Cognitive Impairment in the Emergency Department

Jin H. Han, MD, MScAssistant Professor

Department of Emergency Medicine Research Division

Center for Quality AgingVanderbilt 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 concurrently1. Hustey et al. Ann Emerg Med. 2002;39:248-532. Han et al. Ann Emerg Med. 2011:57:662-713. Carpenter et al. Acad Emerg Med 2011: 18: 374–844. 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 DementiaCharacteristic Delirium DementiaOnset Hours to days Months to

yearsCourse Fluctuating StableInattention Yes RarelyAltered LOC Typically RarelyDisorganized thinking Sometimes RarelyReversible Typically 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 ScreeningIf 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. Kakuma et al. J Am Geriatr Soc. 20032. Lewis et al. Am J Emerg Med. 19953. Han et al. Ann Emerg Med. 20104. 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

Brevity

Accuracy

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;15:613-6Carpenter et al. Ann Emerg Med. 2011; 57:653-61

Delirium Assessment Tools

Confusion Assessment MethodFeature 1

Fluctuation and change in mental status

Feature 2Inattention

Feature 3Disorganized thinking

Feature 4Altered level of consciousness

and either

+

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 patientsHan et al. Ann Emerg Med 2013 (In press).

Modified Richmond Agitation Sedation Scale

In hospitalized patients

Single mRASS: 64% sensitive and 93% specificSerial 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 patientsGaudreau 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 AlgorithmOttawa 3DY

Positive

B-CAMPositive

Yes delirium

Negative

MMSE orMOCA orReferral

Negative

No Cognitive Impairment

No delirium and no dementia

Cognitive and Mood Assessment in the Emergency Department

Roger D. Williams, Ph.D.Zablocki VA Medical Center

Associate Professor of Psychiatry & Behavioral MedicineMedical 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 CorrelatesOutput

Concept FormationReasoning

Logical Analysis

Language Skills Visuospatial Skills

Attention, Concentration, Memory

InputAfter 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 LaundryGrooming Preparing mealsFeeding Self Administer

MedicationsContinence 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 Capacitythe capacity to decide

Executable Capacitythe 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 studied1. Kim et al. Psyciatr Serv 2002;54:1322-4.2. Karawish et al. Neurology 2005; 53:1514-9.3. Etchells et al. J Gen Intern Med 1999;14:27-34.4. 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 Decision-Making 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, LCSWGeriatric 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.e2Paola 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.17.2.86Paola 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.