Solve the Puzzle: How to Assess Altered Cognition in Acute Care

Your evaluation request indicates that you will be seeing a 57-year-old white, divorced, female, with a left hip fracture repair one-day post-surgery. Her chart indicates that prior to the fall that led to her hip repair, she lived in a condo with a roommate and worked at a physician’s office as a filing clerk. She has no previous admissions and no other medical history of note. She is currently weight bearing as tolerated, and plans to return to her home with either home health or outpatient services after the hospital stay.

As you enter the hospital room, you see the patient attempting to pull the tubing out of the IV drip while saying, “I am not going to let you poison me! Not this time!” When you approach her, she startles and demands to talk to her lawyer and to the judge.

She has bilateral soft wrist restraints on as well as several discontinued IV sites on both arms. Her food tray is untouched. She then asks you to call her roommate to bring in her clothing so that she will have something to wear once released.

Suddenly, she pauses and starts to stare at her right hand. She flicks her thumb, index finger, and middle finger of her right hand as though she is trying to get something off it, although there is nothing there. When you attempt to draw her attention back to you, she smiles and asks you what you need.

How do we assess this situation? Let’s start with a list of questions that we need to ask ourselves.

Ask Yourself Key Questions

  1. What is going on here and what do you do next?
  2. What or who else do you want to talk with about this situation?
  3. Did you recognize the possibility of Lewy Body Dementia?
  4. Without a health care proxy, what will you do to gather more background?
  5. Could the fall have been caused by an undetected dehydration or infection in combination with her LBD?
  6. Is her living situation and expectation for discharge realistic? Or will they result in a re-admission with a worsening of the overall outcome?

When it comes to working with people in an acute care setting, we are often uninformed or misinformed about their previous level of function and wellness. When someone comes in through the ER with a traumatic event and is seen post-surgically, it limits our ability to determine whether what we are seeing and experiencing is a true representation of their baseline abilities or an aberration caused by post-surgical delirium. Additionally, a pre-existing mental health condition could also be present and exacerbated by the immediate situation. For a person in this age group, we rarely consider the possibility of undetected dementia.

Account For Multiple Factors

Sorting through the possible causes for an acute state of confusion requires more detective work than most people expect. It’s also more important for successful management and optimal patient outcomes that we take on this clinical challenge.

Recent studies confirm that delirium, depression, anxiety, and dementia are often found in combination.3-10 An acute hospital event can trigger the first episode of interacting symptoms due to a baseline loss of homeostatic reserve in combination with the onset of any of the following factors:

  • Environmental change
  • Metabolic change
  • Pain
  • Medications
  • Routine and/or habit change

Failure to put all the pieces of the puzzle together to determine the best course of action frequently results in extended hospital stays, additional in-hospital negative health events, lack of progress in rehabilitation, higher costs, and rapid re-admissions. It’s equally as important to understand the value of short-term and long-term alternatives.

  1. Collier, Roger. Hospital-induced delirium hits hard. CMAJ. 2012 Jan 10; 184(1): 23–24. doi: 0.1503/cmaj.109-4069
  2. Dementia or Hospital-Induced Delirium? Oceans Behavioral Hospital Katy: News. Website posting Aug 2nd, 2016
  3. Givens, JL, Sanft,TB, Marcantonio, ER. Functional Recovery After Hip Fracture: The Combined Effects of Depressive Symptoms, Cognitive Impairment, and Delirium. JAGS. First published: 18 April 2008, DOI:
  4. Mcclusker, J, Cole, MG, Voyer, P, et al. Six-Month Outcomes of Co-Occurring Delirium, Depression, and Dementia in Long-Term Care.JAGS. 8 December 2014.
  5. Cole, MG, McCusker, J,  Voyer,P, et al.  Subsyndromal Delirium in Older Long-Term Care Residents: Incidence, Risk Factors, and Outcomes. JAGS. 13 September 2011.
  6. Givens, JL, Jones, RN, Inouye, SK. The Overlap Syndrome of Depression and Delirium in Older Hospitalized Patients. JAGS. 3 June 2009.
  7. Tsai, MC, Chou, SY, Tsai, CS, et al. Comparison of Consecutive Periods of 1-, 2-, and 3-Year Mortality of Geriatric Inpatients with Delirium, Dementia, and Depression in a Consultation-Liaison Service. International May 10, 2013. Int J Psych Med.
  8. Anderson, HS. Dementia, Delirium, and Depression. Geriatric Urology. Springer New York, 2014. 73-87.
  9. Fong, TG., Samir RT, and Inouye, SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology 5.4 (2009): 210-220.
  10. Insel, KC., Badger, TA. Deciphering the 4 D's: cognitive decline, delirium, depression and dementia–a review. J Adv Nurs 38.4 (2002): 360-368.