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Psychiatric emergencies involving elderly persons can occur in a crisis center, emergency department (ED), medical-surgical unit. nursing home, or private residence. Because psychiatric disorders are prevalent in older persons (Jenike, 1985; Minden, 1984; Walker and Covington, 1984), the clinician should be familiar with the typical signs of mental disturbance in this population. This chapter focuses on psychiatric disorders that can appear differently in elderly persons than in younger persons and on disorders unique to geriatric patients.
Dementia is a general term for the chronic organic mental disorder that causes loss of intellectual and other higher brain functions. Nearly 40% of those with dementia have treatable or reversible forms (Thompson, 1987). Unfortunately, the term is frequently misused as a synonym for Alzheimer's disease, which can lead to pessimism and passivity among clinicians.
Since dementia itself is not a crisis, the clinician's role is to identify the undiagnosed demented patient, treat presenting problems (such as delirium or psychosis), initiate physical examinations and laboratory studies, and counsel the patient's family.
The patient with dementia is usually brought to the emergency setting by a relative or caregiver. Typical chief complaints include confusion, disorientation, or wandering; inappropriate social behavior; anxiety or depression; delusions (for example, that others are stealing from the patient); or verbal or physical aggression.
As described in the DSM-III-R (1987), major findings in dementia are impaired memory, abstract thinking, and judgment and disruption of higher cortical function. Although both short- and long-term memory are affected, short-term memory loss usually occurs first. A patient with an impaired short-term memory is unable to learn new information, such as recalling three objects after five minutes. Long-term memory deficits are characterized by a loss of recall for past events, such as birthplace, occupation, and well-known dates. Mild memory loss is part of normal aging and not considered dementia.
Patients who are unable to find similarities between words or concepts have impaired abstract thinking. They may also have difficulty in defining previously known words. Impaired judgment is apparent when the patient is unable to make reasonable plans for interpersonal, family, financial, or occupational issues. An impairment in social judgment can lead to inappropriate or disinhibited behavior, such as disrobing in public. Disruption of higher cortical function manifests as aphasia (impairment in receptive or expressive language), apraxia (impairment in purposive motor acts), agnosia (failure to recognize objects, body parts, or persons), or constructional problems (such as an inability to copy a figure on paper).
In conducting the mental status examination, the clinician should use a structured rating instrument (see Appendix C: Folstein Mini-Mental State Examination).
Although no specific guidelines exist for the physical examination of a patient with dementia, conduct a thorough physical and neu-rologic evaluation to rule out the diverse causes of the disorder.
The laboratory evaluation of patients with dementia is extensive: a complete blood count (CBC), electrolyte and glucose levels, hepatic and renal profiles, urinalysis, thyroid profile, syphilis screen, urinan corticosteroids, erythrocyte sedimentation rate, lupus profile, human immunodeficiency virus antibody titer, chest X-ray, and electrocardiogram (ECG). Also order neurologic studies, such as a computed tomography (CT) scan or magnetic resonance imaging, lumbar puncture, and electroencephalogram. Some of these studies can be initiated in the emergency setting while arrangements for hospitalization or other care are made.
The differential diagnosis of dementia is lengthy and cannot be completed in the ED. However, since many causes of dementia are treatable (see Treatable causes of dementia), the clinician should focus on ruling out life threatening causes, such as tumor, infection. and hematoma.
Dementia, a chronic and stable condition that is not accompanied by clouded consciousness, must be differentiated from delirium, an acute illness that causes altered consciousness.
Major depression can resemble dementia. Complaints of impaired memory, thinking, and concentration and an overall decrease in function are consistent with depression-induced dementia, or pseudodementia (Wells, 1979). Unlike a typical dementia, such as Alzheimer's disease, depression-induced dementia has a rapid onset and commonly occurs in patients with histories of depression or bipolar disorder. The pseudodemented patient is more likely than the organically demented patient to complain of memory loss and is also more likely to answer "I don't know" to questions. A timely diagnosis of depression can avert a misdiagnosis of irreversible dementia in an otherwise treatable patient.
Place a patient with dementia in a quiet, well-lighted room, supervised by family or staff members to prevent wandering or accidental injury. Explain the treatment plan to the patient, and avoid subjecting him to multiple interviews. Demented patients need reassurance from a supportive clinician.
| Treatable Causes of Dementia | |
| Cardiac disease (arrhythmias, congestive heart failure, myocardial infarction)
Pulmonary disease Hepatic disease Renal disease Vascular disease Infection Endocrine disease Electrolyte Imbalance Vitamin deficiencies Drugs Exogenous toxins Tumors Normal pressure hydrocephalus Depression |
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Demented patients may be agitated or psychotic. Such patients can be treated with small doses of a neuroleptic agent, such as haloperidol (Haldol) 1 to 2 mg or thiothixene (Navane) 2 to 5 mg orally or I.M. Medications with strong anticholinergic side effects should not be prescribed because they can induce delirium. The clinician should also avoid benzodiazepines, which may cause excessive sedation or exacerbate confusion.
Education is an unrealistic goal for a demented patient in the emergency setting. Family members, however, are an integral part of subsequent care and should receive information on the patient's condition. Unless the cause of the dementia has been previously established, do not assume that the patient has Alzheimer's disease. Explain to the family that Alzheimer's disease is diagnosed by eliminating other dementias, and help them understand that their continued help is essential.
If a treatable cause of dementia is found, reassure the family that the patient does not have Alzheimer's disease. If the dementia is caused by poor self-care (such as malnutrition), the family must make appropriate arrangements for the patient's care.
The diagnosis of an irreversible dementia, such as Alzheimer's disease, is devastating for the patient's family, who will need support and guidance. Discuss such issues as power of attorney and nursing home placement. In addition, refer the relatives to a support group for spouses and family members of Alzheimer's disease victims. Families should know that the patient's angry outbursts, uncharacteristic profanity, and forgetfulness are not willful but part of the progressing disease.
Given the serious prognosis of dementia, most patients should be hospitalized for a thorough evaluation. Based on the patient's condition and the family's cooperation, anticipate the posthosphal disposition by determining whether the family members are willing to continue to keep the patient in their home. Relatives may take a patient to the ED because they are "burnt out" and can no longer care for the patient. In such cases, suggest that the patient live with another relative or in a nursing facility.
Patients with grossly impaired judgment and diminished intellect may be clinically incompetent. Such patients are unable to participate in medical, legal, or financial decisions. In assessing the competence of the demented patient, ask several questions:
A disoriented person is unlikely to be competent. Yet refusing treatment does not indicate that the patient is incompetent and must be weighed against other mental status features. Clinicians can legally provide emergency treatment for clinically incompetent patients. However, the clinician should obtain consent from family members or a legal guardian as soon as the crisis is over.
Delirium in geriatric patients is an acute organic mental disorder with potentially serious consequences. Rapid recognition and reversal of the condition are critical. The essential feature of delirium is a sudden change in behavior. In interpreting the patient's history (which is always obtained from a relative or friend), the clinician must be aware that delirium may be more subtle in an elderly person than in a younger adult. Elderly patients commonly have a "quiet" delirium, which manifests as a loss of interest and concentration but actually represents a change in consciousness. Clues to a diagnosis of delirium are rapid deterioration in behavior or orientation, preexisting dementia, recent infection or head injury, recent change in medication, and new neurologic signs.
Dementia and delirium can coexist; delirium may develop in demented patients as a result of an infection or drug side effect.
The clinician should focus on changes in the patient's daily routine environment, and medical and drug status that occurred about the same time as the change in behavior.
Use of over-the-counter (OTC) drugs or alcohol is also associated with delirium. Many older patients do not perceive OTC preparations as drugs. When questioning the patient, be sure to ask, "Do you buy any medicines off the shelf in the drugstore for sleep, colds, arthritis, or other problems?" Similarly, the elderlv patient may not believe that drinking can be harmful or may deny drinking. Many elderly persons sip sherry, wine, or cordials daily. which can lead to alcohol withdrawal if they are hospitalized for a medical-surgical problem. Encourage family members to report the elderly patient's use of alcohol and prescription or OTC drugs. If possible, they should bring in all the patient's medications for evaluation.
An elderly patient who takes one or more drugs with anticho-linergic (atropine-like) properties is susceptible to central anti-cholinergic syndrome. Signs and symptoms of this delirious state include dry skin and mucosae, blurred vision, constipation, urine retention, tachycardia, dilated and unreactive pupils, and flushed facies. In severe cases, the patient may have seizures, hyperreflexia. fever, slurred speech, and ataxia. Commonly used medications with anticholinergic effects include hypnotics, such as scopolamine (Transderm-V); eye drops, such as atropine (Atroposol), scopolamine (Buscospan), and cyclopentolate (Cyclogyl); antihistamines, such as diphenhydramine (Benadryl), hydroxyzine (Atarax), chlor-pheniramine (Chlor-Trimeton), and promethazine (Pentazine): an-tiparkinsonian agents, such as benztropine (Cogentin) and trihexyphenidyl (Trihexane); tricyclic antidepressants, such as ami-triptyline (Elavil), nortriptyline (Aventyl), imipramine (Tofranil). and doxepin (Sinequan); and neuroleptic agents, such as chlorpromazine (Thorazine), thioridazine (Mellaril), and mesoridazinc (Serentil).
Typical mental status findings in a delirious elderly patient include disorientation, disturbed sleep-wake cycle, clouding of consciousness, visual hallucinations, illusions, delusions, fluctuating symptoms, agitation, and impaired attention, concentration, and memory.
Although delirium does not cause any specific physical symptoms, relevant findings include scalp lacerations or contusions, signs of hypoxemia ("dusty" skin color or blue nailbeds), fever, increased heart rate (greater than 100 beats/minute), and increased respiratory rate (greater than 30 breaths/minute).
The emergence of new neurologic signs—tremors, paralyses, asymmetrical or abnormal reflexes, ocular signs, or aphasia - should immediately trigger a consultation with a neurologist and appropriate diagnostic tests, especially a CT scan. (See Chapter 3, Delirium, for additional physical findings and their interpretation.)
The minimum standard laboratory evaluation of the delirious elderly patient includes blood glucose, electrolyte, and blood urea nitrogen levels; CBC and differential; serum levels of all drugs; ECG; urinalysis; chest X-ray; and arterial blood gas analysis. If these tests are negative, order a lumbar puncture and CT scan.
Because delirium can coexist with dementia, be especially alert for changes in the patient's mental status. When evaluating the patient for the first time, rely on family members to supply the mental status history. A sudden deterioration in mental status should not immediately be ascribed to dementia alone; do not overlook readily reversible causes of delirium, such as urinary tract infection.
The primary intervention is assuring the delirious elderly patient that the condition will pass. The clinician should also conduct frequent orientation and reality checks and involve the patient's family members (familiar faces can help orient the patient). If the patient is combative or agitated, physical restraint (such as a Posey vest) may be needed to prevent self-harm or harm to others. Restraints may also be necessary to ensure that the patient does not disconnect intravenous lines or other equipment.
While investigating the cause of the delirium, the clinician may need to administer psychotropic medication to treat the patients behavioral symptoms. The clinician must avoid further compromising the patient's brain function, which can occur, for example. when chlorpromazine is given to a patient with anticholinergic delirium. Any psychotropic drugs given to delirious patients should be short-acting and relatively free of anticholinergic side effects. Benzodiazepines should not be prescribed for elderly patients with impaired consciousness; these drugs further impair cortical function. To calm a highly agitated patient, the clinician can administer a 1-mg dose of haloperidol I.M. Other high-potency neuroleptic agents can also be used, including fluphenazine (Prolixin) 1 mg, trifluoperazine (Stelazine) 2 mg, and thiothixene 2 mg. These doses can be repeated every 2 hours. Although any psychotropic drug can depress brain function, neuroleptic agents can also cause ex-trapyramidal symptoms. Other pharmacologic interventions are based solely on the diagnosis (for example, to correct an electrolyte or acid base imbalance).
Delirium caused by anticholinergic drugs is a medical emergency. Treat patients who have anticholinergic delirium with phy-sostigmine (Antilirium) 1 to 2 mg I.V. (slow push) or I.M. (Dubin et al., 1986). Since physostigmine's duration of action is 2 hours, the dose can be repeated at 2-hour intervals, or more frequently if needed. Overly aggressive treatment can precipitate a cholinergic crisis, which can be reversed with atropine 0.5 mg for each 1 mg of physostigmine (Hall et al., 1981). Additional complications of physostigmine treatment are vomiting, hypotension, and seizures.
The patient's family or caregiver may benefit from advice about the prevention of drug-induced delirium. Tell them to inform the primary care physician about the patient's use of OTC medications and to monitor the drugs he takes. Advise them to encourage the elderly person to avoid alcohol, and teach them the early signs of mental status changes.
Most delirious elderly patients should be hospitalized for further treatment and evaluation. However, a patient with a transitory, drug-induced delirium can be discharged to the care of family or friends if they schedule a follow-up appointment with the primary care physician. Make reasonable efforts to return the patient to his former environment (Minden, 1984).
Most delirious patients are legally incompetent. However, before initiating treatment or ordering restraints, try to obtain consent from a family member. If such consent cannot be obtained, a second clinical opinion (documented in the medical record) and notification of relatives will suffice.
Adjustment disorders, usually characterized by anxiety and depression, can have an organic, psychodynamic, or psychosocial cause (Goodstein, 1985). To avoid deterioration of the elderly patient who has acute problems in living, institute rapid and appropriate intervention. Some elderly patients have anxiety or depressive symptoms. Others have an increase in bodily complaints, disturbed sleep, problems in concentration and thinking clearly, and forgetfulness or difficulty recalling words.
The key concepts in assessing adjustment disorders in geriatric persons are loss and change. Losses can be physical (diminished vision), personal (death of spouse), occupational or financial (retirement), or symbolic (loss of youth). Changes can also precipitate emotional difficulties, especially a change in residence. A move to a nursing home can be traumatic even for a well-adjusted older person.
Preexisting dementia, such as Alzheimer's disease, exacerbates the adjustment disorder, yet transitory disorders are treatable. A patient should not be disregarded because of a preexisting dementia nor should all emotional symptoms be attributed to "senility" (Goodstein, 1985).
In addition to the usual clinical signs of anxiety and depression, elderly patients (especially those with mild cognitive impairment) may respond to loss or change with apathy, irritability, bodily complaints (pain, disability, constipation), faulty memory, inattention, hopelessness, and paranoia. Also, look for signs of suicidal thoughts or self-destructive behavior. Elderly persons who have physical disabilities or who live alone are at particularly high risk for suicide (Goodstein, 1985; Minden, 1984). Warning signs of suicidal intent include apathy, hopelessness, poor self-care, noncompliance with essential medications, and decreased social contacts.
Adjustment disorder symptoms are commonly related to deterioration of the patient's physical condition. Therefore, check the patient's vision, hearing, dentition, joint mobility, bladder and bowel function, and (in men) sexual potency. The presence of infections or a change in nervous system response must also be determined.
The clinician should base the diagnostic evaluation on known or suspected contributing conditions. Obtain blood levels of any drugs and ensure that the patient has had a recent physical examination. The laboratory tests recommended for delirium may also be of value.
If the typical precipitating events of an adjustment disorder are absent or indistinct, suspect drug toxicity, metabolic disturbance, cerebrovascular disease, early phase primary dementia, or delirium.
The elderly patient taken to the ED by family members or caregivers should be given privacy. Obtain a history from the accompanying person (Minden, 1984). If the diagnosis is adjustment disorder. begin the interpersonal strategy, which takes the form of crisis intervention (Minden, 1984). Try to:
The success of this strategy depends on the patient's premorbid personality, intellect, and current cognitive state. In all cases, the clinician can help the patient and family members by remaining optimistic. However, the immediate need for inpatient treatment takes precedence over crisis intervention in patients who are psychotic, grossly depressed, or suicidal.
"Less is more" characterizes the drug treatment of adjustment problems in elderly patients (Walker and Covington, 1984). Because many psychotropic agents can impair cognitive function, deferring drug treatment is usually best. If the patient is already taking a psychotropic medication, the clinician must rule out drug toxicity as the cause of the problem. Adjustments in dosage can be considered later.
If psychotropic drugs must be prescribed, the dosage for an elderly person is one-third to one-half the usual adult dosage A side effects, such as orthostatic hypotension or sedation, are magnified in the elderly patient.
Do not initiate antidepressant therapy in the emergency setting. If necessary, a patient with mild anxiety, insomnia, or somatic complaints out of proportion to his condition can be given a small dose of a short-acting benzodiazepine. Appropriate drugs are alprazolam (Xanax) 0.25 mg, lorazepam (Ativan) 0.5 mg, or oxazepam (Serax) 10 mg up to three times daily.
Explain to the patient and family that adjustment disorders do not necessarily represent a serious illness or permanent deterioration and that the patient can probably return to his previous level of functioning. Suggest psychotherapy as a possible method of effecting the desired change in the patient's behavior, and emphasize the harmful effects of alcohol on the aging brain.
If an adjustment disorder appears to be a major depression or psychosis, the patient should be hospitalized. Suicide is the most serious potential consequence of failing to hospitalize a severely depressed or psychotic patient. If the patient is discharged, document any recommendations for antidepressant or other pharma-cologic intervention, and notify the primary physician.
Many elderly patients refuse treatment because they feel they have been forced to get help. Even if this feeling is justified, the clinician must choose between honoring the patient's refusal of treatment and addressing the family's demand for action. The key issue is patient competence. A competent patient has a right to refuse treatment. When the patient's health and safety are in jeopardy, however. the refusal can be temporarily overridden. The clinician can treat an incompetent patient but should try to obtain the family's consent first.
Psychotic symptoms in elderly patients can signal a life-threatening illness, so timely intervention is needed. The most common types of psychoses in the elderly population are delirium; organic de-lusional syndrome, usually with Alzheimer's disease; chronic mental illness, especially bipolar disorder; and major depression with psychotic features. The clinician can differentiate among psychotic disorders by reviewing the patient's history. For example, delirium has an acute onset, organic delusional syndrome develops gradually. chronic mental illness is obvious, and major depression is typically accompanied by apathy and suicidal ideation. In patients with bipolar disorder, mood swings accelerate in later life, although the episodes tend to be brief.
The mental status findings in an elderly patient with delirium include clouded consciousness, disoriemation, and hallucinations. A patient with organic delusional syndrome may be suspicious, have delusions of being poisoned or watched by others, and hide things and accuse others of stealing them. A bipolar disorder can cause such symptoms as irritability, grandiosity, poor social judgment, and decreased need for sleep. A patient suffering from major depression is apathetic, feels guilty and hopeless, and has suicidal thoughts and delusions of poverty or disease.
No specific physical findings aid in the diagnosis of a psychotic disorder. However, a long-standing episode of major depression can be accompanied by dehydration and malnutrition.
Beyond the investigation for causes of delirium and other organic conditions, further tests depend entirely on the clinician's judgment. In all cases, order tests for blood levels of any measurable medications.
The main differential diagnosis is between functional psychosis and delirium. Make every effort to identify a reversible cause of the mental status changes; consider the possibility of prescription drug misuse, alcohol-related syndromes, and drug toxicity.
A psychotic elderly patient may be suspicious, agitated, combative, or have a negative attitude. Emergency service staff members must be prepared to provide close, if not constant, supervision until the patient is treated or discharged. Encourage family members or friends to stay with the patient; their presence reassures the patient and reduces the likelihood that physical restraint will be needed.
Most psychotic elderly patients are admitted for inpatient treatment. If interim treatment is necessary, prescribe small doses of an antipsychotic agent. The use of rapid tranquilization in the elderly population has not been well studied. Therefore, a patient given single doses of a neuroleptic drug, such as haloperidol 0.25 to 1 mg I.M. or 0.5 to 1 mg orally, should be observed for at least 1 hour before the dose is repeated. Low-potency neuroleptic agents and benzodiazepines should be avoided in suspected cases of delirium.
Direct all educational efforts toward the family. Inform them about the diagnosis, obtain their consent for treatment, and enlist their help in managing the patient.
A newly psychotic patient should be treated in an inpatient setting. The clinician's time is better spent arranging the transfer rather than trying to reverse the psychosis in the emergency service. Symptoms in a chronically mentally ill person that were exacerbated by medication noncompliance may be treated now with the usual medications. If symptoms respond, discharge the patient. In these cases, give detailed instructions to the family members or caregiver and make plans for follow-up care.
Because psychosis has variable effects on the elderly patient's ability to make treatment decisions, use the mental status examination to assess his competence. Be alert to the possibility that a patient is being forced into the hospital by family members. Any competent patient can refuse treatment. However, a psychotic patient who is a danger to himself or others or who cannot perform self-care may be subject to civil commitment.