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Chapter 8 • Confusion in Older Adults 101
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Box 8-2
Systemic Conditions Associated
with Confusional States
Endocrine
• Hypo/hyperthyroidism
Metabolic
• Anemia (severe)
• Hypo/hypercalcemia
• Hypo/hypercortisolism
• Hypo/hyperglycemia
• Hypomagnesemia
• Hypo/hypernatremia
• Wilson disease (copper disorder)
• Porphyria
Infectious
• AIDS
• Cerebral amebiasis
• Cerebral cysticercosis
• Cerebral toxoplasmosis
• Cerebral malaria
• Fungal meningitis
• Lyme disease
• Neurosyphilis
• TB meningitis
Cardiovascular
• Congestive heart failure
• Hyperviscosity
Cerebrovascular
• Cerebral insufficiency (TIA, CVA)
• Postanoxic encephalopathy
Pulmonary
• COPD
• Hypercapnia
• Hypoxemia
Renal
• Renal failure
• Uremia
Neurological
• Hepatic encephalopathy
• Hypertensive encephalopathy
• Limbic encephalitis
• Head trauma
Other
• Alcoholism
• Anemia (severe)
• Leukoencephalopathy
• Metastatic cancer to brain
• Sarcoidosis
• Sleep apnea
• Vasculitis (e.g., SLE)
• Vitamin deficiencies (B12, folate, niacin, thiamine)
• Whipple disease
which compounds the problem. Further, older adults
may need lower doses or a gradual increase in dosages
of medications used to treat both acute and chronic
conditions.
What risk factors do I need to consider?
Key Questions
n How old is the patient?
n How many medications is the patient taking?
n Is the patient HIV positive?
n Has the patient experienced recent life losses?
Age
Older adults are at risk for the development of confusion, delirium, dementia, and depression. Factors that
place them at risk include the use of multiple medications, the existence of multiple medical conditions,
and the physiological changes associated with aging.
Dementia occurs in approximately 5% to 10% of
adults 65 to 80 years of age, 20% of those older than
80 years, and almost half of those older than 85 years.
Polypharmacy
Older adults who are taking multiple medications are
at risk for medication interactions and resulting confusion (see also the preceding list of medications that can
produce altered mental status).
Human Immunodeficiency Virus
Patients with HIV infection or those who are immunocompromised are at increased risk for the development
of HIV encephalopathy (AIDS dementia complex)
or dementia caused by central nervous system (CNS)
opportunistic infections.
Recent Bereavement
Recent loss and the lack of a social network place an
individual at risk for depression. Both cause profound
biopsychosocial stress that can easily exceed the person’s resources and skills. Extreme mourning or isolation can be physically and emotionally draining.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Take Vital Signs
The presence of a fever can indicate infection or alcohol withdrawal. A diastolic blood pressure greater than
120 mm Hg suggests hypertensive encephalopathy,
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whereas a systolic blood pressure less than 90 mm Hg
can indicate impaired cerebral perfusion.
Note Level of Consciousness
In both dementia and depression, the individual is
likely to be alert and aware, although the mood can be
depressed. With delirium, the patient will have a decreased level of consciousness, be less alert and aware,
and can be difcult to arouse. With an acute confusional state, the patient will demonstrate impaired
concentration and have difculty thinking.
Perform a Mental Status Examination
A thorough mental status examination is essential.
Mental status assessment is used to determine cognitive function. A number of assessment instruments are
available, including the Mini Mental State Examination (MMSE) (see Figure 8-1 for sample items from
the MMSE). Patients with delirium may be unable to
cooperate or answer questions. Patients with dementia
are cooperative and willing to try but make mistakes
and give incorrect or “near miss” answers. Patients
with depression are less cooperative and are more
likely to give “don’t know” answers, refuse to answer
questions, or be less willing to try.
Global cognitive loss is consistent with delirium.
Losses occur in the following areas: memory, thinking,
perception, information acquisition, information retention, information processing, information retrieval, and
information use. Thus the MMSE score will be very
low with inability to perform most or all of the items.
Dementia, particularly early in the disorder, presents with selective cognitive losses that can occur
in one or more of the following areas. Specic losses
include the following:
n Apraxia (i.e., cannot draw simple geometric gures)
n Visuospatial problems (e.g., cannot draw intersecting
pentagons)
n Cannot perform commands
n Selective cognitive loss
n Loss of abstract reasoning
n Problems with orientation
n Problems with recent memory
n Problems with number retention
Fewer cognitive losses occur with depression than
with dementia. Loss of concentration is an important
symptom of depression. The individual is aware of
losses and can highlight disabilities, especially memory
loss. Along with loss of memory, impaired concentration and errors in judgment are common.
Orientation to Time
“What is the date?”
Registration
“Listen carefully, I am going to say three words. You say them back after I stop.
Ready? Here they are. . .
HOUSE (pause), CAR (pause), LAKE (pause). Now repeat those words back to
me.”
[Repeat up to 5 times, but score only the first trial.]
Naming
“What is this?” [Point to a pencil or pen.]
Reading
“Please read this and do what it says.” [Show examinee the words on the stimulus form.]
CLOSE YOUR EYES
FIGURE 8-1 Sample items from the MMSE. For a full copy of the MMSE, administration instructions,
and scoring guidelines, contact Psychological Assessment Resources. (Reproduced special permission
of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, FL
33549, from the Mini Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright
1975, 1988, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources,
Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased
from PAR, Inc., by calling (800) 331-8378 or (813) 449-4065.)
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In older persons, also administer the Geriatric
Depression Scale (Figure 8-2). The test is positive for
depression if the score is above 5.
The Confusion Assessment Method (CAM) can be
used to assess delirium. The CAM instrument assesses
the presence, severity, and uctuation of nine delirium
features: acute onset, inattention, disorganized thinking, altered level of consciousness, disorientation,
memory impairment, perceptual disturbances, psychomotor agitation or retardation, and altered sleep–wake
cycle. The CAM diagnostic algorithm is based on
Geriatric Depression Scale (short form)
Choose the best answer for how you felt over the past week.
1. Are you basically satisfied with your life? yes/no
2. Have you dropped many of your activities and interests? yes/no
3. Do you feel that your life is empty? yes/no
4. Do you often get bored? yes/no
5. Are you in good spirits most of the time? yes/no
four cardinal features of delirium: (1) acute onset and
uctuating course, (2) inattention, (3) disorganized
thinking, and (4) altered level of consciousness. Permission to use the CAM and the training manual for it
can be obtained through ElderLife@hrca.harvard.edu.
Perform a Complete Neurological
Examination
Normal neurological ndings are typical of early dementia and depression. Abnormal ndings suggest
other organic involvement.
6. Are you afraid that something bad is going to happen to you? yes/no
7. Do you feel happy most of the time? yes/no
8. Do you often feel helpless? yes/no
9. Do you prefer to stay at home, rather than going out and doing new things? yes/no
10. Do you feel you have more problems with memory than most? yes/no
11. Do you think it is wonderful to be alive now? yes/no
12. Do you feel pretty worthless the way you are now? yes/no
13. Do you feel full of energy? yes/no
14. Do you feel that your situation is hopeless? yes/no
15. Do you think that most people are better off than you are? yes/no
This is the scoring for the scale. One point for each of these answers. Cut-off: normal
(0-5), above 5 suggests depression.
1. no 6. yes 11. no
2. yes 7. no 12. yes
3. yes 8. yes 13. no
4. yes 9. yes 14. yes
5. no 10. yes 15. yes
FIGURE 8-2 Geriatric Depression Scale (short form). (From Sheikh JI, Yesavage JA: Geriatric Depression
Scale: recent evidence and development of a shorter version, Clin Gerontol 5:165, 1986.)
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Cranial Nerves
Check vision, hearing, and sensory impairment as contributing factors in confusion. Dilated pupils suggest
alcohol withdrawal; pinpoint pupils can indicate narcotic excess or use of eye drops. Changes in pupil size
can also indicate neurological changes, such as those
that occur with stroke or neoplasm. The sense of smell
is often impaired in dementia. Patients with parkinsonism can exhibit a typical facial presentation: masked
facial expression, poor blink reex, and drooling.
Speech is slowed, slurred, and monotonous.
Proprioception and Cerebellar Function
Test coordination through rapid alternating movements
(RAMs), accuracy of movement, balance (Romberg
test), and gait. Slowed RAMs are characteristic of
early HIV encephalopathy. Tremor and restlessness are
associated with alcohol intoxication or withdrawal.
Tremor (especially resting), rigidity, and bradykinesia
indicate parkinsonism. Asterixis, sometimes referred to
as liver ap or liver tremor, is an involuntary tremor of
the hands, tongue, and feet that is characteristic of
hepatic or metabolic encephalopathy. Postural tremor
is present with HIV encephalopathy. Writhing movements (chorea) typify Huntington disease.
Gait abnormalities are found with multi-infarct
dementia, normal pressure hydrocephalus, and HIV
encephalopathy.
and impaired handwriting are consistent with early HIV
encephalopathy.
Language
Aphasia (language disturbance) is often present in
dementia and can occur with CVA and head injury.
Localizing and Lateralizing Signs in CNS
Focal neurological signs (i.e., exaggerated DTRs, positive Babinski sign, gait abnormalities, and hemiparesis) are consistent with multi-infarct dementia. Focal
decits also occur with cerebrovascular injury.
Patients with late HIV encephalopathy demonstrate
weakness that is greater in the legs than in the arms;
ataxia; spasticity and hyperreexia; positive Babinski
sign; myoclonus; and bladder and bowel incontinence.
Psychomotor agitation or retardation is consistent
with depression. An agitated confusional state without
focal signs can occur with head trauma.
Perform a Respiratory Examination
Monitor the rate and effort of respirations. Auscultate
the lung elds. Tachypnea suggests hypoxia. Bibasilar
crackles indicate congestive heart failure (CHF) with
hypoxia. Asymmetrical crackles suggest pneumonia
with hypoxia. Patients with dementia or depression
in the absence of concomitant lung disease will have
normal ndings.
Sensation (Primary and Cortical)
Agnosia (failure to identify or recognize objects despite intact sensory function) is present with dementia.
Deep Tendon Reflexes
Test deep tendon reexes (DTRs) and the supercial
plantar reexes. Hyperreexia and primitive reexes
are present in late dementia. Hyperreexia is also present in multi-infarct dementia, HIV encephalopathy,
and costovertebral angle (CVA).
A positive Babinski sign on testing the plantar reex
is present in multi-infarct dementia, CVA, and head
injury. Cogwheeling (resistance to a passively stretched
hypertonic muscle resulting in a rhythmical jerk similar to a ratchet) suggests parkinsonism.
Motor Tone and Function
Apraxia (impaired ability to carry out motor activities
despite intact motor function) indicates dementia. Motor
weakness, especially of the legs, loss of coordination,
Evaluate the Cardiovascular System
Perform a careful cardiovascular examination. Tachycardia suggests sepsis, hyperthyroidism, hypoglycemia,
agitation, anxiety, or alcohol withdrawal. Be alert for
indicators of cardiovascular problems that can produce
hypoxia, such as CHF or myocardial infarction (MI).
Examine the Abdomen
Examine the abdomen and percuss for CVA tenderness. Specic ndings can indicate a local or systemic
cause for the confusion. For example, urinary retention
suggests urinary tract infection, CVA tenderness points
to pyelonephritis, and an enlarged liver can indicate
hepatic encephalopathy.
LABORATORY AND DIAGNOSTIC
STUDIES
Diagnostic testing is aimed at detecting or conrming
a metabolic/organic cause of the confusion. If dementia seems likely, these same tests can rule in or rule out
Chapter 8 • Confusion in Older Adults 105
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reversible or modiable causes of the dementia. Most
tests will be normal when the diagnosis is depression.
Complete Blood Count
Leukocytosis suggests infection. Anemia as a cause of
confusion in chronic illness can also be detected.
Blood Chemistry
High or low potassium or sodium levels, dehydration,
and acidosis can all produce confusion. Elevated or
depressed magnesium and calcium levels, hypoglyce-
mia, and hyperglycemia can also cause confusion.
Elevated blood urea nitrogen (BUN) and creatinine
levels or an elevated BUN/creatinine ratio can indicate
renal failure. Elevation in liver enzymes suggests liver
dysfunction.
Thyroid Function Tests
Abnormal levels of thyroid-stimulating hormone
(TSH) can indicate thyroid dysfunction, either thyroid
toxicosis or a hypothyroid state. An elevated TSH level
is related to chronic symptoms of depression.
Serum B12 and Folate
Deciencies of vitamin B12 and folate are reversible
causes of dementia.
Serology for Syphilis
A positive test can indicate neurosyphilis as the cause
of confusion.
Arterial Blood Gases
Arterial blood gases (ABGs) are used to determine the
presence or degree of hypoxia.
Toxicology Screen and Blood
Alcohol Level
These tests can be used to determine alcohol or drug
intoxication as a cause of confusion.
Urinalysis
Urinalysis is used to detect infection and can point to
renal indicators of systemic disease. See Chapter 32 for
a complete discussion of urinalysis.
Chest Radiograph
A chest radiograph is used to detect infection, CHF,
COPD, pneumonia, or other respiratory-associated
causes of hypoxia.
Lumbar Puncture
Lumbar puncture is used to rule out bacterial, fungal,
or tumor meningitis (see Chapter 18).
Electrocardiography
Electrocardiography (ECG) is used to rule out certain cardiovascular causes of hypoxia, such as MI or
dysrhythmias.
Electroencephalography
Electroencephalography (EEG) can be used to identify
a seizure disorder as a cause of or a contributing factor
to confusion.
Computed Tomography or Magnetic
Resonance Imaging
Computed tomography (CT) or magnetic resonance
imaging (MRI) is used to diagnose cerebrovascular
bleeding, injury, abscess, or tumor or whether focal
neurological signs are present. These imaging tests
usually do not yield useful information related to the
diagnosis of dementia.
Positron Emission Tomography Scan
Positron emission tomography (PET) is useful in
conrming the diagnosis of Alzheimer disease. PET
images demonstrate the metabolic activity of organs
and other tissues. A radiopharmaceutical, which includes both sugar (glucose) and a radionuclide (a radioactive element) that releases signals, is injected into the
patient and its emissions are measured by a PET scanner. Using the gamma ray signals discharged by the
injected radionuclide, PET measures the amount of
metabolic activity at a site in the body and a computer
reassembles the signals into images. PET highlights
areas with increased, diminished, or no metabolic activity, thereby pinpointing problems. A distinctive image
appears in the area of the brain affected by Alzheimer
disease. It can be seen in early disease. PET also is useful in differentiating Alzheimer disease from other
forms of dementia, such as vascular dementia, and from
other memory disorders, such as clinical depression.
DIFFERENTIAL DIAGNOSIS
Delirium
The incidence of delirium increases progressively after
the fourth decade of life. Because delirium is associated with an increased risk of death, it should always
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be considered rst in patients who exhibit cognitive
impairment or behavioral changes.
Delirium is characterized by reduced ability to
maintain attention to external stimuli, disorganized
thinking, decreased level of consciousness (LOC),
common. Physical examination ndings depend on the
underlying cause of the delirium. The patient often
exhibits asterixis or tremor. Speech is incoherent, hesitant, slow, or rapid. Table 8-1 shows the distinguishing
characteristics of delirium.
perceptual disturbances, disturbed sleep/wake cycle,
disorientation, and memory impairment. The patient
will evidence a decreased LOC and impaired arousal,
increased or decreased psychomotor activity, and irritability. The onset is rapid, and the condition can last
from hours to weeks. Fluctuations over the course of
the day are common, with lucid intervals during the
day and worse symptoms at night. The thought process
is disorganized, and the patient is usually disoriented,
most commonly to time. There is a tendency for
the patient to mistake the unfamiliar for familiar
places and people. Hallucinations, usually visual, are
Table 8-1
CHARACTERISTIC DELIRIUM DEMENTIA DEPRESSION
Onset Sudden Insidious, relentless Sudden or insidious
Duration Hours, days Persistent For longer than 2 weeks
Time of day Increases and decreases
Consciousness Altered Not impaired except in severe
Cognition Impairment of memory,
Activity Increased or decreased, can
Speech/language Rambling and irrelevant
Mood and affect Rapid mood swings; fearful,
Delusions/
hallucinations
Distinguishing Characteristics of Delirium, Dementia, and Depression
during the day
attentiveness, consciousness,
numerous errors in
assessment tasks
fluctuate
conversation, illogical flow of
ideas, incoherent
suspicious
Misperceptions, illusions,
hallucinations, and
delusions
Confusion
Confusion is less abrupt and less severe than delirium,
with less severe disorientation and more subtle motor
signs. The diurnal variation is less severe than in
delirium. The person can be apathetic and drowsy and
will show disorientation—especially for time, less for
place, and almost never for self. Concentration is
impaired, and the person lacks direction and selectivity
and is easily distracted. Errors in thinking are common.
The person may exhibit tremor and difculty in motor
relaxation.
Stable, no change Throughout the greater part
of the day
Not impaired
cases
Minimal cognitive impairment
initially, progresses to
impaired abstract thinking,
judgment, memory, thought
patterns, calculations,
agnosia
Unchanged from usual
behavior
Disordered, rambling,
incoherent; struggles to find
words
Depressed, apathetic,
uninterested
Misperceptions usually absent,
delusions, no hallucinations
Impaired concentration,
reduced attention span,
indecisiveness, slower
thought processes,
impaired short-term and
long-term memory
Insomnia or excessive
sleeping, fatigue,
restlessness, anxiety,
increased or decreased
appetite
Slower speech
Sad, hopeless, feels
worthless, loss of interest
or pleasure
No delusions or
hallucinations
Pathophysiology Associated with infections,
medications, electrolyte and
metabolic disorders, major
organ failure, brain insults, and
acute alcohol withdrawal
Usually related to structural
diseases of the brain
Associated with grief, a
stressful life event, reaction
to medical or neurologic
diseases, or a change in
lifestyle
Chapter 8 • Confusion in Older Adults 107
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Dementia
Dementia is characterized by acquired persistent and
progressive impairment of intellectual function, with
compromise in at least two of the following areas:
n Language (aphasia)
n Memory
n Visuospatial skills (apraxia, agnosia)
n Emotional behavior or personality
n Cognition (e.g., calculation, abstraction, judgment)
Refer to Table 8-1 for the distinguishing character-
istics of dementia.
The onset of symptoms is insidious, with the course
stable through the day and night. The condition can be
present for months or years, with progressive deterioration. Recent and remote memory is impaired. The patient
is alert and attention is relatively unaffected, although
orientation is usually impaired. Hallucinations are
usually absent until late in the course of the disease.
Speech is usually unimpaired although the person has
difculty nding words. Sleep is often fragmented. On
mental status examination, the patient tries hard and provides “near miss” answers. Physical ndings are often
absent. The olfactory sense can be impaired. Box 8-3
lists common presentations of dementia, Box 8-4 lists
phases of Alzheimer-type dementia, and Box 8-5
describes a staging system for Alzheimer disease.
Alzheimer-type dementia can sometimes be distinguished from vascular or multi-infarct dementia (MID)
by obtaining a cardiovascular history, determining the
progression of symptoms, and detecting the presence
or absence of focal neurological signs and symptoms
(Table 8-2).
Depression
Depression can produce confusion, especially in the
elderly. The onset of the confusion is often abrupt,
with some diurnal variation. Generally, depression
is more consistent over time than delirium. The confusion is of short duration compared with dementia.
A past history of psychiatric problems, including
undiagnosed depressive episodes, is common. During mental status examination, the patient tends to
highlight disabilities, especially memory loss. The
memory loss is equal for recent and remote events.
The cognitive losses, however, are uctuating rather
than stable over time. The patient manifests a depressed or anxious mood, including sleep and appetite disturbance. Hallucinations are usually absent,
Box 8-3
Common Presentations
of Dementia
Memory loss Language difficulty
Depression Social withdrawal
Irritability Behavioral change
Poor hygiene Urinary incontinence
Insomnia Hallucinations (late)
Paranoia Anxiety
Weight loss Failure to thrive
Poor work performance Falls, clumsiness
Financial errors
Poor judgment
Delirium
Box 8-4
Phases of Alzheimer-Type
Deteriorating interpersonal
relationships
Personality changes
Dementia
Progression of symptoms corresponds with the progression of underlying nerve cell degeneration. Damage typically begins with cells involved in learning and memory
and gradually spreads to cells that control thinking, judgment, and behavior. The damage eventually affects cells
that control and coordinate movement.
Limbic
• 2 to 3 years after onset
• Olfactory system involved
• Memory loss
• Can perform tasks
Parietal
• 3 to 6 years after onset
• Loss of comprehension of spoken language
• Cannot name common objects
• Apraxia: cannot perform motor skills although motor
system intact
• Agnosia: failure to identify or recognize objects
despite intact sensory function
• Misinterprets visual and auditory stimuli
• Delusions
Late Frontal
• 6 to 8 years after onset
• Motor disturbances: walking, swallowing, moving
• Primitive reflexes
• Seizures
• Sensation remains intact
although the patient may have suicidal thoughts.
Depression as a cause of confusion can be easy to
miss because it is often associated with anger, anxiety, and unclear thinking as well as denial (see
Chapter 3). Table 8-1 presents distinguishing characteristics of depression.
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Box 8-5
Staging systems for Alzheimer’s disease vary. The Alzheimer’s
Association uses seven stages to describe the progression of
Alzheimer’s disease.
Stage 1: No impairment (normal function)
Stage 2: Very mild cognitive decline (may be age-related
changes or earliest signs of Alzheimer’s disease)
• Memory lapses, especially in forgetting familiar words
• Symptoms not evident during a medical examination
Stage 3: Mild cognitive decline
• Problems with memory or concentration; may be
• Friends, family, or co-workers begin to notice
• Common difficulties include:
Stage 4: Moderate cognitive decline (Mild or early-stage
Alzheimer’s disease)
• The affected individual may seem subdued and
• Clear-cut deficiencies in the following areas:
Stage 5: Moderately severe cognitive decline (Moderate or
mid-stage Alzheimer’s disease)
• Major gaps in memory and deficits in cognitive
• Individuals may:
Stages of Alzheimer’s Disease
or names or the location of everyday objects.
or apparent to friends, family, or co-workers.
measurable in clinical testing or apparent during a
detailed medical interview.
deficiencies.
1. Word- or name-finding problems noticeable to
family or close associates
2. Decreased ability to remember names when
introduced to new people
3. Performance issues in social or work settings
4. Reading a passage and retaining little material
5. Losing or misplacing a valuable object
6. Decline in ability to plan or organize
withdrawn, especially in socially or mentally
challenging situations.
1. Decreased knowledge of recent occasions or
current events
2. Impaired ability to perform challenging mental
arithmetic (e.g., counting backward from
100 by 7s)
3. Decreased capacity to perform complex tasks,
such as marketing, planning dinner for guests, or
paying bills and managing finances
4. Reduced memory of personal history
function emerge. Some assistance with day-to-day
activities becomes essential.
1. Be unable during a medical interview to recall
such important details as their current address,
their telephone number, or the name of the college
or high school from which they graduated
2. Become confused about where they are or about
the date, day of the week, or season
3. Have trouble with less challenging mental arithmetic (e.g., counting backward from 40 by 4s or from
20 by 2s)
4. Need help choosing proper clothing for the season
or the occasion
5. Usually retain substantial knowledge about themselves and know their own name and the names of
their spouse or children
6. Usually require no assistance with eating or using
the toilet
Stage 6: Severe cognitive decline (Moderately severe or
mid-stage Alzheimer’s disease)
• Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals
need extensive help with customary daily activities.
• Individuals may:
1. Lose most awareness of recent experiences and
events as well as of their surroundings
2. Recollect their personal history imperfectly,
although generally able to recall their own name
3. Occasionally forget the name of their spouse or
primary caregiver but generally can distinguish
familiar from unfamiliar faces
4. Need help getting dressed properly; without super-
vision, may make such errors as putting pajamas
over daytime clothes or shoes on wrong feet
5. Experience disruption of their normal sleep/wake
cycle
6. Need help with handling details of toileting (flushing
toilet, wiping, and disposing of tissue properly)
7. Have increasing episodes of urinary or fecal
incontinence
8. Experience significant personality changes and
behavioral symptoms, including suspiciousness
and delusions, hallucinations, or compulsive,
repetitive behaviors
9. Tend to wander and become lost
Stage 7: Very severe cognitive decline (Severe or late-stage
Alzheimer’s disease)
• This is the final stage of the disease when individuals
lose the ability to respond to their environment, the
ability to speak, and, ultimately, the ability to control
movement.
1. Lose capacity for recognizable speech, although
words or phrases may occasionally be uttered
2. Need help with eating and toileting and there is
general incontinence of urine
3. Lose the ability to walk without assistance, and
then the ability to sit without support, the ability to
smile, and the ability to hold their head up
4. Reflexes become abnormal and muscles grow
rigid; swallowing is impaired
From Reisberg B, Ferris SH, de Leon MJ, Crook T: The global deterioration scale for assessment of primary degenerative dementia, Am J Psychiatry
139:1136, 1982. Copyright © 1983 by Barry Reisberg, MD. Reproduced with permission.
Chapter 8 • Confusion in Older Adults 109
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Table 8-2
Multi-Infarct Versus Alzheimer-Type Dementia
FACTORS SUGGESTING DEMENTIA HACHINSKI ISCHEMIA POINT SCORE*
Abrupt onset 2
Stepwise deterioration 1
Fluctuating course 2
Emotional lability 1
Relative preservation of personality 1
Depression 1
Somatic complaints 1
History of hypertension 1
History of strokes 2
Evidence of associated arteriosclerosis 1
Focal neurological symptoms
Focal neurological signs
*A score of 4 or more is indicative of Alzheimer-type dementia. A score of 7 or more is indicative of multiinfarct dementia.
†
Focal neurological signs/symptoms: exaggerated DTRs, positive Babinski sign, gait abnormalities, hemiparesis.
From Siu AL: Screening for dementia and investigating its causes, Ann Intern Med 115:122, 1991.
†
2
2
DIFFERENTIAL DIAGNOSIS OF Common Causes of Delirium, Confusion, Dementia,
and Depression
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Delirium Onset abrupt; fluctuations over
course of day common with
lucid intervals during day and
worst symptoms at night; lasts
hours to weeks; unable to
maintain attention to external
stimuli; disorganized thinking, perceptual disturbances,
disturbed sleep/wake cycle;
hallucinations, usually visual,
common
Confusion Less abrupt, less severe than
delirium; diurnal variation
less severe than delirium;
concentration impaired, easily
distracted; errors in thinking
common
Decreased LOC, impaired arousal,
decreased psychomotor activity;
disoriented, most commonly to time;
physical examination findings depend
on underlying cause of delirium; patient
often exhibits asterixis, tremor, and
difficulty in motor relaxation; speech
incoherent, hesitant, slow, or rapid
Apathetic, drowsy; disoriented especially
for time, but less for place, almost never
for self; less severe disorientation, more
subtle motor signs than in delirium
CBC, electrolytes, glucose,
BUN, creatinine, LFTs,
TFTs, serum B12, folate,
serology for syphilis,
ABGs, toxicology screen,
blood alcohol level, U/A,
ECG, EEG, chest radiograph, lumbar puncture,
CT or MRI (when CVA or
injury suspected)
CBC, electrolytes, glucose,
BUN, creatinine, LFTs,
TFTs, serum B12, folate,
serology for syphilis,
ABGs, toxicology screen,
blood alcohol level, U/A,
ECG, EEG, chest radiograph, lumbar puncture,
CT or MRI (when CVA or
injury is suspected)
Continued
110 Chapter 8 • Confusion in Older Adults
https://t.me/med1917
DIFFERENTIAL DIAGNOSIS OF Common Causes of Delirium, Confusion, Dementia,
and Depression—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Dementia Onset insidious, course stable
through day and night; present
for months or years, with progressive deterioration; recent
and remote memory impaired;
hallucinations usually absent
until late in course of disease;
sleep often fragmented
Depression Onset of confusion often abrupt,
with some diurnal variation,
generally more consistent over
time than delirium; confusion of
short duration compared to dementia; past history of psychiatric
problems common, including undiagnosed depressive episodes;
cognitive losses fluctuating rather
than stable over time; sleep/
appetite disturbance; hallucinations usually absent although person can have suicidal thoughts
ABGs, arterial blood gases; BUN, blood urea nitrogen; CBC, complete blood count; CT, computed tomography; CVA, costovertebral angle; DTRs,
deep tendon reflexes; ECG, electrocardiography; EEG, electroencephalography; LFTs, liver function tests; LOC, level of consciousness; MRI,
magnetic resonance imaging; PET, positron emission tomography; TFTs, thyroid function tests; U/A, urinalysis.
Alert, attentive; orientation usually impaired;
on mental status examination, patient
tries hard, provides “near miss” answers;
demonstrates one or more of following
cognitive disturbances: aphasia (language
disturbance); apraxia (impaired ability to
carry out motor activities despite intact
motor function); agnosia (failure to identify
or recognize objects despite intact sensory
function); disturbance in executive functioning (planning, organizing, sequencing,
abstracting); physical findings often absent
in Alzheimer type; olfactory sense can
be impaired; speech usually unimpaired
although difficulty with finding words;
findings in multi-infarct dementia include
focal neurological signs/symptoms: exaggerated DTRs, positive Babinski sign, gait
abnormalities, hemiparesis
Depressed or anxious mood; tends to
highlight disabilities, especially memory
loss; memory loss equal for recent and
remote events; physical examination
often normal
CBC, electrolytes, glucose,
BUN, creatinine, LFTs,
TFTs, serum B12, folate,
serology for syphilis,
ABGs, toxicology screen,
blood alcohol level, U/A,
ECG, EEG, chest radiograph, lumbar puncture,
CT or MRI (when CVA or
injury suspected; does not
yield useful information for
dementia); PET scan
Geriatric Depression
Scale in elderly; CBC,
electrolytes, glucose,
BUN, creatinine, LFTs,
TFTs, serum B12, folate,
serology for syphilis,
ABGs, toxicology screen,
blood alcohol level, U/A,
ECG, EEG, chest radiograph, lumbar puncture,
CT or MRI (when CVA or
injury suspected)
REFERENCES AND READINGS
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Alistair Burns A, Iliffe S: Dementia, BMJ 338:405, 2009.
American Psychiatric Association: Diagnostic and statistical manual
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DC, 2000, American Psychiatric Association.
Bostwick JM: The many faces of confusion: timing and collateral
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Espino DV, Jules-Bradley AC, Johnston CL, Mouton CP: Diagnos-
tic approach to the confused elderly patient, Am Fam Physician
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Galvin JE, Roe CM, Powlishta KK, Coats MA, Muich SJ, Grant E
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Sendelbach S, Guthrie PF: Evidence-based practice guideline: acute
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