History
You visit a 67-year-old man at home who is reported as being confused. His wife is distressed because he repeatedly asks her to swat the flies from the ceiling, when she can see nothing there. He has been in bed for 3 days with a ‘cold’. He frequently gets up and wanders around without knowing where he is going. His wife says on one occasion he burst out laughing without any reason that she could discern. At other times he seems bewildered. She describes that he becomes more confused in the evening and at night, and has urinated in the cupboard. He has no diarrhoea. A week ago he was well and able to do gardening. He has not been confused until recently. On questioning his wife says that while he occasionally forgets the names of village acquaintances, his memory has otherwise been fine. He is not a large user of alcohol and only drinks a small bottle of beer or a sherry once per week. His wife has remained well throughout.
Mental state examination
When you visit he is lying in bed. He is initially suspicious of you and asks if you are an undertaker. He is preoccupied with stripes on the wallpaper and asks his wife several times to get some towels to mop up the water running down the wall. He makes poor eye contact. He is slightly restless in bed and looks dishevelled. There is a strong body odour. He looks perplexed and frightened. He does not appear to be responding to voices, and his wife says he hasn’t mentioned this. He is not able to answer questions about passivity experiences. With respect to delusions his wife says that he thought that she was going to stab him when she was trying to spoon feed him some soup the previous night. He pushed her away but has not hit her. He is unable to say what day of the week it is or what time of day. He names the previous prime minister as the current one, and cannot repeat back an address that you give him to remember. He thinks he is in hospital. You need to repeat questions as he seems preoccupied with his own thoughts or things that he is seeing.
Physical examination
There are no abdominal signs and the cardiovascular system seems normal with good peripheral pulses. His heart rate is 96/min and his blood pressure is 110/68 mmHg. His temperature is normal. He has poor air entry and crackles over the right side of the lower lung, and he has bronchial breathing and dulled percussion in the same area. He has an increased respiratory rate.
ANSWER 64
He is disorientated in time and place and has clouding of consciousness. It is likely that he has delirium. This can be caused by anything that disturbs the functioning of the brain. This usually involves interference with the metabolism, perfusion or oxygenation of the brain. More specifically it will be important to rule out malnutrition, dehydration, drug intoxication or withdrawal states, poisoning, infections (urinary tract infection, septicaemia, chest infection etc.), sleep deprivation and head injury. Sometimes it may occur post surgery and could be related to a range of possible factors including deoxygenation, brain injury, infection or unbalanced metabolism.
The history suggests little evidence of gradual dementia, although vascular dementia may progress with step-wise deteriorations.
Treatment involves two main aspects. The first is to treat the underlying cause. This needs careful assessment to make sure that nothing is missed. The second is to treat the distress or discomfort symptomatically. Sedatives or major tranquillizers for the latter are only used when absolutely necessary and when the underlying cause has been identified. Doses should be reviewed every 24 hours. Haloperidol (or lorazepam for patients with Lewy body dementia or Parkinson’s disease) are commonly used. Some use risperidone as an alternative.
The lung signs in this situation suggest pneumonia and the absence of a fever does not exclude this as a cause. The mainstay of treatment is directed at the cause. Consider treating the infection with antibiotics, ensuring adequate hydration and nutrition, identifying metabolic disturbance and providing corrective treatments, ensuring adequate oxygenation, and identifying any poisoning or withdrawal states and providing necessary treatments.
Poisoning seems unlikely since his wife is well, but doctors should remain vigilant to causes such as carbon monoxide poisoning in these situations. He has not had diarrhoea but may have a urinary tract infection. He has had a cold so an undiagnosed pneumonia is possible. Drug or alcohol states seem unlikely given the history as does head injury although he may have knocked his head without his wife knowing.
Rather than organizing tests and waiting for the results a hospital admission is appropriate to investigate and provide necessary treatment.
• Delirium affects attention, consciousness, perception, thinking, memory and emotions.
• There are usually behavioural effects and an impact on the sleep–wake cycle.
KEY POINTS