Don't Just Blame It On Old Age! Differentiating Delirium and Dementia in the Elderly


Author: 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 emergency.

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 to years.

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

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. (Naughton, 1995)

The mnemonic "VINDICATE" can help you remember common etiologies:

Vascular
Infections
Nutrition
Drugs
Injury
Cardiac
Autoimmune
Tumor
Endocrine

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 and delusions.

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

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 as HIV.

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 another cause:

  • language
  • perception
  • visuospatial function
  • calculation
  • judgment
  • abstraction
  • problem-solving.

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 errors.

  • 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 the house
  • 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 hallucinations

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 build trust.
  • 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 true.
  • 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 problems.

(Adapted from the Alzheimer's Association Handout: Hallucinations and Delusions and Understanding Difficult Behaviors, Anne Robinson, Beth Spencer, Laurie White (1989), Eastern Michigan University.)

Assessment Considerations

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 history.

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, ticlopidine (Ticlid) 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:

  1. 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)
  2. Has the patient had a change in his or her functional activities?
  3. What chronic medical problems exist?
  4. What is the patient's level of alertness?
  5. 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
  6. 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.
  7. Ask about bowel habits, constipation, diarrhea.
  8. Evaluate prescriptions & OTC drug use. 15% of all patients have problems related to drug interactions and / or polypharmacy.
  9. 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:

Delirium Dementia
Onset Rapid Slow and Progressive
Reversibility Potentially reversible Usually not reversible
Deficits

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

Associated features:
Disturbance in sleep-wake cycle
Disturbance in psychomotor behavior
Emotional disturbance
Rapid, unpredictable shifts from one emotional state to another

Impaired executive functioning (e.g., planning, organizing, abstracting)

Significant impairment in social or occupational functioning

Significant decline from previous level of functioning

Etiology Drugs, systemic illness Alzheimer's, vascular
Course Disturbances fluctuate over course of the day Often no fluctuations, but increased agitation or changes at dusk may occur (sundowning)
Urgency Needs immediate emergency evaluation Non-urgent

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. Copyright 1994.

Management

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. (Gerstein, 2001)

Haloperidol (HaldolĀ®) 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