Delirium, Dementia, and Neuropsychiatric Disorders

Almost 25% of elders treated in Emergency Departments have altered mental status as a result of dementia, delirium, or both (Hustey, 2002; Jacqmin-Gadda, 2013). The incidence of dementia in these patients is directly proportional to their age, increasing from 12.7% per year in the 90- to 94-year-old age group, to 21.2% per year in the 95- to 99-year-old age group, to 40.7% per year in the 100+ age group (Corrada, 2010). Some of these elder patients who present to the ED with cognitive deficits are at their baseline level of functioning; for others, however, their altered mental status represents a subacute or acute deterioration precipitated by the emergent medical condition or injury for which they were seeking treatment. The ability of the clinician to obtain an accurate history and physical examination in the ED can often be limited. Moreover, the ED visit only represents one point in the timeline of the patient’s life. Since it is difficult to ascertain the baseline, the degree of acute alteration and the exact cause for the impairment can be difficult to discern. Altered mental status in elder patients contributes to prolonged ED stays, increased use of imaging studies, and delays in diagnosis and disposition, which lead ineluctably to the increased rate of admissions that is commonly seen in this elder patient population.

It has long been suggested that women have a higher rate of dementia than men, particularly the dementia of Alzheimer’s disease (AD). Since women have a longer life expectancy than men, and the risk for AD increases with age, this association does not seem to be particularly surprising. Researchers have reported that the risk for developing AD is consistently greater in women, a finding highlighted in a meta-analysis of four European population-based studies from the 1990s (Andersen, 1995; Azad 2007). Several explanations have been proposed for this observation. One focuses on anatomical differences between men’s and women’s brains: Women have a lower volume of gray matter, a thinner cortex, and decreased brain weight, findings that have been correlated with cognitive deficits and a greater incidence of dementia (Luders, 2002; Ikram, 2010). Another explanation focuses on the fact that men have a higher cognitive reserve than women; this reserve may support the delayed onset of dementia and cognitive decline. The cognitive reserve in men is a result of multiple socioeconomic factors: In the past, men have achieved a higher overall level of education and have worked at more cognitively challenging jobs (Stern, 2010; Letenneur, 2000). Women now surpass men in their level of education and are garnering more cognitively challenging jobs; thus, if these factors are at work, the gender gap in the prevalence of AD should close or even reverse. Other hypotheses suggest the influence of sex-specific hormones on the development of AD and gender bias in diagnostic work-ups, which may lead to a falsely increased prevalence or earlier diagnosis in women. Aside from increasing age, other risk factors for the development of dementia are sex specific. Among men, heart failure, Parkinson’s disease, a family history, and mild depression were significant risk factors, while among women both mild and severe depression, increased fasting blood sugar, and a BMI <24 were significantly associated with AD (Noale, 2013).

The issue of gender and dementia remains controversial. Several recent studies, controlling for life expectancy, level of education, and cardiovascular risk factors, reported equivalent rates of AD and vascular dementia by gender. The literature also suggests that in patients with AD, male gender is associated with a greater mortality (Todd, 2013). But this too remains controversial. It may very well be that there are more women with dementia today simply because there is positive selective pressure favoring the survival of women; men die before they develop AD. A further confounding factor is that men who develop AD have a shorter lifespan than women with AD (Chene, 2014). Clearly these issues await further research.

Delirium is an acute alteration in sensorium or a change in cognition with a waxing and waning of consciousness. Delirium is a significant problem seen in patients in Emergency Departments, inpatient wards, ICUs, and nursing homes. Up to 10% of older ED patients are diagnosed with delirium. Approximately 1.5 million older patients with delirium will be evaluated in the ED each year in the United States (Han, 2009; Elie, 2000).

Delirium complicates up to 20% of hospital admissions for patients >65 and can lead to significant delays in treatment and soaring health care costs (Inouye, 2006). In the oldest-old, delirium was also associated with worsening dementia severity (OR 3.1, 95% CI, 1.5–6.3) as well as deterioration in global function score (OR 2.8, 95% CI, 1.4–5.5) (Davis, 2012). Delirium can often mask underlying medical problems and lead to difficulties in diagnosis: A delirious patient can rarely provide a useful history or participate in a meaningful physical examination. Delirium itself may be difficult to recognize, as it may fluctuate in severity over time. Delirium may be the only presenting symptom of a number of serious medical conditions such as sepsis, stroke, intracranial hemorrhage, or MI. Thus prompt recognition, diagnosis, and treatment of the underlying condition may be lifesaving. Delirium in older ED patients is an independent predictor of increased six-month mortality. Unfortunately, as many as 50% of patients presenting with delirium have a preexisting dementia, making the differentiation between the two entities problematic for emergency medical clinicians caring for these patients (Kakuma, 2003). Delirium in elders is misdiagnosed by emergency medicine practitioners in up to 75% of cases (Hustey, 2003). Many studies demonstrate the association of delirium with prolonged hospital stay, the need for institutionalization, and an overall increase in mortality in elderly patients, reinforcing the importance of early recognition and treatment. The risk factor most strongly associated with delirium is preexisting dementia, followed by medical illness, alcohol abuse, and depression (Elie, 2000). While these conditions have clear gender specificity, research focusing on the presentation and diagnosis of delirium in the ED has not focused on gender at all. This area of clinical significance has great research potential.

Gender differences have been demonstrated in postoperative delirium, a condition that is more common among elderly patients, with incidence rates as great as 55% depending on the type and duration of surgical procedure (Allen, 2012; Ansaloni, 2010). Longer and more critical surgery is associated with greater rates of delirium. In a study of orthopedic surgery patients, men were twice as likely as women to suffer from postoperative delirium after hip fracture repair (Endo, 2005). Additionally, those men were more likely to exhibit the hyperactive form of delirium with signs of aggression and over-agitation, requiring the use of antipsychotic medications with their attendant side effects and morbidity. Women with preoperative dementia were more likely to suffer postoperative delirium, while men without preoperative dementia had a greater incidence of delirium (Lee, 2011). Women also have the additional risk factors of greater age and lower BMI; consequently, women treated acutely for hip fractures should be evaluated for dementia; clinicians should be prepared for early diagnosis and intervention of acute postoperative delirium in women who screened positive.

Mental illness in elders is common and contributes to significant morbidity and increased risk of mortality, especially when associated with other comorbid conditions. Psychiatric illness in older adults is often unrecognized and, even when properly diagnosed, often undertreated. Inadequately treated psychiatric illness in elderly patients can lead to a lower overall quality of life, increased use of medical resources, frequent ED visits, and institutionalization (Katon, 2003; Licht-Strunk, 2009). The patient’s family, the primary care provider, or the patient him- or herself may mistake the early, subtle signs and symptoms of psychiatric illness in elders for normal aging or dementia. The provider must remember that even though elders often experience an increase in the frequency and severity of chronic and acute illness, a decrease in functional status, and the premature loss of loved ones and friends, the development of depression or other mental illness is never a “normal” or acceptable consequence of these events.

The three most common major psychiatric disorders encountered in elderly patients are depression, bipolar disorder, and schizophrenia. Late onset depression is the most common geri-psychiatric disorder. This diagnosis includes those patients who have had a past (even distant) history of depression who now present with a depressive episode, and others who develop their first depressive episode after the age of 65. Clinically significant depressive symptoms affect between 8% and 20% of elders (65+) and are associated with increased morbidity (Barry, 2008). In a study by Luppa, 38.2% of patients older than age 75 reported symptoms on a commonly used instrument (the CES_D) consistent with depression. Depressive symptoms in these patients were significantly associated with divorced or widowed marital status, low educational level, poor self-rated health status, functional impairment, mild cognitive impairment, stressful life events, and poor social network (Luppa, 2012).

Depression in elders (as in their younger peers) is more common in women. Elder women who are not depressed are more likely than men to become depressed and are more likely to remain depressed; depressed women are less likely to receive aggressive pharmacologic treatment but are also less likely to die while depressed (Barry, 2008). More than 7% of women older than age 65 have clinically significant major depression (McGuire, 2006) and up to 12% have symptomatic depressive disorders (Luppa, 2012). This high prevalence has important medical implications, as depression in this demographic group is correlated with an increased frequency of falls, a greater probability of an unhealthy BMI, a greater overall likelihood of ED and outpatient visits, and a higher incidence of fractures.

Several factors may account for this gender discrepancy. Men are less commonly diagnosed with depression than women. Elder men present differently, often coming to medical attention because of anger, agitation, anhedonia, withdrawal, or apathy. Men are less likely to acknowledge or admit feelings of sadness. Men with non-dysphoric depression showed overall poorer long-term outcomes and an increased risk of death at 13-year follow-up than women (Marcus 2005; Crossett, 2004). Men were also less likely to seek help for their symptoms from a physician or mental health professional and had higher successful suicide rates than women (Callanan, 2012). While adults >65 make up 13% of the total population, they account for 24% of completed suicides in the United States. White men older than age 85 have the highest rate of successful suicides with an incidence of 55 per 100,000. Most were in their first episode of depression at the time of successful suicide (Yeates, 2002).

Bipolar disorder and schizophrenia account for a significant proportion of mentally ill older adults. Unlike younger bipolar patients, whose prevalence is roughly equal among men and women, geriatric patients with bipolar disorder tend to be mostly female – approximately 69% according to an epidemiologic review of 17 studies (Depp, 2004). Similarly, women account for the majority of patients presenting with late onset schizophrenia and schizophrenia-like psychosis, with a ratio of approximately 3:2 women to men. This finding is vastly different from that of younger cohorts, in which men with new onset schizophrenia predominate at a ratio of 1.4:1 (Howard, 2000; Haffner, 2003)). One interpretation is that women are more predisposed to psychiatric illness later in life; however, the ratio of women to men increases with age. It could simply be that female longevity accounts for this age discrepancy. Regardless, it is important to suspect, identify, and diagnose psychiatric illness in elderly patients and make appropriate referrals for evaluation to facilitate prompt effective treatment, ameliorating or avoiding adverse outcomes including the increased morbidity and mortality often associated with these disorders.

Traumatic Injuries

Trauma remains a major cause of morbidity and mortality among older adults. Patients older than age 65 account for almost 25% of all trauma patients; in fact, trauma has become the fifth leading cause of death within this population after cardiovascular, neoplastic, cerebrovascular, and pulmonary diseases. The elderly account for 5.9% of all injury-related ED visits. Their rate of injury increases rapidly after age 75; the prevalence of fractures and open wounds is up to five times greater for patients older than age 85 as compared to those between 65 and 75. Treating the injured elderly in the ED costs twice as much as treating younger patients. Elders are also twice as likely to require EMS transport and are five times more likely to require hospital and intensive care admission (Schwartz, 2005).

Every year, more than a third of all elderly sustain falls. Falls account for two-thirds of elders’ accidental deaths, followed by motor vehicle accidents. Polypharmacy is a leading risk factor for elder falls, but only if the patient is taking one of the established fall risk-increasing drugs (diuretics, quinine and derivatives, or psychotropics) (Ziere, 2006). Additionally, the distinct anatomy and physiology of elder patients increase their susceptibility to trauma and predispose them to specific types of injury patterns. While both men and women are predisposed to fall injuries and subsequent hospitalizations, older women are more likely to fall than older men and account for approximately two-thirds of falls (Stevens, 2005). Falls increase dramatically with age; they are four to five times more likely to occur in elders older than age 85 as compared to those between the ages of 65 and 85. Women older than age 65 who fall are much more likely to be injured than those who are younger. Women were more likely than men to inform others of their fall. Not surprisingly, these women were more likely than men to seek treatment in an Emergency Department. They were also more likely to need hospitalization for their traumatic injuries. Nevertheless, if men required hospitalization, their length of stay for acute care and rehabilitation exceeded that of women, and they were less likely to return to their homes and independent living (Close, 2012). The types of sustained injuries, responses to treatment, and overall outcomes also differ between elderly men and women. For example, elder men were 43% less likely than women to have any kind of fracture and less than half as likely to have a hip fracture (Schwartz, 2005). They were also less likely to have a contusion but significantly more likely to have an open wound.

The reasons for elder women’s increased rates of significant injury, ED use, and hospitalization from falls have not been fully elucidated and are difficult to explain, especially in light of women’s decrease in physical activity with advancing age. Women are more likely to limit their physical activity as they age compared to men, probably in part due to their age-related greater fear of falling, often in the setting of osteoporosis. Older men (similar to younger men) tend to engage in higher risk behavior that is not in keeping with their actual physical and balancing skills (Etman, 2012). It has been well established that elders who live alone are more likely to sustain falls, and women who live alone were more likely to sustain falls than men living alone, women living with men, or women living with other women. The positive effect of social support is seen in elders of Hispanic ethnicity who have a reduced risk of fatal falls across all age and gender subgroups, likely reflecting the cultural values of familia (Landy, 2012). As women have historically outlived men, more older women are living, and living alone, who are at a greater risk for falls. Women’s propensity to seek medical attention after a fall may also lead to a greater number of recorded injuries among women (Painter, 2009). From a preventive health perspective, both elder men and women who were treated in an ED for fall-related injuries had a higher likelihood of one or more previous ED visits in the prior year. Furthermore, women with a history of Colles wrist fracture had a lifetime hip fracture risk of 13%. Those with spinal fracture had a risk of 15% as compared to the general population of elderly women, who had a rate of 9% (Haentjens, 2004). Thus, ED treatment for non-hip fracture injuries or illness can provide opportunities for identifying patients at risk for falls, implementing screening, and initiating falls prevention intervention programs to help prevent further serious or fatal injury.

Hip fractures, with an annual incidence of more than 200,000 cases and a cost of more than $10 billion, are the most expensive, morbid, and prevalent fractures among the elderly (Gerson, 2004; Braithwaite, 2003). A majority of elders sustaining these fractures lose significant function; six-month mortality approaches 20% and almost a quarter will require skilled nursing facility placement (Hawkes, 2006). The lifetime risk of hip fracture is about 14% for postmenopausal women and 6% for men (Kanis, 2008). Fracture rates are highest for white women and lowest for black men in all age groups more than age 70 (Trombetti, 2002).

The higher rates of fracture among women can be attributed to more frequent falls, longer life span, and lower bone mass and bone density. The higher prevalence of osteoporosis in elderly women contributes significantly to the greater incidence of injuries in women who do fall. Bone mass for both men and women peaks at age 30 and declines at a rate of approximately 0.5% per year for men and 1% per year for women (Schuit, 2004). The decline of estrogen during menopause further contributes to the rapid progression of osteopenia in this population, making them much more susceptible to fractures (Ensrud, 2007). Women who suffer hip fractures have lower body weight and are taller than those who do not and tend to have less soft tissue covering the hip; the average BMI for these women is <27 (Kanis, 2008).

Although women are almost twice as likely to sustain hip fractures than men, men with hip fractures have a higher mortality rate than women (15% at one month vs. 10%) and are twice as likely to die within the first year after sustaining this injury (Gerson, 2004; Trombetti, 2002). Male gender also seems to be an independent risk factor for postoperative complications such as pneumonia and heart failure in patients with hip fractures (Roche, 2005). At the time of fracture, men tend to be older than women, suffer from more comorbid conditions, have diminished capacity for completing activities of daily living, and are more likely to live in a nursing home and to suffer from depression (Moore, 2009); these factors probably are responsible for the increased mortality. Although moderate drinking has not been demonstrated to increase the risk of hip fracture, heavy alcohol use has been associated with a higher incidence of hip fracture among men.

Depression, more prevalent in elderly women, is strongly associated with hip fractures. In a five-year study of all fractures among 7,518 older women, depressed women had a rate of hip fracture 40% higher than women who were not depressed (Forsen, 1999). This relationship has been attributed to the diminished bone density associated with depression from a decreased propensity to exercise, poor nutrition, alcohol and tobacco use, and the correlation of SSRI use with osteoporosis (Diem, 2007). Insomnia and anxiety can cause sleep deprivation, and pharmacologic treatment with anxiolytics, antidepressants, psychotropics, and sleep medications can result in difficulty concentrating, ignoring environmental hazards, impaired gait and reaction time, and balance disturbance, predisposing the patient to falls. Hormone replacement and calcium supplementation seem to lower the risk of hip fracture among depressed older women (Greenspan, 2003; Hlatky, 2002).

For survivors of hip fracture, disability remains a serious concern (Roche, 2005). Gender may be associated with outcome, as women are more likely to experience moderate disability and men to experience severe disability and increased mortality (Endo, 2005; Holt, 2008). Depression has been associated with delayed recovery and with lasting disability after hip fracture for both men and women. A prospective survey of 374 hip fracture patients hospitalized over a six-month period identified strong correlations between anxiety or depression and severe disability for both sexes (Bertram, 2011).