Delirium

Naeimah & Joyce

Referral and Informants

Patientwas seen on 28th April 2015 in 7B (Medical Ward)

in Sultan Ismail Hospital
Brought in by her daughter
History was taken from:
A) The patient
B) Collateral History ( Daughter)
C) Medical Report
Demographic Details
61 years old, Indian female patient
Married with three children
Ex- kindergarten Principal (retired in 2003)
Presenting Complaint
Patients daughters word:
Looked unwell and very sick
 History of Presenting Complaint
Patient was admitted to ward 7B for right pleural effusion on the
8/4/2015

Patient been bed bond since 8/4/2015 as she has limited movement
due to leg pain due to rheumatoid arthritis.

On 18/4/2015 she was noted to have develop pressure sore over

sacral area and posterior aspect of left feet. (Grade 3 skin peeling)

On 25/4/2015, she was admitted to the ICU due to septic shock

She was transferred to the 7B ward after two days.

 Currently, she is treated as a patient with sepsis secondary
to staphylococcus species

She is also noted to have decompensated Congestive

Cardiac Failure (CCF) with cardio-renal syndrome and liver
congestion which is precipitated by sepsis

Lost appetite since admission ( vomits out the food, only

consumes takes milk)

Blood result showed that she has hyponatremia

 Other Symptoms:
Reduced ability to stay focus in an conversation
Present of sleep disturbance( only sleeps in the morning
1-2 hour)
Patient gets angry, annoyed and shouts to people
approaching her.
Need prompting to recall recent events
Confused and not orientated with place, time and
person
Symptoms fluctuates over the course of the day
Enhanced startle reaction
Past Psychiatric History

Never met with a psychiatrist before

No psychiatric illness
Past Medical History

Rheumatoid Arthritis ( 2 years ago)

Type 2 Diabetes Mellitus (5 years ago)

Colon Polys (2 years ago)

Drug History
Home Medications:
Rheumatoid Arthritis:
I. Hydrocloroquine 200mg BD(Twice daily) Currently, all medications are
stopped since antibiotic started,
II. Sulfasalazine 500mg BD previously compliance to
III. Methotrexate 25mg medication
IV. Prednisolone 7.5mg OD( Once Daily)

. Others:
. Nexium(Esomeprazole) 40mg OD
. Metformin 1g BD

Currently in Ward:
. IV Meropenem 2g since 25/4/2015 ( Antibitiotics)
Family History
Dad passed away at age of 50 due to car accident
Mom passed away at age 72 due to heart failure
No psychiatric illness runs in the family
Personal History
Spontaneous Labor, with no complication
Happy childhood
Completed her secondary level education
Married at age of 21
Worked as a kindergarten principal since 25 years old
No history of abuse of any modalities
In good relationship with the husband and children
Social History
Stays with her husband and her youngest daughter
No financial debt and she is staying in her own house
Likes to socialize with the neighbors around her housing
area

Drug and alcohol History:

o She drinks alcohol occasionally, once a month with her family
members during gathering, 1-2 glass of wine
o Never got involve with any drugs
Forensic History

Never gotten in trouble with the police and the

law
Premorbid History
Daughter described her:
Loving mother

Cheerful person

Likes children, so she takes care of babies prior admission

She is friendly with people surrounding

Mood is normal, appropriate with the situation

Mental State Examination
1. Appearance and Behaviour
Appropriate with age

In the hospital patient outfit

Looks agitated, irritable and fearful,

Scream at the nursing staff ( Can you shut up!)

Poor Eye Contact

Hard to build eye contact

2. Speech
Slow rate, low volume, was mourning couple of times
Mental State Examination (cont.)
3. Mood
Subjectively: normal
Objectively: Angry, Annoyed, Confused
Affect appropriate

4. Thought
Form- No formal thought disorder/ loosening of thought
Stream- No pressure or poverty of thought
Content- Preoccupied ideas(wants to drink water and eat
fruit)
Has delusion that her grandmother is still alive and she is
planning to visit her
Mental State Examination (cont.)
5.Perception
No hallucination of any modalities
6.Cognitive function
Does not appear alert
Disorientated to time, place and person
Unable to recall recent events ( need to be
reminded to recall)
Mental State Examination (cont.)

7. Insight
Poor insight
Summary
61 year old Indian lady patient with known case of rheumatoid arthritis,
type 2 diabetes mellitus and colon polys presented to the hospital
looking severely ill.
She also presented with:
1)Disturbance of consciousness and attention
2)Memory impairment (cant recall recent events)
3)Hyperactive symptoms with emotional disturbance
(agitated, distressed, irritable)
4)Disturbances in sleep-wake cycle( sleeps only in the morning 1-2 hours)

However, there is no hallucination of any modalities.

 Predisposing Precipitating Perpetuating Protective

Age Compliance to
Medical medications
Medical Condition Medical
Biological Condition(Diabetes
(hyponatremia) Condition
No family history
Mellitus, of mental illness
hyponatremia)

Family members
Medical Condition support
Medical
(RA) Stability of life Personality
Psychological Condition (RA)
Sleep disturbance (bed bond) (friendly person)
Education level

-Good hygiene at
home
Medical Lifestyle
Social Lifestyle disturbance
Condition(RA) disturbance
. Good support
. No drug and
alcohol abuse
Differential Diagnosis
Delirium, not induced by alcohol and other
psychoactive substances (F05)

Reduced ability to focus

Impairment of recent memory
Emotional disturbances
Reversal of sleep-wake cycle

Acute onset (Fluctuating)

Systemic infection& electrolyte abnormalities
 Confusion Assessment Method (CAM)

1. Acute onset and fluctuating course

2. Inattention
3. Disorganised thinking
4. Altered level of consciousness
Differential Diagnosis (cont.)
1) Depression in elderly
. May present with clouding of consciousness and
impaired ability to concentrate
. Medical conditions( Rheumatoid arthritis- severe pain)
. It may be hidden or denied

2) Dementia ( lewy bodies)

. Fluctuating course which may mimic delirium
Investigation
1. Septic Screen
2. Identify underlying physical cause for delirium
3. Physical Examination:
I. Full Blood Count
II. U&E
III. Liver function test
IV. Thyroid function test
V. B12+folate, CRP
4. Blood and urine cultures
5. ECG
6. X-rays
7. Full physical examination, including neurological examination
Once patient is stable:
More collateral history from relatives and carers
Full physical examination, including neurological
examination
Confusion Assessment Method (CAM)
Assess patients cognitive function
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment (MoCA)
Consider further tests:
eg. CXR, CT head scan, lumbar puncture, EEG
Management
Treat the underlying cause
Monitor clinical status regularly
Mental state
General behaviour
Pattern of sleep
Provide safe environment
Reassurance and reorientation (routine)
Educate friends and relatives
Management (cont.)
Pharmacological management as last resort:
Benzodiazepine (promote sleep)
Lorazepam

Antipsychotic drug
Haloperidol

Olanzapine
Thank You