Rapid recognition leads to a quick reversal.

Takeaways:

• Assess the full medical history of patients on admission, including bowel and bladder issues to reduce risk of delirium.
• Note that conditions other than the primary diagnosis may cause acute delirium.
• Quick recognition of the causes of acute delirium and immediate treatment are essential to good patient outcomes.

JOHN MCDONALD* is a 72-year-old man with a history of stage III small cell lung cancer, smoking, hyperlipidemia, benign prostatic hyperplasia (BPH), and constipation. A week after his last chemotherapy treatment, he’s admitted to the hospital for generalized weakness. Mr. McDonald is alert and oriented in the emergency department (ED), but he says that he feels “sluggish.”
*Name is fictitious 

History and assessment hints

When you see Mr. McDonald on admission, he’s slightly confused but able to reorient himself. His vital signs are blood pressure 160/72 mmHg, heart rate 98 beats per minute, temperature 98.1° F (36.7° C), respirations 22 breaths per minute, and oxygen saturation 94%. Labs have been drawn, but a urine sample can’t be obtained. Mr. McDonald’s breath sounds are diminished bilaterally, and he has bowel sounds in all quadrants, with slight abdominal distension. He states that he’s having dull lower abdominal pain that he rates as a 2/10. He tells you that he’s had difficulty “going” and that his home health nurse administered a suppository 2 days ago and an enema yesterday. Since then, John has had two large bowel movements but still feels abdominal discomfort.

Eight hours later, you find Mr. McDonald incoherent, restless, and agitated. On assessment, you note that his lower abdomen is significantly distended. When you lightly palpate it, he grimaces and pulls away.

Taking action

Recognizing that Mr. McDonald may be suffering from delirium related to urinary retention (cystocerebral syndrome), you page the provider on call, who orders immediate placement of a coudé catheter and a bladder ultrasound. After catheter placement, the bag quickly fills with over 1.5 L of amber-colored urine. After 2 L, Mr. McDonald’s urinary output slows. The ultrasound shows bladder wall thickening and an enlarged prostate.

Outcome

After Mr. McDonald’s bladder is drained, he stops grimacing and moving restlessly. Within a few hours, he’s back to baseline. The lab results show a potassium level of 2.8 mEq/L, a cause of both weakness and constipation. This cancer-induced hypokalemia is treated with I.V. potassium and resolves. Two days later, Mr. McDonald voids successfully after the catheter is removed and he’s discharged home.

Education and follow up

Delirium is common in older, hospitalized patients and is associated with poor patient outcomes. Causes are multifactorial and often reversible. Any change in the level of consciousness should be assessed as a possible sign of delirium.

On admission, Mr. McDonald complained of constipation and abdominal pain. Constipation can be a cause of delirium, but it had resolved in this case. The patient’s low, dull abdominal pain and distension, along with his BPH history, are more suggestive of urinary retention. Patients with a history of BPH have a high incidence of urinary retention and can benefit from a bedside bladder ultrasound. An enlarged prostate can cause thickening of the bladder wall and obstruct the urethra. Complications from urinary retention include bladder damage, urinary tract infections, and kidney failure.

Cystocerebral syndrome refers to encephalopathy caused by increased bladder wall tension, which in turn causes increased catecholamine production. Left untreated, cystocerebral syndrome may result in acute renal failure. It can develop rapidly (hours to days) and present as hypoactive (lethargy), hyperactive (restlessness), or mixed (combination of symptoms) delirium.

Cystocerebral syndrome is a reversible condition that requires immediate attention. Comorbidities should be assessed, especially if a patient complains of bowel or bladder discomfort. If the issue is urinary retention, immediate bladder decompression is needed. A coudé catheter is frequently used because it can better bypass BPH obstructions. Rapid recognition and treatment of cystocerebral syndrome can improve patient outcomes.

Kaveri M. Roy is an assistant professor of nursing at MGH Institute of HealthProfessions in Boston, Massachusetts.

Selected References: 
Dharmarajan TS, Reddy S, Daniel AJ, Suwandhi P. Hyperactive delirium from a distended urinary bladder and retention: Delayed diagnosis and needless medications may beget more adverse events and institutionalization. J Am Med Dir Assoc. 2015;16(3):B6-7.

Magny E, Le Petitcorps H, Pociumban M, et al. Predisposing and precipitating factors for delirium in community-dwelling older adults admitted to hospital with this condition: A prospective case series. PLoS One. 2018;13(2):e0193034.

Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age Ageing. 2006;35(4):350-64.