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

Disclosures

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

Abstract and Introduction

Abstract

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.

Introduction

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]

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Table 1. Demographics of interview participants
Characteristic	n (%)
Gender
Female	8 (36%)
Male	14 (64%)
Practice setting
Academic	11 (50%)
Academic and community	11 (50%)
Professional role
Attending physician	8 (36%)
Resident physician	4 (18%)
Physician assistant	8 (36%)
Nurse practitioner	2 (9%)
Years practicing emergency medicine (range)
Attending physician	6–41
Resident physician	1–4
Physician assistant	2–17
Nurse practitioner	1–10

Table 2. Summary of themes and illustrative quotations
Theme	Challenges pre-pandemic	Challenges during pandemic
Limited availability of collateral information	"Sometimes you'll call a number that won't work, and then you call the second or third person down the list, and that's when you finally get more of a history." (Participant 106, Female resident physician) "One other challenge is that sometimes we're not there for EMS reports. Sometimes the ambulance gives the EMS report to the triage nurse and then drops the patient off and then you meet them half an hour later. (Participant 111, Male attending physician) "If they came from a facility, I call the facility. That's obviously a huge barrier. Generally, if it happened around the time of shift change, then you're in pretty deep trouble, because you will rarely get somebody who will know what happened." (Participant 109, Female resident physician)	"[COVID is] clearly a game changer. I mean, you just can't get families to come back to talk to them. You can't get them in the E.R. You can't." (Participant 107, Male attending physician) "There's not someone that accompanies the patient versus in the past, it was more like in your face, like somebody would be there saying, 'My mom's not acting right. And I brought her in today.' Now it's someone gets dropped off by EMS. There's often a pretty brief story. And we need to almost, you know, it's much more often that I find myself calling and getting more collateral." (Participant 108, Male resident physician) "So during COVID, the majority of our patients, even those who may be slightly altered, were unaccompanied, would come in alone, and therefore it would delay getting collateral information, sometimes by only 10 or 15 minutes, sometimes longer, depending on the availability of the primary caregiver, whoever is caring for them or lives with them." (Participant 116, Female physician assistant) "[Before the pandemic], I'd be able to get that data from them [family members] in real time when I took my initial history and physical." (Participant 112, Male nurse practitioner) "They don't call you back quick enough to make decisions before you get collateral … So it makes you be a little bit more aggressive, or maybe overtreat, over test." (Participant 123, Male physician assistant)
Concerns over reliability of information received	"I think it can be sometimes challenging to know if you're speaking with the best possible family member or person, or sometimes an elderly person has multiple children. One may be the sort of primary health care support … It's not always clear if the person that we're communicating with is, is the best source of information." (Participant 114, Female physician assistant) "Oftentimes when you call the person on the other end [at a facility], they don't know what's going on in the first place. And they were just covering for the regular nurse for the weekend, they were told. So that the information is highly questionable." (Participant 115, Male attending physician)	"If they're [caregivers are] not seeing them nearly as much because of COVID, they might have less information to be able to give anyway." (Participant 102, Male attending physician) "So I think I think we've lost some collateral, and I think both because the patients' caregivers aren't there, but then some of the family members are not seeing their loved ones as often. And as a result of that, they're not as reliable for collateral because they maybe haven't seen them and, you know, they're trying to stay away." (Participant 117, Male attending physician)
Language barriers with patients and caregivers with limited English proficiency	"I would say sometimes some of the more challenging conversations can be ones where there are multiple language barriers, where the patient has a language barrier, [the] family is not primarily English speaking. I think having a phone conversation through an interpreter is extra challenging because you don't get the nuances of facial expression and body language and things like that. And the interpreter that you're working with may not be able to." (Participant 114, Female physician assistant) "And then I think you lose the nuances of how people speak. And those nuances will sometimes tell you whether or not people are actually, you know, making sense, or that the story is consistent or, or if there are subtle signs of memory, difficulty that you're not picking up on." (Participant 117, Male attending physician)	"Thinking back to my [ED] shift a few days ago, I had three patients that were non-English speaking, elderly, demented. We didn't have any caregivers with them. It was a fight with triage every time trying to get the caregiver back, talking to them on the phone with an interpreter. I couldn't gather whether symptoms were new or chronic. We knew nothing about them. The patients are just so incredibly hard." (Participant 113, Male physician assistant) "Obviously, this is temporary and this is because of the pandemic, where the translator is only on the telephone." (Participant 115, Male attending physician)
Transfer documentation incomplete or insufficient	"Sometimes they [EMS] come with paperwork that gets lost and sometimes the paperwork is inadequate … It doesn't have everything that you would need, including like a [Physician Order of Life Sustaining Treatment] or something like that. So that can be really challenging." (Participant 111, Male attending physician) "Oftentimes there is insufficient information being sent. The only thing that we will get is a medication list and about insurance and contact information, but otherwise very little useful information, in terms of trying to formulate a clinical impression about the patient, in terms of what's going on." (Participant 112, Male nurse practitioner)	Not applicable
Time constraints	"You just don't have the time. And especially [as] one of the many jobs, I could have 11 patients." (Participant 105, Female nurse practitioner) "It's time consuming to spend, you know, minutes trying to search through a chart for someone to call, calling different phone numbers, not being able to reach somebody." (Participant 108, Male resident physician)	"It's just now with COVID, it takes so much time. Before it used to be that they would be, that somebody would be with the patient most of the time and you could just directly talk to them … Now they just come in by themselves and you have to call on the phone and it's just like an extra step. It just takes so much more time. Whereas you could have gotten all that information in your initial assessment of the patient—rather than trying to struggle through your initial assessment and then calling the family and having them tell you something different." (Participant 106, Female resident physician) "Those people are coming in alone more often and there is just an added hurdle or barrier to get some additional information. And that could just take additional time to kind of step out away from the bedside and make a phone call and get additional information, especially if the patient's very sick." (Participant 116, Female physician assistant)