Delirium as a geriatric syndrome in the initial presentation of Takotsubo syndrome

Lopez Gomez, Jesus; Garcia Tercero, Elisa; Avellana Zaragoza, Juan Antonio; Belenguer Varea, Angel; Villalón Rubio, Daniela; Trigo Suarez, Rodrigo; Cunha-Pérez, Cristina; Tarazona-Santabalbina, Francisco José

doi:10.1016/j.regg.2024.101482

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"apellidos" => "González-Montalvo" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211139X23001865?idApp=UINPBA00004N" "url" => "/0211139X/0000005900000003/v2_202409170520/S0211139X23001865/v2_202409170520/es/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "Clinic Case" "titulo" => "Delirium as a geriatric syndrome in the initial presentation of Takotsubo syndrome" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jesus Lopez Gomez, Elisa Garcia Tercero, Juan Antonio Avellana Zaragoza, Angel Belenguer Varea, Daniela Villalón Rubio, Rodrigo Trigo Suarez, Cristina Cunha-Pérez, Francisco José Tarazona-Santabalbina" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Jesus" "apellidos" => "Lopez Gomez" "email" => array:1 [ 0 => "jblg93@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Elisa" "apellidos" => "Garcia Tercero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Juan Antonio" "apellidos" => "Avellana Zaragoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Angel" "apellidos" => "Belenguer Varea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Daniela" "apellidos" => "Villalón Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Rodrigo" "apellidos" => "Trigo Suarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Cristina" "apellidos" => "Cunha-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "Francisco José" "apellidos" => "Tarazona-Santabalbina" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Geriatric Medicine Department, Hospital Universitario de la Ribera, Alzira, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "School of Doctorate, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Medical School, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Delirium como un síndrome geriátrico en la presentación inicial del síndrome de Takotsubo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 719 "Ancho" => 2007 "Tamanyo" => 204169 ] ] "descripcion" => array:1 [ "en" => "Electrocardiographic assessment of the patient conducted in the A&E." ] ] ] "textoCompleto" => "Clinical case presentationWe present a clinical case involving an 88-year-old woman with a medical history marked by depression and knee osteoarthritis, devoid of known cardiovascular risk factors, and undergoing treatment with sertraline and paracetamol. A functional assessment revealed complete self-sufficiency in basic activities of daily living, indicated by a Lawton index score of 3, necessitating external assistance for household chores. Subjective complaints of memory issues, marked by frequent forgetfulness and occasional erratic behaviour, suggest the presence of previously undetected mild cognitive impairment. In terms of the clinical progression, the patient exhibited symptoms 24h before admission typified by aggressiveness and agitation. These behaviours escalated as she exhibited resistance to verbal commands from both relatives and attending clinicians, coupled with fluctuating attention. Relatives reported similar, albeit less intense, symptoms over the past four weeks, primarily occurring at night and subsiding spontaneously. The morning preceding admission, the patient was discovered on the floor of her residence. However, it remained unclear whether she had fallen or chosen to lie down. She presented temporal–spatial disorientation, incoherent speech, prompting evaluation by the primary care physician, who subsequently referred her to the hospital Accident and Emergency Department (A&E).Upon arrival at the A&E, the patient presented haemodynamic stability, registering a blood pressure of 140/90 millimetres of mercury. She remained afebrile, exhibited normal resting respiration, appeared composed, yet demonstrated disorientation concerning time and space. Despite this, she responded to verbal commands without alterations in attention or a propensity towards agitation. Notably, she displayed symptoms of delirium, as indicated by the 4AT scale assessment. Cardiopulmonary auscultation revealed no significant abnormalities, except for wet crackles apparent in both lung bases. Abdominal examination yielded no pertinent findings, with an absence of peripheral oedema or indications of deep vein thrombosis. Furthermore, aside from the manifestations of delirium, no associated neurological focalities were observed. An electrocardiographic assessment unveiled a 2mm ST-segment elevation in the anterior aspect (v2–v4) (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The administration of nitrates in conjunction with dual antiplatelet therapy followed. A cranial CT scan highlighted indications of chronic hypoperfusion coupled with cortical atrophy. Laboratory analysis indicated an initial troponin T elevation of 18,500ng/ml, subsequently escalating to 22,550ng/ml 3h later. The case was deliberated upon by the Emergency Department in consultation with the Intensive Care Unit (ICU), which determined against ICU admission, opting instead to admit the patient to the Geriatric Acute Medical Unit following confirmation of her clinical stability.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Throughout her hospitalization, the patient remained free of chest pain, displaying a gradual improvement in behavioural symptoms. The comprehensive etiological investigation culminated in a haemodynamic catheterization procedure, ruling out a coronary lesion as the instigator of the clinical presentation (<a class="elsevierStyleCrossRef" href="#sec0025">S1, supplementary archive</a>). However, evidence of possible anteroseptal hypokinesia emerged from the procedure. Transthoracic echocardiography corroborated the presence of anteroseptal hypokinesia alongside basal hyperkinesia, resulting in a reduced left ventricular ejection fraction (LVEF) of 30%. The patient exhibited positive clinical progress during her hospital stay. Clopidogrel was discontinued, and pharmacological adjustments were made to address heart failure with a reduced ejection fraction. Following clinical stabilization and a decline in serum troponin T levels, she was discharged from the hospital. Subsequent outpatient assessment at the geriatric clinic revealed no recurrent similar episodes. Mild cognitive impairment of likely vascular origin was noted, devoid of associated behavioural or psychological symptoms.DiscussionIn the depicted clinical scenario, the sequence of events and the exclusion of secondary organic etiologies (including myocarditis, pheochromocytoma, and thyrotoxicosis) associated with Takotsubo syndrome prompt the consideration of hyperactive delirium as the primary organic cause. This hypothesis is likely due to the concomitant adrenergic stimulation in a patient exhibiting a probable cognitive impairment characterized by a vascular profile previously unreported, concomitant with a reduced left ventricular ejection fraction a condition not previously documented, potentially contributing to cerebral hypoperfusion<a class="elsevierStyleCrossRefs" href="#bib0045">1,2</a>.The classic presentation of Takotsubo syndrome commonly involves chest pain, sometimes accompanied by dyspnoea, following an acute stressful event.<a class="elsevierStyleCrossRef" href="#bib0055">3</a> However, it's noteworthy that delirium has not previously been identified or documented as a triggering factor for this cardiac condition.It holds true that the geriatric demographic often exhibits atypical or divergent symptoms compared to the typical manifestations of various pathological conditions. Moreover, the pathophysiological mechanisms linked to delirium, particularly the activation of the sympathoadrenergic axis, may potentially serve as an inducer or causative factor in such scenarios<a class="elsevierStyleCrossRefs" href="#bib0060">4–6</a>.The clinical atypicality observed within this age cohort predominantly stems from the cumulative effects of ageing, which gradually diminish the functional reserves across various organs and tissues, consequently altering their responsiveness. Delirium, as a clinical manifestation, often signifies serious underlying pathologies or emerges as a part of their progression. It can occasionally be linked to the therapeutic regimen administered to the patient, particularly in cases involving inappropriate prescriptions, exacerbating cognitive disorders already present<a class="elsevierStyleCrossRefs" href="#bib0075">7,8</a>.Conflict of interestsThe authors declare no conflict of interest.Ethical considerationsThe authors declare that they have obtained the patient's consent for the publication of this article." 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Revista Española de Geriatría y Gerontología es el Órgano de Expresión de la Sociedad, una de las sociedades que está experimentando mayor crecimiento por lo que respecta al número de afiliados. Revista fundada en 1966, lo que la convierte en la revista decana de la especialidad en lengua castellana. Se publican principalmente artículos Originales de investigación y Revisiones, al igual que Notas clínicas, Informes, Protocolos y Guías de actuación consensuados por la Sociedad. Cubre todas las áreas de la medicina, pero siempre desde el punto de vista de la atención al paciente anciano. Los trabajos siguen un proceso de peer review, revisión por pares externos.

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