Don't Just Blame It On Old Age! Differentiating Delirium and Dementia in the Elderly
Colleen M Hayes, MBA, RN, EMT-P
When Josephine Morgan's 74-year-old mother stopped socializing, laughing and
painting, her doctor said it was because she was "getting old". But
many months later, after seeing a different doctor who specialized in geriatrics,
Josephine and her mother, Sophie Jamieson learned that Sophie's brain wasn't
getting enough oxygen and that she also had severe osteoporosis. A surgical
procedure to remove excessive amounts of atherosclerotic plaque was performed
to restore normal oxygen levels to the brain. Once Sophie's problems were identified
and managed she returned to participating in and planning social events and
resumed painting. Sophie had a much improved quality of life!
When Joe Wright went to visit his 80-year-old father, Michael Briganti, he
noticed that he was acting strangely. He was fatigued and slower than normal
to respond to conversation and questions. Michael is usually active, alert and
plays tennis twice weekly. Michael was completely alert and oriented, but he
just wasn't himself. When his father was unable to walk, Joe called 911 for
assistance to get Michael to the Emergency Room to get evaluated. The paramedics
checked his blood glucose level and it was within normal limits. Since Micheal
had no complaints of pain or difficulty breathing and his vital signs were within
the normal adult range (HR: 90, Sinus Rhythm, RR: 18 and BP: 110/60), they simply
transported him to the hospital for further evaluation. In the ER the patient
was discovered to be suffering from a left lower lobe pneumonia and a serious
lower GI bleed. He required oxygen, IV fluids, antibiotics and required a 2-unit
blood transfusion. Thankfully, he slowly made a complete recovery and was back
to playing tennis two months later!
Unfortunately, misdiagnosis of abnormal behavior, mood or mental status is
common because of a lack of knowledge among health care providers about problems
that strike the elderly and how they present clinically. These errors occur
in physician's offices and they also occur prehospital EMS systems. People age
65 and over make up 12.5% of the U.S. population but make up more than 60% of
preventable injuries that occur because of misdiagnosis or improper medication,
according to the American Association of Retired Persons (AARP) in Washington.
To avoid making serious errors, the first rule of thumb to follow when you
assess something abnormal in behavior, mood or mental status in an elderly person
is "Don't blame it on old age!" The abnormal finding may be
the patient's chief complaint. "I feel so weak and tired" or "My
mother is confused." It may be that the patient's mental status assessment
is clearly abnormal, or the assessment may reveal an alert and oriented person
with vague, generalized signs and symptoms. Alterations in behavior, mood or
mental status can be very confusing to interpret. Is your patient acutely ill,
medically or psychiatrically, or is he/she suffering from an organic brain disease
that requires no emergency treatment? Hyperactivity, hypoactivity, depression,
somnolence, anxiety, paranoia, confusion, disorientation, lethargy are all common
"chief complaints" among elderly patients. When these subtle complaints
are acute, they may be the first clinical sign of an acute medical or surgical
The standard of care is to assume there is an acute treatable cause before
we assign symptoms of an altered behavior, mood or mental status to senility
or organic brain disease. This standard exists to help us avoid making serious
errors. So why do we still miss so many acute treatable problems in the elderly
patient? Hypoglycemia, appendicitis, hypoxia, sepsis, myocardial infarction,
acute arrhythmias, GI bleeds, drug interactions, toxicity...the list of acute
problems we often miss in our elderly patients is very long. Missing these ailments
put the elderly patient at great risk of increased morbidity and mortality!
According to statistics from AARP, the number of Americans over age 65 is projected
to grow from 34 million today to 76 million by 2030. A significant percentage
of our patients who request ambulance services are elderly and we are expected
to be able to prudently assess and treat acute illness to stabilize the patient.
The purpose of this article is to review the assessment of elderly patients
presenting with altered behavior, mood or mental status and to review some of
the key associated pearls and pitfalls. As EMS providers, the main question
we need to be able to quickly answer to determine proper patient care is, "Are
these complaints of alterations in behavior, mood or mental status associated
with delirium or dementia?"
Is it delirium or dementia?
Of greatest clinical importance is avoiding the common clinical error of mistaking
delirium for dementia in a sick elderly patient. Delirium is one of the oldest
syndromes known to medicine. The word is derived from Latin "de" and
"lira," which together mean "off the track," referring to
the sometimes bizarre behavior associated with the condition.
We certainly don't want to treat patients for problems they do not have, but
it is also not acceptable to miss a critical or a potentially reversible emergency
problem either! Wow! It's not easy being an EMS provider! Many times an accurate
past medical history and a clear history of the present illness may allow you
to reliably tell the difference in the field setting. And, we certainly don't
have the luxury of access to old charts, CT scanners or comprehensive lab testing!
In all reasonableness, we have to keep in mind that it may not be easy to discriminate
between the two all the time without hospital tests or if a reliable history
is not available.
Although alterations in mental function like agitation, confusion and / or
disorientation are signs of both delirium and dementia, they are different.
Delirium is an acute confusional state. It is potentially reversible and has
a treatable cause. Dementia is not. Delirium usually occurs over a period of
days to months. Dementia is slow and insidious. It progresses slowly over months
The evaluation of dementia can be slow and prolonged because the cause is rarely
immediately life-threatening. However, because delirium is usually caused by
an acute illness or drug toxicity, patients with it may worsen rapidly and are
at risk of death unless they are quickly diagnosed and treated. Let's take a
closer look at the similarities and differences between delirium and dementia.
Delirium is an acute confusional state and is typically triggered by an underlying
and potentially reversible problem. Delirium is associated with acute problems
and can result from any of the following examples (see below). Delirium rarely
occurs in the young and middle-aged unless associated with alcohol or illicit
drug use. The incidence of delirium increases progressively with each decade
past the age of 40. (Tueth, 1993) Between 10% and 24% of elderly patients presenting
to the emergency room show signs of delirium; some authors report figures as
high as 80%. (Naughton, 1995) More than 50% of demented patients admitted to
hospitals are delirious on admission. At any one time, 15% of hospitalized patients
over the age of 70 years are delirious.
An estimated 15% to 26% of elderly patients with delirium die, usually as
a result of the underlying pathologic process. (Cole, 1993) Elderly patients
with delirium may also have underlying dementia further complicating determining
the etiology. In fact, dementia is a known risk factor for delirium. As many
as 22% of community-dwelling elderly persons with dementia have coexisting delirium.
"VINDICATE" can help you remember common etiologies:
Common signs and symptoms associated with delirium include: rapid decline in
cognitive function, disturbed intellectual function, disorientation, decreased
attention span, poor recent memory, poor immediate recall, poor judgment, restlessness,
altered LOC, suspiciousness, and perceptual alterations like hallucinations
The cause of delirium, as in other common geriatric syndromes, is usually multifactorial.
The patient's baseline vulnerability and number and severity of other health
issues contribute to the risk of developing delirium Other known risk factors
for the development of delirium in the elderly include: age 65 years or older,
dementia, hospitalization, acute illness or injury, postoperative status, underlying
psychiatric disorder, poor nutrition, acute stress (loss of spouse, change of
living environment, etc.), history of substance abuse and/or active substance
abuse, family history of mental illness, history of serious brain trauma or
disease, cancer, and impaired ambulation or nonambulatory status.
Dementia is a progressive, degenerative disease that develops when the parts
of the brain that are involved with learning, memory, decision making and language
are affected by neurological, vascular, infectious, or metabolic diseases. The
most common cognitive impairment is memory loss, but changes in personality,
loss of judgment, difficulty with problem-solving, and language disorders are
also common--just not as easily recognized. Cognitive function is responsible
for our ability to think, learn and carry out conscious mental tasks. Dementia
is not a normal part of aging and it always has a physical cause. The
most common cause is Alzheimer's disease (now known as Dementia of the Alzheimer's
Type [DAT]), but there are as many as 50 other known causes of dementia. Other
causes include neurological disorders, vascular disorders (such as multi-infarct
disease), inherited disorders such as Huntington's disease, and infections such
Dementia affects 3% to 11% of community-dwelling adults older than 65 years.
The prevalence among those older than 85 years ranges from 20% to 50%, with
fewer cases among community-dwelling elderly and greater presence among hospitalized
and institutionalized residents. Among centenarians, nearly 60% are reported
to demonstrate dementia. However, clinicians fail to detect dementia in 21%
to 72% of patients, especially early in the course of disease or may dismiss
true cognitive impairment for normal aging.
The diagnosis of dementia is based on a thorough history and mental status
examination. Dementia is an acquired disorder with evidence of decline in memory
and intellectual skills from a previous level of function, as demonstrated by
history or cognitive testing. According to diagnostic standards, like the DSM-
IV : Diagnostic and Statistical Manual of Mental Disorders at least two domains
of function, one of which is memory, should be affected, and not explained by
- visuospatial function
Any of these skills may become impaired. Dementia can become severe enough
to interfere with a person’s ability to work and to take care of everyday
tasks such as bathing, cooking, dressing and grooming.
Behavioral Signs and Symptoms in Dementia
The demented patient may present with any of the following behavioral signs
or symptoms. Remember, always rule out the possibility of an acute medical problem
with a reversible or treatable cause to avoid making life-threatening assessment
- Accusations of infidelity; false claims of an amorous relationship with
a significant individual
- Beliefs of personal harm (paranoia)
- Fear of abandonment
- Accusations of theft of one's property
- Claims that persons are not whom they claim to be (spouse is imposter)
- Claims that current residence is not one's home; strangers are living in
- Misidentification of individuals (daughter mistaken for spouse)
- Persons or images from television/other media are real and present in the
home; events are occurring to the patient
How to respond to the elderly patient experiencing paranoia, delusions or
People who have dementia may experience paranoia - irrational suspiciousness
and distrust of others. They may have delusions- fixed, false ideas or beliefs
- even with evidence to the contrary. For example, a person may complain that
you have taken all their money or that someone who is deceased is coming to
see them. They may experience hallucinations - sensory experiences that others
do not have; for example, seeing or hearing something that others do not.
- First, assess if the problem is troublesome or frightening to the person
experiencing it. If not, ignoring may be best approach.
- If a person seems to be hallucinating, leave him/her alone or approach slowly,
so as not to frighten him/her. Respond with caution.
- Don't try to argue or rationalize. Realize that hallucinations and delusions
seem very real to the person who is experiencing them and arguing will not
- Offer reassurance and validation - "I know this is troubling for you,
let me see if I can help."
- Check out the reality of the situation; maybe what they see or think is
- Sometimes things in the environment may be misinterpreted (i.e., glare or
shadow in the window, noisy furnace, etc.) and be frightening. Explain potential
or actual misinterpretation, e.g. that noise is the furnace turning on.
- Modify the environment if needed. (A mirror may become distracting or confusing;
adding more lights may be helpful at night.)
- Assess if the person's hearing or vision needs are met to reduce excess
disabilities that contribute to these problems.
- Remember that whispering or laughing around the person may be misinterpreted.
- If the person has misplaced something and thinks you or someone else "stole
it", offer to help look for the item. Have duplicate items that have
importance, e.g. wallets, glasses.
- Do not take accusations personally.
- Use distraction - activity, conversation, food, music - try to pull the
person's attention from the delusion or hallucination.
- If the person asks you directly if you see or hear something, be honest
but don't struggle to convince or reason with them about what is real.
- Try to respond to what the person may be feeling - insecurity, fear, confusion.
- Rule out any illnesses or medications that could be contributing to these
(Adapted from the Alzheimer's Association Handout: Hallucinations and Delusions
and Understanding Difficult Behaviors, Anne Robinson, Beth Spencer, Laurie White
(1989), Eastern Michigan University.)
As an EMS provider you need to rely upon your clinical assessment. After performing
the initial assessment and stabilizing any problems, perform your routine focused
history and physical assessment. It is absolutely essential to obtain a thorough
The history should include baseline mental status, and any changes in behavior.
Symptoms can be subtle, easily missed, and difficult to evaluate if they fluctuate
throughout the course of the day. Knowledge of baseline function is essential
for determining the extent and rate of sign/symptom changes. Duration of onset
as well as relation to trauma, illness, or change of medication should be detailed.
Fluctuation in condition over time and relation to nighttime worsening or environmental
changes, as well as previous episodes, are also important to ascertain. In addition,
knowledge of the patient's life style, including use of alcohol or illicit drugs,
medications, nutritional status, medical and psychiatric history, and exposure
to infections, is very useful.
Some medications can alert you to existing dementia problems. Cholinesterase
inhibitors are used in treating Alzheimer's dementia (DAT) and are used to improve
cognitive function. Tacrine (Cognex), was the first generation drug and is now
rarely prescribed. Donepezil
(Aricept), is commonly prescribed. Other recently approved drugs include rivastigmine
(Exelon, approved in April 2000) and galantamine
(Reminyl) and physostigmine SR (Synapton) are in development. Potential side
effects of cholinesterase inhibitors include nausea, vomiting, insomnia, anorexia,
dyspepsia, leg cramps, bradycardia, and agitation; however, most patients tolerate
these drugs well.
Treatments are available for dementias due to causes other than DAT. For example,
is used to treat vascular dementias. If your patient is on one of these medications
it may yield clues as to his or her past medical history. Remember though, delirium
can occur in a patient with dementia. Obtain a thorough history of the present
illness to help assess the present problem.
Some examples of helpful assessment questions include:
- Are the cognitive or behavioral changes of recent onset or have they been
developing over a period of months? Do they fluctuate or change during a 24
hour period? (sundowning)
- Has the patient had a change in his or her functional activities?
- What chronic medical problems exist?
- What is the patient's level of alertness?
- Has pt. been drinking enough fluids? Does the urine smell strong? Does the
urine look darker than normal? Is the patient urinating more or less frequently
than normal? UTI are common causes of agitation / sudden behavioral changes
- Does the patient hold or protect a part of his body? Moaning, yelling or
screaming is often not a behavioral problem but a pain problem.
- Ask about bowel habits, constipation, diarrhea.
- Evaluate prescriptions & OTC drug use. 15% of all patients have problems
related to drug interactions and / or polypharmacy.
- Evaluate for other substance use.
Commonly Missed Problems
There are common pitfalls associated with the cause of alteration in behavior,
mood and mentation in the elderly patient. While not inclusive, here are some
things you should evaluate for to prevent making common emergency medical mistakes.
- Influenza, pneumonia and sepsis are leading killers. One of the earliest
and most often missed signs are confusion or a vague change in mood or mentation.
- Sudden or rapid altered mental status is NEVER caused by dementia or organic
brain syndrome (OBS).
- Classic signs of abdominal pain may be masked. Mental deterioration can
affect as many as 20% of those over age 80 adding to the risk of missing an
acute abdomen and acute appendicitis.
- The older the patient the higher the risk for atypical and painless MI.
If the patient also has diabetes or is female, the risk is even greater.
- Hypoglycemia can occur in the non-diabetic patient. The patient may even
be alert and oriented, but simply weak or tired.
- Falling is often a marker of disease rather than due to balance problems
or general frailty.
- Dizziness is NOT normal in elderly, but sway (side-to-side movement) is.
Hearing and/or balance disorders are symptoms that may be associated with
tumors of the cerebellum.
- Polypharmacy related problems and medication toxicity is responsible for
an estimated 30% of hospital admissions each year and one-third of those involve
people over age 60. Ex: drug interactions, digitalis toxicity, overmedication
with sedative agents, aspirin use, etc.
- Major depression and risk for suicide are often misdiagnosed. A high proportion
of successful suicides in the elderly population saw their physicians shortly
before their death. Elderly patients do not usually seek our mental health
providers, but simply see their general practitioner. Four of five persons
age 65 and older with mental illness are treated by nonpsychiatric physicians.
A comparison and contrast of delirium and dementia:
Disturbance in consciousness,
with a reduced ability to focus, to sustain focus or to shift attention
Change in cognition
or the development of a perceptual disturbance that is not better accounted
for by preexisting, established or evolving dementia
Disturbance in sleep-wake cycle
Disturbance in psychomotor behavior
Rapid, unpredictable shifts from one emotional state to another
functioning (e.g., planning, organizing, abstracting)
in social or occupational functioning
from previous level of functioning
fluctuate over course of the day
no fluctuations, but increased agitation or changes at dusk may occur (sundowning)
immediate emergency evaluation
Information from American
Psychiatric Association. Diagnostic and statistical manual of mental disorders.
4th ed. Washington, D.C.: American Psychiatric Association, 1994:124-55,339-50.
Prehospital management has several goals: to identify, treat and stabilize
any emergent problems, to provide supportive care, and to prevent the patient
from harming self and others. The specific treatment will differ for each patient
depending on the acute underlying medical problem. Provide oxygen, perform an
EKG, check the blood sugar and provide any other routine care procedures. Here
are some tips for helping you manage the patient suffering from alterations
in behavior, mood or mentation:
Try to maintain a calm and quiet environment to promote cognitive function.
Speak to the patient in a respectful manner. Speak clearly and allow the patient
time to answer your question. Be patient. If the patient is confused, reorient
him or her frequently and provide explanations for all activities taking place.
Speak to the patient in a face-to-face position. Eyeglasses and hearing aids
should be in place to correct sensory deficits. Presence of the patient's family
members is usually reassuring, and they can often help maintain effective communication.
Family members or close friends will also help you validate information given
by the patient.
Severe agitation and other serious aberrations in behavior can be very difficult
to deal with when trying to perform emergency procedures or keep the patient
safe from harming self or others. Restraint of an elderly patient is rarely
required in the prehospital setting. Interventions such as distraction, talking,
redirecting behavior and other similar techniques are often effective. Make
sure you document that non-physical methods of controlling behavior were tried.
Occasionally, when the patient requires immediate emergency procedures or is
such a danger to self or others restraint may be necessary to complete them
and ensure safety.
It is preferable to avoid physically restraining the agitated patient. When
you must restrain the patient carefully consider the benefits of physical versus
pharmacological restraint. Follow your local patient care guidelines. Contact
medical control if necessary to provide help in determining the appropriate
intervention. Many EMS systems are implementing a a chemical restraint or rapid
tranquilization procedure for severely agitated or violent patients. Sometimes
using a pharmacological agent such as haloperidol or a benzodiazepine agent
like lorazepam are the best choice over physical restraint. Remember that restraining
a confused or agitated patient often just makes the patient more agitated. Fighting
restraints and increasing levels of agitation are exhausting to the patient
and can negatively impact respiratory efforts. An example of a serious complication
that could occur in a sick patient who is fighting physical restraint and then
becomes tachycardic is an onset of acute pulmonary edema!
When the choice is made to perform a rapid tranquilization you will want to
be certain that you administer the least harmful drug in the smallest dose possible.
A clearly written prehospital patient care guideline can outline the procedure
and prepare you for any complications that may occur. Once a patient is sedated
or chemically restrained in the field, the Emergency Department's assessment
will be hampered. If the situation allows, consider obtaining a "Mini-Mental
Status Assessment" (Folstein, 1975) or some other comprehensive, but
brief, baseline prior to medicating the patient. Talk to your medical control
physicians and agree on one assessment tool you can use to obtain an assessment
that is a little more in depth than a AVPU or a Glasgow Coma Score.
What medications are appropriate for chemical restraint for the elderly patient?
Neuroleptics and benzodiazepines have been routinely used in emergency practice
to control agitation associated with delirium. Neuroleptics have been reported
to have better calming effects than benzodiazepines in acutely agitated patients.
is a neuroleptic that is very effective, works quickly, has a short half-life
and low incidence of anticholinergic side effects in the elderly. It