To the Editor:—Psychiatrists will frequently be consulted in the ED to assess patients with documented histories of dementia who are exhibiting signs and symptoms of new-onset mental status changes.
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Not uncommonly, spouses, caregivers, or nursing home attendants will accompany the patient and provide a history of observing behavioral or cognitive changes in the person, which have occurred either abruptly or over the course of several days. Although these clinical changes could well be secondary to an underlying psychiatric disorder, it is also critically important to rule out other common causes of behavioral and personality changes in those who, as a result of their underlying cognitive deficits, are unable to provide an accurate or complete history.2
A number of clues can alert both the ED physician and psychiatrist to the likelihood that the new mental or behavioral changes are secondary to an underlying physical disorder or medication: an abnormal level of alertness, psychiatric symptoms that are more sudden or severe than what is normally observed, coexisting chronic medical illness, or recent changes in medications.3
The assessment should begin with a thorough history taken from a reliable informant followed by a comprehensive mental status evaluation and physical examination. Clarification of the diagnosis can be aided by recalling the most common reasons for new-onset mental status changes in this highly vulnerable population. When in the ED, I remember this particular differential diagnosis as The Seven Is.1. Infection
Urinary tract infections and pneumonias are notorious for causing new-onset mental status changes in the geriatric patient. An elderly individual with progressive dementia will always be at high risk for either or both of these infections whether they are living in the community or residing in a skilled nursing facility.
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A thorough physical examination, appropriate lab studies, and possible chest x-ray will help to clarify the diagnosis.2. Infarction
Myocardial infarctions, as well as cerebral vascular accidents, could well present initially as behavioral or cognitive changes in the person with dementia.
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An electrocardiogram and cardiac enzymes could be indicated in a person with a known history of coronary artery disease or if a “silent” myocardial infarction is suspected. In situations when there is evidence of focal neurologic findings on physical examination or a clouded sensorium, a computed tomography scan of the brain could well help identify the primary cause behind the mental status changes in the patient.3. Injury
Individuals with dementia frequently wander, have gait disturbances, or suffer from orthostatic hypotension, which can lead to unwitnessed falls. Fractured hips, subdural hematomas, and painful soft tissue injuries are not uncommon occurrences in this population and can lead to significant mental and behavioral changes before obtaining an accurate diagnosis.
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Clarification of the underlying cause will be derived from obtaining a careful history from a reliable caregiver followed by a focused physical examination and appropriate radiologic studies.4. Iatrogenic
New-onset psychiatric symptoms in geriatric patients can frequently be attributed to the addition, discontinuation, or interaction of medications.
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Because individuals with dementia have compromised central nervous systems, they are particularly vulnerable to medication side effects and adverse interactions. The clinician in the ED should take a thorough inventory of all medications the patient is currently taking, those which could have been added (eg, anticholinergics, steroids), as well as those which have been recently discontinued (eg, benzodiazepines).5. Illness
Exacerbations of chronic medical illnesses such as diabetes, chronic obstructive pulmonary disease, and renal disease can manifest initially with cognitive or behavioral changes in those with comorbid dementia.
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Careful attention to signs of a progressive or sudden worsening of these medical conditions could lead the ED clinician to a better understanding of the changes in the patient’s mental status.6. Impaction
Fecal impaction is a common, and oftentimes overlooked, condition in geriatric patients, which can profoundly affect the person’s behavior and clarity of thinking.
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This population is particularly susceptible to fecal impaction as a result of the contributing effects of immobility, dehydration, and medication side effects. In a demented patient, fecal impaction can lead to great discomfort, high levels of agitation, and a state of worsening confusion.7. Inconsistency
Individuals with dementia are highly sensitive to changes in their environment and daily routine.
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New caregivers, altered schedules for bathing and eating, different sleep patterns, or transfers to entirely new facilities can increase irritability, confusion, and acting-out behaviors. A careful social history taken from a reliable collateral source will oftentimes point to an environmental or social inconsistency as being the primary cause of recent changes in behavior or thinking.Almost any psychiatric syndrome can be mimicked by a medical, neurologic, or environmental change in those who experience moderate to severe dementia.
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ED physicians, in collaboration with the consulting psychiatrist, should rule out these most common causes before attributing new-onset mental status or behavioral changes solely to a mood or psychotic disorder.References
- Life-threatening psychiatric emergencies in the elderly.J Geriatr Psychiatry Neurology. 1999; 12: 60-66
- Geriatric psychiatry in the emergency department, II: evaluation and treatment of geriatric and nongeriatric admissions.J Am Geriatr Soc. 1984; 32: 343-349
- Kaplan B.J. Sadock V.A. Comprehensive Textbook of Psychiatry. 7th ed. Lippincott Williams&Wilkins, Philadelphia2000: 2980-3184
- Resistant pathogens in urinary tract infections.J Am Geriatr Soc. 2002; 50: S230-S235
- Gatifloxacin in community-based treatment of acute respiratory tract infections in the elderly.Diagn Microbiol Infect Dis. 2002; 44: 109-116
- Extrahepatic conditions and hepatic encephalopathy in elderly patients.Am J Med Sci. 2002; 324: 1-4
- Falls and in injuries in frail and vigorous community elderly persons.J Am Geriatr Soc. 1991; 39: 46-52
- Clinical Geriatric Psychopharmacology. Williams and Wilkins, Baltimore, MD1998
- Chronic medical conditions and mental health in older people.Psychol Med. 1997; 27: 1065-1077
- Fecal impaction.British Journal of Community Nursing. 2002; 7: 118-126
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© 2004 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
