Subinternship Medicine · Year 4 · from Subinternship Medicine

Case 2: Frailty, Polypharmacy, and Hospital-Acquired Delirium

Clinical Presentation

Patient Demographics: 82-year-old female

Chief Complaint: "She's not acting like herself" - reported by daughter

History of Present Illness: Mrs. Park is an 82-year-old female admitted 4 days ago for community-acquired pneumonia. She initially improved with antibiotics but for the past 24 hours has been increasingly confused, agitated at night, and refusing medications. Her daughter, who visits daily, reports "this is not my mother - she doesn't recognize me."

Baseline Functional Status:

• Lives independently in senior apartment
• Independent in all ADLs and IADLs
• Drives short distances
• Active in church community
• No prior cognitive impairment (MMSE 28/30 at PCP visit 3 months ago)

Past Medical History:

• Hypertension
• Osteoporosis with vertebral compression fracture (chronic back pain)
• Insomnia
• Anxiety disorder
• Hypothyroidism
• Cataracts (bilateral, untreated)
• Hearing impairment (uses hearing aids)

Current Medications:

• Ceftriaxone 1g IV daily (day 4)
• Azithromycin 500 mg IV daily (day 4)
• Lisinopril 10 mg daily
• Amlodipine 5 mg daily
• Levothyroxine 50 mcg daily
• Alendronate 70 mg weekly
• Calcium 600 mg BID
• Vitamin D 2000 IU daily
• Acetaminophen 650 mg Q6H PRN
• Tramadol 50 mg Q6H PRN (back pain - new, started day 2)
• Zolpidem 5 mg QHS (home medication, continued)
• Lorazepam 0.5 mg Q6H PRN anxiety (new - given 3 doses)
• Diphenhydramine 25 mg QHS PRN (given for insomnia)

Physical Examination:

• Vital Signs: Temperature 37.2C, HR 92 bpm, BP 118/72 mmHg, RR 18/min, SpO2 95% on 2L NC
• General: Elderly female, intermittently agitated, picking at sheets
• HEENT: Hearing aids not in, glasses at bedside
• Lungs: Decreased breath sounds at right base, no crackles (improved from admission)
• Cardiovascular: Regular rate and rhythm
• Neurologic: Oriented to person only, inattentive (unable to recite months backwards), visual hallucinations ("there are children in the room")
• Abdomen: Soft, mildly distended, no bowel movement in 3 days

Delirium Assessment

CAM (Confusion Assessment Method):

1. Acute onset and fluctuating course: YES
2. Inattention: YES
3. Disorganized thinking: YES
4. Altered level of consciousness: YES (fluctuates between drowsy and agitated)

CAM Positive = DELIRIUM

Delirium Risk Factors in This Patient:

• Advanced age
• Acute infection
• Sensory impairment (hearing, vision)
• Constipation
• New psychoactive medications (tramadol, lorazepam, diphenhydramine, zolpidem)
• Sleep disruption in hospital
• Unfamiliar environment

Root Cause Analysis - Medication Review

HIGH-RISK MEDICATIONS CONTRIBUTING TO DELIRIUM:

Beers Criteria Violations:

• Diphenhydramine: Avoid in elderly (anticholinergic, sedating)
• Benzodiazepines: Avoid in elderly (falls, cognitive impairment)
• Zolpidem: Avoid in elderly (falls, delirium)

Treatment Plan

Immediate - Address Reversible Causes:

1. Medication deprescribing:

• Stop tramadol, diphenhydramine, lorazepam, zolpidem
• Use scheduled acetaminophen for pain

1. Constipation: Aggressive bowel regimen (docusate, senna, consider enema)
2. Sensory optimization: Hearing aids in, glasses on, adequate lighting
3. Reorientation: Clock, calendar, familiar photos in room
4. Sleep hygiene: Minimize nighttime interruptions, lights off at night

Environmental/Non-Pharmacologic:

1. Family presence during day
2. Early mobilization with PT
3. Avoid physical restraints
4. Normalize sleep-wake cycle

Pharmacologic (if severe agitation):

1. Haloperidol 0.5-1 mg PO/IV PRN severe agitation (not scheduled)
2. Avoid benzodiazepines except for alcohol/benzo withdrawal

Ongoing Management:

1. Daily reassessment of mental status
2. Transition antibiotics to oral for discharge
3. Family education about delirium and recovery expectations
4. Outpatient cognitive screening at follow-up

Functional Assessment for Discharge Planning

ADLs Assessment (comparing to baseline):

Recommendation: Cannot discharge home independently. Options:

• Short-term rehabilitation for reconditioning
• Home with 24-hour family supervision initially
• Home with home health aides

Clinical Image

Image Description: In patients with new delirium, neuroimaging may be obtained to rule out structural causes such as stroke or subdural hematoma, particularly in those with focal neurologic findings or history of falls.

Image Source: Radiopaedia - "Normal CT head"

• URL: https://radiopaedia.org/cases/normal-ct-head
• License: Educational use - Radiopaedia.org

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