Ula Hwang, MD, MPH

Icahn School of Medicine at Mount Sinai

Pathway to Detection & Differentiation of Delirium & Dementia in the Emergency Department

Health Care Systems

Icahn School of Medicine, Mount Sinai Northwestern University

Ula Hwang, MD, MPH is a professor of emergency medicine and geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai. Her research interests are understanding and improving quality of care for older adults in the emergency department (ED). Dr. Hwang authored the paper “The Geriatric Emergency Department,” the basis of the CMS Health Care Innovation Award program, GEDI WISE (Geriatric ED Innovations in care through Workforce, Informatics, and Structural Enhancements). Her leadership and committee positions involve national efforts to improve care for older adults in the ED. She is Co-PI on the Geriatric Emergency Department Collaborative (GEDC) funded by the John A. Hartford Foundation and Gary and Mary West Health Institute, and PI for the Geriatric Emergency care Applied Research (GEAR) Network, a NIA funded R21/R33. Dr. Hwang’s projects have evaluated the impact on patient outcomes of Geriatric ED interventions, improving emergency provider practices in medication prescribing for older adults, analgesic safety and effectiveness, and ED quality of care with support by the NIA, Veterans Affairs, Health Services Research & Development, and foundations.

RATIONALE: Vulnerable older adults often seek care in emergency departments (EDs). Although assessment for dementia is not traditionally performed in the ED, detection and recognition of unidentified Alzheimer’s disease and related dementias at this point of contact may provide a pathway for improved care delivery and outcomes in this population.

OBJECTIVE: To pilot test and establish the feasibility of a conducting a pragmatic clinical trial to test an effectiveness intervention that embeds cognitive impairment screening into the routine care of older patients in the ED setting and refers those identified as needing formal cognitive evaluation for outpatient assessment.

SETTING: Two academic health care systems in Chicago and New York City, their EDs and outpatient Geriatrics clinic and outpatient Neuropsychiatry clinics.

POPULATION: Community-dwelling patients age over 65, discharged from the ED.

INTERVENTION: The intervention will be embedded into the clinical flow of the ED and consists of:  1. routinized cognitive assessment of subjects by ED clinicians, and when appropriate, 2. referral of older patients with unrecognized cognitive impairment and dementia (UCID) for formal outpatient cognitive evaluation within the health care system network.

OUTCOMES: By leveraging the electronic medical records in the two health care systems, the pilot study will establish the feasibility of collecting the primary clinical outcome defined as the rate of referred ED patients who complete an outpatient cognitive evaluation. Secondary outcomes will include measures of feasibility of subject enrollment, validation of ED cognitive assessment, acceptability of the workflow among ED providers, and disposition of targeted subjects after ED evaluation.

IMPACT: This pilot study will inform and strengthen the design of a large-scale, multicenter embedded pragmatic trial implemented in the Geriatric Emergency Department Collaborative network of hospitals.  Effective cognitive screening and referral from the ED setting could improve detection and subsequent community-based care and assistance with treatment planning for patients with unrecognized cognitive impairment and dementia.