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- Sep 17, 2015
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I was on night float at the VA when I got a call from the ED attending at about 11 pm. He was telling me about a 91-year old male in the ED who he wanted me to see. Basically, he had a fall a couple of weeks prior, was admitted on a medicine unit for about 5 days, and then discharged to a rehab facility to get his strength up. He has no known past psychiatric history but is on Depakote. He also has "advanced dementia", prior stroke without lasting deficits, HTN and DM2. While at the facility, he became combative and struck one of the other residents. Apparently his behavior has been increasingly agitated. Could I come down and see him?
Now, already I'm thinking, no known past psych history, elderly, has dementia. Probably just worsening dementia with maybe a sprinkling of delirium depending on what's happening. I go see him. Sure enough, no past psych history, Depakote was started a couple of days ago at the rehab facility to "stabilize his mood". The guy is really pleasant now but a poor historian so his son provided the history. Patient did say that he was urinating a lot more but no pain/burning. No cough. Has some bruises from the fight but otherwise looking good for his age. He needs help with his ADLs though and previous PT assessment said he needs 24-hour care. Family is already working with a case manager to get him to a long-term nursing care facility after the subacute rehab is done.
I tell this to the overnight attending and propose that the patient be admitted to medicine for dementia, rule out possible delirium. His real issue is needing to get stabilized and then dispo, which he can get far more easily out of a medical than psych unit. Haldol 0.5 mg PO/IM q12h for psychotic agitation, otherwise all the usual delirium/sleep protocol (frequent reorientation, encourage family to bring personal items, early ambulation with help of PT, pain control, lights on during day and off at night, no benzos/anticholinergics, no restraints) and of course thorough work-up for any underlying cause of delirium (the UA was still pending when I was called, asked to add-on TSH, RPR, B12, folate, etc.) Attending rubber stamps, I share with the ED, they are on-board after I explain that the Depakote was recently added, and everyone is happy.
Next day, consult attending is sounding angry and wants to give me some "feedback" about how I handled it, but she then got an urgent consult and didn't see me. Will probably find me tomorrow. I keep looking at the case and I feel that I did the right thing. I wouldn't want to admit someone like this to inpatient psych as they won't get any particular benefit from the unit and there are no SI/HI/psych issues per se.
Does anything glaring pop out to anyone? Would be much obliged to have your thoughts.
Now, already I'm thinking, no known past psych history, elderly, has dementia. Probably just worsening dementia with maybe a sprinkling of delirium depending on what's happening. I go see him. Sure enough, no past psych history, Depakote was started a couple of days ago at the rehab facility to "stabilize his mood". The guy is really pleasant now but a poor historian so his son provided the history. Patient did say that he was urinating a lot more but no pain/burning. No cough. Has some bruises from the fight but otherwise looking good for his age. He needs help with his ADLs though and previous PT assessment said he needs 24-hour care. Family is already working with a case manager to get him to a long-term nursing care facility after the subacute rehab is done.
I tell this to the overnight attending and propose that the patient be admitted to medicine for dementia, rule out possible delirium. His real issue is needing to get stabilized and then dispo, which he can get far more easily out of a medical than psych unit. Haldol 0.5 mg PO/IM q12h for psychotic agitation, otherwise all the usual delirium/sleep protocol (frequent reorientation, encourage family to bring personal items, early ambulation with help of PT, pain control, lights on during day and off at night, no benzos/anticholinergics, no restraints) and of course thorough work-up for any underlying cause of delirium (the UA was still pending when I was called, asked to add-on TSH, RPR, B12, folate, etc.) Attending rubber stamps, I share with the ED, they are on-board after I explain that the Depakote was recently added, and everyone is happy.
Next day, consult attending is sounding angry and wants to give me some "feedback" about how I handled it, but she then got an urgent consult and didn't see me. Will probably find me tomorrow. I keep looking at the case and I feel that I did the right thing. I wouldn't want to admit someone like this to inpatient psych as they won't get any particular benefit from the unit and there are no SI/HI/psych issues per se.
Does anything glaring pop out to anyone? Would be much obliged to have your thoughts.