Is brain imaging necessary for febrile elderly patients with altered mental status? A retrospective multicenter study.

Sungwoo Choi,Hayeong Kang,Hyun Na,Sangsoo Han,Sangun Nah,Juan Manuel Marquez-Romero

doi:10.1371/journal.pone.0236763

Sungwoo Choi, Hayeong Kang + Show 4 more

Open Access

https://doi.org/10.1371/journal.pone.0236763

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Journal: PloS one	Publication Date: Jul 30, 2020
Citations: 2	License type: CC BY 4.0

Affiliation: Bucheon University, Soonchunhyang University

Abstract

Altered mental status (AMS) is one of the most common symptoms in the febrile elderly. Brain imaging tests are an important tool for diagnosing AMS patients. However, these may be prescribed unnecessarily in emergency departments, particularly for febrile patients with AMS for whom infection is suspected, leading to excessive radiation risk and cost. In this study, we investigated the factors that can predict clinically significant abnormal brain imaging (ABI) in the febrile elderly with AMS. This retrospective multicenter study was conducted from July 2016 to June 2019. Febrile patients over the age of 65 years with AMS who visited the emergency department of two tertiary university hospitals were enrolled. Medical records were reviewed, and laboratory results were obtained. Brain imaging results with a formal reading by a radiologist were obtained. In all, 285 patients were enrolled, and 47 (16.49%) showed ABI. The most common diagnoses in patients admitted to the emergency department were intracranial hemorrhage and ischemic stroke for ABI, and pneumonia and urinary tract infection for non-ABI. In multivariate logistic regression analyses, higher systolic blood pressure (odds ratio [OR], 1.017; 95% confidence interval [CI], 1.006-1.028), lower body temperature (OR, 0.578; 95% CI, 0.375-0.892), the presence of lateralizing sign (OR, 45.676; 95% CI, 5.015-416.025), and lower Glasgow Coma Scale (OR, 0.718; 95% CI, 0.617-0.837) were significantly associated with ABI. Lower Glasgow Coma Scale, the presence of lateralizing sign, higher systolic blood pressure, and lower body temperature are significantly associated with ABI in febrile elderly patients with AMS.

Highlights

The number of elderly people in the United States has rapidly increased from 25.5 million in 1980 to 49.2 million in 2016 [1]
The most common diagnoses in patients admitted to the emergency department were intracranial hemorrhage and ischemic stroke for abnormal brain imaging (ABI), and pneumonia and urinary tract infection for non-ABI
In multivariate logistic regression analyses, higher systolic blood pressure, lower body temperature (OR, 0.578; 95% confidence interval (CI), 0.375– 0.892), the presence of lateralizing sign (OR, 45.676; 95% CI, 5.015–416.025), and lower Glasgow Coma Scale (OR, 0.718; 95% CI, 0.617–0.837) were significantly associated with ABI

Summary

Introduction

The number of elderly people in the United States has rapidly increased from 25.5 million in 1980 to 49.2 million in 2016 [1]. In the United States, elderly patients using the emergency room increased from 12.4% in 2006 to 16% in 2016 [2]. Unlike non-elderly patients, elderly patients often experience decreased consciousness due to fever caused by viral or bacterial infections [5, 6]. Brain imaging is very helpful for identifying decreased consciousness due to neurological causes, such as cerebral infarction, but it is not useful when this is caused by infection [7, 8]. Most febrile elderly patients with AMS who have suspected infection have had unnecessary brain imaging tests. It may be risky for a patient with decreased consciousness to leave the emergency department for brain imaging and move to a radiology department [10]

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