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
Compare and contrast the etiological factors of delirium and the causes of urinary tract infections in the two described cases.
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?
Would you institute a nasogastric tube for feeding in Case 1 and Case 2? Explore the pros and cons of each case.
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…