Case Presentation: An 83-year-old woman presented as a transfer to our center for higher level of care in the setting of a mechanical fall with left femur fracture complicated by altered mental status (AMS) and acute onset atrial fibrillation (AF) with rapid ventricular response (RVR). A past medical history was significant for COPD, hypertension, hyperlipidemia, and osteoporosis complicated by falls with prior L1 vertebral body, left humeral and pubic rami fractures. Upon arrival to our facility, she was agitated and alert, but not oriented however able to follow simple commands. At baseline, the family reported that she was indepdent in ADLs and iADLs. Per review of outside records, the patient had been alert and oriented to person, place, and time, however became altered after onset of AF with RVR. CT head was negative for stroke or intracranial hemorrhage. She was given morphine for pain control as well as lorazepam for agitation. Once admitted to our center, she was taken for urgent surgical repair of her femur without postoperative complication. Psychiatry was consulted post-operatively for management of hyperactive delirium and recommended intravenous valproic acid on Hospital Day (HD) 2. She remained altered, for several weeks during which an extensive work-up for causes was pursued. She was treated for two presumed UTI’s and a pneumonia without improvement. Due to ongoing symptoms, on HD 18, MRI brain was obtained demonstrating no acute or subacute pathologies. At this time, the patient was on tubefeeds, having bowel movements without further etiologies to her delirium, which was now described as hypoactive. Considering the duration of AMS, absence of further reversible causes, goals of care conversations were pursued with family. Given the review of shift from hyperactive to hypoactive delirium, on HD 20, the decision was made to discontinue medications to treat delirium, including valproic acid. By HD 26 the patient was again AO x 4, and back to her baseline. She was ultimately discharged to SNF for intensive physical rehabilitation.
Discussion: It is important to acknowledge the spectrum along which delirium can exist; ranging from hypoactive to hyperactive(1) with the vast majority of patients noted to be in a hyperactive state. Notably, our patient concomitantly had three of the most common inciting factors for delirium: infection, hip/femur fracture, and cardiovascular disease(1). Although these three entities each played a role in her initial presentation of hyperactive delirium, her persistent symptoms and failure to recover was iatrogenic. Her delirium pendulum swung towards a severe refractory hypoactive delirium after initiation of valproic acid. It was not until we took a step back and acknowledged that our hesitation to re-visit the hyperactive state was causing her clinical decline. Both polypharmacy and Beers’ Criteria played an instrumental role in our patient’s status(2,3). Since we had reliable collateral regarding high level baseline functioning, there was a clear idea of what our target mental status was.
Conclusions: In patients with AMS, whether organic or inorganic, it is extremely important to understand what a patient’s baseline cognitive status is prior to admission and to obtain collateral to avoid missing a diagnosis of alteration. Furthermore, it is important to recognize the continuum of delirium as it can swing from the under recognized hypoactive delirium to the “classic” hyperactive delirium state, and treatment of one may actually cause the other.