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Case 7: Delirium: Evaluation, Prevention, and Treatment in the Context of Patient Who Presents With Altered Mental Status and Urinary Symptoms

Learning Objectives
1. Assess patients for delirium and evaluate potential causes
2. Recognize the unique needs of the older adult during a hospitalization
0.25 Credit CME

An 83-year-old man is brought to the emergency department (ED) for treatment of fever and altered mental status. The patient resides in a skilled nursing facility (SNF) and was brought to the ED because of a one-week history of increasing agitation and urinary urgency and a one-day history of shaking chills and confusion; the caregiver reports that his urine has been foul-smelling. There is no report of head trauma. The patient has a history of mild Alzheimer's dementia, hypertension, and intermittent anxiety. Medications are donepezil (10 mg daily), paroxetine (20 mg daily), hydrochlorothiazide (25 mg daily), diphenhydramine (25 mg four times daily as needed), and oxybutynin (5 mg three times daily). On admission to the ED, his temperature is 37°C (98.6°F), pulse is 92/min, respirations are 18/min, and blood pressure is 110/70 mm Hg. He is lethargic and unable to answer questions. Neurologic examination shows no focal findings. Blood is drawn, and urine is collected for analysis and culture.

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Advisory Panel

The following members of the advisory panel had no relevant financial relationships with ineligible companies to disclose:

• Ruben Azocar, MD

• George Drach, MD

• Sandhya Lagoo-Deenadayalan, MD, PhD

• Andrew Lee, MD

• Mike Malone MD

• Myron Miller, MD

• Arvind Nana, MD

• Tom Robinson, MD

• Victoria Tang MD, MAS

The following members of the advisory panel have reported relevant financial relationships with ineligible companies that have been mitigated through peer review of planning decisions by persons without relevant financial relationships and recusal from any aspect of planning and content related to the financial relationship:

• Kevin Biese MD, MAT is a paid consultant for Call 9 Telemedicine Medical Advisor and Bristol Meyers Squibb/ Pfizer

• Daniel Mendelson, MS, MD is a paid consultant for Point Click Care Touchscreen

Writing Panel

The following members of the writing panel had no relevant financial relationships with ineligible companies to disclose:

• Tomas Griebling, MD

• Joseph Hejkal, MD

• Melissa Hornor, MD

• Jason Johanning, MD

• Sushila Murthy, MD, MPH

• Tony Rosen, MD, MPH

• Kate Schenning, MD, MPH

The following members of the writing panel have reported relevant financial relationships with ineligible companies that have been mitigated through peer review of content by persons without relevant financial relationships:

• Charles Brown, MD is a paid consultant for and receives grants from Medtronic

• Badrinath Konety, MD, MBA is a paid consultant for NxThera, and Bristol Myers Squibb, Opko and receives grant funding from Photocure, Genentech, and Genomic Health

Reviewers:

The following reviewers had no relevant financial relationships with ineligible companies to disclose:

• Shamsuddin Akhtar, MD

• Patrick Kortebein, MD

• Joseph LoCicero, MD

Support Statement

This CME activity is supported by a grant from the John A. Hartford Foundation.

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References:
1.
Inouye  SK.  Delirium in older persons.  J Natl Med Assoc. 2006;354(11):1157–1165. https://www.nejm.org/doi/full/10.1056/nejmra052321Google Scholar
2.
AGS Expert Panel.  American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults.  J Am Geriatr Soc. 2015;63(1):142–150. https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.13281Google Scholar
3.
AGS Expert Panel.  American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.  J Am Geriatr Soc. 2019;67(4):674–694. https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767Google Scholar
4.
Marcantonio  ER.  Postoperative delirium: a 76-year-old woman with delirium following surgery.  JAMA. 2012;308(1):73–81. https://jamanetwork.com/journals/jama/article-abstract/1172097?tab=cmeGoogle Scholar
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