It is manifested in memory impairment and one or more of the following:
    • Aphasia
    • Apraxia
    • Agnosia
    • Disturbance in executive function

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

slide7

Delirium ≠ Dementia

What’s the difference?

delirium versus dementia
Delirium versus Dementia

Dementia is an important predisposing factor to delirium

Characteristic Delirium Dementia

Onset Hours to days Months to years

Course Fluctuating Stable

Inattention Yes Rarely

Altered LOC Typically Rarely

Disorganized thinking Sometimes Rarely

Reversible Typically Rarely

precipitating factors of delirium
Precipitating Factors of Delirium
  • Systemic
    • Infection / sepsis
    • Dehydration
    • Hypo- or hyperthermia
    • Trauma
    • Inadequate pain control
  • Medications / Drugs
    • Adverse drug reaction
    • Recreational drug or withdrawal
  • CNS
    • Infection
    • Hemorrhage / hematoma
    • CVA
  • Metabolic
    • Thiamine deficiency
    • Renal or liver failure
    • Hypo- or hypernatremia
    • Hypo- or hypercalcemia
    • Hypo- or hyperglycemia
    • Hypo- or hyperthyroidism
  • Cardiopulmonary
    • Shock
    • Hypoxemia
    • Hypercarbia
    • Acute heart failure
    • Acute myocardial infarction
    • Hypertensive encephalopathy
reversible causes of dementia
Reversible Causes of Dementia

Hypothyroidism

Normal pressure hydrocephalus

Vitamin B12 deficiency

Depression can mimic dementia-like symptoms

Reversible causes of dementia are rare

rationale for cognitive screening
Rationale for Cognitive Screening

1. Han et al. Ann of Emerg Med. 2011; 57:662-71

  • Delirium and dementia in the ED is frequently unrecognized
  • Potential safety concern
    • Inaccurate history1
    • Cannot comprehend discharge instructions1
  • Decisional capacity
  • Safe to go home?
rationale delirium screening
Rationale Delirium Screening

Delirium may be the

first manifestation of a underlying illness and can occur prior to any vital sign abnormalities.

rationale for delirium screening
Rationale for Delirium Screening

If you miss delirium, you may miss the underlying illness.

Reeves et al. South Med J. 2010; 111 - 5

rationale for delirium screening1
Rationale for Delirium Screening

Kakuma et al. J Am Geriatr Soc. 2003

Lewis et al. Am J Emerg Med. 1995

Han et al. Ann Emerg Med. 2010

Han et al. Acad Emerg Med. 2011

  • Delirium is associated with:
    • Mortality1,2,3
    • Accelerated cognitive and functional decline
    • Prolonged hospitalizations4
    • Increased hospital complications
    • Increased institutionalization
    • Higher health care costs
global tests of cognition1
Global Tests of Cognition

These tests in and of itself cannot differentiate between dementia and delirium

global tests of cognition2
Global Tests of Cognition
  • 10-15 minutes
    • Mini-mental state examination
    • Montreal Cognitive examination
  • 5 minutes
    • Abbreviated Mini-Cog
    • Short Blessed Test
  • < 5 minutes
    • Six Item Screener
    • Mini-Cog
    • Ottawa 3DY
    • Brief Alzheimer’s Screen
trade off
Trade Off

Accuracy

Brevity

ottawa 3dy
Ottawa 3DY

Month

Year

Spell “WORLD” backwards

Molnar et al. Clin Med Geriatrics. 2008:2:1-11

ottawa 3dy1
Ottawa 3DY

Carpenter CR. AcadEmerg Med. 2011; 18:374-84

  • In older ED patients
    • 95% sensitive
    • 51% specific
six item screener
Six-Item Screener

Ask patient to remember 3 objects

Ask patient the day, month, and year

Ask patient to recall the 3 objects

Callaham et al. Med Care. 2002;40:771-81

six item screener1
Six-Item Screener
  • In older ED patients, 2 or more errors
    • 63% to 74% sensitive
    • 77% to 81% specific

Wilber et al. AcadEmerg Med.2008;15:613-6

Carpenter et al. Ann Emerg Med. 2011; 57:653-61

confusion assessment method
Confusion Assessment Method

Feature 1

Fluctuation and change in mental status

+

Feature 2

Inattention

94 - 100% sensitive and 90 - 95% specific

Feature 3

Disorganized thinking

and either

Feature 4

Altered level of consciousness

Inouye et al. Ann Intern Med. 1990; 113:941-8

cam s diagnostic accuracy
CAM’s Diagnostic Accuracy

Pooled Sensitivity: 86%

Pooled Specificity: 93%

Wong et al. JAMA. 2010.

brief confusion assessment method b cam
Brief Confusion Assessment Method (B-CAM)

84% sensitive and 98% specific in older ED patients

Han et al. Ann Emerg Med 2013 (In press).

modified richmond agitation sedation scale
Modified Richmond Agitation Sedation Scale

In hospitalized patients

Single mRASS:64% sensitive and 93% specific

Serial mRASS: 74% sensitive and 92% specific

Chester et al. J Hosp Med 2011

nursing delirium screen scale nudesc
Nursing Delirium Screen Scale (NuDESC)

86% sensitive and 87% specific in hospitalized patients

Gaudreau et al. Gen Hosp Psychiatry 2005.

single question in delirium
Single Question in Delirium

Sands et al. Palliat Med 2010.

  • “Do you think [name of patient] has been more confused lately?”
    • 80% sensitive
    • 71% specific
  • Validated in an oncology inpatient population
suggested algorithm
Suggested Algorithm

Ottawa 3DY

Positive

Negative

B-CAM

No Cognitive Impairment

No delirium and no dementia

Positive

Negative

Yes delirium

MMSE or

MOCAor

Referral

cognitive and mood assessment in the emergency department

Cognitive and Mood Assessment in the Emergency Department

Roger D. Williams, Ph.D.

Zablocki VA Medical Center

Associate Professor of Psychiatry & Behavioral Medicine

Medical College of Wisconsin

who should be evaluated for dementia
Who Should be Evaluated for Dementia?

People with identified risk factors

People with memory impairment or cognitive complaints, with or without functional impairment

Informant complaint, with or without patient concurrence

People with psychiatric complaints, with or without cognitive complaints

diagnosis of dementia
Diagnosis of Dementia

The diagnosis of Alzheimer’s disease (AD) and related dementias remains a clinical process

Efforts to detect dementia in the Emergency Department improves clinician decision-making, treatment planning and eventual disposition

Since memory impairments are often the earliest signs of dementia, use of cognitive screening is helpful to the diagnostic process

is there cerebral impairment
Is There Cerebral Impairment?

Level of performance

Pattern of performance

Right-left differences

Pathognomonic signs

brain behavioral correlates
Brain-Behavioral Correlates

Output

ConceptFormation

Reasoning

LogicalAnalysis

Language Skills

VisuospatialSkills

Attention, Concentration, Memory

Input

After Reitan & Wolfson, 1993

brief cognitive assessment in the emergency department
Brief Cognitive Assessment in the Emergency Department
  • Mini-Cog
  • Mini Mental Status Examination (MMSE)
    • Cut-off 23/30
  • Montreal Cognitive Assessment (MoCA)
    • Cut-off 23/30
  • St. Louis University Mental Status Exam (SLUMS)
    • Cut-off 20/30 or 19/30 depending on education
clinical dementia rating cdr
Clinical Dementia Rating (CDR)
  • Determines the stage of AD by scoring 6 cognitive/functional areas from 0 (none) to 3 (severe):
    • Memory
    • Orientation
    • Judgment and problem solving
    • Community affairs
    • Home and hobbies
    • Personal care

After Morris. 1993

mood assessment
Mood Assessment
  • Depression (GDS, PHQ-2, PHQ-9)
    • Low motivation and energy, poor appetite
  • Substance abuse (Audit-C)
  • Psychotic Disorders
    • Paranoia, delusions
  • Personality Style
    • Highly value independence
mood assessment1
Mood Assessment
  • Geriatric Depression Scale
    • 30, 15 & 5 item versions available
  • Administration
  • Scoring
    • Cut-off scores (11 or 12/30, 5 or 6/15 & 2/5)
  • Interpretation
putting it all together
Putting it All Together

Brief structured screening tools

Account for sensory-perceptual factors

Consider physical limitations

Weigh demographic factors (e.g., age, education, ethnicity, & background)

Avoid level of performance errors

Close inspection of individual items

references
References

Morris JC. The Clinical Dementia Rating (CDR): Current version and scoring rules. Neurology 1993; 43:2412-2414.

Reitan, R.M., & Wolfson, D. 1993. The Halstead-Reitan Neuropsychological Test Battery: Theory and clinical interpretation (2nd ed). Tucson, AZ: Neuropsychology Press.

Strauss, E., Sherman, E. M. S., & Spreen, O. 2006. A compendium of neuropsychological tests: Administration, norms, and commentary (3rded). New York: Oxford University Press.

Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression rating scale: a preliminary report. J Psych Res. 1983; 17:37-49.

assessing capacity

Assessing Capacity

By

Steven M. Crocker, Ph.D.

what is capacity
What is Capacity

Capacity to make decisions

Decision making capacity

Capability

Competency

Often referred to as global capacity

capacity to make medical decisions
Capacity to Make Medical Decisions

Medical “Capacity” refers to an individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate health-care decisions. (Uniform Health-Care Decisions Act of 1993, 1994).

capacity
Capacity

Decisional Capacity

the capacity to decide

Executable Capacity

the capacity to implement the decision

assessing capacity1
Assessing Capacity
  • Assessing capacity typically consists of
  • Assessing cognitive functioning

Neuropsychological assessment

  • Assessing psychiatric and/or Emotional functioning

Assessing for Delusions and/or hallucinations, severe mood impairments

  • Assessing functional elements
assessing capacity2
Assessing Capacity

Functional Elements

  • The functional elements for medical capacity are primarily cognitive and include:
  • Expressing Choice
  • Understanding
  • Appreciation
  • Reasoning
assessing decision making
Assessing Decision Making
  • Clinical Interview
  • Medical history
  • Social history
  • Objective measures (at a minimum)
    • Dementia Rating Scale (global cognitive functioning assessed)
    • Mini Mental Status Examination (brief screen)
    • St. Louis University Mental Status Examination (brief screen)
    • Montreal Cognitive Assessment (brief screen)
    • Independent Living Scales (functional Assessment)
    • RBANS (Global cognitive functioning assessed)
cognitive assessments for capacity testing
Cognitive Assessments for Capacity Testing
  • May be useful if you are already collecting this data
  • Mini-mental State Examination
    • MMSE scores < 19 likely to be associated with lack of capacity1,2
    • MMSE scores > 23 to 26 likely to be associated with presence of capacity1,2,3,4
  • Other cognitive assessments (e.g., MOCA) not well studied
  • Kim et al. PsyciatrServ2002;54:1322-4.
  • Karawish et al. Neurology 2005; 53:1514-9.
  • Etchells et al. J Gen Intern Med 1999;14:27-34.
  • Raymont et al. Lancet 2004;364:1421-7.
medical decision making
Medical Decision Making

Clinical judgment?

Marsonet al (1997) Found low agreement between five physicians with different specialty training who provided dichotomous ratings of consent capacity in older adults with Alzheimer’s disease. Agreement improved with extra training but still considerable variability.

references1
References

Assessment of Older Adults with Diminished Capacity by the American Bar Association and the American Psychological Association (2008). Available on the APA website:

http://www.apa.org/pi/aging/programs/assessment/index.aspx

Moye, J. and Marson, D. C. (2007) Assessment of Decision-Making Capacity in Older Adults: An Emerging Area of Practice and Research. Journal of Gerontology: PSYCHOLOGICAL SCIENCES, 62B, pg 3-11.

safe discharge from the emergency department for the cognitive impaired
Safe Discharge from the Emergency Department for the Cognitive Impaired

Cynthia Fletcher, LCSW

Geriatric Social worker

James A. Haley Veterans Hospital

Tampa Florida

discharge planning what to do
Discharge Planning: What To Do?

Mr. W. is an 84 year old widower who lives alone. Mr. W. had fall three days prior to arriving to Emergency Department and reports having left rib pain. Mr. W. was found to be alert and oriented x3. However, he was vague in providing a history. Mr. W. was treated with Toradol and Morphine IV for chest contusion.

Mr. W. Active problems list include: Osteoporosis, left femur fracture, Diabetes Type 2, Cataract, Major Depressive Disorder-Moderate Recurrent, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Hypertension, and Mixed hyperlipidemia. Mr. W. has 25 different medications prescribed.

Mr. W. depends on his two neighbors to assist with shopping and transportation to medical appointments. Neighbor reported that Mr. W. has had a decline in mobility, he has not been getting his mail , he is sleeping most of the day and up at night. His Mini–mental status examination: 26/30: loss of one point for recall, two for command and one for copying. Patient was unable to complete a sample of trails A. He listed only 8 objects in one minute.

Findings:

Dementia, suspect vascular with decrease in visual special comprehension and executive function.

discharge planning includes
Discharge Planning Includes:
  • Evaluation
  • Discussion
  • Planning
  • Referrals
evaluation multi disciplinary approach
Evaluation– Multi-disciplinary Approach

Bio-Psychosocial Assessment Includes:

  • Medical History & Cognitive Assessment – including capacity
  • Support System - whom & how often. It is important to get history or prospective from family of veteran’s situation & level of function from family …
  • Level of function – Activates of Daily living & Instrumental Activates of Daily living
  • Environment – fall risk, fire safety, gun safety, exit home safely in emergency…
  • Financial – resources to pay for support services
discussion include the patient s health care surrogate in the process
Discussion– Include the Patient’s Health Care Surrogate in the Process

Sharing the findings of evaluation and recommendations for safe discharge.

Clarify with patient & health care surrogate their understanding of identified needs for a safe discharge. Those with cognitive impairment may not fully understand why there are in the ED. Patient and family may have difficulty excepting a new diagnosis of dementia.

Confirm ability of health care surrogate or support person/s to meet the identified needs of patient.

Education of VA and Community in-home services – Aid & Attendance, Home health aid, respite, adult day care… Let patient and surrogate know there is support for them.

Jin H. Han, Suzanne N. Bryce, E. Wesley Ely, Sunil Kripalani, Alessandro Morandi, AyumiShintani, James C. Jackson, Alan B. Storrow, Robert S. Dittus, John Schnelle : The Effect of Cognitive Impairment on the Accuracy of the Presenting Complaint and Discharge Instruction Comprehension in Older Emergency Department Patients ,Annals of Emergency Medicine, Volume 57, Issue 6, June 2011 Pages 662-671.e2

Paola Chiovenda, Giovanni Maria Vincentelli, FilippoAlegiani, Cognitive impairment in elderly ED patients: Need for multidimensional assessment for better management after discharge, The American Journal of Emergency Medicine, Volume 20, Issue 4, July 2002, Pages 332-335, ISSN 0735-6757

planning to discharge home
Planning - To Discharge Home

Confirm support system is in place – document plan of who will be providing for specific needs and how often. Education of VA and Community in-home services – stress need for follow up with primary care.

Verbal instructions are a critical component of the doctor-patient interaction where the doctor has the opportunity of ensuring that the patient understands the instructions and the patient has the opportunity to ask questions and clarify uncertainties. Poor completion of discharge instructions due to cognitive impairment and literacy may contribute to poor compliance, additional ED visits and increased mortality risk.

Comprehensive written discharge instructions, addressing all relevant aspects of ongoing management is important to increase compliance and may afford medical staff some protection from malpractice litigation.

Follow up with Primary care – is vital , particularly to getting in home services in place.

GraneJA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med1997;15:1–7. J AccidEmerg Med2000;17:86-90 doi:10.1136/emj.17.2.86

Paola Chiovenda, Giovanni Maria Vincentelli, FilippoAlegiani, Cognitive impairment in elderly ED patients: Need for multidimensional assessment for better management after discharge, The American Journal of Emergency Medicine, Volume 20, Issue 4, July 2002, Pages 332-335, ISSN 0735-6757, http://dx.doi.org/10.1053/ajem.2002.33785. (http://www.sciencedirect.com/science/article/pii/S0735675702000128)

discharge to another care facility
Discharge to Another Care Facility

Level of Care – Assisted living versus skilled care facility.

If long term care is recommended - a (3 day )hospital admission is required to satisfy the Medicare component for skill nursing home placement.

Patient or representative may refuse placement and if patient is at risk - a report to Adult Protective Services or a need for 72 hour hold in psychiatric unit should be considered for further assessment of needs such a guardianship.

mandated reporting neglect exploitation or elder abuse
Mandated Reporting: Neglect, Exploitation, or Elder Abuse

Let older victims know, before a disclosure is made, what can happen if they discuss forms of elder abuse. Advise all older victims about what information may and may not be kept confidential.

Let the victim know that, because a report is mandated, you will be contacting a regulatory agency, as required. Tell the victim to what agency the information will be reported (e.g., adult protective services (APS)/elder abuse agency, law enforcement).

Offer to include the victim in the reporting process. The victim may choose to self-report. Self–report is encouraged for firsthand information.

Abandonment in the ED - is not always cause for mandatory reporting. The caregiver may be ill equipped to managed patient. Further evaluation is need.

Tampa VA Policy - all reports are processed through Social Work Chief. Every state has protocol for reporting.

va resources
VA Resources
  • Aid and Attendance Benefits - to off set cost of in-home services or assisted living facility
  • Home Base Primary Care – for home bound
  • Medical Foster Home
  • Home Maker Home Health Aid program – for personal care, homemaking and respite services
  • VA Adult Day Care program
  • Veterans directed care – funding for caregiver to hire help in-home service
  • VA Nursing Home – at no cost for Vet's 70% service connection or higher
conclusion
Conclusion

As we continue to see an increase in the aging population of Veterans in the Emergency Department, it is imperative that medical teams in the ED be adept at recognizing, evaluating and managing patients with cognitive impairment.

Appropriate diagnosis and management of persons with Cognitive impairment may result in significantly improved outcomes for those treated and discharged from the ED.