Altered Mental Status and Delirium
adults; Altered mental status; cognitive impairment; confusion assessment method; delirium; Dementia; Elderly; elderly-patients; Emergency Medicine; Emergency Medicine; emergency-department patients; haloperidol; intensive-care-unit; Length of Stay; Medical decision-making capacity; scale; screening tools
Older patients who present to the emergency department frequently have acute or chronic alterations of their mental status, including their level of consciousness and cognition. Recognizing both acute and chronic changes in cognition are important for emergency physicians. Delirium is an acute change in attention, awareness, and cognition. Numerous life threatening conditions can cause delirium; therefore, prompt recognition and treatment are critical. The authors discuss an organized approach that can lead to a prompt diagnosis within the time constraints of the emergency department.
Wilber S T; Ondrejka J E
Emergency Medicine Clinics of North America
2016
2016-08
Journal Article
<a href="http://doi.org/10.1016/j.emc.2016.04.012" target="_blank" rel="noreferrer noopener">10.1016/j.emc.2016.04.012</a>
An evaluation of two screening tools for cognitive impairment in older emergency department patients
cognitive impairment; delirium; elderly emergency; Emergency department; Emergency Medicine; Examination; mental status; Mini-Cog; Mini-Mental State; prevalence; Six-Item Screener
Objectives: Screening for cognitive impairment in older emergency department (ED) patients is recommended to ensure quality care. The Mini-Mental State Examination (MMSE) may be too long for routine ED use. Briefer alternatives include the Six-Item Screener (SIS) and the Mini-Cog. The objective of this study was to describe the test characteristics of the SIS and the Mini-Cog compared with the MMSE when administered to older ED patients. Methods: This institutional review board-approved, prospective, randomized study was performed in a university-affiliated teaching hospital ED. Eligible patients were 65 years and older and able to communicate in English. Patients who were unable or unwilling to perform testing, who were medically unstable, or who received medications affecting their mental status were excluded. Patients were randomized to receive the SIS or the Mini-Cog by the treating emergency physician. Investigators administered the MMSE 30 minutes later. An SIS score of <= 4, the Mini-Cog's scoring algorithm, and an MMSE score of <= 23 defined cognitive impairment. Results: A total of 149 of 188 approached patients were enrolled; 74 received the SIS and 75 the Mini-Cog. Fifty-five percent were female, the average age was 75 years, and 23% had an MMSE score of <= 23. The SIS had a sensitivity of 94% (95% confidence interval [CI] = 73% to 100%) and a specificity of 86% (95% CI = 74% to 94%). The Mini-Cog had a sensitivity of 75% (95% CI = 48% to 93%) and a specificity of 85% (95% CI = 73% to 93%). Conclusions: The SIS, using a cutoff of <= 4 as impaired, is a promising test for ED use. It is short, easy to administer, and unobtrusive, allowing it to be easily incorporated into the initial assessment of older ED patients.
Wilber S T; Lofgren S D; Mager T G; Blanda M; Gerson L W
Academic Emergency Medicine
2005
2005-07
Journal Article
<a href="http://doi.org/10.1111/j.1553-2712.2005.tb00915.x" target="_blank" rel="noreferrer noopener">10.1111/j.1553-2712.2005.tb00915.x</a>
The six-item screeinier to detect cognitive impairment in older emergency department patients
care; cognitive impairment; delirium; diagnostic testing; elderly emergency; Emergency Medicine; geriatrics; mental status; Mini-Mental State; prevalence
Background: Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patient's mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria. Objectives: The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients. Methods: A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients :65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 31) minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted. Results: The authors enrolled 352 subjects; III were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83). Conclusions: The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.
Wilber S T; Carpenter C R; Hustey F M
Academic Emergency Medicine
2008
2008-07
Journal Article
<a href="http://doi.org/10.1111/j.1553-2712.2008.00158.x" target="_blank" rel="noreferrer noopener">10.1111/j.1553-2712.2008.00158.x</a>
The Role Of Pharmacists In Delirium Prevention And Treatment In The Acute Care Setting
delirium; Geriatrics & Gerontology; interdisciplinary care; pharmacist
Fosnight S; Moss K; Sabo A; Holder C; Hazelett S; Benedict L; Germano S; Allen K
Journal of the American Geriatrics Society
2010
2010-04
Journal Article or Conference Abstract Publication
n/a
Altered Mental Status In Older Patients In The Emergency Department
agitation-sedation scale; cognitive impairment; Coma; confusion assessment method; critically-ill; Delirium; diagnosis; elderly; Emergency department; epidemiology; Geriatrics & Gerontology; glasgow coma scale; hospitalized-patients; intensive-care unit; length-of-stay; management; multicomponent geriatric intervention; patients; risk-factors; Stupor
Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
Han J H; Wilber S T
Clinics in Geriatric Medicine
2013
2013-02
Journal Article or Conference Abstract Publication
<a href="http://doi.org/10.1016/j.cger.2012.09.005" target="_blank" rel="noreferrer noopener">10.1016/j.cger.2012.09.005</a>
Delirium Precipitated by Polycythaemia.
delirium, polycytemia
Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalization and dementia, it remains under diagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM- 5) provides an opportunity to examine the constructs underlying delirium as a clinical entity [1]. We are reporting a case of delirium in a 20 years old female that was precipitated by a secondary polycythaemia caused by a congenital cardiac left to right shunt resulting in a pulmonary hypertension. Our med pub mesh literature search did not yield a previously reported similar case.
Adel S. Zaraa, MD
Journal of Psychology & Clinical Psychiatry
2016
Zaraa A, Miquel MAR, Ahmad M
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
journalArticle
<a href="http://doi.org/10.15406/jpcpy.2016.06.00369" target="_blank" rel="noreferrer noopener">10.15406/jpcpy.2016.06.00369</a>