In most standard textbooks, delirium is characterized as an acute, self-limited global impairment of cognition (chiefly inattention) and contrasted with dementia (modeled on Alzheimer’s disease) as a chronic progressive global cognitive impairment (chiefly with memory impairment) of insidious onset. This account validly captures stereotypes, but more recent data suggest that the generalizeability of these prototypes, and their enshrinement as diagnostic criteria, has been over-played. This presentation will review clinical and population-based data which show that many patients with delirium never have recovery of their pre-morbid function and that subsyndromal phenotypic expression of delirium is common. In addition, many patients with dementia who have episodes of delirium with hallucinations and delusions also have hallucinations and delusions more often throughout the entire course of their dementia. Alternately, many patients with dementia report an acute onset of their cognitive impairment, and an important proportion do not show substantial disease progression over 5 years. As we broaden the spectrum of dementia to include disorders such as dementia following a single strategic stroke and dementia with Lewy bodies, it is important that we re-evaluate criteria modeled on Alzheimer’s disease. Similarly, the common overlap between delirium and dementia, including the apparent presentation of dementia first as delirium and the existence of subsyndromal states challenge us to re-evaluate the criteria for delirium.
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