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Chapter 9 • Confusion in Older Adults
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What does the pattern of cognitive losses tell me?
Key Questions
l
What specic problems with mental abilities or
thinking have you noticed?
l
What behavioral changes or personality changes
have you noticed?
Changes in Mental Abilities and Behaviors
Patients with delirium have global cognitive losses
that involve memory, thinking, perception, and judgment. These patients can become disoriented, irritable,
and fearful. They can be difcult to arouse or conversely have insomnia. Families sometimes note
visual hallucinations.
Patients in an acute confusional state can be
disoriented—especially for time, less for place, and
almost never for self. They show impaired concentration, experience sensory misperceptions, and make
errors in thinking.
Early dementia presents with more selective cognitive losses. Family members report that patients cannot
remember recent events, are disoriented, irritable or
depressed, have poor hygiene, show poor judgment,
make nancial errors, are socially withdrawn, have difculty nding or saying the right words, are clumsy or
fall, have urinary incontinence, have deteriorating interpersonal relationships, and show personality changes.
Fewer cognitive losses occur with depression. These
people can exhibit cognitive losses consistent with
confusion—apathy and drowsiness, impaired concentration, and errors in thinking. The most common cognitive symptoms are severe negative thinking, guilt,
and remorse.
Is the confusion caused by a concurrent health problem?
Key Questions
l
Does the patient have any chronic health conditions?
l
Has the patient been hospitalized recently, and if so,
for what reason?
l
Has the patient been acutely ill recently?
l
Is there a history of mental illness or similar thought
disturbance?
Current and Past Health Status
Obtain past medical records for a complete health history. Most likely, you will have to use a relative or
close friend to determine current and past health status. Many systemic conditions and disorders can produce alteration in mental status, particularly in older
patients (Box 9-2). Chronic health problems (such as
alcoholism, renal failure, liver disease, severe anemia,
chronic obstructive pulmonary disease [COPD], severe cardiovascular disease, and HIV) predispose individuals, especially the elderly, to the development of
Box 9-2
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
CVA, Cerebrovascular accident; SLE, systemic lupus erythematosus; TIA, transient ischemic attack.
Systemic Conditions Associated With Confusional States
• 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
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Chapter 9 • Confusion in Older Adults
confusion. Patients with multiple chronic health problems are particularly at risk.
Could the confusion be caused by medication?
Key Questions
l
What medications is the patient taking?
l
Is the patient taking the medications correctly?
Medications
Drugs that can produce altered mental status include
the following:
l
Alcohol
l
Antibiotics (e.g., isoniazid, aminoglycosides)
l
Anticholinergic agents
l
Anticonvulsants
l
Antidepressants
l
Antihypertensive agents (e.g., reserpine, b-blockers,
methyldopa, clonidine, hydralazine)
l
Antiparkinsonian agents
l
Cardiac drugs (e.g., digitalis, lidocaine, b-blockers,
vasodilators, diuretics)
l
Chemotherapeutic agents (e.g., methotrexate)
l
Gastrointestinal drugs (e.g., H2 blockers, metoclo-
pramide)
l
Illicit drugs (e.g., amphetamines, cocaine, opiates)
l
Narcotics
l
Over-the-counter cold/allergy preparations
l
Sedatives
l
Tranquilizers
Taking Medication Correctly
Combinations of these medications increase the probability of medication-induced confusion. People who
are confused may be taking medications improperly,
which compounds the problem. 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
l
How old is the patient?
l
How many medications is the patient taking?
l
Is the patient HIV positive?
l
Has the patient experienced recent life losses?
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. In the presence of confusion, a diastolic blood pressure greater than 120 mm Hg suggests
hypertensive encephalopathy, 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. In an acute confusional
state, the patient will demonstrate impaired concentration and have difculty thinking.
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
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
Orientation to Time
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“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 five 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 9-1 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 (PAR), 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.)
available, including the Mini Mental State Examination (MMSE). (See Figure 9-1 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 an 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:
l
Apraxia (i.e., cannot draw simple geometric gures)
l
Visuospatial problems (e.g., cannot draw intersecting
pentagons)
l
Cannot perform commands
l
Selective cognitive loss
Chapter 9 • Confusion in Older Adults
l
Loss of abstract reasoning
l
Problems with orientation
l
Problems with recent memory
l
Problems with number retention
101
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.
In older adults, also administer the Geriatric Depression Scale (Figure 9-2). 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 four cardinal
features of delirium: (1) acute onset and uctuating
course, (2) inattention, (3) disorganized thinking, and
(4) altered level of consciousness. Obtain permission to
use the CAM and the training manual for it at www.
hospitalelderlifeprogram.org/pdf/The_Confusion_
Assessment_Method.pdf.
Perform a Complete Neurological Examination
Normal neurological ndings are typical of early dementia and depression. Abnormal ndings suggest other
organic involvement.
EVIDENCE-BASED PRACTICE BOX
Does the Patient Have Delirium?
This systematic review compared several bedside instru ments to assess their accuracy in diagnosing the presence
of delirium in hos pitalized adults. The authors concluded
that the confusion assessment method (CA M) is quick
and easy to use and has the evidence to support its use
at the bedside. Of the instruments evaluated, the MMSE
(score <24) was the least useful i n identifying a patient
with delirium. A caveat: none of the studies in the
systematic review included patients in the primary care
setting.
Reference: Wong CL, Holroyd-Leduc J, Simel DL, Straus SE: Does this
patient have delirium? Value of bedside instruments, JAMA. 304:
779-786, 2010. doi: 10.1001/jama.2010.1182
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Chapter 9 • Confusion in Older Adults
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
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 9-2 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.)
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.
Sensation (Primary and Cortical)
Agnosia (failure to identify or recognize objects despite
intact sensory function) is present with dementia.
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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 cerebrovascular accident (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, 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.
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 costovertebral
angle (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
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 and sodium levels, dehydration,
and acidosis can all produce confusion. Elevated or
depressed magnesium and calcium levels, hypoglycemia, 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.
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Chapter 9 • Confusion in Older Adults
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.
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 19).
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, 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 is also
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 be considered
rst in older 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),
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 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 9-1 shows the distinguishing characteristics of delirium.
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.
Dementia
Dementia is characterized by acquired persistent and
progressive impairment of intellectual function, with
compromise in at least two of the following areas:
l
Language (aphasia)
l
Memory
l
Visuospatial skills (apraxia, agnosia)
l
Emotional behavior or personality
l
Cognition (e.g., calculation, abstraction, judgment)
Refer to Table 9-1 for the distinguishing characteristics
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,
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Table 9-1
Distinguishing Characteristics of Delirium, Dementia, and Depression
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 during
the day
Consciousness Altered Not impaired except in
Cognition Impairment of memory, atten-
tiveness, consciousness, numerous errors in assessment
tasks
Activity Increased or decreased, can
fluctuate
Speech/language Rambling and irrelevant conver-
sation, illogical flow of ideas,
incoherent
Mood and affect Rapid mood swings; fearful,
suspicious
Delusions/hallucinations Misperceptions, illusions, hallu-
cinations, and delusions
Reversibility Potential No, progressive Can be treated, can recur
Pathophysiology Associated with infections,
medications, electrolyte and
metabolic disorders, major
organ failure, brain insults,
and acute alcohol withdrawal
Stable, no change Throughout the greater part
of the day
Not impaired
severe cases
Minimal cognitive impair-
ment 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
Usually related to structural
diseases of the brain
Impaired concentration,
reduced attention span,
indecisiveness, slower
thought processes,
impaired short-term
and long-term memory
Insomnia or excessive sleep-
ing, fatigue, restlessness,
anxiety, increased or
decreased appetite
Slower speech
Sad, hopeless, feels worth-
less, loss of interest or
pleasure
No delusions or
hallucinations
Associated with grief, a
stressful life event, reaction to medical or neurologic diseases, or a
change in lifestyle
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 9-3 lists common presentations of dementia, Box 9-4 lists phases of Alzheimer-type dementia,
and Box 9-5 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
(Box 9-6).
Box 9-3
Common Presentations
of Dementia
• Memory loss
• Depression
• Irritability
• Poor hygiene
• Insomnia
• Paranoia
• Weight loss
• Poor work performance
• Financial errors
• Poor judgment
• Delirium
• Language difficulty
• Social withdrawal
• Behavioral change
• Urinary incontinence
• Hallucinations (late)
• Anxiety
• Failure to thrive
• Falls, clumsiness
• Deteriorating interpersonal
relationships
• Personality changes
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Chapter 9 • Confusion in Older Adults
Box 9-4
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
Box 9-5
Staging systems for Alzheimer disease vary. The Alzheimer
Association uses seven stages to describe the progression of
Alzheimer disease.
STAGE 1
No impairment (normal function)
STAGE 2
Very mild cognitive decline (may be age-related changes or
earliest signs of Alzheimer disease)
• Memory lapses, especially in forgetting familiar words or
names or the location of everyday objects
• Symptoms not evident during a medical examination or
apparent to friends, family, or co-workers
STAGE 3
Mild cognitive decline
• Problems with memory or concentration; may be measurable in clinical testing or apparent during a detailed medical interview.
• Friends, family, or coworkers begin to notice deficiencies.
• Common difficulties include:
• Word- or name-finding problems noticeable to family or
• Decreased ability to remember names when introduced
• Performance issues in social or work settings
• Reading a passage and retaining little material
• Losing or misplacing a valuable object
• Decline in ability to plan or organize
STAGE 4
Moderate cognitive decline (mild or early-stage Alzheimer
disease)
• The affected individual may seem subdued and withdrawn,
especially in socially or mentally challenging situations
Phases of Alzheimer-Type Dementia
Stages of Alzheimer Disease
close associates
to new people
• 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
• Clear-cut deficiencies in the following areas:
• Decreased knowledge of recent occasions or current
events
• Impaired ability to perform challenging mental arithme-
tic (e.g., counting backward from 100 in 7s)
• Decreased capacity to perform complex tasks, such as
marketing, planning dinner for guests, or paying bills
and managing finances
• Reduced memory of personal history
STAGE 5
Moderately severe cognitive decline (moderate or midstage
Alzheimer disease)
• Major gaps in memory and deficits in cognitive function
emerge. Some assistance with day-to-day activities becomes essential
• Individuals may:
• 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
• Become confused about where they are or about the
date, day of the week, or season
• Have trouble with less challenging mental arithmetic
(e.g., counting backward from 40 in 4s or from 20 in 2s)
• Need help choosing proper clothing for the season or the
occasion
• Usually retain substantial knowledge about themselves
and know their own name and the names of their spouse
or children
• Usually require no assistance with eating or using the
toilet
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Box 9-5
STAGE 6
Severe cognitive decline (moderately severe or midstage
Alzheimer disease)
• Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals need
extensive help with customary daily activities
• Individuals may:
• Lose most awareness of recent experiences and events
• Recollect their personal history imperfectly, although
• Occasionally forget the name of their spouse or primary
• Need help getting dressed properly; without supervision,
• Experience disruption of their normal sleep-wake cycle
• Need help with handling details of toileting (flushing
• Have increasing episodes of urinary or fecal incontinence
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.
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, although the patient may have suicidal
thoughts. Depression as a cause of confusion can be
Stages of Alzheimer Disease—cont’d
as well as of their surroundings
generally able to recall their own name
caregiver but generally can distinguish familiar from
unfamiliar faces
may make such errors as putting pajamas over daytime
clothes or shoes on wrong feet
toilet, wiping, and disposing of tissue properly)
• Experience significant personality chan ges and behavioral symptoms including suspiciousness and
delusions, hallucinations, or compulsive, repetitive
behaviors
• Tend to wander and become lost
STAGE 7
Very severe cognitive decline (severe or late-stage Alzheimer
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.
• Lose capacity for recognizable speech, although words
or phrases may occasionally be uttered
• Need help with eating and toileting and there is general
incontinence of urine
• 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
• Reflexes become abnormal and muscles grow rigid;
swallowing is impaired
Box 9-6
Multi-Infarct versus
Alzheimer-Type Dementia
FACTORS SUGGESTING
DEMENTIA
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
Focal neurological symptoms
Focal neurological signs
†
†
HACHINSKI ISCHEMIA
POINT SCORE*
1
2
2
easy to miss, because it is often associated with anger,
anxiety, and unclear thinking as well as denial (see
Chapter 4). Refer to Table 9-1 for distinguishing characteristics of depression.
From Siu AL: Screening for dementia and investigating its causes, Ann
Intern Med
*A score of 4 or more is indicative of Alzheimer-type dementia. A
score of 7 or more is indicative of multi-infarct dementia.
†Focal neurological signs/symptoms: exaggerated DTRs, positive
Babinski sign, gait abnormalities, hemiparesis.
115:122, 1991.
108
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Chapter 9 • Confusion in Older Adults
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
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
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 es-
pecially for time, but less for
place, almost never for self; less
severe disorientation, more subtle motor signs than in delirium
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 multiinfarct dementia include focal
neurological signs/symptoms:
exaggerated DTRs, positive
Babinski sign, gait abnormalities, hemiparesis
CBC, electrolytes, glu-
cose, 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)
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
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