Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities

OBJECTIVES Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) “serious game” to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN Prospective observational study. SETTING ED of a Canadian tertiary care center. PARTICIPANTS We included ED patients, aged 70 years and older, with a minimum 4‐hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%‐100.0%) and 59.7% specificity (95% CI = 52.3%‐66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77‐0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370–2375, 2019

supporting

confidence: 57%

Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium

Lee

Tong

Tierney

et al. 2019

“…(3) Can the patient stop participating in the study if he/she chooses? For patients lacking capacity to consent, consent was sought from a legally authorized representative. This approach adheres to current recommendations for obtaining consent from patients with cognitive impairment . After obtaining consent from either the patient or legally authorized representative, all individuals accompanying the patient were asked to leave the room to limit their influence on patient responses.…”

Section: Methodsmentioning

confidence: 99%

Ability of Older Adults to Report Elder Abuse: An Emergency Department–Based Cross‐Sectional Study

Richmond

Zimmerman

Reeve

et al. 2020

OBJECTIVES To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)–based screen for elder abuse. DESIGN Cross‐sectional study in which participants were screened for elder abuse and neglect. SETTING Academic ED in the United States. PARTICIPANTS Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses. MEASUREMENTS All patients completed the four‐item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients. RESULTS Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5). CONCLUSIONS In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170–175, 2019

“…Presence of dementia was determined according to chart review and direct query of the individual or accompanying persons. In individuals with history of dementia or a positive CAM‐ICU, consent was obtained from a legally authorized representative …”

Section: Methodsmentioning

confidence: 99%

Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department

Caterino

Leininger

Kline

et al. 2017

Objectives To evaluate the accuracy of emergency department (ED) physicians’, the Loeb criteria, and CDC guideline diagnoses of acute bacterial infection in older adults compared to a gold standard expert review. Design Prospective, observational study. Setting Urban, tertiary-care ED. Participants ED patients aged ≥65 years, excluding those incarcerated, traumas, non-English speaking, or unable to consent. Measurements Two physician experts identified bacterial infections using clinical judgement, patient surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines. Results Gold-standard review identified bacterial infection in 77/424 patients (18%): 18(4.2%) lower respiratory, 19(4.5%) urinary tract (UTI), 22(5.2%) gastrointestinal, and 15(3.5%) skin/soft tissue. ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with over-diagnosis. Physician agreement with the gold standard was moderate for infection overall and each infection type (kappa [k] 0.48–0.59), but sensitivity was low (<67%), and negative likelihood ratio (LR[−]) >0.30 for all infections. Loeb criteria had poor sensitivity, agreement, and LR(−) for lower respiratory (50%; k=0.55; 0.51) and UTI (26%; k=0.34; 0.74), but 87% sensitivity (k=0.78; LR[−] 0.14) for skin/soft tissue infection. CDC guidelines had moderate agreement, but poor sensitivity and LR(−). Conclusions Infections are often under- and over-diagnosed by emergency physicians in older adults. The Loeb criteria are useful only for diagnosing skin/soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.