Holden Timothy R, Shah Manish N, Gibson Tommy A, Weiss Robert E, Yagapen Annick N, Malveau Susan E, Adler David H, Bastani Aveh, Baugh Christopher W, Caterino Jeffrey M, Clark Carol L, Diercks Deborah B, Hollander Judd E, Nicks Bret A, Nishijima Daniel K, Stiffler Kirk A, Storrow Alan B, Wilber Scott T, Sun Benjamin C
Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Department of Neurology, Washington University School of Medicine, St. Louis, MO.
Acad Emerg Med. 2018 Aug;25(8):880-890. doi: 10.1111/acem.13414. Epub 2018 Apr 23.
Syncope and near-syncope are common in patients with dementia and a leading cause of emergency department (ED) evaluation and subsequent hospitalization. The objective of this study was to describe the clinical trajectory and short-term outcomes of patients who presented to the ED with syncope or near-syncope and were assessed by their ED provider to have dementia.
This multisite prospective cohort study included patients 60 years of age or older who presented to the ED with syncope or near-syncope between 2013 and 2016. We analyzed a subcohort of 279 patients who were identified by the treating ED provider to have baseline dementia. We collected comprehensive patient-level, utilization, and outcomes data through interviews, provider surveys, and chart abstraction. Outcome measures included serious conditions related to syncope and death.
Overall, 221 patients (79%) were hospitalized with a median length of stay of 2.1 days. A total of 46 patients (16%) were diagnosed with a serious condition in the ED. Of the 179 hospitalized patients who did not have a serious condition identified in the ED, 14 (7.8%) were subsequently diagnosed with a serious condition during the hospitalization, and an additional 12 patients (6.7%) were diagnosed postdischarge within 30 days of the index ED visit. There were seven deaths (2.5%) overall, none of which were cardiac-related. No patients who were discharged from the ED died or had a serious condition in the subsequent 30 days.
Patients with perceived dementia who presented to the ED with syncope or near-syncope were frequently hospitalized. The diagnosis of a serious condition was uncommon if not identified during the initial ED assessment. Given the known iatrogenic risks of hospitalization for patients with dementia, future investigation of the impact of goals of care discussions on reducing potentially preventable, futile, or unwanted hospitalizations while improving goal-concordant care is warranted.
晕厥和近似晕厥在痴呆患者中很常见，是急诊科（ED）评估及随后住院治疗的主要原因。本研究的目的是描述因晕厥或近似晕厥就诊于急诊科且经急诊科医护人员评估患有痴呆的患者的临床病程及短期预后。
这项多中心前瞻性队列研究纳入了2013年至2016年间因晕厥或近似晕厥就诊于急诊科的60岁及以上患者。我们分析了一个由279名患者组成的亚队列，这些患者经急诊科主治医护人员确定患有基线痴呆。我们通过访谈、医护人员调查和病历摘要收集了全面的患者层面、医疗利用及预后数据。预后指标包括与晕厥相关的严重情况和死亡。
总体而言，221名患者（79%）住院，中位住院时间为2.1天。共有46名患者（16%）在急诊科被诊断出患有严重疾病。在急诊科未被诊断出患有严重疾病的179名住院患者中，14名（7.8%）随后在住院期间被诊断出患有严重疾病，另有12名患者（6.7%）在首次急诊科就诊后30天内出院后被诊断出患有严重疾病。总体共有7例死亡（2.5%），均与心脏无关。没有从急诊科出院的患者在随后30天内死亡或患有严重疾病。
因晕厥或近似晕厥就诊于急诊科的疑似痴呆患者经常住院。如果在最初的急诊科评估中未发现严重疾病，其诊断并不常见。鉴于痴呆患者住院存在已知的医源性风险，未来有必要研究照护目标讨论对减少潜在可预防、无意义或不必要的住院治疗同时改善符合目标的照护的影响。
