A patient with giant cell arteritis, slated for temporal artery biopsy, ended up with in-hospital delirium. Why?
Hamilton KT, Lee BJ. Less Is More: In-Hospital Delirium While Awaiting Temporal Artery Biopsy: A Teachable Moment. JAMA Intern Med. Online October 06, 2014. doi:10.1001/jamainternmed.2014.5310
Hospitalization for suspected giant cell arteritis (GCA) left one patient with a cascade of problems, as described in this case-based article in JAMA Internal Medicine.
The details of this case are a cautionary tale about choosing when to admit a patient for observation and testing.
The 68-year-old woman with amyloidosis and peritoneal dialysis for end-stage renal disease presented to the emergency department after experiencing 3 days of pain on the right side of her neck, which progressed to the right side of her head, along with transient blurry vision and tenderness in the right temporal region. CT scan results were unremarkable, but her erythrocyte sedimentation rate was >100 mm/h.
She waS started on a low dose of 20 mg oral prednisone, because she has a history of delirium with higher doses. She was also taking opioids and baclofen for pain.
Because she was admitted for temporal artery biopsy on Saturday night of a holiday weekend, the biopsy was delayed. Meanwhile delirium developed, attributed at first to the medications. This led to imaging to try to determine the cause of the dementia. (Dialysis was also delayed, which might have solved the problem.)
The temporal artery biopsy proved negative, and ultimately musculoskeletal strain took the blame for the head and head pain.
As many as 14% of patients outside the intensive care unit develop delirium during hospitalization, these authors observe. Choosing to hospitalize her for a biopsy that could have been an outpatient procedure led to delirium and put her at other risks, they add.