Evaluating Older Adults With Cognitive Dysfunction

A Qualitative Study With Emergency Clinicians

Anita N. Chary MD, PhD; Noelle Castilla-Ojo BS; Christopher Joshi BS; Ilianna Santangelo BA; Christopher R. Carpenter MD, MS; Kei Ouchi MD, MPH; Aanand D. Naik MD; Shan W. Liu MD, ScD; Maura Kennedy MD, MPH


J Am Geriatr Soc. 2022;70(2):341-351. 

In This Article

Abstract and Introduction


Background: Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic.

Methods: From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10–20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive–inductive approach. Responses regarding experiences before and during the pandemic were compared.

Results: Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic.

Conclusion: Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.


Older adults presenting to emergency departments (EDs) commonly have acute or chronic alterations in mental status.[1,2] About 35% of older adults seen in the ED have cognitive dysfunction, which refers to mild cognitive impairment, dementia, or delirium.[3] People with dementia have disproportionately higher ED use, with one study suggesting that over half of adults with dementia visit the ED annually.[4] Delirium, or acute brain dysfunction, is not detected in about two-thirds of ED cases.[5] Understanding a patient's baseline cognitive status is essential to differentiate these conditions.

In evaluating patients who may not be able to provide an accurate history, emergency clinicians often rely on information from family, caregivers, or residential care professionals about a patient's baseline mental status and the acute concern triggering the ED visit (i.e., collateral information).[6] Collateral history-taking is a common practice in geriatrics inpatient and ambulatory care; however, little is known about clinicians' experiences obtaining collateral information on older adults in emergency care, which is unique in its relatively short timeframe for patient engagement as well as its role in establishing an older adult's care trajectory during acute illness. During ED visits, collateral information is not always readily available from caregivers and referring providers.[6] One study found that baseline mental status and reason for transfer were absent in transfer documentation to the ED from residential care facilities for 75% of patients.[7] Lack of collateral information can lead to delays in establishing diagnoses, recognizing delirium, using delirium screening tools that require caregiver input,[8,9] and differentiating delirium from dementia.[5] The COVID-19 pandemic has greatly exacerbated these challenges,[10] with hospital visitor restrictions leading to bedside absence of caregivers.

We sought to understand emergency clinicians' experiences of obtaining collateral information about older adults with alterations in mental status, both before and during the COVID-19 pandemic. This research focused on understanding the challenges clinicians face. Such understanding can improve geriatric emergency care and ED detection of delirium, in line with current priorities in geriatric emergency medicine.[11,12]