Patients with a variety of clinical syndromes may present in a health care setting for emergency psychiatric treatment (Table 48–4). The following sections discuss the disorders most commonly requiring emergency treatment.
Elderly patients presenting with a psychiatric emergency require careful medical assessment as coexisting medical disorders and medical treatments often precipitate psychiatric presentation. A thorough review of systems, a complete physical examination, and appropriate screening laboratory tests, including a urinalysis, are imperative in this age group. A medically oriented evaluative approach may be more effective than a traditional psychiatric one.
In addition to determining whether the patient may have any sensory deficits, the clinician should speak clearly and slowly to geriatric patients. When a cognitive disorder is suspected, the clinician should ask short and simple questions in a straightforward manner, should repeat them as necessary and should strongly consider a collateral source to ensure the accuracy of the history.
Common geriatric emergencies include delirium, dementia, depression, and psychosis. Delirium and dementia may coexist with each other and with depression and psychosis (Chapter 14).
Because delirium is characterized by an acute change in mental status, presentation for emergency evaluation is not uncommon. Delirium is characterized by acute changes in concentration, which may be accompanied by other cognitive changes, perceptual changes like hallucinations or delusions and behavior changes like psychomotor retardation or agitation.
Delirium is a medical emergency that has a potentially fatal outcome; the possibility that the patient is delirious should be high on the differential list for all elderly patients presenting in the ER with an acute change in mental status or behavior. As soon as the clinician suspects delirium, a thorough medical evaluation should be initiated to determine the etiology. Urinary tract or other infections, onset or worsening of a medical or neurological condition, and adverse drug interactions, drug side effects (especially anticholinergic side effects) or drug intoxication secondary to an unintentional overdose related to cognitive impairment are all potential causes of delirium.
Elderly patients with dementia are often brought to the psychiatric emergency setting with acute psychomotor agitation, including combativeness. If the psychomotor agitation is of new onset, delirium or pain must be suspected and the medical workup initiated. If no medical etiology is found, the possibility that the patient is in pain from constipation, urinary retention, fall or other source should be investigated. If no medical or pain source is identified, the patient may have had onset of a psychotic component to the dementia. If no psychotic component is present, the patient may have been upset by something or someone in the environment and have been unable to express their frustration except through agitation or combativeness. A careful review of the events precipitating the crisis may reveal the environmental issue needing to be changed.
Depressed elderly patients may minimize mood symptoms but exhibit marked diminishment in interest in activities. Suicidal risk is high in elderly white men living alone and so assessment of risk and construction of a treatment plan must be especially carefully considered for this population.
Presentation with new onset psychosis in the elderly necessitates review for coexisting delirium or dementia. However, recent reports have emphasized that up to 10% of patients with a lifetime history of schizophrenia may have late life onset of illness.
Treatment and Discharge Planning
Because of the high likelihood of a coexisting medical illness, elderly patient presenting in the psychiatry emergency setting are best treated in collaboration with a medical team.
For patients with cognitive disorders, the highly stimulating environment of most ERs are difficult to tolerate. If available, these patients benefit from provision of a quieter, less chaotic environment.
Demented patients who present with psychomotor agitation or combativeness due to a frustration with their environment may be calm upon removal from their environment and transfer to the emergency setting. Clinicians in the ER should work with caregivers to determine what the precipitant might have been and determine how to mitigate that precipitant in the future. When possible, it is preferable for elderly demented patients to be returned to their home environment as admission to hospital itself can predispose the demented patient to worsening of their cognitive status. Knowledge of community resources like respite programs, adult day care, and visiting nurse agencies with psychiatric or dementia care expertise can aid in returning the patient to the community.
If an elderly patient remains agitated and or combative in the emergency setting, clinicians should make efforts to determine whether the individual can be managed with close staff attention, diverting the patient's attention to other topics by talking about family or reading a magazine together. Because of the high incidence of side effects in the elderly, medication management in the emergency setting should be avoided if possible. If medication is necessary to control physical aggression a low dose of an antipsychotic (e.g., haloperidol 1 mg) is usually preferable to benzodiazepines. Low-potency antipsychotics (e.g., thioridazine or chlorpromazine) should be avoided due to anticholinergic side effects, which can worsen or precipitate delirium.
Alcohol-related presentations are among the most common psychiatric emergencies. Presentations to emergency settings are most frequently associated with acute alcohol intoxication and withdrawal, including withdrawal delirium.
The clinical picture of intoxication generally depends on the patient's blood alcohol level (BAL) as determined by a breathalyzer test, but BAL cannot be used exclusively. In most jurisdictions, an individual with a BAL of 0.08–0.1 or greater is considered legally intoxicated. If a patient is intoxicated, the clinician must ascertain whether another chemical in addition to ethanol is related to the clinical presentation. A toxicology screen is essential. An intoxicated state is characterized by a combination of markedly maladaptive behavior or psychological changes and physical changes (e.g., slurred speech, ataxia, nystagmus, stupor, coma) that appear during or after alcohol ingestion.
Alcohol withdrawal delirium typically appears three days after cessation of or reduction in the context of heavy and extended alcohol use. It is characterized by a hyper adrenergic state, agitation, insomnia, gastrointestinal symptoms, hallucinations, hand tremors, and seizures.
Psychotic, mood, and anxiety disorders may be related to alcohol use. A thorough medical evaluation is warranted to exclude physical conditions that resemble intoxication or withdrawal.
Treatment and Discharge Planning
Patients with alcohol abuse often present with denial of their illness and should be interviewed in emergency settings in a manner consistent with the tenets of motivation enhancement. Clinicians should be knowledgeable about the availability of detoxification and treatment facilities in order to provide access to treatment if the patient is motivated. Patients presenting with alcohol abuse should have a physical examination including neurological exam to ensure the patient has not sustained injuries due to a fall or other accident while intoxicated.
A common and complex question is determining when a patient with alcohol intoxication or withdrawal is able to be safely discharged from the ER. After the BAL is below the legal limit for intoxication, the clinician must evaluate whether the patient continues to have significant mental or physical problems related to intoxication. If the patient is no longer acutely intoxicated, screening for other symptoms of psychiatric disorder like depression or psychosis and for the presence of suicidal or homicidal ideation should be completed. As substance abuse raises the risk of suicidal and violent behavior, a patient who exhibits these symptoms need to be evaluated and managed carefully, including consideration for inpatient treatment.
When possible it is preferable to discharge a patient with alcohol abuse or dependence accompanied by family or friends. Appropriate referral may include an outpatient detoxification or rehabilitation program, partial hospitalization, intensive or routine outpatient treatment, and Alcoholics Anonymous.