Delirium in Geriatric Psychiatry Patients: Causality and the Role of Empirical Antibiotics in the Management of Urinary Tract Infection

INTRODUCTION Delirium is an acute neuropsychiatric syndrome with a clinical diagnosis.[1] It is a medical emergency that demands prompt identification and management of underlying causes, which can range from cerebrovascular pathology and metabolic changes to infections.[2,3] Delirium is diagnosed in 8%–17% of older adults admitted to hospitals,[4] with urinary tract infections (UTIs) accounting for 15.4% of the infectious causes.[5] Due to the high coprevalence of these two conditions in elderly patients, it is imperative that those with delirium are evaluated and treated for UTIs.[6,7] The Infectious Diseases Society of America acknowledges that elderly patients with cognitive impairment and/or psychiatric comorbidity may not clearly communicate the presence of symptoms. However, it advises against the overt use of antibiotics and recommends investigating other potential causes of delirium.[8,9] This case report highlights the challenges faced in diagnosing and managing delirium in an elderly female with treatment-resistant schizophrenia and tardive dyskinesia. CASE REPORT A 60-year-old female with a 35-year history of paranoid schizophrenia was brought to us during an acute exacerbation. She exhibited delusions of persecution and reference, along with bilateral upper limb dyskinesia. Her past treatment records indicated a history of akathisia, shouting spells, and poor sleep after using clozapine, which had been withdrawn within 4–5 days. Previously, she had been stabilized on quetiapine at a dose of 200 mg/day. The diagnoses of treatment-resistant paranoid schizophrenia, episodic with progressive deficit (F20.01, ICD-10), and tardive dyskinesia (G24, ICD-10) were considered. Quetiapine was increased from 200 mg to 400 mg/day along with the addition of tetrabenazine 25 mg and Vitamin E 800 mg to manage dyskinesia. After an initial brief period of stabilization of florid psychotic symptoms and dyskinesia, she subsequently exhibited episodes of pacing out of home, screaming, undressing, and passing urine and stool in inappropriate places, lasting for about 10 days. These symptoms primarily occurred in the early evenings and worsened at night. There were no associated signs of fever, pain abdomen, burning micturition, cough, or other somatic complaints. Her vitals were stable, but she appeared restless, inattentive, agitated, and was pacing around, and was disoriented to time, place and at times to person. The Confusion Assessment Method (CAM) score was 15 (out of 19). A provisional diagnosis of delirium (F05, ICD-10) for evaluation was made. Initial acute management included injectable haloperidol 2.5 mg and oral clonazepam 0.25 mg, along with a reduction of quetiapine to 200 mg/day. With these changes, the patient was able to sleep for 4–5 h per night; however, confusion in the early evenings and intermittent agitation persisted almost every other evening. Attempts to increase the haloperidol dose led to worsening dyskinesia, so the dose was maintained at 2.5 mg. Delirium lasted for 2 to 3 days before sending for urine culture (as urine report was within normal limits). Empirical antibiotics were initiated simultaneous. Meanwhile, the following assessments were conducted to identify the cause for delirium [Table 1].Table 1: Investigation findingsAfter an empirical initiation of nitrofurantoin 100 mg BD for 5 days (and further continuation as per sensitivity reports), a clinical response was observed, with a gradual increase in lucid intervals. Within 48 h, the CAM score reduced from 15 to 8. DISCUSSION Appropriate diagnosis, differential diagnosis, and timely management in geriatric psychiatry requires a flexible and tailor-made approach. Delirium is one among the various atypical and nonspecific symptoms of UTI, particularly in elderly patients.[5] If not pursued with a high index of clinical suspicion, underlying infective foci may remain obscure, negatively impacting the patient’s quality of life. It is important to note that elderly patients are less likely to develop a fever in response to infections. In addition, those with acute confusion, cognitive impairment, or chronic psychiatric illnesses may not effectively communicate the presence or absence of genitourinary symptoms.[10] Multiple comorbidities and the resultant polypharmacy in the elderly further necessitate careful consideration of potential drug–drug interactions that can precipitate delirium, particularly anticholinergic overload. A Canadian survey on the management of delirium in patients with bacteriuria, but without genitourinary symptoms or fever, found that 38% of physicians initiate empirical antibiotics immediately, 33.8% choose antibiotics based on culture reports, and 14.4% use empirical antibiotics in the absence of other identifiable causes.[11] This highlights the variation in protocols when clear guidelines are lacking for managing delirium in the elderly, especially when routine investigations fail to identify the cause. Therefore, there is a pressing need to develop clinical practice guidelines addressing the management of these cases,[6] reflecting the role of empirical antibiotics. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Author Contributions Dr. Keya Das - Conceptualisation and Primary draft, Editing Dr. Sriraksha R Nayak - Secondary draft, editing. Data availability statement Not applicable. Declaration for AI Use Not used. Declaration of use of copyright tools Not used. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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