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 ataxia in alcohol excess. Acute fluctuating inattention with an infective trigger and prior normal cognition redirects it.
2. Depression Low mood and withdrawal mimicking hypoactive delirium. Acute fluctuating inattention with an infective trigger and prior normal cognition raises it.
3. Non-convulsive status epilepticus Altered awareness from ongoing seizure activity. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it a consideration.
4. Delirium correct Correct. Acute fluctuating inattention with an infective trigger in a previously well older woman is delirium.
5. Stroke or intracranial event Focal neurology with altered consciousness. Acute fluctuating inattention with an infective trigger and prior normal cognition must be excluded.

The point: Delirium is an acute, fluctuating disturbance of attention and awareness with disorganised thinking, developing over hours to days as a direct consequence of another medical problem. It is common in older, frailer and cognitively impaired hospital patients and is often missed, especially the hypoactive form (drowsy and withdrawn), which is easily mistaken for depression or dismissed as tiredness; the hyperactive form (agitated, restless, hallucinating) is more obvious. The key distinction from dementia is the acute onset and fluctuating course with prominent inattention, and the two commonly coexist, with dementia being the biggest risk factor. Causes are usually multiple and are captured by mnemonics such as PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment): infection (especially urinary and chest), drugs (opioids, anticholinergics, sedatives and withdrawal states including alcohol), metabolic derangement, hypoxia, urinary retention and constipation, and pain. Assessment uses a validated tool such as the 4AT, and management is first to find and treat every underlying cause, then supportive non-pharmacological care: reorientation, good lighting, glasses and hearing aids, hydration and nutrition, sleep hygiene, familiar faces and early mobilisation, while avoiding restraints and unnecessary drugs. Antipsychotics such as low-dose haloperidol are reserved for severe agitation that risks the patient or others and are not used in Parkinson's disease or Lewy body dementia. Delirium predicts longer admissions, higher mortality and a greater risk of long-term cognitive decline, so prevention through good ward care matters as much as treatment.

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 Glucose, sodium, calcium, inflammatory markers. Acute fluctuating inattention with an infective trigger and prior normal cognition makes them useful.
2. Septic screen including urine and chest Common precipitants. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it directed.
3. Medication review For culprit and withdrawal drugs. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it important.
4. Assess hydration, bladder and bowels For retention and constipation. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it thorough.
5. A validated delirium screen such as the 4AT correct Correct. A validated tool such as the 4AT detects the delirium.

The point: Delirium is an acute, fluctuating disturbance of attention and awareness with disorganised thinking, developing over hours to days as a direct consequence of another medical problem. It is common in older, frailer and cognitively impaired hospital patients and 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, hallucinating) is more obvious. The key distinction from dementia is the acute onset and fluctuating course with prominent inattention, and the two commonly coexist, with dementia being the biggest risk factor. Causes are usually multiple and are captured by mnemonics such as PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment): infection (especially urinary and chest), drugs (opioids, anticholinergics, sedatives and withdrawal states including alcohol), metabolic derangement, hypoxia, urinary retention and constipation, and pain. Assessment uses a validated tool such as the 4AT, and management is first to find and treat every underlying cause, then supportive non-pharmacological care: reorientation, good lighting, glasses and hearing aids, hydration and nutrition, sleep hygiene, familiar faces and early mobilisation, while avoiding restraints and unnecessary drugs. Antipsychotics such as low-dose haloperidol are reserved for severe agitation that risks the patient or others and are not used in Parkinson's disease or Lewy body dementia. Delirium predicts longer admissions, higher mortality and a greater risk of long-term cognitive decline, so prevention through good ward care matters as much as treatment.

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. Involve family and ensure continuity of care Familiar faces help. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it person-centred.
2. Supportive non-pharmacological care Supportive non-pharmacological care with reorientation and sensory aids is first-line, and acute fluctuating inattention with an infective trigger and prior normal cognition here points elsewhere.
3. Low-dose antipsychotic only for dangerous agitation When the patient or others are at risk. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it reserved.
4. Avoid antipsychotics in Parkinson's and Lewy body dementia They can cause severe reactions. Acute fluctuating inattention with an infective trigger and prior normal cognition makes it a caution.
5. Find and treat every underlying cause correct Correct. Treating the underlying urinary infection and any other cause is the core of management.

The point: Delirium is an acute, fluctuating disturbance of attention and awareness with disorganised thinking, developing over hours to days as a direct consequence of another medical problem. It is common in older, frailer and cognitively impaired hospital patients and 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, hallucinating) is more obvious. The key distinction from dementia is the acute onset and fluctuating course with prominent inattention, and the two commonly coexist, with dementia being the biggest risk factor. Causes are usually multiple and are captured by mnemonics such as PINCH ME (Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment): infection (especially urinary and chest), drugs (opioids, anticholinergics, sedatives and withdrawal states including alcohol), metabolic derangement, hypoxia, urinary retention and constipation, and pain. Assessment uses a validated tool such as the 4AT, and management is first to find and treat every underlying cause, then supportive non-pharmacological care: reorientation, good lighting, glasses and hearing aids, hydration and nutrition, sleep hygiene, familiar faces and early mobilisation, while avoiding restraints and unnecessary drugs. Antipsychotics such as low-dose haloperidol are reserved for severe agitation that risks the patient or others and are not used in Parkinson's disease or Lewy body dementia. Delirium predicts longer admissions, higher mortality and a greater risk of long-term cognitive decline, so prevention through good ward care matters as much as treatment.

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