ABSTRACTIntroductionPatients with Parkinson's disease (PD) frequently present to the Emergency Department (ED). Whether for PD‐related complications or unrelated concerns, maintaining their antiparkinsonian medication regimen without interruption is crucial. Delays or omissions can lead to significant morbidity and mortality. Despite this, the importance of timely ordering and administration of antiparkinsonian medications is often underrecognized in the ED.MethodsWe performed a retrospective chart review across a single health system comprising one academic and five community EDs, three of which are critical access hospitals. Adults aged ≥ 65 years with an active outpatient carbidopa‐levodopa (C‐L) prescription presenting between September 1, 2024, and August 31, 2025, were included. The primary outcome was the proportion of patients who received their prescribed C‐L during the ED encounter. Timeliness was assessed using two definitions: a primary, idealized standard of administration within 30 min of the scheduled dose, and a secondary, system‐based standard of administration within a two‐hour window.ResultsA total of 282 patient encounters involving 87 unique patients were included (mean age 80.1 years; 61.7% male; 99.3% White). Mean ED length of stay (LOS) was 8 h and 53 min. C‐L was administered in only 91 encounters (32.3%). Among the 282 ED encounters, 12 (4.3%) met the idealized timeliness definition for C‐L administration, and 18 (6.4%) met the system‐defined standard. Among the 91 encounters with a C‐L order, 13.2% met the ideal definition and 19.8% met the system standard. Mean time from ED arrival to medication administration was 6 h 11 min. Most administrations occurred 1–4 h (39.6%) or 4–8 h (26.4%) after the scheduled dose.ConclusionLess than one‐third of older adults with PD received their home antiparkinsonian medication in the ED, and fewer than 10% received it on time. Targeted interventions to ensure timely medication administration are needed to prevent iatrogenic harm in this vulnerable population.

ABSTRACTBackgroundPeople with dementia are often hospitalized from the emergency department (ED) for conditions that could potentially be treated in the outpatient setting. In scenarios of clinical equipoise—where either admission or discharge may be appropriate—little is known about how emergency physicians make disposition decisions.MethodsWe conducted a qualitative study with attending emergency physicians at a single academic medical center. Interviews included open‐ended questions about disposition decision‐making in general as well as structured case scenarios using a think‐aloud protocol. We used an inductive approach to code interview data and elucidate themes about the factors emergency physicians consider in disposition decisions for people with dementia in situations of clinical equipoise.ResultsWe interviewed twenty‐one physicians with an average of 10.5 years of clinical practice (range 5–21 years). Five themes emerged: (1) assessing availability of, reliability of, and burden faced by caregivers; (2) anticipating clinical trajectory and feasibility of outpatient follow‐up; (3) identifying acute cognitive changes that may reflect serious underlying illness; (4) navigating medicolegal concerns; and (5) weighing potential harms of hospitalization. Among these, caregiver assessments and clinical trajectories were discussed most frequently, with physicians describing informal and variable approaches to caregiving assessments. While many physicians recognized the risk of discharging a delirious patient, few acknowledged that hospitalization itself could contribute to delirium or other harms. Overall, emergency physicians’ decisions were shaped not only by patient characteristics, but by the surrounding health system's capacity to support timely and safe outpatient care.ConclusionsED disposition decisions for people with dementia often depend on caregiving context and health system constraints. Improving alignment of admission decisions with patients’ and care partners’ values and preferences may require structured approaches to assessing caregiver capacity and communicating risks of hospitalization. Health system investment in outpatient infrastructure and alternatives to admission may better support emergency physicians in making safe, patient‐centered decisions.

ABSTRACTObjectivesPain is common among patients presenting to the emergency department (ED) but is frequently underdetected and undertreated in older people living with dementia (PLWD). This systematic review examined whether dementia‐specific pain assessment tools improve pain management compared with usual care in the ED.MethodsWe conducted a systematic review and have reported the methods and results following PRISMA (PROSPERO: CRD420251044828). Eligible studies included randomized, quasi‐experimental, and observational designs enrolling ED patients aged ≥ 65 years with dementia or cognitive impairment. Interventions were pain assessment tools developed for PLWD, and comparisons were with standard pain scales. Primary outcomes were patient‐reported outcome measures and analgesia administration; secondary outcomes included repeated pain scores, ED revisits, functional decline, mortality, and adverse events. Five databases (Ovid MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo) and two clinical trial registries were searched without language or date restrictions on April 22, 2025, and December 16, 2025, respectively. Two reviewers independently screened, extracted data, and assessed risk of bias using Cochrane RoB‐2.ResultsOf 987 records identified, 18 underwent full‐text review, and one study met eligibility criteria. Fry et al. (2017) conducted a multicenter, cluster‐randomized controlled trial of 602 older adults with suspected long bone fractures, comparing the Pain Assessment in Advanced Dementia (PAINAD) tool with standard pain scales. No significant differences were observed in median time to first analgesia (83 vs. 82 min, p = 0.42) or proportion receiving analgesia within 60 min (28% vs. 32%, p = 0.19). Evidence certainty was rated very low.ConclusionsEvidence on dementia‐specific pain assessment tools in the ED is extremely limited. Available data suggest PAINAD does not improve timeliness of analgesia, underscoring the urgent need for rigorous studies to guide pain management for PLWD in the ED.

ABSTRACTBackgroundThe clinical utility of diagnostic neuroimaging for pediatric patients presenting to the emergency department (ED) for psychosis remains unclear. We sought to estimate the prevalence of and characteristics associated with clinically significant neuroimaging findings among pediatric patients presenting to the ED with symptoms of psychosis who had neuroimaging performed.MethodsThis retrospective cross‐sectional study included visits by patients 5 to < 18 years old presenting with symptoms of psychosis to 28 EDs affiliated with the Pediatric Emergency Medicine Collaborative Research Committee from 2016 to 2019 and had neuroimaging performed. We estimated the rate of clinically significant neuroimaging findings, defined as those resulting in further testing, treatment, or medical admission, overall and by imaging modality. Multivariable logistic regression models examined presenting features associated with clinically significant findings.ResultsClinically significant neuroimaging findings were identified in 5.4% (95% CI 4.2%, 6.9%) of 1118 ED visits (54% male, median [IQR] 14 [11–16] years old). Clinically significant findings occurred in 4.9% (34/699) of head computed tomography scans and 7.5% (45/604) of brain magnetic resonance imaging studies (p = 0.07). In a model that imputed missing data, no presenting features were associated with clinically significant neuroimaging findings. In a model that treated missing documentation as absence of the clinical feature, the adjusted odds of clinically significant neuroimaging findings were lower among ED visits by patients with suspected alcohol or substance use (aOR 0.38, 95% CI 0.16, 0.87).ConclusionAmong pediatric patients presenting to the ED with symptoms of psychosis who had neuroimaging obtained, approximately 1 in 20 had clinically significant findings. Suspected alcohol or substance use was associated with lower odds of clinically significant neuroimaging findings, although this finding was not consistent across modeling approaches. Prospective studies are needed to definitively evaluate the utility of neuroimaging among children and adolescents presenting to the ED with symptoms of psychosis.

ABSTRACTBackgroundMorbidity and mortality in cardiogenic pulmonary edema have been reduced by noninvasive positive‐pressure airway maneuvers. The value of continuous positive airway pressure (CPAP) for the treatment of high‐altitude pulmonary edema (HAPE) is uncertain. The purpose of this study was to evaluate the efficacy and speed of CPAP for HAPE resolution.MethodsA prospective, investigator‐initiated, multicenter, randomized, double‐blind controlled trial of high‐flow oxygen with CPAP versus sham CPAP with high‐flow oxygen (oxygen‐only group) was conducted. Sixty‐four dyspneic adults with maximum oxygen saturation < 85%, recent arrival at high altitude, and noncardiogenic pulmonary edema on chest radiography were randomized to receive CPAP treatment plus usual care or usual care (oxygen‐only) delivered through a sham CPAP mask. The primary endpoint was the clinical resolution of HAPE.ResultsHAPE resolution in the CPAP plus high FiO2 group and the high flow oxygen alone group was similar. However, this finding should be interpreted cautiously due to this study being slightly underpowered. There was no significant difference in time to resolution (CPAP ~158 min vs. oxygen ~178 min, p = 0.297). Both therapies were effective, with a mean time to resolution of HAPE of approximately 2.5 to 3 h. No treatment‐related adverse outcomes, intubations, or mortality were observed in either group.ConclusionBoth CPAP with high‐flow oxygen and high‐flow oxygen alone are highly effective for the treatment of HAPE. CPAP conferred no improvement in the time to resolution of HAPE. High‐flow oxygen therapy requires significantly less resource utilization for similar benefits in the treatment of HAPE.Trial RegistrationClinicalTrials.gov identifier: NCT04186598

Clinical decision instruments for predicting mortality in patients