Asynchrony EM: Dementia and Delirium in the ED

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

 You see them every shift. Could you be taking better care of them?

You see them every shift. Could you be taking better care of them?

This week, we start our Neurology block. There are lots of 'sexy' neuro topics we could be starting off with, but we're starting with care of elderly patients with dementia and delirium in the emergency department. We'll look at how to differentiate between the two diagnoses (which can co-exist), talk about best practices for caring for these patients in the ED, about the burden on caregivers, and some of the more 'humanistic' aspects of dementia. 

No theme song this week; a theme movie trailer instead.  Julianne Moore won the Oscar for her portrayal of 'Alice' in 'Still Alice' (the book is worth a read but I haven't seen the movie.)  

 

Now, before I forget, let's hit it. 

1)From EM Docs, Sept 2016. "Dementia in the Emergency Department: Can You Do Anything About It?" 

 

2)  In 2013, Geriatric ED Guidelines were jointly approved by ACEP, SAEM, the American Geriatric Society, and the Emergency Nurses Association.  But why would these guidelines not apply to the treatment of the elderly in any ED when possible?

Please read starting on page 26 the section entitled "Delirium and Dementia in the Geriatric Emergency Department". Also read the brief Palliative Care section immediately following.  (It's somewhat telling that the Palliative Care section is so short. See our discussion section.)

 

3) Did looking at all those screening tools make you crazy?  Think you can pick up delirium on your own without a screening tool? Well, maybe you can, Superdoc, but most of your colleagues can't: check out this Annals of EM 4 minute podcast about the May 2014 article, "Screening for Delirium in the Emergency Department." The podcast is assigned; reading the article is OPTIONAL.  The take-home point from both is that we stink at identifying delirium, and it's a dangerous thing to miss.

 

4) Now we're going to get a little more...humanistic.

It is difficult sometimes to imagine an elderly, frail, confused patient as the person they might have been once upon a time. We see these patients as a snapshot, without the benefit of knowing them "before,"and without the inherent compassion that comes with that knowing. When the snapshot is a screeching, drooling, vacant, shrunken being, it's easy to restrain or oversedate or ignore. But maybe, the next time (which will of course, be tomorrow) that you see this patient, imagine them as Pam (in this mini-documentary) or Alice, or someone you may have known in your own life that you have watched fall slowly into the abyss. You will find that it does wonders for your patience. 

Not a medical video, but worth watching. An eight minute, beautiful Op-Doc video called "A Marriage to Remember," from the New York Times. This very short film was made by a son documenting his mother's dementia and his father's efforts to care for her over a four year period.

"A Marriage to Remember"


 

5)  As the video above highlights, patients who are cared for at home create a heavy burden on families, even on families with means (as the family in the op-doc appears to have). Caregiver fatigue and burnout is increasingly recognized, and you will see and treat patients with depression and stress-related illness that stems directly from caregiver burnout.  And when caregivers burn out, where do the patients with dementia wind up?

With the silver tsunami gathering strength, it's time for us to learn to 'help the helpers', because they are the ones who will determine how much of an overall burden patients with dementia present to emergency departments.

True story: a few years ago, I treated a man with advanced dementia whose wife called 911 after she knowingly gave him an overdose of his pain medication. She then could not go through with her plan, which was to kill him, and then kill herself. (Both of them became my patients--she was admitted to psychiatry.)  The wife had no previous history of mental illness or depression; her symptoms stemmed entirely from caregiver burnout, and the stress of the promise she had made to her husband to 'never put him in a home.' 

This is an area that is only beginning to be addressed, and is ripe for research. In September 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM, formerly known as the Institute of Medicine) released a very long report on "Families Caring for an Aging America." For our purposes, read this Geri Tech Blog Post. 

 

6) Because it's more prevalent among cognitively impaired patients: Elder Abuse, a quick reminder from LITFL.

 

7) Three quick news blurbs: lots of mainstream news attention on dementia and anti-psychotics/benzo use.  The immediate implications are for long term prescriptions, but you will find that (as in the Geriatric ED guidelines) there is counsel to avoid them even in the ED if non-pharmacologic methods can curb behaviors instead. You should also consider this when sending dementia patients back from whence they came after they are sedated for behaviors in the ED. 

a) From a March 5th, 2015 NPR post:  'Behavioral Therapy Helps More than Drugs' in dementia

b) From the March 1, 2015 NY Times: "Investigators are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions to older Americans with dementia."  This is mostly about anti-psychotic drugs.

c) Couple those with the February 2015 JAMA Psychiatry article "Benzodiazepine Use in the US" (abstract/scroll through is enough) -- and you will find there is a lot of pressure to de-prescribe the elderly, maybe with good reason. 

 

The OPTIONAL (but really worth the time) blurbs:

a) Nursing homes that eschew the use of antipsychotics: from NPR.

b) A recent series from NPR, "Inside Alzheimer's" -- perspective from caregivers and afflicted. 

c) Speaking of non-pharmacologic methods, do you have a working iPod you don't use?  Music and Memory NEEDS IT. Check them out: awesome stuff.

d) If you didn't see the documentary Alive Inside (featuring the work Music and Memory does: won the Audience award at the 2014 Sundance film festival), this stuff is pure genius, and so, so simple.  (I'd love to see a trial of using music to calm and comfort  patients with dementia.)

 

 e) Finally, because the Music and Memory videos above feature the wonderful Dr. Oliver Sacks, who died in 2015, I'm throwing this in: very much worth the short time it takes to read. Not dementia related, but we're in the Neuro block, and he was the world's sweetheart neurologist/writer. If I haven't gotten you teared up yet, keep reading.  "My Own Life: Oliver Sacks on Learning He Has Terminal Cancer."  "Above allI have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure."

That's all for this week. Share any thoughts or other #FOAMed resources you'd like us to know about in the comments.