Case outcome: via telephone

Spouse is instructed to bring patient to local emergency room to be evaluated for this acute neurological event

She is seen and evaluated by emergency room staff

Further investigation

Is there anything else you would especially like to know about this patient?

What did the emergency room determine?

• – Her vital signs were normal initially

• – She had not been hydrating well and may be dehydrated

• – Brain CT scan revealed no abnormalities

• – She developed a fever of 104℉ while being worked up in the emergency room

• – Urinalysis suggested infection

• – Blood work next showed urosepsis

• – She was placed on ciprofloxacin IV, 400 mg IV every 8 h and admitted for further evaluation

Case outcome: first interim follow-up six hours later

Patient went to sleep on the medicine inpatient unit

Six hours later, husband calls to state he went home and went to bed; it is now midnight and the patient has been texting him

• – Part of what she is texting states that “she has to get out” and they are “out to get me”

• – The other part is nonsensical

This is reported to the inpatient internal medicine team in real time

• – They call for consultation and report that she is combative and refusing all medications now

• – On-call team wonders if she is paranoid like this often, and if this is part of her depression

Question

How would you answer?

Yes, sometimes depressives become psychotic acutely

Yes, sometimes depressives become psychotic acutely, but not in this case, as in 30 years she has not presented as such

Yes, but only if she has taken excessive modafinil or stopped taking clonazepam or eszopiclone abruptly, causing an intoxication or a withdrawal effect. However, there is no evidence to support this now

No, patients with MDD, bipolar disorder, or even schizophrenia typically do not go from non-psychotic to psychotic in a few hours’ time

No, she has confusion and orientation problems and these are not part of MDD, GAD, bipolar, or schizophrenia diagnostic criteria, but is more consistent with delirium

Attending physician’s mental notes: six hours later

The patient is frankly paranoid, agitated, even combative now

Symptoms have fluctuated to different degrees over the last several hours, where she has acted normally at some times, psychotic at others

There is no prescription misuse issues and she unlikely has made mistakes following her medication regimen, which has been stable for a few years

There has been no recent MDD, stressors, and no indications that this was an overdose or suicide attempt

Acute onset of clouded sensorium, confusion, behavioral change, and psychosis meets DSM-5 criteria for delirium

Even though they have begun treating her urosepsis with antibiotics, she is still infected, febrile, and she is likely “sundowning” with a worsening of delirium symptoms now in the evening

Question

What would you advise the medical team, as far as treating her cognitive and behavioral symptoms of delirium?

Behaviorally, ask the husband to come in and possibly bring items from home to better orient the patient to self

Ask the nursing staff to frequently introduce themselves, the patient’s hospital location, and reason for being there to orient the patient to time and place

Return her glasses so she can see better to avoid sensory deprivation

Start a low-dose typical antipsychotic such as haloperidol (Haldol)

Start a low-dose atypical antipsychotic such as risperidone (Risperdal)