Delirium, often presenting as acute confusion, is a highly prevalent, preventable, life-threatening clinical syndrome in acutely ill older adults. It is characterized by an acute change in cognition and attention, with disturbances in consciousness, orientation, memory, thought, perception and/or behavior. In contrast to dementia, which is a chronic confusional state, delirium typically develops over a short period of time (hours to days), fluctuates over the course of the day (often worsening at night) with varying inability to concentrate, maintain attention, and sustain purposeful behavior. Anxiety, irritability, and psychomotor restlessness with insomnia are common. These patients may pick at their intravenous lines, take off their oxygen, disconnect monitoring equipment, exhibit poor safety awareness, and/or talk to people who are not present. Other perceptual disturbances (often visual hallucinations) are also commonly accompanied by paranoid delusional thinking exacerbating the patient’s behavioral and emotional manifestations. Agitated behaviors commonly associated with delirium often lead to use of physical and chemical restraints, further compounding the risk of functional loss and serious complications.
Family and caregivers may report the patient was “fine” during the day, but became confused, restless, and agitated during the middle of the night. The change, however, may be even more subtle: “She isn’t acting quite right.” When family and caregivers can pinpoint such a subtle change over the course of a day or week, that should be taken seriously, and delirium should be ruled out. Delirium is considered a medical emergency and should always be ruled out prior to assuming the patient only has dementia or another psychiatric disorder.
Unlike delirium, dementia is more chronic in nature and develops insidiously over months to years. Specifically, dementia is a clinical syndrome characterized by a cluster of signs and symptoms including difficulties in memory, disturbances in language, psychological and psychiatric changes, and impairments in activities of daily living. Although there are many different types of dementia (see Chapter 22, “Cognitive Impairment & Dementia”), Alzheimer disease is the most common cause, occurring in an estimated 50% to 80% of all cases.
Such a dementia typically first appears as forgetfulness of recent events or conversations. Family and loved ones may report that over the past several months or year the patient has been increasingly getting lost in familiar areas; misplacing items; having language difficulties (eg, finding the name of familiar objects); having problems performing tasks that require some thought, but that used to come easily (eg, balancing a checkbook, playing card games, learning new information or routines); and/or experiencing personality changes or a loss of social skills leading to inappropriate behaviors. As the dementia slowly progresses, these symptoms become much more apparent and severe, and interfere with the patient’s ability to care for him-/herself. Patients may also begin to exhibit psychosis, mood and behavioral difficulties (eg, paranoid delusions, hallucinations, depression, physical and/or verbal aggression; social withdrawal), or sleep disturbances (eg, often waking at night), with increasingly poor insight and judgment. Many of these behaviors often present significant caregiving challenges and burden, frequently resulting in institutionalization. In the severe stages, patients are unable to perform basic activities of daily living, recognize family members, understand language, speak, or ambulate independently.
It is important to note that confusion or a decline in cognitive functioning that is abnormal for age and education but does not meet criteria for dementia should not be attributed to normal aging. Mild cognitive impairment (MCI) is the intermediate-stage neurocognitive disorder between normal cognitive aging and dementia. MCI is associated with an increased lifetime risk for developing dementia. A person with MCI will have problems with memory, language, or another mental function severe enough to be noticeable to others and show up on testing, but not serious enough to interfere with daily life. Understanding the degree of functional incapacitation is a key component to determining whether the person has MCI or early dementia.
Depression is the most common psychiatric disorder in the older adult population, primarily affecting those with chronic medical illnesses, cognitive impairment, and disability. It is clinically defined as a syndrome of either depressed mood or loss of interest or pleasure in most activities of the day and these symptoms must represent a change from the person’s usual functioning and be present for at least 2 weeks. Personality changes (eg, social withdrawal, apathy, irritability), forgetfulness, and mood changes (eg, complaints of decreased ability to think, feelings of hopelessness/helplessness, changes in sleep or appetite, psychomotor slowing/agitation) may be signs of depression, dementia, or both. Patients with depression may recognize their feelings of sadness, experience somatic complaints or simply exhibit decreased engagement in activities of daily living. The mnemonic “SIGECAPS” (Table 52–1) can help you remember the 8 major diagnostic symptoms of depression.
Table 52–1.The 8 major diagnostic neurovegetative symptoms of depression (SIGECAPS). ||Download (.pdf) Table 52–1. The 8 major diagnostic neurovegetative symptoms of depression (SIGECAPS).
|Sleep disturbance* (increased during day or decreased at night) |
|Interest reduced (loss of interest in previously enjoyable activities) |
|Guilt (worthlessness*, hopelessness*, regret, self-blame) |
|Energy loss or fatigue* |
|Concentration impairment* |
|Appetite change* (usually decreased; occasionally increased) |
|Psychomotor change (retardation/lethargy or agitation/anxiety) |
|Suicidal thoughts/preoccupation with death |
Unlike dementia, confusion in a patient with depression is more specific than global. For example, the patient may have difficulties with certain activities, like paying bills, but remains capable of completing equally difficult tasks, such as doing a crossword puzzle. Similarly, the patient may not initiate or engage in conversation, but retains the ability to speak. A person with depression is also more likely to relate many themes of loss, as well as detail their cognitive complaints, whereas someone with dementia may be unaware of their cognitive difficulties and/or try to mask their deficits.