Older person: delirium, dementia, frailty and deconditioning

To assess how you tell delirium from dementia, screen with the 4AT, look for the causes, grade frailty, and prevent deconditioning while keeping the person’s dignity and rights at the centre.

Mrs Kathleen Nolan, 88, lives alone with home help twice a day, walks with a stick, and has a diagnosis of Alzheimer’s disease. Admitted two days ago with a chest infection. Her son says that since yesterday she is "not herself": drowsy in the morning, agitated and pulling at her cannula at night, seeing children in the room. She has not been out of bed since admission.

You are required to explain what you think is happening and why, screen her with the 4AT, look for the causes, grade her frailty, and set out the care plan including how you prevent deconditioning.

1. Approach: introduce yourself at eye level, calm voice, her name, one question at a time, glasses and hearing aid in, involve the son
2. Explain delirium against dementia: acute onset over hours or days, fluctuating, inattention, altered alertness, hallucinations; dementia is gradual and progressive
3. Do the 4AT: alertness, AMT4 (age, date of birth, place, year), attention (months backwards), acute change or fluctuation; score and interpret it
4. Look for causes: infection, hypoxia, dehydration, constipation, urinary retention, pain, medication (sedatives, opioids, anticholinergics), withdrawal, unfamiliar environment, sleep loss, sensory impairment
5. Actions: observations and INEWS, treat the infection as prescribed, fluids, bowel and bladder check, pain score and relief, review the medication with the team, glasses and hearing aid, orientation aids, family presence, sleep
6. Keep her safe without restraint: low bed, falls plan, cover the cannula, sit with her, no bed rails as a restraint, sedation only as a last resort and only as prescribed
7. Grade frailty on the Clinical Frailty Scale from her baseline two weeks ago, not from today, and say what the grade changes
8. Prevent deconditioning: out of bed to the chair for meals, walk with the stick and assistance daily, own clothes, physiotherapy and occupational therapy referral, hydration and nutrition
9. Presume capacity for each decision; her will and preferences guide the plan; the son informs, he does not decide
10. Document the 4AT score, the suspected causes, the plan and the review; inform the team and the son

Throughout: communicate in an accurate, clear and effective manner; demonstrate a level of competence essential for safe practice.