Would You Recognize Acute Delirium?

Kevin Biese, MD; Adam Perry, MD


March 28, 2018

Managing Mixed Delirium

This case of mixed delirium with hypoactive and hyperactive episodes illustrates the complexity inherent with presentation in older adults. These include, among potential others, issues of care transitions, limited medical decision-making capacity, and multidisciplinary care coordination.

Older adults frequently arrive by ambulance from nursing homes, a term that colloquially is used for a range of situations including independent living, assisted living, personal care home, postacute or acute rehabilitation facilities, or a long-term care facility. Each setting is unique in the level of assistance available, functional requirements for residents, payment source, and treatment and diagnostic capabilities. Many facilities providing postacute or acute rehabilitation and long-term care can administer IV fluids and medications, as well as perform imaging and laboratory analysis. Understanding the patient's baseline cognitive and functional status and the medical capabilities of the facility is critical to the ED evaluation, as is illustrated in this case, as this conversation informs the nature and likely etiology of her symptoms. You won't know your patient's baseline or what care the facility can provide unless you call the facility and/or family member that sent the patient to the ED.

Attention to information transfer during the transition from nursing facility to ED expedites patient-centered evaluation and disposition. In studies and position papers, both emergency and nursing facility providers stress the need for a more structured transition process to include standardized transfer forms, pretransfer checklists, and, importantly, verbal communication between providers.[2,3]

This case is also complicated by impaired decisional capacity and the need for multidisciplinary coordination. The patient cannot communicate an understanding of her current medical condition or provide a rationale for requesting discharge.[4] Fortunately, a surrogate decision maker, her daughter, is identified. Communication with the facility is key to understanding sudden changes in patients with chronic or acute cognitive impairment, which can inform facility capabilities and the treatment plan. By focusing on transitions and multidisciplinary cooperation, the ED ceases to be a "silo" of care for vulnerable older adults and joins the geriatric continuum of care.

Case Conclusion

The daughter arrives in the ED and has a calming and orienting effect on the patient. Together with the facility provider and daughter, the ED constructs a patient-centered care plan for discharge back to the facility with fluids, medication adjustment, and an evaluation upon arrival there.

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