Advice about language disorder in an elderly person
October 14, 2008 8:04 AM Subscribe
Virus in older person causing language disorders (aphasia or delirium)?
This is posted for a friend. Her mother, who is aged 80, came down with what appeared to be 'flu or a virus at the weekend, with a high temperature. For the last twenty-four hours she has had difficulties using language - her words are garbled, most of what she says is gibberish (with occasional sentences that do make sense). She saw her GP yesterday who carried out a reflex test and thought she had had a stroke. She spent a few hours in hospital but the hospital couldn't find any evidence that she had had a stroke. They attributed her language difficulties (aphasia or delirium?) to a high temperature as a result of an infection, although blood tests showed no sign of infection, and sent her home with instructions to take paracetamol.
Today she does not have a temperature but is still having the same language difficulties and also seems to have different personality characteristics from usual - she seems mostly calm about not being able to communicate, and she would normally be anxious. The GP has visited today and says the language problems may go away on their own and if they do not to let him know tomorrow and she will be re-admitted into hospital.
As we understand it the most usual cause of language disorders like this is a stroke or transient ischemic attack. I know that high temperatures can cause delirium, but as she no longer has a high temperature we are not sure if this would still be the case.
Obviously she is in the NHS system and will get help tomorrow if the problem continues. My friend and her family are very concerned, however, and therefore it would be good to know whether infections can cause language disorders like this, continuing after the person's temperature has returned to normal, or whether this is much more likely to be a stroke/TIA. Online resources or your own experiences would both be helpful in keeping the family's anxiety manageable until tomorrow.
Thank you.
This is posted for a friend. Her mother, who is aged 80, came down with what appeared to be 'flu or a virus at the weekend, with a high temperature. For the last twenty-four hours she has had difficulties using language - her words are garbled, most of what she says is gibberish (with occasional sentences that do make sense). She saw her GP yesterday who carried out a reflex test and thought she had had a stroke. She spent a few hours in hospital but the hospital couldn't find any evidence that she had had a stroke. They attributed her language difficulties (aphasia or delirium?) to a high temperature as a result of an infection, although blood tests showed no sign of infection, and sent her home with instructions to take paracetamol.
Today she does not have a temperature but is still having the same language difficulties and also seems to have different personality characteristics from usual - she seems mostly calm about not being able to communicate, and she would normally be anxious. The GP has visited today and says the language problems may go away on their own and if they do not to let him know tomorrow and she will be re-admitted into hospital.
As we understand it the most usual cause of language disorders like this is a stroke or transient ischemic attack. I know that high temperatures can cause delirium, but as she no longer has a high temperature we are not sure if this would still be the case.
Obviously she is in the NHS system and will get help tomorrow if the problem continues. My friend and her family are very concerned, however, and therefore it would be good to know whether infections can cause language disorders like this, continuing after the person's temperature has returned to normal, or whether this is much more likely to be a stroke/TIA. Online resources or your own experiences would both be helpful in keeping the family's anxiety manageable until tomorrow.
Thank you.
I thought meningitis, too (once an MRI or CT scan officially rules out a stroke). The child of some friends of mine had what they thought was the flu, but then her fever shot up and she started talking gibberish - incomplete and nonsensical sentences. They rushed her to the ER and found out she had meningitis. She recovered fully, but she was only eight years old, not eighty. Best of luck to your friend's mom.
posted by Oriole Adams at 10:20 AM on October 14, 2008
posted by Oriole Adams at 10:20 AM on October 14, 2008
Response by poster: Thanks for your responses. The hospital did an EEG. Have looked up meningitis but 87% of cases have headache as a symptom apparently, and she doesn't.
posted by paduasoy at 10:29 AM on October 14, 2008
posted by paduasoy at 10:29 AM on October 14, 2008
If I recall correctly, I think that urinary tract infections in the elderly have been implicated in dementia. I'm not (yet) officially a medical Cube, so it might not synch up with the type of language difficulty you describe, but it's worth a mention/culture.
posted by Weighted Companion Cube at 10:54 AM on October 14, 2008 [1 favorite]
posted by Weighted Companion Cube at 10:54 AM on October 14, 2008 [1 favorite]
Best answer: Acute brain malfunction such as dysphasia and confusion is likely to be caused by inflammation (i.e. swelling up) of the neuronal network regulating speech and other higher functions. Inflammation can affect the entire brain (in which case the patient is liable to go into coma) or localised areas, resulting in more discrete/limited disabilities. The latter is more likely if the underlying cause of the inflammation is reduced local arterial blood supply (or, less commonly, reduced venous blood drainage) whereas the former is more likely if there is a regional - such as meningitis or encephalitis - or generalised sepsis (infection).
In the elderly, urinary tract infection is probably the commonest cause of sepsis, especially if there are no obvious signs of a chest infection. UTIs are however usually easy to diagnose as you would expect the urine to show elevated protein levels, possibly a trace of blood, be thicker and heavier, and probably smell. Urine culture should demonstrate bugs within 12 hours and yield an identification of the culprit (including its antibiotic senistivities) within 24-48 hours. However, viral infection can cause fever and brain malfunction and may be difficult to nail down. Bacterial infection usually causes the white blood cell count to be raised (although overwhelming sepsis can depress it), but with viral infection this indicator is not reliable. Also, patients on immunosuppressants such as corticosteroids - often prescribed for asthma or polymyalgia rheumatica - may fail to show a WCC elevation even in the presence of sepsis. This is where clinicians need to know as much info as possible about the patients prior medical history.
You mention she had an EEG (electroencephalogram): This somewhat surprises me as it is not a commonly available diagnostic tool outside specialist neuroscience units. If it was indeed an EEG and it was nondiagnostic, than good; but it may be that the routine test of an ECG (electrocardiogram) was performed, and this would have been useful to help rule out a cardiac cause for the brain malfunction (of which there admittedly are a few, such as atrial fibrillation which can cause venous clots inside the heart which can then embolise to the brain).
I agree that it is odd that she does not seem to be upset at her dysphasia. This is where a neurologist is needed to differentiate between different types of dysphasia, and to also make an accurate diagnosis of other helpful neuropatholgical symptoms and signs and follow their timecourse.
Paracetamol would tend to settle most fevers, but if the fever was a secondary phenomenon than its disappearance will not help in treating the underlying cause. An early brain scan may or may not help - many perfusion disorders such as TIA and small strokes are not usually visible in the early stages (or only on an MRI scan, not on CT). By definition, a TIA is transient, although there are also short-term "mini-strokes". The fact that she seemingly developed a fever first and only started showing speech problems later would argue against a TIA or stroke; however this is difficult to rule out early on, and I would presume that the hospital doctors would have considered it and possibly prescribed appropriate treatment such as aspirin.
So, in conclusion, there is no easy way to resolve this dilemma. Having done a reasonable amount of investigating, the best thing may in fact be to sit back and wait - if it's a viral problem, it is likely to resolve of its own accord, if it is caused by a complex pathology, this may prove difficult or impossible to diagnose anyway. Without wanting to appear unfeeling, patients in this age group do have a limited life expectancy and will succumb to something sooner or later, and as an intensive care physician who has looked after very many of them, I cannot help but feel that sometimes relentless investigations can become rather counterproductive and may arguably constitute a form of torture. It's a fine line sometimes, and we should make sure to ascertain what the patient herself thinks (or is known to have thought) about "21st century medical technology and capabilities"...
posted by kairab at 2:10 PM on October 14, 2008 [1 favorite]
In the elderly, urinary tract infection is probably the commonest cause of sepsis, especially if there are no obvious signs of a chest infection. UTIs are however usually easy to diagnose as you would expect the urine to show elevated protein levels, possibly a trace of blood, be thicker and heavier, and probably smell. Urine culture should demonstrate bugs within 12 hours and yield an identification of the culprit (including its antibiotic senistivities) within 24-48 hours. However, viral infection can cause fever and brain malfunction and may be difficult to nail down. Bacterial infection usually causes the white blood cell count to be raised (although overwhelming sepsis can depress it), but with viral infection this indicator is not reliable. Also, patients on immunosuppressants such as corticosteroids - often prescribed for asthma or polymyalgia rheumatica - may fail to show a WCC elevation even in the presence of sepsis. This is where clinicians need to know as much info as possible about the patients prior medical history.
You mention she had an EEG (electroencephalogram): This somewhat surprises me as it is not a commonly available diagnostic tool outside specialist neuroscience units. If it was indeed an EEG and it was nondiagnostic, than good; but it may be that the routine test of an ECG (electrocardiogram) was performed, and this would have been useful to help rule out a cardiac cause for the brain malfunction (of which there admittedly are a few, such as atrial fibrillation which can cause venous clots inside the heart which can then embolise to the brain).
I agree that it is odd that she does not seem to be upset at her dysphasia. This is where a neurologist is needed to differentiate between different types of dysphasia, and to also make an accurate diagnosis of other helpful neuropatholgical symptoms and signs and follow their timecourse.
Paracetamol would tend to settle most fevers, but if the fever was a secondary phenomenon than its disappearance will not help in treating the underlying cause. An early brain scan may or may not help - many perfusion disorders such as TIA and small strokes are not usually visible in the early stages (or only on an MRI scan, not on CT). By definition, a TIA is transient, although there are also short-term "mini-strokes". The fact that she seemingly developed a fever first and only started showing speech problems later would argue against a TIA or stroke; however this is difficult to rule out early on, and I would presume that the hospital doctors would have considered it and possibly prescribed appropriate treatment such as aspirin.
So, in conclusion, there is no easy way to resolve this dilemma. Having done a reasonable amount of investigating, the best thing may in fact be to sit back and wait - if it's a viral problem, it is likely to resolve of its own accord, if it is caused by a complex pathology, this may prove difficult or impossible to diagnose anyway. Without wanting to appear unfeeling, patients in this age group do have a limited life expectancy and will succumb to something sooner or later, and as an intensive care physician who has looked after very many of them, I cannot help but feel that sometimes relentless investigations can become rather counterproductive and may arguably constitute a form of torture. It's a fine line sometimes, and we should make sure to ascertain what the patient herself thinks (or is known to have thought) about "21st century medical technology and capabilities"...
posted by kairab at 2:10 PM on October 14, 2008 [1 favorite]
Could it be a side effect from a med? I was on scopolamine for vertigo once and I could not speak straight on it; very scary.
Is she able to read/write?
posted by Riverine at 5:47 PM on October 14, 2008
Is she able to read/write?
posted by Riverine at 5:47 PM on October 14, 2008
Best answer: Could she have been suffering some kind of dementia and covering for it (a common problem in the elderly- they know something bad is happening and they rightly do everything to hang on to reality), but that this illness broke that down?
Also, you said the GP did a reflex test? She must have failed it if he sent her to get an MRI. Is it possible the MRI result was misinterpreted, and she really did have a stroke? Failing that, investigate what could cause a reflex test to fail and test for those things.
What about things like oxygen deficiency, liver/kidney failure, heart trouble? Vitamin deficiencies?
posted by gjc at 5:24 AM on October 15, 2008
Also, you said the GP did a reflex test? She must have failed it if he sent her to get an MRI. Is it possible the MRI result was misinterpreted, and she really did have a stroke? Failing that, investigate what could cause a reflex test to fail and test for those things.
What about things like oxygen deficiency, liver/kidney failure, heart trouble? Vitamin deficiencies?
posted by gjc at 5:24 AM on October 15, 2008
Response by poster: Thanks to everyone for their responses. Just for future reference, this was in fact a stroke.
posted by paduasoy at 8:34 AM on October 20, 2008
posted by paduasoy at 8:34 AM on October 20, 2008
This thread is closed to new comments.
what kind of tests did they run?
posted by matteo at 8:12 AM on October 14, 2008