Delirium or Primary psych issue

[nexus73]

Elderly patient with hx of schizoaffective disorder and chronic kidney disease initially admitted to psych with mania/psychosis (including profound confusion and disorientation), but transferred to medicine when acute on chronic renal failure and elevated calcium was discovered. Attending psychiatrist suspects delirium.

Medical service treats medical problems over the course of 1 week, but mania/psychosis/confusion persist. Brain imaging and extensive lab workup unremarkable for ongoing organic issues. Psych has been consulting and managing medications covering potential underlying schizoaffective/bipolar, including antipsychotics to manage behavioral disturbance from delirium. Despite this, symptoms persist, with ongoing mania/psychosis and disorientation/confusion. Medical service wants to transfer back to psych unit because "we're not doing anything for him/her". Psych is concerned about persisting delirium slow to clear following acute kidney failure and elevated Calcium (also, patient has chronic anemia related to kidney dz potentially contributing). Prior manic/psychotic episodes were never this severe per spouse, and would typically clear within several days back on meds. Current symptoms persisting 2 weeks back on meds, now 1 week post return to baseline creatinine.

Would you transfer this patient back to the psych unit?

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[thepoopologist]

If the psych unit is not attached to the medical floor, than no I'd push back. However sometimes politics is involved and you take the patient, then call EMS when something is wrong.

So...
Scans and labs unremarkable.
Not a stroke
Not uremic
Still some delirium/mania/psychosis that hasn't really cleared.

How old is elderly? Female you said?
Vital signs?
Any rigidity?
Is she taking PO ok?

Edit: I should add a straightforward answer is she may be taking longer to clear and the treatment is correct. But since this is the psych forum let's zebra on.

 

[J ROD]

A lot of times at my hospital it depends......generally if they are fairly medically stable and have ongoing psych and delirium, we will take the older folks that are ambulatory to our GERI unit. They tend to wander about the medical floor and RN's on those floors tend to heavy handed on the IM shots etc. So, we can usually manage them better in terms of agitation with IM taking a secondary role. And we have the locked unit. Also, their violence level makes a big decision too. If they are so bad, needed restraints and such. We generally keep them on the medical floor and possible ICU.

 

[FlowRate]

I mean, is it a waxing and waning alteration of mental status/arousal and is there also variably affected attention? Confused and disoriented doesn't discriminate between psychosis and delirium.

There's sometimes a tendency to overmedicate behavioral disturbance from delirium which may contribute to prolonged alteration (sedation) of mental status. (But happier nurses.)

 

[nexus73]

I mean, is it a waxing and waning alteration of mental status/arousal and is there also variably affected attention? Confused and disoriented doesn't discriminate between psychosis and delirium.

There's sometimes a tendency to overmedicate behavioral disturbance from delirium which may contribute to prolonged alteration (sedation) of mental status. (But happier nurses.)

This is a good question. In my training/experience, we'd see really severe schizophrenia decompensation and manic episodes, but they would tend NOT to be disoriented or confused. They could be very disorganized, and might have delusional ideas (e.g. this is a government testing site made to look like a hospital but I know the truth)...but they knew where they were and what year it was, for example.

 

[splik]

yes, though ideally transfer to geropsych if available.

 

[nexus73]

yes, though ideally transfer to geropsych if available.

Thanks. We have no gero psych, so patient will be taking up a regular psych unit bed while the ED backs up.

 

[Psychresy]

I mean, is it a waxing and waning alteration of mental status/arousal and is there also variably affected attention? Confused and disoriented doesn't discriminate between psychosis and delirium.

There's sometimes a tendency to overmedicate behavioral disturbance from delirium which may contribute to prolonged alteration (sedation) of mental status. (But happier nurses.)

Have a patient now who is currently psychotic but there also may be a component of delirium overlaying this. Any specific tips or things to look for in order to discriminate the two? The obvious being more of a fluctuation with the delirium of course.

 

[FlowRate]

Have a patient now who is currently psychotic but there also may be a component of delirium overlaying this. Any specific tips or things to look for in order to discriminate the two? The obvious being more of a fluctuation with the delirium of course.

It can be tough, especially if they already have profound negative symptoms or really distracting positive symptoms (things that would preclude attention testing.) Also tough if they're getting frequent heavy doses of sedating antipsychotics (confound for waxing/waning, although if it seems more related to timing of medications that might be a clue that it's not delirum.) There's also some characteristic differences in the hallucinations/confusion/behavior of delirium when compared to psychosis e.g. the picking behavior that's common in delirium (TIL that's called "carphologia"--might be fun to drop that on CL rounds!) or visual hallucinations (or misperception)/location confusion which are also more common in delirium but less typical of schizophrenia.

I guess OP is really asking about how to determine the presence of delirium in addition to psychosis for the purposes of arguing for/against a disposition. I think it's a reasonable debate as to whether the presence of delirium really justifies continued time on the medical floor if their underlying medical insult is resolved. It can take a very long time for delirium to clear (IIRC potentially many months.)

 

[Mass Effect]

It can be tough, especially if they already have profound negative symptoms or really distracting positive symptoms (things that would preclude attention testing.) Also tough if they're getting frequent heavy doses of sedating antipsychotics (confound for waxing/waning, although if it seems more related to timing of medications that might be a clue that it's not delirum.) There's also some characteristic differences in the hallucinations/confusion/behavior of delirium when compared to psychosis e.g. the picking behavior that's common in delirium (TIL that's called "carphologia"--might be fun to drop that on CL rounds!) or visual hallucinations (or misperception)/location confusion which are also more common in delirium but less typical of schizophrenia.

I guess OP is really asking about how to determine the presence of delirium in addition to psychosis for the purposes of arguing for/against a disposition. I think it's a reasonable debate as to whether the presence of delirium really justifies continued time on the medical floor if their underlying medical insult is resolved. It can take a very long time for delirium to clear (IIRC potentially many months.)

And in the case of geri patients, some may never fully return back to baseline.

 

[calvinhobbes]

Always rule out organic causes first. Example, is this a bad UTI?

edit: never mind I re-read your post and saw labs were normal (?)

 

[calvinhobbes]

Until the AKI resolves and calcium stabilizes I would not transfer to psych. Keep her on medicine and act as a consulting psychiatrist 🙂 also some of the nurses on psych may refuse a “medical” patient anyway so it may become a nursing issue too, depends on your hospital’s culture.

 

[calvinhobbes]

Also keep in mind, if this pt is CKD and close to ESRD it’s more likely to be delirium. Any signs of uremia? Possible age-related dementia as well. Yeah, keep her on the medical floor for now until discharge.

 

[bobby pen]

Could consider EEG to help with delirium rule/in out. Pts on dialysis with esrd can have so many causes of delirium like aluminum toxicity etc. Sometimes the need for dialysis keeps pts on medical floors w/ psych following depending on the unit they go to. ED following? Emergency dept? Renal consult and following would be optimal but I know that’s not always the case.

 

[Stagg737]

Have a patient now who is currently psychotic but there also may be a component of delirium overlaying this. Any specific tips or things to look for in order to discriminate the two? The obvious being more of a fluctuation with the delirium of course.

When they're psychotic are they oriented to place/time/date? If they are then it should be easy. If not, it would be harder but can still find ways to gauge orientation. Do they normally recognize you or nurses from previous encounters when psychotic? Delirious patients are unlikely to recognize you if they didn't previously know you well. Can they remember things you talked about 10 minutes ago or even 2 minutes ago? Psychotic people usually can. Delirious people, not so much. Remember, a key deficit of delirium is impairment in attention from baseline.

It can take a very long time for delirium to clear (IIRC potentially many months.)

It can, had a 90+ yo on my geri psych rotation with Charles Bonnet who had "terminal delirium". Was hypoactive and relatively mild delirium for over a year when I was seeing him. Nearly a year later a co-resident rotated through the same unit and guy was still there and intermittently delirious.

Psych has been consulting and managing medications covering potential underlying schizoaffective/bipolar, including antipsychotics to manage behavioral disturbance from delirium. Despite this, symptoms persist, with ongoing mania/psychosis and disorientation/confusion.

Which symptoms are persisting? Just the disorientation and confusion or are there "true" manic/psychotic symptoms persisting?

I'd also have other questions before accepting them back to psych. If this were just gen med patient, would they be safe to discharge or are this still ongoing concerns with agitation or safety? Ie, are they truly "medically stable" or are they turfing the patient? At units I wouldn't accept this patient back until CL team cleared them, but you may not have that luxury.