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Delirium / dementia

Clinical Discipline(s)/Organ System(s)
Geriatric Medicine, Psychiatry/Health Psychology
Progress Test Topic(s)
General duties
Description
You are on call with the orthopaedic house officer and are called to see an 84 year old NZ European woman who has recently returned from the operating theatre after having her femoral neck fracture repaired. She has become 'very confused' and the nursing staff are having difficulties keeping her in bed. You find her trying to climb out of bed despite having surgical drains and a catheter in place. She demands to be left alone and asks to stop being 'tortured'. Her son arrives in the ward after being called by staff and he is able to calm her to some extent but both the son and the ward staff want to know what should be done if this happens again and the son can't attend. You check the most recent investigation results and note that her serum sodium is slightly reduced at 133 mmol/L and the urine is cloudy, has WBC present, and has grown E. Coli.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Pathophysiology and aetiology of delirium
   - Pathophysiology of hyponatremia
   - Pathology of the different types of dementia e.g. Alzheimer's disease, vascular dementia, Lewy Body dementia
   - Genetics of Alzheimer's disease
   - Pharmacology of benzodiazepines, quetiapine, olanzapine, risperidone and flumazenil
Clinical and Communication Skills 
   - Elicit a history from a patient with disorientation; obtain appropriate collateral information (including from GP); consider risk factors for delirium and dementia
   - Perform physical and mental state examination of a disorientated/confused patient
   - Perform and interpret the results of a Montreal Cognitive Assessment (MOCA)and Addenbrooke’s Cognitive Examination-III (ACE-III)
   - Typical symptoms of delirium that differentiate it from a dementia
   - Provide a differential diagnosis of a disorientated patient
   - Interpret relevant investigations: electrolytes, hormonal screening, toxicology screen, imaging
   - De-escalation techniques to reduce aggression and violence; role of restraint
   - Management of disorientation in a medical or surgical patient: general and specific, pharmacological and non-pharmacological
   - Risks of rapid tranquilisation
   - Complications of antipsychotics and benzodiazepines
   - Management of hyponatraemia in an older patient
   - Conduct a functional assessment on an older person
   - Management of dementia; role of memory clinics
   - Prognosis of delirium and dementia
   - Role of multidisciplinary team in the care of the disorientated patient and discharge planning
Personal and Professional Skills 
   - Genetic information: individual and familial aspects
   - Competence, decision-making capacity and consent
   - Ethical issues in the patient with delirium and/or dementia e.g. resuscitation orders, Enduring Power of Attorney, Protection of Personal Property Rights Act (1988), Mental Health Act (1992) and other important legislation
   - Social impact of dementia
   - Medical aspects of fitness to drive (NZTA)
   - Awareness of carer burden, assessing for the presence of this and advising on appropriate support pathways for carers
Hauora Māori 
   - Health disparities in older Māori patients
   - The role of whānau in the patient with dementia; appropriate engagement and consultation with whānau
   - Consideration of access to cultural/spiritual support for patient and whānau
Population Health 
   - Epidemiology of dementia and delirium
Conditions to be considered relating to this scenario
Common
post-general anaesthetic confusion, Alzheimer's disease, Parkinson's disease, uraemic/hepatic encephalopathy, constipation, alcohol withdrawal, opioid toxicity, hypothyroidism, electrolyte imbalance, vascular dementia, fronto-temporal dementia, Lewy body dementia, Parkinson's Plus syndromes, urinary tract infection, drug induced
Less common but 'important not to miss'
cerebral tumour, Wernicke-Korsakoff syndrome
Uncommon
systemic lupus erythematosus (SLE), multiple sclerosis, hypoparathyroidism