Dealing with Dementia in the ED
What to do if you detect a person may have dementia?
An awareness that your patient has dementia will have an effect on each step of the ED process:
- Your ability to gather information (a cognitively intact 90 year-old will likely be able to give his own account of his medical history whereas for a 70 year-old with mild dementia you may need to involve other family or caregivers); perhaps the reason you are getting a “vague history” is because the person cannot REMEMBER their symptoms.
- Your ability to pursue diagnostic testing – the person with cognitive impairment may not be able to understand the risks and benefits of some investigations for which consent is required – eg. scans with contrast, LP, surgical procedures.
- Your ability to engage the patient in a treatment plan – the person with cognitive impairment may become frustrated with waiting and decide to leave – but may not have capacity to “leave against medical advice”; or may not be able to follow through on purchasing or taking prescribed medications or remember the instructions for wound care or head injury management .
- Your ability to establish a safe discharge plan – can the person even make their own way home? Are they at risk for “RISKS”?
Roaming /wandering;
Imminent danger – falls or fire-setting ;
Suicidal ideation ;
Kinship and relationships (elder abuse/adequate social support) ;
Safe driving Substance misuse, Self neglect,
Also if you are the first person to suspect or make a diagnosis of dementia, it will be helpful to that patient to pass the information along to his family doctor or even arrange referral to a Memory Clinic for further investigation. (If you detected that a person had deteriorating coronary artery disease, you’d refer him to an outpatient cardiologist, wouldn’t you?)
Discussion: Dealing with Dementia in the ED
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RISKS mnemonics are good
Do you think it is useful to have a geriatrician on staff on big center emergency departments?
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good info.
Using a poa is helpful
thankfully we have PT and casemgt in ED
PCP involvement
Very helpful
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great mnemonic
great topic
great information
good acronym
very valid- always need to ensure a patient is safe for discharge
good info
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very helpful
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There are patients that you run assess and some would give you the impression that there is a dx of dementia but surprised when the family confirms that there is not even though they also notice the different behavior issues that the patient has developed over a period of time. It’s important that these patients be assessed either by there gp or possibly a referral to a geratric assessment clinic.
thank you
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ol
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helpful mnemonic
I’ve seen pts in the ED with dementia symptoms but I’ve seen a diagnosis made.
Helpful mnemonic!
great information on discharge saftey
This is very help ful
good points on discharge safety
good acronym
caretaker support
there are clearly not enough social workers to assist with helping demented patients
agree
the importance of adequate planning to offer the best treatment for the patient
great thing
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…
discharge planning is so important
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yes
yes
very true
The Mneumonic: Risks was very clever.
I like that you compared dementia to cardiology. People forget that it is a disease process.
good review
Good review
Every ER should have GEM nurses who can help ensure that hess patients are as well supported as possible in the community
seek medical attention if found threat to patient or doctor
agreed
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Helpful
yes
great mnemonic
Fantastic mnemonic.
family involvement is key
helpful
Great mnemonic for patient discharge!
VARGA never new about this one.
RISKS gives important things to consider when thinking about discharge.
helpful
RISKS is great
I like the RISK
helpful
I like the RISKS mnemonic
me too
Muy bueno por que ayudaría a el cuidado del paciente con más apoyo familiar y conocimiento del médico de cabecera
It would definitely help getting further support and a geriatrician involved in the care of a new diagnosis of dementia.
Helpful
Helpful.
useful
useful
How true!
The acronyms are very helpful
another set of useful mnemonics to for assessing for dementia
agreed
RISKS is a helpful tool
so useful to summarize all these points in an easy and simple mneumonic
Helpful mnemonic – RISKS
Easy good reference
We have case managers stationed in the ED that are very good with dealing with these issues
RISKS is a great acronym. Good memory aide.
good criteria to follow when discharging pt, having community support teams like outreach program to help manage these patient safely would be an asset.
Gero-psych consults for these patients will be of immense help
yes
During day hours, we have a dedicated ED case manager to help with this
this can be difficult in busy ED
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It is always helpful to have collateral history to see if others have noticed changes in memory or cognition and how long this has been going on. It is a challenge if the patient does not have a primary care provider, to make sure further investigations occur.
We have great support, at least during the daytime when we see most of our older patients. Multiple levels of help and screening.
i think having GEM nurses in the Ed especially can increase quality centred patient care especially within this often overlooked demographic
Helpful, love the acronyms
helpful
Helpful!
very helpful
absence of resources care givers driving safety and mood disorders all have to be taken in consideration a referal to geriatrics will help as well
Very helpful points
HELFUL.
helpfule
make sure your information is passed along
easy and useful
like RISKS
interesting
I had not seen the RISKS mnemonic used before. Will definitely use that in educating other staff
After ruling out any possibilities of delirium, and dementia is suspected, we can do a proper referral so the patient can be followed for this matter and treated.
I deal with dementia pt’s as a paramedic in their homes as well as a practical nurse in the ER. Thorough assessments are crutial
911 patients often present with cognitive impairment and are poor historians. Assessment is difficult and thus unable to forward accurate events to receiving hospital.
safe DC home, sometimes need to involve social worker if ED has access to one
Great info
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Great mneumonic to remember in the context of safe discharge for a patient with dementia.
RISK Acronym is helpful
Process made infinitely easier when people have present and supportive family!
Identifying RISKS are very important
Detailed history taking from multiple sources including the family members and caregivers should be the initial approach followed by identification of RISK as mentioned.
helpful
I sometimes tend to neglect quizzing about indirect relationship risks, such as friends and secondary family members.
Helpful acronym
Makes you realize the safety issues associated with undiagnosed dementia
very helpfull
A family meeting involving nurses, social worker, OT, PT, and the doctor to involve family in making the best decisions in the hope of the best outcomes for their loved one.
That is a handy acronym. Thanks.
Communication is key. As others have already pointed out, contacting/connecting the patient to a primary care team/geriatrics/outreach team and of course communicating with whomever the patient identifies as their support is also key.
It gets more challenging when a patient is socially isolated and does not have a phone and declines follow up. What do you all find works best for such a vulnerable patient?
involving family and caregivers paramount
helpful
family or friend need assistance to understand and help patient
RISKS – very pertinent mnemonic!
If the pt with suspected dementia has poor or no family support, involving the inter-disciplinary team of social workers, placement advisors, PT/OT, even financial advise may be necessary.
proper assessment and family support
Multi disciplinary team approach best
patients may present with an advanced dementia, never previously diagnosed.
I would want to talk with family regarding referral to cardiologist, talk about dementia, this is a difficult conversation, not easy with first meeting with pt and family
Maybe need to talk palliative care rather than referrals and diagnostics.
excellent idea
educating family caregivers support groups enable community
complete the test and educate the family
Very helpful
🙂
This is helpful
RISKS is a useful aide-memoire to recall suicide risk
Yes, raising the suspicion and involving other health care professionals early can improve outcomes
This is helpful.
gem nurses are required
dealing with dementia can be difficult in the ED.
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This is a great are of the assessment and planning to involve GEM staff
All information should be faxed or made available to related caregivers
Touching base with primary care givers, assistance in community
Does having a GEM RN in the ED require or is it more helpful if you have a Geriatric program for them to ‘call home’?
Diagnosing in the ED is and important first step in the treatment process. It is imperative that this dx is communicated the the patients primary caregivers to ensure proper followup and positive outcomes.
mant docs would view it easier to ignore the diagnosis of dementia, as creating a clear follow up plan is not always easy
Diagnosing someone with Dementia is the first step,connecting with other resources is very important to provide and get the best results.
If the diagnosis of dementia is tentatively made in the ED it needs adequate follow-up with family re adls/iadls/poa/sdm and their family physician to assess the need for medications/ongoing monitoring/driving issues.
Determining patient’s POA or SDM is important for accurate history taking and obtaining consent for treatment. Education to families about what to expect abou the progression of the disease as well as providing AD society pamphlet are all very useful.
Also engaging elderly with dementia in Montessori methods (eg. playing cards) in ED is very successful
Every ER should have GEM nurses who can help ensure that hess patients are as well supported as possible in the community.
Closing the loop by calling the patients primary care provider is essential if anything is going to move forward for this patient. In most communities a referral to geriatrics is not possible from an emergency department
when the diagnosis of dementia is established the degree of it, the functional impairment it may cause the presence or absence of resources care givers driving safety and mood disorders all have to be taken in consideration a referal to geriatrics will help as well