880 - The Challenge of Detecting True Baseline Mental Status in Acquired Brain Injury Patients During Transition of Care

Case Diagnosis: Depakote induced delirium in a baseline independent 86-year-old woman with Intraventricular Hemorrhage (IVH)

Case Description: The patient presented with memory deficits 3 days after a seated fall with head strike. CT Head and Cerebral angiogram demonstrated acute hemorrhage with no clear evidence of vascular etiology. The patient was given Depakote by the critical care team for seizure prophylaxis and to control IVH-associated headache. The patient's mental status declined with no clear explanation. On admission to inpatient rehabilitation, neurologic exam showed the patient was minimally responsive and only able to communicate with single-words or head-nods. Other services corroborated findings, but discussions with family revealed a dramatic deterioration from baseline. Based on this, we pursued a full diagnostic workup. Repeat CT Head demonstrated decreased burden of IVH. Labs showed no metabolic or infectious etiology. Medications were reviewed and Depakote was suspected. Taper was initiated and within six days mental status improved. The patient progressed and was discharged home to the care of family at the supervision level.

Discussions: This case highlights the challenges of identifying medication-associated delirium in patients with acquired brain injury during transition of care. Determining a true baseline mental status is critical and requires information from multiple sources. In this scenario, the patient’s deterioration had occurred during their acute care stay and well in-advance of their transition of care making it more difficult for the rehabilitation team to identify a true baseline. Fortunately, discussions with family and thorough workup lead to the discontinuation of the Depakote and ultimately optimal recovery.

Conclusions: This case underscores the importance of obtaining an accurate history and detailed medication reconciliation during the transition of care to the rehabilitation unit and pursuing diagnostic work up when indicated.