The assessment and management of hypoactive delirium.

While serving as the on-call physician for a nursing home, you are contacted by the floor nurse about A.R., a 78-year-old woman who refused her medications and physical therapy. A.R. was transferred to the nursing home one week earlier for skilled rehabilitation after an elective and uneventful bio-prosthetic aortic valve replacement. Her medical history includes mild Alzheimer’s dementia, bilateral cataracts, congestive heart failure, hyperlipidemia, hypertension, chronic renal insufficiency, osteoporosis, osteoarthritis, urinary incontinence, and multiple urinary tract infections. She has been widowed for five years, and lives in a house with her daughter. Medications include enteric-coated aspirin 81 mg daily, furosemide 40 mg twice daily, potassium chloride 20 mEq daily, atorvastatin 40 mg daily, lisinopril 2.5 mg daily, metoprolol XL 100 mg daily, alendronate 70 mg weekly, acetaminophen/hydrocodone (500/5) 1-2 tabs every 4-6 hr. as needed, ciprofloxacin 250 mg twice daily, zolpidem 5 mg at bedtime, and donepezil 5 mg at bedtime. Her appetite has been only fair since her arrival at the nursing home, and her last bowel movement was two days prior. A Foley catheter has been in place since her hospitalization. The nurse notes that A.R. is slightly more lethargic, a departure from one day earlier, when she cooperated with physical therapy and was pleasant to nurses. The nurse requests that you evaluate A.R. Physical examination is unremarkable. A.R. answers all your questions appropriately, and scores a 26/30 on a Folstein Mini-Mental Examination—an identical score to one conducted prior to surgery. You order laboratory tests and consider the differential diagnosis for A.R.’s fatigue and noncompliance with medication.