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

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.

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