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 patients 1,2,3 – Recognized 20 - 50% of the time 1,4 • Dementia – chronic loss of cognition – Affects 15 - 40% of older ED patients 1,2,3 – Documented in medical record in 3 – 13% of cases.

2,3 • Delirium and dementia often occur concurrently 1. Hustey et al. Ann Emerg Med. 2002;39:248-53 2. Han et al. 3. Carpenter et al. 4. Elie et al. Ann Emerg Med. 2011:57:662-71 Acad Emerg Med 2011: 18: 374–84 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

Onset Course Inattention Altered LOC Disorganized thinking Reversible

Delirium

Hours to days Fluctuating Yes Typically Sometimes Typically

Dementia

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 history 1 – Cannot comprehend discharge instructions 1 • 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: – Mortality 1,2,3 – Accelerated cognitive and functional decline – Prolonged hospitalizations 4 – Increased hospital complications – Increased institutionalization – Higher health care costs 1. Kakuma et al. J Am Geriatr Soc. 2003 2. Lewis et al. 3. Han et al. 4. Han et al. Am J Emerg Med.

Ann Emerg Med. 2010 Acad Emerg Med. 1995 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

Brevity

Trade Off

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;15:613-6 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 Negative Positive B-CAM Negative Yes delirium MMSE or MOCA or Referral 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 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)

Transfers

*Bathing *Toileting

Grooming Feeding Continence

Instrumental Activity of Daily Living (IADL)

*Handling House Finances *Housekeeping

Laundry Preparing meals Self Administer Medications 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 (3 rd 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 capacity 1,2 – MMSE scores > 23 to 26 likely to be associated with presence of capacity 1,2,3,4  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 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, 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. of function from family … It is important to get history or prospective from family of veteran’s situation & level 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.