Interesting case and would appreciate some thoughts.
87-year-old female, lives alone. History breast cancer, Stage 3 CKD, hypothyroid (admit TSH 12, T4 0.9 which is low end normal), HLD, Paroxysmal Afib (current EKG sinus), glaucoma.
Admitted with 1-2 months persecutory delusions someone is trespassing on her property and trying to break in. Has guns at home to defend herself. Police have been called several times by her and brought her to ED because there are no signs of trespassers and she has guns saying she would shoot people on her property. (Admitted to medicine due to mild UTI and AKI)
No psych history, no drugs/alcohol. 30 years smoking history quit 1985. Brain MRI shows small vessel ischemic change, mild cerebral atrophy, otherwise normal.
She's had a few UTIs over the last 2-3 months. UAs in October and early/mid-December strongly convincing for UTI, with Large LE and high WBCs, low squamous. Received ABx to treat.
On admission UA was not very impressive, but abnormal, small LE with 14 WBC. Cr was bumped from baseline of 1.25 to 1.65, so acute on chronic kidney insufficiency believed to be pre renal from mild dehydration. She was admitted to medicine. Creatinine normalized in 2 days to baseline with IV fluids.
Also she takes Tylenol PM to sleep every night, so gets 25 mg Benadryl consistently. Otherwise no home meds concerning for Ach activity, opioids, or benzos.
Has supportive neighbors but no family. There was a burglary in the neighborhood about 2 months ago which increased her anxiety enough she bought a security system with cameras. She's been "seeing" people on the cameras, but when she shows neighbors there's nothing of concern in the image. Seems this aligns with onset of symptoms, as do UTIs.
She is well oriented. Full date, city, hospital. Is able to say that what she's telling the doctors sounds crazy but she knows it's true. She's been calling a lawyer friend to ask for advice, and his advice is to not tell doctors there are intruders to avoid mental health commitment, but she keeps saying it anyways (and tells us she's been calling a lawyer, can't keep secrets). She demonstrates no waxing/waning of attention. Does not appear delirious. Something like La belle indifference is present where she expresses desire to return home, but remains exceedingly pleasant and makes no demands to leave. (Currently on mental health hold pending county eval).
In the hospital patient has "seen" bird seed on the floor, and a garden on the roof outside her room window, she would call for nurses to show them but when they arrive it is gone. She half accuses the nurses of moving the items/garden.
MoCA 22/30. She is highly educated, graduated from well-regarded undergrad, taught business and tech class at college level for decades.
Hospitalist wonder if this is delusional disorder and thinks transfer to inpatient psych. Psychiatry thinks combination of cognitive impairment plus acute medical issues (UTI, AKI), more likely explanation and could clear with time. What do you think diagnostically?
87-year-old female, lives alone. History breast cancer, Stage 3 CKD, hypothyroid (admit TSH 12, T4 0.9 which is low end normal), HLD, Paroxysmal Afib (current EKG sinus), glaucoma.
Admitted with 1-2 months persecutory delusions someone is trespassing on her property and trying to break in. Has guns at home to defend herself. Police have been called several times by her and brought her to ED because there are no signs of trespassers and she has guns saying she would shoot people on her property. (Admitted to medicine due to mild UTI and AKI)
No psych history, no drugs/alcohol. 30 years smoking history quit 1985. Brain MRI shows small vessel ischemic change, mild cerebral atrophy, otherwise normal.
She's had a few UTIs over the last 2-3 months. UAs in October and early/mid-December strongly convincing for UTI, with Large LE and high WBCs, low squamous. Received ABx to treat.
On admission UA was not very impressive, but abnormal, small LE with 14 WBC. Cr was bumped from baseline of 1.25 to 1.65, so acute on chronic kidney insufficiency believed to be pre renal from mild dehydration. She was admitted to medicine. Creatinine normalized in 2 days to baseline with IV fluids.
Also she takes Tylenol PM to sleep every night, so gets 25 mg Benadryl consistently. Otherwise no home meds concerning for Ach activity, opioids, or benzos.
Has supportive neighbors but no family. There was a burglary in the neighborhood about 2 months ago which increased her anxiety enough she bought a security system with cameras. She's been "seeing" people on the cameras, but when she shows neighbors there's nothing of concern in the image. Seems this aligns with onset of symptoms, as do UTIs.
She is well oriented. Full date, city, hospital. Is able to say that what she's telling the doctors sounds crazy but she knows it's true. She's been calling a lawyer friend to ask for advice, and his advice is to not tell doctors there are intruders to avoid mental health commitment, but she keeps saying it anyways (and tells us she's been calling a lawyer, can't keep secrets). She demonstrates no waxing/waning of attention. Does not appear delirious. Something like La belle indifference is present where she expresses desire to return home, but remains exceedingly pleasant and makes no demands to leave. (Currently on mental health hold pending county eval).
In the hospital patient has "seen" bird seed on the floor, and a garden on the roof outside her room window, she would call for nurses to show them but when they arrive it is gone. She half accuses the nurses of moving the items/garden.
MoCA 22/30. She is highly educated, graduated from well-regarded undergrad, taught business and tech class at college level for decades.
Hospitalist wonder if this is delusional disorder and thinks transfer to inpatient psych. Psychiatry thinks combination of cognitive impairment plus acute medical issues (UTI, AKI), more likely explanation and could clear with time. What do you think diagnostically?
Last edited:
