We agree that echocardiography, electroencephalogram, and CSF analysis are not indispensable in the basic diagnostic repertoire. Our explanations of basic diagnostic tools were comprehensive and wide-ranging, as this is how they are conducted in large hospitals.
Echocardiography attempts to detect early in the process the onset of heart failure or infectious cardiac disorders. Heart failure in elderly patients is clinically often difficult to identify in the early stages and can decompensate rapidly in acute medical conditions, including delirium. It is well known that neurological and psychiatric complications, including psychosis and delirium, develop in 20–30% of patients with infectious endocarditis (1). Blood culture results are negative in 10–20% of cases of endocarditis (2). Especially in patients with renal failure, immunocompromised patients, and patients who had preceding antibiotic treatment, echocardiography is a very useful diagnostic examination when trying to identify infectious endocarditis (3).
The EEG is an indispensable diagnostic tool in differentiating non-convulsive epileptic states from confusional states with a different pathogenesis.
Regarding treatment with long acting benzodiazepines we agree with Wolter. Our experiences with “long acting” benzodiazepines relate to midazolam, which we have used with good results especially in confusional states in the palliative phase as a continuous subcutaneous (s.c.) infusion. The indication should be strictly defined and the dosage and application method (for example, s.c. continuously over 24 hours) carefully selected. The advice that benzodiazepines can result in further escalation of the confusional state is important. This applies especially to long acting benzodiazepines in elderly patients. We also found the advice about the duration of confusional states important, which because of their fluctuation cannot be categorized correctly and therefore result in early discharge.
Prof. Dr. Dipl. Pall. Med. (Univ. Cardiff) Stefan Lorenzl
Interdisziplinäres Zentrum für Palliativmedizin
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
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