Dementia is a chronic, progressive decline in cognitive ability. It is a diagnosis that has significant morbidity and mortality associated with it for both the patient and the patient's family. It is vital to rule out dementia mimics including: delirium and depression before a diagnosis of dementia can be made. Prevalence is approximately 10% age >65.

Delirium Edit


1. Disturbance in consciousness - change in focus/attention/ distractible

2. Disturbance in cognition - change in memory, disorientation, trouble with speech/language

3. Temporal fluctuation - develop over short period of time, fluctuates over hours

4. Evidence of underlying medical d/o



  • I- Infections
  • W-withdrawal
  • A-Acute metabolic d/o (lytes, hepatic failure, renal failure)
  • T-Trauma (head trauma, post-operative)
  • C-CNS pathology (CVA, hemorrhage, tumour, seizure)
  • H-Hypoxia
  • D- Deficiencies of vitamins (B12, Folate, thiamine)
  • E-Endocrinopathies (thyroid, parathyroid, adrenal, glucose
  • A-Acute vascular (shock, HTN encephalopathy, vasculitis)
  • T-Toxins, substance use, MEDICATIONS
  • H- heavy metals (arsenic, lead, mercury)


Consider the following based on history, physical

  • Physical: vitals, hydration status, r/o fecal impaction, urinary retention, infected ulcer
  • Blood work: CBC, lytes, Cr, extended lytes - Ca,P,Mg, albumin, TSH, B12, folate, LFTs, glucose, drug levels, tox screen, blood gas, septic w/u - CXR, urinalysis +/- blood cultures, CK, trop
  • Further w/u:ECG, head CT, Lumbar Puncture, EEG

Delirium vs Dementia Edit

PLEASE NOTE the below table is a generalization and there are exceptions to the rules.

Delirium Dementia
Onset Abrupt Gradual
Course Short Long
Fluctuation Present


Hallucinations Present (Normally Absent)
Attention Impaired Normal
LOC Altered Normal
Psychomotor Altered (hyperactive/hypoactive/ mixed) Normal

Depression Edit

See depression page*

Screening: SIGECAPS: sleep disturbance, interest loss, guilt (regrets), energy decreased, concentration difficulties, psychomotor changes, suicidal ideation, low mood

Poor sleep - look for 6 Ps (pain, PND/orthopnea, Pee - BPH, diuretic, partner, pharmaceuticals (diuretic, stimulants, caffeine, cholinesterase inhibitor, physical environment -temperature/noise)

Decreased interest - depression patients operate below their abilities. Dementia - operative above their abilities and withdraw due to social embarrassment

Dementia Edit

Cognitive symptoms Edit

1. Amnesia: short term memory loss, repeating questions/stories, forgetting details of recent important events, trouble with names, increased use of compensatory strategies (e.g. lists)

2. Aphasia: word finding difficulty, decreased fluency, simplified speech, impaired comprehension, decreased reading/writing, mixing up languages

3. Apraxia: dressing apraxia, difficulty following physical examination, hitting nail with hammer, using appliances

4. Agnosia: difficulty recognizing objects/family/faces

5. Visuospatial: easily disorientated/lost in new environment, trouble driving in non-routine places

6. Calculation: financial difficulties

7. Executive functioning: sequence, organization, abstraction, planning. Trouble with ADLs and iADLs

ADLs and iADLSEdit

ADLS: activities of daily living

  • DEATH: dressing, eating, ambulation, transfers, hygiene

iADLS: instrumental activities of daily living

  • SHAFT: shopping, housekeeping/hobbies, accounting, food preperation, telephone/tool use/transportation (driving)/tablets (medications)

** IF lose 1ADL or 2+ iADLS need to R/A driving, finances, medication compliance**

Definition of Dementia Edit

1. Amnesia

2. Apraxia, aphasia, agnosia, executive dysfunction

3. Progressive

4. Impacts on function

Meets criteria #1-4

Types of Dementia: Edit

Alzheimers Disease (AD)  Vascular Mixed Frontotemporal Parkinson's Dementia Lewy-body  Normal Pressure Hydrocephalus Other
progressive decreased short term memory step-wise deterioration Vascular + AD Behavioral issues (frontal lobe) Parkinson symptoms first Hallucinations and vivid nightmares Dementia, gait instability, incontience brain injury
decreased word finding vascular risk factors * Early executive fx loss (important for driving) Cognitive decline 5-10 years after motor symptoms

Dementia at same time as mild Parkinsonian features

Diagnosis: imaging CJD**
decreased insight Neuro-imaging findings

+ symptoms: impulsive, anger control

-symptoms: withdrawn, depressive sx

Early decreased visuospatial, early executive dysfunction
Memory responds to cueing
  • Vascular risk factors: HTN, DM, CAD, CVA, smoking, PVD
  • CJD - creutzfeldt-Jakob disease: rapid, progressive with balance and swallowing change


Mini-mental status examination: MMSE

Montreal Cognitive Assessment MOCA

EXIT-25 (frontal lobe dysfunction)

Frontal Assessment Battery


Trails A & B


  • Refer to alzheimers society
  • Discuss will, power of attorney, safety (driving, home)
  • Review medications and eliminate any unnecessary medications
  • Alzheimers disease
    • Obtain ECG prior to treatment. Avoid AchEI if LBBB, AV blocks, Sick sinus syndrome, bradycardia< 50
    • Donepezil (aricept)
    • Rivastigmine (exelon)
    • Galantamine (reminyl)
    • Memantine (Ebixa)
  • Vascular: modify vascular risk factors
  • Fronto temporal dementia: SSRI or trazodone. NO AchEI!
  • Lewy Body:
    • rivastigmine (exelon)
  • Consider referral for rapid progression, young patients, frontotemporal, lewy body, parkinson's dementia


Patient Handout: 10 Warning Signs of Dementia (Alzheimers Society)