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Written by Sam Parnell
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.
