A Systematic Review of Interventions for Persons Living With Dementia: The Geriatric ED Guidelines 2.0

A Systematic Review of Interventions for Persons Living With Dementia: The Geriatric ED Guidelines 2.0 | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search A Systematic Review of Interventions for Persons Living With Dementia: The Geriatric ED Guidelines 2.0 Sangil Lee , Michelle Suh , Luna Ragsdale , Justine Seidenfeld , James D. van Oppen , Lauren Lapointe-Shaw , Carolina Diniz Hooper , James Jaramillo , Annie B. Wescott , Kaiho Hirata , Maura Kennedy , Lauren Cameron Comasco , Christopher R. Carpenter , Teresita M Hogan , Shan W. Liu , Geriatric ED Guidelines dementia writing group doi: https://doi.org/10.1101/2025.02.28.25323113 Sangil Lee 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine , Iowa City, IA MD, MS Roles: Clinical Associate Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: sangil-lee{at}uiowa.edu Michelle Suh 2 Section of emergency medicine, University of Chicago , Chicago, IL MD Roles: Medical education fellow/clinical associate Find this author on Google Scholar Find this author on PubMed Search for this author on this site Luna Ragsdale 3 Emergency Department, Durham VA Healthcare System, Clinical Associate, Department of Emergency Medicine, Duke University Hospital MD, MPH Roles: Chief Find this author on Google Scholar Find this author on PubMed Search for this author on this site Justine Seidenfeld 4 Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System MD, MHS Roles: Core Investigator Find this author on Google Scholar Find this author on PubMed Search for this author on this site James D. van Oppen 5 Centre for Urgent and Emergency Care Research, University of Sheffield , S1 4DA, UK FRCEM MRCP PhD Roles: Clinical Lecturer Find this author on Google Scholar Find this author on PubMed Search for this author on this site Lauren Lapointe-Shaw 6 Department of Medicine, University of Toronto , Toronto, Canada MD PhD Roles: Assistant Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site Carolina Diniz Hooper 7 Faculdade Ciências Médicas de Minas Gerais , Belo Horizonte, Brazil MD Roles: Research Volunteer Find this author on Google Scholar Find this author on PubMed Search for this author on this site James Jaramillo 8 Frank H. Netter MD School of Medicine, Quinnipiac University BA Roles: Medical Student Find this author on Google Scholar Find this author on PubMed Search for this author on this site Annie B. Wescott 9 Galter Health Sciences Library & Learning Center, Feinberg School of Medicine, Northwestern University MLIS Roles: Research Librarian Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kaiho Hirata 10 Department of Emergency Medicine, International University of Health and Welfare Narita, Chiba, Japan MD Roles: Resident Physician Find this author on Google Scholar Find this author on PubMed Search for this author on this site Maura Kennedy 11 Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School MD, MPH Roles: Associate Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site Lauren Cameron Comasco 12 Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Oakland University William Beaumont School of Medicine , Royal Oak, MI MD Roles: Assistant Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site Christopher R. Carpenter 13 Department of Emergency Medicine, Mayo Clinic , Rochester, MN MD, MSc Roles: Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site Teresita M Hogan 14 Department of Medicine Section of Emergency Medicine, Section of Geriatrics & Palliative Care, University of Chicago , Chicago, IL MD Roles: Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site Shan W. Liu 11 Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School MD, SD Roles: Associate Professor Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background The increasing prevalence of dementia poses significant challenges for emergency department (ED) care, as persons living with dementia (PLWD) more frequently experience adverse outcomes such as delirium, prolonged stays, and higher mortality rates. Despite advancements in care strategies, a critical gap remains in understanding how ED interventions impact outcomes in this vulnerable population. This systematic review aims to identify evidence-based ED care interventions tailored to PLWD to improve outcomes. Methods A systematic review was conducted in Ovid MEDLINE, Cochrane Library (Wiley), Scopus (Elsevier), and ProQuest Dissertations & Theses Global through September 2024. The review protocol was registered on PROSPERO (CRD42024586555). Eligible studies included randomized controlled trials, observational studies, and quality improvement initiatives focused on ED interventions for PLWD. Data extraction and quality assessment were performed independently by two reviewers, with disagreements resolved through discussion. Outcomes included patient satisfaction, ED revisits, functional decline, and mortality. Results From 3,305 screened studies, six met the inclusion criteria. Interventions included nonpharmacologic therapies (e.g., music and light therapy), specialized geriatric ED units, and assessment tools, such as for pain. Tailored interventions including geriatric emergency units and community paramedic care transitions were effective in reducing 30-day ED revisits and hospitalizations. However, heterogeneity in study designs and outcomes precluded meta-analysis. Risk of bias ranged from low to moderate. Conclusion This review underscores the urgent need for standardized and evidence-based interventions in ED settings for PLWD. Approaches including multidisciplinary care models and non-pharmacologic therapies demonstrated potential for improving outcomes. Future research should prioritize consistent outcome measures, interdisciplinary collaboration, and person-centered care strategies to enhance the quality and equity of ED services for PLWD. Key Points Tailored interventions such as geriatric ED units and community paramedic care transitions significantly reduce ED revisits and hospital admissions among persons living with dementia. Non-pharmacologic therapies, including music and light interventions, show potential for improving patient outcomes, though results are heterogeneous and require further validation. The review highlights the urgent need for standardized protocols and interdisciplinary approaches to enhance emergency care for this vulnerable population. Why does this paper matter? This paper addresses critical knowledge gaps concerning emergency care for persons living with dementia, offering evidence-based insights to improve outcomes and guide the development of standardized, person-centered interventions in ED settings. Introduction The number of older Americans (>65 years) with dementia is projected to increase from 7 million to 13 million between 2021 and 2050, 1 while the global burden will triple over the same timeframe. 2 Emergency departments (EDs) are often the first point of contact for individuals with dementia during acute health crises. 3 – 5 People living with dementia (PLWD) are at heightened risk for preventable adverse emergency care outcomes including delirium, prolonged hospital stays, and increased mortality. 6 They are also more likely to revisit the ED within 30 days. 3 , 7 However, ED clinicians report a lack of training and resources to compassionately and cost-effectively manage PLWD during times of emergency, 8 , 9 while emergency medicine-specific dementia detection strategies, best practices, communication strategies, and care transition approaches remain under-researched. 10 – 14 The complexities and heightened risk associated with an ED visit for PLWD raise the need for more tailored approaches in emergency care. Suggested strategies to improve the experience or outcomes of ED care for PLWD include involving dementia care specialists to coordinate their care, engaging and communicating with patient’s care partners early in the episode of emergency care, implementing non-pharmacological interventions to manage agitation, and modifying the clinical environment to reduce stress and confusion. 13 , 15 , 16 There remains a critical gap in measuring and quantitatively synthesizing how specific ED care processes for PLWD are effective. This study aims to fill this gap by systematically synthesizing the evidence linking ED care processes for PLWD with health outcomes. By identifying and analyzing these care practices, we aim to provide evidence-based recommendations to enhance the quality and safety of ED care for dementia patients. This systematic review was conducted as a part of the Geriatric ED Guidelines 2.0 effort. 17 Methods Study overview This is a systematic review and meta-analysis of studies describing ED interventions for PLWD. The study protocol is being reviewed at the PROSPERO (CRD42024586555). This review followed PRISMA 2020 statement guidelines. 18 Eligibility criteria The following criteria for population, intervention, control, type of studies, and outcomes are listed below ( Table 1 ). View this table: View inline View popup Download powerpoint Table 1. PICO question. Population Persons aged 65 or older, living with dementia or cognitive impairment, presenting to ED were the population of interest. We defined dementia as a neurodegenerative process characterized by problems with memory, judgement, orientation, and executive function, 19 and cognitive impairment as a condition that affects a person’s ability to think, learn, and remember, judge, and make a decision. 20 The age cutoff of 65 was used as it was the common definition in the United States, but we allowed the age cutoff to be 60 to capture studies conducted elsewhere. 21 Mild cognitive impairment (MCI) is considered the preclinical stage of dementia in this systematic review. 22 Since our focus is on the dementia population, we included studies with more than 70% of the sample having dementia. Dementia was identified based on the past history, proxy history, risk stratification or assessment tools. Exclusion criteria included non-human, simulation, non-ED outpatient, hospital, intensive care unit (ICU) as a source of the index encounter. An Emergency Medical Services study may be included if the enrollment is in the ED. Intervention and Comparator Studies were included if they described any intervention (including pharmacologic treatments) in the target population performed by physicians, nursing staff and pharmacists, pharmacologic interventions performed by physicians, nursing staff and pharmacists; furthermore, this intervention had to be compared to those receiving usual care. Studies describing screening through various risk scores, without any further intervention thereafter, were excluded. Type of study Randomized control trials (RCT), quasi-experimental, observational study, pre- and post-study, and quality improvement studies were eligible for inclusion. Exclusion criteria included case reports, case series (n up to 5), review articles, scoping/systematic reviews, and qualitative studies. Outcomes Patient or caregiver satisfaction was the primary outcome. Secondary outcomes included patient/caregiver burden, ED revisits, ED length of stay, fall, functional decline, delirium superimposed dementia, mortality, hospital admission rates, hospital length of stay, or sedation for agitation in the ED. Information sources We searched the Ovid MEDLINE, Cochrane Library (Wiley), Scopus (Elsevier), and ProQuest Dissertations & Theses Global databases from inception to September 20, 2024. No language or other restrictions were applied. Search strategy and article selection The search strategy is detailed in Appendix 1 . A medical librarian created the electronic search strategy which was peer reviewed by another librarian who verified the validity and reproducibility. Data collection process Database search results were uploaded to Covidence by the librarian. All entries from the searches were first deduplicated in EndNote and again in Covidence. During title/abstract screening and full text screening, each entry was screened by at least two independent reviewers in Covidence; disagreements were resolved by a third independent reviewer or through discussion in the review team meeting. Data were extracted using a standardized data collection form. Each study was extracted by two independent reviewers; discrepancies were resolved by a third reviewer or through discussion in the review team meeting. Data items Data were extracted for author, year, study design and number of sites, country, study sample characteristics, dementia assessment tool (index or reference test), age (average and SD or IQR), sample size, % male/female, dementia prevalence (%), stage of dementia (if available, descriptive), place of living, comorbidities, frailty scale, ED length of stay. Outcome data included days in hospital, admission rate, ED revisit (time interval up to reviewer), mortality, patient/caregiver satisfaction (if they are reported), patient/caregiver burden, fall (in the ED, hospital, and after getting home), functional decline (after ED visit), delirium superimposed dementia after ED visits, sedation (in the ED), and agitation in the ED. Risk of bias assessment The NewCastle Ottawa tool (cohort study version) for observational studies and the Cochrane risk of bias tool for RCTs were used. The quality of each study was assessed by two independent raters. The rating was provided for selection, comparability, outcome domains and a total score was used to classify them as low (Scores 0-3), moderate (Scores 4-7), and high risk of bias (8-10) for observational studies.( Appendix 4 ) The Risk of Bias 2.0 (RoB 2) tool ( Appendix 5 ) assessed bias in randomized controlled trials across five domains: the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. Each domain included signaling questions that guide judgments on bias risk, categorized as low risk, some concerns, or high risk based on a structured algorithm. The overall risk of bias was determined by aggregating domain-specific judgments, with a study rated as high risk if at least one domain is high or if multiple domains raise concerns. Otherwise, an online scoring guide was used for Cochrane risk of bias tools for parallel arm RCT and cluster RCT. 23 , 24 Disagreements were resolved through discussion between the two raters or in the review team meeting until consensus was reached. Effect measures We reported Absolute/Relative risk (RR), odds ratio (OR), risk difference, hazard ratio, and number needed to treat (NNT) for binary outcomes. These effects were extracted from the publications except NNT calculated from RR or OR using the online tool. 25 Synthesis Meta-analysis was planned but not conducted due to the heterogeneity of identified study designs. Instead, we conducted a qualitative review of the selected studies. Results Study selection A total of 3,309 studies were identified in September 2024. Four duplicates were removed. Of 3,305 remaining studies undergoing title and abstract screening, 3,250 were excluded for ineligibility. Fifty-five studies underwent full text review of which 6 were eligible and included ( Figure 1 ). Download figure Open in new tab Figure 1. Selection of studies (PRISMA) Study characteristics The characteristics of the 6 studies are listed in Table 2 and 3. Three studies were RCTs 26 – 28 two were prospective observational studies 29 , 30 and one was a historical cohort study. 31 The study periods extended from 2018-2023. Two studies were conducted in the United States (Keene, Shah), 26 , 27 two in Australia, 28 , 29 and one study from France 31 and one from Canada. 30 Two studies determined dementia via the Six-Item Screener, 28 , 29 two studies used medical record definitions, 31 , 32 while Keene used the Short Blessed Test 33 and Shah used the Blessed Orientation Memory Concentration Test. 27 View this table: View inline View popup Download powerpoint Table 2. Demographic summary of included studies View this table: View inline View popup Download powerpoint Table 3. Intervention and Outcome Table Types of interventions were very heterogeneous, preventing meta-analysis ( Table 2 and 3). These included light and music therapy, 26 community paramedic Care Transition Intervention (CTI), 27 a multidisciplinary team specializing in care of elderly ED patients, 31 a multicomponent intervention 30 while two examined the Pain Assessment in Advanced Dementia (PAINAD) tool. 28 , 29 Results of individual studies Keene et al. 26 conducted a pilot randomized controlled trial at an urban academic ED to assess the feasibility of using light and/or music therapy in preventing hospital-associated delirium among older adults 65 years and older in the ED. Exclusion criteria included Emergency Severity Index of 1, inability to consent, isolation precautions due to suspected SARS-CoV-2 infection, being legally deaf, intoxication, or presentation with a psychiatric chief complaint. Consented patients were screened for cognitive impairment with the Short Blessed Test (SBT); 33 patients were enrolled in the trial if they tested positive for potential cognitive impairment (SBT score >4). Patients discharged from the ED were ultimately excluded from the study, but expected disposition was not considered an enrollment criterion. The study randomized 133 participants (median age similar across arms) into four parallel groups: music, light, both interventions, and control. The study was not adequately powered as it was a pilot study. Music was available through a bedside wireless speaker with either a classical or non-vocal jazz repeatable 2-hour long playlist. Classical was the default option if the patient was not able to choose. Light therapy was provided by a bedside full spectrum lightbox that mimicked natural light at 6,500 K color temperature and 5,000 lux brightness. The Confusion Assessment Method was performed at enrollment by a research assistant and then repeated by an inpatient bedside nurse upon patient arrival to the floor. Among the groups, delirium incidence was lowest in the music-only group (2/33, RR 0.27, 95% CI 0.06–1.23) and light-only group (3/33, RR 0.41, 95% CI 0.12–1.46). The combined music and light group (8/35, RR 1.04, 95% CI 0.42–2.55) showed no advantage over control (7/32). While statistical significance was not achieved, results suggest potential benefits of these non-pharmacologic interventions for delirium prevention. The study demonstrated feasibility of implementing in the ED and patient tolerance by measuring the completion of interventions and adherence, setting the stage for larger investigations. Shah et al. 27 conducted a pre-planned subgroup analysis of a RCT to evaluate the effectiveness of an adapted version of Coleman CTI, 34 , 35 where no transition coaching was provided while the participant was in the ED, in reducing ED revisits (preplanned analysis) among cognitively impaired older adults. The study included 81 participants with cognitive impairment, identified by scoring > 10 on the Blessed Orientation Memory Concentration, 33 (mean age 78, 57% female) from three university-affiliated hospitals. Participants receiving CTI had a home visit 24-72 hours after ED discharge by a trained community paramedic and follow-up phone calls post-ED discharge. During home visits, paramedics coached participants on CTI’s four self-management pillars: patient follow up, medication self-management, knowledge of red flag symptoms and use of a personal health record. The intervention significantly reduced the odds of 30-day ED revisits (OR 0.25, 95% CI 0.07–0.90) compared to usual care. The CTI did not significantly improve outpatient follow-up or self-management behaviors but demonstrated promise for enhancing ED-to-home care transitions in this vulnerable population. Bosetti et al. 31 conducted a historical cohort study to evaluate the effectiveness of a Geriatric Emergency Medicine Unit, known as the MUPA unit, for managing older patients with neurocognitive disorders (NCD) in the ED. Patients were included who had a diagnosis of NCD by DSM V and a medical record containing the terms: Alzheimer’s, vascular, mixed or frontotemporal dementia, dementia with Lewy bodies, or severe NCD. The MUPA unit is composed of an interdisciplinary team of physicians, nurses and social workers who perform geriatric assessments and individualized care plans for patients. The study included 801 patients aged ≥75 years (mean age 87, 72.5% female), comparing outcomes between those treated in the MUPA unit (n=400) and those receiving standard ED care (n=401). Patients treated in the MUPA unit experienced a 35% lower rate of 30-day readmissions (15.8% vs. 22.2%, adjusted OR 0.65, 95% CI 0.46–0.94) after adjusting for confounders (age, living at home, history of falls, the Charlson Comorbidity Index, and diagnosis of fall risk). Although hospitalization rates were higher in the MUPA group (57.8% vs. 47.1%), the intervention demonstrated the potential benefits of a multidisciplinary geriatric approach for improving outcomes of 30-day readmission (primary outcome) in this vulnerable population. Fry et al. 28 conducted a cluster randomized controlled trial to evaluate the impact of the Pain Assessment in Advanced Dementia (PAINAD) tool 36 on the time to analgesia for cognitively impaired older adults (≳ 65) in the ED with suspected long bone fractures. PAIDAD is a tool developed to assess pain in patients with advanced dementia and particularly useful in patients with aphasia. The study included 323 patients at intervention sites using PAINAD and 279 at control sites using standard pain assessment methods. Patients at all sites were administered the Six Item Screener (SIS) 37 prior to pain assessment by bedside nurses. Cognitive impairment was defined as a SIS score less than 4. At intervention sites, PAINAD was used on patients with a SIS score less than 4. Time to analgesia was defined as time from ED arrival to first dose of parenteral or oral analgesia. The median time to analgesia was 83 minutes at intervention sites and 82 minutes at control sites (p=0.42). A sensitivity analysis showed a non-significant reduction of 13 minutes in time to analgesia for patients at intervention sites (90 vs. 103 minutes, p=0.62). While PAINAD did not significantly reduce time to analgesia, it demonstrated potential clinical utility in improving pain recognition in this vulnerable population. The study highlights the challenges of timely pain management for older adults with cognitive impairment. Beauchet et al. 30 conducted a pre-post intervention study to assess the impact of the “Emergency Room Evaluation and Recommendations” (ER2) tool, 38 which is a validated clinical tool to screen older patients in the ED to identify those at high risk of hospitalization and longer length of stay (LOS) in the ED than those who are not at high risk. In addition to its assessment part, ER2 has a tailor-made intervention guide based on responses to ER2, these recommendations were: 1) medication review by ED physician and pharmacist; 2) discharge planning team; 3) availability of walking aid, fall risk identification and encouraging mobility; 4) reorientation to time and place, assistance with basic needs, and toileting. The study included 356 participants aged ≥75 years with major neurocognitive disorder (MNCD) visiting the Jewish General Hospital ED. MNCD was defined by presence of diagnosis in a patient’s medical chart. During the intervention phase, ER2-tool screening and tailored recommendations for ED staff after triage were compared to usual care, and resulted in a 39% reduction in hospital admissions (OR 0.61, p ≤ 0.022, adjusted for baseline covariates). The authors did not evaluate the rate of return ED visits. However, the LOS in the ED increased significantly, by approximately 4.28 to 5.56 hours (p ≤ 0.008). The study highlights ER2’s potential to prevent hospitalizations through improved geriatric care while acknowledging the trade-off of extended ED stays. Fry et al. 29 (ref, note 2nd fry article) conducted a multi-center observational study in four EDs to evaluate the reliability and utility of the PAINAD scale for assessing pain and improving analgesia in older adults (age mean 85.5, range 63 to 100) with cognitive impairment (CI) identified by SIS score of less than 4 at the bedside. The study included 181 patients (mean age 85, 63% female) with suspected long bone fractures. The PAINAD scale showed good internal consistency (Cronbach’s α = 0.80) and moderate correlation with the Numeric Rating Scale (NRS) for pain (r = 0.39). Despite lower median pain scores on PAINAD compared to NRS (1.0 vs. 5.5), the tool was implemented as a routine pain assessment tool during the study period, suggesting feasibility in this cohort. The study concluded that PAINAD is a possible alternative to NRS for pain assessment in older adults with CI but highlighted the need for broader integration of pain assessment with caregiver input and comprehensive assessment strategies. Risk of bias in studies The risk of bias assessment for the three observational studies with the NewCastle-Ottawa scale showed that one study was rated as low risk of bias, 31 otherwise two other studies 29 , 30 were rated as unclear risk of bias ( Figure 2 ). The RCTs were rated as high risk of bias for one study and some concerns for two studies ( Figure 3 ). Based upon the low quantity of direct evidence, the non-uniform approach to identifying PLWD across the included studies, the lack of a single dementia intervention, and the overall high risk of bias for the included RCTs and non-RCTs, the overall GRADE level of certainty for any ED intervention was very low. 39 Download figure Open in new tab Figure 2. Risk of bias (cohort study) Observational ROB Download figure Open in new tab Figure 3. Risk of bias (RCT parallel and cluster) RCT Discussion Our systematic review identified a paucity of primary research evaluating interventions for PLWD in the ED, with six studies published thru September 2024. 26 , 28 , 29 , 31 , 32 No two studies evaluated the same interventions which included: light and music therapy, community paramedic home visits, a multidisciplinary team specializing in care of older ED patients, a multicomponent intervention; and use of the Pain Assessment in Advanced Dementia (PAINAD) tool. None of these studies defined dementia in the same way, or evaluated the same dementia intervention. Interventions examined many outcomes other than those typically reported (e.g. ED readmissions and hospitalizations). Our systematic review highlights the need for more standard outcome measures, to include patient outcomes, process-oriented outcomes, and patient reported outcome measures. 40 , 41 Despite the increase in incidence of dementia and ED visits by PLWD, 42 the dearth of ED interventions designed to improve the experience, process, or outcomes of care is alarming. Although more than 10 years have passed since the initial Geriatric ED Guidelines 43 were published and 20 years since the American Geriatrics Society Research Agenda Setting process prioritized “interventional trials should be designed to determine the effect on outcomes of better screening and management of cognitive impairment in older ED patients”, 44 trial data is essentially non-existent. Patient stakeholders and multidisciplinary clinical groups identified various challenges associated with the ED care for PLWDs, including identifying and managing functional dependence, behavioral symptoms, and pain management using a unique tool or method to evaluate PLWDs. 13 PLWDs may experience disparities in treatment and negative consequences, such as hospitalization rate, 45 during ED visits. The heterogeneity of interventions evaluated and outcomes assessed, has previously prevented specific recommendations for ED interventions to improve outcomes for PLWD, 45 and our systematic review has yielded similar conclusions. The Geriatric Emergency Care Applied Research Network 2.0 – Advancing Dementia Care (GEAR 2.0-ADC) is a research program aspiring to improve the experience, process, and outcomes of emergency care for PLWD. 10 , 12 – 14 , 16 , 46 GEAR 2.0-ADC has identified research priorities for improving emergency care for PLWD and their care partners. 10 , 12 – 14 , 16 , 46 These priorities pertain to communication and decision making, dementia detection, ED care practices, and care transitions. Some recommendations for improving emergency care for PLWD include: evaluating for cognitive impairment, 47 , 48 limiting the use of sedation and physical restraints, 49 focusing on appropriate autonomy and maintaining functional capacity, 50 adapting communication strategies and conscientious inclusion of care partners, building reliable infrastructure, and using transdisciplinary outcome measures. 51 To address these issues, some experts suggest adopting a partnership approach between carers and ED nurses and developing research priorities through consensus-driven methods involving diverse stakeholders, including patients and care partners. 16 , 45 Given the heterogeneity in interventions and outcomes for the included studies, we were unable to conduct a meta-analysis. However, two studies 30 , 31 report interventions that decreased ED revisits 31 and hospital admissions 30 These interventions included the GEMU and ER2 disposition guide. Shah et al. also reported that a post-ED paramedic visit and a phone call follow-up decreased the rate of 7-day ED return, but not 14-day ED returns. (Shah et al. Cite) EDs are crucial sites of care for older adults, accounting for 18% of visits and 40% of admissions. 52 However, the fast-paced ED environment often conflicts with the complex needs of older patients, particularly PLWD. 52 Research priorities include developing geriatric-focused dementia-friendly EDs, improving pain assessment by using the appropriate tools for PLWD, and implementing care transition interventions. Non-pharmacological interventions, such as individualized music show promise in managing dementia-related behaviors. 53 Overall, these papers highlight the need for tailored, evidence-based approaches to enhance ED care for older adults and dementia patients. 26 – 31 The limited evidence from ED studies might be attributed to the number of studies from ED, funding stream, and regulation related to the institutional review board. 54 , 55 The studies employed interventions that appeared reasonable and likely to be valued by both clinicians and patients. However, the anticipated benefits were not consistently observed when process measures such as increased hospitalizations and longer lengths of stay, were evaluated. This highlights the importance of adopting more standardized application of dementia assessment, reproducible interventions, and the selection of outcomes in the future. This systematic review evaluates the evidence for person-centered interventions in serious physical illness, finding mixed results on traditional outcomes but suggesting incorporating person-centered outcomes could provide a more comprehensive understanding. 56 Incorporating person-centered outcomes alongside conventional service metrics could provide a more comprehensive view of impact of an intervention. Overall, we recommend increasing the consistency of ED intervention for PLWD for reproducibility and external validity, using rigorous study designs, 21 consideration of underlying bias, and transparency around inclusiveness.Interventions should be evaluated with outcome measures that are relevant to patient outcome, such as mortality, 30-day readmission, and disposition to skilled nursing facility, and patient reported outcome measures. Future studies should focus on promising interventions, such as pain measurement, enhanced communications, reducing caregiver stress, the use of an ED activity cart, and reducing delirium superimposed on dementia. Limitations First, it is possible that we did not identify an ongoing intervention study as we did not include grey literature or protocol registries in the strategy. Our search and selection process took place in 2024, and we intended to find all the studies that will have any results before this systematic review was concluded. Second, our review is limited in that literature based on qualitative research study was possibly excluded. Third, there may be interventions outside of the emergency care setting reported in the literature which were not considered but may be relevant for adaptation or implementation. Fourth, without a uniform approach to assessing presence or absence of dementia, each of our included studies may have included different proportions of dementia or stratifications of dementia severity. Lastly, even if all of the included studies used the same method of defining dementia’s presence or absence, relying on past history or proxy history is imperfect in ED settings and may have missed a large proportion of individuals with dementia. 57 Conclusion Despite the growing incidence of dementia and the increasing burden on EDs, the evidence for effective, consistent, and reproducible interventions remains limited. This systematic review showed that few studies have examined the impact of ED-based interventions for PLWD on process outcomes and found no research exploring patient-oriented outcomes. The scant existing literature cannot support any confident management recommendations, thus highlighting the critical need for ongoing study of interventions to improve emergency care for PLWD. While some interventions demonstrated promising outcomes, such as reduced ED revisits and hospital admissions, significant variability in study design, interventions, and outcomes precluded a meta-analysis. This underscores the urgency for standardized protocols and robust research to address the unique challenges faced by PLWD in ED settings. Future efforts should focus on interdisciplinary collaboration, stakeholder engagement, and consensus-driven research priorities to establish evidence-based guidelines that enhance the safety, quality, and equity of emergency care for this vulnerable population. Our future steps include rating the level of certainty using the GRADE approach. Data Availability All data produced in the present work are contained in the manuscript. Geriatric ED Guidelines dementia writing group Scott Dresden, MD Associate Professor Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago, IL Angel Li MD, MBA Assistant Professor Department of Emergency Medicine, The Ohio State University Alexander X. Lo, MD, PhD Associate Professor Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago, IL Cameron J. Gettel, MD MHS Assistant Professor Department of Emergency Medicine Yale School of Medicine New Haven, CT R. Doreen Monks, RN (retired), MSN Board Member Voice of Alzheimer’s Washington DC Appendix 1. Search strategy View this table: View inline View popup Download powerpoint Example Search Methods The review authors partnered with a research librarian (ABW) to create a comprehensive search of the literature. The search was adapted from a previous search created as part of the original GEAR 2.0 scoping review projects. The search strategy combined database-specific controlled vocabulary and keyword searching related to the concepts of dementia in the emergency department setting. The search was conducted on September 20, 2024 in the following databases: Ovid MEDLINE, Cochrane Library (Wiley), Scopus (Elsevier), and ProQuest Dissertations & Theses Global. All databases were searched from inception to present without the use of filters or limits. Records were downloaded and underwent multi-pass deduplication in a citation management software (EndNote) and unique records were uploaded to Covidence for initial screening by two independent reviewers. View this table: View inline View popup Appendix 2. PRISMA checklist for manuscript View this table: View inline View popup Appendix 3. PRISMA checklist for abstract View this table: View inline View popup Appendix 4. New-Castle Ottawa Scale NEWCASTLE - OTTAWA QUALITY ASSESSMENT SCALE COHORT STUDIES 58 Note : A study can be awarded a maximum of one star for each numbered item within the Selection and Outcome categories. A maximum of three stars can be given for Comparability Max score of 9. 0-3 high risk, 4-7 moderate, 8-9 high risk of bias Selection 1) Representativeness of the exposed cohort (0 to 1) a) truly representative of the average ED patients with dementia in the real world* b) somewhat representative of the average ED patients with dementia in the real world* c) selected group of users eg older adults, volunteers d) no description of the derivation of the cohort Dementia defined by past history of dementia, Alzheimer’s disease and related dementia (ADRD), or proxy history of dementia/ADRD, risk stratification tool, or dementia screening/assessment tools, and this is not a new diagnosis made by ED clinicians 2) Selection of the non-exposed cohort (0 to 1) a) drawn from the same community (ED patients with dementia) as the exposed cohort* b) drawn from a different source (For example, ED patients without dementia) c) no description of the derivation of the non-exposed cohort 3) Ascertainment of exposure (0 to 1 for either a or b) a) structured intervention* b) secure record (eg surgical records verifying the receipt of intervention, not counting generic EMR documents)* c) self report d) no description 4) Demonstration that outcome of interest was not present at start of study, in other words, there is a change of status measured (or not measured) at the endpoint (0 to 1) a) yes* b) no Comparability 1) Comparability of cohorts on the basis of the design or analysis (0 to 3) a) study controls for stage of dementia/frailty b) study controls for any additional factor of triage acuity (example, Emergency Severity Index or ESI) c) study control for additional factor of place of living Outcome 1) Assessment of outcome (0 to 1 for a or b) a) independent blind assessment* b) record linkage* c) self-report d) no description 2) Was follow-up long enough for outcomes to occur (0 to 1) a) yes (select an adequate follow up period for outcome of interest-3 months) b) no 3) Adequacy of follow up of cohorts (0 to 1 for either a or b) a) complete follow up - all subjects accounted for* b) subjects lost to follow up unlikely to introduce bias - small number lost - > 20 % (select an adequate %) follow up, or description provided of those lost)* c) follow up rate < 20% (select an adequate %) and no description of those lost d) no statement Appendix 5. Cochrane risk of bias (2.0) tool (for parallel arm) Risk of bias assessment 59 Responses underlined in green are potential markers for low risk of bias, and responses in red are potential markers for a risk of bias. Where questions relate only to sign posts to other questions, no formatting is used. View this table: View inline View popup Download powerpoint Domain 1: Risk of bias arising from the randomization process View this table: View inline View popup Domain 2: Risk of bias due to deviations from the intended interventions ( effect of assignment to intervention ) View this table: View inline View popup Domain 2: Risk of bias due to deviations from the intended interventions ( effect of adhering to intervention ) View this table: View inline View popup Domain 3: Missing outcome data View this table: View inline View popup Domain 4: Risk of bias in measurement of the outcome View this table: View inline View popup Domain 5: Risk of bias in selection of the reported result Overall risk of bias View this table: View inline View popup Download powerpoint This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License . Footnotes Michelle.Suh{at}bsd.uchicago.edu , luna.ragsdale{at}va.gov , justine.seidenfeld{at}va.gov , james.vanoppen{at}nhs.net , lauren.lapointe-shaw{at}uhn.ca , caroldalvarenga{at}yahoo.com.br , James.Jaramillo{at}quinnipiac.edu , annie.wescott{at}northwestern.edu , kaihouhirata{at}gmail.com , mkennedy8{at}mgb.org , lauren.cameron-comasco{at}corewellhealth.org , carpenter.christopher{at}mayo.edu , thogan{at}uchicagomedicine.org , sliu1{at}mgh.harvard.edu CONFLICT OF INTEREST: CRC receives funding as co-Investigator of the Geriatric Emergency Department Collaborative and Geriatric Emergency Care Applied Research Network (R33 AG058926 and R33 AG0698022). SWL, SL received support from John A. Hartford/West Health. REFERENCES 1. ↵ Alzheimer’s Facts and Figures Report | Alzheimer’s Association . Accessed February 27, 2025 . https://www.alz.org/alzheimers-dementia/facts-figures 2. ↵ GBD 2019 Dementia Forecasting Collaborators . 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