1. Differentiating Medical from Psychiatric Disease Dr Peter Jordan Registrar Teaching Northern Hospital 2013

2. Case 1 0220 27 YO Female – Known to CATT Increasing agitation 12/24. HR 122 RR 30 BP 130/70. Cannot accurately record temp (combative) Assessment – Non cooperative – Responding to hallucinations DDx?

3. Evidence Limited largely to surveys/ consensus guidelines Increasing number of prospective trials Approx 25% populations suffer from some form of mental illness 3% ED presentations acute behavioural disturbance 1% Self harm

4. Elderly If>70 40% have altered mental state Elderly patients admitted to the hospital with delirium - mortality 15%-30% 30% of patients older than 64 presenting to ED = clinically depressed - 75% missed by ED doctors Drug toxicity or withdrawal accounts for up to 30% of all cases of delirium Meldon S, Emerman C, Schubert D. Recognition of depression in geriatric ED patients by emergency physicians. Ann Emerg Med 1997;30:442-447.

5. Drug/ alcohol Approx 10% alcohol dependence at some point 5% Drug dependency (life time) Drug dependent - 50% have comorbid psych illness

6. Medical Causes Approx 4% missed Frequency: Infectious Pulmonary Thyroid Diabetic Hematopoietic Hepatic CNS disease

7. Findings suggestive of a medical cause Late age (over 40) of onset No past history of psychiatric illness Sudden onset of altered behavior Presence of a toxidrome Visual hallucinations Known systemic disease with new-onset behaviour change New medication temporal relattionship to a convulsive seizure Abnormal vital signs Disorientation Clouded consciousness

8. Etiology Meningitis/ sepsis Electrolyte abnormality (Na/ Ca) Hypoxia Endocrine Hypoglycaemia (hyper) Thyroid hypopararathytoid (Ca > 1.4) Hypocortisolaemia

9. Definitions: Delirium - Delirium is a disturbance of consciousness that occurs over a short time and primarily affects attention, with subsequent impairment of other cognitive functions Memory impairment usually involves recent memory Develops abruptly and often fluctuates over the course of the day

10. Clinical Features: Onset Delirium: Sudden Dementia: Insidious Psychosis: Sudden Consciousness Delirium: Reduced Dementia: Clear Psychosis: Clear

11. Attention Delirium: Globally disordered Dementia: Normal except in severe cases Psychosis: May be disordered Cognition Delirium: Globally disordered Dementia: Globally impaired Psychosis: Selectively impaired

12. Hallucinations Delirium: Usually visual Dementia: Often absent Psychosis: Predominantly auditory Delusions Delirium: Fleeting, poorly systematized Dementia: Often absent Psychosis: Sustained, systematized

13. Orientation Delirium: Usually impaired, at least for some time Dementia: Often impaired Psychosis: May be impaired Psychomotor activity Delirium: Increased, reduced, or shifting Dementia: Often normal Psychosis: Varies—hypo- to hyperactive

14. Speech Delirium: Often incoherent, slow or rapid Dementia: Perseveration, difficulty finding words Psychosis: Normal, slow, or rapid Involuntary movements Delirium: Often asterixis or coarse tremor Dementia: Often absent Psychosis: Usually absent

15. 24-hour course Delirium: Fluctuating, varies at night Dementia: Stable Psychosis: Stable Physical illness or drug toxicity Delirium: One or both present Dementia: Often absent, especially in Alzheimer’s type Psychosis: Usually absent

16. Anxiety “Anxiety is the space between the ‘now’ and the ‘then.’”— Richard Abell If a patient has a panic attack after age 35, and there is no clear-cut psychological precipitant,suspect a medical cause; hyperthyroidism, hypoxia, hypoglycemia, or drug toxicity

17. Emergency Department Evaluation Four screening criteria for identifying patients with medical illness: disorientation abnormal vital signs clouded consciousness age over 40 with no previous psychiatric history Dubin WR, Weiss KJ, Zeccardi JA. Organic brain syndrome. The psychiatric impostor. JAMA 1983;249:60-62.

18. Priorities Safety - ?search Chemical +/- physical restraint Supportive Care Food/ drink Minimise stimuli Orientating stimuli = friends Reassurance

19. Clinical Assessment Sit/ Listen Non threatening distance/ demeanour Sensitivity for Detecting Medical Cause: History – 94% Exam – 51% Vital signs – 17% Path – 20% Olshaker JS, Browne B, Jerrard DA, et al. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124- 128

20. History “If you talk to God, you are praying; if God talks to you, you have schizophrenia.”—Thomas Szasz The presence or absence of a past psychiatric history is one of the most important determinants of psychiatric vs. medical illness. Most alert adult patients with new psychiatric symptoms who present to the ED have an organic etiology. In one prospective study of 100 consecutive, alert, 16- to 65 year old patients with new psychiatric symptoms evaluated in the ED, 63% had an organic etiology. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994;24(4):672-677.

21. Cost-Effective Strategies For Patients With Altered Mental Status 1. Reserve laboratory tests for those patients with no prior psychiatric history, abnormal vital signs, or other suspicious findings on history or physical examination. Caveat: bedside blood sugar elderly 2. Limit toxicologic screens to those cases where findings will change management (= almost never) Caveat: suicidal patient and paracetamol/ aspirin 3. Reserve CTs for those patients with a focal neurologic findings or altered behaviour of undetermined etiology. Caveat: high-risk patients—warfarin, coagulopathy, elderly, immunosuppressed

22. Drug And Alcohol Testing The most economical and expedient means of detecting drugs and alcohol is to ask the patient or, in the case of alcohol, smell the patient’s breath Self-reporting = 92% sensitive and 91% specific for identifying a positive drug screen Self-reporting = 96% sensitive and 87% specific in identifying a positive ethanol level

23. Neuroleptic Malignant Syndrome Affects about 1% of patients treated with neuroleptics. Most commonly occurs within the first 3-9 days but can occur after chronic use. High mortality rate 12%-20% - usually secondary to renal failure or aspiration pneumonia Clinical Dx: hyperthermia (from 37.5˚C up to 42˚C), autonomic instability, encephalopathy, skeletal muscle rigidity, autonomic instability

24. Management Cease drug Aggressive hydration Fluid monitoring Cooling blankets (antipyretic agents not effective) BDZs, Dantrolene ICU

25. Serotonin Syndrome Encephalopathy, ataxia, nausea, vomiting Marked autonomic instability Neuromuscular signs/ symptoms - myoclonus, rigidity, tremor. Hyperreflexia, especially lower extremity Diaphoresis and mild elevations in temperature (approx 50%) Treatment = supportive +/- BDZs

26. Summary The term “medical clearance” is a misnomer; “medical assessment” is more appropriate Beware – New behavioural symptom after age 40 Sudden onset of psychosis or delirium The presence of a toxidrome Visual hallucinations Disorientation Altered level of consciousness Symptoms that began after starting a new medication Abnormal vital signs