• Elizabeth Varona-Martin

Alteration in mental status is seen in people with different medical conditions, especially the elderly. They’re linked to various complicated underlying medical issues and can be challenging to diagnose. In patients with cognitive impairment, systematic investigations and clinical trials are challenging to conduct. Additional subjective data should include if there is an alteration in awareness and the ability to focus, maintain, or deflect attention. Ask for any sudden and unexpected change in the patient’s behavior, such as increasing disorientation, agitation, or withdrawal, including memory loss, language, and communication difficulties  (Francis, Jr & Young, 2020). The timing, duration, and intensity of symptoms should be included in the history. Also, a list of medications, antidepressants, diuretics, bronchodilators, and antihistamines have been linked to lower urinary tract symptoms( LUTS ). The causes of urinary incontinence should be identified, and patients should be asked about any previous neurologic symptoms, injuries, or diseases (McVary & Saini, 2021).

• Ask the staff and family members if they notice any perception issues. Patients may mistake the caregivers for someone else or believe that objects or shadows in the room are people. Vague fantasies of injury frequently accompany these misperceptions. We should check for any visual, auditory, or somatosensory hallucinations and assess loss of insight because it generally accompanies them: the patients believe they are real. Simple hallucinations, for example, shadows or shapes, and complex hallucinations, such as people and faces. Simple noises or hearing voices with clear words are examples of sounds (Francis, Jr & Young, 2020).

Family members can provide some historical indications of the underlying etiology, for example, recent febrile illness, history of organ failure, a medication list, history of alcoholism or drug abuse, or current depression.

Does he have fever, nausea, or vomiting? Is the urine cloudy? Any change in his oral intake, is he drinking and eating properly?

For additional objective data we should examine the patient for any tenderness in the costovertebral angle, flank or suprapubic discomfort, and costovertebral angle tenderness.Asses him for any dehydration signs, such as dry mucous, slow skin turgor, decreased urine output, tachycardia, and orthostatic blood pressure (Francis, Jr & Young, 2020).

Considering the patient history of recurrent urinary tract infection (UTI) and the use of an indwelling catheter while in the hospital, we should consider the possibility of UTI. Another possible diagnosis is delirium; diverse factors might cause delirium, including bladder catheters, polypharmacy, infection, dehydration, immobility, and restraint use (Francis, Jr & Young, 2020).

Laboratory tests will help to rule out some of the differential diagnosis includes serum electrolytes, creatinine, glucose, calcium, complete blood count, and urinalysis and urine culture

Additional diagnostic studies:

Brain Computed tomography (CT) may be ordered if no apparent cause of delirium is found during the initial evaluation.

Renal/bladder Ultrasonography

Contrasted computed tomography (CT) scanning of the kidney or helical CT scanning (currently preferred by most experts)

Preventing strategies include reducing factors known to cause delirium; orientation protocols; environmental modification; early ambulation and minimizing physical restraints; and visual and hearing aids. Low-dose haloperidol (0.5 to 1 mg orally or intramuscularly [IM]), however, psychotropic medicine should be used only when necessary to treat severe agitation or psychosis that has the potential to cause harm (Francis, Jr & Young, 2020).

Once the primary acute condition that causes delirium is diagnosed, the most effective way of resolving the delirium is to treat that condition.

Antibiotics such as trimethoprim-sulfamethoxazole, ampicillin, amoxicillin, erythromycin, vancomycin, doxycycline, aztreonam, nitrofurantoin, rifampin, are effective in treating UTI (Pasternack, 2019). Providers should avoid indwelling catheters on this patient and look for an alternative like a condom cath.

Sedation and hypotension are uncommon side effects of haloperidol.

Antibiotics can cause nausea, vomiting, and diarrhea; Antibiotic allergies are frequent. Even if they have never reacted to an antibiotic before, they can develop an allergy, and antibiotic resistance develops due to overuse (Pasternack, 2019).

When a cause for acute delirium or disorientation is not immediately apparent, healthcare providers should do a toxic blood and urine screen. They should know that several common medicines are not tested in conventional laboratory tests. As a result, negative toxic screen findings cannot rule out an overdose of these medications (Francis, Jr & Young, 2020).

Delirium is more common in older people who have many medical problems or take a lot of medications, have another brain illness like dementia, or have vision or hearing impairments. Delirium is most likely to happen in the hospital, especially if someone has just had surgery or is in pain.

Referral to a urologist may be most beneficial for patients with recurring infections because they may be related to underlying anatomic abnormalities. 

References

Francis, Jr, J., & Young, G. B. (2020, February 11). Diagnosis of delirium and confusional states. UpToDate. Retrieved April 13, 2022, from https://www.uptodate.com/contents/diagnosis-of-del… 

McVary, K. T., & Saini, R. (2021, May 11). Lower urinary tract symptoms in males. UpToDate. Retrieved April 13, 2022, from https://www.uptodate.com/contents/lower-urinary-tr… 

Pasternack, M. S. (2019, November 12). Approach to the adult with recurrent infections. UpToDate. Retrieved April 13, 2022, from https://www.uptodate.com/contents/approach-to-the-…