Follow-Up Note: Pleasantly Confused Geriatric Patient
Clinical Documentation
Subjective:
- Patient is pleasantly confused, seated comfortably with [RELATIVE] at bedside 1
- No acute concerns voiced by patient or family 1
- Minimal verbal interaction noted during encounter 1
- Forgetfulness consistent with baseline cognitive status 1
- Patient appears comfortable and non-distressed 1
Objective:
- Mental Status: Pleasant affect, limited engagement, forgetful responses consistent with known mild cognitive impairment 1
- Behavior: Calm, cooperative, no agitation or distress 1
- Safety: Patient stable in current environment with family supervision 1
- Vital Signs: Stable (document actual values) 1
Assessment:
- Stable mild cognitive impairment with forgetfulness at baseline level 1
- No acute delirium – absence of acute onset, fluctuating course, or disordered attention/consciousness that would distinguish delirium from baseline dementia 1
- Patient currently taking escitalopram 10 mg daily – appropriate dose for elderly patient with no current signs of hyponatremia-related confusion 2
Medication Safety Review
Current escitalopram therapy:
- Monitor for hyponatremia – elderly patients on SSRIs are at increased risk for SIADH, which can present as confusion, weakness, and unsteadiness 2
- Check serum sodium if any change in mental status occurs, as levels below 110 mmol/L have been reported with escitalopram 2
- Cognitive effects: Escitalopram has minimal anticholinergic activity and does not typically impair cognition in elderly patients; may actually improve cognitive symptoms in depression 3, 4, 5
- Current dose appropriate: 10 mg daily is the recommended dose for elderly patients per FDA labeling 2
Delirium Screening Completed
Two-step screening performed:
- Delirium Triage Screen: Negative for acute delirium 1, 6
- Key distinguishing features assessed: No acute onset, no fluctuating course, attention generally preserved, consciousness preserved – consistent with stable dementia rather than delirium 1
Reversible causes ruled out:
- No anticholinergic burden: Escitalopram has minimal anticholinergic effects unlike older tricyclics 1, 6
- No high-risk medications: Patient not on benzodiazepines, antihistamines, muscle relaxants, or overactive bladder agents that commonly cause confusion 1, 6
- No signs of infection: No fever, respiratory symptoms, or urinary symptoms suggesting UTI or pneumonia 1, 6
- No pain behaviors: Patient appears comfortable without grimacing or guarding 6, 7
Plan
Ongoing monitoring:
- Continue escitalopram 10 mg daily – appropriate dose with favorable cognitive profile for elderly patients 2, 4
- Family education provided: Discussed signs of acute delirium (sudden worsening of confusion, fluctuating alertness, visual hallucinations) that would require immediate evaluation 1
- Safety assessment: Patient has adequate supervision with [RELATIVE] present; home environment appears safe 1
- Medication adherence: Confirm family/caregiver assistance with medication administration given forgetfulness 1
Red flags to prompt urgent re-evaluation:
- Acute worsening of confusion or new fluctuating mental status 1, 6
- New falls, weakness, or unsteadiness – may indicate hyponatremia from SSRI 2
- Fever, cough, or urinary symptoms – infections are leading cause of delirium in elderly 1, 6
- Decreased oral intake or new behavioral changes 1
Follow-up: