Synopsis
Detect delirium, longer-term cognitive disorder, depression and hearing or visual impairment using accessible validated screening, interpret results against baseline and communication barriers, and arrange diagnostic assessment and immediate risk management.
- Screening identifies who needs further assessment; it does not establish dementia, depression, incapacity or a specific sensory diagnosis by itself.
- First priority for new cognitive change is delirium assessment with 4AT and a search for underlying causes; dementia and delirium commonly coexist.
- Establish cognition and function before illness from collateral, then optimise hearing, vision, language, pain and arousal before longer-term testing.
- Use a validated cognition tool appropriate to setting, such as GPCOG in primary care, and interpret education, language, cultural and motor effects.
- Assess daily executive consequences: medicines, money, cooking, navigation, appointments and vulnerability may change before basic memory complaints become obvious.
- Screen mood with direct history plus a validated measure such as PHQ-9 or GDS; bereavement, apathy and somatic illness can alter presentation.
- Always ask directly about hopelessness, self-harm and suicide when depression is possible; a questionnaire score cannot replace risk formulation.
- Hearing assessment starts with history, otoscopy and functional communication; arrange audiology and urgent ENT when the pattern requires it.
- Check visual acuity with usual correction, near vision and field symptoms and ask whether vision limits medicines, falls, reading and faces.
- An abnormal screen leads to collateral, medication and medical review, functional assessment and the appropriate dementia, mental-health, audiology or eye pathway.
Key red flags
Acute or fluctuating confusion, inattention, drowsiness or agitation is delirium until assessed, including in a person with known dementia.
Suicidal thoughts with intent, plan, means, psychosis, severe self-neglect or inability to maintain intake requires same-day mental-health and safety assessment.
Sudden monocular or binocular visual loss, field defect, painful red eye, halos or new temporal headache requires urgent eye or vascular assessment.
Sudden sensorineural hearing loss developing over three days or less is an ENT emergency; do not dismiss it as wax or ageing.
New focal deficit, aphasia, neglect or gait ataxia demands a stroke or neurological pathway even if a cognitive screen is poor.
A low cognitive score obtained without glasses, hearing support, interpreter, literacy context or delirium assessment may be invalid and harmful.
Acute onset, fluctuation, inattention and altered arousal point to brain failure from illness or medication and require immediate cause assessment.
Intent, plan, means, psychosis, severe agitation or inability to sustain basic needs requires urgent protection and specialist assessment.
Investigation priorities
Identify possible delirium rapidly in acute care.
Management branches
A cognitive concern is new or its chronology is uncertain.
- Optimise communication, obtain baseline collateral and use 4AT while assessing acute physiology and medicines.
- Treat underlying causes and repeat cognition after fluctuation, arousal, pain and sensory barriers improve.
- If decline persists, complete validated cognitive, functional, medical and imaging assessment through the dementia pathway.