Psychiatric Case Study: Differentiating Delirium and Dementia in Older Adults

1.This is base on my discussion post on Psychiatric Case study

Elvira Angelica Silva de Vera • TEACHER

Sep 30 10:53am

Reply from Elvira Angelica Silva de Vera Given Ms. Richardson’s overlapping symptoms suggestive of both delirium and dementia with psychosis, what clinical tools or assessments would you prioritize to accurately differentiate these conditions in the acute hospital setting, and how would this distinction impact your immediate treatment approach?

2. Reply from Anita Lucia Mohan

Psychiatric Case Study: Ms. Richardson

Clinical Summary

Ms. Richardson is a 74-year-old African American female brought to the emergency department by police after reports from neighbors of wandering, self-neglect, and confusion. On arrival, she was unkempt, malodorous, and disoriented to time and place, though she knew her name and address. She was minimally responsive, with a flat affect, poor eye contact, and limited insight. She reported generalized weakness, shoulder pain, difficulty swallowing, and not eating for three days. She recalled her dog being tranquilized and erroneously believed it was in “the shop,” showing signs of confusion. She denied hallucinations or prior psychiatric hospitalizations but mentioned seeing a psychiatrist for insomnia in the past. Her home environment was severely unsanitary, with feces and clutter, suggesting severe self-neglect. She was also noted to have uncontrolled diabetes, dehydration, and malnutrition. Subjective data includes weakness, shoulder pain, and not eating for three days, Objective data includes unkempt appearance, malodorous, disoriented to time and place, impaired insight, poor judgment, unsafe environment, uncontrolled diabetes, and difficulty swallowing, dehydration and poor nutritional intake. Her presentation suggests acute cognitive decline with possible chronic neurocognitive disorder (Tusaie, 2023, pp. 328–351).

Primary Diagnosis: F05- Delirium due to Another Medical Condition (DSM-5-TR Code: 293.0; ICD-10 F05)

Ms. Richardson’s presentation is most consistent with delirium due to another medical condition. According to the DSM-5-TR, delirium is defined as an acute disturbance in attention and awareness that develops over a short period, fluctuates in severity, and is associated with additional cognitive impairments such as memory deficits, disorientation, or perceptual disturbances. It must be attributable to a physiological cause such as a medical illness, substance intoxication, or metabolic imbalance (American Psychiatric Association [APA], 2022). According to Tusaie (2023), such presentations in older adults often reflect delirium, a reversible condition commonly triggered by metabolic disturbances or infections. Her risk factors include advanced age, poor glucose control, nutritional deficiency, and social isolation, aligning with known etiologies of delirium (pp. 328–351).

Two Differential Diagnosis

The first differential diagnosis is Major Neurocognitive Disorder (NCD), Unspecified Type (DSM-5-TR Code: 294.20; ICD-10: F03.90). DSM-5-TR defines major NCD as a significant cognitive decline in one or more domains to include memory, executive function, attention, and language that interferes with independence (APA, 2022). Ms. Richardson’s functional decline and neglect could suggest an underlying dementia, which may have been masked by acute delirium. Delirium may occur superimposed on major NCD, and evaluation should be repeated after medical stabilization (Tusaie, 2023, pp. 328–351).

The second differential diagnosis is Depressive Disorder with Cognitive Impairment (Pseudodementia) (DSM-5-TR Code: 311, ICD-10: F32.9). Late-life depression may manifest as cognitive slowing, poor concentration, apathy, and self-neglect, mimicking dementia (APA, 2022). Ms. Richardson’s flat affect and limited responsiveness may represent depressive features. Distinguishing pseudodementia through mood assessment and improvement with antidepressant therapy can help differentiates it from degenerative cognitive disorders (Tusaie, 2023, pp. 328– 351)..

Pharmacological Treatment

The primary pharmacologic goal in Ms. Richardson’s case is to treat the underlying medical cause of delirium. According to NICE (2023) guidelines, management should begin with intravenous fluids and electrolyte correction to address dehydration, along with insulin therapy based on ADA (2023) standards to stabilize hyperglycemia. Nutritional supplements including multivitamins and thiamine help to correct deficiencies contributing to cognitive impairment.

If Ms. Richardson develops behavioral agitation or perceptual disturbances, low-dose haloperidol (0.25–0.5 mg PO/IM every 4–6 hours as needed) may be administered, with ECG monitoring for potential QT prolongation. Haloperidol is often recommended for short-term symptom management in delirium when nonpharmacologic interventions are insufficient (APA, 2023). If cognitive symptoms persist after medical stabilization and a major neurocognitive disorder (NCD) is confirmed, pharmacologic agents such as donepezil (5 mg daily) or

memantine (5 mg daily) may be initiated to support cognitive function (Tusaie, 2023 pp.328-351).

Nonpharmacological Treatment

Nonpharmacological treatment is important in delirium management. The primary goal is to restore orientation, ensure safety, and address modifiable risk factors through environmental and behavioral interventions. Ms. Richardson should be placed in a quiet, well-lit environment with visible clocks, calendars, and familiar objects to enhance orientation and reduce confusion. Consistent caregivers and family involvement can provide reassurance and emotional stability. Reorientation strategies, including frequent verbal reminders of time, place, and situation, can be used throughout the day. To support physiological stability, she should maintain adequate hydration and nutrition. Sleep hygiene is another critical component; nighttime noise and interruptions should be minimized to promote restorative sleep. Collectively, these multicomponent interventions have been shown to reduce both the severity and duration of delirium while promoting functional recovery (Tusaie, 2023, pp. 328–351).

Health Promotion Intervention

Health promotion for Ms. Richardson should focus on chronic disease management, safety, and social support to prevent recurrence of delirium and enhance overall well-being. Education on diabetes self-management is essential, following the American Diabetes Association (2023) standards. This includes teaching her how to monitor blood glucose, adhere to prescribed insulin therapy, and maintain a balanced diet. Given her unsafe home environment and self-neglect, referrals to Adult Protective Services (APS) and home health nursing are warranted for supervision and support would be recommended. Social services can assist in arranging community resources such as Meals on Wheels, senior day programs, and transportation to reduce isolation and improve access to care. If a major neurocognitive disorder or depression is identified, appropriate long-term treatment can be initiated (Tusaie, 2023, pp. 328–351).

Guidelines for Your Assignment

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

1. Introduction (½ page)

   • Briefly introduce Ms. Richardson’s case.

   • State the purpose of your discussion: differentiating delirium, exploring differential diagnoses, and outlining treatment and health promotion strategies.

   • End with a clear thesis statement (e.g., “This paper will analyze Ms. Richardson’s psychiatric presentation by identifying her primary diagnosis, differential diagnoses, pharmacological and nonpharmacological treatments, and long-term health promotion strategies.”).

2. Clinical Presentation and Primary Diagnosis (1 page)

   • Summarize the key subjective and objective data from the case.

   • Explain why delirium due to another medical condition (F05) is the most accurate diagnosis.

   • Support with DSM-5-TR criteria and course text (Siegel, 2018) plus at least one scholarly source.

3. Differential Diagnoses (1 page)

   • Discuss Major Neurocognitive Disorder and Pseudodementia (Depressive Disorder with cognitive impairment).

   • Explain why these are possible but less likely compared to delirium.

   • Reference DSM-5-TR and relevant scholarly literature.

4. Pharmacological Treatment (1 page)

   • Explain the priority: treating underlying causes (hydration, glucose control, vitamins).

   • Discuss potential use of haloperidol for short-term agitation.

   • Mention future use of donepezil or memantine if dementia is later confirmed.

   • Cite APA, ADA, and NICE guidelines.

5. Nonpharmacological Treatment (1 page)

   • Environmental modification (quiet, well-lit room, orientation cues).

   • Caregiver consistency and family involvement.

   • Sleep hygiene and hydration/nutrition support.

   • Show how these reduce delirium severity and promote recovery.

6. Health Promotion Interventions (1 page)

   • Focus on diabetes management, safety, and social support.

   • Include patient education, APS referrals, home health, and community programs.

   • Show how long-term interventions reduce recurrence and improve quality of life.

7. Conclusion (½ page)

   • Summarize the major points: diagnosis, differential diagnoses, treatment strategies, and health promotion.

   • Reiterate the importance of accurate delirium identification in older adults.

8. References Page

   • APA 7th edition format.

   • At least 5–7 scholarly sources (DSM-5-TR, APA, ADA, NICE, Tusaie, Siegel 2018, plus at least one peer-reviewed article).