Download History of Chief Complaint

Delirium CASE
Donald R Noll DO FACOI/ Edward Warren, MD, Chair Geriatrics
Carolinas Campus January 2012
History of Chief Complaint
CC: Acute Confusion
HCC: Mrs. Y is a delightful 96 year old white female who is well known to me. Normally she
is well oriented and has normal cognition and behavior. Presently, she is being seen in
the hospital. Some weeks ago, she was having significant arthritis pain, particularly in her
back. Various pain medications were tried, including an NSAID, but she became more
confused soon after hydrocodone/APAP 5/500 (Lortab) was added to her treatment.
Because of the increased confusion and inability to take care of herself at home, she was
admitted to the hospital, where she was found to have both pyuria, bactiuria and a high
white blood cell count. On admission she had a temperature of 101 degrees. Despite
treatment with antibiotics, she is not better. She has been in this hospital for one week
and still remains very confused. She is hallucinating, believing that she is in a hearse and
that she is giving directions to her son not to open her coffin. She is disoriented to time.
Her days and night are mixed up. At times she believes she is at home and at other times
she gets agitated and throws her coffee at the nurses.
History, Medications & ROS
History: PMH is remarkable for CHF, COPD, hypertension, GERD, severe osteoarthritis,
depression, chronic sinusitis, and glaucoma. PSH – Hysterectomy.
Allergies – PCN, Morphine “intolerance”, Lincocin, sulfa drugs, and Parafon Forte
Medications – celecoxib 200 mg daily; lansoprazole 30mg daily; docusate sodium
100mg bid; Betoptic drops, Alphagan drops, Xalatan drops, and Trusopt drops for
her glacoma; spironolactone 25mg daily, furosemide 20 mg qd; calcium supplement
with Vitamin D, Vitamin C 500mg daily, Zinc 150mg daily. levofloxacin 500 mg daily,
hydrocodone/APAP 5/500 BID.
ROS: disoriented to time, agitated at times, complains of back pain, appears
uncomfortable, can’t locate discomfort well, no chest pain, no shortness of breath,
no nausea, vomiting or diarrhea.
Exam and Tests
Exam: BP = 160/65, R = 20, P = 72.
HEENT - unremarkable, neck supple, mouth moist, pupils equal and reactive to light
Skin – good turgor and texture, no rash, but a skin tear on the lower extremity
Lungs - Clear to auscultation
Heart – Regular rate and rhythm without murmur
Abdomen - soft with normal bowel sounds
Extremities – 3+ pitting edema, significant arthritic changes in weight bearing joints.
Ecchymotic lesions on the lower extremities and a 2 cm skin tear noted on the
posterior aspect of the left calf, properly dressed with no signs of infection.
Neurologic Exam – confused, no focal deficits
CT Scan – only showed diffuse cerebral atrophy
Repeat WBC 9,800 Repeat UA is unremarkable
Impressions
Impressions
1. Acute Delirium/change in mental status – multi-factorial
2. Advanced osteoarthritis with poor pain control
3. Recent skin tear – non-infected
4. Urinary Tract infection – Day 7 of treatment with levofloxacin
5. Hallucination secondary to the delirium
6. Heart failure – stable
7. Glaucoma - stable
Question 1
In this case, the attending stopped two medications and replaced them with
one new medication. Pick two medications to stop.
A. celecoxib
B. lansoprazole
C. docusate sodium
D. Betoptic drops
E. Alphagan drops
F. spironolactone
G. calcium with vitamin D
H. hydrocodone/APAP
Question 2
Which medication would you start to address the acute confusion problem.
Pick only one.
A.
B.
C.
APAP 650 mg po qid (for better pain control)
nitrofurantoin 100 mg bid (to switch to a different antibiotic)
lisinopril 10 mg PO daily (for better control of heart failure)
Question 3
Should you add an anti-psychotic for the short term, such as
haloperidol or risperidone to the treatment to control neurobehavioral
symptoms?
A. Yes
B. No
Question 4
Which of the following are likely causes for her delirium. While delirium has
numerous causes, and each of these options can potentially contribute to
delirium, pick the three most significant contributing causes in the list below.
A.
B.
C.
D.
E.
F.
G.
H.
I.
the hospitalization (unfamiliar surroundings)
celecoxib
hydrocodone/APAP
furosemide
the UTI
levofloxacin
the glaucoma medications
the skin tear / wound on the left calf
the high white blood cell count
Question 5
Which type of delirium is most often associated with drug or alcohol
withdrawal?
A.
B.
C.
D.
Hypersomnolent delirium
Hypervigilant delirium
Mixed delirium
No consistent association with any type
Question 6
A damaged brain is much more likely to go into brain failure (AKA
delirium or acute confusion).
A.
B.
Yes
No
Question 7
Which neurotransmitter deficiency is most associated with delirium?
A.
B.
C.
D.
E.
Norepinephrine
Dopamine
Glutamine
Acetylcholine
Serotonin
Question 8
In this case, the attending ordered the patient be kept in a well lit room,
no overstimulation, and staff and family members to re-orient the
patient periodically. Is this a reasonably good treatment plan?
A.
B.
Yes
No
Question 9
Because of this one episode of delirium, how does this roughly change
her 12 month survival prognosis?
A.
B.
C.
D.
She is about twice as likely not to die
It does not change her mortality risk
She is about twice as likely to die
There are too many variables to determine this
Question 10
How long will it most likely take for the patient in this case to fully
recover and return to her previous cognitive baseline?
A.
B.
C.
D.
E.
4 hours
4 days
4 weeks
4 months
4 years
Answer Key
•
•
•
•
•
Q1 = A and H
Q2 = A
Q3 = A
Q4 = A, C, E
Q5 = B
•
•
•
•
•
Q6 = A
Q7 = D
Q8 = A
Q9 = C
Q10 = C
Answers
1. The celecoxib is a poor idea to treat pain
of any kind in the elderly and especially
with CHF, since it causes fluid retention
by decreasing renal blood flow. The
hydrocodone/APAP is the proximate
cause of her delirium and certainly needs
to be removed.
Answers
2. Acetaminophen is an excellent analgesic,
especially when given routinely. There is no
reason to switch antibiotics unless the C&S
indicates the need. She has no symptoms
of uncompensated CHF.
3. An antipsychotic is indicated for the agitation
and psychotic symptoms.
Answers
4. The multifactorial scenario is the strange
hospital environment, the opioids, and the
infection.
5. Hypervigilance occurs due to the sudden
removal of a CNS suppressive substance.
6. The damaged brain is more likely to fail just
as a damaged heart is more likely to fail.
Answers
7. Acetylcholine deficiency from the effect of
anticholinergics causes delirium.
8. This plan will help calm this agitated patient.
9. Delirium is a serious complication and
doubles the risk of death in the next year.
10.While it can resolve in a week, 4 weeks is
not surprising and is often seen.