Case Study: Acute confusion

Presenting Complaint:

• Patient: David, a 82-year-old male, presented to the emergency department with sudden-onset confusion and agitation, reported by his daughter over the last 24 hours.

  
  

History of Presenting Complaint:

• David’s daughter reports that he has become increasingly confused, disoriented, and agitated over the past day. He has difficulty recognizing familiar people, is unable to recall recent events, and has been repeatedly asking the same questions.

• He appears restless and has been wandering around the house aimlessly. He also has episodes of hallucinations, seeing "people in the room" who are not there.

• There is no history of head trauma, recent falls, or seizures. He has not had a similar episode in the past.

• David has been complaining of generalized weakness and reduced appetite over the past few days, but no other specific symptoms such as chest pain, shortness of breath, or abdominal pain.

• His daughter also noticed a decrease in his urine output and a strong smell of urine.

Past Medical History:

• Hypertension (diagnosed 10 years ago)

• Chronic Kidney Disease (Stage 3)

• Type 2 Diabetes Mellitus (diagnosed 15 years ago)

• Osteoarthritis

• Benign Prostatic Hyperplasia (BPH)

• No known history of dementia or psychiatric illness

Medication History:

Allergies:

• No known drug allergies (NKDA).

Family History:

• Father died at age 70 due to a stroke.

• Mother had type 2 diabetes and hypertension.

• No family history of dementia or psychiatric conditions.

Social History:

• David is a retired teacher and lives alone. His daughter visits him regularly.

• He is a non-smoker and does not consume alcohol.

• He is independent in daily activities but requires assistance for shopping and transportation.

• No recent travel or exposure to infectious diseases.

Systemic Review:

• Neurological: Confusion, disorientation, visual hallucinations; no history of seizures or head trauma.

• Cardiovascular: No chest pain, palpitations, or syncope.

• Respiratory: No cough, shortness of breath, or recent respiratory infections.

• Gastrointestinal: Reduced appetite, no abdominal pain, nausea, or vomiting. No recent changes in bowel habits.

• Genitourinary: Decreased urine output, malodorous urine. No dysuria or hematuria reported.

• Musculoskeletal: Generalized weakness but no recent falls, joint pain, or swelling.

Physical Examination:

• General: Elderly male, appears agitated and confused, restless, and intermittently shouting.

• Vital Signs:

  • Temperature: 37.8°C

  • Blood Pressure: 150/85 mmHg

  • Heart Rate: 95 bpm, regular

  • Respiratory Rate: 20 breaths per minute

  • Oxygen Saturation: 96% on room air

• Neurological:

  • Confused and disoriented to time, place, and person.

  • No focal neurological deficits (strength 5/5 in all limbs, normal reflexes, no cranial nerve deficits).

  • Unable to complete cognitive assessment due to agitation.

• Cardiovascular:

  • Normal heart sounds (S1 and S2), no murmurs.

• Respiratory:

  • Clear lung fields on auscultation.

• Abdominal:

  • Soft, non-tender, no palpable masses.

  • Bladder is not palpable, no suprapubic tenderness.

• Genitourinary:

  • No external signs of infection or trauma.

• Musculoskeletal: No obvious deformities or signs of injury.

Summary of Patient's Problems:

• Acute confusion, agitation, and disorientation.

• History of hypertension, chronic kidney disease, diabetes, and benign prostatic hyperplasia.

• Possible urinary symptoms with decreased output and malodorous urine.

Questions:

1. What are the main differential diagnoses for this patient’s symptoms?

2. What initial investigations would you perform to confirm the diagnosis and identify any underlying causes?

3. What is your immediate management plan for this patient?

Differential Diagnosis:

Based on David’s clinical presentation and history, the primary differential diagnoses include:

1. Delirium (Acute Confusional State):

   • The most likely diagnosis given the sudden onset, fluctuating course, and presence of inattention and disorientation. Potential underlying causes could be infection (e.g., urinary tract infection), electrolyte imbalance, medication side effects, or metabolic disturbances.

2. Urinary Tract Infection (UTI):

   • Likely cause of delirium in an elderly male, especially with symptoms of decreased urine output and malodorous urine.

3. Electrolyte Imbalance:

   • Conditions like hypernatremia, hyponatremia, hypercalcemia, or hypoglycemia could cause confusion and agitation, particularly in a patient with chronic kidney disease and diabetes.

4. Hypoglycemia:

   • Diabetes patients are at risk for hypoglycemia, which can present with confusion, agitation, and altered mental status.

5. Stroke or Transient Ischemic Attack (TIA):

   • Possible, though less likely without focal neurological deficits. Should still be considered given the patient’s history of hypertension and risk factors for cardiovascular disease.

6. Medication Side Effects or Toxicity:

   • Some medications, such as antihypertensives (like amlodipine) or those affecting renal function (like lisinopril in CKD), could potentially contribute to confusion. Polypharmacy in the elderly also increases the risk of adverse effects.

7. Dehydration:

   • Could cause delirium, particularly in an elderly patient with decreased oral intake and potential diuretic effect from medications.

8. Dementia:

   • While dementia is unlikely to present with such a sudden onset, pre-existing undiagnosed dementia could be exacerbated by acute illness.

Initial Investigations:

1. Blood Tests:

   • Complete Blood Count (CBC): To check for infection or anemia.

   • Urea and Electrolytes (U&E): To assess renal function and electrolyte levels, particularly sodium, potassium, and calcium.

   • Blood Glucose: To rule out hypoglycemia or hyperglycemia.

   • Liver Function Tests (LFTs): To assess for hepatic encephalopathy.

   • Thyroid Function Tests (TFTs): To rule out thyroid dysfunction as a cause of confusion.

   • C-reactive Protein (CRP): To assess for infection or inflammation.

2. Urine Analysis:

   • Urinalysis and Urine Culture: To check for evidence of a urinary tract infection or other abnormalities (e.g., blood, protein, glucose).

3. ECG:

   • To assess for any cardiac arrhythmias or evidence of ischemia that could contribute to confusion.

4. Imaging:

   • Chest X-ray: To rule out pneumonia or other causes of hypoxia that could contribute to confusion.

   • CT Brain (if indicated): Consider if there are any focal neurological signs or if stroke/TIA is suspected.

5. Cognitive Assessment:

   • Confusion Assessment Method (CAM): To confirm delirium and assess the severity of cognitive impairment.

Management Plan:

1. Immediate Management:

   • Ensure Patient Safety: Provide a calm, well-lit environment to reduce agitation. Consider a sitter or family member at the bedside to prevent falls or wandering.

   • Hydration and Nutrition: Administer IV fluids (e.g., normal saline) if dehydration is suspected and encourage oral intake.

   • Treat Underlying Causes:

     • Start empirical antibiotics (e.g., Ceftriaxone) if there is suspicion of a UTI, pending culture results.

     • Correct any identified electrolyte imbalances.

     • If hypoglycemia is detected, administer IV glucose.

   • Review Medications: Discontinue any non-essential medications that could contribute to delirium (e.g., sedatives, antihistamines).

2. Symptomatic Management:

   • Agitation Management: Consider low-dose antipsychotics (e.g., Haloperidol) if non-pharmacological measures are ineffective and the patient poses a risk to themselves or others.

   • Monitor Vital Signs and Neurological Status: Regular monitoring to detect any deterioration or improvement.

3. Further Management:

   • Referral to Specialists: Consult a geriatrician for further evaluation if delirium persists.

   • Cognitive Rehabilitation: Involve occupational therapy for cognitive rehabilitation if the patient stabilizes.

4. Long-Term Management:

   • Address Contributing Factors: Optimize the management of hypertension, diabetes, and CKD.

   • Lifestyle Modifications: Encourage a healthy diet, physical activity, and social engagement.

   • Home Safety Evaluation: Assess home environment safety if discharge is considered.

5. Follow-Up Plan:

   • Regular follow-up to reassess cognitive function, monitor treatment efficacy, and review medication use.

   • Support for the family and caregivers, providing education on delirium and strategies for managing at home.

Results of Investigations:

• CBC: Elevated white blood cell count (WBC 13,000/mcL) suggesting infection.

• Urea and Electrolytes: Sodium 128 mmol/L (low), Potassium 4.5 mmol/L, Urea 15 mmol/L, Creatinine 1.8 mg/dL (elevated, consistent with CKD).

• Blood Glucose: Normal at 105 mg/dL.

• Urinalysis: Positive for nitrites, leukocyte esterase, and bacteria; urine culture pending.

• ECG: Normal sinus rhythm.

• Chest X-ray: Clear lung fields, no consolidation.

• CT Brain: No acute ischemic changes or hemorrhage.

Diagnosis:

• Delirium secondary to Urinary Tract Infection with possible contributing factors, including hyponatremia and CKD.

Further Management Plan:

• Continue Antibiotics: Continue antibiotics according to culture sensitivity.

• Monitor Electrolytes: Correct hyponatremia slowly to avoid complications.

• Rehydrate: Continue IV fluids to address dehydration and support renal function.

• Monitor Cognitive Status: Regular cognitive assessment to track improvement with treatment.

*All cases are fictional and any resemblance to real life is coincidental