A change from baseline can be the most useful detail in a call with no clear chief complaint.

The following case is fictional and created for educational discussion.

An 82-year-old woman is sitting at her kitchen table when an emergency medical services (EMS) crew arrives. Her daughter says she has been unusually quiet since breakfast. The patient says she is fine. She knows her name and where she is, denies pain, and would prefer that everyone stop worrying.

Then her daughter adds a detail: yesterday, her mother made breakfast, discussed the news, and walked to the mailbox. Today, she needed help getting out of her chair and has barely touched her food.

“She’s just not herself” sounded vague at dispatch. At the kitchen table, it becomes a description of a meaningful change.

Turn a general concern into a specific history

Baseline is individual. A useful history establishes how this person normally communicates and functions, what is different now, and when that difference began. Family members, caregivers, and facility staff can supply information the patient cannot. The review of the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) tool emphasizes baseline mental status and the time course of change in evaluating older adults with altered behavior.1

Questions that make that history concrete include:

  • What could they do yesterday that they cannot do today?
  • When were they last definitely acting like themselves?
  • Was the change sudden, gradual, or coming and going?
  • Who actually witnessed the change, and how can we reach them?

“Confused at baseline” is an incomplete description. A patient may usually need help remembering the date but still recognize family, follow conversation, and walk independently. Losing one of those abilities is information worth carrying forward.

The quiet patient deserves attention, too

Delirium does not always look like agitation. The National Institute for Health and Care Excellence (NICE) highlights the quieter pattern: withdrawal, slowed responses, reduced movement, difficulty concentrating, and reduced appetite. These changes can be missed because the patient is not disruptive.2

In our case, being able to answer two orientation questions does not explain the daughter’s observations. The conversation should continue: does the patient stay engaged, understand what is being asked, and respond as she normally would? Describing the actual behavior is more informative than documenting only “alert.”

Dementia also does not explain every new change. Delirium can occur on top of an existing cognitive disorder.1 Knowing a patient has dementia should sharpen the baseline questions, not end them.

More recent guidance reinforces the need for deliberate assessment. The Geriatric Emergency Department Guidelines 2.0 delirium recommendations, published online in October 2025 and in a February 2026 journal issue, address structured screening and assessment in older emergency department patients. Their recommendations are conditional and based on very low-certainty evidence.3 These are hospital-based recommendations, not a mandate to adopt a particular screening tool in the field. For EMS clinicians, the relevant discussion remains how to recognize and clearly describe an acute change while following local assessment protocols.

Keep the assessment broad

Potential contributors to acute behavioral change include oxygenation or glucose problems, infection, neurologic illness, medication effects, and metabolic disturbances. The ADEPT review stresses addressing immediate threats and considering a broad range of underlying causes.1

For an EMS discussion, the important question is how the history fits the findings gathered under local assessment protocols. What do breathing, circulation, glucose, neurologic findings, temperature when available, and serial vital signs add to the picture? Is there evidence of a fall or another event the original caller did not mention? What remains unexplained?

A list of possible causes is useful only if it keeps the team curious. It should not become a reason to postpone time-sensitive care or transport while trying to establish a definitive diagnosis in the home.

Do not let “probably a urinary tract infection (UTI)” close the case

A family member may report that a previous episode of confusion was attributed to a urinary tract infection. That history is worth documenting, but it does not establish the cause of today’s change.

The Infectious Diseases Society of America (IDSA) specifically recommends looking for other causes when an older patient with functional or cognitive impairment has bacteria in the urine (bacteriuria) and delirium without urinary symptoms or systemic signs of infection. Its recommendation concerns a defined clinical situation; it does not mean infection can be dismissed in an acutely ill patient.4 The practical lesson is to keep a familiar explanation from becoming an unsupported conclusion.

Make the medication history usable

Medication adverse effects are among the contributors discussed in the ADEPT review.1 A list is a starting point. Ask about recent additions, changed doses, missed doses, and nonprescription products. Record what is known and what could not be confirmed.

In the fictional case, imagine the daughter brings over a prescription bag and says, “One of these changed last week, but I don’t know which.” That uncertainty belongs in the handoff. It is more useful than a confident statement that the medications are unchanged.

Carry the change forward in the handoff

A concise handoff might begin: “She normally walks independently and holds a conversation. Her daughter last saw that baseline yesterday evening. Today she needs help standing and is responding more slowly.” Follow with the relevant assessment findings, trends, interventions, response, and remaining uncertainties.

The exact diagnosis may still be unknown. The value of the EMS assessment is that the receiving team now understands what changed, when it changed, and who can explain the patient’s usual function.

Discussion prompt: When a caller says someone is “not themselves,” what question helps your crew turn that concern into useful clinical information?

Keep building your assessment skills

Explore Self-Paced course options or plan your broader continuing education with DistanceCME’s Paramedic and Advanced Emergency Medical Technician (AEMT) refreshers and Emergency Medical Technician (EMT) and Emergency Medical Responder (EMR) refreshers.

References

  1. Shenvi C, et al. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Annals of Emergency Medicine. 2020;75:136–145. doi:10.1016/j.annemergmed.2019.07.023. Full text via the American College of Emergency Physicians (ACEP).
  2. NICE. Delirium: prevention, diagnosis and management in hospital and long-term care (CG103), recommendations. Updated January 18, 2023. Hospital and long-term-care guidance used here for recognition principles, not as an EMS treatment protocol.
  3. Lee S, et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. Academic Emergency Medicine. 2026;33(2):e70167. Published online October 27, 2025. doi:10.1111/acem.70167. Open-access full text. GRADE stands for Grading of Recommendations Assessment, Development, and Evaluation.
  4. Infectious Diseases Society of America. 2019 Clinical Practice Guideline Update for the Management of Asymptomatic Bacteriuria, section V.