Old Person + Delirium = Head CT

Written by Sam Parnell

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Among patients ≥65 years who presented to the ED with delirium, confusion, or altered mental status, 15.6% had an abnormal head CT. Presence of neurologic deficit was a significant predictor for abnormal CT, but anticoagulation was not.

Why does this matter?
Altered mental status is a common chief complaint, especially in older patients, and multiple studies have demonstrated that delirium is associated with significant morbidity and mortality in the geriatric population.^1-3 The etiologies are diverse and multifactorial, so diagnostic workup is often broad and includes brain imaging. Previous inpatient studies have suggested head CT may be low yield and is likely overutilized.^4-5 However, there is limited data on the utility of such imaging studies in the ED setting and no consensus on what patients with altered mental status benefit from head CT.^6-7

AMS in the elderly can be such a headache…
This was a systematic review and meta-analysis that included patients ≥65 years who received CT neuroimaging in the ED for delirium, confusion, or altered mental status. Six studies were included, with a total of 909 patients. Overall, the proportion of older patients with altered mental status who had an abnormal head CT scan was 15.6% (95%CI 7.3-26.2%). An abnormal head CT was characterized by findings of ischemia, hemorrhage, or mass.

The pooled odds ratio for abnormal head CT among patients on anticoagulation was a nonsignificant 1.18 (95%CI 0.43-3.25; 2 studies). The prevalence of focal neurologic deficit was 0.13, and the pooled odds ratio for abnormal head CT among patients with neurologic deficits was 110.2 (95%CI 30.5-340.1; 2 studies). The included studies were not able to determine association between headache or trauma and abnormal brain imaging.

There were several limitations to this systematic review and meta-analysis, and most of the included studies were retrospective and relatively small, with intermediate to high risk of bias. However, based on this study, head imaging appears to have significant utility for geriatric patients with altered mental status. Consequently, I will continue to send elderly patients who present with confusion or delirium to the good ole donut of truth.

Source
Head Computed Tomography Findings in Geriatric Emergency Department Patients with Delirium, Altered Mental Status, and Confusion: A Systematic Review. Acad Emerg Med. 2022 Nov 4. doi: 10.1111/acem.14622. Online ahead of print.

Works Cited

1. Kennedy M, Enander RA, Tadiri SP, Wolfe RE, Shapiro NI, Marcantonio ER. Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department. J Am Geriatr Soc. Mar 2014;62(3):462-9. doi:10.1111/jgs.12692
2. Carpenter CR, Hammouda N, Linton EA, et al. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med. Jan 2021;28(1):19-35. doi:10.1111/acem.14166
3. Han JH, Vasilevskis EE, Schnelle JF, et al. The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients. Acad Emerg Med. Jul 2015;22(7):878-82. doi:10.1111/acem.12706
4. Finkelmeier F, Walter S, Peiffer KH, et al. Diagnostic Yield and Outcomes of Computed Tomography of the Head in Critically Ill Nontrauma Patients. J Intensive Care Med. Nov-Dec 2019;34(11-12):955-966. doi:10.1177/0885066617720901
5. Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium. J Hosp Med. Aug 2014;9(8):497-501.doi:10.1002/jhm.2198
6. Hardy JE, Brennan N. Computerized tomography of the brain for elderly patients presenting to the emergency department with acute confusion. Emerg Med Australas. Oct 2008;20(5):420-4. doi:10.1111/j.1742-6723.2008.01118.x
7. Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med. Feb 2020;75(2):136-145. doi:10.1016/j.annemergmed.2019.07.023