You are the nurse working triage in the emergency department. this afternoon, a woman brings in her father, K.B., who is 74 years old

Question

the daughter reports that over the past year she has noticed her father has
progressively had problems with his mental capacity. these changes have developed gradually but seem
to be getting worse. at times he is alert and at other times he seems disoriented, depressed, and tearful.
He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and
sugar in the refrigerator. K.B. reports that he has been having memory problems for the past year and
at times has difficulty remembering the names of family members and friends. His neighbor found him
down the street 2 days ago, and K.B. did not know where he was. this morning he thought it was night-time and wondered what his daughter was doing at his house. He could not pour his own coffee, and he
seems to be getting more agitated. a review of his past medical history is significant for hypercholester-olemia and coronary artery disease. He had a myocardial infarction 5 years ago. K.B.'s vital signs today are
all within normal limits.

What are some cognitive changes seen in a number of elderly patients?

You know that physiologic age-related changes in the elderly can influence cognitive
functioning. Name and discuss one.

For each behavior listed, specify whether it is associated with delirium (DL) or dementia (DM).
______ a. Gradual and insidious onset
______ b. Hallucinations or delusions
______ c. A sudden, acute onset of symptoms
______ d. Progressive functional impairment
______ e. Inability to perform activities of daily living (ADLs)
______ f. Incoherent interactions with others
______ g. Possible wandering behavior
______ h. Behavioral disorders that often worsen at night

Based on the information provided by the daughter, do you think K.B. is showing signs of
delirium or dementia? Explain.

You know that there are several types of dementia that result in cognitive changes. List two of
these types of dementia.

How can the level or degree of the dementia impairment be determined?

A number of diagnostic tests have been ordered for K.B. From the tests listed, which would
be used to diagnose dementia?
______ Mental status examinations
______ Toxicology screen
______ Mini-Mental State Examination
______ Electrocardiogram
______ Electroencephalogram
______ Complete metabolic panel
______ Complete blood count with differential
______ Thyroid function tests
______ Colonoscopy
______ Rapid plasma reagin (RPR) test
______ Serum B12 level
______ Bleeding time
______ Human immunodeficiency virus screening
______ Liver function tests
______ Vision and hearing evaluation
______ Magnetic resonance imaging (MRI)

Answer 1

• Loss of short-term memory and accompanying benign forgetfulness
• Poorer performance on complex learning tasks
• Slowing of the thought processes

• Decreased visual acuity and accommodation can result in decreased ability to process visual cues.
Yellowing and flattening of the cornea can lead to difficulty distinguishing colors.
• Fewer functional cochlear cells can lead to a decreased ability to process auditory input.

Answers:
Delirium:b, c, e, f, h
Dementia:a, d, g

Dementia. The onset has been gradual, he has had progressive cognitive impairment (forgetting
things, placing milk in the cupboard, wondering about his daughter, unable to pour coffee, difficulty
remembering names), and he has shown wandering behavior. This behavior does not show the
sudden onset, hallucinations, or incoherent interactions that are more likely to occur with delirium. A
distinguishing feature between dementia and delirium is the onset, with dementia demonstrating a
slow onset, whereas delirium has a sudden onset.

• Alzheimer's disease
• Diffuse Lewy body dementia
• Frontotemporal dementia
• Vascular dementia
• Parkinson's disease dementia

A psychologist administers neuropsychological testing in the major domains of thinking and
memory, verbal and expressive abilities, constructional skills, and executive functions. This
information helps determine whether the patient can continue to handle his or her own finances, to
drive, or to perform instrumental activities of daily living.

Only the colonoscopy and bleeding time would have no relevance in diagnosing a dementia
disorder.