CARE OF THE ELDERLY

DELIRIUM

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Take a focused history from a patient presenting with probable delirium and consider appropriate differential diagnoses
Suggest and interpret results of relevant investigations for delirium
Understand the management and prevention of delirium, suggesting appropriate adjustments to the inpatient setting

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Kit Tigwell

Uploaded:

18th September 2019

Last updated:

18th September 2019

Resources needed for this session:

Patient, paper, pen

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

None

Activity 1: History Taking Skills and Clinical Assessment

20 min

Find a patient who has presented with acute or acute-on-chronic confusion that is suitable to speak to students for around 10-15 minutes. Before the student(s) go and see the patient, brief them as follows:

Explain that the patient is confused and may not be able to give a clear history of events preceding admission.
Encourage students to act as detectives to put clues together to work out how the patient came to be admitted to hospital.
Discuss tools that can be used to formally assess cognition in the acute setting e.g. AMTS and 4AT.
Signpost students to these tools and encourage them to practice using them on the patient they are about to see.

Ask student(s) as far as possible to take a focused history from the patient (maximum 10 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. This can be observed if capacity of tutors allows.

Following the history, reassure students that it is not always possible to follow this structure on acutely confused patients! Discuss other sources of information they could use.

Activity 2: Diagnostic Reasoning

10 min

Ask the student(s) to present the key findings of the case. Discuss:

What differential diagnoses have you considered and why are these less likely?
What investigations would be useful acutely and what are you expecting them to show?
What factors may be contributing to this patient’s altered mental state?
How can delirium be distinguished from dementia in the acute setting?

Feedback on history taking style & presentation (max 1 minute).

Activity 3: Investigations

15 min

Allow the student(s) to view the blood results, an ECG and chest x-ray from the patient. If none is available, use the examples below. They can scan the QR code on their phone if needed.

Ask the student(s) to highlight the key abnormalities on each one and how these results impact on the differential diagnoses they have considered.

Blood test results - example 1:

Na 128

K 4.1

Ur 10

Cr 159

eGFR 43

CRP 115

Hb 143

WCC 13.1

Neuts 12.4

Activity 4: Management Decisions

10 min

Using local guidelines on management of patients with delirium, discuss the following points:

How can patients be effectively monitored for delirium?
What non-pharmacological interventions (environment, communication, sleep etc) may prevent and/or manage?
How might family/carers assist in the management of delirium?
What pharmacological management may be necessary in delirium?
What follow up should be arranged on discharge?

Students may want to access local guidelines on hospital intranet. The QR code opposite links to the British Geriatric Society endorsed SIGN guidelines.