1. The Mumbling Lady Side Effects Case

2. Presentation 69-year-old female with Alzheimer’s disease 69-year-old female with Alzheimer’s disease Over the last few days she has grown confused, slurred speech, gait changes with near falls, sedation Over the last few days she has grown confused, slurred speech, gait changes with near falls, sedation No change in her back and knee pain when awake and alert No change in her back and knee pain when awake and alert

3. Medical History High blood pressure High blood pressure Arthritis in her knees Arthritis in her knees Heart disease Heart disease Depression Depression Peripheral neuropathy Peripheral neuropathy Diabetes Diabetes Hypothyroidism Hypothyroidism Constipation Constipation Disk disease in her back Disk disease in her back

4. Medications Metoprolol Metoprolol Aspirin Aspirin Ultram Ultram Elavil Elavil Paroxetine Paroxetine Gabapentin Gabapentin Synthroid Synthroid Colace Colace Calcium plus vitamin D Calcium plus vitamin D Benedryl Benedryl Senna Senna

5. Acute Problems Last week Last week Increased pain Increased pain Ultram added as a standing dose medication as well as prn Ultram added as a standing dose medication as well as prn Nighttime awakening Nighttime awakening About 1-3am About 1-3am Doesn’t return to bed until 5 or 6 am Doesn’t return to bed until 5 or 6 am Benedryl added Benedryl added Ambien caused a rash previously Ambien caused a rash previously

6. Medical Workup Vitals normal except blood pressure low Vitals normal except blood pressure low Some readings 80/50 range Some readings 80/50 range Laboratory all normal Laboratory all normal Thyroid, electrolytes, CBC, urinalysis, B12 Thyroid, electrolytes, CBC, urinalysis, B12 Radiology Radiology CT scan without acute findings CT scan without acute findings New medications New medications Ultram Ultram Benedryl (diphenhydramine) Benedryl (diphenhydramine)

7. Nursing Management Reported to the provider the change in condition immediately Reported to the provider the change in condition immediately Maintained a sleep chart to provide information about wake and sleep during the day and night Maintained a sleep chart to provide information about wake and sleep during the day and night Established fall precautions Established fall precautions Daily orthostatic blood pressure and pulse to assess whether orthostasis is the reason for falls Daily orthostatic blood pressure and pulse to assess whether orthostasis is the reason for falls

8. Nursing Management Monitored eating to look for choking with the development of slurred speech Monitored eating to look for choking with the development of slurred speech Looked for weakness on side of the body or facial droop Looked for weakness on side of the body or facial droop Assessed possibility of constipation Assessed possibility of constipation DON discussed new findings with nurses and CNAs on all three shifts DON discussed new findings with nurses and CNAs on all three shifts

9. Plan Likely a delirium Likely a delirium Ultram Ultram Recently added Recently added Can cause delirium Can cause delirium Discontinued and acetaminophen added Discontinued and acetaminophen added Anticholinergic agents Anticholinergic agents Cause delirium often in dementia Cause delirium often in dementia Taken paroxetine for years Taken paroxetine for years Amitriptyline used at very low dose for pain and also on board for over a year Amitriptyline used at very low dose for pain and also on board for over a year Diphenhydramine given over the last three days Diphenhydramine given over the last three days Discontinued immediately Discontinued immediately

10. Outcome Delirium cleared Delirium cleared Pain under fair control with acetaminophen Pain under fair control with acetaminophen Ultram not added back Ultram not added back Diphenhydramine discontinued Diphenhydramine discontinued Consider changing paroxetine to another antidepressant Consider changing paroxetine to another antidepressant Contemplate nortriptyline rather than amitriptyline Contemplate nortriptyline rather than amitriptyline Monitor sleeping led to nonpharmacologic interventions which aided sleep Monitor sleeping led to nonpharmacologic interventions which aided sleep