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Morning Report

Morning Report. Steve Hart 4/19/2006. Case Presentation. 77 y/o AAF with ESRD presents to ED with lower extremity weakness x 1-2 days and elevated blood pressure. Feeling generally weak, now unable to ambulate Off BP meds for about a week “BP controlled with Dialysis” Headaches

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Morning Report

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  1. Morning Report Steve Hart 4/19/2006

  2. Case Presentation • 77 y/o AAF with ESRD presents to ED with lower extremity weakness x 1-2 days and elevated blood pressure. • Feeling generally weak, now unable to ambulate • Off BP meds for about a week • “BP controlled with Dialysis” • Headaches • Poor vision • Some SOB and coughing • Per social worker and daughter, mental status changed from baseline

  3. PMHx • HTN • Glaucoma • Cataract • Anemia • Recent AV graft infection • Social Hx • Lives at home with daughter • Quit smoking in 50’s

  4. Allergies – none • Meds • Lisinopril • Aranesp • Xalatin eye drops • Phoslo • Nephrocaps • Zocor • Aspirin

  5. Vitals T 97.1 HR 79 R 14 BP 175/69 Pox 98% 2L Physical Exam Gen – Alert, oriented? Female, HEENT – PERRLA, EOMI, MMM Neck – JVD, nl thyroid Chest – bilateral rhonci CV – RRR, nl S1 and S2, no edema, no bruits Abd – soft, NT/ND, no HSM Ext – no E/C/C Neuro – equal/symetric +1 reflexes., CN intact, nl cerebellar signs, +5 strength in UE, -5 in LE Neg Rhomberg

  6. Labs 138 96 7 3.7 33 2.5 13.6 5.3 218 41.5 90 Ca 9.7 CKMB 1.8 Trop I 0.05 EKG NSR, No ST changes CXR NAD Diff: N65 L20 M10 UA: 1.006, 8.5, prot 100, occ bact, LE large, 27 WBC

  7. Imaging • Head CT • Small vessel disease with age indeterminate infarcts in internal capsule. Possible subacute on old? • MRI Head • moderate deep and sub-cortical ischemic white matter changes – non acute • Bilateral patchy ischemic foci in the lentiform nucleus and pons. No intracranial mass lesion • remote micro hemorrhage in the right posterior inferior aspect of the thalamus

  8. Problem List Geriatric Weakness, ambulatory only with assistance - new Recent decline in mental status HTN, uncontrolled ESRD UTI Impaired vision SOB, hypoxic Small vessel disease, lacunar infarcts

  9. Hospital Course • Day 1 • Started on routine SQ heparin and pepcid on admission • MI ruled out with serial enzymes and EKGs • Cultures negative, no empiric antibiotics • Remained afebrile • SOB and hypoxia relieved with dialysis • Blood pressure poorly controlled • Neurology consulted for mental status changes

  10. Hospital Course • Mental Status quickly deteriorated • Hallucinations • Fluctuating mental status • Alert but not oriented at times • Unable to concentrate • Tangential thought • “sundowning” • Patient placed in restraints

  11. Delirium

  12. Delirium • Definition • reduced ability to focus, sustain, or shift attention • change in cognition or the development of a perceptual disturbance • Acute onset (hours to days) • Identifiable cause

  13. Epidemiology • At admission prevalence 14-24% • Hospitalization incidence 6 to 56% • 15-53% geriatric patients post-op • 70-80% older patients in ICU • 60% nursing home will have at some time • 83% of geriatric patients prior to death

  14. Delirium….Why should I care? • Mortality rate in hospitalized patients 22-76% • One year mortality rate is 35-40% • Prolongs hospital course • Increased cost of care in hospital • Increases likelihood of disposition to nursing home, functional decline and loss of independence

  15. More reasons to care • Strong association with underlying dementia • Frequently, patient may never return to baseline or take months to over a year to do so • Delirium is often the sole manifestation of serious underlying disease

  16. Pathophys • EEG shows diffuse cortical slowing • Neuropsyc and imaging • Disruption of higher cortical function • Prefrontal cortex • Subcortical structures • Thalamus • Basal ganglia • Frontal and temporoparietal cortex fusiform cortex • Lingual gyri • Effect greatest on non-dominant side.

  17. Pathogenesis • Involves • Neurotransmission • Inflammation • Chronic stress

  18. Pathogenesis • Neurotransmission • Cholinergic deficiency • Anticholinergics can precipitate delirium • Serum anticholinergic activity increased in those with delirium • Cholinesterase inhibitors can reverse this effect • Dopaminergic excess • Neuropeptides, endorphins, serotonin, NE, GABA may play a role.

  19. Pathogensis • Cytokines • Interleukins and interferons • Often elevated in Delirium • Have known strong CNS effects • Primary role – sepsis, bypass surgeries, dialysis, cancers

  20. Pathogensis • Chronic stress • Untreated pain / analgesia are strong risk factors • Elevated cortisol assoc with delirium

  21. Risk Factors • Underlying brain disease • Dementia • Stroke • Parkinson’s • Advanced Age • Sensory Impairment • Bladder Caths

  22. Differential • Psychiatric Illness • Depression • mania • Dementias • Nonconvulsive status epilepticus • Especially in ICU • Wernicke’s aphasia • Occipital lesions • (cortical lesions and confabulations) • Bifrontal lesions (tumors or trauma)

  23. Diagnosis • Clinical Step #1 – Recongnize the disorder Step #2 - Uncover underlying medical illness

  24. Recognize Often unrecongnized, >70% of cases Behavioral or cognitive issues often wrongly attributed to age, dementia or other mental disorders determine acuity of change in mental status. if no historian available, one should assume acute and delirious until proven otherwise

  25. Recognize • Disturbance in consciousness and alterned congnition • Consciousness • Attention – poor • Subtle loss of mental clarity initially • Patient “isn’t acting right” • Distractability • Tangential or disorganized thought • Acute/subacute onset • Fluctuating course throughout a day

  26. Recongnition • Congition • Memory loss • Disorientation • Difficulty with language and speech • Perceptual disturbances • Delusions • Hallucination

  27. Assessment Formal mental status evaluation in all geriatric patients (ie. MMSE or CAM) Arouse all older patients daily to evaluate hypoactive form of delirium Search for causes of delirium

  28. Causes D Drugs, Drugs and toxins, too E Eyes, ears L Low O2 states (MI, ARDS, PE, CHF, COPD, stroke, shock) I Infection R Retention (of urine or stool). Restraints I Ictal U Underhydration, Undernutrition M Metabolic (hypo/hyper glycemia, calcemia, uremia, liver failure, thyroid disorders)

  29. Other Causes • Foley catheter • Invasive procedure • Sleep deprivation • Pain

  30. Drugs • Accounts for 30% of all cases • Common culprits • Anti-histamines • Anti-cholinergics • Antibiotics • Some antidepressants • Dopamine agonists • Hypoglycemics • Benzos • Opiates

  31. Patient • Poor vision • Evidence of old and recent strokes • Infection - UTI • Restrainted • Multiple medications • Pepcid started on admission • ESRD • Hypoxia

  32. Treatment • Correct all identifiable causes • Delirium is usually multifactorial • Correction of multiple causes is often necessary for recovery • Pharmacologic – if needed • Antipsychotics • Avoid benzos except with ETOH withdrawl • Orient Patients • Provide clocks, calenders, windows, structured activities • Hearing aides, glasses

  33. The End – Questions/Comments?

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