From the Guidelines
Yes, hypercalcemia can cause confusion in a 76-year-old female, even with otherwise unremarkable Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) results. This is because hypercalcemia, or elevated calcium levels, can interfere with normal neurotransmission in the brain, leading to neurological symptoms such as confusion, lethargy, and altered mental status, particularly in elderly patients 1. The classic symptoms of hypercalcemia are often summarized as "bones, stones, groans, and psychiatric overtones," with confusion falling into the latter category.
Causes and Treatment of Hypercalcemia
The patient should be evaluated for causes of hypercalcemia, which commonly include hyperparathyroidism, malignancy, certain medications (like thiazide diuretics or lithium), excessive calcium supplementation, or vitamin D toxicity. Treatment depends on the severity and underlying cause but may include IV fluids, bisphosphonates, calcitonin, or addressing the primary cause. According to the most recent guidelines, bisphosphonates, such as zoledronic acid, are preferred for the treatment of hypercalcemia 2. Prompt medical attention is warranted as untreated hypercalcemia can lead to more serious complications.
Key Considerations
- Hypercalcemia should be suspected in patients with acute or subacute confusion, asthenia, or drowsiness, even if symptoms are indolent 1.
- Hypercalcemia-induced delirium is often reversible, but both hypercalcemia and delirium are independent negative prognostic factors for survival in cancer patients 1.
- Treatment of hypercalcemia should be individualized based on the underlying cause and severity of symptoms.
- Zoledronic acid is a preferred bisphosphonate for the treatment of hypercalcemia, due to its efficacy in normalizing calcium levels 2.
From the Research
Hypercalcemia and Confusion
- Hypercalcemia is defined as a serum calcium concentration >10.5 mg/dL and can be classified into mild, moderate, and severe, depending on calcium values 3.
- The clinical manifestations of hypercalcemia are related to calcium levels, with higher values leading to more pronounced symptoms, including neurological symptoms such as confusion 3, 4.
- Severe hypercalcemia, defined as total calcium of 14 mg/dL or greater, can cause nausea, vomiting, dehydration, confusion, somnolence, and coma 4.
- In a 76-year-old female with hypercalcemia, confusion can be a symptom, especially if the hypercalcemia is severe or develops rapidly over days to weeks 4.
Diagnosis and Treatment
- The initial approach to hypercalcemia involves vigorous intravenous hydration and drugs to reduce bone resorption, such as bisphosphonates 3, 5.
- In patients with severe hypercalcemia, treatment should be started immediately, and may include calcitonin, corticosteroids, and denosumab 5, 6.
- The underlying cause of hypercalcemia should be identified and treated, and treatment reduces serum calcium and improves symptoms, at least transiently 4.
Specific Considerations
- Primary hyperparathyroidism and malignancy are responsible for greater than 90% of all cases of hypercalcemia, and the hypercalcemic symptoms are usually fewer and subtle in primary hyperparathyroidism 5.
- In patients with hypercalcemia of malignancy, the prognosis is poor, and treatment should focus on controlling the underlying cancer 7.
- Denosumab can be used successfully as a bridge to surgery in patients with severe hypercalcemia due to primary hyperparathyroidism, and cinacalcet can be an effective therapeutic option in cases of persistent hypercalcemia of malignancy 6, 7.