Emergency departments need to do more to support older adults with cognitive impairment

Researchers from the University of Alberta reviewed 15 studies published between 1994 and 2009, covering 4,431 patients from the USA, Canada, Australia, Italy, New Zealand and Israel.

They point out that a large proportion of older adults over 65 visit emergency departments (EDs) in high-income countries. For example, in North America, older adults visit EDs more than any other age group, are more likely to request an ambulance and receive more acute interventions on arrival. Similar trends have been observed in New Zealand, Australia, Great Britain and other European countries.

Despite this, there is little research into how people with cognitive impairment - who can account for up to 40 per cent of older ED patients - are assessed, treated or supported during their visit.

"Older patients with cognitive impairment are unable to make decisions for themselves or function independently when they visit an emergency department" explains lead author Dr Belinda Parke, Assistant Professor in the University's Faculty of Nursing. "They tend to be more helpless, demand special attention and fail to co-operate, posing many challenges for healthcare staff during admission, assessment and treatment.

"But, as one of the studies we reviewed rightly points out, there is a profound difference between saying that a patient is difficult and realising that patient care is difficult."

Key findings of the review include:

• Most of the studies defined older patients as 65 plus, with the starting point for inclusion varying from 64 to 75 years of age.
  
• Delirium was the most common cognitive impairment, but was poorly recognised, difficult to identify and often overlooked by ED physicians. And when it was identified, it was inadequately assessed.
  
• Only one of the 15 studies identified the significance of dementia in the ED, underlining the need for individual care tailored to the needs of people with cognitive impairment.
  
• A wide range of assessment tools for cognitive impairment featured in the studies, but none were deemed ideal for use in a busy ED where time is often limited.
  
• The review also uncovered a debate about whether the ED was an appropriate setting for screening and detecting cognitive impairment and questioned the health providers' obligation to patients once it had been detected.
  
• It also highlighted questions about who should carry out cognitive impairment assessments - including physicians, nurses, social workers and psychologists - and who was proficient to do so.
  
• None of the published papers reported first-hand studies about what people with cognitive impairment or their carers felt was important when they visited an ED, with some suggestions that these older patients are excluded from research.

"Although the available research indicates that older people over 65 with cognitive impairment pay a large number of ED visits, little is known about what enables or prevents these patients from receiving safe, meaningful and comprehensive care" says Dr Parke. "It is very clear that more research is needed into this area, which will become even more important as our population ages.

"Hospitalised older adults face a greater risk of adverse outcomes than younger patients and these can have a lasting and detrimental effect on them. The failure to address the needs of older patients with cognitive impairment can mean that an ED visit can become a negative and possibly life-changing event for them."

The authors believe that their research review highlights three key priorities for clinical practice and/or policy:

• Firstly, healthcare professionals need to know more about the conditions and processes that influence outcomes for older people with cognitive impairment in the ED if they are to develop effective interventions for them.
  
• Secondly, it is vital to talk to older people with CI and their carers to ensure that any quality improvements are appropriate for their often complex and specific needs.
  
• Last, but not least, a clinically relevant interdisciplinary cognitive impairment screening tool, appropriate for use in EDs, is needed.

"Our review exposes a lack of research into this vital area of healthcare and it is clear that we need a greater understanding of how this patient group is assessed and treated in ED departments" concludes Dr Parke. "Without this much-needed research, any quality improvements could prove an ineffectual use of vital resources."

More information: Contextual factors influencing success or failure of emergency department interventions for cognitively impaired older people: a scoping and integrative review. Parke et al. Journal of Advanced Nursing. 67.7, pp1426-1448. doi: 10.1111/j.1365-2648.2011.05611.x

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