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ACUTE GRIEF WITH DELIRIUM IN AN ELDERLY: HOLISTIC CARE

SB Khoo FRACGP,Penang Adventist Hospital. (Khoo Siew Beng)

Address for correspondence: Dr Khoo Siew Beng, Family Physician, Penang Adventist Hospital, No 465, Jalan Burma, 10350 Penang. Tel: 604-2227 200, Email: khoosiewbeng@pah.com.my

INTRODUCTION

Delirium affects 14-56% of elderly patients admitted in the hospitals.² Generally, patients with delirium in the community are not as frail as those in the hospital. Recent-onset delirium in the community is mainly associated with old age, dementia, infections, and medications that can be successfully treated in the primary care setting.³

Family Medicine advocates minimal tests to rule in diagnosis; not a routine battery of tests to rule out diagnosis. Principles of good clinical assessments, prioritisation, use of time as diagnostic and therapeutic tool, consideration of environmental and psychosocial influence, weighing risks versus benefits of investigations and pharmacological treatment, and respecting the wish of patient and family carers are of paramount importance.

This clinical case analysis highlights the importance of bio-psychosocial spiritual model of care in dealing with delirium in an elderly patient at home. It also illustrates the application of facts from textbooks to clinical practice on a personal individual case basis.

CASE HISTORY

Mr A is an 82-year-old man with hyperlipidaemia, hypertension and diabetes mellitus (DM). He was diagnosed with thromboembolic stroke 12 months earlier. He is conscious and alert but with resultant mild dysarthria, left hemiparesis and right upper motor neuron facial nerve palsy. He does not have problem swallowing semi-solid food and is able to walk with support and supervision. He has been partially dependent on the care of his 75-year-old wife (until three weeks ago) with the help of an Indonesian maid. Mr and Mrs A lived together in a medium cost apartment on the ground floor in Penang. Both of them are devout Buddhists from young. They have a son who is working as an engineer and who is currently living in Sarawak with his family. He embraced the Christian faith during his college days in Singapore.

Three weeks ago, Mrs A, who had hypertension, ischaemic heart disease and congestive cardiac failure for years, suddenly collapsed while taking a bath. She died before she could be taken to the hospital. After the funeral, it was decided that Mr A and the Indonesian maid should move over to Sarawak to stay with his only son and his family.

Since his wife passed away, Mr A has been having difficulty in sleeping at night. He has not been eating well and is rather quiet and withdrawn. He developed low grade fever for the past two days associated with mild cough and running nose. He was seen by a general practitioner who prescribed for him paracetamol, diphenhydramine cough mixture and midazolam 7.5 mg on PRN basis. Mr A is currently taking lovastatin 20 mg ON, metformin SR 800 mg daily, aspirin (cardiprin) 100 mg daily and perindopril 4 mg OM for his chronic illnesses.

For the past two days, Mr A seems to be restless, irritable and is behaving abnormally. He thinks he is still in his old apartment in Penang and has persistently demanded that his wife must take him out for his usual “evening walk” and to take him to the police station to make a report. He claims that someone had broken into his room the previous night and stole his wallet though there was no sign of a break in and nothing has gone missing.

Mr A’s son requested you to come to the house to have a look at his father.

CLINICAL FINDINGS BASED ON YOUR ASSESSMENTS ON MR A

During lucid intervals, Mr A expressed the painful loss of his wife, to whom he was very close for the past 50 years. He has much concerns and anxiety over his future on whether he could come back to his hometown in Penang. He worries whether his son, being a Christian, would be able to carry out Buddhist rites for him when he dies and whether his body could be transported back to Penang to be buried next to his wife in the reserved burial plot. But at other times especially in the evening, he does not remember where he is and what day it is. He keeps saying he is “muddled up in his head”; he finds it hard to concentrate on anything; everything is a “blur”; he is afraid of “losing control” of himself.

There was no history of a fall or any evidence to suggest possible head injury. There was no history of intellectual impairment or behavioural changes suggestive of dementia in the past.

Clinical assessment showed a low grade fever of 38°C, mild dehydration, bladder distension and no bowel movement for the past three days although there was no faecal impaction felt per rectum. There was no sign of pallor; blood pressure (BP) was normal; lungs were clinically clear; no heart murmur or cardiac arrhythmia; post stroke neurological status remained the same as before with no signs of recent neurological deficits.

CLINICAL CASE ANALYSIS

CLINICAL DIAGNOSIS

Delirium or acute confusion is a syndrome caused by physiologic alteration that temporarily impairs the autonomic nervous system. It develops over a short period (hours or days) and is clinically characterised by disturbances in attention, memory and perception. There is often one or more identified underlying causes.⁴ Delirium is a non-specific sign of illness in a vulnerable group of patients. Similar to pain or fever, it may be caused by a simple treatable condition or signal a potentially life-threatening problem. It is reversible once the underlying condition resolves.⁴

Idiopathic confusion occurs when the patient loses a sense of pattern, meaning, or continuity in life. Potential triggers include losing a loved one, sleep interruptions, and hospitalisation. Most patients with idiopathic confusion respond well to reorientation and techniques that help them link the past to the present.⁴

From the medical history, Mr A is diagnosed to have both acute and idiopathic confusion. He showed memory deficit and disorientation; he had misperceptions that his wife was alive and that they were still living in Penang. He also experienced delusion that someone had broken into his room to steal his wallet. He showed mixed hypoactive behaviour of quietness and withdrawal during the day and hyperactive irritability with insistence on making a police report in the evenings. There were lucid periods interspersed with confused episodes.⁴ His confusion was of acute onset with close links to recent bereavement, immense psychosocial and environmental changes, multiple medical problems, and poly-pharmacy. Diagnosis of depression has to be considered and assessed too. Mr A did not have past history of chronic psychotic disorder or any indication of dementia.

CLINICAL ASSESSMENTS

The diagnosis of delirium rests solely on clinical skills; no diagnostic test exists.⁵ Obtaining a good medical history from a family member or carer on the recent cognitive changes of Mr A is the key to recognising delirium and identifying the complex psychosocial issues and medical problems that may contribute to the delirium of Mr A.

Table 1 summarises the appropriate questions and areas to cover in the medical history. Special attention should be given to assessment of physical, psychological and social impacts on Mr A brought about by the recent demise of his wife. Elderly people may be especially vulnerable when they lose a spouse because it means losing a lifetime of shared experiences. In Mr A’s situation, the severe emotional shock was compounded by the fact that his wife’s death was sudden and unexpected; they used to have a good close marital relationship; Mr A is disabled with stroke and was dependent on his wife as the main carer; and the demise of his wife necessitated major social readjustments for Mr A.

Table 1: Medical history

MEDICAL HISTORY
AREAS TO EXPLORE		QUESTIONS TO ASK
1.	Main presenting complaint	Details of delirium – onset/presenting features of change of behaviour, perceptions, orientation, presence of delusion and hallucination
2.	Details of other recent complaints	Onset and duration of fever/cough/associated symptoms Current specific treatment Possible side effects of cough mixture – difficulty in micturition/constipation/drowsiness/blurring of vision
3.	Details of chronic illnesses and other past medical problems	Hypertension/DM/hyperlipidaemia Duration/progress/latest BP and blood test results/current treatment Past history of dementia/complications of chronic illnesses
4.	Grief reactions	Assess physical/social/psychological impact of bereavement on patient Marital relationship with wife before she passed away
5.	Depression	Assessment for presence of depression Distinguish between clinical depression and grief reaction due to bereavement
6.	Social and environmental changes	Family support/usual lifestyle/eating habit/sleeping habit Impact of current environmental and psychosocial changes on patient Relationship with son’s family
7.	Religious/cultural/financial/legal issues	Any problems imposed by difference in religion between Mr A and son’s family? Future plan with regard to legal matters/medical interventions/religious rites/anxiety and fear of death and dying/burial sites or cremation
8.	Systemic review	Visual and hearing deficit Recent neurological deficits Assessment for pneumonia/urinary tract infection (UTI)/cardiac problems/central nervous system (CNS) infection and tumours/head injury
9.	Functional assessment	Mobility Physical assessment of activities of daily living Mental assessment
10.	Environmental assessment	Recent history of falls Potential environmental risks for elderly falls
11.	Current medication	Alcohol history/over the counter drugs/traditional medication/current prescription drugs
12.	Perception and insight of patient in his own words	What does he think is wrong with him? How does he feel about his problems? How can others help him?

Dying is a natural and inevitable part of living. Elderly patients, having led a long life, are more open and accepting to discussions on death and dying. Open ended questions can be used to explore Mr A’s feelings towards bereavement of his wife and issues confronting his own death. Cultural competence and communication skills of the physician will enable him to recognise the need to explore Mr A’s anxiety, worries and preferences with regard to specific cultural and religious issues in the present circumstances.

Table 2 consists of a list of clinical findings suggestive of presence of medical problems that the family physician should be on the lookout for.

Table 2: Clinical examination

PHYSICAL EXAMINATION
PHYSICAL CONDITIONS TO CONSIDER:		CLINICAL CUES TO LOOK FOR:
1.	Difficulty in micturition	Distended bladder/prostatic hypertrophy
2.	Constipation	Abdominal faecal mass/impacted faeces in the rectum
3.	Dehydration	Low BP/sunken eyes/loss of skin turgor
4.	Anaemia/Hypotensive shock	Bleeding tendency/pallor/low BP/tachycardia
5.	Pneumonia	Increasing fever and cough/lung crepitations and rhonchi
6.	Urinary tract infection	High fever and rigor/dysuria/hesitancy/foul smelling cloudy urine/haematuria/lumbar pain and tenderness
7.	Acute myocardial infarct	Chest pain/hypotension/tachycardia/arrhythmia
8.	Congestive cardiac failure	Dyspnoea/orthopnoea/ankle oedema/basal lung crepitations/hepatomegaly
9.	TIA/stroke/head injury	Recent onset or worsening of concurrent neurological deficits/impaired consciousness/seizures
10.	CNS infection	High fever/change in conscious level/neck stiffness/vomiting/headache/purpuric rash
MENTAL STATE EXAMINATION
11.	Confusion Assessment Method (CAM)20	Deficits in orientation, attention, memory, language, and visuo-construction abilities
12.	Folstein Mini Mental State Examination (MMSE)21
13.	Delirium Index (DI)7

CONTRIBUTING FACTORS

A unifying approach is to regard delirium as a clinical syndrome resulting from an interconnection of several underlying causes (risk factors such as old age, dementia, chronic illnesses, stroke) and precipitating factors (bereavement, dehydration, constipation, infection, drugs).⁵

Likely potential causes and factors contributing to Mr A’s delirium are summarised in Table 3. Perhaps the most important contributing factor is personal grief experience that Mr A is going through at present.

Table 3: Summary of factors contributing to delirium of Mr A

POTENTIAL FACTORS		INDICATORS
1.	Acute grief reaction	Wife just passed away three weeks earlier. Second phase acute grief process
2.	Depression	Clinical presentation of insomnia/loss of appetite/withdrawn Precipitating factors of grief/chronic illnesses/stroke/physical disability and immobility/change in social circumstances
3.	Adverse effects of drugs	On midazolam (benzodiazepines)/cough mixture (anticholinergic)
4.	Common infection URTI/UTI	Fever, cough and running nose/post stroke neurogenic bladder
5.	Urinary retention	Anticholinergic effects of cough mixture/prostatic hypertrophy
6.	Constipation	Drug side effects/limited mobility/poor oral intake
7.	Social changes	Loss of wife as main caregiver/environmental changes/religious and cultural issues
8.	Hypo or hyperglycaemia	Diabetes mellitus/poor oral intake/stress of infection and depression
9.	Electrolyte imbalance	Poor oral intake/side effect of perindopril (hyperkalaemia)
10.	CNS problems	High cardiovascular risk factors/past history of stroke

Table 4 lists down the possible reactions of Mr A as part of his way of handling the stress and anxiety of his loss.⁶ Grief experience impacts all aspects of the being of an individual. Manifestations listed are more intensified when there has been a sudden unanticipated death. There is no timetable for grieving; various emotional and behavioural grief reactions are presented in an unpredictable and haphazard manner, an experience that the patient would describe as an “emotional roller coaster”. Patient may feel sad and depressed at one moment, and peace and contentment at the next moment.⁶