In this point prevalence survey among patients ≥ 75 years in ten Norwegian EDs, 17 per cent showed findings consistent with delirium, while another 30 per cent showed findings consistent with other forms of cognitive impairment, as determined by the 4AT screening tool. All categories of departments received patients with delirium. All participating hospitals received patients with signs of delirium or other types of cognitive impairment.
The prevalence of delirium was somewhat higher than in equivalent studies from other countries, where a prevalence of approximately 10 per cent was found in EDs
(8–11). One likely reason is that whereas we included patients ≥ 75 years, these studies had an inclusion threshold of 65 years. Norwegian emergency departments also have a more selected group of patients than similar departments in other countries, to which patients may turn directly, as they would to an A&E centre. The prevalence of cognitive impairment at 47 per cent is approximately the same as in other studies, which identified cognitive impairment in approximately one-half of all elderly patients in emergency departments (25, 26).
Patients with cognitive impairment are at a high risk of developing delirium and other complications during hospitalisation
(17). Since delirium is associated with a poor prognosis (3), complications, extended hospitalisation periods and increased costs (4), it is crucially important that the hospitals maintain a focus on prevention and appropriate management of delirium. A meta-analysis concludes that close to one-half of all cases of delirium can be prevented with the aid of simple, but personnel-intensive measures such as orientation, a focus on hydration and nutrition, patient activation, mobilisation and good sleep hygiene (18). Such interventions also have a documented effect on manifest delirium, in contrast to psychotropic drugs, which should not be used as a routine (2). We are concerned, however, that conditions such as overcrowded wards, corridor patients, short hospitalisation periods and low staffing all contribute to an increased prevalence and suboptimal treatment of delirium.
Since delirium is common, associated with a long series of negative outcomes and largely preventable, we believe that better prevention and management of delirium would have a major positive effect on patient safety in Norwegian hospitals. We call for a proactive stance with regard to delirium and cognitive impairment and we believe that including these conditions as focus areas in the patient safety programme would be a natural choice
(27). Our results illustrate that patients with both delirium and other kinds of cognitive impairment are admitted to most types of departments, underpinning the assertion that concrete plans for management of patients with delirium and cognitive impairment ought to be available in all departments that treat elderly patients, and not be regarded as a concern only for geriatrics departments.
We also recommend the introduction of procedures for examination for delirium and cognitive status in EDs
(4, 25, 26). This will help identify patients with delirium, and since delirium is a sign of illness, it will most likely lead to more thorough diagnostics and better treatment. Recognition of delirium will also reduce the risk of the condition being misinterpreted as dementia. Early identification of patients with cognitive impairment will also enable the staff to provide adapted information, initiate targeted measures to prevent delirium and other complications (17, 18), and improve discharge planning for these patients. Recognition of delirium may also identify patients who will need closer follow-up after discharge. Since delirium is underdiagnosed (15, 16), we recommend using a standardised screening tool. 4AT can provide a meaningful score also for patients who are unable to answer questions, and the tool provides an indication of whether patients without delirium may have underlying cognitive impairment.
Strengths and limitations
Strengths and limitations
The key strengths of this study are its use of a validated screening tool for delirium and that it was conducted in ten different hospitals by doctors with long-standing experience of work with elderly patients. However, the dataset is relatively small and restricted to the date in question. We wish to emphasise that 4AT is a screening tool and must therefore not be used as a basis for final diagnoses such as dementia or mild cognitive impairment. Other limitations include non-registration of other risk factors for delirium, such as frailty, multimorbidity, polypharmacy or known cognitive impairment.