This Paper was prepared for_________ taught by___________
Introduction. Distinguishing between dementia, delirium and depression in geriatric population can be a challenge. This paper describes the clinical case of a patient brought to the emergency room and focuses on assessment, differential diagnosis, and treatment options.
Clinical management. Based on the information presented in the case (the clinical examination data only) it is not possible to precisely define the cause of delirium. Slightly increased blood pressure(150\90) and subfebrile temperature (99F) may be both consequences of agitation and other causes as e.g side effects of some medications taken by Mrs.Mayfield, or their interaction (e.g.opioids, benzodiazepines, antiarythmics, steroids) which is one of the common reasons of delirium in elderly (APA,2010). As delirium is very frequent in Mrs.Mayfield’s age due to multiple sensory impairment and cognitive regression (APA, 2010), more in-depth medical history insight and clinical and laboratory examination (blood and urine tests etc.) are necessary. Possible causes to differentiate are: a) occult infection (e.g. urinary tract) demonstrated by subfebrile temperature b) polypharmacy, with enhancing drugs’ side effect due to reduced hepathic metabolism c) overlapping diseases effects resulting in biochemical disorders (e.g.hyponatraemia, hypercalcaemia, hyperglycemia) d) underlying dementia. As the most challenging diagnosis is between delirium and delirium superimposed on a preexisting dementia (APA, 2010), it may be appropriate to gently try a mini-mental state examination (MMSE) to define “a baseline” for evaluation of actual change in the patient’s basic cognitive functioning (Alici & Breibart, 2009; Flaherty & Resnick, 2014). As the patient is clean and well-nourished, she obviously resides in home setting, defining location of which and speaking to relatives to obtain the underlying information and to explain the need for sedation, can be useful. The patient also needs gentle explanation of her state and reassurance. As delirium is an emergency state requiring immediate medical attention, pharmacological treatment (low dose (0.5mg) haloperidol once or twice a day as a standard of care for the elderly (APA, 2010; Flaherty & Resnick, 2014) should be introduced. In case of any extrapyramidal side effects in response to haloperidol, Lewi dementia can be suspected and the clinical diagnosis\ management further adjusted (APA, 2010). If agitation persists, risks and benefits of restraints use should be carefully weighted (APA, 2010). It will be vitally important to find the underlying cause of delirium and to treat it wherever possible.
Conclusion. To distinguish between delirium, dementia and depression, evaluation of onset speed, disturbance in arousal level and temporal sequence of symptoms is necessary. In the clinical case described, the patient presents with signs of delirium which underlying causes should be investigated, and the preexisting dementia condition confirmed or excluded. The standard treatment with low-dose haloperidol should be started immediately, with the diagnosis\clinical management subsequent adjustment depending on the delirium underlying reason and leading symptoms.
Alici, Y., &Breibart, W. (2009). Delirium in Palliative Care.Primary Psychiatry,16(5),42-48.
American Psychiatric Association (APA) (2010). Practice guideline for the treatment of patients with delirium. Retrieved from: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/delirium.pdf
Flaherty, E., &Resnick, B. (Eds.) (2014). Geriatric nursing review syllabus:A core ciricullum in advance practice pediatric nursing (4th ed.).New York, NY:American Geriatric Society