Acute Confusion in a Nursing Home Resident with Bruises

The key judgement is that this is delirium superimposed on dementia, not 'progression of dementia'. Dementia does not change over two days. The CAM features are present: acute onset, fluctuating course, inattention, and altered behaviour. In an 86-year-old, delirium is often the first and only sign of infection or another physical stressor - fever may be low-grade or absent, and the usual localising symptoms are missing.

Search for causes, in order of likelihood here:

• Urinary tract infection: cloudy, malodorous urine with a low-grade temperature. Send a urine sample for culture before assuming, and do not treat on the dipstick alone in an asymptomatic patient - but she is symptomatic.
• Constipation and fecal impaction: five days without a bowel movement can cause agitation, and impaction can also cause urinary retention and overflow.
• Pain, dehydration, and the recent environmental change (new care worker) as contributing stressors.
• Medication review for anticholinergics, sedatives and recent changes.

Actions today: notify the physician the same day; obtain urine culture and consider blood tests; assess hydration, bowel and bladder status; check for pain using a behavioural scale; start a bowel regimen; keep her out of bed in daylight, maintain her usual routine, and have the same staff member care for her to reduce unfamiliarity.

Do not use an antipsychotic or a restraint as the first response; treating the trigger resolves the delirium.

What the findings suggest. Bruises on both inner upper arms, of different ages, are an unusual site for self-inflicted injury in a woman who needs full ADL assistance; 'she grabs herself there' does not fit the location or the number. The daughter's request to tie her to a chair is itself a statement of intent to use physical restraint, which the Act treats as abuse, and twice refusing needed medical care is neglect. Neither proves who caused the bruises - that is not my role to determine.

My legal and professional obligations:

• Duty to report. Staff engaged in elder care must report suspected abuse to the municipality, and the reporting duty attaches to the individual, not the institution. Good-faith reporting is protected; I do not need certainty, only reasonable suspicion.
• Report through, not instead of, the proper route: inform the facility's abuse-prevention officer immediately and document in parallel, so the report is not delayed by internal discussion.
• Do not investigate, confront the family, or question the suspected worker. That risks destroying evidence, retaliation against the resident, and contaminating any later investigation.
• Document objectively: site, size, colour and estimated age of each bruise, what was said and by whom, with date and time. Use quotation marks for statements; avoid conclusions such as 'abuse'.
• Secure immediate safety: observe who handles her, avoid leaving her alone with the suspected worker, and ensure her medical needs are met despite the daughter's refusal.

The resident's safety outranks the family's wishes and the facility's reputation.

First, hear the concern. The daughter is not asking for restraint out of cruelty; she is afraid her mother will fall or wander and be hurt, and she may also be exhausted and grieving the change in her mother. Name that: 'You are worried she will fall - that is a real risk, and we want the same thing.'

Then be clear about the limit. Physical restraint is permitted only in a genuine emergency to protect life and limb, must be ordered and reviewed by a physician, and must be the least restrictive option for the shortest time. Tying her to a chair to stop wandering is not an emergency measure; it is restraint as convenience, it is defined as abuse under the Act, and it would worsen her agitation, cause incontinence, pressure injury, contractures and delirium. I would say this plainly but without blaming her.

Offer concrete alternatives for this resident:

• A falls-risk review and a low bed, hip protectors, and a sensor mat rather than restraint.
• Supervised walking and activity at the times she wanders; wandering is often purposeful - toileting, pain, boredom or a search for something familiar.
• Treat the delirium trigger first; agitation from a UTI or impaction often resolves with treatment.
• A care conference with the daughter, the physician and the care manager, with a written plan and a review date, so she is a partner in the decision rather than an opponent.

Document the conversation, the alternatives offered and the daughter's response.