Absence of risk factors cannot exclude abnormal imaging findings in older delirious emergency department patients

Head computed tomography (CT) is routinely performed in older delirious emergency department (ED) patients, but little evidence-based guidance exists as to when it should be obtained. We sought to determine if the absence of risk factors was sufficient to not obtain a head CT in this population.

This was a secondary analysis of two prospective observational studies. Delirious ED patients ≥ 65 years old were included. We evaluated risk factors most associated with abnormal head imaging, including anticoagulant use, recent head trauma, focal neurological deficits, headache, or altered level of consciousness. Our primary outcome was "Positive composite head CT"-an acute pathological finding on the index hospitalization head CT OR, if a patient did not receive a head CT, as an acute pathological finding on imaging or new neurological diagnosis within 30 days post-ED visit. Sensitivities, specificities, and likelihood ratios (LR) with 95 % confidence intervals were calculated.

A total of 160 patients were included. The median (IQR) age was 76 (69, 83) years old. There were 25 (15.6 %) older delirious patients with a positive composite head CT. Having any risk factor was 92.0 % (81.4-100.0 %) sensitive and 13.3 % (7.6-19.1 %) specific for a positive CT, with a negative LR of 0.6 (0.3-2.43) and positive LR of 1.1 (0.9-1.2).

In older ED delirious patients, the proportion of positive CTs was high. The absence of any risk factor minimally decreased the likelihood of having a positive head CT. Our data suggests that head CTs should be considered in all older ED patients with delirium.