EPM Monthly Quiz: Living with altered mental status

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What’s the treatment for this female patient’s agitation?

 


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An 81-year-old female is brought to the emergency department by her family for altered mental status.  The patient lives with her family due to a gradual decline in cognition over the last few years. She is normally able to care for herself, but she has been experiencing more frequent episodes of agitation and confusion over the last two days, as well as urinary incontinence. On examination, the patient is agitated and easily distracted, oriented to herself and has symmetric motor strength. Vitals signs are HR 110, BP 102/56, T 39°C (102.2°F).  What is the most effective treatment for this patient’s agitation?

Question Answer Choices:

  1. Amantadine
  2. Ceftriaxone
  3. Donepezil
  4. Haloperidol
  5. Lorazepam

Question Explanation:


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Correct answer: B. Ceftriaxone

An antibiotic is most indicated because this patient is experiencing acute delirium, likely due to a urinary tract infection, given the fever and urinary incontinence. Delirium is characterized by an acute onset of disturbances in alertness, attention, memory, cognition and perception from baseline that fluctuate over hours to days. Reversible causes include electrolyte or endocrine derangements, infection, toxic exposures, cardiac ischemia or stroke.

Delirium is a clinical diagnosis after other etiologies are evaluated. The DSM V has four key characteristics: 1) attention disturbance, 2) change over short time, 3) additional cognitive disturbances and 4) no other etiology explains the changes. Diagnosis of delirium in the ED is critical because mortality rises from 10% when delirium is diagnosed in the ED to 36% when it is missed. Several new screening tools exist for the ED specifically, but none have passed the test of time nor have extensive validity studies. Examples are the mCAM-ED and the delirium triage screen (DTS).

Treatment of acute delirium is focused on treatment of the underlying condition and protecting the patient from self-harm and falls. Improving the sleep/wake cycle, ambulation and dexmedetomidine, which helps with sleep/wake cycle, are the only therapies repeatedly shown to improve delirium.


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Incorrect answer choices:

Amantadine (Choice A) is indicated in late stage Alzheimer’s dementia to improve cognition. Patients with dementia have a progressive and permanent decline in orientation and memory, which distinguishes it from this patient whose symptoms are acute and fluctuating. This patient may have dementia given the gradual decline in cognition over the years requiring her to move in with family, but she is typically able to care for her own ADLs, so amantadine would not be effective for her at this time. Acute delirium can occur in patients with dementia if a reversible condition arises, which is what this patient is experiencing.

Donepezil (Choice C) is indicated for this patient’s progressive cognitive decline with long-term benefit, but will not improve the acute agitated delirium.

Haloperidol (Choice D) could be used in agitated (hyperactive) delirium if the patient’s agitation puts her at risk for harming herself or others, but this patient does not meet that criteria.  Hypoactive delirium is characterized by sluggishness and lethargy and has a worse prognosis if not recognized.

Lorazepam (Choice E) may worsen delirium and should be avoided. The first line treatment in anxiety or agitation in patients with dementia is avoidance of triggers that produce these behaviors.

References:

Abraham G and Zun LS. Chapter 94. Delirium and Dementia. In Walls RM, Hockberger RS, Gausche-Hill M, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia: Elsevier. 2018.

Cordell CC et al. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s and Dementia 2013;9:141-150.

Trzepacz P et al.  Practice Guideline for the Treatment of Patients with Delirium. American Psychiatric Association Practice Guidelines 2010; 1-38.

 

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