General overview of confusion in elderly General - DDx: o Delirium o Dementia o Depression o Psychoses - Assume delirium until another cause

identified - Common problem in people > 65yo - Acute OR Chronic and Progressive Delirium - Definition o Transient global disorder of cognition and consciousness o Reversible if treat underlying condition - Causes o Metabolic disorders electrolytes, hypoxia, hypoglycaemia, azotemia o Infections o Decreased cardiac output o Stroke small cortical o Medications o Intoxication - Risk factors o >65yo o Demented o Hospitalisied o Post-operative o Poor nutrition o Hx of substance abuse o Hx of brain trauma o Underlying psychiatric disorder Diagnostic features of delirium o ALOC + decreased ability to focus or maintain attention o Change in cognition or perceptual disturbance which is of new onset o Develops over short period of time + fluctuates during course of day o Hx. Physical exam, lab tests disturbance is direct physiological consequence of a general medical condition, substance intoxication or withdrawal, medication or toxin exposure, or a combination of these factors o Associated features Disturbance in sleep-wake cycle Disturbance in psychomotor behaviour Emotional disturbance Rapid, unpredictable shifts from one emotional state to another

Dementia - Definition o Decline in intellectual functioning to the extent that the patient is unable to perform the usual activities of daily living o Memory deficit large component - Causes o Reversible Thyroid dysfunction Vit B12/folate deficiencies Infections neurosyphilis Metabolic abnormalitie o Irreversible Alzheimers Vascular Parkinsons Picks disease HIV infection Huntingtons - Diagnostic features of dementia o Memory impairment and at least one of the following: Aphasia difficulty understanding or articulating words Apraxia difficulty in performing voluntary movements Agnosia loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss o Impaired executive functioning e.g. planning, organizing, abstracting o Significant impairment in social or occupational functioning o Significant decline from previous level of functioning Depression - Diagnostic features o Occurrence of five or more of the following for at least 2 weeks (a change from prior function; one sx must be either depressed mood or loss of interest or pleasure): Depressed mood Decreased interest or pleasure in most activities (anhedonia) Change in weight and appetite Insomnia/hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excess guilt Diminished ability to concentrate or make decisions Recurrent thoughts of death or suicidal ideation, attempts or plans

Diagnostic approach to the confused elderly patient History o Questions to ask? Are the cognitive or behavioural changes of recent onset or have they been developing over a period of months? Has the patient had a change in his or her functional activities? What chronic medical problems exist? What is the patients level of alertness? o Family plays a big role in provifing hX Dementia Gradual onset Chronic illness progresses over years Usually irreversible and progressive Disorientation later (after mon-yrs) Generally stable Less prominent physiologic changes Consciousness changed later Attention span not characteristically affected Disturbed sleep wake cycle day-night reversal Late psychomotor changes Depression Abrupt onset Short duration Previous psychiatric Hx Complains of memory loss I dont know answers Fluctuating cognitive loss Equal memory loss for recent and remote events Depressed mood (if present) occurs present

Delirium Abrupt onset Acute illness days-weeks Usually reversible Disorientation early Mental status fluctuates throughout day Prominent physiologic changes ALOC Short attention span Disturbed sleep-wake cycle hr-to-hr variation Marked psychomotor changes Dementia Gradual onset Long duration No psychiatric Hx Often unaware of memory loss Near-miss answers Stable cognitive loss Memory loss greatest for recent events Memory loss occurs first Medication review o Polypharmacy o Meds a/w confusion Analgesics Pyschotropic drugs Hypnotics Antihistamines Antihypertensives Antimicrobiuals Antiparkinsonian drugs Cardio drugs Hypoglycaemics

Physical examination o Distinguish between neurologic and psychiatric disorders o Examinations Cardiovascular Neurologic Psychiatric o Components required Level of arousal Orientation Focal neurologic signs Mental status examination o MMSE Evaluates Orientation Registration Attention Memory Language Scores <24 = abnormal o Not diagnostic but reflects severity of cognitive impairment Adjustments Educational bias o Short portable mental status questionnaire (SPMSQ) Advantages Quick Easy to adminster Assess orientation, mathematic skills and short- and long-term memory o EEG Detect patterns of characteristic of delirium Lab tests/imaging o FBC o BSL o EUC o LFTs o MCS blood (if shows signs of sepsis) and urine o Toxicology screen o CT/MRI