The prevalence and documentation of impaired mental status in elderly emergency department patients

Study objective: We sought to determine the prevalence of mental status impairment in elderly emergency department patients and to assess documentation of and referrals by emergency physicians for mental status impairment after discharge from the ED. Methods: We performed a prospective, observational study of a convenience sample of 297 patients 70 years or older presenting to an urban teaching hospital ED over a 12-month period. Patients were screened with the Orientation-Memory-Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Documentation, dispositions, and referrals were abstracted from chart review. Results: Two hundred ninety-seven of the 337 eligible patients were enrolled. Seventy-eight of the 297 (26%; 95% confidence interval [Cl] 21 % to 31 %) patients had mental status impairment; 30 (10%; 95% Cl 7% to 14%) had delirium; 48 (16%; 95% Cl 12% to 20%) had cognitive impairment without delirium; 17 (6%; 95% Cl 3% to 9%) screened positive on both examinations. Only 22 (28%; 95% Cl 19% to 40%) of the 78 patients had any documentation of mental status impairment by the emergency physician. Specific mention of delirium, cognitive impairment, or an acceptable synonym was noted in 13 (17%; 95% Cl 9% to 27%). Of 34 (44%; 95% Cl 32% to 55%) patients with mental status impairment discharged home, only 6 (18%; 95% Cl 7% to 35%) had plans documented by the emergency physician to address impairment. Eleven (37%; 95% Cl 20% to 56%) of the 30 patients with delirium were discharged home. Sixteen (70%; 95% Cl 47% to 87%) of the 23 patients with cognitive impairment who were discharged home had no prior history of dementia; these patients were less likely to have specialized assistance with care (13%; 95% Cl 4% to 27%) than those with known dementia (58%; 95% Cl 28% to 85%). Conclusion: Impaired mental status is common among older ED patients. Lack of documentation, admission, or referral by emergency physicians suggests a lack of recognition of this important problem.