Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA.
Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
Acad Emerg Med. 2023 Jun;30(6):616-625. doi: 10.1111/acem.14622. Epub 2022 Dec 5.
Delirium, altered mental status (AMS), or confusion among older adults are common presentations to the emergency department (ED). We aimed to report the proportion of older ED patients presenting with delirium who have acute abnormal findings on head imaging. We also assessed whether anticoagulation, neurological deficits, trauma, or headache were associated with head imaging abnormalities in these patients.
A systematic review was performed using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8, 2021. Citations were included if they described patients aged 65 years or older who received neuroimaging at the time of ED assessment for delirium, confusion, or AMS. Screening, data extraction, and bias assessment were performed in duplicate. The estimated proportion of patients with abnormal neuroimaging and odds ratios (ORs) for each predictor were calculated.
The search strategy identified 3014 unique citations, of which six studies reporting on 909 patients with confusion or AMS were included. None of the studies formally diagnosed delirium. Overall, the proportions of older ED patients with AMS or confusion were found to have an abnormal head computed tomography (CT) was 15.6% (95% confidence interval [CI] 7.3%-26.2%). The prevalence of focal neurologic findings was 13.0% (66/506) and for anticoagulation was 9.8% (33/337) among the studies who reported them. The presence of a focal neurological deficit was associated with abnormal head CT (OR 101.8, 95% CI 30.5-340.1). Anticoagulation was not associated with abnormal head CT (OR 1.2, 95% CI 0.4-3.3). No studies reported on the association between headache or trauma and abnormal neuroimaging.
The proportion of abnormal findings on CT neuroimaging in older ED patients with AMS or confusion was 15.6%. The presence of a focal neurological deficit was a strong predictor for the presence of acute abnormality, whereas anticoagulation was not.
老年人在急诊科（ED）出现谵妄、精神状态改变（AMS）或意识混乱较为常见。我们旨在报告以谵妄为主诉的老年 ED 患者中，急性头部影像学异常的比例。我们还评估了这些患者中抗凝、神经功能缺损、创伤或头痛是否与头部影像学异常相关。
我们使用 Ovid Medline、Embase、Clinicaltrials.gov、Web of Science 和 Cochrane Central 从构思到 2021 年 4 月 8 日进行了系统综述。如果描述了在 ED 评估谵妄、意识混乱或 AMS 时接受神经影像学检查的年龄在 65 岁或以上的患者，则纳入研究。筛选、数据提取和偏倚评估均由两人进行。计算了异常神经影像学的估计比例和每个预测因子的比值比（OR）。
搜索策略确定了 3014 条独特的引文，其中 6 项研究报告了 909 例意识混乱或 AMS 患者，纳入了这 6 项研究。这些研究均未正式诊断为谵妄。总的来说，发现以 AMS 或意识混乱为主诉的老年 ED 患者中，头部计算机断层扫描（CT）异常的比例为 15.6%（95%置信区间 [CI] 7.3%-26.2%）。报告了存在局灶性神经体征的研究中，局灶性神经体征的发生率为 13.0%（66/506），抗凝的发生率为 9.8%（33/337）。存在局灶性神经功能缺损与头部 CT 异常相关（OR 101.8，95% CI 30.5-340.1）。抗凝与头部 CT 异常无关（OR 1.2，95% CI 0.4-3.3）。没有研究报告头痛或创伤与神经影像学异常之间的关系。
以 AMS 或意识混乱为主诉的老年 ED 患者中，CT 神经影像学异常的比例为 15.6%。局灶性神经功能缺损是急性异常存在的强预测因素，而抗凝则不是。
