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Delirium CASE

Delirium CASE. Donald R Noll DO FACOI/ Edward Warren, MD, Chair Geriatrics Carolinas Campus January 2012. CC: Acute Confusion

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Delirium CASE

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  1. Delirium CASE Donald R Noll DO FACOI/ Edward Warren, MD, Chair Geriatrics Carolinas Campus January 2012

  2. 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 of Chief Complaint

  3. 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. History, Medications & ROS

  4. 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 Exam and Tests

  5. Impressions Acute Delirium/change in mental status – multi-factorial Advanced osteoarthritis with poor pain control Recent skin tear – non-infected Urinary Tract infection – Day 7 of treatment with levofloxacin Hallucination secondary to the delirium Heart failure – stable Glaucoma - stable Impressions

  6. In this case, the attending stopped two medications and replaced them with one new medication. Pick two medications to stop. celecoxib lansoprazole docusate sodium Betoptic drops Alphagan drops spironolactone calcium with vitamin D hydrocodone/APAP Question 1

  7. Which medication would you start to address the acute confusion problem. Pick only one. 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 2

  8. Should you add an anti-psychotic for the short term, such as haloperidol or risperidone to the treatment to control neurobehavioral symptoms? Yes No Question 3

  9. 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. 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 4

  10. Which type of delirium is most often associated with drug or alcohol withdrawal? Hypersomnolent delirium Hypervigilant delirium Mixed delirium No consistent association with any type Question 5

  11. A damaged brain is much more likely to go into brain failure (AKA delirium or acute confusion). Yes No Question 6

  12. Which neurotransmitter deficiency is most associated with delirium? Norepinephrine Dopamine Glutamine Acetylcholine Serotonin Question 7

  13. 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? Yes No Question 8

  14. Because of this one episode of delirium, how does this roughly change her 12 month survival prognosis? 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 9

  15. How long will it most likely take for the patient in this case to fully recover and return to her previous cognitive baseline? 4 hours 4 days 4 weeks 4 months 4 years Question 10

  16. Q1 = A and H Q2 = A Q3 = A Q4 = A, C, E Q5 = B Q6 = A Q7 = D Q8 = A Q9 = C Q10 = C Answer Key

  17. 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

  18. 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. An antipsychotic is indicated for the agitation and psychotic symptoms. Answers

  19. The multifactorial scenario is the strange hospital environment, the opioids, and the infection. Hypervigilance occurs due to the sudden removal of a CNS suppressive substance. The damaged brain is more likely to fail just as a damaged heart is more likely to fail. Answers

  20. Acetylcholine deficiency from the effect of anticholinergicscauses delirium. This plan will help calm this agitated patient. Delirium is a serious complication and doubles the risk of death in the next year. While it can resolve in a week, 4 weeks is not surprising and is often seen. Answers

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