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Many Factors Influence Cognitive Impairment

Dementia. Delirium. Depression. These are the "three Ds" that can cause cognitive impairment in elderly patients, and it's important to look at all three when treating this age group, according to an expert from Boston's Harvard Medical School.

"Dementia, which is thought to be a chronic problem, can often be at least partially reversible," says Edward Marcantonio, M.D. "And some forms of delirium are turning out to be chronic in some cases. Then depression can coexist with dementia, delirium, or both."

Rather than approaching the three conditions separately, it makes more sense to identify any kind of decline in cognitive function, and then look for reversible causes and treat them. What's left after that can be managed to maximize patients' quality of life, Marcantonio told an audience of physicians this week at the annual meeting of the American College of Physicians/American Society for Internal Medicine, in Philadelphia.

Symptoms of cognitive impairment include short-term memory loss, language difficulties, disorientation, poor judgment, and paranoia or extreme suspiciousness, said Marcantonio. But it's important to identify normal "slowing down" in elderly patients as opposed to abnormal mental functioning. The best way of doing this is to find out about things that patients used to be able to do, but can't anymore. This could include hobbies or social activities, activities such as shopping, housework, or finances, or basic tasks like bathing and dressing.

Delirium, marked by disorientation, confused thinking, and incoherent speech, is often caused by other medical conditions or by medications used to treat other illnesses. When this is the case, treating the condition or changing medications can often reverse symptoms. Dementia tends to affect factors such as memory, abstract thinking, judgment, and often personality itself, but it doesn't cloud awareness as delirium does.

Another reversible cause of cognitive problems is depression. Even when patients don't meet the clinical diagnosis, their depressive symptoms should be treated, says Marcantonio. These can include lack of interest in activities, changes in sleeping or eating patterns, lack of energy, concentration problems, and feelings of guilt about "being a burden". Preoccupation with death or thoughts of suicide are clear warning signs. Depressive symptoms can often be treated effectively with medication and/or counseling, and this treatment often allows patients to function better mentally.

Depression and delirium are often mistaken for dementia, which is a progressive worsening of cognitive function, but these two conditions can also mask dementia as well, says Marcantonio. For example, a patient with mild dementia may experience a lingering delirium that doesn't respond to treatment or changes in medical management. The more obvious symptoms of the delirium may keep doctors and family members from noticing the underlying deterioration in mental ability.

Marcantonio's message: elderly patients shouldn't be medicated for dementia until after any reversible factors have been identified and dealt with. And although doctors can't yet reverse chronic dementia, there are medications that can improve patients' ability to function and their overall quality of life.