Mr. and Mrs. Sol
Mrs. Sol, a 77 year old woman, arrives in the Ambulatory Area with knee pain after having a fall at home. Mrs. Sol is accompanied by her husband and they are both very focussed on her knee pain, even though she is ambulatory and the x-rays of her knee are normal.
- Watch the video below and answer the questions that follow.
- What do think is missing from this assessment? What would you do differently?
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Outcome
This patient went home, continued to be confused and inattentive, fell down a flight of stairs, and returned with multiple fractures. She died on her 80th day in hospital. An internal review of ED procedures for assessing older patients was carried out.
- What would happen if you took 30 seconds longer with this same patient?
- What do you see the doctor doing well here?
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Outcome
This patient had a complete delirium work-up which detected an acute-on-chronic subdural hematoma (from a recent unwitnessed fall). It was drained. She was discharged home at her baseline function in a week.
The Confusion Assessment Method will be reviewed later in this module. Continue on to learn more.
Important Concepts
- Addressing the presenting problem ONLY without thoroughly assessing the underlying cognitive status in older patients is likely to miss important findings.
- It is often difficult for health care providers to sort out the difference between chronic changes (dementia) and acute changes (delirium) especially when symptoms of impaired mental status are common to both. Often close care-givers will also have difficulty distinguishing the two.
- Dementia (an already vulnerable brain) is the principal risk factor for developing delirium.
- It is essential to recognize delirium as the symptom of a life-threatening underlying medical or surgical condition.
Discussion: Mr. and Mrs. Sol
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k
Waiting in an emergency room can make people lose their sanity
I still think is important to aks the patient how she feels and ask her in search of abuse
Dedicar unos minutos mas de tiempo y siendo ordenados, nos ayudaría a ser mas precisos en el diagnóstico.
agree with above
AS providers, we have to dive deeper into the history when events seem unclear in order to ensure safety for our patients.
Agree
great tips for suspecting delirium on top of existing dementia
agree
spending a few more seconds can be very helpful when dealing with the elderly
Second video shows much better assessment. Open-ended questions, more thorough, body language is better, listens to the family member.
thorough
family members are vital assets
better assessment, taking family members concerns into account
This was a great eye opener to ensure we listen carefully to what family and take it seriously. Good assessment questions led the doctor to assess for all potential causes for the acute changes in the patients behaviour. Overlooking the husbands concerns would have led to a miss disagnosis
physician listed to the husband, provided important information the patient could not provide, asked husband appropriate questions
ok
better follow up by the doctor
ok
active listening and empathy alone with clarifying the patient’s timeline in chronological order is important.
He’s being more attentive and exploring alot more. Distinguishing between acute and chronic changes
agreed
ok
.
thanks
agreed
Agree
good
.
great
not that easy
Doctor included family member in mental assessment. Good for getting a sense of her baseline abilities at home
good point
agree
good presentation
…
.
.
great answer
good info
yes
eye contact
This gentleman has been taking care of his wife for 3 years. He is in need of assist at home or perhaps placement for his wife in assistive living facility close to home so he can visit daily.
x
Active listening
yyes
ok
Good active listening and common ground!
this was an eyeopener. have to be so observant
helpful
good
Didn’t really speak much to the patient.
challenging and need more time
Dementia does not preclude delirium.
Well said, it does however likely make the diagnosis of delirium much more difficult and time consuming due to contacting family and/or caregivers.
knee injury
Yes, knee injury could be only iceberg what could be wrong with lady.
In second video doctor took much more attention to what husband says
the knee injury is what brought the patient into the ER, however, concerns of husband about patient not being at baseline definitely would need addressed.
second assessment more thorough. As stated above a screening for possible UTI would help rule in or out reasoning for acute change
Easy to see how acute changes can be missed so easily in patients with baseline dementia
Great assessment, and picking up that this may not be a progression of dementia, but a fluctuation in cognition.
he listened to family but still never interview or assessed the patient
He did at least show concern enough that he continued to work patient up. He knew not to send home where patient would not be safe.
better
good
Round two much better. There always seems to be complacency and I wish there wasn’t.
agree
It was important for the physician to ask questions and find out how how acute the problem was and what further studies needed to be done
listening to patient and family
good easy to understand
Family involvment is very important.
I agree!
Thanks!
It’s so important engage families about patients’ baselines!
I feel like even in the second video, the doctor failed to even attempt in involving Mrs. Sol in the conversation, and they’re talking about her as if she isn’t right there. Not very therapeutic in my opinion.
agreed. Here the focus seems to be on assessment using cognitive impairment tools that are important to consider. Having dementia as a predisposition to delirium definitely warrants further assessment.
agree with comments
very good concept summary
A lot more information was obtained in the repeat evaluation exploring recent changes in cognitiver function
The second case showed what taking the time to explore further can do for our pts. Although it would be interesting to qwery depression as well
I agree!
the patient definitely appears uninterested in the current situation so a depression evaluation would be important.
I couldn’t agree more
Sometimes family members or loved ones give important information, so good listening skill and allowing them to explain what has happen or why may lead to better treatment plan for the pt and family.
I agree! Family centred care is very important to provide optimal patient centred care
Often healthcare professionals tend to focus on addressing the presenting problem but this presentative illustrates importance of assessing patient’s cognitive status before we tackle other health problems. Mental health does matters.
Glad to see he took the additional few seconds to make a better diagnosis and have a better outcome for this patient.
In the second interview the physician was patient and was listening to what the husband had to say. Based on listening the physician was able to treat the patient properly.
Good example of a pt experiencing delirium w/ previous diagnosis of dementia as well.
agree with comments
a comment
Difficult cases in ED
The relative concerns abot the fall and the acute changes haave not been put under the same umbrella. People with dementia definately need careful asssessment and exanination.
In the ER, it’s easy to brush off patient’s complaints and send them on their way home. It takes a good clinician to look at the bigger picture and tease out the subtle signs/symptoms that could’ve precipitated the patient’s original complaint.
I agree with you Jerry. Often ER focus on addressing the presenting problem and does not try enough to find the underlying cause.
In the second interview the doctor listens to the spouse’s concerns,which prompt him to ask about the circumstances of the fall and the changes in his wife with comparable timelines. Her history of dementia does not rule out acute medical problems.
agree with comments above,
Allowing the patient’s husband to describe the situation in further detail alerted the practitioner of the possibility of a changing diagnosis.
Second video was good
yes
agree
true
agreed
Not focused on why/ how she fell
agreed
agreed
Good presentation of determining chronic from acute changes.
true
true
GOOD REVIEW
.
helpful
Agree with comments.
Falls at the number 1 chief complaint for patients over 70 in our ED and that chief complaint creates and anchoring bias on trauma rather than the cause of the fall. After stabilization, the investigation chief complaint of fall should always start with “why” followed by “why” and usually another “why.”
helpful
listen!
good listening skills-taking time for the why
History history history… More question to both Wife and husband, possible CCAC referral.
.
Great case
good case
important to remember than delirium can complicate demential in an acute on chronic type picture.
Good case
Great post.
Delirium is much more readily considered in an agitated patient than a hypoactive patient. Can be chalkedup to depression or dementiat too easily.
family member and caregiver information is vital when dealing with an impaired patient
Good info..esp dementia being principal risk factor for delirium
No further comments
Families can provide very valuable input
great example!
It’s essential to explore the words pts/family members use to describe various scenarios; it can definitely reveal more than one would think.
you need a short story not a snap shot in order to suss out acute from chronic contributing factors
an assessment what contributes to the fall is also beneficial
Having a family member is key to understanding the situation of many elderly patients. Listening is the other key.
Hypoactive delirium is much harder to recognize compared to the agitated patient. Must maintain high level of suspicion for delirium — consider at every encounter with a demented patient.
Too hurried to take the time to address the issue of client’s mood and functioning
history taking is just important if as diagnostic imaging
The second interview went better because the doc was more open to hearing what they had to say and doing further work-up.
very helpful
the elderly require more time to be interviewed and have to be insistent with the issues
Family history is very important
I like that the physician was not dismissive of the family concerns and actually reinforced the importance of further assessment for a fluctuating LOC and not just attributing it to further decline of an elderly patient. Often, the elderly patient is pressured and rushed into expressing their reason for visiting the ER and it leads to further distress, inadequate or incomplete history and/or failure to build rapport/trust.
Another example of extending the conversation for a brief time and learning key, potentially life-saving information.
More thorough in second video and less dismissive
It is all about listening and asking the good questions.Let time to the patient or family to explain.
yes
more thorough in second video
Much better questioning. I would add interaction with the patient and then ask husband to comment.
better
actively listening to the patient and the patients spouse assisted in a more thorough assessment and differential diagnosis of this patients concerns
In the second video the Dr was willing to make the husband more comfortable to speak about what was going on with the wife . He did not speak with the pt but was willing to investigate further
We often assume that all mental status issues in patients with dementia can be attributed to the dementia, but we need to explore these in detail to determine whether there are other acute changes and find out why. Also, even with a confused patient, we need to talk to the patient, not just their relative.
I liked the second approach that was not simply dismissive of existing dementia diagnosis- important to have knowledge of baseline vs presenting behaviour.
the elderly require more time to be interviewed and have to be insistent with the issues
🙂
Would speak more with patient directly, screen with CAM to ensure so delirium on dementia. Perhaps arrange caregiver supports.
I learnt that geriatric patients are not “older adults” challenging case for the ER doctor
He listened attentively for clues of delirium .
I learned a lot.
person can have superimposed delirium with dementia but signs and symtoms would be different
x
definitely not a RAZ patient
Agreed.
xx
difficult to assess the many layers of cognitive changes
Active listening and taking the time to sit with a patient to see what exactly is happening speaks volumes.
I think this is so important. This reminds me of a clinical pearl I heard recently – ‘never rely just on an x-ray’. It’s a stretch, but I think at the core of it all, we must really use our good history taking skills (patient and collateral esp. in the elderly, esp. when dementia is a factor) and actually placing a hand on the patient. This will allow us to not only find out the mechanism of injury but also in this case what led to the injury, frequency of falls, change in baseline behaviour and this changes management and can make a difference for the patient.
listening to patient if there is anything beyond
Listening to the patient and or family and clarifying the description of changes in cognition are instrumental in a geriatric assessment. Older adults need to be given time to describe their symptoms and as clinicians we need to dig a bit to ensure we aren’t overlooking something very significant. Even in the ER.
So true. In geriatrics it’s a lot about context. Especially since older adults present with multiple comorbidities, layers of complexities, we need to be that much more mindful to allow the patient & caregiver to share the story to find out what has changed.
I would add that even when patients come in with UTI’s and there is + findings on their urine dip. It is also worthwhile to assess any other changes in their function and signs or symptoms. Too often patients get diagnosed with a UTI when in fact the culture will come back negative and they have asymptomatic bacteruria.
done,not accepted
What preventive measures should be done post drainage of subdural hematoma?
Agree ,there is no simple solution. One has to consider also quality of life and patient’s ‘wishes.
What outcome can we expect after drainage of Subdural hematoma,risk of reccurence .
Any preventive measures?
Agree with comments above.
Also technology is very important when detailed Hx sis provided.
Why I am missing assessment of : neurologic status,gait, and the MEDICATION list.
It is important to recognize that someone with dementia could also have superimposed delirium or depression.
Yes, good point. Depression is another big one that we need to assess/keep an eye out for as it often coexists with dementia and because patients do present atypically at times when depressed.
It’s challenging with a person who already has behavior changes from dementia to sort it out.
Not a good case for a RAZ!
How perceptive of you! And yet a RAZ is just the kind of “nether world” that such a vague patient would get banished to!