Morning Report
Steve Hart
4/19/2006
Case Presentation
77 y/o AAF with ESRD presents to ED
with lower extremity weakness x 1-2 days
and elevated blood pressure.
Feeling generally weak, now unable to ambulate
Off BP meds for about a week
“BP controlled with Dialysis”
Headaches
Poor vision
Some SOB and coughing
Per social worker and daughter, mental status
changed from baseline
PMHx
HTN
Glaucoma
Cataract
Anemia
Recent AV graft infection
Social Hx
Lives at home with daughter
Quit smoking in 50’s
Allergies – none
Meds
Lisinopril
Aranesp
Xalatin eye drops
Phoslo
Nephrocaps
Zocor
Aspirin
Vitals
T 97.1 HR 79 R 14 BP 175/69 Pox 98% 2L
Physical Exam
Gen – Alert, oriented? Female,
HEENT – PERRLA, EOMI, MMM
Neck – JVD, nl thyroid
Chest – bilateral rhonci
CV – RRR, nl S1 and S2, no edema, no bruits
Abd – soft, NT/ND, no HSM
Ext – no E/C/C
Neuro – equal/symetric +1 reflexes., CN intact, nl cerebellar
signs,
+5 strength in UE, -5 in LE
Neg Rhomberg
Labs
138 96
3.7
7
33 2.5
Ca 9.7
CKMB 1.8
Trop I 0.05
EKG NSR, No ST changes
CXR NAD
13.6
90
5.3
218
41.5
Diff: N65 L20 M10
UA: 1.006, 8.5, prot 100,
occ bact, LE large, 27
WBC
Imaging
Head CT
Small vessel disease with age indeterminate
infarcts in internal capsule. Possible subacute
on old?
MRI Head
moderate deep and sub-cortical ischemic white
matter changes – non acute
Bilateral patchy ischemic foci in the lentiform
nucleus and pons. No intracranial mass lesion
remote micro hemorrhage in the right posterior
inferior aspect of the thalamus
Problem List
Geriatric
Weakness, ambulatory only with assistance - new
Recent decline in mental status
HTN, uncontrolled
ESRD
UTI
Impaired vision
SOB, hypoxic
Small vessel disease, lacunar infarcts
Hospital Course
Day 1
Started on routine SQ heparin and pepcid on
admission
MI ruled out with serial enzymes and EKGs
Cultures negative, no empiric antibiotics
Remained afebrile
SOB and hypoxia relieved with dialysis
Blood pressure poorly controlled
Neurology consulted for mental status changes
Hospital Course
Mental Status quickly deteriorated
Hallucinations
Fluctuating mental status
Alert but not oriented at times
Unable to concentrate
Tangential thought
“sundowning”
Patient placed in restraints
Delirium
Delirium
Definition
reduced ability to focus, sustain, or shift
attention
change in cognition or the development
of a perceptual disturbance
Acute onset (hours to days)
Identifiable cause
Epidemiology
At admission prevalence 14-24%
Hospitalization incidence 6 to 56%
15-53% geriatric patients post-op
70-80% older patients in ICU
60% nursing home will have at some
time
83% of geriatric patients prior to
death
Delirium….Why should I care?
Mortality rate in hospitalized
patients 22-76%
One year mortality rate is 35-40%
Prolongs hospital course
Increased cost of care in hospital
Increases likelihood of disposition to
nursing home, functional decline and
loss of independence
More reasons to care
Strong association with underlying
dementia
Frequently, patient may never return
to baseline or take months to over a
year to do so
Delirium is often the sole
manifestation of serious underlying
disease
Pathophys
EEG shows diffuse cortical slowing
Neuropsyc and imaging
Disruption of higher cortical function
Prefrontal cortex
Subcortical structures
Thalamus
Basal ganglia
Frontal and temporoparietal cortex fusiform cortex
Lingual gyri
Effect greatest on non-dominant side.
Pathogenesis
Involves
Neurotransmission
Inflammation
Chronic stress
Pathogenesis
Neurotransmission
Cholinergic deficiency
Anticholinergics can precipitate delirium
Serum anticholinergic activity increased in those with
delirium
Cholinesterase inhibitors can reverse this effect
Dopaminergic excess
Neuropeptides, endorphins, serotonin, NE,
GABA may play a role.
Pathogensis
Cytokines
Interleukins and interferons
Often elevated in Delirium
Have known strong CNS effects
Primary role – sepsis, bypass surgeries,
dialysis, cancers
Pathogensis
Chronic stress
Untreated pain /
analgesia are strong
risk factors
Elevated cortisol
assoc with delirium
Risk Factors
Underlying brain disease
Dementia
Stroke
Parkinson’s
Advanced Age
Sensory Impairment
Bladder Caths
Differential
Psychiatric Illness
Depression
mania
Dementias
Nonconvulsive status epilepticus
Especially in ICU
Wernicke’s aphasia
Occipital lesions
(cortical lesions and confabulations)
Bifrontal lesions (tumors or trauma)
Diagnosis
Clinical
Step #1 – Recongnize
the disorder
Step #2 - Uncover
underlying medical
illness
Recognize
Often unrecongnized, >70% of cases
Behavioral or cognitive issues often wrongly
attributed to age, dementia or other
mental disorders
determine acuity of change in mental status.
if no historian available, one should assume
acute and delirious until proven otherwise
Recognize
Disturbance in consciousness and alterned
congnition
Consciousness
Attention – poor
Subtle loss of mental clarity initially
Patient “isn’t acting right”
Distractability
Tangential or disorganized thought
Acute/subacute onset
Fluctuating course throughout a day
Recongnition
Congition
Memory loss
Disorientation
Difficulty with language and speech
Perceptual disturbances
Delusions
Hallucination
Assessment
Formal mental status evaluation in all
geriatric patients (ie. MMSE or
CAM)
Arouse all older patients daily to
evaluate hypoactive form of delirium
Search for causes of delirium
Causes
D Drugs, Drugs and toxins, too
E Eyes, ears
L Low O2 states (MI, ARDS, PE, CHF, COPD,
stroke, shock)
I Infection
R Retention (of urine or stool). Restraints
I Ictal
U Underhydration, Undernutrition
M Metabolic (hypo/hyper glycemia, calcemia, uremia,
liver failure, thyroid disorders)
Other Causes
Foley catheter
Invasive procedure
Sleep deprivation
Pain
Drugs
Accounts for 30% of all cases
Common culprits
Anti-histamines
Anti-cholinergics
Antibiotics
Some antidepressants
Dopamine agonists
Hypoglycemics
Benzos
Opiates
Patient
Poor vision
Evidence of old and
recent strokes
Infection - UTI
Restrainted
Multiple medications
Pepcid started on
admission
ESRD
Hypoxia
Treatment
Correct all identifiable causes
Delirium is usually multifactorial
Correction of multiple causes is often
necessary for recovery
Pharmacologic – if needed
Antipsychotics
Avoid benzos except with ETOH withdrawl
Orient Patients
Provide clocks, calenders, windows, structured
activities
Hearing aides, glasses
The End – Questions/Comments?