Syncope with fall at home and now hallucinations?

[al7139, ASN, RN]

Hi,

I am a new (11 months) nurse on a tele unit. I had an 80+ yo male pt the last 2 nights who was admitted for syncope with a fall at home. He hit his head on falling (Bruise on the left temporal). On tele with normal sinus rhythm, no history of cardiac problems, on eye drops for glaucoma, and a statin for cholesterol prior to admission. The pt had been there for 2 days before I got him as a pt. The first night I had him, he was alert and oriented, getting fluids for dehydration, vs wnl, and a very pleasant patient to work with. Towards the end of my shift, he called me to the room, and asked if there was construction going on. I asked him what he meant, and ha described very vividly that there were people renovating his room. I did a neuro exam, which was totally normal. He was still A&Ox3, and no sign of a stroke or a brain injury, but I of course called the doc (alas, it was his colleague on call) to inform them of this new onset hallucinations, and ask for further orders, stressing that the ED had not done a head CT (which is usually protocol for a fall with a head injury). The on call doc told me to do neuro checks q4hrs and call if there was a change in baseline...no head CT.

The next day, I got the pt again, and the pts MD had not ordered a CT like I felt should be done, even though the pt said he had told him about the hallucinations. I immediately called this MD, who was unaware of the pts condition. He immediately ordered a head CT with a wet read, which was done, and showed no bleed, infarct, or anything abnormal. His hallucinations had gotten better, and his neuro checks were totally normal. I wondered if his meds could be causing it, but I looked up all his meds, and none had hallucinations as a side effect.

I am stumped. Even though the pt was 82, he was totally normal neurologically.

Anyone ever seen a pt with these symptoms? Could it have been fluid overload or just being in an unfamilliar place?

I would love to know if someone has seen this before and what it is attributed to.

BTW, labs were WNL too.

Thanks, Amy

[ghillbert, MSN, NP]

Sounds like "sundowners syndrome" aka acute hallucination. In elderly patients, it's often a result of medications or putting them in new environments that confuses them. In addition to a fall and bump on the head, I would have been surprised if he had NOT been confused.

[Jolie, BSN]

Thank you for being persistent in getting the head CT ordered to rule out a bleed.

Hubby and I were responsible for his elderly aunt who lived in a nursing home. She began to have frequent falls, none of which seemed like much taken individually, but over time, we became concerned about her repeated head bumps. We had a devil of a time getting the nurses or physician to consider the need for a head CT. Finally, they did one to shut us up. I was relieved that it did not show a bleed, but I would have been heartbroken if something treatable had been overlooked.

[suanna]

You will find most 75+ patients get confused or hallucinosis or both after a few nights in the hospital. This is especialy true on critical care or tele units where there sleep is somewhat disturbed by alarms or Q2-4vs checks. I have never found a cure other than trying to get them adequate sleep and get them home as soon as you can. CT was a good idea but I would have been suprised if it showed anything without more focal deficits present.

[Virgo_RN, BSN, RN]

Sound like delirium. I've seen it a lot. There are a lot of things that can cause it. UTI, hypoxia, hypercapnia, ETOH w/d, to name a few.

[al7139, ASN, RN]

Hi all thanks for your replies,

I have seen lots of patients sundown, and usually they are so confused already with alzheimers or dementia, that you really don't ever know if they are hallucinating, etc.

It was just wierd, since the pt showed totally normal neuro wise, except for the hallucinations, he was totally normal, and able to tell me what was happening to him.

I though about sundowning, but as he was completely rational, and not demented figured it was not (the guy was sharp as a tack).

I guess it could have been just plain old sleep deprivation coupled with being in a strange setting (I always joke that I send my patients home to get sleep, since we are constantly waking them up to do stuff).

Amy