What is the most likely diagnostic confirmation for an 87-year-old man with mild dementia, presenting with acute worsening of gait and mental status after a fall?

From the Guidelines

The most likely test to confirm the diagnosis in this case is a CT scan of the head (option D). This 87-year-old nursing home resident presents with acute worsening of gait and mental status changes, including new disorientation, confusion, and inability to perform routine tasks. The presence of a forehead contusion and history of a recent fall strongly suggests a traumatic brain injury, specifically a subdural hematoma. Elderly patients with brain atrophy are particularly susceptible to subdural bleeding even after minor head trauma, and the symptoms can develop or worsen over hours to days. The clinical picture of fluctuating confusion, disorientation, and gait disturbance in the setting of known head trauma makes intracranial bleeding the most likely diagnosis. According to the study by 1, identifying patients with altered mental status (AMS) or delirium secondary to acute intracranial pathology is extremely important to guide management and ensure early appropriate triage. Some key points to consider in this case include:

• The patient's age and residence in a nursing home, which are risk factors for delirium 1
• The presence of a focal neurologic deficit (unsteady gait) and suspicion of head trauma, which warrant further investigation with neuroimaging 1
• The potential for acute intracranial pathology, such as intracranial hemorrhage (ICH) or ischemic stroke, which can present with AMS or delirium 1 A CT scan would rapidly identify the presence of a subdural hematoma or other intracranial pathology requiring urgent intervention. While the other tests might be appropriate for evaluating chronic causes of cognitive decline, they would not address the acute change in status following head trauma that is evident in this case. In particular, the study by 1 notes that the yield of neuroimaging studies in patients with AMS is low, but in cases with suspected intracranial pathology or focal neurologic deficit, CT scan is the most appropriate initial imaging test.

From the Research

Diagnosis Confirmation

To confirm the diagnosis of the 87-year-old man with mild dementia, who has experienced worsening gait and mental status changes, the following options are considered:

• The patient's symptoms, such as unsteady gait, contusion over the left forehead, and disorientation, suggest a possible traumatic brain injury (TBI) due to the fall.
• The patient's age, medical history, and current symptoms are relevant factors in determining the most likely diagnosis.

Relevant Studies

Studies have investigated the utility of repeat head CT scans in patients with mild TBI, including those with isolated subarachnoid hemorrhage (SAH) or subdural hematoma:

• A study published in 2019 2 found that less than 10% of patients with mild TBI and isolated SAH had worsening of their head injury on repeat CT scanning.
• Another study published in 2021 3 found that follow-up CT brain imaging performed at 10 hours after the typical baseline CT scan was of value in detecting the evolution of intracranial neurological pathology.
• A study published in 2024 4 found that isolated tSAH on head CT is often not the sole intracranial traumatic injury in patients with GCS 13-15 TBI, and that plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries.
• A study published in 2018 5 found that isolated falcotentorial subdural hematomas in blunt traumatic brain injury average 2.8 mm in thickness and do not increase in size on short-term follow-up CT.
• A study published in 2021 6 found that iSAH in mTBI seems to be a radiological stable entity over 72 h with no neurological deterioration, and that the clinical utility of a repeat head CT in such patients is questionable.

Most Likely Diagnosis Confirmation

Based on the patient's symptoms and the studies mentioned above, the most likely option to confirm the diagnosis is:

• D) CT scan of the head: This option is most likely to confirm the diagnosis, as it can help identify any intracranial injuries, such as subdural hematoma or subarachnoid hemorrhage, that may be causing the patient's symptoms.