DSM-IV Definition

  • Major impairment in learning and memory plus impairment in handling complex tasks, impairment in reasoning ability, impaired spatial ability and orientation, or impaired language
  • Symptoms significantly interfere with work, usual social activities, relationships
  • Significant decline from previous level of functioning
  • Disturbances are insidious and progressive
  • Disturbances are not occurring exclusively during the course of delirium
  • Disturbances are not accounted for by major psychiatric diagnosis
  • Disturbances are not accounted for by systemic disease or another brain disease

Inappropriate Medications in Dementia[1]

  • Most common: Cholinesterase inhibitors, memantine hydrochloride, lipid lower agents, antiplatelet (except aspirin)
  • Others: hormone antagonists, leukotriene inhibitors, cytotoxic chemotherapy, immunomodulators

Clinical Features

  • Loss of mental capacity
  • Slow and steady course
  • Hallucinations, delusions, repetitive behaviors, and depression are all common
  • May coexist with delirium
  • Poor score on Mini-Mental Status Exam

Differential Diagnosis

Dementia Acronym

D = drug-induced

E = emotions (depression especially)

M = metabolic and endocrine issues

E = eyes and ears (sensory problems)

N = nutritional issues (B12 and Vit. D)

T = tumors

I = infections

A = alcohol

S = sleep disorders and rarely seizures



Major workup consists of ruling out treatable causes of dementia / delirium

  • Mini mental status exam
  • Six item screen
  • CBC
    • Megaloblastic anemia points to vitamin B12 deficiency
    • Normocytic anemia with an elevated RDW may indicated B12 deficiency as well if there are some RBCs with a small MCV and many with a large MCW.
  • Chemistry 10
  • LFTs
  • Urinalysis
  • ECG
  • CXR
  • ETOH
  • Utox
  • Head CT
  • Consider
    • LFTs, TSH
    • B12, RPR, ESR, ANA, Folate, Thiamine, HIV
    • Neuropsych eval
    • Consider LP, urine heavy metals, EEG


  • Treat underlying cause (if possible)

See Also


  1. Tjia J et Al. Use of Medications of Questionable Benefit in Advanced Dementia. JAMA Intern Med. Published online September 08, 2014. doi:10.1001/jamainternmed.2014.4103