Delirium Case Study
Acute confusional states also known as delirium are medical emergencies associated with substantial morbidity, mortality, and healthcare burden (Bassetti, 2007). The core characteristics of delirium are acute cognitive dysfunction and inattention. Delirium can result in permanent sequelea or become chronic (Fong, Tulebaev, and Inouye, 2009). This paper will examine the case of a 64-year old lady who presents with acute confusion, disorientation, and agitation. It will identify the key information provided and other essential information that needs to be identified. It will also examine the differential diagnoses and the most probably diagnosis for the patient. It will explore the pathophysiology of the most likely diagnosis and the paramedic implications of the case.
The information known about the patient is her age, gender, presenting complaint, and past medical-surgical history. The patient is a 64-year old lady who had been found wandering in the streets by her neighbors. The neighbors had called the ambulance service because this was not her normal behavior. Her husband also reported that she had become increasingly forgetful, confused, and agitated over the preceding days. On assessment, she was found to be alert but anxious, disoriented, and confused. Her skin was pale and yellow tinged. Her sclera was also yellow tinged. She had mild non-specific tenderness of the right upper quadrant and a positive murphy’s sign. Her vital signs were as follows, BP 145/85 mmHg, HR 95bpm, and RR 24/min. Other observations were SaO2 97%, capillary refill <2 secs, and pupil size 2 EARRTL. She had a medical history of mild asthma and hypertension. She was on the following medications atenolol, enalapril, and salbutamol inhaler. She is also reported to have been taking a cleansing substance from a local neuropath over the preceding one week. She had no history of smoking and took alcohol occasionally.
The key information about the patient provided includes information about the ABCDE survey. An ABCDE survey should be conducted on all patients even if they do not seem unwell at first as it helps to identify potentially serious pathology and the deteriorating patient (Ambulance Service of New South Wales, 2011). In this case, the patient is alert and parameters for breathing (respiratory rate and arterial oxygen concentration) are normal. On circulation, the blood pressure and pulse rate are elevated. On disability, the patient is alert but confused and disoriented. The other key information available includes the onset and duration of the current symptoms that is less than a week after the patient started taking the cleansing substance. The other vital information about the patient includes her age, in-depth medication history, and findings of the physical assessment. The other essential information that should be sought includes the time the patient last had a meal. A random blood sugar needs also to be done as hypoglycemia can cause acute confusion (Australian Government Department of Health and Aging, 2010). It is also important to establish the doses of enalapril and atenolol the patient is currently taking and whether she administers the medications by herself to rule out the possibility of drug overdose. Enalapril has been shown to cause cholestatic liver injury which can present with jaundice and a positive murphy’s sign (Waldmann, Soni, and Rhodes, 2008). Atenolol, on the other hand, can cause neuropsychiatric symptoms (Jain, 2012).
The patient has acute confusion and disorientation. The possible differential diagnoses for this patient include dementia, psychosis, and delirium (Gleason, 2003). The most probable diagnosis of this patient is delirium because of the acute onset of changes in cognition, signs suggestive of an underlying medical condition, and the lack of a prior history of mental illness. The pathophysiology of delirium is not fully elucidated. It is, however, thought that it can arise due to an array of different pathogenic mechanisms. The existing evidence suggests that inflammation, drug-toxicity, and acute stress response can all disrupt neurotransmission significantly and ultimately cause delirium. The delirium the patient is suffering from is most likely due to drug-induced hepatic inflammation due to the presence of right upper quadrant tenderness and a positive Murphy’s sign. It is possible that the cleansing substance that the patient has been taking caused hepatic injury and inflammation (acute viral hepatitis). Accumulating experimental and clinical evidence suggests that surgery, infection, and trauma can trigger increased production of pro-inflammatory cytokines that can induce delirium in susceptible individuals. Cytokines secreted peripherally can induce exaggerated responses from the microglia and in effect cause severe brain inflammation. Proinflammatory cytokines can significantly disrupt the synthesis/ release of dopamine, acetylcholine, 5-HT, and norepinephrine and in effect disrupt neuronal communication. They can also have a direct neurotoxic effect. Notably, it has been shown that proinflammatory cytokine levels are elevated in patients with delirium (Fong, Tulebaev, and Inouye, 2009). In addition, atenolol, one the drugs the patient has been taking is extensively metabolized by the liver. Therefore, hepatic injury may have reduced the amount of atenolol metabolized by the liver and in effect, increased the concentrations of atenolol in plasma. It has been shown that atenolol can cause neuropsychiatric symptoms (Jain, 2012).
The paramedic implications for this case study are far-reaching. The preceding discussion has demonstrated that acute confusional states can be due to psychiatric and non-psychiatric causes. Delirium is an emergency that is frequently associated with significant mortality and morbidity. Therefore, it is important for paramedics to utilize the ABCDE algorithm in their initial assessment of all patients so as to identify the deteriorating patient. It is also vital for paramedics to take a thorough history for all patients presenting with delirium so as to facilitate accurate identification of underlying causes and timely and appropriate management of patients presenting with delirium. In particular, patients with acute onset of delirium should be transferred to hospitals as soon as possible for further evaluation and management. Some causes of delirium such as hypotension, hypoxia, and hypoglycemia can be corrected en-route to the hospital. It is also essential for paramedics to be aware of the various underlying causes of delirium.
In summary, this paper has examined the case study of a 64 year old female patient who presented with delirium of acute onset. It has identified the key information provided about the patient such as her age, findings of vital signs and physical examination, presenting complaint and history of onset of symptoms, current medication history, and past medical history. It has also found that other essential information such as patient’s random blood sugar needs to be obtained as aids to diagnosis. The most likely diagnosis in this patient is drug-induced delirium. It is possible that the cleansing substance the patient had been taking caused hepatic inflammation. The proinflammatory cytokines produced by the liver caused brain inflammation and disrupted production of neurotransmitters and in effect, affected neurotransmission. Reduced metabolism of atenolol may have exacerbated the neuropsychiatric symptoms. The case study has significant implications on paramedic practice especially on pre-hospital assessment and management of the patient with delirium.
Reference List
Ambulance Service of New South wales, 2011. Protocols and pharmacology. [Online] Available at: < http://libweb.anglia.ac.uk/referencing/harvard.htm> [Accessed 14 October 2016].
Australian Government Department of Health, 2010. Delirium care pathways. Melbourne: Commonwealth of Australia.
Bassetti, C.L., 2007. Differential diagnosis and management of non-psychiatric acute confusional states. Schweizer Archiv Fur Neurologie Und Psychiatrie, 158(8), pp. 368-379.
Fong, T. J., Tulebaev, S. R., and Inouye, S. K., 2009. Delirium in elderly adults: Diagnosis, prevention, and treatment. Nat Rev Neurol., 5(4), pp. 210-220.
Gleason, O. C., 2003. Delirium. American Family Physician, 67(5), 1027-1035.
Jain, K. K., 2012. Drug-induced neurological disorders. 3rd ed. Abingdon: Hogrefe Publishing.
Waldmann, C., Soni, N., and Rhodes, A., 2008. Oxford desk reference: Critical care. New York: Oxford University press.
