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Practice Easily Missed?

Subdural haematoma in the elderly

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1682 (Published 11 March 2014) Cite this as: BMJ 2014;348:g1682

Rapid Response:

Re: Subdural haematoma in the elderly

The article on subdural haematoma was a welcome review. It highlighted the important message that patients with a subdural haematoma do not always have a history of head trauma and the diagnosis should be considered with several varied presentations.

I was surprised however, to see psychosis as a presenting feature of subdural haematoma. There are two references for this assertion. The first reference is a ‘self assessment question’. This describes a patient who was admitted to the psychiatric unit because he would not get out of bed and slept a lot. On examination he needed to be roused from sleep. This does not support the assertion that patients presenting with acute psychosis could have a subdural haematoma. His presentation was reduced GCS which is a clear indication for a intracranial imaging. Secondly, as it is a self assessment question it is not even clear whether this is a real patient.

The second reference describes an 80 year old man from rural India who was treated by a private psychiatrist after presenting with ‘seven days of irrelevant talk, suspiciousness, smiling and muttering to himself, irritability, wandering tendency, sleep disturbances, and decreased appetite’. This presentation has overlapping features of delirium and psychosis and warrants urgent intracranial imaging. This is not a typical presentation for acute psychosis and so it cannot be used to assert that subdural haematoma presents with acute psychosis. In summary, the evidence presented to support the assertion that subdural haematoma can present as acute psychosis consists of two weak case reports.

A study by Parmar et al which showed that of 191 patients presenting with acute psychosis who had testing as part of medical screening, only one patient had an abnormal result that led to a change in disposition.1

The appropriate management for patients presenting with acute psychosis without clinical features of organic aetiology is an urgent psychiatric review, not an extensive workup in the Emergency Department or Acute Medical Unit to 'medically clear' the patient.

1. Parmar, Parveen; Goolsby, Craig A; Udompanyanan, Kavid; Matesick, Leslie D; Burgamy, Kirk P; & Mower, William R. (2012). Value of Mandatory Screening Studies in Emergency Department Patients Cleared for Psychiatric Admission. Western Journal of Emergency Medicine, 13(5). uciem_westjem_6754. Retrieved from: http://escholarship.org/uc/item/ 1tt2g29p

Competing interests: No competing interests

21 March 2014
David Hodgson
Emergency Medicine Registrar
Mersey School of Emergency Medicine
Macclesfield