75 years old female who is diabetic x12 + CABGx3d.

She lays in bed most of the day and is not

interacting with staff, which is impairing her recovery. She is confused, and appears sad and
unmotivated. Is she depressed???.”

WHAT IS YOUR DIFFERENTIAL DIAGNOSIS

WHAT OTHER INFORMATION WOULD YOU LIKE TO KNOW ABOUT MRS. x ?

1. Past psychiatric history

2. Past medical history
3. Current medications
4. Pre-morbid cognitive status

You now attempt to see Mrs. X to obtain her history and observe her current mental status. She is
dressed in a hospital gown lying in bed, looking older than her stated age. Her eyes are closed, and you
have a difficult time rousing her.

Her words are slurred and difficult to understand. She is unable to respond appropriately to your
questions. She appears to be picking at things in the air. You are unable to assess her mood, but her
affect is restricted. She is confused, and when asked where she is mumbles something about “being in
Newfoundland”. You attempt to perform an MMSE, but Mrs. X is unable to pay attention long enough
to complete the test

As you are unable to obtain much information from Mrs.x, what should you do now?

OBTAIN COLLATERAL

You review the medical chart and speak with Mrs. x’s daughter to obtain collateral information. You
find out the following information.

No prior psychiatric problems

– No history of depression
Past medical history:
1. Angina
2. Hypertension
3. Dyslipidemia
4. Hearing impairment
– Uses hearing aid
5. Hysterectomy (1985)
6. Smoker (30 pack years)
Medications

1. Atenolol 25 mg BID
2. Atorvastatin 20 mg OD
3. Aspocid 81 mg OD
4. Multivitamin ī tab OD
5. Amitriptyline 10 mg HS
 6. Ramipril 5 mg OD*
7. Ranitidine 150 mg OD*
8. Hydromorphone 2-4 mg on demand Receiving approx. 6 mg/day

Pre-morbid cognitive functioning

– Mrs. x has occasionally been forgetting names of friends/family over the past year, but
there are no other memory deficits.
– She is independent for all IADL’s/ADL’s
– She scored 30/30 on a recent MMSE done at her GP’s office
– Her family now find her drowsy and confused, which gets worse later in the day
Now that you have collateral information, you summarize the case:

– 76 year old female post-CABG

– Decreased level of consciousness
– Confused and disoriented
– Amotivated and apathetic
– Fluctuation of symptoms
– No prior history of depression
– No prior history of dementia
– What is the diagnosis?
– What is the subtype?
– WHAT SHOULD YOUR NEXT STEP BE?
– Is it a medical emergency?
– WHAT INVESTIGATIONS WOULD YOU CONSIDER ORDERING?

You perform an appropriate work-up and order investigations. You obtain the following ABNORMAL
results:

Na 147
BUN 17.2
All other results are normal

WHAT DO THE ABOVE RESULTS SUGGEST?

WHICH MEDICATIONS MAY CAUSE HER CONDITION?

CAN HER CONDITION BE A MULTIFACTORIAL ONE?

PROPER MANAGEMENT??
Mr E is a 71 yo gentleman with hx of asthma, BPH and HTN admitted to medicine 3 days ago for bilateral
lower extremity cellulitis. AT the time of admission he was cooperative and oriented but over the past
24 hours has become occasionally confused, agitated, uncooperative and somnolent. He appears to be
talking to someone in his room when no one is there.

His current meds include: lisinopril, naproxen, cimetadine, albuterol/ipratroprium inhaler, levofloxacin,
oxygen via nasal canula prn

He has no known psych history, drinks 1-2 glasses of wine/night

The medicine service is concerned he is psychotic and requests help managing his behavior.

 When you speak to him he is difficult to rouse and falls asleep several times. He struggles to
maintain focus on questions and is unable to perform the mental status exam. He believes he is
in Oklahoma and that you are his cousin.

What points to delirium???

 Altered mental status developing over a short period of time

 Alternating agitation, confusion and somnolence

 Auditory hallucinations in a 70 yo with no previous psych history

 Several of his meds could cause delirium including cimetadine, inhalers, naproxen. He is also
need O2 which indicates hypoxia at times

Multiple medical possibilities including:

 Meds including cimetadine, inhalers, naproxen.

 Hypoxia- he is needing O2 at times

 Cellulitis

 Stroke with his history of HTN

 UTI with history of BPH

 Metabolic abnormalities including electrolyte or glucose disturbances, liver or renal

dysfunction, thyroid dysfunction

 Alcohol withdrawal
 Mr R is 83 yo gentleman with a long history of hypertension, diabetes with peripheral
neuropathy and occasional angina admitted to medical department 4 days ago for failure to
thrive. Two weeks prior to admission he missed his weekly bridge game which he has not done
in 12 years. The day prior to admission his friend found him asleep in front of the TV and was
difficult to rouse. He was minimally communicative, had been incontinent of urine and hadn’t
eaten in several days. His friend denied history of mental illness, substance abuse and noted he
is usually social and friendly.

 On admission he was calm, cooperative but withdrawn. He was hyponatremic and had a UTI
which have been treated but remains somnolent and withdrawn. requesting assistance for
evaluation of depression.

 Current meds: insulin, atenolol, lisinopril, temazepam, azithromycin, aspirin.

On exam he is quite, answers questions with monosyllabic answers, has poor eye contact and scores a
9/30 on MMSE with very poor effort

He is presenting as a classic example of hypoactive delirium however:

 Urinary incontinence with altered mental status should prompt concerns about normal pressure
hydrocephalus

 He could have had a stroke or fall given his diabetes, hypertension and peripheral neuropathy-
he needs a head CT

 The UTI and hyponatremia could cause delirium and even with appropriate treatment mental
status may take weeks and even months in the elderly- some may never return to baseline

Other possible contributing factors

 Meds such as benzodiazapines

 Glycemic abnormalities- how are his blood sugars?

 Would need to rule out alcohol withdrawal or overdose-always do a urine tox screen

 Is he depressed?

 Is he demented?

 The low MMSE reveals severe impairment which is common in delirium. His poor effort could
signal inattention or depression.
 An elderly woman is admitted for TAH BSO. At baseline she has mild dementia, but is pleasant
and functional.

 Yesterday she was doing well. Today postoperative day #4, she is talking to herself, and it is
difficult to understand what she is saying. She is anxious, yelling at you, and repeatedly pulling
at her clothes. She argues with the nursing staff and refuses blood draws.

 What is this patient displaying

 Your approach

 An elderly woman is admitted for TAH BSO. Previously she was independent and active. She is
POD #1 and you have not heard any calls from the RN overnight. On your morning rounds, she is
sleepy and falls asleep as you talk to her. You return to her room at 2:00 PM and she is napping
again. she missed her breakfast and lunch because she was asleep. she has not used any of her
medications.

 What is this patient displaying

 Your approach