1. 1
Mental Health Consultation
Patient Name: Common Combination Facility: XXXX
Date: X-X-XX (VaD + CKD = Delirium)
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: XX-year-old, white, xxxx, female… I was asked to evaluate her because
of: gross confusion and disorientation; delusional thinking (sister and brother taking her money
and abandoning her); fluctuating moods (weeping); possible visual hallucinations (talking to
someone who “grabbed my xxx”) and physically aggressive behavior (choking other residents).
She was admitted from home on X-XX-XX.
Background Information:
Throughout the month of xxxx she was ABT for UTI after which she was
prophylactically maintained on antibiotics for recurrent UTI. During this time in various
notes she was described as having “anger, hallucinations, delusions and agitation”.
Hallucinations were attributed to Wellbutrin which is extremely unlikely.
She has requested prn Haldol daily; “it calms me right down”
X-XX-XX--- BIMS score = 6/15; PHQ9 score = 6/27. No lab results in her chart.
1-8-13--- Neurologic evaluation at XXXX: Dx = mild cognitive impairment; MMSE =
24/30; neuroimaging: “moderate atrophy… periventricular subcortical white matter
disease… small vessel disease… ischemic injury possibly within the right MCA
watershed due to large vessel or small vessel disease”. There was some speculative talk
about a history of bipolar disorder in the xxxx notes.
Current Medications: ASA, Acetaminophen, Crestor, Effexor XR 300mg qd, Exelon patch
9.5mg/24hr, Diltiazem CD, Oxybutynin, Lorazepam 0.5mg tid, Ranitidine, Trazodone 150mg
qhs, Folic acid, Vitamin B-12, Haldol 1mg bid and 5mg q 4hr IM prn, Amoxicillin.
Medical History: Anxiety State, Stress Incontinence, Unspecified Psychosis, Dementia with
Behavior Disturbance, Hypertension, Anemia, Insomnia, Osteoporosis, GERD, Type II Diabetes
Mellitus, Hyperlipidemia, Diverticulosis, Insomnia, Depressive Disorder, Vitamin B-12,
Osteoarthritis, Stage III Chronic Kidney Disease
Mental Status Exam: She was a well groomed, cooperative, pleasant, slightly tremulous
woman who said “You should have seen me this morning; I was so much more shaky”. She was
grossly confused and disoriented. She thought she was in the hospital in Warsaw. When I asked
if her husband was alive she responded, “I would have to check on that”. She identified the
photo of her husband as “my grandpa”. When I asked about children she responded, “yes, but I
don’t know anything more about them”. Her speech was disorganized and perseverative. Her
affect was constricted. Her mood was, to use her words, “nervous… anxious …it’s because I
can’t sleep”. She did not express any overtly delusional thoughts during the interview nor did
she appear to be hallucinated. Her insight and judgment were limited.
2. 2
Findings and Recommendations: I believe that diagnostically this is a straightforward case.
This lady has a fairly severe vascular dementia which makes her highly vulnerable to delirium
and due to her chronic kidney disease and her recurrent urinary tract infections she has been
subject to a chronic delirium. There were no obvious clinical manifestations of Bipolar Disorder.
Subcortical arteriosclerotic encephalopathy is a vascular dementia (VaD) involving the small
penetrating vessels supplying the deep white matter of the cerebral hemispheres. It occurs in
elderly individuals with a history of chronic hypertension. A gradually progressive course with
dementia and personality change is typical. Neuropsychiatric findings include memory
impairment, poor judgment, lack of spontaneity, perseveration, psychomotor slowing, general
dilapidation in cognitive functioning and apathy. Gait problems and falls, weakness, ataxia,
rigidity, dysarthria, Parkinsonism and urinary incontinence are frequent neurological signs. TIAs
and “stroke-like” episodes are common features of this disease process. Episodes of nocturnal
confusion, “delirium-like” episodes and fluctuating mental status are common in VaD patients.
She at times has shown nearly all the S/S of Delirium: a.) visual illusions and/or hallucinations
b.) fragmented and disordered stream of thought c.) psychomotor acceleration vs. stupor d.) fear
and/or apprehension e.) disrupted sleep /wake cycle f.) clouding of consciousness
g.) fluctuating levels of awareness h.) gross confusion.
Her current mental status represents a major change from that which is depicted in the report
from xxxx; this supports a diagnosis of delirium. She is improving now because of treatment
with Haldol since 8/27.
1. Would discontinue Haldol; no need to risk causing an extrapyramidal syndrome
(parkinsonism, dystonia, akathisia or dyskinesia) and start Risperdal 0.5mg bid and
0.5mg q 6hr prn titrating up quickly if necessary. Risperdal is highly antidopaminergic
which makes it nearly as effective as Haldol in treating delirium.
2. Would discontinue lorazepam. Benzodiazepines can cause or worsen disinhibition in
delirious patients.
3. Delirious patients are hyper-responsive to stimuli. Keep her exposure to high levels
stimulation to an absolute minimum.
4. Allow physical activity (do not try to restrict her restless movements) and encourage rest,
sleep and nutrition and attend to her physical comfort.
5. Would obtain new comprehensive labs including: CMP, CBC, and UA with C&S trying
to identify any delirium producing condition(s). (Look for high BUN)
6. Create a soothing, familiar environment in her room with soft music and dim lighting.
7. Frequent, brief, reassuring contacts by staff…move and speak slowly around her.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist
