GEAR 2.0 Priorities – Detection of People with Dementia in the ED
Older adults use the emergency department (ED) as an important source of acute medical care, making 20 million visits annually. People with dementia are twice as likely to use the ED and 1.5 times more likely to have an avoidable visit. When in the ED, they often struggle with the fast-paced setting and may not be able to give a complete medical history. These challenges, along with other adverse events, put patients with dementia at greater risk for poor outcomes.
Three decades of research has shown that dementia is under-recognized in emergency departments, despite a proliferation of screening tools. Under-recognition of dementia in the ED leads to under-recognition in inpatient services, which has broad-reaching consequences, such as longer hospital stays, lower patient satisfaction, accelerated cognitive declines, and increased health care costs. Yet, little research has explored how to improve emergency clinical care for people with dementia.
Background
Emergency care for older adults is suboptimal, and care is especially poor for older adults with dementia, even though these adults seek ED-based care more regularly than matched controls. ED identification of people living with dementia (PLWD) is particularly poor. Better detection of dementia may improve the ED staff’s ability to implement interventions that can reduce the rate of cognitive decline and improve care coordination and patient safety.
The GEAR Detection Work Group (WG) examined the potential role of the ED in dementia detection. Based on group consensus, it focused its literature review by:
- replacing age cutoffs with exclusion of children in order to include all affected adult populations and
- conceptualizing the ED’s role as screening for rather than diagnosing dementia.
- PICO-1: How can the ED best identify cognitive impairment? (Best in terms of sensitivity or reliability, etc.) Are there differences by race or ethnicity?
- PICO-2: Are there pragmatic cognitive impairment screening tools that can identify patients at risk of dementia? (Pragmatic in terms of ease of use, training, quickness to complete, etc.)
Top Research Priority Areas
The top voted detection research priority areas ranked during the 2021 GEAR 2.0 Consensus Conference based on the scoping reviews are as follows:
- What is the best approach in the ED to screen for cognitive impairment? (e.g., population definitions, using data sources, screening tests effectiveness, efficacy, referral, etc.)
- What are the most accurate and feasible tools and data to identify cognitive impairment in the absence of delirium or known dementia?
- What is the value and potential unintended consequences of screening for cognitive impairment in the ED?
- How can EDs feasibly take into account culture, language, ED environment, and communities of the population served when screening cognitive impairment in the ED? (e.g., does English as a second language impact screening of dementia?)
- What information is needed to differentiate delirium vs. undiagnosed cognitive impairment vs. known dementia vs. mental health conditions?