Behavioral Emergencies: Exams Bypassed in Aged

NEW YORK – Geriatric patients presenting to the emergency department with behavioral emergencies are often referred to psychiatric services without having a basic medical work-up prior to transfer, according to the findings from a small retrospective.

“Despite the fact that it is well-known that many psychiatric emergencies in the geriatric population have an organic etiology, and the American College of Emergency Physicians [ACEP] policy recommends that these patients be evaluated for medical illness before being transferred for psychiatric care, the medical work-ups are frequently not happening,” said Dr. Kathleen C. Diller, of Temple University Hospital in Philadelphia.

In a retrospective study conducted in an urban university-based psychiatric emergency setting, Dr. Diller and Dr. Ruth M. Lamdan of Temple University School of Medicine reviewed the charts of 105 patients aged 65 years and older who were seen in the university hospital's psychiatric emergency service between April 1, 2004, and March 31, 2007, and compared their clinical presentations, diagnoses, work-ups, and outcomes with those of 105 gender- and race-matched 18- to 64-year-old controls.

Compared with the controls, the geriatric patients were significantly more likely to present disoriented and on an involuntary commitment, to have significantly more medical diagnoses, to be on more nonpsychiatric medications, to present with psychosis or with cognitive impairments, and to be admitted to a psychiatric facility, Dr. Diller said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

Despite these differences, “the elderly patients were not more likely to be seen in the medical emergency department prior to or after presenting to the psychiatric emergency service, nor were they more likely to receive a medical work-up in the emergency department.”

Specifically, urinalysis was ordered for only 9.5% of the older group, and brain imaging was done in only 5.7% of them, Dr. Diller reported. “Documentation of complete cognitive evaluation was missing in 45.7% of the older adult examinations, and orientation evaluation was not done in 27.6% of them,” she said.

The geriatric patients included in the sample were more likely to receive some element of a medical work-up in the psychiatric emergency services, “but these were not guided by chief complaint of physical examination finding,” said Dr. Diller, who noted that ACEP recommends that medical evaluations be guided by patients' chief complaint.

Although limited by its retrospective design and by the possibility that older adults with significant medical comorbidities may have received a medical work-up in the emergency department and been admitted to medical facilities rather than referred to the psychiatric emergency service, the study findings suggest that many emergency clinicians were skipping even the most basic, inexpensive elements of the medical work-up, such as cognitive testing and urinalysis, Dr. Diller said.

Prospective comparisons are needed in order to make final recommendations for the emergency evaluation of the older adult who presents with psychiatric symptoms, but “specific protocols should be put in place to make sure all geriatric patients with psychiatric emergencies receive an adequate medical work-up,” Dr. Diller stated.

Toward this end, she recommended that geriatric screening protocols should be incorporated into residency training programs and that residents be reminded to have a heightened index of suspicion for medical illness as the cause of psychiatric symptoms in elderly patients.

In addition, she noted, “residents must be able to screen for delirium in all clinical settings, and psychiatric residents must be able to perform a directed medical work-up based on patient history.

Both Dr. Diller and Dr. Lamdan reported having no financial conflicts of interest with respect to this research.

NEW YORK – Geriatric patients presenting to the emergency department with behavioral emergencies are often referred to psychiatric services without having a basic medical work-up prior to transfer, according to the findings from a small retrospective.

“Despite the fact that it is well-known that many psychiatric emergencies in the geriatric population have an organic etiology, and the American College of Emergency Physicians [ACEP] policy recommends that these patients be evaluated for medical illness before being transferred for psychiatric care, the medical work-ups are frequently not happening,” said Dr. Kathleen C. Diller, of Temple University Hospital in Philadelphia.

In a retrospective study conducted in an urban university-based psychiatric emergency setting, Dr. Diller and Dr. Ruth M. Lamdan of Temple University School of Medicine reviewed the charts of 105 patients aged 65 years and older who were seen in the university hospital's psychiatric emergency service between April 1, 2004, and March 31, 2007, and compared their clinical presentations, diagnoses, work-ups, and outcomes with those of 105 gender- and race-matched 18- to 64-year-old controls.

Compared with the controls, the geriatric patients were significantly more likely to present disoriented and on an involuntary commitment, to have significantly more medical diagnoses, to be on more nonpsychiatric medications, to present with psychosis or with cognitive impairments, and to be admitted to a psychiatric facility, Dr. Diller said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

Despite these differences, “the elderly patients were not more likely to be seen in the medical emergency department prior to or after presenting to the psychiatric emergency service, nor were they more likely to receive a medical work-up in the emergency department.”

Specifically, urinalysis was ordered for only 9.5% of the older group, and brain imaging was done in only 5.7% of them, Dr. Diller reported. “Documentation of complete cognitive evaluation was missing in 45.7% of the older adult examinations, and orientation evaluation was not done in 27.6% of them,” she said.

The geriatric patients included in the sample were more likely to receive some element of a medical work-up in the psychiatric emergency services, “but these were not guided by chief complaint of physical examination finding,” said Dr. Diller, who noted that ACEP recommends that medical evaluations be guided by patients' chief complaint.

Although limited by its retrospective design and by the possibility that older adults with significant medical comorbidities may have received a medical work-up in the emergency department and been admitted to medical facilities rather than referred to the psychiatric emergency service, the study findings suggest that many emergency clinicians were skipping even the most basic, inexpensive elements of the medical work-up, such as cognitive testing and urinalysis, Dr. Diller said.

Prospective comparisons are needed in order to make final recommendations for the emergency evaluation of the older adult who presents with psychiatric symptoms, but “specific protocols should be put in place to make sure all geriatric patients with psychiatric emergencies receive an adequate medical work-up,” Dr. Diller stated.

Toward this end, she recommended that geriatric screening protocols should be incorporated into residency training programs and that residents be reminded to have a heightened index of suspicion for medical illness as the cause of psychiatric symptoms in elderly patients.

In addition, she noted, “residents must be able to screen for delirium in all clinical settings, and psychiatric residents must be able to perform a directed medical work-up based on patient history.

Both Dr. Diller and Dr. Lamdan reported having no financial conflicts of interest with respect to this research.

NEW YORK – Geriatric patients presenting to the emergency department with behavioral emergencies are often referred to psychiatric services without having a basic medical work-up prior to transfer, according to the findings from a small retrospective.

“Despite the fact that it is well-known that many psychiatric emergencies in the geriatric population have an organic etiology, and the American College of Emergency Physicians [ACEP] policy recommends that these patients be evaluated for medical illness before being transferred for psychiatric care, the medical work-ups are frequently not happening,” said Dr. Kathleen C. Diller, of Temple University Hospital in Philadelphia.

In a retrospective study conducted in an urban university-based psychiatric emergency setting, Dr. Diller and Dr. Ruth M. Lamdan of Temple University School of Medicine reviewed the charts of 105 patients aged 65 years and older who were seen in the university hospital's psychiatric emergency service between April 1, 2004, and March 31, 2007, and compared their clinical presentations, diagnoses, work-ups, and outcomes with those of 105 gender- and race-matched 18- to 64-year-old controls.

Compared with the controls, the geriatric patients were significantly more likely to present disoriented and on an involuntary commitment, to have significantly more medical diagnoses, to be on more nonpsychiatric medications, to present with psychosis or with cognitive impairments, and to be admitted to a psychiatric facility, Dr. Diller said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

Despite these differences, “the elderly patients were not more likely to be seen in the medical emergency department prior to or after presenting to the psychiatric emergency service, nor were they more likely to receive a medical work-up in the emergency department.”

Specifically, urinalysis was ordered for only 9.5% of the older group, and brain imaging was done in only 5.7% of them, Dr. Diller reported. “Documentation of complete cognitive evaluation was missing in 45.7% of the older adult examinations, and orientation evaluation was not done in 27.6% of them,” she said.

The geriatric patients included in the sample were more likely to receive some element of a medical work-up in the psychiatric emergency services, “but these were not guided by chief complaint of physical examination finding,” said Dr. Diller, who noted that ACEP recommends that medical evaluations be guided by patients' chief complaint.

Although limited by its retrospective design and by the possibility that older adults with significant medical comorbidities may have received a medical work-up in the emergency department and been admitted to medical facilities rather than referred to the psychiatric emergency service, the study findings suggest that many emergency clinicians were skipping even the most basic, inexpensive elements of the medical work-up, such as cognitive testing and urinalysis, Dr. Diller said.

Prospective comparisons are needed in order to make final recommendations for the emergency evaluation of the older adult who presents with psychiatric symptoms, but “specific protocols should be put in place to make sure all geriatric patients with psychiatric emergencies receive an adequate medical work-up,” Dr. Diller stated.

Toward this end, she recommended that geriatric screening protocols should be incorporated into residency training programs and that residents be reminded to have a heightened index of suspicion for medical illness as the cause of psychiatric symptoms in elderly patients.

In addition, she noted, “residents must be able to screen for delirium in all clinical settings, and psychiatric residents must be able to perform a directed medical work-up based on patient history.

Both Dr. Diller and Dr. Lamdan reported having no financial conflicts of interest with respect to this research.