DELIRIUM OR DEMENTIA??

  Background:  77 year old white male, non-drinker, light smoker, divorced
               for 25 years
  Symptoms:  Paranoia (family is trying to kill him, people poison his food,
             we're all after his money, etc)
             Sadness (starts crying for no reason, says he doesn't know why,
             "It just comes over him sometimes"
             Hallucinations (sees people / things that aren't there, hears
             voices and other sounds that don't exist, sees people he knows
             on the TV, etc)
             Confusion:  Thinks he has won the lottery, doesn't know current
             day or year (thinks it is November 1988), doesn't always recognize
             us or call us the right names, can't remember what things are
             used for (tried to put out a cigarette in a paper napkin instead
             of the ashtray, tried to get into an apartment that belonged to
             someone else and couldn't figure out why his key wouldn't work),
             told the nurse his daughter was also a nurse, etc.
             Anger:  Sometimes he is glad to see us, but can change on a
             moments notice.  Will rant and rave about the fact that we are
             "restricted" and can't be on his property (even though we are in
             our own house.  Threatens to call the cops to have us put in jail,
             but can't remember how to use the phone.  Extremely uncooperative,
             to the point that last week we had to have the paramedics restrain him
             so we could get him to the hospital to be treated for dehydration.
  Physical condition:  Had a blocked carotid artery surgery cleared on May
             5, 1998.  Was fine for the first 5 days after surgery, then
             suddenly started having confusion, disorientation.  Has gotten
             progressively worse.  On June 5, surgeons drilled two holes in
             his skull to relieve pressure from an abnormal accumulation of
             cerebral spinal fluid that was on top of his brain.  No idea
             why it was there, was the only "abnormal" thing all the tests
             showed.  Fluid started coming back, so on June 8th, they put in
             a lumbar shunt to keep fluid drained.  This has not helped his
             confusion or other symptoms.  He also suffers from high blood
             pressure, is borderline diabetic, tends to get dehydrated and
             severely constipated easily, and is taking medication for
             ulcers.
  We have been doing research on everything we can think of, trying to help
  him.  The phychiatric center seems to think it is "delirium" instead of
  dementia, partly due to the fact that it happened so suddenly.
  Would really appreciate your insight.  Can provide more detail if needed.
  Thanks so much !!
  Ann
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Tough to figure this one out.
Seems like an underlying dementia, with acute changes after the surgical procedure. People with dementia often have a coincident depression or psychosis (hallucinations, paranoia). Delirium really refers to fluctuating level of attention, and the behavioral changes you described don't really fit that description.
Look into the possibility that all this is an atypical presentation of depression, with psychotic features, and "pseudodementia." That would be likely the most treatable diagnostic possibilty, so it is really worth looking into.
The most important step is have him evaluated by a dementia expert. There are many causes of dementia, and an expert can systematically evaluate each possibility. A neuropsychologic test battery (performed by PhD psychologist specialists) may be helpful in difficult cases such as this.
I hope this helps. As you know, this information is provided for your medical education only. Specific advice regarding diagnosis, treatment options, or prognosis must come from your doctor after appropriate evaluation. CCF MD mdf.