Kara McLoughlin, Susan O’Reilly, Louise Martin, Niamh O’Regan, Suzanne Timmons, Rachel Doyle 
Ireland 

There is a steady growth in population ageing, with the number of those aged sixty-five and above increased by 31% from 2006 (1).

With this, we have seen an increase in frailty, which is present in up to 60% of older attendees in Emergency Departments (ED) (2).  A common adverse outcome for frail older adults is delirium. Delirium is a clinical syndrome characterized by disturbed attention, consciousness, cognitive function or perception, which has an acute onset and fluctuating course.

Although delirium awareness has improved in recent years, it is still often missed, particularly in ED. Han et al (2009) reported that 76% of delirium was missed within the ED. Missed delirium leads to worse outcomes, including prolonged inpatient admission; increased risk of hospital acquired falls, infections, and pressure sores; increased need for long term care; and higher mortality. The Irish National Audit of Dementia (INAD-2; 2020) found that even among people with known dementia (who are at extremely high risk of delirium), less than 20% were screened for delirium at any time during a hospital admission.

In the era of COVID, identifying delirium is even more important.  Kennedy et al (2020) reported that 28% of older people with COVID had delirium at presentation, and delirium was the sixth most common presenting feature. Among delirious patients, 16% presented with delirium as a primary symptom and 37% had no typical COVID-19 symptoms or signs.

A national working group was formed in 2019 by the Health Service Executive’s (HSE) National Dementia Office to develop national dementia pathways for use in acute hospitals. This was based on the National Dementia Strategy (2014) which stated that “The HSE will develop and implement a dementia and delirium care pathway,….., to be developed and implemented on a local level in each acute hospital” and that “Hospitals will be required to ensure that people with dementia have a specific pathway through EDs …. that is appropriate to their particular sensory and psychosocial needs”. The working group comprised of 22 members, across medicine (gerontology, emergency medicine, psychiatry), nursing, occupational therapy, and physiotherapy.

In addition to developing these pathways, the group updated an existing, but rarely used, national ED delirium algorithm, from 2015. The medication section needed to be updated and the algorithm needed to align with the in-development pathway and care bundle for people with possible or known dementia in ED. This alignment was crucial given the close links and overlap between delirium and dementia, where many older people with delirium have underlying dementia, which is often not yet diagnosed at the time of the delirium.

The ED algorithm recommends screening for delirium in all older adults (65+) who present to ED, at triage or at first point of contact afterwards, by any trained staff member. The recommended delirium screening tool is the 4AT, which has been validated in older adults in an Irish ED setting (7), and is used widely internationally in clinical practice. The 4AT aims to identify those with likely delirium while also identifying those with cognitive impairment who may be at high risk of developing delirium.

Following the assessment, the ED staff member follows a flow chart which includes delirium prevention and management strategies, with a focus on non-pharmacological approaches.  For those requiring medications, clear guidance and dose recommendations are included. Assessing for potential causes of delirium is simplified using the ‘PINCH ME’ acronym- Pain, INfection, Constipation, Hydration, Medication and Environment.

The algorithm was endorsed in 2020 for use in all EDs throughout Ireland by the National Clinical Programmes in Emergency Medicine, Acute Medicine, Surgery, and Older Persons, and by the National Dementia Office, but it needs to be implemented at local level. An ED delirium working group, and local delirium champions, can support this. A number of Irish EDs have taken this approach with an emphasis on delirium education to all ED staff, provision of delirium prompt cards, altered ED paperwork to ease assessment burden, and environmental changes including comfort trolleys and functional aids to optimise orientation and independence. The presence of ED frailty teams also helps with delirium assessment and management, during core working hours. Funding was secured by the National Dementia Office in 2021 for 6 dedicated dementia clinical nurse specialist. These posts will support care for more complex delirium cases, and, where possible, support safe discharge home of a person with dementia at high risk of delirium in the ED. Additional funding is being sought for dementia delirium quality improvement for each hospital group for 2022 – 2024 and for additional dementia clinical nurse specialists to ensure all hospitals with an ED have such a post.

The ED Delirium Algorithm, and the linked dementia-delirium ED pathway template(8) (which can be locally modified), are found here. We also recommend reviewing the EUSEM delirium and cognitive impairment education posters //posters.geriemeurope.eu/posters/geriEM-P04-EN.pdf to assist local education.

References:

1. Public Health England (2019) Launch of the new Productive Healthy Ageing Profile toolBackground on the development and outline of current and planned content. Available at: //fingertips.phe.org.uk/profile/healthy-ageing
2. O’Caoimh, R., Costello, M., Small, C., Spooner, L., Flannery, A., O’Reilly, L., Heffernan, L., Mannion, E., Maughan, A., Joyce, A. and Molloy, D.W.(2019). Comparison of frailty screening instruments in the emergency department. International journal of environmental research and public health, 16(19), p.3626.
3. Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A, Dittus RS, Storrow AB, Ely EW. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009 Mar;16(3):193-200.
4. Kennedy M, Helfand BKI, Gou RY, et al. Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Netw Open.2020;3(11): e2029540. //doi:10.1001/jamanetworkopen.2020.29540
5. O’Sullivan,D. Brady,N. Manning, E. O’Shea,E. O’Grady, S. O ‘Regan, N. Timmons, T.  Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees, Age and Ageing, Volume 47, Issue 1, January 2018, Pages 61–68, //doi.org/10.1093/ageing/afx149
6. Lucke JA, Mooijaart SP, Heeren P, Singler K, McNamara R, Gilbert T, Nickel CH, Castejon S, Mitchell A, Mezera V, Van der Linden L, Lim SE, Thaur A, Karamercan MA, Blomaard LC, Dundar ZD, Chueng KY, Islam F, de Groot B, Conroy S. Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine. European geriatric medicine, 1-9 2021