Dementia Screening in the Emergency Department: A Communication‐Centered Process

Emergency clinicians frequently care for patients with unrecognized cognitive impairment [1]. Recognizing cognitive impairment in the emergency department (ED) has immediate clinical relevance for medication safety, delirium diagnosis, disposition decision‐making, and care transitions [2]. The ED also represents a critical access point for individuals who may otherwise lack access to outpatient evaluation for cognitive impairment and dementia [3]. Accordingly, the Geriatric Emergency Department (GED) Guidelines recommend screening older patients for cognitive impairment, allowing emergency clinicians to refer patients for diagnostic testing and newly available interventions (e.g., disease modifying antibody treatments, caregiver support programs) [4].

However, cognitive impairment screening is infrequently implemented; among accredited GEDs it is the least commonly implemented of the recommended geriatric screenings [5, 6]. Across all ED settings, challenges to cognitive impairment screening have been framed largely in terms of workflow, time constraints, and accuracy [7, 8, 9].

In our experience, however, this framing is incomplete. Cognitive impairment and dementia are terms that can carry stigma and provoke fear, uncertainty, and misconceptions among patients and caregivers [10]. Thus, ED screening for cognitive impairment necessitates communication‐intensive processes, including extended multi‐party conversations to interpret findings and to overcome misconceptions, fears, and knowledge gaps. Other GED screening topics, such as falls risk, lack this stigma and easily lead to discrete and immediate clinical actions even if they identify conditions with a much greater one‐year mortality rate [11]. Communication shapes whether cognitive impairment and dementia screening is understood, accepted, and actionable for patients and families. Attention to how screening is introduced, discussed, and interpreted offers important insights into why the screening is complex to implement and why lessons from real‐world practice settings are needed. We offer four key lessons learned from implementing an ED dementia screening program and argue that successful screening programs require communication infrastructure—including clinician training, caregiver engagement, referral pathways, and longitudinal follow‐up—rather than simply incorporating a screening tool into ED workflow.

We implemented a pilot dementia screening program in an urban safety net ED serving a low‐income, racially and ethnically diverse patient population. The ED did not have geriatric accreditation or age‐friendly designation. Prior discussions with ED leadership and qualitative research with frontline ED nurses in the health system indicated that time constraints, crowding and boarding, and needs for staff training would make it infeasible for ED clinicians to perform cognitive screening in routine practice [8]. As such, a geriatrics consult service screened eligible ED patients. Patients had to be age ≥ 60 years, not critically ill, with normal vital signs, have 3+ risk factors for dementia [12], and no prior diagnosis of cognitive impairment or dementia. Geriatrics consultants assessed patients for dementia using the St. Louis University Mental Status Exam (SLUMS) and the Eight‐item Informant Interview to Differentiate Aging and Dementia (AD8) when caregivers were present at bedside and/or available by phone at the time of the ED visit. Geriatrics consultants administered the Confusion Assessment Method (CAM) to assess for and exclude patients with delirium. For patients who screened positive for dementia, the geriatrics consultants provided counseling about recommended outpatient follow‐up testing, anticipatory guidance about future care, and local and online caregiving and dementia information resources. Community health workers offered care navigation for patients with positive screening, which included scheduling outpatient follow‐up with geriatrics or primary care for further evaluation, help understanding insurance coverage and applying for a local financial assistance program, reminder phone calls about upcoming appointments, and discussion about cognitive health concerns. Over the first six months, we performed 100 cognitive assessments, with 50 older adults screening positive for cognitive impairment. Among those we screened, the majority spoke Spanish as their primary language (53%). Drawing from this experience, we identified recurring communication considerations that shape the feasibility and impact of ED‐based cognitive impairment screening.

First, introducing cognitive impairment screening to patients in the ED requires careful attention to language, timing, and patient context. In our setting, patients were not universally familiar with the term “dementia,” and for some it carried stigma. Patients more readily engaged with the concept of “memory testing,” even though this framing simplifies the broader cognitive and functional dimensions of dementia. Screening must be framed in ways that patients understand and accept.

The timing of these conversations is also crucial. Patients were more receptive to screening after their acute symptoms and the primary reason for the ED visit had been addressed, underscoring the need to ground conversations about screening in the patient's immediate needs. We also found that framing screening in relation to patients' own experiences and priorities facilitated engagement. Some patients described prior episodes of confusion during hospitalizations or after surgery, motivating their participation. Others spoke about wanting to get their memory tested to ensure they could continue living independently or remain in caregiving roles. Connecting screening to these concerns made it more meaningful and relevant to patients.

Second, communicating results was not a simple task and required navigating uncertainty and subtle and complicated concepts. While a positive screen raises the possibility of cognitive impairment, it does not confirm a diagnosis of mild cognitive impairment or dementia. Geriatrics consultants had to explain the limits of testing, especially in the ED context where acute symptoms, treatment, and even the environment can impact cognitive performance. They then had to guide patients and caregivers on next steps in evaluation. While a negative screen may be reassuring, it reflects cognitive performance at a single time point, and geriatricians had to convey that it does not preclude development of cognitive impairment in the future. In cases where cognitive impairment was present and dementia was likely, during the ED visit itself, geriatrics consultants led conversations about longer‐term caregiving needs, financial planning, and goals of care as well as local community resources. Community health workers reinforced information about community resources during phone calls following the ED visit. In these ways, conversations with patients and caregivers extend beyond simply conveying results.

Related to communicating results, geriatrics consultants had to ensure that patients and families understood and could act on screening results after the ED encounter. Patients often had limited recall of what was discussed in the ED, particularly if cognitive impairment was present. This highlights a fundamental limitation of ED‐based communication: a single encounter may be insufficient to convey information and ensure retention. Engaging caregivers, either at the bedside or by phone, was often essential to facilitate follow‐up and future healthcare decision‐making. Even when patients and caregivers voiced understanding of the information we provided, their ability to act on that information depended on factors outside the ED encounter, including access to outpatient care and continuity with a primary care provider. For patients with primary care providers within the health system, the geriatrics team and community health workers directly communicated screening results via messages in the electronic health record. For patients with primary care providers outside of the health system and for those without primary care providers, we provided a physical referral letter detailing screening results.

Fourth, language concordance was a critical component of communication in ED‐based dementia screening. In our safety net hospital setting, over half of older adults speak a primary language other than English, most commonly Spanish. ED cognitive assessment tools have largely been validated in English [2, 9], and in some cases, Spanish [13] or French [14]. We encountered patients who spoke languages for which no validated instruments exist. Rather than excluding these patients, geriatrics consultants worked with interpreters and relied heavily on clinical judgment and collateral information to interpret screening findings. At the same time, interpreter‐mediated communication added time and introduced potential opportunities for misunderstanding. Language‐concordant encounters—such as those with Spanish‐speaking geriatricians and community health workers—allowed for more direct and nuanced discussions.

Together, our observations suggest that cognitive impairment screening in the ED is not simply a single test, but a series of communication processes that unfold across time, settings, and relationships. Conversations about screening and results are inherently complex and may not easily align with the time‐limited, interruption‐prone ED environment. Yet our argument is not that cognitive screening is too complex for the ED, but rather that the ED can identify cognitive impairment responsibly only when screening is paired with infrastructure that makes results understood, accepted, and actionable—clinician training, caregiver engagement, referral pathways, and longitudinal follow‐up.

Some of our lessons transfer readily and depend more on approach than resources: framing screening in accessible terms, timing conversations after acute concerns are addressed, and prioritizing language‐concordant communication. Others—the extended conversations about diagnosis and care navigation—were carried out by a geriatrics consult service and community health workers, resources unavailable in most EDs. Rather than a universal staffing model, these illustrate the functions any ED cognitive screening program must fill: someone must interpret results with patients and caregivers, and someone must coordinate and support follow‐up beyond the ED. Settings without geriatrics consultants might meet these functions through protocolized caregiver engagement, standardized referral pathways, community partnerships, or telehealth support. If the ED is to serve as a site for identifying cognitive impairment, the question is less whether to screen than whether the surrounding system can support what a screen sets in motion.

Author Contributions

Concept and design: A.N.C., A.B.M., and A.D.N. Acquisition of data: A.N.C., A.D., and A.B.M. Analysis and interpretation of data: All authors. Drafting of the manuscript: A.N.C. Statistical expertise: N/A. Acquisition of funding: A.N.C.

Funding

This work was supported by the Alzheimer's Association (A.N.C.). A.N.C. and A.D.N. receive support from the Houston Veterans Administration Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (CIN13‐413).

Conflicts of Interest

The authors declare no conflicts of interest.

Chary A. N., Dobecka A., Katsouli P., Naik A. D., Major A. B., and Shah M. N., “Dementia Screening in the Emergency Department: A Communication‐Centered Process,” Academic Emergency Medicine 33, no. 8 (2026): e70391, 10.1111/acem.70391.

Data Availability Statement

The authors have nothing to report.