Updated: 9/14/2018

Delirium vs. Dementia

Review Topic
  • A 68-year-old patient presents to your service brought in by EMS from his retirement home.  He was found non-responsive by his nurse which prompted him to be brought in.  When you examine the patient you find a fiesty, responsive elderly gentleman who is alert and oriented x2 (he thinks it is 1940).  When you revisit the patient the next day he is difficult to arouse and responds with only incoherent grunts and keeps trying to sleep.  Patient has no significant past medical history and is on oxybutinin, lorazepam PRN for anxiety at night, and aspirin 81 mg.  Of note patient's hearing aid was broken recently in a rough game of dominoes.
  • Acute onset change of consciousness with waxing and waning 
    • ↓ attention span
    • ↓ level of arousal
  • Characterized by 
    • acute changes in mental status
    • disorganized thinking
    • hallucinations (often visual)
    • illusions
    • misperceptions
    • disturbance in sleep-wake cycle
    • cognitive dysfunction
    • abnormal EEG
  • Most common psychiatric illness on medical and surgical floors
    • drugs 
      • anticholinergic effects  
      • benzodiazepines 
    • other causes include CNS disease, infection, trauma, withdrawal, and substance abuse
    • often reversible
  • Common causes
    • infection
    • UTI
    • URI
    • medications
    • substance abuse
    • alcohol
    • drugs
    • urinary/fecal retention
  • Management
    • treat the underlying cause
    • supportive measures
      • fluids
      • VDRL/RPR
      • B12 levels
      • thiamine, niacin, folate levels
      • TSH
      • depression screen
  • A 76-year-old patient is brought into your office by his son.  The son claims that about 3 years ago his father had to move in with him since he was having trouble paying his bills and maintaining his house.  This past year he states that his father is now having trouble dressing himself, and sometimes wanders away and can't find his way home.  He can no longer bathe himself either which prompted the son to bring in the father.  On physical exam you find an elderly, unshaven gentleman who is alert and oriented x2 (not sure of the date).  The patient is able to answer some questions, but cannot remember where he lives, or why he is at the doctor currently.
Major Neurocognitive Disorder
  • Major neurocognitive disorder (DSM-V)
    • formerly dementia and amnestic disorders under the DSM-IV
    • can be subcategorized into major and minor neurocognitive disorder
      • difference in diagnosis is arbitrary, but allows for stratification of severity of symptoms
  • Gradual loss in cognition
    • NO CHANGE in level of consciousness
    • memory loss is present
    • symptoms are NOT fluctuating in a rapid fashion
  • Characterized by
    • memory deficits
    • aphasia
    • apraxia
    • agnosia
    • loss of abstract thought
    • behavioral/personality changes
    • impaired judgment
    • no loss of alertness
    • ↑ incidence with age
    • normal EEG
  • Caused by
    • Alzheimer's disease
    • thrombosis/hemorrhage
      • can have acute onset / step-wise progression
    • HIV
    • Pick's disease (fronto-temporal dementia) MRI demonstrating frontotemporal degeneration in Pick's disease
    • Lewy-bodies (Parkinson's dementia) Lewy Body dementia - Lewy bodies
    • substance abuse (neurotoxicity)
    • CJD CJD - Spongiform change
  • Diagnostic tests
    • B12, thiamine, folate, niacin levels
    • VDRL/RPR
    • TSH
    • screen for depression
    • rule out metabolic cause (CMP)
  • Depression may present as dementia in elderly patients
    • known as pseudodementia

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

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(M1.PY.28) A 78-year-old male has been hospitalized for the past 3 days after undergoing a revision left total hip replacement. Over the past several hours, the nursing staff reports that the patient has exhibited fluctuating periods of intermittent drowsiness and confusion where he has been speaking to nonexistent visitors in his hospital room. The patient's daughter is present at bedside and reports that the patient lives alone and successfully manages his own affairs without assistance. Which of the following is most likely true of this patient's current condition? Review Topic

QID: 100028

Anticholinergic medications may alleviate his symptoms




Beta-amyloid plaques and neurofibrillary tangles are pathologic findings associated with this condition




Short-term memory is often impaired, with sparing of remote memory




The condition is typically irreversible, representing a common complication of aging




Possible etiologies include infection, trauma, or polypharmacy




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