50 yr old obese AAF, past hospitalizations to psychiatry, medical hx of PE on warfarin stable, patient comes in with BAL 316 to ED, comes to psych floor and develops altered mental status (confused, not answering, sleepy, falls) goes to medical floor. CT scan head shows mild diffuse atrophy, mild ventricular enlargement (slightly worse from the one done in 2009). Patient transferred back to psych floor once she is awake and delusional (from the sleepy state). Now she stops eating, develops hypernatremia so sent back to medical floor. Next day Na+ is normal and patient is more awake but very confused. Sleeps during conversations, responds to internal stimuli, cannot follow directions, oriented only to her own name. Neuro consulted in past said alcohol related dementia. Now they want to transfer pt back to psych floor. I feel it is delirium, doesnt look psychosis. They say its psychosis, and she is not eating intentionally (swallow evaluation clear per them). Meds are Haldol 2 mg po tid, depakote 500 bid (ammonia 26) other labs normal. Any ideas welcome (I asked them to do LP, EEG but they said unlikely to yield anything )..
delirium vs dementia vs zebra
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Please tell me this patient got thiamine. I'm worried about Wernicke encephalopathy. Any ataxia, nystagmus?
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How are her vitals? Any autonomic instability pointing to DTs as well? Or ataxia/urinary incontinence pointing to NPH?
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Agree with ? Wernicke's. What other labs have been done? Liver's ok, huh? Pancreas? PRES?
Nitpicky point: Psychosis is a symptom (or cluster of symptoms), not a diagnosis. In fact, it can be a symptom of delirium (amongst a zillion other conditions). As such, it is incorrect to say "it is delirium, doesn't look like psychosis." What you mean, of course, is that it doesn't look like a primary thought disorder. It just drives me crazy when doctors use these terms inappropriately, sorry.
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This is not due to a psychiatric condition, though it can be due to psychiatric meds.
Also, unless I missed it, you never told us her prior psychiatric diagnoses, only that she has been hospitalized before.
Wernicke's I think too ( as mentioned in neuro consult already ) but Internists are kind of throwing it at me as they believe it is just psych. Thanks for the replies, sorry about the psychosis part.. But you know what I mean 🙂
And past diagnosis was Bipolar, didn't mention it as usually I don't agree with the past diagnosis 😉 it is a community hospital, notes are not indicative of real symptomatology in the past. Spoke to patient's family who said that she has never been like this before. She has some gait instability but no incontinence. Does have urine retention.
I think mainly I am trying to vent here, so that I don't feel guilty that I didn't accept her again to my floor yet, even though it is in her best interest.
And past diagnosis was Bipolar, didn't mention it as usually I don't agree with the past diagnosis 😉 it is a community hospital, notes are not indicative of real symptomatology in the past. Spoke to patient's family who said that she has never been like this before. She has some gait instability but no incontinence. Does have urine retention.
I think mainly I am trying to vent here, so that I don't feel guilty that I didn't accept her again to my floor yet, even though it is in her best interest.
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Primary psychosis or psychotic mania wouldn't cause disorientation and fluctuating consciousness.
Did she get thiamine in the ED? If not, I think that most of us would call it Wernicke's.
Are her vital signs stable? If not, I think that most of us would call it delirium.
UA? CBC?
What's her baseline mental status like?
Are there any focal deficits on neuro exam? Considering the urinary retention, I'm concerned about a focal lesion.
Is she on any other medications?
How hypernatremic was she? How rapidly was the hypernatremia corrected?
Considering the diffuse atrophy and her alcohol history, I think alcohol related dementia sounds about right, with acute deterioration likely from Wernicke-Korsakoff syndrome. Psychiatric illnesses don't cause fluctuating alertness and diffuse cerebral atrophy. Prior diagnosis of bipolar might have been because she acted crazy when she was withdrawing from alcohol.
Did she get thiamine in the ED? If not, I think that most of us would call it Wernicke's.
Are her vital signs stable? If not, I think that most of us would call it delirium.
UA? CBC?
What's her baseline mental status like?
Are there any focal deficits on neuro exam? Considering the urinary retention, I'm concerned about a focal lesion.
Is she on any other medications?
How hypernatremic was she? How rapidly was the hypernatremia corrected?
Considering the diffuse atrophy and her alcohol history, I think alcohol related dementia sounds about right, with acute deterioration likely from Wernicke-Korsakoff syndrome. Psychiatric illnesses don't cause fluctuating alertness and diffuse cerebral atrophy. Prior diagnosis of bipolar might have been because she acted crazy when she was withdrawing from alcohol.
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well you're the psychiatrist, so it's your job and area of expertise to tell them whether or not you a mental disorder explains the patient's presentation. You can write something along the lines of: "the patient's history of alcohol-induced major neurocognitive disorder, current altered level of consciousness, disorientation, dysexecutive functioning, distractibility, day-night reversal, and perceptual distortions are not consistent with any major mental illness and suggest a delirious process. There is no evidence of any depressive, manic, or Schneirderian symptoms, and although the patient is endorsing beliefs that could be consistent with delusions, the overall clinical picture is not consistent with an affective of schizophreniform disorder".
The problem is you cannot really exclude that this patient isn't manic or depressed right now, on top of whatever brain rot she might have. I would be amazed if this pt had Wernicke's at that would border on malpractice- every alcoholic admitted to psychiatry gets thiamine. at any rate, the patient should have gotten thiamine by now, and it is not going to cause any harm to give 100mg TID if need be, sometimes I recommend as high as 500mg TID IV. The tests to confirm thiamine deficiency are useless (erythrocyte transketolase levels) as it takes forever to come back and is usually a send-out. MRI brain has a high specificity (>90%) but low sensitivity (~50%) for Wernicke's (look for hemorrhages typically of periaqeductal grey area, thalami, mammilary bodies typically). It sounds like the AMS developed before the hypernatremia, but one might also one to consider possibility of CPM (central pontine myelinolysis) which doesn't always present w/ the classic tetraplegia, and can cause peduncular hallucinosis so if there is suspicion of that (which doesn't sound like there is, then MRI may be warranted).
The other problem is that it's not really true that delirium is always reversible. For a 50 year old to be delirious that is not substance related (presume this isn't delirium tremens, doesn't sound like it), severe sepsis, or AIDS-related, the patient already has significant brain rot or dementia. Usually patients take a hit and never return exactly to baseline. Many patients never recover from their delirious process. Given patient has a more subcortical dementia anyway, it can be difficult to tease apart from delirium as attentional impairments, fluctuations of consciousness, apathy, and executive functioning impairments are common. So she could end up stuck like this.
Unfortunately, we have abdicated our right to tell people that we want MRIs, EEGs, LPs and the like and these services won't take kindly to you suggesting it. Fair enough, it's not in our training (though I think it should be). However you have every right to refuse to admit this patient if you believe there is no evidence of major mental illness, and that the patient's needs wouldn't best best served on a psychiatric floor. If they are just gonna kick her to the curb and you think she needs to be in the hospital, I would probably take her to psych all the while documenting that you think the patient is likely delirious.
The problem is you cannot really exclude that this patient isn't manic or depressed right now, on top of whatever brain rot she might have. I would be amazed if this pt had Wernicke's at that would border on malpractice- every alcoholic admitted to psychiatry gets thiamine. at any rate, the patient should have gotten thiamine by now, and it is not going to cause any harm to give 100mg TID if need be, sometimes I recommend as high as 500mg TID IV. The tests to confirm thiamine deficiency are useless (erythrocyte transketolase levels) as it takes forever to come back and is usually a send-out. MRI brain has a high specificity (>90%) but low sensitivity (~50%) for Wernicke's (look for hemorrhages typically of periaqeductal grey area, thalami, mammilary bodies typically). It sounds like the AMS developed before the hypernatremia, but one might also one to consider possibility of CPM (central pontine myelinolysis) which doesn't always present w/ the classic tetraplegia, and can cause peduncular hallucinosis so if there is suspicion of that (which doesn't sound like there is, then MRI may be warranted).
The other problem is that it's not really true that delirium is always reversible. For a 50 year old to be delirious that is not substance related (presume this isn't delirium tremens, doesn't sound like it), severe sepsis, or AIDS-related, the patient already has significant brain rot or dementia. Usually patients take a hit and never return exactly to baseline. Many patients never recover from their delirious process. Given patient has a more subcortical dementia anyway, it can be difficult to tease apart from delirium as attentional impairments, fluctuations of consciousness, apathy, and executive functioning impairments are common. So she could end up stuck like this.
Unfortunately, we have abdicated our right to tell people that we want MRIs, EEGs, LPs and the like and these services won't take kindly to you suggesting it. Fair enough, it's not in our training (though I think it should be). However you have every right to refuse to admit this patient if you believe there is no evidence of major mental illness, and that the patient's needs wouldn't best best served on a psychiatric floor. If they are just gonna kick her to the curb and you think she needs to be in the hospital, I would probably take her to psych all the while documenting that you think the patient is likely delirious.
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The complicating feature in this story is that the patient started out on the psych ward before being transferred to medicine; maybe that is why you (the OP) is getting so much resistance- every one views the patient as "your patient". It doesn't sound like the patient is at high risk for acute medical decompensation at this point; if I was in your situation I would take bake the patient to the psych ward, order the MRI/EEG, and perform the LP myself
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This is the classic issue of non psych md seeing a psych med or questionable psych dx and dumping ams on psych before ruling out all else. When neuro doesnt want to see ppl, esp psych pts, everything is functional. At my institution, they routinely get away with blocking anything thats not an acute cva, and the ED plus any non naive IM intern/resident will push hard for psych either sincerely or conveniently believing there is nothing to "find." WE will have a hell of a harder time saying "no" when people resist an objective w/u that's supposedly not indicated for any "non-focality." Sometimes it's pure laziness on the part of other services. Beyond that, there is an educational component missing with other services where they don't realize one may never find "the cause," and not finding a cause doesn't make it psychiatric by default. The problem is, they latch on to "prior psych history." It's crappy pt care. Perhaps it'd help psych and neuro to have the same training in intern year. On our end, we could stop psychiatricizing substances for something other than what they are; it ultimately harms these pts when medically ill. Especially when pt's become equipped with psychiatric jargon and use these words to describe their experience of delirium. The only way to deconstruct such a mess is to document that collateral information makes the pt's current presentation inconsistent with their "psychiatrically ill" baseline.
A good example of something like this was an alcoholic we had in the inpatient service who had hepatic encephalopathy/delirium due to hyperammonemia and was consequently manic-like in presentation. Yes, mania due to a medical cause. Whew.
He got dumped on us because he previously received a dx of bipolar (as a much older adult) while chronically encephalopathic from drinking/liver problems. The attending didn't really care what the cause was so long as lithium was a "first line" treatment. When lactulose was started, he started improving but the psych nurses weren't keen on pt code browning all over the psych unit. Sad. So the other "educational component" for non psych services is that delirium not only has etiologies that aren't always uncovered and can last for a very long time after labs have normalized, but that it presents in many different ways...
A good example of something like this was an alcoholic we had in the inpatient service who had hepatic encephalopathy/delirium due to hyperammonemia and was consequently manic-like in presentation. Yes, mania due to a medical cause. Whew.
He got dumped on us because he previously received a dx of bipolar (as a much older adult) while chronically encephalopathic from drinking/liver problems. The attending didn't really care what the cause was so long as lithium was a "first line" treatment. When lactulose was started, he started improving but the psych nurses weren't keen on pt code browning all over the psych unit. Sad. So the other "educational component" for non psych services is that delirium not only has etiologies that aren't always uncovered and can last for a very long time after labs have normalized, but that it presents in many different ways...
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Sounds like medicine is frustrated (perhaps with the pt's difficult behavior) and wants to turf the pt back to psych. This is typical behavior in my facility.
So she is retaining urine? They need to check a UA.
So she is retaining urine? They need to check a UA.
when I heard this story, the first thing I thought is: how was this patient functioning before she came in the hospital? What was her living situation? It seems very likely that there is no great pathology here- just as very low functioning alcoholic with pre-existing brain damage from alcoholic dementia, possibly pre-existing brain damage from being smi, and given the medical hit she has taken over the last few days(hypernatremic) probably isn't back to her (very crappy)premorbid function just yet......I guess I'd probably take her back on psych, but the real issue is going to be placement. You need to come to terms with the fact that there likely isn't anything to 'treat' now(for a medicine or psych service) and that when she is discharged she is going to be discharged very low functioning.
Thanks for all the replies.
I was not the attending psychiatrist during her first 6 days of initial psych admission, someone transferred to me when they thought they were capped and they wanted to transfer only this pt. Second, yes, major fight is related to stigma of a psychiatry patient , seems like ED and medical floor don't even want to work up a patient who has been in psych floor. Third, even psychiatrists are not doing their jobs well when they have been giving Bipolar diagnosis to all drug and alcohol induced problems. Last, visitaril you are right, she is homeless, years of alcoholic street lifestyle. But then obamacare has kicked in and my social workers had already started the process for transfer to a skilled nursing facility . Only problem, how to discontinue the sitter for 1:1 so that they accept her. She has been getting thiamine from the start and this is not cpm.
I was not the attending psychiatrist during her first 6 days of initial psych admission, someone transferred to me when they thought they were capped and they wanted to transfer only this pt. Second, yes, major fight is related to stigma of a psychiatry patient , seems like ED and medical floor don't even want to work up a patient who has been in psych floor. Third, even psychiatrists are not doing their jobs well when they have been giving Bipolar diagnosis to all drug and alcohol induced problems. Last, visitaril you are right, she is homeless, years of alcoholic street lifestyle. But then obamacare has kicked in and my social workers had already started the process for transfer to a skilled nursing facility . Only problem, how to discontinue the sitter for 1:1 so that they accept her. She has been getting thiamine from the start and this is not cpm.
What was the time course for the AMS? Also, how did they present clinically with a BAL of 316? If they were able to hold a conversation beyond whatever conversation someone makes when they lose all respiratory drive, I'd assume this patient has a pretty remarkable alcohol tolerance and would be going into some serious withdrawal within a couple of days. That is unless they were put on a benzo taper, in which case you could then blame benzo toxicity (worsened by the underlying dementia). So I would at least ask medicine to get a CIWA score before taking her back to psych, as this sounds like it could be a very complicated withdrawal.
It might be also be an opportunity to educate medicine that the psych floor isn't some dumping ground to throw dispositionally patients; it actually has a therapeutic function. If the patient could benefit from milieu therapy, attend groups, or adhere to a behavioral plan managed by a well-trained staff, than I would bring her right away to psych. If she's using the TV remote to call 1994 to pick her up from the morgue, then it doesn't matter which floor she is on. Unless they can prove to you she's not receiving adequate treatment on the medicine floor that she would otherwise be getting on psych, there's no rush to get her out. They're just as good at giving haloperidol, although they are much better at resolving electrolyte abnormalities.
If that doesn't give you any mileage, you can spin a story that her her unexplained PE could be Trousseau's syndrome secondary to some malignancy. As an aside, the Depakote can also increase the warfarin levels, so I'd at least ask medicine to help get her to an appropriate level before they ship her back.
Edit: I realize re-reading this that it comes across as tactical/confrontational. The ultimate goal isn't to block or punt the patient; its to get them good care. As long as you're acting in their best interest (and I don't really see how its in the patient's best interest to be on a non-medicine floor), then you're in the right.
It might be also be an opportunity to educate medicine that the psych floor isn't some dumping ground to throw dispositionally patients; it actually has a therapeutic function. If the patient could benefit from milieu therapy, attend groups, or adhere to a behavioral plan managed by a well-trained staff, than I would bring her right away to psych. If she's using the TV remote to call 1994 to pick her up from the morgue, then it doesn't matter which floor she is on. Unless they can prove to you she's not receiving adequate treatment on the medicine floor that she would otherwise be getting on psych, there's no rush to get her out. They're just as good at giving haloperidol, although they are much better at resolving electrolyte abnormalities.
If that doesn't give you any mileage, you can spin a story that her her unexplained PE could be Trousseau's syndrome secondary to some malignancy. As an aside, the Depakote can also increase the warfarin levels, so I'd at least ask medicine to help get her to an appropriate level before they ship her back.
Edit: I realize re-reading this that it comes across as tactical/confrontational. The ultimate goal isn't to block or punt the patient; its to get them good care. As long as you're acting in their best interest (and I don't really see how its in the patient's best interest to be on a non-medicine floor), then you're in the right.
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Agree with most of the thoughts of Salpingo/vistaril.
You may want to try slowly tapering the psych meds, and see if the patient can get by on a dose of Haldol 1-2 mg/day and perhaps VPA 500 mg/day.
You may want to try slowly tapering the psych meds, and see if the patient can get by on a dose of Haldol 1-2 mg/day and perhaps VPA 500 mg/day.
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How about some MMSE scores? LP and EEG aren't going to show anything (if no headache, no leukocytosis....EEG is going to show you what "diffuse slowing, suggestive of encephalopathy." Agree with above (Wernicke's? DTs? and tapering off psyc meds - which if you don't think she's psychotic and is delirious - should be done). There is no point to admit her psychiatrically just because other idiots don't know how to do their job. You recommend what to do (thiamine, taper meds, withdrawal precautions). Someone saying "it's psychosis" means nothing (I had a senior neurology attending telling me a patient was "looking really paranoid" - pt was not paranoid - but he kept insisting "no he is" - which is why he's not a psychiatrist). If they want to discharge a delirious patient, just ask "so, is your malpractice premium paid up? Great, good luck with that"
