Patient Management Exercise For Delirium

CBC: wbc 16.8, hem 10.8, hct 31.4, plt 82

BASIC: Na 127, K 2.4, Cl 99, HCO3 28, Cr 3.2, BUN 148, GLU 188

COMP: Cal 9.7, Alb 3.2, Prot 5.4, AST 26, ALT 22, Alk Phos 177

Urinalysis: leukocyte esterase positive, nitrite positive, wbc>25 per hpf, rbc 2–5 per hpf, hyaline casts 2–3 per hpf

Urine drug screen: positive for opiates, benzodiazepines

Oxygen saturation was 92% on 3 liters via nasal cannula

B1. ____Tell the intern that the patient is very likely “sundowning” and that the most appropriate step would be to give him 10 mg i.m. haloperidol immediately. Tell him that you will be there shortly to assess the patient and make further recommendations.

B2. ____ Tell the intern that the patient is likely “sundowning” and that the best course of action is to reorient him, maintain him in four-point restraints, and administer 2 mg of lorazepam intramuscularly or orally every 4 hours for agitation.

B3. ____ Tell the intern that the description of the patient suggests that he is suffering an acute dystonia, likely secondary to the large doses of haloperidol. Tell him that you will be there shortly, but he should immediately give the patient 50 mg i.v. of diphenhydramine. Tell him that an anticholinergic agent could worsen the delirium but that because patients can develop laryngeal dystonia, treatment is necessary. Tell him to remove the restraints as soon as the patient calms down.

B4. ____ Tell the intern that the patient probably has a CNS infection and should be transferred immediately to the intensive care unit. Tell him that an intravenous haloperidol drip of 0.2 mg per hour should be started and a lumbar puncture performed and that empirical treatment of bacterial meningitis should be considered while the patient’s cerebrospinal fluid is evaluated.

B5. ____ Tell the intern that the patient should be placed in a Posey restraint as well as the four-point leather restraints to keep him in bed. Tell him that there is no treatment for this condition and that the patient must “ride it out.” Assure him that this episode will be over within 4–6 hours.

Glyburide 5 mg p.o. daily

Metformin 500 mg p.o. b.i.d.

Insulin sliding scale with Humalog

Aspirin 81 mg p.o. daily

Furosemide 160 mg p.o. daily

Piperacillin/tazobactam 3.375 grams i.v. every 6 hours

Gentamycin 2 grams i.v. every 8 hours

Atenolol 50 mg p.o. b.i.d.

Lisinopril 20 mg p.o. daily

Clonidine 0.2 mg p.o. b.i.d.

Fluoxetine 60 mg p.o. daily

Fluticasone/salmeterol 5/500 2 puffs b.i.d.

Albuterol 2 puffs b.i.d.

Haloperidol 10 mg p.o. or i.m. every 6 hours p.r.n. for agitation (total 40 mg in 3 days)

Trazodone 200 mg p.o. h.s.

Zolpidem 10 mg p.o. h.s.

D1. ____Numerous new medications starting during the hospitalization

D2. ____Any iatrogenic event

D3. ____Use of a bladder catheter

D4. ____Visual impairment

D5. ____None of the above

A1. +5 History: Determine what the patient’s baseline mental status was prior to admission. Has the patient had previous bouts of mental status changes? If so, what was done?

A2. +5 Psychiatric conditions: The patient was described as “depressed.” Does he have a preexisting psychiatric condition? Has he ever been on any psychotropic medications?

A3. +5 Medications: What medications is the patient currently taking? What medications was the patient taking prior to admission? Check for drug-drug interactions and iatrogenic causes.

A4. +5 Substances/alcohol: The patient’s urine drug screen was positive for opiates and benzodiazepines. Does the patient have a history of abuse or dependence on alcohol or other substances? Is the patient within the window of withdrawal from any of the possible offending agents?

A5. +5 Endocrine: Is the patient eating adequately while receiving treatment for diabetes? Is this renal failure or liver failure? Are endocrine abnormalities possible, such as hypo- or hyperthyroidism or hypo- or hyperparathyroidism?

A6. +5 Metabolic: Could the delirium be secondary to a thiamine or other nutritional deficiency? Is there an acid-base disturbance? Could the patient be in heart failure?

A7. +5 Vascular: The patient is hypertensive. Could he have hypertensive encephalopathy? Cerebral arteriosclerosis? Could he have cardiac emboli from atrial fibrillation? Patent foramen ovale? Endocarditic valve?

A8. +5 Infectious: Does the patient have a urinary tract infection? Obtain a urinalysis with culture and susceptibility, and also look at the urine to see if it is clear or cloudy. Given the patient’s multiple sources of infection, it is reasonable to pan-culture the patient’s infectious sources. Is he becoming septic/encephalitic/meningitic from bacteria or virus? He is less likely to have a parasitic or fungal infection, but this may need to be ruled out given the possibility of immunocompromise from multiple medical problems. The patient has multiple sources of possible infection, with a dehisced amputation wound, pneumonia or other lung infection, septic joint, sacral decubitus ulcer, and so on.

A9. +5 Brain hypoxia: Could the patient have brain hypoxia secondary to cardiac insufficiency, pulmonary infection, or chronic obstructive pulmonary disease? Could anemia be causing the delirium?

B1. −5 You do not know how much haloperidol the patient has received to this point. Moreover, the patient’s symptoms sound like acute dystonic reaction, an extrapyramidal side effect. You do not wish to worsen these symptoms, so it makes sense to back off the haloperidol and give a trial of 50 mg i.v. of diphenhydramine or 1–2 mg i.v. of benztropine to see if the symptoms abate. If the symptoms continue unchanged or worsen, then other causes must be explored, especially a CNS infection.

B2. −3 First, perform a bedside neurological exam and a Mini-Mental State Examination to establish a current baseline. Data are limited on the efficacy of benzodiazepines for the treatment of delirium, except in the case of alcohol or benzodiazepine withdrawal. Although there are reports of successful use of a combination of a benzodiazepine and an antipsychotic in treating delirium, these reports are inconclusive and did not use standardized assessment tools. Benzodiazepines can increase sedation and cause behavioral inhibition, amnesia, ataxia, respiratory depression, physical dependence, rebound insomnia, withdrawal reactions, and delirium. Lorazepam, oxazepam, and temazepam are primarily metabolized by glucuronidation, not oxidated, and clonazepam is acetylated. Thus, all are relatively unaffected until parenchymal liver disease is quite severe; they are subsequently relatively safer in the context of liver failure if a benzodiazepine is necessary to treat withdrawal symptoms, to raise seizure threshold, or to counteract anticholinergic side effects or akathisia associated with concurrent use of antipsychotics. For this patient, whose medical history includes extensive lung disease, obstructive sleep apnea, chronic renal insufficiency, and hepatic encephalopathy, benzodiazepines are relatively contraindicated.

B3. +3 Because this seems a likely cause of the current classical manifestation of an extrapyramidal acute dystonic reaction (thickened tongue, stiffening, torticollis, and facial grimacing), a small trial of an anticholinergic is reasonable. Anticholinergics, antiparkinsonian agents, and antihistamines such as trihexyphenidyl, benztropine, biperiden, procyclidine, and diphenhydramine are all commonly used for the treatment of neuroleptic-induced parkinsonism and acute dystonic reactions. Diphenhydramine can be given up to a total of 400 mg/day. Keep in mind that you have not yet seen the patient and may be surprised when you get to the bedside. Typically in these circumstances the patient must be reevaluated frequently, and physical restraints should be removed once the patient is considered safe from harm to himself or others.

B4. +2 A CNS infection is lower on the differential diagnosis but must still be considered, especially if the more likely scenario of acute dystonic reaction secondary to antipsychotic use is ruled out. If suspicion of a CNS infection rises, computed tomography of the head and a lumbar puncture are indicated, in which case the patient will likely require sedation to lie still through the procedures.

B5. −5 This response is inappropriate in a hospital. Patients’ comfort and safety must be maintained, and this patient’s condition is very likely treatable and not something to “ride out.”

Drug-drug interactions

Disease contraindications

General

D2. 0 An iatrogenic event does not necessarily put the patient at risk for a delirium.

D3. +1 An indwelling catheter puts patients at risk of developing a bladder infection and subsequent sepsis. In elderly patients the first sign of sepsis may be a change in mental status.

D4. +2 Impairment of vision and/or hearing places patients at risk of developing a delirium.

Advanced age (especially over 80 years)

Severe illness (especially cancer)

Dehydration

Dementia

Fever or hypothermia

Substance abuse

Azotemia

Hypoalbuminemia

Abnormal sodium levels