(067) Delirium and Dreams Influenced by Complex Bereavement Disorder

Abstract: -Background– Delirium presents as acute, fluctuating changes within attention, awareness, and cognition, triggered by physiologic pathologies or complex biopsychosocial stressors. Current literature suggests bereavement promotes biological dysregulation and a subsequent widespread inflammatory stress response. Despite research highlighting that inflammatory mediators reversibly disrupt neuronal function resulting in delirium, no link has been established between complex grief and delirium. In this case report, we describe a patient with encephalopathy of unspecified etiology, characterized by vivid hallucinations and dreams, whose symptoms of complex bereavement disorder seemed to influence her delirium.

-Methods– A 79 year-old female with history of dementia, urinary tract infections, and suspected neurosarcoidosis presented to the hospital with altered mental status significantly worse than her baseline cognitive impairment. Psychiatry was consulted for management of agitation, suspected insomnia, and suspected grief reaction, due to the patient’s husband passing away the previous year. Scheduled mirtazapine and quetiapine were initiated, along with quetiapine as needed; the patient’s sleep disturbance gradually improved. However, her mentation did not improve as she continued experiencing fixed delusions and vivid dreams related to her husband. Thus, during medication titration, the psychiatry team also attempted therapeutic interviews regarding her grief.

-Results– An extensive work-up guided by multiple specialty consultants, along with trials of prednisone and broad-spectrum antibiotics, revealed no clear etiology for the patient’s persisting encephalopathy. However, the patient’s daily fluctuations in mental status and sleep disturbance did gradually stabilize until patient discharged to assisted living. Repeated conversations with the patient clarified that her grief significantly contributed to her cognitive decline; addressing this built significant rapport and helped to temper future episodes of agitation and anxiety.

-Discussion– The patient’s grief displayed features of complex bereavement disorder and contributed to the content and severity of her encephalopathy symptoms. Although an additional organic cause was likely, addressing the patient’s grief increased rapport and mood stability, and decreased anxiety during clinician interaction. Due to the patient’s fluctuating mental status, these benefits did not build over time, though they did allow more productive daily interviews between the psychiatry team and the patient as other symptoms, like sleep disturbances and agitation, were more productively addressed.

-Conclusion– Severe grief reactions, including complex bereavement disorder, can worsen baseline cognitive decline and symptoms of toxic-metabolic encephalopathy. They can also influence the content of hallucinations and dreams during encephalopathic episodes. When treating a dementia or encephalopathic patient, addressing their feelings of grief enhances the physician-patient relationship, thereby assisting the management of other associated symptoms.

-References-

1. Brown RL, LeRoy AS, Chen MA, et al. Grief Symptoms Promote Inflammation During Acute Stress Among Bereaved Spouses. Psychol Sci. 2022;33(6):859-873.

2. Cunningham C. Systemic inflammation and delirium: important co-factors in the progression of dementia. Biochem Soc Trans. 2011;39(4):945-953.

3. Nakajima S. Complicated grief: recent developments in diagnostic criteria and treatment. Philos Trans R Soc Lond B Biol Sci. 2018 Sep 5;373(1754):20170273.

4. Khoo S. Acute grief with delirium in an elderly: holistic care. Malays Fam Physician. 2011 Aug 31;6(2-3):51-7.

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: Consult-liaison psychiatrists must be able to provide excellent, holistic care across diverse age groups, including the historically marginalized group of elderly neurocognitive patients. These patients' symptoms and presentations are often simplistically attributed to dementia disorders or acute toxic-metabolic encephalopathy. This case report sheds further light on how elderly patients with pre-existing neurocognitive disorders may demonstrate grief reactions distinctly from other populations, and how their grief reactions may influence the course of their age-related cognitive decline.