Failure to Cope (Social)MANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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540 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Acute anxiety Acute psychosis Agitation-behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Dementia and behavioral crisis Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp34

Immediate priorities

›Acute medical threat exclusion

›Altered mental status or new confusion

›Delirium workup: infection, metabolic, medication, stroke

›If GCS < 14, escalate to resuscitation bay

›Fever or hypothermia

›Sepsis screening: suspected infection with organ dysfunction

›Lactate if sepsis suspected (target < 2 mmol/l)

›New focal neurological deficit

›Stroke protocol activation

›NIHSS assessment

›Hemodynamic instability

›SBP < 90 mmHg or MAP < 65 mmHg

›IV access and fluid resuscitation

Red flag triggers

›Escalation criteria

›Signs of trauma inconsistent with history

›Elder abuse/neglect mandatory reporting

›Adult Protective Services notification

›Suicidal ideation

›Elderly patients have highest completed suicide rate of any demographic

›Psychiatric consultation immediately

›Severe malnutrition or pressure ulcers

›BMI < 18.5 or BMI < 22 in patients >70 years

›Neglect (self or caregiver) concern

›Inability to ambulate or new immobility

›Fracture, spinal cord pathology, severe deconditioning

02History/hx54

Functional baseline

›ADL and IADL assessment

›Activities of daily living: bathing, dressing, toileting, feeding, transferring

›Instrumental ADLs: cooking, medications, finances, shopping, transportation

›Functional trajectory: what could the patient do independently 2 weeks ago vs. now

›Assistive devices in use: walker, wheelchair, home health aide

Onset and precipitating event

›Timeline and trigger

›Acute decline (hours to days) suggests medical precipitant

›Infection, stroke, medication change, fall

›Subacute decline (weeks to months) suggests progressive disease

›Dementia progression, worsening heart failure, malignancy

›Precipitating event: recent fall, illness, hospitalization

›Loss of caregiver: bereavement, caregiver burnout, caregiver illness

Nutritional history

›Intake and weight

›Appetite changes: anorexia, early satiety, dysphagia

›Weight loss: >5% in 1 month or >10% in 6 months is clinically significant

›Ability to prepare and access food independently

›Financial barriers to food access (food insecurity)

›Dental or denture problems causing dysphagia

Cognitive and mood history

›Neuropsychiatric symptoms

›Memory complaints: new vs. chronic

›Confusion: acute (delirium) vs. chronic (dementia)

›PHQ-2 depression screen: anhedonia, depressed mood most of the day

›Sleep disturbance, anxiety, hallucinations

›Alcohol use (often underrecognized in elderly)

03Physical Exam/exam38

Vitals and general appearance

›Stability and nutritional snapshot

›Temperature: hypothermia in elderly sepsis is common

›Orthostatic blood pressure: drop >=20 mmHg systolic or >=10 mmHg diastolic on standing

›Heart rate, SpO2, weight (compare to prior documented weight)

›BMI < 22 in patients >70 years suggests malnutrition

›General: hygiene, clothing appropriateness, signs of self-neglect

Cognitive screen

›Bedside cognitive tools

›Mini-Cog: 3-item recall plus clock draw; score 0-2 suggests dementia

›4AT delirium screen: alertness, AMT4, attention, acute change; score >=4 indicates possible delirium

›Montreal Cognitive Assessment (MoCA): score < 26 out of 30 indicates mild impairment

›Orientation to person, place, time, situation

Functional assessment

›Mobility and fall risk

›Gait observation: steady, shuffling, wide-based, use of aids

›Timed Up and Go (TUG): >12 seconds associated with fall risk

›Chair rise test: inability to rise without arms suggests lower extremity weakness

›Romberg test: balance assessment

Musculoskeletal and skin exam

›Musculoskeletal findings

›Muscle wasting: temporal, thenar, quadriceps

›Joint deformity, swelling, or restricted ROM limiting function

›Pressure ulcers: stage and location (sacrum, heels, hips)

›Skin turgor, mucous membrane moisture (hydration status)

›Bruising inconsistent with stated history: elder abuse concern

Neurological exam

›Focal deficits and tone

04Differential Diagnosis/ddx44

Life-threatening and urgent diagnoses

›Must-not-miss conditions

›Sepsis: UTI, pneumonia, cellulitis — most common acute precipitant in elderly

›ICD-10: A41.9 Sepsis, unspecified organism

›Delirium (medication-induced, metabolic, infectious)

›ICD-10: F05 Delirium due to known physiological condition

›Stroke or TIA with subtle presentation

›ICD-10: I63 Cerebral infarction; I45.9 TIA

›Elder abuse or neglect

›ICD-10: T74 Adult maltreatment and neglect

›Acute cardiac: heart failure exacerbation, arrhythmia, ACS

›ICD-10: I50.9 Heart failure, unspecified

Medical causes of functional decline

›Systemic and metabolic

›Hypothyroidism

›ICD-10: E03.9 Hypothyroidism, unspecified

›Hyperglycemia or hypoglycemia

›ICD-10: E11.65 Type 2 diabetes with hyperglycemia

›Hyponatremia: sodium < 135 mmol/l

›ICD-10: E87.1 Hypo-osmolality and hyponatremia

›Hypercalcemia: corrected calcium > 2.6 mmol/l

›ICD-10: E83.52 Hypercalcemia

›Vitamin B12 deficiency

›ICD-10: E53.8 Deficiency of other specified B group vitamins

›Anemia

›ICD-10: D64.9 Anaemia, unspecified

›Occult malignancy: GI, lung, hematologic

›ICD-10: C80.1 Malignant neoplasm, unspecified

05Laboratory Tests/lt48

Metabolic and infection workup

›Core panel

›Complete blood count

›Leukocytosis or leukopenia: infection, hematologic malignancy

›Anemia: hemoglobin < 120 g/l women, < 130 g/l men — functional decline contributor

›Thrombocytopenia: sepsis, hematologic cause

›Electrolyte panel with creatinine

›Sodium: hyponatremia < 135 mmol/l common in elderly on diuretics

›Potassium: hypo/hyperkalemia with diuretic or ACE inhibitor use

›Creatinine: AKI or CKD with eGFR; guides medication dosing adjustments

›Glucose: hypoglycemia (< 3.9 mmol/l) or hyperglycemia (> 11 mmol/l)

›Calcium

›Corrected calcium > 2.6 mmol/l: malignancy, hyperparathyroidism

›Corrected calcium < 2.1 mmol/l: hypoalbuminemia, malabsorption

›Liver function tests

›Albumin: < 35 g/l indicates hypoalbuminemia and malnutrition risk

›Transaminases, bilirubin: hepatic cause of decline

Thyroid, nutritional, and hematologic

›Targeted panel

›Thyroid stimulating hormone

›TSH < 0.4 mIU/l: hyperthyroidism (weight loss, atrial fibrillation)

›TSH > 4.0 mIU/l: hypothyroidism (fatigue, weight gain, cognitive decline)

›Vitamin B12

›B12 < 148 pmol/l: deficiency causing cognitive impairment, neuropathy

›High prevalence in elderly, especially those on metformin or PPIs

›Folate

›Low folate associated with anemia and cognitive impairment

›Iron studies

06Diagnostic Tests/dt62

Scoring Systems

›Functional decline and frailty tools

›Clinical Frailty Scale (CFS)

›Score 1-9: 1 = very fit, 9 = terminally ill

›CFS >=6 (moderately frail): increased mortality, institutionalization risk

›Predicts 6-month mortality and adverse outcomes in elderly ED patients

›Timed Up and Go (TUG)

›> 12 seconds: fall risk

›> 30 seconds: dependent in ADLs

›Mini Nutritional Assessment-Short Form (MNA-SF)

›Score 0-7: malnourished; 8-11: at risk; 12-14: normal nutritional status

›Best validated nutritional screen for elderly in ED (Robertson, Am Fam Physician 2004)

›4AT Delirium Screen

›Items: alertness, abbreviated mental test 4 (AMT4), attention, acute change

›Score >=4: possible delirium, further assessment warranted

›Score >= 1 and < 4: possible cognitive impairment

›GLIM Criteria (Malnutrition)

›Phenotypic criteria: weight loss, low BMI, low muscle mass

›Etiologic criteria: reduced intake, inflammation/disease burden

›Up to 50% of acutely ill elderly in ED meet GLIM criteria for malnutrition

›PHQ-2 Depression Screen

›Two questions: anhedonia, depressed mood over past 2 weeks

›Score >= 3: positive screen, proceed to PHQ-9

MRI

›Brain MRI indications

›Suspected stroke or TIA with normal CT

›DWI sequence detects ischemia within minutes to hours

›Higher sensitivity than CT for posterior fossa and cortical infarcts

07Disposition/dispo38

Admission criteria

›Inpatient admission indications

›Acute medical illness requiring inpatient treatment

›Sepsis, stroke, ACS, decompensated heart failure

›Delirium requiring workup and monitoring

›Ongoing confusion with unclear etiology

›Unsafe for discharge

›No caregiver and unable to perform basic ADLs

›Inability to ambulate safely

›Unable to eat, drink, or take medications independently

›Concern for elder abuse or neglect requiring safe placement

›Dementia with behavioral disturbance no longer manageable at home

›Suicidal ideation requiring psychiatric admission

Observation indications

›Short-stay monitoring

›Borderline cases awaiting social work evaluation

›Awaiting home services setup or family meeting

›Capacity assessment pending

›Awaiting geriatrics or psychiatry consultation

Discharge criteria

›Safe for discharge criteria

›Acute medical issues resolved or stable

›Adequate functional status to return home

›Can ambulate, toilet, and feed self; or has caregiver available

›Home services arranged: home health, Meals on Wheels, PT/OT

›Safe home environment confirmed via collateral

›Follow-up arranged within 1 to 2 weeks

08Treatment/t57

Acute medical stabilization

›Immediate interventions

›Treat identified acute medical conditions

›Sepsis: broad-spectrum antibiotics within 1 hour (Class I recommendation)

›Dehydration: IV normal saline 250 to 500 ml bolus, reassess

›Hypoglycemia: 50% dextrose 50 ml IV or oral glucose if alert

›Decompensated thyroid: endocrine consultation

›Delirium prevention bundle

›Reorientation: name, date, location at each interaction

›Minimize tethers: urinary catheters, IV lines not needed

›Avoid unnecessary sedation and anticholinergic medications

›Correct sensory deficits: ensure glasses and hearing aids in use

›Early mobilization

Medication reconciliation

›Fall-risk medication reduction (FRIDs)

›Discontinue or reduce benzodiazepines

›Taper over 4 to 8 weeks if chronic use to avoid withdrawal

›Reduce or eliminate anticholinergics

›Review against AGS Beers Criteria and STOPPFall tool

›Antihypertensives: reduce dose if orthostatic hypotension present

›Review opioid necessity; lowest effective dose if required

›Gabapentinoids: taper if contributing to sedation and falls

Nutritional support

›Nutrition interventions

›Oral nutritional supplements

›200 to 400 kcal/day supplement drinks (e.g., Ensure, Boost)

›Evidence: reduces complications and length of stay in malnourished elderly

›Refeeding syndrome prevention in severe malnutrition

›Check and correct phosphate, potassium, magnesium before refeeding

›Thiamine 100 mg IV or PO before carbohydrate administration

›Vitamin D supplementation

›800 to 1000 IU daily for fall prevention (AGS recommendation)

›Class I recommendation for fall reduction in vitamin D-deficient elderly

›Dietitian referral for outpatient malnutrition management

Depression and psychiatric treatment

›Pharmacological treatment

›SSRI first-line for depression in elderly

›Sertraline 25 mg PO daily, titrate to 50 to 100 mg over 4 to 6 weeks

›Escitalopram 5 mg PO daily, titrate to 10 to 20 mg

›Avoid TCAs (anticholinergic burden) and mirtazapine as first choice

›Avoid starting benzodiazepines for anxiety or insomnia in elderly

›Significant fall risk; cognitive impairment risk

›If suicidal ideation: urgent psychiatric referral; do not discharge

Cognitive impairment treatment

›Dementia management initiation

›Avoid anticholinergics in known or suspected dementia

›Refer for outpatient cholinesterase inhibitor evaluation

›Donepezil 5 mg PO nightly, may increase to 10 mg after 4 to 6 weeks

›Environment modifications: consistent routines, orientation aids

›Behavioral: non-pharmacological first (music, activity, redirection)

Frailty and rehabilitation

›Exercise and functional rehabilitation

›Multicomponent exercise programs: strength, balance, aerobic

›Evidence supports fall reduction and functional improvement (Kim, NEJM 2024)

›Physical therapy referral for gait training and home exercise program

›Occupational therapy referral for ADL assessment and adaptive equipment

›Fall prevention: remove trip hazards, improve lighting, install grab bars

Pain management

›Analgesic strategy

›Preferred: acetaminophen < 3 g/day (< 2 g/day with hepatic disease)

›Avoid NSAIDs in elderly: GI bleeding, renal toxicity, hypertension

›If opioids required: lowest effective dose, short-acting agents

›Hydromorphone 0.2 mg IV q4h PRN (renal dosing if CKD)

›Monitor for respiratory depression, constipation, falls

09Special Populations/sp42

Pregnancy

›Pregnancy considerations

›Failure to cope presentation is rare in the reproductive age group

›Consider postpartum depression, perinatal mental health crisis

›Postpartum depression: Edinburgh Postnatal Depression Scale (EPDS) screening

›Score > 10: positive screen, refer to perinatal mental health

›Social isolation in new mothers: screen for caregiver support adequacy

›Domestic violence screen: universal in pregnancy-related ED visits

›HITS or SAFE tool for intimate partner violence

›Medication safety if breastfeeding

›SSRI: sertraline preferred with lowest breast milk transfer

›Avoid benzodiazepines: sedation and withdrawal risk in neonate

Geriatric

›Geriatric-specific management

›Prevalence of failure to cope increases sharply after age 75

›Highest rates in patients >85 years

›Smulowitz et al. JAMA Internal Medicine 2023

›Functional status assessment drives all disposition decisions

›Difficulty with 5 ADLs increases ED admission by 8.5 percentage points

›Cognitive impairment increases admission by 4.6 percentage points

›Frailty screening with Clinical Frailty Scale

›CFS >= 6 identifies patients benefiting from comprehensive geriatric assessment

›Comprehensive geriatric assessment reduces 1-year mortality and institutionalization

›Delirium recognition

›Superimposed on dementia in up to 40% of admitted elderly patients

›4AT score >=4 warrants delirium workup

›Goals of care discussion

›Failure to cope often signals turning point in trajectory of chronic illness

10Background/b54

Epidemiology

›Population and prevalence

›Failure to cope is predominantly a geriatric presentation

›Age >75 most commonly affected; peak incidence age >85 years

›Geriatric patients represent 25% of all ED visits in high-income countries

›88% of patients admitted under failure to cope have an identifiable acute medical diagnosis

›Tsui et al. BMC Geriatrics 2020 (matched case-control study)

›Malnutrition prevalence: up to 50% of acutely ill elderly ED patients meet GLIM criteria

›Munoz Fernandez et al. Clinical Nutrition 2021

›Social isolation: most common social risk factor (39% of elderly ED patients)

›Living alone increases ED admission probability by 5 percentage points

›Caregiver burden is a powerful independent predictor of institutionalization

›SDOH screening active in approximately 78% of US EDs (JAMA Network Open 2025)

›Falls: leading cause of injury-related death in adults >65 years

›Ganz and Latham NEJM 2020

Pathophysiology

›Mechanism of functional decline

›Multifactorial syndrome: no single cause in most cases

›Medical, functional, cognitive, nutritional, and social domains interact

›Frailty phenotype

›Fried criteria: weight loss, exhaustion, low physical activity, slow gait, weakness

›Frailty increases vulnerability to stressors (infection, medication change, fall)

›Kim and Rockwood NEJM 2024

›Sarcopenia

›Age-related loss of muscle mass and strength

›Contributes to falls, functional decline, metabolic vulnerability

›EWGSOP2 criteria: low muscle strength (handgrip) plus low muscle mass

›Nutritional pathway

11Patient Discharge Instructions/pdi38

copy discharge instructions

›Discharge instructions for Failure to Cope (Social)

›What happened today

›You came to the emergency department because you or your family were having difficulty managing at home

›We checked for medical causes of your difficulties and treated what we found

›We have arranged support services to help you at home

›Medications

›Take all medications exactly as prescribed

›Do not stop any medications without calling your doctor first

›If a medication makes you feel dizzy, drowsy, or causes a fall, call your doctor

›Bring all medications in their original bottles to your next appointment

›Nutrition

›Try to eat three meals per day even if your appetite is low

›Drink at least 6 to 8 cups of fluid daily unless your doctor has restricted fluids

›Use nutritional supplement drinks (such as Ensure or Boost) if meals are difficult

›If you cannot eat or drink for more than 24 hours, return to the emergency department

›Fall prevention at home

›Remove loose rugs, cords, and clutter from walking areas

›Install grab bars in the bathroom near the toilet and in the shower

›Improve lighting in hallways, stairways, and bathrooms

›Use your walker or cane at all times when walking

›Wear non-slip footwear indoors and outdoors

›Follow-up appointments

›See your family doctor within 1 to 2 weeks

›Home health nurse or therapist will visit within 48 hours of discharge if ordered

›Geriatrics referral has been arranged if applicable

›Return to the emergency department immediately if you experience

›New confusion, increased disorientation, or unusual behaviour

12References/r31

Guidelines and key sources

›Primary evidence sources

›Tsui C, Kim K, Spencer M. The Diagnosis "Failure to Thrive" and Its Impact on the Care of Hospitalized Older Adults. BMC Geriatrics. 2020

›88% of failure to thrive admissions have acute medical diagnosis at discharge

›Smulowitz PB et al. Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the ED. JAMA Internal Medicine. 2023

›Quantifies functional, cognitive, and social admission predictors

›Kim DH, Rockwood K. Frailty in Older Adults. New England Journal of Medicine. 2024

›Clinical Frailty Scale, frailty phenotype, therapeutic implications

›Cruz-Jentoft AJ, Volkert D. Malnutrition in Older Adults. New England Journal of Medicine. 2025

›GLIM criteria, nutritional interventions, oral supplementation evidence

›Ganz DA, Latham NK. Prevention of Falls in Community-Dwelling Older Adults. NEJM. 2020

›Multicomponent fall prevention, vitamin D, exercise evidence

›Colon-Emeric CS et al. Risk Assessment and Prevention of Falls in Older Adults. JAMA. 2024

›AGS and World Falls Guidelines summary

›Molina MF et al. Screening and Response for Adverse Social Determinants of Health in US EDs. JAMA Network Open. 2025

›78% of EDs with SDOH screening programs

›Ellis G, Marshall T, Ritchie C. Comprehensive Geriatric Assessment in the ED. Clinical Interventions in Aging. 2014

›CGA reduces institutionalization and mortality

›Naylor MD et al. Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders. JAMA. 1999

›Randomized trial: discharge planning reduces readmissions

›Deardorff WJ, Burke RE, Makam AN. Navigating Postacute Care Options After Hospital Discharge. JAMA Internal Medicine. 2026

›SNF, home health, PACE options and criteria

›Geriatric Emergency Department Guidelines. Annals of Emergency Medicine. 2014

›ACEP and AGS joint guidelines for geriatric ED care

›Robertson RG, Montagnini M. Geriatric Failure to Thrive. American Family Physician. 2004

›MNA-SF, clinical domains, treatment approach

›Sarkisian CA, Lachs MS. Failure to Thrive in Older Adults. Annals of Internal Medicine. 1996

›Foundational framework for geriatric failure to thrive

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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