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Confusion and Agitation in the Elderly ED Patient

Section IconAssess
Perform a thorough evaluation to determine the underlying cause.
As with any patient, evaluate for life-threats or conditions that would require immediate intervention, such as hypoxia, hypoglycemia, stroke symptoms, or STEMI.
Delirium and dementia-related psychoses are most common causes of confusion and agitation. New onset psychosis and schizophrenia are exceedingly rare. Older patients with hallucinations, agitation or altered sensorium usually have delirium or dementia. Delirium can be hyperactive (agitation and restlessness) or hypoactive (somnolence or decreased mental status) or mixed (fluctuating symptoms of hyperactive and hypoactive). Hypoactive delirium is the most common, has higher mortality, and is more often missed.
For agitated patients, immediately assess safety risk for the patient and staff. Assess for suicidal or homicidal ideation, auditory or visual hallucinations.
Evaluate falls risk, and establish precautions if appropriate, or 1:1 sitters to prevent injury while in the ED.
The history, medication review, and collateral information are crucial.
Confusion and agitation are frequently due to medication side effects or changes. Obtain the patient's medication history, including use of OTC medications, alcohol use, illicit drug use, recent changes or altered compliance with medications, and missed medications. High risk medications: sedatives, steroids, anti-histamines, anti-cholinergics, TCAs, muscle relaxants, or opioids.
Contact family or facility staff familiar with the patient to gather collateral information. Identify available support services or resources for information and disposition assistance.
Establish the patient’s baseline mental status and level of functioning. Does s/he perform their ADLs, drive, care for themselves, or are normally ambulatory and fully oriented?
Perform a thorough physical exam
Vital signs
Finger stick blood sugar should be obtained early.
Fully expose the patient to examine the back, sacrum, genitalia, and feet for possible ulcers or infections.
Assess for trauma, accidental, self-inflicted, or non-accidental.
Neurological exam for signs of stroke, intra-cranial hemorrhage, or subclinical seizures.
References
Rosen, T et al. Assessment and Management of Delirium in Older Adults in the Emergency Department, Advanced Emergency Nursing Journal, Vol. 37, No. 3, pp. 183–196
Brendel RW, Stern TA. Psychotic symptoms in the elderly. Prim Care Companion J Clin Psychiatry 2005;7: 238-241
Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A, Dittus RS et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 2009;16: 193-200
Section IconDiagnose
Screen for delirium in any agitated or confused older patient.
Delirium is the most common syndrome underlying behavioral changes, agitation, and confusion in older adults in the ED. Delirium is frequently missed if clinicians do not screen for it, leading to worse outcomes and mortality.
The hallmarks of delirium include acute onset, waxing and waning symptoms, inattention (eg. unable to recite days of the week backwards), change in cognition (eg new memory deficit, disorientation, perceptual disturbance, or disorganized thinking) or altered level of awareness (reduced orientation to environment such as RASS other than 0). Learn More
Use the delirium triage score (DTS Calculator) and brief CAM (BCAM Calculator) to help identify patients with delirium
Screen for underlying major neurocognitive disorder (dementia).
If the patient is able to cooperate, use a test such as the mini-cog: Ask the patient to repeat 3 items (banana, sunrise, chair), draw a face clock showing 10 minutes past 11, then recall the 3 items at 5 minutes.
While dementia itself can cause behavioral changes, agitation, and psychotic symptoms, these symptoms should raise concern for delirium in a patient without a preexisting diagnosis of dementia.
References
Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 2013;62: 457-465
LaMantia MA, Messina FC, Hobgood CD, Miller DK. Screening for delirium in the emergency department: a systematic review. Ann Emerg Med 2014;63: 551-560
Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000;15: 1021-1027
Section IconEvaluate
Perform a thorough, focused medical workup for agitation or confusion.
The top two causes of delirium are infections and medication complications or side effects. Recognize that the causes are often multi-factorial.
The workup should be driven by the H&P.
Look for a specific underlying cause, though the cause may be multi-factorial and include environmental factors such as a recent hospitalization or change in environment.
General tests for most patients will include:
Blood glucos – finger stick is quickest.
Complete cell count – anemia, leuokocytosis.
Basic metabolic panel – hypo/hypernatremia, dehydration, AKI, hyper/hypokalemia, hypercalcemia.
Urinalysis and culture – UTI. There are high rates of baseline, incidental pyuria and asymptomatic bacteriuria in older adults, especially those who are institutionalized or incontinent. Mild leukocyte esterase and a few WBCs on the urinalysis could be incidental. Consider waiting for culture results to treat in borderline UAs without symptoms. Treat if the patient has symptoms of UTI or pyelonephritis, or has other signs of infection, such as fever or leukocytosis.
EKG – dysrhythmias and ischemic changes.
Specific, targeted testing and evaluation may include:
Infection: Chest X ray, blood cultures, lactate, chest or abdomen/pelvis CT, LP
Drug or medication complications: Specific drug levels (such as lithium, digoxin, acetaminophen, salicylate), venous blood gas
Drug or alcohol abuse or withdrawal: ethanol level, urine drug screen, CIWA scoring
Electrolyte and metabolic derangements: complete metabolic panel, liver function tests, venous blood gas, ammonia (which may be elevated due to various medications or liver failure)
Trauma evaluation: CT head – if focal deficits, signs of head injury, severe headache, otherwise unexplained decreased level of arousal, or seizure, coagulation studies
Cardiac disease: EKG, troponin, BNP, chest X-ray
Other considerations: venous blood gas for hypercarbia, thyroid stimulating hormone level if history/exam suggestive of hypo or hyperthydoidism, carboxyhemoglobin if other symptoms suggestive of possible CO toxicity. Core temperature if concern for hypo- or hyperthermia
References
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014;383: 911-922
Aslaner MA, Boz M, Celik A, Ahmedali A, Eroglu S, Metin Aksu N et al. Etiologies and delirium rates of elderly ED patients with acutely altered mental status: a multicenter prospective study. Am J Emerg Med 2017;35: 71-76
Gower LE, Gatewood MO, Kang CS. Emergency department management of delirium in the elderly. West J Emerg Med 2012;13: 194-201
Hardy JE, Brennan N. Computerized tomography of the brain for elderly patients presenting to the emergency department with acute confusion. Emerg Med Australas 2008;20: 420-424.
Lai MM, Wong Tin Niam DM. Intracranial cause of delirium: computed tomography yield and predictive factors. Intern Med J 2012;42: 422-427.
Section IconPrevent
Individual patient measures to prevent or manage delirium:
Treat the underlying condition such as infection, electrolyte disorders, dehydration, or medication-related cause of the agitation or confusion.
Treat symptoms such as pain, nausea, constipation.
Restart home meds unless contraindicated.
Avoid the use of high-risk medications: benzodiazepines, diphenhydramine, sedatives, muscle-relaxants, anti-cholinergics, anti-histamines, high-dose anti-psychotics.
Normalize daily function: provide hydration, food, access to toileting, mobility, visual, hearing assists, day/night signals, and limit disruptions and unnecessary VS checks and BP cuff cycling.
Avoid tethers unless necessary, including: Foley catheters, continuous IV infusions, BP cuffs, monitors
Hospital and systems-based measures to prevent or manage delirium:
Provide reassurance, redirection, distraction (eg activities or busy vests) and means for self-orientation (clocks, calendars, signs). Some disoriented patients may become more agitated when their perception of reality is actively challenged. Encourage family members or caregivers who demonstrate a calming presence to remain at bedside.
Prevent injury: Confused patients are at high risk for falls. Lower beds, provide chairs, and use non slip floors or socks. Very agitated or high risk patients should have a 1:1 sitter.
Reduce ED length of stay: increased ED length of stay is associated with worse outcomes, and may increase the risk or severity of delirium. Avoid boarding in hallway beds and prioritize transfer to a floor bed once admission decision is made.
ED MD and RN should communicate to inpatient MD and RN presence of dementia, delirium and/or agitation.
References
Geriatric ED guidelines. Carpenter CR, Bromley M, Caterino JM, Chun A et al. Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Ann Emerg Med 2014 vol 63, issue 5. Pages e1-3
Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016;3: CD005563
Bo M, Bonetto M, Bottignole G, Porrino P, Coppo E, Tibaldi M et al. Length of Stay in the Emergency Department and Occurrence of Delirium in Older Medical Patients. J Am Geriatr Soc 2016;64: 1114-1119
Section IconTreat
Take a multi-modal approach to treatment
Treat the underlying medical condition or derangements identified on exam and testing.
Treat symptoms such as pain, nausea, etc.
Follow the prevention steps listed above.
Use verbal de-escalation principles:
Respect personal space
Do not be provocative
Establish verbal contact
Be concise and use simple language
Identify the patient’s wants and feelings
Listen closely to what the patient is saying
Agree or agree to disagree
Set clear limits
Offer choices and optimism
Debrief the patient and staff
If needed, start with oral Medications.
If medications are needed, start with low doses and titrate. If the patient is prescribed an anti-psychotic at home, then first try restarting this medication. If the patient is at risk of harming themselves or others due to agitation, consider one of the following options.
Medication and Oral Dose
Specific Contra-indications and Risks
Risperidone ≤1mg
Caution in frail or volume-depleted patients, may cause orthostatic hypotension
Olanzapine 2.5-5mg
May cause orthostatic hypotension and somnolence
Quetiapine 25-50mg
May cause orthostatic hypotension and somnolence
Quetiapine 25-50mg
May cause orthostatic hypotension and somnolence
Carefully consider the use of IM or IV medications.
If oral medications are not effective, consider IM or IV medications. Use lowest dose possible to maintain patient and staff safety. Medications can be re-dosed as needed. AVOID doses of 5-10mg IM haloperidol as these can have prolonged side effects and sedation.
Medication and IM or IV Dose
Specific Contra-indications and Risks
Olanzapine 2.5-5mg IM
Caution in intoxicated or volume-depleted patients.
Ziprasidone 10 IM
Caution in uncontrolled heart failure or cardiac disease, intoxicated, or volume depleted/orthostatic patients.
Haloperidol 1-2.5 mg IM Haloperidol 0.25-1mg IV
Higher risk for extra-pyramidal side-effects than the atypical anti-psychotics. High risk with IV, so IM is preferred
Black Box Warning: All the above anti-psychotics have a black-box warning that they are not approved for dementia-related psychosis due to an increased mortality risk in elderly patients with dementia. It is unclear how the medications contribute to increased mortality which is typically due to infection or cardiovascular causes.
Avoid benzodiazepines if possible unless in withdrawal
If a patient is chronically on benzodiazepines, do not stop these precipitously. Otherwise avoid the use of benzodiazepines if possible. They may cause prolonged sedation, paradoxical agitation, or worsening of delirium. If benzodiazepines are used, then the doses should be small, such as 0.5-1mg lorazepam PO, IV, or IM.
Be cautions to prevent harm and minimize side effects
Do not use medications such as diphenhydramine for agitation in elderly patients. It can cause anti-cholinergic side effects and prolonged sedation. There are currently no studies evaluating sub-dissociative dose ketamine for agitation in older adults. More research is needed in the field of geriatric agitation, confusion, and delirium in the ED to improve care and patient outcomes.
References
Richmond JS 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. 2012;13(1):17-25.
Erstad, B. L., & Patanwala, A. E. Ketamine for analgosedation in critically ill patients. J Crit Care, 2016, 35, 145-149. doi: 10.1016/j.jcrc.2016.05.016
Girard, T. D. et al.. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med, 2010 38(2), 428-437.
Lonergan, E., Luxenberg, J., & Areosa Sastre, A. (2009). Benzodiazepines for delirium. Cochrane Database Syst Rev(4), CD006379. doi: 10.1002/14651858.CD006379.pub3
CPE RCC Research priorities paper in geriatric psychiatric emergencies(submitted).

Acknowledgments

Contributors
Christina Shenvi, MD, PhD, FACEP Maura Kennedy, MD MPH Michael P. Wilson, MD, PhD, FACEP Charles A. Austin, MD Michael Gerardi, MD, FACEP

ACEP & EMF Staff
Sandy Schneider, MD, FACEP Jana Nelson Cynthia Singh, MS Loren Rives, MNA Steven Morrissey

Support for this tool made possible through a grant from the Allergan Foundation.

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