380
DIAGNOSTIC ISSUES (CONT’D)

if score <4, likely Alzheimer’s disease; if
>7, likely vascular dementia
CLOCK DRAWING a test of constructional apraxia
with many technical variants. Wolf Klein method
provides patient with paper and preprinted circle (4
in. in diameter) and instructions to ‘‘draw a clock.’’
‘‘Normal’’ clock has numbers clockwise in correct
order and near rim, even without hands on clock.
Abnormal clock drawing argues for dementia (LR+
5.3). Normal clock drawing not useful (as half of
demented patients can produce normal clock)
CRITERIA FOR PERFORMING CT HEAD age <60,
rapid (1 2 months) unexplained decline in cognition
or function, dementia of short duration (<2 years),
unexplained neurological symptoms (e.g. new onset
headache or seizures), early incontinence/gait disor
der (NPH), recent head trauma, history of cancer, use
of anticoagulants or history of bleeding disorder, new
localizing signs, unusual or atypical cognitive symp
toms or presentation (e.g. progressive aphasia)
CMAJ 1999 160:12; Canadian Consensus
Conference on Dementia
 UTILITY

MANAGEMENT

RISK REDUCTION anti hypertensive (see HYPER
TENSION p. 57), dyslipidemia treatment (see DYSLI

PIDEMIA p. 62)
DISEASE MANAGEMENT anticholinesterase may
be considered for Alzheimer’s disease and include
donepezil 5 10 mg PO qhs, rivastigmine 1.5 6 mg
PO BID, and galantamine ER 8 24 mg daily. Avoid if
seizures, cardiac conduction problems, significant
asthma, COPD, or recent GI bleed. Memantine
5 10 mg PO BID may be used as a single agent or
as add on therapy to cholinesterase inhibitor
SYMPTOM MANAGEMENT treat problem beha
viors with non pharmacological and pharmacological
approaches (trazodone, atypical antipsychotics). Treat
co existing depression
TUBE FEEDING generally not recommended for
advanced dementia because of increased complica
tions without evidence of clinical benefit (e.g.

Delirium

MANAGEMENT (CONT’D)

survival, quality of life, prevention of aspiration pneu
monia, reduction of pressure sores or infections, func
tional improvement)
SPECIFIC ENTITIES

SEQUENCE OF SYMPTOMS IN ALZHEIMER’S DIS
EASE mood changes, cognitive decline, loss of
functional autonomy, neuropsychiatric manifesta
tions, parkinsonism

LESS COMMON CAUSES OF DEMENTIA
 NORMAL PRESSURE HYDROCEPHALUS (NPH)
 PATHOPHYSIOLOGY inflammation and fibrosis
of the arachnoid granulations ! decreased
absorption of CSF ! hydrocephalus ! normal
opening pressure but elevated pressure over
periventricular white matter tracts
 CAUSES idiopathic or secondary, e.g. subarach
noid hemorrhage, chronic meningitis
 CLINICAL FEATURES classic triad of gait apraxia
(magnetic gait as feet are stuck to floor), urge
incontinence, and cognitive decline. Also may
have postural instability, lower extremity spasti
city, hyperreflexia, and extensor plantar responses
 DIAGNOSIS clinical diagnosis and MRI. Improve
ment of gait or cognition 1 h after removal of
30 50 mL of CSF can be helpful for diagnosis (Fisher
test, PPV 90 100%, NPV 30 50%). An improvement
also predicts responsiveness to shunting
 TREATMENTS lumbar puncture, shunts (ventricu
loperitoneal, ventriculoatrial, lumboperitoneal)
 PARKINSON’S-PLUS SYNDROMES include progres
sive supranuclear palsy, multiple system atrophy
and corticobasal ganglionic degeneration
 CREUTZFELDT–JAKOB DISEASE rapid progression,
characteristic EEG, myoclonic jerks, and expected
death in 6 12 months
 HUNTINGTON’S DEMENTIA autosomal dominant
with incomplete penetrance; premorbid DNA test
ing quantifies risk, severity, and age of onset

 CORTICONUCLEAR DEGENERATION marked visual
spatial impairment, substantial apraxia, but mem
ory impairment less noticeable

Delirium

NEJM 2006 354:11

DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS (CONT’D)

wDIMSw
DRUGS wABCDw
 ALCOHOL intoxication, withdrawal, Wernicke
Korsakoff
 ANTICHOLINERGICS atropine,
benztropine,
scopolamine
 ANTIDEPRESSANTS SSRIs, TCA







ANTICONVULSANTS carbamazepine, phenytoin,
valproate, phenobarbital
ANALGESICS opioids, NSAIDs, steroids

ANTIBIOTICS penicillins, quinolones, sulfona
mides, isoniazid, rifampin, streptomycin,
chloroquine, acyclovir
ANTI-HISTAMINES cimetidine,
famotidine,
ranitidine


381

Delirium

DIFFERENTIAL DIAGNOSIS (CONT’D)

DIFFERENTIAL DIAGNOSIS (CONT’D)

BENZODIAZEPINES AND BARBITURATES
 CARDIAC amiodarone,
b blockers, digoxin,
diuretics
 DOPAMINE AGENTS amantadine, bromocriptine,
levodopa
INFECTIOUS pneumonia, UTI, meningitis, ence
phalitis, abscess, sepsis
METABOLIC
 ORGAN FAILURE hepatic, azotemia, hypothy
roidism, hypoxia, hypercapnia, hypothermia,
hypertensive
 ELECTROLYTE IMBALANCE ketoacidosis, glucose
(hypo, hyper), hyponatremia, hypernatremia,

hypomagnesemia, hypercalcemia
STRUCTURAL
 HEMORRHAGE subarachnoid, epidural, subdural,
intracerebral

 STROKE



basilar

 TUMOR
 ABSCESS

SEIZURES
PATHOPHYSIOLOGY

HOSPITALIZATION hospitalized patients, particularly
the elderly, are at high risk of developing delirium. The
prevalence of delirium in geriatric patients on admis
sion to hospital is 14 24%. The estimated incidence is
up to 40% on the medical ward, 7 26% for general
surgery, 29 42% for vascular surgery, 8 42% for cardiac
surgery, and 16 62% for orthopedic surgery
FRAILTY IN ELDERLY limited reserve so easily
tipped over by any event, leading to delirium

DISTINGUISHING FEATURES BETWEEN DELIRIUM AND DEMENTIA
Delirium
Dementia

Onset
Abrupt
Insidious
Course
Fluctuating, usually reversible
Slowly progressive and usually irreversible
Duration
Days to weeks
Years
Level of consciousness
Hyperactive or hypoactive
Affected in late stages
Attention span
Usually affected
Affected in late stages
Orientation
Usually affected
Usually affected
Memory
May be affected
Usually affected
CT head
May be normal; structural changes
White matter changes, atrophy
PATHOPHYSIOLOGY (CONT’D)

DELIRIUM SUBTYPES
characterized by agitation
and/or hallucinatory symptoms
 MIXED DELIRIUM variable course with alternating

hyperactive and hypoactive features. A majority of
patients with delirium fall under this category
 HYPOACTIVE DELIRIUM characterized by excessive
drowsiness and decreased level of consciousness.
May mimic depression
COMPLICATIONS delirium can have a negative
impact on patients’ quality of life, symptom expres
sion, emotions, and decision making ability. Delirium
also prolongs hospitalization and is associated with a
poor prognosis and caregiver distress
 HYPERACTIVE DELIRIUM

CLINICAL FEATURES (CONT’D)

2. INATTENTION difficulty focusing/difficulty following
conversation (serial subtraction with distraction)
3. DISORGANIZED THINKING rambling, irrelevant, illo
gical conversation
4. SENSORIUM CHANGE (ALTERED LOC) agitated,
hyperalert, lethargic, stuporous, or comatose
EXAMINATION OF THE DELIRIOUS PATIENT in
addition to general physical and neurological exam
inations, obtain a baseline mini mental status exam
ination (useful for monitoring)
INVESTIGATIONS

BASIC
CBCD, lytes, urea, Cr, glucose, Ca, urinalysis
CXR, head CT
 MICROBIOLOGY urine C&S, blood C&S (if any fever)

SPECIAL
 METABOLIC WORKUP TSH if suspect thyroid dis
ease, AST, ALT, ALP, bilirubin, INR, PTT, NH4 if
suspect liver disease, Mg, PO4
 CARDIAC WORKUP ECG, CK, troponin if suspect
ACS
 SEIZURES WORKUP EEG
 LABS

 IMAGING

CLINICAL FEATURES

CONFUSION ASSESSMENT METHOD (CAM) posi
tive test argues strongly for delirium (LR 10.3) and
negative test argues against delirium (LR 0.2). Posi
tive test requires both major criteria 1+2 and either of
the minor criteria 3 or 4 wAIDSw
1. ACUTE ONSET AND FLUCTUATING CONFUSION abnor
mal behaviors come and go, "/# severity


382

Falls

INVESTIGATIONS (CONT’D)

medication serum
levels (e.g. digoxin, phenytoin salicylate, aceta

minophen), alcohol level, osmolality
MENINGITIS WORKUP lumbar puncture

 DRUG



OVERDOSE

WORKUP

DIAGNOSTIC ISSUES

PERSISTENT DELIRIUM if delirium persists despite
basic workup, think through differential diagnosis
again (VERY CAREFULLY). Also consider dehydration,
depression, urinary/fecal retention, abscess
MANAGEMENT

PREVENTION ensure adequate O2, fluid and elec
trolyte balance, pain management, reduction in use
of psychoactive drugs, bowel and bladder function,
nutrition, early mobilization, prevention of postop
complications, appropriate environmental stimuli,
and treatment of symptoms of delirium
TREAT UNDERLYING CAUSE discontinue offend
ing medications. Delirium may take days/weeks to
resolve even after the precipitating cause is removed
and treated
NON PHARMACOLOGICAL MEASURES reduce

noise, orient patient frequently, early mobilization,
provide proper hearing and visual aids, provide
clock/calendar and familiar objects (personal photos)
and people (family), supervision for meals, restoration

MANAGEMENT (CONT’D)

of day night cycle (optimal lighting during day, pro
mote sleep hygiene at night), avoidance of unneces
sary interventions (physical or chemical restraints,
urinary catheters, central lines)
PHARMACOLOGICAL MEASURES neuroleptics
for agitated patient (haloperidol 0.5 2 mg PO/IV/SC
q4 6h and q1h PRN, loxapine 2.5 5 mg PO/SC BID
and q6h PRN, risperidone 0.25 mg PO BID PRN, olan
zapine 2.5 5 mg PO daily PRN, quetiapine 25 mg PO
BID PRN), benzodiazepines may precipitate or wor
sen delirium and should generally be avoided except
for patients with alcohol or benzodiazepine withdra
wal (lorazepam 0.5 1 mg PO/SL daily QID PRN)
TREATMENT ISSUES

CONSENT FOR TREATMENT if patient delirious
and need to clarify direction of care, try to find
agent for personal directive and/or proxy. If not avail
able, consider calling closest family to discuss treat
ment options
Related Topics
Alcohol Withdrawal (p. 105)
Hypercalcemia (p. 353)

Meningitis (p. 241)
Metabolic Acidosis (p. 77)
Overdose (p. 102)

Falls

JAGS 2000 48:8; NEJM 2003 348:1

DIFFERENTIAL DIAGNOSIS

PATHOPHYSIOLOGY (CONT’D)

SYNCOPE neurogenic, cardiogenic, neurocardiogenic
DROP
ATTACKS transient
vertebrobasilar
insufficiency
POSTURAL HYPOTENSION
CONFUSION delirium
DIZZINESS vertigo, dysequilibrium
FALLS accidental, imbalance

 SOMATOSENSORY

PATHOPHYSIOLOGY

 ENVIRONMENT

PREDISPOSITION TO FALLS IN ELDERLY multi
factorial in nature; 50% of patients who fall do so

repeatedly. Multiple falls are a marker for other
underlying factors, including chronic diseases and
functional disability
 HIGHER CORTICAL/CNS decreased reaction time
 VESTIBULAR SYSTEM decreased balance
 VISUAL SYSTEM presbyopia, decreased peripheral
vision, and accommodation
 AUTONOMIC SYSTEM postural hypotension





SYSTEM decreased sensation,
proprioception, vibration perception
MUSCULOSKELETAL SYSTEM weakness
GAIT
INCOORDINATION Parkinson’s,
cerebellar
ataxia, stroke, normal pressure hydrocephalus
MEDICATIONS (strongest risk factor for falls) SSRIs,
TCAs, neuroleptics, anticonvulsants, benzodiaze
pines, class IA antiarrhythmics

infection, infarction, medications,
social stress
COMMUNITY DWELLING 41% of falls secondary to
environment (trips, slips), 13% weakness or gait/bal
ance disorder
NURSING HOME DWELLING 26% of falls second

ary to weakness, gait/balance disorder, 16% environ
ment related
COMPLICATIONS institutionalization, fear of recur
rent falls, long lies (risk for dehydration, pressure
sores, pneumonia, rhabdomyolysis), and death

 PRECIPITANTS


383

Urinary Incontinence

CLINICAL FEATURES

HISTORY wSPLATw Symptoms associated with
fall (circumstances, onset, frequency), Previous falls,
Past medical history, Location, Activity preceding fall,
Toxin (meds), and Trauma
PHYSICAL vitals (postural HR and BP, tempera
ture), cardiovascular (murmurs, rhythm, volume sta
tus), respiratory (adventitious sounds), musculoskele
tal (strength in knee/hip extensors, joint stability and
range of motion, pain, feet, footwear, walking aids),
neurologic (focal signs, vision/hearing, cerebellar,
sensory), cognitive exam (MMSE, CAM)
PERFORMANCE ORIENTED EVALUATION OF GAIT
AND BALANCE
 TIMED UP AND Go TEST rise from chair, walk 10 ft,
turn, and return to chair. Should finish in less than

10 s. If takes >20 s, further evaluation required
 TINETTI’S PERFORMANCE-ORIENTED ASSESSMENT
easy to administer, incorporates gait, and balance
scales to identify high risk of falls, score 20/28
predictive of recurrent falls
RATIONAL CLINICAL EXAMINATION SERIES:
WILL MY PATIENT FALL?
RISK FACTORS FOR FALLS
LR+
Fallen in the past year
2.3 2.8
Clinically detected abnormalities of gait 1.7 2.4
or balance
Age, visual impairment, medication variables,
decreased activities of daily living, and impaired
cognition did not consistently predict falls across
studies. Orthostatic hypotension did not predict
falls after controlling for other factors

CLINICAL FEATURES (CONT’D)

APPROACH ‘‘screening for risk of falling during
the clinical examination begins with determining if
the patient has fallen in the past year. For patients
who have not previously fallen, screening consists
of an assessment of gait and balance. Patients who
have fallen or who have a gait or balance problems
are at higher risk of future falls’’
JAMA 2007 297:1
INVESTIGATIONS


BASIC
CBCD, lytes, urea, Cr, glucose, TSH, CK,
ESR, urinalysis
 IMAGING head CT
SPECIAL
 CARDIAC WORKUP ECG, Holter monitor if suspect
arrhythmia
 SEIZURES WORKUP EEG if suspect seizures
 NEUROLOGIC WORKUP EMG/NCS if significant
weakness thought to be related to peripheral
lesion
 LABS

MANAGEMENT

PREVENTION education (proper shoes, avoid hot
tubs, drink 1.5 2 L/day, getting up slowly). Exercise
(balance and gait training, muscle strengthening, day
programs). Environmental assessment (remove
loose rugs, non slip bath mats, lighting, stair rails).
Tapering and discontinuation of medications, if
appropriate. Referral (physiotherapy, occupational
therapy, ophthalmology, geriatrics, cardiology if
appropriate). Treatment and prevention of osteo
porosis (see OSTEOPOROSIS)

Osteoporosis
See OSTEOPOROSIS (p. 354)


Urinary Incontinence

CMAJ 1997 157:8; NEJM 2008 358:10

DIFFERENTIAL DIAGNOSIS OF CHRONIC URINARY
INCONTINENCE

DIFFERENTIAL DIAGNOSIS OF CHRONIC URINARY
INCONTINENCE (CONT’D)

URGE (most common. Sudden, uncontrollable.
Associated with urinary frequency and nocturia)

STRESS (small volumes with " abdominal pressure)
 URETHRAL HYPERMOBILITY childbirth, menopausal
 SPHINCTER WEAKNESS TURP
OVERFLOW (over distended bladder, small volumes
but continuous leakage, incomplete emptying)
 BLADDER OUTLET OBSTRUCTION BPH, prostate
cancer

 IDIOPATHIC

/
HYPERREFLEXIA normal
pressure hydrocephalus, dementia, stroke
GU BLADDER/DETRUSOR INSTABILITY infection,
stone, tumor, inflammation

 NEUROLOGIC DETRUSOR




384

Urinary Incontinence

DIFFERENTIAL DIAGNOSIS OF CHRONIC URINARY
INCONTINENCE (CONT’D)

/

 URETHRAL BLADDER NECK STRICTURE

peripheral neu
ropathy, alcohol, herniated disc, spinal stenosis,
fibrotic detrusor
MIXED/DETRUSOR
HYPERACTIVITY
WITH
IMPAIRED CONTRACTILITY (DHIC) combines
symptoms of urge and overflow incontinence
with frequency and large volume, usually late
stages of above (e.g. BPH or diabetes mellitus)
REDUCED MOBILITY (inability to ambulate to toilet)
 DETRUSOR HYPOCONTRACTILITY

DIFFERENTIAL DIAGNOSIS OF TRANSIENT URINARY
INCONTINENCE


wDIAPERSw
DELIRIUM
INFECTION symptomatic UTI
ATROPHIC VAGINITIS/URETHRITIS
PROSTATE
PHARMACY diuretics, benzodiazepines, alcohol
PSYCHOLOGICAL
ENDOCRINE hypercalcemia, diabetes, diabetes
insipidus
RESTRICTED MOBILITY
STOOL IMPACTION
PATHOPHYSIOLOGY

PHYSIOLOGY OF URINATION
 DETRUSOR MUSCLES parasympathetic S234 (con
tract), b2 sympathetic T10 L2 (relax)
 INTERNAL SPHINCTER a1 sympathetic T10 L2 (contract)
 EXTERNAL SPHINCTER somatic S234 (contract)
RATIONAL CLINICAL EXAMINATION SERIES:
WHAT TYPE OF URINARY INCONTINENCE DOES
THIS WOMAN HAVE?
LR+ LR
Stress incontinence
Simple question: ‘‘Do you lose urine 2.2
0.39
during sudden physical exertion,
lifting, coughing or sneezing? ’
Filled bladder stress test (fill bladder 9.4
0.07
with 200 cc of saline, supine, and

observe while cough)
Systematic assessment
3.7
0.20
Urge incontinence
‘‘Do you experience such a strong
4.2
0.48
and sudden urge to void that
you leak before reaching the
toilet?’’
APPROACH ‘‘a systematic approach that includes
a history, physical examination, and stress test
increases the likelihood of correctly classifying the

PATHOPHYSIOLOGY (CONT’D)

type of incontinence. The most helpful component
of the assessment for determining the presence of
urge incontinence is a history of urine loss asso
ciated with urinary urgency. A filled bladder stress
test may be helpful for diagnosing stress inconti
nence. For primary care physicians unable to
perform stress tests in their office, it would be
reasonable to refer patients for further evaluation
when a diagnosis is needed with more certainty.
Measurement of the post void residual urine
volume detects incomplete bladder emptying, but
no data support using this in women for separating
out incontinence type’’

JAMA 2008 299:12
INVESTIGATIONS

BASIC
 LABS

lytes, urea, Cr, glucose, Ca, urinalysis
urine C&S

 MICROBIOLOGY

SPECIAL
 URODYNAMIC STUDIES

MANAGEMENT OF CHRONIC URINARY
INCONTINENCE

GENERAL MEASURES
 ABSORPTIVE PADS incontinence pad or adult dia
pers (depends)
 CATHETERIZATION/DIAPERS indwelling
catheter,
condom catheter, timed collection, intermittent
self catheterization
URGE INCONTINENCE behavioral modification,
anticholinergic (# detrusor contraction, " bladder
volume; oxybutynin 2.5 5 mg PO BID TID or XL
5 30 mg PO daily; tolterodine 1 2 mg PO BID or LA
2 4 mg PO daily). TCA (imipramine 25 100 mg PO
qhs; associated with significant adverse effects, parti

cularly in the elderly). Estrogen
STRESS INCONTINENCE bladder training (30 50
pelvic floor exercises/day). Weight loss if obesity.
SSRI (duloxetine hydrochloride). Intravaginal pes
saries/tampons to exert pressure to provide urethral
support
OVERFLOW INCONTINENCE a1 antagonist (only
if BPH; tamsulosin 0.4 0.8 mg PO daily; terazosin
1 10 mg PO qhs; doxazosin 1 5 mg PO qhs). 5a
reductase inhibitor (only if BPH; finasteride 5 mg
PO daily)
OVERFLOW WITH NEUROGENIC BLADDER acet
ylcholine agonist (" bladder contractility; bethane
chol 10 30 mg PO BID QID for short term only, may
require clean intermittent catheterization)
RESTRICTED MOBILITY bedside urinal/commode,
call bell, prompted voiding