In a confused older patient, ask the date of the fall you have not been told about

Chronic subdural haematoma presents as anything: a few weeks of being slower, a new headache, unsteadiness, a fluctuating confusion that the family attributes to ageing or to the dementia the patient already has. The classical history of head injury is absent in a large proportion of cases, and where it exists nobody thinks to mention it, because the fall was minor and happened two months ago.

So ask for it specifically, and ask the relative rather than the patient: has there been any fall, any knock to the head, any trip in the last three months, however minor. Then check the drug chart for anticoagulants and antiplatelets, and ask about alcohol. Those three questions together change the pretest probability enough to justify imaging in a patient whose presentation would otherwise be filed as progression of their dementia.

The cost of missing it is specific: this is a treatable cause of decline in exactly the population in which decline is assumed to be untreatable.

• Ask the accompanying relative about falls in the last three months, not the patient
• Ask about minor knocks explicitly — patients do not report what did not hurt
• Check the chart for anticoagulants and antiplatelets before concluding anything
• Take fluctuating confusion in a known dementia as a reason to image, not as expected progression
• Record the interval from injury; it changes what the scan is expected to show

Why it matters

It is a treatable diagnosis hiding inside a population whose decline is routinely assumed to be irreversible.

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