Assessing Dementia and Delirium

Screening Questions

Orientation

What’s your full name?

Where are we right now?

What’s today’s date?
Short-term memory

Repeat these three words: ball, chair, purple. Keep them in mind, because I’m going to ask you to repeat them in a couple of minutes.

Personal and general information Name the last three presidents.

Who was George Washington? Abraham Lincoln? Martin Luther King, Jr.? Shakespeare?

When was World War II? When was John F.

Kennedy assassinated?

What’s your address and phone number?

What are your spouse’s/children’s/siblings’/parents’ names and birthdays?

When and where were you married?

In Chapter 21, I outline a rapid cognitive examination with components based on studies showing them to be effective in identifying patients with cognitive deficits. In this chapter, I show you how to tailor your questions to the patient who may have either delirium or dementia. In delirium, attention is impaired, and all of the cognitive processes are therefore also impaired. In dementia, attention is intact, but the cognitive processes, particularly memory, are impaired.

With this in mind, let’s look at the DSM-IV-TR criteria for both dementia and delirium and then review interview techniques for making the diagnoses.

DELIRIUM

Impaired Attention

The key to diagnosing delirium is establishing an impairment in your patient’s attention, which is what the DSM-IV-TR
means by “disturbance of consciousness” (Table 28.1). A delirious patient has difficulty sustaining his attention for a significant period. As in Chapter 21, I discourage reliance on traditional and unproved tests of attention, such as the SSST, and instead encourage you to rely on your patient’s ability to respond to routine questions.

Most of your interviews with delirious patients will occur in a hospital setting, often when you have been asked to see the patient by the primary care physician. In such settings, there are two types of delirious patients: the loud and the quiet. The loud delirious patient will typically be rambling incoherently and may be struggling against restraints in an effort to leave the hospital bed or to pull out intravenous lines.

The quiet delirious patient, on the other hand, requires some verbal probing to make a diagnosis. It’s often helpful to begin by saying nothing—that is, by walking into the room and observing your patient’s behavior. A person with normal cognitive abilities will generally look at you and make some kind of greeting, then wait for you to respond. A delirious patient may glance at you briefly and then pay little attention to you. He may be talking softly to himself. He may be looking all around the room, tracking a hallucinated bird or insect.

Hello, Mr. Brown. What brings you into the hospital?

TABLE 28.1. DSM-IV-TR criteria for delirium

(Note: The DSM-IV-TR specifies a number of different types of delirium, but the core diagnostic criteria as listed below do not change.)
Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention
A change in cognition (e.g., memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting dementia
A disturbance developing over a short period (usually hours to days) and fluctuating during the course of the day
Mnemonic: Medical FRAT
	Medical cause
	Fluctuating course
	Recent onset
	Attentional impairment
	Thinking impairment
Adapted from American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association.

The patient should be able to answer coherently. If the patient answers incoherently, you have to assess the nature of the incoherence. In many mental disorders, the patient’s attention is normal, but the TP or TC is disordered in some way.

Of the following three clinical vignettes, for example, only the third describes true delirium.