Clinical Trial Details
— Status: Active, not recruiting
Administrative data
| NCT number |
NCT04929704 |
| Other study ID # |
DISCUSS-CT |
| Secondary ID |
|
| Status |
Active, not recruiting |
| Phase |
|
| First received |
|
| Last updated |
|
| Start date |
June 11, 2021 |
| Est. completion date |
May 31, 2023 |
Study information
| Verified date |
April 2022 |
| Source |
Groupe Hospitalier Paris Saint Joseph |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Observational
|
Clinical Trial Summary
The confusional syndrome is defined by the acute or subacute onset of a deficit syndrome
(temporo-spatial disorientation, memory and concentration disorders, abnormal behavior,
impairment of intellectual efficiency, fluctuation of disorders with an increase in the
evening) that may be associated with a productive syndrome (visual or auditory
hallucinations, delusional elements) (French College of Neurology). It is a frequent, serious
and costly problem in hospitalized patients and in emergency rooms.
Its prevalence is between 10 and 31% of cases in emergency rooms and concerns up to one out
of two elderly patients during a hospitalization. The potential morbidity and mortality of
the confusional syndrome is due in part to the difficulty of identifying and treating rapidly
the triggering and aggravating factors that are often interrelated in the elderly. Most
often, these are drug effects, metabolic disorders, infections, consequences of prolonged
immobilization or physical restraint. The lack of rapid treatment of these causes increases
the risk of medium and long-term cognitive problems.
Because of the aging population, this is an increasingly expensive problem. In 2012, the
World Health Organization Regional Office for Europe study conducted in 18 European countries
combined estimated its cost at $182 billion per year. The management of confusional syndrome
in the elderly is now a major public health issue. It is a targeted indicator of the safety
and quality of care for the elderly.
Description:
However, in the majority of situations, an appropriate history, an analysis of the patient's
treatments, a rigorous physical examination, and a blood biology examination are sufficient
to quickly identify and treat the cause(s) of the confusional syndrome. In the practice of
emergency departments, a brain scan without injection of contrast medium is nevertheless
frequently prescribed for an elderly person presenting a recent alteration of his cognitive
functions. One explanation is that clinical signs suggestive of intracranial lesion may be
more difficult to detect in frail elderly patients with a significant history, in the same
way as those of sepsis for example. On the other hand, an alteration of the cognitive
function without any known antecedents for the patient, probably leads emergency physicians
to suspect too frequently a central neurological cause. However, the cause is most often of
extracerebral origin.
At Paris Saint Joseph Hospital, the number of emergency room visits increased by 4% between
2018 and 2019. The Emergency Department is the second largest emergency department in Ile de
France in terms of attendance of a geriatric patient base (20% of patients seen). These
observations prompt an urban emergency department like ours to evaluate the relevance and
quality of our geriatric emergency medicine practices.
In the literature, several American studies, mostly monocentric and retrospective, have
examined the diagnostic utility of brain scans in elderly patients with confusional syndromes
during their observation in the emergency department. The discovery of a scannographic
abnormality explaining the symptomatology occurred in 10 to 39% of cases depending on the
series. The patient cohorts differed in terms of age and clinical presentation. Some were
predominantly composed of patients with a focal neurological sign associated with confusion,
others exclusively of patients with head trauma. We did not find any study that specifically
evaluated the diagnostic contribution of an emergency brain scan in the elderly patient ≥ 75
years of age with isolated confusion, i.e., in the absence of a neurological localizing sign
and in the absence of a head injury under antiplatelet therapy (AAP) and/or anticoagulant
therapy, for which the indication of brain imaging is not debatable. One study evaluated the
diagnostic yield of brain scans in the emergency department in adult patients with an acute
delirious episode. However, it was more about exploring a first psychiatric episode in rather
young patients. This problem appears interesting in the confused elderly subject because the
realization of a CT scan is time-consuming, expensive, and irradiating. It has an impact on
the length of stay in the emergency department, the prolongation of which is itself a source
of a confusional episode, with its share of complications: fall, agitation, disorientation,
mechanical restraint, inappropriate use of benzodiazepines and neuroleptics, for example.
Given the ageing of the population, the morbidity of confusional episodes in the elderly in
the absence of rapid adapted treatment, and the frequent saturation of emergency departments,
it is useful to know the real diagnostic yield of the brain scan performed for an isolated
confusional syndrome observed in the elderly in the emergency department. At the same time,
in France, targeted studies have highlighted an unregulated growth in the prescription of
certain medical imaging procedures. Possible reasons for this include the practice of
defensive medicine by extension of the precautionary principle, and the high expectations of
patients, their relatives, or treating physicians, who may exert pressure to prescribe.
Finally, acting also under the pressure of time management, where the clinical time spent
with each patient tends to be reduced, it is paradoxical that the prescription of brain
imaging examinations has increased in the emergency department in recent years. Determining
the organizational impact on the duration of care would allow us to meet a quality of care
objective.
