Case 21: Feeling confused. Expert comment by Dr Sana Mufti

Thanks to everyone who contributed to the discussions about Mr Vincent an 81 year old man who was sent to hospital with confusion.

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This case’s question setter and expert was Dr Sana Mufti, ST5 Geriatrics, Whipps Cross Hospital. 

Information available at the start of the week:

Mr Vincent tells you he isn’t sure why he is in the hospital and how he ended up here. He insists he is well and can’t understand why everyone is fussing over him. When you ask him direct questions about his health, he denies all symptoms. He tells you he works as an accountant and lives with his parents and when you try and ask further questions about his social history, he becomes agitated and asks you to leave.

GP Letter:

Dear Medical Doctor,

Mr Smith’s  son asked me to go and see him urgently at home. I haven’t seen him for a while but he certainly looks like he’s not had much to drink the last few days and appears to be confused and can’t stay at home like this. There’s no history of dementia but when he came to see the practice nurse for a blood pressure check last year she commented he wasn’t as sharp as he had been. 

PMH: Hypertension and Benign Prostatic Hypertrophy

DH: tamsulosin 400mcg, bendroflumethiazide 2.5mg. He has also recently been prescribed oxybutynin 2.5mg BD after being seen in Urology OPD.

SH: He lives alone since his wife passed away 8 years ago. He is a non smoker and drink 4 units of alcohol a week. There is no documented family history of note.

I tried to examine him but he told me, in quite rude terms, to go away so I didn’t persist. I hope you have better luck.

Thank you for your ongoing care

Dr D Tennant

The nurse manages to take some vital signs: 36.2 C, HR 80bpm, BP 135/70, RR 12 and CBG 5mmol/L and tells you Mr Vincent seems to be more co operative now and might let you examine him.

Question 1: In each body system – what common precipitants of delirium will you be looking for on examination? 

His temperature is 36.2, HR 80bpm, BP 135/70, RR 12 and CBG 5. His

Abbreviated Mental Test Score is 6/10 (losing points for recall, orientation and attention).

He appears agitated and is only able to follow one step commands but his speech appears normal. Cardiovascular and respiratory examinations are normal.

When you examine his abdomen, he has a fullness suprapubically with mild tenderness. This area is dull to percussion. Bowel sounds are normal and there are no hernias found.

It is difficult to perform a full neurological examination due to his agitation but there is no evidence of menigism, no evidence of head injury and the examination is grossly normal (including normal reflexes and downgoing plantars bilaterally). He is a bit unsteady on his feet but when prompted to use a zimmer frame is independently mobile.

Investigations:

Routine bloods sent on admission which are normal apart from a slightly raised ALP of 150IU/L and a slightly low corrected calcium of 2.10mmol/L.

Question 2. What do the ECG and Chest x-ray show?

ECG

Chest_Xray_PA_3-8-2010

 

Question 3: What immediate management option will make Mr Vincent feel better?

Question 4: What is the underlying precipitant of his presentation?

Question 5: Does he now have a diagnosis of dementia?

Expert Comment

Key points:

1. The importance of a collateral history from family or carer

2. Full drug history, including any new drugs, changes in doses and over the counter medications

3. Think of delirium, then look for delirium in order to diagnose and treat it!

4. Look hard for underlying causes and treat

5. Risk assess everyone >65 years and put every effort in reducing risk of developing delirium

6. Explanation to patient and family

7. Follow up to look for development of dementia

Resources:

  1. NICE Guidance Delirium CG 103
  2. NICE Guidance Dementia CG 42
  3. RCP Guidelines No. 6 (Prevention, Diagnosis and Management of Delirium in Older People)

Dr Sana Mufti, ST5 Geriatrics, Whipps Cross Hospital says:

This was an interesting scenario which brought out some important points in the management and diagnosis of delirium

Delirium can be a confusing topic, not helped by the number of synonyms that exist! Delirium can also be called acute confusional state, organic brain syndrome and toxic encephalopathy to name but a few.

In hospital, delirium can be described as agitated, confused, combative, ‘poor historian’ and uncooperative. Again, just a few examples.

Delerium

The DSM IV broad definition is a change in consciousness and cognition that develops over a short period of time and fluctuates throughout the course of the day. There has to be evidence from the history, examination or investigations that it is a direct consequence of a general medical condition, drug withdrawl or intoxication.

Delirium is often not recognised so a high index of suspicion is required. There are 3 types of delirium:

  1. Hyperactive
  2. Hypoactive – most difficult to diagnose
  3. Mixed

Delirium is important because it is very common with an approximate prevalence of 20-30% on medical wards and up to 50% on surgical wards! Additionally, the hospital environment often precipitates/ exacerbates delirium. There is a high mortality associated with it as well as more associated complications (for example: falls, pressure sores). If that isn’t convincing enough, delirium is also related to longer length of stay and greater chance of institutionalisation on discharge. One reason for these poor outcomes is lack of recognition and therefore poor management.  Delirium is potentially preventable and an individual is three times more likely to develop dementia after delirium episode

As mentioned before, in order to diagnose delirium, the first step is to think about it. Once you have thought about it, history will be the most valuable tool you will have available to diagnosis it. This might be history from the patient or if not available, history from a relative or carer. Other important points to focus on are:

  • Previous intellectual function (who looks after household affairs/bills/medications)
  • Functional status (Activities of Daily Living)
  • Onset and course of confusion
  • Previous episodes of acute or chronic confusion
  • Sensory deficits – hearing, sight, speech & aids used
  • Symptoms suggestive of underlying cause (eg. infection)
  • Pre-admission social circumstances / care package
  • Full drug history including non-prescribed drugs/cessation
  • Alcohol history

There are many ways to diagnose delirium (once you have thought about it) but one of the easiest tools to use is ‘CAM’ : Confusion Assessment Method.

The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4

 Acute Onset or Fluctuating Course (1)

AND

Inattention (2)

Disorganized thinking (3)

OR

Altered Level of consciousness (4)

Attention is a basic cognitive function but is often neglected. It can be formally tested by Serial &s or spelling ‘WORLD’ backwards as 2 examples.

 This differs from dementia which is usually gradual onset, characterised by a memory disturbance rather than inattention, with minimal fluctuations and is irreversible.

Everyone with delirium or suspected delirium needs a full systemic examination including a full neurological examination. The aim is to find the cause of the delirium (e.g. infection, drug intoxication/withdrawal, rectal examination for faecal impaction). Investigations again need to be directed at the cause of delirium, directed by the history and examination findings.

There are many causes and causes maybe multifactorial. Here are a few common causes:

  • Infection
  •  Cardiac cause
  •  Respiratory disorder
  •  Electrolyte imbalance (eg dehydration, renal failure, hyponatraemia)
  •  Endocrine and metabolic disorder (eg cachexia, thiamine deficiency, thyroid dysfunction)
  •  Drugs (anticholinergic, tricyclic antidepressants, anti-parkinsonian, opiates, analgesics, steroids)
  •  Drug (especially benzodiazepine) and alcohol withdrawal
  •  Urinary retention
  •  Faecal impaction
  •  Severe pain
  •  Neurological problem (eg stroke, subdural haematoma, epilepsy, encephalitis)

The most important action is the identification and treatment of the underlying cause. For example:

  •  Incriminated drugs should be withdrawn if possible
  •  Biochemical derangements should be corrected
  •  Infection is one of the most frequent precipitants of delirium. Appropriate cultures should be taken and antibiotics commenced promptly, selecting a drug to which the likely infective organism will be sensitive.
  •  Parenteral thiamine should be administered when alcohol abuse or undernutrition is apparent.

Nurse in a good sensory environment with a reality orientation approach, and involve the MDT

  •  Appropriate lighting levels for time of day
  •  Regular and repeated (at least three times daily) cues to improve personal orientation
  •  Use of clocks and calendars to improve orientation
  •  Hearing aids and spectacles available/ working order
  •  Continuity of care from nursing staff
  •  Encouragement of mobility and engagement in activities
  •  Patient is approached and handled gently
  •  Elimination of unexpected and irritating noise (eg pump alarms)
  •  Regular analgesia
  •  Visits from family/friends who may help calm the patient
  •  Explanation to relatives. Bring in familiar objects and picture & participate in rehabilitation
  • Good diet, fluid intake and mobility to prevent constipation
  •  Adequate oxygenation
  • Good sleep pattern (milky drinks at bed, exercise during day)

Avoid:

  •  Inter- and intra-ward transfers
  •  Physical restraint
  •  constipation
  •  Anticholinergic drugs if possible & keep drugs to a minimum
  •  Catheters where possible

The case of Mr Vincent

Referring to the case of Mr Vincent, it is clear he is ‘confused’. To be more precise he has hyperactive delirium. His change in mental state seems to be acute (hence referral from GP), he is inattentive and has disorganised thinking. From the history provided, the points that should leap out at you are the recent change in drugs – oxybutynin and apparent urinary retention on examination. His raised Alk P and low calcium are likely due to osteomalacia from Vitamin D deficiency (common in older people) and are red herrings – they are unlikely to have caused his delirium.

Cause and treatment of delerium

The probable cause of his delirium is the anticholinergic (oxybutynin for detrusor instability) and resultant urinary retention (though for completeness he should have a rectal examination to look for faecal impaction and prostate size). His oxybutynin should be stopped, he should be catheterised and a urine dipstick performed to exclude infection. He should be reoriented and kept hydrated orally and his falls risk should be assessed on the ward.

The next most important step is to find out more information, either from the GP or family. It seems he may have some pre-existing memory problems (consultation with the nurse). If the collateral history does uncover problems with memory, this will need to be followed up once the delirium has settled.

Dementia is rarely diagnosed in an acute hospital setting as a patient needs to be assessed when they are well with no co-existing delirium in an environment that is known or comfortable for them (at home or in outpatients). He would need to be screened for reversible causes of dementia, such as B12 and folate deficiency and hypo-/hyper-thyroidism. He will need brain imaging, preferably MRI and then detailed neuropsychological assessment and follow up in memory clinic by either a old age psychiatrist or geriatrician with specialist interest in dementia.  This can be done as an outpatient once he has recovered sufficiently to be discharged.

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