Angela R. Akinpelu, PA-S UMES 2012

January 16, 2011 (as found in patients MR)ID: An 81 y/o W

CC: Presented to the ED previous night with CC of dyspnea and altered mental statusHPI: An 81 y/o W presented with altered mental status and cough productive of clear sputum. Pt. is poor historian. Husband says for last 2 weeks, pt. forgets words, acting more confused. Believes coincides addition of Abilify to Pristiq. Also given SoluMedrol last week followed by Medrol pack for interstitial pneumonitis. Family believes confusion became worse with addn of steroids. On admission, confusion worsened and had visual hallucinations; angry and agitated.

PMH: Breast CA, 1999, tx L-sided lumpectomy, radiation; recurrence 2008 in same breast, tx L-sided mastectomy, chemo; recurrence 2010, enlarged R axillary node, tx Aromasin, plus enrolled in blinded study (Afinitor/Everolimus). Interstitial pneumonitis, 2 to chemo; seen on chest CT last week TB, treated 50 y/o, INH & streptomycin H/o trigeminal neuralgia HTN Hyperlipidemia IOP Anxiety and depression

Rx: Lipitor, levobunolol, Toprol XL, amlodipine, Vasotec, Pristiq, Aromasin, Everolimus

Sx: lumpectomy, mastectomyAllergies: Codeine, Fentanyl, digoxin FH: daughter h/o breast CA, father and sister have asthma, HTN in several family members

SH: (-) tob/EtOH, married, lives family, retired school teacher

ROS: Denies recent wt. Denies CP/palp./GI or GU complaints/endocrine or MS problems. PE: VS: Temp 36.8C, RR 23, HR 97, BP 137/86 Gen: 81 y/o W, AOx3 but forgets thoughts easily, a little agitated. HEENT: PERRLA. Normal cranial nerves. Trachea midline. Neck: Supple, no lymphadenopathy or thyromegaly, no JVD, no carotid bruits. Chest/lungs: Hyperinflated lung fields, fair air entry bilat., no audible wheeze/crackles. CV: HRRR, S1/S2, no S3/S4/m/r/g; palpable peripheral pulses, minimal pedal edema. Abd: Soft, nontender, NABS, masses or organomegaly. Neuro: sensory deficit.

Labs/Diagnostics:

9.6 6.2 29.5 436

139 3.9

103 24

151.01

128

Lactic acid: 1.8 UA: 10 20 WBCs, many bacteria CXR: mild infiltrates CT head: focal parenchymal loss in left cerebellar hemisphere (congenital or old infarct), no acute ischemic changes PFT: consistent pneumonitis

Assessment: Altered mental status confusion & memory loss, possibly 2 to hypoxia (current SaO2 98% but low last night), Abilify, UTI, or steroid-induced psychosis Pulmonary infiltrates, pneumonitis vs. pneumonia vs. recurrence of TB; most likely pneumonitis 2 to chemo UTI H/o breast CA metastasis HTN Hyperlipidemia Anxiety and depression Plan: Given Risperdal last night, mental status returned to normal overnight Pt. has contd O2 tx; breathing is improved F/u pulmonary, oncology, PCP 1-2 weeks Continue home Rx. Empiric Rocephin & Zosyn d to Cipro 250 mg po bid x 3 days for UTI. Prednisone taper for pneumonitis D/C to home

Delirium Defined

A transient global disorder of cognition; usually reversible cause of cerebral dysfunction; hallmarks are acute onset, decreased attention span, and waxing/waning confusion. High M&M medical emergency Early dx and tx outcomes Syndrome, not disease

In the elderly: Can lead to loss of independence 1-year mortality of 35 to 40% Accounts for > 49% of all hospital days Increases hospital costs by $2500/pt. $6.9 billion in Medicare Additl costs incurred: institutionalization, rehabilitation, home health care, informal caregiving 30-40% delirium cases preventable or iatrogenic

3 types delirium, based on arousal status Hyperactive: EtOH w/d, intoxication phencyclidine (PCP), amphetamine, lysergic acid diethylamide (LSD) Hypoactive: hepatic encephalopathy, hypercapnia Mixed: daytime sedation, nocturnal agitation & behavioral problems

Not elucidated; result of structural or physiologic insults Reversible impairment of cerebral oxidative metabolism & multiple NT abnormalities, i.e., ACh, DA, GABA, others Inflammatory mechanisms: IL-1, IL-6 in infection, inflammation, toxic insult, head trauma, ischemia Psychosocial stress & sleep deprivation Structural: lesions, disruption of BBB allows neurotoxins, inflammatory cytokines Hypoglycemia, hyperthermia, metabolic/electrolyte abnormalities, malnutrition Polypharmacy

14-56% of hospitalized elderly 10-22% of elderly on admission, 10-26% mortality 10-30% after admission, 22-76% mortality 40% ICU pts., 70-80% of elderly ICU pts. 5-10% post general surgery; 42% post orthopedic Up to 83% near death Up to 60% NCF patients More common in elderly Can present with existing dementiahx from family, staff, and chart review pertinent Sex and race indiscriminate

Clinical dx Detailed hx from family, caregivers, staff, records Acute or subacute deterioration in behavior, cognition, function Visual hallucinations, persecutory, or grandiose delusions May be homicidal or suicidal MMSE, CAM, Mini Cog, GDS Depression common Agitation, psychosis, abnormal behavior Develops within hours

Disturbance of sleep/wake cycle Daytime drowsiness Disorientation, illusions, hallucinations, altered consciousness Memory deficit, language disturbance Dysphagia, dysarthria, tremor, asterixis Hypervigilance or hypoactivity Fluctuating course, days to weeks, usually reversible Prodrome: hours to days; sleep disturbance, vivid dreams, frequent calls for assistance, anxiety

DSM-IV-TR diagnostic criteria Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention Change in cognition (e.g., memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day Evidence from the history, physical exam, or lab findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause

Nearly any medical illness, intoxication, or medication; often multifactorial DSM-IV-TR classification General medical condition Substance intoxication Substance withdrawal Multiple etiologies Not otherwise specified (NOS)

Infectious CNS infections (meningitis) Encephalitis HIV-related brain infections Septicemia Pneumonia Urinary tract infections

Assessment: Altered mental status confusion & memory loss, possibly 2 to hypoxia, Abilify, UTI, or steroid-induced psychosis Pulmonary infiltrates, pneumonitis vs. pneumonia vs. recurrence of TB; most likely pneumonitis 2 to chemo UTI H/o breast CA HTN Hyperlipidemia Anxiety and depression Plan: Given Risperdal last night, mental status returned to normal overnight Pt. has contd O2 tx; breathing is improved F/u pulmonary, oncology, PCP 1-2 weeks Continue home Rx. Empiric Rocephin & Zosyn d to Cipro 250 mg po bid x 3 days. Prednisone taper for pneumonitis

Metabolic Fluid and electrolyte abnormalities, acid-base disturbances, hypoxia Hypoglycemia Hepatic or renal failure Vitamin deficiency, esp. thiamine & cyanocobalamin Thyroid/parathyroid endocrinopathies

Hypoperfusion states Shock CHF Cardiac arrhythmias Anemias

Structural changes Closed head injury or cerebral hemorrhage Cerebrovascular accidents Cerebral infarcts Subarachnoid hemorrhage Hypertensive encephalopathy Primary or metastatic brain tumors Brain abscess

Toxic Causes Substance intoxication: EtOH, heroin, MJ, PCP, LSD Substance withdrawal: EtOH, opiods, benzos Medication-induced: anticholinergics (Benadryl, TCAs) Narcotics (meperidine) Sedative hypnotics (benzos) H-2 blockers (cimetidine) Corticosteroids Centrally acting HTNsives (methyldopa, reserpine) Anti-Parkinson rx (levodopa)

Assessment: Altered mental status confusion & memory loss, possibly 2 to hypoxia, Abilify, or steroid-induced psychosis Pulmonary infiltrates, pneumonitis vs. pneumonia vs. recurrence of TB; most likely pneumonitis 2 to chemo UTI H/o breast CA HTN Hyperlipidemia Anxiety and depression Plan: Given Risperdal last night, mental status returned to normal overnight Pt. has contd O2 tx; breathing is improved F/u pulmonary, oncology, PCP 1-2 weeks Continue home Rx. Empiric Rocephin & Zosyn d to Cipro 250 mg po bid x 3 days. Prednisone taper for pneumonitis

Sensory deprivation, sleep deprivation, fecal impaction, urinary retention, change of environment Perioperative Meds at therapeutic doses Risk factors: physical restraints, malnutrition, bladder catheter, any iatrogenic event, Rx 3, dementia, dysmorphic mood, hopelessness

CBCD Electrolytes Glucose ABG Renal and LFTs Thyroid panel UA Urine and blood tox screen Thiamine and Vit B-12 levels ESR HIV Tests for bacterial, viral, other infectious etiology S-100 B (calcium-binding protein; serum marker)

CT, MRI of head EEG (alcohol/sedative w/d, hepatic encephalopathy, metabolic derangements) CXR (PNA, CHF) LP (CNS infection) Pulse oximetry ECG

Labs/Diagnostics:

9.6 6.2 29.5 436

139 3.9

103 24

151.01

128

Lactic acid: 1.8 UA: 10 20 WBCs, many bacteria CXR: mild infiltrates CT head: focal parenchymal loss in left cerebellar hemisphere (congenital or old infarct), no acute ischemic changes PFT: consistent pneumonitis

Medical Care Fluid & nutrition

Environmental

Manage electrolytes, volume resuscitation Multivitamins, esp. thiamine if suspicion of EtOH intoxication or w/d Reorientation (calendar, clock, photos) Stable, quiet, well-lit reassurance Vision & hearing correction Avoid physical restraints! Use sitters if necessary.

D/C any contributory, offending agents Reassessment Psychiatric Consult Consult other specialists as appropriate

Pharmacologic Tx Neuroleptics, MOC for psychotic symptoms; newer drugs have less extrapyramidal symptoms, neuroleptic malignant syndrome, tardive dyskinesia Haloperidol: high-potency; one of most effective; less sedating than phenothiazine Risperidone: improves negative symptoms of psychoses

Short-acting sedatives Reserved for seizures, w/d from EtOH, sedative hypnotics, ingestion of hallucinogen, cocaine, PCP, amphetamines Benzodiazepines preferred over neuroleptics CNS depressants Lorazepam: short-acting, IM or IV, no active metabolites

Vitamins Thiamine

Alcoholism, Wernickes, malnutrition

Cyanocobalamin (vit B12)Pernicious anemia, gastrectomy, distal ileum disease

Follow-up Recovery in elderly may be 6 weeks F/u with PCP, psychiatry, social workers, others involved in care

Early intervention: M/M, hospital stay, $$$ Monitor nutrition & hydration Minimize polypharmacy Substance abuse counseling Practice good sleep hygiene Correct visual & hearing defects Provide calm environment Social stimulation Physical exercise Educate pt. and family regarding disease etiology/course, risk factors, reorientation

Poor nutrient intake Decreased function and mobility Pressure ulcers from immobility Aspiration pneumonia Injury from falls and behavior Long-term impairment

January 14, 2012 CC: recent fall, generalized weakness HPI: appetite few weeks; chronic weakness but worse over past few days; dizzy upon standing fall; (+) night sweats, palp., emesis this a.m., urinary freq foul odor.; () diarrhea, dysuria, urine color PE: AOx3, agitated & animated, tachycardic

Labs/Diagnostics:11.8 10.1 35.5 433

135

98 24

18 0.92

116

3.7

ABG: 7.65/18/98/20/97%, 21% Lactic acid: 1.8UA: yellow/cloudy/SG 1.016/LE 3+/N /pH 8.0/Prot 2+/Glu 10-20 WBCs/HPF, 5-10 RBCs/HPF, moderate bacteria CXR: no acute disease

Presyncope: 2 to dehydration from poor oral intake/vomiting; hydration, PT Moderate dehydration: NS IV Respiratory alkolosis compensatory metabolic acidosis Hyponatremia: hypovolemic Anemia: hemoconcentration UTI: Cipro Non-sustained PVCs: remote telemetry D/C to Manokin Manor NF

January 27, 2012 CC: HA HPI: Stopped participating in PT at MMNF due to constant HA x 1 wk. Overall decline in function x 2 days malaise, lethargy, & fatigue. Eating/drinking x 24-48 hr. Fell from bed last night; minor bruise L forehead. Recent outpatient MRI negative for mets PE: lethargic but arousable.

HA: r/o giant cell arteritis; initiate steroids Mental status: r/o underlying infection, possibly urinary; empiric Rocephin IV Dehydration: IV fluids Gait dysfunction & deconditioning: head CT; avoid sedatives & hypnotics, cont. Pristiq at family request

1/31/2012 Head CT: normal L temporal artery biopsy, (); ESR, CPR normal; no jaw claudication; (+) diplopia disconjugate lateral gaze, HA, confusion; steroid taper. Consider carcinomatous meningitis or diabetic neuropathy for causes of cranial nerve impairment.

2/9/12: Admitted, c/o fall, chills, confusion, refusing food & drink. Minimally verbal, cachectic, frail, chronically ill appearing.

2/25/12, additl labs drawn B. burgdorferi (IgM, IgG, IgA serum) (-) B. burgdorferi (IgM, IgG, IgA CSF) (-) CSF: clear/ xanthochromia/ protein 72/glu 24/ WBC/ RBC CSF: VDRL (-) CSF: oligoclonal banding assay 18 (90% of MS patients have oligoclonal IgG bands in the CSF. Oligoclonal bands are also seen occasionally in some chronic CNS infections, SLE, paraneoplastic disease, neurosarcoidosis, Lyme disease, syphilis, SA hemorrhage, Devics disease, aka neuromyelitis optica.)

CSF cytology

Leptomeningeal carcinoma

Cytology consistent with breast carcinoma metastasis

CSF cytology

Tx: intrathecal methotrexate 2 treatments received Preservative-free unavailable; methotrexate in short supply Prognosis: poor; 3 months Family is considering hospice care

Delirious by DSM-IV-TR criteria?A.

42 y/o AA Dean of Medicine of prominent university, POD #0 inpatient, s/p LTKA, rips out his IV and throws his lunch tray across the room. He violently insists that the food in this country club is awful, and wants his money back or else hes leaving! His nurse calls you into the room urgently to apprise you of the recent event. When you arrive, the patient is sitting up in bed, calmly observing the nurse reinsert his IV, and is inquiring about the IV rate of flow settings. 76 y/o widower, 2 days s/p emergent ligation of esophageal varices. Hospital stay has been benign until one hour ago when patient began rambling incoherently. During exam, he is generally uncooperative, but you are able to hold his attention long enough to ascertain the presence of nystagmus. 81 y/o W is in the step-down unit for seven days after leaving the ICU. On days 3-5, she was relatively sociable with the nurses, despite being bed bound. She slept most of day 6 and spent most of night 6 unnecessarily calling out to the nurses for help. Today, she is again quietly napping the day away but is arousable. All of the above A and B only Discussion: Which criteria are met? What are the red flags? On a CAM assessment, is the 1 and 2 and 3 or 4 criteria for delirium met? What actions might you consider taking?

B.

C.

D. E.

All of the following are false EXCEPT: A. Delirium is never diagnosed in patients under the age of 21. B. Medicare incurs $6.9 million dollars annually in hospital care for the elderly with delirium. C. Delirium can be preventable. D. Assessment tools for delirium include the Mini Cog, CAM, MMSE, and MUGA test.

Therapy for delirium includes all of the following except: A. Haldol B. Family photos C. Anticholinergics D. Atypical antipsychotics

The three types of delirium are: A. Hypotensive, hypertensive, and normotensive delirium B. Hypotonic, hypertonic, tonic-clonic delirium C. Hypoactive, hyperactive, mixed delirium D. Hypoclonic, hypererclonic, tonic-clonic delirium

63 year old male patient presents with acute onset delirium. History obtained from patients wife includes no recent illness or exposure, last doctors visit was 3years ago for hemorrhoidectomy, no chronic medications, h/o pack of cigarettes/day, occasional beer after work, patient is a sanitation engineer. PE reveals an inattentive, disoriented, icteric male with diminished breath sounds, increased AP thoracic diameter, facial spider nevi, gynecomastia, testicular atrophy, scant axillary hair, clubbing, distended abdomen, and tea-colored 2nd and 3rd distal phalanges of the left hand. To confirm your suspicions, you order: A. A karyotype and hcg to confirm that he is actually a pregnant she! B. A BAL, vit B1 assay, vit B12 assay, hepatic panel, a banana bag. C. 10 cc Sodium Pentothal, rapid IV push STAT; followed immediately by a polygraph test D. A&C E. B&C

Peninsula Regional Medical Center Databases http://www.mc.vanderbilt.edu/icudelirium/docs /CAM_ICU_worksheet.pdf http://www.uptodate.com/contents/pathophysi ology-clinical-features-and-diagnosis-ofleptomeningeal-metastases-carcinomatousmeningitis?source=see_link http://brainmetsbc.org/index.php?q=node/44 http://emedicine.medscape.com/article/288890 DSM-IV-TR Neurologic Complications of Cancer. DeAngelis, Lisa M., Posner, Jerome B. Oxford University Press, Inc. NY, NY. 2009. Delirium in Older Persons. Inouye, Sharon K. N Engl J Med 2006; 354:1157-65.