The Geriatric Psychiatry Patient
in the Emergency Department
Stephen M. Scheinthal, D.O., FACN
Associate 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 diet
B. Poor relationship with children
C. Death wish
D. No medical care
E. Loss of wife
Pretest Question 2
A 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 2
Upon 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 – WNL
CXR – Neg
CT of head – Neg
BAL - 170
Pretest Question 2
What is the most likely diagnosis?
A. Alcohol intoxication
B. Stroke
C. Cannabis/Formaldehyde intoxication
D. Brief Reactive Psychosis
E. 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 IV
B. Hydroxyzine 50mg IM
C. Risperidone 37.5mg IM
D. Lorazepam 2 mg IM
E. 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
• Presentation
• 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. Symptoms
B. Excludes other mental health DX
C. Symptoms Cause Dysfunction
D. Exclude Medical Illness or Substance Use
Age/Gender
•
•
•
•
•
•
Schizophrenia
Bipolar Disorder
Major Depression
Anxiety Disorder
Dementia
Delirium
18-35, 65-75
20-30 (men = women)
(women > men)
(women > men)
50% of people > 80
caused by underlying
medical illness
What is the most common psychiatric
disorder in the elderly?
A. Dementia
B. Anxiety
C. Depression
D. 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 stays
Park 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)
2)
3)
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.
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)
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’d
4)
5)
6)
7)
8)
9)
insomnia or hypersomnia nearly every day.
psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).
fatigue or loss of energy nearly every day.
feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick).
diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others).
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 olds
B. 25-35 year olds
C. 40-50 year olds
D. 60-70 year olds
E. 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. Men
B. Women
Who abuses prescription medication
more?
A. Men
B. 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 % - women
Satre 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 (DSMIV-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
Photo Credit: Corbis
– Less likely to think substance use in elderly
Wilber ST. Emerg Med Clin N Am 2006;24:219-316.
Substance Use
• Screening Tools
• CAGE
Cutback
Annoyed
Guilty
Eye 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 Test
SMAST
13 Item test to assess longitudinal alcohol use
Satre 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. Schizophrenia
B. Brief Psychotic Disorder
C. Substance intoxication
D. Dementia
E. Psychosis due to general medical condition
Psychosis
• 16-23% of elderly had a medically based
psychosis
• Risks
–
–
–
–
–
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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. Thorazine
B. Ketamine
C. Haldol
D. Ativan
E. 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. 1:1
B. 10:1
C. 50:1
D. 100:1
E. 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