Psychiatry · Year 3 · from Psychiatry

Case 1: Delirium

Patient Demographics

  • Age: 78 years old
  • Sex: Male
  • Occupation: Retired engineer

Chief Complaint

Per nursing staff: "He's confused and trying to pull out his IV. He was fine yesterday."

History of Present Illness

The patient is a 78-year-old man admitted 3 days ago for elective right hip replacement surgery. The surgery was performed on hospital day 2 and was uncomplicated. On post-operative day 1, nursing staff noted an acute change in mental status. The patient became agitated during the night, attempting to climb out of bed and stating he needed to "get to work" and "they're coming for me." He did not recognize his wife when she visited and accused nursing staff of trying to poison him. His level of alertness fluctuates throughout the day - he was somnolent and difficult to arouse during morning rounds but became agitated and combative in the evening.

Pre-operatively, the patient was described by his family as cognitively intact, living independently with his wife, managing his own finances and medications, and volunteering at a local museum. He has no history of psychiatric illness or cognitive impairment.

Medical History

  • Hypertension
  • Type 2 diabetes mellitus
  • Benign prostatic hyperplasia
  • Osteoarthritis
  • Mild hearing loss (uses hearing aids)

Medications (Current)

  • Oxycodone 5 mg q4h PRN for pain
  • Diphenhydramine 25 mg PRN for sleep (received 2 doses)
  • Famotidine 20 mg BID
  • Metoprolol 50 mg BID
  • Metformin 1000 mg BID (held)
  • Tamsulosin 0.4 mg daily

Mental Status Examination

Appearance: Elderly man in hospital gown, disheveled, Foley catheter and IV in place

Behavior: Variable - during examination was picking at IV tubing and bed sheets; intermittently agitated; poor eye contact

Speech: Disorganized, mumbling, sometimes incoherent

Mood: Unable to assess

Affect: Fearful, suspicious, irritable

Thought Process: Disorganized, tangential, difficult to follow

Thought Content:

  • Paranoid content ("they're trying to kill me")
  • Disoriented to place (thinks he's at work)
  • Unable to assess for suicidal or homicidal ideation due to disorganization

Perceptions: Appears to be responding to visual hallucinations (reaching for things not present, startled by unseen stimuli)

Cognition:

  • Attention severely impaired: Cannot spell WORLD backward, cannot count backward from 20
  • Orientation: Knows name only; disoriented to place (thinks he's at his old workplace), date (states it's 1987), and situation
  • Memory: Unable to register 3 words
  • Fluctuating level of consciousness - alternates between hyperalert and somnolent

Insight: None - does not recognize he is confused

Judgment: Severely impaired

Assessment with CAM (Confusion Assessment Method)

Feature 1 - Acute Onset and Fluctuating Course: YES

  • Acute change from baseline (was cognitively intact pre-operatively)
  • Mental status fluctuates throughout the day

Feature 2 - Inattention: YES

  • Cannot spell WORLD backward
  • Easily distracted, cannot maintain conversation

Feature 3 - Disorganized Thinking: YES

  • Incoherent, tangential speech
  • Illogical flow of ideas

Feature 4 - Altered Level of Consciousness: YES

  • Fluctuates between hyperalert/agitated and lethargic

CAM Result: POSITIVE for delirium (Features 1 + 2 + 3 and 4)

Diagnostic Workup

Laboratory Studies:

  • CBC: WBC 12.4 (elevated), Hgb 10.2
  • CMP: Na 148 mEq/L (elevated), BUN 32, Cr 1.4 (elevated from baseline 1.0), glucose 186
  • UA: Positive for leukocyte esterase, nitrites, WBC >50
  • Blood cultures: Pending
  • TSH: 2.1 (normal)

Imaging:

  • CT Head: No acute intracranial abnormality
  • Chest X-ray: No infiltrate

Diagnosis

Delirium Due to Multiple Etiologies (F05)

DSM-5 Criteria Met: A. Disturbance in attention and awareness (reduced ability to focus, sustain, shift attention) B. Develops over short period (hours), represents change from baseline, fluctuates C. Additional cognitive disturbance (disorientation, memory, language, perception) D. Not better explained by pre-existing NCD, does not occur in coma E. Evidence of medical etiology (UTI, dehydration, medications)

Subtype: Mixed (alternating hyperactive and hypoactive features)

Identified Contributing Factors:

  1. Urinary tract infection
  2. Dehydration/hypernatremia
  3. Medications: Oxycodone (opioid), Diphenhydramine (anticholinergic)
  4. Post-operative state
  5. Sensory deprivation (hearing aids not used in hospital)
  6. Sleep deprivation
  7. Unfamiliar environment

Treatment Plan

Treat Underlying Causes:

  • Start empiric antibiotics for UTI (ciprofloxacin or alternative based on local resistance patterns)
  • IV fluid resuscitation for hypernatremia and dehydration
  • Discontinue diphenhydramine (anticholinergic)
  • Reduce/taper oxycodone, transition to scheduled acetaminophen with PRN low-dose opioid
  • Optimize glucose control

Non-Pharmacological Management:

  • Ensure hearing aids are in place
  • Reorientation: Place clock and calendar at bedside, have family photos visible
  • Consistent nursing staff when possible
  • Minimize room changes
  • Preserve sleep-wake cycle: Minimize nighttime interruptions, open blinds during day
  • Early mobilization as orthopedics allows
  • Remove Foley catheter as soon as possible
  • Have family present during daytime hours
  • Avoid physical restraints

Pharmacological Management (for agitation/safety):

  • Haloperidol 0.5-1 mg PO/IM PRN for severe agitation (low dose given age)
  • Monitor QTc
  • Avoid benzodiazepines (would worsen confusion)

Monitoring:

  • CAM assessment every shift
  • Daily reassessment of medications
  • Electrolytes daily until normalized
  • Fall precautions

Expected Course:

  • Delirium typically resolves in days to weeks once underlying causes addressed
  • Full cognitive recovery expected given intact baseline
  • Counsel family about fluctuating course

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