For emergency physicians, the month is also a useful prompt to reexamine how dementia presents in the emergency departmentAlzheimer’s & Brain Awareness Month, observed each June, is a moment to recognize the more than 6.7 million Americans living with Alzheimer’s disease and to acknowledge the broader population of patients with related dementias and mild cognitive impairment. For emergency physicians, the month is also a useful prompt to reexamine how dementia presents in the emergency department, where these patients show up frequently, often through family who cannot keep them safe at home that night. The clinical scenario is familiar. An older adult is brought in for “acting different,” more confused than usual, agitated, withdrawn, or simply not themselves. The differential is wide. The risk of missing acute, reversible pathology is real. And the workup must move quickly enough to identify treatable contributors while not over-investigating a patient whose baseline cognition is already impaired. This article examines four clinical dimensions of the dementia patient in the ED: recognition of delirium superimposed on dementia, the role of anticholinergic burden in older adults, the most common reversible contributors to acute change, and the often invisible load carried by family caregivers. June’s awareness focus is a fitting time to sharpen these habits.
The “Acting Different” Presentation
Family members rarely arrive at the ED with a precise clinical complaint. They describe what they see: confusion that is worse than yesterday, agitation that began this morning, a parent who suddenly cannot recognize them, a spouse who slept through the day and is now awake and disoriented. These descriptions matter. The acuity, fluctuation, and inattention they imply are the defining features of delirium, and family observation is often the most reliable source of that history.
Delirium and dementia are not interchangeable, and conflating them is one of the most common errors in the workup. Dementia describes a chronic, progressive decline in cognition. Delirium describes an acute change in attention and arousal, with a fluctuating course, that signals an underlying medical disturbance. A patient can have both simultaneously, and frequently does. The clinician’s job is to identify the acute layer, find its cause, and treat it.
Several validated tools support rapid screening at the bedside. The Confusion Assessment Method (CAM), originally described by Inouye and colleagues in 1990, remains the most widely used delirium screen in the United States. The 4AT, a brief four-item assessment validated by Bellelli and colleagues in 2014, has been increasingly adopted in emergency and acute care settings because it requires no specialized training, takes about two minutes, and performs well in patients with established cognitive impairment.
A delirium screen at triage or shortly after arrival shifts the workup. It anchors the team to look for the trigger rather than attribute the presentation to “advanced dementia” and disposition the patient prematurely.
Delirium Superimposed on Dementia
Delirium superimposed on dementia is common, frequently missed, and clinically significant. Studies in emergency medicine have shown that older ED patients with delirium have substantially worse short-term outcomes. Delirium in the emergency department has been identified as an independent predictor of death within six months of the visit, with hypoactive presentations particularly likely to be missed because they look more like fatigue or withdrawal than agitation.
The clinical patterns most likely to slip past a busy ED include the quietly confused patient who answers a few questions appropriately, the patient who falls asleep mid-sentence and is presumed to be tired, and the patient whose family is told that the change “is just the dementia getting worse.” None of these can be safely attributed to baseline cognitive decline without a structured assessment.
Several questions help separate acute change from baseline:
- When was the patient last clearly at their baseline (hours, or days)?
- Is the level of attention fluctuating today?
- Did the change come on over hours rather than weeks?
- Is the patient more drowsy, more agitated, or both at different points?
Affirmative answers to any of these should drive an active workup for an acute cause: infection, hypoxia, metabolic derangement, medication effect, pain, urinary retention, fecal impaction, or central nervous system pathology. The decision to image, to obtain cultures, to check a venous gas, or to admit becomes substantially clearer once the team has named the acuity rather than absorbed it into the chronic picture.
Anticholinergic Burden in Older Adults
Few medication patterns affect cognition in older adults as predictably as anticholinergic burden. Many drugs commonly used in EDs and dispensed at discharge carry anticholinergic activity, and their effect is cumulative, dose dependent, and often clinically meaningful. The American Geriatrics Society Beers Criteria, most recently updated in 2023, identifies a long list of medications that are potentially inappropriate in older adults, with a strong emphasis on agents with anticholinergic properties.
A body of literature on the impact of anticholinergics on the aging brain has demonstrated that even short courses of strongly anticholinergic medications can precipitate or worsen cognitive impairment, and that cumulative burden over time is associated with measurable decline. In the ED, several patterns are worth scrutinizing:
- Diphenhydramine used for sleep, mild allergic symptoms, or as a sedative adjunct. In older adults, it is a common and avoidable contributor to acute confusion.
- First-generation antihistamines and scopolamine for vestibular symptoms.
- Antimuscarinic agents for overactive bladder.
- Tricyclic antidepressants, often continued from outpatient regimens without review.
- Promethazine and certain other antiemetics, particularly when stacked with home medications already carrying anticholinergic load.
Practical strategies are simple: review the home medication list for cumulative anticholinergic burden, prefer non-anticholinergic alternatives when treating symptoms in the ED, and avoid prescribing diphenhydramine for sleep at discharge in older adults. When sedation is genuinely necessary, lower-risk alternatives should be considered first, and the decision documented with the patient’s cognitive baseline in mind.
Reversible Contributors: Infection, Hypoxia, Pain, and the UTI Question
Once delirium is recognized, the workup is essentially a search for reversible contributors. Infection remains the most common precipitant in older adults presenting with acute change, with pneumonia, urinary tract infection, cellulitis, and bacteremia all well represented in the literature. Hypoxia, even modest, can precipitate confusion in patients with limited cerebral reserve. Pain, urinary retention, constipation, and dehydration are easily overlooked but reliably contributory.
The relationship between urinary tract infection and delirium deserves a more careful treatment than it often receives. Asymptomatic bacteriuria is common in older adults, particularly women, and a positive urinalysis in a confused patient is not by itself a diagnosis. Recent guideline literature has cautioned against attributing acute confusion to a UTI without clinical features of urinary infection, as treating asymptomatic bacteriuria leads to antibiotic exposure without clinical benefit and can delay identification of the true cause of delirium. The clinical question is not “is there bacteria in the urine?” but “is there a urinary tract infection driving this presentation, and have I excluded other contributors?”
Medication review remains central. Beyond anticholinergics, opioids, benzodiazepines, sedating muscle relaxants, and certain antiepileptics are common contributors. Polypharmacy itself is a risk factor, and discharge planning should include attention to which medications can be safely held, reduced, or substituted.
The Family at the Bedside
Caregivers carry much of the work that does not appear in the ED chart. The most recent national report on caregiving in the United States describes more than 53 million Americans providing unpaid care to an adult or child, with a substantial share supporting older relatives with dementia. Many of those caregivers arrive at the ED exhausted, frightened, and unsure whether the change they are seeing is a medical emergency, a behavioral crisis, or the next phase of a long decline.
Clinicians can offer several things that meaningfully help:
- Validation that the change they noticed is real and worth taking seriously.
- A clear explanation of what has been ruled out and what is being treated.
- Practical guidance on what to watch for at home and when to return.
- Connection to social work, case management, or community resources when the home situation has exceeded what one person can manage.
- An acknowledgment that bringing the patient in was the right decision, even if no acute cause is found.
For patients with established dementia, the most important documentation often concerns what was at baseline. A note that reads “family reports the patient was conversational and walking with a walker last week” gives every subsequent clinician a reference point that the patient cannot provide. It also protects the patient against the gradual normalization of decline.
Building a More Coherent Approach
The population of older adults with dementia is growing, and emergency departments will continue to be a critical access point for these patients and their families. The clinical habits that improve their care are not exotic. Screen for delirium when family reports an acute change. Distinguish acuity from baseline. Take anticholinergic burden seriously. Avoid reflexively attributing acute confusion to a urinary tract infection. Document the patient’s true baseline. Engage the family as the primary historian and as the patient’s most consistent advocate.
Alzheimer’s & Brain Awareness Month is an opportunity to look at these habits with fresh eyes. The work is not glamorous and rarely produces a single decisive moment of intervention. But the cumulative effect of careful recognition, thoughtful workup, and respectful engagement with caregivers is substantial, and the patients and families who pass through the department feel the difference even when they cannot name it.
References
Alzheimer’s Association. (n.d.). Alzheimer’s & Brain Awareness Month. Retrieved May 2026, from https://www.alz.org/abam
Bellelli, G., Morandi, A., Davis, D. H. J., Mazzola, P., Turco, R., Gentile, S., Ryan, T., Cash, H., Guerini, F., Torpilliesi, T., Del Santo, F., Trabucchi, M., Annoni, G., & MacLullich, A. M. J. (2014). Validation of the 4AT, a new instrument for rapid delirium screening: A study in 234 hospitalised older people. Age and Ageing, 43(4), 496-502. https://doi.org/10.1093/ageing/afu021
Boustani, M., Campbell, N., Munger, S., Maidment, I., & Fox, C. (2008). Impact of anticholinergics on the aging brain: A review and practical application. Aging Health, 4(3), 311-320. https://doi.org/10.2217/1745509X.4.3.311
By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
Han, J. H., Shintani, A., Eden, S., Morandi, A., Solberg, L. M., Schnelle, J., Dittus, R. S., Storrow, A. B., & Ely, E. W. (2010). Delirium in the emergency department: An independent predictor of death within 6 months. Annals of Emergency Medicine, 56(3), 244-252. https://doi.org/10.1016/j.annemergmed.2010.03.003
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941-948. https://doi.org/10.7326/0003-4819-113-12-941
National Alliance for Caregiving & AARP. (2020). Caregiving in the United States 2020. Retrieved May 2026, from https://www.aarp.org/pri/topics/ltss/family-caregiving/caregiving-in-the-united-states.html
National Institute on Aging. (n.d.). Alzheimer’s disease fact sheet. U.S. Department of Health and Human Services. Retrieved May 2026, from https://www.nia.nih.gov/health/alzheimers-and-dementia/alzheimers-disease-fact-sheet
Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., Eckert, L. O., Geerlings, S. E., Köves, B., Hooton, T. M., Juthani-Mehta, M., Knight, S. L., Saint, S., Schaeffer, A. J., Trautner, B., Wullt, B., & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83-e110. https://doi.org/10.1093/cid/ciy1121