P s y c h i a t r i c Em e r g e n c i e s i n

t h e El d e r l y
Veronica Sikka, MD, PhD, MHA, MPHa,b,*, S. Kalra, MD, MPH
c
,
Galwankar Sagar, DNB, MPH, Diplomat. ABEMa

KEYWORDS
 Geriatric psychiatric emergencies  Elderly  Dementia  Abuse
 Psychiatric emergencies  Depression  Delirium  NPH

KEY POINTS
 Over the last few decades, there has been a constant increase in the number of geriatric
patients visiting the emergency department.
 Besides correct diagnosis, it is important the clinician provide elderly patients with appro-
priate resources for admission or discharge.
 Resources also often extend to the patients’ families, but diagnosis and having a broad
differential diagnosis to identify a potentially serious underlying psychiatric emergency
in the elderly population is the first, vital step.
 Diagnosis and treatment of geriatric patients can be particularly challenging, given the
associated medical comorbidities, polypharmacy, and underlying psychosocial issues
that do not make for a straightforward diagnosis and management.

INTRODUCTION

“I can see the words hanging in front of me and I can’t reach them, and I don’t know who I
am, and I don’t know what I’m going to lose next,” says Alice Howland, the main character
in the 2015 film Still Alice that highlights the reality of progressive Alzheimer disease and
its emergent manifestations. In 2012, the number of people older than 65 years was 43.1
million, composing about 13.7% of the total population. By 2050, the population of Amer-
icans 65 years and older is expected to be nearly 87 million and will compose nearly 21%
of the total population. This number represents a 147% increase in the geriatric age group
compared with a mere 49% increase in the population younger than 65 years.1 Over the
last few decades, there has been a constant increase in the number of geriatric patients

Disclosures: none.
a
Orlando VA Medical Center Emergency Medicine, Richmond, VA, USA; b Emergency Medi-
cine, UCF School of Medicine, Orlando, FL, USA; c Department of Research and Innovation,
St Luke’s University Health Network, Bethlehem, PA, USA
* Corresponding author. 13800 Veterans Way, Orlando, FL 32827.
E-mail address: Veronica.Sikka@va.gov

Emerg Med Clin N Am 33 (2015) 825–839

http://dx.doi.org/10.1016/j.emc.2015.07.009 emed.theclinics.com
0733-8627/15/$ – see front matter Published by Elsevier Inc.
826 Sikka et al

visiting the emergency department (ED). According to the 2011 Centers for Disease Con-
trol and Prevention National Hospital Ambulatory Medical Care Survey, almost 15% of
total ED visits comprised patients 65 years and older.2 Diagnosis and treatment of these
patients can be particularly challenging given the associated medical comorbidities, pol-
ypharmacy, and underlying psychosocial issues that do not make for a straightforward
diagnosis and management. This review article identifies common psychiatric emergen-
cies among the geriatric population and its associated management.

DELIRIUM

According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)
(DSM-IV) criteria, delirium is an acute disturbance of consciousness with decreased
attention, change in cognition, or development of perceptual disturbance that de-
velops over a short period of time with diurnal fluctuations and evidence that the
disturbance is caused by a general medical condition, substance abuse or withdrawal,
or multiple causes. Although delirium is a common psychiatric emergency that affects
an estimated 30% to 50% of hospitalized elderly patients,3 delirium still poses signif-
icant diagnostic challenges with nondetection rates as high as 70%.
The onset of delirium is normally rapid with fluctuations in consciousness. The pa-
tient history is very helpful in ascertaining sudden changes in cognition that are
perhaps related to underlying medical conditions (ie, urinary tract infection [UTI],
recent fall), medication use, and risk of withdrawal from drugs or alcohol. Delirium
can be categorized into 3 subtypes: hyperactive, hypoactive, and mixed.4 Patients
with hyperactive delirium present very hypervigilant, restless, or agitated and can
complain of auditory or visual hallucinations. The hypoactive form of delirium is asso-
ciated with increased lethargy, somnolence, and dulled psychomotor function. This
form of delirium is often overlooked by clinicians and mistaken for depression.5 Finally,
mixed delirium is associated with features of both hyperactive and hypoactive types.
Tools that can be used in the ED include the Confusion Assessment Method (CAM),
which is a short, standardized diagnostic algorithm of delirium and the Memorial
Delirium Assessment (MDA) scale, which can be used to quantify the severity of the
delirium. CAM includes 2 parts. Part 1 is an assessment instrument that screens for
overall cognitive impairment. Part 2 includes only those 4 features that were found
to have the greatest ability to distinguish delirium or reversible confusion from other
types of cognitive impairment. The tool can be administered in less than 5 minutes.
It closely correlates with the DSM-IV criteria for delirium. Boxes 1 and 2 list the
CAM instrument and diagnostic algorithm.
The MDA scale is a 10-item, 4-point, clinician-rated scale that is designed to quan-
tify the severity of delirium. Fig. 1 lists the 10 questions associated with the MDA.
MDA total scores differ significantly between patients with delirium and those with
other cognitive impairment disorders or no cognitive impairment. It is also used for
making the diagnosis of delirium, and a cutoff score of 13 has been shown to be useful
for making the diagnosis of delirium.6 In a fairly robust study that compared assess-
ment scales for delirium, it was found that the CAM is the most useful instrument in
terms of its accuracy, brevity, and ease of use by clinicians and lay interviewers.7
Managing delirium implies identifying and managing the underlying cause. Environ-
mental interventions, such as noise reduction, proper illumination, stimulus modifica-
tion, cueing, and reassurance, are integral parts of delirium treatment.8 If patients’
safety and ability to participate in medical management is compromised, pharmaco-
logic interventions may be required. Most evidence supports the use of low-dose
haloperidol, with higher doses being associated with adverse effects.9
 Psychiatric Emergencies in the Elderly 827

Box 1
CAM instrument

1. Acute onset: Is there evidence of an acute change in mental status from the patient’s
baseline?
2A. Inattention: Did the patient have difficulty focusing attention, for example, being easily
distractible or having difficulty keeping track of what was being said?
2B. If present or abnormal: Did this behavior fluctuate during the interview, that is, tend to
come and go or increase and decrease in severity?
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?
4. Altered level of consciousness: Overall, how would you rate this patient’s level of
consciousness? (Alert [normal]; vigilant [hyperalert, overly sensitive to environmental
stimuli, startled very easily]; lethargic [drowsy, easily aroused]; stupor [difficult to arouse];
coma [unarousable]; uncertain)
5. Disorientation: Was the patient disoriented at any time during the interview, such as
thinking that he or she was somewhere other than the hospital, using the wrong bed,
or misjudging the time of day?
6. Memory impairment: Did the patient demonstrate any memory problems during the
interview, such as inability to remember events in the hospital or difficulty remembering
instructions?
7. Perceptual disturbances: Did the patient have any evidence of perceptual disturbances, for
example, hallucinations, illusions, or misinterpretations (such as thinking something was
moving when it was not)?
8A. Psychomotor agitation: At any time during the interview, did the patient have an
unusually increased level of motor activity, such as restlessness, picking at bedclothes,
tapping fingers, or making frequent sudden changes of position?
8B. Psychomotor retardation: At any time during the interview did the patient have an
unusually decreased level of motor activity, such as sluggishness, staring into space,
staying in one position for a long time, or moving very slowly?
9. Altered sleep-wake cycle: Did the patient have evidence of disturbance of the sleep-wake
cycle, such as excessive daytime sleepiness with insomnia at night?

From Inouye S, van Dyck C, Alessi C, et al. Clarifying confusion: the confusion assessment
method. Ann Intern Med 1990;113(12):941–8. Ó 2003 Sharon K. Inouye, MD, MPH.

DEMENTIA

Dementia is a common neuropsychiatric syndrome associated with progressive

decline in function across multiple cognitive domains. It affects anywhere from 8%
to 10% of people older than 65 years and nearly 50% of those older than 85 years.10
Alzheimer disease is the most common cause of dementia followed by vascular de-
mentia and dementia with Lewy bodies. About 80% of patients with dementia expe-
rience some form of behavioral or psychological symptoms of dementia (BPSD).
These symptoms include agitation and aggression, delusions, hallucinations and mis-
identifications, screaming and repetitive vocalizations, circadian rhythm dysregula-
tion, and wandering.
The first step in evaluating behavioral disturbance in patients with dementia is to
assess for medical, pharmacologic, and environmental variables that may have
precipitated the behavior. Possible causes of BPSD11 are listed in Box 3.
828 Sikka et al

Box 2
The CAM diagnostic algorithm

Feature 1: Acute-onset and fluctuating course

This feature is usually obtained from a family member or nurse and is shown by positive re-
sponses to the following questions: 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 and decrease in severity?

Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the patient have
difficulty focusing attention, for example, being easily distractible or having difficulty keeping
track of what was being said?

Feature 3: Disorganized thinking

This feature is shown by a positive response to the following question: 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?

Feature 4: Altered level of consciousness

This feature is shown by any answer other than alert to the following question:
Overall, how would you rate this patient’s level of consciousness? (alert [normal], vigilant
[hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma
[unarousable]).

The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.
From Inouye S, van Dyck C, Alessi C, et al. Clarifying confusion: the confusion assessment
method. Ann Intern Med 1990;113(12):941–8. Ó 2003 Sharon K. Inouye, MD, MPH.

Diagnosis can be challenging given the fluctuating nature of the symptoms and the
patients’ impeded ability to communicate. Validated and reliable scales, such as the
Behavioral Pathology in Alzheimer disease Rating Scale or the Cohen-Mansfield
Agitation Inventory, provide additional aid in evaluating and tracking behavioral
changes in patients with dementia.12
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.13
There is currently no Food and Drug Administration (FDA)–approved 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 signif-
icantly curtail prescribing practices.14

DEPRESSION

Out of the various psychiatric disorders in the elderly, depression is most common.
However, it is often underdiagnosed and inadequately treated.15,16 The symptoms
 Psychiatric Emergencies in the Elderly 829

Fig. 1. MDA scale. (From Breitbart W, Rosenfeld B, Roth A, et al. The memorial delirium
assessment scale. J Pain Symptom Manage 1997;13(3):128–37; with permission.)

of depression may overlap with various medical disorders. A meta-analysis of 20 pro-

spective studies on depression among elderly subjects indicated that various factors,
such as bereavement, sleep disturbance, disability, prior depression, and female sex,
were associated with an increased risk for depression.17 Unrecognized and untreated
depression is associated with increased morbidity and mortality from coexisting con-
ditions and suicide.18
Depression is the most common risk factor in elderly individuals who commit sui-
cide, reported to be as high as 85%.19 As compared with younger individuals, it has
830 Sikka et al

Fig. 1. (continued).

been observed that a greater proportion of the elderly who attempt suicide are actually
successful.20
In diagnosing depression, it is important to consider the DSM-IV criteria for major
depressive episode as listed here:
 Depressed mood
 Loss of interest
 Anhedonia
 Anorexia
 Insomnia/hypersomnia
 Decreased concentration
 Wishes to die
 Psychiatric Emergencies in the Elderly 831

Fig. 1. (continued).

Box 3
Possible causes of BPSD

Medication side effects: especially anticholinergic, antimuscarinic

Delirium (infection, dehydration, acute medical illness)
Pain linked to chronic or acute medical problems
Frustration caused by progressive memory/cognitive failure
Physical needs (hunger, need for toileting)
Emotional needs (separation from family)
Environmental overstimulation (noise, overcrowding, understimulation)
Rigid caregiving

From Piechniczek-buczek J. Psychiatric emergencies in the elderly. Psychiatr Times 2010. Avail-
able at: http://www.psychiatrictimes.com/special-reports/psychiatric-emergencies-elderly/
page/0/1.
832 Sikka et al

 Fatigue
 Psychomotor agitation
 Worthlessness/guilt
Antidepressants are considered safe and effective in targeting depressive symp-
toms. In elderly patients, selective serotonin reuptake inhibitors (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.19
Psychotherapeutic interventions that enhance adherence to treatment, provide ed-
ucation, increase self-esteem, strengthen social supports, and diminish hopelessness
are clinically recommended.21 Studies also support the effectiveness of electrocon-
vulsive therapy for treatment of geriatric depression22; but adverse effects, such as
cardiac complications, cognitive decline, or delirium, limit its use in some patients.

SUICIDE

Among all the age groups, elderly people have the highest risk of death caused by suicide.
The risk is much higher among elderly people older than 85 years, whereby the suicide
rate has been reported to be higher than 18 per 100,000 individuals.23 It has been
observed that elderly people use more violent methods for attempting suicide, such as
shooting with handgun, jumping, and hanging.24–26 The elderly plan their suicidal act
over a period of time compared with younger individuals who often committed it impul-
sively. As compared with the younger individuals, it has been observed that, in the elderly
population, a greater proportion of attempted suicides culminate in a fatal outcome.20
Elderly persons with underlying psychiatric illness are at a high risk of attempting sui-
cide. In most of these cases, affective illness has been found to be the primary under-
lying psychiatric illness in 54% to 87% of cases.27 A history of substance abuse,
particularly alcohol dependence is commonly associated with a risk of completed sui-
cide. Elderly persons with multiple comorbid conditions are at a higher suicide risk. In a
study of 1354 elderly patients who died of suicide, various associated chronic medical
illnesses were commonly present. Inability to cope up with various stressful life events,
which accompany later life, such as bereavement, financial stressor due to retirement,
lack of social support and physical disability, are associated with increased suicidal ten-
dencies.28 Pathways of certain biomarkers such as serotonin, nor-adrenaline and
neuro-hormones have been associated with higher suicidal tendencies.29 Personality
traits, such as hopelessness, seclusiveness, hostility, timidity, and a rigid lifestyle,
have been noted to be associated with suicidal tendencies in the geriatric population.
Nearly 90% of elderly suicide cases have an underlying major psychiatric illness.28
Conwell and colleagues30 reported that more than 70% of the elderly suicide victims
had visited their primary care physician within a month before attempting suicide. Of
these, nearly a third were seen within a week before the act of suicide.
These findings indicate that detailed evaluation of elderly patients can identify those
who are at a higher risk of suicide. All patients must undergo a detailed physical and
psychological evaluation. In patients with a high risk of suicide, hospitalization should
be advised, as it would also help in exploring the underlying cause of suicidal ideation
and any coexisting chronic illnesses and their management. In patients with severe
depression, it is imperative to start treatment.

ALCOHOL DEPENDENCE AND SUBSTANCE ABUSE

Alcohol dependence and substance abuse are common problems in the elderly and
are frequently overlooked by the ED staff. The prevalence of alcohol dependence in
 Psychiatric Emergencies in the Elderly 833

the elderly ranges from 0.6% to 3.7%, and the incidence of heavy drinking (between
12–21 drinks per week) is from 3% to 9%.31 Although the use of alcohol declines in
older age groups, the rates of heavy drinking among elderly persons are much higher
as compared with a younger individual. Most elderly individuals with alcoholism are
early onset drinkers. On the other hand, a few are late-onset drinkers, who develop
problem drinking after a traumatic life event.32,33 Nearly 0% of elderly men and 10%
of elderly women have been reported to have a problem drinking level.34 Because
of impaired metabolism and a decrease in the volume of distribution, alcohol intoxica-
tion may occur with a smaller dose of alcohol and withdrawal symptoms may be more
pronounced.35 Factors associated with an increased risk of alcohol abuse in the
elderly include social isolation, history of alcohol abuse in the past, and higher educa-
tional qualification.36 In addition, alcohol may interact with various drugs being pre-
scribed for other medical conditions commonly present in the elderly, resulting in
adverse effects.
Common presenting symptoms of geriatric alcohol and substance abusers in the
ED are dementia, delirium, gait disturbances, hypoglycemia, dehydration, hypother-
mia, Korsakoff psychosis, head and pelvic trauma. All elderly people presenting in
ED should be screened for evidence of alcohol and substance abuse. Usually, older
people do not volunteer information about alcohol abuse. Various quick screening
tools, such as the CAGE (cut down, annoyed, guilty, eye opener) questionnaire and
Short Michigan Alcohol Screening Test–Geriatric Version, are available, which may
be used.37

POLYPHARMACY

Elderly patients are the highest patient population at risk for polypharmacy, with nearly
100,000 patients being admitted annually through the ED for adverse drug events.38,39
On average, geriatric patients in the ED receive 4.2 medications per day, with 91%
receiving at least one and 13% receiving 8 or more drugs.40 Given these staggering
numbers, it is not hard to believe that nearly 11% of ED visits in patients older than
65 years are caused by adverse drug reactions compared with only 4% in the general
population. This finding is primarily related to the fact that the elderly have impaired
rates of drug metabolism and excretion, which result in adverse clinical outcomes.41
Various antipsychotic drugs may be associated with adverse effects, such as tar-
dive dyskinesia, akathisia, and parkinsonism. Rarely, the use of haloperidol may result
in life-threatening complications, such as neuroleptic malignant syndrome (NMS),
which may present with hyperthermia, dysautonomia, muscular rigidity, cardiac ar-
rhythmias, and renal failure.42 It is often difficult to differentiate NMS from serotonin
syndrome, which is caused by toxicity caused by SSRIs. Table 1 differentiates
NMS from serotonin syndrome.

Table 1
Serotonin syndrome versus NMS

Serotonin Syndrome NMS

Onset Abrupt Gradual
Course Rapidly resolving Prolonged
Clinical findings Myoclonus & tremor Diffuse rigidity
Reflexes Increased Decreased
Pupils Mydriasis Normal
834 Sikka et al

Furthermore, sudden cessation of SSRIs may result in serotonin discontinuation

syndrome, which is associated with insomnia, dizziness, and agitation.43
Various tricyclic antidepressants should be used carefully in the elderly because
they may result in conduction abnormalities and cardiac dysfunction, especially in pa-
tients with underlying coronary artery disease. Lithium is commonly used in patients
with affective disorders, such as bipolar mania and depression. It has a narrow ther-
apeutic margin, and older patients are at a greater risk for developing lithium toxicity.
Use of concomitant medications, such as nonsteroidal antiinflammatory drugs, furo-
semide, and lisinopril, may precipitate lithium toxicity resulting in drowsiness, ataxia,
and respiratory failure, leading to a fatal outcome. Salt restriction and dehydration may
aggravate drug toxicity; hence, adequate replenishment of fluids and electrolytes is
crucial for managing these patients in the ED. In severe cases, lithium can be removed
from the body by emergency hemodialysis.
Benzodiazepines are frequently prescribed among geriatric patients for sleep and
anxiety disorders. Prolonged use of benzodiazepines may result in fatigue, somno-
lence, and gait disturbances, thereby predisposing them to injuries secondary to an
increased fall risk. In severe cases, hallucinations, dementia, drug dependence,
aggression, and respiratory depression may occur. In cases with acute toxicity caused
by benzodiazepines, flumazenil can be effectively used for reversal of symptoms.

ELDER ABUSE AND NEGLECT

Elder abuse and neglect are being recognized as an emerging area of concern for health
care providers across various specialties. There are several definitions for describing
elder abuse. However, the key components involve an intentional or neglectful act by
the caregiver or trusted person, which may result in harm or threaten the well-being
of older persons.44,45 This abuse may take various forms, such as physical abuse, psy-
chological abuse, caregiver neglect, sexual abuse, and financial exploitation.46,47
Nearly 10.0% of older adults and 5.6% of older couples experience some form of abuse
or neglect every year, and there is an increasing trend in its incidence.48–52
Various factors that increase the risk for elder abuse may be associated with the elder
person, perpetrator, relationships, and environment. In a systematic review of 49 studies,
various risk factors for elder abuse were identified and are summarized in Table 2.
The pattern of injuries may point toward elder abuse as the underlying etiologic fac-
tor. A study on the elderly people presenting in the ED revealed that victims of severe
traumatic elder abuse were more likely to have penetrating injuries.53 The most

Table 2
Risk factors for elder abuse

Elderly Perpetrator Relationship Environment

Cognitive impairment Caregiver burden or stress Familial discordance Poor social
Behavioral problems Psychiatric illness Conflict support
Psychiatric illness
Functional dependency
Poor physical health
Frailty
Low income
Trauma or past abuse
Ethnicity

Data from Friedman LS, Avila S, Tanouye K, et al. A case-control study of severe physical abuse of
older adults. J Am Geriatr Soc 2011;59:417–22.
 Psychiatric Emergencies in the Elderly 835

common types were open wounds (56%), internal injuries (24%), and fractures (22%).
They were more likely to suffer injuries to the head and trunk. Another study assessing
the use of ED by victims of elder abuse found that 15.4% of the visits had physical in-
juries as their presenting complaint.54
The Joint Commission has mandated hospitals for written criteria for identifying all
victims of violence, including elder abuse.55 Suspicion of elder abuse may be made in
elderly persons who present with multiple injuries, poor general hygiene, malnutrition,
and nonadherence to medical care. Eliciting evidence of elder abuse or mistreatment
may be difficult on account of several reasons. The elderly may try to misinform the
health care provider on account of fear of being ostracized by the caregiver or being
placed in a nursing facility. The elderly should be interviewed in the absence of the
caregiver; if the need arises, they should be referred to Adult Protective Services.

Fig. 2. Work-up of altered mental status in the ED. AMS, altered mental status; CBC, com-
plete blood count; EEG, electroencephalogram; IV, intravenous. (From Xiao H, Wang Y,
Xu T, et al. Evaluation and treatment of altered mental status in the emergency department:
Life in the fast lane. World J Emerg Med 2012;3(4):270–7; with permission.)
836 Sikka et al

Table 3
Differential diagnosis of delirium

Delirium Dementia Depression Psychotic Illness

Onset Acute Gradual Variable Variable
Course Fluctuating Progressive Recurrent Chronic
Consciousness Altered Normal Normal Normal
Attention Impaired Normal until late May be impaired May be impaired
Orientation Fluctuating Impaired Normal Normal
Hallucinations Common Rare until late Rare Common
Duration Hours–months Months–years Weeks–months Months–years

From Piechniczek-Buczek J. Psychiatric emergencies in the elderly. Psychiatr Times 2010. Available
at: http://www.psychiatrictimes.com/special-reports/psychiatric-emergencies-elderly/page/0/1.

ALTERED MENTAL STATUS

This article would be remiss if it did not include the fact that elderly patients can pre-
sent to the ED seeming depressed or altered but not for an underlying psychiatric
cause. It can be purely related to a medical cause, such as a UTI, sepsis, cerebral
hemorrhage, meningitis, or abnormal electrolytes. Fig. 2 is a concise flow chart on
the work-up of the altered mental status in the ED.

SUMMARY

The diagnosis of psychiatric emergencies in the elderly population who presents to the
ED is complex and often multifactorial. It is very important the ED clinician differentiate
delirium from depression, dementia, and primary psychoses. Table 3 lists the key dif-
ferential characteristics.3,56
Besides correct diagnosis, it is important that the clinician provide elderly patients
with appropriate resources for admission or discharge. Often these resources extend
to the patients’ family as well; but diagnosis and having a broad differential diagnosis
to identify a potentially serious underlying psychiatric emergency in the elderly popu-
lation is the first, vital step.

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