More than delirium

Grand Rounds Predisposing factors for delirium

More than delirium the author

GERONTOLOGY

Investigating physical causes for mental health presentations in the elderly is essential. History Professor Daniel Chan is a professor of geriatrics at the University of NSW and the University of Western Sydney. He is director of aged care and rehabilitation at Bankstown-Lidcombe Hospital, Sydney, NSW.

dehydrated, as she is drinking less, but her heart failure medication is unaltered. A dipstick of her urine is positive for leucocytes and nitrites.

Staff from a nursing home request a GP visit for Victoria, a 76-year-old woman who has been drowsy over the past three days. She seems to be less active, eating and drinking less. She is a new resident in the facility, having arrived one month ago. The staff are concerned about her. Up to a week ago, Victoria was active. She has moderate dementia with behavioural problems and restlessness at night. Her night-time sedation was increased a week ago. Her daytime drowsiness is initially thought to be caused by the increased sedation. The sedation is ceased, but she remains drowsy in the morning with fluctuating lucid periods. Apart from dementia, Victoria also has cardiac failure and is on frusemide 40mg daily along with Slow K 1bd. In addition, she is on an ACEI.

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Decreased oral intake Dehydration Malnutrition

Cognitive status Dementia Cognitive impairment History of delirium Depression

Medications Treatment with multiple psychoactive drugs Treatment with many drugs Alcohol abuse

Functional status Functional dependence Immobility Low level of activity History of falls Sensory impairment Visual impairment Hearing impairment

Co-existing medical conditions Severe illness Multiple coexisting conditions Chronic renal or hepatic disease History of stroke Neurologic disease Metabolic derangements Fracture or trauma Terminal illness Infection with human immunodeficiency virus

Suzie Ferrie

Investigation Victoria’s blood tests show slightly raised white cell count of 13x109/L, raised urea at 16mmol/L and creatinine of 120µmol/L, raised sodium, 149mmol/L and raised potassium, 5.7mmol/L. These results are consistent with dehydration and pre-renal impairment. Urgent microscopy of her MSU reveals there are plenty of white cells, red cells and bacteria, highly suggestive of a UTI, which would explain her delirium.

Difficult to swallow

Progress and outcome Victoria is started on an antibiotic to treat her UTI. Her frusemide, Slow K and ACEI are withheld. Staff are instructed to feed her during her lucid periods carefully while she sits upright and likewise to encourage fluid intake. Over the following week, Victoria remains more confused than usual although less drowsy. Her attention span slowly improves. However, she does not seem to be willing to feed herself voluntarily unless she is pushed. She also refuses to mobilise or participate in activities. Staff are concerned and the GP requests a psychogeriatric review. The psychogeriatrician discovers Victoria is depressed as she misses her home. The depression may also explain her restlessness symptoms. She is started on an antidepressant, and over the next month, her behaviour gradually improves, she

Examination

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Nutrition

Demographic characteristics Age of 65 years or older Male sex

On examination, Victoria is drowsy, engages in conversation briefly but drifts off and falls asleep again. She is disorientated in time and place (scoring 0/10), poor in attention span (0/5), and impaired in short-term memory (0/3). Her total mini-mental state examination score is 11/30. Neurological examination reveals no focal signs and there is no abnormal reflex or meningism. She appears slightly dehydrated. Her blood pressure is 110/70mmHg lying and drops to 90/60mmHg sitting up. She also has a low-grade fever. Initial diagnosis is delirium, supported by poor attention span (on examination) and fluctuating course (lucid and drowsy periods as reported by nursing staff). There is also concern that she is

becomes more co-operative and more engaged in group activities.

Discussion Poor attention span (as illustrated by “serial 7” counting or spelling “world” backwards) and fluctuating nature of mental state of acute onset are salient features of delirium.1 The occurrence should alert GPs of this diagnosis and to search for the cause(s) of delirium. While hyperactive delirium with features of agitation and hyperactivity are easier to diagnose, hypoactive delirium is often missed, as features of drowsiness or hypoactivity may be dismissed as tiredness or the result of having a poor night sleep.

Inouye states: “While hyperactive delirium is more easily recognised, many patients with hypoactive delirium are mistaken as tired or drowsy, as they are seen as resting in bed; so be aware of missing it”.2 Not uncommonly, a few factors can co-exist causing delirium, as illustrated by this case, with UTI as the main cause, worsened by dehydration and electrolyte disturbance. While these factors may not cause serious disturbance in mental function in a cognitively intact patient, in a patient with limited or inadequate cognitive reserve (older age or dementia), severe acute disturbance can occur, resulting in delirium. Delirium, dementia and depression are impor-

tant differential diagnoses of one another. This case illustrates that delirium, dementia and depression can co-exist, and it is sometimes difficult to separate the diagnoses. Should the patient be slow to improve after delirium, one should consider possibilities such as very severe background dementia, other missed causes of delirium or a new cause for delirium occurring, or concomitant depression. l

Reference 1. C  han, Daniel KY. Chan’s Practical Geriatrics. 3rd edn. BA Printing and Publishing Services, Sydney, 2015. 2. Inouye, Sharon. Delirium in Older Persons. New England Journal of Medicine 2006; 354:1157-65.

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Manuel, aged 67, has Parkinson’s disease. His dysphagia has recently worsened, and a speech pathologist assessment indicates delay in triggering swallow, incomplete laryngeal closure, impaired chewing movements, and problematic ‘tongue-pumping’ movements that push food forward during eating. He has reflux after eating. Manuel continues to receive small amounts of a modified-texture diet with thickened fluids under close supervision. He is unable to meet his nutritional needs fully and tube feeding is commenced via a gastrostomy tube. Manuel and his wife, Juanita, are provided with pre-discharge training on tube feeding. He is taking one tablet of levodopa-carbidopa 250mg/25mg, three times daily, dispersed in water and flushed into the feeding tube. Ms Ferrie is a critical care dietitian at Royal Prince Alfred Hospital and clinical affiliate at the University of Sydney, NSW.

TRUE OR FALSE? 1. Parkinson’s disease means that the tube feeding regimen needs to be altered. TRUE. Because levodopa competes with protein for blood–brain barrier transport, a highprotein diet is avoided. A standard tube-feeding formula is acceptable. Levodopa may be more effective when taken on an empty stomach, and this might mean altering the feeding regimen to allow a one-hour gap before each dose. Manuel’s reflux, and increased aspiration risk, may mean dispensing with overnight feeding, and intermittent periods of daytime feeding, or slow bolus feeds, might be used instead.

2. Parkinson’s disease does not affect eating ability. FALSE. Dysphagia occurs frequently in Parkinson’s disease, as does dry mouth, often worsened by higher doses of levodopa, and drooling, which occurs even with a dry mouth. Patients often experience reflux and constipation. Dementia in later-stage Parkinson’s disease makes eating less safe as the patient becomes more impulsive and less able to heed safe swallowing reminders. Discussion For Manuel, an enteral formula avoiding excess protein is chosen with adequate fibre and fluid

to prevent constipation. The daytime tubefeeding regimen is altered to allow levodopa dosing to be given half an hour before each oral meal. This maximises his swallowing muscle control at mealtimes to enjoy his food. His wife helps him with meals and monitors his swallowing to ensure that he clears his mouth and has no signs of aspiration. In between meals, he keeps his mouth moist with regular swabs. Regular re-assessment by a dietitian and speech pathologist ensures his diet and feeding continues to meet his nutritional needs safely.

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• Dr Ewa Szymlek-Gay, Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University

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21 August 2015 | Australian Doctor |

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