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Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment

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AANPCB Adult-Gerontology Primary Care Nurse Practitioner A-GNP

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1 Exam Structure, APRN Foundations & Geriatric Assessment

A-GNP Exam Logistics, Blueprint & Scoring Structure APRN Scope of Practice, Consensus Model & Interprofessional Collaboration Comprehensive Health History & Subjective Assessment Across Adult Lifespan Comprehensive Physical Examination & Clinical Assessment Skills

2 Health Assessment, Diagnostic Reasoning & Clinical Procedures

Diagnostic Reasoning, Test Interpretation & Clinical Decision-Making Screening Guidelines & Evidence-Based Health Promotion (USPSTF) Comprehensive Geriatric Assessment (CGA), Frailty & Function In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills

3 Cardiovascular & Peripheral Vascular Disorders

Essential Hypertension & Hypertensive Urgency/Emergency Management Coronary Artery Disease, Acute Coronary Syndromes & Post-MI Care Heart Failure (HFrEF & HFpEF) Diagnosis, Staging & 4-Pillar GDMT Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD

4 Respiratory, HEENT & Dermatological Disorders

Asthma Management across the Adult Lifespan (GINA Guidelines) Chronic Obstructive Pulmonary Disease (COPD) Staging & Management (GOLD Guidelines) Community-Acquired Pneumonia & Lower Respiratory Tract Infections Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration

5 Endocrine, Metabolic & Renal/Genitourinary Disorders

Type 2 Diabetes Mellitus Management Thyroid Disorders: Hypothyroidism, Hyperthyroidism & Subclinical Disease Chronic Kidney Disease (CKD) Staging & Diabetic/Hypertensive Nephropathy Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis

6 Gastrointestinal, Hematologic & Immunologic Disorders

Upper Gastrointestinal Disorders: Dyspepsia, GERD, PUD & H. pylori Lower Gastrointestinal Disorders: IBS, IBD, Diverticulitis & Colorectal Screening Liver, Biliary & Pancreatic Disorders: NAFLD/MASLD, Cirrhosis & Cholecystitis Hematologic & Immunologic Disorders: Anemias, Anticoagulation & Immunizations

7 Neurological, Cognitive & Psychiatric Disorders

Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment Neurological Disorders: Stroke, TIA, Parkinson's Disease & Headache Syndromes Major Depressive Disorder & Anxiety Disorders in Adults & Older Adults Sleep Disorders, Insomnia & Restless Legs Syndrome

8 Geriatric Syndromes, Polypharmacy & Deprescribing

The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use Polypharmacy Management, Pharmacokinetics/Pharmacodynamics in Aging & Deprescribing Protocols Fall Risk Assessment (CDC STEADI), Gait/Balance & Mobility Impairments Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment

9 APRN Professional Practice, Ethics, Quality & Healthcare Policy

Musculoskeletal Disorders: Osteoarthritis, Osteoporosis, Gout & Back Pain Dermatological Disorders: Lesions, Skin Cancers, Infections & Rash Evaluation Palliative Care, Advance Care Planning, Pain Management & End-of-Life APRN Professional Practice, Quality Improvement, Ethics & Healthcare Policy

Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment

Key Takeaways Explain This Topic AI

Delirium is an acute, fluctuating cognitive disturbance with inattention requiring CAM criteria (acute onset, fluctuating course, inattention, plus disorganized thinking or altered consciousness).

Alzheimer's disease treatment involves cholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine) for mild-to-moderate stages and Memantine (NMDA antagonist) for moderate-to-severe disease.

Lewy Body Dementia features visual hallucinations, parkinsonism, REM sleep behavior disorder, and life-threatening neuroleptic sensitivity to typical antipsychotics.

Vascular dementia is characterized by a stepwise cognitive decline tied to cerebrovascular events and cardiovascular risk factors.

The MoCA is the most sensitive screening tool for Mild Cognitive Impairment (MCI) and executive dysfunction, whereas the Mini-Cog provides rapid clinic screening.

Last updated: July 2026

Cognitive Assessment and Neurocognitive Disorders

Evaluating cognitive complaints in adult and older adult populations is a cornerstone of primary care and gerontological nursing practice. Patients frequently present with memory loss, word-finding difficulty, spatial disorientation, or behavioral changes. The primary care nurse practitioner (NP) must systematically differentiate between benign age-associated memory impairment, subjective cognitive decline (SCD), mild cognitive impairment (MCI), dementia (major neurocognitive disorder), and acute medical syndromes such as delirium and depression.

Mild Cognitive Impairment (MCI) and Reversible Causes

Mild Cognitive Impairment (MCI) represents an intermediate stage between normal cognitive aging and early dementia. Patients with MCI exhibit objectively measured cognitive decline in one or more cognitive domains (memory, executive function, attention, language, or visuospatial skills) greater than expected for age and education level. Crucially, individuals with MCI retain independence in basic and instrumental activities of daily living (ADLs and IADLs), though tasks may require compensatory strategies. MCI is subclassified into amnestic MCI (predominantly memory impairment, carrying a 10% to 15% annual conversion rate to Alzheimer's disease) and non-amnestic MCI (executive function or language deficits).

Prior to diagnosing irreversible neurocognitive decline, NPs must complete a comprehensive evaluation to rule out secondary, treatable causes of cognitive dysfunction:

Metabolic and Endocrine: Hypothyroidism (evaluated with serum TSH) and hypercalcemia.

Nutritional Deficiencies: Vitamin B12 deficiency (serum B12 < 200 pg/mL confirms deficiency; levels between 200–400 pg/mL require serum methylmalonic acid [MMA] testing).

Infectious Disease: Neurosyphilis (rapid plasma reagin [RPR]) and HIV-associated neurocognitive disorder.

Structural Lesions: Subdural hematoma, normal pressure hydrocephalus (NPH—classic triad of gait ataxia, urinary incontinence, and dementia: "wobbly, wet, and wacky"), or intracranial mass lesions, evaluated via non-contrast head CT or brain MRI.

Medication Toxicity & Polypharmacy: Anticholinergic drugs, sedatives, central nervous system depressants, and polypharmacy.

Diagnostic Triad: Delirium, Dementia, and Depression

Differentiating among delirium, dementia, and depression (pseudodementia) is essential because management strategies and clinical urgencies differ drastically.

  • Diagnostic Feature Delirium Dementia Depression (Pseudodementia)
  • Onset Acute (hours to days) Insidious (months to years) Subacute (weeks to months)

Course Fluctuating; worse at night ("sundowning") Chronically progressive; stable day-to-day Diurnal variation; worse in the morning

Consciousness Altered (hyperactive, hypoactive, or mixed) Clear and alert until end-stage Clear and alert

Attention Markedly impaired; severe inattention Intact until advanced disease stages Intact, though patient may seem distracted

Reversibility Potentially fully reversible Generally irreversible and progressive Fully reversible with psychiatric treatment

Testing Effort Fluctuating, inconsistent responses Tries hard to answer; may confabulate Highlights deficits; frequent "I don't know" answers

Delirium Assessment and Clinical Management

Delirium is a medical emergency representing acute, transient brain dysfunction triggered by underlying physiological stressors, acute illness, or drug toxicity.

The Confusion Assessment Method (CAM) is the gold-standard bedside diagnostic instrument. A positive CAM diagnosis requires:

  • Feature 1: Acute Onset and Fluctuating Course (sudden change in mental status that fluctuates), AND
  • Feature 2: Inattention (difficulty focusing or maintaining attention),

PLUS either:

Feature 3: Disorganized Thinking (incoherent speech), OR

Feature 4: Altered Level of Consciousness (hyperalert, lethargic, or comatose).

Common precipitants of delirium are summarized by the mnemonic DELIRIUMS :

  • D rugs (anticholinergics, benzodiazepines, opioids, sedative-hypnotics, diphenhydramine)
  • E lectrolyte imbalances (hyponatremia, hypercalcemia, dehydration)
  • L ack of drugs/withdrawal (alcohol or benzodiazepine withdrawal)
  • I nfection (urinary tract infection [UTI], pneumonia, sepsis)
  • R educed sensory input (uncorrected vision or hearing loss)
  • I ntracranial pathology (stroke, TIA, subdural hematoma)
  • U rinary retention or fecal impaction
  • M yocardial or pulmonary events (MI, heart failure, hypoxia, hypercapnia)
  • S urgery or severe unmanaged pain

Management: Non-pharmacological interventions are first-line, including reorientation, early mobilization, sleep hygiene, and providing hearing aids/glasses. Pharmacological management (e.g., low-dose haloperidol or quetiapine) is strictly reserved for severe agitation threatening immediate safety. Avoid benzodiazepines unless delirium is caused by alcohol/sedative withdrawal.

Dementia Subtypes and Pharmacotherapy

Dementia (Major Neurocognitive Disorder) involves significant decline in cognitive domains interfering with independent daily functioning.

1. Alzheimer's Disease (AD)

Accounting for 60% to 80% of cases, AD pathologically features extracellular beta-amyloid plaques and intracellular hyperphosphorylated tau tangles. Presentation includes insidious short-term memory loss, followed by executive dysfunction, aphasia, apraxia, and agnosia.

Cholinesterase Inhibitors (AChEIs): First-line for mild-to-moderate AD. Donepezil (5–10 mg daily), Rivastigmine (oral or patch), and Galantamine . They increase synaptic acetylcholine. Adverse effects include GI distress, vagotonic bradycardia, and syncope. Transdermal rivastigmine reduces GI side effects.

NMDA Receptor Antagonist: Memantine (5–10 mg BID or 28 mg ER daily) is indicated for moderate-to-severe AD. It blocks pathological N-methyl-D-aspartate receptor stimulation by excess glutamate. Memantine can be used alone or combined with an AChEI.

2. Vascular Dementia (VaD)

Caused by cerebrovascular disease (ischemic strokes or microvascular small-vessel disease). Classically presents with a stepwise decline in cognitive function, early executive dysfunction, apathy, and focal motor signs. Management relies on cardiovascular risk factor modification (blood pressure < 130/80 mmHg, statins, antiplatelet therapy).

3. Lewy Body Dementia (LBD)

Caused by alpha-synuclein protein deposition (Lewy bodies). Diagnostic triad:

Fluctuating cognition with variations in attention.

Recurrent detailed visual hallucinations .

Spontaneous parkinsonism (bradykinesia, rigidity, resting tremor).

Patients exhibit REM Sleep Behavior Disorder and autonomic dysfunction. Severe Neuroleptic Sensitivity Warning: Typical antipsychotics (e.g., haloperidol) can precipitate severe extrapyramidal toxicity, neuroleptic malignant syndrome, or death. Low-dose quetiapine or pimavanserin are preferred if antipsychotics are required.

4. Frontotemporal Dementia (FTD)

Includes behavioral variant FTD (early disinhibition, hyperorality, apathy) and primary progressive aphasia. Onset occurs earlier (50–65 years). Memory is spared early on. AChEIs are ineffective; SSRIs or trazodone manage behavioral symptoms.

Standardized Cognitive Screening Tools

MMSE: 30-point tool (score < 24 suggests impairment). Influenced by education; lacks sensitivity for MCI.

MoCA: 30-point tool highly sensitive for MCI and executive deficits (cutoff < 26 points indicates impairment).

Mini-Cog: Rapid 3-minute screen combining 3-item recall with a clock drawing test. Recalling 0 items indicates dementia; 3 items indicates normal cognition. Recalling 1–2 items uses clock drawing as tiebreaker (abnormal clock = cognitive impairment).