Mental capacity concerns

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Cognitive Impairment

Dementia: Progressive decline in cognitive function affecting memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment.
Delirium: Acute, fluctuating state of confusion; commonly triggered by infection, medication, or surgery; distinguishable by rapid onset and fluctuation.
Mild Cognitive Impairment (MCI): Cognitive decline greater than expected for age but not severe enough to interfere with daily life; may progress to dementia.
Learning Disabilities: Developmental disorders leading to impaired cognitive function from childhood, may impact decision-making capacity.

Psychiatric Disorders

Depression: Can impair concentration, decision-making, and memory; often reversible with treatment.
Schizophrenia: May impair insight and judgment; delusions or hallucinations can affect decision-making capacity.
Bipolar Disorder: During manic or depressive episodes, individuals may have impaired judgment or insight, affecting capacity.
Personality Disorders: Certain types (e.g., borderline personality disorder) may affect the stability of decisions and understanding of long-term consequences.

Medical and Environmental Factors

Medication Effects: Sedatives, anticholinergics, and opioids can impair cognitive function; reversible on stopping the drug.
Substance Use: Acute intoxication or chronic use (e.g., alcohol, drugs) can impair judgment and decision-making.
Acute Medical Illness: Conditions like sepsis, hypoglycemia, or stroke can lead to transient or permanent cognitive impairment.
Sensory Impairments: Hearing or visual loss can affect communication and perceived capacity; often improves with aids.

Key Points in History 🥼

Symptomatology

Onset and Course: Sudden versus gradual onset of symptoms; acute changes suggest delirium or acute medical issues, while gradual decline suggests dementia.
Memory and Cognition: Assess for memory loss, difficulties with understanding or reasoning, disorientation, and impaired executive function.
Psychiatric Symptoms: Hallucinations, delusions, mood swings, or changes in personality may indicate a psychiatric disorder affecting capacity.
Insight and Judgment: Evaluate the patient’s insight into their condition and judgment in decision-making; poor insight may indicate a lack of capacity.
Communication Difficulties: Assess whether communication issues are due to language barriers, sensory impairments, or cognitive deficits.

Background

Past Medical History: Look for history of neurological disorders (e.g., stroke, dementia), psychiatric conditions, or chronic illnesses that can affect cognition.
Drug History: Review current and past medications, including over-the-counter and recreational drugs that might impair mental capacity.
Family History: Consider family history of dementia, psychiatric disorders, or hereditary conditions that may impact mental capacity.
Social History: Assess for social factors such as isolation, recent life changes, or stressors that may impact mental health and capacity.
Legal and Financial History: Relevant if there are concerns about the patient’s ability to manage finances or make legal decisions.

Possible Investigations 🌡️

Laboratory Tests

Full Blood Count: To rule out anemia or infection that might be contributing to confusion or cognitive impairment.
Electrolytes and Glucose: Check for electrolyte imbalances or hypoglycemia that can affect mental function.
Liver and Renal Function Tests: Assess for hepatic or renal encephalopathy.
Thyroid Function Tests: Hypothyroidism or hyperthyroidism can mimic or exacerbate cognitive impairment.
Vitamin B12 and Folate: Deficiencies can lead to reversible cognitive impairment; consider in elderly or malnourished patients.
Toxicology Screen: Consider in cases of suspected substance use or overdose.

Imaging and Specialist Tests

CT or MRI Brain: Consider for structural causes of cognitive impairment, such as stroke, tumors, or hydrocephalus.
Electroencephalogram (EEG): Useful in suspected cases of epilepsy or encephalopathy.
Neuropsychological Testing: Detailed cognitive assessment to evaluate the extent and type of cognitive deficits; can aid in differentiating between types of dementia and assessing capacity.
Cognitive Screening Tools: Use tools like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) as part of the capacity assessment process.

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