Delirium
A patient presents with acute onset of confusion and fluctuating attention over the course of a day. What core cognitive domain is primarily impaired in delirium?
Attention (and awareness).
What psychotherapy modality has strongest evidence in late-life depression?
Cognitive Behavioral Therapy (CBT).
An 81-year-old man shows gradual decline in memory and executive function over years. What feature confirms this is dementia and not mild cognitive impairment?
Loss of independence in daily activities (ADLs or IADLs).
You’re called to see an 81-year-old with dementia who suddenly becomes disoriented and agitated overnight. Name two features that make you suspect delirium superimposed on dementia rather than dementia progression.
1️⃣ Abrupt onset and 2️⃣ Fluctuating course (also inattention, altered consciousness).
What clinical feature distinguishes depression-related cognitive impairment (“pseudodementia”) from true dementia?
Depression has abrupt onset, inconsistent effort, and improves with antidepressant treatment.
What two cognitive domains are typically impaired earliest in Alzheimer’s disease, and what brain regions correspond to these deficits?
Episodic memory (hippocampus/medial temporal lobe) and executive function (frontal lobe circuits).
In delirium pathophysiology, which two neurotransmitters are most implicated and how do they change?
↓ Acetylcholine and ↑ Dopamine.
What is the term for the co-existence of depressive and cognitive symptoms that improve when depression is treated?
Pseudodementia
A patient with dementia has a stepwise decline and focal neurologic signs. What is the most likely underlying pathology, and how does it differ in progression from Alzheimer’s disease?
Vascular dementia — due to cumulative ischemic injury; shows abrupt, stepwise decline rather than gradual.
The Confusion Assessment Method (CAM) requires the presence of two core features plus one of two additional features. Name the combination that confirms delirium.
Feature 1: Acute onset/fluctuating course Feature 2: Inattention PLUS either (3) Disorganized thinking or (4) Altered level of consciousness.
Describe the neurobiological mechanism linking chronic depression and increased risk of later dementia.
Chronic elevated cortisol → hippocampal atrophy and impaired neuroplasticity.
How does Lewy body dementia differ from Parkinson’s dementia in timing of cognitive and motor symptoms?
LBD: cognitive first or simultaneous; PDD: motor symptoms precede dementia by >1 year.
Despite treatment of the underlying UTI, your patient remains delirious and agitated at night. You’ve optimized environment and hydration. What non-antipsychotic pharmacologic option could you consider to help restore sleep–wake cycle, and why?
Melatonin — helps re-entrain circadian rhythm; safer than benzodiazepines or antipsychotics.
List two physiological changes in aging that increase vulnerability to antidepressant side effects.
Reduced renal/hepatic clearance and altered neurotransmitter sensitivity.
Name two potentially reversible causes of dementia that should be ruled out.
Hypothyroidism, B12 deficiency, NPH, subdural hematoma, depression (“pseudodementia”).