Building delirium care for people with dementia into the emergency department (ED): Systematic development of the Delirium Action Response in ED (DARe-ED) intervention

Project Investigators Dr. Linda Schnitker

Project Researchers Prof. Elizabeth Beattie

Year: July 1, 2016


Program Overview:

This project aims to find the components of best practice preventing delirium in older people with dementia in Emergency Departments (ED).

Older people with dementia are at increased risk of developing delirium, an acute confusional state, when in ED. Delirium is common (~10%) in older ED patients and is positively linked to negative patient health results (e.g. death) and increased healthcare costs. Besides risk factors as being older, having cognitive impairment (a sign of dementia), and being acutely sick (wherefore presenting to ED), the ED environment itself and ED processes can trigger delirium. For example the ED environment, which is often hectic and noisy, has limited orientation cues (e.g. no daylight, clocks, poor signage), uncomfortable trolleys, limited strategies relevant to the care of older people with dementia, and staff with poor geriatric knowledge.

Some ED processes, such as (long) waiting times, treatment with multiple and incorrect medications, poor recognition of cognitive impairment, can also contribute to delirium. In the literature, delirium has been described as an avoidable syndrome, and it appears that a number of those ED processes, ED structures, and patient-specific delirium risk factors are modifiable.

There is a lack of evidence on what the best intervention strategies are to prevent delirium in older patients with dementia in ED. Based on the research team’s experience and what consumers tell us, older people with dementia may benefit from multiple changes in current ED processes (e.g. having protocols relevant to pain assessment, nutrition, bladder catheter use, and cognitive screening) and structures (e.g. having orientation cues and engagement activities, geriatric streaming, policies relevant to geriatric emergency care). In the acute care setting, multi-component delirium prevention interventions have been proven effective.

Consequently, multiple strategies targeting those adjustable ED processes, structures and patient-specific delirium risk factors can be developed in the form of a multi-component intervention that suits the ED setting and this vulnerable ED population. This project aims to develop a useable multi-component delirium prevention intervention relevant for older people with dementia presenting to EDs in the form of clear protocols, guidelines and manuals. This new intervention, the Delirium Action Response in ED (DARe-ED) intervention, will be developed in order to improve care and health outcomes of acutely sick people with dementia visiting EDs who are at risk of delirium.

The development of the DARe-ED intervention for older ED patients with dementia will be realised by:

  1. approaching the literature and translating evidence and the research team’s experience into a draft multi-component delirium prevention intervention, and
  2. consulting an expert panel using a structured communication method. An international panel of experts consisting of consumers (i.e. people with dementia and/or their carers) and skilled workers in the field of geriatric emergency medicine and nursing, dementia care, and research will be consulted to assist in establishing the DARe-ED intervention. A defined implementation plan outlining the relevant steps to successfully apply the DARe- ED intervention into Australian ED settings will be constructed.

Ultimately, this project will optimise clinical care for acutely sick people with dementia in ED environments, in which delirium may be easily triggered, by translating evidence into a practical intervention, which is likely to benefit older ED patients and Australian health care. In addition, this proposed research project has the potential to inform further research. For example, a study to test the cause-effect relation between this new intervention and older ED patients’ health results and health care costs.

Successful Grant Recipient 2016

Team members:

A/Prof Glenn Arendts, The University of Western Australia;
A/Prof Christopher Carpenter, Washington University;
A/Prof Dina Lagiudice, The University of Melbourne;
A/Prof Gideon Caplan, University of New South Wales;
Prof Elizabeth Beattie, Queensland University of Technology.