Linda Schnitker

What is the evidence to guide best practice for the management of older people with cognitive impairment presenting to emergency departments? a systematic review

The aim of this study was to conduct a systematic literature review of research-based studies to identify practices designed to meet the specific care needs of older cognitively impaired patients in emergency departments (ED). A systematic literature review of studies was completed using PRIMSA methodology. The search criteria included articles from both emergency and acute care settings. A total of 944 articles were screened, and a total of 43 articles were identified as eligible. The review found a number of intervention studies to improve quality of care for older persons with cognitive impairment carried out or commenced in emergency settings, including interventions to improve cognitive impairment recognition (n = 9) and clinical approaches to reduce falls (n = 1) and both delirium incidence and prevalence (n = 2). Relevant studies carried out in acute care settings regarding cognitive impairment recognition (n = 4) and primary and secondary prevention of delirium (n = 18) and intervention studies that reduced the prescription of deliriogenic drugs (n = 1), reduced behavioral symptoms and discomfort (n = 7), and improved nutritional intake (n = 1) in hospitalized older persons with dementia were also identified. There is limited research available that reports interventions that improve the quality of care of older ED patients with cognitive impairment. Although this review found evidence obtained from the acute care setting, additional research is needed to identify whether these interventions are beneficial in fast-paced emergency settings.

Methodology for developing quality indicators for the care of older people in the Emergency Department

BackgroundCompared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department.Methods/designFollowing input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process.DiscussionThe predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.

Appraisal of the quality of care of older adults with cognitive impairment in the emergency department.

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

People with dementia getting lost in Australia: Dementia‐related missing person reports in the media

This study aimed to understand the circumstances in which people with dementia become lost, and the outcomes of these incidents.

204 Accuracy of Dementia Screening Instruments in Emergency Medicine: A Diagnostic Meta-Analysis

Results: Of the 198 patients in the study population 54% were deceased 30 days after hospital discharge with only 25.7% alive at 15 months. Admitted patients had a mean hospital length of stay of 7 days with 73% requiring intensive care. 40.4% of the patients received a formal palliative care intervention during their hospitalization from either the palliative care consult service (12.1%) or by embedded supportive care nurses (28.3%). Formal palliative care interventions occurred a median of 3 days into hospitalization and often changed the direction of care with 85% of patients downgrading their advanced directive wishes and discharge occurring a median of 1 day after intervention. Few formal palliative care interventions began from the emergency department (9.1%). Interestingly, 47.1% of patients who did not receive any documented goals of care discussions or palliative care interventions were deceased at 15 months post-discharge. Conclusions: Elderly patients from long-term care facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment and improve end-oflife care in this vulnerable population and should be considered early in the hospitalization and where available, be initiated in the emergency department.