This week's content discussed common psychiatric disorders in the Adult and Older Adult client.  Often a secondary diagnosis is masked due to their psychiatric disorder.  Review the following case study and answer the following questions.  Mr. White is a 72-year-old man, with a history of hypertension, COPD and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today. Mr. White's presentation is most consistent with an acute delirium (acute change in cognition, perceptual derangement, waxing and waning consciousness, and inattention).  1. What is the most likely diagnosis to frequently cause acute delirium in patients with dementia? 2. What additional testing should you consider if any? 3. What are treatment options to consider with this patient? Jessica Alper Cause of acute delirium in elderly patients with dementia            Many older people, with and without dementia can be all of a sudden be affected by delirium, which is defined as acute sudden confusion. When an elderly patient becomes confused very suddenly, it is important to look at all possible underlying causes. Mayne et al. (2019) state that “non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI”. Delirium in the elderly is usually associated with lengthened hospital stays, complexed care, institutionalization, along with high mortality rates, difficulties for the caregivers and increased healthcare costs. Signs and symptoms associated with UTIs in the elderly include confusion or delirium, increased lethargy, blunted fever response, new-onset incontinence, as well as anorexia (Rodriguez-Manas, 2020). There are various risk factors associated with UTIs in a male patient. Some of these include prostatic hypertrophy, diabetes, or both, which can lead to high post-void residuals.  Testing            A confused patient who has recently become delirious should be investigated for the source of the delirium. Krinitski et al. (2021) state that “the diagnosis of UTI requires not only confirmed bacteriuria but also the presence of genitourinary symptoms, which often cannot be reliably confirmed in the many delirious individuals who are unable to adequately express themselves”. However in this case study, it is know that the patient is experiencing urinary incontinence, which further justifies the diagnosis of UTI.             A urinary analysis and culture are both highly suggested for this patient. When bacteria from the UTI has been detected in the elderly, providers usually “consider behavioral or mental changes, including delirium, as non-urinary manifestations of UTI, especially in patients with cognitive impairme.

1. This week's content discussed common psychiatric disorders in
the Adult and Older Adult client. Often a secondary diagnosis
is masked due to their psychiatric disorder. Review the
following case study and answer the following questions.
Mr. White is a 72-year-old man, with a history of hypertension,
COPD and moderate dementia, who presents with 4 days of
increased confusion, nighttime restlessness, visual
hallucinations, and urinary incontinence. His physical exam is
unremarkable except for tachypnea, a mildly enlarged prostate,
inattentiveness, and a worsening of his MMSE score from a
baseline of 18 to 12 today.
Mr. White's presentation is most consistent with an acute
delirium (acute change in cognition, perceptual derangement,
waxing and waning consciousness, and inattention).
1. What is the most likely diagnosis to frequently cause acute
delirium in patients with dementia?
2. What additional testing should you consider if any?
3. What are treatment options to consider with this patient?
Jessica Alper
Cause of acute delirium in elderly patients with dementia
Many older people, with and without dementia can be all
of a sudden be affected by delirium, which is defined as acute
sudden confusion. When an elderly patient becomes confused
very suddenly, it is important to look at all possible underlying
causes. Mayne et al. (2019) state that “non-specific symptoms,
such as confusion, are often suspected to be caused by urinary
tract infection (UTI) and continues to be the most common
reason for suspecting a UTI”. Delirium in the elderly is usually
associated with lengthened hospital stays, complexed care,
institutionalization, along with high mortality rates, difficulties

2. for the caregivers and increased healthcare costs. Signs and
symptoms associated with UTIs in the elderly include confusion
or delirium, increased lethargy, blunted fever response, new-
onset incontinence, as well as anorexia (Rodriguez-Manas,
2020). There are various risk factors associated with UTIs in a
male patient. Some of these include prostatic hypertrophy,
diabetes, or both, which can lead to high post-void residuals.
Testing
A confused patient who has recently become delirious
should be investigated for the source of the delirium. Krinitski
et al. (2021) state that “the diagnosis of UTI requires not only
confirmed bacteriuria but also the presence of genitourinary
symptoms, which often cannot be reliably confirmed in the
many delirious individuals who are unable to adequately express
themselves”. However in this case study, it is know that the
patient is experiencing urinary incontinence, which further
justifies the diagnosis of UTI.
A urinary analysis and culture are both highly suggested
for this patient. When bacteria from the UTI has been detected
in the elderly, providers usually “consider behavioral or mental
changes, including delirium, as non-urinary manifestations of
UTI, especially in patients with cognitive impairment, from
whom local urinary tract symptoms are often difficult to obtain”
(Krinitsky et al., 2021). Depending on the bacteria that is
growing, different types of antibiotics may be used.
Treatment option
Males experience disturbed normal voiding mainly due to
their benign prostatic hyperplasia (BPH). Due to their enlarged
prostate, “generation of a retrograde turbulent urine flow,
enabling the ascension of uropathogens to the bladder and
eventually into the prostate, which explains the high frequency
of prostatic involvement in males with UTI” (Smithson et al.,
2019). As such, fluoroquinolones such as cipro can be used in
order to treat the UTI with adequate prostatic diffusion.
It is also important to note that normal voiding in the
elderly patients is the first line of defense against UTIs. In a

3. patient with dementia however, it may be difficult to trust that
they will void regularly and that they take their medications
properly and at the right time. Nothing that the patient’s MMSE
score dropped from 18 to 12, this patient has progressed from
moderate to severe dementia. Because of this change of
cognition, it would be more beneficial and appropriate for this
patient to be admitted to the hospital for IV antibiotics. A
referral to the emergency department is therefore warranted.
References
Krinitski, D., Kasina, R., Klöppel, S., & Lenouvel, E. (2021).
Associations of delirium with urinary tract infections and
asymptomatic bacteriuria in adults aged 65 and older: A
systematic review and meta-analysis. Journal of the American
Geriatrics Society, 69(11), 3312–3323.
https://doi.org/10.1111/jgs.17418
Mayne, S., Bowden, A., Sundvall, P., & Gunnarsson, R. (2019).
The scientific evidence for a potential link between confusion
and urinary tract infection in the elderly is still confusing - a
systematic literature review. BMC Geriatry, 19(32).
https://doi.org/10.1186/s12877-019-1049-7
Rodriguez-Mañas L. (2020). Urinary tract infections in the
elderly: a review of disease characteristics and current
treatment options. Drugs in context, 9, 2020-4-13.
https://doi.org/10.7573/dic.2020-4-13
Smithson, A., Ramos, J., Nino, E., Culla, A., Pertierra, U.,
Friscia, M., & Batisda, M. T. (2019). Characteristics of febrile
urinary tract infections in older male adults. BMC Geriatrics,
19(334).
https://doi.org/10.7573/dic.2020-4-13