GERIATRIC UPDATE

CAR VERSUS TREE: ACCIDENT OR SUICIDE ATTEMPT?

Authors: Joan Somes, RNC, PhD, CEN, CPEN, FAEN, and Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, St. Paul, MN and New Wilmington, PA

Earn Up to 8.5 CE Hours. See page 209.

92-year-old man was brought to the emergency department after crashing head-on into a tree while driving his car at a high rate of speed. It was the middle of a summer day and the road was straight and dry. Medics reported no skid marks and significant damage to the front of the vehicle. The patient was alone in the vehicle, he was not wearing a seat belt, and the air bag deployed. The patient denied loss of consciousness but could not explain why he had crashed. Upon arrival in the emergency department, the patient was alert but disoriented. His airway was clear; his breathing was labored, shallow, and rapid; and his skin was warm, dry, and pink. He had a small laceration on his forehead but denied having neck pain. The left side of the chest was positive for crepitus, pain with palpation, and decreased breath sounds. No open chest wounds were present. His abdomen was soft with generalized tenderness. He reported pain upon palpation of all extremities, and more so over joints and bony prominences. He had no obvious deformities, bleeding, or large bruised areas. His initial vital signs were as follows: blood pressure, 130/76; heart rate, 100; respiratory rate, 24 per minute; oxygen saturation, 90% on 2 L per nasal cannula; and oral temperature, 98.2F. A chest radiograph showed multiple rib fractures on the left side, a 25% pneumothorax, and a small hemothorax. A computerized tomography scan of the head, neck, chest, and abdomen showed no other pathology, The rib fractures were actually a flail segment, and

Joan Somes, Member, Greater Twin Cities Chapter ENA, is Staff Nurse/ Department Educator, St. Josephs Hospital, St. Paul, MN. Nancy Donatelli, Member, CODE Chapter ENA, is Assessment Nurse, Shenango Presbyterian SeniorCare, New Wilmington, PA. For correspondence, write: Nancy Donatelli, RN, MS, CEN, NE-BC, 155 Leesburg Station Rd, New Wilmington, PA 16142; E-mail: question4gene@gmail.com. J Emerg Nurs 2011;37:179-81. Available online 18 October 2010. 0099-1767/$36.00 Copyright 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.09.014

before long more respiratory distress developed. The ED physician and surgeon carried out rapid sequence induction, intubation, and insertion of a chest tube that drained 250 mL of blood. A drop in blood pressure occurred during intubation and chest tube insertion thus requiring fluids and pressors for stabilization prior to transport to the ICU. While accompanying the family to ICU, the ED nurse was told, This poor man has all these painful things going on and he is so tired of pain! When prompted to elaborate, the family member went on to say the patient had chronic pain over his entire body and despite multiple attempts, his doctors had been unsuccessful in finding the source of the pain. The family had recently noted more and more verbalization of discouragement with life as the result of having to live with constant pain. In fact, he recently had been admitted to another hospital for depression. However, he was not taking any medications for depression; his only medications were Warfarin and drugs for pain control. The family members comment, plus the mechanism of injury and lack of reason for the crash, was enough to raise a red flag for the ED nurse. She asked that the patient undergo a crisis evaluation, which in her facility was a nursing-generated order. Suicide precautions were initiated until the evaluation could be completed. Because the patient was currently chemically immobilized, few precautions were needed, but actions were planned for postventilator weaning. Geriatric patients have the highest success rate of suicide of any age group in the United States. On average, every 90 minutes an adult older than 65 years of age commits suicide.1 This patients high-speed crash into a tree and the fact that he wasnt wearing a seat belt made the nurses wonder if attempted suicide was the cause of the crash. Sometimes an attempt at taking ones life is obvious. A gunshot wound is easily recognizable as a suicide attempt. Seventy-one percent of geriatric patients who ended their lives in 1998 used firearms. Geriatric patients attempts to end their lives using a gun are usually successful. The second most common method of attempting suicide is through an overdose of liquids, pills, or gas, and the third most common method is asphyxia.1

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When a geriatric patient uses less obvious methods in an attempt to commit suicide, it may not cross the mind of the caregiver that suicide was the goal. Many medications taken by the older adult have a narrow therapeutic window. Overdosing on life-stabilizing medications or not taking them at all can be done by by accident or design. Potassium, insulin, anti-hyperglycemic agents, Warfarin, calcium channel blockers, -blockers, and psychiatric medications can easily be miss taken, leading to loss of life. Geriatric patients who refuse to eat, drink, or take their medications because they no longer want to live are attempting to end their life. Motor vehicle incidents, either when one is a driver or a pedestrian, can be blamed on inattention, poor sight or hearing, slow reactions, and other medical issuesor they could be intentional! When a geriatric patient presents with a life-threatening injury or symptoms that could be intentional, ED staff should look carefully at the patients social history, medical history, and the circumstances surrounding the event. This patient met several of the criteria that placed him at risk for suicide. He had chronic pain, was widowed, and had voiced dissatisfaction with life. Being male also added to his risk factors. In 1998, men accounted for 84% of the suicides in the 65-year-and-older age group.1 He also had a diagnosis of depression. Geriatric patients sometimes experience mental health problems that can be of new onset or may be related to a continuing or recurrence of problems from a younger age. Medications, physical illness, medical treatments, or a change in life circumstances may be the cause of mental health problems. Adjustment difficulties, stress, anxiety, psychosis, alcohol use/abuse, and depression can lead to suicidal ideation and attempts. Depression can keep older adults from functioning at their highest level. This situation is aggravated by chronic pain. Fifteen percent to 30% of the older population have symptoms of depression.2 Women are twice as likely to be depressed, but men are more likely to consider suicide.2 It should be noted that although depression is frequently seen in the older population, it is not a normal part of aging. Other signs that an older adult is considering ending his or her life include suddenly calling friends and family, giving away property and treasured items, and voicing unhappiness. Events that may trigger suicide include loss of friends, family members, a spouse, ones home, and ones independence. Forced retirement, forced life changes, a new diagnosis such as stroke, cancer, hypothyroidism, Alzheimer disease, Parkinson disease, epilepsy, congestive heart failure, and social isolation have been identified as precipitating factors.2

It should be noted that many medications can lead to or aggravate depression. -Blockers, digitalis, procainamide, clonidine, guanethidine, reserpine, methyldopa, spironolactone, thiazide diuretics, corticosteroids, corticotrophin, estrogen, anti-anxiety agents, psychotropic drugs, alcohol, haloperidol, flurazepam, barbiturates, benzodiazepines, narcotics, nonsteroidal anti-inflammatory drugs, cimetidine, L-dopa, and tamoxifen have all been associated with increased signs of depression.2 During assessment of a geriatric patient, consider using the Geriatric Depression Scale. The short form version consists of 15 questions that ask about satisfaction with life, activities and interests, boredom, happiness, helplessness, spirits, energy, hopelessness, a sense of life being empty, feelings that something bad will happen, memory problems, a willingness to try new things, and a sense of how well the patient thinks he or she is doing. Answers are assigned point values, with a score of 5 to 10 indicating a need for follow-up related to depression.3 An alternative approach involves asking about loss of interest or pleasure. An affirmative answer to this question, plus issues in at least 5 other areas, including problems with sleep, changes in appetite, concentration, or energy, a lack of interest in life, feelings of guilt, suicidal thoughts/attempts, and recurrent thoughts of death with or without a plan, indicate that the patient is at risk of depression or suicide and that there is reason to obtain a mental health intervention.2 As you assess the geriatric patient, also consider answers to questions related to how or why the patient ended up in the emergency department. Are the circumstances suspicious? Because a stigma often is associated with seeking help for mental illness issues among older adults, they may not ask for help outright but present with vague complaints. Family may bring the patient to the emergency department with concerns that they are not their normal self. It is recommended that the patient be asked outright, Do you want to hurt yourself or end your life? Asking the question will not put the idea into the patients head but will allow the patient to be forthright with his or her answer. One should be nonjudgmental when investigating whether the patient has a plan and if he or she has acted or would act on it. One must determine the seriousness, lethality, and ability of the patient to carry out the plan. While you are conducting this assessment, the patient should be in a safe environment without access to materials or equipment that could be used to cause harm. They should not be allowed to leave. A psychiatric consult should be obtained, and medication should be considered to decrease anxiety. If the patient becomes upset, remember that overstimulation may lead to increased agitation.

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Typically several weeks pass before antidepressants are effective, and a careful review of the patients current medications, along with potential interactions, must be conducted prior to use. Many of the adverse effects of antipsychotic medications are magnified in geriatric patients, and careful monitoring will be needed. Postural hypotension is especially noted as a potential adverse effect to be aware of, along with constipation, dry mouth, insomnia, and gastrointestinal upset. Geriatric patients may respond to electroconvulsive therapy if medications are not effective. In the emergency department, the goal is to keep the patient safe, assess for depression and risk of suicidal behavior, rule out other causes for this behavior, and obtain psychiatric help for the patient. The patient described in this article ultimately survived his injuries. It was never determined why he crashed his car, but a thorough evaluation of his life situation and resources was conducted.

REFERENCES
1. National Strategy for Suicide Prevention. At a glancesuicide among the elderly. http://mentalhealth.samhsa.gov/suicideprevention/elderly.asp. 2010. Accessed July 21. 2. ANCC Institute for Credentialing Innovation. Nursing Review and Resource Manual Gerontological Nursing. 2nd ed. Silver Spring, MD: ANCC Institute for Credentialing Innovation; 2009. 3. Kurlowicz L, Greenberg S. The Geriatric Depression Scale. Try This Best Pract Nurs Care Older Adults. 2007;4. http://consultgerirn.org/uploads/ File/trythis/try_this_4.pdf. Accessed October 3, 2010.

Submissions to this column are encouraged and may be sent to Joan Somes, RNC, PhD, CEN, CPEN, FAEN somes@black-hole.com or Nancy Stephens Donatelli, MS, RN, CEN, NE-BC question4gene@gmail.com

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