DEAR DR. ROACH: My 73-year-old husband was just hospitalized for an emergency appendectomy. Pre-surgery, he had a low-grade fever and some stomach tenderness — symptoms that he thought was a stomachache. He had not eaten or slept very much for a couple of days. The surgeon said he had an abscess on his appendix.
Post-surgery, he was on IV antibiotics, had a surgical drain and, of course, was trying to come out of the anesthesia. He did not have much pain, but still had trouble sleeping and had very little appetite. On the morning he was to be discharged, he decided that he had enough and yanked out the IV. Luckily, the doctor felt that my husband had already received the amount of antibiotic that was ordered. Since he has been home, he has been lucid and insists that he knew exactly what he was doing.
My question is, was this a case of delirium, or could it have been just a “temper tantrum” due to all of the factors I mentioned? I was puzzled that the nurses seemed surprised, since I read that about 24 percent of elderly patients can have an episode of delirium. — Anon.
ANSWER: Delirium is an acute change in mental status (lasting for hours or days), such as a change in the ability to focus one’s attention or thinking, using memory or language. A person’s mental state tends to get better and worse during the course of delirium. Unlike dementia, which is a slowly progressive issue, delirium is sudden and should be considered an urgent or emergent problem that should be evaluated rapidly. (One of my colleagues called it “chest pain of the brain” as an analogy for its urgency.)
You are right that as many as 30 percent of older people will experience delirium with surgery and hospitalization. There is often an identifiable medical cause for delirium, such as infection; medications; changes in body chemistry (sugar, sodium, thyroid, oxygen); seizures; organ failure (especially heart, liver, lung and kidney); and many others. Your husband probably had evaluations for many of these, but he may not have had a thorough evaluation if delirium wasn’t considered.
In about 70 percent of cases, delirium is not recognized. I don’t have enough information to know for sure, but I suspect you may be right that this was an episode of delirium. Family members can sometimes be valuable in making the diagnosis by telling us that the patient just isn’t acting themselves and especially by looking for fluctuations that are so characteristic of delirium. If he isn’t the sort of person to normally have a “temper tantrum,” then this was likely delirium.
If he is completely back to normal now, there probably isn’t a lot to do, but his doctor should be made aware of this event. If he requires another hospitalization, there are steps the medical team can take to reduce the risk of recurrent delirium.
DEAR DR. ROACH: Are intramammary lymph nodes problematic? (i.e., can they become cancerous?) — R.P.
ANSWER: Lymph nodes are normal structures and are not problematic themselves. They often become enlarged when there is infection. However, enlarged lymph nodes in a person with cancer are concerning because they might represent the spread of cancer, as many cancers first spread to the lymph nodes before going to more distant sites such as the lungs.
Enlarged intramammary (within the breast) lymph nodes in a person with breast cancer are usually removed for pathological evaluation, although their appearance on a mammogram and sonogram can give the radiologist a good idea of whether they are likely to be benign or malignant.