Important: Exam dates, fees and policies can change. Verify time-sensitive details on the official Medical Council of Canada website.

Home / Station 21: Older adult with acute confusion

NAC OSCE preparation

Station 21: Older adult with acute confusion

Complete the task in 11 minutes. Reveal the full standardized-patient script, examiner prompts and structured debrief only after your attempt.

Station time

11:00

Ready for an 11-minute attempt.

Candidate instructions

Older adult with acute confusion

11 minutes

Discipline: Geriatric Medicine
Station type: Collateral history + delirium plan
Setting: Emergency department observation unit

Your task

Take a focused history from the patient's daughter, then state your assessment and immediate plan.

Information available at entry

HR 108/minBP 104/62 mm HgRR 24/minT 38.2°CSpO₂ 90% room airGlucose 7.1 mmol/L

Coach prompt: Recognize delirium, identify precipitants and protect the patient while treating causes.

In Exam Mode, coaching cues are hidden. Ask a partner to use the standardized-patient script after you start the timer.

Finished your attempt?Reveal the full station only after completing or stopping the timer.

Complete station package

Standardized-patient script and structured debrief

Station 21 of 30

Standardized-patient profile

NameMrs. Eleanor Wu

Age82

Pronounsshe/her

RolePatient with daughter present

Demeanour: Drowsy, inattentive and intermittently pulling at oxygen tubing.

Opening statement: “She was completely herself three days ago. Since yesterday she has been confused and seeing children in the room.”

History and standardized-patient responses

Time course and cognition

Candidate explores	Standardized-patient response
Baseline	Independent in basic activities; mild forgetfulness but manages medications and finances.
Onset/fluctuation	Abrupt onset over 24 hours; alternates between agitation and sleepiness.
Attention	Cannot follow conversation or recite months backward.
Perceptual symptoms	Visual hallucinations beginning with the acute illness.

Precipitants

Candidate explores	Standardized-patient response
Infection	Productive cough, reduced intake and rigors for two days.
Medications	Diphenhydramine nightly and new oxybutynin started one week ago.
Pain/retention/constipation	Suprapubic discomfort; no bowel movement for four days.
Substances	No alcohol or recreational drugs.

Function and safety

Candidate explores	Standardized-patient response
Falls	Nearly fell overnight.
Hydration/nutrition	Very little fluid since yesterday.
Supports	Lives with spouse; daughter nearby.
Goals/SDM	Daughter is not formal substitute decision-maker; patient usually capable.

Physical findings

General: ill appearing, dry mucous membranes.
Chest: right basal crackles.
Attention impaired; disoriented to place and date.
No focal neurologic deficit.
Suprapubic fullness; bladder scan available on request shows 650 mL.

Examiner prompts

Most likely diagnosis?

Delirium, likely multifactorial from pneumonia/hypoxia, dehydration, urinary retention, constipation and anticholinergic burden.

Immediate priorities?

Oxygen/supportive care, sepsis assessment, treat infection, relieve retention, stop offending drugs and institute non-pharmacologic delirium care.

Medication for agitation?

Not routine; use only if severe distress or imminent danger after reversible causes and de-escalation are addressed, with cautious selection and monitoring.

Differential diagnosis

Delirium due to infection/hypoxia
Medication-induced delirium
Urinary retention/constipation
Metabolic disturbance
Stroke
Dementia with superimposed delirium

Investigations

CBC, electrolytes, renal/liver tests and glucose
Blood cultures/lactate when sepsis suspected
Urinalysis only if clinically indicated
Chest radiograph
ECG and medication review
Bladder scan

Management

Supplemental oxygen and ABC assessment
Prompt pneumonia/sepsis treatment
IV/oral fluids as appropriate
Catheterize significant retention and manage constipation
Stop deliriogenic medications
Frequent reorientation, sleep preservation, mobility and sensory aids
Escalate if deteriorating

Communication behaviours

Speak slowly and use one-step instructions
Explain fluctuation to family
Seek the patient's participation whenever possible and reassess capacity by decision

Critical safety actions

Do not label abrupt confusion as dementia
Treat hypoxia/sepsis promptly
Avoid physical restraint unless immediate safety requires it

Model closing summary

Mrs. Wu has an acute fluctuating disturbance of attention and awareness consistent with delirium, most likely driven by pneumonia with hypoxia and dehydration, compounded by anticholinergic medication, urinary retention and constipation. I would stabilize oxygenation, investigate and treat infection, stop offending drugs, relieve retention, correct hydration and provide non-pharmacologic delirium care with frequent reassessment.

Common pitfalls

Long cognitive testing during acute illness
Ordering broad tests without bedside causes
Using benzodiazepines routinely
Ignoring retention or medication effects

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

1. Chest pain in a 58-year-old 2. Acute dyspnea with wheeze 3. Palpitations followed by syncope 4. Upper gastrointestinal bleeding 5. Sudden focal weakness 6. Fever with hypotension 7. Acute right-lower-quadrant abdominal pain 8. Fever on postoperative day five 9. Severe leg pain after tibial fracture 10. Consent for lumbar puncture 11. First-trimester pain and bleeding 12. Postpartum low mood and unusual beliefs 13. Contraception counselling 14. Fever in an eight-week-old infant 15. Child with severe wheeze and respiratory distress 16. Two-year-old with language delay 17. Adolescent confidentiality and sexual health 18. Depression with suicidal thoughts 19. First-episode psychosis 20. Severely agitated patient 21. Older adult with acute confusion 22. Recurrent falls and dizziness 23. Driving safety in early dementia 24. Breaking a new colorectal cancer diagnosis 25. Disclosure of an insulin medication error 26. Refusal of blood transfusion 27. Cardiovascular examination in heart failure 28. Respiratory examination with pleural effusion 29. Focused neurologic examination for stroke 30. Painful swollen knee