Family Medicine · Year 3 · from Family Medicine

Case 2: Delirium in an Older Adult

Patient Demographics

  • Age: 79 years old
  • Sex: Male
  • Occupation: Retired engineer
  • Living Situation: Lives with wife of 52 years

Chief Complaint

Wife reports: "He's not acting like himself. He's been confused since yesterday and didn't recognize our granddaughter this morning."

History of Present Illness

Mrs. Martin brings her 79-year-old husband, Harold, to the office because of acute confusion that began yesterday. She notes that he was his usual self two days ago, but yesterday he seemed "foggy," asking repetitive questions and having difficulty following conversations. This morning he did not recognize their granddaughter who visits weekly. He has been more drowsy than usual, sleeping during the day, but restless at night. She also notes he has been urinating more frequently and complaining of mild suprapubic discomfort. He has had no fever, cough, falls, or head injury.

Pertinent History

  • Baseline cognition: Wife reports he has had "some forgetfulness" over the past 2 years - occasionally misplaces items, sometimes repeats stories - but has been functionally independent and managing all IADLs

Past Medical History

  • Mild cognitive impairment (diagnosed 1 year ago)
  • Benign prostatic hyperplasia
  • Type 2 diabetes mellitus
  • Hypertension
  • Coronary artery disease (stent 5 years ago)

Current Medications

  • Metformin 1000 mg twice daily
  • Lisinopril 10 mg daily
  • Aspirin 81 mg daily
  • Atorvastatin 40 mg daily
  • Tamsulosin 0.4 mg daily

Physical Examination

  • Vital Signs: BP 108/64 mmHg (lower than baseline), HR 88, Temp 99.4F (37.4C), RR 16, SpO2 96%
  • General: Drowsy but arousable; intermittently alert; picks at bedsheets
  • HEENT: Dry mucous membranes
  • Cardiovascular: Regular rhythm, no murmurs
  • Pulmonary: Clear to auscultation
  • Abdomen: Mild suprapubic tenderness, no distension
  • Neurological:
  • Fluctuating attention - difficulty counting backwards
  • Disoriented to date and place (knows name and wife)
  • No focal motor deficits
  • No meningismus

Confusion Assessment Method (CAM)

  1. Acute onset and fluctuating course: YES (developed over 1-2 days, worse in morning)
  2. Inattention: YES (cannot count backwards from 20)
  3. Disorganized thinking: YES (speech tangential at times)
  4. Altered level of consciousness: YES (drowsy/lethargic)

CAM POSITIVE for Delirium (requires 1+2 plus either 3 or 4)

Clinical Image

Image: Comparison chart showing the key distinguishing features between delirium (acute onset, fluctuating, reversible) and dementia (gradual onset, progressive, generally irreversible).

Image Source: Wikimedia Commons Attribution: National Institute on Aging, Public Domain URL: https://commons.wikimedia.org/wiki/File:Delirium_dementia_comparison.png

Laboratory Studies

  • Urinalysis: Positive for leukocyte esterase, nitrites, and bacteria; WBC 50-100/hpf
  • Urine culture: Pending
  • CBC: WBC 11,200 (mildly elevated)
  • BMP: Na 136, K 4.2, BUN 28 (elevated), Creatinine 1.4 (baseline 1.1), Glucose 156
  • TSH: 2.1 (normal)
  • Chest X-ray: No infiltrate

Assessment and Diagnosis

  1. Delirium (hypoactive subtype) - acute change from baseline
  2. Urinary tract infection - likely precipitating cause
  3. Mild dehydration - contributing factor (elevated BUN, dry mucous membranes)
  4. Underlying mild cognitive impairment - major risk factor for delirium
  5. Benign prostatic hyperplasia - predisposing to UTI

Management Plan

Treat Underlying Cause:

  • Ciprofloxacin 500 mg twice daily for 7 days (complicated UTI in male)
  • Alternative: Trimethoprim-sulfamethoxazole if culture sensitivities allow

Supportive Measures:

  • Encourage oral fluid intake; goal 1.5-2 liters daily
  • Maintain day-night orientation (open blinds during day, dark quiet room at night)
  • Frequent reorientation by wife
  • Avoid restraints
  • Maintain mobility - walk with assistance
  • Ensure glasses and hearing aids are in place

Avoid Deliriogenic Medications:

  • Review all medications - avoid adding anticholinergics, sedatives, or opioids
  • If agitation occurs, try non-pharmacologic measures first
  • If medication absolutely needed for severe agitation, use lowest dose quetiapine (12.5-25 mg)

Safety:

  • Wife instructed on 24-hour supervision during delirium
  • Remove fall hazards
  • Night light for bathroom trips
  • Do not leave patient unattended

Disposition Decision

Given supportive wife, ability to maintain oral intake, and absence of severe agitation, patient can be managed at home with close follow-up.

Follow-Up

  • Phone call in 24 hours
  • Office visit in 2-3 days to reassess mental status
  • If not improving or worsening, emergency department evaluation

Expected Course

  • Delirium from UTI typically resolves within days to 1-2 weeks with treatment
  • May have prolonged cognitive effects; some patients do not return fully to baseline
  • Delirium is a marker of brain vulnerability - increases future dementia risk

Teaching Points

  1. Delirium is a medical emergency - it indicates an underlying medical condition and is associated with significant morbidity and mortality
  1. CAM is the gold standard diagnostic tool - requires acute onset/fluctuation PLUS inattention PLUS either disorganized thinking OR altered consciousness
  1. UTI is the most common cause of delirium in older adults - always check urinalysis, even without classic urinary symptoms
  1. Baseline cognitive impairment is the strongest risk factor for developing delirium
  1. Hypoactive delirium (lethargic) is more common but often missed - hyperactive delirium (agitated) is more recognizable but less prevalent
  1. Treat the underlying cause, not the symptoms - antipsychotics should be reserved only for severe agitation that poses safety risk
  1. Prevention is key - in hospitalized patients, the Hospital Elder Life Program reduces delirium incidence by 30-40%

All cases for this lecture as Markdown