Geriatric Case 1: Delirium

This case is the first in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Victoria Brazil, Nemat Alsaba, and Rebecca Shaw.

Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com). Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia.

Why it Matters

As our global patient population ages, it is increasingly important that emergency physicians have specialized knowledge in the care of elderly patients. This is particularly true when managing patients with baseline dementia or presenting to the ED with delirium. This case highlights specific challenges in these patients, including:

  • The need to recognize delirium as symptom of a large array of potential medical illnesses
  • The importance of a medical work-up in patients with delirium (including blood work, urine, and possible imaging)
  • The need for health care workers to have a toolbox of de-escalation techniques at their disposal

Clinical Vignette

Patient is sitting on the edge of the ED bed, looking perplexed. She/he is fidgeting and not concentrating on the questions being asked, she/he is staring around the room, looking in his/her bag and picking at the BP cuff and bed sheet. The ED nurse is attempting to do some baseline vital signs on the patient.

Participants asked by ED RN “Could you please go and assess this patient? She/he has just been brought in to the ED by ambulance after a friend found her/him confused at home”

Case Summary

An 81-year-old (wo)man is brought to the ED by her/his friend as she/he is confused and agitated. In the ED, her/his confusion worsens. Initially she/he is fidgety but as the case progresses she/he becomes more agitated and confused. She/he will be fairly uncooperative, moving around and not able to follow many commands. The participants should be looking for a source of infection and evidence of any recent trauma.  They are expected to use both non-pharmacological and safe pharmacological options in order to control the situation, ensure patient safety, and facilitate investigations.

Download the case here: Geri EM Delirium

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