Polypharmacy-Induced Delirium: A Case Report

Abstract

Introduction. Delirium is an acute disturbance of brain function, characterized by confusion, disorientation and hallucinations. In clinical practice, it is more common in older people and often becomes apparent at night. Risk increases when predisposing factors are present, such as cerebrovascular disease (CeVD) and anemia. It is often triggered by precipitating factors, such as medications, hospitalization, drug interactions. Methods. A clinical case involving an 85-year-old woman is presented. Data were obtained from medical records and inpatient treatment. Medications were reviewed for potential interac- tions and their link to the observed neuropsychiatric symptoms. Results. The patient had chronic anemia and a history of CeVD. After a fall, back pain devel- oped. Tramadol was prescribed for persistent pain. She was also taking: amitriptyline, duloxetine, cabamazepine, bromazepam. After starting tramadol, she developed disorientation, drowsiness and incoherent speech. When tramadol is combined with amitriptyline or duloxetine, it may in- crease adverse drug reactions. On admission, ketoprofen was prescribed for pain control. During the treatment course, fluctuating neuropsychiatric symptoms appeared. At night, she talked to herself, was disoriented and had visual hallucinations. By day, she was oriented and appropriate, but did not recall the night episodes. Given the acute onset, symptomatic treatment with tiapride was initiated, as it is often well tolerated in geriatric patients. Night-time agitation decreased and the hallucinatory symptoms resolved. The patient was discharged home with continuation of the prescribed treatment. Conclusions. This case shows geriatric delirium in a patient with polypharmacy, older age, anemia and a history of CeVD. A newly prescribed opioid likely triggered acute confusion, diso- rientation and visual hallucinations. A neuroleptic reduced night-time agitation and resolved hallucinations. Long-term prevention requires addressing precipitating factors and reviewing medications.