Keys to diagnosis, assessment, and management.
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.
Depression with suicidality
Late-life depression is a common and potentially life-threatening illness. If unrecognized and untreated, it is associated with significantly increased morbidity and mortality from coexisting medical conditions and suicide.22-24 The prevalence of major depressive disorder (MDD) varies from 1% to 5% in community-dwelling elders and 5% to 10% in patients in medical outpatient settings. Between 10% and 15% of patients who are medically hospitalized have MDD, as do up to 42% of older patients living in long-term care facilities.25
Depression is the predominant risk factor in older persons who commit suicide-it is found to be present in 85% of elderly suicide victims.26 The rate of completed suicide is the highest in this age-group and reaches an estimated 14.3 per 100,000. However, attempted suicide is far less frequent in later life than in younger age-groups (the ratio of suicide attempts to completed suicide is 4:1 in the elderly vs 20:1 in the general population).27 The reasons for increased lethality in the elderly may be multifactorial and include the use of more violent means, decreased physical resilience, and social isolation.28
DSM-IV-TR (Table 6) delineates diagnostic criteria for MDD. Depression in older adults, however, frequently presents somewhat differently than in younger patients. Elderly patients are more likely to endorse feelings of worthlessness and guilt; they are more likely to suffer sleep disturbances and to complain about concentration and memory difficulties as well as attention problems.29 In addition, older patients frequently present with vague somatic complaints or have medical problems that mask or mimic depression.30 Standard screening tools, such as the self-rated Geriatric Depression Scale (30, 15, and 5 items), are widely used to assess mood symptoms and monitor treatment response.31
Diagnostic assessment should include a detailed review of medical and neurological problems, concurrently used medications and drugs, evaluation of psychiatric history and social situation, and an evaluation of cognition.32 The presence of depressive symptoms should prompt physicians to introduce questions about death wishes, thoughts of suicide, intent to harm self, and access to means.33 The Suicide Ideation scale or the Chronological Assessment of Suicide Events scale can be used to improve detection of suicidality.34,35
Late-life depression is heterogeneous: some patients have early onset depression with recurrent episodes, and in some, de novo depressive symptoms develop late in life. Patients with late-onset depressive disorder tend to have a family history of less frequent mood disorders, a higher incidence of medical and neurological comorbidities, and a higher prevalence of cognitive impairment. In turn, depression can exacerbate cognitive and medical limitations that lead to social isolation. Social disruption further exacerbates both depression and cognitive dysfunction and contributes to late-life suicide.36
Suicide is not a specific disorder but a painful process typically mediated by a number of complex vulnerabilities-only some of which are modifiable (Table 7).37 Abnormalities in serotonergic, noradrenergic, and neuroendocrine systems have been implicated in the pathophysiology of suicide in the general population; however, the evidence is inconclusive in the elderly because of limited data.38
Clinical strategies that target high-risk individuals are more effective in preventing suicide than interventions solely aimed at individuals with active suicidal ideation and intent.39 Therefore, it has been proposed that the prevention of elderly suicide in crisis situations and in the long run is best achieved by improved recognition and effective treatment of depression.40 Pharmacological interventions, psychotherapy, and electroconvulsive therapy (ECT) are effective treatments for depressed elderly patients.
Antidepressants are considered safe and effective in targeting depressive symptoms; clinical recommendations favor SSRIs. SSRIs are generally well tolerated and have fewer sedative and anticholinergic adverse effects as well as a reduced risk of lethal overdose compared with tricyclic antidepressants.26
Various forms of psychotherapy may provide significant benefits in suicidal patients. Psychotherapeutic interventions that enhance adherence to treatment, provide education, increase self-esteem, strengthen social supports, and diminish hopelessness are clinically recommended.25
A large number of studies support the effectiveness of ECT for treatment of geriatric depression,41 but adverse effects such as cardiac complications, cognitive decline, or delirium limit its use in some patients.
Estimates of the prevalence of alcoholism among the elderly vary because studies define use differently (self-reports vs strict diagnostic criteria) and have targeted different populations (community vs medical settings). Approximately 2% to 4% of community-dwelling elders, 14% of emergency department (ED) older patients, 18% medical inpatients, and more than 20% of psychiatrically hospitalized elderly patients meet criteria for alcohol abuse or dependence.42 Problem drinking affects the elderly population differently than the younger patients in that it is more likely to complicate the course of comorbid medical conditions, can adversely influence effects of commonly prescribed medications, and can exacerbate cognitive problems, which lead to markedly increased morbidity and mortality.43,44
Age-related physiological changes make elderly patients more vulnerable to the intoxicating effects of alcohol. The volume of distribution for alcohol diminishes as the total body water decreases, leading to higher peak concentration for a given amount of alcohol. Also, decreased activity of alcohol dehydrogenase in the stomach increases the intoxicating effects of alcohol.45 Alcoholism develops in about two-thirds of elderly alcoholics before age 40; early-onset alcoholism tends to have more pervasive psychiatric and medical comorbidities and a higher incidence of familiar patterns of use. One-third of elderly alcoholics began the problematic drinking pattern later in life, typically in response to stressful life events (eg, retirement, functional decline, or death of a spouse).
Alcohol abuse and dependence are frequently underrecognized and undertreated. The reasons that the diagnosis is missed appear to be multifactorial. First, applying DSM-IV-TR criteria for substance abuse and dependence may be difficult in this population (Table 8). Second, patients, families, and providers may assume that older adults’ quality of life will remain poor even if they are successfully treated for their substance abuse.46 Third, many older drinkers attribute their alcohol problems to a breakdown in moral values that causes a sense of shame and stigma and ultimately prevents them from seeking help. Furthermore, difficulty applying criteria to a variety of nonspecific symptoms (falls, sleep problems, confusion, irritability), stereotyping (physicians are less likely to detect alcohol problem in women, the educated, and those of higher socioeconomic status), and abbreviated office/ED visits may further impede the clinician’s ability to detect alcohol-related problems in the elderly.47-49
Routine screening is recommended in all older patients, particularly those undergoing major life transitions or presenting with nonspecific physical symptoms. Several brief, practical, and well-validated screening tools for alcoholism are available. The AUDIT-C (Alcohol Use Disorders Identification Test) questionnaire and the MAST-G (Michigan Alcoholism Screening Test–Geriatric Version) are commonly used tools that can facilitate detection.50
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 to treat withdrawal may significantly increase the risk of complicated withdrawal syndrome in this population.51 A history of complicated detoxifications, seizures or delirium tremens, or unstable medical comorbidities warrant inpatient detoxification.52 Following completion of medical detoxification, elderly patients should be referred to residential, day treatment, or outpatient programs where psychological interventions such as psychoeducation, counseling, and motivational interviewing can be provided.
The use of medications to promote abstinence has not been studied extensively in elderly persons. Naltrexone showed some efficacy (prevention of relapse) in patients aged 50 to 74 years.42 Project TREAT (Trial for Early Alcohol Treatment) and Project GOAL (Guiding Older Adults Lifestyles) investigated the impact of brief physician advice with at-risk, nondependent drinkers and demonstrated a positive effect on drinking patterns.53
Dementia is a common neuropsychiatric syndrome associated with progressive decline in function across multiple cognitive domains. It affects 8% to 10% of people older than 65 years and nearly 50% of those older than 85 years.54 Alzheimer disease is the most common cause of dementia (60%), followed by vascular dementia (20%), and dementia with Lewy bodies (15%).55 About 80% of patients with dementia experience some form of behavioral or psychological symptoms of dementia (BPSD). These include agitation and aggression,delusions, hallucinations and misidentifications, screaming and repetitive vocalizations, circadian rhythm dysregulation, and wandering.
BPSD can cause significant distress for patients and their caregivers and is associated with poorer prognosis, rapid cognitive decline, diminished quality of life, and institutionalization.56 Successful treatment of psychiatric and behavioral problems is associated with better outcomes, such as improved quality of life, decreased caregiver stress, and reduced patient suffering.57
The first step in evaluating behavioral disturbance in a patient with dementia is to assess and explore medical, pharmacological, and environmental variables that may have precipitated the behavior. Table 9 presents possible factors that lead to behavioral escalation in patients with dementia.58 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. Validated and reliable scales, such as the Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) or the Cohen-Mansfield Agitation Inventory (CMAI) provide additional aid in evaluating and tracking behavioral changes in dementia patients.59
The causes of BPSD are multifaceted and include neurobiological, psychological (premorbid coping styles), and social aspects. The neurobiology of behavioral manifestations involves a correlation between the decreasing cholinergic function, the depletion of serotonin and norepinephrine levels in depressive and agitation symptoms, and the dysregulation of g-aminobutyric acid, serotonin, and norepinephrine in association with aggressiveness and impulsivity.60
Care of patients with BPSD typically involves a wide range of psychosocial treatments with a focus on the patient’s physical health, safety of the environment, and psychiatric symptoms (Table 10). Behavioral complications that are primarily treated nonpharmacologically include circadian rhythm abnormalities, wandering, vocalizations, and catastrophic reactions (emotional response of various intensity to an overwhelming task or situation).61 Other symptoms such as psychosis, agitation, and aggression historically have been described as “medication-responsive.”
It is important to point out that there is no FDA-approved indication for a medication to treat these common and debilitating behavioral problems. Antipsychotic medications have been used off-label, but the FDA black-box warning that links these medications to increased mortality (most commonly from cardiac or infectious causes) and research findings that emphasize either modest medication efficacy or lack of it, significantly curtail prescribing practices.62
In a 2008 American College of Neuropsychopharmacology white paper, a group of experts made several recommendations about treatment of agitation and psychosis in patients with dementia.62 Identification and correction of possible reversible causative factors along with environmental, interpersonal, social, and medical interventions should be considered first. Families, patients, and caregivers should be involved in the decision-making process, with a full appreciation of the benefits and shortfalls of currently available strategies.
Consider continuous pharmacological management only for patients with persistent and severe symptoms and provide ongoing monitoring of effectiveness. Use the lowest effective medication dosages for the shortest period necessary to stabilize symptoms in this population.63
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