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CHAPTER

9 Confusion in Older Adults

Confusion is a symptom rather than a disease state. It is the inability to think quickly or coherently. A confused patient is disoriente d to time, person, or place and may demonstrate impaired cogn1t1ve function. Older adults are far more likely to experience an acute c onfusional state as a result of hospi­ talization or surgery, systemic or electrolyte imbalance, organ failure, excessive medica­ t:io~ nutritional deficiency, systemic infec­ tion, or cerebral insufficiency (e.g., stroke or transient iscbemic attacks [TIAs]). When an older patient presents with confusion, the dif­ ferential diagnosis includes delirium, demen­ tia, and depression.

Delirium , caused by alterations in brain metaboli s m , is characterized by an abrupt onset, redluced level of acute consciousness, and sleep-wake cycle disturbance. D e lir­ ium is a medical e m ergency and can occur as a re s ult of medications, alcohol u se or alcohol w ithdrawal, narcotic reaction or narcotic withdrawal, Wernicke-Korsakoff syndrome (vitamin B 12 deficiency), hepatic encephalopathy, acute illness, chronic ill­ ness, interacting diseases, or trauma (e.g., head injury).

Dementia, a chronic generalized impair­ ment of brain function , affects thinking but not the leve l of consciousness (LOC). A com­ mon early complaint in dementia i s forgetful­ ness, w ith loss of concentration and loss of memory. C auses of dementia can be classified as revers ible (or partially reversible), modifi­ able, or irreversible (Box 9.1).

Depress ion as a cause of confusion, espe­ cialJy in older adults, is considered a revers­ ible cause of dementia. When anxiety symp­ toms are also present, depress ion can manifest as mild delirium (see Chapter 4 ).

DIAGNOSTIC REASONING: FOCUSED HISTORY Obtaining an appropriate history from a con­ fused patient involves the use of another per­ son as the historian. Preferably that person is someone who bas had consistent contact with the patient and can report about usual behav­ ioral patterns and the conditions involved with this episode.

Is this a condition that requires immediate intervention?

Key Questions • How abruptly did the confusion start? • Is the patient alert and aware of time, person,

and place? • Has the patient expressed thoughts ofsuicide

(in words or actions)? • Does the patient use alcohol or other

drugs? Confusion that is acute in onset and persis­

tent can indicate delirium, a cerebrovascular event, cerebral infection, subdural hematoma, or neoplasm. A history of altered LOC along with the current confusion indicates a condi­ tion that requires immediate interve ntion. Acute-onset confusion can produce paranoia and aggression. Suicidal ideation can accom­ pany depression and is an indication for im­ mediate intervention and further evaluation. If the patient has been misusing alcohol or other chemical s ubstances, acute withdrawal can require immediate medical intervention.

I f the onset is gradual and the patient is not seriously ill , consider depression or dementia. Unless the patient is suicidal or seriously ill, both depression a nd dementia can be handled in a more temperate manner.

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~ Chapte< 9 • Confusion in Olde< Adults

What distinguishing characteristics ofconfusion does this patient exhibit?

Key Questions • Was the onset of the confusion abrupt (i.e.,

over a p eriod of minutes or hours) or grad­ ual (i.e., a few days, weeks, or months)?

• Does the confusion change within a 24-hour period (stable or fluctuating)?

• Is there a c hange in the s leep pattern? • Is the patient alert and aware? • Has the patient experienced seeing, h ear­

ing, or feeling things that are not there? • Is there any history of head trauma?

Onset and Duration Confusion that is abrupt in onset but short-Jived can indicate a TIA. Sudden onset, us ually over a period of hours, is characteristic of delirium. In delirium, the condition is persistent but has been present for no longer than 1 month. In an acute confusion episode, the symptoms are Jess severe than with delirium and have a less sud­ den onset. The onset of confusion in depression is usually gradual, over a period of weeks, and is persistent over time. In dementia, the onset is insidious and gradual; the condition has often been present for many weeks or months.

Fluctuation in Symptoms With de lirium, the symptoms can fluctu over the course of a day and frequently ate

worse at night and with fatigu e. The coursear_e more stable with both depression and dem

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. . en­ tia, with little vanat1o n over a 24- bour period

Disturbance in Sleep-Wake Cycle The s leep-wake cycle in delirium is impaired Either the patient gets little or no sleep or h~ night insomnia and is drowsy and tired during the day. Thus, the s leep-wake cycle is usually fragmented, and the patient tends to be rest­ less and agitated and hallucinates while awake during the night.

Level of Consciousness In both dementia and depression, the individ­ ual is likely to be both a lert and aware although the mood can be depressed. With delirium, the patient wi ll have a decreased

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M:f.iifil Causes of Dementia REVERSIBLE CAUSES OF DEMENTIA D Drugs o r medications E Emotional illness or depression M Metabolic or endocrine disorders E Eye or ear involvement or environmental N Nutritional or neurologic T Tumors or trauma I Infec tion A Alc oholism, anemia, or a therosclerosis

MODIFIABLE CAUSES OF DEMENTIA • Normal- pressure hydrocephalus • Hepatic encephalopathy • HIV encephalopathy (AIDS dementia

complex)

IRREVERSIBLE CAUSES OF DEMENTIA • Alzheimer disease • Multi- infarct dementia • Dementia with Lewy bodies • Frontotemporal lobar degeneration

LOC, be less alert and aw are, and can be difficult to arouse. In an acute confusional state, the person will demonstrate impaired concentration and make errors in thinking.

Hallucinations Visual, tactile, and auditory hallucinations are common with delirium, especia lly at night when changes in e n vironment or activity oc­ cur. Hallucinations are uncommon in both depression and dementia, although hallucina­ tions can occur in late-stage dementia. Visual hallucinations are the symptoms of Lewy body disease and precede cognitive impair­ ment. The occurrence of visual hallucination early in the symptom history is Lewy body disease until proven otherwise

Head Trauma Head trauma can produce confusion and dis­ orientation. In older adults, common causes of head trauma include motor vehicle crashes, physical abuse, and falls .

Are there any associated symptoms that will point me in the right direction?

Key Questions • Has the patient s hown any tremor, espe­

c iaJly at rest?

Has the patient had any trouble walking?• Has the patient reported severe h eadache• or nausea? Has the patient had a fever?• Has the patient gained or lost weight?• Does the patient engage in his or her usual• activities?

Tremor and Gait Disturbance Tremors are assoc iated with parkinsonism, human immunodeficiency virus (HIV), en­ cepha lopathy, and liver disease. Gait disorder is associated with parkinsonism, medication reactions, and head trauma.

Headache, Nausea, and Fever Headache and nausea are associated with head trauma, stroke, and tumor. Fever is usu­ ally present with HIV-associated infection, other systemic infections, or acute alcohol withdrawal.

Change in Weight and Usual Activities Patients with depression can exhibit vegeta­ tive symptoms (e.g., cessation of talking, eat­ ing, dressing, and toileting; insomnia; weight loss or gain; diminished interest in most ac­ tivities or former pleasures) and feelings of worthlessness.

What does the pattern ofcognitive losses tell me?

Key Questions • What specific problems with mental abilities

or thinking have you noticed? • What behavioral changes or personality

changes have you noticed?

Changes in Mental Abilities and Behaviors Patients with delirium have global cogmt1ve losses that involve memory, thinking, percep­ tion, and judgment. These patients can be­ come disoriented, irritable, and fearful. They can be difficult 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

Chapter 9 • Confusion in Older Adults

impaired concentration, experie nce sensory misperceptions, and make errors in thinking.

Early dementia presents with more selec­ tive cognitive losses. Family members report that patients cannot remember recent events; are disoriented , irritable, or depressed; have poor hygiene; show poor judgment; make financial errors; are socially withdrawn; have difficulty finding or saying the right words; are c lumsy or fall; have urinary incontinence; have deteriorating interpersonal relationships; and show personality changes. Memory loss is typical of Alzheimer disease. Loss of ex­ ecutive function occurs early with vascular causes of dementia. Language disturbance is typical of frontotemporal lobe dementia, and clumsiness or falling typifies Lewy body disease.

Fewer cognitive losses occur with depres­ sion. These individuals can exhibit cognitive losses consistent with confusion- apathy and drowsiness, impaired concentration, and er­ rors in thinking. The most common cognitive symptoms are severe negative thinking, guilt, and remorse.

ls the confusion caused by a concurrent health problem?

Key Questions • Does the patient have any chronic health

conditions? • Has the patient been hospitalized recently,

and if so, for what reason? • Has the patient been acutely ill recently? • Is there a history of mental illness or simi­

lar 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 cur­ rent and past health status. Many systemic conditions and disorders can produce a ltera­ tion in mental status, particularly in older pa­ tients (Box 9.2). Chronic health problems (e.g., a lcoholism, renal failure, liver disease, severe anemia, chronic obstructive pulmonary disease [COPD], severe cardiovascular dis­ ease, and HIV) predispose individuals, espe­ cially older adults, to the development of

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Chapter 9 • Confusion in O lder Adults

i:J.f:lfl Systemic Conditions Associated with Confusional States NEUROLOGICENDOCRINE • Lyme disease

Neurosyphilis • H epatic encephalopathy• Hypo- or hyperthyroidism • • TB meningitis • Hypertensiveij METABOLIC e n cephalopathy

• Anemia (severe) CARDIOVASCULAR • Limbic encephal itis ij • Hypo- or hypercalcemia • Congestive heart failure • Head trauma

• Hypo- or hypercortisolism • Hyperviscosity OTHER• Hypo- or hyperglycemia • Alcoholism• Hypomagnesem ia CEREBROVASCULAR • Anemia (severe)• Hypo- or hypernatremia • Cerebral insufficiency • Leukoencephalopathy• Wilson disease (copper (TIA, CVA)

disorder) • Postanoxic encepha lopathy • Metastatic ca ncer to brain• Porphyria

PULMONARY • Sarcoidosis INFECTIOUS • COPD • S leep apnea • A IDS • Hypercapnia • Vasculitis (e.g., S LE) • Cerebral amebiasis • Hypoxemia • Vitamin deficiencies • Cerebral cysticercosis (vitamin 8 12 , folate, • Cerebra l toxoplasmosis RENAL niacin , thiamine) • Cerebra l malaria • Renal failure Whipple disease• • Fungal meningitis • Uremia

CVA, Cerebrovascular accident; SLE, systemic l upus erythematosus; TB, tubercu losis; TIA , transient ischem ic attack.

confusion. Patients with multiple chronic • Gastrointestinal drugs (e.g., H 2 blockers, health problems are particularly at risk. metocloprarnide)

• Illicit drugs (e.g., amphetamines, cocaine, opiates)

Could the confusion h e caused by • Narcotics

medication? • Over-the-counter cold or a llergy prepara­

Key Questions tions • What medications is the patient taking? • Sedatives • Is the patient taking the medications

Taking Medication Correctlycorrectly? Combinations of these medications increase

Medications the probability of medication-induced confu­ Drugs that can produce a ltered mental status sion. People who are confused m ay be taking include the fol lowing: m edica tions improperly, which compounds • Alcohol the problem. Older adu lts m ay need lower • Antibiotics (e.g., isoniazid, aminoglycosides) doses or a grad ual increase in dosages of • Anticholinergic agents medications u sed to treat both acute and • Anticonv ulsants chronic cond itions. The exception to the "start

Antidepressants low, go s low" ru le is antidepressants in older • Antihypertensive agents (e.g., reserpine, adults because of the high rate of suicide. In

~-blockers, rnethyldopa, clonidine, hydral­ that case, start low but be aggressive in titrat· azine) ing up to goal dose. Chronic kidney disease,

• Antiparkinsonian agents common in o lde r adu lts, can affect drug me­ • Cardiac drugs (e.g., digitalis, lidocaine, tabo lism and elimination, so dosing adjust­

~-blockers, vasodilators, diuretics) ments and monitoring may be necessary to • Chemotherapeutic agents (e.g., rnethotrexate) ensure therapeutic benefit.

lf'hal risk/actors do 1 need to consider?

Key Questions • How o ld is the patient? • How many medications 1s the patient

taking? • Is the patient HIV positive? • Has the patient experienced recent life

losses?

Age Older adu lts are at risk for the development of confusion, delirium, dementia, and depres­ sion. Factors that place them at risk include the use of multiple medications, the existence of multiple medical conditions, and the physi­ ological changes associated with aging. De­ mentia occurs in approximately 5% to I 0% 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 medica­ tions are at risk for medication interactions and resulting confusion (see also the preced­ ing 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, encephalopa­ thy (AlDS dementia complex), or dementia caused by central nervous system opportunis­ tic 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 the Vital Signs The presence of a fever can indicate infection or alcohol withdrawal. ln the presence of

Chapter 9 • Confusion in Older Adults

confusion, a diastolic blood press ure greater than 120 mm Hg s uggests hypertensive en­ cephalopathy; a systolic blood pressure less than 90 mm Hg can indicate impaired cerebral perfusion.

Note the Level of Consciousness In both dementia and depression, the individ­ ual is likely to be alert and aware, although the mood can be depressed. With delirium, the patient will have a decreased LOC, be less alert and aware, and can be difficult to arouse. In an acute confusional state, the patient will demonstrate impaired concentration and have difficulty thinking.

Perform a Mental Status Examination A thorough mental status examination is es­ sential. Mental status assessment is used to determine cognitive function. A number of assessment instruments are available, includ­ ing the Montreal Cognitive Assessment (available at http://www.mocatest.org) and the Mini-Cog (available at http://mini-cog. com). 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 de­ lirium. Losses occur in the following areas: memory, thinking, perception, information ac­ quisition, information retention, information processing, information retrieval, and informa­ tion use. Dementia, particularly early in the disorder, presents with selective cognitive losses that can occur in one or more of the following areas: • Apraxia (i.e., cannot draw simple geometric

figures) • Visuospatial problems (e.g., cannot draw

intersecting pentagons) • Cannot perform commands • Selective cognitive loss • Loss of abstract reasoning • Problems with orientation • Problems with recent memory • Problems with number retention

Chapter 9 • Confusion in Older Adults

Fewer cogni tive losses occur with d e pres­ s ion than with d e m e ntia. Loss of concentra­ tion is an impo rtant symptom of depression. The individu a l is aware of losses and can hi g hli g ht di s ab ili ties, esp ec ially memory loss. A long with loss of memory, impaire d concentration, a nd errors in judgment are common.

[n o lder adults, the Geriatric Depression Scale (Fig. 9. 1) is pos itive for d e pression if the score is above 5. T h e Personal Health Questionnaire (PHQ-9) has a lso been vali ­ dated in older ad ults a nd is positive for de­ pression if the score is 10 or greate r (avai lable at http://www.cqaimh.org/ pdf/tool_phq9.pdf) .

The Confus ion Assessment M e thod (CAM) can b e used to assess delirium. The C AM in. strumen.t assesse~ th e p~e.sence, severity, and fluctuati o n of nme delinum feature s: acut onset, inattention, disorga nized thinking, al~ te re d LOC , disorientation, memory impair­ ment, perce ptual dis turbances, psychomotor agitation or retardation, and a lte red s leep/wake cycle . The CAM diagnostic a lgorithm is based o n four card ina l features of del irium: ( I) acute onset and fluctuating course, (2) inattention (3) disorganized thinking, and (4) a ltered Loe'. Obtain permission to use the CAM and the training manual for it at https ://www.hospital e lde rlifeprogram.org/delirium-instruments/

Geriatric Depression Scale (short form)

Choose the best a n swer for how you felt over the p ast week.

1 . Are you basically sat isfied with your life? yes/no

2 . H ave you dropped many of your activities and interests? yes/no

3. Do you fee l that your life is empty? yes/no

4 . Do you often get bored? yes/no

5 . Are you in good spirits mos t of the time? yes/no

6 . Are you afraid that something bad is going to h appen 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 b e 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 s ugges ts 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 .1 Geriatr ic Depression Scale (short form). (From Sheikh J I, Yesavage JA: Geriatric Depression Scale: recent evidence and development of a shorter version, Clin Gerontol 5: 165, 1986.)

Chapter 9 • Confusion in Older Adults

2EVIDENCE-BASED PRACTICE Does the Patient Have Deliril1111? This systematic review compared several bed­ side instruments to assess their accuracy in diagnosi ng the presence of delirium in hospital­ ized adults. The authors concluded that the confusion assessment method (CAM) 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 in 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 et al, 2010. MMSE. Mini-Mental State Examination

Perform a Complete Neurologic Examination Normal neurologic findings are typical of early dementia and depression. Abnormal findings suggest other organic involvement.

Cranial nerves

Check vision , hearing, and sensory impair­ ment 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 neurologic changes, such as those that occur with stroke or neoplasm. The sense of smell is often impaired in de­ mentia. Patients with parkinsonism can ex­ hibit a typical facial presentation: masked facial expression, poor blink reflex, and drooling. Speech is slowed, slurred, and monotonous .

Proprioception and cerebellarfunction

Test coordination through rapid alternating movements (RAMs), accuracy of movement, balance (Romberg test), and gait. Slowed RAMs are characteristic of early HIV en­ cephalopathy. Tremor and restlessness are associated with alcohol intoxication or with­ drawal. Tremor (especially resting), rigidity, and bradykinesia indicate parkinsonism. As­ terix is, sometimes referred to as liver flap 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 Hun­ tington disea se.

Gait abnormalities are found with multi­ infarct dementia (MID), normal pressure hy­ drocephalus, and HIV encephalopathy.

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 reflexes (DTRs) and the superficial plantar reflexes. Hyperreflexia and primitive reflexes are present in late de­ mentia. Hyperreflexia is also present in MID, HIV encephalopathy, and cerebrovascular accident (CVA).

A positive Babinski s ign on testing the plantar reflex is present in MID, CVA, and head injury. Cogwheeling (resistance to a pas­ sively stretched hypertonic muscle, resulting in a rhythmical jerk similar to a ratchet) s ug­ gests parkinsonism.

Motor tone and function

Apraxia (impaired ability to carry out motor activities des pite intact motor function) indi­ cates dementia. Motor weakness, especially of the legs; loss of coordination; and impaired handwriting are consistent with early HIV encephalopathy.

Language

Aphasia (language dis turbance) is often pres­ ent in dementia and can occur with CVA and head injury.

Chapter 9 • Confusio n in Older Adults

Localizing and late raJW ng signs in the central nervous system

Focal neurologic signs (i.e., exaggerated DTRs. positive Babinski sign, gait abnormali­ ties, and hemiparesis) are consistent with MID. Focal deficits a lso occur with cerebro­ vascular injury.

Patients with late HIV encephalopat hy demonstrate weakness that is greater in the legs than in the arms, ataxia, spasticity and hyperreflexia, positive Babinski sign, myoc­ lonus, and b ladder and bowel incontinence.

Psychomotor agitation o r retardation is consiste n t with d epression. An agitated confu­ sional state without foca l signs can occur with head trauma.

Perform a Respiratory Examination Monjtor the rate and effort of respirations. Auscultate the lung fields. Tachypnea sug­ gests hypoxia. B ibasi lar crackles indicate congestive heart failure (CHF) with hypoxia. Asymmetrical crackles suggest pneumonia with hypoxia. Patients with dementia or d e ­ pression, in the absence of concomitant lung disease, wi ll have normal findings.

Evaluate the Cardiovascular System Perform a careful cardiovascular examina­ tion. Tachycardia suggests sepsis, hyperthy­ ro idjsm. hypoglycem ia, agitat ion, anxiety, or alcohol withdrawal. Be alert for indicators of cardiovascular problems that can produce hypoxia., such as CHF or myocardial infarc­ tion (M]).

Examine the Abdomen Examine the abdomen and percuss for costo­ vertebral ang le (CVA) tenderness. Specific findings can in dicate a local or systemic cause for the confusion. For example, urinary retention suggests urinary tract infect ion, CVA tenderness points to pyelonephritis, and an enlarged liver can indicate hepatic encephaiopathy.

LABORATORY AND DIAGNOSTIC STUDIES D iagnostic testing is aimed at detecting or con firming a metabolic o r organic cau se of

the confusi on. If dementia seems likely, theSc same tests can ru le in or rule o ut reversible or modifiab le causes of the dementia. M0st tests wi ll be normal when the diagnosis is depression.

Complete Blood Count Leukocytosis suggests infection. Anemia asa cause of confusi on in c hronic illness can also be detected.

Blood Chemistry H igh or low potassium and sodium levels, dehydration , and acidosis can all produce confusi on. E l evated or d epressed magne. sium and calciu m l evels, hypoglycemia, and hyperg lycemia can a lso cause confusion. E l evated b lood urea nitrogen (BUN) and creat1n1ne level s or an elevated BUN-to. creatinine ratio can indicate renal fai lure. E levation in liver enzymes suggests liver dysfunction.

Thyroid Function Tests Abnormal levels of t h yroid-stimulating hor· mon e (TSH) can indicate thyroid dysfunction, either thyroid toxicosis o r a hypothyroid state. An elevated TSH level i s related to chronic symptoms of depression.

Serum B12 and Folate Deficiencies of v itamin B 12 and folate are reversible causes of dementia.

Serology for Syphilis Perform if indicated by medical or social history. A positive test result can indicate neurosyphil~ as the cause of confusion.

Arterial Blood Gases Arterial blood gases are used to determine the presence or degree of hypoxia.

Toxicology Screen and Blood Alcohol Level These tests can be used to d etermine alcohol or drug int:oxicatio n as a cau se of confusion.

Urinalysis Urin a lysis can point disease.

1s to

used renal

t o in

detect i dicators

nfection and of systemic

Chest Radiograph A chest radiograph is used to detect infection, cHF. COPD, pneumonia, or other respiratory­ associated causes of hypoxia.

Lumbar Puncture Lumbar puncture (LP) is used to rule out bacterial, fungal , or tumor meningitis (see Chapter 19). LP is used to test cerebrospinal fluid for Alzheimer disease biomarkers and tau-opathies. High-volume LP decompresses a normal-pressure hydrocephalus (NPH), which may or may not reverse the dementia syndrome, depending on how long the NPH bas been pres­ ent and how long it has compressed the brain.

Electrocardiography Electrocardiography is used to rule out certain cardiovascular causes of hypoxia, such as MI or dysrhythmias.

Electroencephalography Electroencephalography can be used to iden­ tify a seizure disorder as a cause of or a con­ tributing factor to confusion.

Computed Tomography or Magnetic Resonance Imaging Computed tomography or magnetic resonance imaging is used to diagnose whether cerebro­ vascular bleeding, injury, abscess, tumor, or whether focal neurologic signs are present. In the diagnosis of dementia, structural imaging yields limited but helpful diagnostic informa­ tion. Signs may include decreased hippocampal size (Alzheimer disease), microvascular change (vascular dementia ) , or atrophy in frontotem­ poral lobes greater than in other areas.

Positron Emission Tomography Scan Positron emission tomography (PET) is useful in confirming the diagnosis of Alzheimer dis­ ease. PET is also useful in differentiating Al­ zheimer 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 progres­ sively after the fourth decade of life. Because

Chapter 9 • Confusion in Older Adults ..

delirium is associated with an increased risk of death, it s hould be considered first in older patients who exhibit cognitive impairment or behavioral changes.

Delirium is characterized by reduced abil­ ity to maintain attention to external stimuli , disorganized thinking, decreased LOC, per­ ceptual disturbances, disturbed sleep-wake cycle, disorientation, and memory impair­ ment. The patient will evidence a decreased LOC and impaired arousal, increased or de­ creased 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 in­ tervals during the day and worse symptoms at night. The thought process is disorganized, and the patient is usually disoriented, most commonly to time. The1e is a tendency for the patient to mistake the unfamiliar for familiar places and people. Hallucinations, usually vi­ sual, are common. Physical examination find­ ings 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 distin­ guishing 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 disori­ entation, 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 difficulty in motor relaxation.

Dementia Dementia is characterized by acquired persis­ tent and progressive impairment of intellectual function, with compromise in at least two of the following areas: • Language (aphasia) • Memory • Visuospatial skills (apraxia, agnosia) • Emotional behavior or personality • Cognition (e.g., calculation, abs traction,

judgment)

Chapter 9 • Confusion in Older Adults

Table 9.1 Distin g uishing Characteristics of Delirium, Dementia, and Depression

CHARACTERISTIC DELIRIUM DEMENTIA DEPRESSION

Onset Sudden I nsidious, relentless Sudden or insidious

Duration Hours, days Persistent > 2 weeks

Time of day Increases and decreases during the day

Stable, no change Throughout the greater part of th e day

Consciousness A ltered Not impai red except in Not impaired seve re cases

Cognition Impairment of mem­ Min imal cognitive Impaired co ncentration, ory, atte nt iveness, impairment initially, reduced attention consciousness, progresses to impaired span, indec i siveness,

numerous er rors abstract thin king, slower thought pro­ in assessment judgment, memory, cesses, impaired short­

tasks th ought patterns, and long-t erm memory ca lcu lations, agnosia

Activity I ncreased or Unchanged from usual I nsomnia or excessive decreased; behavior sleeping, fatigue, can fluctuate restlessness, anxiety,

increased or decreased appetite

Speech o r Rambling and irrele­ Di sordered, rambling, Slower speech language vant conversation, incoherent; struggles

illogica l flow of to find words ideas. incoherent

·~

M ood and Rapid mood swings; Depressed, apathetic, Sad, hopeless, feels affect f earfu l, suspicious uninterested worthless, loss of inter­

est or pleasure Delusions or Misperceptions, illu­ M isperceptions u s ually N o delusions or halluci­

hallu c in a­ sions, hallucinations, absent, delusions, n o nations tions and delusions hallucinations

Reversibility Potentia l N o, progressive Can be treated; c an recur Pathophysiology Associated with infec­ Usually related to struc­ Associated with grief, a

tions, med ication s, tural diseases of the stressful life event. electrolyte and met­ brain reacti o n to medical abolic disorders, or neurologic diseases, major organ failure, or a change in lifestyle brain insults, and acute alcohol withdrawal

Refer to Table 9. 1 for the distinguishing characteristics of d e mentia.

The onset ofsymptoms is insidiou s, with the course stable through the day and night. T he condition can be present for months o r years, with progressive deterioration. Recent and re­ mote m e m ory is impaired. The patient is a lert, and attentio n is relatively unaffecte d , a ltho ug h o rientation is us u a lly impaired. Hallucinations are usually absent until late in the course of the disease. Speech is usually unimpaired, although

th e p erson has difficulty finding words. S leep is often fragmented. On mental status examina­ tion, the patient tries hard and provides '·near­ miss" a nswers. Physical find ings are often absent. T h e olfactory sen se can be impaired. Box 9 .3 lists common presentations of demen­ tia, Box 9.4 lists phases of A lzheimer-type dementia, and Box 9.5 des c ribes a staging system for A lzheimer disease.

A lz heimer-type dementia can sometimes be distinguished from vascular o r MJ D by

• •

Common Presentations of Deme ntia

Memory loss Soc ia l w ithdrawa l Depression • Beh av ioral change • Irritabi l ity • U r i n ary i n cont i­• Poor hygiene nen ce• Insomnia • H allucinations (late)• Paranoia • Anxiety• Weight loss • Failu re t o t hrive• Poor work • Falls, c l u m siness• performance • Deterio r at in g Financ ia l e rrors i nterper sona l•

• Poor judgment relatio n shi p s Delirium • Per sona l ity•

• Language d ifficulty cha n ges

Chapter 9 • Conf usion in O lder Adults

o b taining a cardiovascul ar history, d etermin­ ing the progression of symptoms, and detect­ ing the presence or absence of focal neuro­ Iogic signs and symp toms (Box 9.6).

Depression Depression can p roduce confusion, especia lly in o lder adul ts. The onset of the confusion is often abrupt, w ith some d jumal variation. Gen­ erally, depression is more consistent over time than delirium. The confusion is of short d ura­ tion comp ared with d ementia. A past rustory of psychiatric problems, including unruagnosed d epressiv e epis odes, is common. During men­ tal status examination, the patient tends to highl ight disabilities, especially memory loss.

++fill Phases of Alzheimer-Type Demen tia Progression of sym ptoms corresponds with the • Cannot n ame common objects progression of u n d erlying n erve cel l degenera­ • Apraxia: ca nn ot perfor m motor ski l ls, tion. Damage typica lly begins with ce lls involved a lthough motor system intact in learning and m e m ory a n d grad u al ly spreads to • Agnosia: fai l ure to identify or recogn ize cells that contro l thi n k ing, judgmen t, and be­ objects despite in tact sensory functio n havior. T he damage even t u al ly a ffects ce ll s that • M i si nte r p rets v isua l a n d a udi t ory stimul i contro l a nd coor d inate m ovem ent. • Del u sions

LIMBIC LATE FRONTAL • 2-3 years after onset • 6-8 years after onset • Olfactory system i nvo lved • Motor disturbances: wal king, swallowi n g, • Memory loss movi ng • Can perform tasks • Prim i tive reflexes

• Seiz u res PARIETAL • Sensat ion rem a ins intact • 3-6 years after onset • Loss of comprehension of s p oken language

l:§Ji Stages o f Alzheimer D isea se Staging systems for A lz h eimer disease vary. The • Symptoms not eviden t dur ing a medical ex­ Alzheimer Associatio n uses seve n st ages t o de­ a min at ion or app arent t o friends, family, or scribe the progression of A l zhei m er disease. coworkers

STAGE 1 STAGE 3 No impairment ( n o rma l fu nct ion) M il d cognitive decline

STAGE 2 • Problems with memory or conc entrati o n ;

may be measurab le in c lin ical testing or ap­ Very mild cognit i ve decl ine ( m ay be age­ related changes or earl iest signs of A lzheimer disease)

• parent d u r ing a d e tailed medical int erview Fr iends, family, or c oworkers begi n to not ice deficiencies.

• Memory lapses, espec ial l y in forgett ing fa­ • Common d ifficu l t ies i ncl ude: miliar words o r n a m es or t h e locati o n of ev­ • Word- or name-fin ding problem s notice- 1 eryday objects a bl e to f amily or close assoc iates

Continued

Chapter 9 • Confusion in Older Adults

l:J.IJI Stages of Alzheimer Disease--cont' d • Decreased ability to remember names

when introduced to new people • 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 w ithdrawn, especially in socially or mentally challenging situations.

• Clear-cut deficiencies in the following areas: • Decreased knowledge of recent occasions

or current events • Impaired ability to perform challenging

mental arithmetic (e.g., counting back­ ward 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 cogni­

tive function emerge. Some assistance with day-to-day activities becomes essential.

• I ndividuals 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 sc hool 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).

• N eed help choosing proper clothing for the seaso n or the occasion .

• Usually retain substantial knowledge about themselves and know their own name and the names of their spouse or children.

• U sually require no assistance with eating or using the toilet.

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 as wel I as of their surroundings. • Recollect their personal history imper­

fectly, although general ly able to recall their own name.

• Occasionally forget the name of their spouses or primary caregivers but gener­ ally can distinguish familiar from unfa­ miliar faces.

• Need help getting dressed properly; without supervision, may make such errors as putting pajamas over daytime clothes or shoes on wrong feet.

• Experience disruption of their normal sleep- wake cycle.

• Need help with handling details of toilet­ ing (flushing toilet, wiping, and disposing of tissue properly).

• Have increasing episodes of urinary or fecal incontinence.

• Experience significant personality changes and behavioral symptoms, including sus­ piciousness 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 abi lity to co ntrol movement. • Lose capacity for recognizable speech ,

although words or phrases may occasion­ ally be uttered .

• Need help with eating and toileting and there is general incontinence of urine.

• Lose the ability to w alk w ithout assis­ tance and then the abi l ity to sit without support, the ability t o sm ile, and the abi I ity to hold their h e 2d up.

• Reflexes become abno rm al and muscles grow rigid; swallowing is impaired.

From Reisberg 8, 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 9 • Confusion in Older Adults I

123

18 l\tlulti-Infarct versus Alzheimer-Type Dementia

' A score of 4 or more is ind icative of Alzheimer-type dementia . A score of 7 or more is indicative of multi- infarct dementia. oFocal neurologic signs or sympt o ms: exaggerated deep tendon reflexes, positive Babinski sign, gai t abnorma li ties,

~ DIFFERENTIAL DIAGNOSIS OF Co111111011 Causes <~/· Deliri11111, Confu.,·ion.

FACTORS SUGGESTING DEMENTIA

Abrupt onset Stepwise deterioration Fluctuating course Emotional labi Iity Relative preservation

of personality Depression Somatic complaint s

HACHINSKI ISCHEMIA POINT SCORP

2 1 2 1 1

1 1

FACTORS SUGGESTING HACHINSKI ISCHEMIA DEMENTIA POINT SCORP ~~~~~~~~~~~~~~~~~~~~~

Hist ory o f 1 hypertension

History of strokes 2 Evidence of associated 1

arteriosclerosis Focal neurologic 2

symptomsb Foca l neurologic signsb 2

hemiparesis.

The memory loss is equal for recent and re­ mote events. The cogniti ve losses, however, are flucruating rather than stable o ver time. The patient manifests a depressed or anxious mood, inducting s leep and appetite disturbance. Hallucinations are usually absent, although the

De111e11tia, and Depression

CONDITION HISTORY PHYSICAL FINDINGS Delirium

Confusion

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 atten­ tion to external stimuli; disorganized thinking, perceptual disturbances, disturbed sleep-wake cycle; hallucinations, usually visual, common

Less abrupt , less severe than deliriu m ; diurnal variation less severe than delirium; concentra­ tion impaired, easily distracted ; e rrors i n thinking common

Decreased LOC, impaired arousal , decreased psy­ chomotor activity; disori­ ented, most commonly to time; physical exam ina­ tion findings depend on underlying cause of delir­ ium; patient often exhib­ its asterixis, tremor, and difficulty in motor relax­ ation; speech incoherent, hesitant, slow, or rapid

Apathetic , drowsy; disori ­ ented especially for time, but less for place, almost never for self; less severe disorienta­ tion, more subt le motor signs than in delirium

patient may have suicidal thoughts. Depression as a cause of confusion can be easy to miss because it is often associated with anger, anxi­ ety, and unclea r thinking as well as d enial (see Chapter 4). Refer to Table 9.1 for the dis tin­ guishing characteris tics of depression.

DIAGNOSTIC STUDIES

CBC, electrolytes, glucose, BUN, creat i­ nine, LFTs, TFTs, serum B 1 2 , folate , serology for syphi li s, ABGs, toxicology screen, blood alcohol level, U/A, ECG , EEG, chest radiograph, lumbar puncture, CT or MR I (when CVA o r injury suspected)

CBC , electrolytes, glu­ cose, BUN, creatinine, LFTs, TFTs, serum B 12 , 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

---

Chapter 9 • Confusion in Older Adults

_.5 DIFFERENTIAL DIAGNOSIS OF Co111111011 Causes of· Delirit1111. Co11ji1.\·io11, ·--- De111e11tia. t111d Depressio11- co11t •t1

CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES

Dementia Onset insidious, course stable through day and night; present for months or years, with progressi ve deterioration ; recent and remote memory impaired; hallucinations u s u ally absent until late i n course of disease; s l eep often fragmented

Depression Onset of confusion often abrupt, with some diurnal variation, generally more consistent over t ime than delirium; confusion of s hort duration compared to dementia; past h istory of psychiatric problems com­ mon, inc luding undiag­ nosed depressive episcx:les; cognitive losses f luc tuating rather than stable over time; s leep/appet ite distur­ bance; hallucinations usu­ ally absent a lthough person can have suicidal thoughts

Alert, attentive; orientation u sually impaired; on mental status examina­ tion, patient tries hard, provides " n ear-miss" answers; demonstrates one or more of following cogn itive disturban ces: aphasia (language distur­ bance); apraxia (impaired abi l ity t o carry out motor activities despite intact motor function); agnosia (failure t o identify or recognize object s despite intact sensory function); disturbance in executive functioning (planning, organizing, seq u encing, abstracting) ; physical findings often absent i n Alzheimer type; olfactory sense can be impaired; speech usually unim­ paired, although difficulty with finding words; fi nd­ ings in MID include focal neu rologic signs or symp­ toms: exaggerated DTRs, positive Babinski sign, gait abnorma lities, hem i paresis

Depressed or anxious mood; tends to highlight disabilities, especially memory loss; memory loss equal for recent and remote events; physical exami nation often normal

Cognitive test i ng CBC, electrolytes,

glucose, BUN, creatinine, LFTs, TFTs, serum 8 12, folate, serology for syphilis, ABGs, toxi­ cology screen, blood a l cohol level, U/A, ECG, EEG , chest radiograph, lumbar puncture, to test CSF for Alzheimer d isease biomarkers and tau­ opath ies ; CT or MRI (when CVA or injury suspected ; does not yield useful informa­ tion for dementia); PET sca n

Geriatric Depression Scale; PHQ-9; CBC, electrolytes, glucose, BUN , c reatinine, LFTs, TFTs, serum B i 2 , toIate , serology for syphi l is, ABGs, toxi co logy screen, bl ood alcohol level, U / A, ECG , EEG , chest radiograph, lumbar puncture, CT or MRI (wh e n CVA or injury suspected)

ABGs, arterial blood gases; BUN, blood urea nitrogen ; CBC, complete blood count: CT. comp uted tomography; CVA, costovertebral angle; DTRs, deep tendon reflexes; ECG, electrocardiography; EEG, electr~ncephalography; LFTs, liver func tion t ests; LOC, level of consciousness; MID, multi- infarct dementia; MRI, m ag:-ietic resonance imaging; PET, positron emission tomography; TFTs, thyroid func tion tests; U/ A , urinalysis.