IM25.{3,5-7} | Geriatric Neuropsychiatric Syndromes — Summary & Reflection

KEY TAKEAWAYS

Delirium (acute confusional state): acute onset + fluctuating course + inattention + disorganised thinking / altered consciousness (CAM criteria). Subtypes: hyperactive (recognised), hypoactive (missed most often), mixed. Causes: PINCH ME (pain, infection, nutrition/fluid, constipation/retention, hypoxia, medication, environment). Management: treat the cause; non-pharmacological bundle (HELP programme); haloperidol 0.25–0.5 mg only if risk to self/others. Avoid benzodiazepines except in withdrawal delirium.

Dementia (major neurocognitive disorder): insidious onset; significant functional impairment; types:
- Alzheimer (60–70%): amyloid plaques + neurofibrillary tangles; memory-first; hippocampal atrophy; AChEI + memantine
- Vascular: stepwise; focal signs; white matter lesions; risk factor management
- Lewy body: fluctuating + visual hallucinations + parkinsonism; AChEI; neuroleptic contraindicated
- Frontotemporal: behaviour/language-first; age 50–65; no AChEI benefit

Reversible causes of cognitive impairment: depression (pseudodementia), drugs, delirium, hypothyroidism, B12/folate deficiency, NPH, SDH, neurosyphilis

Geriatric depression: GDS ≥5/15 = probable; SSRI first-line (sertraline/escitalopram); avoid TCAs; ECT for severe/treatment-resistant; CBT equally effective for mild-moderate

Personality change in elderly: usually organic — frontotemporal dementia, frontal vascular lesions, Parkinson disease

REFLECT

Revisit the two encounters from the hook: Mr Nair's acute delirium (resolved fully) and his subsequent dementia presentation (progressive). The episode of delirium was not simply 'fixed' — research suggests that an episode of delirium in an already cognitively vulnerable patient accelerates the trajectory toward dementia. Does this alter how aggressively you would prevent delirium in a hospitalised elderly patient who has mild cognitive impairment? And for his wife, who has been managing his Alzheimer dementia at home for a year — what does the concept of 'the 36-hour day' mean for her health? How would you incorporate a caregiver assessment into a routine dementia follow-up visit? The competency this module builds is not only diagnostic — it is the clinical compassion and systemic thinking to care for both the patient and the family unit surrounding them.