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An 84-year-old woman brought to hospital after being found wandering in the street at night by
the neighbours.
The patient is very disoriented and confused. She is alert but restless and agitated. She is
convinced that she is late for work. A telephone call to her niece confirms that the patient has
been somewhat confused and forgetful for the past 9 months or so. Further enquiry reveals that
the patient needs help with her household and financial affairs. She has never wandered before.
Examination discloses AF (heart rate 126/min), cardiomegaly, mitral incompetence and
peripheral oedema. Her feet are in a state of neglect and there is an infected bunion. Abbreviated
mental test is 4/10. There are no focal neurological signs. The remainder of the examination is
unremarkable.

Tasks:
1. Give the most likely causes of the patient’s confusional state.
Task 1 (3.5) - The history is very suggestive of an acute-on-chronic confusional state, the
former precipitated by acute illness(es). Underlying cognitive impairment as a result of
early Alzheimer’s diseases is quite likely in this setting but must not be assumed. A
search for acute illnesses such as infection (UTI, infected bunion, respiratory), side
effects of medication, heart failure and metabolic disturbance (e.g. diabetes, uraemia) is
essential. The patient was found wandering at night, so hypothermia must be considered.

In addition to an acute illness, causes of chronic confusion must be considered, such as


dementia (Alzheimer’s or vascular brain disease), thyroid dysfunction, vitamin B12
deficiency and hypercalcaemia. If there is a poorly maintained gas appliance at home,
chronic carbon monoxide (CO) poisoning may need to be excluded.

2. What initial investigations should you perform?

3. Task 2 (3.0) - FBC – anaemia, infection


4. urinalysis and MSU (midstream specimen of urine (MSU) – infection, diabetes
5. blood cultures and swab from infected bunion
6. plasma electrolytes, glucose and renal function – metabolic disturbance and uraemia
7. calcium – confusion caused by hypercalcaemia
8. thyroid function tests – often difficult to interpret in acute illness, but in this case
important to exclude thyroid dysfunction, particularly hyperthyroidism as a result of AF
and heart failure
9. chest radiograph – infection, heart failure
10. ECG – to confirm AF
11. arterial oxygen saturation (and spectrophotometry for carboxyhaemoglobin if CO
poisoning suspected).
12. Once the acute illnesses have settled, and if chronic confusion persists, CT of the brain
should be considered to exclude potentially treatable causes of chronic confusion such as
hydrocephalus, meningioma and chronic subdural haematoma.
13. Vitamin B12 and folate levels are needed if there is macrocytic anaemia.

3 What treatment would you consider appropriate?


The patient’s niece is worried about her aunt returning home alone at the conclusion of the
hospital admission. How would you address this concern?

Task 3 (3.5) -This is a difficult issue and there is insufficient information provided to formulate
a full answer to this question. Once acute confusion has settled, the patient’s cognitive and
functional status should be reassessed by the multidisciplinary team (in particular, the
occupational therapist and social worker).
An old-age psychiatry consultation may be required, particularly if a new or former diagnosis of
dementia is confirmed, so that an assessment of the patient’s mental capacity can be made. If the
patient insists on returning home alone, a formal judgement as per the Mental Capacity Act 2005
concerning her capacity to assess the risk involved will be important. If the patient is judged to
have capacity regarding discharge destination, the risks associated with returning home should be
minimized by her family and the multidisciplinary team, including social services if required.
Assessment of the patient’s home environment will also be important before a decision about
discharge is finalized. If the patient lacks capacity to make decisions about her discharge
destination, a formal ‘best interests meeting’ as per the Mental Capacity Act will need to be
convened. Discharge home may still be the preferred option after full assessment.
Acetylcholinesterase inhibitor therapy (e.g. donepezil) to enhance cognition is contraindicated in
this patient because of significant cardiac disease.
Task 3 (3.5) -This is a difficult issue and there is insufficient information provided to formulate
a full answer to this question. Once acute confusion has settled, the patient’s cognitive and
functional status should be reassessed by the multidisciplinary team (in particular, the
occupational therapist and social worker). An old-age psychiatry consultation may be required,
particularly if a new or former diagnosis of dementia is confirmed, so that an assessment of the
patient’s mental capacity can be made. If the patient insists on returning home alone, a formal
judgement as per the Mental Capacity Act 2005 concerning her capacity to assess the risk
involved will be important. If the patient is judged to have capacity regarding discharge
destination, the risks associated with returning home should be minimized by her family and the
multidisciplinary team, including social services if required. Assessment of the patient’s home
environment will also be important before a decision about discharge is finalized. If the patient
lacks capacity to make decisions about her discharge destination, a formal ‘best interests
meeting’ as per the Mental Capacity Act will need to be convened. Discharge home may still be
the preferred option after full assessment. Acetylcholinesterase inhibitor therapy (e.g. donepezil)
to enhance cognition is contraindicated in this patient because of significant cardiac disease.

Final score: