Background

The World Health Organization declared dementia to be the leading cause of dependency and disability among older people in high, middle and lower income countries.1 The number of people living with dementia worldwide is currently estimated at 47.5 million and is projected to increase to 75.6 million by 2030 and 135.5 million in 2050.1 The total estimated worldwide cost of dementia was US $604 billion in 2010. These costs are around 1% of the world's gross domestic product, varying from 0.24% of GDP in low income countries to 0.35% in low-middle income countries, 0.50% in high-middle income countries and 1.24% in high income countries. One in 40 Canadians aged 65-74 years and one in three Canadians aged 85 years and older have age-related dementia.2 The Rising Tide report projects a rise in the number of people with dementia (PWD) in Canada from 480,600 in 2008 to 1.125 million by 2038.2

At any one time, a quarter of acute hospital beds in England are in use by PWD.1 Entry into an emergency department is a defining moment in the life of someone with dementia and often heralds an avoidable downward spiral. A study by Phelan et al.3 compared hospitalization rates for those with ambulatory care-sensitive conditions (ACSCs) (Appendix I) for which proactive outpatient care might prevent the need for a hospital stay and found that the crude admission rate was as much as 78% higher among PWD. Hospitalizations for ACSCs are considered potentially avoidable as these are physical conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely adequate treatment at a lower level of care. These can be classified as: chronic conditions where effective care can prevent flare-ups, acute conditions where early intervention can prevent more serious progression, and preventable conditions where immunization and other interventions can prevent illness.4

People with dementia are prone to develop unexpected acute illness and/or deterioration of their chronic illness, which necessitate visits to the Emergency Department (ED) for medical assessment and management.5 People with dementia have 20% higher visits to ED than those without dementia, and they also have a 40% higher probability of preventable hospital admissions.6 There are several potential explanations for the increase incidence of hospitalizations for ACSCs in PWD. People with dementia are more prone to infection due to reduced mobility, inadequate fluid intake and impaired performance of activities of daily living such as personal hygiene. Moreover, PWD tend to delay seeking help because of either reduced recognition of symptoms or impaired communication skills. Consequently, acute illness might not be diagnosed in PWD until physical symptoms become severe. Reducing hospitalizations for ACSCs has been an important health care policy for decades.7 Approximately 21-40% older adults who visit the ED have some form of dementia and 21.8% screen positive for dementia without delirium.7 A study conducted more than a decade ago found that PWD were more likely than persons without dementia to be admitted to the hospital for dehydration, urinary tract infection, pneumonia, delirium and adverse effects from medications.4

Dementia and ED do not mix successfully, and the ED experience is "vulnerable to a rapid escalation of risks."8^(p.1742) Dementia lowers the threshold for sensory overload, distress and disruptive behaviors. Hospital stays are very difficult for PWD as they are more likely to require restraints, develop delirium or experience falls, thus prolonging stays and increasing costs. Evidence shows that once PWD are admitted to hospital, they have a higher risk of institutionalization and death than people without dementia. Those with dementia are also at heightened risk of developing major complications such as pressure ulcers, delirium, fall and related injuries, incontinence, depression, malnutrition and functional decline.7 Long-term care home residents with dementia who underwent multiple hospitalizations had poorer survival rates than those without dementia.9 There are several challenges involving the presentation of those with dementia at the ED. Emergency Department staff report feeling burdened by cognitively impaired people who require additional time and resources.10 Emergency Department physicians reported cognitive impairment as the greatest barrier in providing the best ED care.11 The literature strongly indicates how a typical ED is not ideally suited for a medically complex older person with impaired memory, impaired mobility and impaired social supports. "The current model[s] of ED care was designed for the acutely ill and injured patient, not a medically complicated, slow-moving, functionally impaired geriatric patient".12^(p.272)

People with dementia use ED services at a higher rate, require more resources and are more likely to experience adverse health outcomes after an ED visit compared to cognitively intact people. To successfully reduce or prevent hospital admissions of PWD, understanding the available ED interventions for PWD presenting to ED with ACSCs is vital. Studies indicated that the implementation of ad-hoc strategies and adoption of clinical pathways13 implementation of nurse practitioners14 and provision of clinical education to nursing home staff to increase assessment skills15 could reduce hospital transfers of long-term care (nursing) home residents. Other strategies identified are the better staffing levels, appropriate training to ED physicians and nurses to enhance sensitivity, knowledge and skills in dealing with PWD,8 multifactorial fall prevention intervention, interventions to improve patient comfort and nutritional intake, and the interventions designed to prevent delirium.16

Little research evidence has been reported in the literature with a specific focus of avoiding hospital admissions for PWD in the ED. Appropriate discharge planning appears to be a core component of caring for those with dementia who seek emergency medical treatment, and this links closely to assessment issues.17 The appropriate client-centered and comprehensive discharge planning of those with dementia is not part of the core business of EDs, where the focus remains on rapid assessment, treatment and turnover. People with dementia who present at EDs and do not receive comprehensive assessments examining their cognitive, functional and social support capacities and status amid appropriate discharge support plans are more likely to re-present to the ED than those who have.17

The current scoping review will allow synthesis and mapping of the characteristics of the available ED/urgent care interventions for PWD presenting with ACSCs related to disposition (admission and transfer) from EDs. This scoping review could therefore contribute toward future ED/urgent care initiatives to develop new service provisions and change in contextual factors for PWD presenting with ACSCs and identify gaps in research.

Prior to commencement of this review, the Cochrane Database of Systematic Reviews, the JBI Database of Systematic Reviews and Implementation Reports and PROSPERO International Prospective Register of Systematic Reviews as well as Epistemonikos were searched, and no previous systematic reviews or scoping reviews on this specific topic were found or identified as being underway.

Inclusion criteria

Types of participants

The current review will consider studies with adults (18 years or older) with any type of dementia/cognitive impairment presenting to any ED with ACSCs. Diagnoses of dementia/cognitive impairment will be considered as defined by the primary studies.

Concept

The current review will examine the characteristics of interventions and strategies as implemented in EDs for PWD presenting with ACSCs. The concept of interest also includes the relationship between the identified interventions and the contextual factors and disposition of the PWD.

Context

Studies must be conducted in EDs. People with dementia may present to the ED from their own home or nursing homes/residential care homes with ACSCs.

Types of studies

The current scoping review will consider any existing literature such as primary research studies, both qualitative and quantitative, systematic reviews, meta-analysis, guidelines and opinion papers.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE (Ovid) and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. In 1991, the Canadian Consensus Conference on the Assessment of Dementia developed the initial guidelines for the evaluation of people with suspected dementia;18 therefore, studies published from June 1991 will be considered for inclusion in this review. Only studies published in English will be included. The reviewers will contact authors of primary studies or reviews for further information, if necessary. Because of the iterative nature of a scoping review search, careful tracking of the strategy results and frequent reviewer meetings will ensure rigor.

The databases to be searched include CINAHL, MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The search for unpublished studies will be conducted in the following sources:

For theses and dissertations: ProQuest Dissertations & Theses, Ethos, DART Europe, Trove.

For conference papers: Conference Papers Index, Conference Proceedings Citation Index.

For guidelines: Guidelines.gov, NICE, CMA Infobase, JBI Database of Systematic Reviews and Implementation Reports.

For gray literature: OpenGrey Repository, Google and websites of selected organizations including, but not limited to, Emergency Nurses Association, Alzheimer Scotland, Dementia Services Development Centre.

Initial keywords to be used will include, but not be limited to, the following keywords and subject headings:

Dementia OR Alzheimer's Disease OR alzheimer^* OR "cognitiv^* impair^*";

Emergency Service OR "emergency room^*" OR "emergency department^*" OR "emergency ward^*" OR "accident and emergency" OR "casualty department^*" OR Emergency Nursing OR Emergency Medicine.

Extracting and charting the results

Data will be extracted using a charting table and that will be trialed between two reviewers prior to full data extraction. The charting table will be modified as needed for different studies (e.g. research, opinion and guidelines). The two reviewers will then extract the data independently with any conflict being resolved with team consultation to ensure consistency with the question and the purpose. Since data extraction can be considered an iterative process, the charting table will be reviewed as necessary as the data extraction proceeds and will be determined during weekly team meetings. The charting table will include key information about the studies (Appendix II).

Presentation of the results

The results of the search strategy will be presented as a PRISMA flow diagram. Data extracted from each of the studies will be mapped and presented in a form that logically reflects the objective of the scoping review. The review findings will be presented in narrative form and will use tables and figures to summarize or illustrate key findings if necessary.

Acknowledgements

The current scoping review is supported by a research award from the Manitoba Centre for Nursing and Health Research at the College of Nursing, University of Manitoba.

Appendix I: List of ambulatory care-sensitive conditions

Appendix II: Data extraction and charting table

References