A 66 year old white male is brought to your office for evaluation of progressive memory loss over the last several months. The problem seems to wax and wane significantly over the course of days and weeks. At times when he is more confused, he tends to have visual and auditory hallucinations that he is back fighting in Vietnam, thinking a ringing telephone is calling in fighter jets. He has also been falling occasionally.
On physical examination, he has a resting tremor in his left leg, and rigidity of his upper body and face. A full medical workup, including standard blood work and a CT scan, shows no abnormalities that suggest delirium, stroke, or other primary etiologies.
Which one of the following is the most likely diagnosis?
Correct Answer B:
Dementia with Lewy bodies is currently considered one of the most common etiologies of dementia in elderly patients, representing up to 20%-30% of those with significant memory loss. The clinical presentation consists of parkinsonian symptoms (rigidity, tremor), fluctuating levels of alertness and cognitive abilities, and behavior sometimes mimicking acute delirium. Significant visual hallucinations are common, and delusions and auditory hallucinations are seen to a lesser degree. On pathologic examination, Lewy bodies (seen in the substantia nigra in patients with Parkinson’s disease) are present diffusely in the cortex. There is currently no specific treatment.
A 75-year-old male is brought in by his family due to concerns about memory loss.
Which one of the following is best for determining whether or not he has dementia?
Correct Answer A:
There are no biologic markers for Alzheimer’s disease or most other dementias; the diagnostic criteria include elements obtained only from a history and physical examination, including results from a Mini-Mental State Examination (MMSE) or other cognitive testing. Brain imaging is recommended for evaluation, but cannot confirm the diagnosis of dementia. An EEG should be ordered if there is history to suggest seizures, and a lumbar puncture is indicated is infection or cancer is a concern.
A 7-year-old girl hospitalized for a tonsillectomy awakens and cries out in fright that a "big bear" is in her room. She is relieved when a nurse, responding to her cry, enters the room and turns on the light, revealing the bear to be an armchair covered with a coat.
This experience would be an example of:
Correct Answer C:
A delusion is a belief that is pathological (the result of an illness or illness process). As a pathology it is distinct from a belief based on false or incomplete information or certain effects of perception which would more properly be termed an apperception or illusion.
An illusion refers to a specific form of sensory distortion. An optical illusion is always characterized by visually perceived images that, at least in common sense terms, are deceptive or misleading. Therefore, the information gathered by the eye is processed by the brain to give, on the face of it, a percept that does not tally with a physical measurement of the stimulus source.
In the emergency department you are asked to assess a 67-year-old man with alcoholic cirrhosis and recent alcohol cessation. He is agitated, confused and hallucinating. You make a presumptive diagnosis of delirium tremens.
What is the best treatment for his condition?
Correct Answer D:
Delirium tremens (DT), a very serious set of symptoms, may result if alcohol withdrawal is left untreated. Delirium tremens usually does not begin immediately; rather, it appears about 2 to 10 days after the drinking stops. In delirium tremens, the person is initially anxious and later develops increasing confusion, sleeplessness, nightmares, excessive sweating, and profound depression. The pulse rate tends to speed up. Fever typically develops.
DT is treated with benzodiazepines. Among the benzodiazepines, diazepam offers the most rapid time to peak clinical effects, which limits oversedation.
If > 65 years old or severe liver disease, severe asthma, or respiratory failure are present, use short acting benzodiazepine - lorazepam PO/SL/IM.
A 30-year-old man presents in emergency with right lower quadrant abdominal pain. His wife reports that he had been drinking heavily in response to marital problems and had never had such pain before. Appendicitis was diagnosed and an appendectomy was successfully performed. Four days later the patient was anxious, restless, unable to sleep and claimed his wife was a stranger trying to harass him.
The most likely diagnosis is:
Delirium tremens (DTs), a very serious set of symptoms, may result if alcohol withdrawal is left untreated. Delirium tremens usually does not begin immediately; rather, it appears about 2 to 10 days after the drinking stops. In delirium tremens, the person is initially anxious and later develops increasing confusion, sleeplessness, nightmares, excessive sweating, and profound depression. The pulse rate tends to speed up. Fever typically develops.
The episode may escalate to include fleeting hallucinations, illusions that arouse fear and restlessness, and disorientation with visual hallucinations that may incite terror. Objects seen in dim light may be particularly terrifying, and the person becomes extremely confused. The floor may seem to move, the walls fall, or the room rotates. As the delirium progresses, the hands develop a persistent tremor that sometimes extends to the head and body, and most people become severely uncoordinated. Delirium tremens can be fatal, particularly when untreated.
Click to expand