What Are Cognitive Disorders? A Foundational Overview and Acute Confusional States

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What Are Cognitive Disorders? A Foundational Overview and Acute Confusional States

Abnormal Psychology · Chapter 20: Cognitive Impairments: Disorders of Thinking and MemorySection 20.1 · lesson 75 of 9717 min · free with a free account

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In this lesson

Acquired decline - and the acute confusion that is a medical emergency.

  • Define cognitive disorders, and separate symptom, syndrome, and disease
  • Distinguish mild from major neurocognitive disorder, and both from normal aging
  • Recognize delirium - especially the hypoactive form
  • Tell delirium, dementia, and depression apart

Transcript

Everything said in the video, section by section (2,262 words). Read along, or search it.

Cognitive Impairments: Disorders of Thinking and Memory

Cognitive Disorders and Delirium

Chapter twenty covers cognitive impairments, disorders of thinking and memory. This first section lays the foundations, and covers acute confusional states. We define cognitive disorders, separate symptoms from syndromes and diseases, and distinguish mild from major decline, and both from normal aging. Then we turn to delirium, a medical emergency that is frequently missed. We finish by telling delirium, dementia, and depression apart, with two composite cases.

Before You Begin

The Most Important Statement First

One statement comes before anything else, because it is the most important practical point in this section. Any new or worsening confusion, in any person, requires urgent medical assessment. That applies whether or not the person has a known cognitive condition. This material is educational, and not a basis for diagnosing yourself or anyone else. Some viewers will have personal experience of these conditions, in themselves or someone close to them. If you are concerned about yourself or someone else, please speak with a qualified professional, or seek medical attention.

What Cognitive Disorders Are

Acquired Decline - Compared With What?

Cognitive disorders are conditions whose primary feature is an acquired decline in cognitive function, from a level the person previously attained. The crucial word is acquired. That separates these conditions from a lifelong difference in cognitive functioning, which belongs to the next chapter. So the first question is always, compared with what? Without a baseline, decline cannot be established, which is why collateral history matters so much. The current classification replaced the term dementia with major neurocognitive disorder, and introduced mild neurocognitive disorder for lesser decline. The older term carried stigma, and implied a loss of mind. It was associated with old age, though these conditions occur in younger adults too. And it implied progression, though some are static and some improve. In practice both terms are in use, and dementia is what most people say. What is not acceptable in either vocabulary is demented, which reduces the person to the condition, or senile, which blames age itself.

3 Levels

Symptom, Syndrome, Disease

Three levels must be kept distinct. Confusing them is the most common conceptual error in this area. A cognitive symptom is a single observed difficulty. Trouble recalling recent events, or losing the thread of a conversation. A cognitive syndrome is the pattern those symptoms form, with its severity and functional impact. For example, a major neurocognitive disorder with predominant memory impairment. The underlying disease is the process producing the syndrome. Alzheimer's disease, cerebrovascular disease, an infection, or a metabolic disturbance. Naming the syndrome is not naming the cause. Two people with an identical syndrome may have entirely different diseases, with different prognosis, management, and, crucially, reversibility. So recording a major neurocognitive disorder is the beginning of the diagnostic work, not the end.

Table 20.1.1

6 Cognitive Domains, 6 Ways to Fail

Six cognitive domains are recognized, and each fails in a distinctive way. Complex attention covers sustaining and dividing attention. When it fails, a discussion in a noisy room becomes impossible to follow. Executive function covers planning, sequencing, and flexibility. A familiar recipe with several stages can no longer be completed in order. Learning and memory covers forming and retrieving new information. The person asks the same question several times in an hour, without recalling having asked. Language failure shows in word-finding, a general word substituted because the name will not come. Perceptual-motor failure shows in getting lost on a route walked for years. And social cognition failure shows in remarks in company that the person would never previously have made. Which domain is affected first is the most informative early clue to the underlying disease. A presentation beginning in social cognition points somewhere quite different from one beginning in memory.

Mild and Major

Independence Is the Pivot

Mild and major neurocognitive disorder differ in the degree of decline. But the real pivot is independence in everyday activities. In mild disorder, independence is preserved, though it takes more effort, strategy, or accommodation. In major disorder, independence is interfered with, and help is needed. That criterion is defensible, because it is what matters to the person. But it is genuinely hard to apply, because circumstances mask and magnify impact. Imagine two people with identical decline. The first lives with a partner who has gradually taken over the finances, the driving, and the appointments. The person appears to be managing, because someone else is managing. The second lives alone and runs a complex household, and the same decline produces a visible crisis. What differs is the environment. So ask what the person does unaided, not what gets done. Ask an informant specifically what they have taken over, and when. And watch for the reverse error, where demanding circumstances make someone look more impaired than they are.

Normal Aging

Slowing Is Ordinary - Losing Ability Is Not

Some cognitive change with age is ordinary, and not a disorder. Processing speed tends to slow. Retrieval becomes less efficient, like the name that takes a moment to arrive, and then does. And dividing attention gets harder. Meanwhile vocabulary, accumulated knowledge, and well-practiced skills are typically preserved, or keep developing. But significant cognitive decline is not a normal part of aging, and must never be dismissed as such. That dismissal is common, made by families and sometimes by clinicians. It delays the identification of reversible causes, delays access to support, and denies people the chance to plan. Slowing slightly is ordinary. Being unable to manage what one previously managed is not, at any age.

Reversible Contributors

Look for These First

Before concluding that a progressive condition is present, several contributors must be considered, because many are treatable, and treatment can restore function. Medication effects, at class level. Several classes affect cognition, and the effect grows when a person takes many medications together. Any change is made with a prescriber. Metabolic and endocrine conditions, including thyroid and electrolyte disturbance. Nutritional deficiency, including deficiencies of certain vitamins. Infection, which in older adults may show up as confusion before anything else. Sensory impairment, because a person who cannot hear the question or see the material may appear impaired, and not be. Sleep disorders. And depressive presentations, which can produce prominent cognitive complaints. These are looked for first. A progressive condition diagnosed without excluding them may be a treatable condition left untreated.

Delirium

A Medical Emergency

Delirium is a medical emergency. It is not a psychiatric condition to be managed psychologically. It is an acute disturbance of brain function, caused by an underlying physical problem, and that problem must be identified and treated urgently. Identifying and treating the cause is the treatment. Delirium is associated with longer hospital stays, functional decline, and increased mortality, and outcomes worsen the longer it goes unrecognized. Three features define it. First, acute onset. It develops over hours or days, not months. Second, a fluctuating course. The person may be lucid at one point and markedly confused hours later, which is why a single assessment can miss it entirely. Third, impaired attention as the core disturbance. The person cannot sustain or shift attention, which distinguishes it from the memory-led presentations later in the chapter.

3 Presentations

Hypoactive Delirium Is the Most Missed

Delirium has three presentations. Hyperactive delirium involves restlessness, agitation, and heightened arousal. It is recognized readily, because it demands attention. Hypoactive delirium involves reduced activity, withdrawal, drowsiness, and slowed responses. In some settings it is the most common form, and it is by far the most frequently missed. It is quiet, it makes no demands, and it is routinely put down to low mood, tiredness, or the person being a bit flat. Mixed delirium fluctuates between the two, which adds to the difficulty. In practice, remember that the core disturbance is attention, not mood. So ask the person something requiring sustained attention, rather than asking how they feel. Fluctuation is the giveaway. And a collateral informant answers the decisive question. Is this a change from last week? Being quiet is not being less unwell.

Table 20.1.3

Ordinary Causes, Found If Someone Looks

The causes of delirium are mostly ordinary. Infections, urinary, respiratory, and others. In older adults, confusion may be the first or only sign. Metabolic disturbance, found through blood investigation. Medication effects, where risk rises with the number of medications. So review everything, including anything started shortly before onset. Substance withdrawal, which is a medical matter. Hypoxia, meaning reduced oxygen delivery. And pain, which is frequently missed, especially in people who cannot report it. Surgery and hospitalization, with an unfamiliar environment, disrupted sleep, and immobility. And dehydration and constipation, common, easily overlooked, and readily corrected. That ordinariness is why delirium is an emergency with a good outlook when caught. The causes are common, identifiable, and mostly treatable, provided somebody looks.

Figure 20.1.5

How Vulnerability and Insult Combine

Two kinds of factor combine. Predisposing factors make a person vulnerable. Advanced age, existing cognitive impairment, frailty, sensory impairment, and multiple medical conditions. Precipitating factors are the acute insults that trigger it, the causes we just listed. In this schematic, vulnerability runs along the bottom, and the size of insult needed runs up the side. The curve is the threshold for delirium. A healthy younger person, at the left, needs a major insult to cross it. A frail person with existing impairment, at the right, can cross it with something as ordinary as constipation or a urinary infection. So in a vulnerable person, look for small causes. The absence of a dramatic cause is not evidence against delirium. And existing cognitive impairment is the strongest single predisposing factor, which sets up the second case in this section.

Prevention

Organizational, Not Sophisticated

Delirium can often be prevented, and the evidence for prevention is good. Multicomponent, non-drug prevention programs are among the better-evidenced interventions in this area. They target the modifiable contributors all at once. Orientation, with clocks, calendars, consistent staff, and explaining what is happening. Mobility, getting people up and moving rather than leaving them in bed. Sensory aids, making sure glasses and hearing aids are present and working, which is startlingly often not the case in hospital. Sleep, protecting the night and reducing disturbance. And hydration and nutrition. Nothing on that list is technically sophisticated, which is part of the point. What works here is organizational and attentional.

Table 20.1.4

Delirium, Dementia, or Depression?

Delirium, dementia, and depression are confused constantly. Onset, course, and attention settle most cases. Delirium begins over hours to days. Dementia begins insidiously over months to years. Depression often develops over weeks to months. Delirium fluctuates markedly across the day, with lucid intervals. Dementia is generally stable within a day. Depression is relatively stable. In delirium, attention is impaired, and it is the core disturbance. In dementia, attention is preserved until later stages. In depression, it may be reduced by preoccupation. Alertness is altered in delirium, and normal in the other two. And delirium is usually reversible if the cause is treated, while depression is treatable. The consequence of confusing them runs one way. Missing delirium means missing a treatable medical emergency. And they frequently coexist. A person with dementia is at high risk of delirium, and depression is common in both. A known diagnosis in the notes is not a reason to stop assessing. It is a reason to ask what has changed.

In the Clinic

Sudden Change Is an Emergency Until Proven Otherwise

The single most useful habit here is treating acute change as acute change, whatever the person's baseline. A change over hours or days is an acute process by definition. It needs urgent medical assessment, not a mental health referral in the first instance. She has dementia does not explain a change that happened this week. Dementia does not progress over three days. The order is medical first. Examination, observations, investigation, and medication review, with the cognitive question following. Ask the informant one question above all others. When was this person last themselves? The answer separates acute from chronic more reliably than any examination. Collateral history is essential, not merely desirable. Screening tools exist, but they need training, and they are not diagnostic. None appears in this course.

Case Vignette 1 (Composite)

Eileen: Delirium Mistaken for Low Mood

Now two composite cases, constructed for instruction. Eileen is eighty-one. On the third day after an operation, nursing staff recorded that she seemed low in mood and withdrawn. She lives independently, and her daughter describes her as sharp and sociable. She has stopped engaging with staff, eats little, and spends most of the day drowsy. A referral was made for assessment of depression. That was understandable, since the picture looked depressive. But it asked the wrong question, and delayed the right one by a day. Two things identified the real problem. Her daughter, asked when Eileen was last herself, answered without hesitation. Two days ago. And observed across the day, Eileen was oriented and chatting in the morning, and markedly confused by evening. That fluctuation does not occur in depression, and does not occur in dementia over hours. So medical assessment comes first. Infection and metabolic checks, a review of every medication, and assessment of pain, hydration, and constipation. The decisive question was asked of an informant, not the patient.

Case Vignette 2 (Composite)

Bernard: Delirium on Top of Dementia

Bernard is seventy-six. His wife called their doctor because he became acutely confused and agitated overnight. He was diagnosed with a major neurocognitive disorder two years ago, and has declined gradually, needing help with finances and appointments, but managing his own personal care. Over about thirty-six hours, that changed. He can no longer reliably wash or dress, and yesterday he did not recognize his daughter. The trap is to absorb this into his diagnosis, and say his dementia has progressed. It has not. A progressive disorder does not produce a step change over thirty-six hours. And he was at high risk. Existing cognitive impairment is the strongest predisposing factor, so a minor precipitant is enough, and the absence of an obvious cause counts for nothing. He has a major neurocognitive disorder, and a delirium on top of it. The first explains his baseline. It explains nothing about this week. In anyone with a known cognitive condition, ask what has changed, and over what period. A known diagnosis raises the probability of delirium, rather than reducing it.

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FAQ

Questions students ask us

About What Are Cognitive Disorders? A Foundational Overview and Acute Confusional States

What is delirium?
Delirium is an acute disturbance of brain function caused by an underlying physical problem, and it is a medical emergency. It has three defining features: onset over hours or days, a fluctuating course across the day, and impaired attention as the core disturbance. Common causes include infection, metabolic disturbance, medication effects, dehydration, pain, and surgery. Finding and treating the cause is the treatment, and unrecognized delirium is linked with longer hospital stays and higher mortality.
What is hypoactive delirium?
Hypoactive delirium is a form of delirium marked by reduced activity, withdrawal, drowsiness, and slowed responses, rather than agitation. In some settings it is the most common form, yet it is the most frequently missed because it is quiet and is often put down to low mood or tiredness. Testing sustained attention, watching for fluctuation, and asking an informant whether this is a recent change help identify it.
How is delirium different from dementia?
Delirium begins over hours to days, fluctuates markedly across the day, impairs attention and alertness, and is usually reversible when its cause is treated. Dementia, now called major neurocognitive disorder, begins insidiously over months to years, is generally stable within a day, and leaves attention preserved until later stages. The two often coexist, and a sudden change in someone with dementia should be treated as possible delirium.
What is the difference between mild and major neurocognitive disorder?
Mild and major neurocognitive disorder differ in degree of acquired cognitive decline, but the key dividing line is everyday independence. In mild neurocognitive disorder, the person still manages daily activities, though with more effort or strategies. In major neurocognitive disorder, the DSM term that replaced dementia, decline interferes with independence and help is needed. Clinicians ask what the person does unaided, since a supportive partner can mask decline.

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