Mr. and Mrs. Lowe
You pick up the chart for Mr. Lowe, a 78 year old man. His chart reads “Anxiety/Multiple Complaints”. The nurses notes show he has normal Vital signs. Mr. Lowe’s physical exam is unremarkable and in addition, his blood work, ECG/cardiac markers and CT abdomen all show normal results.
- Watch the video below and answer the questions that follow.
- What do think is missing from this assessment? What would you do differently?
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Outcome
This patient went home and that night took a mixed overdose of all his medication, spent seven days in the ICU, and eventually required long-term care because of his hypoxic acquired brain injury. A legal action was commenced by his family.
- What would happen if you took 30 seconds longer with this same patient? Watch the video below for an example, and answer the question that follows.
- What do you see the doctor doing well here?
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Outcome
This patient was referred for emergency assessment by a psychiatrist. He was admitted to hospital on an involuntary basis because of his high suicide risk. He started on anti-depressant medication, and was followed by his family doctor after discharge to the resolution of his depression at six months. He later sent a note of appreciation for the doctor’s compassionate care.
Important Concepts
- New mental status changes (in this case anxiety) are not normal at any age.
- A significant change from a person’s baseline (in this case increased anxiety and psychosomatic pre-occupation) need further exploration because it may be a symptom of significant even life-threatening disease.
- Anxiety and a preoccupation with physical symptoms are common symptoms of depression in the elderly.
- The elderly are the highest risk group for completion of a first suicide attempt in depression
Discussion: Mr. and Mrs. Lowe
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What would prompt you to screen for cognitive impairment?
– caregivers concerns, vague answers, sudden change in function without explanation
How would you do that?
– ask mroe questions, rule out other causes
– focused assessment
What tools would you use?
– MOCA, mini-mental
How do you know if someone has cognitive impairment?
– relying on history, physical and collateral information – if concerns raised by pt, caregiver, or phsyician likley needs to be pursued
make a complete history with the patient, validate the information with his wife
Asking patients in a standard manner “how do you find your memory (or thinking) is?” and then asking a family member or someone with the patient “how do you find it” a very nonjudgemental ways of introducing it. If there are flags or indicators I may do something more formalized like a Mini-Cog.
I agree, It is important for patients feel they are in a safe space to discus concerns in open and non-judgmental way
agree
solicit patient and caregiver concerns, ask about changes in mood/behavior/cognition. I personally start with bCAM screening or DTS to assess for delirium, and if that’s negative I have done Mini-Cogs and PHQ2s. In the acute care setting, my main concerns are delirium and depression. While we can suspect underlying dementia in many cases, often it is best to re-test these patients 6-8 weeks after their acute care stay and ensure connection with good outpatient follow up.
From an ER prospective, we care about the reason why this patient has these changes. Was there a traumatic event, chronic underlying issue that is not addressed? How long has the insomnia been going on. Mini mental exams are very limited , mostly stroke oriented.
I agree. its so important to take the time to throughly assess these patients. Not just for delirium/ early signs of cognitive impairment but for mental health issues as well.
assess caregiver opinion, acute change in mood, behavior, screen patient’s mood and suicidal ideation
!Ask more questions, consider other non-emergent reasons for concerns and utilize the CAM scale. !!!
!Ask more questions, consider other non-emergent reasons for concerns and utilize the CAM scale.
Ask more questions, consider other non-emergent reasons for concerns and utilize the CAM scale.
Ask more questions, consider other non-emergent reasons for concerns, utilize the CAM scale.
Ask more questions, consider other non emergent reasons for concerns, utilize the CAM scale for delirium and use MMSE/MOCA for cognitive impairment.
Ask more questions, consider other non emergent reasons for concerns, utilize the MMSE/MOCA for cognitive impairment
Consider the Geriatric depression scale and utilize the CAM for delirium
agreed
Ok
more probing questions with patient and partner elicit valuable information
ok
better assessment asks caregiver opinion, establishes acute change in mood, behaviour, screens mood, suicidal ideation
good idea to do more detailed screen of mood, suicidal ideation and ask partner’s prespective
Many EDs have a standard MH/suicide risk assessment in the triage process.
good
Mini cog, MMSE, Further metabolic workup
Ok
Good
Herramienta: Mini-Cog
Involucrar a la familia
Cuanto ha deteriorado y el tiempo en el que lo ha hecho
Realizar un acrenning que se adapte a los servicios de emergencias como CAM, además de involucrar a los familiares
history of other used medications
assessment of cognitive by asking about orientation
I know I have to screen for cognitive impairment the moment his caregiver explains he has changed his usual recently, there are various tools to do so, I’m not sure which one is best in this particular case.
I would have conducted a more thorough assessment if the pt had a flat affect, appeared more anxious or if family had concerns like this pt’s wife. I would have screened the pt for risk of suicide or homicide. You gain can for more information by asking open ended questions which forces the pt to elaborate.
Good History taking goes a long way
Mini Mental Examination, MOCA, SLUMS test
need to use others to gather information about the state of mind of the patient. also need to acknowledge the patients concerns, as did this physician, without blatantly stating that something is wrong with his thinking.
Agree.
Would first acknowledge patient’s concern
Then would use open ended questions, be empathetic
would build reapport and use some screening tool
agree
The patient had new symptoms of mental anxiety. A cognitive screening tool
MMSE/MOCA for cognitive impairment
Geriatric depression scale
CAM for delirium
agree
good interaction with family members adds significantly to history taking
If family member states acute change of behaviour, or somatic-type symptoms have negative workup, I consider cognitive/mental health screening. Depression – PHQ-2, then PHQ-9. Dementia MMSE or MOCA, or mini cog (clock drawing, three word recall, world backwords (and forwards!)
labs suicide and depression screening
I would screen with multiple methods, imaging /labs
Any change in a patient’s behaviour, mood, thought process, activities of daily living, etc.
Sometimes it takes listening just a few extra minutes to a patient’s concern to figure out what is going wrong
any changes in personality or cognition should prompt questions to wife and overall a deeper dive
Lack of detail. Wife’s concern. Vague complaints.
I would be prompted to assess for cognitive impairment if the patient is presenting strangely, confused, not normal in themselves and especially if there were family concerns regarding how they are personally. I would initially complete an AMT4 as this is quick and easy to do in the ED. If they drop any points this could be an indication of CI however further assessment and investigations would be needed.
agreed
Patients who describe a “big change” in non specific ways, focus on physical symptoms even when “medically cleared”, persist with multiple presentations for the same symptom, or if family/friends have concerns.
I will be prompted to assess cognition if my patient appears incoherent or behaves in a way that does not seem right. Other things that may prompt me to assess cognition would include patient’s appearance, relative concern. I would use CAM for my assessment and maybe MMSE if dementia is suspected
based on the patients responses I would be inclined to ask him about mood changes. as a result I could use the PHQ-9 or BDI questionnaires for a thorough workup including labs and other investigations.
i would be prompted if patient seemed to not be answering my questions correctly or with confidence
I think just passive observation and active listening to patients and their family members can prompt a screen for CI. I would use tools like MOCA or CAM.
amt4 or minicog
when no organic etiology of symptoms. Irrational worry.
changes in mental status, vague sympthomps and lack of resolution/reassurance w/ normal workup should prompt us to think of cognitive impairment
Empathic listening is key here
Gross cog. deficits on MMSE provide clues for cog. deficits. Mini-Cog. Reliable collateral. Rule out reversible causes for confusion/ cog. changes.
ok
Takes a little time. Often limited by available resources in the ED.
extra time to listen to patients and carers would give us a better insight of what is really happening to them
– Concern from family members
– Unkempt appearance or concern of state of house by SJA/family
– CAM
A history from a loved one stating that they’ve noticed decline at home.
change in baseline, MMSE, Psychiatry Hx
unkept appearance, vague answers to questions, confusion
Good video- always should be digging deeper into new anxiety in the elderly- it is not normal.
good video
Addressing patient and family concerns and looking for possible underlying mental health disorder if no other etiology for symptoms are found.
collateral history with by involving family members, carers and family physician.
Concise testes like 4AT score.
Concern from family member or signs from an interaction. I would use tools such as the MoCa, which may be positive if there is cognitive impairment.
ok
Use the Mini-Cog, a validated tool to prove basic impairment.
ok
Listen to what the patient and family are truly worried about. Ask every patient questions to determine their level of cognition. When there has been an acute change I would want to focus on that change and determine the underlying cause.
repetitive questions/answers, concerns from family/caregivers or nursing staff
standardized screening can help mitigate this and change the culture of what the ED teams focus on during a visit beyond the acute issue. covid has made having conversations with family etc more challenging
ok
.
listen for cues from patient and family, ask about day to day activities to assess how they have been managing at home, can often raise suspicion for cognitive impairment if let the patient talk long enough
I check mental status in the elderly question by asking open questions, exploring context and if I pick up clues that my patient might have cognitive impairment, i ask more specifically about orientation, praxis etc
significant changes with comprehensive approach
.
Ok
ok
.
none
Do minicog in the and CAM for delirium. For mood geriatric depression scale
ep
mmse and safety screening for each patient over 65 by nurse on intake
I would assess for cognitive impairment if there is a change in his daily activities of living. Assess for anxiety and depression and the severity. I would employ tools as suicide risk assessment, CAM ,Mental Status Exam. I would have a high index of suspicion if the patient has a change in baseline characteristics and functioning together with a mood disorder.
MMSE could have been used as a screening tool. family members concern should not be ignored.
Try to avoid rushing, gather thorough info at beginning- may save time re ultimate dispo
Any recent change in an older person’s behaviour , thorough history from close family member to be done. For cognitive assessment and screening for depression, anxiety and risk assesment needs to be done
Family input is important. MMSE or another tool to assess cognition. All these assessments don’t matter if you don’t talk to the patient and get look at them. Asking them about their family or support.
Confussion, weakness, or family concerns in elderly. Complete minicog assessment
A family member’s concerns should never be ignored.
agreed
agree
validating the patient’s concerns is important
agreed
less is more, using our eyes and ears before our mouth, eliciting a persons concerns and hopes at the beginning can avoid a lot of unneeded and expensive investigations, use discriminatory clinical questions to direct lines of enquiry or thought while assessing alertness, attention, awareness and affect
I use minicog with discriminatory questions from CAM, GDS and MOCA
Good
History of a new change in the mental status of the patient. CAM and MMSE tools should be completed.
good
Vague answers, confusion would prompt. Use CAM, MMSE.
Again patient needs further eval of cognitive function/prob eval by psych
Mini cog/MMSE/further metabolic workup
Good
seeing changes from the baseline assessment
Subjective change according to the patient. Further investigation is required.
agree
What would prompt you to screen for cognitive impairment? How would you do that? What tools would you use? How do you know if someone has cognitive impairment?
Any change in an older person’s mental state should prompt a screen for cognitive impairment. This could be in the form of confusion, inattention, aggression, depression/anxiety, perseveration over physical symptoms or ALOC.
I would use the CAM tool given its highly positive and negative LR when undertaken by a physician.
The diagnosis of cognitive impairment can be based on personal and collateral history followed by findings of a formal screening tool.
Agree with above
I need to personally review the various screening tools, but with the 3 cases above , the key seems to be really listening, getting collateral , taking a little extra time.
really addresses the importance of digging a little deeper, especially when no obvious cause is identified after what sounded like a very involved work-up.
This case was simpler; just asking the patient’s wife what was going on provided the crucial clue and led to the correct diagnosis. If the patient had been alone, it would have been more challenging, but the physician asked the patient all the right questions as well.
good point
agree
agree
hreat
I would do a 4AT, MMSE and GDS
One take home point for me, is that in the ER, sometimes the volume of patients that are there to be seen can be so overwhelming but as noticed in the videos, when we spent that extra time asking the right questions and probing, the solution was simple. I think when dealing with elderly patients, being very observant as it related to changes in their behaviors, mood and mental state are vital for picking up on cues that would indicate some cognitive impairment.
Excellent point.
Agree
Elderly patients seems to pose a fast paced department. The doctor’s in an ER setting have the challenge to gather as much information from a situation whether it is a coherent patient or someone unconscious to combative or catatonic, to young or elderly. Elderly patients on a whole become the famous saying ‘once a man,twice a child’ as they become more dependent on others to assist in everyday routines. Care and time must be invested in each elderly patient as they are usually ignored with subtle changes missed. Excellent presentation in the videos.
Changes in behaviour and baseline mental status should prompt further investigations invloving family members and care givers who are familiar with the pt will help establish timelines and provide better treatments plans/goal outcomes
agreed
.
The doc picked up the cues in the second video
agreed
The doctor picked up cues in the second video
I liked the video
…
What would prompt you to screen for cognitive impairment? Patient describing behaviours that might make you worried for cognitive impairment (change in behaviours, mood). If family is expressing concern, if patient themselves is concerned. Could think about it in older patients, especially if they have certain comorbidities (e.g. HTN for vascular dementia)
How would you do that? Could start with the Mini Cog and if there was any abnormalities, consider a more fulsome screening tool (MOCA, if time allowed) OR engaging specialists for consult.
How do you know if someone has cognitive impairment? A combination of screening tools, history from patient, and getting collateral.
I agree with your comment
.
Good info
geri-vet consult
Screens for mood disorders are super important, and should be accompanied by screening for cognitive impairment, particularly in elderly patients.
Ideally, all patients should be screened for cognitive impairment. However, this should definitely be done more frequently in elderly patients. Performing a quick assessment with the mini-cog would be beneficial.
agreed
Ideally it should be performed in all elderly patients presenting to the ED. In the UK, 4AT is a quick screening tool for this (as time is always a problem). Co-lateral history is especially important as delirium is fluctuant and the patient may appear ‘normal’ at that point in time to the physician.
Agreed
I would screen for cognitive impairment in adults over the age of 65 years old and are showing symptoms of cognitive impairment.
MD needed a full assessment once patient stated he had means to hurt himself. I am glad to see he kept him in the hospital. Hopefully on a suicide watch.
take into account family concerns, “not quite right” as a red flag
minicog
mini mental exam
would do CAM and mini-cog
Patient has risk factors for delirium including his age, gender, and overall presentation. Can screen for delirium by asking patient to tell you months of the year backwards or spell WORLD backwards, assess if patient is AAOx3, GCS, CAM.
Any changes in memory/mood in an older adult. I would screen for both depression and cognition (MOCA/MMSE)
I believe the provider should use specific appropriate assessments such as Mini-Cog. He could also spend more time in discussing symptoms with the patient himself along with his wife.
Agree
agree
ok
agreed
Patient’s forgetfulness.I will use the mini cog initially and then follow-up with either the MMSE or MOCA as screening tools.I will then screen for depression by using the Beck’s Depression Inventory or the Geriatric Depression Scale.
I would screen for CI if the patient presents with complaints that don’t make sense or fit with a unifying dx. I would screen for CI if patient appears disoriented. Other clues would be family members talking about patient “not being themselves” or having more trouble with things they used to be able to do.
screen for new findings/ change in condition
yes
Anyone giving a vague information about self and the reasons and circumstances of their presence in the health settings. The age of the patient is an element that can also help to place special care in discovering cognitive impairments for its overall implications in in the diagnostic, management, discharge plan, self care and future compliance with the treatment.
Very well done
this shows me the elderly need more care
Ask the spouse about any changes in behavior. Use screening tools such as any depression screening. was helpful to have family at bedside to help with cognitive impairment but spending more time with the patient and reviewing the chart to see what baseline is can help.
The spouse seems concerned. Mini Cog?
any change in mental status or change in baseline function would prompt me to look deeper into cognitive function and same can be assessed in the ER setting using the Mental Status Exam questions and open ended questions to gather more information as to how the patient feels or what are the biggest concerns.
great
agreed
I think the main thing would be any clues to cognitive impairment that is new – main source being the information given by the wife
Completely agree. Allow ample time for responses. Use appropriate assessments.
This patient was high risk and could have easily been missed if we don’t ask the right questions and treat them as a higher priority
I would screen for cognitive impairment by asking simple questions that would assess the patient’s awareness of the situation.
Acute change in mental status, including mood such as anxiety, would prompt me to perform a cognitive assessment on Mr. Lowe. I would start my asking simple orientation questions, such as person, date, location, situation, and then perform a more thorough assessment with the b-CAM or MMSE. Given wife’s concern for anxiety and depression, performing a thorough psychiatric evaluation with history and SAD-PERSONS scale would be a good start. Given his high risk for self harm, an emergency psychiatric evaluation is appropriate.
agree
What would prompt you to screen for cognitive impairment? How would you do that? What tools would you use? How do you know if someone has cognitive impairment?
Any patient who has family/caregiver concerns over pt behaviour and report that it is not normal for the person. Also, when speaking to the patient if there are any signs of confusion or disorganized thought without any history of cognitive issues. In the case above, mental health needs to be considered as a cause for cognitive impairment. Using the CAM or MMSE would be a good starting point. In the case above the pt demonstrated signs of depression and simple questions about self harm were answered honestly, this will allow for the pt to stay safe while he remains for mental health assessment.
Discovering if someone has cognitive impairment hinges heavily on finding out if this acute or chronic and the persons state of health and history. This will often need to be done through consultation with family/friends/caregivers.
mmse
use the MMSE
use the MMSE
yes
Doctor didn’t take mental health issue in consideration at all.
Pt, if anything looks very depressed and concern, There is a hx of anxiousness as well
Yes MMSE needed to be done but at least K 10 or DASS as well.
Call mental health for help and opinion in E&A
Also is he suicidal or homicidal Risk assessment needed to be done
Hx of previous Mental health issues if any…
medication hx
MMSE
I agree with many of the comments. The physician needs to keep in mind what the patient’s baseline is and consider the timeline of events.
evaluate mini cog and mmse. just give them time and try to see if they have stm loss
further assess; mmse, cam, etc
exactly
Great assessment by the physician when the wife addressed “this is not my husband”. Asked appropriate and nonjudgmental questions.
Prompt was when the wife said “this is not my husband.” Screen by asking the patient questions. Use mini cog. Impairment based off his answers and behavior.
mini cog
using or obtained collateral
pay attention to patients posture, facial expressions, eye contact
agreed
Address patient verbalized symptoms.
Any new mental status changes reported by HCP, patient or family/friends would prompt further assessment into cognitive impairment and differential diagnoses for delirium, dementia, and depression.
We need to take the time to listen and look at patients, especially if they are at risk for harming themselves. Simple questions that ask about thoughts of harming self, or tools for delirium/dementia such as the CAM, memory questions, talking to family members.
mini mental status exam
already done
it seems these types of patients are not “true” emergencies which could make it easier to overlook the potential for self harm.
It seems like the older population gets written off a lot easier than the younger generation.
very sad that our society now days doesn’t listen to those who have been there done that.
minicog
This patient demonstrates many symptoms suggestive of depression and requires psychiatric evaluation.
He does well in the second video to respond to concerns of family member.
However, he could have done more to better assess the situation.
Provider needs to have a more in depth systematic approach; more eye contact and observations to identify abnormalities
Would do MMSE and Columbia. Do full assessment and involve family to ensure that he is safe.
What would prompt you to screen for cognitive impairment? How would you do that? What tools would you use? How do you know if someone has cognitive impairment?
During visit if patient displays any vagueness, or concerns or if family expresses concerns on behavioral change. If patient brought in my first responders or neighbors and displays any vagueness, poor judgement then would prompt more thorough assessment.
Through examination, focusing on neuro exam
Several tools; MMSE, IQCODE, Isaact Wet Test, Functional Assessment,Geriatric depression score, Labs, Imaging to r/o other causes
Well said
-Any inconsistencies/vagueness in pt history during the interview, family concerns,
-Have a conversation with the pt, CAM screen, MMSE, clock drawing test
-Keep CI in the back of your mind when treating elderly pts, it might not always be obvious so at least if it’s on your radar, then you are less likely to miss the diagnosis.
Primeramente explicaría el lenguaje y la atención del paciente así como signos de alteraciones en cambios agudos de conciencia, o cambios crónicos, apoyados en la historia de la familia también, revisar notas anteriores y si usa medicamentos en el hogar
It’s important to address family members concerns and take the time to go into more depth with the patient. It is easy to overlook cognitive and psychiatric problems in our aging population with complicated medical histories.
Simple questions
Look to family for help if cognitive impairment is new or old.
Love the video comparisons
it can be difficult to identify both the physiologic and psychological components of vague complaints. I am often hesitant to ascribe a patient’s symptoms to anxiety or worry prior to a thorough medical evaluation.
good easy to understand
What would prompt you to screen for cognitive impairment? How would you do that? What tools would you use? How do you know if someone has cognitive impairment?
You would need to spend time speaking with them. Garnering their level of consciousness and orientation. You would need to know if there have been any acute changes or if they were progressive. You would use assessment/screening tools to help determine. Positive signs from screening tools as well as patient history given by family or close loved one (in the case the patient themselves cannot answer).
Thanks!
thanks!
Any older adult with a presentation/hints on history that would suggest CI on history eg. confusion, disorientation, word finding difficulties, behavioural/psychiatric symptoms, etc. Through MiniCog in ED, MOCA in office, CAM if concerned about delirium.
Agreed!
If a patient seems confused, inattentive or disoriented, or if a family member mentions cognitive changes. You can ask open ended questions, investigate cognitive changes, ask about mood, and use tools like CAM or MMSE.
I agree!
agree
great responses everyone. I agree with what is being said! Incorporating change in cognitive impairment should be done for all pt’s!
I agree with this
using MMSE tool
Use CAM and also determine if the patient is alert and oriented. If not then do further investigation.
I would screen for cognitive impairment by asking simple questions that would assess the client’s awareness and orientation.
I would screen for cognitive impairment by asking simple questions that would assess the client’s awareness and orientation. Difficulty answering these questions will lead me to further assess the client using the MMSE. Also asking the family and other direct health care staff on the history of the client.
Question for Discussion: What would prompt you to screen for cognitive impairment? How would you do that? What tools would you use? How do you know if someone has cognitive impairment?
The patients physical behavior is closed and guarded, he is focused on physical symptoms and vague in his answers. he would start with the Phq9 then Columbia screen in the ED, if + going to comprehensive suicide screen would all have been done prior to this conclusive encounter. phq9, ccss, css, delirium triage screen, and the brief cam. Unable to complete simple assessments such as spelling of answer orientation questions. also pts ability to describe how they complete their adls
I screen nearly every single patient using the AVPU scale and GCS. Additionally, I attentively listen to the patient especially when they are talking about mental health symptoms and screen for suicide risk. The CAM tool is regularly used where I practice to screen for mental status changes.
agreed
Important to always keep CI on your differential. Screen anyone who is vague, makes poor eye contact, is unable to answer questions appropriately using an MMSE, clock draw, orientation.
More recent downward trends in cognitive changes that represent a significant alteration in function.
-recognizing flat affect, reduced ability to converse with open questions, simply answering yes/no
-inquiring about home life, family members, home supports and social supports
-using standardized tools such as the MMSE, MOCA, CAM assessment to clinically assess for presence of cognitive impairment
-performing simple neuro assessments to assess baseline neurological function
i would also use the assessments listed above as they would be very thorough in examining the client’s condition and could better individualize the care provided
agree
Using mental health assessment or CAM assessment. We can recognize people with cognitive impairment by their mood, feelings and especially change in their mental status.
Very important to corroborate or differentiate evidences from the support network. Really helps to prompt the pt to respond and express themselves. Family medicine practice at it’s best. Much better approach in the second video!
The patient’s disposition is already concerning for potential psychological involvement – i.e. his anxious state, his flat affect – but I think even if this were missed, when there’s a disconnect between physical symptoms and exam findings/investigations, it’s worth considering a psychological component to the presentation. I’d screen with PHQ-2 and GAD-2 to start, with plans to use more comprehensive assessments if positive, and with the possibility of also doing an MMSE if there’s any question of cognitive impairment.
great in-depth answer! great understanding of the video
MMSE is a great tool.
listening to the patient complaints and the concerns at home by the spouse would lead me to assess patient using Mini Cog/ GEM/ mental health screen. Would do referral for patient to see Geriatrician.
Quick MH referral & exam was just what this patient needed.
Mental status should be assessed on all patients arriving to the ED. Using the CAM et. Also all patients should be asked if they are feeling depressed or have suicidal thoughts. Part of standard care
I agree
Agree
Patients with lack of orientation or confusion should have further investigation with screening tool such as MMSE
MMSE
na
MMSE, depression screen,GEM
Use available tools such as CAM.
agree
Including a mental health assessment on all ED pts is important.
Including a mental health assessment on all ED patients, regardless of age, should be done.
depression screen
a comment
patients who seem strangely reserved, present with a range of symptoms from multiple systems or are frequent flyers to the ED with a myriad or complaints and after thorough work-up nothing significant found should be screened for cognitive impairment or psychiatric illness. MMSE and PHQ-9 are good scores
if the patient seems disoriented/altered you should always perform a MMSE. There are other simple tests that can be done such as MOCA and memory testing. the results of these simple tests can help you determine if a patient is cognitively impaired.
disoriented, change in mental status. MMSE
MMSE, depression screen, talking with family members
minicog.
GEM assessment and followup referral care is needed.
Depression screen
Yes, using appropriate screening assessments for older patients is necessary
true
Patient’s presenting with a history of “forgetfulness”, recurrent ED visits, delayed answering during the history would require congnitive screening. I would use the Ottawa 3dY or the Six item Screener in the Emergency Department.
interesting differences
Change in baseline behaviour, altered cognition or level of consciousness. I would assess by starting with a mental status exam during the interview.
I would ask his wife about any changes in memory or function and ask the patient some simple questions to assess orientation and short term memory. I would then do a mini cog.
I would screen for cognitive impairment if the patient has memory loss, is found wandering and I would use the mmse or mimi cog test
Inconsistent answers, family member doing all the talking, concern out of keeping with presentation; screen with open ended questions, starting with the patient; focus on timelines of symptoms/changes; screen with basic cognitive tests first, then more complete (and engage geriatrics if available); consider….date/time, world backwards, clock drawing, short term recall as a screen.
It is so easy to handle physical problems that once the tests results are good we assume that will bring comfort to the patient. so looking futher for clinical signs of emotional distress is of great importance. simple things such as posture and tone of voice after good news my be things that trained clinicians may need to pay attention to.
I listen to the family or regular staff (if pt. is in a nursing/retirement home) to find out if there is a difference in the pt’s mentation, or something in their story that does not seem to make sense to me. What is different, when did that occur (symptoms/hx since time of change, ie fall). For acute changes R/O delirium–using CAM and diagnostic tests–watch for inattention. For slower, progressive changes I would use dementia screening tools, such as mini cog/MOCA. Ask if there are any changes in medications or dosages. When possible always ask the patient first about their concerns, before getting a corroborating/differing history from the family, they are the ones that can usually supply you with a baseline. This baseline is essential to determine if there is cognitive impairment,changes from pt’s normal.
Always conduct a mental status exam and address psychosocial concerns. Anxiety and SI can occur at any age.
agreed; and open ended questions.
Inconsistent answers or answers out of context. repeated concerns despite “answers”
Doing a cognitive assessment, or asking to have geriatrics involved would benefit
agree
assess support network and pursue further questioning
he’ll be prompted to look for cognitive impairment given the patient’s depressed mood, and that he seems to forget that they have been progressing all of his physical complaints. Performing a Mini-Mental status exam and asking questions about his mood would be the ideal way to pursue it
Important to be receptive and dig further when family or patient note a significant change in status (even if nothing objective to see as the provider)
vague
start with more simple questions
Picking up on non-verbal clues, observing body language, memory etc.
agree
true
Picking up on non-verbal clues, observing body language, memory etc.
agree
yes
Agree
useful info
helpful
1
11
If there seems to be unclear answers and communication with the patient, I would screen for cognitive impairment. I would do that by asking open-ended questions so that I can get a bigger picture of the patient’s status and find an underlying concern.
Agreed
I would involve the patient’s family, for instance his wife, to gain more information about the changes in behaviour.
agreed
I would assess for cognitive impairment by exploring changes in the the persons routines and abilities
agreed
I would be prompted to screen for cognitive impairment when a patient seems confused or the family is worried that the patient is acting differently. Although it does take more time, an MMSE or MOCA would be useful. Also, asking the patient and their family about recent changes is helpful. A quick screen by asking the date and place, spelling world backwards could be helpful as in one of the videos.
To assess for cognitive impairment I would ask the client or the support network whether they have noticed any changes in the patients behaviours.
agreed
agreed
Difficult to do in the ER setting
Whenever I think patient has a cognitive problem then ask Q time,place,person
What happened? Is often helpful
MMSE and MoCA are good tools in assessing cognitive impairment but MoCA takes significantly longer; depending on resources available, setting aside 10 minutes to do MoCA would be ideal but I think it would also be acceptable to do MMSE or a shorter screen if they can follow up with primary care for further screening and planning, which also establishes good continuity of care.
In this case his mood symptoms clearly took the forefront and the doctor was correct to screen for acute psychiatric concerns primarily.
What would prompt you to screen for cognitive impairment? because they are older patients, they are out of normal, they are worried that they is something out of the usual.I would use the mini cog test
What would prompt me to screen for cognitive impairment are his complaints and the level of anxiety they are causing him to feel. I would assess his symptoms, what his mood change is like with the help of his spouse to get a full picture. CAM and MSE.
use MMSE
very good
this is sillyu
not sure about this
agree with comments
helpful
Agree with comments.
Just taking the time to assess the patient and address the concerns of patient/family
I would be prompted to screen for CI in any older adult w/ reports or concerns regarding memory, mood or behavior. I like to use a CAM to do a quick scan for delirium, and then typically use the MOCA to formally assess for CI. I would diagnose CI w/ a MOCA score representative of this as well as absence of other possible causes of change in cognition.
Any change in mood can hint at cause or consequence of cognitive impairment = importance of evaluating cognitive function when changes in mood occur. Use of MMSE or MoCA for cognitive function, use of CAM is delirium suspected.
any cognitive impairment, CAM assessment, history from family or facility
If I, the patient or entourage of the patient notices a change in mental status (decline in memory, in attention or anxious/depressive symptoms), I do a timeline of the symptoms and question further to search for causes/risk factors. Then physical exam appropriate to the history. Then screening tool (MMSE, MOCA, CAM, Clock) and workup (labs, scan if needed).
changes in mood and increased anxiety.
When the relatives detect a change in the patient like mood, forgetfulness, depression, those things may prompt me to further investigate. It is important to get the supplementary history from those who interact with and live with the patient as well as the patient themselves. Incongruent histories of the presenting complaint could then also be a red flag.
Assessing the cognition may require baseline tests like bedside blood glucose, serum electrolytes or other investigations such as the Confusion Assessment Method (CAM) especially for the delirious patient, Mental Status Exam (MSE), Mini Cog with 3 word recall and Clock drawing, Six Item Cognitive screening test as well.
These can have scoring systems that would make the physician lean towards a diagnosis involving cognitive impairment.
Don’t ever rush in your history taking. His mood problem was “written all over his face and posture” – tune in and listen to what the real concern is
don’t rush to diagnose
Establish baseline cognitive function by MMSE or mini-cog. Be aware of relatives concern and body language following consultation of both patient and relative.
A quick screen of cognitive state can be done in all elderly patients – it is just a few extra questions (the geriatric depression scale) and MiniCog screen can be done.
The second approach was much better, showing care is never a bad thing.
mini mental status
An elderly patient with acute or progressive change in their mental status should prompt cognitive evaluation.
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Great case
acknowledging a change from baseline, engaging the patient
History and physical
MMSE, MOCA, Mini-COG, clock drawing test
acknowledging change from baseline
engaging relative
Mini-cog
SWIGECAPS
observing new onset of mental status
talking to family members
swigecaps
mmsee
madrs
phq
Good case, two different approaches makes Hugh difference in patient life.
MMSE and depression scale
mmse
SIGECAPS. PHQ-9.
mini cog
depression screen
Mini mental
depression scale
Good case!
change in baseline function would prompt me to screen for cognitive impairment using an MMSE or MOCA
quick screening like the mini-cog or even asking about their orientation to person/place/time/reason for visit
Even a quick orientation and recent events screen might be able to prompt you do a more thorough evaluation like the MoCA or MMSE.
Assess orientation
At times, I’ve used MME
good case
Assess orientation on every elderly patient. If any concern perform MMSE or MOCA, get collateral history to establish baseline and if there has been a change.
Would screen for cognitive impairment when story given by patient is inconsistent or when patient’s family is concerned about the diagnosis .
Cognitive Impairment Screening – depending on suspicion of dementia vs. delirium. For Dementia (MMSE, MoCA) while for delirium CAM-ICU or simply orientation questions and simple exercises (spell WORLD backwards, subtract 7 from 100, etc.)
Mini-cog, CAM
The MD failed to do a depression screening exam
The patients mood and fixation/focus on certain things (suicidal thoughts, worry about health) and vague complaints/demeanor almost “crying out for help”. A simple non-judgemental conversation would be a decent prelude to some impairment tests. Useful tools would include CAM, MMSE, DRS, GAR. I think the most obvious way to tell would be to ask the primary caregiver/spouse/family. They are often the first to notice the change.
A change in behavior or mood would prompt an assessment of cognitive impairment. Establishing a baseline through corollary history (from family, nursing home, etc), in addition to a screening tool such as the Confusion Assessment Method and MMSE, are important to screen for the presence of dementia/delirium.
When pt’s present with varying issues at the same time (and doesn’t add up)
MSE, Cognitive Assessment, GDS, CAM, MMSE, MoCA
Noted change of patient’s mood, behavior, or abilities as reported of those closest to them and finding patient is not communicating efficiently or seems confused. It’s important to listen to family and patient. MMSE, general orientation questions, and depression scale can be helpful. If there are no relatives or caregivers to give input, reading notes on the patient from previous visits at ED or PCP can help determine what the patient’s “norm” is.
I am prompted to perform cognitive assessment when I detect poor understanding or communication in my history and examination. Taking a thourough history and asking a patient to co-operate with an examination provides useful information which can then be quantified with a MMSE. Asking family members about their level of function at home is also helpful.
Multiple repetitive complaints
MMSE
Depression Scale
From Cognitive assessment screening, Previous MMSE or other cognitive assessments, GP or specialist letters
Collaterals from Friend and family
Older patients who present are screened for dementia and delirium
Especially if concern from relatives or change from pre-morbid state
Use of MMSE, MINI-cog, quick confusion scale and CAM
Based on different parameters of each, able to better assess patient
I am prompted to screen for cognitive impairment in older patients based on age, how they may answer questions (delayed, word finding difficulties, superficial answers, tangential answers, avoidance behaviours). I use the Minicog, CAM and screen for depression. A standardized tool is effective for screening, however to diagnose we must spend more time in thorough social and functional history taking. The screen is only the first step. To diagnose cognitive impairment I review the patients performance in multiple domains including but not limited to BADL, and more complex IADLs. Collateral information is crucial. Utilize and refer to your geri NP’s or other GEM staff, they often have rolls which allow for more time to be spent gathering information.
Cognitive impairment can be difficult to pick up if subtle, in an emergency department setting. it requires a high index of suspicion to suspect and further investigate. Here I feel that the patient clearly had not taken in or understood the investigations being done which would lead me to ask why? Is this delirium/dementia possibly with some depression as his affect is quite flat.
Tools for assessment include 4AT, CAM, MMSE in conjunction with other blood work and imaging as completed. However if these is a concern that the patient may be cognitively impaired then this may warrant further hospital admission for workup if the home environment is not safe or equipped to do so.
k
good case
CAM, MMSE, medication review. Touch base with family physician to establish baseline and further management.
MMSE or MOCA for cognitive assessment
confusion, incoherent words, “not myself” “not themselves”; would use tools such as CAM, MMSE, mini-cog.
Family provides a good clue to deeper issues even if they have some challenges.
Effective time given to patients in the ED for communication. Medical staff ensuring time to listen to patients and their relatives. asking open questions. encouraging conversation regarding mood and thoughts and feelings. not just looking at the physical ailments, as these can be made worse by mood alone.
cognition screening is appropriate on any one you suspect has delirium to assertion their needs.
I agree that a more thorough assessment by the ER staff of this patient’s cognition would have benefited the patient and this family. It is key in the ED to take the time during the initial exam to initiate the mini – cog assessment( clock and X3 word repetition ) to ensure that this patient is not in an acute state and has the appropriate support at home to assist.
He needs to do more assessment. Like most of everyone suggested Mini-c0g, CAM etc..
While I find there is so much pressure to “be fast” in the ED, it really doesn’t take long to ask a few extra questions to patient/family about the bigger picture. I find the discharge planning nurses and social work invaluable in the complete assessment of this type of patient.
Cognitive impairment should be assessed in all patients who have a change in their baseline using tools such as the monumental state exam.
any changes in rational thinking. Concrete thinking obvious and no abstract thinking. Red is red for this group of people.
Tools that I would use are: Minicog assessment, counting backwards , spelling backwards, recalling words,
Collateral history taking from family members for patients baseline, any recent changes and medications and past medical history of this patient
and for depression using MI PASSECG 5 OUT OF 9 WITH AT LEAST ONE BEING FROM THE mood and interests hobbies fields. If signs of depression present indulge more into this by paying attention to the SADPERSONS mnemonic. Especially risky for elderly and males and association with depression and Alcohol abuse. Objective plans for this and previous attempts would make this patient a candidate to be involuntarily admitted.
The flat affect, vague answers, somatization and wife’s collateral provide major cues to the possibility of a significant depression
Mr. Lowe represents at at risk demographic that is sufficiently functional to be easily seen as “safe” in the absence of CNS, or Cardiorespiratory abnormalities, that as male is reluctant to acknowledge depression or anxiety, and that has the energy and resource to execute suicide.
Any elderly who appears vague, inconsistent, has poor hygiene, doesn’t make sense, abnormal affect must undergo detail evaluation by MMSE or CAM method. Detail history from multiple sources like wife, daughter, son should be taken. Elderly with polypharmacy are at increased risk of medication errors and needs a medication administration under supervision.I always ask for any self harm behavior or any suicidal thoughts as these elderly needs constant observation and supervision.
I would start with MMSE ask more questions in the depression chapter,
I would ask about his mood and ask if he has had any suicidal thoughts. He has not been sleeping and he has been down, i would use SIGECAPS to screen for depression.
Well ,the Empathy from physician missing
Need to take Hx about depression and any suicidal thoughts.Social Hx and any triggering factors? Duration of Sx important for Diagnosis.
Need quick bedside Ax of Cognition.
Medication Hx important.
Confidentiality and resistance to patient is missing.
Always helps to do kind of minciog in elderly patients. Dosent take too long to find out cause of many problems.
Allow patient and family to express their concerns in detail which will open clues for the physician to further investigate.
Screen for cognitive impairment in the patient who is vague, inconsistent, has poor hygiene, doesn’t make sense, abnormal affect, I don’t know what’s going on, family expresses concern, that kind of thing. I might use a screening tool like MOCA but in my department I am lucky to generally have good access to a geriatric team, so I can keep a low threshold to get them involved if I sense things are not quite right, or I can ask internal medicine to admit (they often don’t have beds but they can at least spend a bit more time figuring out the problem. Not everyone has these resources and even for me they are not available 24/7 — have to be willing to spend more time, observe longer, get more collateral history. Nurses, social workers and pharmacists can also be great resources. Make sure the patient gets fed while waiting!!
After discussion with patients often there are a few triggers that would flag a further cognitive assmt- how they are coping at home, missing medications (how they take meds blister packs vs bottles if they get help), how they get places, if/what they are getting help with at home. Often screen pts who answer they care coping fine but very vague.
Tools: primarily MMSE to start then MOCA.
if history suggests change from pt’s baseline, family or caregiver is concerned these are reasons to do a cognitive assessment. I would use MMSE for level of cognitive impairment & CAM to screen for delirium
Dr. is taking time to assess both family member and client’s complaints and observations.
Mini-Cog and SIG E CAPS
I do at the very least an Ottawa 3DY assessment if not a full CAM for any pt who is >70yo and is not likely being admitted. I started using ISAR too to quickly identify high risk patients for functional decline.
Elderly can feel overwhelmed. Simple discussions can assist
CAM, talk to the family, ask for changes on the basal behavior
Mood change prompts depression in elderly
I think that giving the patient more time to speak – and discuss things with his family who knows him best – is an advantage to picking up cognitive impairments. If the physician does all the talking, you can’t pick up on these. Can start with MMSE and close discussion of timeline of cognitive changes with family.
Reports by patient family of acute or progressive behavior change should prompt a further cognitive and mood assessment. Elderly patients often have complex health histories, it’s important not to overlook or dismiss a change in mood or increasing complaints of vague health concerns.
Lack of testing and physical exam leads to mood assessment. At least start with MMSE
It is important to recognize that Emergencies include Mental Health emergencies- whether it is heightened suicide risk, acute psychosis etc. Physical health emergencies are easier to recognize and manage. It may also be that more physicians are confident of their skills in managing physical health than mental health and are, therefore, less efficient.
If pt has trouble with remembering things, reports from family or caregivers about memory, abnorma responses to questions,perceptual distubances
Change in baseline behaviour, altered cognition or level of consciousness. I would assess by starting with a mental status exam during the interview. Tools I would use include- CAM, MOCA, SIS
If a patient is vague in reporting complaints, repetitive, trouble rememebering history, medications, etc and/or family brings forth concerns about patient’s mental status. After starting with a thorough history including collateral info from family, could do Mini-Cog, MMSE, MOCA.
x
Use the Mini-cog
It too easy in ED to focus on excluding organic disease and avoid the holistic assessment and making full use of all available collateral history.
Good assessement and history
Including a quick GCS score in your general assessment may actually quicken the diagnostic process.
I would ask more in depth questions based on patients repeated questions and concerns, his whole affect was concerning
Vague answers, the age, general appearance of Pt.
Vague history by patient, unkempt appearance or report from family about memory problems or behavior changes.
Do CAM, MMSE/MOCA
Ask about ADLs and IADLs. Mood Screen – assess risk
good history taking is important
Get history from all family members
behavioural changes and concern from family would cause concern for cognitive impairment. baseline testing would help to establish degree of impairment
Behavior change in a patient with normal diagnostic results… look for cognitive impairment.
makes sense
check and check again
could use mini-cog and the RISKS assessment tools
changes in behavior out of the normal for the person; stress factors; changes of any sort to use the process of elimination to ascertain as much of the picture as one can get.
He needs more probing into and a more thorough evaluation
through patient interview-if patient seems to be non specific about symptoms but has multiple areas of concern, unable qualify issues, flat affect during interview. would include accessing patient chart or spouse (in this case) someone who knows the patients “normal”
What would prompt you to screen for cognitive impairment? Just paying attention to the patient and assessing the situation. How would you do that? Questioning and listening What tools would you use? No specific tools. Just listen to see if there is impairment
communication with pt can indicate a necessity to assess further . one may want to use tools such as MMSE ,OMCT or SIS. Outcomes of any of these tools will indicate impairment
Change in baseline. Using all available tools such as CAM. Would get more information from family and listen to what they find is different in the person.
Reminds us how easy it is to ignore patients’ mental status. Good job of addressing mood and suicide risk head on.
Screening for cognitive impairment if observed changes in memory or thinking abilities. Relevant history from care givers. Discussions with family or care givers to determine impairment. Could use the mini-mental exam, DSI (Dementia Screening Indicator). It would not take long after a thorough work up, discussions with the patient & family members to dx a cognitive impairment.
CAM, Mini mental status examination, family history and listen to the family’s concerns
As a Paramedic, I sometimes have the luxury of seeing patients in their home setting. Cues such as piled up uncleaned dishes in the kitchen, items that are out of place around the home, and evidence of pots left on the stove too long are very obvious clues that the patient is becoming cognitively impaired.
Change in mental/behavioural baseline. Perform mmse and assess for depression.
I would be prompted to assess cognition if there are subjective complaints of memory loss (either patient and/or family members), recurrent falls, abnormal gait, complaints from patients/family that the patient is not him/herself
Use the MMSE to get a comprehensive look if time permits, in ER, SIS/ CDT would be helpful to characterize issues.
Difentes applying the test to assess cognition and extending the time of interview
You have to find criteria that guide us to think about the problem and make better clinical analysis and applying cuetinando more specific tests
a detailed history and addressing the concerns of relatives may reveal impaired cognition as a part of the patients pathology. using the CAM and mini mental status can confirm that. the onus is on the doctor to assist the patient by determining cause, and initiating appropriate investigations and treatment. an assessment of social support is integral to the continuation of care
🙂
Screen for depression, also mini mental state
Always keep a high index of suspicion for cognitive impairment on older clients. MMSE and FAQ are good starting points. Comprehensive and patient centered approach always works the best even this is more time consuming
I would screen for depression using the GDS, inquire more about anxiety and proceed with initial cognitive screens if CAM is negative
Every patient is screened by speaking to them. Then if necessary move onto a cognitive assessment.
El abordaje del paciente geriátrico desde el punto de vista integral es fundamental para la correcta resolución de los problemas físicos y cognitivos. Obviar la parte cognitiva conlleva un alto riesgo de cometer errores y pasar por alto aspectos del adulto mayor que han demostrado aumentar la mortalidad
Any elderly patient presenting with fall, vague symptoms, who gives an unclear history, who I am going to admit.
I usually screen just with orientation and a few questions about their history. I also like to get a baseline from family when I can. That is not always possible.
Anytime a patient is not able to provide an accurate history or is vague in reporting complaints or family reports concers/changes in patient’s mental status (whether memory, behaviour etc), I would do a further cognitive assessment. CAM is a good start to ensure it’s not positive for suspected delirium. Mini-Cog would be helpful and asking questions to get a sense of patient’s insight and ask about any changes in ability to do ADLs, IADLs. To get a sense of patient’s mood, I would ask “do you feel satisifed with life?” or “do you feel life is not worth living?” and often probe further with a SIG E CAPS screen.
I learned a lot.
x
Active listening, talking to the patient may save from unnecessary exams down the road
xx
If the family is expressing concerns about the pts mentation or if I find the patient is easily distracted or needs to be constantly redirected
I would screen for cognitive impairment by asking about someone baseline behaviour. I could look at past records. I would screen for this by asking about fluctuating behavious, level of conciousness, ability to care for self.
More thorough assessment of cognition would benefit the patient, family and ED in the long run. Very important to take the time on initial exam to ensure an acute change isn’t occurring, thus a more positive outcome.
MMSE could be used as a screening test, using orientation questions
Concerns of family or presenting complaint would suggest need to screen for cognitive impairment. I would use the MMSE as well as collateral history. A documented change from baseline not due to delirium/mood would indicate cognitive impairment.
Cognitive assessment
CAM, mini-COG
I would screen for cognitive impairment or depression when the family members raise concerns. I would consider it if there are multiple physical complaints without diagnosis after testing, etc.
A little extra time up front can save time down the road.
acute changes in LOC/behaviour
patient’s current list of medications
functional decline
tools: clock drawing, mini-COG, six-item test
In any elderly these condition should be considered:
1.medication and polypharmacy
2.imbalance and risk of fall
3.memory and cognition (patient’s appearance&attitude +MMSE)
4.incontinence
5.self care
Anxiety and vagueness – Minicog and or MOCA test to screen for early cognitive impairment
Would also screen patient for depression with the GDS.
The patient could present with cognitive impairment, but may actually be depressed and need that treated before determining his cognitive baseline.
3 questions
1. sadness? 2. helpless? 3. down-hearted?
Changes in mental status will prompt further assessment using geriatric depression scale, MMSE, CAM
I think it is key to invest the time to get collateral from family/NH staff, to assess functional changes. I want to know what is different about them today. I also use the Geriatric Depression Scale, Mini-Cog and CAM.
MMSE, GDS, CAM assessment, med review
minicog.
GEM assessment and followup referral care is needed.
Depression screen
done
I would review fce status and collateral Hx.What has changed in his quality of life.MMSE and MoCA are better to intro in familiar environment.Mental exam” re sleep pattern,apetite,other issues as Habits.Should have comprehensive geriatric assessment.
he is worried and depressed, he has physical signs of depression, (since tests were negative). he needs a psych or geriatrician consult. They are asking for help, his family doc doesn’t seem to get it either. speak to the family, is he suicidal? at least give them some hope and say you will refer them to someone that can help more.
Having done investigations for the physical complaints and not finding an appropriate answer to explain the symptoms, it helps to go back to the pt’s initial complaint – or really “what is bothering/worrying them” that precipitated the ER visit TODAY?
The multiple vague symptoms suggest taking a more detailed Hx and broadening the DDx for mental health issues.
vague answers that don’t add up
minicog
a lot of patients are brought in to emergency with a diagnosis of failure to cope”.It is either care-giver burn out or there might be a acute reason other then a physical problem as the video eluded to. CCAC unfortunately may take time to do a home assessment and the families in crisis may bring the patient to emerg. We have to be aware that there probably is a cognitive decline/depressive component.Its an interesting stat that depressed elderly complete their suicide on the first try. comment later
He is vague, forgetful, and anxious, and despite over-testing him, he has not been assessed or diagnosed with the problem her presented with. Instead of doing endless unnecessary investigations, why not just talk to the patent and his wife?
I know this video oversimplify things but really it doesn’t take a whole lot longer in real life. What takes so long is all the tests we did in the first place to rule out medical problems. This conversation could have taken place before the CT scan.Blood work and a stool for FOB could have been still been done.
start with simple questions
quickest test is clock drawing,
MOCA
progressive steady deterioration of memory etc.
Is this patient really an emergency?
He needs more probing into and a more thorough evaluation?
Interesting question. As the development of this case illustrates, it probably IS an emergency. We generally think of conditions with potentially life-threatening outcomes (like suicidal behaviour) as emergencies! The point is that with older people and their frequent atypical presentation of disease (here depression presenting as psychosomatic symptoms and anxiety unlike younger people where mood symptoms predominate), it’s important to keep an open mind and avoid premature closure. I agree fully with your instincts that this needs more probing and evaluation.
These patients are usually taken at “face value” and worked up in the ‘acute’ side of the department, where monitors are more plentiful and privacy is less. Because of this, both patient and health care provider may be reluctant to discuss sensitive topics. I agree that family members are crucial in such instances, occasionally stopping the busy practitioner from breezing over a pressing issue as they try to dispo the patient.
Yes it’s pretty easy to “pave over” a slow-talking, vague, non-specific older person — but really at everyone’s expense — certainly the patient, the provider (who is left with that awful feeling that you just didn’t get to the heart of the matter) and your ED which is probably left to deal with the patient on the next visit. Every Emerg doc knows that it’s better to do a good job the first time.
Has to be routine if not prompted by history/exam/”what has changed” ie mental status then cognition then dementia screen then depression
I agree it feels inefficient however looking for tale signs unkempt befoudled will lead to a cognitive assessment and a better outcome
I think that because of the complexity of older patients, they can sometimes feel a bit overwhelming when you’re trying to move “efficiently through an Emerg shift. We are often looking to “make things simple” by looking for the easiest answer to a complex problem — after all that’s what Occam’s razor is for! However in all of these cases looking further into the complex situation actually seemed to turn up a relatively simple solution. Involving other people also seems to help — and listening to twhat they’re saying) . But that’s something we often try to avoid because of confidentiality issues or time considerations.
agree
Agreed!
Agreed
100% agree.
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