Acute Delirium in the Elderly – Post Test

A frail, 78-year-old lady who lives alone presents to the emergency department (ED) with a 24-hour history of confusion. She has a history of hypertension, previous TIAs, glaucoma and hypercholesterolaemia. She is able to manage all activities of daily living (ADL), providing she wears her glasses.

Which of the following is not a recognised risk factor for delirium in this lady?

An elderly gentleman is brought into the ED by his daughter. She says he has been confused for 3 days since starting a new drug. His five medications are listed below.

Which one is most likely to be the new drug?

While on duty during a busy shift in the ED, a junior colleague asks you how to best assess the mental state of a confused elderly patient she has just seen. You are aware that time is limited and want to give her an evidence-based answer.

Which technique do you advise her to use?

A 79-year-old lady presents to the ED with a 2-day history of progressive confusion. From a limited initial history, you find she has 24 hours increasing shortness of breath. Her vital signs are pulse 100, respiratory rate 18, temperature 36.9o^C and saturation 94%.

Which of these might be the most helpful initial investigation?

An old lady calls 999 after falling at home. She presents to your ED with unremarkable ABC examination findings. Her Glasgow coma score (GCS) is 15 with no lateralising signs, mental state exam demonstrates inattention and rambling speech at times. There is a left occipital haematoma. Temperature is 37.8o^C.

In addition to routine bedside and laboratory testing, which of the following would be most useful?

It is the middle of the night and you are in the process of managing an acutely-confused, elderly man in the ED. You think a urinary tract infection is the cause, and have started antibiotic treatment. He keeps trying to get off the bed.

Which of the following is best for the patient?

A confused, elderly patient whom you have been trying to assess in the ED is perpetually combative and refusing to allow any observations or examination. You have made the decision to sedate her to enable a full assessment. Her past medical history is only hypertension, and she is on no medication.

Which of the following is most appropriate?

You have just received the blood results from a 92-year-old man who has presented with acute confusion. You think the cause is infective. He is awaiting transfer to the medical assessment unit.

His results are Na 126, K 4.5, Ur 6.2 and Cr 78.

His medications are Furosemide, Aspirin, Atenolol and Paracetamol.

What is the best thing to do?

When performing the 4AT to evaluate one of your ED patients, you find the following:

• Mild sleepiness
• 2 mistakes on the AMT4 (doesn’t know current place or year)
• Can count only 4 months of the year backwards
• A history of a rapid deterioration in mental functioning

What is the most likely diagnosis?

An 80-year-old man presents in a confused state, having been found on the floor one morning. You speak to the neighbour and she confirms his confusion is new, though he has been troubled recently by an increase in the severity of his Parkinson’s disease. While in the department, he becomes combative and, despite all efforts, you decide he needs some sedation to ensure staff safety.

Which of the following is most appropriate?