Emergency Department Interventions for Persons with Dementia Presenting with Ambulatory Care-Sensitive Conditions: a Scoping Review Protocol

SYSTEMATIC REVIEW

Emergency department interventions for persons with dementia presenting with ambulatory care-sensitive conditions: a scoping review protocol

1 1,2 1 3 4 Beverley A. Temple Preetha Krishnan Beverly O’Connell Lyle G. Grant Lisa Demczuk

1College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada, 2Winnipeg Regional Health Authority, Winnipeg, Canada, 3Institute for Nursing Scholarship, Saskatchewan Institute of Applied Science and Technology, Regina, Canada, and 4Elizabeth Dafoe Library, University of Manitoba, Winnipeg, Canada

Review question/objective: The objective of this scoping review is to examine and map, within existing literature, the characteristics of emergency department/urgent care interventions, strategies or contextual factors, implemented to reduce unnecessary hospitalization of people with dementia (PWD) presenting at the emergency department/urgent care with ambulatory care-sensitive conditions (ACSC). More specifically, the review questions are: What non-pharmacological interventions or strategies, including, but not limited to, screening, assessments, clinical pathways, appropriate referrals and sensory overload reduction, are used in emergency departments for PWD presenting with ACSC? What are the characteristics and settings of these interventions, and how do they affect the disposition of PWD? What contextual factors, including, but not limited to, staff education, staffing mix and levels, and alterations to the physical environment, exist in emergency department/urgent care? What are the characteristics of these factors and the settings in which they are used? Keywords Alzheimer’s disease; ambulatory care-sensitive conditions; dementia; emergency departments JBI Database System Rev Implement Rep 2017; 15(2):196–201.

Background and one in three Canadians aged 85 years and older 2 he World Health Organization declared demen- have age-related dementia. The Rising Tide report tia to be the leading cause of dependency and projects a rise in the number of people with dementia T (PWD) in Canada from 480,600 in 2008 to 1.125 disability among older people in high, middle and 2 lower income countries.1 The number of people million by 2038. At any one time, a quarter of acute hospital beds living with dementia worldwide is currently esti- 1 mated at 47.5 million and is projected to increase in England are in use by PWD. Entry into an to 75.6 million by 2030 and 135.5 million in 2050.1 emergency department is a defining moment in the life of someone with dementia and often heralds an The total estimated worldwide cost of dementia was 3 US $604 billion in 2010. These costs are around 1% avoidable downward spiral. A study by Phelan et al. of the world’s gross domestic product, varying from compared hospitalization rates for those with ambu- 0.24% of GDP in low income countries to 0.35% in latory care-sensitive conditions (ACSCs) (Appendix low-middle income countries, 0.50% in high-middle I) for which proactive outpatient care might prevent income countries and 1.24% in high income the need for a hospital stay and found that the crude countries. One in 40 Canadians aged 65–74 years admission rate was as much as 78% higher among PWD. Hospitalizations for ACSCs are considered Correspondence: Beverley A. Temple, [email protected] potentially avoidable as these are physical conditions Centers conducting the review: University of Manitoba and Queen’s that can often be treated safely at a lower level of Collaboration for Health Care Quality: a Joanna Briggs Institute Centre care or occur as a result of lack of timely adequate of Excellence. treatment at a lower level of care. These can be There is no conflict of interest in this project. classified as: chronic conditions where effective care DOI: 10.11124/JBISRIR-2016-003263 can prevent flare-ups, acute conditions where early

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intervention can prevent more serious progression, burdened by cognitively impaired people who and preventable conditions where immunization and require additional time and resources.10 Emergency other interventions can prevent illness.4 Department physicians reported cognitive impair- People with dementia are prone to develop unex- ment as the greatest barrier in providing the best pected acute illness and/or deterioration of their ED care.11 The literature strongly indicates how a chronic illness, which necessitate visits to the Emer- typical ED is not ideally suited for a medically gency Department (ED) for medical assessment and complex older person with impaired memory, management.5 People with dementia have 20% impaired mobility and impaired social supports. higher visits to ED than those without dementia, ‘‘The current model[s] of ED care was designed and they also have a 40% higher probability of for the acutely ill and injured patient, not a medically preventable hospital admissions.6 There are several complicated, slow-moving, functionally impaired potential explanations for the increase incidence of geriatric patient’’.12(p.272) hospitalizations for ACSCs in PWD. People with People with dementia use ED services at a higher dementia are more prone to infection due to reduced rate, require more resources and are more likely to mobility, inadequate fluid intake and impaired per- experience adverse health outcomes after an ED visit formance of activities of daily living such as personal compared to cognitively intact people. To success- hygiene. Moreover, PWD tend to delay seeking help fully reduce or prevent hospital admissions of PWD, because of either reduced recognition of symptoms or understanding the available ED interventions for impaired communication skills. Consequently, acute PWD presenting to ED with ACSCs is vital. Studies illness might not be diagnosed in PWD until physical indicated that the implementation of ad-hoc symptoms become severe. Reducing hospitalizations strategies and adoption of clinical pathways13 imple- for ACSCs has been an important health care policy mentation of nurse practitioners14 and provision of for decades.7 Approximately 21-40% older adults clinical education to nursing home staff to increase who visit the ED have some form of dementia assessment skills15 could reduce hospital transfers of and 21.8% screen positive for dementia without long-term care (nursing) home residents. Other strat- delirium.7 A study conducted more than a decade egies identified are the better staffing levels, appro- ago found that PWD were more likely than persons priate training to ED physicians and nurses to without dementia to be admitted to the hospital for enhance sensitivity, knowledge and skills in dealing dehydration, urinary tract infection, pneumonia, with PWD,8 multifactorial fall prevention interven- delirium and adverse effects from medications.4 tion, interventions to improve patient comfort and Dementia and ED do not mix successfully, and the nutritional intake, and the interventions designed to ED experience is ‘‘vulnerable to a rapid escalation of prevent delirium.16 risks.’’8(p.1742) Dementia lowers the threshold for Little research evidence has been reported in the sensory overload, distress and disruptive behaviors. literature with a specific focus of avoiding hospital Hospital stays are very difficult for PWD as they are admissions for PWD in the ED. Appropriate dis- more likely to require restraints, develop delirium or charge planning appears to be a core component of experience falls, thus prolonging stays and caring for those with dementia who seek emergency increasing costs. Evidence shows that once PWD medical treatment, and this links closely to assess- are admitted to hospital, they have a higher risk ment issues.17 The appropriate client-centered and of institutionalization and death than people with- comprehensive discharge planning of those with out dementia. Those with dementia are also at dementia is not part of the core business of EDs, heightened risk of developing major complications where the focus remains on rapid assessment, treat- such as pressure ulcers, delirium, fall and related ment and turnover. People with dementia who injuries, incontinence, depression, malnutrition and present at EDs and do not receive comprehensive functional decline.7 Long-term care home residents assessments examining their cognitive, functional with dementia who underwent multiple hospitaliz- and social support capacities and status amid appro- ations had poorer survival rates than those without priate discharge support plans are more likely to dementia.9 There are several challenges involving re-present to the ED than those who have.17 the presentation of those with dementia at the The current scoping review will allow synthesis ED. Emergency Department staff report feeling and mapping of the characteristics of the available

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ED/urgent care interventions for PWD presenting MEDLINE (Ovid) and CINAHL will be undertaken with ACSCs related to disposition (admission and followed by analysis of the text words contained transfer) from EDs. This scoping review could there- in the title and abstract, and of the index terms used fore contribute toward future ED/urgent care initiat- to describe article. A second search using all ident- ives to develop new service provisions and change in ified keywords and index terms will then be under- contextual factors for PWD presenting with ACSCs taken across all included databases. Third, the and identify gaps in research. reference list of all identified reports and articles Prior to commencement of this review, the will be searched for additional studies. In 1991, Cochrane Database of Systematic Reviews, the the Canadian Consensus Conference on the Assess- JBI Database of Systematic Reviews and Imple- ment of Dementia developed the initial guidelines for mentation Reports and PROSPERO International the evaluation of people with suspected dementia;18 Prospective Register of Systematic Reviews as well therefore, studies published from June 1991 will be as Epistemonikos were searched, and no previous considered for inclusion in this review. Only studies systematic reviews or scoping reviews on this published in English will be included. The reviewers specific topic were found or identified as being will contact authors of primary studies or reviews for underway. further information, if necessary. Because of the iterative nature of a scoping review search, careful Inclusion criteria tracking of the strategy results and frequent reviewer Types of participants meetings will ensure rigor. The current review will consider studies with adults The databases to be searched include CINAHL, (18 years or older) with any type of dementia/cog- MEDLINE, Embase, PsycINFO, Web of Science and nitive impairment presenting to any ED with ACSCs. Google Scholar. The search for unpublished studies Diagnoses of dementia/cognitive impairment will be will be conducted in the following sources: considered as defined by the primary studies. For theses and dissertations: ProQuest Dissertations & Theses, Ethos, DART Europe, Trove. Concept For conference papers: Conference Papers Index, The current review will examine the characteristics Conference Proceedings Citation Index. of interventions and strategies as implemented in For guidelines: Guidelines.gov, NICE, CMA Info- EDs for PWD presenting with ACSCs. The concept base, JBI Database of Systematic Reviews and of interest also includes the relationship between the Implementation Reports. identified interventions and the contextual factors For gray literature: OpenGrey Repository, Google and disposition of the PWD. and websites of selected organizations including, but not limited to, Emergency Nurses Association, Context Alzheimer Scotland, Dementia Services Develop- Studies must be conducted in EDs. People with ment Centre. dementia may present to the ED from their own Initial keywords to be used will include, but not home or nursing homes/residential care homes be limited to, the following keywords and subject with ACSCs. headings: Dementia OR Alzheimer’s Disease OR alzheimerÃ Types of studies OR ‘‘cognitivÃ impairÃ’’; The current scoping review will consider any existing Emergency Service OR ‘‘emergency roomÃ’’ OR literature such as primary research studies, both ‘‘emergency departmentÃ’’ OR ‘‘emergency wardÃ’’ qualitative and quantitative, systematic reviews, OR ‘‘accident and emergency’’ OR ‘‘casualty meta-analysis, guidelines and opinion papers. departmentÃ’’ OR Emergency Nursing OR Emer- gency Medicine. Search strategy The search strategy aims to find both published and Extracting and charting the results unpublished studies. A three-step search strategy will Data will be extracted using a charting table and that be utilized in this review. An initial limited search of will be trialed between two reviewers prior to full

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data extraction. The charting table will be modified 4. Lyketsos CG, Sheppard JM, Rabins PV. Dementia in elderly as needed for different studies (e.g. research, opinion persons in a general hospital. Am J Psychiatry 2000;157(5): and guidelines). The two reviewers will then extract 704–7. the data independently with any conflict being 5. Valeriani L. Management of demented patients in Emer- resolved with team consultation to ensure consist- gency Department. Int J Alzheimers Dis 2011;2011:1–5. 6. Robinson S, Mercer S. Older adult care in the emergency ency with the question and the purpose. Since data department: identifying strategies that foster best practice. extraction can be considered an iterative process, the J Gerontol Nurs 2007;33(7):40–7. charting table will be reviewed as necessary as the 7. Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Long- data extraction proceeds and will be determined ano J. Delirium and other cognitive impairment in older during weekly team meetings. The charting table adults in an Emergency Department. Ann Emerg Med will include key information about the studies 1995;25(6):751–5. (Appendix II). 8. Clevenger CK, Chu TA, Yang Z, Hepburn KW. Clinical care of persons with dementia in the Emergency Department: a Presentation of the results review of the literature and agenda for research. J Am Geriatr Soc 2012;60(9):1742–8. The results of the search strategy will be presented 9. Mitchell SL, Teno JM, Kiely DK, Shaffer ML, Jones RN, as a PRISMA flow diagram. Data extracted from Prigerson HG, et al. The clinical course of advanced demen- each of the studies will be mapped and presented in tia. N Engl J Med 2009;361(16):1529–38. a form that logically reflects the objective of the 10. McNamara RM, Rousseau E, Sanders AB. Geriatric emer- scoping review. The review findings will be pre- gency medicine: a survey practicing emergency physicians. sented in narrative form and will use tables and Ann Emerg Med 1992;21(7):796–801. figures to summarize or illustrate key findings 11. Schumacher JG, Deimling GT, Meldon S, Woolard B. Older if necessary. adults in emergency department: predicting physicians burden levels. J Emerg Med 2006;30(4):455–60. 12. Adams JG, Gerson LW. A new model for emergency care of Acknowledgements geriatric patients. Acad Emerg Med 2003;10(3):271–4. The current scoping review is supported by a 13. Loeb M, Carusone SC, Goeree R, Walter SD, Brazil K, Krueger research award from the Manitoba Centre for Nurs- P, et al. Effect of a clinical pathway to reduce hospitalizations ing and Health Research at the College of Nursing, in nursing home residents with pneumonia: a randomized University of Manitoba. controlled trial. JAMA 2006;295(21):2503–10. 14. Klaasen K, Lamont L, Krishnan P. Setting a new standard of care in nursing homes. Can Nurse 2009;105(9):24–30. References 15. Foster SJ, Boyd M, Broad JB, Whitehead N, Kerse N, Lumley T, 1. World Health Organization, Alzheimer’s Disease International. et al. Aged Residential Care Health Utilization Study Dementia: a public health priority Geneva: World Health Organ- (ARCHUS): a randomized control trial to reduce acute hos- ization; 2012; Available from: http://www.who.int/mental_ pitalisations from residential aged care. BMC Geriatr health/publications/dementia_report_2012/en/. [Accessed 2012;12(54):1–6. March 20, 2014]. 16. Andrews J, Christie J. Emergency care for people with 2. Alzheimer Society, Canada. Rising tide: the impact of dementia. Emerg Nurs 2009;12(5):14–5. dementia on Canadian society Toronto, ON: Alzheimer 17. Moons P, Arnauts H, Delooz HH. Nursing issues in care for Society; 2010; Available from: http://www.alzheimer.ca// the elderly in the Emergency Department: an overview of media/Files/national/Advocacy/ASC_Rising_Tide_Full_ the literature. Accid Emerg Nurs 2003;11(2):112–20. Report_e.pdf. [Accessed March 15, 2014]. 18. Clarfield AM. Assessing dementia: the Canadian Consensus. 3. Phelan EA, Borson S, Grothaus L, Balch S, Larson EB. Associ- Organizing Committee, Canadian Consensus Conference ation of incident dementia with hospitalizations. JAMA on the Assessment of Dementia. Can Med Assoc J 2012;307(2):165–72. 1991;144(7):851–3.

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Appendix I: List of ambulatory care-sensitive conditions

Medical conditions Grand mal seizure disorders Severe ear, nose and throat infections Tuberculosis Chronic obstructive pulmonary disease Bacterial pneumonia Asthma Congestive heart failure Hypertension Angina Cellulitis Diabetes with ketoacidosis or hyperosmolar coma Diabetes with specified complications Diabetes without specified complications Hypoglycemia Gastroenteritis Kidney/urinary tract infection Dehydration Iron-deficiency anemia Nutritional deficiency Dental conditions

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Appendix II: Data extraction and charting table

Contextual factors (staff Intervention/ Author education, recommendation Year of environmental (sensory overload publication changes and reduction and country of origin Aims/purpose Methodology/methods policies) referrals) Key findings

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