Delirium

“Mr. A” is a 79-year-old man with type 2 diabetes, hypertension, and hyperlipidemia who was brought to the emergency department for confusion. His home health aide reports that Mr. A has increasingly been refusing his medications lately and has also refused to see his primary care physician for a nonhealing leg wound. On arrival at the emergency department, Mr. A has a temperature of 101.5°F, pulse of 126 bpm, respirations of 22 breaths per minute, and blood pressure of 79/52. Initial laboratory tests demonstrate leukocytosis (WBC 14.6), prerenal azotemia (creatinine, 2.1 mmol/L; blood urea nitrogen, 54 mg/dL), and a lactate level of 4.3 mmol/L. The patient's hemoglobin A1C is 9.6%. Blood cultures show methicillinresistant Staphylococcus aureus in 4/4 bottles. On physical examination, the patient is tachycardic and tachypneic; abdominal examination is benign. Skin examination demonstrates bilateral venous stasis changes, with a large, shallow ulcer along the left tibia with dusky borders and central eschar. Mental status examination reveals a disoriented, inattentive, disheveled elderly male who is picking at his hospital gown and calling out to his wife, who is deceased. He is diagnosed with sepsis and admitted to the medicine service for further workup and treatment. A psychiatric consultation is obtained to assess the patient's mental status and assist with management of agitation. Mr. A remained on the medical service for 6 days, during which time his sepsis was treated with intravenous antibiotics and his leg ulcer debrided and dressed. His renal function recovered with adequate hydration, and his vital signs rapidly renormalized. To address Mr. A's delirium, his nurses provided frequent reorientation regarding the date and situation and ensured that he received plenty of light exposure during the daytime while preserving a quiet, dark, minimally disturbed environment overnight. A medication reconciliation demonstrated a previous outdated prescription for meclizine for vertigo, which was discontinued given its strong anticholinergic activity and absence of active dizziness. Mr. A's home health aide brought in the patient's glasses, hearing aids, and dentures for his use in the hospital. The physical therapy department worked with the patient beginning on the second day of his admission and found him increasingly able to participate in active mobilization as his medical problems and mental status improved. The patient had orders for standing melatonin, 3 mg h.s., as well as quetiapine, 12.5 mg b.i.d. p.r.n., and he required two evening as-needed doses of quetiapine. Both medications were fully discontinued before discharge. Mr. A was discharged to acute rehabilitation before returning home. At an outpatient follow-up appointment 6 months later, his home health aide remarked that the patient was now more forgetful and appeared cognitively slower than he had been before the infection, and that he now required around-the-clock assistance with activities of daily living. © 2019 American Psychiatric Association. All rights reserved.