College of Medicine

Clinical Affairs

MEDN 513 PBL Case No. 6

LOST THE PLOT

Presentation

Shama Ibrahem, a 83-year-old woman, is brought to the emergency department by her 84-
year-old husband. He reports that she has become increasingly confused and drowsy over
the last few days. She appears lethargic and drowsy.

Problem/ Differential Diagnosis (DD)

Questions

1. What problem/s is the patient presenting with?

2. What are the most likely hypotheses to account for the problem/s?

Clinician's Response

Problems:

1. Confusion
2. Drowsiness

Differential diagnosis:

 Acute confusional state (delirium)

a. Metabolic disorders/organ failure
- electrolyte disorders
- dehydration
- hyper/hypoglycamia
- hyper/hypothermia
- hyper/hypothyroidism
- hypoxia
- uraemia
b. Infection - urinary tract infection, chest infection or other systemic
infection
c. Medication - exposure or withdrawal
d. Intracranial pathology
- Vascular - infarct, haemorrhage
- Tumour - meningioma, glioma
- Infection - viral encephalitis

Clarifying comments:
A short history of increasing confusion and drowsiness in an aged patient mandates a search
for a potentially reversible cause or causes, which have precipitated the neurological
deterioration. A wide variety of structural and metabolic causes must be considered.
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History

Questions

 What additional history do I need to test these hypotheses?

Additional Case Information

History of presenting illness:

There is a 12 month history of gradually progressive memory impairment, associated with
moderate apathy and functional decline (e.g. domestic chores, socialisation). An
antidepressant was commenced 6 months ago by her GP, who increased the dose 2 weeks
before presentation. Over the last week she had been increasingly lethargic, with increasing
drowsiness and confusion. She has been incontinent of urine on several occasions. On the
morning of presentation her husband had difficulty waking her from sleep.

Past history:
Osteoarthritis, involving knees, hips and shoulders.
Total knee replacement 3 years ago, currently taking a non-steroidal anti-inflammatory drug.
Hypertension, diagnosed 29 years ago and well controlled for the last 8 years with a beta-
blocker.
Cardiac failure diagnosed 3 years ago on the basis of ankle oedema, stable with Moduretic
(thiazide diuretic).

Family history:
Mother died at age 80 with dementia, and father died at age 65 years with heart disease.
Sister has dementia at age 75. No other sisters or brothers.

Personal history:
Lives at home alone with husband. Up until the last 2 weeks, Shama had been cooking most
of the meals, and performing most of the housework. Their two daughters live 2 hours drive
away, and comment that they are concerned about their parent's ability to function at home.
The daughters are concerned that they are not eating well.
Non smoker and non drinker.

Medication:
Indomethacin - 50 mg BD
Metoprolol 50 mg BD
Moduretic 1 mane (Amiloride 5 mg and Hydrochlorothiazide 50 mg)
Sertraline 100 mg daily
Diazepam 5 mg nocte
No known allergies

Problem Reformulation

Questions

1. In light of the available history do I need to reformulate the patient's problems?

2. What is the differential diagnosis at this stage?
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Clinician's Response

Reformulated problems:

1. Delirium on a background of dementia

2. Hypertension
3. Cardiac failure
4. Osteoarthritis

Differential diagnosis:

 Underlying dementia with urinary tract infection as acute precipitant of confusional

state.
 Vascular dementia with recent cerebral ischaemic episode.
 Undiagnosed diabetes with recent exacerbation by intercurrent illness.
 Undiagnosed hypothyroidism with recent decompensation.
 Electrolyte disturbance.
 Depressive illness not responding to therapy.
 Dehydration from poor appetite and diuretic use.
 Chronic renal failure.

Examination

Questions

 What particular signs will I be seeking on physical examination to help clarify the
diagnosis?

Additional Case Information

General observations:
Drowsy, but easily roused. Falls back to sleep during the examination. Disorientated in time
and place. Unable to complete a Mini Mental Status Examination.
Generalised brief jerking movements of all four limbs.
Appears well hydrated.
o
Temperature 36.8 C.
Changes of mild osteoarthritis in knees and hands, scar on left knee.

Cardiovascular:
BP 130/70, pulse 88/min regular in rate and rhythm. Heart sounds normal, JVP not raised,
apex not displaced, no peripheral oedema.

Respiratory:
Respiratory examination normal.

Abdomen:
Abdominal examination normal.

Neurological:
Neurological examination normal except for mental state changes and myoclonic jerks.
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Urinalysis:
Negative for protein, blood, glucose and leukocytes.

Refinement of DD

Questions

 Based on this additional information, how would I refine the differential diagnosis?

Clinician's Response

 Acute confusional state without an obvious aetiology.

 Intracranial pathology possible, but less likely without focal CNS signs.
 Infection still possible, despite a normal temperature and without an obvious focus.
 A purely depressive illness is unlikely due to the features of a delirium.
 Other metabolic and drug related causes of delirium not excluded and therefore
need to be investigated. (see above).

Investigations

Questions

 What particular investigations will help to clarify the diagnosis?

Additional Case Information

cf. Normal Ranges

INVESTIGATIONS

Full blood count:

9
Hb 11.0 g/dL, WCC 5.0x10 /L (3.5 neut, 0.8 lymph, 0.4 mono, 0.2 eos, 0.1 baso), Plat 160 x
9
10 /L, ESR 25 mm/hr.

Biochemistry:
Na 109 mmol/L, K 2.4 mmol/L, Cl 86 mmol/L, Urea 4.0, Creatinine 0.07 mmol/L, glucose 4.5
mmol/L, Ca 2.30 mmol/L, Total Protein 75 gm/L, Albumin 33 gm/L.Plasma osmolarity 240
mosm/kg.

Urinary electrolytes (spot specimen):

Na 55 mmol/L, K 3 mmol/L, Osmolarity 290 mosm/kg.

Additional tests:
Imaging:

CT scan of brain:
Generalised atrophy.
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Bloods:
TFT's normal, B12/Folate normal, VDRL non reactive.

Working Diagnosis

Questions

1. How would I summarise the main problem/s?

2. What is my provisional diagnosis?

Clinician's Response

Clinician's problem summary and provisional diagnosis:

 Iatrogenic disease: Hyponatraemia secondary to diuretics, plus possible contribution

of SSRI-induced SIADH and of NSAIDS. Diuretic induced hypokalaemia.
 Delirium secondary to metabolic derangement.
 Likely underlying chronic cognitive disorder.

1. DRUG-INDUCED HYPONATRAEMIA AND HYPOKALAEMIA.

2. DELIRIUM (SECONDARY TO SEVERE HYPONATRAEMIA).
3. POSSIBLE UNDERLYING DEMENTIA.

EBM

Questions

 What are some relevant questions for which I would like more evidence from the
literature in order to make decisions about diagnosis and management.

Clinician's Response

 What is the evidence that SSRI's cause hyponatraemia?

 What is the prevalence of dementia in patients presenting with delirium?
 What are the current guidelines for the rate of plasma Na correction in relation to
the risk of central pontine myelinolysis

Management

Questions

1. What are the short and long term management goals?

2. What management would I recommend?

Clinician's Response

Short & long term goals:

 Correct hyponatraemia
 Treat depression with alternative antidepressant, if necessary.
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 More complete cognitive assessment when delirium resolved.

 Geriatric assessment re ability to manage at home (husband as well).

Clinician's recommended management:

Initial management:
Fluid restriction to 500mL of fluid per day was commenced, and her usual medication was
ceased. The low potassium required KCl replacement via a long line intravenously.

Progress & Outcome

Questions

 What progress do I expect the patient will have?

Additional Case Information

Following water restriction, the serum Na increased by 10 mmol/L in the first 24 hours, and
the patient improved slightly.
The second evening, Shama became extremely confused and agitated. She climbed over the
bed rails and fell onto the floor, sustaining an injury to her left hip.

The attending RMO contacted the on-call Geriatrician about giving 10mg Haloperidol and
applying physical restraints. The RMO was instead advised about appropriate delirium
management, which included the use of a "sitter" or "special nurse", avoidance of physical
and/or chemical restraints and the institution of a reducing regime of diazepam (the patient
was identified to have been on long-term benzodiazepines).
The next day, there was a noticeable improvement in her agitation and an X-Ray of her hip
demonstrated only degenerative changes, and no fractures.

She continued to improve, becoming less drowsy and her serum Na increasing to 125
mmol/L over the first 4 days.

o
On day five following admission she was noted to have a temperature to 38.9 C, and her
blood pressure fell to 90/60mmHg, with a heart rate of 108/min (regular in rate and rhythm).
A CXR revealed right lower lobe airspace infiltrate, and a catheter urine specimen was
positive for blood, protein and leukocytes. Her temperature and blood pressure improved
following intravenous antibiotics (Ampicillin and Gentamicin) and some intravenous fluids.
The intravenous antibiotics were changed to oral amoxicillin after 4 days. The urinary
catheter was removed.

The acute confusional state improved, but some mild memory impairment continued.
A physiotherapist and occupational therapist undertook an assessment of her mobility,
activities of daily living, and her home situation. This assessment included a home visit. She
was discharged home with a variety of community services: Meals on Wheels and home
help.
Referral was also made for a dementia day care centre, and respite options were discussed
with her husband. Further cognitive review was planned in the outpatients' department for
5-6 weeks following discharge.
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Discussion Points

Questions

 What discussion points and learning topics arise from this case?

Additional Case Information

Major discussion points & learning topics:

 Iatrogenic disease
 Medication-related adverse events (SSRI's, diuretics, diazepam withdrawal,
haloperidol induced aspiration).
 Complications of hospitalisation (falls, confusion, aspiration).
 Complications of medical procedures (urinary catheterisation).
 Diagnosis and management of SIADH.
 Diagnosis of delirium.
 Management of the acutely confused elderly patient.
 Diagnosis of dementia in the presence of delirium, or a recent delirium.
 Community supports for the frail and demented elderly.
 Pharmacological changes associated with ageing

Reference Material

Additional Case Information

References:

 Delirium in hospitalized elderly patients: A meta-analyisis [Prognosis] ACP Journal

Club. v119:87, Nov-Dec, 1993
 A 6-point risk score predicted which elderly patients would fail in hospital
[Miscellaneous] ACP Journal Club. v128:81, May-June 1998
 Delirium predicts 12-month mortality independent of dementia status. ACP Journal
Club. V139(3):80, Nov-Dec, 2003
 Multidisciplinary team interventions for delirium in patients with chronic cognitive
impairment. Britton A, Russell R, The Cochrane Library, 2005, 4
 Nutritional interventions for preventing and treating pressure ulcers G Langer, G
Schloemer, A Knerr, O Kuss, J Behrens, The Cochrane Collaboration, 2003.
 Delirium in older people. ASGM Position Statement Number 13. S Maher 2005.
http://www.asgm.org.au/documents/PositionStatementNo13_001.pdf

Websites:

 Community & Doctor Modules "Careres and Social Support Aspects of Illness" and
"Continutiy of Care"
 Alzheimers Association of Australia