A 72-year-old retired man with end-stage renal disease becomes agitated during dialysis and attempts to abruptly leave in the middle of the procedure. The patient accuses the staff of violating his rights and stealing his belongings but then appears to fall asleep. Fifteen minutes later, he becomes violent and requires restraints. Medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease. The patient has a history of major depression that has been in remission for 15 years. His wife says that he has experienced mild memory and word-finding difficulties over the last year and that he often needs to make lists to remind himself of errands; however, she has never witnessed this type of agitated behavior. Temperature is 38.3 C (100.9 F), blood pressure is 112/63 mm Hg, pulse is 93/min, and respirations are 18/min. The patient has a left carotid bruit, and a dialysis catheter is present in the right internal jugular vein. Bronchial breath sounds are heard at the right lung base. During neurologic evaluation, he is confused but cooperative with no focal findings. Which of the following is the most likely explanation for this patient's current behavior?

Question

A 72-year-old retired man with end-stage renal disease becomes agitated during dialysis and attempts to abruptly leave in the middle of the procedure.  The patient accuses the staff of violating his rights and stealing his belongings but then appears to fall asleep.  Fifteen minutes later, he becomes violent and requires restraints.  Medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease.  The patient has a history of major depression that has been in remission for 15 years.  His wife says that he has experienced mild memory and word-finding difficulties over the last year and that he often needs to make lists to remind himself of errands; however, she has never witnessed this type of agitated behavior.  Temperature is 38.3 C (100.9 F), blood pressure is 112/63 mm Hg, pulse is 93/min, and respirations are 18/min.  The patient has a left carotid bruit, and a dialysis catheter is present in the right internal jugular vein.  Bronchial breath sounds are heard at the right lung base.  During neurologic evaluation, he is confused but cooperative with no focal findings.  Which of the following is the most likely explanation for this patient's current behavior?

Quizplus · Accepted Answer

11ec160b_3614_8aec_9249_8d65639c751a_MD0001_00 This acute onset of mental status change is most suggestive of delirium. Delirium is a reversible, acute confusional state involving a reduced or fluctuating level of consciousness (eg, somnolent to combative within a short time); there are difficulties sustaining attention and significantly impaired memory and executive function. It is most commonly seen in elderly patients with medical illness and is often associated with anxiety, agitation, delusions, and/or hallucinations. Patients of advanced age and with neurologic conditions such as Parkinson disease, dementia, and prior stroke are more likely to develop delirium due to reduced cognitive reserve. The presence of delirium in this patient indicates an unstable underlying medical condition that must be identified and treated. The patient's elevated temperature and bronchial breath sounds are likely due to an underlying pulmonary infection. Once the underlying medical condition is effectively treated, the delirium should resolve. (Choices A, E, and F) In contrast to delirium, the dementia in Alzheimer disease, frontotemporal dementia, and vascular dementia is gradual in onset and progressive without much fluctuation. In Alzheimer disease, attention and remote memory are spared initially, and there is no impairment of consciousness until late in the disease. Frontotemporal dementia presents with early behavior change (eg, disinhibition, apathy), followed later by memory impairments. Vascular dementia involves a stepwise decline typically associated with focal neurologic signs and does not impair consciousness in the early stages. Although this patient's mild cognitive impairments over the past year may gradually progress to dementia, they would not explain his acute confusional state, which is a rapid change from his baseline. (Choice B) Brief psychotic disorder is characterized by the sudden onset of psychotic symptoms lasting ≥1 day but <1 month that is not better explained by another medical condition. In contrast to patients with delirium, those with psychotic disorders are typically alert and oriented. (Choice D) Major depression can sometimes be accompanied by delusions or hallucinations (eg, voices telling patients they are worthless). The absence of current depressive symptoms, acute onset, and fluctuating level of consciousness make this diagnosis unlikely. Educational objective: Delirium is a reversible, acute-onset confusional state characterized by a fluctuating level of consciousness with deficits in attention, memory, and executive function. In contrast, dementia has a gradual onset, is irreversible, and does not involve fluctuations in consciousness. __________ References: Geriatric psychiatry review: differential diagnosis and treatment of the 3 D's - delirium, dementia, and depression. (http://www.ncbi.nlm.nih.gov/pubmed/23636988) Delirium in older persons: advances in diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28973626)

A 72-Year-Old Retired Man with End-Stage Renal Disease Becomes Agitated