Attending physician’s mental notes: interim follow-up information through 72 hours

This presentation was not due to MDD or GAD and was secondary to urosepsis, dehydration, and possible anticholinergic-induced delirium

This was managed appropriately per guidelines

• – The underlying cause was detected and treated

• – Behavioral techniques were used to manage aggression and paranoia

• – Pharmacological treatments were refused but actually not needed

• – Physical restraints were not needed

• – Her complicated psychotropic regimen was assessed and altered to avoid making the delirium worse

Will see patient in a few weeks and likely reinstate her usual medications systematically to her usual successful regimen to make sure she does not begin an MDD or GAD recurrence

Case outcome: interim follow-up information through 72 hours

Patient refuses oral risperidone (Risperdal) 0.5–1 mg dose and becomes selectively mute

A nurse was stationed in the medical room for constant observation

Nurse employed behavioral techniques (see previous case)

This, as well as having the husband present, calmed the patient and she slept without further incident

Awakens in the next morning without any abnormal mental state findings

Later becomes afebrile and the infection is clearing

The norriptyline (Pamelor) level came back elevated at 176 ng/ml and it was lowered

• – This level is considered potentially toxic

• – It likely elevated due to dehydration as her usual levels are half this amount and she is on no CYP450 2D6 inhibitors

• – EKG was normal

• – This TCA has anticholinergic potential that might worsen or prolong delirium, and lowering it makes clinical sense regardless

The wakefulness agent/stimulant, modafinil, is discontinued as there are case reports noting it may cause psychosis and delirium, although this often occurs at drug initiation

The BZ clonazepam and BZRA eszopiclone are continued to avoid sedative withdrawal effects and to prevent complicating her already delirious presentation

The SSRI sertraline is continued to avoid SSRI discontinuation syndrome and to prevent complicating her already delirious presentation

L-methylfolate (Deplin) is continued

The patient is discharged home in a normal mental state the next day

Case outcome: interim follow-up visits through 80 hours

The patient went home in the afternoon and went to sleep after her hospital stay

Awoke the next day appearing slightly confused, repeatedly stating that she has to “get out”

Attempts to leave the house in a nightgown and husband tries to passively restrain her inside the house and coerce her to get dressed

Became verbally aggressive, began throwing objects, physically forced herself out of the house

She was selectively mute, unresponsive again

Ambulance was called and she reluctantly, but docilely returned to the emergency room where she presented as paranoid, refusing all treatment, and refusing to talk

Agitation reached a dangerous level at one point where she received injections of the BZ sedative lorazepam (Ativan) 2 mg and typical antipsychotic haloperidol (Haldol) 5 mg

She calmed down and slept

Emergency room called for consultation and stated that the urosepsis had been successfully treated. As a result, the paranoia now “appeared psychiatric” and not due to delirium. They requested that the patient be admitted to a psychiatric unit