Your Next Patient: A confused 80 year old man

An 80 year old man is brought into your emergency room by his adult son. The son tells you that his Dad seems completely confused. He was up all night looking in all of the rooms of the house, and he seems agitated. He is also a little unsteady on his feet. He was generally well until 10 days ago when he had an exacerbation of his COPD. He was hospitalized for 3 days and went back to his sons house with some puffers and medications. Initially he was improving but the last two days have been ‘terrible’ according to the son.

He is worried that his father has dementia, or has had a stroke. He says that 2 weeks ago his Dad was ‘the kind of guy who still put up the neighbours Christmas lights, but now he is totally out of it.’

The past medical history is notable for COPD, hypertension and restless legs syndrome. He does not drink alcohol, and he is an ex-smoker.

His medications include: Amytryptilline 50mg hs (for restless legs), Nifedipine 30mg BID (for hypertension), Ipratropium MDI (for COPD), Moxifloxacin 400mg OD (for AECOPD), Prednisone 60mg OD (for AECOPD), and Diphendryramine 50mg OD (for nausea associated with moxifloxacin)

EVERY medication on this list is associated with delirium. The BEERS list provides a useful reference for medications that can be problematic for elderly patients.

The diagnostic criteria for delirium in the DSM-IV are:

  1. Disturbance of consciousness with reduced ability to focus change or shift attention.
  2. A change in cognition or perceptual disturbance not better accounted for by pre-existing dementia.
  3. The disturbance develops over a short period of time and tends to fluctuate.
  4. History, physical and ancillary tests indicate the disturbance is caused by a general medical condition.

On examination the patients vital signs are HR95, BP140/85, RR20, Temp 37.7C, O2 97%RA His skin is slightly flushed. Ears, nose and throat exam is normal. The respiratory exam is normal, there is no wheeze and good air entry to all fields. Cardiac exam, abdominal exam and head & neck exam are all normal. There are no focal neurological signs but you note that the patient is unsteady on his feet, and disoriented to time and place.

There remains a broad differential diagnosis for altered mental status in the elderly patient. The mnemonic AEIOU TIPS is often suggested as a memory aid to help sort out the cause.

  • A – Alcohol (intoxication or delirium tremens)
  • E – Epilepsy, Endocrine, Electrolytes, Encephalopathy
  • I – Insulin (hypo or hyperglycemia)
  • O – Oxygen (hypoxia), Opiates, Overdose
  • U – Uremia (encephalopathy)
  • T – Trauma, Toxidromes
  • I – Infection (Sepsis, meningitis, UTI)
  • P – Psychiatry (Depression, Psychosis, Dementia), Porphyria, Pharmacy (medication side effect)
  • S – Stroke, Space occupying lesion, Subarachnoid haemorrhage
This is an excellent mnemonic to remind us to consider  every possible medical condition in the evaluation of the altered elderly patient. Unfortunately it is far too broad to guide a work-up, and at the same time leaves out causes of altered mental status (STEMI/ACS may, for instance, present as confusion or AMS in an elderly patient).
In reality a patient driven work-up is required. When I see an elderly patient with AMS I ask myself; Is this inter-cranial catastrophe? Is this trauma? Is this Infection? Is this encephalopathy or metabolic derangement? Is this a toxidrome or medication side effect? Is this a systemic illness manifesting as AMS? Is this dementia or a psychiatric process?
A careful initial evaluation can guide an initial work-up designed to rule in or out important causes of AMS that threaten life or long term function.

You order some investigations; ECG, CBC, electrolytes, BUN, Creatinine, Lactate, Troponin, Urinalysis, Chest x-ray, and CT head. All of these investigations are within normal limits.

The patient is on 3 medications with significant anti-cholinergic properties; amitryptilline, diphenhydramine and ipratropium.

You decide that the patient is having delirium, likely related to his current medications. You suspect that his anticholinergic medications are the culprit, especially given his slightly elevated temperature and flushed skin. His prednisone, moxifloxacin and nifedipine could also be the culprit, but you consider this less likely. As far as you can tell the patient has recovered from his exacerbation of COPD, and currently has a normal respiratory exam.

Elderly patients with delirium require supervision at a level that is rarely possible in the home environment and often require hospitalization. These patients are at risk for falls and wandering.

Any underlying precipitant of the delirium should be treated, and in the case of medication side effect the offending agent(s) should be weaned or removed. Severe agitation may require treatment (ie. with low doses of haloperidol) but excessive sedation should be avoided. Verbal calming and reorientation is a key part of treatment.

The patient was admitted to the hospital and all of his medications were discontinued. Initially he required constant bedside supervision and haloperidol 1mg po qhs for night-time agitation. His delirium settled over 1 week, and eventually he was discharged into his son’s care.

Delirium in elderly patients is associated with poor prognosis. In the year following an episode of delirium 20% of patients will be admitted to long term residential care (nursing homes), and 10% will die. Delirium is also associated with cognitive injury and many patients never regain their pre-morbid cognitive state.

It is unclear to what extent these outcomes are the result of delirium versus delirium being a marker of poor physiological reserve.

 

Code white considerations

“Code white”, “Code black”, “Dr. Murphy to room 202″, every hospital has an overhead page that means that there is a disruptive person or patient who needs to be controlled, either for their safety or for the safety of others. Who attends these calls at your hospital? I had always assumed that these calls were similar to a code blue in mandating the immediate attendance of your critical care team leader (in my shop thats the ED doc). However at some hospitals the extra staff attending these calls is security staff, and the on call doctor is only notified by phone.

Most of these calls are for patients already admitted and on hospital wards. You might ask why we as emergency doctors should take this job onto our already overfull plate. The answer is simple, these are patients who have, with some regularity, severe underlying illness requiring recognition and treatment in a setting that allows for only incomplete information and evaluation. In other words, although these patients are (mostly) already hospitalized they require the particular set of skills and expertise that an emergency doctor brings to the table.

The classical approach to these patients has been to regard them as disruptive or demented and give them a dose of haloperidol and lorazepam and cinch the restraints nice and snug. This brute force approach fails the patients who need us most, and probably causes harm. Like everything in emergency medicine it pays to have an approach and a short differential to consider each time you evaluate an agitated patient.

Is this patient actually agitated?

When you walk into the scene assess if the patient is actually agitated or simply annoying. Occasionally sedation is being forced on the annoying and while we all know a few people who would benefit from sedation, forced sedation is an invasive action and only allowed in certain circumstances.

Does the patient understand the situation? This question assesses the patients capacity for medical decision making. Is the patient currently a risk to harm themselves or someone else? This question guides the pace of the intervention.

What are the patients vitals?

The usual answer is ‘unknown’, the patient is too agitated to take vitals. Actual vital signs are an early priority but prior to that look at the patients respiratory rate and effort, and assess their perfusion and skin colour. Your disruptive patient may actually be hypoxic, or in a shock state.

Is there evidence of trauma?

Elderly anticoagulated people at risk of falls are not suddenly not at risk by virtue of hospitalization. Trauma, including head trauma, can and does happen in the hospital.

Does the patient have alcohol withdrawal?

Elderly patients are at particular risk for unrecognized alcohol withdrawal. Delirium tremens is a life threatening but treatable medical problem. Many agitated patients are treated with antipsychotics such as haloperidol or loxapine, which have a limited role in alcohol withdrawal. Is the patient tremulous, tachycardic or hyperadrenergic? Consider alcohol withdrawal.

Does the patient have infectious or metabolic encephalopathy?

Consider (meningo) encephalitis, sepsis, uremia and elevated ammonia, if the picture fits.

Does the patient have a medication reaction?

Since hospitalization has the patient been started on a medication that could cause disinhibition and delerium? In particular look for anticholenergic drugs, tricyclic antidepressants and benzodiazipines.

In summary, the agitated hospitalized patient represents an emergency situation. Some of these patients do simply have behavioural problems, dementia or psychiatric disorders, but many others have emergency medical problems that need to be urgently addressed. The mortality rates for hospitalized patients who develop delirium of any cause is high (reported variously between 20 and 50% 6 month mortality). Some of that mortality is simply because delirium itself is a associated with frailty in the elderly, but some likely represents the various underlying diseases that can present as agitation and delirium.

When you are called to a ‘code white’ keep your wits about you, and evaluate the patient just like you would in the ED. Check vitals, consider hypoxia, trauma, shock, withdrawal, encephalitis and drug effects. and treat accordingly.

If you like saving truly sick patients from dangerous interventions then start attending these calls. You’ll find patients with hypoxia, PE’s, brain abscesses, intercranial bleeds and anticholinergic drug toxicity (all things I have actually found in these patients). And the best part is that the patient is already admitted!

 

‘Isolated’ Trauma in the Elderly

An 82 year old woman arrives in your emergency room with a shortened and externally rotated hip. She does not remember falling but was found down in the assisted care facility she lives in. The x-ray confirms a displaced sub-capital hip fracture. This is a slam dunk easy case, right? We see this everyday; admit to ortho for ORIF, write some holding orders, (maybe do a 3 in 1 block if you believe in pain control), and move on to the next patient. Right?

Trauma in the elderly is common and we see it everyday. We see hip fractures, wrist fractures and head lacerations usually as a consequence of falls. Those of us in community hospitals may become unaccustomed to dealing with major trauma, as well developed EHS systems tend to route these cases to trauma centres, but the flow of injured elderly continues uninterrupted. In general elderly patients cope poorly with trauma, and have much higher morbidity and mortality than our younger patients, and this is predictable based on burden of concurrent chronic disease and decreased physiological reserve. These patients often have an obvious injury and this is best viewed as a distraction during the first phase of the assessment.

When an elderly patient arrives with what seems to be an isolated traumatic injury resist the temptation to prematurely close the case, and resist the pressure to assess them in the low acuity area of your department. These patients frequently have a more complex story than initially meets the eye.

Our 82 year old patient with a hip fracture is best viewed as a trauma patient, and our assessment should proceed along those lines. The ABCDE approach of ATLS provides a good framework for initial assessment. Additionally there are some important questions you must ask yourself as your assessment proceeds:

  1. Is this patient unstable? Remember elderly patients may not mount a tachycardia, and a ‘normal’ blood pressure may represent relative hypotension.
  2. Does this patient have another injury? Just like in any trauma patient, palpate everything. In particular consider the possibility of c-spine injury, rib fractures, and inter cranial bleeding.
  3. Does this patient have a concurrent disease that will impact or be impacted by their injury? Baseline physiology will impact a patients response to injury, and capacity for recovery.
  4. Does this patient take a medication that will impact or be impacted by this injury? Consider medications that may impact the trauma (ie. anticoagulants), affect the physiological response (ie. beta-blockers, calcium channel blockers, digoxin) or those which may have precipitated the trauma (ie. opioids, benzodiazipines, tricyclic antidepressants).
  5. Is this patients trauma the result of a destabilized/acute medical problem? The cause of trauma is often subtle and discriminating a trip and fall from a syncope is important.
Our 82 year old hip fracture is actually an 82 year old trauma patient. As we would with any trauma patient we should proceed with a complete assessment. we should do a primary survey (ABCDE), protect the C-spine, do a complete secondary survey and ask ourselves the above questions. Ancillary tests should be used liberally. In particular there are few (none) elderly trauma patients who should not have a chest x-ray and ECG. If the patient is altered, anti-coagulated or has external head injury liberal use of CT-head is advisable. The C-spine should also be considered and liberally imaged if tender or the mechanism suggests injury.

 

Trauma is usually portrayed as a dashing specialty area of emergency medicine. Trauma doctors are handsome, poorly shaved and sleep deprived heroes who save the lives of the young and beautiful when they play too hard and drive too fast. As a community emergency doctor I can only assume that this image of big trauma centres, as portrayed on TV, is completely accurate and I wish these heroes all the best, but trauma in my emergency room is often a little bit different.

I am frequently confronted by seemingly simple cases of elderly patients with supposed isolated trauma. By refusing to accept premature closure on these cases, and insisting on running them all as traumas I have been surprised by the frequency with with significant concurrent injury or unstable medical condition is discovered. Inter-cranial haemorrhage and rib fractures are particularly common concurrent injuries, and electrocardiographic explanations for syncope not infrequent. So the next time an elderly injured person arrives in your ambulance bay don’t just close the case and admit to ortho, hunt for injuries, and you will be surprised by what you find.