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
• Screening for cognitive impairment in the
emergency department
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
• 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
1.
2.
3.
4.
Hustey et al. Ann Emerg Med. 2002;39:248-53
Han et al. Ann Emerg Med. 2011:57:662-71
Carpenter et al. Acad Emerg Med 2011: 18: 374–84
Elie et al. CMAJ. 2000:163:977-81
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?
• 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)
Delirium ≠ Dementia
What’s the difference?
Delirium versus Dementia
Characteristic
Delirium
Dementia
Onset
Course
Inattention
Altered LOC
Disorganized thinking
Reversible
Hours to days
Fluctuating
Yes
Typically
Sometimes
Typically
Months to years
Stable
Rarely
Rarely
Rarely
Rarely
Dementia is an important predisposing
factor to 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
• Hypothyroidism
• Normal pressure hydrocephalus
• Vitamin B12 deficiency
• Depression can mimic dementia-like
symptoms
Reversible causes of dementia are rare
Rationale for Cognitive Screening
• Delirium and dementia in the ED is frequently
unrecognized
• Potential safety concern
– Inaccurate history1
– Cannot comprehend discharge instructions1
• Decisional capacity
• Safe to go home?
1. Han et al. Ann of Emerg Med. 2011; 57:662-71
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
If you miss delirium, you may miss the
underlying illness.
Reeves et al. South Med J. 2010; 111 - 5
Rationale for Delirium Screening
• Delirium is associated with:
–
–
–
–
–
–
Mortality1,2,3
Accelerated cognitive and functional decline
Prolonged hospitalizations4
Increased hospital complications
Increased institutionalization
Higher health care costs
1.
2.
3.
4.
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
Global Tests of Cognition
Global Tests of Cognition
• These tests in and of itself cannot
differentiate between dementia and
delirium
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
Accuracy
Brevity
Ottawa 3DY
• Month
• Year
• Spell “WORLD” backwards
Molnar et al. Clin Med Geriatrics. 2008:2:1-11
Ottawa 3DY
• In older ED patients
– 95% sensitive
– 51% specific
Carpenter CR. Acad Emerg Med. 2011; 18:374-84
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 Screener
• In older ED patients, 2 or more errors
– 63% to 74% sensitive
– 77% to 81% specific
Wilber et al. Acad Emerg Med. 2008;15:613-6
Carpenter et al. Ann Emerg Med. 2011; 57:653-61
Delirium Assessment Tools
Confusion Assessment Method
Feature 1
Fluctuation and change in
mental status
+
Feature 2
Inattention
Feature 3
Disorganized thinking
and either
Feature 4
Altered level of consciousness
94 - 100% sensitive and 90 - 95% specific
Inouye et al. Ann Intern Med. 1990; 113:941-8
CAM’s Diagnostic Accuracy
Pooled Sensitivity: 86%
Pooled Specificity: 93%
Wong et al. JAMA. 2010.
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
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)
86% sensitive and 87% specific in hospitalized patients
Gaudreau et al. Gen Hosp Psychiatry 2005.
Single Question in Delirium
• “Do you think [name of patient] has been
more confused lately?”
– 80% sensitive
– 71% specific
• Validated in an oncology inpatient
population
Sands et al. Palliat Med 2010.
Suggested Algorithm
Ottawa 3DY
Positive
B-CAM
Positive
Yes delirium
Negative
No Cognitive Impairment
No delirium and no dementia
Negative
MMSE or
MOCA or
Referral
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?
 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
 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?
 Level of performance
 Pattern of performance
 Right-left differences
 Pathognomonic signs
Brain-Behavioral Correlates
Output
Concept Formation
Reasoning
Logical Analysis
Language Skills
Visuospatial Skills
Attention, Concentration, Memory
Input
After Reitan & Wolfson, 1993
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)
 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
Functional Assessment
Activities of Daily Living
(ADL)
Instrumental Activity of Daily
Living (IADL)
Transfers
*Handling House Finances
*Bathing
*Housekeeping
*Toileting
Laundry
Grooming
Preparing meals
Feeding
Self Administer Medications
Continence
Using the telephone
*Driving
*Shopping
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 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
 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
 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 (3rd ed). 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
By
Steven M. Crocker, Ph.D.
What is Capacity
 Capacity to make decisions
 Decision making capacity
 Capability
 Competency
Often referred to as global capacity
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
 Decisional Capacity
the capacity to decide
 Executable Capacity
the capacity to implement the decision
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 Capacity
Functional Elements
 The functional elements for medical capacity are
primarily cognitive and include:
–
–
–
–
Expressing Choice
Understanding
Appreciation
Reasoning
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
 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
1.
2.
3.
4.
Kim et al. Psyciatr Serv 2002;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
 Clinical judgment?
Marson et 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.
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 DecisionMaking 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
Cynthia Fletcher, LCSW
Geriatric Social worker
James A. Haley Veterans Hospital
Tampa Florida
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:
 Evaluation
 Discussion
 Planning
 Referrals
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
 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, Ayumi Shintani, 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, Filippo Alegiani, 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
 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.
Grane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med1997;15:1–7. J Accid Emerg
Med2000;17:86-90 doi:10.1136/emj.17.2.86
Paola Chiovenda, Giovanni Maria Vincentelli, Filippo Alegiani, 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
 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
 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
 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
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.