Pneumonia and delusions/disorientation.

[mycrofft]

It has been observed many times that pneumonia patients, especially elderly ones, have a tendency to become mentally disoriented and sometimes delusional. Is the due to hypoxia, disease process or toxins, or what? Other people with similar respiratory and oxygenation issues don't as a rule, or do they?

Since this is seen most often (not exclusively) in elderly patients, who also have a habit of not running a fever the same as the rest of you do, is there some tie to that curiosity as well?

This is of interest here because a patient may be presenting with disorientation, weakness, and productive cough, but without a fever...psych eval with masks on might take up valuable time and delay proper triage.

 

[mycrofft]

One NIH source suggests hypoxia or hypercapnea.

ALso, it suggests a link between this and hx of CVA or other brain insult. No mention of toxins.

 

[Veneficus]

Geri meets Psy

The easiest question ever posed, with the simplest answer:

Yes.


Now let me complicate it:
Organic causes can and do create symptoms of psychosis.

The official treatment: Whatever the treatment for that disease is.

In the elderly, it is observed that in pathological aging (I did pay some attention in geriatrics) the compensatory mechanisms may be functioning at such a constant and extreme rate that it is often observed all diseases present with a handful of similar symptoms.

The solution is lots and lots of diagnostics.

But you can't always tell what specific disease process or combination is the main culprit. So you start treating what you think may be serious as you find it.

At some point you may have to give up and decide the best you can do is treat a handful of things you can find and call that "new baseline."

Finding out if psychosis is a symptom of an organic disease, a primary pathology, or a combination can be the result of treating other pathologies rather than the psychotic symtoms dictating treatment course.

 

[mycrofft]

Impact on field EMS?

or receiving EMS?

 

[Veneficus]

or receiving EMS?

Effect on EMS?

High index of suspicion, do not dismiss minor symptoms as nothing wrong, use maximum diagnostics to rule out occult pathology inconsistent with symptoms.

 

[RocketMedic]

I reckon the psychological effect of knowing that they're seriously, chronically ill probably contributes to psychosis as well in everyone, especially those who have not yet come to terms with their health.

 

[mycrofft]

Psychological and psychotic...we're talking about delirium.

I'm trying to parse your sentence but it doesn't.
Now, knowing you are chronically ill will depress you, sure, but that is not delirium. Nor is it psychosis. In fact, there is evidence that a CVA may biologically induce depression.

 

[RocketMedic]

The more you know....I thought that some depression could manifest as a psychosis-like state.

Could it be related to acidosis?

 

[mycrofft]

Hypercapnia would have a decreased pH.

There's being depressed, and experiencing a clinical depression, which is usually either major depressive disorder, or the "downswing" of bipolar disorder.
Anyone can be depressed. Just because one is psychotic does not mean one doesn't have very bad days, weeks or months...in fact, there's a very good chance one WOULD have them, but that is not clinical depression.
Delirium is generally cause by a physiological mechanism, like detox, drugs, other toxins (ammonia). Hypercapnia is listed as a cause for "hypoactive delirium".

Alzheimers is associated with depression, not clear in each and every case whether due to encephalopathy or realizing their days are numbered. Was that what you were aiming for?
http://emedicine.medscape.com/article/288890-overview

 

[BLS Systems Limited]

A few antibiotics can make 'em go a bit wonky. Seen it more than a few times and have heard testimonials by hospital staff that experienced it themselves. If they have been pre-treated for pneumonia and deteriorated at home, it could be a source of their confusion/delusion. Hypoxia, BP changes (up or down) can also affect behaviour.

 

[mycrofft]

Citations?

...........

 

[BLS Systems Limited]

Both penicillin and clarithromycin have been seen to affect mental status (where stopping the medication improved neurological symptoms). Here's a few links to articles.

http://www.ncbi.nlm.nih.gov/pubmed/21269833
http://www.ersj.org.uk/content/28/3/671.full
http://ndt.oxfordjournals.org/content/19/5/1341.full
http://jac.oxfordjournals.org/content/59/2/331.full

 

[Veneficus]

I'm trying to parse your sentence but it doesn't.
Now, knowing you are chronically ill will depress you, sure, but that is not delirium. Nor is it psychosis. In fact, there is evidence that a CVA may biologically induce depression.

Multiple pathologies can manifest with psych symptoms, it is labled an "organic" cause. The treatment is patho specific.

Most often this is manifest from dementia, but obviously can have other causes, like medications, hypoxia, azotemia, etc.

 

[mycrofft]

True, we're talking pneumonia and especially in the elderly.

I helped care for an unrecognized polypharmacy victim in a nursing home at my second nursing job ever. Old doc died, new doc looked at the meds list and started taking them off. Started with Tagamet, pt because delusional and assaultive. She had been admitted six months before with broken hip, which healed, but between meds to help her pain, meds to help her sleep, meds to counteract the side effects of the other meds, she was on a handful. She was sent home as unmanageable. Her family diode not continue most of the meds. She cleared up after a couple weeks.
But no pneumonia. Lucky her.

Reason for decomp was that apparently the Tagamet prolonged the half-life of one of her sedatives, she was going into detox.

 

[Localmotion34]

especially elderly ones, have a tendency to become mentally disoriented and sometimes delusional.

While not ALWAYS delirium, the DSM-IV specifically states that delirium is a change in consciousness that develops over time, usually within minutes to hours. It can also fluctuate, within each day, and day to day.

"Fluctuation during the course of the day could be exemplified by a patient coherent and cooperative in the morning, but at night insist on pulling out intravenous lines and going home to parents who died years ago" - DSM-IV

This is easily mistaken for delusions and/or psychosis. You will usually find that an elderly patient with delirium will NOT meet criteria in the DSM-IV for a major depressive disorder, or Axis I disorders.

Delirium however can be SUPERIMPOSED upon dementia, major depressive disorder, and other categories of the DSM-IV.

Delirium can be caused by Substance intoxication, Substance withdrawal, and General medical conditions, including UTIs and other infections.

 

[mycrofft]

Delirum versus delusion

By the way, the last reply was good. But the use of the word "delusional" can be either diagnostic or simply descriptive. (Or hyperbolic).
If I am delirious (I have delirium), and I think my deceased grandfather is calling my cell phone, (a delusion), then I am diagnostically delirious but "delusional"describes how my delirium is coming along. Like saying your Pontiac is green; you aren't driving a "Green", but a descriptor of your Pontiac is that it is green.
ANYHOO, good reply.