A 78-year-old woman is brought to the emergency department due to insomnia and frequent episodes of agitation over the past 2 days. The patient was confused yet calm on arrival; but now she is yelling loudly and trying to pull out her intravenous lines, take off her clothes, and run away while being examined. She is a nursing home resident. Her recent medical history includes severe memory loss. The patient's chronic medical issues include hypertension, type 2 diabetes mellitus, peptic ulcer disease, and chronic pyelonephritis. Her temperature is 37.2 C (99 F), blood pressure is 162/96 mm Hg, and pulse is 95/min and regular. Pulse oximetry shows 96% oxygen saturation on room air. ECG shows normal sinus rhythm, left ventricular hypertrophy, a normal QTc interval, and no acute ischemic changes. Laboratory studies are as follows: Urinalysis shows trace protein, numerous leukocytes, and occasional erythrocytes. Which of the following is the best initial treatment for this patient?

Question

A 78-year-old woman is brought to the emergency department due to insomnia and frequent episodes of agitation over the past 2 days.  The patient was confused yet calm on arrival; but now she is yelling loudly and trying to pull out her intravenous lines, take off her clothes, and run away while being examined.  She is a nursing home resident.  Her recent medical history includes severe memory loss.  The patient's chronic medical issues include hypertension, type 2 diabetes mellitus, peptic ulcer disease, and chronic pyelonephritis.  Her temperature is 37.2 C (99 F), blood pressure is 162/96 mm Hg, and pulse is 95/min and regular.  Pulse oximetry shows 96% oxygen saturation on room air.  ECG shows normal sinus rhythm, left ventricular hypertrophy, a normal QTc interval, and no acute ischemic changes.  Laboratory studies are as follows:  Urinalysis shows trace protein, numerous leukocytes, and occasional erythrocytes.  Which of the following is the best initial treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d1bb_b834_bc81_b97e4cf1f015_MD0003_00 Delirium (waxing and waning alteration in consciousness) in hospitalized patients is usually due to toxic- metabolic or infectious etiologies. Advanced age and dementia are also important risk factors. A workup for the cause of delirium (review of medication list, blood work, urinalysis, possible imaging) is needed (Table). If an infection is identified, treatment should be initiated as soon as possible. In this patient with underlying dementia, delirium may be due to a urinary tract infection given the pyuria seen on urinalysis. Regardless of the etiology of her dementia and delirium, this patient has severe agitation, which may compromise her safety and interfere with medical management (eg, difficulty with intravenous fluid or antibiotic administration, radiologic testing). In such cases, low-dose haloperidol can be considered. Atypical antipsychotics (quetiapine, risperidone) may also be used. Usage should be limited to the shortest possible duration, as prolonged use of antipsychotics can increase mortality in the elderly. Typical antipsychotics should not be used in patients with Lewy body dementia, who may exhibit neuroleptic hypersensitivity (severe parkinsonism and impaired consciousness with neuroleptic administration). (Choice A) Amitriptyline is a tricyclic antidepressant used to treat depression, sleep disorders, and neuropathic pain. It has significant anticholinergic side effects. For this reason, amitriptyline usage for elderly patients is generally discouraged, especially for those with underlying dementia. (Choice B) Clopidogrel is sometimes used in the management of acute coronary syndrome and ischemic stroke. It plays no role in treating agitation/delirium. (Choice D) Lorazepam and other benzodiazepines may be used to treat agitation in young patients. However, they are typically contraindicated in older patients, who are at increased risk for adverse events (eg, withdrawal, dependence, motor impairment), may experience worsening agitation (paradoxic effect), and tend to metabolize benzodiazepines slowly, making their effects very long-lasting. (Choice E) Memantine is an agent used to treat moderate to severe Alzheimer disease. It works by blocking the action of glutamate on the N-methyl-D-aspartate (NMDA) receptor. Memantine may improve the cognitive symptoms associated with this patient's dementia, but it will not help her acute agitation. Educational objective: Toxic-metabolic and infectious etiologies are the most common causes of delirium in a hospitalized patient. Patients with dementia have an increased risk of developing agitated delirium in the hospital. Typical and atypical antipsychotics are useful for treating acute agitation in elderly patients with dementia. Benzodiazepines are typically not recommended in this setting. References: Prevention of delirium in demented hospitalized patients. (http://www.ncbi.nlm.nih.gov/pubmed/22284240)

A 78-Year-Old Woman Is Brought to the Emergency Department Due