Cognitive Assessment in the ED

This week I had on my plate to review and comment an article about an interesting way the screen for cognitive impairment in the ED: the Bergman-Paris Question (BPQ). Here is what I knew about this one: NADA. Let’s do a quick review on how would be the best way to do a cognitive assessment in the ED with our older adults.

The geriatric emergency guidelines recommend to a comprehensive assessment of elderly who presents in the ED with an evidence of a cognitive impairment either a delirium, encephalopathy or dementia. Easy thing to say, harder to actually do.

But why is that? Easy answer. There is dozens of publication that state that delirium increased mortality, admission, length of stay in the hospital, relocalization in long term care. When discharged from the ED, an unrocognized delirium could lead to adverse outcomes compared to non-delirious patient and even compared to patient with a known delirium (1). It is important to detect delirium and therefore to find the cause and to administer a treatment plan.

Let’s start we something we actually know. We all know the difference between dementia and delirium in a “theoric” point of view (I remember the table in the ROSEN very well…!). But do we bother to even make the difference clinically? We often hear in the ED: ”This patient is confused”.

I was able to quickly find three studies that stated the same thing. The prevalence of delirium in the ED is about 15% and we miss 2/3 of these (2-4). We have to get our games to an upper level. Is this patient acutely confused or it is his usual state of mind? This is very simple and is the basis of this test: The Confusion Assessment Method (CAM).

The CAM takes less than 5 minutes to take but you will probably need the help of a proxy. In various studies, the CAM is often used as the diagnostic tool of choice for delirium. Even though it seems like the “new thing”, it is fairly old. The first publication about the CAM was in 1990. Its sensitivity is very variable (70-95%) but very specific (95%). This is why it is more of a diagnostic tool than a screening tool.

We should use it. It should be part of an initial assessment of a confused elderly.

The sceptical in me will ask, is there other tests?

**I will not talk about the MOCA, the 3MS, the MMSE, the TICS-m. These take more than 10-15 minutes to take and even though some of them are validated in an emergency context, I would not even ask an to start doing these tests, it is unrealistic (I won’t do it myself anyway…).**

Another list of tests:

What else is out there then?

The Ottawa 3DY scale is very promising. Debra Eagles who is very implicated in the care of elderly in the emergency department published a thesis on the performance of this test.

Here is her conclusion: “Use of the Ottawa 3DY scale increased screening (this is what we want) for altered mental status in elderly patients when implemented in the ED. It was found to be feasible, sensitive, specific and to have a good inter-rater reliability. Its use will lead to increased identification of altered mental status in elderly ED patients and ultimately result in improved care and outcomes in this vulnerable population.”

The Ottawa 3DY scale seems easy to administer, easy scoring and good sensibility? This is all we need.

Should we use the Ottawa 3DY instead of the CAM? I have not seen a comparative study between those two tests though. But this could be an interesting research question!

Ok back to the Bergman-Paris Question. “Would you be comfortable leaving your family member home alone for 3 months if you went away on a trip to Paris and if other members of the family were also away?” A “No” suggests there is a cognitive impairment. A “Yes” from the caregiver suggests an independent patient with no cognitive impairment.

Interesting question to ask. I could not find anything on the subject other than the original study published in 2009 by a searcher from Montreal (5). This retrospective study was done with 67 outpatients from the memory clinic. They found a sensitivity of 95%, specificity 63%, PPV 82% and NPV 88%. It is pretty good for a very brief screening tool. Of course you need a caregiver or a family member present to answer this question. We assume that they all know well their older relatives but in fact, is it always the case?

In conclusion on the cognitive assessment in the ED, it is a POSSIBLE task, and various tests exist. The important thing is when you pick a test for your ED, you need to know the following: its strength, its weakness. They all have weaknesses, but if you are aware of it, it becomes a strength!

References

  1. Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, et al. Delirium in older emergency department patients discharged home: effect on survival. Journal of the American Geriatrics Society. 2003 Apr;51(4):443-50. PubMed PMID: 12657062.
  2. Suffoletto B, Miller T, Frisch A, Callaway C. Emergency physician recognition of delirium. Postgraduate medical journal. 2013 Nov;89(1057):621-5. PubMed PMID: 23788663.
  3. Press Y, Margulin T, Grinshpun Y, Kagan E, Snir Y, Berzak A, et al. The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital. Archives of gerontology and geriatrics. 2009 Mar-Apr;48(2):201-4. PubMed PMID: 18313774.
  4. Singler K, Thiem U, Christ M, Zenk P, Biber R, Sieber CC, et al. Aspects and assessment of delirium in old age. First data from a German interdisciplinary emergency department. Zeitschrift fur Gerontologie und Geriatrie. 2014 Dec;47(8):680-5. PubMed PMID: 24733451.
  5. Christine Caporuscio JM, Susan Gold, Michele Monette, Keith O’Rourke. Ability of the “Bergman-Paris” Question to detect dementia in community-dwelling older people. Canadian Journal of geriatrics. 2009;12(3):101-3.

 

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