Undiagnosed Cognitive Impairment in the Emergency Department: Evidence From the Senior Assessment and Goal Evaluation Prospective Cohort Study

Patients with cognitive impairment, including mild cognitive impairment and dementia, benefit from heightened communication efforts, additional care partner involvement, detailed discharge planning, and enhanced precautions to prevent delirium. Detection of cognitive impairment in the ED is therefore essential, yet rarely implemented. We sought to determine the prevalence of undiagnosed cognitive impairment in two mid-sized, urban EDs.

Adults ≥65 presenting to two EDs (60,000 and 45,000 visits annually) were approached for enrollment by research assistants using a consent/assent model. Participants were assisted by their care partner (family member or professional caregiver) in answering the questions when needed. Participants were administered a survey which was then merged with electronic health record data (EHR). Cognition was assessed via the Short Blessed Test, a 6-question validated instrument scored on a 28-point scale.

Among 290 participants, the mean age was 74.5 years and 55.5% were female. 127 of participants screened positive for possible cognitive impairment (SBT ≥5), yielding a prevalence of 43.8% (95% CI 38.2–49.5). Of these, 8 participants (6.3%) had an EHR diagnosis or reported having been told by a doctor that they had cognitive impairment or dementia. Overall, 20.0% of all participants screened positive for possible mild impairment (SBT 5-9), and 23.8% screened positive for impairment consistent with dementia (SBT ≥10). Black participants were more likely to have evidence of impairment consistent with dementia (63.8% vs. 27.5%, p<0.001).

In this cohort of older ED patients, nearly half screened positive for cognitive impairment and approximately one in four had scores consistent with dementia. Despite this, fewer than 1 in 15 had been previously identified as having impairment. ED screening for cognitive impairment could improve detection and subsequent care both in the ED and after the ED visit, such as initiation of disease-modifying therapies.