1/8. Anticipating and preventing delirium.delirium is one of the most common complications in elderly hospitalized patients. It is a predictor of poor prognosis. Despite its high incidence, studies have shown that physicians fail to detect at least half of all cases of delirium. This presentation will briefly discuss the diagnostic criteria according to the fourth edition of diagnostic and statistical manual of mental disorders, the incidence and characteristics of delirium. It will then go on to discuss in more detail risk factors that assist in anticipating the development of delirium. Finally, attention will be given to specific interventions to use with patients in high-risk categories with the goal of preventing the development of delirium in these individuals.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/8. Olanzapine-induced vasculitis.INTRODUCTION: Elderly patients are particularly vulnerable to adverse drug reactions as a result of polypharmacy and metabolic changes associated with aging. We present a case of leukocytoclastic vasculitis induced by olanzapine, a medication commonly used in elderly patients. CASE SUMMARY: An 82-year-old woman was admitted to the extended-care center for short-term rehabilitation after prolonged hospitalization for a pulmonary embolism requiring mechanical ventilation. The pulmonary problem resolved, but her hospitalization and subsequent rehabilitation were complicated by agitated delirium, which was treated with olanzapine and modification of contributory factors. At the time of admission to the rehabilitation facility, the patient had been receiving warfarin for 2 weeks and olanzapine for 6 days. On the eighth day after initiation of olanzapine, erythematous skin lesions developed on dependent areas. The international normalized ratio for warfarin was within the acceptable range; however, because warfarin has been associated with subcutaneous bleeding presenting as petechiae and ecchymosis, subcutaneous enoxaparin was substituted for warfarin. The skin lesions continued to worsen over the next week and developed into palpable lesions. biopsy of the rash revealed leukocytoclastic vasculitis. In the absence of another cause, olanzapine was discontinued and the rash improved significantly. When the agitation recurred, risperidone was initiated, but the patient experienced dizziness with this agent. Olanzapine was resumed and the skin lesions recurred. Olanzapine was then changed to quetiapine, and the skin lesions improved over the next few weeks. DISCUSSION: Olanzapine is commonly used in elderly patients to control behavioral disturbances associated with dementia, delirium, and other psychiatric disorders. Leukocytoclastic vasculitis is an infrequently reported adverse drug reaction with olanzapine. Its exact pathogenic mechanism is unknown, but both cell-mediated and humoral immunity appear to play important roles. Because drug-induced vasculitis has an identical clinical presentation and identical serologic/pathologic parameters to idiopathic forms of vasculitis, a high index of suspicion is necessary for its accurate diagnosis. CONCLUSIONS: Because adverse drug reactions are common in elderly patients taking multiple medications, physicians should be vigilant when starting new medications and should attempt to eliminate unnecessary medications. Clinicians should be aware of the potential for leukocytoclastic vasculitis in association with olanzapine.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/8. Does delirium need immediate medical referral in a frail, homebound elder?BACKGROUND AND PURPOSE: This case report describes the clinical decision making process of a physical therapist whose examination of a home bound elderly woman led to a referral for hospitalization. We illustrate how the use of a comprehensive systems screen and thorough examination identified a patient with treatable conditions that required medical care. CASE DESCRIPTION: The patient was a frail 93-year-old woman. She was referred for home-care physical therapy with multiple medical comorbidities and functional decline following a short hospitalization for fall-related injuries. Her function improved after several visits, but upon resuming treatment after a 2- week hiatus, the patient demonstrated major decline in cognitive and physical function. OUTCOMES: The comprehensive systems screen revealed that the patient had increased pallor, loose and frequent bowel movements, urinary incontinence and increased frequency of micturition, confusion and apathy, and extreme fatigue. Her examination showed large declines in scores for Functional Independence Measures, Mini Mental Status Examination, Berg Balance Test, and Timed Up and Go. These results were consistent with indicators for delirium, dehydration, and anemia. The findings were reported to the patient's physician and family members agreed to have the patient evaluated in the local emergency room. CONCLUSIONS: This case report illustrates how knowledge of the pathologies associated with delirium and thorough examination can assist the physical therapist in making clinical decisions when homecare patients require prompt medical referral.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/8. Evaluation and treatment of mental disorders in patients with AIDS.Mental symptoms are common in patients with AIDS. Optimal management involves the identification and treatment of underlying mental disorders rather than symptomatic treatment alone. Organic mental disorders are very frequent in AIDS, particularly with seriously ill patients who are medical inpatients. There is a high priori probability that such common symptoms as agitation, irritability, and insomnia will be caused by an organic mental disorder. psychopharmacology in the patient with AIDS requires considerable caution. Lower doses and careful surveillance for subtle neuropsychiatric side effects are necessary. Routine medical contact with a compassionate physician may be of inestimable value to the patient in coping with the fear and dread that surround the illness.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/8. Altered mental status in the elderly.Misdiagnosis of treatable dementia in the aged is costly to society and the family, and is unmeasurable in personal tragedy. The 4 Ds of the elderly--dementia, depression, delirium, and delusion--are discussed. family physicians are encouraged to seek out treatable disease.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/8. The role of the psychiatrist in otolaryngology.The patient, staff, and physician benefit when the otolaryngologist and psychiatrist are able to work closely together. Not only is clinical care improved, but time can be spent more efficiently in dealing directly with the patient's problem.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/8. Angel's Trumpet psychosis: a central nervous system anticholinergic syndrome.The authors warn physicians that intoxication by Angel's Trumpet (datura sauveolens) is becoming more frequent due to its use by adolescents and young adults as a legal, readily available hallucinogen. Ingestion of Angel's Trumpet flowers or a tea brewed from them results in an alkaloid-induced central nervous system anticholinergic syndrome characterized by symptoms such as fever, delirium, hallucinations, agitation, and persistent memory disturbances. Severe intoxication may cause flaccid paralysis, convulsions, and death. Treatment with intravenous physostigmine reverses the toxic effects of Angel's Trumpet.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/8. Problems associated with underrecognition of delirium in critical care: a case study.delirium, a syndrome that results in high morbidity and mortality rates in the elderly, continues to be underrecognized by physicians and nurses. Factors influencing the underrecognition of delirium are specific to individual institutions and their health care providers. The factors leading to the underrecognition of delirium must be identified so that changes can be made to increase early recognition. A case study conducted in a critical care unit in a midwestern hospital from interviews of nurses, chart audit, and patient observation, identified two major problems associated with the lack of recognition of delirium in that institution: (1) lack of knowledge on the part of nurses about the criteria and methods of detecting delirium, and (2) ineffective communication between all staff members in relaying symptoms of onset of the disorder. As a result of this study, staff education, assessment protocols, and improved communication and documentation techniques are indicated as targeted methods for improving recognition and treatment of delirium in this setting. Similar case studies can be performed to evaluate institutional practice, and thereby identify barriers to early recognition of delirium.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |