Delirium, Dementia and Depression

Dementia

• Multiple cognitive deficits including:– 1. Memory impairment

– 2. At least one of the following:• Aphasia• Apraxia• Agnosia

• Disturbance in executive functioning

Dementia con’t

• Onset: insidious

• Duration: months to years

• Usually alert

• Affect: labile

• Orientation: may get near miss answers

DSM-IV criteria Dementia

• Criteria A 1. Memory impairment ( As seen on MMSE)

• Criteria B 2. A,A,A, Impairment Executive functioning

• CriteriaC: Both memory impairment and cognitive disturbances must be significant enough to cause a serious impairment in social, or occupational functioning

Types of Dementia

• Senile dementia/ Alzheimers Type (SDAT)– A. NFT are characteristic

– B. Dx confirmed post mortum– C. Progressive slow decline– D. 3X as many women than men

• Multi Infarct Dementia: Vascular Dementia– A. Muliplt mini strokes

– B. Atherosclerotic plaques in bv, Diabetic deterioration of bl vessels

– C. Stepwise progressive decline– D. Affects twice as many men as women

• Dementia secondary to other medical conditions:– PD can lead to irreversible dementia secondary

to dopamine insufficiency– Huntington’s disease– B1 vitamin deficiencies usually secondary to

ETOH

Differentiating Acute Delirium from Chronic Dementia

Feature Delirium Dementia

Onset Acute Insidious

Duration Brief Chronic, unless reversible

Consciousness fluctuates static

Orientation Abnormal Normal in mild cases

Memory Recent defective Recent/later loss Initial ST loss

Delirium vs dementia con’t

Attention Always impaired

May be intact

Perception Freq. Disturbed Flat empty talk

Thinking Disorganized, contents rich

Impaired, contents empty

Judgement Poor poor

Insight Present in lucid intervals

May be absent

Sleep Always disturbed

Variable

Assessment tools

• MMSE:– Further eval if score < 25/30

Assessment tools

• Pfeiffer Short Portable Mental Status Questionnaire:– Further evaluation necessary if score is <8/10

Assessment con’t

• FAST Functional Assessment Staging of Alzheimer’s Disease– Identifies other causes of regression

More Assessment

• Functional Rating Scale for Sx of Dementia– This questionnaire predicts clients appropriate

for NH placement.– 83% of those appropriate have:

– Incontinence of B&B

– Inability to speak coherently

– Inability to bathe and groom self

Some stats

• 1.5-2.3 million persons have mild to mod dementia

• Cognitive impairment affects > 5% of those over 65 years., ~20% of those over 75

• Approximately 50% of nursing home residents have irreversible dementia

• ~70% of primary medical pt.s presenting with cognitive deficits may have SDAT

Intervention with confused pt.s

• Validation techniques should be employed• Beliefs and values of validation:

– People are unique– There are reasons for disruptive behaviors– Behavior reflects physical,social and psych

changes across the lifespan not just anatomic changes

– Behaviors can be changed only if a person wants to change

Validation con’t

– People must be accepted non-judgmentally– When more recent memory fails, elders try to

restore balance to their lives by retrieving earlier memories

– When a trusted listener acknowledges pain, pain diminishes

– Empathy builds trust, reduces anxiety and restores dignity

Depression

• Def: Alteration or disturbance of mood.

• Onset: recent

• Duration variable

• Alertness: diminished ability to communicate

• Orientation: “Don’t know answers”

• Affect: Flat

Depressive Disorders common in the elderly

• Major Depressive Disorder• Dysthymic Disorder• Mood disorder Due to General Medical

Condition• Adjustment disorder with Depressive Mood

• Depressive Disorder Not Otherwise Specified

Differentiating Dementia from Depression

Feature Organic Dementia

Depression

Onset Slow Rapid

Course Slow, worse at night

Rapid and uneven same at night

Memory Greater loss recent

Apathetic I don’t know

Orientation Approximate, perserverant

Apathetic as above

`

Affect Inappropriate Constricted

Neuro vegetative signs

None Possible sleep,appetite, bowel or bladder, sex dys

Factors leading to depression

• 1. Grief/ bereavement

• 2. Change in support network

• 3. Change in physical function

Medical disorders causing depressed mood

• Occult malignancy• Infectious process

• Hypothyroidism• Apathetic

hyperthyroidism• Cushing’s syndrome• Addison’s disease

• Panhypothyroidism• Parkinsons

• Dementing illness• CHF• CRF

• COPD

Meds Asc. With depressed mood

• Antihypertensives• Reserpine

• Methyldopa• Beta blockers• Hydralazine

• Histamine type II Receptors/Blockers

• Digoxin

• Oral hypoglycemics• CNS depressants

• Barbituates• Neuroleptics• Opiates

• Alcohol• Steroids• Cytotoxics

Depression Assessment tools

• Beck- Long form cut off score of 10 indicates depression. Short form is just as good and takes just 5 minutes.

• Zung- self report. The greater the score the greater the depression. Not the best for elderly since it was validated on college students. 80 is the highest score and most indicative of depression.

Depression assessment tools con’t

• Geriatric Depression scale: a score of >8 is 90%sensitive,80%specific for depression. A score of over 5 may indicate depression. Of the 30 items, one point is awarded for each response that matches the yes or no at the end of the question.

Holmes and Rahe Social Adjustment Scale

Why is the identification of depression so important?

• Hip fracture outcomes, have been shown to depend on the absence or presence of depression.

• ~13-18% of the community dwelling elderly have depression

• Elderly medical pts. ~ 20% are depressed!• Suicide rates are disproportionately high among

the elderly• Report your potential findings to the team so that

this disorder can be treated.