The patient with dementia is ubiquitous across medical and psychiatric settings, and will often be the focus of psychiatric consultation. These patients all have in common an underlying brain disease that impairs memory function in addition to one or more of the following cognitive skills: language (aphasia), recognition (agnosia), motor ability (apraxia), and executive function (1). At present, there are over 5 million Americans with Alzheimer disease alone, representing 60% to 70% of all dementia patients (2). Vascular dementia and dementia with Lewy bodies are the next most common forms of dementia, followed by frontotemporal dementia and then various dementias associated with medical disease, substance use, or trauma (3). For the majority of affected individuals, dementia is both a progressive and irreversible disease.

Psychiatric emergencies with dementia patients typically involve one or more of the following conditions: delirium, agitation, psychosis, suicidal ideation, or failure to thrive. Although each of these conditions may have multiple causes, it is the presence of dementia that incurs the vulnerability. These emergencies can present in many settings, including at home or in a long-term care facility, emergency department (ED), or an inpatient unit. Regardless of the setting, family caregivers—typically an older spouse or an adult daughter—who have shouldered the burden of whatever factors are driving the emergency are often present. These caregivers are critically impor- tant informants as well as partners in treatment, and should always be engaged. They can help reduce the complexity of care for the dementia patient to a few basic elements.

Delirium is defined as an acute, transient alteration in brain function characterized by fluctuating levels of consciousness, distractibility, psychosis, and agitation. It most commonly occurs in older patients with dementia, and presents as a psychiatric emergency because of the risk of self-harm or harm to others as well as the increased rate of mortality in both the acute and recovery phases. There is always an underlying medical cause, with infection being the most common etiology, particularly in long-term care settings (4). Sedating and anticholinergic medications are common culprits as well. The prevalence of delirium ranges from 10% of ED patients to 30% or more of medical inpatients, especially hospitalized elderly individuals after cardiac or orthopaedic surgeries (5). Individuals with delirium are unable to fully attend to or cooperate with daily care, and may engage in impulsive and unsafe behaviors as they attempt to deal with what they perceive to be an unfamiliar and frightening environment.

Acute agitation and psychosis associated with dementia pose psychiatric emergencies due to the risk of self-harm or harm to others, either from physically aggressive behaviors or refusal to comply with necessary medications, hygiene, medical treatments, or hydration and nutrition. Up to 50% of individuals with dementia demonstrate psychotic symptoms such as paranoid delusions or hallucinations, and up to 90% demonstrate agitation at one point or another during their course (6). These two types of symptoms often go hand in hand, especially when paranoia breeds fear and anger toward caregivers. Resultant behaviors include refusal to accept care, physical measures to prevent caregivers from approaching (e.g., not answering the door or
telephone, barricading a doorway), and aggression toward caregivers who are perceived as threats.

Rates of major depression increase in the early and middle stages of dementia and may involve acute suicidal ideation (7). In general, rates of suicide are highest in older white men, with the presence of psychosocial losses and chronic illnesses such as dementia being major risk factors (8). Refusal to eat, drink, take medications, or comply with other aspects of daily care (e.g., necessary blood draws or glucose checks, wound care) on the part of a dementia patient can lead to precipitous weight loss and overall cachexia, a condition known as failure to thrive. Depression is the most common cause, and the refusal to eat or drink may represent an indirect suicidal or life-threatening behavior. Other causes for failure to thrive include delirium, paranoia, dysphagia, pain, and apathy. Failure to thrive is a psychiatric emergency because continued weight loss and the lack of adequate nutrition and hydration can quickly become life threatening in a frail individual (9).

Although thorough assessment should always precede treatment, psychiatric emergencies in the dementia patient often require immediate interventions because of imminent risk of harm. For states of delirium, agitation, and suicidal ideation, one-to-one monitoring is necessary to keep individuals from physically harming themselves or someone else, and to restrict their range of travel and avoid unsafe situations. When a demented individual living in the community needs more intensive monitoring and management than the 24-hour presence of a caregiver can provide, transfer to either an ED or a psychiatric unit should be considered. In nursing home or hospital settings, a 24-hour sitter, preferably someone with psychiatric experience, may be sufficient. Keep in mind that even in an intensive care unit with constant nursing care, a demented and delirious person can quickly pull out a tracheotomy or nasogastric tube if not watched closely. An individual with failure to thrive might need immediate transfer to an appropriate setting where he or she can receive intravenous hydration and perhaps even a feeding tube.

In these acute situations, clinicians should first attempt to communicate with the dementia patient on his or her level, providing reassurance and reorientation to person, place, and time. To the best of their ability, clinicians should try to eliminate environmental stresses such as overstimulating lights or sounds and address unmet needs such as hunger, thirst, bladder or bowel pressure, pain, anxiety, fear, and boredom that might be triggering or exacerbating the disruptive behaviors. Acute agitation sometimes responds to verbal or physical distraction, such as changing the subject of conversation or taking the person to a quieter or more stimulating location, depending on the nature of the situation. The patient’s ability to understand and respond to this communication and behavioral redirection will determine the next steps: If he or she cannot exercise some control over the behaviors, and the risk of harm persists, then more restrictive measures must be considered.

Physical restraints are used for highly agitated individuals whose movements pose an imminent risk of self-harm or harm to others and who have not responded to other interventions. These restraints take many forms, including soft hand mitts to prevent self-injury, a vest or other form of physical barrier while sitting in a chair, or a netted enclosure attached to and surrounding a bed. The least restrictive method is always preferred, with constant monitoring and for the least amount of time possible. The use of such restraints has actually decreased in long-term care settings over the last decade, as it has become apparent that they may not always provide the degree of safety intended and can even exacerbate agitation and paranoia (10).

Psychotropic medications are used for immediate intervention for highly agitated individuals but will not work quickly for symptoms of psychosis, suicidal thinking, or failure to thrive. The goal is to select an appropriate medication for the target symptoms, administer an adequate dose in a manner that will bring quick results (i.e., intramuscularly or intravenously), and then monitor for therapeutic response and side effects. More detailed use of these medications, including dosing strategies, is reviewed in a later section of this chapter.

In the evaluation of the dementia patient during a psychiatric emergency, several basic clinical facts need to be ascertained as quickly as possible: the patient’s baseline cognitive and functional status prior to the crisis (including the stage of dementia, ranging from mild to severe), the exact nature of the emergent change, and whether there is an imminent risk of harm. Because many dementia patients are not able to provide extensive or accurate history, the evaluation will require knowledgeable informants. If the patient resides in an assisted or long-term care facility, it is important to review any available records, with specific attention to medical history, laboratory findings, recent injury, and medication use as listed on an updated medication administration record.

Establishing rapport with dementia patients can be challenging, especially when they are in a state of acute confusion, agitation, or psychosis or are severely withdrawn. There are several rules of thumb: Approach the patient calmly, provide a clear but brief orientation to the nature of the interview and your role in it, and inquire as to his or her concerns or needs. Make eye contact, smile, and do not rush questions. Make sure that the patient can hear and see you, and find ways to overcome sensory limitations (e.g., ensure patients have glasses or hearing aids available, if possible). With an uncooperative patient, ask for his or her help and do not threaten. Even highly agitated, paranoid, and confused patients can sense an insensitive, impatient, or disrespectful approach.

Once the nature of the problem has been determined, all available history gathered, and an introduction made, the next step is to conduct a focused mental status examination (MSE) that includes a cognitive screen. The MSE should note aspects of appearance, alertness, attention and concentration, speech and language, affect, mood, thought process and content, motoric behavior, abstract thinking, insight, and judgment. The cognitive screen is a quick, easily administered and easily scored instrument that gathers data on various cognitive skills. The most popular screens include the Mini Mental Status Examination (11), the Mini-Cog (12), and the clock drawing test (13,14). If an acutely agitated or confused dementia patient is not able to cooperate with any of these screens, the MSE will be based on observation.

The remainder of the evaluation of the patient will vary depending on the nature of the psychiatric emergency. Obvious delirium requires simultaneous medical and psychiatric evaluation, although if the psychiatrist sees the patient first, he or she should obtain vital signs and order a urinalysis and culture, a complete blood count, a fingerstick glucose level, and a basic chemistry profile without waiting for the internist. A computerized tomographic scan of the brain is necessary whenever there has been recent head injury or when there is suspicion of an intracranial process. For the agitated and psychotic patient, an immediate pain assessment is necessary, as well as a urinalysis and culture, and a survey of the care environment to identify potential causes. With all psychiatric emergencies, a review of concurrent medical conditions and recent medication use may help identify a culprit that is causing altered mental status or behavioral changes. Major medical conditions that can cause these conditions are listed in Table 21.1. Medications that are common causes of mental status or behavioral changes include opioid analgesics, steroids, psychostimulants, antihistamines, and anticholinergic agents.