Table 1: Comparing Characteristics of Dementia, Depression, and Delirium Characteristic Dementia Depression
Delirium Sudden.
Symptom onset
Slow.
Usually gradual, although onset may be associated with crisis/ event.
Early symptoms
Memory loss.
Anhedonia (lack of joy).
Fluctuating mental status.
Level of consciousness
Normal until late in disease.
Normal (although likely subdued). Skills intact, but may be noncommunicative.
May present as lethargic, hyperactive, or alternating. Disorganized, illogical, tangential. Varies, may appear to have short-term memory loss.
Speech and language
Anomia, slow processing, decreased initiation. Significant short-term memory loss; may have long-term memory loss.
Memory
Normal, although decreased attention and interest can be mistaken for memory loss.
Nighttime effect
May be worse (sundowning).
May impact sleep cycle.
Often worse.
Lucid intervals
Not usually (only early in disease).
Generally lucid.
May have periods of lucidity.
Hallucinations
More likely with LBD than AD or vascular dementia.
No.
Possibly, may be vivid.
Note. From Western Schools, 2020.
Consider the following case study: Clara is an 82-year-old woman with mild-moderate dementia admitted 3 days ago to your subacute rehab unit; her status is post open reduction internal fixation for a right femoral shaft fracture. The fracture was the result of a fall in her home where she reportedly tripped over the cat. She has always been fit and active. She lives with her husband in a one-level home. Her two adult children live nearby and are very supportive. They regularly visit and take Clara for outings in the community. Past medical history includes: Alzheimer’s disease diagnosed 4 years ago, hypertension, hyperlipidemia. Medications : ● Donepezil/Aricept 5 mg. ● Simvastatin/Zocor 10 mg. ● Carvedilol/Coreg 3.125 mg. ● Paracetamol/Tylenol 500 mg prn. Weight bearing status : Weight bearing as tolerated right lower extremity. Pain : Appears to be well-managed. Upon PT examination on the day of admission, Clara presented with a baseline state of mild confusion, but she was pleasant and cooperative and expressed she was anxious to return home with her family. She was motivated and participatory with therapy and able to follow one-step commands. Transferring sit-to-stand and stand-to-sit required minimal assistance and she successfully trained with a rolling walker with contact guard and cues to walk 20 feet, weight bearing as tolerated on the right lower extremity. Initial impressions suggested she would be in the subacute setting for no longer than a week and would be ready for discharge to home with home care follow-up. Over the past 2 days, the therapist notices she is more confused and withdrawn than her baseline. She appears somewhat lethargic and disorganized in her thought expression. She is now requiring minimal to moderate assistance for transfers and has not improved in her ambulation status; she doesn’t seem less stable, just doesn’t seem to making progress. Nursing and support staff have not been consistent, so there is no other individual providing the continuity of care who can compare Clara’s current status to her admission status. Clara’s
husband visits and remarks that he is worried her Alzheimer’s is progressing because last night she reported seeing forest animals in her room. Questions 1. What are possible causes of Clara’s declining status? Given the specifics of the case, what is the most likely culprit? 2. What is the role of the therapist in facilitating optimal care? What is the next step? Responses 1. Clara’s declining status could be caused by the following: a. Progression of dementia : This is an unlikely cause, as the rapid change in her status over the course of a few days is contrary to the typical slow, steady course of Alzheimer’s dementia. b. Depressive episode : This is possible, but unlikely, given the specific characteristics of Clara’s behavior. While depression can lead to social withdrawal and could be perceived by others as lethargy, the disorganized thought and hallucinations are not typical of depression. c. Normal pressure hydrocephalus : This is possible, but the clinical picture does not match the classic 3 Ws of NPH: wet (incontinence), wild (uncharacteristic behavior), wobbly (unsteady gait). Clara is showing none of these signs. d. Delirium : This is the most likely of causes, given the rapid onset, the lethargy, the disorganized thinking, and the hallucinations. 2. Suspecting delirium, the therapist approaches the medical team to suggest/discuss appropriate workup to reveal what might be causing the episode. Medications are often implicated in delirium, so an immediate review of Clara’s medication list is in order. The only medication that is new to her is the Tylenol, which is unlikely to interact with her other medications to cause these cognitive side effects. Infection/ sepsis is another common cause of delirium, with urinary tract infections being a common source. Urinalysis and blood work reveals this to be the case and Clara is treated with a course of IV antibiotics. Within 24 hours of treatment, she is back to her pleasant, motivated self and ready to participate in physical therapy.
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