What is the best course of action for an 81-year-old female patient experiencing hallucinations and constipation after a Transcatheter Aortic Valve Replacement (TAVR) procedure?

Management of Post-TAVR Hallucinations and Constipation

Immediately conduct a comprehensive medication review focusing on opioid analgesics used for pain management, as these are the most likely culprit for both hallucinations and constipation in this elderly post-TAVR patient, and discontinue or reduce the dose while implementing a bowel regimen.

Immediate Assessment and Medication Review

The post-TAVR guidelines emphasize meticulous attention to complications in elderly, frail patients, with specific focus on appropriate pain management and mental status monitoring 1. In this clinical scenario, the temporal relationship between TAVR discharge and these symptoms strongly suggests medication-related adverse effects.

Priority Actions:

• Review all pain medications, particularly opioid analgesics (narcotics) prescribed post-procedure, as guidelines specifically mention these are used for post-TAVR pain management 1
• Monitor mental status closely as recommended in immediate post-procedure protocols 1
• Assess for delirium triggers including infection, metabolic derangements, and polypharmacy 1

Differential Diagnosis Considerations

Medication-Related Causes (Most Likely):

• Opioid toxicity: Both hallucinations and constipation are classic adverse effects in elderly patients 1
• Anticholinergic medications: Can cause both cognitive changes and constipation
• Benzodiazepines or sedatives: May have been used during conscious sedation or for anxiety 1

Procedure-Related Complications to Exclude:

• Neurological complications: Post-TAVR stroke occurs in 4.2-6.7% of patients and requires urgent evaluation 2
• Metabolic derangements: Guidelines emphasize monitoring renal function and metabolic panels post-TAVR 1
• Infection: Urinary tract infections and respiratory infections are common readmission causes 1

Diagnostic Workup

Obtain immediately:

• Complete blood count and comprehensive metabolic panel to assess for infection, renal dysfunction, and electrolyte abnormalities 1
• Urinalysis and culture (UTIs occur in 6.5% of catheterized TAVR patients) 3
• Focused neurological examination to exclude stroke or transient ischemic attack 1
• Review of all current medications with attention to recent additions or dose changes 1

Consider if initial workup unrevealing:

• Brain imaging if any focal neurological deficits present 1
• ECG to assess for new arrhythmias (atrial fibrillation occurs in <1-8.6% post-TAVR) 1

Management Algorithm

For Hallucinations:

1. Discontinue or reduce opioid analgesics if pain is adequately controlled or can be managed with non-narcotic alternatives 1
2. Stop any anticholinergic medications or other psychoactive drugs
3. Treat underlying causes identified in workup (infection, metabolic abnormalities)
4. Avoid antipsychotics if possible in this elderly population due to increased mortality risk; use only if patient is danger to self or others

For Constipation:

1. Implement aggressive bowel regimen immediately:
   • Stool softeners (docusate)
   • Osmotic laxatives (polyethylene glycol)
   • Stimulant laxatives if no bowel movement within 48 hours
2. Reduce or eliminate opioid medications as clinically appropriate 1
3. Ensure adequate hydration while monitoring volume status (guidelines emphasize adequate hydration post-TAVR) 1
4. Encourage early mobilization as recommended in post-TAVR protocols 1

Critical Pitfalls to Avoid

• Do not assume symptoms are "normal" post-operative changes: The ACC guidelines emphasize that readmissions within the first year are common (>40%), with respiratory problems, infections, and bleeding being frequent causes 1
• Do not overlook stroke: While less likely given the constipation, neurological assessment is mandatory as stroke significantly impacts mortality and quality of life 2
• Do not continue opioids unnecessarily: Guidelines specifically note that post-TAVR pain is minimal, especially with transfemoral approach, and medications should be used at the lowest effective doses 1
• Do not delay intervention: Both delirium and severe constipation can lead to serious complications including aspiration, bowel obstruction, and falls 1

Follow-Up Coordination

• Contact the TAVR team as they are responsible for care during the first 30 days post-procedure 1
• Coordinate with primary care provider who should be involved in post-TAVR care starting at 30 days 1
• Schedule close follow-up within 24-48 hours after intervention to reassess symptoms 1
• Consider geriatric consultation if delirium persists despite medication adjustment, as these patients often have multiple comorbidities requiring integrated care 1