Which nursing diagnoses are most appropriate for mr. jones’s cognitive disturbances?

M. Kathryn Mutter, MD, MPH, Assistant Professor, Department of Emergency Medicine, University of Virginia, Charlottesville.

Diane Snustad, MD,Associate Professor of Medicine, Division of General, Geriatric, Palliative, and Hospital Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville.

Peer Reviewer

Michael C. Bond, MD, FACEP, FAAEM, Associate Professor, Residency Program Director, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore.

Statement of Financial Disclosure

To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Farel (CME question reviewer) owns stock in Johnson & Johnson. Dr. Stapczynski (editor) owns stock in Pfizer, Johnson & Johnson, AxoGen, Walgreens Boots Alliance Inc., and Bristol Myers Squibb. Ms. Mark (executive editor) reports that her husband works for a company that creates advertising for Uroplasty. Dr. Schneider (editor), Dr. Mutter (author), Dr. Snustad (author), Dr. Bond (peer reviewer), and Mr. Landenberger (editorial and continuing education director) report no financial relationships with companies related to the field of study covered by this CME activity.

Executive Summary

• Dementia is the slow, progressive loss of cognitive function. Delirium is rapid onset, with loss of attention, fluctuations through the day, and often abnormal vital signs.
• Most causes of dementia are not treatable, and of those that are treatable, they rarely completely resolve.
• Patients with dementia who become agitated should be treated with nonpharmacologic interventions first. Antipsychotics should be avoided if possible.
• Confusion may be the presenting symptom of infection or acute myocardial infarction in the older patient with dementia.

The term dementia is derived from the Latin word for “out of one’s mind.” It describes a deterioration of intellectual faculties, which may include memory, attention, learning, and judgment, and can be accompanied by emotional disturbance and personality changes. It is most often a result of a neurodegenerative process, such as Alzheimer’s disease, but also can be caused by more than 50 different diseases and disorders, including strokes, trauma, infectious diseases, and metabolic disorders.

Although there are exceptions, dementia is primarily a disease of older adults. Elderly patients, generally defined as age 65 or older, represent up to one quarter of all emergency department (ED) visits, and up to 22% of the elderly ED population has a form of cognitive impairment.1 Globally, about 24.3 million persons suffer from dementia, with an annual incidence of 4.6 million. In the United States alone, the National Institutes of Health (NIH) reports that at least 5 million elderly Americans have Alzheimer’s disease, the most common form of dementia.2 Additionally, the number of Americans with dementia will likely increase during the next 40 years as the population of Americans older than the age of 65 is expected to double.2,3 The personal, familial, and societal demands of dementia are tremendous, and the ED is an integral part of the network of clinical care for such patients and their families.

Despite the prevalence of cognitive disorders, emergency physicians recognize a diagnosis of delirium or cognitive impairment only 28-38% of the time, and this has prompted the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force to include “cognitive assessment” as one of three domains for quality indicators in geriatric emergency care.4,5 Recognition of cognitive impairment has implications for the evaluation of the patient, the need for admission, patient understanding of instructions, discharge planning, and types of medications prescribed. In the evaluation of patients with acute or new cognitive complaints, it is helpful for the emergency physician to be able to perform a quick screening test for dementia, evaluate for possible reversible causes of dementia, and be able to differentiate delirium from dementia. In the evaluation of a patient with known dementia, the emergency physician should be able to recognize acute illness and co-morbid delirium, address behavioral problems associated with dementia, and understand common pharmacologic and nonpharmacologic tools for management of behavioral problems. This article will address tools for clinical evaluation, as well as explore the complex context of illness in the patient with dementia, challenges for management, and current best practices for the management of patients with dementia in the ED.

Definition

Dementia is a clinical syndrome that involves a progressive and sustained loss of memory and intellectual function that causes interference in daily functioning. It is distinguished from mild cognitive impairment by this loss of functional ability. A key feature of dementia is a gradually progressive course over months to years without disturbance of consciousness. It is associated with impaired abstract thinking and judgment, as well as disordered higher cortical function, with or without personality change. Dementia can be categorized into subtypes: potentially reversible, such as thyroid dysfunction and vitamin B12 or folate deficiency; and irreversible, such as Alzheimer’s disease and vascular dementia. However, less than 10% of dementias are potentially reversible and even fewer fully reverse when treated.6

The definition and categories applied to this cognitive decline have been defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), although a major shift has recently occurred in the 2013 DSM-5.7,8 The words “dementia” and “mild cognitive impairment” were removed, in favor of the more general grouping “neurocognitive disorders,” major versus minor. The shift has not been without controversy, as the Alzheimer’s Association and the National Institute on Aging continue to use the word “dementia” in their most updated definitions. For the purposes of the emergency physician, it may be helpful to have in mind both the DSM-IV and DSM-5 definitions, as many patients will still carry with them the diagnosis of dementia as defined by the DSM-IV. For the purposes of this article, “dementia” will continue to be used rather than “neurocognitive disorder” because the term is currently more commonly used in practice by providers.

Central to the definition of dementia in the DSM-IV is the presence of impairment in memory, as well as impairment in one or more of the cognitive domains (executive function, language, praxis, gnosis), not occurring in delirium, and impacting chronic daily function.8 The new DSM-5 definition no longer requires memory impairment, and instead groups it with the other cognitive domains. Cognitive decline must be apparent in one or more cognitive domains based upon concern of the patient or another individual and quantified clinical assessment or neuropsychological test. Cognitive deficits are then specified to a particular disorder, among them Alzheimer’s disease, frontotemporal lobar degeneration, Lewy body disease, and vascular disease, and they are further categorized according to the presence of behavioral disturbance and severity of impact on daily living. With mild disorder, patients’ capacity for independent living is still possible, with an effect upon housework, managing money, and other nonbasic activities. With moderate disorder, basic hygiene is impacted and independent living becomes hazardous. With a severe disorder, continuous supervision is necessary. Mild neurocognitive disorder effectively replaces the former definition of mild cognitive impairment and continues to be distinguished by its lack of interference with daily functioning.

Etiology

Dementia can be categorized into potentially reversible and nonreversible subtypes, as well as into degenerative and nondegenerative subtypes. Alzheimer’s disease comprises approximately 60% of cases of dementia; vascular dementia, mostly multi-infarct dementia, accounts for another 20%; and the remaining cases have almost 50 known causes. As previously noted, very few dementias fall under the potentially reversible category, and even fewer fully reverse when treated. However, an important aspect of the ED evaluation in cases of cognitive complaints is to be able to rule out potentially reversible causes of dementia. The most frequent potentially reversible causes reported are depression, thyroid disease, B12 deficiency, alcohol dependence syndrome, hydrocephalus, space-occupying lesions, and epilepsy.9,10 Adverse drug reactions from medications, such as psychotropic medications, antihypertensives, anticholinergics, anticonvulsants, and antiparkinsonism medications, may cause dementia or delirium in the elderly. Hearing loss can be a cause of, or contributor to, confusion, and sometimes removal of cerumen can immediately improve cognitive function. Alcohol dependence should be considered in any person with cognitive complaints and can be difficult to differentiate from associated depression. Alcohol consumption may be successfully hidden from family and friends for years, particularly in the elder population. A more exhaustive list of potentially reversible dementias can be found in Table 1.

Table 1. Potentially Reversible Causes of Dementia

• Depression or pseudodementia
• Hydrocephalus
• Thyroid disease
• Space-occupying brain lesions
• Alcoholism, alcohol dependence syndrome
• Epilepsy
• Toxins
• Adverse drug reactions
• Autoimmune disorders
• Trauma
• Infections, viruses (HIV)
• Nutritional deficiencies
• Organic poisons
• Vasculitis
• Metabolic disorders
• Heavy metals

Depression in the elderly can cause cognitive decline that mimics dementia. Pseudodementia is a term used to describe patients who have impairment in cognitive function caused by depression. If depression is the primary problem, then the cognitive problems may be partially or fully reversed with successful treatment of the depression. However, depression can coexist with dementia and can be an early manifestation of cognitive decline. There also has been evidence pointing to depression as a risk factor for dementia.11

Nonreversible types of dementia can be further classified into degenerative and nondegenerative dementias, with the latter category including many of the etiologies that are also found under potentially reversible dementias. Neurodegenerative diseases of the central nervous system include Alzheimer’s disease, dementia with Lewy bodies, Parkinson’s disease, progressive supranuclear palsy, Pick’s disease, and Huntington’s disease. Nondegenerative causes include vascular dementias, such as multi-infarct dementia, arteritis, and subcortical vascular dementia; chronic traumatic encephalopathy (formerly known as dementia pugilistica); and infection-related dementia, such as HIV, opportunistic infections, Creutzfeldt-Jakob disease, progressive multifocal leukoencephalopathy, and post-encephalitis dementia. See Table 2 for a summary of nonreversible dementias.

Table 2. Degenerative and Nondegenerative Dementias

Degenerative

• Alzheimer’s disease
• Cerebral amyloid angiopathy
• Frontotemporal dementia spectrum
• Parkinsonian dementias

Nondegenerative

• Vascular dementia
• Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
• Collagen disorders and vasculitis
• Dementias associated with infectious diseases
• Normal-pressure hydrocephalus
• Alcoholic dementia
• Multiple sclerosis
• Neoplasms and paraneoplastic limbic encephalitis
• Depression manifesting as dementia or cognitive impairment
• Posttraumatic dementia
• Posttraumatic stress disorder
• Psychogenic cognitive deficits
• Metabolic causes of dementia

Alzheimer’s disease is the most common and best studied of the dementias, and it is the sixth leading cause of death in the United States.12 The histologic hallmarks of Alzheimer’s disease are neuritic or amyloid plaques of tau protein and neurofibrillary tangles. These hallmarks are associated with cell death, but the relationship is incompletely understood. Until recently, Alzheimer’s disease was a diagnosis of exclusion, with conclusive diagnosis dependent upon pathologic exam. Recent advances in biomarkers and imaging, when used in conjunction with clinical criteria, have made it possible to diagnose Alzheimer’s disease with confidence without microscopic examination of brain tissue.13 This new approach to diagnosis has expanded research avenues and possible treatments.

Vascular dementia and Lewy body dementia account for the most common dementias after Alzheimer’s disease. Multi-infarct dementia is a common type of vascular dementia that occurs when a patient has recurrent cortical or subcortical strokes, many of which are too small to cause focal neurologic deficits. The clinical hallmark is stepwise or insidious worsening of cognitive function, rather than an acute change that would be associated with a clinically evident cerebrovascular event. Multi-infarct dementia occurs more commonly in men and patients with risk factors for atherosclerosis. In Lewy body disease, protein aggregates called Lewy bodies form inside nerve cells. Core features of Lewy body dementia are fluctuating cognition, visual hallucinations, and Parkinsonian motor signs. Often, difficulty sleeping and psychiatric symptoms precede movement and severe cognitive problems, which can lead to a misdiagnosis of a psychiatric disorder.

Differential Diagnosis: Delirium vs. Dementia

In a patient who presents to the ED with new cognitive complaints, the first consideration is whether this represents dementia, delirium, or delirium imposed upon underlying dementia. Delirium in ED patients is associated with an increase in mortality and inpatient length of stay.14,15 Cognitive impairment and delirium are associated with a risk of repeat ED visits and increased length of stay.16,17 Generally, a major difference between delirium and dementia is the rapidity of onset: Progression of symptoms is usually acute in delirium, rather than insidious and slowly progressive as in dementia. However, a stroke could also cause a rapid decline in cognition that could be defined as dementia. Additionally, delirium may cause disturbance in the level of consciousness, attention, and vital signs, whereas dementia should not. The DSM-5 defines delirium as a disturbance from baseline in attention, awareness, and cognition, over a short period of time, with fluctuation in severity throughout the day.7 These changes must not be explained by another neurocognitive disorder, and there must be evidence that the condition is explained by another condition such as infection, substance intoxication (including antihistamines or sedatives), or withdrawal. For any patient with a subacute or chronic complaint of cognitive difficulty, depression should be considered in the differential. Acute psychosis may be considered if the behavior change occurs abruptly, but is more likely in a patient with a preexisting psychiatric history. Table 3 compares some clinical differences in the presentations of dementia, delirium, and acute psychosis.

Table 3. Comparison of Clinical Presentation of Dementia, Delirium, and Acute Psychosis

As mentioned in the introduction, the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP) created the Geriatric Task Force to improve the care of the elderly in the ED. In 2009, the task force published their quality indicators for geriatric emergency care and included “cognitive assessment” as one of three quality indicator domains.5 Included under cognitive assessment is the recommendation that elderly patients receive cognitive screening in the ED, and, if an abnormality is discovered, that a determination whether a change in baseline has occurred. Additionally, the Emergency Care Panel of the Research Collaboration for Quality Care of Older Persons, an international research network primarily located in Australia with a Harvard University affiliation, published a set of process, structural, and outcome quality indicators in 2015. The project was implemented in eight hospitals across Australia, and supported and supplemented the Geriatric Task Force recommendation that cognitive screening be a quality indicator for the care of elderly patients presenting to the ED.18,19

There are a myriad of mental status screening tests available to the emergency physician for detecting both delirium and dementia. The challenge is finding a test that is both useful within the time parameters of an ED encounter and sufficient for guiding immediate management. Unfortunately, no test that can be performed quickly is perfect, but several have been studied and validated, and will be discussed. For delirium and cognitive impairment screening, the Mini-Mental State Examination (MMSE) is a highly validated tool. However, it is slightly cumbersome, and many emergency physicians will find it too time intensive (it can take up to 10 minutes to perform and requires the patient to draw).20,21 The MMSE has been used as the standard against which many ED administered tests have been tested.22 There is no delirium screening test that has been tested in a larger multicenter capacity, but there are a few promising tests for emergency medicine providers that should be studied further.23 The Confusion Assessment Method (CAM) and its shorter derivatives (bCAM and CAM-ICU) have been validated in small studies for use in the ED.24-26 Han et al describe a combination of Delirium Triage Screen (DTS, a highly sensitive screening test) and the Brief Confusion Assessment Method (bCAM, a highly specific screening test) in the ED.25 With the combination of both tests, the physicians achieved 82% sensitivity and 95.8% specificity in screening for delirium. The Quick Confusion Scale also shows good correlation with the MMSE in detection of cognitive dysfunction in the ED, though the validation studies also were done in small populations.27-29

For broader cognitive disorder screening, there are again limited studies validating the use of specific screening tools in ED populations. Currently, the best-validated test is the Orientation-Memory-Concentration Test (OMCT), also known as the Short Blessed Test (SBT). This test can be performed in less than 5 minutes and has been used in several emergency department-based studies.18,22 The OMCT/SBT is a weighted six-item test that evaluates for mild, moderate, and severe cognitive deficits. It measures orientation, memory, and attention, using counting, recall, orientation, and repetition questions. The OMCT/SBT has been found to have a sensitivity and specificity of 95% and 65%, respectively, for identifying cognitive deficits compared to the MMSE in ED patients.22

Evaluation

The clinical workup for new or worsened cognitive impairment includes a detailed history, physical examination, and selected laboratory testing. In addition to obtaining a history from the patient, family or friends should be interviewed to establish the nature and progression of both cognitive symptoms, as well as other symptoms they have noticed that may help define the etiology. The clinician should perform a thorough physical examination, including a neurological evaluation looking for focal neurological deficits, extrapyramidal symptoms, gait instability, Parkinsonian signs, and lower and upper motor neuron signs that may offer a clue to the etiology. A mental status examination, as discussed above, should be performed. The laboratory workup includes a complete blood chemistry profile, including electrolytes, glucose, BUN, creatinine, and hepatic panel. In addition, thyroid function tests, serum vitamin B12 and folic acid levels, an electrocardiogram (ECG), a chest X-ray study, and a brain computed tomography (CT) scan are often obtained in initial evaluation, though they may not be required. A lumbar puncture is indicated when signs or symptoms of central nervous system infection are present.

Common Complications with Dementia

There are multiple reasons that a patient with a known diagnosis of dementia, or previously undetected dementia, may be brought to the ED by family members, caregivers, or nursing home staff, including medical, social, and behavioral issues. Early recognition of cognitive impairment allows the emergency physician not only to tailor the interview and exam to the needs of the family and patient, but also to mobilize early planning that may enable discharge home vs. appropriate admission to the hospital.

Medical Presentations

Patients with dementia are more likely than nondemented controls to present to the ED with syncope, femur fracture, bronchopneumonia, urinary tract infections, falls, and behavioral problems.30,31 Illnesses often present atypically in older patients, making the diagnosis challenging. This is especially true in patients with dementia, who may not be able to recognize and communicate their symptoms. In elders with a serious infection, fever may be absent or blunted 20-30% of the time. The presence of fever is more likely to indicate a serious infection in the elderly compared to younger patients.32 Older patients with myocardial infarctions often lack the classic symptoms of ischemia, and instead may present with syncope, dizziness, weakness, or falls. In 20% of patients older than 85 years of age with acute myocardial infarctions, confusion is the primary or only manifestation.33 Elderly patients presenting with infections may not have any of the hallmark signs of serious illness, such as fever, elevated white count, or tachycardia. The abdominal exam of an older person with appendicitis or diverticulitis may be unimpressive and lack rebound tenderness, rigidity, or guarding. The addition of cognitive impairment creates a complicated context for evaluation and diagnosis, and the emergency physician should have a high index of suspicion for serious pathology behind subtle complaints.

Falls are the leading cause of trauma in elderly populations, and they occur more frequently in patients with dementia.34 Elderly patients also are more susceptible to serious injury from trauma because of changes in physiology and medical co-morbidities. Falls usually occur from standing in a patient’s home, and risk factors for falls include not only cognitive impairment, but also weakness, balance and gait problems, visual and hearing deficits, and poor functional status, all of which can coexist with cognitive impairment.35 It is important to consider other potential contributors to a fall, such as medication side effects, orthostatic hypotension, or acute illness (e.g., infection or dehydration). Imbalance and falls can also be precipitated by ear pathology, such as cerumen impaction or eustachian tube dysfunction. Cerumen and middle ear effusions can cause imbalance and dizziness, which can increase agitation as well as falls. Finally, early assessment and intervention in environmental and medical risk factors has been shown to reduce future falls, so a referral should be made to primary care, rehabilitation, or other fall prevention resource in the area, if the patient is being discharged from the ED.35

Behavioral Presentations

Behavioral symptoms are often grouped with neuropsychiatric symptoms in research and termed behavioral and psychological symptoms of dementia (BPSD). During a 10-year period after the time of onset of dementia, more than 80% of patients with dementia exhibit a neuropsychiatric symptom (NPS).36 Even more remarkable, a population-based sample of dementia cases in 2006 found that close to 97% of patients experience one or more NPS over a five-year period.37 This study found depression, apathy, and anxiety to be the symptoms with highest prevalence, and elation and disinhibition to be the least common. Additional symptoms commonly seen in dementia patients are delusions, hallucinations, irritability/lability, agitation/aggression, repetitive vocalizations, wandering, and aberrant motor behavior.

Presentations in the ED for BPSD typically represent exacerbations of baseline behavior. It is important to consider that there may be an organic cause for a psychiatric or behavioral symptom. Evaluation for an infectious etiology is often warranted, although metabolic disarray, stroke, or transient ischemic attack (TIA), substance intoxication or withdrawal, or endocrine abnormality could also be considered within the context of the presenting complaint and patient’s medical history. Regardless of the etiology, a patient’s behavior has the potential to be heightened by the overstimulating, chaotic, and disorienting environment of the ED. Management of behavioral problems, both pharmacologic and nonpharmacologic, will be addressed below.

Social Presentations

The stress of caring for people with dementia can be significant, and increasing levels of caregiver burden are associated with higher incidence of depression and anxiety.38 Higher caregiver stress has been associated with younger caregiver age, being a spouse, caregiver depressive symptoms, and limited finances, as well as taking care of a person with dementia with neuropsychiatric symptoms, delirium, and greater functional deficits.39 Caregivers may bring the patient with dementia to the ED due to family or personal stress, rather than a change in medical condition.

When caregiver stress is evident, referral to appropriate community resources for support or help in caregiving may be the most useful intervention. Social workers and case managers are invaluable resources in providing information about local resources, such as respite programs and support groups for both patients and families. Resources also include primary care referral, home health aid assistance, senior centers, medical transportation services, Meals on Wheels, religious communities, elder daytime programs, and hospice care. A practical book that has been helpful to many families managing a loved one with dementia is The 36-Hour Day, which covers the basics of dementia, coping, how to find community resources, and how to address financial and legal issues.40 Respite programs may be available to provide care for dementia patients in a setting other than their home, and can reduce the burden on the patient’s usual caregivers. Adult day care programs are often located in community centers or churches, and are sometimes sponsored by community agencies such as the local Area Agency on Aging. Overnight respite programs are sometimes offered by nursing facilities. Occasionally, stress is so great, particularly when combined with behavior problems, that a patient will require hospital admission for respite. Third-party payers may not pay for these admissions unless the patient has an additional reason for admission and meets the appropriate criteria for acuity.

The majority of caregivers are remarkably selfless and dedicated, but the emergency physician should be attuned to the possibility of abuse in the elderly, particularly in the cognitively impaired population. Elder abuse is the “mistreatment of an older adult that threatens his or her safety,” and it includes self-neglect, physical abuse, sexual abuse, emotional abuse, caregiver neglect, and financial exploitation.41 Abuse can be very difficult to detect, particularly in the ED, and it may mimic signs of common medical symptoms. (See the June 28, 2015 issue of Emergency Medicine Reports on “Identification of Elder Abuse in the ED.”) Many states require that clinicians who have any suspicion of abuse, even in the absence of proof, report concerns to the designated authority. In most jurisdictions, Adult Protective Services (APS), the Area Agency on Aging, or the county Department of Social Services receive and investigate allegations of elder abuse and neglect. When elderly patients present to the ED by ambulance, Emergency Medical Services (EMS) providers should be questioned about the safety and state of the home (sanitation, heat, water, infestation) and the family dynamics. This contact may be the only time a medical provider is able to see the home environment of an elderly person, and this can be very useful information for the emergency physician in determining whether APS should be involved. The American Medical Association and the American College of Emergency Physicians both recommend ED protocols to be in place for detection and management of possible cases of elder abuse.42,43

Nonpharmacologic Therapy for Dementia

Neuropsychiatric and Behavioral Symptoms. There has been increasing interest in nonpharmacological interventions for BPSD in recent years, at least partially due to research indicating that the use of antipsychotic medications in patients with dementia is associated with an increase in mortality. Antipsychotic medications have been a mainstay of treatment for BPSD. The Food and Drug Administration (FDA) now requires a black box warning in the product literature of all antipsychotics, noting this increase in mortality. In addition, federal and state agencies are monitoring the use of these agents in nursing homes, and campaigns are in effect to discourage the use of medications, especially antipsychotics, in treating behavioral symptoms of dementia. However, this warning does not appear to be changing current prescribing practices.44

Interventions for BPSD fall into three main categories: unmet needs interventions, such as responding to a patient expressing pain or a need for social interaction through abnormal behavior; learning and behavioral interventions, such as responding to a patient who has learned that a behavior elicits a wanted response; and environmental vulnerability and reduced stress-threshold interventions, such as responding to a patient who cannot manage his or her environment or a particular situation.45

There are several interventions that can be useful in the setting of an ED or hospitalization. For agitation, it is important to avoid triggers of agitation or disruptive behaviors. Family members or caregivers may be able to provide information about previous triggers or precipitants. For agitation: stay calm in the face of agitation and avoid arguments; consider that the patient may be experiencing pain or discomfort; redirect the patient or distract him or her from the potential problem; and consider that bright light has been shown to help reduce agitation.46 The intense sensory input of the ED may cause agitation. As much as possible, excess sensory input should be eliminated. Any unfamiliar environment may increase confusion or disorientation in a patient with dementia, and attempts to orient the patient, including providing familiar faces or objects, may be helpful. ED personnel should introduce themselves verbally and in writing. They may need to remind the patient of their identity each time they return to the patient after an absence. For wandering behavior, labels and visual cues can be helpful, such as large signs over the bathroom, calendars, and wall clocks. For hallucinations or delusions, avoid arguing or attempting reorientation if the symptoms do not disturb the patient.

Communication is an important aspect of interaction between patients with dementia and medical personnel in the ED. It is helpful to slow down, use a calm voice, allow the patient sufficient time to respond, provide simple commands, use light touch, and help the person find words if necessary.47 Sleep disturbance in the ED or hospital can be a precipitant for worsened behavior; bright light in the day, as well as reduction of noise, distractions, lighting, and interruptions at night, is helpful to maintain sleep routines. Although more difficult to implement in the ED, aromatherapy and aroma-acupressure have shown promise with reduction of agitation scores, but they have yet to show success in a well-designed randomized controlled trial (RCT).48,49 Successfully implementing nonpharmacologic techniques is very dependent upon a team approach, with reliance upon caregivers and education of medical personnel about the importance of using these techniques. Protocols, specifically trained ED nurses, and geriatric EDs are being implemented and studied to incorporate many of these ideas into the structure and environment for geriatric ED care.

Cognitive Function

Nonpharmacologic therapy for cognitive function has been researched in a variety of different forms, although most studies are small with heterogeneous populations. The most well-studied intervention is exercise, and there is strong evidence showing that aerobic exercise can moderately improve cognitive function in healthy older adults, in the domains of motor function, cognitive speed, memory, executive function, and auditory and visual attention.50,51 While this is not an emergency treatment, it may be useful advice to help caretakers reduce agitation after discharge from the ED. There are many possible mechanisms for exercise currently being researched: decreasing inflammation, improving cerebral blood flow, improving neuroplasticity, and hippocampal neurogenesis. Exercise is a known modifier of atherosclerotic cardiovascular risk and, therefore, has a known effect on the risk of vascular dementia. Additionally, the risk factors for vascular dementia and neurodegenerative dementia overlap, including insulin resistance, hypertension, hyperlipidemia, and obesity, all of which can be attenuated by exercise. It is more controversial whether aerobic exercise directly modifies risk for and progression of neurodegenerative and age-related dementia. However, given the low risk and potential for benefit, exercise should be one part of treatment recommendations for patients with cognitive impairment. The National Institute on Aging has guidelines for physical activity in older adults and a helpful website that can be shared with patients at https://go4life.nia.nih.gov.52

Cognitive therapy may be useful as an outpatient to manage cognition through cognitive stimulation, cognitive training, and cognitive rehabilitation. Cognitive stimulation has been shown in a Cochrane review to improve cognitive function and quality-of-life measures through enjoyable thought and memory activities in a social setting and reality orientation.53 On the other hand, cognitive training, which involves guided instruction with standardized tasks on paper or with a computer using memory, attention, and problem-solving skills, has not been shown to have the same benefits as cognitive stimulation.54 Cognitive rehabilitation, which has an emphasis on improving real-life tasks to improve functioning in real-time contexts, was shown in a randomized controlled trial to have benefit in terms of improved quality of life and social relationships.55 All types of therapy need further study, but all patients and families should be encouraged to participate in cognitively stimulating activities.

Pharmacologic Therapy for Dementia

Neuropsychiatric and Behavioral Symptoms. There will be patients with dementia in the ED for whom initial nonpharmacologic management of agitation or delirium does not succeed. When there is a risk of harm to the patient or staff, the emergency physician should consider a pharmacologic treatment. The oral route is always preferred to the intramuscular route, given its lower side effect profile. Additionally, a monotherapeutic approach with small doses may reduce the risk of side effects and oversedation.56 If dementia alone appears to be the cause of the agitation, atypical antipsychotics have been shown to cause less cognitive impairment and less dyskinesia than typical antipsychotics.57 This, of course, has to be weighed against the black box warning regarding atypical antipsychotics in dementia, but given that the risk appears to be with long-term use, they appear to be the best option if pharmacologic management is required. Appropriate choices would be oral risperidone, aripiprazole, quetiapine, or olanzipine; or intramuscular ziprasidone or olanzipine. Ziprasidone has been avoided in the elderly due to concerns about QT prolongation. Olanzipine has a higher rate of serious adverse effects with intramuscular use, particularly in higher doses and when combined with another central nervous system (CNS) depressant.56 If the oral route is possible, risperidone and aripiprazole appear to have the best evidence for efficacy, although olanzipine and quetiapine also have shown effectiveness in a series of trials.58 Haloperidol continues to be the drug of choice for delirium, unless there is a concern for lowered seizure threshold.56 Generally, benzodiazepines should be avoided for treatment of insomnia, agitation, or delirium in the elderly.59 They may be considered in a case of severe behavioral disturbance if a patient has high risk for adverse effects with an antipsychotic, such as long QT syndrome.

For non-emergency management, antipsychotics have been frequently prescribed as the first-line treatment for behavioral and psychiatric symptoms of dementia.60 Elderly patients with dementia are 17 times more likely than non-demented elderly patients to be prescribed an antipsychotic.61 This occurs despite the black box warning and the fact that antipsychotic treatment for BPSD is an off-label use. Clinical benefits have been shown to be limited for both typical and atypical antipsychotics, and adverse effects and an increase in mortality are a potential consequence of use. Side effects that have been observed include extrapyramidal symptoms, sedation, confusion, and falls.62 Overall, a review of off-label use of atypical antipsychotics showed that the effect size on average is a very small improvement in neuropsychiatric symptoms.63 The small benefits that have been shown must be weighed against the small but significant increased risk of death and stroke as compared to placebo or nonuse in patients with dementia.64,65 The typical antipsychotic haloperidol may show some benefit over other typicals with aggression, but otherwise there are no differences between typical antipsychotics in efficacy for neuropsychiatric symptoms.62 Consultation with a specialist is advised before starting an antipsychotic, and antipsychotic use should be reserved for cases in which nonpharmacologic therapy has not succeeded and the symptoms are severe enough to cause harm to the patient or others. The “Choosing Wisely” campaign recommends that antipsychotics not be a first choice for BPSD and that they only be considered after an attempt to identify and address potential causes of disruptive behavior, and after non-pharmacologic treatment has been tried and found to be ineffective.66

If an antipsychotic is prescribed on discharge, several practice guidelines have been established.67 A course of antipsychotics can be considered in non-psychotic patients who are in an acute extreme situation due to BPSD, such as harmful aggression, severe physical exhaustion, or risk of malnourishment or dehydration. It should again be considered that the behavior could be due to a psychiatric disorder, such as anxiety or depression, or a somatic disorder, such as pain, hunger, infection, or constipation. Assessment of medical comorbidities and type of dementia is important, and an ECG should be obtained to ensure that the patient does not have a prolonged QT. Finally, the caregiver should understand the risks and benefits of treatment with an atypical antipsychotic and know that periodic attempts to decrease the dose or stop the medication are advised. In nursing homes, an attempt to decrease psychoactive medications is required every six months, unless the physician certifies that such an attempt is contraindicated.

There has been a suggestion that opioids may hold promise for reducing agitation in dementia, either due to the relief of untreated pain from communication difficulties, or a broader role of the opioid.68,69 However, a 2015 Cochrane review concluded that there is currently insufficient evidence to establish efficacy and safety for this type of use.70 As mentioned earlier, pain may present as agitation in a demented patient, and treatment of the pain should be pursued with the medication with the fewest potential side effects.

Pharmacologic treatment of insomnia or sleep disturbance in patients with dementia is generally not recommended, given the increased risk of side effects in this population. “Choosing Wisely” also recommends against using benzodiazepines or other sedative-hypnotics in the elderly population for insomnia, agitation, or delirium, as these medications have been shown to more than double the risk of motor vehicle collisions, falls, and hip fractures, therefore increasing the risk of hospitalization and death.66 There is some evidence of success with sleep disturbances using a low dose of trazodone, particularly in Alzheimer’s disease, although more evidence is needed.71 Melatonin has been suggested as a well-tolerated treatment for sleep disturbances and agitation, but a recent Cochrane review states that there is no clear benefit based on studies to date.71

Depression may be a contributor to behavioral symptoms associated with dementia, and it is difficult to diagnose in this population. A psychiatrist, preferably one with expertise in treating elderly patients, or geriatrician should be consulted for severe cases in the ED, or a referral for outpatient evaluation may be appropriate for more subtle cases. Although seritonergic antidepressant medications, with the exception of citalopram, have not been found to improve BPSD, sertraline has been found to be effective for treatment of depression, and responders may have improvement in non-mood neuropsychiatric symptoms.62 As with all medications in this population, the possible small benefit must be weighed against the potential risks, including falls, QT prolongation, and hyponatremia.

Cognitive Function

Pharmacologic therapy for cognition is more appropriately initiated under the guidance of a primary care provider or geriatric specialist. However, it is helpful for the emergency physician to understand the profile and side effects of the currently approved treatments for cognitive function in dementia. There are four medications in two different classes, cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonists, currently approved by the FDA for the treatment of dementia: rivastigmine, donepezil, and galantamine; and memantine. All drugs are only approved for Alzheimer’s disease, except for rivastigmine, which is also approved for Parkinson’s disease dementia.

Cholinesterase Inhibitors (ChEI). These drugs are the core of pharmacologic therapy for the cognitive symptoms of dementia, based upon the theory that cholinergic transmission is central to memory and attention. ChEIs work to stop the breakdown of acetylcholine by enzymes in the synaptic cleft and increase acetylcholine transmission. They have been shown to have possible benefits in cognition, activities of daily living, global function, quality of life, and behavior, and may stabilize or slow decline in these areas, although they do not change the overall course of disease.72,73 The challenge with ChEIs is tolerability, as there are a significant number of patients that experience gastrointestinal side effects, such as nausea, vomiting, and diarrhea. The more serious side effects noted are related to increased parasympathetic activity, including syncope and bradycardia. The “Choosing Wisely” campaign has recommended that if a ChEI is started, a trial of 12 weeks should be considered along with nonpharmacologic interventions, with the plan to reevaluate periodically for gastrointestinal side effects and perceived cognitive benefits.66

Memantine. Memantine is an NMDA receptor antagonist, with its use based on the theory that excessive stimulation of the NMDA receptor by glutamate may cause neurotoxicity. Memantine may have minimal benefits in moderate to severe Alzheimer’s dementia, for which it is approved, and it may have benefits in vascular dementia.74 It has not been shown to have benefit in Parkinson’s disease dementia or Lewy body dementia.74 It is generally well tolerated, with possible gastrointestinal effects, and a low incidence of bradycardia, syncope, hypertension, confusion, dizziness, and headache.

Other Medications. It is important to ask patients about dietary supplements, as patients will commonly forget to list them with prescribed medications. Possible herbal or dietary supplements with significant side effects include gingko biloba, ginseng, B vitamins, vitamin E, omega-3 fatty acids, and phospholipids. For example, ginkgo biloba has antiplatelet activity and may increase the risk of bleeding if taken with other anticoagulants.75

Best Practices in the Emergency Department for Patients with Dementia

As discussed throughout this article, the fast-paced, noisy, and sometimes chaotic environment of the ED can be a challenging setting for the care of a person with dementia. Assessment, communication, staff awareness, and physical setting all present significant challenges when combined with the needs of cognitively impaired patients. The Geriatric Task Force, as well as the Research Collaboration for Quality Care of Older Persons: Emergency Care Panel have created guidelines for best practices for the care of patients with dementia and elderly patients with an unknown cognitive status, and this section will summarize and combine these recommendations.5,18,76

Assessment

The Geriatric Task Force recommends that all elderly patients should have cognitive assessment or screening. Despite the assumption on the part of many ED providers that patients are being evaluated by a primary care doctor for cognitive disorders, one study found that almost 70% of elderly patients with cognitive impairment discharged home from the ED had no prior diagnosis, therefore potentially missing many new diagnoses.4 The time burden and training necessary to do a full cognitive assessment renders it impractical for the emergency physician; therefore, it is helpful to learn brief cognitive screening tests, understand their implications and numerical cutoffs, and use them regularly with elderly patients. Great Britain’s National Health Service requires that patients with any evidence of confusion go through a cognitive screening by an ED nurse, which triggers a red flag for staff.77 There continue to be questions about the best test for widespread screening in the ED, although the ones described in this article are a good starting point.

Cognitive impairment also creates challenges for medical assessment, given that memory difficulties may impede recall of history of present illness and past medical history. Cognitive screening provides a red flag, which alerts the nurse and physician that more investigation is required. They should also seek confirmation of the information given by a patient with cognitive deficits, particularly regarding the reason for the ED visit and past medical history. If the patient arrives from a long-term care facility or nursing home, an effort should be made to communicate with the facility to understand clearly why the patient was sent. If delirium is recognized, a search for the etiology should be initiated.

Pain assessment of the elderly, including patients with dementia, is important. Advanced age is the strongest predictor that a patient will not receive pain medicine for a painful condition. One study showed that more than one-third of elderly patients with long bone or hip fractures did not receive pain medicine while in the ED, compared to 20% of non-elderly patients.78 In the cognitively impaired, this may require a standardized pain score, behavioral assessment, or a proxy for pain.18 Additionally, if a patient is discharged home with a narcotic medicine, the patient or caregiver should be made aware of possible cognitive or sedative side effects, and the patient should be given an appropriate bowel regimen to prevent the commonly encountered side effect of constipation.79

Communication

Communication with a patient with dementia requires patience and education. Cognitive impairment reduces a person’s ability to remember, perform self-care, solve problems, communicate, and follow directions. Improved communication can reduce anxiety and help prevent escalation of behavior symptoms of dementia. There are multiple approaches to improving communication: speak slowly and calmly, use eye contact and appropriate touch to direct the patient, give single-step commands, repeat statements, and reduce distractions and extra noise or stimuli. Make sure that a patient is able to hear: look in the ears for cerumen impaction, use a portable amplifier or “pocket talker,” speak in a deep voice, and do not yell. If a patient has a severe hearing impairment, be sure that the patient can see your lips, speak slowly, and provide good lighting. Keep in mind that a patient’s behavior can be a form of communication about needs, such as pain, discomfort, a need or inability to urinate, hunger, or thirst.

Discharge planning is an essential part of communication with the patient and his or her care provider. Many patients will require additional conversations beyond the patient discussion to ensure that a care provider, legal decision maker, or facility knows what was done for the patient in the ED and what is recommended post-discharge. Instructions should also be clearly documented in the discharge papers. If a patient is found to have a cognitive impairment that was not previously recognized, a follow-up plan should be communicated for further assessment. Finally, many patients with late-stage dementia will be appropriate for a referral to palliative care. Palliative care physicians and nurses have particular skill in managing common symptoms associated with dementia, such as difficulty with swallowing, weakness, incontinence, sleep disruption, pain, anxiety, and depression. Hospice care can improve quality of life for patients and caregivers and can help provide a better dying experience.80

Physical Environment

Aspects of the physical environment of the ED can be tailored to reduce risk of delirium and iatrogenic complications for patients with dementia. The interaction between susceptibility, environment, and physical discomfort (e.g., dehydration, pain, pressure sores, or incontinence) may produce or worsen delirium. Interventions include improved lighting, private rooms, sound-proofing, minimization of alarms and other noises, non-skid mats, regulation of the ambient temperature, hearing aids, large visual aids or orientation clues (signs to the bathroom), pressure-reducing mattresses, food and oral rehydration availability, avoidance of physical restraints, and reclining chairs. If possible, provide the patient’s own glasses and hearing aids and offer the patient assistance to the bathroom. Given the susceptibility of the patient with dementia to delirium, these should be part of a multifactorial delirium and fall prevention program, with the downstream effect of potentially reducing iatrogenic complications and improving cost-effectiveness of care.81

Education

Compliance with many of these strategies of care for persons with dementia in the ED may be significantly improved with educational initiatives or protocols in place. Training nurses and physicians in communication techniques and nonpharmacologic approaches to behavioral disturbances can mitigate the stress and resultant worsening behavior that patients may display in the ED.77 There has been increasing research and interest in geriatric EDs, which would incorporate many best practices in care for patients with dementia.82 A set of geriatric ED guidelines was published in 2013 as a collaboration between the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.83 The recommendations include structural, policy, procedural, staffing, and physical environment recommendations, but at the core of the recommendations is the recognition that staff education regarding the needs of the geriatric population and appropriate care techniques is central to successful care of the elderly patient.

Summary

Dementia is a complex disease process, and the number of patients with cognitive impairment will continue to rise as the number of elderly in the United States increases. A diagnosis of dementia for a patient may be followed by visits to the ED with medical and behavioral complications, as well as complications related to family stress and caregiver burden. There is a need for increased training and preparation of ED medical personnel; it is important for emergency medicine physicians and other personnel to gain expertise not only in screening tools for dementia and delirium, but also in evaluation and management of medical and behavioral problems in the cognitively impaired population. The ED will continue to be a critical part of the network of care for patients with dementia, along with caregivers, extended family, primary care physicians, geriatric specialists, social workers, therapists, community support, and religious institutions. As geriatric protocols and adapted physical environments become more widespread in EDs throughout the United States, care for the patient with dementia will continue to improve.

Case Scenarios

Following are some case examples that illustrate the evaluation of patients with dementia or delirium in the ED.

Case 1. A 76-year-old male, Mr. Jones, with no known history of cognitive impairment or dementia, is brought to the ED by family because he is not “acting right.”

Mr. Jones is brought to the ED by his wife and daughter, who live with him in their family home. The patient’s wife and daughter state that Mr. Jones has been more forgetful over the past year, and he has lost his way driving home from the grocery store several times. They initially thought these changes were signs of “old age,” but this week the symptoms seem much more severe. He is mixing up family members and seems to think he still lives in his former hometown. They brought Mr. Jones to the ED because he refuses to participate in his usual activities this week. Today he said to his daughter that life is not worth living if he cannot drive himself places. Mr. Jones says he believes his family has taken the keys to the car unfairly. He has not seen his primary care doctor in two years, and he has a history of hypertension and high cholesterol, which in the past has been well controlled with lisinopril and diet.

For the emergency physician, the patient’s initial history is concerning for the development of cognitive impairment with symptoms of depression, delirium over an underlying cognitive disorder, or pseudodementia. The EP attempts to delineate symptoms of delirium or dementia in the patient history and finds that Mr. Jones’ symptoms have become noticeable over the past year and appear to be exaggerated in the past several weeks by symptoms that may be consistent with depression.

Mr. Jones has appropriate attention and level of consciousness. His family does not report fluctuations in his cognitive abilities, which reduces the EP’s suspicion of delirium. Mr. Jones and his family report symptoms of loss of appetite, weight loss, and insomnia. Mr. Jones does not admit to suicidal or homicidal ideations. He has not had any medication changes recently. There is no family history of dementia. He does not complain of dry skin or fatigue (which could be suggestive of thyroid disease). He has generalized weakness, but no parasthesias or painful tongue (could be suggestive of B12 or folate deficiency). He has no gait abnormalities or incontinence (which could be suggestive of intracranial mass or normal pressure hydrocephalus).

The EP performs an OMCT screening test, which suggests cognitive impairment. The patient’s vital signs are all normal. The EP performs a general physical exam with a thorough neurologic exam, and Mr. Jones does not have ataxia, focal weakness, asymmetry, myoclonus, tremor, or chorea (if present, the EP would have considered a head CT and neurologic consultation). The EP also examines the patient specifically for dry skin/delayed deep tendon reflexes, pallor, bruising/contusions, and cerumen impaction or middle ear effusion.

For ancillary testing, the EP orders a complete blood count, electrolytes and glucose, renal function, urinalysis, thyroid stimulating hormone, and an ECG. All labs are normal. After reassurance from this initial evaluation, the family, patient, and EP agree that the patient should have urgent referrals for more formal cognitive testing and psychiatric evaluation. The family is comfortable with discharge home. The primary care doctor is contacted and agrees to see the patient within a week for follow up, as well as arrange for formal cognitive assessment.

Case 2. Mrs. Smith, an 81-year-old female with Alzheimer’s dementia, is sent to the ED from her nursing home residence with a change in behavior. Normally calm and pleasant, she has become increasingly agitated over the past week, and the nursing home is now concerned for her safety.

Mrs. Smith arrives by ambulance from the nursing home. Her power of attorney is her son, and the EP is able to locate her son’s phone number in Mrs. Smith’s records. On initial evaluation, Mrs. Smith is restless in bed, with incomprehensible speech. She does not seem to be aware that the EP is in the room. EMS reports that at the nursing home she attempted to walk out of her room unassisted today, even though she usually uses a walker. She became very agitated when the nurse’s aid tried to guide her back to a chair. On further discussion with the nursing home, the EP determines that she is normally calm and has never had behavioral issues. The nursing home is not aware of any falls or environmental changes, though they note that she was started on oxybutinin for urinary incontinence 10 days ago. The EP is concerned that the patient is delirious.

The general physical exam is focused upon screening for causes of delirium, such as trauma, infection, or pain. The bCAM is performed and supports the diagnosis of delirium. The patient’s vital signs are normal. She has no signs of trauma (tenderness, contusions) or dehydration (dry lips, poor skin turgor). The EP evaluates Mrs. Smith’s ears for cerumen impaction, infection, or effusion. Her skin is exposed to look for medication patches, pressure sores, cellulitis, abscess, or ulcers. The patient is not cooperative with a neurologic exam, though grossly she appears to have symmetric strength and movement, with no facial droop.

For ancillary testing, a complete blood count, electrolyte and glucose levels, renal function, urinalysis from an in and out catheterization, and ECG are performed. Given the patient’s age, a troponin is ordered to evaluate for acute coronary syndrome (ACS). A chest radiograph is performed to rule out pneumonia. All labs are within the normal range, troponin is negative, and the ECG shows no indications of ACS or arrhythmia.

Mrs. Smith continues to be agitated in the ED, although she is unable to get out of bed with the side rails up and locked. The EP attempts nonpharmacologic interventions to help calm the patient. Mrs. Smith is placed in a quiet room, and staff introductions occur on every encounter. Staff use a calm and low voice. The EP plans to use intramuscular haloperidol, at a low dose, if the patient’s agitation escalates and she cannot be reoriented or calmed.

Given the patient’s presentation and recent history, with normal labs and chest radiograph, the EP determines that this is most likely delirium secondary to the anticholinergic effects of oxybutinin. The patient is admitted to the hospitalist service for delirium, with recommendations to discontinue the oxybutinin. The EP discusses Mrs. Smith with her son, the power of attorney, and advises that the oxybutinin be discontinued on discharge from the hospital.

REFERENCES

1. Naughton BJ, Moran MB, Kadah H, et al. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med 995;25(6):751-755.
2. National Institutes of Health, National Institute of Neurological Disorders and Stroke (NINDS) and National Institute on Aging (NIA). The dementias: Hope through research. 2013;_13-2252.
3. Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: A delphi consensus study.Lancet 2005;366(9503):2112-2117.
4. 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.
5. Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16(5):441-449.
6. Clarfield AM. The decreasing prevalence of reversible dementias: An updated meta-analysis. Arch Intern Med 2003;163(18):2219-2229.
7. American Psychiatric Association, ed. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
8. American Psychiatric Association, ed.Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev ed. Arlington, VA: American Psychiatric Association; 2000.
9. Hejl A, Hogh P, Waldemar G. Potentially reversible conditions in 1000 consecutive memory clinic patients. J Neurol Neurosurg Psychiatry 2002;73(4):390-394.
10. Knopman DS, Petersen RC, Cha RH, et al. Incidence and causes of nondegenerative nonvascular dementia: A population-based study. Arch Neurol 2006;63(2):218-221.
11. Bennett S, Thomas AJ. Depression and dementia: Cause, consequence or coincidence? Maturitas 2014;79(2):184-190.
12. Alzheimer’s Association. 2015 Alzheimer’s Disease Facts and Figures. http://www.alz.org/facts/overview.asp. Updated 2015. Accessed July 2, 2015.
13. Dubois B, Feldman HH, Jacova C, et al. Research criteria for the diagnosis of Alzheimer’s disease: Revising the NINCDS-ADRDA criteria. Lancet Neurol 2007;6(8):734-746.
14. 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.e1.
15. Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: Effect on survival. J Am Geriatr Soc 2003;51(4):443-450.
16. McCusker J, Healey E, Bellavance F, et al. Predictors of repeat emergency department visits by elders. Acad Emerg Med 1997;4(6):581-588.
17. Saravay SM, Kaplowitz M, Kurek J, et al. How do delirium and dementia increase length of stay of elderly general medical inpatients? Psychosomatics 2004;45(3):235-242.
18. Schnitker LM, Martin-Khan M, Burkett E, et al. Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med 2015;22(3):285-298.
19. Schnitker LM, Martin-Khan M, Burkett E, et al. Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments.Acad Emerg Med 2015;22(3):273-284.
20. Cullen B, O’Neill B, Evans JJ, et al. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry 2007;78(8):790-799.
21. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189-198.
22. Carpenter CR, Bassett ER, Fischer GM, et al. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: Brief alzheimer’s screen, short blessed test, ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 2011;18(4):374-384.
23. LaMantia MA, Messina FC, Hobgood CD, et al. Screening for delirium in the emergency department: A systematic review. Ann Emerg Med 2014;63(5):551-560.e2.
24. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113(12):941-948.
25. 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.
26. 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.
27. Stair TO, Morrissey J, Jaradeh I, et al. Validation of the quick confusion scale for mental status screening in the emergency department. Intern Emerg Med 2007;2(2):130-132.
28. Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: Comparison with the mini-mental state examination. Am J Emerg Med 001;19(6):461-464.
29. Irons MJ, Farace E, Brady WJ, et al. Mental status screening of emergency department patients: Normative study of the quick confusion scale. Acad Emerg Med 2002;9(10):989-994.
30. Natalwala A, Potluri R, Uppal H, et al. Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002-2007. Dement Geriatr Cogn Disord2008;26(6):499-505.
31. Nourhashemi F, Andrieu S, Sastres N, et. al. Descriptive analysis of emergency hospital admissions of patients with alzheimer disease. Alzheimer Dis Assoc Disord 2001;15(1):21-25.
32. Norman DC. Fever in the elderly. Clin Infect Dis 2000;31(1):148-151.
33. Rich MW. Epidemiology, clinical features, and prognosis of acute myocardial infarction in the elderly. Am J Geriatr Cardiol 2006;15(1):7-11.
34. Bergen G, Chen LH, Warner M, et al. Injury in the United States: 2007 chartbook. National Center for Health Statistics, Hyattsville, MD: 2008.
35. Rubenstein LZ. Falls in older people: Epidemiology, risk factors and strategies for prevention. Age Ageing 2006;35 Suppl 2:ii37-ii41.
36. Lyketsos CG, Lopez O, Jones B, et al. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: Results from the cardiovascular health study.JAMA2002;288(12):1475-1483.
37. Steinberg M, Shao H, Zandi P, et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: The Cache County Study.Int J Geriatr Psychiatry 2008;23(2):170-177.
38. Parks SM, Novielli KD. A practical guide to caring for caregivers. Am Fam Physician 2000;62(12):2613-2622.
39. Shankar KN, Hirschman KB, Hanlon AL, et al. Burden in caregivers of cognitively impaired elderly adults at time of hospitalization: A cross-sectional analysis. J Am Geriatr Soc 2014;62(2):276-284.
40. Mace NL, Rabins PV, eds.The 36-hour Day. Rev Ed ed. New York, NY: Warner Books; 1992.
41. Hildreth CJ, Burke AE, Golub RM. JAMA patient page. Elder Abuse. JAMA 2011;306(5):568.
42. American Medical Association, ed. Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, Il: American Medical Association; 1992.
43. American College of Emergency Physicians. Management of elder abuse and neglect. Ann Emerg Med 1998;31(1):149-150.
44. Singh RR, Nayak R. Impact of FDA black box warning on psychotropic drug use in noninstitutionalized elderly patients diagnosed with dementia: A retrospective study. J Pharm Pract 2015 Apr 27.
45. Ayalon L, Gum AM, Feliciano L, et al. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: A systematic review. Arch Intern Med 2006;166(20):2182-2188.
46. Lovell BB, Ancoli-Israel S, Gevirtz R. Effect of bright light treatment on agitated behavior in institutionalized elderly subjects.Psychiatry Res 1995;57(1):7-12.
47. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012;308(19):2020-2029.
48. Yang MH, Lin LC, Wu SC, et al. Comparison of the efficacy of aroma-acupressure and aromatherapy for the treatment of dementia-associated agitation. BMC Complement Altern Med 2015;15:93.
49. Forrester LT, Maayan N, Orrell M, et al. Aromatherapy for dementia. Cochrane Database Syst Rev 2014;2:CD003150.
50. Angevaren M, Aufdemkampe G, Verhaar HJ, et al. Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev 2008;(2):CD005381.
51. Smith PJ, Blumenthal JA, Hoffman BM, et al. Aerobic exercise and neurocognitive performance: A meta-analytic review of randomized controlled trials. Psychosom Med 2010;72(3):239-252.
52. The National Institute on Aging. Go4Life. https://go4life.nia.nih.gov/. Accessed July 2, 2015.
53. Woods B, Aguirre E, Spector AE, et al. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev 2012;2:CD005562.
54. Bahar-Fuchs A, Clare L, Woods B. Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer’s disease and vascular dementia. Cochrane Database Syst Rev 2013;6:CD003260.
55. Clare L, Linden DE, Woods RT, et al. Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer disease: A single-blind randomized controlled trial of clinical efficacy. Am J Geriatr Psychiatry 2010;18(10):928-939.
56. Baker SN. Management of acute agitation in the emergency department. Adv Emerg Nurs J 2012;34(4):306-18; quiz 319-20.
57. Nassisi D, Korc B, Hahn S, et al. The evaluation and management of the acutely agitated elderly patient. Mt Sinai J Med 2006;73(7):976-984.
58. Tan L, Tan L, Wang HF, et al. Efficacy and safety of atypical antipsychotic drug treatment for dementia: A systematic review and meta-analysis. Alzheimers Res Ther 2015;7(1):20-015-0102-9. eCollection 2015.
59. 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.
60. Ballard C, Day S, Sharp S, et al. Neuropsychiatric symptoms in dementia: Importance and treatment considerations. Int Rev Psychiatry 2008;20(4):396-404.
61. Guthrie B, Clark SA, McCowan C. The burden of psychotropic drug prescribing in people with dementia: A population database study. Age Ageing 2010;39(5):637-642.
62. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. JAMA2005;293(5):596-608.
63. Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: A systematic review and meta-analysis. JAMA2011;306(12):1359-1369.
64. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials.JAMA 2005;294(15):1934-1943.
65. Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med2007;146(11):775-786.
66. AGS Choosing Wisely Workgroup. American geriatrics society identifies another five things that healthcare providers and patients should question.J Am Geriatr Soc 2014;62(5):950-960.
67. Zuidema SU, Johansson A, Selbaek G, et al. A consensus guideline for antipsychotic drug use for dementia in care homes. Bridging the gap between scientific evidence and clinical practice. Int Psychogeriatr 2015:1-11.
68. Husebo BS, Ballard C, Cohen-Mansfield J, et al. The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatry 2014;22(7):708-717.
69. Fainsinger RL, Waller A, Bercovici M, et al. A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med 2000;14(4):257-265.
70. Brown R, Howard R, Candy B, et al. Opioids for agitation in dementia. Cochrane Database Syst Rev 2015;5:CD009705.
71. McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in Alzheimer’s disease. Cochrane Database Syst Rev 2014;3:CD009178.
72. Tan CC, Yu JT, Wang HF, et al. Efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease: A systematic review and meta-analysis. J Alzheimers Dis 2014;41:615-631.
73. Birks J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev 2006;(1)(1):CD005593.
74. Buckley JS, Salpeter SR. A risk-benefit assessment of dementia medications: Systematic review of the evidence. Drugs Aging 2015;32(6):453-467.
75. Ernst E. The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John’s wort, ginseng, echinacea, saw palmetto, and kava. Ann Intern Med 2002;136(1):42-53.
76. Clevenger CK, Chu TA, Yang Z, et al. Clinical care of persons with dementia in the emergency department: A review of the literature and agenda for research. J Am Geriatr Soc 2012;60(9):1742-1748.
77. Andrews J, Christie J. Emergency care for people with dementia. Emerg Nurse2009;17(5):12, 14-15.
78. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. Am J Emerg Med 1996;14(2):157-160.
79. Neighbor ML, Honner S, Kohn MA. Factors affecting emergency department opioid administration to severely injured patients. Acad Emerg Med 2004;11(12):1290-1296.
80. Teno JM, Gozalo PL, Lee IC, et al. Does hospice improve quality of care for persons dying from dementia?J Am Geriatr Soc 2011;59(8):1531-1536.
81. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: A meta-analysis. JAMA Intern Med 2015;175(4):512-520.
82. Hwang U, Morrison RS. The geriatric emergency department.J Am Geriatr Soc 2007;55(11):1873-1876.
83. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Acad Emerg Med 2014;21(7):806-809.

What are the most common cognitive assessment tools used for assessing patients with possible cognitive disorders?

What are the nursing diagnosis of dementia?

What are some considerations for working with elderly clients who may have cognitive memory impairment?

Which manifestations would a nurse observe in a patient with mild cognitive impairment?