Disease Severity, Volume Status, Cognition and Delirium in Older Patients in the Emergency Department, a Pilot Study

Objective: Cognitive impairment and delirium occur frequently in older emergency department (ED) patients and could be caused by low volume status and acute disease severity. Unfortunately, frail older patients can be difficult to include in clinical trials due to problems with informed consent and the burden of participation. To assess the feasibility and acceptability of obtaining informed consent, cognitive impairment, frailty, volume status and disease severity of older ED patients. Secondly, to assess disease severity and volume status in the patients with or without cognitive impairment and delirium.
Material and Methods: A prospective study including ED patients ≥70 years who were hospitalized with a suspected infection or hip fracture was conducted. We assessed the Modified Early Warning score (MEWS; acute disease severity) and inferior vena cava (IVC) collapsibility with ultrasound; low volume status. Primary outcomes were the feasibility of obtaining informed consent and the experienced burden. Secondary outcomes were cognitive impairment in the ED [4 ‘A’s test (4AT) score] and delirium (Delirium Observation Screening score) on the ward.
Results: Health-care professionals found the study feasible, and all 28 included patients experienced no burden. Eighteen of 28 (64%) patients had >50% vena cava inferior-collapsibility, despite fluids being hardly administered. Patients with a 4AT ≥1 had higher MEWS. Nine of 28 (32%) patients developed delirium during hospitalization, of whom 56% had 4AT ≥1 and all had IVC <2.1 cm.
Conclusion: The study was feasible and acceptable for health care professionals and older ED patients. Acute disease severity in these patients was associated with impaired cognition, which was highly prevalent in those who developed delirium during hospitalization. Low volume status was also observed in these patients.

Keywords: Fluid resuscitation, geriatrics, geriatric emergency medicine, cognitive function, delirium