Cognitive and Mental Health
Core concepts
Distinguish delirium (acute, fluctuating, inattention), dementia (chronic, progressive cognitive decline affecting function), and depression (which can mimic dementia as "pseudodementia"). Delirium is a medical emergency-look for causes (infection, medications, pain, retention, constipation, hypoxia, metabolic). Dementia types include Alzheimer disease, vascular, Lewy body (with visual hallucinations and parkinsonism), and frontotemporal. Use validated screens (Mini-Cog, MMSE, MoCA). Depression in older adults may present with somatic complaints or apathy rather than sadness, and is underrecognized. Assess safety: driving, wandering, elder abuse, and suicide risk. Nonpharmacologic approaches are first-line for behavioral symptoms of dementia.
Traps
The most common trap is missing delirium by labeling acute confusion as "dementia." Another is using antipsychotics first-line for behavioral symptoms instead of nonpharmacologic strategies. Watch for depression masquerading as cognitive decline and for attributing apathy to "normal aging."
Rule of thumb
Acute + fluctuating + inattention = delirium until proven otherwise-find and treat the cause before anything else.
Worked example
A hospitalized 78-year-old becomes agitated and inattentive overnight. The best first step is to evaluate for a cause (infection, medication, pain, retention, constipation) and use nonpharmacologic measures-not to start an antipsychotic reflexively.