Could you recognize the signs and symptoms of delirium, as opposed to depression and dementia in your elderly patient? While all three can coexist simultaneously, the ability to differentiate can be difficult and is of great importance when working with older adults. Delirium in older adults is commonly undiagnosed, misunderstood, and responsible for unnecessary hospitalizations. It is estimated that delirium affects 14% to 56% of all hospitalized elderly patients. Each year in the US, at least 20% of the 12.5 million patients over the age of 65 experience some form of complication due to delirium.1

Delirium can be defined as a transient mental disorder causing a sudden and rapid change in cognition, lasting from a few hours or up to a few months. Clinical features of delirium include a reduced ability to focus on an external stimulus, inability to shift attention to a new external stimulus, and disorganized thinking which is manifested by rambling or incoherent speech.2 Symptoms of delirium can be classified as hyperactive, hypoactive, or a mixed combination of both. Common symptoms can include: a reduced awareness of their environment, decreased activity level, poor short-term memory, disorientation, difficulty speaking or understanding speech, anxiety, apathy, fear, aggression or anger, restlessness, sleep disturbance, and lethargy. While these symptoms can fluctuate, they are often absent during the day, but worsen in the evening.3

Dementia is a neurocognitive disorder characterized by a slow gradual onset of reduced ability to reason and make sound judgments, loss of social skills, and development of regressed or antisocial behaviors.2 Common forms of dementia include Alzheimer’s disease, frontotemporal lobe or Pick’s disease, Lewy body dementia, vascular dementia, Parkinson disease, Creutzfeldt-Jakob disease, and Wernicke-Korsakoff syndrome. Signs and symptoms of dementia include memory loss, executive dysfunction, wandering, abnormal gait, falls, impaired visual spatial ability, apraxia, agnosia, and depression.3,4

Depression is a mood disorder characterized by a slow gradual onset that can cause cognitive issues and affects the way an individual feels and behaves.3 Depression can be classified as clinical depression or depressed mood depending on the presentation and duration of symptoms. Common signs and symptoms of depression include persistent feelings of sadness, withdrawal, unexplained weight loss or gain, sleep disturbance, anxiety, fatigue, trouble concentrating, and thoughts of death or suicide.3,5 Psychiatrist Dr. Bonnie Wiese states, “older persons may demonstrate apathy, fatigue, somatic complaints, sleep disturbances, anger out of proportion to incident, and other atypical presentations rather than tearfulness or sadness.”5 These atypical presentations should be considered when working with the older adult population.

As clinical professionals, it is our duty to identify these signs and symptoms as early as possible. Recognizing the onset, duration, and course of these symptoms will help in determining if they are caused by delirium, dementia, or depression. If symptoms fall outside of your professional scope of practice, a referral should be made to the patient’s primary care physician, neurologist, or neuropsychologist.

References

  1. US Department of Health and Human Services. CMS statistics. Washington, DC: Centers for Medicare and Medicaid Services; 2004. (publication no. 03445)
  2. Staples W, Heitzman J, Kegelmeyer D. Geriatric Physical Therapy. New York: McGraw-Hill; 2016.
  3. Marshall, Katherine DNP, NP, PMHCNS-BC, CNE; Hale, Deborah MSN, RN, ACNS-BC Delirium, Dementia, and Depression, Home Healthcare Now: October 2017 - Volume 35 - Issue 9 - p 515-516
  4. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220. doi:10.1038/nrneurol.2009.24
  5. Harris M. Cognitive Issues: Decline, Delirium, Depression, Dementia. Nurs Clin North Am. 2017;52(3):363-374.

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