Episode 3: Cognitive Impairment In The ED- Tips & Tricks
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Terry Quinn @Drterryquinn
Dr Terry Quinn
Dr Terry Quinn is Stroke Association / Chief Scientist Office Senior Clinical Lecturer based in the Institute of Cardiovascular and Medical Sciences, University of Glasgow.
Terry has a broad research portfolio. Research interests include trial methodology, functional/cognitive assessment and neuropsychological consequences of cardiovascular disease. He has authored over 100 research papers, including publications in NEJM, Lancet, BMJ and Annals Internal Medicine.
Terry has various editorial board positions, including coordinating editor of Cochrane Dementia and Clinical Synopsis editor for Stroke (American Heart Association). He is part of the NIHR Complex Reviews Support Group; chair of the psychology and stroke group of the World Federation of Neurorehabilitation and is founder and co-chair of the Scottish Care-Home Research Group.
Terry’s work has always maintained a clinical focus. He combines research with teaching and clinical commitments in the wards of Glasgow Royal Infirmary.
Eoghan and Terry discuss cognitive impairment and delirium in the Emergency Department - why and how we should assess for it, how we should treat it and some other useful pearls of wisdom.
Take Home Messages
Why should we assess for it?
- It is very common (any unwell patient is at risk)
- The presence of cognitive impairment is a powerful prognostic marker – they do worse
- Patients say it is more important to them than the physical disability of illness
Advantage of assessing in ED: often easier access to a friend/relative who can provide a collateral history
Package of assessment:
- Assess for cognition at current point in time: AMT4 or AMT1
- Find out (from informant) about how that has changed over past few months
- AD8 or IQ code questionnaire
- Can be completed by informant as you assess patient
- Assess for delirium
- 4A test
How do we treat?
- There are no good treatments to prevent or reduce severity/duration
- Antipsychotics can turn a hyperactive delirium into a hypoactive one – this does not improve outcome
- Optimize physiology
- Hydrate and provide DVT prophylaxis
- Treat the underlying cause
- Infection/MI etc
- Antibiotics if indicated
- If patient has low cognitive reserve then minor ailments can cause such as constipatio
- Relieve family distress (consider information leaflets)
- Early mobilization and reorientation on the wards
Carphology = aimlessly picking at bedclothes
Floccilation = plucking at the air
These are pathognomonic of Delirium
Cognitive change over time
Assessment of delirium
Carphology and Floccilation