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Collateral history for Delirium / Dementia

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s and relative’s names
  • Explain the need for a collateral history
  • Establish their relation to the patient

Presenting complaint

  • Confusion/memory loss

History of presenting complaint

  • Onset: determine if it is acute, chronic, or acute-on-chronic (establish baseline function and cognition)
  • Progression: slowly progressive (Alzheimer’s), step-like (vascular)
  • Triggers: infection, stress
  • Associated symptoms
    • Depression
    • Psychiatric symptoms: hallucinations/delusions
    • Behavioural change: agitation, aggression, wandering, disinhibition, calling out
    • Sleeping pattern: awake at night (Alzheimer’s), early morning waking (depression), fluctuating consciousness (delirium)
    • Cognitive disturbances: aphasia, apraxia, agnosia, difficulty planning/organising

Past medical history

  • Ask about: Parkinson’s disease, vascular disease/diabetes, head injuries, recent infections
  • Psychiatric history

Drug history

  • Blood pressure/diabetes medication
  • Parkinson’s drugs
  • Alzheimer’s drugs: galantamine, donepezil, rivastigmine
  • New medications
  • Allergies

Family history

  • Related conditions, e.g. dementia, vascular disease, depression

Social history

  • Living situation, carer/home support
  • Mobility/walking aids
  • Effect on function/coping with activities of daily living: washing, dressing, cooking, cleaning
  • Working/driving
  • Smoking, alcohol and other cardiovascular risk factors
  • RISK
    • To self: wandering, leaving gas on, abuse, neglect by self or others
    • To others: aggression, risky behaviour
  • Carer’s needs: empathise with the demands; ask about stress, coping, and support

Ending

  • ICE (Ideas, Concerns, Expectations): how does the relative/carer expect you to help? What are they worried about?
  • Summarise situation and patient needs. Thank relative.

Causes of dementia

  • Alzheimer’s: most common; prevalence increases with age; some genetic association. Slowly progressive. Presents with memory/cognitive impairment (5A’s: Anomia, Apraxia, Agnosia, Amnesia, Aphasia). Due to generalised atrophy of cortex with amyloid plaques and neurofibrillary tangles.
  • Vascular Dementia: stepwise deterioration. Often have multiple cardiovascular risk factors. May have focal neurology. CT head may show areas of ischemia or small vessel disease.
  • Lewy-Body Dementia: progressive dementia with daily fluctuations of awareness due to Lewy bodies in the cerebral cortex. Parkinsonian features (e.g. bradykinesia, tremor, rigidity) and psychiatric symptoms (e.g. hallucinations) are common.
  • Other causes/differentials: frontotemporal lobe dementia, Creutzfeldt-Jakob disease, depression (‘pseudodementia’), HIV, Huntington’s disease, normal pressure hydrocephalus, space-occupying lesion, nutritional deficiencies (thiamine, nicotinic acid, B12), alcohol abuse, neurosyphilis, hypothyroidism, autoimmune/paraneoplastic

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