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A 76-year-old female is admitted to the hospital because of an altered mental status. She has a history of diabetes, hypertension, osteoporosis, and mild depression. At home, she was on metoprolol, rosiglitazone, hydrochlorothiazide, and sertraline. She also takes alendronate on a weekly basis. She has been on these medications for a number of years. Before admission, she was living independently in her apartment and was able to perform nearly all day-to-day activities. It was her daughter who found her in her apartment, very confused in her bed. On examination, you see a drowsy, frail, elderly woman in no acute distress. Her temperature is 36.7 C (98 F), blood pressure is 110/50 mmHg, pulse is 88/min, and respirations are 16/min. Her oxygen saturation is 97% on room air. The neck is supple without any jugular venous distention or thyroid enlargement. The oropharynx is dry. Pupillary reflexes are intact. There is no obvious pallor or icterus. Lungs are clear to auscultation. Cardiovascular and gastrointestinal systems are unremarkable. On neurological examination, the patient is not very cooperative. She knows her name but is disoriented to time and place. She can move all her extremities. Touch sensations are grossly intact and deep tendon reflexes are symmetric. On laboratory investigation, total and differential white count is normal. Her hemoglobin and hematocrit are 12.3 g/dL and 36.5, respectively. The basic metabolic panel is normal, including calcium levels. Liver function tests are normal. Her urine examination is unremarkable. Chest x-ray is normal. A CT scan of the head performed in the emergency department shows generalized cerebral atrophy. What is the most appropriate next step in the management of this patient?
A. Discontinue rosiglitazone
B. Discontinue hydrochlorothiazide
C. Discontinue metoprolol
D. Order thyroid function tests
E. Perform lumbar puncture
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Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
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Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
5
Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
5
Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
5
Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
5
Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
5
Posts: 3,675,933
Threads: 734,342
Joined: Sep 2021
Reputation:
5
The most common causes of mental status change in elderly patients are medications, infections (UTI and pneumonia), and metabolic abnormalities. A high index of suspicion is required for making a diagnosis of apathetic thyrotoxicosis. Elderly patients may not have classical manifestations of thyrotoxicosis and can present with apathy, depression, loss of appetite, and severe weight loss. This patient may have apathetic thyrotoxicosis; therefore, this needs to be ruled out first.
(Choice A) Discontinuing rosiglitazone will not help in the management of this patient. Rosiglitazone improves blood glucose in diabetes by improving insulin sensitivity. It does not usually cause hypoglycemia. The effect of rosiglitazone can last for few days after discontinuation.
(Choice B) Hydrochlorothiazide can cause mental status changes by lowering sodium levels and, in some cases, by increasing serum calcium levels. The patient's basic metabolic panel and calcium levels are normal; therefore, hydrochlorothiazide is not responsible for causing the change in her mental status.
(Choice C) The patient has been on metoprolol for a number of years. It is unlikely that metoprolol is responsible for her current symptoms.
(Choice E) There is no indication that this patient has meningitis (no fever, no headache, and no neck stiffness); therefore a lumbar puncture should not be performed as a next step.
Educational Objective:
The most common causes of mental status change in elderly patients are medications, infections (UTI and pneumonia), and metabolic abnormalities. A high index of suspicion is required for making a diagnosis of apathetic thyrotoxicosis. Eelderly patients with thyrotoxicosis may not have classical symptoms.
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You gotta r/o all potential medical causes of AMS; Getting a TSH is right up there w/ ordering a B12 in the initial eval.
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