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Managing Delirium In The Emergency Department: Tools For Targeting Underlying Etiology

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology
  6. Pathophysiology And Subtypes
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Screening Tools
  10. Diagnostic Studies
  11. Management
    1. Medical Management
    2. Nonpharmacological Management
      1. Verbal De-escalation
      2. Physical Restraints
      3. Multicomponent Protocols
    3. Pharmacological Management
      1. Typical Antipsychotics
      2. Atypical Antipsychotics
      3. Benzodiazepines
      4. Ketamine
      5. Combination Therapy
  12. Controversies And Cutting Edge
    1. Risk Stratification Tools
    2. Triage Tools
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Delirium In The Emergency Departmen
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Diagnosing And Managing Delirium In The Emergency Department
  19. Tables and Figures
    1. Table 1. Precipitating Factors For Delirium
    2. Table 2. Delirium Versus Dementia
    3. Table 3. Vulnerability Factors In Delirium
    4. Table 4. Emergency Department Evaluation Of Delirium
    5. Table 5. Medications For Management Of Delirium And Acute Agitation
    6. Figure 1. Richmond Agitation-Sedation Scale
  20. References

Abstract

Delirium represents the complex junction between vulnerable patients, medical conditions, and environmental factors. Given the varied presentations of this disorder and the emergency department clinical environment, recognition and treatment may be challenging. Delirium can be diagnosed using validated standardized screening tools such as the Confusion Assessment Method. Management of delirium is directed towards rapidly treating the underlying medical condition while preventing and managing the behavioral symptoms with nonpharmacological (first-line) and pharmacological (second-line) interventions. In the severely agitated patient, pharmacological treatment tailored to the patient’s age and comorbidities may be required as the initial treatment to facilitate evaluation and management of the underlying medical condition. Effective risk stratification and triage tools can positively impact patient and staff safety, as well as patient outcomes.

Case Presentations

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.

Introduction

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.

Critical Appraisal Of 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.

Risk Management Pitfalls For Delirium In The Emergency Department

  1. “I thought that this was the patient’s baseline dementia.”
    Dementia is a common confounder for delirium, but it is also a major risk factor for the development of delirium, as the neurologic pathology follows similar pathways. Demented patients are a higher-yield group for delirium screening and they benefit from additional attention and specialized care.
  2. “I didn’t have time to do a delirium screen on this patient.”
    While the time pressures of the ED environment are uniquely challenging, brief tools have been developed for ED use; specifically, the short version of the CAM takes about 2 minutes to administer.
  3. “The patient was agitated, so we sedated and restrained him and put him in the corner.”
    Agitated patients often have underlying metabolic disturbances. Once sedated, they are at risk for respiratory depression and, if placed on supplemental oxygen, would benefit from additional ventilatory monitoring in the form of end-tidal CO2 monitoring. Furthermore, if the patient meets criteria for excited delirium syndrome, there is an increased chance of arrhythmia.
  4. “We did not find anything wrong with the patient, so we sent him home with our usual discharge instructions.”
    While a certain subset of delirious patients are appropriate for discharge, overall, there is an increased risk of recidivism, morbidity, and mortality, especially in the elderly patient. At the very least, many of these patients have an increased need for coordination of care and may benefit from team-based services such as medication reconciliation, geriatric consultation, home-based assessment, and establishment of support networks.
  5. “Our elderly patient had a urinary tract infection, so we admitted her to the floor with a urinary catheter.”
    While often indicated, urinary catheters are a known precipitant for delirium and should be avoided, when possible. Admitted patients may benefit from a team-based approach to prevent delirium and other geriatric syndromes. Many hospitals currently have specialized geriatric wards or delirium units that may be more appropriate for elderly patients at risk for delirium.
  6. “Our elderly patient had mild pneumonia and confusion, so I discharged her.”
    While pneumonia severity scoring systems do not supersede clinical judgment, they include factors such as age and mental status changes that indicate poorer outcomes and warrant increased consideration for admission.
  7. “He was agitated, so we restrained him right away.”
    Providing visual and hearing assistive devices should be attempted first. Alternative nonpharmacological techniques include verbal de-escalation, show of force, one-to-one observation, decreased environmental stimulation, food or drink, limiting tethering and medical procedures, reorienting and cognitively stimulating patients, verbal orientation from family members, and avoiding medications known to precipitate delirium. If patient or staff safety is a concern, restraints and pharmacological agents may be indicated as first-line treatment.
  8. “The patient had a psychiatric history, so we assumed this was his usual psychosis.”
    Patients with an episode of acute psychosis may be difficult to distinguish from patients with delirium due to a medical etiology, and they are easy to dismiss as having a strictly functional diagnosis. However, these patients are also at increased risk for delirium, and, specifically, excited delirium syndrome is associated with baseline psychiatric comorbidity. Pay particular attention to the patient's baseline, usual episodes, changes in attention, cognition, and the time course of these changes, as well as any signs or symptoms pointing to a medical diagnosis.
  9. “The patient said he was fine and did not know why he was even in the hospital.”
    Patients with delirium often have baseline confusion, and it is vital to the workup to obtain corroborating information via proxy. A specific timeline of cognitive change is high-yield, as acute alterations or fluctuation are a hallmark of delirium.
  10. “The patient said she was not prescribed any new medications.”
    Medications are a particularly prevalent cause of delirium, especially in older patients. Even without new prescriptions, it is important to obtain a detailed medication history as changes in dosages and interactions with over-the-counter medications can lead to unintended delirium.

Tables And Figures

Table 1. Precipitating Factors For Delirium

References

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.

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Association; 2013. doi:10.1176/appi. books.9780890425596.744053. (Book)
  2. Nassisi D, Okuda Y. ED Management Of Delirium. Emergency Medicine Practice. 2007;9(1):1-20. (Review)
  3. Han JH, Schnelle JF, Ely EW. The relationship between a chief complaint of “altered mental status” and delirium in older emergency department patients. Acad Emerg Med. 2014;21(8):937-940. doi:10.1111/acem.12436. (Retrospective; 400 patients)
  4. Barron EA, Holmes J. Delirium within the emergency care setting, occurrence and detection: a systematic review. Emerg Med J. 2013;30(4):263-268. doi:10.1136/emermed-2011-200586. (Systematic review)
  5. Kennedy M, Enander R, Tadiri SP, et al. Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department. J Am Geriatr Soc. 2014;62(3):462-469. doi:10.1111/jgs.12692. (Prospective; 700 patients)
  6. Thompson K, Allen SC. Outcomes of emergency admission of older patients: impact of cognitive impairment. Br J Hosp Med (Lond). 2008;69(6):320-323. (Review)
  7. * Han JH, Wilber ST. Altered mental status in older patients in the emergency department. Clin Geriatr Med. 2013;29(1):101- 136. doi:10.1016/j.cger.2012.09.005. (Review)
  8. * Wilber ST. Altered mental status in older emergency department patients. Emerg Med Clin North Am. 2006;24(2):299-316. doi:10.1016/j.emc.2006.01.011. (Review)
  9. Witlox J, Eurelings LS, Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality. JAMA. 2010;304(4):443-451. (Systematic review)
  10. Carpenter CR, Griffey RT, Stark S, et al. Physician and nurse acceptance of technicians to screen for geriatric syndromes in the emergency department. West J Emerg Med. 2011;12(4):489-495.(Prospective; 55 participants)
  11. Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39(3):248–253. doi:10.1067/ mem.2002.122057. (Prospective; 297 patients)
  12. Press Y, Margulin T, Grinshpun Y, et al. The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital. Arch Gerontol Geriatr. 2008;48(2):201-204. doi:10.1016/j.archger.2008.01.008. (Retrospective; 319 patients)
  13. Davis D, MacLullich A. Understanding barriers to delirium care: a multicentre survey of knowledge and attitudes amongst UK junior doctors. Age Ageing. 2009;38(5):559-563. doi:10.1093/ageing/afp099. (Prospective; 784 patients)
  14. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013;62(5):457-465. doi:10.1016/j.annemergmed.2013.05.003. (Prospective; 406 patients)
  15. * American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, et al. Geriatric emergency department guidelines. Ann Emerg Med. 2014;63(5):e7-e25. doi: 10.1016/j.annemergmed.2014.02.008. (Practice guidelines)
  16. Wei L, Fearing M, Sternberg EJ, et al. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc. 2008;56(5):823-830. doi:10.1111/j.1532- 5415.2008.01674.x. (Systematic review)
  17. * Inouye S. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165. (Review)
  18. Mariz J, Santos NC, Afonso H, et al. Risk and clinical-outcome indicators of delirium in an emergency department intermediate care unit (EDIMCU): an observational prospective study. BMC Emerg Med. 2013;13:2. doi:10.1186/1471- 227X-13-2. (Prospective; 238 patients)
  19. Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193- 200. doi:10.1111/j.1553-2712.2008.00339.x. (Prospective; 303 patients)
  20. Uthamalingam S, Gurm GS, Daley M, et al. Usefulness of acute delirium as a predictor of adverse outcomes in patients > 65 years of age with acute decompensated heart failure. Am J Cardiol. 2011;108(3):402-408. doi:10.1016/j.amj-card.2011.03.059. (Prospective; 883 patients)
  21. * LaMantia M, Messina FC, Hobgood CD, et al. Screening for delirium in the emergency department: a systematic review. Ann Emerg Med. 2014;63(5):551-560. doi:10.1016/j.annemergmed.2013.11.010. (Systematic review)
  22. Dhaussy G, Dramé M, Jolly D, et al. Is health-related quality of life an independent prognostic factor for 12-month mortality and nursing home placement among elderly patients hospitalized via the emergency department? J Am Med Dir Assoc. 2012;13(5):453-458. doi:10.1016/j.jamda.2011.10.002. (Prospective; 1306 patients)
  23. Dramé M, Lang PO, Novella J-L, et al. Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort. Rev Epidemiol Sante Publique. 2012;60(3):189-196. doi:10.1016/j.respe.2011.11.004. (Prospective; 1306 patients)
  24. Pieralli F, Vannucchi V, Mancini A, et al. Delirium is a predictor of in-hospital mortality in elderly patients with community acquired pneumonia. Intern Emerg Med. 2014;9(2):195- 200. doi:10.1007/s11739-013-0991-1. (Retrospective; 443 patients)
  25. Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med. 2010;56(3):244-252. doi:10.1016/j. annemergmed.2010.03.003. (Prospective; 628 patients)
  26. Maclullich AMJ, Ferguson KJ, Miller T, et al. Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses. J Psychosom Res. 2008;65(3):229-238. doi: 10.1016/j.jpsychores.2008.05.019. (Review)
  27. Han JH, Wilson A, Ely EW. Delirium in the older emergency department patient: a quiet epidemic. Emerg Med Clin North Am. 2010;28(3):611–31. doi:10.1016/j.emc.2010.03.005. (Review)
  28. Flacker JM, Lipsitz L. Neural mechanisms of delirium: cur-rent hypotheses and evolving concepts. Journals Gerontol Ser A Biol Sci Med Sci. 1999;54(6):B239–B246. doi:10.1093/ gerona/54.6.B239. (Review)
  29. Meagher DJ, O’Hanlon D, O’Mahony E, et al. Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci. 2000;12(1):51-56. (Review)
  30. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922. doi:10.1016/ S0140-6736(13)60688-1. (Review)
  31. Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome (ExDS): redefining an old diagnosis. J Forensic Leg Med. 2012;19(1):7-11. doi:10.1016/j.jflm.2011.10.006. (Review)
  32. Vilke GM, DeBard ML, Chan TC, et al. Excited delirium syndrome (ExDS): defining based on a review of the literature. J Emerg Med. 2012;43(5):897–905. doi:10.1016/j. jemermed.2011.02.017. (Review)
  33. Strote J, Walsh M, Auerbach D, et al. Medical conditions and restraint in patients experiencing excited delirium. Am J Emerg Med. 2014;32(9):1093-1096. doi:10.1016/j. ajem.2014.05.023. (Retrospective)
  34. Gordon C, Schmelzer M. Care of the patient in excited delirium. J Emerg Nurs. 2013;39(2):190-196. doi:10.1016/j. jen.2012.03.007. (Review)
  35. Trzepacz P, Breitbart W, Franklin J, et al. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am Psychiatr Assoc. 1999;156(5 Suppl):1-20. (Guideline)
  36. Huff JS. Rosen's Emergency Medicine – Concepts and Clinical Practice. 7th ed. New York, NY: Saunders; 2010. doi:10.1016/ B978-0-323-05472-0.00013-X. (Textbook)
  37. Gillis A, MacDonald B. Unmasking delirium. Can Nurse. 2006;102(9):18-24. (Review)
  38. Gower LEJ, Gatewood MO, Kang CS. Emergency department management of delirium in the elderly. West J Emerg Med. 2012;13(2):194-201. doi:10.5811/westjem.2011.10.6654. (Review)
  39. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. doi:10.1111/ j.1532-5415.2012.03923.x. (Guideline)
  40. Carpenter CR. Which medications are associated with incident delirium? Ann Emerg Med. 2012;59(4):321-322. doi:10.1016/j.annemergmed.2011.05.029. (Systematic review)
  41. Davis DHJ, Skelly DT, Murray C, et al. Worsening cognitive impairment and neurodegenerative pathology progressively increase risk for delirium. Am J Geriatr Psychiatry. 2014:1-13. doi:10.1016/j.jagp.2014.08.005. (Prospective; 465 patients)
  42. Inouye S, Charpentier P. Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852- 857. (Prospective; 508 patients)
  43. Koponen H, Stenbäck U, Mattila E, et al. Delirium among elderly persons admitted to a psychiatric hospital: clinical course during the acute stage and one-year follow-up. Acta Psychiatr Scand. 1989;79(6):579-585. (Prospective; 70 patients)
  44. Shah MN, Jones CMC, Richardson TM, et al. Prevalence of depression and cognitive impairment in older adult emergency medical services patients. Prehosp Emerg Care. 2011;15(1):4-11. doi:10.3109/10903127.2010.514093. (Prospective; 1342 patients)
  45. Frisch A, Miller T, Haag A, et al. Diagnostic accuracy of a rapid checklist to identify delirium in older patients transported by EMS. Prehosp Emerg Care. 2013;17(2):230-234. doi:1 0.3109/10903127.2012.744785. (Prospective; 259 patients)
  46. Burnett AM, Peterson BK, Stellpflug SJ, et al. The association between ketamine given for prehospital chemical restraint with intubation and hospital admission. Am J Emerg Med. 2015;33(1):76-79. doi:10.1016/j.ajem.2014.10.016. (Retrospective)
  47. Burnett AM, Watters BJ, Barringer KW, et al. Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehosp Emerg Care. 2011;16(3):412-414. doi:10.3109/10903127.2011.640766. (Case report)
  48. Le Cong M, Gynther B, Hunter E, et al. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J. 2012;29(4):335- 337. doi:10.1136/emj.2010.107946. (Review)
  49. Ho JD, Smith SW, Nystrom PC, et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehosp Emerg Care. 2013;17(2):274-279. doi:10.3109/10903127.2012.729129. (Case report)
  50. Hogan TM, Losman ED, Carpenter CR, et al. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Acad Emerg Med. 2010;17(3):316-324. doi:10.1111/j.1553-2712.2010.00684.x. (Guideline)
  51. Sendelbach S, Guthrie P. Evidence-based practice guideline: acute confusion/delirium. J Gerontol Nurs. 2009;35(11):11-18. doi: 10.3928/00989134-20090930-01. (Practice guidelines)
  52. Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model for delirium in hospitalized elderly medical pa-tients based on admission characteristics. Ann Intern Med. 1993;119(6):474-481. doi:10.7326/0003-4819-119-6-199309150- 00005. (Prospective; 281 patients)
  53. Potter J, George J. The prevention, diagnosis and management of delirium in older people: concise guidelines. Clin Med (Northfield Il). 2006;6(3):303-308. doi:10.7861/clinmedicine.6-3-303. (Guideline)
  54. Suffoletto B, Miller T, Frisch A, et al. Emergency physician recognition of delirium. Postgrad Med J. 2013;89(1057):621- 625. doi:10.1136/postgradmedj-2012-131608. (Prospective; 259 patients)
  55. Grossmann FF, Hasemann W, Graber A, et al. Screening, detection and management of delirium in the emergency department - a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the emergency department (mCAM-E). Scand J Trauma Resusc Emerg Med. 2014;22:19. doi:10.1186/1757-7241-22-19. (Prospective; 207 patients)
  56. Monette J, Galbaud du Fort G, Fung SH, et al. Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room. Gen Hosp Psychiatry. 2001;23(1):20-25. (Prospective; 100 patients)
  57. Han JH, Wilson A, Graves AJ, et al. Validation of the Confusion Assessment Method for the intensive care unit in older emergency department patients. Acad Emerg Med. 2014;21(2):180-187. doi:10.1111/acem.12309. (Prospective; 406 patients)
  58. Heppner HJ, Cornel S, Peter W, et al. Infections in the elderly. Crit Care Clin. 2013;29(3):757-774. doi:10.1016/j. ccc.2013.03.016. (Review)
  59. Grosmaitre P, Le Vavasseur O, Yachouh E, et al. Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Arch Cardiovasc Dis. 2013;106(11):586- 592. doi:10.1016/j.acvd.2013.04.010. (Retrospective; 255 patients)
  60. Gleason OC. Delirium. Am Fam Physician. 2003;67(5):1027- 1034. (Review)
  61. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. doi:10.1097/CCM.0b013e3182783b72. (Guideline)
  62. Steinberg M, Lyketsos CG. Atypical antipsychotic use in patients with dementia: managing safety concerns. Am J Psychiatry. 2012;169(9):900-906. doi:10.1176/appi.ajp.2012.12030342. (Review)
  63. Rea RS, Battistone S, Fong JJ, et al. Atypical antipsychotics versus haloperidol for treatment of delirium in acutely ill patients. Pharmacotherapy. 2007;27(4):588-594. doi:10.1592/ phco.27.4.588. (Systematic review)
  64. Hardy JE, Brennan N. Computerized tomography of the brain for elderly patients presenting to the emergency department with acute confusion. Emerg Med Australas. 2008;20(5):420-424. doi:10.1111/j.1742-6723.2008.01118.x. (Prospective; 106 patients)
  65. Segard J, Montassier E, Trewick D, et al. Urgent computed tomography brain scan for elderly patients: can we improve its diagnostic yield? Eur J Emerg Med. 2013;20(1):51-53. doi:10.1097/MEJ.0b013e32834f9d51. (Retrospective; 291 patients)
  66. Naeije G, Gaspard N, Depondt C, et al. Acute confusional state of unknown cause in the elderly: a study with continuous EEG monitoring. Epilepsy Behav. 2012;23(3):330-334. doi:10.1016/j.yebeh.2012.01.023. (Retrospective)
  67. Douglas VC, Josephson SA. Delirium. Continuum (Min neap Minn). 2010;16(2 Dementia):120-134. doi:10.1212/01. CON.0000368215.71588.22. (Review)
  68. Zeller SL, Rhoades RW. Systematic reviews of assessment measures and pharmacologic treatments for agitation. Clin Ther. 2010;32(3):403-425. doi:10.1016/j.clinthera.2010.03.006. (Systematic review)
  69. Irwin SA, Pirrello RD, Hirst JM, et al. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med. 2013;16(4):423-435. doi: 10.1089/jpm.2012.0319. (Review)
  70. Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med. 1993;119(6):474-481. (Two prospective cohort studies; 107 and 174 patients)
  71. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332(20):1338-1344. doi:10.1056/ NEJM199505183322006. (Prospective; 651 participants)
  72. Fox MT, Persaud M, Maimets I, et al. Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis. J Am Geriatr Soc. 2012;60(12):2237-2245. doi:10.1111/jgs.12028. (Systematic review and meta-analysis)
  73. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17–25. doi:10.5811/westjem.2011.9.6864. (Guideline)
  74. Cole MG. Delirium in elderly patients. Focus (Madison). 2005;3(2):320–332. doi:10.1176/appi.ajgp.12.1.7. (Review)
  75. Price O, Baker J. Key components of de-escalation techniques: a thematic synthesis. Int J Ment Health Nurs. 2012;21(4):310-319. doi: 10.1111/j.1447-0349.2011.00793.x (Literature review; 11 papers)
  76. Holloman GH, Zeller SL. Overview of Project BETA: Best practices in evaluation and treatment of agitation. West J Emerg Med. 2012;13(1):1-2. doi:10.5811/westjem.2011.9.6865. (Guideline)
  77. Fishkind AB. Calming agitation with words, not drugs: 10 commandments for safety: Curr Psych. 2002;1(4):32-39. (Review)
  78. Isbister GK, Calver LA, Page CB, et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401. doi:10.1016/j. annemergmed.2010.05.037. (Prospective; 91 patients)
  79. Downey LVA, Zun LS, Gonzales SJ. Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department. Gen Hosp Psychiatry. 2007;29(6):470-474. doi:10.1016/j.genhosppsych.2007.07.006. (Survey; 391 emergency departments)
  80. Schmidt P, Snowden T. The effects of positional restraint on heart rate and oxygen saturation. J Emerg Med. 1999;17(5):777-782. (Prospective; 18 participants)
  81. Stratton SJ, Rogers C, Brickett K, et al. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med. 2001;19(3):187-191. doi:10.1053/ajem.2001.22665. (Review)
  82. Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009;27(4):655-667. doi:10.1016/j. emc.2009.07.003. (Review)
  83. Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. J Am Geriatr Soc. 2011;59 Suppl 2:S295- S300. doi:10.1111/j.1532-5415.2011.03678.x. (Retrospective; 2 hospitals)
  84. Aizawa K-I, Kanai T, Saikawa Y, et al. A novel approach to the prevention of postoperative delirium in the elderly after gastrointestinal surgery. Surg Today. 2002;32(4):310-314. (Prospective; 40 patients)
  85. Mouzopoulos G, Vasiliadis G, Lasanianos N, et al. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol. 2009;10(3):127-133. doi:10.1007/s10195-009-0062-6. (Prospective; 219 patients)
  86. Rubin FH, Williams JT, Lescisin D, et al. Replicating the hospital elder life program in a community hospital and demonstrating effectiveness using quality improvement methodology. J Am Geriatr Soc. 2006;54(6):969-974. doi:10.1111/j.1532- 5415.2006.00744.x. (Prospective; 4763 patients)
  87. Naughton BJ, Saltzman S, Ramadan F, et al. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005;53(1):18-23. (Prospective; 374 patients)
  88. Sanon M, Baumlin KM, Kaplan SS, et al. Care and Respect for Elders in Emergencies program: a preliminary report of a volunteer approach to enhance care in the emergency department. J Am Geriatr Soc. 2014;62(2):365-370. doi:10.1111/ jgs.12646. (Review)
  89. Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA psychopharmacology workgroup. West J Emerg Med. 2012;13(1):26- 34. doi:10.5811/westjem.2011.9.6866. (Guideline)
  90. Thomas H, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med. 1992;21(4):407-413. doi:10.1016/ S0196-0644(05)82660-5. (Prospective; 68 patients)
  91. Chase PB, Biros MH. A retrospective review of the use and safety of droperidol in a large, high-risk, inner-city emergency department patient population. Acad Emerg Med. 2002;9(12):1402-1410. (Retrospective)
  92. Ballard C, Grace J, McKeith lan, et al. Neuroleptic sensitivity in dementia with Lewy bodies and Alzheimer’s disease. Lancet. 1998;351(9108):1032-1033. doi:10.1016/S0140- 6736(05)78999-6. (Review)
  93. McKeith I, Fairbairn A, Perry R, et al. Neuroleptic sensitivity in patients with senile dementia of Lewy body type. BMJ. 1992;305(6855):673-678. doi:10.1136/bmj.305.6855.673. (Retrospective; 41 patients)
  94. Weintraub D, Hurtig HI. Presentation and management of psychosis in Parkinson’s disease and dementia with Lewy bodies. Am J Psychiatry. 2007;164(10):1491-1498. doi:10.1176/ appi.ajp.2007.07040715. (Review)
  95. Cummings JL, Street J, Masterman D, et al. Efficacy of olanzapine in the treatment of psychosis in dementia with Lewy bodies. Dement Geriatr Cogn Disord. 2002;13(2):67-73. (Post-hoc subgroup analysis)
  96. Currier GW, Chou JC-Y, Feifel D, et al. Acute treatment of psychotic agitation: a randomized comparison of oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam. J Clin Psychiatry. 2004;65(3):386-394. (Prospective; 162 participants)
  97. Chan EW, Taylor DM, Knott JC, et al. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81. doi:10.1016/j.annemergmed.2012.07.118. (Multicenter randomized double-blind placebo-controlled trial; 336 participants)
  98. Battaglia J. Pharmacological management of acute agitation. Drugs. 2005;65(9):1207-1222. (Review)
  99. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006;104(1):21-26. (Retrospective)
  100. Nobay F, Simon BC, Levitt MA, et al. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744- 749. (Prospective; 111 participants)
  101. Lonergan E, Luxenberg J, Areosa Sastre A. Benzodiazepines for delirium. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD006379. doi: 10.1002/14651858.CD006379.pub3. (Systematic review; 1 trial)
  102. Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005063. doi: 10.1002/14651858.CD005063.pub3. (Meta-analysis; 64 studies, 4309 participants)
  103. Roberts JR, Geeting GK. Intramuscular ketamine for the rapid tranquilization of the uncontrollable, violent, and dangerous adult patient. J Trauma. 2001;51(5):1008-1010. (Review)
  104. Hopper AB, Vilke GM, Castillo EM, et al. Ketamine use for acute agitation in the ED. J Emerg Med. 2015;48(6):712-719. (Retrospective; 27 patients)
  105. Rund DA, Ewing JD, Mitzel K, et al. The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. J Emerg Med. 2006;31(3):317-324. doi:10.1016/j. jemermed.2005.09.021. (Systematic review)
  106. Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med. 1997;15(4):335-340. (Prospective; 98 patients)
  107. Gillies D, Sampson S, Beck A, et al. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2013 Sep 18;9:CD003079. doi:10.1002/14651858. CD003079.pub4. (Meta-analysis; 21 trials, 1968 participants)
  108. D’Onofrio G, Jauch E, Jagoda A, et al. NIH Roundtable on opportunities to advance research on neurologic and psychiatric emergencies. Ann Emerg Med. 2010;56(5):551-564. doi:10.1016/j.annemergmed.2010.06.562. (Guideline)
  109. Schrijver EJ, de Vries OJ, Verburg A, et al. Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial. BMC Geriatr. 2014;14:96. doi:10.1186/1471-2318- 14-96. (Study protocol)
  110. Hare M, Arendts G, Wynaden D, et al. Nurse screening for delirium in older patients attending the emergency department. Psychosomatics. 2014;55(3):235-242. doi:10.1016/j. psym.2013.08.007. (Prospective; 320 patients)
  111. Hustey FM, Meldon SW, Smith MD, et al. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5):678-684. doi:10.1067/mem.2003.152. (Prospective; 784 participants)
  112. Lewis LM, Miller DK, Morley JE, et al. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13(2):142- 145. doi:10.1016/0735-6757(95)90080-2. (Prospective; 385 patients)
  113. Kakuma R, Galbaud du Fort G, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4):443-450. (Prospective; 268 patients)
  114. Han JH, Bryce SN, Ely EW, et al. The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Ann Emerg Med. 2011;57(6):662-671. doi:10.1016/j.annemergmed.2010.12.002. (Prospective; 202 patients)
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Authors

Nelson Wong, MD; Gallane Abraham, MD

Publication Date

October 1, 2015

  

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