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.
The nurse calls you back in twenty minutes. She states that she gave a dose of prn (as needed) medication which was ordered by a physician before. She arranged an ambulance to transfer the patient to a nearby hospital. Her temperature is 36.7 C (98 F), blood pressure is 116/78 mmHg, pulse rate is 76/min, and respiratory rate is 18/min. She is still agitated, and she is now disoriented to place and person. She gets easily distracted, and she is having auditory hallucinations. In the hospital, her physical examination is unremarkable. What is the most appropriate next step in the management of her condition?

Question

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.
The nurse calls you back in twenty minutes.  She states that she gave a dose of prn (as needed) medication which was ordered by a physician before.  She arranged an ambulance to transfer the patient to a nearby hospital.  Her temperature is 36.7 C (98 F), blood pressure is 116/78 mmHg, pulse rate is 76/min, and respiratory rate is 18/min.  She is still agitated, and she is now disoriented to place and person.  She gets easily distracted, and she is having auditory hallucinations.  In the hospital, her physical examination is unremarkable.  What is the most appropriate next step in the management of her condition?

Quizplus · Accepted Answer

Explanation: This patient is still exhibiting the classic signs and symptoms of delirium. Cognitive and perceptual disturbances including hallucinations are very common in delirious patients. As described above, virtually any acute medical condition can precipitate delirium in an older demented patient. It is important to perform a complete physical examination and obtain basic laboratory studies to identify or rule out the potential causes of delirium, especially the reversible causes, which include: dehydration, hypo/hypernatremia, infections, hypoglycemia, hypercalcemia, uremia, and liver failure. (Choices A and B) The use of psychotropic medications to calm this patient is not recommended at this time. It is prudent to rule out the reversible medical causes of delirium before prescribing psychotropic medications or obtaining a psychiatric consultation. (Choice D) There is no history of head trauma or any focal neurological signs and symptoms; therefore, a head CT scan is not indicated at this point. (Choice E) Physical restraints should be used only as a last resort in an agitated and delirious patient. They frequently increase confusion and agitation. Constant observation, preferably by someone familiar to the patient, is more helpful in such situations. Educational objective: Focused history, physical examination and basic laboratory work-up should be performed early in the initial evaluation of delirium in any patient.

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