How should I manage a patient presenting with mild AMS symptoms in a primary care setting?

When a patient presents with mild altered mental status symptoms in a primary care setting, it is crucial to consider potential underlying causes, including delirium, and to assess for specific indicators and risk factors ².

• Recognising Delirium Indicators: Be aware of recent (within hours or days) changes or fluctuations that may indicate delirium ². These can be reported by the patient, a carer, or a relative ². Key changes to look for include worsened concentration, slow responses, or confusion ². Other indicators are changes in perception (e.g., visual or auditory hallucinations), physical function (e.g., reduced mobility, restlessness, changes in appetite, sleep disturbance), and social behaviour (e.g., withdrawal, mood alterations) ². It is particularly important to be vigilant for signs of hypoactive delirium, such as withdrawal, slow responses, reduced mobility, and worsened concentration, as these are often missed ².
• Identifying Risk Factors for Delirium: Patients aged 65 years or older, those with cognitive impairment or dementia, a current hip fracture, or severe illness are at increased risk of delirium ².
• Initial Assessment and Documentation: If indicators of delirium are identified, a competent health or social care practitioner should carry out an assessment, typically using the 4AT tool ². Any changes that may indicate delirium should be documented in the patient's record or notes ². If delirium is diagnosed, this should also be documented in the primary care health record ².
• Management Principles (if delirium is suspected/diagnosed): The initial management involves identifying and addressing the possible underlying cause or causes ². Effective communication, reorientation (explaining where the person is, who they are, and your role), and reassurance are important ². Involving family, friends, and carers can assist with this ². A suitable care environment should be provided ². For distressed patients, verbal and non-verbal de-escalation techniques should be used first ².
• Information and Support: Offer information to patients at risk of or with delirium, and their families/carers, explaining that delirium is common and usually temporary ². Encourage them to report any sudden changes in behaviour to the healthcare team ².
• Memory Problems in Adults Under 50: For adults under 50 presenting with memory problems but no other neurological signs, routine referral is not typically needed if brief testing shows normal memory function and symptoms are consistent with concentration difficulties ¹. Be aware that such problems can be caused by recreational or some prescription drugs, alcohol, affective disorders, or stress ¹.