Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool

Abstract

Twitter: @clshenvi.Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the inperson meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

Delirium prevention and treatment in the emergency department (ED): a systematic review protocol

“…The importance of delirium prevention and management in the ED setting is underscored by the inclusion of delirium recognition and management as a best practice in the Geriatric ED Guidelines, 43 a quality indicator for geriatric emergency care, 44 a core competency for emergency medicine residents 45 as well as by the recent dissemination of the ADEPT tool. 26 Although guidelines and core competencies reflect the expert consensus-based best practices in EM, high-quality research evidence to support ED delirium prevention and intervention approaches have been lacking. This review will address a critical need to synthesise research into delirium prevention and management in the ED setting to further improve the care of older ED patients with or at risk for delirium and create a roadmap for future researchers.…”

“…Recognising the importance of improved delirium evaluation, management and prevention, the American College of Emergency Physicians developed an electronic tool, the ADEPT tool, to help improve care provided of older adults with or at risk of delirium in the ED. 26 ADEPT stands for Assess, Diagnose, Evaluate, Prevent, and Treat, and is used as a checklist to aid in the care of the confused and agitated elderly patient. The purpose of this study is to better understand which delirium prevention or treatment strategies provide the most compelling evidence of effectiveness and feasibility in ED settings.…”

The agitated older adult in the emergency department: a narrative review of common causes and management strategies

“…Once the diagnosis of delirium is made or suspected in a patient, it is important to look for an underlying cause 39,40 . Delirium can occur due to environmental factors, such as a new living environment or lack of visual or hearing aids, but it most often has an underlying medical cause such as dehydration, electrolyte disorders, infection, medication side effects or interactions, cardiovascular disorders, neurological problems, and trauma.…”

“…The diagnostic workup should be guided by the findings on the history and physical. When the history and physical do not yield a clear cause, it is reasonable to cast a broad net including an electrocardiogram and laboratory tests including a complete blood count, complete metabolic panel, and urinalysis; neuroimaging should be reserved for patients with signs of trauma, focal neurologic deficit, somnolence, and/or on anticoagulation 40 …”

“…39,40 Delirium can occur due to environmental factors, such as a new living environment or lack of visual or hearing aids, but it most often has an underlying medical cause such as dehydration, electrolyte disorders, infection,…”