1. The patient has a history of alcohol use, head injury, and medical issues that have contributed to periods of delirium and confusion. 2. During an evaluation in 2013, the patient exhibited signs of acute delirium such as disorientation, hallucinations, delusions, and bizarre behavior. Laboratory results found high ammonia levels and abnormal liver function, contributing to her delirium. 3. The psychologist determined the patient's delirium was resolving with medication adjustments and treatment of her medical issues. Continued monitoring of symptoms and labs was recommended to prevent re-emergence of delirium.

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Mental Health Consultation
Patient Name: Resolving Delirium Facility: XXXX
Date: 8-12-13
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: XX-year-old, white, xxxxxx, female… I was asked to evaluate her because of
periods of increased confusion, verbally aggressive behavior and false accusations aimed at staff.
She was admitted from home on xxxxx.
Background Information:
 During her first year (2010) at XXXX she was mostly described as “alert and oriented times
3 with good verbal communication skill and able to make her needs and wishes known to
staff”. Her 3-25-10 MMSE score = 28/30. Her 10-5-10 MMSE score = 28/30 and on 2-16-12
she scored 24/30. During this period, she was seen going through other residents drawers and
when confronted she denied it.
 In 2013 the picture changed; her MMSE score plummeted to 18/30 on 6-21-13. She
reportedly complained of hallucinations (seeing her dead husband in her room at night). She
would occasionally call 911 to report imaginary intruders and she accused staff of stealing
many of her things and her money. She also expressed delusions about “people coming into
my room to have sex and get impregnated” and at times became physically and verbally
aggressive…“yelling...Leave me the fuck alone” Accusing staff of “running a whore house;
the police need to know about this” “Looking for her brother under the chair cushion”
 She is alienated from 5 of her 6 children. Reportedly, the one she does have contact with is in
prison and he takes advantage of her. She had subdural hematoma evacuated possibly after
being assaulted by her husband. The seizure disorder may be a consequence of this.
 Hospitalized at XXX in August of xxxx for acute pancreatitis and in March of xxxx and
January 2012 for a GI bleed and UTI. Had positive UAs on 6-27-13 and 7-3-13. Around that
time had? NKDA, elevated Bilirubin and ALK. Ammonia level on 6/27= 149.8 and on 6/15=
219.8
Current Medications: Prilosec, Norvasc, Aldactone, Lamictal 100mg bid, Cymbalta 60mg qd,
Abilify increased to 5mg qd on 6/5.
Medical History: GERD, Depressive Disorder, Alcohol Dementia, Alcohol Dependence,
Hypertension, Anemia, Obesity, Seizure Disorder, PVD, S/P Subdural Hematoma
Mental Status Exam: She was an obese, gregarious, well groomed, woman who wore a great deal
of makeup. She had an outgoing even flirtatious manner. Her conversation was full of sexual

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references… “Why did God invent sex?” And she talked frequently about sex between residents.
Her style was theatrical and conspiratorial, as if to include me in a secret. At times her laughter was
quite inappropriate; “My son robbed and stabbed a 96-year-old man in a wheelchair, ha…ha…ha.”
At other times, she was quite engaging and appropriate. Her speech was mostly logical, coherent and
relevant. Her affect was full. There were no signs of depression. She was fully oriented. There were
many word finding pauses in her speech. She admitted to some memory problems. She said at one
time in her life she drank 1quart of liquor every other day but she denied ever having experienced
ETOH withdrawal symptoms. She did say that she received alcoholism treatment at XXXX in
xxxxxxx.
Findings and Recommendations: We have three chronologically distinct clinical pictures here:
First in the period before 2013 we see her baseline where she is described as “alert and oriented
times three with good verbal communication skills” and her MMSE score is 28/30. She also takes
things from other residents then denies it. I do not believe that this behavior is a product of
confusion. She admitted she just “needed some black stockings”. At baseline, she does have some
mild cognitive dysfunction which I think is related to her brain injury not representative of an
alcohol dementia. She does not show the range of signs and symptoms associated with alcohol
dementia.
At baseline she seems to have something of a sociopathic/ histrionic personality disorder which
could include such elements as: a lack of loyalty and honesty, which prevents her from achieving
enduring or satisfactory relationships, a failure to sustain commitments, a tendency to evade
obligations and betray promises, impulsivity, melodramatic theatricality and the exaggerated
expression of emotion. This could be compounded by minimal brain dysfunction due to head injury.
Then in mid-2013 she began showing signs of acute delirium including: gross confusion (MMSE
dropped to 18/30, oriented to name only), sensory misperceptions/ visual illusions/hallucinations;
worse at night (dead husband in her room, imaginary intruders in bathroom), bizarre delusions
(running a whore house, brother under the chair cushion), fear and apprehension (staff out to get
her, people stealing from her).The brain injury makes her vulnerable to delirium.
The cause appears to have been related to recurrent UTIs and very high Ammonia levels, as well as,
abnormal liver function tests. She does not have a cirrhosis or hepatic encephalopathy diagnosis. She
does have a history of GI bleeds. In any case, Dr. xxxxxx has addressed all of this and worked it out
because:
Her current mental status is one of a resolving delirium. She is again well oriented and free of
delusions and hallucinations. However, residual delirium signs can be seen in her preoccupation with
sex, poor judgment and inappropriate affect (laughing at her son’s crimes). I do not see any current
signs of depression but she could have been depressed in the past.
1. It is clear that the last increase in Abilify helped a great deal. I would stick with it for the
time being possibly even increase it to 10mg qd depending on her current symptoms but if
we run into problems in the future, I suggest we switch to Risperdal. When treating a
delirium the more antidopaminergic the drug is the better it is. Also we could use Risperdal
as a prn but Abilify cannot be used as a prn.

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2. Notes suggest that she had “brain surgery due to a subdural hematoma”. Records related to
this including neuroimaging would be very helpful. It would also be helpful to gather her
ETOH treatment records from XXXX.
3. I noted that various staff attempted to “reason with her”. When she is delirious never attempt
to reason with her, ask questions or explain things. Doing so will almost certainly cause the
situation to escalate. Use no choice instruction “come along with me”
4. Delirious patients are hyper-responsive to stimuli. When she is delirious keep her exposure
to stimulation to an absolute minimum. Find a quiet spot for her.
5. Her delirium is resolving now; after I have seen her at base line for a while I will offer more.
6. In the meantime, we should continue to monitor her labs and observe for the following signs
of a re-emerging 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
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Drew Chenelly, Psy.D.
Clinical Neuropsychologist