**TABLE 8-1** Comparison of Delirium, Dementia, and Depression
	Delirium	Dementia	Depression
Onset	Sudden, rapid	Insidious, gradual	Usually develops over days to weeks
Course	Fluctuates over hours to days	Progression over 8 to 10 years	Variable; 4 months or longer if untreated
Cognition	Acutely disrupted; may change rapidly	Chronic, progressive deterioration	Generally intact; slowed, distorted
Behavior	Mixed agitation and lethargy	Psychomotor restlessness, wandering, apathy	Psychomotor retardation or agitation
Sleep/wake cycle	Disturbed; caused by symptom fluctuation	Widely variable; may mistake night for day (differential variation)	Variably disturbed; insomnia, hypersomnia, early-morning awakening
Defining characteristics	Fluctuating levels of consciousness and cognition; impaired short-term memory	Memory impairment (short-term/long-term global memory loss)	Depressed mood, anhedonia
Diagnosis	Difficult to diagnose; often missed or misdiagnosed	Delayed because of gradual progression of symptoms	Readily recognizable by professional
Treatment	Acute Identification/treatment of cause Alleviation of symptoms	Early stages: medications to prolong onset Late stages: complete client support; caregiver education/support	Suicide prevention Antidepressants Cognitive-behavioral therapy Client support Family education
Prognosis	May be reversible if recognized	Irreversible (Alzheimer’s type): steady, slow decline to death	Remission in majority of clients
Prognosis	May be reversible if recognized		May recur

Early recognition of delirium by nurses and other medical professionals is key in the prevention and treatment of delirium. Risk factors for delirium include the following:

▪ Accidental or intentional poisoning

▪ Elderly clients

▪ Recent major surgery

▪ Preexisting cognitive dysfunction

▪ Multiple drug therapy, especially polypharmacy of high-dose psychotropic drugs

▪ High doses of hypnotics

Delirium is a prevalent disorder. Study results vary because of the different populations studied who develop delirium, including children who swallow poisons or have high fevers, adolescents or adults who abuse drugs, and elderly persons who are hospitalized for surgeries or who have dementia. Depending on the study, estimates for elderly clients who are hospitalized for acute physical illnesses and then develop delirium range from 14% to 80%. Clients who have delirium while hospitalized have longer hospital stays than those without delirium, experience greater decline in function, and have higher rates of nursing home admissions. Hospital mortality rates for clients who have delirium are high. The belief that delirium is rapid, transient, and temporary sometimes is a myth. Approximately two thirds of elderly clients who experience delirium while hospitalized demonstrate the symptoms after discharge. More than half of these clients live alone and are expected to carry out postdischarge medical and nursing orders in addition to their daily activities while in this compromised state. In addition, the cost of caring for clients who are delirious is increased because of the need for more demanding and continuous intervention from staff or other caregivers.

Dementia

Dementia of the Alzheimer’s type is the most prevalent dementia. The onset and course for this disorder is slow, insidious, progressive, and terminal. It usually takes 8 to 10 years from onset of symptoms to death; however, some individuals live for 15 years or more with this stealthy, relentless thief of life.

The trend of lengthening life span will continue throughout the twenty-first century. By 2010, approximately 300 million people will live in the United States, 15% of whom will be older than age 65. Alzheimer’s-type dementia, one of the diseases most dreaded by elderly persons, their families, and the government, will strike 8% to 15% of those older than age 65. That number doubles every 5 years after age 65. Costs of caring for clients with dementia are currently estimated at more than $100 billion annually, and costs will continue to increase.

The recent Surgeon General’s Report on Mental Health states that education, measured by number of years of schooling, is a reliable predictor of late-life cognitive functioning. Highest percentages of Alzheimer’s-type dementia occur in those with the least number of years of education. Also, those with higher education who remain cognitively active and engaged in their environment and life interests have less incidence or have symptoms later in life.

Amnestic and Other Cognitive Disorders

Onset and course for amnestic and other cognitive disorders vary widely depending on the primary cause. For example, traumatic brain injury, sudden stroke, or neurotoxic poisoning from any source may erupt into an acute amnestic syndrome. On the other hand, chronic alcoholism, other prolonged drug abuse, malnutrition, or continuous exposure to toxic chemicals over an extended period usually results in a more insidious onset and persistent course. Amnestic disorder may be temporary, as in a brain injury from which the individual may fully recover, or permanent, as in individuals who chronically abuse alcohol and fail to eat a nutritional diet.

ASSESSMENT AND DIAGNOSTIC CRITERIA

A shared symptom in delirium, dementia, and amnestic disorders is memory impairment. As noted, making a definitive diagnosis within this category of disorders may be difficult, and a thorough assessment helps to distinguish the cause of delirium (Box 8-3). The disorders differ in regard to additional symptoms that accom-pany memory disturbance, defining characteristics, and in some cases etiology (see DSM-IV-TR boxes).

BOX 8-3

Delirium Assessment

Physiologic assessment is based on the following workup:

▪ Vital signs/electrocardiogram (ECG)/oxygen saturation

▪ Pain (as fifth vital sign)

▪ Medication/alcohol/substance use history (see Chapter 9)

▪ Neurologic examination

▪ Mental status examination

▪ Step-by-step physical examination by organ system

▪ Electroencephalogram (EEG)

Vital signs/ECG offer a baseline of the client’s physical status (e.g., blood pressure, cardiac problems).

Medication/alcohol/substances can contribute to the client’s delirium and confusion.

Neurologic examination can rule out a stroke or transient ischemic attack (TIA). Examination of the cranial nerves and extraocular (eye) movements can reveal neurologic impairment. Older adults with cataracts are at risk for delirium, which is why patching one eye at a time prevents “black patch” delirium.

Mental status examination can rule out depression and other treatable mental disorders. Persons with delirium or acute confusion are often distracted during this examination, whereas persons with dementia struggle to come up with answers that they often nearly miss.

Step-by-step physical examination by organ system searches for metabolic disturbances: cardiovascular and pulmonary (arterial blood gases, chest radiograph, oxygen saturation/hypoxia), renal (electrolyte imbalance, uremia, dehydration), endocrine (thyroid panel, diabetes, glucose, calcium), and liver (hepatic function tests). A search for infection (sepsis, occult abscess, meningitis, urinary tract infection, pneumonia) is critical.

EEG may be normal in dementia but is often abnormal in delirium (shows diffuse slowing); therefore it is a very sensitive test for identifying delirium, although not necessarily pinpointing a cause. EEG abnormalities may show different patterns (low amplitude, fast activity) in alcohol withdrawal and sedative-hypnotic withdrawal. EEG abnormalities may continue after the clinical symptoms of the brain syndrome are gone.

N ote: Finding the underlying cause of delirium or confusion is important for treatment to be effective. Although there are many causes, the assessment process is consistent.

Delirium

The defining characteristics of delirium are disturbances of consciousness and cognition. Delirium typically occurs over a short period, usually hours or days, and levels of consciousness fluctuate without following a set pattern, as evidenced by increased or decreased awareness of the environment. Ability to focus, sustain focus, or voluntarily shift attention is greatly impaired; therefore the client may be easily distracted by any stimulus or may be unable to refocus attention away from a task or thought if asked. The client may become comatose.

In regard to the common symptom of impaired memory, recent memory is affected in delirium. For example, when asked to remember a specific item, the client may be unable to recall it after only a few minutes. The client may repeat within minutes what he just told the nurse. The client may ask, “When will the doctor be here?” after the physician has just left.

Disorientation usually occurs in regard to time. For example, the client may arise in the middle of the night and start to dress for breakfast. The client may tell the nurse he is going to sleep for the night when it is noon.

Language and speech disturbances vary widely, as evidenced by impaired ability to articulate (dysarthria), to name objects (dysnomia), or to write (dysgraphia). The client may ramble or may be completely unable to communicate through speech, writing, or signs (aphasia). Aphasia may be sensory (receptive) or motor (expressive).

DSM-IV-TR

American Psychiatric Association
Delirium

Delirium due to a general medical condition (name condition)

Substance-induced delirium

▪ Substance intoxication delirium

▪ Substance withdrawal delirium

Delirium due to multiple etiologies (e.g., cardiac failure, sedative intoxication)

Delirium not otherwise specified

DSM-IV-TR

American Psychiatric Association
Dementia

Dementia of the Alzheimer’s type (early onset by age 65)

▪ Uncomplicated

▪ With delirium

▪ With delusions

▪ With depressed mood

Dementia of the Alzheimer’s type (late onset after age 65)

▪ Uncomplicated

▪ With delirium

▪ With delusions

▪ With depressed mood

▪ With depressed mood

Dementia due to HIV disease

Dementia due to head trauma

Dementia due to Parkinson’s disease

Dementia due to Huntington’s disease

Dementia due to Pick’s disease

Dementia due to Creutzfeldt-Jakob disease

Dementia due to other general medical conditions

Substance-induced persisting dementia

Dementia due to multiple etiologies

Dementia not otherwise specified

Sensory-perceptual disturbances are common in delirium and may manifest as illusions (e.g., thinks slippers are rodents), hallucinations (e.g., hears voice of dead mother, sees people who are not actually there walk into the room), or misinterpretations (e.g., thinks loud noise in hallway was automobile accident). Delusional thinking may develop around the sensory disturbances as the individual attempts to make sense of the changing symptoms.

Associated behavioral disturbances frequently follow cognitive disturbances and range from psychomotor hyperactivity (e.g., restlessness, pacing, screaming, cursing) to psychomotor hypoactivity (e.g., lethargy, inability to move from bed or chair, moaning).

Emotional disturbances usually occur in delirium. Labile moods with rapid, unpredictable changes from one mood state to another, often without provocation, are common. Shifts among anxiety, depression, irritability, elation, agitation, and fear may occur in no set pattern.

Sleep pattern disturbances frequently occur in delirium. The sleep/wake cycle may be completely reversed, with the client unable to fall asleep at night, lying awake and agitated, then sleeping all day long. In the phenomenon called sundown syndrome, the client is relatively alert and has marginally intact cognition, then suddenly becomes confused, agitated, and restless as night approaches. Symptoms may be triggered by changes in light and other environmental stimuli coupled with fatigue at the end of the day and compromised age-related senses (decreased vision/hearing). Sundown syndrome occurs frequently in clients who have dementia. Delirium may also be superimposed on dementia.

Dementia

The defining characteristics of dementia are multiple cognitive deficits, especially memory impairment, and one or more of the following: aphasia, apraxia, agnosia, and impaired executive function.

As with delirium, symptoms for dementia are directly related to either a medical condition, ongoing effects of a substance, or a combination of the two. All symptoms represent a decline from previous function and interfere with social function (e.g., family, friends, organizations) and occupational function (e.g., job, homemaker).

The symptoms of dementia are progressive and develop slowly through four stages (Box 8-4). As a result, clients frequently cover up the symptoms as they deny the inevitable and attempt continued functioning. Close family members are usually aware of changes long before casual acquaintances, who may argue that the client “seems normal.”

BOX 8-4

Stages of Dementia

STAGE 1

Client:

▪ Demonstrates minor short-term memory problems.

▪ Displays subtle mental and physical decline.

▪ Covers up errors.

▪ Has difficulty focusing attention.

▪ Starts to lose interest in environment, events, and situations.

▪ Demonstrates deterioration of social courtesies.

▪ Becomes uncertain in actions.

▪ Probes for right words.

▪ Shows difficulty making decisions.

STAGE 2

Client:

▪ Demonstrates obvious memory deficits.

▪ Hesitates with verbal initiation or responses.

▪ Is disoriented to time.

▪ Complains of neglect.

▪ Forgets appointments, routines, and events.

▪ Accuses other clients of stealing.

▪ Hides possessions, then forgets location.

STAGE 3

Client:

▪ Demonstrates severe memory loss.

▪ Is disoriented to time, place, person.

▪ Displays motor deterioration.

▪ Wanders, then cannot find way back.

▪ Licks lips; uses chewing motions.

▪ Becomes hyperoral.

▪ Demonstrates immodest behavior.

▪ Has unsteady gait; shows physical incompetence.

▪ Displays poor communication; repeats words.

▪ Cannot read or write.

▪ Does not recognize self in mirror.

▪ Needs help with all daily activities.

▪ Has catastrophic reactions.

STAGE 4 (TERMINAL STAGE)

Client:

▪ Demonstrates global memory loss.

▪ Displays ataxic movements.

▪ Demonstrates psychotic behavior.

▪ Displays extreme psychomotor retardation.

▪ Recognizes no one.

▪ Needs complete assistance.

▪ Cannot eat; tube-fed.

▪ Becomes susceptible to infection.

▪ Loses weight.

▪ Is incontinent.

As in delirium and amnestic disorders, the hallmark symptom for dementia that must be present to make the diagnosis is impaired memory, which is described as (1) inability to learn new material or (2) inability to recall previously learned material. Clients with dementia usually have both deficits. At first, long-term memory often is retained as clients begin to forget immediate events, situations, and everyday routines. In early stages they forget appointments, where they put the car keys, or where the car is parked after shopping. This progresses to inability to remember their birthday or how to return home from a local familiar place, which causes fright and anxiety. Progressively, the client fails to identify relatives or own name, eventually experiences global memory loss, and is unable to recall either remote or recent events or situations.

Mild cognitive impairment(MCI) describes early neurocognitive dysfunction in which the person can still compensate for deficits in memory, executive function, (making plans, balancing checkbook), attention, language, and perceptual motor ability (integration of information with motor activity). Several studies are in progress for MCI because 15% to 20% of these clients develop dementia of the Alzheimer’s type (Surgeon General’s Report on Mental Health, 1999).

Speech and language deteriorate noticeably through-out the course of dementia, and aphasia develops. An extensive vocabulary acquired over a lifetime diminishes as the disorder progresses. When describing events, the client cannot think of appropriate words and begins to call many items “that thing” or may use extraneous words while searching for the right ones. Poverty of speech occurs, and sometimes unusual patterns of speech occur. For example, the client may repeat words of the person talking to them (echolalia). Eventually all speech may disappear and the client becomes mute.

Another symptom that occurs in dementia is apraxia, referring to the inability to use objects correctly or perform intentional motor function and purposive movements, even though comprehension and sensorimotor systems are intact. The client may name objects correctly (fork, shoes, comb) but may be unable to use them as intended.

The loss of ability to recognize, comprehend, and identify objects is known as agnosia. The client’s vision and sensorimotor systems may be intact, but the client may be unable to name specific indicated objects (e.g., light, table, flowers). As the disorder progresses, the client is unable to recognize own spouse or even own image in a mirror.

Disturbance of executive function refers to the inability to carry out higher-level thinking such as planning, organizing, initiating functions, performing tasks in a new way, or sequencing objects or tasks. Clients also have difficulty thinking abstractly. For example, clients find they are unable to take care of finances, organize a trip, or comprehend and participate in discussions unless the topics are concrete.

Sensory-perceptual alterations frequently occur in the later stages of dementia. Psychotic symptoms may manifest as hallucinations, delusions, or illusions.

All symptoms of dementia represent a decline from the client’s usual or normal functioning and culminate in an inability to participate in life that eventually leads to death. In addition to cognitive impairments, multiple physical symptoms arise as part of the progressive decline (see Box 8-4).

N ote: Delirium may occur in dementia.

Amnestic and Other Cognitive Disorders

The defining characteristic of amnestic disorder is impaired memory directly related to effects of a general medical condition or to ongoing effects of one or more substances (drugs of abuse, medications, toxins), or a combination of the two. The ability to learn and recall new information is always impaired in amnestic and other cognitive disorders. Depending on the areas of the brain affected, clients are unable to recall verbal or visual information that was communicated a few minutes before. Recent memory is impaired. Remote memory is frequently intact; the client is able to remember stories from the distant past, but may be unable to tell the nurse how he got to the health care facility, who brought him, or the name of the agency. The client may confabulate (create information to fill in memory gaps) in early stages of amnestic disorder.

Disorientation to person and place is common in amnestic and other cognitive disorders; disorientation to self is usually associated with dementia. Because of lack of insight in amnestic disorder, the client with severe memory impairment may become argumentative when confronted, even though situational facts and events confirm the memory deficit.

INTERVENTIONS

For effective intervention with delirium, dementia, and amnestic and other cognitive disorders, it is imperative to determine the correct diagnosis, which is often missed. Also with this category of disorders, where one diagnosis may be superimposed on another, the examiner must conduct a careful complete history, physical examination, and mental status assessment (including diagnostic laboratory tests) to determine the correct treatment focus. Because of the nature of the symptoms in these disorders, it is usually necessary to interview the family or others who are close to the client to validate that information is correct.

In addition to targeting specific causes, if found, the nurse focuses on (1) symptom alleviation; (2) preven-tion of mental and physical complications; (3) main-tenance of fluid, electrolyte, and nutritional balance; and (4) therapeutic interpersonal support of the client and family.

Treatment Settings

Medications

A variety of medication types are employed to treat these complex disorders. In general, the medications used depend on the symptoms, as well as the underlying cause or causes. Effective results of medication often rely on early detection, in which case the disease process may be slowed. A common rule of thumb for older adults is to begin drug therapy with low doses and proceed slowly with additional medications. Polypharmacy (use of multiple medications) and drug-to-drug interactions can cause confusion or agitation and result in falls or increased risk of falls. For more complete information, refer to Appendix H.

Other Treatments

Support of physiologic function for this population is an ongoing and primary objective for nurses. Because of the symptoms, clients are often unable to effectively communicate their needs. Nurses must be vigilant and observant for physical problems with these clients. For example, the nurse may misinterpret and falsely report physical pain as lethargy, inactivity, depression, agitation, or behavioral acting out when the client does not fully comprehend the problem and is unable to communicate the pain. Effective skills for assessment and alternative communication are essential to meet client needs, which are often unspoken but usually communicated in some way by the client. Box 8-5 presents a general set of strategies for working with these clients.