ELDERLY PATIENTGeneral Medical Emergencies 119Disordered behaviour in the elderly
A breakdown in a patient’s normal, socially acceptable behaviour is best
con sidered in three broad categories, that can overlap and or be mistaken for each
other:
● Delirium – acute transient organic brain syndrome with global disorder of
cognition
● Dementia – progressive intellectual decline
● Depression – pathological, unrelenting and disabling low mood.
DIAGNOSIS1 Delirium (see p. 81)
(i) This includes clouding of consciousness, inattention and failure
of recent memory.
(ii) It results in an acute or fluctuating confusional state associated
with restless sometimes aggressive behaviour and non-auditory
hallucinations. It is often worse at night.
(iii) Causes are many, including:
(a) infection – pneumonia, urinary tract infection (UTI),
cholecystitis, septicaemia
(b) hypoxia – respiratory disease, heart failure, anaemia
(c) cerebral lesion – haematoma, tumour, infection, stroke
(d) iatrogenic – many drugs (remember poisoning, both
accidental and deliberate), alcohol
(e) metabolic – including dehydration, electrolyte imbalance,
hypoglycaemia or hyperglycaemia and thyroid disease
(f) urinary retention, faecal impaction, pain, cold or change in
environment (these are rarely the sole cause).
2 Dementia
(i) This includes disorientation in place, time and person, abnormal
or antisocial behaviour, short-term memory loss, loss of intellect,
and loss of insight. There is no clouding of consciousness.
(ii) The causes are many, although a definitive new diagnosis is
seldom made in the ED.
(iii) However, look for and exclude the causes listed in 1 (iii) above if
a known demented patient is brought into the ED with a recent
deterioration.
3 Depression
(i) This includes difficulty in sleeping, demanding, anxious or
withdrawn behaviour, hypochondriasis, a loss of self-interest and
a sense of futility.
(ii) Suicide is a particular risk, especially if the patient lives alone
and is physically incapacitated, or has made previous attempts at
suicide.