Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent response - Altered Mental Status / Confusion
• 85-year-old female, acute confusion and agitation
• Possible infection / Delirium
• Patient not responding normally
• Family member present

On Arrival

Paramedics arrive at a residential address. The patient's son meets them, stating his mother, who has mild dementia but is usually cooperative and oriented to person/place, became acutely confused and agitated over the past 24 hours. She has been accusing him of trying to poison her, seeing insects on the walls (visual hallucinations), and refusing care. He notes she seemed unwell with possible urinary symptoms (malodorous urine, slight frequency) a couple of days ago but didn't complain much. Patient is found sitting in her lounge room, looking fearful, picking at her clothes, and muttering suspiciously.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (Son collateral essential, Patient input unreliable/paranoid)

Vital Signs/Assessment (Initial)

Physical Examination (Focused)

• **Mental State Exam (MSE) / Delirium Screen:**
  • **Consciousness:** Alert but level fluctuates.
  • **Attention:** Inattentive, easily distractible (key feature of delirium).
  • **Orientation:** Disoriented to time, place, situation.
  • **Speech:** Disorganized, tangential, may be incoherent.
  • **Thought Content:** Paranoid delusions, misinterpretations.
  • **Perception:** Visual hallucinations reported/apparent.
  • **Behaviour:** Agitated, restless, fearful, may resist care.
  • Compare current state to baseline dementia (acute change, fluctuating course, inattention, disorganized thinking = delirium).
• **Physical:** Check for signs of dehydration (dry mucous membranes, skin turgor). Palpate abdomen for suprapubic tenderness (suggestive of UTI/retention). Check lungs for signs of pneumonia. Brief neurological screen to rule out focal deficits (e.g., stroke).
• Consider other common causes of delirium in elderly: Infection (pneumonia, skin), medication side effects/interactions, metabolic disturbance (electrolytes, renal failure), hypoxia, constipation/urinary retention, pain, stroke, subdural haematoma (esp. if fall risk).

Assessment and Treatment

Appropriate Management

• Recognise Acute Delirium (hyperactive type) in an elderly patient with dementia, highly suspicious for underlying Urinary Tract Infection (UTI).
• **Prioritise Safety:** Ensure scene safety, patient safety (risk of falls, wandering, resisting care), and safety of crew/family.
• **Communication & De-escalation:** Approach calmly and reassuringly. Use simple, clear language. Reorient frequently. Validate feelings of fear without confirming delusions ("It sounds like you're feeling very scared right now"). Involve family member for reassurance/familiarity. Minimise environmental stimuli.
• **Assessment:** Primary survey (ABCDE). Obtain vital signs including temperature and BGL. Focused physical exam looking for source of infection/other causes of delirium. Use collateral history extensively.
• **Rule out/Manage Reversible Causes:** Check and treat hypoglycaemia. Ensure adequate oxygenation.
• **Supportive Care:** Provide reassurance. Maintain hydration if possible (sips of water if safe).
• **Sedation:** **Generally AVOIDED** prehospital for delirium unless severe agitation poses immediate danger to self/others and verbal de-escalation fails completely. If essential, use low-dose medication cautiously per protocol (e.g., small dose Olanzapine or Haloperidol - check contraindications/QTc), monitor closely. Benzodiazepines often worsen delirium in elderly (unless alcohol withdrawal related).
• **Physical Restraint:** Avoid if possible. Use only as last resort for safety, minimum force, per protocol.
• **Transport:** Transport to Emergency Department is required for investigation of delirium cause (likely UTI), treatment of underlying infection, and management of behavioural disturbance.
• **Involve Family:** Keep son informed and involved in plan. He should accompany patient if possible.
• **Pre-notify:** Inform receiving hospital about elderly patient with acute delirium (hyperactive, psychotic features) on background of dementia, suspected UTI trigger, vital signs (esp. temp), BGL, key MSE findings, behaviours, baseline function vs current state, relevant PMHx. Request geriatric/medical assessment.
• Documentation: Detailed record of baseline vs acute change, delirium features (inattention, fluctuation, disorganized thought, ALOC), vital signs, suspected cause, collateral info, de-escalation strategies, rationale for transport.