Acute confusion in an older adult — delirium
PLAB 2 & PRES 3 · geriatrics · hard · 8 minutes
Candidate brief
You are an FY2 doctor/SHO in the Emergency Department. Mrs Margaret O’Connor, 82, has been brought in by her daughter because she has become confused and unusually drowsy since yesterday. Assess the patient, obtain relevant information from her daughter, explain your concerns and initiate an appropriate management plan. Verbalise any examinations, investigations or treatments you would undertake.
What examiners look for
Delirium is an acute, fluctuating disturbance of attention and cognition. Dementia usually develops gradually, although delirium can occur on top of dementia. Hypoactive delirium may present with quietness, drowsiness, reduced movement or withdrawal and is easily missed. Obtain collateral history to establish the patient’s normal cognition, function and the exact onset and fluctuation of symptoms. Use ABCDE, full observations and capillary glucose. Look for multiple possible causes, including infection, hypoxia, dehydration, medicines, pain, constipation, urinary retention, metabolic disturbance, stroke and injury. Use the 4AT or the applicable validated local delirium assessment tool. Do not diagnose a urine infection from confusion or a urine dipstick alone. Seek urinary symptoms, fever and other clinical evidence, and consider alternative causes. Treat the underlying contributors. In this patient, codeine, dehydration, acute kidney injury, constipation and urinary retention are likely contributing factors. Use reorientation, hearing and visual aids, family involvement, hydration, nutrition, mobility, sleep support and a safe environment. Sedation does not treat delirium. Consider medication only when severe distress or danger persists despite de-escalation and correction of reversible causes. Capacity is decision-specific and may fluctuate. Continue supporting the patient to participate as much as possible.
Guideline references
- https://www.nice.org.uk/guidance/cg103
- https://www.nice.org.uk/guidance/cg103/chapter/Recommendations
- https://www.nice.org.uk/guidance/qs63
- https://www.nhs.uk/symptoms/confusion/
- https://www2.healthservice.hse.ie/documents/8795/Irish-National-Early-Warning-System-User-s-Guide-incorporation-COMPASS-PDF-5.7_Ly1sZfD.pdf
- https://healthservice.hse.ie/documents/10524/HSE_Skip_the_Dip_A5_Staff_Booklet_2026.pdf
- https://www.gmc-uk.org/professional-standards/the-professional-standards/decision-making-and-consent
- https://www.gov.ie/en/department-of-justice-home-affairs-and-migration/publications/assisted-decision-making-capacity-act-2015/
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