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The Mumbling Lady

The Mumbling Lady. Side Effects Case. Presentation. 69-year-old female with Alzheimer’s disease Over the last few days she has grown confused, slurred speech, gait changes with near falls, sedation No change in her back and knee pain when awake and alert. Medical History.

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The Mumbling Lady

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  1. The Mumbling Lady Side Effects Case

  2. Presentation • 69-year-old female with Alzheimer’s disease • Over the last few days she has grown confused, slurred speech, gait changes with near falls, sedation • No change in her back and knee pain when awake and alert

  3. Medical History • High blood pressure • Arthritis in her knees • Heart disease • Depression • Peripheral neuropathy • Diabetes • Hypothyroidism • Constipation • Disk disease in her back

  4. Medications • Metoprolol • Aspirin • Ultram • Elavil • Paroxetine • Gabapentin • Synthroid • Colace • Calcium plus vitamin D • Benedryl • Senna

  5. Acute Problems Last week Increased pain Ultram added as a standing dose medication as well as prn Nighttime awakening About 1-3am Doesn’t return to bed until 5 or 6 am Benedryl added Ambien caused a rash previously

  6. Medical Workup • Vitals normal except blood pressure low • Some readings 80/50 range • Laboratory all normal • Thyroid, electrolytes, CBC, urinalysis, B12 • Radiology • CT scan without acute findings • New medications • Ultram • Benedryl (diphenhydramine)

  7. Nursing Management • Reported to the provider the change in condition immediately • Maintained a sleep chart to provide information about wake and sleep during the day and night • Established fall precautions • Daily orthostatic blood pressure and pulse to assess whether orthostasis is the reason for falls

  8. Nursing Management • Monitored eating to look for choking with the development of slurred speech • Looked for weakness on side of the body or facial droop • Assessed possibility of constipation • DON discussed new findings with nurses and CNAs on all three shifts

  9. Plan • Likely a delirium • Ultram • Recently added • Can cause delirium • Discontinued and acetaminophen added • Anticholinergic agents • Cause delirium often in dementia • Taken paroxetine for years • Amitriptyline used at very low dose for pain and also on board for over a year • Diphenhydramine given over the last three days • Discontinued immediately

  10. Outcome • Delirium cleared • Pain under fair control with acetaminophen • Ultram not added back • Diphenhydramine discontinued • Consider changing paroxetine to another antidepressant • Contemplate nortriptyline rather than amitriptyline • Monitor sleeping led to nonpharmacologic interventions which aided sleep

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