Psychiatric Emergencies in the Elderly
Psychiatric Emergencies in the Elderly
Psychiatric emergencies are common among the elderly. Diagnosis and treatment can pose a significant challenge because of the high incidence of medical and neurological comorbidities, psychosocial problems, and adverse effects of medications. The most common psychiatric emergencies in this population are delirium, depression with suicidality, substance abuse, and dementia accompanied by aggression.
This article identifies key issues that will allow psychiatrists to diagnose, assess, and manage these prevalent psychiatric emergencies in geriatric patients.
Delirium is a neuropsychiatric syndrome characterized by an acute disturbance in cognition, attention, and level of consciousness, frequently accompanied by changes in sleep-wake cycle and psychomotor disturbances. Although a common psychiatric emergency that affects an estimated 30% to 50% of hospitalized elderly patients, delirium still poses significant diagnostic challenges. Nondetection rates reach up to 70%.1,2 The emergence of delirium is associated with a number of adverse consequences, including increased mortality, prolonged hospitalization, and heightened risk of institutionalization, as well as impeded physical and cognitive recovery at 6 and 12 months.3-5 Early identification of delirium and prompt management of the underlying medical factors reduce its severity and duration and lead to improved outcomes for the patient.6
The onset of delirium is typically rapid, with a diurnal fluctuating course. Table 1 lists the DSM diagnostic criteria for delirium. The diagnosis is based on the clinical history, behavioral observations, and cognitive assessment. The patient history is used to ascertain sudden changes in cognition, explore intercurrent medical conditions, medications use, risk of withdrawal from drugs or alcohol, and changes in the environment.
The clinical presentation varies and, on the basis of psychomotor behavior, can be categorized into 3 subtypes: hyperactive, hypoactive, and mixed.7 Patients with hyperactive delirium appear restless, agitated, and hypervigilant and frequently experience hallucinations and delusions. Patients with the hypoactive form of delirium may be lethargic, somnolent, subdued, and psychomotorically slowed. The hypoactive subtype occurs more often in the elderly and is frequently overlooked by clinicians.8 Mixed delirium is associated with features of both hyperactive and hypoactive types.
The Confusion Assessment Method (CAM)—a standardized, brief, validated diagnostic algorithm—helps with identification of delirium. The Memorial Delirium Assessment Scale can be used to quantify delirium severity. Delirium must be differentiated from depression, dementia, and primary psychoses (Table 2).9,10
The pathophysiology of delirium is still under debate, and a variety of pathogenic mechanisms may ultimately be involved. Good evidence supports neurotransmitter disturbances, especially acetylcholine deficiency and dopamine excess.11 Increasing evidence suggests that trauma (including surgery) and infection can cause increased production of proinflammatory cytokines that lead to delirium in susceptible individuals.12,13 In addition, high levels of cortisol associated with acute stress and direct neuronal injury caused by direct metabolic or ischemic insults have been hypothesized to precipitate and maintain delirium.14,15
Delirium is conceptualized as a multifactorial syndrome emerging from the interaction of predisposing and precipitating factors. Its severity and likelihood increase with the number of risk factors. Predisposing factors describe patient vulnerabilities and include age, preexisting cognitive impairment, and sensory deficits.16 Precipitating factors, on the other hand, delineate hospital-related insults that have been linked to the onset of the syndrome (Table 3).17 Because elderly patients are intrinsically at risk for having a number of predisposing factors, delirium is more likely to develop even in response to seemingly benign triggers.18 An iatrogenic etiology should not be overlooked: medication use may be the sole precipitant in 12% to 39% of cases of delirium in the elderly (Table 4).11
? The targeting of modifiable risk factors such as sleep deprivation, immobility, hearing and visual impairment, and dehydration can significantly reduce the incidence of delirium in the geriatric population.
? In older adults, depression frequently presents somewhat differently than it does in younger patients. Elderly patients are more likely to experience feelings of worthlessness and guilt, to have sleep disturbances, and to complain about concentration and memory difficulties as well as attention problems.
? The first step in treating substance-abusing elderly patients is to determine the risk of withdrawal syndrome. The presence of comorbid medical problems, limited reserve, susceptibility to kindling, and vulnerability to adverse effects of the medications used for treatment of withdrawal may significantly increase the risk of complicated withdrawal syndrome.
? The first step in evaluating behavioral disturbance in patients with dementia is to assess and explore medical, pharmacological, and environmental variables that may have precipitated the behavior. It is essential to identify and correct all modifiable causes of behavioral distress; however, the evaluation can be challenging because of the fluctuating nature of the symptoms and the patient’s impeded ability to communicate.
Approximately 30% to 40% of cases of delirium are avoidable. There is growing evidence that several nonpharmacological interventions may help prevent delirium.19 The targeting of modifiable risk factors, such as sleep deprivation, immobility, hearing and visual impairment, and dehydration has resulted in a significant reduction in the incidence of delirium in the geriatric population.20 Relatively small trials have assessed medications (eg, haloperidol and cholinergic enhancers) in delirium prevention. However, further studies are needed before specific conclusions can be drawn about pharmaceutical agents as preventive measures.
Delirium is a medical emergency, and once it emerges, the most important first step is prompt identification and correction of the underlying causes. Environmental interventions, such as noise reduction, proper illumination, stimulus modification, cueing, and reassurance, are integral parts of current delirium treatment.21 Pharmacological interventions are primarily reserved for patients with behavioral disturbances that might compromise their safety and ability to participate in necessary medical treatments. Neuroleptics are the preferred agents; most evidence supports haloperidol use.
Table 5 summarizes currently available medications for delirium accompanied by agitation and hallucinatory experiences.