Arendts, Glenn

ABSTRACT Objectives This portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED). Methods A multidisciplinary group applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and develop recommendations related to older ED patients with possible delirium. Results The GED Guidelines 2.0 Delirium Work Group derived six evidence‐based recommendations for risk stratification, diagnosis, and brain imaging. To reduce universal screening, the Delirium Risk Score may be used to identify older adults at low risk for delirium, though the evidence certainty is very low. In adults over 65 admitted to ED observation units, Zucchelli's risk assessment tool (threshold ≥ 4) may stratify delirium risk, also with very low certainty. For adults over 75, the REDEEM Score may be used to identify low‐ or high‐risk individuals, again with very low certainty. For diagnosis, 4AT, bCAM, CAM‐ICU, mCAM, AMT‐4, or RASS may be used to rule delirium in or out, based on very low certainty. The Delirium Triage Screen (DTS) may be used to rule out, but not to rule in, delirium, also with very low certainty. For diagnostic imaging, there is very low certainty of evidence to recommend for or against obtaining a head CT as part of the evaluation for older ED patients with delirium. All recommendations are conditional, reflecting very low certainty of evidence due to the lack of high‐quality ED‐based studies and comparative effectiveness research. Conclusion Rigorous ED‐based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.

Abstract Introduction Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test–treatment thresholds for ED delirium screening. Methods We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta‐analysis and estimated delirium screening thresholds. Results Full‐text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta‐analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7–20.7) and rule out (pooled negative likelihood ratio [LR−] 0.18, 95% CI 0.09–0.34) delirium. We also conducted meta‐analysis of two studies that quantified the accuracy of the Abbreviated Mental Test‐4 (AMT‐4) and found that the pooled LR+ (4.3, 95% CI 2.4–7.8) was lower than that observed for the 4AT, but the pooled LR− (0.22, 95% CI 0.05–1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. Conclusions The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED‐based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM‐ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single‐center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single‐center study.