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Delirium is complex and multifactorial syndrome resulting from global organic cerebral dysfunction (Bush et al., 2017).  Delirium is a frequent cause of psychotic symptoms, bizarre delusions, abnormal behavior and thought disorders.  Delirium in the elderly is frequent during hospitalizations.  Delirium fluctuates dramatically and includes the patient’s appearance, affect, mood, thoughts including hallucinations and delusions, inquiry into self-destructive behavior, homicidal behavior, judgment, and orientation (immediate, recent, and long-term memory) (Alagiakrishnan, 2019).  Delirium can develop quickly and an acute change in consciousness or difficulty focusing regarding the conversation may occur during an interview.  Patients who develop delirium and frequently unable to recall why they are where they are or the events which lead them to be in their current location.  Patient may develop false beliefs or see or hear things which are not really present.  These patients may misjudge their level of wellness and leave a healthcare setting or end needed healthcare (Alagiakrishnan, 2019). 

The diagnosis of delirium is clinical related to the delirious patient is usually unable to provide accurate information.  The patient information will need to be obtained from the family or caregivers.  Documentation of previous care are beneficial to assess for episodes of disorientation, abnormal behavior, and hallucination (Alagiakrishnan, 2019).  The provider in screening for delirium should obtain a baseline cognitive screen and then use a validated delirium screening tool.  Then they should observe and investigate any changes in the patient’s cognitive status, behavior, or self-care.  The provider must identify differences between dementia, depression and delirium.  The provider must: 1. obtain a recent medical history, including function, cognition, diet, falls, bowel, and bladder function; 2. Complete a medication review, noting any changes in medications; 3. Complete a physical and mental status exam, including VS, chest examination, cognitive and delirium screening; 4. Complete urinalysis, CBC and chest x-ray.  A tool used to assess delirium is the Confusion Assessment Method (CAM).   

 

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According to the American Psychiatric association (2017), a mild or major neurovascular disorder is diagnosed by memory impairment and one of the following aphasia, apraxia, agnosia or disturbance in executive function. Additionally, the impairment has caused social or occupational function deficits that were not present before. In contrast, a major or mild neurocognitive disorder with Lewy bodies (NCDLB) is diagnosed when a patient has one core feature and one suggestive feature. The core features are fluctuating cognition with pronounced variations in attention and alertness, reoccurring visual hallucinations that are detailed, features of Parkinsonism with onset after cognitive decline. The suggestive features are rapid eye movement sleep behavior problems, or severe neuroleptic sensitivity. Differentiation occurs when a disturbance is not better explained by cerebral neurovascular disease or another neurodegenerative disease, substance abuse, or other disorder (American Psychiatric Association, 2017). To differentiate between the two we can look at the progression of Lewy body neurocognitive disorder. Early stages may involve hallucinations, delusions, restlessness, acting out during sleep and urinary urgency. Middle stages may include motor difficulty, speech difficulty, swallowing difficulty and increased paranoia. Later stages include speech difficulty, ADL difficulty, extreme muscle rigidity, and sensitivity to touch (Sadock, Sadock, & Ruiz, 2017).

      Differentiation is done by assessment and physical exam. During the diagnostic part of the comprehensive exam, MRI or CT can rule out neurovascular disorder (Domino, Baldor, Golding, & Stephens, 2020). During the HPI section of the comprehensive assessment persons with neurocognitive disorder with Lewy bodies can present with fluctuating cognition. A family member might state one day the patient is fine and the next day the patient’s memory is impaired. Whereas, neurovascular disorders will present with sudden and sustained deficits. Another condition present in Lewy body disease not present in neurovascular disease is the complaint of sleep disturbance (American Psychiatric Association, 2017). A family member or patient may mention this as a chief complaint or describe this in the HPI. It may even come up in the comprehensive assessment when talking about sleep patterns and hours of sleep. During physical assessment, neurovascular disorder may affect one side of the body. Therefore, there will be impaired motor activity to one side despite intact motor function on the other side. Likewise, there may be a failure to identify an object despite intact sensory function. Neurocognitive disorder with Lewy body is also progressive. Over several visits the practitioner may find that motor function is declining more or speech may be declining more. In contrast, neurovascular disorders present more suddenly. Finally, during assessment of social history neurovascular disorder patients will have a sudden decline in social or occupational function. NCDLB may decline gradually over a long period (American Psychiatric Association, 2017).

Current research is looking at genetic biomarkers for diagnostic testing for early identification of NCDLB. Five Alpha-synuclein genes were tested for biomarkers in blood and temporal cortexes. SNCA transcripts that were specific for NCDLB patients were found to increase in the brain and diminish it blood test. This shows some promising results in the possibility of using biomarkers, which are not currently present, to help diagnose NCDLB (Marsal-García et al., 2021).

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