Case 2: An older woman found confused in the park

01The case

A woman comes for advice about her 75-year-old mother, who lives alone in a flat. Lately her mother has several times left the front door unlocked and the taps at the sink running. Twice the neighbours have told the daughter that her mother was found in the nearby park in a state of "confusion".

02Summary

Diagnosis

Most likely dementia; its type is not yet known.

What points to it

• Memory clearly impaired, enough to leave the door open and the taps on.
• Disorientation in a familiar place, the park near her home.
• Her age. Ask the daughter when it began and whether it came on gradually: a slow decline points to dementia, a sudden change to delirium.

What else it could be

The key question is whether the spells in the park were delirium, an acute confusion with clouded consciousness laid on top, or disorientation from memory loss with a clear mind. Brief spells of clouding on top of memory loss point more towards vascular dementia, or Lewy body dementia, where alertness fluctuates, once an infection or a medicine has been ruled out as the cause; the type found guides treatment. Also consider depression, which can mimic dementia in older people, and reversible causes: thyroid disease, low vitamin B12 or folate, raised calcium, medication, alcohol, a subdural haematoma, normal pressure hydrocephalus.

Management

• Assessment: history from the daughter, physical and neurological examination, cognitive testing (such as MMSE or MoCA), blood tests for reversible causes, and brain imaging.
• Explain the condition to the family, and plan care and supervision.
• Safety at home: the cooker and taps, going out alone, a key holder, help from social services, and whether she can still live alone.
• Routine and continuity: a fixed daily pattern, the same carers, personal hygiene, activities that mean something to her.
• Treat the type of dementia once known: for Alzheimer's disease a cholinesterase inhibitor (donepezil, rivastigmine or galantamine) and later memantine; for vascular dementia, control of blood pressure and the other vascular risk factors.
• Insomnia and behaviour: non-drug measures first. Avoid antipsychotics where possible, and use sedatives sparingly.

Outlook

Dementia progresses. Planning early, while she can still take part, makes the later stages safer: care at home, legal arrangements such as a power of attorney, and support for her daughter.