Worsening agitation and hallucinations: Could it be PTSD?
Mr. G, age 57, presents with confusion, hallucinations, and agitation. He has a history of PTSD, depression, anxiety, and lung cancer. What could be causing his psychiatric symptoms?
The authors’ observations
DSM-5 criteria for delirium has 4 components:
- disturbance in attention and awareness
- change in cognition
- the disturbance develops over a short period of time
- there is evidence that the disturbance is a direct consequence of a medical condition, medication, or substance, or more than 1 cause.3
Mr. G presented with multi-factorial delirium, and as a result, all underlying contributions, including infection, polypharmacy, brain metastasis, and steroids needed to be considered. Treating delirium requires investigating the underlying cause and keeping the patient safe in the process (Figure). Mr. G was agitated at presentation; therefore, low-dosage olanzapine was initiated to address the imbalance between the cholinergic and dopaminergic systems in the CNS, which are thought to be the mechanism behind delirious presentations.
In Mr. G’s case, methadone was lowered, with continual monitoring and evaluation for his comfort. Infections, specifically urinary tract infections and pneumonia, can cause delirium states and must be treated with appropriate antibiotics. Metastatic tumors have been known to precipitate changes in mental status and can be ruled out via imaging. In Mr. G’s case, his metastatic lesion remained stable from prior radiographic studies.
TREATMENT Delirium resolves
Mr. G slowly responds to multi-modal treatment including decreased opioids and benzodiazepines and the use of low-dosage antipsychotics. He begins to return to baseline with antibiotic administration. By hospital day 5, Mr. G is alert and oriented. He notes resolution of his auditory and visual hallucinations and denies any persistent paranoia or delusions. The medical team observes Mr. G is having difficulty swallowing with meals, and orders a speech therapy evaluation. After assessment, the team suspects that aspiration pneumonia could have precipitated Mr. G’s initial decline and recommends a mechanic diet with thin liquids to reduce the risk of future aspiration.
Mr. G is discharged home in his wife’s care with home hospice to continue end-of-life care. His medication regimen includes olanzapine, 10 mg/d, to continue until his next outpatient appointment, trazodone, 50 mg/d, for depression and PTSD symptoms, and clonazepam is decreased to 0.5 mg, at bedtime, for anxiety.
The authors’ observations
Mr. G’s case highlights the importance of fully evaluating all common underlying causes of delirium. The etiology of delirium is more likely to be missed in medically complex patients or in patients with a history of psychiatric illness. Palliative care patients have several risk factors for delirium, such as benzodiazepine or opioid treatment, dementia, and organic diseases such as brain metastasis.6 A recent study assessed the frequency of delirium in cancer patients admitted to an inpatient palliative unit and found that 71% of individuals had a diagnosis of delirium at admission and 26% developed delirium afterward.7 Despite the increased likelihood of developing delirium, more than one-half of palliative patients have delirium that is missed by their primary providers.8 Similarly, patients with documented psychiatric illness were approximately 2.5 times more likely to have overlooked delirium compared with patients without psychiatric illness.9
Risk and prevention
Patients with risk factors for delirium—which includes sedative and narcotic usage, advanced cancer, older age, prolonged hospital stays, surgical procedures, and/or cognitive impairment—should receive interventions to prevent delirium. However, if symptoms of AMS are present, providers should perform a complete workup for underlying causes of delirium. Remembering that individuals with delirium have an impaired ability to voice symptoms, such as dyspnea, dysuria, and headache, clinicians should have a high index of suspicion for delirium in patients at heightened risk.10
Perhaps most important, teams treating patients at high risk for delirium should employ preventive measures to reduce the development of delirium. Although more studies are needed to clarify the role of drug therapies for preventing delirium, there is strong evidence for several non-pharmacotherapeutic interventions including:
- frequent orientation activities
- early mobilization
- maintaining healthy sleep–wake cycles
- minimizing the use of psychoactive drugs and frequently reviewing the medication regimen
- allowing use of eyeglasses and hearing aids
- treating volume depletion.10
