acute or chronic?

Dementia vs Delirium

The test is not "is the patient confused?" It is tempo plus attention: years of cognition loss is dementia; hours to days of attention failure is delirium until proven otherwise.

Commit first: An 82-year-old man with Alzheimer disease is admitted for pneumonia. Yesterday he recognized his daughter. Tonight he is pulling at the bed rails, seeing insects on the wall, and cannot repeat the months backward. Temperature is 38.6 C and O2 saturation is 89%.
Good instinct to notice the dementia history, but the new problem is the abrupt attention crash. Dementia lowers the reserve. Pneumonia, hypoxia, pain, urinary retention, withdrawal, or medications can shove the brain into delirium. Chronic memory loss is dementia. Acute attention failure is delirium.

The First Split

Tap between the chronic brain failure and the acute attention failure. Then run the bedside attention test.

Dementia

A chronic neurocognitive decline. The patient slowly loses memory, executive function, language, personality, or visuospatial skill while level of consciousness stays clear early.
TempoMonths to years, progressive.
AttentionRelatively preserved until later disease.
EEGOften normal early or nonspecific.
MoveClassify the dementia type, rule out reversible mimics, protect function.

Delirium

An acute reversible brain state from a body problem, drug problem, withdrawal state, or environmental trigger. Attention and arousal are the core casualties.
TempoHours to days, fluctuates across the day.
AttentionBad immediately: cannot track, repeat, or sustain focus.
EEGDiffuse background slowing can appear.
MoveFind and fix the cause: infection, oxygen, pain, dehydration, electrolytes, retention, medication, withdrawal.
Say WORLD
Choose a bedside prompt. Delirium breaks sustained attention before it breaks stored identity.

Acute AMS Decision Tree

The test move is simple: first decide whether attention failed, then chase the body trigger.

1
Did the mental status change happen over hours to days?
2
Is attention impaired: cannot track conversation, repeat digits, or do months backward?
3
Is there a body trigger: infection, hypoxia, dehydration, withdrawal, pain, urinary retention, or medication?
Delirium Circuit Model
BRAIN RESERVE older age + dementia lowers buffer ATTEND TRIGGER infection hypoxia drugs FIX oxygen fluids source

Reserve

Dementia does not protect you from delirium. It makes delirium easier to trigger because the brain has less spare capacity.

Haloperidol Sidecar

Delirium treatment is cause-first. Haloperidol is a behavior-control tool when needed, and its side effects are testable.

Delirium Management
Fix the trigger before treating the noise.
Oxygen, fluids, infection control, pain control, sleep, orientation, calm room.
Why This Works
Cause map
Delirium is not a primary memory disease. It is the cortex losing stable attention because the body is stressing it.
Board trap
A sedating drug can quiet the room while the cause keeps burning. The answer is usually to identify and treat the underlying problem.
D2 Blockade
Haloperidol and high-potency typical antipsychotics.
EPS, QT prolongation, hyperprolactinemia, and rare NMS.
Why This Happens
Cause map
Blocking dopamine in the nigrostriatal pathway removes movement modulation. Too little dopamine tone looks like the basal ganglia brake is stuck on.
Timing ladder
Hours to days: dystonia. Days: akathisia. Weeks: drug-induced Parkinsonism. Months to years: tardive dyskinesia. Fever, rigidity, unstable vitals, and CK rise: NMS.

Three Locks

Predict the rule, then check it against the lock text.

The tempo lock
Dementia is a slow dimmer. Delirium is a light switch flickering on bad wiring.
tempo beats label
The attention lock
If they cannot hold the task in their head, call it delirium first and find the trigger.
attention beats age
The EEG lock
Delirium can slow the background rhythm. Dementia can have a normal EEG, especially early.
function beats structure

Reference Images

Use these to anchor the diagnostic tools: structural atrophy belongs to chronic cognitive disease; EEG is a functional brain readout that can slow in delirium.

Brain MRI showing medial temporal lobe atrophy in Alzheimer disease and dementia with Lewy bodies
Dementia MRI · medial temporal atrophy
Brain atrophy from vascular dementia with ex vacuo ventricular enlargement
Vascular atrophy · chronic structural loss
EEG recording cap with electrodes
EEG · functional rhythm readout

Walkthrough Bank

Twenty-five cases. Right-click or long-press to cross out. Double-click or double-tap to mark. Answer choices shuffle every case.

Case 1 / 25

KEEP GOING

Up one level
Neurology
Localize the brain, nerves, movement, and cognition patterns.
Related
Dementia Subtypes
Compare Alzheimer, Lewy body, frontotemporal, vascular, and reversible mimics.
Medically reviewed by Kaitlyn Cocuzzo, MD and Fatima Ali, DO · Last updated July 8, 2026 at 12:27 AM ET