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Question: Aged patients in emergence department are identified as high risk of dementia during the care? P I C O Aged people 65+ · Action to reduce the occurrence (i.e. prevent) · Duration · severity of prevalent or incident delirium; Standard care ED length of stay ED returns quality of life Structure of the report Please structure your report under these headings and include the information below (See rubric). • Introduction (200 words) o Describe the aim of the report and briefly state the importance of the chosen topic o Describe your searchable question using the PICO method, including what the PICO is and the rationale for using the PICO (supported by evidence) o Present a table with the PICO information o Show the readers about what is to be reported in this document • Methodology (500 words) o Describe the database used, search terms, Boolean operators, number of papers at each stage of the search, criteria used to eliminate papers, and how the best study was chosen. o Include your ‘Search History’ and then explain the above search process o Provide a brief statement on the reasoning in the choice of paper and its relevance to the PICO question • Results (600 words) o State the research question in the study, the study design, and whether the design is appropriate to the question in the study o State the study setting and selection of participants, including sample size, any inclusion/exclusion criteria used, and comment on the adequacy of the sample o State the methods of data collection and whether they are appropriate o State the methods of data analysis and whether they are appropriate o Briefly state the findings, including the level of statistical significance o Do not copy any figures, diagrams, or tables from the included study o The included study is referenced once only, but other statements or rationales will be supported by research evidence • Discussion (600 words) o Discuss the validity, any biases, and design strengths o Appraise the significance of the results and note any limitations of the data presented o Comment on whether the data reported allows for determining clinical significance • Relevance for clinical practice (600words) o State the relevance of the paper to the question asked o Apply the evidence to clinical practice based on their analysis o Provide a concluding statement about the value of writing this report and applying evidence for clinical practice References Your report must include a minimum of 10 reputable references to support your statements. These references are within the last 10 years unless the reference is seminal literature or the best available evidence. Try to reduce the number of references (a maximum of five) from websites. If you do, ensure they are from reputable websites, such as those ending with gov. or org. Your chosen paper is included in the number of references (you need to use in-text referencing for your chosen paper ONCE). Avoid using SCU’s Blackboard content as the reference. Use APA 7th reference style. For your reference list: • Start on a new page • Consistency, such as the format of DOI, capital, or lowercases • Alphabetical order • Ensure all references that appear in the report are listed in your referencelist Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis GERIATRICS/SYSTEMATIC REVIEW/META-ANALYSIS Cont Volume 78, no. Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis Lucas Oliveira J. e Silva, MD; Michelle J. Berning, BS; Jessica A. Stanich, MD; Danielle J. Gerberi, MLS; Mohammad Hassan Murad, MD, MPH; Jin H. Han, MD, MSc; Fernanda Bellolio, MD, MSc* *Corresponding Author. E-mail:
[email protected]. We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence basedmedicine reviews, EMBASE, MEDLINE, Scopus, andWeb of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age � 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random- effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study’s protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions. [Ann Emerg Med. 2021;78:549-565.] Please see page 550 for the Editor’s Capsule Summary of this article. inuing Medical Education exam for this article is available at http://www.acep.org/ACEPeCME/. 0196-0644/$-see front matter Copyright © 2021 by the American College of Emergency Physicians. https://doi.org/10.1016/j.annemergmed.2021.03.005 INTRODUCTION Background Delirium is a neuropsychiatric emergency characterized by a disturbance in attention and awareness. It is accompanied by an acute loss of cognition over a short period of time, which cannot be explained by a preexisting or evolving neurocognitive disorder such as dementia.1 Approximately 10% of undifferentiated older adults exhibit delirium during their emergency department stay.2 This syndrome is a major concern for geriatric patients presenting to EDs because its diagnosis is associated with prolonged hospitalization,3 functional decline,4 cognitive decline,5,6 and higher health care costs.7 More importantly, delirium is independently associated with increased mortality.8 Despite these negative consequences, delirium can be missed by ED providers in 57% to 83% of cases when active screening is not performed.9,10 The use of an active approach with structured instruments improves 4 : October 2021 diagnostic performance. The delirium triage screen tool, for example, has a sensitivity of 98%, whereas the brief confusion assessment method has a sensitivity of 84% and specificity of 96% even when used by nonclinicians.11 Importance Although hyperactive (agitated) delirium is easily diagnosed because of its obvious and flourished symptomatology, most cases of ED delirium in the geriatric population are hypoactive.12 Hypoactive delirious older adults are quiet and withdrawn, and unless actively searched for, its diagnosis is missed. In a study by Kakuma et al,13 overlooked delirium might have had downstream consequences because patients whose delirium was not detected in the ED had higher 6-month mortality when compared to those whose delirium was detected and nondelirious patients. Active screening using standardized diagnostic delirium tools has been advocated, and missing Annals of Emergency Medicine 549 mailto:
[email protected] http://www.acep.org/ACEPeCME/ https://doi.org/10.1016/j.annemergmed.2021.03.005 http://crossmark.crossref.org/dialog/?doi=10.1016/j.annemergmed.2021.03.005&domain=pdf Risk Factors for Delirium in Older Adults in the Emergency Department Oliveira J. e Silva et al Editor’s Capsule Summary What is already known on this topic Among older adults receiving emergency care, delirium is common, associated with poor outcomes, and often missed. What question this study addressed What are the risk factors for delirium on presentation to the emergency department (ED)? What characteristics of ED care are risk factors for the development of delirium during hospitalization? What this study adds to our knowledge Nursing home residence (4 studies), cognitive impairment (7 studies), hearing impairment (3 studies), and history of stroke (3 studies) were associated with ED delirium. ED length of stay greater than 10 hours (1 study) and severe pain (1 study) were associated with development of delirium during hospitalization. How this is relevant to clinical practice These results can inform delirium screening and prevention efforts as well as clinician intuition. ED delirium has been described as a quality-of-care problem.14 In this context, geriatric ED guidelines have recommended that screening for delirium should be a standard of care.15 Nevertheless, the effect of ED screening on improved detection rates and patient-important outcomes is questionable.16 Additionally, screening every older adult who presents to the ED may not be feasible because of the challenges of implementing such a strategy in an often-chaotic acute care setting. Most recently, the Geriatric Emergency Applied Research network emphasized this challenge and set as a key priority the development of a screening instrument or risk score that does not entail additional clinician workload.17 The identification of a subset of high-risk patients is, therefore, paramount for optimizing the delirium screening process in EDs. Besides that, the risk factors that make a patient susceptible to delirium may be similar across the spectrum of geriatric needs. Only narrative reviews have evaluated the risk factors for delirium in EDs, but they failed to include the whole body of evidence or provide quantitative estimates.18,19 Moreover, they did not take into consideration differences in risk factors for delirium at the time of ED presentation (ie, prevalent delirium or delirium diagnosed early during 550 Annals of Emergency Medicine ED evaluation) or delirium that develops during hospitalization (ie, incident delirium) in patients who are initially nondelirious. A sizable share of delirium is preventable, and evidence exists to support nonpharmacologic multicomponent interventions for decreasing the risk of incident delirium among hospitalized patients.20 Although the risk factors for prevalent and incident delirium may overlap, delirium that develops during hospitalization can be affected by ED-related iatrogenic risk factors. Identifying these factors can result in a change if they are modifiable and allow EDs to funnel recourses to patients who absolutely require them. Goals of This Investigation We aimed to systematically evaluate the body of evidence available to answer 2 main questions: (1) What are the most important risk factors for having delirium in the ED? and (2) What are the ED-based modifiable risk factors for developing delirium during hospitalization? For the first question, we evaluated observational studies that reported the prevalence of ED delirium in geriatric patients with and without potential risk factors. For the second question,