100 Cases in Clinical Medicine

CASE 74: CONFUSION

History

An 86-year-old man has been in a residential home for 3 years since his wife died. He was
unable to look after himself at home because of some osteoarthritis in the hips limiting his
mobility. Apart from his reduced mobility, which has restricted him to a few steps on a
frame, and a rather irritable temper when he doesn’t get his own way, he has had no prob-
lems in residential care.

However, he has become much more difficult over the last 36 h. He has accused the staff
of assaulting him and stealing his money. He has been trying to get out of his bed and his
chair, and this has resulted in a number of falls. On some occasions his speech has been
difficult to understand. He has become incontinent of urine over the last 24 h. Prior to this
he had only been incontinent on one or two occasions in the last 6 months.

The duty doctor is called to see him and finds that he is rather sleepy. When roused he
seems frightened and verbally aggressive. He thinks that there is a conspiracy in the ward
and that the staff are having secret meetings and planning to harm him. He is disorien-
tated in place and time although reluctant to try to answer these questions.

He is a non-smoker and drinks 1–2 units a month. On a routine blood test 8 years ago he
was diagnosed with hypothyroidism and thyroxine 100 mg daily is the only medication he
is taking. The staff say that he has taken this regularly up to the last 36 h and his records
show that his thyroid function was normal when it was checked 6 months earlier.

The staff say that he is now too difficult to manage in the residential home. They feel that
he has dementia and that the home is not an appropriate place for such patients.

Examination

There is nothing abnormal to find apart from blood pressure of 178/102 mmHg and limi-
tation of hip movement with pain and a little discomfort in the right loin.

Normal

Thyroxine 125 nmol/L 70–140 nmol/L

Thyroid-stimulating hormone 1.6 mU/L 0.3–6.0 mU/L

Blood glucose 6.2 mmol/L 4.0–6.0 mmol/L

Urine dipstick: – sugar,'protein,''blood

INVESTIGATIONS

Question

• What should be done?