Prepare for the PANCE® with this challenging clinical scenario involving a 72-year-old woman showing signs of confusion. Which of the findings are consistent with delirium?
A 72-year-old woman is brought by ambulance to the emergency department because of confusion. The patient is a professor at the local university and appeared confused during a lecture, prompting students to call an ambulance. Past medical history is significant for hypertension for which the patient takes amlodipine. The patient had two teeth extracted four days ago and has been taking oxycodone 5 mg orally every six hours for pain control. Vital signs are within normal limits. On physical examination, the patient appears confused. She has no focal neurologic deficits. Pupils are miotic but reactive. The lower abdomen is distended without tenderness to palpation. Rectal exam reveals hard, firm stool in the rectal vault.
Which of the following findings would be most consistent with a diagnosis of delirium?
A. Inability to spell the word ‘WORLD’ backwards
B. History of increasing difficulty remembering words in her lectures for the past year
C. Normal immediate recall of events just prior to the lecture
D. Lack of interest in usually pleasurable activities for the past 3 months
E. One-year history of telling family and friends that a government agency is spying on her
Scroll down to find the answer!
The correct answer to today’s PANCE® Question is…
A. Inability to spell the word ‘WORLD’ backwards
Correct: See Main Explanation.
Incorrect Answer Explanations
B. History of increasing difficulty remembering words in her lectures for the past year
Incorrect: This would be more of an indication of dementia rather than delirium. Delirium has an acute and fluctuating course and develops over the course of hours to days. Dementia has a more chronic and progressive course.
C. Normal immediate recall of events just prior to the lecture
Incorrect: Patients with dementia often have good immediate recall, while immediate recall is often impaired in patients with delirium.
D. Lack of interest in usually pleasurable activities for the past 3 months
Incorrect: This is more indicative of depression rather than delirium.
E. One-year history of telling family and friends that a government agency is spying on her
Incorrect: Patients with delirium may have delusions, but these typically exist for hours to days. Having ongoing delusion over months to years is more consistent with dementia or psychosis.
Main Explanation
This patient who was prescribed opioid medication presents with confusion, miotic pupils, and a rectal exam that suggests constipation. These findings are consistent with opioid use and opioid intoxication causing delirium. Attention span, thought processes, and level of consciousness can all be altered in delirium. This patient’s mental status should be assessed, and focus should be on determining the patient’s ability to sustain and shift attention appropriately. Being able to spell the word ‘WORLD’ backward (or serial 7s in non-English speakers) requires focused attention. Attention should also be assessed globally, which can be done while taking the history.
Delerium can often be missed in patients in the hospital. A widely used and validated scale to screen patients for delirium is the Confusion Assessment Method (CAM), which includes 4 fundamental features of delirium: (1) acute onset and fluctuating course, (2) inattention, and either (3) disorganized thinking, or (4) altered level of consciousness.
Major Takeaway
Delirium refers to an acute and fluctuating state of altered mental status where decreased attention is a hallmark feature. A global assessment of the patient’s attention should be made, and questioning during the mental status exam should test patients’ ability to maintain and shift attention appropriately.
Want to learn more about this topic?
Watch this Osmosis video: Delirium
References
- American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults (2015). American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. Journal of the American Geriatrics Society, 63(1), 142–150.
- Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., Joffe, A. M., … Alhazzani, W. (2018). Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Critical care medicine, 46(9), e825–e873.
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