and mind (see chapter 25).Delirium, a form of encephalopathy, is an acute, confusional state with disturbance of awareness and is characterized by deficits in attention, delusions, hallucinations, and agitation––often due to medication effects, systemic illness, sleep deprivation, infection and other factors.
The evaluation in these cases relies on history from the patient, family and other sources, and on physical and mental status examinations. The provider develops a set of hypothetical diagnoses and may test these with a set of tools including imaging, electrophysiologic, laboratory and cognitive (neuropsychological) tests. Using the history, examination and test results, the provider solidifies a diagnosis and treatment plan.
Memory concerns
The patient whose memory has been failing may forget recent events or conversations, repeat the same story or questions already asked and answered, lose track of an ongoing task and start a new one, forget what is not written down, pay the same bill twice, or fail to turn off the stove. Short- term memory and remembering incidental information tend to be most affected. Patients may not recall an event or item even after reminders. Recent emotional events, and events that occurred long ago or were rehearsed over the years, are less affected. Cognitively intact individuals often realize they have forgotten something; patients may not recognize their lapse or impairments and forget that they forget (Table 6.2).
Failure to execute
A common complaint is the patient failing to initiate or perform customary tasks. The family may find the patient’s house in disarray, food spoiled, and pets unfed. The patient may show poor hygiene, wear the same unwashed clothes, omit items of clothing, or dress inappropriately for a situation. Bills may be go unpaid or unnoticed and simple domestic problems go unresolved.
A patient may complain that the TV is broken when it is just unplugged. This may be due to lack of recognition, recall of what needs repaired, problem-solving skills, or even finding where and who to call for help.
These circumstances raise concerns of patient safety and well-being. The examiner should query activities of daily living, including bathing, toileting, preparing meals, dressing, and mobility—including recent falls. The family may notice that the patient’s weight has been drop- ping without easy explanation. A patient may be incontinent of bowel or bladder because of insufficient awareness, poor planning or trouble reaching the bathroom, or managing their clothes.
Patient errors may be classified as knowledge- or rule-based errors, slips or lapses2–4. Errors should be considered in the context of premorbid expectations, including level of education, past job performance, and cognitive abilities. For example, it would be alarming for a retired accountant to become unable to balance a checkbook. It may be less concerning for a characteristically
“absent-minded” person to misplace his or her glasses. Knowledge-based “mistakes” signify inappropriate planning due to failure to comprehend because the person is overwhelmed by the complexity of a situation and lacks information to interpret it correctly.“Slips”are errors where an intention is incorrectly carried out because the intended action sequence departs slightly from routine, closely resembles an inappropriate but more frequent action, or is relatively automated.
Table 6.2 Differentiating common from abnormal cognitive complaints.
Abnormal Cognitive Complaints “Normal”Cognitive Complaints
Complete inability to find on’s car in the parking lot Misplacing keys
Paying the same bill or running the same errand twice Forgetting what one came into the room for Repeating the same story or question within the same
conversation
Loosing one’s train of thought Not recognizing a good friend or family member Forgetting an aquantance’s name Having no recollection of an important recent event even
after prompting
Forgetting a recent conversation, but is easily reminded of it.
Getting lost in one’s neighborhood Missing a turn Frequently forgetting important appointments and
meetings
Needs to write things down or use lists Forgetting how to prepare a certain meal Forgetting to add a certain ingredient
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The“reins of action”of perception are captured by a contextually appropriate strong habit due to lack of close monitoring by attention. Lapses represent failure to carry out an action (omission of a correct action rather than commission of an incorrect action), may be caused by interruption of an ongoing sequence by another task, and give the appearance of forgetfulness. Rule-based mistakes occur when persons believe they understand a situation and formulate a plan by“if-then”rules— but the “if”conditions are not met, a “bad” rule is applied, or the“then”part of the rule is ill-chosen. Patients may not reach medical attention until their behavior and errors produce financial loss, embarrassment, or other adversities. Patients with anosognosia fail to recognize their impairments and are less likely to reach attention without a confederate observer. This underscores the potential value of family and friends accompanying the older patient to clinic.
Social withdrawal
The family may note the patient’s withdrawal from social contact. To avoid scrutiny and disclosure, the patient may avoid old friends or settings where he or she must converse with others. The patient may reduce exposure to complex tasks such as driving in heavy traffic or cooking a complicated meal with many ingredients and steps. Associated changes in personality include short temperedness, rudeness, or fatigue. Personality and behavior changes associated with depression, insomnia, or chronic pain must be identified. Depression can result in social avoidance and withdrawal independent of cognitive dysfunction. The patient should be assessed for feelings of hopelessness, helplessness,anhedonia(or the inability to enjoy things), and other signs of major depression.
Thought, behavior, and personality change
Gradual mental status changes can be punctuated by drama, such as getting lost near home or wandering unclothed in public due to confusion. Confusion reflects inability to maintain a coherent line of thought despite adequate arousal and language function. This is characteristi- cally worse with unfamiliar settings, polypharmacy or psychoactive medications. Some patients display delusions, false beliefs that are fixed inasmuch as patients seem unable to relinquish them. The delusion could be infidelity of a faithful spouse, that a grandchild is a secret govern- ment spy, that the local bodega is a front for a drug cartel, or that a neighbor is stealing the car every night and returning it before anyone notices. In Capgras Syndrome, the patient believes a familiar person (even a spouse) or place has been replaced with a doppelgänger, an exact duplicate.5,6
Patients may have hallucinations, perceptual experiences in the absence of external sensory stimuli. Hallucinations may occur with altered mental status such as toxic or abnormal metabolic states, neurodegenerative dementia such as Lewy body or Alzheimer’s diseases, psychiatric disorders, or drug withdrawal. Visual hallucinations also occur in psychologically normal individuals with visual loss due to central visual pathway or eye disorders such as macular degeneration as can be seen in Charles Bonnet Syndrome.7Auditory hallucinations are more characteristic of mental illnesses, including schizophrenia, than that of aging mind and brain disorders.
Patients with dementia are more prone to episodes of delirium. Delirium is an acute confusional state with disturbance of consciousness, characterized by attentional deficits, delusions, and hallucinations. The acute confusional state evolves rapidly and may present as a hypoaroused (lethargic) or hyperaroused (agitated) state. The patient may become disoriented, agitated, sleepy and yet unable to stay asleep. This is not uncommon during a hospitalization or after a minor
106 T. Scott Diesing and Matthew Rizzo
procedure. The delirium usually resolves completely. Delirium confounds accurate determinations of cognitive baseline in cases where dementia is in question. Repeated episodes of delirium suggest their cognitive status is fragile and may portend neurodegenerative disease.
Practical indices of cognitive decline
The most effective way to gauge mental status change is in comparison with a patient’s past baseline. Ideally, a past psychological or neurological examination is available for comparison.
When there has been no prior neuropsychological testing, identification of surrogate measures of cognition and behavior of daily life should be sought. For example, if the patient does the crossword puzzle in the daily paper, find out if they are able to complete as much of the puzzle or as fast as they once did. If a person is a longstanding fan of the local sports team, ask if they can they name as many players as they once did or if they know how his or her team is faring lately.
Ask about the most challenging mental task the patient performs each week and if it now takes longer to complete the task. Driving a vehicle is a common and complicated task. Inquiries on driver wayfinding (getting lost), driver restriction, traffic citations, near crashes, and crashes can be useful.
Bladder and bowel control
Incontinence is not unusual in the elderly, especially in small volume or with straining, coughing, or laughing. New-onset or large-volume incontinence without a sense of urgency suggests a greater problem. Bladder control and micturition depend on central and peripheral nervous system integrity and can be affected by many neurologic conditions. An obtunded or sedated patient may be unaware of the need to urinate. Incontinence is common in late stages of degenerative demen- tias and earlier in particular conditions that affect neurologic control of the bladder and micturi- tion. These include normal pressure hydrocephalus (NPH), anticholinergic medication side effects, multisystem atrophy or frontotemporal dementia.
Frontal lobe lesions can affect the frontal lobe micturition center. Frontotemporal dementia may present with bladder control, and behavioral and cognitive problems. Multisystem atrophy (MSA) affects the autonomic nervous system, which can affect sweating, salivation, blood pressure, and bladder control. In NPH, excessive cerebrospinal fluid and intermittent increased ventricular pres- sure are linked with urinary incontinence, cognitive impairment, and gait dysfunction. Medications can also affect bladder control, especially anticholinergic medications, which include some antihis- tamines, antidiarrheals and antidepressants. Side effects include urinary retention, constipation, dry mouth, somnolence and confusion. (For further details, see chapter 19.)
Medications
Polypharmacy, the use of multiple medicines often for multiple conditions, is common among the elderly, with complex drug interactions and unanticipated side effects. Common medications, such as cardiac, antihypertensive, neurological, and psychiatric medications, can have cognitive effects.
Anticholinergic medications may alter cognition and behavior. Neuroleptic medications for psy- chosis and behavioral disturbances due to neurodegenerative conditions can produce sedation and Parkinsonian features.“Hangover” effects from sedatives, hypnotics, and pain medications can accrue over weeks and months after prescription. (See Table 6.3 for a list of medications that can affect mental status and cognition.) Assessment of current medications, including withdrawal effects, is essential for the evaluation of encephalopathy (see Chapter 25).
107 Medical Assessment of the Aging Mind and Brain