Geriatric medicine for MRCP Part 1

An 82-year-old woman admitted with a urinary tract infection becomes acutely confused overnight, drifting in and out of attention, agitated at times and picking at the bedsheets, then drowsy by morning. She was cognitively well at home a week ago. A 4AT score is elevated. What is the most likely diagnosis?

1. Wernicke encephalopathy Confusion with eye signs and unsteady walking in someone who drinks heavily. Here, sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before points elsewhere.
2. Depression Low mood and withdrawal that can look like the drowsy form of delirium. It does not fit sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before.
3. Non-convulsive status epilepticus Altered awareness caused by ongoing seizure activity that is not obvious to see. That does not match sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before.
4. Delirium correct Correct. Sudden confusion that comes and goes, with an infection as the trigger, in a previously well older woman, is delirium.
5. Stroke or intracranial event A focal nerve problem together with altered consciousness. But sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before does not point to it.

The point: Delirium is a sudden problem with attention and awareness that comes and goes, with muddled thinking, developing over hours to days as a direct result of another medical problem. It is common in older, frailer patients and those with existing memory problems in hospital, and it is often missed, especially the hypoactive form (drowsy and withdrawn), which is easily mistaken for depression or dismissed as tiredness; the hyperactive form (agitated, restless, seeing or hearing things that are not there) is more obvious. The key way to tell it apart from dementia is that delirium comes on suddenly and comes and goes, with attention badly affected, whereas dementia is a slow, steady decline; the two often exist together, and dementia is the biggest risk factor for delirium. There is usually more than one cause, remembered by mnemonics such as PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment): infection (especially of the urine or chest), drugs (opioids, drugs that block a nerve chemical called acetylcholine, sedatives, and coming off drugs including alcohol), an upset in the body's chemistry, low oxygen, a full bladder that will not empty, constipation, and pain. Assessment uses a validated screening tool such as the 4AT, and management means first finding and treating every underlying cause, then giving supportive care without drugs: helping the patient stay oriented to time and place, good lighting, glasses and hearing aids, enough fluids and food, good sleep habits, familiar faces, and getting the patient moving again early, while avoiding physical restraints and unnecessary drugs. Antipsychotic drugs such as low-dose haloperidol are kept in reserve for severe agitation that puts the patient or others at risk, and are not used in Parkinson's disease or Lewy body dementia, where they can cause serious harm. Delirium predicts longer hospital stays, a higher risk of death, and a greater risk of long-term decline in memory and thinking, so preventing it through good ward care matters as much as treating it once it happens.

Source: NICE CG103 — delirium: prevention, diagnosis and management NICE · tier 1, national regulator or guidance

An 82-year-old woman admitted with a urinary tract infection becomes acutely confused overnight, drifting in and out of attention, agitated at times and picking at the bedsheets, then drowsy by morning. She was cognitively well at home a week ago. A 4AT score is elevated. What is the most appropriate investigation?

1. Bloods for metabolic and infective causes Blood tests for sugar, sodium, calcium and markers of infection. Here, sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before points elsewhere.
2. Septic screen including urine and chest Checks for infection, a common trigger. But sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before does not point to it.
3. Medication review Checking the drug chart for culprit drugs and withdrawal states. It does not fit sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before.
4. Assess hydration, bladder and bowels Checking for dehydration, a full bladder and constipation. That does not match sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before.
5. A validated delirium screen such as the 4AT correct Correct. A validated tool such as the 4AT picks up the delirium.

The point: Delirium is a sudden problem with attention and awareness that comes and goes, with muddled thinking, developing over hours to days as a direct result of another medical problem. It is common in older, frailer patients and those with existing memory problems in hospital, and it is often missed, especially the hypoactive form (drowsy and withdrawn), which is easily mistaken for depression or dismissed as tiredness; the hyperactive form (agitated, restless, seeing or hearing things that are not there) is more obvious. The key way to tell it apart from dementia is that delirium comes on suddenly and comes and goes, with attention badly affected, whereas dementia is a slow, steady decline; the two often exist together, and dementia is the biggest risk factor for delirium. There is usually more than one cause, remembered by mnemonics such as PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment): infection (especially of the urine or chest), drugs (opioids, drugs that block a nerve chemical called acetylcholine, sedatives, and coming off drugs including alcohol), an upset in the body's chemistry, low oxygen, a full bladder that will not empty, constipation, and pain. Assessment uses a validated screening tool such as the 4AT, and management means first finding and treating every underlying cause, then giving supportive care without drugs: helping the patient stay oriented to time and place, good lighting, glasses and hearing aids, enough fluids and food, good sleep habits, familiar faces, and getting the patient moving again early, while avoiding physical restraints and unnecessary drugs. Antipsychotic drugs such as low-dose haloperidol are kept in reserve for severe agitation that puts the patient or others at risk, and are not used in Parkinson's disease or Lewy body dementia, where they can cause serious harm. Delirium predicts longer hospital stays, a higher risk of death, and a greater risk of long-term decline in memory and thinking, so preventing it through good ward care matters as much as treating it once it happens.

Source: NICE CG103 — delirium: prevention, diagnosis and management NICE · tier 1, national regulator or guidance

An 82-year-old woman admitted with a urinary tract infection becomes acutely confused overnight, drifting in and out of attention, agitated at times and picking at the bedsheets, then drowsy by morning. She was cognitively well at home a week ago. A 4AT score is elevated. What is the most appropriate management?

1. Find and treat every underlying cause correct Correct. Treating the underlying urinary infection, and any other cause found, is the core of management.
2. Low-dose antipsychotic only for dangerous agitation Used only when the patient or others are at risk from severe agitation. But sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before does not point to it.
3. Involve family and ensure continuity of care Bringing in family and keeping the same staff involved, because familiar faces help. Here, sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before points elsewhere.
4. Avoid antipsychotics in Parkinson's and Lewy body dementia Avoided in these conditions because they can cause serious harm. That does not match sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before.
5. Avoid restraints and unnecessary sedation Avoiding physical restraints and unneeded sedatives, because they make delirium worse. It does not fit sudden confusion that comes and goes, with an infection as the trigger, in someone whose memory was normal before.

The point: Delirium is a sudden problem with attention and awareness that comes and goes, with muddled thinking, developing over hours to days as a direct result of another medical problem. It is common in older, frailer patients and those with existing memory problems in hospital, and it is often missed, especially the hypoactive form (drowsy and withdrawn), which is easily mistaken for depression or dismissed as tiredness; the hyperactive form (agitated, restless, seeing or hearing things that are not there) is more obvious. The key way to tell it apart from dementia is that delirium comes on suddenly and comes and goes, with attention badly affected, whereas dementia is a slow, steady decline; the two often exist together, and dementia is the biggest risk factor for delirium. There is usually more than one cause, remembered by mnemonics such as PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment): infection (especially of the urine or chest), drugs (opioids, drugs that block a nerve chemical called acetylcholine, sedatives, and coming off drugs including alcohol), an upset in the body's chemistry, low oxygen, a full bladder that will not empty, constipation, and pain. Assessment uses a validated screening tool such as the 4AT, and management means first finding and treating every underlying cause, then giving supportive care without drugs: helping the patient stay oriented to time and place, good lighting, glasses and hearing aids, enough fluids and food, good sleep habits, familiar faces, and getting the patient moving again early, while avoiding physical restraints and unnecessary drugs. Antipsychotic drugs such as low-dose haloperidol are kept in reserve for severe agitation that puts the patient or others at risk, and are not used in Parkinson's disease or Lewy body dementia, where they can cause serious harm. Delirium predicts longer hospital stays, a higher risk of death, and a greater risk of long-term decline in memory and thinking, so preventing it through good ward care matters as much as treating it once it happens.

Source: NICE CG103 — delirium: prevention, diagnosis and management NICE · tier 1, national regulator or guidance