1.This is base on my discussion post on Psychiatric Case study
Elvira Angelica Silva de Vera
• TEACHER
Sep 30 10:53am
Reply from Elvira Angelica Silva de Vera
Given Ms. Richardson’s overlapping symptoms suggestive of both delirium and
dementia with psychosis, what clinical tools or assessments would you prioritize to
accurately differentiate these conditions in the acute hospital setting, and how would
this distinction impact your immediate treatment approach?
2. Reply from Anita Lucia Mohan
Psychiatric Case Study: Ms. Richardson
Clinical Summary
Ms. Richardson is a 74-year-old African American female brought to the emergency
department by police after reports from neighbors of wandering, self-neglect, and confusion. On
arrival, she was unkempt, malodorous, and disoriented to time and place, though she knew her
name and address. She was minimally responsive, with a flat affect, poor eye contact, and limited
insight. She reported generalized weakness, shoulder pain, difficulty swallowing, and not eating
for three days. She recalled her dog being tranquilized and erroneously believed it was in “the
shop,” showing signs of confusion. She denied hallucinations or prior psychiatric
hospitalizations but mentioned seeing a psychiatrist for insomnia in the past. Her home
environment was severely unsanitary, with feces and clutter, suggesting severe self-neglect. She
was also noted to have uncontrolled diabetes, dehydration, and malnutrition. Subjective data
includes weakness, shoulder pain, and not eating for three days,
Objective data includes unkempt appearance, malodorous, disoriented to time and place,
impaired insight, poor judgment, unsafe environment, uncontrolled diabetes, and difficulty
swallowing, dehydration and poor nutritional intake. Her presentation suggests acute cognitive
decline with possible chronic neurocognitive disorder (Tusaie, 2023, pp. 328–351).
Primary Diagnosis: F05- Delirium due to Another Medical Condition (DSM-5-TR
Code: 293.0; ICD-10 F05)
Ms. Richardson’s presentation is most consistent with delirium due to another medical
condition. According to the DSM-5-TR, delirium is defined as an acute disturbance in attention
and awareness that develops over a short period, fluctuates in severity, and is associated with
additional cognitive impairments such as memory deficits, disorientation, or perceptual
disturbances. It must be attributable to a physiological cause such as a medical illness, substance
intoxication, or metabolic imbalance (American Psychiatric Association [APA], 2022).
According to Tusaie (2023), such presentations in older adults often reflect delirium, a reversible
condition commonly triggered by metabolic disturbances or infections. Her risk factors include
advanced age, poor glucose control, nutritional deficiency, and social isolation, aligning with
known etiologies of delirium (pp. 328–351).
Two Differential Diagnosis
The first differential diagnosis is Major Neurocognitive Disorder (NCD), Unspecified
Type (DSM-5-TR Code: 294.20; ICD-10: F03.90). DSM-5-TR defines major NCD as a
significant cognitive decline in one or more domains to include memory, executive function,
attention, and language that interferes with independence (APA, 2022). Ms. Richardson’s
functional decline and neglect could suggest an underlying dementia, which may have been
masked by acute delirium. Delirium may occur superimposed on major NCD, and evaluation
should be repeated after medical stabilization (Tusaie, 2023, pp. 328–351).
The second differential diagnosis is Depressive Disorder with Cognitive Impairment
(Pseudodementia) (DSM-5-TR Code: 311, ICD-10: F32.9). Late-life depression may manifest as
cognitive slowing, poor concentration, apathy, and self-neglect, mimicking dementia (APA,
2022). Ms. Richardson’s flat affect and limited responsiveness may represent depressive features.
Distinguishing pseudodementia through mood assessment and improvement with antidepressant
therapy can help differentiates it from degenerative cognitive disorders (Tusaie, 2023, pp. 328–
351)..
Pharmacological Treatment
The primary pharmacologic goal in Ms. Richardson’s case is to treat the
underlying medical cause of delirium. According to NICE (2023) guidelines, management
should begin with intravenous fluids and electrolyte correction to address dehydration, along
with insulin therapy based on ADA (2023) standards to stabilize hyperglycemia. Nutritional
supplements including multivitamins and thiamine help to correct deficiencies contributing to
cognitive impairment.
If Ms. Richardson develops behavioral agitation or perceptual disturbances, low-dose
haloperidol (0.25–0.5 mg PO/IM every 4–6 hours as needed) may be administered, with ECG
monitoring for potential QT prolongation. Haloperidol is often recommended for short-term
symptom management in delirium when nonpharmacologic interventions are insufficient (APA,
2023). If cognitive symptoms persist after medical stabilization and a major neurocognitive
disorder (NCD) is confirmed, pharmacologic agents such as donepezil (5 mg daily) or
memantine (5 mg daily) may be initiated to support cognitive function (Tusaie, 2023
pp.328-351).
Nonpharmacological Treatment
Nonpharmacological treatment is important in delirium management. The primary
goal is to restore orientation, ensure safety, and address modifiable risk factors through
environmental and behavioral interventions. Ms. Richardson should be placed in a quiet, well-lit
environment with visible clocks, calendars, and familiar objects to enhance orientation and
reduce confusion. Consistent caregivers and family involvement can provide reassurance and
emotional stability. Reorientation strategies, including frequent verbal reminders of time, place,
and situation, can be used throughout the day. To support physiological stability, she should
maintain adequate hydration and nutrition. Sleep hygiene is another critical component;
nighttime noise and interruptions should be minimized to promote restorative sleep. Collectively,
these multicomponent interventions have been shown to reduce both the severity and duration of
delirium while promoting functional recovery (Tusaie, 2023, pp. 328–351).
Health Promotion Intervention
Health promotion for Ms. Richardson should focus on chronic disease management, safety,
and social support to prevent recurrence of delirium and enhance overall well-being. Education
on diabetes self-management is essential, following the American Diabetes Association (2023)
standards. This includes teaching her how to monitor blood glucose, adhere to prescribed insulin
therapy, and maintain a balanced diet. Given her unsafe home environment and self-neglect,
referrals to Adult Protective Services (APS) and home health nursing are warranted for
supervision and support would be recommended. Social services can assist in arranging
community resources such as Meals on Wheels, senior day programs, and transportation to
reduce isolation and improve access to care. If a major neurocognitive disorder or depression is
identified, appropriate long-term treatment can be initiated (Tusaie, 2023, pp. 328–351).
