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1940 SECTION 24: Psychosocial Disorders promethazine, use of second-generation antipsychotics does not cause as much somnolence.47 One expert consensus panel on the treatment of agitation recommended that medications be selected to target the pre sumed etiology of the agitation and that second-generation antipsychotics were almost always first-line treatment for agitation of psychiatric origin (Figure 287-1 and Table 287-2). OTHER TREATMENTS  VERBAL DE-ESCALATION A variety of other approaches have been recommended for the treatment of agitated patients. Perhaps the most common recommendation is the use of verbal de-escalation or “talking down” the patient. 48 Use of verbal de-escalation is standard in many psychiatric settings49 and may even be useful in patients with dementia.50 The goal of verbal de-escalation is to help the patient regain control. Clinicians should use the 10 principles in Table 287-3 to optimize the chances for successful verbal de-escalation.2,49 Verbal de-escalation likely does not need to be provided for long periods of time and may allow PO medication over IM injections. 44 In some clinical trials of agitation, a high proportion of patients have been ineligible for medication treatment after successful verbal calming.  RESTRAINTS The decision to restrain has philosophical and legal implications. 21,52,53 If possible, restraint should be placed by police, security officers, or similarly trained individuals. According to guidelines published by the American College of Emergency Physicians, restraint should be per formed in the least restrictive manner possible (e.g., never face down) and only after verbal de-escalation is attempted. 54 Although clinicians often assume that a restrained patient is safer for staff than an unre strained patient, this may not be true, as most of the injuries to both TABLE 287-2 Treatment of Agitation: Comparison of Agents Drug PO or IM Dose Half-Life Comments on IV Dosing Risperidone (Risperdal®) 1–6 milligrams/d, divided daily or twice a day 20 h N/A Olanzapine (Zyprexa®) 10 milligrams × 1, may repeat   2 h after 1st dose, then 4 h after 2nd dose to max 30 milligrams Consider lower doses or oral route in elderly or alcoholintoxicated patients. 21–54 h Some studies have shown that IV olanzapine is efficacious, although it has a greater risk of airway adverse effects; it is not FDA approved for this route. IV route may not offer additional advantages over PO or IM route. Ziprasidone (Geodon®) 20 milligrams × 1 (may repeat every 4 h to maximum dose of 40 milligrams); alternatively, may administer 10 milligrams every 2 h 7 h Not studied Haloperidol (Haldol®) 0.5–10 milligrams every 1–4 h (use lowest effective dose; do not exceed 100 milligrams/d) 21–24 h FDA black box warning for IV use Abbreviations: FDA = U.S. Food and Drug Administration; N/A = not applicable. TABLE 287-3 Principles of Verbal De-escalation •   Respect personal space •   Do not be provocative •   Establish verbal contact •   Be concise •   Identify wants and feelings •   Listen closely to what the patient is saying •   Agree or agree to disagree •   Lay down the law and set clear limits •   Offer choices and optimism •   Debrief the patient and staff Source: Reproduced with permission from Richmond JS, Berlin JS, Fishkind AB, et al: Verbal De-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

t clear limits •   Offer choices and optimism •   Debrief the patient and staff Source: Reproduced with permission from Richmond JS, Berlin JS, Fishkind AB, et al: Verbal De-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med 13: 17–25, 2012. patients and staff occur during restraint episodes. 55,56 In addition, there are many disadvantages of restraint; it may consume a disproportionate share of ED resources, result in increased lengths of stay in the ED, and be associated with poorer outpatient follow-up. 57-59 In one study on ED lengths of stay, Weiss and colleagues 59 found that restrained patients remain 4.2 hours longer on average in the ED than other psychiatric patients. SPECIAL POPULATIONS Pregnant women, elderly patients, and children represent specific subgroups in whom nonpharmacologic approaches are generally preferred over antipsychotics or benzodiazepines, 60-63 even though acute short-term use of these agents has occasionally been suggested in the ED literature. 64 Extra attempts should be made to use nonpharmaco logic treatments such as verbal de-escalation, which may work even in patients with dementia. 50,65 If medications must be used as a final resort, second-generation agents are preferred over first-generation agents. 66-68 In elderly patients with delirium, the safest approach is to treat the underlying cause that is producing both the delirium and agitation. 5,69,70 If medications are needed, second-generation agents and low-dose haloperidol (<3.0 milligrams/d) do not seem to worsen delirium. 67,71 Avoid benzodiazepines and antihistamines. For further discussion, see Chapter 149, “Behavioral Disorders in Children, ” and Chapter 288, “Mental Health Disorders of the Elderly. ” REFERENCES The complete reference list is available online at www.TintinalliEM.com. CHAPTER Mental Health Disorders of the Elderly Christina L. Shenvi INTRODUCTION The proportion of ED visits by older adults is expected to continue its rapid increase over the coming decades. 1 As a result, we can expect to see many patients who present for, or present with, mental health dis orders. In 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, 2 in which they introduced the terms mild and major neurocognitive disor der, the latter of which was previously called dementia. We will continue to use the term dementia to represent major neurocognitive disorder in this chapter. Delirium, dementia, and depression affect many older Tintinalli_Sec24_p1933-1966.indd 1940 8/2/19 5:19 PM

ntroduced the terms mild and major neurocognitive disor der, the latter of which was previously called dementia. We will continue to use the term dementia to represent major neurocognitive disorder in this chapter. Delirium, dementia, and depression affect many older Tintinalli_Sec24_p1933-1966.indd 1940 8/2/19 5:19 PM CHAPTER 288:  Mental Health Disor ders of the Elderly      1941 adults, and the differentiation of these disorders can be challenging because they are interrelated. Patients with dementia are more likely to develop delirium, 3 and patients who experience delirium are more likely to develop dementia later in life.4-7 It can also be difficult to diagnose depression in patients with dementia, as both disorders can demonstrate similar symptoms such as apathy and behavioral changes. 8 Also, depression in late life has been associated with an increased risk of developing dementia, further dem onstrating that dementia, delirium, and depression are interconnected, increase the risk of each other, and are all associated with an increased risk of mortality and morbidity. 9-15 Table 288-1 provides distinguishing features of delirium, dementia, and psychiatric disorders. Chapter 168, “ Altered Mental Status and Coma, ” and Chapter 286, “Mental Health Disorders: ED Evaluation and Disposition, ” also discuss the distinc tions between delirium, minor neurocognitive disorder, and psychiatric disorders. Finally, the management of acute delirium, psychosis, or behavioral disturbances in older adults in the ED can be difficult. Medications such as benzodiazepines and antipsychotics, which are frequently used in younger agitated patients, may have significant side effects in older patients, such as prolonged sedation, or paradoxical agitation with benzodiazepines. Medications for acute agitation should be selected care fully and typically at lower doses than for younger patients, and should only be used after nonpharmacologic modifications and interventions have been exhausted. DELIRIUM Delirium is an acute change in cognition that fluctuates rapidly over time and is often reversible. Delirium is frequently the first sign of an underlying acute medical illness. Patients demonstrate altered levels of consciousness, inattention, disorganized thinking, and altered per ception. There are three main types of delirium: hypoactive, hyperac tive, and mixed. 16 By far, the most common types are hypoactive and mixed delirium, which also have the highest potential to be missed. 17-23 Hypoactive delirium has been called “quiet delirium” because patients have decreased psychomotor activity and can appear somnolent. If hypoactive delirium is confused for depression, the underlying medical disorder causing the delirium can be missed. 24-26 Hyperactive delirium, in contrast, is characterized by increased psychomotor activity. Patients with hyperactive delirium are often agitated, anxious, and sometimes combative. Mixed type can present with a combination of both hyperactive and hypoactive states that fluctuate over time. Delirium is present in 7% to 10% of older patients presenting to the ED. 17,27,28 Environmental risk factors for delirium include functional dependence, living in a nursing home, and hearing impairment. 17,29 Delirium in the ED is an independent predictor of 6-month mortality. Delirium is associated with a longer hospital length of stay, more inhospital complications, higher likelihood of discharge to long-term care facilities, and lasting cognitive deficits. 30-37 Even though delirium is a common disorder in the elderly, the diagnosis may be missed by providers in 57% to 83% of cases. 27,38–41 If delirium is missed in the ED, it is likely to be missed on the inpatient services as well.

er likelihood of discharge to long-term care facilities, and lasting cognitive deficits. 30-37 Even though delirium is a common disorder in the elderly, the diagnosis may be missed by providers in 57% to 83% of cases. 27,38–41 If delirium is missed in the ED, it is likely to be missed on the inpatient services as well. 17  CLINICAL FEATURES The differential diagnosis of delirium includes minor neurocognitive disorder, depression, or another underlying psychiatric disorder. Such conditions can also be comorbidities of each other. However, it is important to first assess for delirium and then consider the possibility of the other disorders. If delirium is suspected, the history and physical should be thorough to help determine the underlying cause. History It is important when taking the history to find out the patient’s baseline mental status and level of functioning, and the time course of changes. This may require calling the patient’s family members or their facility to obtain collateral information. Patients with delirium may not be able to provide a clear history, or may confabulate. Ask a reliable source about past medical history and recent illness. Obtain an accurate medication list, and ask about over-the-counter medications, particularly medications with anticholinergic properties, or any new medications. 42 Ask about substance abuse to assess the likelihood of intoxication or withdrawal. Any past psychiatric history requires close investigation of prior diagnoses, hospitalizations, and medications. Determine the patient’s ability to make informed medical decisions, and determine whether another individual has legal power of attorney for medical decision making. When attempting to differentiate delirium from minor neurocognitive disorder, consider several key factors. An acute change in mental status is more consistent with delirium than with minor neurocognitive disorder, and a fluctuating course over time is also more likely due to delirium. 43 Altered level of consciousness, inattention, and disorganized thinking are all more common in delirium than in minor neurocogni tive disorder.43 However, delirium is more likely to occur in patients who have underlying minor neurocognitive disorder, so features of both may be present. Physical Examination The physical examination should be thorough. Vital signs must be complete, including oxygen saturation and temperature. Baseline blood pressures are usually higher than in younger age groups, with a wider pulse pressure. Older patients may not be able to mount a tachycardic response to physiologic stress either due to effects of medications such as β-blockers, or because of physiologic limitations. Older patients have lower basal temperatures, with means of 97.3 to 97.8°F depending on the time of the day, so the threshold for a fever is lower. 44 Look for evidence of trauma, as patients may not recall falling or injuring themselves. Examine the entire body, making sure to look at the patient’s back and heels for evidence of decubitus ulcers. Check between the toes for infections such as tinea or cellulitis. Perform a complete neurologic exam, looking for focal findings, abnormal posturing, or difficulty with gait, coordination, or vision. A normal physical examination does not exclude the diagnosis of delirium. Mental Status Examination Mental status examination is per formed to identify delirium and to differentiate it from other condi tions.27,35,38–41,45,46 The examination consists of an assessment of six mental-behavioral components (Table 288-2).

. A normal physical examination does not exclude the diagnosis of delirium. Mental Status Examination Mental status examination is per formed to identify delirium and to differentiate it from other condi tions.27,35,38–41,45,46 The examination consists of an assessment of six mental-behavioral components (Table 288-2). Two of the most common screening tests used to detect delirium are the Confusion Assessment Method for general use and the Confusion Assessment Method–Intensive Care Unit for intubated patients who TABLE 288-1 Features of Delirium, Dementia, and Psychiatric Disorder Characteristic Delirium Dementia Psychiatric Disorder Onset Over days Insidious Varies Course over 24 h Fluctuating Stable Varies Consciousness Reduced or hyperalert Alert Alert or distracted Attention Disordered Normal May be disordered Cognition Disordered Impaired Rarely impaired Orientation Impaired Often impaired May be impaired Hallucinations Visual and/or auditory Often absent May be present Delusions Transient, poorly organized Usually absent Sustained Movements Asterixis, tremor may be present Often absent Varies Tintinalli_Sec24_p1933-1966.indd 1941 8/2/19 5:19 PM

mpaired Rarely impaired Orientation Impaired Often impaired May be impaired Hallucinations Visual and/or auditory Often absent May be present Delusions Transient, poorly organized Usually absent Sustained Movements Asterixis, tremor may be present Often absent Varies Tintinalli_Sec24_p1933-1966.indd 1941 8/2/19 5:19 PM 1942 SECTION 24: Psychosocial Disorders are not heavily sedated.47,48 Figure 288-1 outlines the components of the Confusion Assessment Method. Inattention is characterized by an easily distracted patient who has difficulty keeping track of the conversation. Disorganized thought processes are rambling, unclear, or illogical. An altered level of consciousness is lethargy, lack of responsiveness, or coma—essentially anything other than alert. The diagnosis of delirium requires features 1 and 2 and either 3 or 4. See Table 288-3 for further details about using the Confusion Assessment Method and the Confu sion Assessment Method–Intensive Care Unit. 47,48 There are also standardized questions that can be used to formalize the Confusion Assessment Method assessment. One such method is the 3D-Confusion Assessment Method, which is a 3-minute struc tured assessment developed and validated for Confusion Assessment Method–defined delirium, with tasks or questions to test for each of the Confusion Assessment Method criteria. 49,50 Laboratory Testing and Imaging Laboratory testing and imaging are obtained to identify the underlying causes of delirium (Table 288-4) and to direct treatment.46 In geriatric patients, infections, such as urinary tract infections and pneumonia, are associated with nearly 50% of delirium cases, 51 and medications account for another 40%.52-54 Laboratory Testing for Delirium Check point-of-care glucose as soon as possible after the patient arrives in the ED. Other laboratory testing should be directed by the patient’s symptoms and presentation. However, often a broad range of tests may be needed to determine the underlying cause of the delirium. Obtain a CBC and basic metabolic studies and liver function tests. A urinalysis is necessary because urinary tract infections are a frequent cause of delirium. However, the results of the urinalysis should be considered within the clinical context of new symptoms such as fever, dysuria, or new incontinence. It is also important to know that asymptomatic bacteriuria is very common in older adults, with rates of 5% for men and 6% to 10% for women who are community dwelling, and as high as 15% to 35% for men and 25% to 50% for women who are institutionalized. 55 Incidental pyuria is also common, especially in those with chronic incontinence. Obtain cardiac markers and consider a blood gas analysis, especially in patients with chronic lung disease, because hypercarbia can cause delirium. 42 Urine or serum toxicologic studies, a troponin level, and thyroid-stimulating hormone level 56 may be in order. Lumbar puncture may be necessary (after CT scan) if there is suspicion for meningitis or encephalitis or if the patient has had a new-onset seizure. 44 Further studies may be needed depending on the results of history, examination, and basic tests. Imaging/Ancillary Tests ECG and chest radiograph are essential. 57 Head CT scan is advised for patients with signs of, or a history of, trauma, focal neurologic deficits, impaired level of consciousness, or an otherwise unrevealing evaluation. 58,59  TREATMENT Prevention Patients can develop delirium or their delirium can worsen while they are in the ED both because of their underlying dis ease process and because of the unfamiliarity and chaotic nature of the environment.

ic deficits, impaired level of consciousness, or an otherwise unrevealing evaluation. 58,59  TREATMENT Prevention Patients can develop delirium or their delirium can worsen while they are in the ED both because of their underlying dis ease process and because of the unfamiliarity and chaotic nature of the environment. In high-risk patients, such as the very old or those with a history of minor neurocognitive disorder, avoid medications that could be deliriogenic, such as anticholinergics or antihistamines, unless necessary. Titrate pain medications carefully to treat pain but avoid sedation. In addition, try to ensure the patient has access to fluids, hearing aids, and glasses whenever possible. Allow family or caregivers to stay at the bedside, provide frequent reorientation about surroundings and course of care, and make sure there is access to a bathroom. 60 The Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients study identified six risk factors for the development of delirium and targeted each risk factor with specific interventions carried out by a multidisciplinary team. The risk factors included cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. 60 Precipitating factors in the development of delirium in the hospital include the use of physical restraints, malnutrition, use of a bladder catheter, more than three medications added, and any iat rogenic event. 61 Preventing and minimizing these factors are especially important when long ED stays are unavoidable. Medical Treatment Treatment should be directed toward the under lying cause of delirium. Withhold or remove medications that may be responsible for the delirium. Treat infection, provide IV fluids for dehydration, correct hypoglycemia and other metabolic derangements, and treat pain. Agitation If the patient is agitated, begin with a nonpharmacologic approach by addressing patient needs (such as using the restroom and, if possible, allowing the patient to eat or drink), providing comfortable surroundings, and having the family close by. 60,62 Avoid bladder catheters unless unavoidable. If these basic interventions and the preventive measures above are not successful, consider medication (Figure 288-2). We recommend the avoidance of benzodiazepines in the elderly if at all possible, unless alcohol withdrawal is the cause of delirium. Benzodiazepines can cause paradoxical disinhibition and increased agitation in the elderly. If a benzodiazepine is used, consider a shortacting agent such as lorazepam to minimize prolonged benzodiazepine effects. Avoid antihistamines, because this drug class has strong anti cholinergic effects and can induce or worsen delirium in the elderly. Physical restraints should be an absolute last resort when patient or staff safety is in jeopardy. When it comes to psychiatric medications for acutely agitated older patients, the adage “start low and go slow” is particularly apt.  DISPOSITION AND FOLLOW-UP The vast majority of patients with delirium should be hospitalized. Cri teria for possible discharge include the following: the source of delirium Feature 1: Acute onset of mental status changes or a fluctuating course Feature 2: Inattention Feature 4: Altered level of consciousness OR++ Feature 3: Disorganized thinking FIGURE 288-1. Confusion Assessment Method (CAM). To make a diagnosis of delirium, the patient must have features 1 and 2 and either 3 or 4. TABLE 288-2 Mental Status Examination Appearance, behavior, and attitude •  Is  dress appropriate? •  Is  motor behavior at rest appropriate? •  Is  the speech pattern normal? Disorders of thought •  Are  the thoughts logical and realistic? •  Are  false beliefs or delusions present?

features 1 and 2 and either 3 or 4. TABLE 288-2 Mental Status Examination Appearance, behavior, and attitude •  Is  dress appropriate? •  Is  motor behavior at rest appropriate? •  Is  the speech pattern normal? Disorders of thought •  Are  the thoughts logical and realistic? •  Are  false beliefs or delusions present? •  Are  suicidal or homicidal thoughts present? Disorders of perception •  Are  hallucinations present? Mood and affect •  What  is the prevailing mood? •  Is  the emotional content appropriate for the setting? Insight and judgment •  Does  the patient understand the circumstances surrounding the visit? Sensorium and intelligence •  Is  the level of consciousness normal? •  Is  cognition or intellectual functioning impaired? Tintinalli_Sec24_p1933-1966.indd 1942 8/2/19 5:19 PM

he emotional content appropriate for the setting? Insight and judgment •  Does  the patient understand the circumstances surrounding the visit? Sensorium and intelligence •  Is  the level of consciousness normal? •  Is  cognition or intellectual functioning impaired? Tintinalli_Sec24_p1933-1966.indd 1942 8/2/19 5:19 PM CHAPTER 288:  Mental Health Disor ders of the Elderly      1943 has been identified and treated; the patient has returned to baseline function and mentation in the ED; the patient can be cared for after discharge by a capable individual or a responsible facility; and the patient has access to follow-up in 24 hours or has the ability to return immedi ately to the ED if the condition deteriorates. Patients with unrecognized delirium who are discharged home are less able to understand discharge instructions and less likely to seek further treatment, underscoring the importance of screening for delirium in geriatric patients. DEMENTIA (MAJOR NEUROCOGNITIVE DISORDER) In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders published in 2013, dementia was retermed major neurocognitive disorder, and the criteria for diagnosis were modified.2 The diagnosis now requires significant decline in cognitive function in one or more of the following cognitive domains: learning and memory, language, executive function, complex attention, perceptual-motor, and social cognition. The diagnosis cannot be made in the setting of delirium, and deficits should be severe enough that they interfere with the ability to live independently and perform all activities of daily living or independent activities of daily living. In addition, the cognitive deficits should not be attributable to other mental disorders such as major depressive disorder or schizophrenia. The most common type of dementia (major cognitive disorder) is Alzheimer’s disease, which affects approximately 5 million people in the United States. 65 Alzheimer’s disease is reported in 6% to 8% of those over 65 years old and in ≥30% of those over 85 years old. 66 Some other common types are vascular dementia, Lewy body dementia, frontotemporal dementia, dementia associated with Parkinson’s disease, and mixed dementia. TABLE 288-3 Confusion Assessment Method and Confusion Assessment Method (CAM)–Intensive Care Unit * Confusion Assessment Method Confusion Assessment Method–Intensive Care Unit Version Feature 1. Acute Onset or Fluctuating Course Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase or decrease in severity? Sources: Family or nurse Is there evidence of an acute change in mental status from the baseline? Did the (abnormal) behavior fluctuate during the past 24 h, that is, tend to come and go or increase and decrease in severity? Sources of information: Serial Glasgow Coma Scale or sedation score ratings over 24 h, as well as readily available input from the patient’s bedside critical care nurse or family Feature 2. Inattention Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? Did the patient have difficulty focusing attention? Is there a reduced ability to maintain and shift attention? Sources of information: Attention screening examinations by using either picture recognition or Vigilance A random letter test. Neither of these tests requires verbal response, and thus they are ideally suited for mechanically ventilated patients. Feature 3. Disorganized Thinking Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

ts requires verbal response, and thus they are ideally suited for mechanically ventilated patients. Feature 3. Disorganized Thinking Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Was the patient able to follow questions and commands throughout the assessment? “Are you having any unclear thinking?” “Hold up this many fingers.” (Examiner holds two fingers in front of the patient) “Now, do the same thing with the other hand.” (Not repeating the number of fingers) Feature 4. Altered Level of Consciousness Is the patient’s mental status anything other than alert, for example, vigilant, lethargic, stuporous, or comatose? Any level of consciousness other than “alert.” Alert—normal, spontaneously fully aware of environment and interacts appropriately Vigilant—hyperalert Lethargic—drowsy but easily aroused, unaware of some elements in the environment, or not spontaneously interacting appropriately with the interviewer; becomes fully aware and appropriately interactive when prodded minimally Stupor—difficult to arouse, unaware of some or all elements in the environment, or not spontaneously interacting with the interviewer; becomes incompletely aware and inappropriately interactive when prodded strongly Coma—unarousable, unaware of all elements in the environment, with no spontaneous interaction or awareness of the interviewer, so that the interview is difficult or impossible even with maximal prodding *To diagnose delirium, the patient must have features 1 and 2 and either 3 or 4. TABLE 288-4 DELIRIUM: Mnemonic for Reversible Causes of Delirium Drugs Any new additions, increased dosages, or interactions Consider over-the-counter drugs and alcohol Consider high-risk drugs* Electrolyte disturbances Dehydration, sodium imbalance, thyroid abnormalities Lack of drugs Withdrawals from chronically used sedatives, including alcohol and sleeping pills Poorly controlled pain (lack of analgesia) Infection Especially urinary and respiratory tract infections Reduced sensory input Poor vision, poor hearing Intracranial Infection, hemorrhage, stroke, tumor Rare; consider only if new focal neurologic findings, suggestive history, or diagnostic evaluation otherwise negative Urinary, fecal Urinary retention: “cystocerebral syndrome” Fecal impaction Myocardial, pulmonary Myocardial infarction, arrhythmia, exacerbation of heart failure, exacerbation of chronic obstructive pulmonary disease, hypoxia *High-risk drugs: anticholinergics, anticonvulsants, antidepressants, antihistamines, antiparkinsonian agents, antipsychotics, barbiturates, benzodiazepines, H2-blocking agents, zolpidem, opioid analgesics. Reproduced with permission from Marcantonio ER: Delirium. In: Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine , 7th ed. New York, NY: American Geriatrics Society; 2010:297. Tintinalli_Sec24_p1933-1966.indd 1943 8/2/19 5:19 PM

blocking agents, zolpidem, opioid analgesics. Reproduced with permission from Marcantonio ER: Delirium. In: Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine , 7th ed. New York, NY: American Geriatrics Society; 2010:297. Tintinalli_Sec24_p1933-1966.indd 1943 8/2/19 5:19 PM 1944 SECTION 24: Psychosocial Disorders  PATHOPHYSIOLOGY Alzheimer’s disease has a gradual onset and primarily affects memory. The disease can also result in personality changes and visual-spatial problems. 65 Vascular dementia characteristically has a sudden or stepwise onset, and symptoms typically correlate with the affected area of brain ischemia. 65 Lewy body dementia has a gradual onset of memory deficits, and patients will also frequently have hallucinations and parkinsonianlike features. 65 Patients with Lewy body dementia do very poorly when given typical antipsychotics, so avoid them in these patients.67,68 Patients with Lewy body dementia also frequently resemble patients with delirium. They can have a rapid decline, fluctuating course, and perceptual disturbances. 43 Frontotemporal dementia often presents in patients less than 60 years old and is associated with disinhibition, apathy, language difficulties, and atrophy in the frontal and temporal lobes.  CLINICAL FEATURES The main long-term pharmacologic therapy for patients with dementia is cholinesterase inhibitors such as donepezil. The side effects of these medications may prompt an ED visit and include GI upset, anorexia, urinary incontinence, bradycardia, dizziness, and abdominal cramps. Behavioral disturbances are frequently encountered in patients with dementia and are common reasons for ED presentation, especially when caregivers are feeling overwhelmed. The first steps are to screen for delirium and to identify the presence of a comorbid medical dis order (see earlier discussion and Tables 288-1, 288-3, and 288-4, and Figure 288-1). Subsequent management strategies for agitation are listed in Figure 288-2. Mental Status Examination Perform a mental status exam on all geriatric patients because patients with dementia can often appear intact if a formal evaluation is not performed. In the ED, short screen ing tests such as the Mini-Cog, which takes 3 minutes to complete, can be used efficiently. The Mini-Cog ( Figure 288-3) combines a threeword recall with a clock drawing test. 69 Ask patients to remember three words (e.g., apple, table, penny). Then ask them to immediately repeat the words and remember them. Three minutes later, ask for the three words again. If patients can recall all three words, they do not need to complete the clock drawing test and do not have signs of cognitive impairment. If patients are not able to recall any of the words, they may have cognitive impairment, and the clock drawing test is not needed. If patients recall one or two words, they will need to perform the clock drawing test. Ask the patient to draw a specific time, indicating hour and minute. The test is graded as either normal (negative for cognitive impairment) or abnormal (positive for cognitive impairment). 69 Alternatively, while waiting the 3 minutes to test the patient’s recall, ask the patient to draw the clock, as valuable information can be obtained from that exercise alone.

ating hour and minute. The test is graded as either normal (negative for cognitive impairment) or abnormal (positive for cognitive impairment). 69 Alternatively, while waiting the 3 minutes to test the patient’s recall, ask the patient to draw the clock, as valuable information can be obtained from that exercise alone. Preferred pharmacotherapy Risperidone (Risperdal®) ≤1 milligram PO Olanzapine (Zyprexa®) 2.5–5 milligrams PO/IM (NO BZDs with IM) Quetiapine (Seroquel®) ≤50 milligrams PO Haloperidol (Haldol®) 1–2.5 milligrams PO/IM Lorazepam (Ativan®) 0.5–1 milligram (PO, IM, IV) Oxazepam (Serax®) 10 milligrams PO Temazepam (Restoril®) 7.5 milligrams PO Alternative pharmacotherapy (Higher risk of QTc prolongation) Ziprasidone (Geodon®) 10–20 milligrams IM Haloperidol (Haldol®) 0.25–1 milligram IV Reorientation Modify environment Attend to basic needs Treat pain Consider nonpharmacologic treatment first Consider delirium and possible causes Avoid physical restraints Treatment Stage 1 Use oral route if possible Use lowest effective dose and repeat if needed (60 min) Benzodiazepines within 1–2 hours of IM olanzapine are contraindicated Cardiac history required with ziprasidone Treatment Stage 2 Benzodiazepines are linked with causing or worsening delirium Avoid benzodiazepines unless otherwise indicated (seizures, withdrawal, catatonia) Choose agents with lower risk of accumulation Treatment Stage 3 FIGURE 288-2. Acute agitation in the elderly: dosing considerations. BZDs = benzodiazepines. Mini-Cog Recall all 3 Recall 1–2 Recall none Clock normal Clock abnormal Demented Not demented FIGURE 288-3. Mini-Cog Screening Test. Scoring is as follows: 1 point for each word recalled and clock drawing test is rated as either normal or abnormal. If the patient scores a 0 in word recall or can recall one or two words but has an abnormal clock drawing test, this is consistent with cognitive impairment. Tintinalli_Sec24_p1933-1966.indd 1944 8/2/19 5:19 PM

g is as follows: 1 point for each word recalled and clock drawing test is rated as either normal or abnormal. If the patient scores a 0 in word recall or can recall one or two words but has an abnormal clock drawing test, this is consistent with cognitive impairment. Tintinalli_Sec24_p1933-1966.indd 1944 8/2/19 5:19 PM CHAPTER 288:  Mental Health Disor ders of the Elderly      1945 MENTAL HEALTH DISORDERS As the population of older adults continues to increase, so will the number of geriatric patients with mental health disorders. One estimate predicts that the number of geriatric patients with mental illness will increase by 275% from 4 million in 1970 to 15 million in 2030. 70 The most common mental health disorders in older adults are major depression and alcohol use disorders. 71 Significant research remains to be done in the field of geriatric psychiatry. The next sections will give a short overview of what is currently known regarding several mental health disorders found in older patients including depression, bipolar disorder, schizophrenia, and eating disorders.  DEPRESSION AND SUICIDE Although the prevalence of major depressive disorder among com munity-dwelling older adults is low (1.4% to 4.4%), the proportion of patients with symptoms of depression below the threshold of major depressive disorder can be quite high, around 8% to 16%. 8,72,73 Older patients with overt or subclinical depression can both benefit from treatment. Depression in the geriatric population is associated with chronic medical illness, disability, increased use of health services, and poor health outcomes. 8,74,75 Risk factors associated with development of depression in older adults include lack of social support, living alone, being unmarried, cognitive impairment, bereavement, and lower socioeconomic status. 8,75 Depression presents differently in older adults compared to younger age groups. Older adults with depression frequently report loss of appetite and sexual interest, rather than crying spells, sadness, or feelings of failure. 8 They are more likely to be irritable and withdrawn than sad. 76 Older patients may also present with somatic or cognitive complaints when they are actually suffering from depression, which can make the diagnosis difficult. 8 Caregivers and patients themselves may attribute depressive symptoms to normal aging, again making the diagnosis dif ficult.8 Comorbid anxiety is common with depression, and generalized anxiety disorder is frequently seen in the elderly population, with a reported lifetime prevalence of 15% in older adults. There are several screening tests for depression currently available to practitioners. Many are lengthy and would be difficult to use in the ED setting. The Patient Health Questionnaire-2 and Patient Health Questionnaire-9 are two- and nine-item self-administered questionnaires that have been developed to screen for depression based on Diagnostic and Statistical Manual of Mental Disorders , fourth edition, criteria. 78 The Patient Health Questionnaire-9 assesses nine features of depression: anhedonia, depressed mood, trouble sleeping, feeling tired, change in appetite, guilt or worthlessness, trouble concentrat ing, feeling slowed down or restless, and suicidal thoughts. The Patient Health Questionnaire-2 has two questions addressing anhedonia and low mood, and has sensitivity and specificity of 83% and 90%, respec tively. 78 See Table 288-5 for the Patient Health Questionnaire-2. 79 Both questionnaires can easily be located and are comparable to longer scales used to screen for depression with more evidence supporting the use of the Patient Health Questionnaire-9.

mood, and has sensitivity and specificity of 83% and 90%, respec tively. 78 See Table 288-5 for the Patient Health Questionnaire-2. 79 Both questionnaires can easily be located and are comparable to longer scales used to screen for depression with more evidence supporting the use of the Patient Health Questionnaire-9. 80 Several sources recommend starting with the Patient Health Questionnaire-2 and, if positive, then administering the Patient Health Questionnaire-9. Treatment for depression combines both nonpharmacologic and pharmacologic interventions. 8 It is unlikely that new medications will be started in the ED for depression in geriatric patients, but recogniz ing depressive symptoms and ensuring that the patient has appropriate follow-up are important. Review antidepressant doses, side effects, and drug interactions, as ED visits may be precipitated by symptoms from side effects or interactions. Selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors are some of the most fre quently prescribed and effective antidepressants, but they can be associated with serotonin syndrome. Screening for suicide is vital in the assessment of geriatric patients with depression. 81 People over 65 years old have the highest rates of completed suicide of any age group.82 Older adults may give fewer warning signs of suicidal intent, and they are more successful in attempting suicide.83 Depression is the largest risk factor for suicide. Other risk factors include perceived poor health status, poor sleep quality, alcohol abuse, absence of a confi dant, physical illness, functional decline, and presence of a firearm.  SUBSTANCE ABUSE Substance abuse is relatively common in the geriatric population and may increase with the aging baby-boomer cohort. 84 The number of older adults who will need substance abuse treatment is expected to increase from 1.7 million in 2000–2001 to 4.4 million in 2020. 84 Although the vast majority of substance abuse in the elderly is related to alcohol and prescription medications, there are reports of increased illicit drug use as well, highlighting the need to ask all patients about drug use. Alcohol abuse in older adults is the most prevalent substance use problem. In a cross-sectional study of 12,000 older adult primary care patients, 15% of patients were felt to be at risk for, or were affected by, high-risk drinking. 86 Other community surveys estimate the prevalence of highrisk drinking to be between 1% and 15%. 87–89 Physiologic changes from advancing age decrease alcohol tolerance, increasing the risk of complications.90 Current guidelines consider high-risk drinking in older adults to be either more than one standard drink per day or more than three drinks on an occasion. 90 Alcohol-related problems, such as falls, confu sion, and malnutrition, may be misattributed to normal aging, and thus alcohol misuse may be missed. 90 If you identify high-risk drinking, refer the patient to an inpatient or outpatient treatment facility. Also, if the plan is to admit a patient with known alcohol or substance abuse, notify the admitting physician so withdrawal symptoms can be monitored.  BIPOLAR DISORDER Research regarding bipolar disorder in older adults is limited. The prevalence of bipolar disease in older adults is approximately 0.08% to 0.5%.91 Older adults who present with new-onset mania therefore require a complete medical evaluation before a new diagnosis of bipolar disorder is made. While the overall prevalence is very low, one study found that 17% of patients over 60 years old presenting to a psychiatric ED carried a diagnosis of bipolar disorder. 92 There are some differences between younger and older patients with bipolar disorder. Older patients are more likely to be female.

disorder is made. While the overall prevalence is very low, one study found that 17% of patients over 60 years old presenting to a psychiatric ED carried a diagnosis of bipolar disorder. 92 There are some differences between younger and older patients with bipolar disorder. Older patients are more likely to be female. Late-onset bipolar disorder (onset between age 30 and 50 years) is associated with fewer genetic associations and more neurologic illnesses. 93 The frequency of psychotic features is essentially the same in young and old patients with bipolar disorder.93 Patients may present to the ED both for symptoms of bipolar disorder and from adverse effects of the treatments. One of the most common medications used for bipolar disorder is the mood stabilizer lithium. 94,95 Older patients can benefit from lithium even at lower serum levels than younger patients. The renal clearance of lithium decreases with age, increasing the elimination half-life and predisposing to lithium toxicity. 96 Side effects of lithium include tremor, muscle twitches, GI symptoms, and CNS effects such as sedation. 96 Many common medications interact with lithium, including thiazide diuretics, NSAIDs, and TABLE 288-5 Patient Health Questionnaire-2 •   Scores range from 0 to 6. A score of 3 or greater indicates the need for further screening. •   Over the past 2 weeks, how often have you been bothered by any of the following problems? •  Feeling  down, depressed, or hopeless? 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day •  Have  you often been bothered by little interest or pleasure in doing things? 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Tintinalli_Sec24_p1933-1966.indd 1945 8/2/19 5:19 PM