Cognitive Impairment in Older People Presenting to ED

An increasing number of frail older people are attending emergency departments. Many of these have existing cognitive impairment (e.g. a dementia), whilst for others, there may be an acute confusional state (e.g. delirium). Cognitive impairment is commonly missed in the ED, and this has been associated with poor outcomes. People with frailty and dementia are particularly susceptible to delirium, and this is typically precipitated by additional stressor (e.g. acute illness or a recent change in medications). Cognitive impairment may or may not be the cause of the presentation, but in all cases, it is imperative to consider and screen for the possibility of new (delirium) or existing (dementia) cognitive impairment, paying particular attention to the possibility of coexistence of these conditions. A collateral history from people who know the patient well is imperative and should form part of the routine assessment for frail older people. Screening for cognitive impairment in the ED should use evidence-based tools to identify potential precipitating factors, some of which may be modifiable. The diagnosis of delirium is clinical, and there are no specific investigations although routine investigations may point to potential contributing factors or help to exclude other causes of cognitive impairment. Delirium management is focused on addressing the modifiable contributing factors, and we should refrain from pharmacological interventions unless behaviour poses a significant risk of harm. A calm environment for people with both dementia and delirium is key, and as far as possible, sensory stimuli should be minimised. Reorientation (time, place and person) is a simple, yet important intervention.