It is the beginning of another Saturday night shift, and as you walk in, you see security and the outgoing attending wrestling a large 20-something-year-old man to the bed. He is yelling about a government conspiracy and his right to freedom of speech. A nurse injects medicine into his left deltoid. You are looking forward to the sign-out on this gentleman and wonder what he was injected with and whether there was another way to manage him.
As your colleagues manage the young man, you scan the board and see that the next patient to be seen is a 79-year-old lady who presents for altered mental status. As you approach the bed, you do not see anyone with her. You begin to take her history, and observe that she seems a bit lethargic and is tangential in her thinking. She is able to tell you that she lives with her husband and has a history of high blood pressure and confusion. She then mentions that you look like a friend of hers from work and asks whether you are married. You see your colleagues finishing up with their patient, so you extricate yourself and return to the physician station wondering why this patient is so lethargic and why her attention is so decreased.
Finally, just as rounds are about to begin, you see an intubated patient in the first resuscitation bay starting to buck at his vent. You notice his hands and feet are in 4-point restraints. After inquiring about the reason for his visit, you are informed that he is a chronic alcoholic who had been attempting to detoxify at home and has come in today in delirium tremens, requiring intubation and large doses of benzodiazepines. You are concerned about the 4-point restraints, which you know are not favored, and you wonder if there was a better (and safer) way to manage the patient’s agitation.
Delirium is a complex neuropsychiatric disorder that often manifests secondary to a discrete medical condition. The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) describes delirium as an acute (usually developing over hours or a few days) and/or fluctuating disturbance in attention and cognition due to a medical condition, intoxicating substance, or multiple etiologies.
In the younger population, delirium encompasses common chief complaints such as agitation and altered mental status.2,3 Among the elderly population, it is estimated that 7% to 24% of patients presenting to the emergency department (ED) will have delirium, and up to 80% of critically ill intensive care patients will have delirium.4 A diagnosis of delirium carries with it significant morbidity and mortality, in addition to increased utilization of resources.5–9
Studies have shown that most emergency clinicians do not screen for or document their findings of delirium.10-12 Because of this lack of screening and the fluctuating course of the condition, the overall incidence of delirium in the ED is unknown. Some posit that emergency clinicians are aware of the impact of delirium on patient outcomes but are not knowledgeable about its diagnosis and management.13
Emergency clinicians are trained to manage the overt signs of delirium while concurrently searching for its underlying etiology. However, gaps in screening, knowledge, and understanding contribute to a missed diagnosis rate in the range of 54% to 89%.4,14 Additional complicating factors include the varied presentations of these patients and the inherent time and environmental pressures of the ED clinical environment. Diagnostic accuracy has been poor, and much of the emergency medicine literature on delirium is focused on the issue of recognition. Regarding the prevention and management of delirium in the ED, current guidelines are generalized from inpatient and postoperative studies. This issue of Emergency Medicine Practice focuses on the challenge of evaluating and managing the patient with delirium in the ED using the best available evidence from the literature.
A literature search was performed on PubMed using the search terms delirium OR agitation OR acute confusion AND emergency. Additional references were obtained from the bibliographies of the articles reviewed. A search of the Cochrane Database of Systematic Reviews yielded several reviews regarding the pharmacological management of delirium, as well as 1 review of multicomponent interventions for preventing delirium in hospitalized patients, and 1 study protocol for interventions to prevent delirium in patients in institutional long-term care.
Clinical policies in the National Guidelines Clearinghouse (www.guideline.gov) and the American College of Emergency Physicians (ACEP) were also searched. Emergency medicine societies weighing in on the diagnosis and management of delirium include ACEP, the Society of Academic Emergency Medicine (SAEM), the Emergency Nurses Association (ENA), and the American Association of Emergency Psychiatry (AAEP). In 1999, ACEP published the “Clinical Policy for the Initial Approach to Patients Presenting with Altered Mental Status,” which critically reviewed the literature and provided an evaluation framework; however, it did not address specific pharmacological interventions for delirium. While altered mental status, as a chief complaint, is not sensitive, it has been noted to be specific for delirium, when documented.3 In 2013, ACEP, the American Geriatrics Society, ENA, and SAEM jointly published “Geriatric Emergency Department Guidelines,” which included recommendations regarding the workup and management of delirium in elderly patients presenting to the ED.15
Various regional and national guidelines for the diagnosis and management of delirium in inpatient settings also exist. Within these guidelines, specific delirium recommendations for the ED are rare, but they can be found in the United Kingdom’s National Institute for Health and Care Excellence (NICE) 2010 guideline, “Delirium: Diagnosis, Prevention and Management,” and in “Delirium: Model of Care,” from the Department of Health of the State of Western Australia.
Overall, the evidence to guide the screening and diagnosis of delirium in the ED is robust, while the literature regarding the subsequent management of delirium in the ED is less exhaustive and more reliant on expert consensus or data extrapolated from inpatient settings. The populations studied in the literature skew heavily towards the elderly patient.
The emergency medicine literature reflects the realities of the ED practice environment, with an emphasis on the management of the acutely agitated patient, in contrast to the work done in other specialties that focuses on prevention and management of delirium in the elderly patient. This dichotomy provides unique challenges in the interpretation of the existing evidence.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Nelson Wong, MD; Gallane Abraham, MD
October 1, 2015
October 31, 2018
Upon completion of this article, participants should be able to:
Date of Original Release: October 1, 2015. Date of most recent review: September 10, 2015. Termination date: October 1, 2018.
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Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 31, 2014. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common mediocolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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