A 75-year-old woman is evaluated for agitation and confusion while hospitalized. She was admitted 4 days ago due to fever, productive cough, and shortness of breath. The patient was diagnosed with community-acquired pneumonia and her condition has improved with antibiotics. However, for the past 2 days, she has had episodes of confusion and agitation, especially during the evening and night. The patient's medical history includes hypertension, osteoarthritis, and mild dementia. She lives with her husband at a senior living facility and is able to perform her daily activities with minimal assistance. Her temperature is 37.0 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 84/min. Pulse oximetry is 98% on room air. The patient recognizes her husband at the bedside but is not oriented to time or location. During the examination, she repeatedly tries to climb out of bed but calms when reoriented. The patient follows simple instructions and has no focal weakness or sensory loss. She has moist mucous membranes and crackles in the right upper lung. Laboratory testing shows an improving leukocytosis and normal electrolytes. Which of the following would be most helpful in managing this patient's current condition?

Question

A 75-year-old woman is evaluated for agitation and confusion while hospitalized.  She was admitted 4 days ago due to fever, productive cough, and shortness of breath.  The patient was diagnosed with community-acquired pneumonia and her condition has improved with antibiotics.  However, for the past 2 days, she has had episodes of confusion and agitation, especially during the evening and night.  The patient's medical history includes hypertension, osteoarthritis, and mild dementia.  She lives with her husband at a senior living facility and is able to perform her daily activities with minimal assistance.  Her temperature is 37.0 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 84/min.  Pulse oximetry is 98% on room air.  The patient recognizes her husband at the bedside but is not oriented to time or location.  During the examination, she repeatedly tries to climb out of bed but calms when reoriented.  The patient follows simple instructions and has no focal weakness or sensory loss.  She has moist mucous membranes and crackles in the right upper lung.  Laboratory testing shows an improving leukocytosis and normal electrolytes.  Which of the following would be most helpful in managing this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d557_7c4e_bc81_058c3528aa74_MD0003_00 This hospitalized patient with acute-onset agitation and confusion associated with disorientation and increased motor activity (eg, trying to climb out of bed frequently), especially in the evening and night, likely has delirium. This condition can be seen in any hospitalized patient but most often occurs in the elderly and those with underlying dementia or previous stroke (likely due to reduced cognitive reserves). It is thought to be related to increased oxidative stress, neuroinflammatory mediators, and impaired neurotransmitter functioning. It occurs relatively quickly (over hours to days) and manifests with vacillating severity (better in morning, worse at night) and changes in level of consciousness. Precipitating factors are listed in the accompanying table. Delirium is reversible in the majority of cases. Management includes identifying and treating the underlying inciting factor (eg, pneumonia with antibiotics) as well as introducing nonpharmacological measures such as reduction of nighttime noise and disturbances, frequent verbal orientation, reassurance, interactions with family members, or the presence of a trained sitter at the bedside. (Choices A and F) Using soft bilateral physical restraints and encouraging bed rest in an attempt to minimize falls can worsen agitation and result in impaired mobility and pressure ulcers. In general, these measures are used only when nonpharmacological measures are ineffective and patients remain a significant risk to themselves or others despite the use of medications (eg, antipsychotics). (Choice B) Benzodiazepines (eg, lorazepam) are medications with a rapid onset of action that can be used to control agitation and combative behavior. However, they can have a paradoxical effect in the elderly by causing disinhibition, thereby worsening delirium. (Choice C) Limiting a patient's interactions with family members can worsen delirium by disorienting them further. Most patients have improved outcomes by interacting with familiar people. (Choice D) Providing sensory overstimulation to keep the patient attentive can worsen agitation and lead to worsening confusion by not allowing for proper rest. Educational objective: Delirium is a reversible disorder characterized by agitation and confusion, most frequently seen in the elderly or those with underlying dementia. Determining the underlying cause, avoiding unnecessary medications, treating infections and metabolic disturbances, and encouraging regular activity during the day while minimizing disturbances at night can help patients recover more quickly. References: Interventions for preventing delirium in older people in institutional long-term care. (http://www.ncbi.nlm.nih.gov/pubmed/24488526) Synopsis of the National Institute for Health and Clinical Excellence guideline for prevention of delirium. (http://www.ncbi.nlm.nih.gov/pubmed/21646557)

A 75-Year-Old Woman Is Evaluated for Agitation and Confusion While