Mr. L continues to be depressed and irritable with delusional jealousy. Mirtazapine is continued at 30 mg/d at bedtime. Aripiprazole and trazodone are discontinued and Mr. L is started on olanzapine, 10 mg/d, and haloperidol, 1 mg 4 times a day as needed for agitation. He requires multiple “as needed” haloperidol doses because of intermittent episodes of agitation. Mr. L is then transferred to the inpatient psychiatric unit for continued evaluation and treatment.
The authors’ observations
The fact that Mr. L is alert and oriented is encouraging; however, it does not rule out delirium because this condition is characterized by fluctuating levels of consciousness. Therefore, it is important to reassess him over time and perform a more thorough evaluation of cognitive function, especially attention and concentration, in addition to alertness and orientation. Psychomotor activation could suggest agitated depression, anxiety, mania, psychosis, substance intoxication, akathisia from antipsychotics, or delirium (Table 2).4 Initial evaluation— especially in older patients—should include a thorough history (including collateral sources) and be guided by the clinical presentation and physical examination, taking into consideration life-threatening conditions and common causes of mental status change such as infections, hypoxia, substance or medication effects, acute coronary syndromes, acute neurologic events, and metabolic conditions.
Table 2
DSM-IV-TR criteria for delirium caused by a medical condition
| A. Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention |
| B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia |
| C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day |
| D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition |
| Source: Reference 4 |
Reconsider the diagnosis
Even after being treated for hyperaldosteronism and discontinuing unnecessary medications, Mr. L continued to be treated for MDD with psychotic features despite intermittent confusion and agitation. At this point, it might have been useful to reconsider whether MDD with psychotic features was the most appropriate diagnosis to explain his mental status changes.
Mental status changes caused by medical disorders or medications do not immediately clear after the medical disorder is corrected or the medication is discontinued; it could take days or weeks for a patient to return to baseline. In Mr. L’s case it may be useful to simplify his medication regimen because polypharmacy contributes to delirium. Finally, olanzapine could worsen his condition because of its anticholinergic effects.5
EVALUATION: Poor cognitive status
Mental status examination upon admission to the psychiatric unit reveals a poorly cooperative patient with irritable mood and affect with slowed psychomotor activity. Mr. L’s thought process is organized with normal associations and thought content does not reveal suicidality or homicidality. However, he verbalizes delusions about his wife having an affair with a neighbor. He is partially oriented to time but believes he is in Germany. His insight is limited and he demonstrates impaired attention and concentration. We cannot complete a Mini-Mental State Exam (MMSE) because Mr. L does not cooperate.
After admission, Mr. L is intermittently confused, agitated, and disoriented. Between these episodes he is pleasant, cooperative, and oriented. Jealous delusions regarding his wife continue. Olanzapine and mirtazapine are tapered and discontinued. Haloperidol dose is changed to 1 mg 3 times a day, then to 1.5 mg in the morning and 3 mg in the evening. Prednisone is tapered and discontinued.
The authors’ observations
Cognitive testing is essential for the diagnosis and treatment of patients with mental status changes and for evaluating their response to treatment. Although the MMSE is widely used, other scales—including the Confusion Assessment Method, the Organic Brain Syndrome Scale, the Memorial Delirium Assessment Scale, and the delirium severity index6—may be more sensitive for detecting delirium. All of these scales can be difficult to complete when evaluating confused and combative patients. Quick screening instruments for inattention, such as the digit span test and listing days of the week backwards, could be used as well.
HISTORY: Surgical complications
Further questioning of Mr. L’s family reveals that his behavior started to change 7 months ago; this was 1 month after undergoing hip replacement surgery, which was complicated by a surgical wound infection and worsened his medical illnesses. Within a month, Mr. L became withdrawn and appeared depressed. He was confused and intermittently disoriented to place and time. He became irritable and started reporting concerns about his wife having an affair. During this time different medications were introduced, including steroids and several antibiotics.