● Imbalances in intake (dehydration, renal failure, hyponatremia). ● Long-term care admission. ● Pain (acute or chronic). ● Stress (acute or chronic, notable risk during loss or bereavement). ● Substance use and alcohol withdrawal (alcohol is greatest offense). Known causes that induce acute delirium include the following (Sadock et al., 2015): ● Seizures. ● Trauma (especially head trauma after a fall). ● Diabetes. ● Infection. ● Insufficient nutritional status. ● Uncontrolled pain. ● Medications (e.g., pain medication, antibiotics, antivirals, antifungals, steroids, anesthesia, cardiac medications, anticholinergics). ● Serotonin syndrome. ● Over-the-counter substances (e.g., herbs, teas, supplements). ● Cardiac disturbances (failure, arrhythmias, myocardial infarction). ● Disease (abnormality or failure in pulmonary, endocrine, renal, and hepatic systems). Mild cognitive impairment (MCI) MCI lives in the space between normal age-related cognitive changes and dementia. Older adults with MCI are at greater risk for developing dementia or Alzheimer’s disease (NIA, 2022f). The mental healthcare provider can note subjective data from the older adult or from caregivers, family, or friends (with consent). Data to note for older adults with suspicion of MCI: increased frequency of losing items; forgetting important dates, events, or appointments; and difficulty with word selection (NIA, 2022f). These symptoms can be concerning to the older adult. The NIA recommends tips to improve MCI. These suggestions can empower the older adult who feels embarrassed or saddened by their cognitive state. Recommendations for improving memory include the following (NIA, 2022f): ● Stick to a daily routine—predictability is key.
Delirium can be life threatening but is usually reversible with treatment. The healthcare worker must be able to identify the signs of delirium. Key features of delirium include rapid and abrupt onset, decreased level of consciousness, altered attention, impaired cognitive functioning (can look like disorientation), and diminished memory (Sadock et al., 2015). It can present like other mental health disorders. A psychotic episode of schizophrenia, mania, or a factitious disorder can look like delirium upon the first encounter. Generally speaking, schizophrenia presents with better organization and a more stable level of consciousness; mania will be explained historically with a bipolar diagnosis or become apparent over time; and in a factitious disorder, inconsistencies will surface during examination or be easily revealed after an electroencephalography (Sadock et al., 2015). The healthcare worker can provide or request further examination of the older adult. Cognitive testing can be administered and compared to a baseline examination if available, along with laboratory studies looking for underlying causes of delirium. The treatment will often be dependent on the underlying cause of the delirium. Caution is needed for the older adult receiving treatment for psychosis. The AGS (2019) highly recommends avoidance of antipsychotic medications such as haloperidol (Haldol), risperidone (Risperdal), and quetiapine (Seroquel) due to their increased affiliation with tremors, fall risk, stroke, and death in patients with dementias. A refined assessment and understanding of underlying sequalae of psychosis are needed for treatment of delirium long term. ● Utilize tools such as calendars, to-do lists, notes, and reminders. ● Place daily objects in the same place in your house. ● Consider learning a new skill (check community resources). ● Volunteer time (give back to the local community). ● Increase time spent with friends and family. The older adult with MCI needs to be assessed regularly to recognize increased symptoms that would warrant intervention. The findings of MCI do not predict further impairment, do not necessitate treatment, and can cease without medical intervention (NIA, 2022f). Further evaluation by a neurologist or neuropsychologist can be provided if desired. completed (NIA, 2022g). One unfortunate truth about vascular dementia is the irreversibility of its damage. Treatment can include preventing further strokes by thinning the blood and lowering risk factors with lifestyle changes and medications (NIA, 2022g). Another subtype of dementia is Lewy body disease (LBD). It presents similarly to Alzheimer’s but it is distinguished by areas in the brain lumped with proteins known as alpha-synuclein and called Lewy bodies after the physician who discovered them (NIA, 2022e). The accumulation of Lewy bodies causes destruction and death of neurons and results in gradually decreasing brain activity (NIA, 2022e). There are two types of Lewy body dementia—dementia with Lewy bodies and Parkinson’s disease dementia. The biggest difference between Lewy body and Parkinson’s dementia is the timing and disruption in thought and movement. Classification of dementia with Lewy bodies (NIA, 2022e): Problems with thinking, unpredictable change in attention and alertness, and visual hallucinations develop early in relation to movement symptoms, such as slow movement, difficulty walking, and muscle stiffness. Classification of Parkinson’s dementia (NIA, 2022e): ● Ensure adequate sleep at night. ● Prioritize exercise and nutrition. ● Avoid alcohol (receive help if needed). Movement symptoms start first and are consistent with a diagnosis of Parkinson’s disease. Later, problems with thinking and changes in mood and behavior develop.
Dementia (vascular, lewy body, frontotemporal, Alzheimer’s disease) Dementia is a major neurocognitive disorder classified in the DSM-5 by severe impairment of memory, judgment, orientation, and cognition (APA, 2013). It is not part of normal aging and is common in older adults. Half of older adults age 85 years or older have a diagnosis of dementia (NIA, 2022c). Not all causes of dementia are known, and differentiating them can be challenging to the healthcare worker. If a specific dementia cannot be categorized but symptoms meet criteria, the
diagnosis of general dementia will stand. Delirium and dementia are often confused, but they can be contrasted by several clinical features. The most distinguishable characteristic of delirium is the rapid onset of presentation and attention level. Delirium has an abrupt beginning and inconsistent level of attention, while most dementias occur over the course of time and maintain a consistent level of attention (Sadock et al., 2015). Although vascular dementia, which is caused by a stroke, presents very similarly to delirium, it can be separated by clinical evaluation. Vascular dementia is one of the several subcategories of dementia. It is the second most common type behind Alzheimer’s disease (NIA, 2022g). Those most at risk for developing vascular dementia are men, people with hypertension (especially uncontrolled), people with high cholesterol, and those who have other cardiovascular diseases (Sadock et al., 2015). The cognitive invasion of this type of dementia is a result of an infarcted plaque or emboli traveling to the brain. A diagnosis can be made after cognitive testing is performed, a medical history is taken, and brain imaging is
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