Dementia/Delirium

Question 1

2020 stem: You are a GP seeing an 82 F at a nursing home, semi cooperative with hospital staff. Previously independent in ADLs except in last 2 weeks. BG of some cognitive decline at review 6 months ago. Currently - confused and disoriented, agitated, walking into other patient’s rooms. But calmed down whenever daughter came to visit. Medical assessment 6 months ago (CTB, bloods, urine) normal. Husband - was admitted to hospital with an MI 2 weeks ago. What are some different causes to explain this behaviour? What are your differential diagnoses? Outline your assessment. Outline your management plan.

Answer 1

Impression
Acute presentation of hyperactive delirium in the setting of likely dementia, esp given reduction in symptoms when visited by familiar family member.

DDx
Dementia
o

There are many potential causes of delirium to consider in this patient, identifying and treating is imperative for resolving the delirium in a timely fashion.

• recent stressors with husband recent MI
• infection (UTI, URTI)
• autoimmune disease
• malignancy
• recent poor nutrition
• medications changes

Types o

Other aetiologies to consider:

• may be related to rapid deterioration of dementia
• psychiatric: acute psychosis, etc
• intoxication

Question 2

Delirium - History

Answer 2

History

• May require collateral history to gain full information regarding patient’s prior cognitive state, and to elicit precipitating factors
• PC: fluctuating consciousness, confusion, agitation, (hyper vs hypoactive delirium)
• HPI: infective sx, malignancy red flags,
• PMHx: prev delirium, cardiac/respiratory
• medications
• SNAP

Question 3

Delirium - Examination

Answer 3

Examination

• general appearance + vitals
• neurological assessment
• systems review (cardio, reps, GIT)
• mental state examination

Question 4

Delirium - Investigations

Answer 4

Investigations

• Bedside: vitals, 4AT rapid clinical test or CAM (confusion assessment method), urinalysis + MCS, urine too screen
• Bloods: full bloods screen
• Imaging: nil CTB given recent, ?MRI
• cognitive assessment: MoCA, MMSE

Question 5

Delirium - Management

Answer 5

Management
- best to identify patients at risk of delirium and utilise preventative

Definitive

• identify and remove precipitating agent (cease medications, treat infection/other medical conditions)
• if severely agitated and at risk to other patients/staff, consider pharmacological sedation with anti-psychotic (haloperidol) - single dose usually appropriate. However medication to be avoided if possible.

Supportive

• approach patient front on
• keep patient in same room/ward
• bring in homely comforts/familiar things, encourage regular family visits
• regular obs/continuous observation
• patient and family education
• treat and comorbid conditions (withdrawal, etc)