CARE OF THE ELDERLY

Find a patient who has presented with acute or acute-on-chronic confusion that is suitable to be assessed for around 10-15 minutes. It is worth discussing with the nurse or doctor caring for the patient to confirm that they are well enough to be seen. You will need to remember:

• The patient is confused and may not be able to give a clear history of events preceding admission.

• You will need to be a detective to put clues together to work out how the patient came to be admitted to hospital.

• Consider using to formally assess cognition in the acute setting e.g. AMTS and 4AT.

As far as possible take a focused history from the patient (maximum 15 minutes), to include a past medical history, drug history, full social history (comprising mobility, care needs, cognition etc.) and assessment of cognition/mental state as outlined above.

Bear in mind that it is not always possible to follow this structure on acutely confused patients! You may find your history is a lot more disjointed and round-about than with a not confused patient - this is ok but be sure to reflect on your experiences - could you have done anything differently?

Document your findings in a systematic manner. You may want to use a local clerking proforma or have a look at this useful summary from Geeky Medics.

When assessing patients with confusion, particularly older patients, who often have comorbidities, it is usually more appropriate to write a 'Problem List' rather than a 'Diagnosis' (though there is clearly some overlap). The 'Problem List' should include anything of relevance to the patient's current presentation.

Things to consider:

• What is the most likely cause of the patient's confusion?

• Are there any additional causes that may be contributing?

• What is their baseline cognition? i.e. are they normally confused at all? If so, to what degree?

• How is their confusion affecting their day-to-day functioning and activities of daily living?

Have a go at writing a Problem List for the patient you have seen. Compare this with the patient's clinical notes. You may also want to refer to the Comprehensive Geriatric Assessment tool available in your hospital - or use the version online here.

Consider ways you can manage the patient's delirium. Write down some initial ideas, then consider:

• Are there any simple ways you can reassure and manage the patient?

• Have you addressed each of the causes you identified?

• Are there any medications that may need reviewing?

• What pharmacological options for managing delirium are there?

• What might be the risk(s) of these medications?

• When should pharmacological options be considered?

See if you can find some local guidelines on the management of delirium from your hospital. You may also want to read the national SIGN Guidelines available here.

For some practical tips about managing delirium in older people, read this blog post from a care of the elderly registrar.

1. https://oscestop.com/Collateral_history.pdf

2. https://www.cgakit.com/brief-cga-template

3. https://sean9n.wordpress.com/2018/10/26/how-to-take-a-collateral-history/

4. https://sean9n.wordpress.com/2014/02/13/twenty-one-tips-for-junior-doctors-working-with-older-people/