[Guides and standards: delirium in elderly persons in emergency departments - prevention, assessment and management]

Shun P, Hallée S
Record ID 32018012107
Original Title: Délirium chez les personnes âgées à l’urgence : prévention, évaluation et prise en charge
Authors' objectives: Delirium is characterized by acute and fluctuating changes in mental status as well as disturbances of attention and consciousness. It usually lasts a few hours to a few weeks or even months, and the consequences are sometimes irreversible. Delirium is associated with an increased risk of morbidity and mortality, prolonged hospital stays, hospital readmissions and institutionalization – making it a medical emergency. People aged 65 and older are more likely to develop delirium because of greater age-related brain vulnerability. From 10 to 18% of older people in emergency departments develop delirium; however, up to 85% of these cases are not detected and therefore, not managed. Given this context, the Institut national d’excellence en santé et en services sociaux (INESSS) was approached by the Ministère de la Santé et des Services sociaux (MSSS) to develop a clinical support tool for the prevention, assessment and management of delirium in elderly persons in emergency departments.
Authors' results and conclusions: RESULTS (#1 IDENTIFY ELDERLY PERSONS AT RISK OF DELIRIUM AND IMPLEMENT NON-PHARMACOLOGICAL INTERVENTIONS TO PREVENT DELIRIUM ONSET): The main risk factors for delirium are advanced age, cognitive impairment and frailty which can be observed in persons with reduced mobility or needing assistance with daily activities. • Upon the first contact with an elderly person in the emergency department, it is recommended that those who are at risk of delirium be identified so that preventive measures can be put in place. (#2 SCREEN FOR DELIRIUM WITH A STANDARDIZED SCREENING TOOL): Bearing in mind that delirium is underdetected in elderly people in emergency departments, professionals should become familiar with the potential signs and symptoms of delirium and screen for delirium using a standardized tool. • Particular attention should be paid to hypoactive delirium since it often goes unnoticed. • Currently, the 4AT is the preferred choice for a screening tool since it is adequately sensitive and specific, available in a French Canadian version and requires only a short time to administer. (#3 IDENTIFY AND TREAT UNDERLYING MEDICAL CAUSES AND PRIORITIZE A NON-PHARMACOLOGICAL APPROACH WHEN MANAGING ELDERLY PATIENTS WITH DELIRIUM): Delirium is often multifactorial in origin. It may be caused by one or more medical conditions and it may be precipitated by factors related to the physical or social environment. Identifying and treating the medical cause(s), as well as implementing non-pharmacological interventions, is therefore essential in its management. • The non-pharmacological interventions recommended for prevention are the same as those advocated for management. • It is important to use communication methods adapted to a person with delirium who is struggling with hallucinations, illusions or delusions (e.g., avoid confrontation) in order to avoid the escalation of disruptive behaviours. (#4 CONSULT AND INVOLVE CAREGIVERS AND KEEP THEM INFORMED): Caregivers know the elderly person best and know how the person usually functions in daily life. Professionals should consult caregivers at each stage of the clinical process since they can provide information likely to help in identifying risk factors and patients’ needs. • Caregivers can also implement non-pharmacological interventions in delirium prevention and management. CONCLUSION: The recommendations made in the management support tool do not replace clinical judgment but they should help improve delirium prevention, assessment and management in elderly persons in emergency departments. A number of issues, particularly those relating to professional practice, were taken into consideration during the development of this tool and of a memory aid in order to adapt them to Quebec emergency departments context. Nevertheless, several stakeholders highlighted the fact that there are barriers to mastering and implementing best practices due to how emergency department services are organized and because of the physical settings which are poorly adapted to meet the needs of elderly people. All of these issues suggest a need for support in implementing best practices.
Authors' methods: A review of clinical practice guidelines and systematic reviews was conducted to identify best practices. An advisory committee of professionals and researchers from various specialties and areas of expertise validated the scientific evidence and participated in developing recommendations. The perspective of caregivers who accompanied an elderly person with delirium in an emergency department was also taken into consideration. The data collected (scientific, contextual and experiential) was analyzed to develop a management support tool containing recommendations for best practices adapted to Quebec’s healthcare context. The work was presented to a monitoring committee made up of representatives from the MSSS, professional associations and colleges, and to one of INESSS’ deliberative committee. In addition, further validation was carried out by consulting future users (i.e., emergency department professionals who did not participate in the work) and external reviewers with expertise in the field of interest.
Project Status: Completed
Year Published: 2024
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Delirium
  • Aged
  • Emergency Room Visits
  • Emergency Service, Hospital
  • Geriatric Assessment
  • Surveys and Questionnaires
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)
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