Case Study: Mrs. Sol

The clinician has not listened carefully to what the husband is communicating, and is not speaking directly to the patient.

• He has not established a timeline on the cognitive changes (ie. distinguishing between “for a while” and “for some time”),
• He has allowed the presence of dementia to exclude any other diagnosis like delirium.
• He has focused on the presenting complaint without exploring what led up to the injury.
• He has not included cognitive changes as part of his differential diagnosis.

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 the hospital. An internal review of ED procedures for assessing older patients was carried out.

The clinician asks “What has changed? What is different”.

• He established the timeline of the cognitive impairment by teasing out the chronic from the acute changes.
• He seems to be aware of the components of delirium and is using the Confusion Assessment Method (CAM) to screen for it.
• He has an approach to the assessment of delirium.

While this did take slightly longer, the outcome is significantly different.

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.