An 82-year-old woman is brought to the emergency department with high-grade fever. She resides at a local nursing home. The nursing home staff reports that in the past few days she has been quieter than usual but is otherwise at her baseline mental status. In the hospital, the patient is calm and cooperative and says that she feels "tired." Medical history includes diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, and severe, deforming rheumatoid arthritis. Her history is also significant for severe alcohol use disorder, which is in remission. The patient's medications include aspirin, insulin, albuterol inhaler, levothyroxine, warfarin, and low-dose prednisone. Temperature is 38.9 C (102 F), blood pressure is 126/84 mm Hg, pulse is 92/min, and respirations are 20/min. Oxygen saturation is 96% on 3 L of oxygen. The patient is awake and alert but subdued and minimally conversant. The mucous membranes are extremely dry. The rest of the physical examination is unremarkable. Initial laboratory results are as follows: Other laboratory results are within normal limits. The patient is admitted to the hospital, and intravenous fluids and antibiotic therapy are administered. During the night, she becomes very restless, confused, and agitated. She pulls out her intravenous line, causing significant bleeding. When the staff arrives, she insists that one of the nurses is her mother, attempts to leave the bed, and pushes an aide aside. Which of the following is the most appropriate course of action?

Question

An 82-year-old woman is brought to the emergency department with high-grade fever.  She resides at a local nursing home.  The nursing home staff reports that in the past few days she has been quieter than usual but is otherwise at her baseline mental status.  In the hospital, the patient is calm and cooperative and says that she feels "tired."  Medical history includes diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, and severe, deforming rheumatoid arthritis.  Her history is also significant for severe alcohol use disorder, which is in remission.  The patient's medications include aspirin, insulin, albuterol inhaler, levothyroxine, warfarin, and low-dose prednisone.  Temperature is 38.9 C (102 F), blood pressure is 126/84 mm Hg, pulse is 92/min, and respirations are 20/min.  Oxygen saturation is 96% on 3 L of oxygen.  The patient is awake and alert but subdued and minimally conversant.  The mucous membranes are extremely dry.  The rest of the physical examination is unremarkable.  Initial laboratory results are as follows:  Other laboratory results are within normal limits.  The patient is admitted to the hospital, and intravenous fluids and antibiotic therapy are administered.  During the night, she becomes very restless, confused, and agitated.  She pulls out her intravenous line, causing significant bleeding.  When the staff arrives, she insists that one of the nurses is her mother, attempts to leave the bed, and pushes an aide aside.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: This patient's acute-onset mental status change is most suggestive of delirium, a reversible, acute confusional state that involves a reduced/fluctuating level of consciousness and attention with difficulties in memory and thought processes. It is most common in older patients and/or in those with diminished cognitive reserve and may manifest with anxiety, physical/verbal agitation, delusions, and/or hallucinations. This patient most likely had a quiet/hypoactive delirium, which then developed into an agitated state. The presence of delirium indicates an underlying medical condition that must be immediately identified and treated (a probable urinary tract infection in this case). Mild confusion and agitation can be managed with environmental interventions (eg, reassurance, frequent reorientation, a sitter). However, when severe agitation poses a safety risk to the patient and staff (eg, pulling IV lines, hitting, falling, wandering off), low-dose antipsychotics (eg haloperidol) are appropriate for controlling agitation, preventing harm, and allowing the continuation of safe treatment. Judicious, short-term use of antipsychotics reduces the risk of harm to the patient and others, which outweighs the potential increased risk of adverse effects from the medications. (Choices A and C) Benzodiazepines (eg, chlordiazepoxide, lorazepam) may cause disinhibition and worsen delirium, particularly in older adults. They are appropriate only when delirium is due to alcohol withdrawal. However, withdrawal is unlikely as this patient's alcohol use disorder is in remission. (Choice D) Physical restraints are generally used as a last resort when the patient's safety is in immediate jeopardy. Risks of physical restraints include increased agitation, prolonged delirium, reduced mobility, and aspiration. Using them without haloperidol in this patient would likely prolong the amount of time that restraints are needed. (Choice E) Frequent reorientation is helpful in cases of mild delirium but is unlikely to manage this patient's severe agitation. Patients with delirium typically have no insight, and challenging hallucinations may lead to further agitation, so it should be avoided. Educational objective: Delirium is a manifestation of an underlying medical condition and is characterized by acute-onset confusion, inattention, and disturbances in level of consciousness. It may manifest with psychotic symptoms and/or behavioral agitation. Low-dose antipsychotics are appropriate when severe agitation or psychotic symptoms place the patient or staff at risk for harm. References: Clinical review: agitation and delirium in the critically ill--significance and management. (http://www.ncbi.nlm.nih.gov/pubmed/17521456)

An 82-Year-Old Woman Is Brought to the Emergency Department with High-Grade