Knowledge, skills and attitudes of doctors towards assessing cognition in older patients in the emergency department.

PURPOSE OF THE STUDY: Although cognitive impairment and delirium are highly prevalent in older patients who present to the emergency department, multiple studies have highlighted inadequate detection by doctors. This study investigated potential reasons underlying this. STUDY DESIGN: A 14-item self-administered questionnaire was distributed to all medical, surgical and emergency department physicians involved in the care of older patients in the emergency department of an urban university teaching hospital between January and March 2012. RESULTS: The questionnaire was completed by 76/97 (78%) of eligible respondents. Respondents reported screening an average of one in four older patients that they reviewed. Almost one-third (22/76, 29%) felt they lacked the relevant expertise to perform cognitive screening: those with training in geriatrics were less likely to cite lack of expertise as a factor. While the majority felt screening for cognition in the emergency department-setting was important (59/76, 78%), several limiting factors were identified: lack of a screening tool; lack of privacy; too much noise; and time constraints. There was no consensus on who should perform screening. CONCLUSIONS: Doctors reviewing patients in the emergency department-setting reported several important factors limiting their ability to screen older patients for cognitive impairment. Respondents to this questionnaire did not feel the emergency department environment was conducive towards the assessment of cognition in older patients. Clarification of each discipline's responsibility in the detection, assessment and management of delirium and/or dementia, and the implementation of emergency department cognitive screening instruments more suited to this setting would likely improve detection and management.

Dolasetron overdose resulting in prolonged QTc interval and severe hypotension: a case report and literature review.

Dolasetron (Anzemet) overdose is uncommon, and, to our knowledge, this is the only case report of an intentional overdose. Dolasetron (dolasetron mesylate) is a selective 5-hydroxytryptamine 3 antagonist derived from pseudopelletierine, and is used in the prevention and treatment of nausea and vomiting. Transient and asymptomatic ECG changes, including QRS widening and PR and QTc prolongation, have been reported in therapeutic doses. The case of a 21-year-old woman who presented after an intentional overdose of 10x200 mg dolasetron tablets resulting in prolongation of the QTc interval and severe hypotension is reported here. Management of hypotension included intravenous fluid resuscitation and norepinephrine infusion with invasive monitoring in a high dependency unit. Sodium cardiac channel block contributes to cardiotoxicity observed in dolasetron overdose. Sodium bicarbonate was used in an attempt to reduce cardiac sodium channel block, although we observed no apparent benefit. As dolasetron becomes more commonly used in the outpatient setting, both doctors and patients need to be aware of the dangers of dolasetron in toxic doses. The pharmacology and toxicology of dolasetron are discussed.

Simvastatin induced rhabdomyolysis and an important clinical link with hypothyroidism.

An 85-year-old woman with renal impairment and hypothyroidism was commenced on high dose simvastatin (80 mg) for better lipid control. Shortly after this she developed severe muscular weakness and laboratory evidence of rhabdomyolysis. Despite having hypothyroidism controlled for years with L-thyroxine (100 mcg), her biochemistry now reflected a hypothyroid state with inadequate thyroid replacement. On discontinuing her simvastatin to treat her rhabdomyolysis, the patient's TSH level decreased to normal within 4 weeks without any change in L-thyroxine dosage. To our knowledge this is only the second case reported in the literature of a rare but important interaction between simvastatin and L-thyroxine and the first case reported with associated rhabdomyolysis.

Postpartum spontaneous coronary artery dissection: an important clinical link with anticardiolipin antibody.

A 34-year-old woman presented to the Emergency Department with substernal chest pain, 7 days after a normal vaginal delivery. Acute myocardial infarction was diagnosed based on ECG changes and elevated serum troponin levels. Coronary angiography revealed a spontaneous coronary dissection of the left anterior descending (LAD) coronary artery. The patient was managed medically and recovered well clinically with healing of the dissection on repeat angiography 10 days later. Of note the patient had a high titre of anticardiolipin antibody (IgM) detected and this is only the second case described in the literature of an association between spontaneous coronary artery dissection and antiphospholipid antibody syndrome.