Confusion and Hallucination in a Geriatric Patient. Pitfalls of a Rare Differential: Case Report of an Anti-LGI1-Encephalitis

Background

Confusion and hallucinations in geriatric patients are frequent symptoms and typically associated with delirium, late-life psychosis or dementia syndromes. A far rarer but well-established differential in patients with rapid cognitive deterioration, acute psychosis, abnormal movements and seizures is autoimmune encephalitis. Exemplified by our case we highlight clinical and economic problems arising in management of geriatric patients with cognitive decline and psychotic symptoms.

Case Presentation

A 77-year-old female caucasian patient with an unremarkable medical history was hospitalized after a fall in association with diarrhea and hyponatremia. Upon adequate therapy, disorientation and troubled short-term memory persisted. Within a week the patient developed visual hallucinations. Basic blood and urine samples and imaging (cranial computed tomography and magnetic resonance imaging) were unremarkable. With progressive cognitive decline, amnestic impairment, word finding difficulty and general apathy, psychiatric and neurologic expertise was introduced. Advanced diagnostics did not resolve a final diagnosis; an electroencephalogram showed unspecific generalized slowing. Extended clinical observation revealed visual hallucinations and faciobrachial dystonic seizures. A treatment with anticonvulsants was initiated. Cerebrospinal fluid ultimately tested positive for voltage-gated potassium channel LGl1 (leucine-rich-inactivated-1) antibodies confirming diagnosis of autoimmune anti-LGI1 encephalitis. Immediate immunotherapy (high-dose glucocorticoids and administration of intravenous immunoglobulin G) led to a rapid improvement of the patient’s condition. After immunotherapy was tapered, the patient had one relapse and completely recovered with reintroduction of glucocorticoids and initiation of therapy with rituximab.

Conclusion

Rapidly progressive dementia in geriatric patients demands a structured and multidisciplinary diagnostic approach. Accurate management and financially supportable care is a major issue in rare diseases such as anti-LGI1-encephalitis. Education and awareness about autoimmune encephalitis of all physicians treating a geriatric population is important in order to involve expertise and establish treatment within reasonable time.

Meningoencephalitis associated with COVID-19: a systematic review

With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to summarize the clinical profile, investigations, and radiological findings among patients with SARS-CoV-2-associated meningoencephalitis in the form of a systemic review. This review was carried out based on the existing PRISMA (Preferred Report for Systematic Review and Meta analyses) consensus statement. The data for this review was collected from four databases: Pubmed/Medline, NIH Litcovid, Embase, and Cochrane library and Preprint servers up till 30 June 2020. Search strategy comprised of a range of keywords from relevant medical subject headings which includes "SARS-COV-2," "COVID-19," and "meningoencephalitis." All peer reviewed, case-control, case report, pre print articles satisfying our inclusion criteria were involved in the study. Quantitative data was expressed in mean ± SD, while the qualitative date in percentages. Paired t test was used for analysing the data based on differences between mean and respective values with a p < 0.05 considered to be statistically significant. A total of 61 cases were included from 25 studies after screening from databases and preprint servers, out of which 54 of them had completed investigation profile and were included in the final analysis. Clinical, laboratory findings, neuroimaging abnormalities, and EEG findings were analyzed in detail. This present review summarizes the available evidences related to the occurrence of meningoencephalitis in COVID-19.

Pyridoxine Add-On Treatment for the Control of Behavioral Adverse Effects Induced by Levetiracetam in Children: A Case-Control Prospective Study

BACKGROUND

Few studies on adult and pediatric patients have shown pyridoxine efficacy as additional therapy for those receiving levetiracetam (LEV) to prevent and mitigate behavioral adverse effects (BAEs).

OBJECTIVE

The aim of our study was to analyze the safety and efficacy of pyridoxine supplementation in the prevention of LEV adverse effects, including suicidal ideation.

METHODS

This randomized, case-control trial included patients receiving LEV as monotherapy treatment. Patients were subdivided into 2 groups, according to whether they were treated with LEV only (group 1) or LEV with supplemental pyridoxine (group 2).

RESULTS

In both cohorts, the most frequent BAEs were irritability/aggression followed by depression and confusion. Those patients (92%) who initiated pyridoxine after 1 month of LEV treatment did not need to change or suspend LEV ( P < 0.001), and BAE improved after 9.06 ± 3.05 days of pyridoxine supplementation. None of the patients complained of symptoms of pyridoxine toxicity, and no new adverse effects of LEV off-label were reported.

CONCLUSIONS

In our study, we found pyridoxine to be safe and effective in controlling LEV-induced BAEs in children.

[Mental confusion in elderly patients with dementia]

Authors have studied the psychopathological structure, risk factors and predictors of mental confusion in 102 patients with dementia of different etiologies (Alzheimer's disease (AD), cerebrovascular dementia (CVD) and mixed Alzheimer disease/vascular dementia). The high frequency (>40%) of mental confusion in patients with dementia admitted to geriatric departments of a psychiatric hospital has been identified. Mental confusion was most frequently characterized by a syndrome of memory and/or confabulatory confusion. The causes of mental confusion in elderly patients with dementia, including the exacerbation of a somatic pathology and changes in conditions of patient's staying in hospital, have been specified. The frequency of mental confusion is correlated with patient's age: more than 55% of cases has been noted in the group aged over 70 years. Mental confusion develops 6 times more frequent in patients with moderately severe and severe dementia than in those with mild dementia. Timely diagnosis and adequate treatment are predictors of favorable outcome in most patients. Treatment of this syndrome should be strictly differential. Antipsychotic treatment is needed in case of persistent psychotic symptoms and severe behavioral disturbances. Drugs for pathogenetic therapy of dementia have been used in the complex treatment of mental confusion in patients with dementia, in particular AD.

Zolpidem improves neuropsychiatric symptoms and motor dysfunction in a patient with Parkinson's disease after deep brain stimulation

PURPOSE

To illustrate the beneficial effect of zolpidem on the neuropsychiatric and motor symptoms in a patient with Parkinson disease (PD) after bilateral subthalamic nucleus deep brain stimulation.

CASE REPORT

The 61-year-old housewife was diagnosed to have PD for 12 years with initial presentation of clumsiness and rest tremor of right limbs. She was referred to our hospital in March 2009 due to shortening of drug beneficial period since 3 years ago and on-phase dyskinesia in recent 2 years. Bilateral STN DBS was conducted on 18 June, 2009. Fluctuating spells of mental confusion were developed on the next day after surgery. Electric stimuli via DBS electrodes were delivered with parameters of 2 volts, 60 μs, 130 Hz on bilateral STN 32 days after DBS. The incoherent behaviors and motor fluctuation remained to occur. The beneficial effect of zolpidem on her neuropsychiatric and motor symptoms was detected incidentally in early July 2009. She could chat normally with her caregiver and walk with assistance after taking zolpidem. The beneficial period may last for 2 hours. Zolpidem was then given in dosage of 10 mg three times per day. The neuropsychiatric inventory was scored 56 during zolpidem 'off' and 30 during zolpidem 'on'. To understand the intriguing feature, we conducted FDG-PET during 'off' and 'on' zolpidem conditions. The results revealed that the metabolism was decreased in the right frontal, parietal cortex and caudate nucleus during zolpidem 'off'. These cool spots can be partially restored by zolpidem.

CONCLUSION

Zolpidem ameliorated the neuropsychiatric and parkinsonian motor symptom in the PD patient. Since GABAA benzodiazepine receptors are widely distributed throughout the central nervous system, zolpidem probably acts via modulating structures lying within the cortico-subcortical loop or by direct effect on these cortical regions.

[Neurosyphilis: unexpected reunion with an old acquaintance]

A 45-year-old man was admitted to a psychiatric hospital with confusion and disorientation; he was suspected of having Korsakoff syndrome. He was known to have a history of alcohol abuse, complicated by epileptic fits, and to have had a recent ischaemic cerebrovascular attack. Unexpectedly, screening for syphilis turned out to be positive. Examination of the cerebrospinal fluid led to the diagnosis of neurosyphilis. Most neurological and psychiatric symptoms disappeared after treatment with antibiotics.

[Efficacy and safety of rivastigmine (exelon) in the confusion syndrome in the acute phase of ischemic stroke]

There is ample evidence that the poststroke confusion syndrome or delirium is a manifestation of cholinergic deficit. Given this conception, we conducted a controlled study of efficacy and safety of acetylcholinesterase inhibitor rivastigmine in patients developed a delirium in the acute phase of ischemic stroke. The study included 224 consecutive stroke patients: 68 patients developed a delirium in the acute phase of disease. Severity of delirium was scored with the Delirium Rating Scale (DRS). A main group included 21 patients with delirium treated with rivastigmine in individually tailored doses. A control group included 47 patients with delirium who received only vascular and anticoagulant treatment, i.e. haloperidol. Cognitive functions were tested 3 and 6 months after stroke with the MMSE, the FAB, the Luria 10 point verbal test. The Zarit Burden Interview (ZBI) was used after 3 and 6 months to measure caregiver burden. In patients treated with rivastigmine, the delirium phase was significantly shorter (p<0,001) compared to the control group. In patients without delirium in the acute phase of stroke, the results of neuropsychological study were better (p<0,001) than in patients with delirium. Total ZBI scores were more favorable in the rivastigmine group than in the control one (p<0,05). To the end of the study, 5 patients died in the rivastigmine group, 17 patients in the control group and 3 patients in the group without delirium. Rivastigmine was safe in the acute phase of stroke patients even after the rapid titration.

The efficacy of sodium valproate and a MRA finding in confusional migraine

Confusional migraine (CM) is recognized as a kind of pediatric migraine equivalent. We report that a 10-year-old girl had repeated attacks of confusional state and of migraine with aura. She suffered from total of six CM attacks and migraine attacks with aura almost once a month. Therefore, sodium valproate (VPA) was initiated to prevent these attacks. They have been controlled after increasing her dosage to 600mg/day. The intracranial magnetic resonance angiography (MRA) during the last CM attack indicated narrowing of left middle and posterior cerebral arteries. However, MRA during the attack free period at 41-day follow-up showed normal vessels. Electroencephalograms showed severe slowing without seizure discharges during the CM attacks. This case indicates that VPA is an effective treatment for the prophylaxis of CM and migraine with aura. MRA is considered helpful for the diagnosis of this kind of migraine in children because of noninvasive neuroimaging.

Protracted ictal confusion in elderly patients

BACKGROUND

Ictal confusion, particularly if protracted, often presents a diagnostic challenge.

OBJECTIVES

To define protracted ictal confusion in elderly patients and to characterize its features and outcome.

DESIGN

Case series.

SETTING

Neurology outpatient and emergency departments at 2 tertiary care centers.

PATIENTS

Consecutive series of 22 ambulatory patients with acute ictal confusion.

MAIN OUTCOME MEASURES

Duration of ictal confusion was correlated with age and lesions noted on cerebral images and videoelectroencephalographic studies.

RESULTS

The ictal basis underlying confusion was not recognized for up to 5 days in 22 patients (mean +/- SD age, 70 +/- 8.5 years). Twenty patients had partial complex status epilepticus, and 2 patients had newly diagnosed primary generalized status epilepticus. Motor movements were not present in either group, although reduced mood states and ictal neglect were noted in some patients. Fifteen patients had previous episodes (2-10) of protracted ictal confusion. Once identified, treatment reversed confusion, and eventually patients were discharged to home, although a few patients sustained persistent reduction in baseline cognition.

CONCLUSIONS

Protracted ictal confusion is often not considered in the ambulatory elderly patient, with resulting delay in diagnosis. Electroencephalographic and videoelectroencephalographic studies performed while the patient is experiencing symptoms are crucial to early diagnosis and timely management.

Until the chemist opens - palliation from the doctor's bag

BACKGROUND

People with a life limiting illness may have unpredictable exacerbations of their symptoms requiring after hours care by general practitioners using medications that are readily accessible. All doctors are provided with injectable 'doctor's bag' emergency drugs for use in such a crisis.

OBJECTIVE

This article aims to: identify which medications from the doctor's bag can be used in the palliative care crises that are most frequently encountered, present the best possible evidence for these indications, and to provide GPs caring for palliative care patients after hours with management strategies so, whenever appropriate, they can continue to be managed at home.

DISCUSSION

The clinical context, including disease trajectory and patient and caregivers' wishes, must be assessed in palliative care crises. Having excluded reversible problems, symptoms can be treated using doctor's bag medications. Attention must be given to route of administration, duration of effect, and appropriate doses for effective palliation.

Executive dysfunction in hyperhomocystinemia responds to homocysteine-lowering treatment

An elevated serum homocysteine level is a risk factor for the development of cognitive impairment. Reported is a late-onset case of hyperhomocystinemia due to a vitamin B12 metabolic deficit (cobalamin C) with cognitive impairment, primarily in frontal/executive function. After homocysteine-lowering therapy, the patient's functional and neuropsychological status improved in conjunction with a decrease in leukoariosis on his MRI scan. These findings suggest that homocysteine-related cognitive impairment may be partially reversible.

In whose best interests? Nurses' experiences of the administration of sedation in general medical wards in England: an application of the critical incident technique

BACKGROUND

Despite concern expressed in recent government documents in the UK about the inappropriate use of sedation when a patient is agitated or confused and cannot consent, there is little nursing literature on the topic. The general legal and ethical principles apply that a patient who is unable to consent should be given care that is in his or her 'best interests'.

AIM

The aim of this paper is to report on qualitative data concerning nurses' use of sedation which were obtained as part of a larger study to explore the way in which nurses obtain consent prior to nursing care procedures.

METHOD

A purposive sample of 30 qualified nurses in two teaching hospitals in England was obtained. One hundred critical incidents were collected through 30 in-depth interviews as a means of focusing on specific incidents concerning informed consent prior to nursing care procedures in clinical practice.

FINDINGS

The administration of sedation to patients who cannot consent was a major theme to emerge. Sedation was sometimes given in the interests of other patients or staff rather than the patient and before alternative strategies had been considered. Nurses were uneasy about the use of sedation in such circumstances, and lacked knowledge as to when it may be appropriate to do so.

CONCLUSIONS

Nurses need to be familiar with the relevant ethical and legal principles and professional guidance in their own countries for caring for people who cannot consent, and need to be confident in their understanding and application of these principles to ensure that sedation is administered appropriately.

Electroconvulsive monotherapy in the treatment of acute confusion psychosis. A case report

This report focuses on the successful treatment of a most acute case of confusion psychosis according to the concept of Karl Leonhard. The 18-year-old patient was hospitalized three times before the current episode and his case has been characterized as pharmacologically treatment-resistant psychosis since he failed to respond to any psychopharmacological therapy including sufficient clozapine medication. In the patient's history, typical and atypical antipsychotic as well as mood-stabilizing and sedating pharmacological treatments have been conducted. However, only adverse effects could be observed. When receiving electroconvulsive monotherapy (ECT), the patient showed a marked reduction of symptoms while experiencing no adverse effects. The implications of this finding are discussed with regard to Leonhard's diagnostic system.

Food-cobalamin malabsorption in elderly patients: clinical manifestations and treatment

PURPOSE

Approximately 15% of people aged more than 60 years old have a cobalamin (vitamin B12) deficiency, mainly in relation with food-cobalamin malabsorption (FCM). To date, no study has documented this disorder in the elderly. There is also little information on clinical consequences.

SUBJECTS AND METHODS

We studied 92 elderly patients with well-established FCM who were extracted from an observational cohort study (1995-2004) of 172 consecutive elderly patients with documented cobalamin deficiency.

RESULTS

The median patient age was 76 +/- 8 years; 60 patients were women. The most common clinical manifestations were neurologic or psychologic: mild sensory polyneuropathy (44.6%), confusion or impaired mental functioning (22.8%), and physical asthenia (20.7%). Hematologic abnormalities were reported in at least one third of the patients: anemia (21%), leukopenia (10.9%), thrombopenia (8.7%), and pancytopenia (6.5%). All patients had low serum vitamin B12 levels (<200 pg/mL), with a mean value (+/- standard deviation) of 131 +/- 38 pg/mL and total serum homocysteine level of 22.1 +/- 9.3 micromol/L. The mean hemoglobin level was 10.9 +/- 2.5 g/dL and the mean erythrocyte cell volume 95.7 +/- 12.7 fL. Correction of the serum vitamin B12 levels and hematologic abnormalities was achieved equally well in patients treated with either intramuscular or oral crystalline cyanocobalamin.

CONCLUSIONS

This study suggests that in elderly patients, FCM may be associated with significant neurologic, psychologic, and hematologic abnormalities, which seem to respond equally well to either oral or parenteral vitamin B12 therapy.

[How you can ease the suffering of the dying patient]

Taking care of the dying is an important and demanding concern for the general physician. In addition to the amelioration of pain, he also has to help the patient to cope with dyspnea, vomiting, constipation, depression and anxiety. To this end, not only morphine but also anti-emetic drugs, laxatives and peristalsis-stimulating suppositories, benzodiazepines and neuroleptics with a sedating effect can make it easier for the patient during the terminal phase of his life. As least as important as the support provided by medication, however, are sympathetic communication with the patient and human warmth.

Evaluating Risk Factors for the Development of Ifosfamide Encephalopathy

BACKGROUND

Ifosfamide is an important part of chemotherapeutic regimens used to treat a variety of malignancies. One potential side effect of the drug is encephalopathy, which may manifest itself as a variety of symptoms, ranging from agitation to seizures and coma. The goal of this review is to identify the prevalence of ifosfamide encephalopathy at Barnes-Jewish Hospital from 1995 to 2003, and to identify risk factors associated with the condition.

METHODS

A retrospective cohort study of all patients receiving ifosfamide at Barnes-Jewish Hospital in St. Louis, Missouri, from late 1995 to early 2003 was performed. In sum, the authors reviewed chemotherapy administrations for a total of 237 individual patients. Patients were divided into control subjects and cases of encephalopathy.

RESULTS

A total of 237 patients received ifosfamide during the study period. Thirty-eight patients (16%) underwent chemotherapy rounds during which encephalopathy occurred. Serum albumin was significantly lower in the case population (3.3 g/dL) compared with the control population (3.7 g/dL). The odds ratio of hypoalbuminemia for the development of encephalopathy was calculated as 4.3 (CI, 2.26-8.3). The average creatinine values were in the normal range for both groups, although slightly higher in the case population with statistical significance. Age and ifosfamide dose were not significantly different between the 2 groups. The most common manifestation of encephalopathy was confusion. Methylene blue, which has been thought to reverse the condition, was administered in 26 cases.

CONCLUSION

The prevalence of ifosfamide encephalopathy during the study period was 16%. Albumin was significantly lower among those patients who experienced encephalopathy, whereas age, creatinine, and ifosfamide dose were not significantly different between the 2 groups.

[Management of psychiatric complications of Parkinson's disease]

Psychic disturbances are frequently present in patients with Parkinson's disease. They increase the disability and handicap, contribute to poor quality of life and often make the treatment of motor symptoms more difficult. Cognitive impairment may be restricted to subtle changes on neuropsychological testing, but the evolution towards a dementia appears more frequent than previously thought. Depression, anxiety and hallucinations are common but may be underestimated. During recent years, new psychiatric aspects have been described such as apathy and the so-called syndrome of dopamine dysregulation.

A randomized controlled trial of a behavior advisory service for hospitalized older patients with confusion

OBJECTIVE

To determine whether individualized advice on non-pharmacological strategies for hospitalized older patients with confusion and behavioral problems can improve levels of agitation and reduce the use of psychotropic medication.

METHOD

Pragmatic randomized controlled trial in two metropolitan teaching hospitals in South Australia. Seventy-one older patients with confusion and a behavioral disturbance were randomly allocated to receive either an assessment and ongoing individualized advice from an extended practice nurse on non-pharmacological strategies or usual care. Usual care included an assessment by a geriatrician.

MEASUREMENTS

Primary outcomes were levels of agitation (Pittsburgh Agitation Scale), appropriateness of psychotropic medication prescribing (Medication Appropriateness Index) and levels of psychotropics administered (chlorpromazine and diazepam dose equivalents). Secondary outcomes were length of stay, discharge destination, number of falls, restraint use and satisfaction from nursing staff and next of kin.

RESULTS

Levels of agitation were modest at baseline with mean PAS intervention group 3.4 (SD = 0.5) and control group 4.0 (SD = 0.4) and both groups improved over time to 1.7 (SD = 0.4) for the intervention group and 1.8 (SD = 0.3) for the control group on the final day of data collection. Median length of follow-up was nine days. There was no effect of the intervention on levels of agitation, amount and appropriateness of psychotropic medication prescribed and administered, falls, length of stay, discharge destination, restraint use and nursing and next of kin satisfaction.

CONCLUSION

A nursing consultation service providing individualized non-pharmacological advice does not improve patient agitation or use of psychotropic medication for older patients with confusion and behavioral problems in an acute hospital.

Risperidone in the treatment of acute confusional state (delirium) due to neuropsychiatric lupus erythematosus: case report

Acute confusional state (delirium) appears as one of the common neuropsychiatric manifestations of systemic lupus erythematosus (SLE). It has been suggested that neuropsychiatric SLE (NP-SLE) could promote the occurrence of drug-induced extrapyramidal symptoms (EPS). Atypical antipsychotics have been thought to be useful in management of delirium because of their low incidence of adverse effects including EPS. However, no reports of the use of atypical antipsychotics in delirium due to NP-SLE have been published. Here we report a case of NP-SLE presenting an acute confusional state (delirium), which was successfully managed by risperidone.

Lamotrigine in the treatment of confusion psychosis. A case report

We report on the successful treatment of four patients suffering from confusion psychosis according to the classification of Leonhard. The patients did not sufficiently respond to neuroleptic treatment or mood stabilizers like carbamazepine and valproate, but improved when lamotrigine was added, showing a marked reduction in clinical signs and symptoms. The implications of these findings including the possible mechanisms involved are discussed.

Homeopathy in dementia and agitation

Three cases of elderly, institutionalised patients with problems relating to dementia and agitation and good response to homeopathic treatment are presented.

Using thiamine to reduce post-ECT confusion

Cognitive side-effects are commonly seen following electroconvulsive therapy which convey no therapeutic benefit but are troublesome to both patient and clinician. Various efforts have been made in the past to minimize these symptoms. Although modification of technical parameters related to ECT administration has led to some limited improvement in this regard, attention is now being increasingly focussed on pharmacological approaches. A number of agents have been explored in this context, however, as far as we are aware, the use of thiamine has not yet been investigated. We present three cases of elderly patients undergoing ECT for major depression in whom thiamine administration was associated with beneficial effects on post-ECT confusion. We review the evidence suggesting that thiamine deficiency may be implicated in the confusional state following ECT and recommend that consideration be given to its use in preventing and treating this problematic side-effect, especially in elderly patients.

[Confusion and delusions occurring during interferon-alpha treatment]

A number of side effects occurring during IFN therapy have been described. Psychiatric side effects include cognitive, behavioural and affective changes, confusion and, less commonly, psychotic symptoms. We report the case of a 52-year-old patient who had been treated for almost three years with IFN alpha for a chronic myelogenous leukemia and who presented an acute confusional episode with delusions, following the reintroduction of IFN alpha after a therapy suspension of 2 weeks. Clinical improvement occurred quite rapidly after cessation of the IFN treatment; this evolution and the normality of the biological tests, EEG and cerebral imagery suggest a causal relationship between this treatment and the psychiatric symptoms.

[Mental confusion and multifocal lymphatic and pulmonary tuberculosis. A case report]

This report describes a case of mental confusion associated with ongoing adenitis and pulmonary tuberculosis in a 20-year-old man with no history of psychiatric disorders. Diagnosis was based on clinical and laboratory findings. Tranquillizers improved mental status and antituberculosis treatment was administered before referring the patient to an internal medicine department. The authors emphasize the rarity of these cases in the Senegalese medical literature and discuss possible diagnostic pitfalls.

[Clomethiazole as an adjuvant in the treatment of confusional psychosis]

We report on the successful treatment of two female patients with the clinical features of severe confusional psychosis. The clinical picture of these cases was characterized by lability of mood, disorientation, delusions, hallucinations, misidentification of persons, severe thought disorder and impaired memory. A 55-year old female inpatient suffered from a psychotic episode with the clinical features of confusional psychosis. Medical history showed three proceeding confusional psychotic episodes. In the second case a 32-year old female inpatient suffered from a severe postpartum psychosis with the clinical features of confusional psychosis. In this case there was no clinical history of psychotic episodes. After nonresponsive treatment with neuroleptics and mood-stabilizers, both responded rapidly to additional medication with clomethiazole within a week, exhibiting a marked reduction in clinical signs and symptoms. A brief review about this delirium-like psychosis and current knowledge of therapeutic strategies is presented. We discuss clomethiazole as a possible potential adjunct in the treatment of confusional psychoses.

[Etiology of initially unexplained confusion of excitability in deadly nightshade poisoning with suicidal intent. Symptoms, differential diagnosis, toxicology and physostigmine therapy of anticholinergic syndrome]

HISTORY AND ADMISSION FINDINGS

After a walk in a wood a 55-year-old teacher was admitted to the emergency unit of a university hospital because of somnolence and excitability. Her rectal temperature was 37.8 degrees C, she had sinus tachycardia (rate of 130/min) but no other significant findings.

INVESTIGATIONS

With the exception of C-reactive protein (10 mg/dl), MCV (101 fl), MCH (34 pg) and arterial blood gases (pH 7.483, pCO2 35.5 mmHg, base excess 5.1 mmp/l) laboratory tests were within normal limits. Qualitative screening of serum for benzodiazepines, barbiturates and antidepressives was negative. Neurological examination, including lumbar puncture and cranial computed tomography were noncontributory.

TREATMENT AND COURSE

10 hours after admission the patient developed signs of an anticholinergic syndrome with mydriasis, dry mouth, tachycardia, hot skin and an atonic bladder. Physostigmine 2 mg completely reversed the neurological and mental symptoms. After gas chromatography, mass-spectrometry of a urine sample showed an atropine molecular fragment with a molecular weight of 271. At intervals of 3 to 5 hours the recurrence of confusion and excitability required 4 further i.v. injection of physostigmine. The patient subsequently became accessible to psychiatric examination and reported that during the walk she had swallowed 8-10 berries of deadly nightshade with suicidal intent.

CONCLUSION

In case of excitability and confusion as well as somnolence or coma of uncertain aetiology an anticholinergic syndrome caused by ingestion of atropine-containing plants or psychoactive drugs (phenothiazines, butyrophenones, tri- or tetracyclic antidepressants) should be included in the differential diagnosis. If there are suggestive clinical findings (tachycardia, somnolence, coma or threatened respiratory arrest, physostigmine should be given if there are no contraindications.

Nonconvulsive status epilepticus causing acute confusion

PRESENTATION

an elderly patient presented with acute confusion and was found to have nonconvulsive status epilepticus. She responded to treatment with anti-epileptic drugs.

OUTCOME

this case illustrates an important, under-recognized and reversible cause of acute prolonged confusion.

Gender differences in the treatment of behavior problems in Alzheimer's disease. SAGE Study Group. Systemic Assessment of Geriatric drug use via Epidemiology

OBJECTIVE

To define gender differences in noncognitive behavioral problems of patients with AD and differences in the associated treatment of those problems.

DESIGN/METHODS

We performed an observational study using the Systematic Assessment and Geriatric drug use via Epidemiology (SAGE) database, which contains data collected with the Minimum Data Set on a cross-section of nursing home residents in five US states. Behavior problems were documented at the first assessment of 28,367 residents with AD. We evaluated the role of gender differences in behavior as predictors of differences in nonpharmacologic versus specific pharmacologic therapies with psychoactive medications using logistic regression.

RESULTS

Men were more likely than women to exhibit behavior problems such as wandering, abusiveness, and social impropriety (59% versus 50% for any behavior problem). Hallucinations and delusions as well as depression were equally prevalent in men and women. Nevertheless, men were more likely to receive psychoactive medications. Among the specific drug categories examined, and controlling for age and degree of cognitive impairment, men were more likely to receive antipsychotic drugs and less likely to be receiving antidepressants.

CONCLUSION

Gender appears to play an important role in determining the frequency of behavioral problems in nursing home residents with AD, which may influence choice of treatments as well as the decision whether to treat. The use of more potent tranquilizers in men with problem behaviors has potential implications for morbidity, deserving further investigation.

Managing acutely disturbed behaviour

Managing acutely disturbed behaviour is difficult, particularly in environments which are not designed for dealing with such conduct. An understanding of factors which can lead to this behaviour and clear management policies and procedures are needed.

Quetiapine as an alternative to clozapine in the treatment of dopamimetic psychosis in patients with Parkinson's disease

There are many difficulties associated with the late stages of Parkinson's disease (PD), but psychosis and agitation may be the most disturbing for both patients and care givers, and often precipitate the pivotal decision for long-term nursing home placement. While the addition of antipsychotic drugs or the withdrawal of antiparkinsonian drugs may improve the behavioral problem, these strategies usually worsen the motor difficulties. Clozapine has been studied in PD for over a decade, and while it appears to be effective, there are safety and tolerability concerns associated with it. In addition, in New Jersey, Medicaid no longer pays for the home blood draws that are required for home-bound patients. This led to a situation in which we had patients who needed to stop clozapine and begin an alternative therapy. Because quetiapine seems particularly well suited to patients with PD based on in vitro and in vivo studies we have begun to try this medication in PD patients who need to stop clozapine. This article reports three case histories of patients with PD, confusion and dopamimetic psychosis who had been previously managed with clozapine and who were successfully switched to quetiapine. At doses from 12.5 to 150 mg/day quetiapine was well tolerated, resulting in behavioral improvement and no real increase in parkinsonism. These case histories raise the possibility that quetiapine may represent a viable alternative to clozapine in PD patients with dopamimetic psychosis and behavioral disturbances.

Nurses' perceptions of chemical restraint use in long-term care

The purpose of this pilot study is to validate the use of the Perceptions of Restraint Use Questionnaire (PRUQ) in assessing chemical restraint perceptions among nurses working in long-term care. The convenience sample includes 60 licensed nurses working in six long-term care facilities in Illinois. The reliability analysis for a modified version of the PRUQ, based on the research sample chosen, was found to have a Cronbach's coefficient alpha of .9450. Study findings reflect a moderately positive attitude toward chemical restraint use by nurses in long-term care.

A case report of acute confusional state in thyrotoxicosis

Confusion is a rare manifestation of thyrotoxicosis. The patient presented with an acute confusional state and had clinical and biochemical features of thyrotoxicosis. His illness was well controlled with antithyroid therapy. It is thus concluded that thyroid function should be evaluated in otherwise unexplained encephalopathy as response to treatment is dramatic and most rewarding.

Divalproate augmentation in lithium-resistant rapid cycling mania in four geriatric patients

This report describes four geriatric patients, with rapid cycling bipolar disorder, who were treated successfully with divalproex sodium in combination with lithium carbonate, noting that both drugs were necessary for clinical remission of symptoms. Divalproex sodium may actually enhance the sensitivity to lithium carbonate in this population, potentially leading to treatment with lower lithium concentrations. This strategy has an advantage in enabling a greater safety range in the use of lithium carbonate in elderly patients. This report further raises questions as to the nature of rapid cycling illness in the "old-old" population.