ANSWER 74
This is not the picture of dementia. The acute onset with clouding of consciousness, hal-
lucinations, delusions, restlessness and disorientation suggest an acute confusional state,
delirium. There are many causes of this state in the elderly. It can be provoked by drugs,
infections, metabolic or endocrine disorders, or other underlying conditions in the heart,
lungs, brain or abdomen.
There is no record of any drugs except thyroxine, although this should be rechecked to rule
out any analgesics or other agents that he might have had access to or that might not be
regarded as important.
The thyroid abnormality is not likely to be relevant. The lack of replacement for 2 days
will not have a significant effect and the normal results 6 months earlier make this an
unlikely cause of his current problem. The sugar is normal. Other metabolic causes such
as renal failure, anaemia, hyponatraemia and hypercalcaemia need to be excluded.
The falls raise the possibility of trauma, and a subdural haematoma could present in this
way. However, it seems that the falls were a secondary phenomenon. The most likely cause
is that he has a urinary tract infection. There is blood and protein in the urine, he has become
incontinent and he has some tenderness in the loin which could fit with pyelonephritis. We
are not told whether he had a fever, and the white cell count should be measured.
If this does seem the likely diagnosis it would be best to treat him where he is, if this is safe
and possible. He is likely to be more confused by a move to a new environment in hospi-
tal. There is every likelihood that he will return to his previous state if the urinary tract
infection is confirmed and treated appropriately, although this may take longer than the
response in temperature and white cell count. Treatment should be started on the pre-
sumption of a urinary tract infection, while the diagnosis is confirmed by microscopy and
culture of the urine. The most likely organism isEscherichia coli, and an antibiotic such
as trimethoprim would be appropriate, although resistance is possible and advice of the
local microbiologist may be helpful. From the confusion point of view he should be treated
calmly, consistently and without confrontation. If medication is necessary, small doses of
a neuroleptic such as haloperidol or olanzapine would be appropriate.
- Acute changes in mental state need to be explained even in the elderly with baseline
mental problems. - In delirium, consciousness is clouded, disorientation is usual and delusions may
develop. The onset is acute. In dementia, there is an acquired global impairment of
intellect, memory and personality, but consciousness is typically clear.