What are the possibilities for change in Mrs. Smith’s current mental status?

Discussion #1

What are the possibilities for change in Mrs. Smith’s current mental status?

          Mrs. Smith could be possibly experiencing delirium. Delirium is a sudden change in the mind that can cause confusion and a disrupted emotional state (Badii, 2018). Delirium can be caused by infections such as urinary tract infections or pneumonia, metabolic conditions such as hypoglycemia, certain medications, illicit drugs, alcohol withdrawal, a decrease of oxygen in the body, etc. (Badii, 2018).

          Mrs. Smith is diabetic, she could be experiencing a state of hypoglycemia which can lead to an acute state of confusion and change of behavior which can go unnoticed by the patient, family members, and physicians (Steckl, 2015). People with diabetes are at higher risk of developing dementia, Mrs. Smith has a history of both diabetes and hypertension which can lead to constriction of blood vessels, reduced oxygen to the brain, and cause damage to the brain overtime (Steckl, 2015). 

 What is your top differential diagnosis? Give 3 reasons why you chose that diagnosis.

My top diagnoses is delirium because Mrs. Smith had an abrupt change and experienced confusion, restlessness, poor appetite, and shows no signs of infection such as a fever which are related to delirium (Badii, 2018).

How can you differentiate depression, dementia and delirium?

Depression is a chronic illness that can lead to patients feeling uncontrollable sadness and hopelessness (McCance & Huether, 2014). Patients can experience agitation, insomnia, a decreased interest in activities or relationships, and a decrease in appetite which can later lead to weight loss (McCance & Huether, 2014). These symptoms can come abruptly and can last up to months, but patients will stay oriented (McCance & Huether, 2014).

Dementia is a decline of brain function, it is progressive, and affects a person’s behavior, memory, orientation, and language (McCance & Huether, 2014). Dementia can be caused by trauma, atherosclerosis, increased intracranial pressure, neurodegeneration, and hydrocephalus and might not be relate to infections, and certain conditions/diseases like delirium (McCance & Huether, 2014). A patient’s behavior is usually not affected and are oriented within the first stages of dementia. The patients can show a slow irreversible decline that can last up to years (McCance & Huether, 2014).

Delirium can have an abrupt onset, as mentioned above, and can lead to confusion, a disrupted emotional state, restlessness, poor appetite, and irritability (Badii, 2018). Delirium can be caused by infections such as urinary tract infections or pneumonia, metabolic conditions such as hypoglycemia, certain medications, illicit drugs, alcohol withdrawal, a decrease of oxygen in the body, etc. (Badii, 2018). 

Explain to Mrs. Smith’s daughter what treatment is needed and what you think her prognosis is.

          Delirium can be reversible. Treatment involves finding the cause and using the needed treatments to manage that cause (McCance & Huether, 2014). In Ms. Smith’s case a complete history and physical will be needed, lab work, an EKG and chest x-ray, blood glucose and urine specimen and from those results the next steps will be taken.

Discussion #2

1) What are the possibilities for change in Mrs. Smith’s current mental status?

Mrs. Smith is an 85 year female with a history of hypertension (HTN), diabetes (DM) and osteoarthritis (OA). It is possible that Mrs Smith is experiencing mental status changes due to acute delirium, dementia, urinary tract infection (UTI), diabetes (hypo/hyperglycemia), hypoxemia or as a result of medications. There might be a combination of the causes mentioned above.

2) What is your top differential diagnosis? Give 3 reasons why you chose that diagnosis.

After reviewing Mrs. Smith symptoms, my top differential diagnosis would include, acute confusional state (ACSs) also referred as acute organic brain syndromes. These syndromes are associated with cerebral dysfunction secondary to drug intoxication, alcohol or drug withdrawal, metabolic disorders (hypoglycemia, thyroid storm), nervous system disease, trauma or surgery, febrile illnesses, and electrolyte imbalances. ACSs may also be associated with systemic disease such as liver, kidney, and heart failure (McCance, 2014). Mrs. Smith might possibly experiencing delirium (hyperkinetic confusional state). This is an acute state of brain dysfunction associated right middle temporal gyrus or left temporo-occipital junction disruption. Increased and decreased levels of several neurotransmitters are involved. Involvement includes: An increase in acetylcholine, dopamine, and serotonin, and increased or decreased levels of gamma-aminobutyric acid (GABA). Inflammatory cytokines (interleukins, interferon, and tumor necrosis factor-alpha) may also assist in delirium by altering the blood-brain barrier permeability, thus causing disturbances in the neurotransmission and altering neurobehavioral and cognitive symptoms (McCance, 2014). Hypokinetic delirium is more likely to be associated with right-sided frontal-basal ganglion disruption. These areas regulate motor exploratory aspects of attention. Most metabolic disturbances that cause a confusional state interfere with neurotransmission at the synapse. Symptoms of ACSs can fluctuate and include confusion, inability to focus or maintain attention, delusions, and hallucinations. The onset of an ACSs is abrupt and typically develops over 2 to 3 days. Delirium initially presents as difficulty concentrating, restlessness, irritability, insomnia, tremulousness, and poor appetite. In hypokinetic delirium there is a decrease in mental function, alertness is decreased, alterations in the environment are noted, and forgetfulness is prominent. I chose this diagnosis due to Mrs. Smith’s, due to the acuteness of her forgetfulness, confusion, restlessness, and poor appetite. The dry cough could be in relation to an inflammatory response causing sinus drainage. Crackles in the left lower base could be a sign of CHF, however, crackles in the elderly is often a common finding, and recognition of age related crackles is important because such clinically unimportant crackles are common among the elderly population.

3) How can you differentiate depression, dementia and delirium?

Depression- is a mood disorder that causes a persistent feeling of sadness and loss of interest. It affects how you feel, think, and behave and can lead to a variety of emotional and physical problems.

Dementia- is not a specific disease. Dementia describes a group of symptoms that progressively affect memory, thinking, and social abilities that eventually interfere with daily functioning. Alzheimer’s disease is the most common cause of progressive dementia. Depending on the cause, some dementia symptoms can be reversed.

Delirium- is a serious disturbance in mental abilities that result in confused thinking and reduced awareness of the environment. The onset of delirium is usually rapid (within hours or a few days). It can often be traced to one or more contributing factors, such as a severe chronic illness, changes in metabolic balance, medication, infection, surgery, or alcohol or drug intoxication or withdrawal.

4) Explain to Mrs. Smith’s daughter what treatment is needed and what you think her prognosis is. In order to be able to make a diagnosis, I would inform Mrs. Smith’s daughter that several physical exams and tests would be needed. Tests will include, mental status exam, physical and neurological exams, laboratory tests such as blood and urine, electrocardiogram, imaging tests of head (CT and/or MRI), cerebral spinal fluid (CSF), and radiologic studies.  If delirium is indeed the diagnosis, then I would inform her that once the underlying cause of the delirium is recognized then the delirium may last only a few hours or as long as several weeks or months, depending on the cause. The degree of recovery often depends on the health status before the initial onset. I would also explain that those with serious, chronic illnesses may not regain the levels of thinking skills or functioning that they had before the onset of delirium (Mayoclinic, 2018).