title: Does delirium need immediate medical referral in a frail, homebound elder?
abstract: OBJECTIVE
  This case report describes the clinical decision making process of a physical therapist whose examination of a home bound elderly woman led to a referral for hospitalization. We illustrate how the use of a comprehensive systems screen and thorough examination identified a patient with treatable conditions that required medical care.
  
  
  METHODS
  The patient was a frail 93-year-old woman. She was referred for home-care physical therapy with multiple medical comorbidities and functional decline following a short hospitalization for fall-related injuries. Her function improved after several visits, but upon resuming treatment after a 2- week hiatus, the patient demonstrated major decline in cognitive and physical function.
  
  
  RESULTS
  The comprehensive systems screen revealed that the patient had increased pallor, loose and frequent bowel movements, urinary incontinence and increased frequency of micturition, confusion and apathy, and extreme fatigue. Her examination showed large declines in scores for Functional Independence Measures, Mini Mental Status Examination, Berg Balance Test, and Timed Up and Go. These results were consistent with indicators for delirium, dehydration, and anemia. The findings were reported to the patient's physician and family members agreed to have the patient evaluated in the local emergency room.
  
  
  CONCLUSIONS
  This case report illustrates how knowledge of the pathologies associated with delirium and thorough examination can assist the physical therapist in making clinical decisions when homecare patients require prompt medical referral.
authors.affiliation: Department of Physical Therapy, Arcadia University, 450 S. Easton Road, Glenside, PA 19038, USA. millera@arcadia.edu
authors.forename: Amy Heritage
authors.initials: AH
authors.lastname: Miller
authors.forename: Kathleen Kline
authors.initials: KK
authors.lastname: Mangione
mesh_terms: D000369:Aged, 80 and over; D003681:Dehydration / Q000150:complications / Q000175:diagnosis; D003693:Delirium / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D016330:Frail Elderly / Q000523:psychology*; D015577:Geriatric Assessment; D006699:Home Care Services; D018577:Homebound Persons; D006801:Humans; D026761:Physical Therapy Specialty; D012017:Referral and Consultation