Self-assessment Cases

Chapter 14 Understanding delirium and confusion

George, a 76-year-old male, retired carpenter, lived with Dorothy, his 73-year-old wife, in a suburban bungalow. He was ambulatory and independent in activities of daily living prior to his cancer diagnosis. His past medical history was unremarkable. Dorothy had multiple health problems, including congestive heart failure, hypertension and diabetes, though she too was ambulant and functionally independent at that time. They had a son living about a mile away and a daughter who lived 30 miles away.

Cancer diagnosis
Ten months ago, George was diagnosed with non–small-cell lung cancer. Initially, his imaging results were consistent with disease localised to one lung and hilar nodal involvement. He received an initial combination of chemotherapy and radiotherapy. Despite an initial response to these treatments, as based on re-imaging 4 months later, he subsequently developed progressive weakness and fatigue, and his chemotherapy was discontinued 3 months ago.

First presentation with symptoms of delirium
George developed his first episode of delirium 2 months ago. He was brought to the hospital emergency department with acute onset cognitive impairment, behavioural disturbance and two episodes of nearly falling in the preceding 48 hours. A collateral history from Dorothy revealed that he tended to drift off to sleep in the middle of conversation. He was found to be sleepy during the daytime but restless and awake for most of the night, and at times he appeared to be hallucinating. He was noted to be making the motions of someone hammering a nail. There was also some suggestion that he had upper abdominal pain, but this was very difficult to clarify, as his complaints were vague. He also developed more rapid breathing and appeared to develop respiratory distress in the 2 days prior to his presentation at the emergency department of the hospital.

Delirium diagnosis
The initial clinical examination of George involved a Confusion Assessment Method (CAM) assessment. He was asked to count from 20 to 1 backwards and to name the months of the year backwards. He made multiple errors on both of these tests. He was found to have a positive CAM, based on meeting all the four CAM criteria: (1) acute onset and fluctuating course, (2) inattention, (3) disorganised thinking and (4) altered level of consciousness. Mixed hypo- and hyperactive delirium was diagnosed.

Decision making and clarifying the goals of care
A decision was made to admit George to hospital as an inpatient. A discussion took place between the family and a physician from the admitting medical team. The nature of delirium was explained to the family. Initially, the family questioned the burden and benefit of further investigations when clearly George had got much weaker and appeared to be very much reaching the end of his life. However, George’s daughter was pregnant and her expected date of delivery was in 2 weeks. George had been very excited about this and was very much looking forward to seeing his first grandson or granddaughter. The consensus reached with the family was to investigate the delirium and treat any potentially reversible causes.

Investigations and treatment in hospital
Laboratory investigations revealed hypercalcaemia and chest imaging revealed consolidation, consistent with pneumonia in his left lower lobe. George received intravenous fluid and antibiotics and an infusion of pamidronate, a bisphosphonate to treat his hypercalcaemia. He also was given haloperidol 0.5 mg twice daily and hourly as needed, to symptomatically treat his delirium. Nursing staff monitored his level of distress and provided consistent on-going support for his family. George’s delirium mostly reversed over the course of about 3 days. Unfortunately, further imaging revealed both hepatic and adrenal metastases. There were no brain metastases. His functional performance status had by now deteriorated to the point that he was confined to bed or chair for more than 50% of waking hours. He was discharged home with support from his general practitioner (GP) and the community palliative care (PC) services.

Immediate course post discharge from hospital
Although he had even further worsening of his fatigue and very mild intermittent cognitive deficits, he was alive and very much able to appreciate the arrival of his first grandson about 2 weeks following his discharge from the hospital. This made him very proud and happy, and he felt that he had reached his goal.

Second and final presentation with full-blown delirium
George managed to remain at home for 4 weeks before he developed a further delirium. About 10 days after the birth of his grandson, he developed increasing abdominal pain and symptoms similar to the first episode of delirium, except that his agitation was much more pronounced on this occasion. He was paranoid, thinking that his family were trying to poison him, and at times refused extra rescue analgesia, despite appearing to be in pain. Based on his care needs, family exhaustion, a perception of inadequate pain control, and on the advice of his GP and the community PC services, he was admitted to a local hospice for in-patient care. Consistent with both his and his family’s wishes, and following discussion with the family, the consensus on this occasion was not to do further laboratory investigations but to simply treat his symptoms. He received parenteral opioid for his pain and midazolam to control his agitation, and he died peacefully a week later.

• 1. During George’s first episode of delirium, what aspects of his history are helpful in determining whether he meets the third criterion of the CAM, disorganized thinking?

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  Correct answer:
  George was noted to be hallucinating by his wife, including making the motion of hammering a nail. Asking George about his pain also allows you to assess whether George’s thinking is disorganized or incoherent. You could also observe for rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject.

• 2. Which causes of George’s first episode of delirium are reversible? Are there possible irreversible causes contributing to his first episode of delirium?

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  Correct answer:
  Hypercalcemia and pneumonia are two reversible causes of George’s first episode of delirium. It is possible that hepatic dysfunction (caused by hepatic metastases) is contributing to George’s first episode of delirium. This is an irreversible cause of delirium and could explain why George’s delirium did not fully resolve.

• 3. What non-pharmacological treatments for George’s episodes of delirium would you consider?

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  Correct answer:
  Encouraging George’s family to visit and sit with him would help reduce his distress. Placing George in a room close to the nursing station would allow for close monitoring of his symptoms as well as frequent reassurance. Other strategies for general medical patients include providing vision and hearing aids, ensuring there is a clock and calendar in the patient’s room and avoiding physical restraints.

• 4. If George had developed side effects to haloperidol during his first delirium episode, what other pharmacological treatments could have been considered for his symptoms of delirium?

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  Correct answer:
  Atypical antipsychotics, such as olanzapine or risperidone, could have been considered, if George was able to swallow. Methotrimeprazine could have been considered if George was unable to swallow and required an antipsychotic to be administered by injection. Benzodiazepines would only be considered if there was a history of alcohol withdrawal or deeper sedation was required and antipsychotics were ineffective.

• 5. Why is it important to educate George’s family about delirium? How would you do this?

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  Correct answer:
  Educating family or caregivers about delirium can be helpful in alleviating the high emotional distress that families report when a loved one experiences delirium. You could counsel George’s family regarding the cause, likelihood of reversal and treatment of delirium, as well as the potential for misinterpreting symptoms (e.g. restlessness as pain). You could also provide advice on how to reassure George if he appears distressed (e.g. using a soft voice, reminding the patient you are sitting with them and will help take care of them).