Computed Tomography Scanning and Delirium in Elder Patients

Abstract

Objective: 1 ) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions. Methods: This was a 2-part study. Part 1 was a prospective, observational study of 560 adults >70 years of age evaluated at 3 separate EDs using a 200-hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records ( n = 279) for patients >70 years of age i n the prospective sample (11 = 79) and from a sample ( n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan. Results: Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, irnpaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned ( p < 0.001). Part 2: Of 279 C T scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space-occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED. Conclusions: Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population. Key words: CT scans; delirium; elders; emergency department. 13,703. Fax: 716-859-1491; e-mail: dr1?77@po'.bgii.edi~ I Elder adults may present with neurologic conditions such as delirium.' These conditions generally have a wide range of precipitating etiologies. Presently there are few data to guide the selective ordering of head CT scans for delirious patients.' Improved efficiency in the use of CT scanning could shorten length of stay in the ED, reduce costs, and, if clinical findings prove to be valuable for triage, promote an individualized approach to the tare of cognitively-impaired elder adults. Our previous work outlines some of the challenges for assessing cognitively-intact vs cognitively-impaired elder adult^.^ As background f o r guideline development for the evaluation and management of cognitive impairment, es- Acad

Pathophysiology of Delirium in the Intensive Care Unit

“…Frank hemorrhage or ischemia may cause delirium. In these cases [26][27][28][29][30][31][32][33][34][35], delirium is more likely to have been a result rather than a cause of stroke. In other studies, the lines of causation between delirium and structural changes may be less clear [23][24][25].…”

“…The few functional neuroimaging studies that have evaluated delirious patients in acute states are reviewed [19][20][21]. Structural imaging findings are then examined that describe neuronal atrophy that may be related to delirium [22][23][24][25][26][27][28][29][30][31][32][33][34][35].…”

“…Several studies have used CT or MRI to examine lesions or other structural abnormalities associated with delirium [23][24][25][26][27][28][29][30][31][32][33][34][35]. Frank hemorrhage or ischemia may cause delirium.…”

“…Has the potential to account parsimoniously for multiple instances of delirium [19][20][21][22][23][24][25][26][27][28][29][30]34,35].…”

Altered Mental Status in Older Emergency Department Patients

“…9,10 These two forms of acute brain dysfunction occur over a period of hours to days and represent the most severe disruptions in both the level and content of consciousness. Stupor (RASS −4) is a condition of deep sleep or similar behavioral unresponsiveness from which the patient can be aroused only with vigorous and continuous stimulation.…”