If someone presents in a confused state consider if this is an acute delirium, due to an underlying physical problem, or a depression or a more long standing dementia. The duration of symptoms is important and a guide. The observations of others such as carers or relatives are crucial. The diagnosis is made by triangulation of clinical assessment by the doctor, with those observations of others, and supplemented by the use of mental health assessment tools. An excellent summary is in the British Medical Journal by John Young, David Meagher and Alasdair MacLullich (BMJ 10.9.11 Vol 343 pages 527-531) which includes the references below on cognitive tests.
Usuallly clinically unwell. Look for urine infection as this may be hidden. A short duration of symptoms is a key. Check Blood pressure, pulse and temperature as the minimum core indicators that may point to underlying physical illness.
Be on the look out for depression at all times. How do you feel when you meet the patient? If you sense you are a bit low in yourself as a result of meeting then consider depression in your patient. Ask about depression. Don’t forget to ask “if it has been so bad you could end if all” and then confirm they are not suicidal. The PhQ 9 score is a point score accessible on the internet. The PhQ 2 score is shorter for screening
Patient health questionnaire 2 (PHQ2):
“Over the last two weeks, how often have you been bothered by any of the following problems: (1) Little interest or pleasure in doing things; (2) Feeling down, depressed, or hopeless?” For each option the respondent chooses from “not at all” (score 0), “several days” (1), “more than half the days” (2), and “nearly every day” (3). A score of ≥3 suggests depression. A large study of over 8000 community dwelling older people showed a sensitivity of 100% and specificity of 77%. Li C, et al Validity of the patient health questionnaire 2 (PHQ-2) in identifying major depression in older people. JAGS 2007;55:596-602 (Quote from Young J et al BMJ 10.9.11 Vol 343 pages 527-531)
The opinion of relatives is key following your observations about the conversation you have had with your patient.
Informant Based Ascertain Dementia 8 (AD8) questionnaire
Person who knows patient well is asked if a change noted
- Judgement problems (finance scams etc)
- Hobbies or activites loss interest
- Questions stories or statements repeat
- Trouble learning new activities
- Forgets correct month or year
- Difficulty handling the complex eg finances
- Appointment recall problems
- Thinking or memory problems
Two positive responses indicate possible dementia – sensitivity 92%, specificity 46% from Jorm AF The informant questionnaire on cognitive decline in the elderly (IQCODE): a review International Psychogeriatrics 2004;16:1-19. (Quote from Young J et al BMJ 10.9.11 Vol 343 pages 527-531)