Discussion 3

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Case 17.2 Agitated and Confused

José R. Maldonado, M.D.

Wesley Brown, a 63-year-old white businessman, was “found down” in the road by police and

brought to the emergency room (ER) of a large university-affiliated hospital. The psychiatry

service was consulted for management of “psychotic behavior” in the ER. The patient’s family

reported that the patient had exhibited an approximately 2-week history of “strange behavior.”

According to his sister, Mr. Brown had been running around the kitchen with knives, sending

paranoid e-mails about the justice system to his friends, showing his guns to the neighbors,

seeing people in the walls, having paranoid thoughts that his wife was having an affair, and not

sleeping. The patient’s wife had reported him missing 3 days prior to admission. Notably, his car

was found a few blocks away with a large box in its trunk containing numerous medications and

the patient’s extensive gun collection.

Mr. Brown’s vital signs were within normal limits. His medical records revealed a history of

coronary artery disease and a coronary artery bypass graft 5 years prior to admission, as well as

chronic back pain and several spinal surgeries, with an associated history of daily opiate use. He

had no prior psychiatric history, including any history of depression or antidepressant

medications. His outpatient medications included metoprolol, cyclobenzaprine, and morphine (in

the form of MS-Contin).

His physical examination was notable for heavy sedation, mydriasis, hypoactive bowel sounds,

urinary retention, epistaxis, and depressed reflexes. A computed tomography (CT) scan of the

head was negative, and CT of the cervical spine showed degeneration. His blood alcohol screen

was negative, and complete blood count and comprehensive metabolic panel results were within

normal limits, as were an electrocardiogram and cerebrospinal fluid from a lumbar puncture. His

urine toxicology screen was positive for “benzodiazepines and tricyclics.”

Mr. Brown’s mental status examination revealed waxing and waning alertness, an unkempt

appearance, lack of cooperation with nursing and medical personnel, somewhat slurred speech,

and signs of psychomotor retardation. His affect alternated between subdued/somnolent and

restless/agitated. He denied suicidal or homicidal ideation but reported significant paranoid

ideation that focused on his wife’s suspected affair. His thought process was notably tangential.

He denied both auditory and visual hallucinations. His judgment and insight were impaired.

During his initial evaluation, the patient was noted to have a Mini-Mental State Examination

score of 16 of 30 possible points. He lost 7 of 10 points for orientation, 3 for attention and

calculation, 2 for recall, and 1 each for sentence writing and copying design.

Diagnosis

• Delirium

Discussion

Mr. Brown was “found down” after a 2-week episode of uncharacteristically strange behavior

that was of apparently sudden onset. According to his wife and sister, he had been paranoid and

threatening, waving knives and showing off his guns. He had been missing for a few days before

being brought to the ER. His mental status examination was notable for a marked disturbance in

both attention and awareness. His level of attention fluctuated over hours. Various cognitive

deficits were new and were seemingly unrelated to another neurocognitive disorder.

Although someone in the ER called this behavior “psychotic,” Mr. Brown presents with a fairly

classic DSM-5 delirium. One criterion for delirium is often particularly difficult to identify:

evidence from the history, physical examination, or laboratory findings that the disturbance is

caused by the physiological consequence of another medical condition, substance intoxication or

withdrawal, or a toxin exposure (or a combination of such factors).

Mr. Brown’s initial workup was notable for a toxicology screen positive for benzodiazepines and

tricyclic antidepressants (TCAs). His physical examination revealed mydriasis, hypoactive bowel

sounds, urinary retention, depressed reflexes, and fluctuating levels of sedation. These results

point toward an anticholinergic delirium. Potential sources of anticholinergic delirium include

benzodiazepines and TCAs (as per Mr. Brown’s positive toxicology screening test). In addition,

opioid agents could be implicated, especially given the patient’s history of chronic pain and

opioid use. Although Mr. Brown’s toxicology screen was negative for opiates, short-acting

opioids might have precipitated the delirium but then been out of his system by the time he

arrived in the ER. He also has a long-standing history of pain, which itself is associated with

both the development and the severity of delirium.

The presence of TCAs in Mr. Brown’s toxicology screen is puzzling. His family insisted he had

never taken antidepressants, and his records seemed to back them up. His medications did

include cyclobenzaprine, however, a commonly used centrally acting muscle relaxant. It is often

used to assist during opioid tapers. Cyclobenzaprine also happens to have a tricyclic structure

and shares many of the pharmacological characteristics and psychoactive effects of TCAs. Mr.

Brown’s delirium was, therefore, likely caused by some combination of cyclobenzaprine,

opioids, and benzodiazepines. Lack of sleep could have been the result of the delirium and then a

factor in its perpetuation.