|Year : 2020 | Volume
| Issue : 1 | Page : 51-57
Clinical profile of older adults presenting to psychiatric emergency services: A retrospective study from South India
Shiva Shanker Reddy Mukku1, Suchandra Hari Hara2, Palanimuthu Thangaraju Sivakumar1, Krishna Prasad Muliyala2, V Senthil Kumar Reddi2, Mathew Varghese1
1 Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
2 Emergency Psychiatry and Acute Care, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
|Date of Submission||14-Sep-2019|
|Date of Decision||01-Dec-2019|
|Date of Acceptance||12-Jan-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Palanimuthu Thangaraju Sivakumar
Department of Psychiatry, Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Older adults constitute an important subgroup among those presenting to psychiatric emergency services. Psychiatric emergencies in older adults are particularly understudied in India. Objective: The objective was to study the clinical profile of older adults presenting to psychiatric emergency services. Method: All case records of older adults (60 years and above) presenting to Emergency psychiatry and Acute care (EPAC) in a tertiary care Neuropsychiatric institute from July 2018 to December 2018 were reviewed. The details pertaining to sociodemography, clinical profile, medical comorbidity and clinical management were reviewed and analyzed. Results: 230 older adults were seen in EPAC during the study period. This constituted 6.7% of the 4200 patients of all age groups seen in EPAC during this period. The mean age of the study group was 68.77 years (standard deviation-7.23) with 61.30% males and 38.69% females. The frequency of individuals with at least one co-morbid medical illness was 62.6%. The common diagnosis was mood disorders (30.87%), followed by dementia (16.52%) and delirium (10.43%. Agitation/aggression (46.52%), confusion (31.74%), and risk of self-harm (13.47%) were the most frequent reasons for presentation to EPAC. Neuropsychiatric disorders (31.30%) and mood disorders (30.87%) constituted the most common diagnosis in the group. Among those who required parenteral sedation, lorazepam (18.7%) was the most preferred agent followed by haloperidol (16.1%). Discussion and Conclusion: Older adults in our study predominantly had depression, behavioral and psychological symptoms of dementia and delirium although the proportion of delirium is smaller when compared to western studies. The most common reason for older adults' visit to emergency was agitation/aggression which is in agreement to other similar studies. Nearly half were managed without emergency sedation. However, smaller proportion of patients received sedation with haloperidol and lorazepam. The study was done in a primary psychiatry setup where general medical emergency is not available. This could be the probable reason for lower prevalence of delirium in our study compared to previous studies which is a limitation.
Keywords: Delirium, older adults, psychiatric emergency, sedation, self-harm
|How to cite this article:|
Reddy Mukku SS, Hara SH, Sivakumar PT, Muliyala KP, Kumar Reddi V S, Varghese M. Clinical profile of older adults presenting to psychiatric emergency services: A retrospective study from South India. J Geriatr Ment Health 2020;7:51-7
|How to cite this URL:|
Reddy Mukku SS, Hara SH, Sivakumar PT, Muliyala KP, Kumar Reddi V S, Varghese M. Clinical profile of older adults presenting to psychiatric emergency services: A retrospective study from South India. J Geriatr Ment Health [serial online] 2020 [cited 2020 Jul 2];7:51-7. Available from: http://www.jgmh.org/text.asp?2020/7/1/51/288237
| Introduction|| |
Population ageing is a significant change in terms of demographics across the world. In India with 1.3 billion people, there is steady increase in the number of older adults. The older adult population was 25 million in 1950 which has increased to 103.9 million in 2011, constituting 9% of total population in India. This number is estimated to increase to 150 million by 2025 and 300 million by 2050. With increasing population of older adults, there is significant increase in the prevalence of noncommunicable diseases, contributing to increased morbidity and mortality. In terms of mental health and illness, older adults bring unique challenges such as isolation, frailty, bereavement, abuse and failing sensory organs. They also have higher prevalence of cognitive disorders such as delirium and dementia, comorbidity with medical illnesses, and propensity to drug-related adverse effects. All these can present as potential psychiatric emergencies.
Psychiatric emergency is defined as an acute disturbance of behavior, thought, or mood of a patient which if untreated may lead to harm, either to the individual or to others. The common psychiatric emergencies are suicidal self-harm behavior, catatonia, poor nutritional intake due to psychiatric condition, severe agitation and aggression, delirium and severe behavioral problems related to dementia. Severe adverse effects due to psychotropic drugs are also an important reason for visit to psychiatric emergencies in older adults., With current trends of growth in the population of older adults, there is an increase in number of older adults presenting to emergency departments. The older adults presenting to psychiatric emergency services pose several challenges in the assessment and management. There is limited literature available on psychiatric emergencies from India ,, and paucity of literature on psychiatric emergencies in older adults. The objective of this study is to investigate the clinical profile of older adults presenting with psychiatric emergencies. Another objective is to discuss the unique challenges associated with psychiatric emergencies in older adults.
| Method|| |
The study was conducted at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore. The study was approved by the institute's ethics committee. The retrospective review included all older adult patients aged 60 years and above who sought treatment from Emergency Psychiatry and Acute Care (EPAC) at NIMHANS from July 2018 to December 2018. All patients visiting EPAC had case record with unique identity number and along with EPAC register recording preliminary information and identity number. The case records subsequently were sent to the hospital medical record section after discharge of patient from EPAC as routine procedure. The hospital unique identity number of these patients were retrieved from the EPAC register maintained. Using the register database, the medical records of these patients were traced. The medical records were reviewed by two qualified psychiatrists (MSR, SCH). The details of sociodemography, clinical profile, medical comorbidity, diagnosis and management were extracted from the file records. Any disagreement on including or excluding the case in the final analysis was taken after discussion with a senior psychiatrist (PTS).
EPAC is a specialized psychiatric service run by the Department of Psychiatry, NIMHANS. EPAC is a 20-bedded, 24 × 7 tertiary care emergency service for patients presenting with psychiatric emergencies catering to all age groups. EPAC service team includes a postdoctoral psychiatrist, postgraduate trainee resident (every day on rotation) and a consultant psychiatrist with experience in emergency Psychiatry. EPAC team liaises with other specialties including the Geriatric Psychiatry services for the management of their respective patients. The EPAC team receives every patient with potential psychiatry emergency to their ward, assess the patients quickly along with specific indicated investigations and goes ahead with immediate plan on managing the emergency. Once patient is stabilized or acute issue gets better the patient will be transferred to respective Psychiatry unit for further care. Geriatric Clinic and Services, a specialized multidisciplinary unit with both outpatient as well as inpatient care for older adults, works in liaison with EPAC team in managing older adults presenting with psychiatric emergencies.
In emergency the diagnosis was initially made by postgraduate trainee as per International classification of disorders-10 followed by discussion with qualified psychiatrist (postdoctoral fellow) to reach at provisional diagnosis. In most cases the patients were given appointment on outpatient department basis for detailed interview where a definitive diagnosis is made.
The data gathered from the medical records of these patients were analyzed using descriptive statistics. The confidentiality of the patients was maintained using an alphanumeric code.
| Results|| |
Of 4200 patients across all age groups who presented to EPAC services during the 6 months' period, 280 were older adults. This constituted 6.7% of all the patients seen in EPAC. 35 patients were excluded from the study group as there was no clear indication for emergency consultation as per the case record. They would have been registered under EPAC due to some logistic reasons related to facilitation of their clinical care. Fifteen patients were excluded from the study sample as their case records were missing.
The mean age of patients was 68.77 years (standard deviation [SD] =7.23) with age ranging from 60 to 94 years. Among them males were 141 (61.30%) and female were 89 (38.69%). The median years of education of the sample was 5.0 years implying that most have up to primary level of education. In terms of marital status, 194 (84.3%) were married and continued to be with their spouse. In 36 (15.65%) of the cases, spouses had died at the time of presentation. 93 (40.44%) belongs to lower socioeconomic status and 137 (59.56%) belongs to either middle or upper socioeconomic status. Few others sociodemographic details are as shown in [Table 1].
The predominant reasons for the caregivers bringing patients to the emergency have been categorized. In patients with more than one factor we considered the most distressing and most acute one as the reason for consultation. Most common reasons for emergency consultation in descending order were severe agitation/aggression in 107 (46.52%), acute confusion/cognitive symptoms in 73 (31.74%), risk to self-harm/suicide in 31 (13.47%), risk to others/property in 11 (4.7%), catatonia in 5 (2.17%), and drug-related adverse effects in 5 (2.17%). The less common causes were panic attacks, acute onset headache, wandering, and disinhibition as shown in [Table 2].
The psychiatric diagnosis of these patients is shown in [Table 3]. Neuropsychiatric disorders were the most common group constituting 31.30%. Mood disorders constituted 30.87%. Psychotic spectrum disorders constituted 22.17% of the presentations and Substance use disorders constituted 10.87%. A small proportion of older adults presented with catatonia (2.17%), anxiety disorder (0.43%), and with adverse effects of psychotropic medications (2.17%) [Table 3].
|Table 3: Diagnostic spectrum details of elderly presenting to psychiatry emergency|
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When comparison was done gender wise there are was no statistical significant difference in terms of reasons for visit to emergency. However, with regard to diagnostic spectrum, psychosis spectrum and depressive spectrum disorders were higher in females than males, which was statistically significant, whereas men had higher frequency of substance use disorders. There was no statistically significant difference in the prevalence of delirium, dementia, bipolar disorders and neuropsychiatric conditions between both the genders as shown in [Table 4]. The investigative workup in our sample is shown in [Table 5]. 97.83% underwent EKG, blood investigations (Liver Function tests (LFT), Renal Function tests (RFT), serum electrolytes, random blood sugar) and 84.78% underwent neuroimaging (computed tomography [CT]-brain).
Nearly half the number of older adults, 124 (53.91%) received pharmacological therapy for immediate tranquilization to reduce the immediate risk to self and others. The pharmacological methods were tried in each case only after reasonable application of psychological intervention. The decision to give pharmacological agents was taken after weighing the risk and benefits and discussion with family members of patient which was done as routine practice in our setup. Parental tranquilization was received by 63 (27.15%) of older adults. The most common antipsychotics used parenterally was haloperidol (16.1%). The most common parenteral benzodiazepines (BZD) used was lorazepam (18.7%). Oral tranquilization was received by 61 (26.5%) of older adults. The common psychotropic used orally was antipsychotic - 14.35% (in descending order were quetiapine, risperidone, and olanzapine) followed by BZD - 12.17% (in descending order were lorazepam, clonazepam, and diazepam) as shown in [Table 5]. In terms of chlorpromazine equivalents, the mean dose of antipsychotic given was 118 mg (SD - 99.5). BZD received alone or with antipsychotics constituted 30.86% of sample. Among those received BZD, 14.78% had mood or psychotic disorders, 10.87% had alcohol dependence syndrome, 3.04% had neuropsychiatric conditions, and 2.17% had catatonia.
In terms of outcome after the brief assessment and intervention, 58 (25.22%) older adults were admitted for detailed evaluation and management. Few older adults on brief evaluation found to have medical issues either contributing directly to the current condition or present as acute comorbidity were referred to neurology/neurosurgery (2.6%), cardiology (2.17%) and General hospital (11.30%) depending on the condition. Majority of the patients (58.7%) were discharged after acute intervention. These patients were given specific outpatient department appointment for subsequent evaluation and management. Amongst them, 43.48% older adults returned to the outpatient clinic. Nearly, 15.22% were lost to follow-up.
| Discussion|| |
Older adults presenting to emergency psychiatry services for acute issues though constituted only a minority, it was nearly proportional to the proportion of older adults in India. The older adults group presented with psychiatric emergencies such as agitation/aggression, confusion, risk of suicide/self-harm, poor food intake secondary to psychiatric condition and acute neurological deficits with behavioural manifestation.
The literature on older adults presenting with psychiatric manifestation to Emergency department is sparse. According to the 2011, Centre for Disease Control and Prevention National Hospital Ambulatory Medical Care Survey, almost 15% of total visits to Emergency department comprised patients with age 65 years and older. A cross-sectional study in tertiary care center from northern India evaluated psychiatry comorbidity in older adults presenting to medical emergency. They found 62% psychiatric comorbidity, with delirium being the commonest disorder seen in one-third of patients. Another study from tertiary care center from north-east studied the referrals to psychiatry emergency retrospectively over a period of 1 year. This study reported a referral rate of 2.8% with stress-related and somatoform disorders being the commonest diagnostic group. This study included patients across all age groups. A prospective study from Chandigarh investigated the pattern of psychiatric referral from medical emergency in 2002. The study reported the psychiatric referral constituted only 1.42% of all patients presented to medical emergency. The most common diagnosis was substance use disorder, followed by dissociative disorder. The common presenting symptoms were pain/numbness, palpitation, sadness of mood, and substance related withdrawal. In a systematic review by Barratt et al. that included 18 observational studies of patients attending Emergency department with mental health issues, 4% of those had presented with Psychiatric emergencies. The commonest reason for emergency department visit was self-harm/suicidal ideation and among them 58% had psychiatric illness. In another study on patients attending with mental health issues to emergency, the commonest reason was found to be depressive symptoms, agitation and psychoactive substance use. The commonest diagnosis were substance use disorders and depressive disorders. In latest systematic review by Barron and Holmes, among the patients admitted to the emergency department, 7%–20% had delirium. The drawback of this review was that many studies included in this study used nonvalidated scales to screen delirium. A retrospective study from USA studied the data on the older adults presenting to Emergency department with psychiatric emergencies and later referred to psychiatry team. The study reported that the most common reason in older adults for emergency visit was delirium (61.6%) followed by anxiety disorders (16.7%) and mood disorders (12.3%). However patients with delirium were less often referred to psychiatry team compared to older adults with other psychiatric presentations. In our study, the most common reason for emergency visit was agitation/aggression followed by confusion/cognitive symptoms and risk of self-harm. The most common diagnosis of older adults in our study was neuropsychiatric disorders and mood disorders which is slightly different from the above studies. In our study delirium constituted only 16.08% (including delirium tremens) which is lower in comparison to the studies mentioned earlier. This could be due to the difference in the clinical setting being psychiatric rather than general medical setting. Delirium and substance use has higher prevalence in general medical emergency. In our study, the prevalence of substance use is lower compared to other studies which included all age groups.
The prevalence of chronic medical illness increases with age from 39% in 60 to 64 years to 55% in those older than 70 years. Another study found that morbidity among the older adults is higher in the urban areas as compared with the rural areas. A survey conducted in seven states of India in 2011 on chronic diseases and disability in older adults reported 73 per cent have at least one physical disability. In our study, 62.5% of older adults had one or more chronic medical illness and patients with two or more medical illness were 33.5%. The commonest medical illness was hypertension followed by diabetes and ischemic heart disease which is in agreement with other studies on older adults in India. In our study there was higher proportion of males (2/3rd) compared to other studies showing female preponderance. This could be due to cultural factors influencing the gender differences in those seeking emergency care.
In terms of gender differences, our study found no significant difference in the prevalence of neuropsychiatric conditions (delirium, dementia, other neuropsychiatric conditions), which was similar to study by Grover et al. who reported no differences gender wise in delirium and dementia. However, females predominate in psychosis and depressive spectrum, whereas male predominate in bipolar and substance use disorders which was in agreement with previous studies.,,, Older adults require laboratory investigations as part of evaluation for their acute condition as well as to know the status of their chronic medical illnesses. In our study, majority of patients have undergone investigations. This could possibly be due to higher suspicion of neuropsychiatric conditions which was also reported in earlier studies on older people presenting with psychiatric emergencies.
There are few studies on usage on pharmacological agents in older adults mainly from developed countries. A retrospective study from Australia reviewed the management of 43 acutely ill older adults with agitation and behavioral problems with predominant diagnosis of dementia (72%). It was found that pharmacological sedation was used in 88% patients among them 19% had received parenteral sedation. Another study from UK retrospectively looked at the safety of sedation in older adults received during the emergency visits. The study reported that, of the 740 older adults who received sedation, there were 19 severe adverse events recorded. In that 10 had apnea, 5 had hypotension, 2 had hypoxia, and another 2 had both hypoxia and hypotension. The type of agent received in descending order were propofol, followed by morphine and midazolam. In our study, 53.91% of older adults received pharmacotherapy for acute management of symptoms. The commonest parenteral antipsychotic used was haloperidol and oral antipsychotic used was quetiapine which in agreement with previous studies., In terms of BZD the commonest parenteral as well as oral agent used was lorazepam. The BZD use in our sample can be understood by nature of presenting illness per se (substance use disorders, mood disorder, psychotic disorders or catatonia) as an indication., In retrospective study by Silwanowicz et al., inferred from their data that dementia patients with behavioral problems are likely to receive psychotropics which was reflected in our study which included significant number of dementia cases. In our sample nearly half of older adults were managed with brief behavioral/psychological intervention. This in contrary to the earlier studies where high percentage studies of older adults required pharmacotherapy.
The guidelines on management of agitation or acute behavioral problems in older adults includes risk assessment and finding the underlying the etiology for agitation., The guidelines recommend to use nonpharmacological techniques as initial method of management in all older adults presenting with agitation/aggression as was done in our sample. In older adults whose agitation/aggression cannot be managed by nonpharmacological methods, physical restraint can be used briefly after weighing the risk and benefits with frequent monitoring. Then comes the psychotropic medication for controlling acute behavioral problems in older adults. The evidence for using the pharmacological treatment for acute agitation/aggression comes primarily from studies on delirium and dementia. The first generation antipsychotic low dose haloperidol found efficacy comparable to atypical antipsychotics in older adults with delirium. Haloperidol also has shown effectiveness in controlling aggression in dementia compared to placebo. However the use of first generation antipsychotics is not recommended in cases with possible Diffuse Lewy body dementia More Details (DLBD), visual hallucination or fluctuating cognition. In case of atypical antipsychotics, low dose intramuscular (IM) olanzapine was found to be superior to placebo in controlling acute agitation in dementia in a meta-analysis of three studies. IM olanzapine was also found to be better than lorazepam in decreasing the agitation at 24 h after the last dose. Risperidone is another atypical antipsychotic though indicated for severe agitation and psychosis in dementia, it was not particularly studied in emergency setting. BZD were another class of agents used often for controlling acute agitation in emergency setup. Though a range of BZD were being used, lorazepam was studied at an randomized controlled trial level and found to be superior to placebo. BZD are considered safer to antipsychotics but in older adults, BZD can increase the risk of falls, aspiration, excessive drowsiness, paradoxical reaction and respiratory depression. Overall the evidence guiding the using the psychotropics for acute behavioral problems in older adults with psychiatric conditions is limited.
Managing older adults with acute behavioral issues in emergency department is associated with several challenges. The challenge begins with collecting accurate history from older adults due to their sensory impairments, confusion and memory disturbances. Another challenge is ensuring the safety of older adults in emergency setting in view of frailty, sensory function impairments, confusion, medical illness, tendency to fall which requires more staff and infrastructure to manage. Older adults often have medical illnesses either chronic or acute which present with psychiatric manifestation and requires a multidisciplinary team to manage. This may not be available in many centers. As mentioned in our study, majority of patients undergone neuroimaging due to neuropsychiatric manifestation and atypical presentation of psychiatric disorders. Accessibility to these investigations is another challenge in developing countries like India. Poor tolerability, risk of adverse effects and limited evidence on pharmacotherapy on the management of confusion, agitation, and aggression is another challenge while treating older adults at emergency department. Availability of consultation liaison psychiatry or geriatric psychiatry services in India are restricted to larger cities as of now. In most places either general psychiatrist or emergency physician with minimal experience in handling older adults are only available to provide services.
To summarize, our study found that older adults coming with psychiatric emergencies had high prevalence of neuropsychiatric conditions and mood disorders. Many older adults required basic blood investigation and CT-brain for evaluation. Though majority had medical comorbidities only few required referral for behavioral issues primarily due to medical illness or decompensated medical illness. Majority of older adults were managed with brief behavioral interventions without pharmacotherapy in emergency. In most hospitals with psychiatrist working as on-call duty with medical team, there is a need for increasing the awareness on neuropsychiatric conditions and psychiatric emergencies commonly seen in older adults among medical doctors. Along with above it is advisable to use pharmacotherapy with caution in older adults with psychiatry emergencies.
| Conclusion|| |
Older adults are known to present to emergency department with a variety of psychiatric and neuropsychiatric symptoms. Often the management is complicated by the poor history, medical illnesses and many psychosocial issues. The available literature of psychiatric emergencies in older adults was done predominantly on delirium and dementia. In our study commonest presenting symptom to emergency was agitation/aggression, confusion and risk of self-harm. The commonest diagnostic group in our study was neuropsychiatric disorders followed by mood disorders. Nearly half of patients were managed without pharmacological agents for acute management. Our study highlight that though older adults have medical comorbidity and neuropsychiatric conditions, majority can be managed by a psychiatrist with behavioral interventions and with judicious use of psychotropics. However, there is need for larger prospective studies to formulate guidelines with respect to use of sedation in acutely disturbed older adults in emergency settings.
The limitations of our study include retrospective design and lack of comparison group. Others limitation was lack of structured assessments used in emergency services for diagnosis. Lack of structured assessment to quantify the severity of psychiatric emergency is another limitation. The follow-up details of these patients in our sample were not looked into which is a limitation. The study was done in a primary psychiatry set-up where general medical emergency is not available. This could be the probable reason for lower prevalence of delirium in our study compared to previous studies which is another limitation.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]