NURSINGS

Clinical Care of Persons with Dementia in the Emergency Department: A Review of the Literature and Agenda for Research
Carolyn K. Clevenger, DNP,* Thasha A. Chu, BS, Zhou Yang, PhD, and Kenneth W. Hepburn, PhD

The segment of older adults who present to the emergency department (ED) with cognitive impairment ranges from 21% to 40%. Difculties inherent in the chaotic ED setting combined with dementia may result in a number of unwanted clinical outcomes, but strategies to minimize these outcomes are lacking. A review of the literature was conducted to examine the practices undertaken in the care of persons with dementia (PWD) specic to the ED setting. PubMed and Cumulative Index to Nursing and Allied Health Literature were searched for published articles specic to the care of PWD provided in the ED. All English-language articles were reviewed; editorials and reective journals were excluded. Seven articles ultimately met inclusion criteria; all provided Level 7 evidence: narrative review or opinions from authorities. The articles recommended clinical practices that can be categorized into ve themes: assessment of cognitive impairment, dementia communication strategies, avoidance of adverse events, alterations to the physical environment, and education of ED staff. Many recommendations are extrapolated from residential care settings. Review results indicate that there is minimal guidance for the care of PWD specic to the ED setting. There are no empirical studies of the care (assessment, interventions) of PWD in the ED. The existing (Level 7) recommendations lack a research base to support their effectiveness or adoption as evidence-based practice. There is a signicant opportunity for research to identify and test ways to meet the needs of PWD in the ED to ensure a safe visit, accurate diagnosis, and prudent transfer to the most appropriate level of care. J Am Geriatr Soc 60:17421748, 2012.

Key words: dementia; Alzheimers disease; emergency care; emergency nursing

From the *Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education and Clinical Center, Atlanta, Georgia; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia; and Rollins School of Public Health, Emory University, Atlanta, Georgia. Address correspondence to Carolyn K. Clevenger, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, NE, Atlanta, GA 30322. E-mail: ccleven@emory.edu DOI: 10.1111/j.1532-5415.2012.04108.x

ementia affects 5.4 million Americans, a number expected to increase to 16 million by 2050.1 Persons with dementia (PWD) access care at many points, including the emergency department (ED); they have a 40% higher probability of preventable hospitalization and a 20% higher probability of visiting the ED than those without dementia.2 Between 21% and 40% of older adults who present to the ED are cognitively impaired, 21.8% screen positive for dementia without delirium,3 and 40% are positive for any cognitive impairment including delirium.4 These individuals come for after-hours care, urgent prescription rells, triage of trauma-associated injury, assessment of new symptoms, and caregiver reassurance.5 Dementia and the ED do not mix successfully; the ED experience is vulnerable to a rapid escalation of risks.6 Dementia lowers the threshold for sensory overload, distress, and disruptive behaviors. The ED is fast paced and overwhelming even to cognitively intact individuals. Dementia may contribute to inaccuracies in the medical or medication history, difculties gathering a history of the present illness, or an individuals inability to comprehend or follow complex discharge instructions. Any of these may cause untoward clinical outcomes. Emergency department staff report feeling burdened by cognitively impaired individuals, noting that older adults in require additional time and resources the ED.7 ED physicians report older adults cognitive impairment as the greatest barrier to providing the best emergency care.8 ED nurses have indicated need for continuing education about cognitive impairment in older adults, but education relating to mental status testing resulted in minimal practice changes.9 Given that PWD (and their family caregivers) and ED providers report negative impressions of ED encounters,10 a review of the literature was conducted to examine what clinical practices for the care of PWD specic to the ED setting the research supports.

JAGS 60:17421748, 2012 2012, Copyright the Authors Journal compilation 2012, The American Geriatrics Society

0002-8614/12/$15.00

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METHODS Data Sources and Search Strategy

The authors searched the PubMed (beginning 1946) and Cumulative Index to Nursing and Allied Health Literature (beginning 1981) databases for articles published in English through August 2010 using the following combined Medical Subject Heading terms: dementia & emergency nursing; dementia & emergency medicine; dementia & emergency services; Alzheimers disease & emergency nursing; Alzheimers disease & emergency medicine; and Alzheimers disease & emergency services. This review includes only publications specic to clinical care of PWD in the ED setting. Clinical care includes steps to diagnose and treat acute illness such as assessments, medical management, and nursing interventions performed during the visit. Primary research and review articles were accepted; editorials and reective journals were excluded. The following data were extracted from each article selected for review: focus (e.g., assessment and screening,

dementia-specic interventions, modications to acute illness diagnosis and treatment), recommendations, level and source of evidence, and intended audience (medicine, nursing). Levels of evidence were graded according to Polit and Becks Hierarchy of Evidence11 (from systematic reviews of randomized and nonrandomized clinical trials (Level 1) to expert opinion (Level 7)). Figure 1 illustrates the search strategy and its results. Primary causes of exclusion were lack of specicity to the ED (n = 91) and lack of specicity to dementia care (n = 87). Publications lacking specicity to the ED focused on care of hospitalized PWD or those in transit (n = 35), primary or home care (n = 25), and use of the entire healthcare system (n = 25). Publications lacking specicity to dementia typically concentrated on psychiatric emergencies (n = 25) or on delirium or depression (n = 12). Other less-common causes for exclusion were a focus on the epidemiology of dementia in the ED (n = 6), staff education, and those that used ED visits as an outcome to a community-based intervention (n = 14). Twelve excluded articles outlined the reliability and validity of cognitive

PubMed: Dementia/ Alzheimer's Disease & Emergency Nursing N=71

SEARCH

CINAHL: Dementia/ Alzheimer's Disease & Emergency Nursing N=11

PubMed: Dementia/ Alzheimer's Disease & Emergency Services N=159

CINAHL: Dementia/ Alzheimer's Disease & Emergency Medicine N=5

PubMed: Dementia/ Alzheimer's Disease & Emergency Medicine N=86

CINAHL: Dementia/ Alzheimer's Disease & Emergency Services N=6

Total Retrieved N=338

Unique Publications N=209

EXCLUSIONS

Staff Education N=3

The ED visit is the outcome N=14 Epidemiology of Dementia N=6

Assessment and Recognition of Dementia in the ED N=12 Not Dementia Specific N=87
Care Coordination N=10 Delirium or Depression N=12 Editorial/Other N=5 Geriatrics N=35 Neuropsychiatric and Drug Reactions N=25

Not ED Specific N=91

Inpatient N=33 Home/Outpatient N=25 Healthcare System N=25 Editorial/Other N=4 EMS/Ambulance N=2

Care of Persons with Dementia in the ED

Figure 1. Selection strategy for included and excluded articles. ED = emergency department.

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screening tools for use in the ED. Many publications met multiple exclusion categories.

RESULTS
The search identied 338 articles; removal of duplications yielded 209 unique records. Each abstract was reviewed for inclusion; 30 full articles were reviewed. Only publications addressing the clinical care (assessments or interventions) of PWD in the ED were included. Seven articles published between 1995 and 2009 met all inclusion

criteria; all provided Level 7 evidence-expert opinions or narrative reviews. Before the 1990s, publications focused on emergency psychiatric services for psychosis rather than medical needs. National Health Service (NHS) consensus recommendations for caring for PWD in the ED prompted the two most recent publications in the review. Major themes identied in the reviewed articles include assessment of cognitive impairment, dementia communication strategies, avoidance of adverse events, alterations to the physical environment, and ED staff education. Table 1 outlines the content, recommendations, and

Table 1. Publications Describing Care of Persons with Dementia (PWD) in the Emergency Department (ED)
Source of Evidence

References

Focus

Recommendations

Location

Audience

Andrews & Christie13

Implementation of Scottish Government recommendations for the care of PWD in emergency settings

Birrer, Singh, & Kumar14

Best practices for medical management of persons who are functionally dependent and demented in the ED; Ranges from assessment of cognition and function to screening for competency and abuse to recommendations for care and disposition

Cunningham & McWilliam15

Prevalence of dementia in UK EDs; nursing management of individuals with dementia in the ED setting, including communication, environment and common complications (dehydration, anxiety)

James & Hodnett18

National Health Service aims for improving dementia care and how they might be implemented in the ED setting

McBrien19

Ethical and legal considerations when deciding whether to physically or chemically restrain an individual with Alzheimers disease in the ED

Tueth17

Range of behavioral complications of dementia that emergency physician might face, including activity and psychotic, aggressive, and other disturbances

Zimmerman & Ortigara16

Overview of pathophysiology of Alzheimers disease and interventions for ED nurses; interventions based in literature originally intended for family caregiving and nursing home staff

Identication of PWD and alert others to the condition, avoid admission and unnecessary transfers, educate staff to reduce discrimination and improve management of disturbing behaviors Standardized assessment to recognize dementia when it exists, use of a separate space for older adults presenting to the ED, staff education on age-related decline, minimization of door-to-discharge time, improved communication during transitions (e.g., nursing home transfers) and hospital admission only when medically necessary Keep communication simple, clear, and reinforced; assess for delirium; monitor for dehydration; maintain safety by using separate area or more-frequent observation; avoid physical and chemical restraints; Provide eye-level signage to reorient to surroundings, particularly toilets Designated space for persons with dementia, new toilet signage, distraction aids, reduction of stress during procedures, pain management, use of specially trained volunteers Decision to restrain individual with Alzheimers disease in the ED a question of paternalism versus patient autonomy; recommendations by the Joint Commission reiterated that restraints are last resort and minimal level of restraint should be used and patient continuously observed Emergency physician should attempt to gather full history (from family or facility caregiver, if possible); nonpharmacological interventions including avoidance of nighttime uid and diuretics, pain management, sleep hygiene promotion, and limited environmental overload; soft restraints and bedrails listed; pharmacological interventions include neuroleptics, antipsychotics, and benzodiazepines Limit environmental stimuli such as bustling activity in center of ED; give simple, one-step instructions; ascertain information from caregivers; use touch; and be exible and creative in providing care based on patient needs

Opinions from authorities

Scotland

Nursing

Narrative review

United States

Medicine

Narrative review

United Kingdom

Nursing

Opinions from authorities

England

Nursing

Expert opinion

Ireland

Nursing

Narrative review

United States

Medicine

Narrative review

Authors, United States; Journal, United Kingdom

Nursing

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intended audiences of the seven reviewed articles. Five articles focus on care in the United Kingdom, where the NHS has an agenda to improve the quality of care provided to PWD in emergency care because of the increasing prevalence of dementia and its potential to alter the presentation and treatment of acute illness.12

Assessment
Three of the seven publications address assessment; two recommend use of standard cognitive screening as a strategy for recognizing dementia in the ED,13,14 and one includes assessment of delirium.15 One article14 asserts that incorporating assessment of cognitive functioning in the ED should be part of the skill set of any emergency physician. It notes that ED physicians lack of recognition of dementia may result in poor quality of care measured by delayed and missed diagnoses and increased morbidity and suggests the addition of three questions: Who brought the patient? Where had the patient been? How did they arrive at the ED?14 One of these studies explains that the NHS requirement that all older people with apparent confusion in EDs should undergoassessmentsto identify those who have dementia requires cognitive screening by ED nurses. This assessment, when positive, triggers a ag system to alert other staff to the presence of dementia.13 Another makes the compelling statement that, when dementia is identied, the question remains about what is to be done for the patient during the ED visit.15

PWD in the ED is acute medical need. Its inventive care strategies are aimed entirely at reducing stress and subsequent adverse events during ED visits.16 Use of distraction aids and analgesic gels during procedures and a nonverbal pain scale to guide nursing assessment of pain and treatment options are recommended.18 Physiological complications include dehydration,15 untreated pain,17,18 and functional incontinence.15,18 Specic recommendations are presented such as encouragement of oral uids, analgesic strategies, and clear, disability-related toilet signage. Physical restraints are described as a last resort19 but outlined in the list of options for management in another study.17

Physical Environment
Five articles discussed the ED physical environment and the movement of PWD through and beyond it; four of these urged some form of seclusion for PWD. Recommendations included designated space18 with adequate lighting and space for caregivers,14 spaces that reduce or avoid environmental overload,16,17 locations near the nurses station,15 and a consistent staff member to assist the patient in navigating the space.15 Specic changes to important areas such as restrooms as recommended by occupational therapists and a design team are outlined.18 The use of a Specialist Volunteer who supports the nursing staff in accomplishing the goals of the NHS is described.15 Addressing stimulus reduction and continuity, shorter lengths of stay with appropriate disposition sites, including Acute Care for Elders (ACE) units for those admitted as inpatients, with handover information readily available for the next provider are recommended.14

Communication
Three publications discuss the importance of communication in the care of PWD with specic strategies outlined. Each recommends use of simple, one-step commands repeated as needed. One speaks to the positioning of the caregiver in front of the person, recommends eye contact and appropriate pace of speech, and states that any oral or written information provided to PWD should take account of their disabilities.15 Another study expands oral communication to include use of touch, as appropriate, and the counterintuitive approach of repeating statements exactly as initially stated. It discusses meeting patients in their own reality, relating to the meaning behind the words of an agitated patient.16 Another article, focused exclusively on behavioral symptoms of dementia, also emphasizes tone, suggesting a low, soft voice.17

Staff Education
Three articles recommend staff education for clinicians who may interact with PWD. Specic recommendations for dementia care education for emergency nurses include communication strategies13,15,18 and management of disturbing behaviors.13,18 Education on caregiver involvement and maintaining safety for PWD and that staff education should also include an assessment of staff attitudes toward PWD were emphasized.13 Specic content on advocacy, pain management and ethics is included.18

DISCUSSION
These articles highlight gaps in research about PWD in the ED. The selection process resulted in the inclusion of seven papers identied in a comprehensive literature search, most of which were published outside the United States. The major themes presented in the Results section represent a governmental consensus statement, expert opinion, and narrative review. There has been no intervention research to support implementing these recommendations in the ED. The recommendations are grounded in research, but it is research conducted in settings other than the ED (e.g., residential care) or in a broader population-based context (geriatrics). Below the research literature that supports these themes is briey discussed, and an agenda is provided for research that is summarized in Table 2.

Adverse Events
Five articles outline recommendations for managing complications that may arise before or during an ED visit. Three address behavioral complications, and two address physiological. One, identifying behavioral complications as a common reason for use of ED care by PWD, outlines pharmacological and nonpharmacological interventions for behavioral home management, depending on the type of problem (activity, psychotic, aggressive, or other). Nonpharmacological strategies entail a structured home routine with appropriate levels of stimulation.17 Another study indicates that the most common reason for nurses to see

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Table 2. Summary of Research Agenda for Dementia in the Emergency Department (ED)
Theme Implications for ED Care Research Agenda

Assessment

Adverse events

Communication

Physical environment Staff education

Memory loss impairs ability to recall symptom history and elements of past medical history Communication difculties may alter subjective presentation of acute illness Potential for drugdisease interaction is signicant Delirium and behavioral and psychological symptoms of dementia may arise during ED visit because of acute illness and environment Physiological complications may arise because of decline in ability to communicate needs Memory loss complicates processing and retention of instructions and orientation to surroundings Decline in verbal uency makes it difcult for PWD to communicate needs or clearly identify symptoms Caregivers must supplement the information provided by the PWD and administer the treatment plan PWD have a lower stress threshold, which may lead to behavioral and psychological symptoms of dementia such as aggression and irritability Care of PWD does not represent a disease-based clinical care pathway but rather a modication of usual care

Methods of recognition of cognitive impairment for ED clinicians Cognitive screening feasibility and utility

Anticipation of needs for hydration, pain, toileting. Effectiveness of modied physical environment and personnel (see communication) Rate of physical restraint use for PWD in the ED Effectiveness of communication strategies including verbal, nonverbal, visible signage

Effectiveness of restraint minimization, appropriate signage, placement of PWD in areas with less human trafc and increased nursing visibility Evaluation of dementia training by record review, observation for quality assurance Appropriate content for staff beyond dening the syndrome of dementia to what clinical practices should be undertaken in the care of PWD in the ED

PWD = person with dementia.

Assessment
Few ED providers recognize dementia without use of standard screening instruments.20 Recognition of acute or chronic cognitive impairment informs any dementia- and ED-specic care that might improve patient outcomes. This step in ED care for PWD cannot be omitted because there is often no prior record of impairment and no access to outside medical records, and the assessment can bear importantly on care issues beyond diagnosis and treatment plan. Transition management, especially important for PWD, must assure that the site of disposition is ready to receive the patient and has vitally needed information to provide effective, dementia-informed care. Although several brief dementia screening tools have been tested for reliability and validity,4,21,22 only one study examined their implementation in the ED, and research staff performed assessments in that study.22 Many practical questions remain regarding the feasibility and utility of cognitive screening and assessment in the ED: what is the value of cognitive screening when added to the intake assessment; how able are ED staff to maintain interrater reliability on screenings; do results contribute to accurate diagnoses and appropriate plans of care; does cognitive screening affect common adverse events?

Communication
Dementia communication strategies are of great concern given the vulnerability of PWD in a chaotic and overwhelming ED. Ineffective or counterproductive communication strategies by ED staff can increase the anxiety and cognitive decits of PWD; resulting communication

difculties can undermine diagnostic and treatment processes, potentially leading to adverse events. Recommendations (e.g., single-step commands, positioning of speaker, touch) are based largely on residential care and community settings, with some deriving from the acute setting. For example, a study of long-term care nursing assistants demonstrated that alpha commands (those that are that clear, concise, and feasible) produced greater cooperation in PWD than ambiguous, interrupted, and not feasible beta commands.23 The Try This guide for geriatric nursing in acute settings recommends that clinicians recognize that PWD behavior is a form of communication, potentially the expression of unmet needs.24 No comparable research in the ED setting examines communication strategies or explores ways for ED clinicians to interpret behavior-based PWD communication. Most likely, ED nurses use alpha commands (given that they are often in urgent or emergent situations, and their needs are critical and time-sensitive), and there are similarities between the acute and ED environments; still, research is needed to establish evidence-based communication practices in the ED. Research is similarly needed regarding involvement of and communication with caregivers who accompany PWD to the ED. Their support is paramount to an accurate medical and symptom history, management of the discharge plan, and implementation of any treatments ordered.

Common Adverse Events

Common adverse events for PWD in the ED include poor outcomes (dehydration, infection, antipsychotic use)15 and poor health utilization outcomes (return visits for the same

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complaint).14 Most suggestions to reduce and prevent common adverse events are extrapolated from research on caregiver education, residential-based care, and psychiatric nursing care of difcult or violent clients. Coexisting or emergent delirium, a primary concern in itself, functions in a vicious loop with other adverse events, and physical complications (dehydration, untreated pain, incontinence) often underlie the development of delirium.25 Management of these physical complications requires a proactive approach not dependent on a complaint by the PWD. Appropriate interventions include encouragement of oral uid intake, pain recognition and management, and frequent and feasible toileting opportunities. Delirium may manifest as verbal and physical agitation, leading to use of antipsychotic medications and physical restraints, which are still in widespread use despite federal regulations issued in 1999. A recent study of restraint use in 434 units of 40 hospitals found a restraint rate ranging from 4.7 to 94 restraint days per 1,000 patient-days; this study excluded EDs.26 Prevention or management of disruptive behaviors and the management of delirium are topics of greater importance in the ED, and research is needed to establish the evidence for best practice there. It is particularly important to establish and assess the feasibility and effect of intervention strategies and standing protocols for PWD in the ED.

for ED nurses had similar results, with nurses self-reporting improvement in their ability to screen for depression and dementia.9 Evaluations of staff education in this topic area do not establish effectiveness through more-objective means or measures than self-report, including chart reviews, observations of subsequent completion of cognitive assessments and patient care provision, prevalence of delirium (increased because of awareness of risk and confusion assessment), caregiver satisfaction, and use of antipsychotic medication and physical restraints. Additionally, factors such as the receptiveness of professionals, the feasibility of proposed changes, and the professional social system affect the intended result of training: nursing practice changes that improve patient care.30 Staff education that attends to these other factors has the most promise for improved care and patient outcomes. This kind of study has been conducted in acute care, but not yet in the ED.28

LIMITATIONS
This review has potential limitations inherent in the search strategy employed. Publications included in the review were limited to English, and publication bias may have affected the results.

CONCLUSIONS
Using the Polit and Beck11 method of ranking evidence, the authors found no high-level evidence to support care recommendations for PWD in the ED. Seven papers describing best practices in PWD care were included, ve of which describe guidelines outside of the United States; the suggested interventions are based on convention and traditional practice and have not been rigorously validated. Most of the suggestions have been extrapolated from other settings, most notably residential and long-term care, environments with little in common with the ED. Separate from a focus on clinical care for PWD, there is a growing body of evidence on dementia screening tools for the ED setting.4,2022 Although screenings have been tested for reliability and validity in the older ED population, no studies examined the implementation of these assessments in the ED. This mirrors the overall scarcity of research about PWD in the ED in the other areas identied as important in the review: communication strategies, prevention of adverse events, physical environment, and staff education. In the face of a paucity of evidence-based interventions for PWD in the ED, the extrapolation of care recommendations from other settings is reasonable, but to leave the care recommendations in this state does not provide the impetus for the seeking of evidence-based dementiainformed care for PWD in the ED. Each outlined theme should be evaluated for effectiveness through empirical research. The process of ED care encompasses nursing triage assessments and the diagnostic examination and treatment of acute illness. Each of these points of care is vulnerable to the effects of a dementing disorder and is a potential target for intervention and performance improvement to ensure a safe ED visit, during which an accurate diagnosis is made, the patients needs are met. and safe handoff to the next site of care occurs.

Physical Environment
ED units are often located in underground sections of hospitals, without windows or other sources of natural light. They typically employ an open design effective for care of acutely ill patients, a design that produces a bustling, overpopulated, noisy space. The environmental modications recommended in the reviewed articles are well aligned with geriatric ED interventions, which include better lighting; sound-proong; nonskid walking surfaces; pressure-reducing mattresses and cushions; availability of visual aids, hearing devices, and adaptive equipment; and appropriate ambient temperature.27 The interventions seek to improve the ED experience for older adults in general and are not specic to PWD, although signicant overlap exists. Although these recommendations have not been empirically tested in the ED setting, similar changes in acute care environments have been successful in reducing delirium and iatrogenic complications and thus reducing cost, hospital length of stay, and nursing home admissions.28

Staff Education
Staff education remains the primary tactic to change staff behavior. Given the lack of empirical evidence supporting specic clinical practices, it is difcult to say what content should be included in staff education on care of PWD in the ED. Geriatric Emergency Nursing Education (GENE) is a program intended to improve ED nursing practice for older adults and includes content on dementia care. An evaluation of GENE using self-report of nurses who completed the educational session demonstrated an increase in knowledge, self-rated ability to care for older PWD, and use of a cognitive assessment tool.29 A 1-day workshop

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ACKNOWLEDGMENTS
Conict of Interest: No nancial or personal conicts of interest to disclose. Author Contributions: Clevenger C.K., Hepburn K.W. Study concept and design; Clevenger C.K., Chu T.A., Yang Z. Acquisition of data; Clevenger C.K., Chu T.A.: Analysis of data; Clevenger C.K., Hepburn K.W.: Interpretation of data; Hepburn K.W., Chu T.A., Yang Z., Hepburn K.W. Preparation of manuscript. Sponsors Role: None.

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