Differentiating Delirium, Dementia, and Depression (2023)

Lippincott Nursing Pocket Card - February 2022

Differentiating Delirium, Dementia, and Depression (1)

Differentiating Delirium, Dementia, and Depression (2)

Definitions

Elderly patients are at high risk of mood and cognitive impairments such as depression, delirium and dementia. Delirium is an acute, transient and reversible cause of brain dysfunction, usuallytriggered by one or more precipitating factors, including infection, medications, pain and dehydration. Dementia is usually subtle in its onset and may not be recognized until it has affected one or more cognitive domains. Depression is characterized by low mood, loss of interest or pleasure in most activities, sleep disturbance, anxiety, and social withdrawal.

Delirium, dementia, and depression have overlapping characteristics, and patients may experience more than one of these conditions at the same time. It is essential to differentiate between these conditions, particularly if delirium is present, because this is an acute medical emergency that requires rapid assessment and management. Nurses in both outpatient and hospital settings can have a significant role in the identification, assessment and management of patients with dementia, delirium and depression.

(Video) The Clinical Differences Between Depression, Delirium, and Dementia
Differentiating Delirium, Dementia, and Depression (3)

Dementia

Signs and Symptoms

Dementia is the most common disorder of cognition, and is characterized by a decline in one or more of these cognitive domains (Larson, 2019):

  • Memory (remote memories versus recent memories)
  • Language (word retrieval, comprehension)
  • Learning new skills (following linear instructions, with ability to repeat skills)
  • Executive function (ability to shop, do laundry, write a check)
  • Complex attention (completing multi-step tasks)
  • Social cognition (remembering family connections, names)
  • Perceptual-motor skills (dressing, bathing)

The decline in function must not be attributable to other organic disease or due to an episode of delirium and must be severe enough to interfere with independence or daily functioning.

Dementia Syndromes

While the majority (60-80%) of cases of dementia are related to Alzheimer’s disease (AD), other major dementia syndromes include (Larson, 2019):

  • Dementia with Lewy bodies (DLB)
  • Frontotemporal dementia (FTD)
  • Vascular dementia (with or without prior stroke)
  • Parkinson disease with dementia (PDD)


Less common syndromes that may present with dementia are:

(Video) Mental Health Defining Dementia Depression and Delirium - Promo

  • Alcohol-related dementia
  • Progressive supranuclear palsy (PSP)
  • Huntington disease
  • Creutzfeldt-Jakob disease


Frequently, dementia has more than one cause or contributing factor and the elderly patient may also be suffering from other medical illnesses or comorbidities that exacerbate the course and progression of their dementia.

Clinical Presentation

The subtleties of dementia may be difficult to detect during routine clinical practice. Often the best assessments come from family or caregivers involved with the daily life of the patient. Family or caregivers will offer clinicians a glimpse into the patient’s historical baseline and current state of cognitive function related to:

  • Forgetfulness
  • Ability to retain new information
  • Behavior and how patient manages new situations
  • Language skills
  • Orientation to place and spatial abilities, such as getting lost in familiar places
  • Reasoning skills and how the patient manages unexpected events

Diagnosis
A comprehensive assessment by a neurologist or neuropsychiatrist is required for definitive diagnosis of dementia. The assessment will include clinical history (taken from patient and caregiver separately), physical exam, cognitive testing, neuroimaging (MRI is preferred over CT), and metabolic evaluation (Dening, 2019). All patients being evaluated for dementia, should be screened for depression. Cognitive decline is often a primary complaint in a patient with depression (Larson, 2019).

Delirium

In stark contrast to the insidious and gradual onset of dementia, delirium is an acute change often associated with inattention, confusion, and/or a clouding of the senses (Larson, 2019) and should be considered a medical emergency. Delirium is a complex neuropsychiatric syndrome which tends to develop over a period of hours or days and may fluctuate throughout the course of a day (Paulo et al., 2017).

Signs and symptoms may include:

  • Inability to focus, sustain attention, or shift attention between tasks
  • Hypervigilance
  • Agitation and restlessness
  • Tremulousness
  • Hallucinations (visual, auditory, tactile)
  • Somnolence, decreased mental status, hypoactivity

Delirium may be precipitated by (Francis, 2020):

(Video) Evaluating the Difference between Delirium, Depression and Dementia

  • Side effects of anesthesia, medication, or interactions of medications
  • Intoxication with prescribed medication due to accumulated doses
  • Infections, such as sepsis, pneumonia, or urinary tract infections
  • Dehydration
  • Electrolyte imbalances, including hypoglycemia
  • Metabolic disturbances including hypoxemia and hypercarbia
  • Sleep disturbances, insomnia due to hospitalization
  • Immobilization, altered care setting, lack of usual assistive devices for mobilization
  • Sensory impairment, not having glasses or hearing aids available

Treatment and Management
Avoiding delirium in the elderly is the best approach. Preventive measures include avoiding factors known to precipitate episodes, such as polypharmacy and dehydration, and promoting situational awareness in hospitalized patients.

When delirium is present, the primary objective is to identify the instigating factor(s) and provide definitive treatment. While caring for the patient with acute delirium, non-pharmacologic measures offer the safest care options allowing the primary cause time to resolve. Providing a supportive and restorative setting, with respect for hours of sleep, limiting sensory overload, and creating a home-like setting are known to decrease the incidence and duration of delirium in the highest risk patients (Francis, 2020).

Nonpharmacologic Interventions

  • Altering patient environment, decreasing ambient noise, improving lighting
  • Providing frequent reassurance through touch and verbal reorientation
  • Using familiar staff or family to reassure and observe patient
  • Neither endorsing nor challenging hallucinations or delusions


It is recommended that physical restraints are avoided, as they contribute to poor physical outcomes (aspiration, lost mobility, pressure ulcers), prolonged duration of delirium, and are not proven to be effective (Francis, 2020).

Pharmacologic Interventions

When delirium is manifest by disruptive behavior, especially agitation, symptom control may be necessary to allow for evaluation and treatment. A trial of psychotropic medication such as haloperidol, quetiapine, risperidone, and olanzapine may be warranted. Prescribers are urged to use the lowest dose possible of the shortest acting pharmacologic agent available. Benzodiazepines should be avoided because of their tendency to worsen confusion and delirium (Francis, 2020).

Depression

Depression can present as a confounding factor when examining elderly patients suffering from cognitive decline. Elderly patients with depression will often be able to self-report that they are experiencing memory problems, and may make weak attempts to perform cognitive exams, stating “I just can’t do this” (Larson, 2019). Depression may affect anyone, and the elderly are no exception. Those with baseline dementia may also suffer from depression, and it is therefore recommended that clinicians screen for depression in the elderly, as it is a treatable/reversible comorbid condition that can contribute to dementia and cognitive decline.

Risk Factors for Depression in the Elderly (Espinoza & Unutzer, 2019):

  • Female sex
  • Social isolation
  • Widowed, divorced, or separated marital status
  • Comorbid medical conditions
  • Functional or cognitive impairment
  • Insomnia
  • Uncontrolled pain

Signs and symptoms may include:

  • Decreased concentration or attention span
  • Impaired judgement
  • Self-reported memory loss
  • Feelings of hopelessness, often worse in morning
  • Impaired sleep

Depressive Syndromes:

  • Pathologic grief reactions (loss of spouse)
  • Major or minor depression
  • Dysthymic disorder

Management and Treatment (Espinoza & Unutzer, 2019):

  • Psychotherapy
  • Antidepressant medications
  • Neurostimulation therapies
  • Bright light therapy
  • Exercise
  • Family support

The family or caregivers of those suffering with dementia may also need support, particularly during an acute illness or a combined bout of delirium. Seeing a loved one in acute delirium may leave caregivers feeling frustrated, frightened, and depleted. Consider that delirium may need weeks or months to resolve fully, and this will require care to continue in other less acute settings. Communication with family, care team, and anticipated long-term care facilities should include details about the patient’s mental status and cognitive needs.

Comparing Dementia, Delirium and Depression (Dening, 2019)
DementiaDeliriumDepression

Onset and duration

  • Slow and insidious onset
  • Deterioration is progressive over time
  • Permanent
  • Sudden onset – over hours or days
  • Duration – hours to less than one month, but can be longer
  • Fluctuating clinical features
  • Usually reversible with treatment of underlying cause
  • Recent change in mood persisting for at least two weeks – may coincide with life changes; can last for months or years
  • Usually reversible with treatment
Psychomotor activity
  • Wandering/exit seeking
  • Agitated
  • Withdrawn (may be related to coexisting depression)
  • Hyperactive delirium: agitation, restlessness, hallucinations
  • Hypoactive delirium: sleepy, slow-moving
  • Mixed: alternating features of the above
  • Usually withdrawn
  • Apathy
  • May include agitation
Attention
  • Generally normal
  • Impaired or fluctuates, difficulty following conversation
  • May appear impaired
Mood
  • Depression may be present in early dementia
  • Fluctuating emotions, for example: anger, tearful outbursts, fear
  • Depressed mood
  • Lack of interest or pleasure in usual activities
  • Change in appetite (increase or decrease)
Thinking and speech
  • Difficulty with word-fluency, word-retrieval, and abstraction
  • Disorganized, distorted, fragmented, incoherent
  • Intact; themes of helplessness and hopelessness present
(Video) The 3Ds of Geriatric Psychiatry - Delirium, Dementia, Depression, Pauline Wu, DO | UCLAMDChat
References:
Dening K. H. (2019). Differentiating between dementia, delirium and depression in older people.Nursing standard (Royal College of Nursing (Great Britain): 1987),35(1), 43–50. https://doi.org/10.7748/ns.2019.e11361

Espinoza, R. & Unutzer, J. (2019, November 22). Diagnosis and management of late-life unipolar depression. UpToDate. https://www.uptodate.com/contents/diagnosis-and-management-of-late-life-unipolar-depression

Francis, J. & Young, G. (2020, February 11). Diagnosis of delirium and confusional states. UpToDate. https://www.uptodate.com/contents/diagnosis-of-delirium-and-confusional-states

Larson, E. (2019, May 3). Evaluation of cognitive impairment and dementia. UpToDate. https://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia

Paulo, M., Scruth, E. A., & Jacoby, S. R. (2017). Dementia and delirium in the elderly hospitalized patient: Delirium is a medical emergency.Clinical nurse specialist (CNS),31(2), 66–69. https://doi.org/10.1097/NUR.0000000000000271

FAQs

Can delirium and depression be mistaken for dementia? ›

Delirium and depression can cause cognitive changes that may be mistaken for dementia. Delirium can also be superimposed on dementia, particularly in older hospitalized patients. Clinicians and caregivers need to learn to distinguish the differences.

What are the major differences between delirium and dementia? ›

): Delirium is typically caused by acute illness or drug toxicity (sometimes life threatening) and is often reversible. Dementia is typically caused by anatomic changes in the brain, has slower onset, and is generally irreversible.

What are the 3 D's of dementia? ›

Understanding the Three D's: Dementia, Delirium and Depression - For Health Care Professionals.

Can depression look like dementia in the elderly? ›

Although rare, there are cases of depression that develop into severe dementia-like conditions. When an older adult is depressed and cognitive function is impaired, it should not be so quickly judged as an early symptom of dementia. Treatment of depression can improve cognitive function [69].

How can you tell the difference between dementia and mental illness? ›

Dementia is a brain disorder that results in memory loss and trouble communicating. Unlike depression or other forms of mental illness that happen more suddenly, people living with dementia decline over a period of time, this depends on the form of dementia they have.

What are three main differences between dementia and depression? ›

Here are the differences: Depression develops faster than dementia (dementia takes weeks or months to develop). Despite memory lapses, those with depression will be able to remember something when asked. Impaired judgment in those with depression is usually caused by the lack of concentration.

What are the 4 cardinal features of delirium? ›

The short version includes a diagnostic algorithm, based on four cardinal features of delirium: (1) acute onset and fluctuating course; (2) inattention; (3) disorganized thinking; and (4) altered level of consciousness.

What are 3 characteristics of delirium? ›

The CAM diagnostic algorithm evaluates four key features of delirium: 1) Acute Change in Mental Status with Fluctuating Course, 2) Inattention, 3) Disorganized Thinking, and 4) Altered Level of Consciousness.

What are 5 warning signs of dementia? ›

Symptoms
  • Memory loss, which is usually noticed by someone else.
  • Difficulty communicating or finding words.
  • Difficulty with visual and spatial abilities, such as getting lost while driving.
  • Difficulty reasoning or problem-solving.
  • Difficulty handling complex tasks.
  • Difficulty with planning and organizing.

What is the hallmark symptom of dementia? ›

Visual hallucinations are one of the hallmark symptoms in Lewy body dementia (LBD) and often occur early in the illness. In other dementias, delusions are more common than hallucinations, which occur well into the disease cycle, if at all, and are less often visual.

What stage of dementia is depression? ›

Depression is very common among people with Alzheimer's, especially during the early and middle stages.

How do doctors tell the difference between dementia and Alzheimer's? ›

While dementia is a general term, Alzheimer's disease is a specific brain disease. It is marked by symptoms of dementia that gradually get worse over time. Alzheimer's disease first affects the part of the brain associated with learning, so early symptoms often include changes in memory, thinking and reasoning skills.

Does a person with dementia know they are confused? ›

In the earlier stages, memory loss and confusion may be mild. The person with dementia may be aware of — and frustrated by — the changes taking place, such as difficulty recalling recent events, making decisions or processing what was said by others. In the later stages, memory loss becomes far more severe.

What is the 3 word memory test? ›

The Mini-Cog test.

A third test, known as the Mini-Cog, takes 2 to 4 minutes to administer and involves asking patients to recall three words after drawing a picture of a clock. If a patient shows no difficulties recalling the words, it is inferred that he or she does not have dementia.

How can you identify delirium? ›

Recognising delirium: signs and symptoms

Increased confusion. Hallucinations or delusions. Sleep disturbance. Being less co-operative.

What are the 3 D's in assessment stage? ›

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium)

What are the similarities between dementia and depression? ›

Both can display the same symptoms, from lethargy to confusion, yet they have notable differences that define them. One can even mask the other. Add the hospice component to the equation and your loved one's symptoms may be compounded. The good news is that quality of life can be improved with proper treatment.

What is the 4a test for delirium? ›

The 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. A score of 4 or more suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis.

What is a core symptom of delirium? ›

The core features of delirium include altered consciousness, global disturbance of cognition, fluctuating course with a rapid onset, perceptual abnormalities, and evidence of a physical cause.

What can delirium be mistaken for? ›

People with delirium often have terrifying hallucinations, delusions, and are unable to think clearly or focus. In older hospital patients, these symptoms can be misdiagnosed as dementia.

What is the most commonly used assessment of delirium? ›

Short-Confusion Assessment Method (short-CAM)

The short-CAM has high inter-rater reliability and is the most widely used validated tool for the diagnosis of delirium [Inouye, 2014].

What are the 5 causes of delirium? ›

Delirium can often be traced to one or more factors. Factors may include a severe or long illness or an imbalance in the body, such as low sodium. The disorder also may be caused by certain medicines, infection, surgery, or alcohol or drug use or withdrawal.

What are the two most common psychotic features in dementia? ›

Symptoms. As the term might suggest, people with dementia-related psychosis have the decline in thinking and problem-solving skills of dementia, as well as delusions or hallucinations of psychosis. (Delusions are more common.)

What are the first subtle signs of dementia? ›

The 10 warning signs of dementia
  • Sign 1: Memory loss that affects day-to-day abilities. ...
  • Sign 2: Difficulty performing familiar tasks. ...
  • Sign 3: Problems with language. ...
  • Sign 4: Disorientation to time and place. ...
  • Sign 5: Impaired judgement. ...
  • Sign 6: Problems with abstract thinking. ...
  • Sign 7: Misplacing things.

What is the clock test for dementia? ›

The clock-drawing test is a quick way to screen for early dementia, including Alzheimer's disease. It involves drawing a clock on a piece of paper with numbers, clock hands, and a specific time. The inability to do so is a strong indication of mental decline.

What is one of the first signs of cognitive decline? ›

Signs that you may be experiencing cognitive decline include:
  • Forgetting appointments and dates.
  • Forgetting recent conversations and events.
  • Feeling increasingly overwhelmed by making decisions and plans.
  • Having a hard time understanding directions or instructions.
  • Losing your sense of direction.
6 Sept 2020

Do dementia patients eyes look different? ›

Many people with Alzheimer's disease have visual problems, such as changes in color vision, and past studies have shown retinal and other changes in their eyes.

What sleeping position is linked to dementia? ›

A 2019 study published in Journal of Alzheimer's Disease, showed among 165 participants (45 with diagnosed neurodegenerative disease, 120 controls) a supine sleep position (on back, head at body level) for more than 2 hours per night increased the risk of dementia by almost four times (3.7 times greater).

What is the most common type of hallucination for a person with dementia? ›

Visual hallucinations (seeing things that aren't there) are the most common type experienced by people with dementia. They can be simple (for example, seeing flashing lights) or complex (for example, seeing animals, people or strange situations).

Which symptom is the most common in both depression and early dementia? ›

Apathy as a neuropsychiatric symptom may be noted in both dementia and depression.

Do antidepressants work for dementia patients? ›

Antidepressants such as sertraline, citalopram, mirtazapine and trazodone are widely prescribed for people with dementia who develop changes in mood and behaviour. There is some evidence that they may help to reduce agitation – particularly citalopram.

Is there a link between dementia and depression? ›

Both studies found that prolonged depressive symptoms in later life (in the decade before dementia onset, and not earlier) are good predictors of increased dementia risk. Other studies have also found similar associations such that having depression in later life can double the risk of developing dementia.

› get-support › daily-living ›

Delirium is a common, serious but often treatable condition that starts suddenly in someone who is unwell. It's much more common in older people, especially...
Anticholinergic medications are a well-known cause of acute confusional states, and patients with impaired cholinergic transmission, such those with Alzheimer d...
Delirium is a common clinical syndrome characterized by inattention and acute cognitive dysfunction. The word 'delirium' was first used as a medical ter...

What conditions can be mistaken for dementia? ›

Conditions that may be mistaken for dementia
  • Delirium. Delirium is a change in mental state or consciousness. ...
  • Depression. Depression is an illness where you have a continuous low mood and/or a loss of interest and enjoyment in your life. ...
  • Anxiety. ...
  • Mild cognitive impairment (MCI) ...
  • Hormone (gland) conditions.

Can delirium be misdiagnosed? ›

Unfortunately, prolonged delirium is often unrecognized or misdiagnosed as other psychiatric conditions in clinical practice, such as dementia, mood disorders, or psychosis.

What type of dementia most resembles delirium? ›

Symptoms of dementia with Lewy bodies

Fluctuating cognition that is delirium-like.

Can dementia look like mental illness? ›

Misdiagnosis of mental illness in seniors is very easy to make, as symptoms tend to be so similar to dementia, such as confusion and erratic behavior. It's important to get a clear look at the symptoms of dementia and the symptoms of mental illness.

What are 7 common indicators or symptoms of dementia? ›

Symptoms
  • Memory loss, which is usually noticed by someone else.
  • Difficulty communicating or finding words.
  • Difficulty with visual and spatial abilities, such as getting lost while driving.
  • Difficulty reasoning or problem-solving.
  • Difficulty handling complex tasks.
  • Difficulty with planning and organizing.

What is the difference between depression and dementia? ›

Differences between depression and dementia

A person with depression may sometimes say they can't remember something but then remember when they are prompted. However, a person with dementia (particularly Alzheimer's disease) is likely not to remember recent events. They may also try to cover up their memory loss.

What is one of the first signs of cognitive decline? ›

Signs that you may be experiencing cognitive decline include:
  • Forgetting appointments and dates.
  • Forgetting recent conversations and events.
  • Feeling increasingly overwhelmed by making decisions and plans.
  • Having a hard time understanding directions or instructions.
  • Losing your sense of direction.
6 Sept 2020

What is the hallmark symptom of delirium? ›

The clinical hallmarks of delirium are decreased attention or awareness and a change in baseline cognition. Delirium often manifests as a waxing and waning type of confusion.

What are 3 characteristics of delirium? ›

The CAM diagnostic algorithm evaluates four key features of delirium: 1) Acute Change in Mental Status with Fluctuating Course, 2) Inattention, 3) Disorganized Thinking, and 4) Altered Level of Consciousness.

How do you rule out delirium? ›

What tests are used to diagnose delirium?
  1. Blood test.
  2. Urine test.
  3. Imaging tests, including chest X-ray, CT or MRI scan.
16 Sept 2020

What are the 4 cardinal features of delirium? ›

The short version includes a diagnostic algorithm, based on four cardinal features of delirium: (1) acute onset and fluctuating course; (2) inattention; (3) disorganized thinking; and (4) altered level of consciousness.

How do you distinguish delirium? ›

Some differences between the symptoms of delirium and dementia include:
  1. Onset. The onset of delirium occurs within a short time — within a day or two. ...
  2. Attention. The ability to stay focused or maintain focus is impaired with delirium. ...
  3. Rapid changes in symptoms.
14 Oct 2022

What are the 3 subtypes of delirium? ›

The three subtypes of delirium are hyperactive, hypoactive, and mixed. Patients with the hyperactive subtype may be agitated, disoriented, and delusional, and may experience hallucinations. This presentation can be confused with that of schizophrenia, agitated dementia, or a psychotic disorder.

Does a person with dementia know they are confused? ›

In the earlier stages, memory loss and confusion may be mild. The person with dementia may be aware of — and frustrated by — the changes taking place, such as difficulty recalling recent events, making decisions or processing what was said by others. In the later stages, memory loss becomes far more severe.

What are psychotic symptoms in dementia? ›

Psychotic features of dementia include hallucinations (usually visual), delusions, and delusional misidentifications. Hallucinations are false sensory perceptions that are not simply distortions or misinterpretations. They usually are not frightening and therefore may not require treatment.

Is dementia psychiatric or neurological? ›

Comment: With improvements in neuroimaging, researchers are learning much more about the underlying processes that cause Alzheimer's disease and other types of dementia.

Videos

1. Three "Ds" in geriatric evaluation: Delirium, dementia, and depression
(Pearson Assessments US)
2. The 3 D's: Dementia, Delirium, and Depression | How do they differ?
(Caring With Bambu)
3. What's new in Best Practices? Delirium, Depression and Dementia in Older Adults: Assessment and Care
(Registered Nurses' Association of Ontario)
4. 3D Drugs: Delirium, Depression, Dementia
(Geriatrics ACE Flix)
5. DELIRIUM OR DEMENTIA: KNOW THE DIFFERENCE
(Ivanhoe Web)
6. The 3 D's: Delirium, Depression & Dementia
(C. O. Older Adult Behavioral Health Initiative)
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