Clinical Geriatrics

Case Presentation
Mr. R is a 78-year-old married male who was living at home with his wife of 55 years. He suffers from hypertension that is well controlled on losartan 50 mg daily, and also takes finasteride 5 mg daily for benign prostatic hypertrophy. Mr. R suffers a fall while crossing the street when he is out walking with his wife. He is unable to get up and is brought to the emergency room by EMS. Mr. R appears somewhat confused and complains of pain in his right leg. He is found to have a fracture of the right hip. An orthopedic surgeon, Dr. F, is called for consultation and recommends open reduction and external fixation of the fracture. Mr. R is admitted to the hospital, and surgery is performed the following morning. Dr. F reports to Mrs. R that the surgery went well and that her husband will be “as good as new.”

Mr. R has a complicated postoperative course. He is very confused and tries to climb out of bed on the day following surgery. He is found to have a urinary tract infection and is treated with intravenous levofloxacin. Mr. R begins calling out and is given haloperidol 2.5 mg by intramuscular injection twice daily. His oral intake is poor, and by the fourth postoperative day he has difficulty sitting in a chair due to restlessness, and is unable to follow the directions of the physical therapist. Mrs. R is very distressed by her husband’s condition. She visits him daily and feels that he is declining. Mr. R is evaluated by a neurologist, who orders a computed tomography scan of his head that reveals diffuse cortical atrophy but no signs of any stroke or hematoma. Results of his blood tests, including chemistry panel, thyroid profile, and vitamin B12 and folate levels, are within normal limits. The neurologist considers a diagnosis of prolonged delirium, but also notes that the patient may have preexisting cognitive loss.

A psychiatry consultation is requested after Mr. R has been in the hospital for 10 days. Mrs. R is very angry when the psychiatrist comes to evaluate her husband. She reports that he is a retired high school principal who was doing well until his surgery. She insists that he has no psychiatric problems, and she feels that “something must have happened” during the operation that is making her husband confused. Mrs. R denies any problems prior to the hip fracture and states that her husband was perfectly fine. The psychiatrist finds Mr. R somewhat drowsy, with very poor attention and concentration. He is perseverative when trying to answer questions, stating “I’m fine, let’s go” many times. Mr. R tries to draw a clock, but is unable to place any numbers except a 12 at the top. He is able to repeat three words but cannot recall any of them after 2 minutes. He displays a mild pill-rolling tremor in his right hand. The psychiatrist suggests that the haloperidol be discontinued due to side effects of sedation and drug-induced extrapyramidal symptoms. The psychiatrist is concerned about adverse drug effects as a contributing factor to his delirium. Mr. R becomes more alert, and after 15 days in the hospital is transferred to a subacute unit of a nursing home for continued rehabilitation.

Discussion
Delirium is an acute confusional state characterized by a disturbance of consciousness with fluctuations over time.¹ A reduced ability to focus, sustain, or shift attention is a central feature of delirium. Sleep-wake cycle disturbances are common. Abnormalities of cognition, perceptual disturbances, and a reduced awareness of one’s environment typically accompany delirium.^2,3

Although many physicians associate delirium with its hyperactive type, this presentation of confusion, agitation, hallucinations, and hyperalertness accounts for only 25-30% of cases.⁴ More common is the hypoactive form of delirium, characterized by somnolence, apathy, sluggishness, and withdrawn behavior.