You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times. This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient.
Item 1 of 3
Which of the following is the most appropriate next step in the management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient is suffering from an acute confusional state, also known as delirium. Delirium is extremely common in old nursing home patients. It manifests as a change in the level of awareness, easy distractibility, cognitive and perceptual disturbances including memory loss, disorientation, and even agitation. It typically develops over hours to days, and this acute onset distinguishes it from dementia. Delirium is a multifactorial disorder. The factors that increase the risk of delirium are subdivided into those that increase the susceptibility to delirium and those that precipitate delirium. The most common factors that increase the patient's susceptibility to delirium include advanced age and an underlying brain disorder (i.e., dementia, Parkinson's disease, and history of prior stroke). The factors that precipitate delirium include multiple medication use (polypharmacy), infections (i.e., urinary tract infections and pneumonia), fluid and electrolyte disturbances (dehydration, hyponatremia, or hypernatremia), malnutrition, immobility (including the use of restraints), use of bladder catheters, and a wide variety of other medical conditions. In fact, delirium may be the only presenting complaint in an older demented patient suffering from an acute medical illness; therefore, checking this patient's vital signs should be the first step to rule out early infections and fluid and electrolyte disturbances. (Choice A) Transferring this patient to a hospital may be necessary for further evaluation of the cause of the delirium; however, this should not be the first step in the management of this patient. (Choices B and D)Misuse of antipsychotics and benzodiazepines is very common in managing behavioral problems in demented nursing home patients. It leads to frequent adverse effects and worsening of the cognitive status; therefore, it is important to rule out any medical, environmental, or psychosocial causes before prescribing any psychotropic medications. (Choice E) As explained above, the use of physical restraints can precipitate and even worsen the delirium, and should therefore be avoided. Educational objective: Delirium can be the only finding of an acute medical condition in older demented individuals. Use of psychotropic medications as a first line therapy for behavioral problems is not recommended.

You Are the Current "On Call Physician" for Your Group