1st February 2024

Assessment

History

• Detailed history from the individual
• Collateral history from the relatives, carers and ward staff 
• Information in chronological order about situations or history that led to the present symptoms
• Details about substance misuse, medications- particularly CNS effects, new addition, discontinuations, changes in dose, overdosing

Mental State examination

The following should be assessed as part of the mental state examination:

• DSM-5/ ICD-11 criteria
• Appearance and behaviour, speech, mood and affect, thought form and content, perceptional abnormalities, insight
• Attention
• Memory

Examination

• Physical examination:
  • Vital signs
  • Hydration
  • Signs of infection
  • Systemic examination- CVS, Respiratory examination, Abdominal and Neurological examination
  • Head-to-toe examination 
• Cognitive assessment
  • AMTS- Abbreviated Mental State Score/ the Hodkinson Mental test- A score of 6 or less than 6 suggests dementia or delirium but needs further tests for confirmation
  • CAM- Confusion Assessment Method- The diagnosis of delirium needs both A and B with either C and/or D
    • Acute onset and fluctuating course
    • Inattention- Difficulty in focusing and easily distracted
    • Disorganised thinking- disorganised and incoherent. This could include rambling speech and unpredictable switching of subjects. Illogical flow of ideas and unclear thoughts
    • Altered level of consciousness- hyper-vigilant or drowsy, stuporous or comatose
  • 4-AT Test- Rapid clinical test for delirium. It is scored from 0 to 2/4. A score of more than 4 is suggestive of Delirium. It is helpful in ED settings, care homes, emergency settings, etc. More details can be obtained from 4AT preview — 4AT – RAPID CLINICAL TEST FOR DELIRIUM (the4at.com)

Investigations

• Bloods – FBC, renal and liver function tests, vitamin B12/ folate, vitamin D, TFTs, blood glucose
• Blood cultures and urine cultures
• CXR to look for infection 
• EEG and lumbar puncture if required