What questions should I ask the family of an elderly patient with Alzheimer's dementia presenting to the Urgent Care (UC) with vomiting?

Essential History Questions for Elderly Alzheimer's Patient with Vomiting

When evaluating an elderly patient with Alzheimer's dementia presenting with vomiting, your primary goal is to distinguish delirium from other causes, as missing delirium doubles mortality and represents a critical diagnostic pitfall. 1, 2

Immediate Assessment: Rule Out Delirium First

Ask the family about acute changes in mental status over hours to days, fluctuating consciousness, and worsening confusion—these distinguish delirium (the most common cause of acute symptoms in elderly ED patients) from baseline dementia. 3, 1, 2

Critical Delirium Screening Questions:

• When did the vomiting start? Acute onset over hours to days suggests delirium rather than chronic progression 1, 2
• Has the patient's level of alertness or consciousness changed or fluctuated today? Altered consciousness indicates delirium, not primary dementia 1, 2
• Is the patient more confused than usual, and does this confusion come and go? Fluctuating course is pathognomonic for delirium 3, 2
• Can the patient pay attention during conversations, or are they easily distracted? Inattention is a core feature of delirium 3, 2

Medication History: High-Yield Causative Factors

Obtain a complete medication list with special attention to recent changes, as medications are among the most common reversible causes of both vomiting and delirium in this population. 3, 2

Specific Medication Questions:

• Is the patient taking cholinesterase inhibitors (donepezil, rivastigmine, galantamine)? These have the highest effect size for causing vomiting (RR 6.06) among dementia medications 3
• Any anticholinergic medications, benzodiazepines, or sedative-hypnotics? These are highest-risk medications for causing delirium 3, 2
• Recent medication changes or dose adjustments in the past week? Temporal relationship between medication changes and symptom onset is critical 3
• Is the patient on opioids, digoxin, metformin, antibiotics, or NSAIDs? All can affect appetite and cause gastrointestinal symptoms 3
• Any diuretics that could cause dehydration? Elderly patients with dementia have reduced thirst perception, making them vulnerable to dehydration 3

Infectious and Medical Causes

Ask about symptoms of the two most common infectious causes of delirium and systemic illness in elderly patients: urinary tract infection and pneumonia. 3, 2

Infection Screening Questions:

• Any fever, chills, or recent temperature elevation? 3
• Urinary symptoms: burning, frequency, urgency, or foul-smelling urine? UTI is the most common infectious cause of delirium 2
• Respiratory symptoms: cough, shortness of breath, or increased work of breathing? Pneumonia is the second most common infectious cause 2
• Any recent falls or head trauma? Critical for determining need for neuroimaging 1

Nutritional and Functional Status

Assess baseline eating patterns and recent changes, as malnutrition is widespread in dementia patients and can contribute to acute illness. 3

Nutritional Assessment Questions:

• What was the patient eating and drinking before the vomiting started? Establish baseline intake 3
• Any recent weight loss? Should trigger nutritional screening 3
• Who manages the patient's meals and medications at home? Identifies the reliability of the historian 3
• Any difficulty swallowing or choking episodes? Dysphagia can cause aspiration pneumonia 3

Behavioral and Psychiatric Symptoms

Inquire about new or worsening behavioral disturbances, as these may indicate delirium superimposed on dementia rather than disease progression alone. 3

Behavioral Questions:

• Any new hallucinations, delusions, or paranoia? New psychotic symptoms suggest delirium over baseline dementia 3, 1
• Increased agitation, combativeness, or personality changes? These can accompany delirium 3
• Any signs of depression: loss of interest, withdrawal, or sleep changes? Depression is often untreated in dementia patients 3

Gastrointestinal-Specific History

Determine the pattern and associated symptoms of vomiting to assess for bowel obstruction, which antiemetics can mask. 4

Vomiting Characteristics:

• How many episodes of vomiting? What does the vomit look like? 3
• Any abdominal pain, distension, or constipation? Progressive ileus must be ruled out before antiemetic use 4
• Last bowel movement? Any diarrhea or blood in stool? 3
• Is the patient able to keep down any fluids? Assess hydration status 3

Functional Baseline and Advance Directives

Establish the patient's baseline functional status and goals of care, as this guides appropriate diagnostic workup intensity and treatment decisions. 3

Baseline Function Questions:

• What activities of daily living could the patient perform independently before this illness? 3
• Does the patient have advance directives or a healthcare proxy? 3
• What is the family's understanding of the disease stage and prognosis? 3

Common Pitfalls to Avoid

• Don't attribute all symptoms to dementia progression without investigating acute causes—this is the most common error in geriatric emergency care 2
• Don't overlook polypharmacy—perform medication reconciliation on every visit 2
• Don't delay neuroimaging if focal neurological signs, head trauma history, or atypical features are present 1
• Don't prescribe antiemetics before ruling out bowel obstruction, as they can mask progressive ileus 4
• Don't forget that hypoactive delirium is more common than hyperactive delirium in elderly patients and carries worse prognosis 2