To the Editor: Persons with dementia present more frequently to the emergency department (ED) than their non-cognitively impaired counterparts1,2. Caring for these patients is challenging, as they often have multiple comorbidities3, an inability to accurately recount their histories4, and express their goals of care5. Standard diagnostic and treatment approaches used in the ED have not traditionally considered patients’ cognitive status3.
Chest pain is a chief complaint in the ED with standard diagnostic and treatment approaches. Dementia may necessitate changes in those standard plans, such as minimizing testing, depending on patient preferences and care goals. Because of this, it is imperative to identify patients with dementia, assess whether their dementia and associated goals of care affect desired clinical diagnostic testing and treatments, and document the clinical approach and its rationale. Unfortunately, dementia is under-recognized and under-documented by ED providers6. No prior studies have identified factors that are associated with documentation of dementia diagnosis among ED patients. The identification of such factors would inform the construction of tailored interventions to improve ED care for patients with dementia.
In a population of ED patients with a known diagnosis of dementia who present for evaluation of chest pain, we evaluated whether clinicians documented these diagnoses in the ED records and whether documentation was associated with patient and provider factors, the care the patient received, and the location of the pre-ED diagnosis.
We performed a retrospective cohort study of all persons 65 years and older presenting to a single academic ED with chest pain between 2012 and 2015 with a known prior diagnosis of dementia (N=205) according to administrative diagnostic codes and confirmed by abstraction within the EHR.7 We collected EHR data of these patients, including all notes from the ED encounter, including post-ED hospitalization. We recorded the presence or absence of documentation of a dementia diagnosis in the ED notes, and compared differences in the location of the pre-ED dementia diagnoses, provider and patient factors, and clinical care received between those with and without documented dementia diagnoses using χ2 tests of homogeneity.
Over the study period, 51% of the subjects did not have their dementia diagnosis documented in any ED nursing or physician notes (Table 1). Patients with an ED-documented dementia diagnosis were significantly more likely to have an activated HCPOA (p<0.001), be residing within an institution (p=0.002), and be wearing a DNR bracelet (p=0.02). No significant differences were found between those with and without ED-documented dementia diagnoses in measures of clinical care received; nearly all patients received troponin testing and EKGs, while about half received any medication during their ED encounter. This raises concerns as care delivery and communication with dementia patients should be tailored to their cognitive impairment. Further research must be done to determine if this represents a deviation from the patients’ stated goals of care.
Table 1.
Sample Demographics and Factors Associated with Dementia Documentation
| Overall (N = 205) | Dementia Undocumented (n = 101) | Dementia Documented (n = 104) | P-Value | |
|---|---|---|---|---|
| Sample Demographics | ||||
| Mean Age (SD) | 81 (7.58) | 81 (7.45) | 82 (7.76) | 0.35 |
| Female, N (%) | 125 (60.98) | 63 (62.38) | 62 (59.62) | 0.68 |
| Non-White, N (%) | 19 (9.27) | 6 (5.94) | 13 (12.50) | 0.10 |
| Location of Pre-ED Dementia Diagnosis | ||||
| Patient Problem List, N (%) | 36 (17.56) | 20 (19.80) | 16 (15.38) | 0.41 |
| History of Taking Dementia-Specific‡ Medication, N (%) | 42 (20.49) | 26 (25.74) | 16 (15.38) | 0.07 |
| Both Problem List and Dementia-Specific Medication, N (%) | 77 (37.56) | 19 (18.81) | 58 (55.77) | <0.001 |
| Other Clinical Documentation, N (%) | 50 (24.39) | 36 (35.64) | 14 (13.46) | <0.001 |
| Provider Characteristics, N (%) | ||||
| Medical Student Involved in Care | 20 (9.90) | 9 (8.91) | 11 (10.89) | 0.64 |
| Resident Involved in Care | 139 (67.65) | 70 (69.31) | 68 (65.38) | 0.55 |
| Patient Presents During Clinic Hours | 122 (59.51) | 64 (63.37) | 59 (56.31) | 0.30 |
| Patient Presents on Weekend | 45 (22.06) | 20 (19.80) | 25 (24.27) | 0.44 |
| Patient Characteristics, N (%) | ||||
| Caregiver Present | 87 (42.44) | 37 (36.63) | 50 (48.08) | 0.10 |
| HCPOA* Document Present | 85 (41.46) | 45 (44.55) | 40 (38.46) | 0.38 |
| Activated HCPOA | 57 (27.80) | 15 (14.85) | 42 (40.38) | <0.001 |
| Patient Resides in Institution | 63 (30.73) | 22 (21.78) | 44 (42.31) | 0.002 |
| Patient Wearing DNR† Bracelet | 17 (8.33) | 4 (3.96) | 13 (12.62) | 0.02 |
| Presented to ED in Previous 6 Months | 92 (44.88) | 45 (44.55) | 47 (45.19) | 0.83 |
| Clinical Characteristics, N (%) | ||||
| ECG Performed in ED | 98.51% | 99.01% | 98.02% | 0.56 |
| Troponin Drawn in ED | 98.02% | 97.03% | 99.01% | 0.31 |
| Medication Administered in ED | 50.49% | 53.46% | 47.52% | 0.40 |
HCPOA = Health Care Power of Attorney
= Donepezil, Galantamine, Memantine, or Rivastigmine
DNR = Do Not Resuscitate
These findings are consistent with previous literature which demonstrates that dementia is under-documented and likely under-recognized in the ED6,8. No provider or system related factors were associated with documentation, which implies that lack of documentation is a problem that persists across providers and presentation time and day. It should also be noted that the factors associated with documentation, such as having an activated HCPOA, are also factors associated with more severe dementia clinical states, which may suggest that a larger proportion of patients with more mild symptoms are going unrecognized in the ED, which has implications for their care. Regardless of documentation, all patients received the same or similar care. ED chest pain protocols were followed even though they may have ultimately not been in alignment with patient-specific goals of care for all of these patients with dementia. To our knowledge, this is the first study to identify factors associated with dementia documentation in the ED, which may be an important first step towards improved diagnosis recognition and goal-concordant care for this population.
While using documentation as a proxy of recognition may not fully represent provider behavior or awareness, this would be an excellent focus for future prospective study. Also, this was an assessment of a single academic medical center and may not be representative of nor generalizable to all similar populations. More research on this is needed.
Clear documentation of dementia diagnoses in the ED should occur consistently, as it may be a key step in improving goal-concordant care decisions and delivery. From the findings noted in this study, more work in this area is needed.
ACKNOWLEDGEMENTS
The authors would like to thank Steven Wang and Laura Block for their assistance in abstracting medical records. This project was supported by National Institute on Aging Awards (P30AG062715 [PI Asthana; Care Research Core PI: Kind] and K24AG054560 [PI Shah]), the American Federation for Aging Research, the John A. Hartford Foundation, and the Centers of Excellence National Program. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. This material is the result of work also supported with the resources and the use of facilities at the University of Wisconsin Department of Medicine Health Services and Care Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Sponsor’s Role
The funding organizations for this study had no role in study concept or design, acquisition of the data, analysis or interpretation of the data, or in the preparation, review, or approval of the manuscript.
Footnotes
Conflicts of Interest
The authors have no conflicts of interest to report.
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