title: Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes.
abstract: OBJECTIVE
  Missing delirium in the emergency department (ED) has been described as a medical error, yet this diagnosis is frequently unrecognized by emergency physicians (EPs). Identifying a subset of patients at high risk for delirium may improve delirium screening compliance by EPs. The authors sought to determine how often delirium is missed in the ED and how often these missed cases are detected by admitting hospital physicians at the time of admission, to identify delirium risk factors in older ED patients, and to characterize delirium by psychomotor subtypes in the ED setting.
  
  
  METHODS
  This cross-sectional study was a convenience sample of patients conducted at a tertiary care, academic ED. English-speaking patients who were 65 years and older and present in the ED for less than 12 hours at the time of enrollment were included. Patients were excluded if they refused consent, were previously enrolled, had severe dementia, were unarousable to verbal stimuli for all delirium assessments, or had incomplete data. Delirium status was determined by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants (RAs). Recognition of delirium by emergency and hospital physicians was determined from the medical record, blinded to CAM-ICU status. Multivariable logistic regression was used to identify independent delirium risk factors. The Richmond Agitation and Sedation Scale was used to classify delirium by its psychomotor subtypes.
  
  
  RESULTS
  Inclusion and exclusion criteria were met in 303 patients, and 25 (8.3%) presented to the ED with delirium. The vast majority (92.0%, 95% confidence interval [CI] = 74.0% to 99.0%) of delirious patients had the hypoactive psychomotor subtype. Of the 25 patients with delirium, 19 (76.0%, 95% CI = 54.9% to 90.6%) were not recognized to be delirious by the EP. Of the 16 admitted delirious patients who were undiagnosed by the EPs, 15 (93.8%, 95% CI = 69.8% to 99.8%) remained unrecognized by the hospital physician at the time of admission. Dementia, a Katz Activities of Daily Living (ADL) < or = 4, and hearing impairment were independently associated with presenting with delirium in the ED. Based on the multivariable model, a delirium risk score was constructed. Dementia, Katz ADL < or = 4, and hearing impairment were weighed equally. Patients with higher risk scores were more likely to be CAM-ICU positive (area under the receiver operating characteristic [ROC] curve = 0.82). If older ED patients with one or more delirium risk factors were screened for delirium, 165 (54.5%, 95% CI = 48.7% to 60.2%) would have required a delirium assessment at the expense of missing 1 patient with delirium, while screening 141 patients without delirium.
  
  
  CONCLUSIONS
  Delirium was a common occurrence in the ED, and the vast majority of delirium in the ED was of the hypoactive subtype. EPs missed delirium in 76% of the cases. Delirium that was missed in the ED was nearly always missed by hospital physicians at the time of admission. Using a delirium risk score has the potential to improve delirium screening efficiency in the ED setting.
authors.affiliation: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. jin.h.han@vanderbilt.edu
authors.forename: Jin H
authors.initials: JH
authors.lastname: Han
authors.forename: Eli E
authors.initials: EE
authors.lastname: Zimmerman
authors.forename: Nathan
authors.initials: N
authors.lastname: Cutler
authors.forename: John
authors.initials: J
authors.lastname: Schnelle
authors.forename: Alessandro
authors.initials: A
authors.lastname: Morandi
authors.forename: Robert S
authors.initials: RS
authors.lastname: Dittus
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D003693:Delirium / Q000175:diagnosis* / Q000503:physiopathology; D004636:Emergency Service, Hospital; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D016015:Logistic Models; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D008609:Mental Status Schedule; D011446:Prospective Studies; D011595:Psychomotor Agitation; D012372:ROC Curve; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric