The Geriatric Psychiatry Patient

in the Emergency Department

Stephen M. Scheinthal, D.O., FACNAssociate Professor, Psychiatry

New Jersey Institute for Successful Aging

UMDNJ-School of Osteopathic Medicine

Stratford, NJ

The Geriatric Psychiatry Patient in the Emergency Department

This Care of the Aging Medical Patient in the Emergency Room (CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the

New Jersey Institute for Successful Aging.This lecture series is supported by an educational

grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

Learning Objectives

• To list risk factors for suicide in the elderly

• To recognize the behaviors and symptoms that indicate possible substance abuse

• To demonstrate best practices for proper rapid tranquilization of the agitated geriatric patient in the emergency department

• To outline the criteria for voluntary and involuntary commitment

Pre-Test Question 1

A 78 year old male tells you he just has no energy. His wife died six months ago. His family reports that he is not eating and stays in bed all the time . He says, “It is an effort to do anything. Of course I miss my wife. I wish I were with her.” When asked if he eats, he states, “I eat enough. I don’t like what my daughters make for me. I order in food.” When asked about his children, he replies, “We were never close. I think they feel guilty because their mother is gone.” When asked if he is depressed, the patient replies, “No, I’m not depressed. I’m lonely.”

Medical workup is unremarkable.

Pretest Question 1

Which of the following risk factors should raise your concern about this patient’s safety?

A. Poor dietB. Poor relationship with childrenC. Death wishD. No medical careE. Loss of wife

Pretest Question 2A 72 year old female presents to the ED very confused and rambling. Her husband brought her to the emergency department. He reports that everything was fine: “We were having a great time at a party, laughing, drinking, having a good time. Then, all of a sudden, she started seeing bugs crawling all over the room. She quickly became very paranoid. I’ve never seen her like this before.”

No prior psychiatric history and no family psychiatric history.

Past Medical History – Hyperlipidemia., Hypertension

Case description continues…

Pretest Question 2Upon examination, patient has a heart rate of 120, BP 160/90. Her oral mucosa is dry, her conjunctiva are injected. Patient is very disorganized and paranoid. She states the devil is chasing her.Labs – CBC, BMP, UA – WNLCXR – NegCT of head – NegBAL - 170

Pretest Question 2

What is the most likely diagnosis?

A. Alcohol intoxicationB. StrokeC. Cannabis/Formaldehyde

intoxicationD. Brief Reactive PsychosisE. Schizophrenia

Pretest Question 3

A 80 year old female presents to the ED via local EMS. Neighbors called the police because the patient was reported to be throwing furniture off the balcony on the 10th floor. The patient is very labile and thrashing about, shouting obscenities, and swinging at the nursing staff. When the gurney straps are released, she lunges wildly at staff and other patients.

Patient has never been to your hospital before. Family cannot be located.

Pretest Question 3

Your best course of action for the safety of this patient and your staff is:

A. Haloperidol 5 mg IVB. Hydroxyzine 50mg IMC. Risperidone 37.5mg IMD. Lorazepam 2 mg IME. Haloperidol 2 mg IM

Stigma

• GOMER• THE WALL

– Samuel Shem, House of God

Edvard Munch. The Scream. 1893. The National Gallery, Oslo.

Anatomy of Mental Illness

• Age• Presentatio

n• DSM-IV TR

ABPI 2003 www.abpi.org.uk

Psychiatric Diagnosis

• Axis – 1 Major Mental Illness• Axis – 2 Personality Disorder/Mental

Retardation• Axis – 3 General Medical Condition• Axis – 4 Psychosocial/

Environmental• Axis – 5 Global Assessment of

Functioning

DSM IV - TR

A. SymptomsB. Excludes other mental health DXC. Symptoms Cause DysfunctionD. Exclude Medical Illness or

Substance Use

Age/Gender

• Schizophrenia 18-35, 65-75

• Bipolar Disorder 20-30 (men = women)

• Major Depression (women > men)

• Anxiety Disorder (women > men)

• Dementia 50% of people > 80

• Delirium caused by underlying medical illness

What is the most common psychiatric disorder in the

elderly?A. DementiaB. AnxietyC. DepressionD. Substance Use (Alcohol

Abuse/Dependence)E. Delirium

Depression

• Most common psychiatric disorder in the elderly–5% in community meet criteria for

Major Depression–8 – 16% have a sub-syndromal

depression• Four times more likely to die• More frequent ED visits• Longer lengths of hospital staysPark M, Unutzer J. Psychiatri Clin North Am 2011;34(2):469 – 487.

DSM-IV-TR Diagnostic Criteria for Depression

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.Note: Do not include symptoms that are clearly due to a general medical condition, or mood-

incongruent delusions or hallucinations.

1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

DSM-IV-TR Diagnostic Criteria for Depression

A. Cont’d4) insomnia or hypersomnia nearly every day.5) psychomotor agitation or retardation nearly every day

(observable by others, not merely subjective feelings of restlessness or being slowed down).

6) fatigue or loss of energy nearly every day.7) feelings of worthlessness or excessive or inappropriate guilt

(which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

DSM-IV-TR Diagnostic Criteria for Depression

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

Depression

• Risk Factors:–Medical Illness–Functional Disability –Social Isolation–Life Stressors–Losses

Park M, Unutzer J. Psychiatri Clin North Am 2011;34(2):469 – 487.

Photo: Microsoft Office Images #MP900442315 by Fotolia (http://office.microsoft.com/en-us/images/)

Depression

• Failure to detect depression:–Overuse of medical services–Frequent referrals to specialists–Frequent ED visits– Increased medication usage

Park M, Unutzer J. Psychiatri Clin North Am 2011;34(2):469 – 487.

What age group is at the highest risk for completing

suicide?

A. 12-20 year oldsB. 25-35 year oldsC. 40-50 year oldsD. 60-70 year oldsE. 80-90 year olds

Case• 78 year old male• Concentration Camp Survivor• Retired Nuclear Physicist • Wife died 6 months ago• Hopeless, Helpless• Withdrawn• Not Eating• “Life not worth living.”

Mental Health Crisis

• 85+ highest risk for suicide• 60% see the doctor 1 month prior to

suicide• Lethal means• More physical burden/less resilience• 11th leading cause of death

Suicide Risk

• Older white male• Single• No close family or friends• Multiple medical problems• Alcohol usage (3-44% of elderly

suicides)• Usually was powerful at work

Suicide Rates

Conwell Y, Van Orden K, Caine E. Psychiatri Clin North Am 2011;34(2):451–469.

Suicide• Questions to Ask:

– Prior suicide attempts– Past/Current history of depression– Psychosis or mania– Substance use– Impulse control issues– Social support– Recent stressful life events

Loss of friends Loss of spouse/partner Loss of pets

Who uses/abuses alcohol more?

A. MenB. Women

Who abuses prescription medication more?

A. MenB. Women

Substance Use

• Use in past 30 days men and women > 60 years– Alcohol

52% - men 50% - women

– Cannabis 12.3% - men 4.2% - women

Satre D, Sterling S, Mackin RS, Weisner C. Am J Geriatr Psychiatry 2011;19(8):695-703.

Substance Use• Use in past year men and women

>60 years old– Opioids

8.8 % - men 1.0 % - women

– Amphetamines 5.3 % - men 2.1% - women

– Sedatives 21.1% - men 17.7 % - womenSatre D, Sterling S, Mackin RS, Weisner C. Am J Geriatr Psychiatry 2011;19(8):695-703.

Substance Use• Alcohol Abuse

– Failure to fulfill obligations– Drinking in hazardous situations– Social/occupational problems

• Alcohol Dependence– Tolerance– Withdrawal– Lack of control– Unsuccessful efforts to quit

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

Substance Use

• Physiology– Volume distribution of substances

decreases Increased body fat Decreased lean body mass Decreased total body water Decreased alcohol dehydrogenase

Substance Use

• Atypical Presentation– Falls– Sleep Problems– Confusion– Irritability

• Stereotyping– Less likely to think substance use in

elderly

Wilber ST. Emerg Med Clin N Am 2006;24:219-316.

Photo Credit: Corbis

Substance Use• Screening Tools• CAGE

CutbackAnnoyedGuiltyEye Opener– Caution

Elderly may not feel guilty Elderly may not need eye openers

Satre D, Sterling S, Mackin RS, Weisner C. Am J Geriatr Psychiatry 2011;19(8):695-703.

Substance Use

• Michigan Alcohol Screening Test-Geriatric MAST – G– Developed in ‘91 at University of

Michigan– Designed for the older adult user

• Short Michigan Alcohol Screening TestSMAST

13 Item test to assess longitudinal alcohol useSatre D, Sterling S, Mackin RS, Weisner C. Patterns of alcohol and drug use among depressed

older adults seeking outpatient psychiatric services. Am J Geriatr Psychiatry 2011;19(8):695-703.

When a geriatric patient presents as psychotic, what is the most likely

diagnosis?A. SchizophreniaB. Brief Psychotic DisorderC. Substance intoxicationD. DementiaE. Psychosis due to general medical

condition

Psychosis• 16-23% of elderly had a medically

based psychosis• Risks

– Dementia– Hearing loss– Visual loss– Social isolation– Substance use– Multiple medication usage

Wilber ST. Emerg Med Clin N Am 2006;24:219-316.

Psychosis

• Thorough workup is critical• Careful evaluation of all medications• Past psychiatric history• Detailed substance history

Psychosis

• Early onset– Underlying psychiatric illness– Substance Use/Abuse

• Late onset– With or Without Dementia– Delirium– Due to General Medical Condition

Wilber ST. Emerg Med Clin N Am 2006;24:219-316.

What is your favorite agent to calm an agitated older

adult?A. ThorazineB. KetamineC. HaldolD. AtivanE. Abilify

Agitation

• Medication should be the first choice to prevent harm in aggression or severe agitation

• Provide a quiet room: ED environment can escalate behavior

• Educate families/caregivers• In severe anticholinergic delirium,

physostigmine can be effective

Thorazine = How much Haldol?

A. 1:1B. 10:1C. 50:1D. 100:1E. 200:1

Image: Smith Kline & French Laboratories

Agitation

• Haldol PO/IM– 0.5 to 1 mg Q 1 hour until sedation is

achieved– Rate of medication onset:

PO 1.5 hours IM/IV 45 minutes

Anon. Am J Psych 1999;156(5 Suppl):1-20.

Agitation

• Haldol IV– NOT FDA APPROVED– 10 mg bolus followed by 5-10 mg/ hour– Patient must be monitored– Risk of Torsade des pointes– Rate of onset

45 min

Anon. Am J Psych 1999;156(5 Suppl):1-20.

Agitation

• Atypical Antipsychotics– Risperidone oral is well studied

0.5 mg every 2 to 4 hours to max 2 mg/24 hours

– Data does not yet support other atypicals at this time

• Benzodiazepines– Can exacerbate behavior through

disinhibition– Should be reserved for substance

induced agitation– Appropriate for treatment of withdrawal

Anon. Am J Psych 1999;156(5 Suppl):1-20.

Involuntary Hospitalization

• State by state regulations: Know your state!– PA allows families to petition– MI, NJ do not

• In most states, PES is really a screening center– Determines if patient needs

hospitalization• Most families think PES is a

treatment center

Involuntary Hospitalization

• Least restrictive setting• Taking away someone’s rights

– May be other consequences– In NJ

Loss of medical license Loss of gun permit

• Safety for patient (what is the benefit?)

Pearls

• Careful assessment is key• Not every psychosis is psychiatric• Elderly have multiple medical

problems and require more time to assess

• Presentation are frequently atypical and not quickly separated

Pearls

• Managing agitation– Calm environment– Support family/caregivers– Haldol is the drug of choice

PO/IM 0.5 to 1 mg Q 1 hour till effect reached

– Avoid Benzodiazepines in the elderly• You can make a difference• We will all be older adults