Mad House mAd school: Grandpa is Crazy, Again!

“72 y/o female Nursing Home resident who was sent by the nursing home complaining of new change in mental status”
“No man, please, I hate these admissions”
“Sorry, I don’t have anyone else”
“Whatever”
“Look, she was here last month and her discharge summary says she has mild dementia. Now, she’s alert and oriented times zero”
“Not so mild I guess”
“Shut up”
“So what do they think?”
“So far everything is negative, they’re tapping her now”
“Tapping? Wow. Who down there had the initiative to do the LP?”
“No one, I just told them the patient isn’t going anywhere without one and, VIOLA, LP is done”

An old lady who comes with acute change in mental status, meaning, she wasn’t this confused before and, over hours to days, she now is. It’s a very common admission and I thought I’d teach a few aspects of real life and med school medicine that goes into the thought process of what’s happening with crazy Grandma.

The condition is termed “Delirium”, literally “off the tracks” in Greek. It’s easily confused for Dementia but the main difference is that Dementia occurs over a longer time period (ie. Months to years, not hours to days). It’s an important distinction for many reasons, including which consults get to sleep through the night and who gets to be woken up.

Hospital Late Night Medicine:

Medicine Residents hate admissions for Delirium. I shouldn’t generalize, so actually, this medicine resident hates delirium admissions, because they are actually difficult admissions. The patients can’t give a good history (They’re loopy remember) and there are many different causes. It makes the actual diagnosis very difficult.

Usually, a whole bunch of tests are run, basically like fishing in a big pond. The most painful of these is the LP, or Lumbar Puncture. Basically, it’s sticking a big ass needle into a nice little old lady’s back and drawing some spinal fluid. Really, not fun, not for the patient and not for the resident. The procedure requires cooperation and these patients are obviously suboptimal.

My Medical Admitting Resident blocked the admission so that they would do the LP downstairs in the Emergency Room. This was huge. Not even small time huge this was GIGANTIC huge. The third year Resident saved my sorry exhausted ass a half hour to forty five minutes minimum, not to mention all the aggravation.

Sometimes the admission is fun. Mainly because Interns make the mistake of calling Psychiatry right away and end up saying something like “We have this old lady whose suddenly gone nuts” (I may be changing the text slightly but basically that’s the meaning). Usually the poor intern gets dished out by the psych resident for an obvious failure to recognize an ACUTE change in mental status which is technically a medicine problem and has nothing to do with psychiatry. I love watching interns apologize. Really, just ask Shrinkette, she gets tons of these consults, she told me so.

Medicine Aspect (Mainly for me to review, really, you shouldn’t read this. Really. GO AWAY!)

The main symptoms of Delirium are a sudden clouding of consciousness, Illusions, Hallucinations and difficult maintaining or shifting attention, as well as disorientation. The patient above was Alert and Oriented times zero, which means she didn’t know her name, where she was, or what day, month or year it was either, she was mentally kaput.

In elderly patients delirium is often a presentation of an underlying illness, most commonly an infection. Usually it’s in their piss, sorry, they have a “Urinary Tract Infection”. Patients with preexisting dementia are especially susceptible, grandpa with Alzheimer’s can really lose it with a little E. Coli.

The “official” DSM-IV Criteria: (the DSM is the manual for Psychiatric illnesses)
1. Disturbance of consciousness. (Being oriented to zippo).
2. Change in cognition that is not better accounted for by a preexisting dementia. (Don’t call Psych yet, pretend to TRY to do something first).
3. The disturbance develops over a short period (usually hours to days) and fluctuates during the course of the day. (They drive you crazy at night. You will want to calm them down, they won’t calm down. The Nurses will want Haldol, you won’t. They will scare you, telling you the patient will fall. You will give in and prescribe Haldol).
4. Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. (Good luck with that).

Some common reversible causes are: (Long list, ready?) Hypoxia, Hypoglycemia, Hyperthermia , Anticholinergic delirium , Alcohol or sedative withdrawal, Infections, Metabolic abnormalities, Structural lesions of the brain, Postoperative states, Miscellaneous causes, such as sensory deprivation, sleep deprivation, fecal impaction, urinary retention, and change of environment. Oh yeah, another is just being in the Hospital, so psycho may be nuts because she’s here and not here ‘cause she’s nuts.

In summary, here are the basic five categories: Infectious, Metabolic abnormalities, Hypoperfusion States, Structural changes and Toxic. Sometimes having your body sliced in half can do it too so it’s very common after surgery.

Hope you enjoyed my first ever attempt at sounding intelligent. I may do more of these, mostly because Blogging is interfering with studying so I decided to combine the two. You may one day even get to graduate the Mad House mAd school.