Alton Simmons
additional reading
- derived from Delirium by Ugochi Ohuabunwa, Emory University, downloaded with permission from MedEdPortal
HPI: Alton Simmons is an 82 year-old man brought into the emergency department with a 1- week history of confusion and agitation. His wife found him in the bathroom on the day of presentation and at the time appeared confused, weak and could not get up without assistance. The night before presentation to the hospital, Mr. Simmons had complained of severe knee pain. His wife gave him Tylenol PM to help him rest.
PMH: His medical history includes severe osteoarthritis for 10 years.
Medications: Multivitamins, extra strength Tylenol.
Social history: He has been married for 50 years, lives with his wife. He quit smoking 10 years ago. He does not drink alcohol.
Review of Systems: Fatigue, diffuse weakness, difficulty in ambulating due to knee pain, decreased po intake, minimal cough.
Physical exam: He was afebrile with a heart rate 103, a respiratory rate of 18 per minute, a blood pressure of 95/60, and an oxygen saturation of 94 % in room air, with no acute distress. His mucous membranes appeared dry. He had occasional inspiratory crackles in the left lower lung field. Motor strength was 4/5 in the upper and lower extremities. The sensory exam was normal, with symmetric reflexes. The patient could recall his name and where he lived but did not know the name of the hospital, the date, or the year. Rest of his physical exam was unremarkable.
Question: What are the predisposing factors for delirium in older patients?
Question: What are the signs and symptoms of delerium?
Question: What lab and imaging workup should be carried out for patients with newly presenting delirium?
Hospital course: Initial work-up revealed a left lower lobe infiltrate on chest x-ray. Because of his urinary incontinence, a Foley catheter was placed into his bladder while the patient was in the emergency room. The patient was admitted to the medicine ward with diagnosis of dehydration and community-acquired pneumonia. Code status was discussed with Mrs. C.R. who indicated a DNR status which was consistent with Mr.C.R.’s goals of care and previously expressed wishes. The next day on team rounds, he remained agitated and confused. After reviewing the medication records and progress notes, you found out that the patient was given Haldol and placed in soft restraints by the cross cover intern because patient pulled his IV line.
Question: What are the criteria for diagnosis of delirium?
By the fourth hospital day, Mr. C.R.’s clinical condition improved. He was conversant, interactive, and lucid. He could identify the month and the year and stated that he felt better.
Question: What interventions are most likely to improve altered mental status in Mr. C. R and other patients who present with similar symptoms?
Resources and References
Inouye SK. Delirium in older persons. N Engl J Med. 2006: 16; 354(11): 1157-65.
Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999; 340(9): 669-676
Elie M, et al. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med.1998: 13(3): 204-212
Inouye SK et al., Clarifying confusion: The Confusion Assessment Method (CAM). Ann Intern Med. 1990; 113 (12): 941-948.
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