Among patients who are seen in the psychiatric emergency department, geriatric patients—defined as patients aged 65 years and older—are statistically underrepresented (1,2). Geriatric persons account for only 5 to 6 percent of all psychiatric emergency service visitors—even though they account for about 12 percent of the population at large and represent the fastest growing segment of the population.
In addition to differences in demographic characteristics—such as the gender imbalance (more females than males) or the preponderance of patients with a fixed income—other special considerations exist for geriatric patients in the psychiatric emergency service. First is the high rate of comorbid medical and neurological problems, which can be chronic or acute (3). Behavioral disturbances can result from major medical problems, such as stroke, and from relatively minor problems, such as urinary tract infection. The increased risk of medical problems carries with it a risk of adverse drug reactions from the simultaneous use of multiple medications. The psychiatric consultant must be vigilant in screening for medical and neurological problems or be confident that the other physicians in the emergency department have already addressed them.
Geriatric patients are also at risk of pharmacological emergencies—medical emergencies that are related to psychiatric medications. Possible problems include agranulocytosis secondary to antipsychotics, hypotension or cardiac conduction disturbances that are caused by the use of antipsychotics or antidepressants, neuroleptic malignant syndrome, lithium toxicity, anticholinergic delirium, and acute dystonia (4).
Another critical factor in evaluating geriatric patients in the psychiatric emergency service is the risk of suicide, which is much higher among geriatric patients than younger patients. The suicide rate for white men aged 80 to 84 years is six times that of the general adult population (5). Clinicians in the psychiatric emergency service need to calibrate their index of concern about the risk of completed suicide for elderly psychiatric emergency service patients who present with depression, alcohol abuse, or other risk factors for suicide.
Because of these and other special considerations that apply to the geriatric patient, we suggest certain maxims that may prove useful in guiding the clinician's work. They are formulated as ten "do's" and "don't's" for the psychiatric emergency service clinician, constituting a list that cannot claim to be comprehensive.
1. Establish the situational context. It is no accident that more patients from nursing homes are referred to the emergency psychiatric service on Friday nights than on any other night of the week. Usually, Friday evening is when staffing levels and programming decline for the weekend, which leads to an increased likelihood that nursing home residents will become symptomatic and that staff members will worry about their capacity to handle residents' problem behaviors. Only 5 percent of persons who are aged 65 years and older live in nursing homes; however, the prevalence of psychiatric disorders in these settings is at least 80 percent. Resources to take care of patients with psychiatric illness—including training and supervising caregivers as well as having access to psychiatric consultation—may be lacking (6). The same resource shortages could be true for caregivers in the home.
2. Communicate with third parties, taking the presenting complaint of the referral source seriously. In the evaluation of children, the involvement of parents, teachers, and other individuals is taken for granted—if only for legal reasons. However, in the evaluation of an older person, family members' or caregivers' input is often invaluable in determining a pattern of behavioral change—such as threatening or assaultive behaviors toward caregivers or roommates—that easily escapes a one-point observation. Obtaining consent and calling family members, primary care physicians, visiting nurses, adult protective workers, and other parties should be part of the protocol for evaluating geriatric patients. Most elderly patients do not come to the psychiatric emergency service on their own but are brought in by family members or others (7). Elderly patients may minimize or outright deny important issues, such as environmental problems—including changes in the home environment—and psychiatric symptoms.
3. Determine the accompanying psychopathology. Rarely will an older person develop new psychiatric symptoms without precipitants. For instance, a new onset of psychotic symptoms demands an evaluation of cognitive functions to determine whether underlying dementia or delirium exists. Attention to the milieu interne and milieu externe is critical. An infectious disease, a transient ischemic episode, a change of cardiovascular medication, the loss of a pet, or the death of a roommate in the nursing home can trigger a psychiatric crisis. As with younger patients, it is appropriate to screen for affective and anxiety symptoms—such as changes in sleep, appetite, energy, and mood—as well as psychotic symptoms—such as auditory hallucinations and paranoid ideation (8).
4. Assess cognitive functioning. The Folstein Mini-Mental State Examination is a brief objective screen for cognitive impairment (9). Even though behavioral problems, not memory problems, lead to admission to the psychiatric emergency service, a cognitive evaluation is mandatory for each geriatric patient. The presenting complaint of the referral source should be taken seriously. Nursing home staff members are all too quickly accused of "dumping" patients. However, nursing home staff members cannot reasonably be expected to manage an agitated patient with dementia who threatens to assault staff or his roommate. Combativeness among elderly people with dementia is dangerous and requires a high level of staff monitoring as well as access to psychopharmacological medication, seclusion rooms, and restraints, which are available only in a hospital setting.
5. Suspect extrinsic substances. Elderly patients receive a disproportionate number of prescribed medications. Polypharmacy is probably the most common reason for delirium in the elderly patient, and a review of all medications in the patient's nursing home chart or in the home medicine cabinet is necessary. Older persons have a reduced tolerance for the central nervous system effects of prescribed medications and of alcohol and street drugs. Even though substance abuse seems to be less common among elderly persons, intoxication and withdrawal should be considered in the differential diagnosis for patients who present in a psychiatric emergency service, irrespective of their age. Also, a breath analysis and urine drug screens should be obtained if substance abuse is suspected.
6. Screen carefully for suicidal ideation and behavior. Among geriatric patients, compared with other age groups, suicidal action is highly correlated with lethal outcomes. Mood disorders are common among older psychiatric patients, and the presenting affect, even in a manic state, is more often dysphoric compared with that of younger patients. Other risk factors for suicide, such as being unmarried and having a chronic medical illness, are also common in this population.
7. Consider the situation that awaits the patient after discharge from the psychiatric emergency service. Questions to be considered include: Did this patient's home situation contribute to admission to the psychiatric emergency service? If so, has the home situation changed? Evaluators should try to put themselves in the patient's and caregiver's shoes. For instance, the case should be handled as it would if it involved a family member. The presence of an outreach team can dramatically alter the disposition options (10).
8. Consider the possibility of elder abuse. The patient may be the carrier of symptoms for a dysfunctional social unit. The elderly person with "failure to thrive" or with multiple falls should not be too quickly seen as depressed. Memory impairment or intimidation can disguise recent abuse by the spouse, adult children or grandchildren, and others. The patient should be interviewed separately from the caregivers after the initial part of the interview and screened for abuse.
9. Get a second opinion when in doubt. Older patients may not be routinely seen in the psychiatric emergency service. So that an important aspect of a geropsychiatric assessment will not be missed, a consultation with a colleague may be helpful. An internist or family practitioner with experience in geriatrics may be particularly helpful in dealing with medical and psychosocial problems.
10. Document the dispositional decision and its rationale, and communicate it to the referral source. An attempt should be made to give the patient's caregivers and primary care physician a copy of any notes relating to the dispositional decision and its rationale. The failure to communicate across institutional or disciplinary boundaries creates particular problems for older persons who are served by a variety of systems or agencies.
The assessment of geriatric patients in the psychiatric emergency service can be more time intensive because of the necessity of investigating multiple domains—medical conditions; medications, whether prescribed or not; substances of abuse; and psychiatric symptoms. In addition, the patient may not be a reliable historian because of cognitive impairment or acute behavioral disturbance. Good outcomes depend on careful, comprehensive assessments. Often, psychiatrists will need to work with other health care professionals, including internists, family practitioners, social workers, and nurse specialists. This team approach promotes good communication and aids in establishing a comprehensive biopsychosocial database. This approach can also decrease the individual clinician's burden of performing a time-intensive assessment. The patient also benefits from a team of professionals who may be able to provide increased resources after the psychiatric emergency has been resolved but ongoing treatment needs to be continued on an outpatient or institutional basis.
A majority of older patients are not demented, frail, depressed, or suicidal. But all these conditions are more prevalent among older adults. In addition, all these conditions can be predisposing factors for psychiatric emergencies. Chronic medical conditions, social problems, and depression all contribute to the markedly elevated risk of suicide among older patients. A careful assessment of a geriatric patient should lead to a safe disposition and be the first step in a well-designed treatment plan.
Dr. Thienhaus is professor of psychiatry and psychology and Dr. Piasecki is associate professor of psychiatry at the University of Nevada School of Medicine, Mail Stop 354, Reno, Nevada 89557-0272 (e-mail, email@example.com). Douglas H. Hughes, M.D., is editor of this column.