Week 3 - Confusion

Question 1

Mr. JD is a 68-year-old retired doctor. Brought in by his wife Doris a retired teacher. She is worried John is having episodes of confusion.

Take a history of this patient.

• Episodes of confusion, getting stiff and uses wheely walker now.
• Forgetful, does not know day or time, cannot concentrate. Old age?
• Fluctuation in symptoms (sometimes fine, sometimes not). Drowsy, getting worse over the year (progression).
• Losing key, leaving tap running, shopping list.
• P/H - UTI and confusion → given haloperidol → stiffness got worse.
• Mood - tearful at times. Angry, lost interest in cricket and TV.
• Sleep disturbed, sleep wakeful, visual hallucinations (animals).
• No appetite, lost weight 5kg.
• No weakness, no neurological symptoms, no headache.

Answer 1

HPC:
• Onset - when did the episodes of confusion start? Was there something that brought it on.
• Character - tell me about the confusion.
• Alleviating factors.
• Timing - experienced it before? Constant or intermittent? How long do they last? Worse at a particular time?
• Exacerbating factors.
• Severity.
• Associated symptoms i.e. neurological symptoms emotional problems, problems with language, decrease in motivation.
• Effect on lifestyle.

• What day is it today?
• How long have you been here?
• What is the name of the place we are in?
• Do you remember my name?
• Trouble staying awake?
• Ability to concentrate vary from moment to moment?
• Did these problems begin suddenly?
• Delirium (acute brain syndrome - fluctuating) - fluctuating confusion and clouding of consciousness. May be accompanied by poor concentration, poor memory, disorientation, inattention, agitation, emotional upset, hallucinations, visions or illusions, suspiciousness and disturbed sleep (reversal of sleep pattern).
• Dementia (chronic brain syndrome - gradual decline) - loss of memory (especially short term), loss of orientation, deterioration in social functioning and behaviour and emotional control (may be easily upset - tearful or irritable).
• Parkinson/Lewy body dementia - cognitive decline, slow gait, depression, resting tremors, visual hallucinations, episodes of ‘absent’, ‘confused’. Rigid muscles, loss of recent memory.
• Depression
• Have you been feeling in yourself?
• What has your mood been like?
• Have you been feeling sad, blue, down or depressed?
• Have you lost interest in things you usually enjoy?
• How have you been sleeping?
• Somatic (sleep disturbance, change in appetite, fatigue and weight), psychological (low self-esteem, worry-anxiety, guilt, suicidal ideation), affective (sadness, irritability, loss of pleasure and interest in activities) and psychomotor (retardation or agitation) symptoms.
• Hypothyroidism - cold intolerance, apathy, dry skin/hair, constipation, weight gain, weakness, voice change
• Malignancy - weight loss, fatigue, loss of appetite.

Other causes of dementia - alcohol/drug abuse, repeated head trauma

PMHx:
• Past medical history of any hypertension, hypercholesterolaemia, diabetes mellitus, CVD, stroke, dementia, hypothyroidism, depression, malignancy.

PSHx:
• Any past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, Pneumococcal.

FHx:
• Family history of dementia

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

• Cranial nerves.
• Cog wheel rigidity.
• Shuffling gait.
• Resting/rolling tremors.
• Stooped posture and expressionless face.
• Slow movements but normal strength.
• Micrographia.
• Reflexes and sensation normal.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Lewy body dementia.
• DDx:
• Dementia.
• Parkinson’s.
• Alzheimer’s disease.
• Vascular dementia - multiple infarcts leading to dementia.
• Hypothyroidism.
• Depression.
• Malignancy.
• Delirium - I WATCH DEATH - many causes.
- Narcotics, benzos, anti-histamine.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC
• BSL
• ESR
• U+Es
• Ca2+
• LFT
• TSH
• Autoantibodies
• B12/folate
• Syphilis serology
• CT/MRI (for vascular damage, haemorrhage or structural pathology).
• Consider also: EEG, CSF, functional imaging (FDG, PET, SPECT). Metabolic, genetic and HIV tests if indicated.
• Urine dipstick.
• CXR - pareneoplastic syndrome.
• MSE.

Question 5

What treatment does this patient require?

Answer 5

• Care coordinator.
• Capacity.
• Develop routines.
• Plan ahead.
• Day services.
• Pharmacological interventions.
• Management of depression.