GERIATRICS/REVIEW ARTICLE

Managing Delirium and Agitation in the Older

Emergency Department Patient: The ADEPT Tool
Christina Shenvi, MD, PhD*; Maura Kennedy, MD, MPH; Charles A. Austin, MD, MSCR; Michael P. Wilson, MD, PhD;
Michael Gerardi, MD; Sandy Schneider, MD

*Corresponding Author. E-mail: [email protected], 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 in-
person 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. [Ann Emerg Med. 2020;75:136-145.]

Continuing Medical Education exam for this article is available at http://www.acep.org/ACEPeCME/.

0196-0644/$-see front matter
Copyright © 2019 by the American College of Emergency Physicians.
https://doi.org/10.1016/j.annemergmed.2019.07.023

INTRODUCTION The care of agitated patients in the ED can be

Older adults, defined as aged 65 years and older, challenging. The presence of agitation or behavioral changes
frequently present to the emergency department (ED) for is often a clue to underlying delirium, but the diagnosis of
or with agitation, confusion, or behavioral changes.1 The delirium is often not formally made in the ED setting.5
number of older patients who present to the ED is expected Delirium is an acute change in mental status, with waxing
to increase as the population ages. In older patients and waning symptoms, that can present with hyperactive,
presenting with behavioral changes, there is more often an hypoactive, or mixed symptoms. Its presentation can be
underlying medical condition or trigger causing the acute subtle or can be confounded by other symptoms or
change than in younger patients. It is rare for patients in disorders, such as strokes, sepsis, adverse drug reactions, or
this age group to present with a new-onset primary intoxication. A greater understanding and recognition of
psychotic disorder or new-onset schizophrenia, so a medical delirium may help clinicians better care for patients and
cause should almost always be assumed until proven prevent symptom progression. In addition, when patients are
otherwise. Furthermore, the signs and symptoms of these agitated or delirious, clinicians often use pharmacologic
patients’ presentation may be subtle or atypical, so the measures such as antipsychotics or benzodiazepines for
evaluation should be thorough. Management should focus symptom control. However, these medications have
on treatment of the underlying disorder, proactive measures significant potential complications, so nonpharmacologic
to prevent worsening symptoms, and treatment of measures should be used first when possible.
agitation, with a cautious awareness of the high risk of To address the knowledge translation and implementation
potential medication adverse effects. Delirium is frequently gaps that exist in the field, the Coalition on Psychiatric
underrecognized in the ED2,3 and is an independent Emergencies convened an expert panel on this topic in 2017.
predictor of 6-month mortality.4 These experts were tasked with creating an easy-to-use

136 Annals of Emergency Medicine Volume 75, no. 2 : February 2020

Shenvi et al Managing Delirium and Agitation in the Older Emergency Department Patient

Figure 1. ADEPT tool.

reference tool for emergency physicians, the product of which device app intended for use by clinicians on shift. This article,
was the Assess, Diagnose, Evaluate, Prevent, and Treat by presenting the background and supporting evidence for
(ADEPT) tool (Figure 1).6 The ADEPT acronym stands for each aspect of the ADEPT tool, will provide a recommended
5 core principles that can help ensure adequate and thorough approach to the screening, diagnosis, and treatment of
care for older adults with agitation or delirium: assess, patients with agitation and delirium.
diagnose, evaluate, prevent, and treat. ADEPT is an open- The Coalition on Psychiatric Emergencies includes more
access Web-based tool and is available on the American than a dozen professional organizations and patient advocacy
College of Emergency Physicians (ACEP) emPOC mobile groups. The organization was founded in December 2015

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Managing Delirium and Agitation in the Older Emergency Department Patient Shenvi et al

with the mission of unifying various nonprofit mental health baseline mental status and the time course of any changes, a
advocacy groups in the United States. In partnership with the process that will typically require contacting a family
ACEP, the Coalition on Psychiatric Emergencies steering member or caregiver.
committee created a working group to design the geriatrics Infections, neurologic disorders, and metabolic or
agitation tool. The working group was composed of 6 electrolyte disorder are 3 of the most common causes of
academic and community physicians with expertise in the acute alterations in mental status among older patients.9
areas of geriatric emergency medicine, delirium, agitation Adverse medication effects are another common cause. A
pharmacology, geriatrics, and critical care. Through an list of medications that are high risk for causing
iterative process of literature review, development, review, confusion, altered mental status, or delirium is shown in
revision, and consensus building, the working group created Table 1.
the ADEPT tool. An initial, broad literature review was The patient should be given a gown to wear and
performed on each of the aspects of the ADEPT tool. examined for signs of trauma or infection, including
Individuals with expertise in each respective area were checking for sacral ulcers. Bruising or abrasions could be a
responsible for developing initial recommendations for each sign of accidental trauma from falls, but clinicians should
of the 5 components of ADEPT. As a group, their also be aware of the physical signs of potential
recommendations were reviewed, honed, and revised nonaccidental trauma or neglect, which are often
according to the literature. Feedback was also sought from the underrecognized in older adults.10,11 The physical
ACEP Emergency Medicine Clinical Practice Committee, examination should assess for signs of stroke, intracranial
members and leaders of the Academy of Geriatric Emergency hemorrhage, or subclinical seizures, all of which are less
Medicine, and an experienced ED pharmacist. The final common but potentially life-threatening causes of agitation
recommendations were further edited into their succinct or altered mental status.
version that was then published online as the ADEPT tool.
Each part of the ADEPT tool is explained in further DIAGNOSE
detail here. In older adults with undifferentiated agitation Second is “Diagnose.” Delirium is a common syndrome
or confusion, it is important to recognize and establish that that presents with confusion, agitation, or both in older
there has been a change, diagnose the condition, and patients. Older patients who present with hallucinations or
determine the underlying causes if possible.7 altered sensorium are more likely to have delirium or, less
commonly, dementia-related psychosis, rather than acute
ASSESS psychotic break. New-onset psychosis or schizophrenia is
First is “Assess.” Once life threats and immediately rare in this population.12
treatable conditions such as hypoxia, hypoglycemia, and Despite delirium’s prevalence among geriatric ED
ST-segment elevation myocardial infarction have been patients, emergency clinicians formally diagnose it in less
ruled out and patient and staff safety are ensured, the next than 20% of delirious patients.2,3 Underrecognition of
step is to determine whether there has been a change from delirium may result in adverse outcomes, including
baseline and the time course.8 First establish the patient’s higher mortality.4 Distinguishing between delirium,
Table 1. Common and important precipitants of or contributors to delirium, agitation, confusion, or altered mental status.
Category Examples
Readily reversible causes Hypoxia, hypercarbia, hypoglycemia, hyperglycemia, hyponatremia, hyperkalemia
Infection Urinary tract infection, pneumonia, intra-abdominal infections, meningitis/encephalitis, sepsis
from other source
Neurologic Transient ischemic attack, stroke, intracranial hemorrhage, intracranial mass
Medication-induced adverse effects, intentional or Anticholinergic medications (including tricyclic antidepressants, antihistamines, muscle
unintentional overdose, supratherapeutic levels relaxants, promethazine, typical antipsychotics, sedative hypnotics (benzodiazepines,
because of renal or liver disease zolpidem), corticosteroids, polypharmacy (considered 4 medications), salicylate toxicity
Toxicologic Intoxication with alcohol or substance use, alcohol or benzodiazepine withdrawal
Metabolic Hyper- or hypoglycemia, hyper- or hyponatremia, dehydration, acute kidney injury, uremia,
diabetic ketoacidosis
Cardiopulmonary Acute coronary syndrome, dissection, hypoxia, hypotension, anemia
Environmental factors New or unfamiliar environment, lack of sleep, lack of hearing or vision aids
Other factors Pain, urinary retention

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Shenvi et al Managing Delirium and Agitation in the Older Emergency Department Patient

Figure 2. Delirium Triage Screen.16 RASS, Richmond Agitation-Sedation Scale; DTS, Delirium Triage Screen.

dementia, and primary psychiatric conditions can be states. Risk factors for delirium include a history of
challenging in older adults because neuropsychiatric neurocognitive disorder (dementia), previous episodes of
symptoms, such as depression, agitation, and psychotic delirium, increased age, vision or hearing impairment,
symptoms, are common in patients with dementia.13 In previous stroke, impaired functional status, nursing
addition, patients with baseline dementia are at increased facility residence, or home health aide for activities of
risk of developing superimposed delirium during an daily living.
acute illness. There are numerous brief tools that can be used to
The hallmarks of delirium include acute onset, diagnose delirium in the ED. The Delirium Triage Screen
waxing and waning symptoms, inattention (eg, unable to (Figure 2) can be rapidly administered, does not require
recite the months of the year or days of the week collateral information, and is very sensitive, so it functions
backwards), change in cognition (new memory deficit, well as a screening tool.16 It consists of a formal assessment
disorientation, perceptual disturbance, or disorganized of the level of arousal (normal, sedated, or agitated) and a
thinking), or altered level of awareness (reduced test of attention. A positive Delirium Triage Screen result
orientation to environment such as somnolence or should trigger confirmation with a test that is more specific,
agitation).14 such as the Confusion Assessment Method or Brief
Delirium can be subcategorized into 3 main Confusion Assessment Method (Table 2).16-18 A patient is
psychomotor types. Hyperactive delirium is characterized delirious if he or she has acute onset or fluctuating course,
by agitation, increased psychomotor activity, and inattention, and either disorganized thinking or altered
heightened level of arousal. It is the most recognizable level of consciousness.
type but accounts for less than 10% of delirium observed When family or caregivers are present, key
in the ED.15 Hypoactive delirium is by far the most questions to help differentiate between delirium,
common type, accounting for approximately 90%.1 It is dementia, and a psychiatric condition include the
characterized by somnolence and psychomotor following (Table 3):
retardation. It is more likely to be missed by the clinician 1. Previous diagnosis of dementia or psychiatric
because patients may be somnolent, quiet, and unlikely to disease. In the absence of a preexisting diagnosis
draw attention to themselves. Hypoactive delirium is of dementia or psychiatric illness, hallucinations or
associated with the highest mortality rate.1 Finally, mixed behavioral disturbances should raise concern for
delirium involves alternating hypoactive and hyperactive delirium.

Table 2. Comparison of brief delirium assessment tools.

Tool Administration Time Sensitivity, % Specificity, % Requires Collateral
16
Delirium Triage Screen 20 s 98 55 No
Brief Confusion Assessment Method16 1 min 78–84 96–97 Yes
3D-Confusion Assessment Method73 3 min 95 94 Yes
74
Confusion Assessment Method 5 min 94 89 Yes

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Managing Delirium and Agitation in the Older Emergency Department Patient Shenvi et al

Table 3. Distinguishing features between delirium, dementia, and psychosis.

Characteristic Delirium Dementia Psychosis
Onset Acute Gradual Variable
Course Fluctuating Progressive* Chronic
Diminished level of consciousness May be present (hypoactive/mixed delirium) Absent Absent
Orientation Fluctuating Impaired Normal
Duration Hours to months Months to years Months to years
Hallucinations Common Rare until end stage Common
Attention Impaired Preserved until end stage May be impaired
Sleep-wake pattern Disrupted Normal or fragmented Variable

*Exception: fluctuations in cognition are present in Lewy body dementia.23

2. Presence of changes in the patient’s cognition or EVALUATE

behavior. If changes are present, obtain information Third is “Evaluate.” Although the “Diagnose” step
on the onset, duration, and fluctuations in symptoms. focuses on determining whether delirium is present, the
Delirium is characterized by acute onset. Fluctuations “Evaluate” step focuses on evaluation for underlying causes
are a key feature of both delirium and Lewy body (Table 1).26 The evaluation should be directed by a focused
dementia. history and careful physical examination.
3. Presence of hallucinations. With the exception of Infections are the most common cause of delirium
Lewy body dementia, hallucinations rarely occur in identified in ED studies, responsible for 30% to 40% of
dementia until late stages of the disease. cases, followed by acute neurologic disorders such as
4. Sleep/wake disturbances. ischemic stroke, intracranial hemorrhage, or intracranial
Patients with delirium or suspected delirium should mass.9,27 Adverse effects of medications commonly cause
undergo an evaluation to assess for underlying precipitating delirium and are estimated to be responsible for 12% to
causes and receive nonpharmacologic measures to limit the 39% of delirium across medical settings.28 Accordingly, it
duration and severity of delirium. is critical that the emergency clinician perform a
Nondelirious patients presenting with confusion, medication review to identify recent medication changes
agitation, or hallucinations should be screened for dementia and use of medications at high risk of causing delirium
and depression. Although primary psychotic disorders are (Table 1). Delirium is also frequently multifactorial.29 For
rare in older adults, with prevalence less than 1%,19 16% to example, a patient with a urinary tract infection may
23% of older adults develop psychotic symptoms primarily experience delirium from the infection, but other
related to advanced dementia.20 There are a number of brief compounding factors such as dehydration, pain, new
screening tools that can be used to assess for underlying antibiotic medications, and change in environment can also
major cognitive disorder, such as the Mini-Cog,21 brief contribute.
Alzheimer’s Screen, Short Blessed Test, Ottawa 3DY, and Although every evaluation should be tailored to the
caregiver-completed AD8.17,22 Depressed older patients patient, most patients should receive an ECG, CBC count,
may present with symptoms mimicking delirium, including metabolic panel, point-of-care glucose level test, and a
psychomotor retardation or agitation, decreased urinalysis with culture. Although urinary tract infections
concentration, and sleep disturbances.23 Approximately 6% are a common delirium precipitant, asymptomatic
of older adults have major depressive disorder, but the bacteriuria is also very common in geriatric populations.
prevalence is much higher in patients with comorbid Among community-dwelling older adults, 5% of men and
medical conditions, including cognitive impairment. Older 6% to 10% of women have asymptomatic bacteriuria. The
adults can be screened for depression with very brief rates of asymptomatic bacteriuria are higher among
screening tests, such as the Patient Health Questionnaire–2 institutionalized older adults, with 15% to 35% of men
or Emergency Department Depression Screening and 25% to 50% of women having asymptomatic
Instrument.24,25 A positive screen result for depression bacteriuria.30 Pyuria with or without bacteriuria is also
should prompt subsequent questions on suicidal thoughts common in asymptomatic older adults, particularly those
and attempts because suicidal older patients are more likely with chronic incontinence.30 Emergency clinicians should
to use lethal means.23 be wary of premature diagnostic closure, incorrectly

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Shenvi et al Managing Delirium and Agitation in the Older Emergency Department Patient

attributing behavioral changes to a urinary tract infection Therefore, systems measures and protocols that reduce ED
when the evidence for this condition is sparse. length of stay and avoid boarding patients in hallways
Additional tests may be warranted according to the should be considered for patients at risk of delirium.
history or physical examination and should be directed Prioritizing the transfer of older or frail patients to floor
according to symptoms, history, and presentation. Routine beds when they become available is one potential measure.
computed tomography of the brain is low yield overall but In addition, it is important that the ED clinicians and
should be performed for patients with focal neurologic nursing staff communicate the presence of delirium or
deficits, fall, or head trauma, or decreased level of agitation to the inpatient team. When the diagnosis of
consciousness, and should be considered in patients delirium is not made in the ED, it is also more likely to be
receiving anticoagulation.31-33 missed by the inpatient teams,1 so it is important that the
diagnosis be communicated explicitly.

PREVENT
The fourth is “Prevent.” Most EDs are busy, bright, noisy, TREAT
and potentially deliriogenic environments, especially for The fifth is “Treat.” The overall goal for treatment of
older patients. However, there are measures that can be delirium in the ED is to identify and address the underlying
undertaken for individual patients to prevent the development cause while avoiding actions or inactions that may worsen
of delirium, to prevent its progression, and to mitigate its delirium. Following the preventive steps outlined in this
symptoms.34,35 These include treating the underlying review will assist with these goals. Some patients may
condition and managing pain,36 ideally with nonsedating, require additional interventions or medications to
nonopioid medications if possible. Treatment of other successfully and safely manage their agitation.44
bothersome symptoms such as nausea, vomiting, and If the patient is agitated, it is imperative to calm and
constipation can be helpful. Unless contraindicated, a patient’s protect him or her and staff, and to allow the patient to
home medications should be administered on schedule to participate in care to whatever extent is possible.
prevent exacerbation of baseline medical problems. Nonpharmacologic interventions such as verbal de-
Medications that can cause delirium should be avoided escalation, distraction, and reassurance can be used with
(Table 1). Normalize the patient’s daily function by assistance from sitters, family, or staff.45-47 Successful de-
providing hydration, food (unless contraindicated), access escalation helps the patient regain control without need for
and assistance to toileting, mobility assistance or aids, and further treatment45,48 and may even be effective in patients
hearing-assistive devices. Limit unnecessary disruptions. with cognitive deficits such as dementia.49 A video
Unless medically necessary, things that tether the patient to recording message of family members can also help calm
the bed should be avoided, including blood pressure cuffs, and de-escalate agitated older patients.50 Medications may
monitor leads, continuous intravenous infusions, and be needed if the above measures fail. However, if at all
bladder catheters. Greater numbers of restraints or tethers, possible, physical restraints should be avoided because they
immobilization, and use of bladder catheters are associated can lead to injuries.51
with higher rates of delirium.29,37 If nonpharmacologic management and verbal de-
Although the measures just discussed can be accomplished escalation are unsuccessful, pharmacologic interventions
in any ED, other measures require hospital- or systems-based may be necessary. It is important to select medications
organization and planning. Providing large-font clocks and carefully, dose them appropriately, and reassess their effects
other visual cues about the date and location can help self- frequently. All available antipsychotics and benzodiazepines
orientation.38 In addition, promoting and creating a culture are listed as potentially inappropriate by the Beers criteria,
that encourages family members and caregivers who and even at low doses, these medications may have
demonstrate a calming presence to remain at the bedside can increased adverse effects such as prolonged sedation or
be helpful.29 If feasible, volunteers can be trained to help paradoxic agitation (with benzodiazepines) in older
redirect and calm patients.39 Patients with delirium are at patients.52,53 In addition, all antipsychotics have a Food
higher risk for falls,40 so measures should be taken to help and Drug Administration black-box warning that they are
prevent injury while still promoting mobility, if possible. not approved for dementia-related psychosis because of an
Some measures include low beds, getting out of bed to chairs, increased mortality risk in older patients with dementia.
physical therapy, nonslip floors or socks, and 1:1 sitters.41,42 Although it is unclear how these medications increase
An ED length of stay of greater than 10 hours has been mortality in this population,54 antipsychotics should be
demonstrated to double the risk for incident delirium.43 used with caution in patients with a history of dementia.

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Managing Delirium and Agitation in the Older Emergency Department Patient Shenvi et al

However, many patients are prescribed antipsychotics long an ECG for QT-interval evaluation before administration.
term and may need them while in the ED. The oral route of administration is preferred because of
When medications are used for agitated delirium in fewer adverse effects.61 Although antipsychotics can help
older patients, the goal should not be sedation, but rather manage symptoms of delirium or agitation, meta-analyses
sufficient treatment for safe symptom management.55,56 If do not demonstrate any benefit in terms of outcomes such
medication is required, the recommendations are similar to as symptom duration, severity, hospital length of stay,
those for nongeriatric patients, although lower doses should disposition location, or mortality.29,62-66
be used (Table 4). Although the few existing high-quality If a patient has a history of long-term benzodiazepine use,
studies have not noted a difference between low-dose do not stop these medications precipitately because it may
haloperidol, olanzapine, or risperidone for the lead to withdrawal and worsening delirium. Benzodiazepines
pharmacologic treatment of delirium in hospitalized should be avoided in individuals not already receiving them
patients,57 the best current consensus evidence is for the because there is increased risk of prolonged sedation,
use of low-dose olanzapine or risperidone.58,59 Olanzapine paradoxic agitation, and worsening delirium.52,57
and risperidone have minimal effects on the QT interval, Diphenhydramine should not be used for the treatment
but can be associated with other adverse effects, such as of older individuals. Its anticholinergic adverse effects can
orthostatic hypotension.60 Clinicians should be cautious in lead to worsening delirium and prolonged sedation.52 There
regard to geriatric patients who may be receiving multiple is currently no evidence for or against subdissociative-dose
QT-interval-prolonging medications and should consider ketamine for agitation in older adults. However, studies of

Table 4. Summary of low-, intermediate-, and high-risk interventions, as well as risks or contraindications of certain medications, and
interventions to avoid.
Intervention Risk Category Intervention Details
Low-risk interventions or activities: Treat underlying conditions and symptoms, restart home medications if possible.
for all patients Follow prevention steps.
Transfer to hospital-style bed or chair/recliner instead of gurney, which limits mobility/independence and
may increase falls risk.
Verbal de-escalation if actively agitated.
Medium-risk interventions: for moderate Step 1: PO medications.
agitation or patient at risk of If the patient is prescribed an antipsychotic at home, administer this. Other options include the following:
harming self or staff Risperidone 1 mg. Caution in frail or volume-depleted patients; may cause orthostatic hypotension.
Olanzapine 2.5–5 mg. Contraindications/risks: Caution in intoxicated or volume-depleted patients; may
cause orthostatic hypotension or sedation.
Quetiapine 25–50 mg at night. May cause orthostatic hypotension and somnolence.
Haloperidol 1–2 mg PO. May have more extrapyramidal adverse effects than the atypical antipsychotics.
Step 2: IM or IV medications if patients are not cooperative with PO medications or are at risk of harming
themselves or staff:
Ziprasidone10–20 mg IM. Caution in uncontrolled heart failure or cardiac disease, intoxicated patients,
or volume-depleted/orthostatic patients.
Olanzapine 2.5–5 mg IM. Caution in intoxicated or volume-depleted patients; may cause orthostatic
hypotension or sedation.
Haloperidol 0.5–1 mg IM. Higher risk for extrapyramidal adverse effects than the atypical antipsychotics.
Higher risk with IV, so IM is preferred. Can redose if needed, but avoid doses of 5–10 mg haloperidol
because it may cause prolonged effects/sedation, EPS, or other adverse effects. Use caution or avoid IV
haloperidol because of adverse effects.
High-risk interventions Benzodiazepines should be avoided if possible because they may cause prolonged sedation, paradoxic
agitation, or worsening of delirium. If they are used, low doses such as 0.5 mg lorazepam should be
given rather than the more common 2 mg used in younger patients. However, if a patient is receiving
benzodiazepines long term, his or her home medication should be continued to prevent precipitating
withdrawal.
Physical restraints should be avoided if at all possible because patients can become injured, and their
use precludes mobility.
Interventions to avoid Diphenhydramine is appropriate for treatment of acute allergic reactions or anaphylaxis, but should not be
used for agitation because of its sedative and anticholinergic properties.

PO, Oral; IM, intramuscular; IV, intravenous.

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Shenvi et al Managing Delirium and Agitation in the Older Emergency Department Patient

subdissociative ketamine for pain in older adults found that should be screened and what screening methods should be
it was effective but limited by adverse effects.67,68 More used. Because delirium is underrecognized in ED
research is needed into the effects of low-dose ketamine in patients,2,3 some individuals advocate ED-based screening
older adults before this medication can be recommended for of older patients for cognitive impairment.71 However, to
routine use in the ED for agitation. our knowledge, to date there are no randomized controlled
Most patients with delirium in the ED will require studies examining the effect of routine delirium screening
admission or observation unless there is a clear, easily in the ED setting. Benefits of screening include earlier
reversible underlying cause, they have a caregiver who can diagnosis of delirium and potential avoidance of
monitor them closely, and their symptoms are improving. inappropriate discharge, which may be associated with
In summary, the treatment of delirium and agitation in the increased mortality4; however, the potential risks include
ED should focus on identifying and reversing the underlying false-positive diagnoses, which may result in unnecessary
causes. Nonpharmacologic interventions are preferred resource use, including hospitalization and the potential for
because of their negligible risk. Pharmacologic interventions inappropriate treatment with antipsychotic
should be used only to preserve the safety of patients and staff. medications.63,72
If pharmacologic interventions are necessary, then low doses We have reviewed the ED screening, diagnosis, and
should be used. Atypical antipsychotics may have a better treatment of older patients with alterations of mental
profile of efficacy to adverse effects. status, using the ADEPT framework. A freely available
There are several areas in which current clinical electronic version of the tool is available for clinicians and
controversies exist and further research is needed. One is trainees at http://www.acep.org/adept.6 It is designed to be
the best timing and use of medications for delirium. succinct, easily accessible, and used during patient care. In
Although medications such as antipsychotics may help the coming decades, older patients will make up an even
manage symptoms, they do not provide any outcome greater portion of ED patients. They frequently present
benefit in terms of hospital or ICU length of stay, with or develop delirium or agitation in the ED. It is
disposition, or mortality.29,62-66 Although many authors therefore important for hospitals to develop protocols and
recommend avoiding antipsychotic medications in all but procedures to help reduce the development and severity of
the most agitated delirious patients, most of the studies agitation and delirium, and for every clinician to be
were performed on admitted patients, providing little educated and prepared to care for patients with delirium.
evidence in regard to optimal ED treatment. Another
outstanding question is what the minimum, routine The authors acknowledge the support of the Coalition on
evaluation should be for older patients who present with Psychiatric Emergencies as the convening body for the
agitation. We have made suggestions here, but there is no development of the tool and article.
widely recognized formal recommendation.
Further work is also needed to identify the best ways to Supervising editor: David L. Schriger, MD, MPH. Specific detailed
prevent or manage delirium in the ED. There has been information about possible conflict of interest for individual editors
significant work done in the inpatient setting, in which is available at https://www.annemergmed.com/editors.
interprofessional teams provide multicomponent Author affiliations: From the Department of Emergency Medicine
interventions to help prevent delirium.63,69 To our (Shenvi) and Department of Internal Medicine, Division of
knowledge, similar studies have not been performed in the ED. Pulmonary Diseases and Critical Care Medicine (Austin), University
Because of the high morbidity and mortality associated of North Carolina, Chapel Hill, NC; Massachusetts General Hospital
Department of Emergency Medicine and Harvard Medical School,
with delirium and because individuals with delirium may Boston, MA (Kennedy); the University of Arkansas for Medical
have an impaired ability to comprehend and adhere to Sciences, Department of Emergency Medicine, Little Rock, AR
discharge instructions,70 we recommend admission of most (Wilson); the Department of Emergency Medicine, Morristown
delirious patients to the hospital for continued medical Medical Center, Morristown, NJ, and Coalition on Psychiatric
treatment and monitoring. However, the environmental Emergencies (Gerardi); and the American College of Emergency
Physicians, Irving, TX, the Department of Emergency Medicine,
changes associated with hospital admission can precipitate John Peter Smith Hospital, Fort Worth, TX, and Hofstra Northwell
delirium or contribute to its prolongation. Whether there School of Medicine, Hempstead, NY (Schneider).
are patients whose care would be optimized through
Author contributions: SS, CS, and MW conceived of the project. All
alternatives to hospitalization remains unstudied. Further
authors analysed the data, developed the methods, and refined
research is needed in this realm. the results. All authors contributed substantially to the
Finally, perhaps the largest controversy pertains to development of the manuscript. CS takes responsibility for the
optimal delirium screening strategies; in particular, who paper as a whole.

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Managing Delirium and Agitation in the Older Emergency Department Patient Shenvi et al

All authors attest to meeting the four ICMJE.org authorship criteria: 15. Han JH, Eden S, Shintani A, et al. Delirium in older emergency
(1) Substantial contributions to the conception or design of the department patients is an independent predictor of hospital length of
work; or the acquisition, analysis, or interpretation of data for the stay. Acad Emerg Med. 2011;18:451-457.
work; AND (2) Drafting the work or revising it critically for important 16. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older
emergency department patients: validity and reliability of the delirium
intellectual content; AND (3) Final approval of the version to be
triage screen and the brief confusion assessment method. Ann Emerg
published; AND (4) Agreement to be accountable for all aspects of Med. 2013;62:457-465.
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