Delirium Scenario

The daughter arrives and explains the patient self-catheterises. She feels this is the reason why he has recurrent UTI’s. While you are on scene, the daughter completes a dipstick test on urine she has found in his urine bottle. 

Is this test still valid and be used for assessment? 

You continue with your assessment and manage to get one set of observations with difficulty: 105 HR, 18 RR, 137/72 BP, 98% Sp02, Temp 36.9, BM 10.1. The daughter advises that his PMH includes dementia (but considered mild), enlarged prostate, and type 2 diabetic. He has recently been discharged from hospital after sustaining a NOF fracture and subsequent surgery. What other tests would you like to complete to determine the cause of this patient’s presentation?

Again, these assessments are quite difficult to complete due to patient reluctance to comply, but you are unable to find anything noteworthy. The daughter visited the previous evening, and the patient presented very well and in good spirits. You are concerned as to why the patient is presenting like this and whether something serious may be underlying. Do you…?

You take a bit more time to assess the patient and think of other reasons the patient may be presenting with acute confusion. What does ‘PINCH ME’ stand for?

You go through each of the causes with the help of the daughter to try to determine what may be underlying. The patient had a good meal last night. He has had no recent medication changes. No recent ill-health. You are unsure of his bowel and urinary movements as he manages this himself. You can’t find anything abnormal on a physical examination, but you do consider it is a new social environment for the patient. What diagnosis would you broadly put this patient under?

What screening tool can you use that is specific to delirium in older patients?

The patient is very drowsy and keeps trying to fall back asleep when not being talked to. He can say his age, current year and date of birth but is unsure of the building he is in. You instruct the patient to list months of the year in reverse order, but he is unable to say more than 5 months backwards. You have noted there is significant change in his alertness and cognition since last night. What is this patients 4AT score?

You revisit the causes and the only one you are unsure about is urinary and constipation. You get the patient up on the edge of the bed and ask if they can self-catheterise. The patient conducts the procedure, and they urinate into a bucket by the bed. There is a lot of volume.  

Afterwards, the daughter helps to clean him up and get changed. Whilst doing so the patient starts to improve significantly. Within 30 minutes the patient is talking as normal, is sat in his front room and having his breakfast. What subtype of delirium would you query this patient experienced? 

You and all parties are happy the patient is back to their normal presentation and is reporting no pain or abnormalities. However, because of how severe their confusion was, do you still think it is appropriate getting the patient assessed at hospital?

Treating delirium is about the identification of the cause and treating that cause?

If discharging a patient at home with delirium, it is beneficial to leave some advice to prevent further cases in the future. What advice could this include? 

What symptoms would you expect to see in a patient with hyperactive delirium? 

What risk factors are associated with developing delirium?

The prevalence of delirium in long-term care facilities aged 65 and over can be as high as…?

Delirium is 10 times more common in persons with dementia?