Case 172: Agitated And Confused José R Maldonado Mdwesley Br

Case 172 Agitated And Confusedjosé R Maldonado Mdwesley Brown A

Case 172 involves Wesley Brown, a 63-year-old male who exhibited a two-week history of unusual and paranoid behavior, culminating in being found unconscious and brought to the emergency room. His presentation included agitation, paranoia, visual and auditory hallucinations, and cognitive impairment. His physical examination revealed signs consistent with anticholinergic toxicity, and his toxicology screen was positive for benzodiazepines and tricyclic antidepressants (TCAs). The clinical picture, along with his history and laboratory findings, suggests a diagnosis of delirium, likely caused by anticholinergic toxicity from medications such as cyclobenzaprine, benzodiazepines, and possibly opioids. This case underscores the importance of recognizing features of delirium, particularly in patients with complex medication histories and comorbidities.

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Delirium is a common and serious neuropsychiatric syndrome characterized by an acute disturbance in attention, awareness, and cognition. It is particularly prevalent among hospitalized elderly patients but can occur at any age, especially in the setting of underlying medical illnesses, medication effects, or toxins. The case of Wesley Brown exemplifies the typical presentation of delirium, marked by acute onset, fluctuating mental status, cognitive deficits, and altered consciousness. Understanding the neurobiology, risk factors, diagnostic criteria, and management strategies for delirium is crucial for clinicians to improve patient outcomes.

Delirium's pathophysiology is multifaceted, involving neurotransmitter imbalances—particularly cholinergic deficiency and dopaminergic excess—along with neuroinflammation, oxidative stress, and metabolic disturbances (Khan et al., 2009). The cholinergic system's role is especially pertinent, as its impairment leads to attentional deficits and consciousness disturbances, hallmark features of delirium. This neurochemical imbalance can be precipitated by medications with anticholinergic properties, metabolic derangements, or direct neurotoxicity. The case highlights how medications like cyclobenzaprine, benzodiazepines, and opioids can collectively contribute to delirium’s development.

In Wesley Brown’s case, the positive toxicology screen for benzodiazepines and TCAs suggests an anticholinergic burden, likely exacerbated by his chronic pain management with opioids and muscle relaxants. Cyclobenzaprine, a centrally acting muscle relaxant with a tricyclic structure, can produce anticholinergic side effects such as dry mouth, urinary retention, confusion, and hallucinations (Tune et al., 1992). These effects, combined with benzodiazepines' sedative properties and potential residual effects of opioids, create a neurochemical milieu conducive to delirium.

Clinically, delirium manifests with a constellation of symptoms including inattention, disorganized thinking, fluctuating levels of consciousness, psychomotor disturbances, and perceptual disturbances. In Wesley Brown's presentation, key features included fluctuating alertness, confusion, visual hallucinations, paranoid ideation, and difficulty with orientation and attention—characteristics aligning with DSM-5 criteria for delirium (American Psychiatric Association, 2013). Physical signs such as mydriasis, hypoactive bowel sounds, urinary retention, and depressed reflexes further support anticholinergic toxicity.

Diagnosing delirium involves a comprehensive evaluation, including detailed history, physical examination, laboratory tests, and neuroimaging when necessary. Routine labs, including metabolic panels, are essential to rule out metabolic causes like hypoglycemia or electrolyte imbalances. Imaging, such as head CT scans in this case, helps exclude structural brain abnormalities. Wesley Brown’s neuroimaging was unremarkable, indicating a functional rather than structural cause of his symptoms. His cognitive testing showed significant impairment, with a Mini-Mental State Examination score of 16, evidencing severe cognitive disturbance.

Management of delirium requires identifying and treating underlying causes—here, medication toxicity and potentially other metabolic or infectious factors. Discontinuing offending agents, providing supportive care, and ensuring adequate hydration and nutrition are primary steps. Pharmacologically, the use of antipsychotics like haloperidol can help control agitation and psychotic features if necessary (Maldonado, 2008). Importantly, care must be taken to avoid medications with anticholinergic properties, which can worsen delirium.

Prevention of delirium involves careful medication management, especially in elderly or cognitively vulnerable patients. Using medications with minimal anticholinergic effects, regular monitoring, and minimizing polypharmacy are critical strategies. Non-pharmacological interventions such as reorientation, sleep promotion, early mobilization, and ensuring sensory aids are essential components of delirium prevention and management (Khan et al., 2009).

The case of Wesley Brown underscores the importance of recognizing delirium as a medical emergency requiring prompt identification of causative factors and swift intervention. It highlights the risks associated with polypharmacy, especially in patients with multiple comorbidities and chronic pain management, emphasizing the need for vigilance in medication prescribing practices. Ultimately, understanding delirium’s complex neurobiology and clinical features enables healthcare providers to improve diagnostic accuracy and therapeutic outcomes.

References

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