LO054: The emergency department usage and utility of ISAR and CAM assessment tools in identifying hip fracture patients at risk for developing delirium

Introduction: Delirium is an acute state of mental confusion that is a frequent complication in older adults with a hip fracture, and is often unrecognized by clinicians in the emergency department (ED). It is associated with prolonged hospitalization, functional decline, hospital readmission, and death. The Identification of Seniors At Risk (ISAR) and Confusion Assessment Method (CAM) are two standardized tools designed to facilitate prompt screening and detection of functional decline and delirium respectively amongst adults 65 and older. The objective of this study was to determine the ED usage and utility of ISAR and CAM assessment tools in identifying hip fracture patients at risk for developing delirium. Methods: This was a retrospective chart review of patients aged 65 and older, presenting to an academic ED (annual census 60,000) with a discharge diagnosis of hip fracture from January 1st 2014 to July 31st 2015. At this institution, both the ISAR and CAM are included in the standard ED nursing documentation and are intended to be completed for all patients over 65 years of age. Results: Of the 243 hip fracture cases included in this study, the ISAR and CAM scores were completed for 131 (53.9%) and 69 (28.4%) patients, respectively. There were 43 (17.7%) cases of recorded in-hospital acute delirium. Of the delirium cases, 20 (46.5%) had an ISAR assessment. Patients with an ISAR score of ≥3 were more likely to experience delirium compared to those with lower ISAR scores (28.3% vs 8.3%; Δ 20.0%, 95% CI: 6.6%, 34.9%). Of the 43 patients with delirium, 11 (25.6%) had a CAM score recorded. Patients with a positive CAM score (meeting 3 of 4 criteria in the diagnostic algorithm) were more likely to experience delirium compared to those with negative CAM scores (66.7% vs 11.1%; Δ 55.6%, 95% CI: 17.5%, 79.9%). Conclusion: Vigilant efforts are needed to ensure these screening tools are applied for all patients over the age of 65 presenting to the ED to improve the recognition and early management of delirium. Future research should focus on initiatives to improve delirium screening compliance by ED personnel.