Case Studies

Case 1 - An 84-year-old woman with confusion

An 84-year-old woman is admitted to an acute medical ward where you are working as a psychiatric liaison doctor. She lives alone. According to her neighbour she remained active until a few days ago doing voluntary work for the League of Friends; she has some problems with her breathing. He recalls she was in hospital with a chest infection last year, but he has never noticed her having any problems with her memory or any abnormal thoughts. She was admitted with confusion, after being found on the floor by paramedics called by concerned neighbours who had not seen her for days. The patient tells you she was beaten up by the secret service who took her to a police station. She believes the secret police followed her home due to connections that her dead husband had with a foreign police force. She is irritable and has at times asked to go home as she believes she is still in the police station and has spent enough time there. She describes seeing many police officers sitting around drinking tea. Her speech is difficult to follow. She scores poorly on cognitive testing, most of which she is unable to complete due to poor concentration. The nurses tell you she was quite lucid earlier that day and they thought she had improved, but her confusion has now worsened.

• (a) What psychotic symptoms are present?

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  Correct answer:

  Persecutory delusions; visual hallucinations

• b. What is the most likely diagnosis, and what aspects of the history lead you this conclusion?

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  Correct answer:

  Acute confusional state; the history of an acute onset, and the fluctuating level of confusion are typical of an acute confusional state; other symptoms suggestive of this are irritability, incoherent speech, visual hallucinations (police officer) and persecutory delusions.

• c. List five common causes of an acute confusional state.

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  Correct answer:

  The history is suggestive of chronic pulmonary disease, so a chest infection is a likely cause in this case; urinary tract infection is also a very common cause of confusion. Other common causes include alcohol withdrawal, hypoxia, electrolyte disturbance (e.g. hyponatraemia) (see Chapter 31 for more).

• d. What advice would you give regarding non-drug treatment of her confusion?

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  Correct answer:

  Non-pharmacological measures would include reassurance, nursing in a well-lit room, avoiding frequent changes of staff, ensuring glasses and hearing aid were available if she uses them.

• e. What advice would you give regarding drug treatment of her confusion?

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  Correct answer:

  Avoid drug treatment if possible, but if required to prevent severe distress or risk of harm to others, a benzodiazepine (e.g. lorazepam) would be a first choice.

• f. What should happen if she asks to leave the ward?

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  Correct answer:

  She should be assessed for a section 5(2), and detained if thought to be at risk of harm to herself or others if she left the ward. A Mental Health Act assessment could then be arranged.