Comprehensive Geriatric Assessment: Delirium Management, Falls Prevention, Medication Review and Safe Discharge Planning
Your Role — Nurse
Aged Care Facility
Your 84-year-old female patient was admitted to the aged care facility following a hip fracture repair. The daughter reports acute confusion starting two days after surgery. The patient has background hypertension, osteoarthritis, and had two falls at home in the past year. She is on ramipril, bendroflumethiazide, and paracetamol. You are the registered nurse conducting a comprehensive geriatric assessment including delirium workup, falls risk assessment, medication review, and discharge planning with the daughter who works full-time and is the primary carer.
- •Listen to the daughter's concerns. Establish the timeline of confusion onset and differentiate delirium from dementia. Assess baseline cognition and function before admission.
- •Conduct delirium assessment using 4AT or CAM. Explore potential causes: UTI, medication side effects, dehydration, pain, sleep deprivation, constipation, and environmental change.
- •Perform falls risk assessment: review fall circumstances, home environment, vision, footwear, medications causing dizziness or nocturia, balance and gait. Discuss fear of falling.
- •Review medications: identify anticholinergic burden, sedatives, diuretics contributing to nocturia. Plan GP review of antihypertensives and diuretics. Check need for bone protection.
- •Discuss discharge planning and carer support: OT and physio referrals, home equipment, social work involvement, respite care options for the daughter, and a written care plan with follow-up GP appointment.
The Interlocutor
Played by the actor / assessor
You are the daughter of an 84-year-old woman who had a hip fracture repair and has been confused since surgery. She was previously independent. She is now confused, not eating, withdrawn, and has had multiple falls. You work full-time and are worried about how she will manage at home.
- •Say your mother was independent before — managing finances, cooking, living alone. Confusion started 2 days after hip surgery. She also had a UTI in hospital.
- •Say she is not eating well, seems sleepy during the day but restless at night. She had 2 falls at home this year.
- •Ask whether the confusion could be caused by her medications. She takes blood pressure tablets and water tablets.
- •Express concern about going home — you work full-time and cannot provide round-the-clock care.
- •Say you feel reassured by the comprehensive plan. Ask for written information about medications and follow-up.
Sample Role-play
Thank you for coming in. I am the registered nurse looking after your mother. I understand you have been worried about her since the surgery. Can you tell me what changes you have noticed?
She is just not herself at all. Before the fall she was completely independent — managing her finances, cooking, living alone. Now she is confused, not eating properly, and just sits there withdrawn. She also had two falls at home before this one.
That must be very distressing for you. When did the confusion first start? Was it sudden like a switch being turned or more gradual over weeks?
It started suddenly about two days after her hip surgery. She was absolutely fine the day of the operation, talking normally, but the next night she became confused and aggressive. It has been nearly two weeks now and she still is not back to normal.
The sudden onset after surgery is a very important clue. What you are describing sounds like delirium — an acute confusional state that is completely different from dementia. The good news is that delirium can be reversible once we identify and treat the underlying cause. Common triggers in older hospitalised patients include infections, medication side effects, dehydration, uncontrolled pain, and sleep deprivation.
Could the confusion be caused by her pain medication?
That is a very good question. Yes certain painkillers particularly strong opioids and some sedatives can cause or worsen confusion in older adults especially after surgery. We will review all her medications including any pain relief to identify any that may be contributing to the delirium.
How long does it usually take for the confusion to improve?
She had a urinary tract infection in hospital. They treated it with antibiotics but I am not sure it has fully cleared.
That could certainly be contributing. Let us do a urine test today to check. I will also review all her medications — some painkillers given after surgery and certain blood pressure tablets can cause confusion in older adults. How has her appetite and fluid intake been?
She is barely eating or drinking. I have to remind her to take each sip.
Dehydration can both cause and worsen delirium. We will monitor her fluid intake closely and offer fortified supplements if needed. Now you also mentioned she has had multiple falls. Can you tell me more about the circumstances of the fall that caused her hip fracture?
She got up in the middle of the night to use the bathroom and was found on the floor beside her bed. She must have tripped or lost her balance.
Getting up at night to use the bathroom is one of the most common scenarios for falls in older adults. This could be related to her water tablets which increase urination at night, poor lighting, vision problems, or balance issues. I will conduct a full falls risk assessment which includes reviewing her medications, checking her vision, assessing her balance and gait, and looking at her home environment for trip hazards.
She has been on a water tablet for years. She also needs new glasses.
That is very helpful information. I will review her medications with the GP — the bendroflumethiazide may be contributing to both the confusion and the falls risk. I will also arrange an eye test and refer her to the physiotherapist for balance exercises. The occupational therapist can assess her home for safety equipment like grab rails and a raised toilet seat.
I am also very worried about how she will manage when she goes home. I work full-time and I have my own children to look after.
That is a very valid concern and it is excellent that you are thinking about this early. We will involve the social worker and occupational therapist from now to plan a safe discharge. The options might include a period of rehabilitation in a step-down unit to build her strength, a package of care at home to help with personal care and meals, or equipment and home modifications. We will also discuss carer support options for you because supporting a parent after a hospital stay can be very demanding.
A rehabilitation stay sounds like the best option. She needs to build her strength before coming home.
I will start those referrals today. Let me summarise our plan. One: urine test and medication review to address the delirium. Two: hydration and nutrition monitoring. Three: falls risk assessment with physio and OT referrals. Four: eye test arranged. Five: discharge planning with social worker including rehabilitation options and carer support. I will keep you updated on her progress daily. Here is my contact number if you think of any other questions.
Thank you. I feel much more reassured knowing there is a clear plan and that her falls risk is being addressed properly.
You are welcome. We will take good care of her and keep you informed every step of the way.
Useful Phrases
Clinical Background
Delirium is a medical emergency in the elderly and is often multifactorial: infection (especially UTI), polypharmacy, dehydration, pain, sleep deprivation, and environmental change. Key nursing interventions: cognitive screening (4AT or CAM), urinalysis, medication review, pain assessment, family involvement, and reorientation strategies. Delirium superimposed on dementia is common and requires careful differentiation.
Common Mistakes to Avoid
- ✕Assuming confusion is just 'dementia' or 'old age' rather than investigating reversible causes.
- ✕Not involving the family in providing baseline function information.
- ✕Failing to assess for pain as a cause of agitation and confusion in a patient who cannot verbalise.