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Clinical Case Presentation April 2024

Presenter: Dr Zahira Zohari

Supervisor: Dr Elizabeth Chong Gar Mit


We present two cases of hospitalised older adults who are both referred for the management of delirium.


CASE 1

  • Mr JD

  • 83-year-old Malay man

  • Underlying illness: • Hypertension • Type II DM: latest hbA1C in Jan 2024 – 7.2%

  • Retired teacher

  • Widower

  • Staying in a double-storey terrace house with daughter (main- carer).

  • Daughter works as a salesperson from 9am to 5pm


PRESENTATION

  • Presented with fever with chills and rigor 3/7 before admission. Lethargic and poor oral intake.

  • Daughter brought to hospital.

  • In ED, BP was 92/60, HR 123 with temperature of 37.2*C

  • He was alert but lethargic looking. GCS E3V5M6. Dehydrated

  • Clinical examination was unremarkable.

  • Blood ix in ED: TWC 14.6/ CRP 98/ Urea 8/ Creat 100

  • Urine FEME: protein 2+, bacteria 3+, nitrite positive

  • Admitted to ward: BP responded to fluid bolus and added on maintenance hydration

  • Started on IV Cefuroxime


Referred for delirium

  • 10 days in the ward

  • The patient is drowsy and sleepy most of the time.

  • Lethargy, disinterested in surroundings

  • Unable to focus on the conversation.

  • Very poor oral intake. Refused any oral feeding

  • Family not around with him.


PREMORBID


COGNITIVE

• The daughter noted patient

frequently misplaces his money

and glasses

• But denied any significant short- term memory loss.

• able to engage in complex

conversations

• Aware of current news and make

informed decisions.

MOBILITY

• Walks independently without aid.

• Denied any recent fall


iADL

• Able to read newspapers every day

• Not using the smartphone so much

anymore as difficulty remembering

the buttons and apps.

• Handles own medication

• Make his own bed, wash own

dishes. Other house chores are

done by the daughter.

• Social gathering with friends in

coffee shop once in a while

INCONTINENCE

• Nocturia 2-3x/day

• Increased urinary frequency in

the past 1 year

• Difficulty initiating urine.

bADL

• maintained his independence in

daily living

DIET

• Vegetarian

• Bfast: bread/coffee

• Lunch: rice/noodles with vegetables

(protein – sometimes taking egg/tofu)

• Dinner: same as lunch

Physical Examination

Day 8 of admission


O/E: Appears lethargic and disinterested in the surroundings.

Poor eye contact and limited response to verbal stimuli.

Dry lips, Coated tongue, dry skin

Feeble pulse volume


VS: BP 102/56. HR 98, SPO2 97% under RA, Afebrile

I/O yesterday: 1150/950 (on 2pints NS/24hours)


NBO 3/7

- Yesterday minimal stool

Urine in CBD bag: concentrated


Neurological Exam:

Motor Exam: Normal muscle tone. Unable to assess full

neurological exam.


Reflexes: Normal and symmetric.


CVS, Respi system unremarkable


P/A: soft, not tender, not distended, renal punch negative


Appearance: Disheveled, given his decreased attention to personal

hygiene during the hospital stay.

Speech: Low volume, slow rate, and reduced spontaneity.

Mood: Difficult to assess but appears flat or indifferent.

Behaviour: No delusions or hallucinations reported or observed.

Sleeping most of the time

Cognition: Orientation to person but not to time or place. Impaired

immediate and short-term recall. Unable to perform serial 3s or spell

"world" backward due to decreased attention and engagement.


Investigations


Assessment:

  • E.Coli Urosepsis with AKI secondary to infection and dehydration with underlying BPH

  • Hypoactive Delirium



CASE 2


  • Mrs MN

  • 70-year-old Chinese lady


  • Underlying illness: • Hypertension • Type II DM: latest hbA1C in March 2023 6.6% • Hx of Stroke with right-sided hemiparesis 2012 – no residual weakness • Dementia: Mixed AD and VD – diagnosed in 2018 • Moderate to severe stage

  • Nursing home resident since 2020 • Bungalow with 18 other residents - some are independent, 3 bed bound • 3 NH staff

  • Sent to the nursing home by her younger sister. The family is unable to take care of her. They were concerned regarding safety. • The patient was living alone in a flat house. • House was unkempt. • Had episodes of forgetting to turn off tap water, causing flooding and leaking to neighbour’s house.

  • Unmarried, Nulliparous

  • Ex-hawker


Presentation

  • The caregiver noticed a significant decline in responsiveness

  • Having feeding difficulties and very poor oral intake for 1/52

  • Thus she was brought to the hospital

  • In ED, BP was 100/62, HR 92 with a temperature of 36.7*C

  • Very lethargic looking. E2V2M5.

  • In examination: clinically dry, bladder palpable

  • Urine catheter inserted: 500ml of cloudy urine

  • Blood ix in ED: TWC 16/ CRP 112/ Urea 12/ Creat 154

  • Urine FEME: protein 2+, bacteria 3+, nitrite positive

  • Started on IV Cefuroxime

  • Admitted to medical ward


Referred for Delirium

  • Not opening eyes

  • Significant lethargy and disengagement from her surroundings

  • Very poor oral intake. Refused any oral feeding


PREMORBID


COGNITIVE

• Memory has been progressively

worsening

• Unable to recognize family

members anymore

• Communication is limited - almost non-verbal, relying on non- verbal cues or sounds rather than

forming coherent words or

sentences.

MOBILITY

• Had a history of fall end of the

year next to the bed

• Bed bound, requiring wheelchair

for movement.

• Full assistance with transferring

and moving from bed to chair.

MOOD

• Has moments of agitation and

distress if left alone.

iADL

• All are managed by the NH staff

bADL

• required assistance with most

ADLs, including bathing, dressing

• Wearing diapers – unable to

indicate

• Feeding by NH staff

DIET

• Bfast: few spoons of oats/half biscuit/tea

• Lunch: 3-4 spoons of porridge with either chicken or fish (small

amount)

• Tea: small amount of kuih/tea

• Dinner: 3-4 spoons of porridge (same as lunch)

• Not on any milk/ ONS

• Refused water – able to drink only

1-2 cups per day

Poor dentition

- Unable to chew on hard food

 

NBO 3/7

Has urinary and bowel incontinence,

is completely unaware and is unable

to communicate needs for toileting.

Physical Examination

Day 8 of admission


O/E: Thin built, sunken eyes

Very lethargic looking.

Minimal response to verbal or physical stimuli.

Dry lips and coated tongue, dry skin of both UL and LL

Brittle nails

Hands muscles wasting

Loss of temporal muscle.

Poor dental hygiene


VS: BP 99/56. HR 100, SPO2 97% under RA, Temp 37.5

Feeble pulse volume


Neurological Exam:

Motor Exam: Normal muscle tone. Unable to assess full neurological

exam.


Reflexes: Normal and symmetric.


CVS, Respi system unremarkable

P/A: soft, not tender, not distended


Appearance and Behavior: More withdrawn than usual, with no

interaction with her environment. Sleeping the whole day.

Mood: Appears flat, with limited emotional expression.


Investigations



Assessment:

  • E.Coli Urosepsis with AKI secondary to infection and dehydration

  • Hypoactive Delirium.


Questions


  1. Compare and contrast the etiological factors of delirium and the causes of urinary tract infections in the two described cases.

  2. Both patients have not been taking orally well for more than 10 days post-admission. Would you manage them differently? Is there any special consideration for feeding?

  3. Would you institute a nasogastric tube for feeding in Case 1 and Case 2? Explore the pros and cons of each case.



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Unknown member
Apr 03

Q 1

Case 1

Predisposing/precipitating factors-age, dehydration, AKI, probable underlying mild dementia, constipation

Causes of UTI—DM, prostatism

Case 2

Predisposing/precipitating factors- age, underlying dementia, dehydration, history of stroke, AKI, constipation

Causes of UTI- urinary and fecal incontinence, DM, constipation contributing to AUR

Q 2/3

Case 1

Patient was bADL independent prior with fair nutrition and sudden reduced oral intake – therefore would support nasogastric feed (supplemental) besides other measures (regular oral feeding with favourite food, ONS). Supportive feeding is likely temporary while the patient is recovering from hypoactive delirium (which should be reversible).

Case 2

Patient was already malnourished and in advanced stage of dementia. Current condition is likely reflective of her severely frail state. Nasogastric feed may not improve…

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