|Year : 2014 | Volume
| Issue : 2 | Page : 118-120
Missed diagnosis-persistent delirium
Aseem Mehra1, Indu Surendran1, Vikas Suri2, Sandeep Grover1
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||3-Mar-2015|
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Delirium is in general considered as an acute short lasting reversible neuropsychiatric syndrome. However, there is some evidence to suggest that in a small proportion of cases delirium may be a chronic or persistent condition. However, making this diagnosis requires clinical suspicion and ruling other differential diagnosis. In this report, we present a case of a 55-year-old man who had cognitive symptoms, psychotic symptoms and depressive symptoms along with persistent hypokalemia and glucose intolerance. He was seen by 3 psychiatrists with these symptoms and was initially diagnosed as having depressive disorder and later diagnosis of bipolar affective disorder (current episode mania), and psychosis were considered by the third psychiatrist. However, despite the presence of persistent neurocognitive deficits, evening worsening of symptoms, hypokalemia and glucose intolerance diagnosis of delirium was not suspected.
Keywords: Delirium, hypokalemia, persistent
|How to cite this article:|
Mehra A, Surendran I, Suri V, Grover S. Missed diagnosis-persistent delirium. J Geriatr Ment Health 2014;1:118-20
| Introduction|| |
Delirium is one of the most common psychiatric disorders seen in medically ill-patients.  It is characterized by inattention, disturbance of consciousness, disorientation, disturbances in other cognitive functions, including memory along with disturbances in sleep.  In general it is understood as an acute onset, fluctuating, short lasting reversible syndrome.  However, data suggest that in some of the patient's delirium can become chronic or persistent. Further, it is known that persistent delirium is associated with poorer outcome compared with the short lasting delirium.  In this report, we present the case of male who had cognitive symptoms, sleep disturbances, psychotic symptoms and affective symptoms in the background of persistent hypokalemia, who was diagnosed as having persistent delirium and discuss the importance of recognizing this diagnosis.
| Case Report|| |
A 55-year-old male, who was premorbidly well-adjusted with no past and family history of mental disorder, with no history of any substance use presented to emergency outpatient services. On mental status examination, he was disoriented, had poor attention concentration, had speech difficulty and persecutory delusions. On physical examination was found to have emaciation and muscle weakness. On investigation was found to have hypokalemia (serum potassium level of 2.3 mEq/dL) and hyperglycemia. A provisional diagnosis of delirium was considered. His mini mental state examination score was 5 and delirium rating scale-revised 98 version score was 35. He was started on tablet haloperidol. Further exploration of the history revealed that he was maintaining well 2 months prior to presentation. To start with, following a stressor he developed fluctuating low mood, difficulty in falling asleep with intermittent awakening, anhedonia and pessimistic view about the future. However, within 5-6 days developed suspiciousness, confusion and irritability, which would be more in the evening hours. Within 2 weeks of onset of symptoms, he was seen by a psychiatrist and diagnosed to have depressive disorder and was detected to have hypertension. He was started on tablet escitalopram 10 mg/day and amlodipine 10 mg/day. However, with this treatment his condition worsened further. Over the next 2 weeks his predominant symptoms were in the form of confusion, disorientation, misrecognition, poor attention concentration, irritability, abusiveness, suspiciousness and transient claim of grandiose identity in which he would consider himself to be a "religious guru." He was again seen by another psychiatrist, who considered the diagnosis of bipolar affective disorder, current episode mania with psychotic symptoms. On investigations was found to have hypokalemia (2.8 mEq/dL). However, this finding was not given much importance, and he was prescribed tablet divalproex 750 mg/day and tablet risperidone 2 mg/day and anti-hypertensive agents were continued. Over the next 1-week there was further worsening of his condition with an increase in frequency of irritability, suspiciousness, occasional fearfulness and cognitive disturbances. His disturbance would worsen during the night time, and he would mostly remain awake throughout the night and would have occasional daytime naps. Following this he was seen by another psychiatrist and was diagnosed with psychotic illness. On investigation was found to have diabetes mellitus along with hypokalemia. He was started on tablet haloperidol up to 60 mg/day and tablet olanzapine 30 mg/day. Throughout the symptomatic phase there was no history suggestive of executive dysfunction, aphasia, language problems, gait disturbances, tremors, motor imbalance, rigidity or spasticity, history of falls, diplopia, vision problems, drug abuse, use of over the counter medications, fever, skin lesions, development of extrapyramidal symptoms while on various antipsychotics.
He was thoroughly investigated to find the cause of persistent hypokalemia. Investigations in the form of complete blood count, liver function tests, renal function test, serum cortisol levels, serology for human immunodeficiency virus, blood culture, magnetic resonance imaging of brain and functional neuroimaging in the form of single photon enhanced computerized tomography did not reveal any abnormality.
In view of persistent hypokalemia and diabetes mellitus along with mental symptoms despite adequate treatment for all the symptoms for the initial 2 weeks in the inpatient setting a provisional diagnosis of Cushing disease (secondary to metastatic tumor) was considered despite having normal cortisol levels and he underwent bilateral adrenalectomy. After the surgery, all his mental symptoms cleared in 3-4 days. His mini mental state examination score improved to 25 and delirium rating scale-revised 98 version score reduced to 4. He was oriented to time, place and person. He had preserved immediate and remote memory. However, recent memory for the period of the episode was impaired. After 1-week, tablet haloperidol was stopped. His blood glucose and potassium levels also normalized. However, during the postoperative he developed aspiration pneumonia and expired.
Based on the outcome final diagnoses of persistent delirium (first possibility) versus organic psychosis were considered.
| Discussion|| |
In general it is suggested that delirium usually lasts for less than a week. However, in occasional cases it can last longer, and some studies report delirium lasting for 60 days or more. , When delirium lasts for longer duration, it is often referred as persistent delirium.
However, there is no formal definition of persistent delirium, and many authors have described it variously. In a systematic review of the data the authors defined persistent delirum as a "cognitive disorder that met accepted diagnostic criteria for delirium at admission (or shortly after admission) and continued to meet criteria for delirium at the time of discharge or beyond." Others authors have defined it by duration, and this has varied from duration of 7 days  to more than 4 weeks. , Other authors have attempted to define persistence of delirium based on the definition used for resolution of symptoms. Accordingly a resolution is defined as either absence of all the symptoms of delirium or it is defined as having fewer delirium symptoms than those required to meet the nosological diagnosis of delirium.  Others have defined persistent delirium if the patient is found to have a presence of delirium either in the form of continuous symptoms or recurrence of symptoms at longer time frames lasting for up to 1-year. Accordingly the prevalence rate of persistent delirium has varied from one study to another, and the range varies from 0% to 78%.  Accordingly, it can be said that there is no consensus with regard to the definition of persistent delirium and there is a need to develop a consensus on the same to further the research in this area. We consider that presence of symptoms of delirium lasting for more than 1-month should be evaluated as a cut-off to define persistent delirium.
Studies which have evaluated the risk factors for persistent delirium suggest that the chances of persistent delirium increase in the background of dementia, higher number of medical conditions, higher severity of delirium, presence of hypoactive symptoms and hypoxia. 
We considered the diagnosis of persistent delirium in the index case in view of presence of cognitive symptoms since the beginning of the symptomatology, presence of sleep disturbances, evening worsening of symptoms, associated psychotic symptoms and temporal correlation of onset of symptoms with development of a physical disorder (detected to have hypokalemia at the beginning and throughout). Further, the patient did not fulfill the diagnosis of depression, mania and functional psychosis at any time. A differential diagnosis of organic psychosis was considered because of temporal correlation of onset and resolution of symptoms with the associated physical disorder. In view of the presence of cognitive symptoms throughout the history and diurnal variation of symptoms, diagnosis of persistent delirium was considered as the first possibility.
There is some data to suggest a patient with delirium can also meet the criteria of major depressive disorder.  In fact some authors have noted that less proportion of patients with depression meet the criteria of delirium, in contrast, higher proportion of patients with delirium meet the diagnostic criteria for depression. Accordingly, presence of depressive symptoms should not be used to rule out the diagnosis of delirium. The index case also initially had symptoms suggestive of a possible depressive episode.
The index case description depicts that when even an elderly patient presents with a mental disorder, an organic basis should always be suspected and patient need to be evaluated accordingly. The case also highlights the fact presence of occasional abnormalities on investigations must not be neglected. Further, this case also demonstrates the importance of taking proper history before making a psychiatric diagnosis in an elderly. Patient was seen by 3 psychiatrists prior to consulting our services, but a diagnosis of delirium or organic psychosis was not considered, and the patient was treated with high dose of psychotropics.
To conclude this case highlight the fact that in some cases delirium can last longer and in such a scenario it often indicates poor outcome.
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