A number of tools can be added to the ED work flow to better identify older patients with important conditions that will make a difference to their care in the ED, their care if admitted, and appropriate discharge planning.
Screening for Delirium
A second important domain for screening is delirium. ED-based studies over twenty years suggest that delirium complicates the ED presentation of up to 10% of all older patients, that EDs identify it in one-third of cases, and don’t identify it in two-thirds! A standardized approach to screening for an important and common geriatric condition is valuable in the senior-friendly ED.
A number of tools exist:
- The Delirium Triage Screen (DTS) followed by the b-CAM
The DTS (despite its name, it’s probably best done by the primary nurse) consists of a subjective assessment of the person’s level of arousal using the RASS (Richmond Agitation-Sedation Score which is already in common use in EDs for monitoring conscious sedation) followed by a simple test of attention (“Please spell lunch backwards.”) Here is a link to an instruction manual for the DTS http://eddelirium.org/wp-content/uploads/2016/05/DTS-Training-Manual-Version-1.0-09-01-2015.pdf If the DTS is positive, a simple ED-validated version of the Confusion Assessment Method can follow. http://www.icudelirium.org/docs/bCAM_Flowsheet.pdf
2. The Confusion Assessment Method
It would also be possible to build the four domains of the Confusion Assessment Method into the primary nurse assessment for all patients over the age of 65. Here is the version that VIHA uses. And a training manual for each of the CAM assessment tools available. Mount Sinai Hospital has included the CAM in our Emergency Nursing Care Record, along with other key assessments for geriatric patients.
A quick screen that is widely used is the 4AT. You can read more about the 4AT and download it in multiple languages here. It has also been validated as an effective tool for screening in the ED here.
Screening for Dementia
A third domain would be screening for the presence of chronic cognitive impairment or dementia which is often not identified in the ED and has a major impact on the clinicians’ ability to get an accurate history, on the patient’s ability to participate and cooperate with care, and with planning discharge and discharge instructions.
Formal testing using the MMSE or MoCA is beyond the usual scope of ED practices but adding one of the following tools is practical:
- This article by Chris Carpenter et al. highlights four screening tools to detect cognitive impairment in older patients in the ED. These include the Brief Alzheimer’s Screen, the Short Blessed Test, the Ottawa 3DY, and the Caregiver-completed AD8
Screening for Functional Decline
One important domain is assessing for function and risk of functional decline. A number of tools exist:
- The Identifying Seniors at Risk (ISAR) was developed by Jane McCusker. It consists of six simple questions where two or more positive responses suggest a need for further attention to the person’s ability to function in the home environment now when faced with a new medical or surgical condition.
- Before the injury or illness, did you need someone to help you on a regular basis?
- Since the injury or illness, have you needed more help than usual?
- Have you been hospitalized for one or more nights in the past six months?
- In general, do you see well?
- In general, do you have serious problems with your memory?
- Do you take more than 3 medications daily?
The ISAR can be used in various ways. It can be used to trigger a further assessment in the ED if you have access to a geriatric nurse specialist or interdisciplinary team in order to plan more appropriate care. It can result in a flag to community-based services (home care) if the person is subsequently discharged. It can be used as a cue to the physician of some impairments that may not come up in the usual medical assessment (how often do MDs ask about hearing and vision or home care needs?) If the patient is admitted, it can result in a different in-hospital management algorithm (at some sites, a high-ISAR score would mandate a Geriatric Medicine consultation or management on an Acute Care of the Elderly unit.)
If you choose to institute such a screening tool, it will be important to build it into the ED work flow. Although it was designed as a triage tool, it is probably more appropriately used during a primary nursing assessment. Build it into the electronic medical record is available in several EMR systems (EPIC, Cerner, MediTech, other.)
- The interRAI ED Screener or Assessment Urgency Algorithm has been described as the “new and improved” ISAR. It uses an app on a smart phone or tablet or hospital computer to quickly screen patients into six levels, where a score of 5-6 suggests the need for urgent further assessment by geriatrician or much increased care at home. Here is the interRAI ED Contact Assessment form which, in the absence of a geriatric ED nurse specialist, could be used to provide a more thorough non-medical assessment of the patient. At Grand River Hospital, this tool was added to their screening procedures with great success. Read their story here.
References and Resources
- Carpenter CR, Bassett ER, Fischer GM, et al. Four sensitive screening tools to detect cognitive impairment in geriatric emergency department patients: Brief Alzheimer’s Screen, Short Blessed Test, Ottawa3DY, and the Caregiver Administered AD8. Acad Emerg Med. 2011 18: 374-384.
- Carpenter CR, DesPain B, Keeling TK, et al. The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med. 2011;57: 653-661.