Acute Confusion

Question 1

What is needed before doing a home visit?

Answer 1

• Patient demographics
• Significant diagnoses
• Repeat medications list and allergies
• Acute medications prescribed in the last 6 months
• Details of any consultations in the last 6 months
• Recent investigation results such as BP, blood test results and imagin

Question 2

What is the acronym for recognising stroke/TIA?

Answer 2

F: FACE - any facial asymmetry?
A: ARMS - can patient raise their arms
S: SPEECH - is it slurred?
T: TIME: if any of these are present, call 999 immediately

Question 3

What are some causes of confusion in an elderly patient?

Answer 3

• Dehydration (one of the most common)
• Urosepsis
• Chest infection
• Encephalitis
• Wernicke’s encephalopathy
• Stroke
• Trauma - head injury
• Worsening dementia
• Iatrogenic
• Drug overdose
• Alcohol (can also cause hyponatraemia) and smoking (SIADH with lung cancer)
• Electrolyte imbalance (especially if taking NSAIDs, omeprazole can cause hyponatraemia)
• Hyper/hypocalcaemia
• Vitamin B12 deficiency (unlikely in very acute presentation)
• Hypoxia e.g. due to PE, pneumonia
• Thyroid disorder: severe hypothyroidism > lead to myxoedema crisis > hypothyroidism, hypothermia, hyponatraemia, hypercarbia and hypoxemia (more common in older patients, especially women)
• Psychosis

Question 4

What questions can be asked to identify the cause of confusion?

Answer 4

• Pain: helps localise problem and can deal with pain symptoms
• Fevers: more likely to be infective
• Feeling cold: might indicate fever or hypothyroidism
• Urine issues: UTI or urosepsis
• Bowels: electrolyte imbalance from diarrhoea, or hypercalcaemia causing changes in bowel movements, maybe thyroid disorder
• Breathing/cough: PE, chest infection/pneumonia > can cause hypoxia/sepsis
• Head trauma: intracranial bleed
• Weakness: stroke, intracranial bleed, encephalitis, neurological symptoms (B12 deficiency)
• Hallucinations: psychosis
• Medication: overdose
• Alcohol: delirium tremens

Question 5

What medications can cause hyponatraemia?

Answer 5

• Ramipril
• Omeprazole
• Citalopram

Question 6

What tests/investigations can be done for a confused patient?

Answer 6

• U&E: hyponatraemia and uraemia can cause acute confusion
• FBC: raised WBC > infection
• LFTs: acute hepatic failure can cause confusion
• CRP
• TSH: myxoedema crisus
• Blood glucose: may be DKA
• Bone profile: hyper/hypocalcaemia
• Haematinics: B12 deficiency
• CXR: pneumonia
• Abdo USS: could show bowel pathology
• CT brain: fluid build-up e.g. haemorrhage

Question 7

What is a Lasting Power of Attorney (LPA)?

Answer 7

A legal document that lets an
individual (the ‘donor’) appoint 1
or more people (known as ‘attorneys’) to help make decisions or to make decisions on the donor’s behalf in the future if they lose mental capacity. There are 2 types of LPA:
- Health and welfare
- Property and financial affai
rs

Question 8

What is an Advanced Statement?

Answer 8

A written statement written by the patient, setting out preferences, wishes, beliefs and values
regarding future care, to provide a guide to anyone who might have to make decisions in that patient’s best interest, if in future, that patient does not have capacity to make decisions or to communicate them. It is not legally binding (meaning the parties are not legally obligated to carry out the wishes).

Question 9

What is an Advance Decision or advance decision to refuse treatment?

Answer 9

A decision a patient with capacity can make to refuse specific treatments in the future. An advance decision is legally binding, as long as it meets the necessary criteria for it to be considered valid and applicable.

Question 10

What is a living will?

Answer 10

An alternative term for an Advance Decision.