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Delirium Dementia and Depression spr 2011-1

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    Delirium, Dementia andDepression

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    DementiaMultiple cognitive deficits including: 1. Memory impairment 2. At least one of the following:

    AphasiaApraxia

    AgnosiaDisturbance in executive functioning

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    Dementia contOnset: insidious

    Duration: months to yearsUsually alertAffect: labile

    Orientation: may get near miss answers

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    DSM-IV criteria DementiaCriteria A 1. Memory impairment ( Asseen on MMSE)Criteria B 2. A,A,A, Impairment ExecutivefunctioningCriteriaC: Both memory impairment and

    cognitive disturbances must be significantenough to cause a serious impairment insocial, or occupational functioning

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    Types of Dementia

    Senile dementia/ Alzheimers T ype (SDA T ) A. NF T are characteristic B. Dx confirmed post mortum C. Progressive slow decline D. 3X as many women than men

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    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

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    Dementia secondary to other medicalconditions: PD can lead to irreversible dementia secondary

    to dopamine insufficiency Huntingtons disease

    B1 vitamin deficiencies usually secondary toET OH

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    Differentiating Acute Deliriumfrom Chronic Dementia

    Feature Delirium Dementia

    Onset Acute InsidiousDuration Brief Chronic, unless

    reversibleConsciousness fluctuates static

    Orientation Abnormal Normal in mildcases

    Memory Recent defective Recent/later lossInitial S T loss

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    Delirium vs dementia contAttention Always

    impairedMay be intact

    Perception Freq. Disturbed Flat empty talk T hinking Disorganized,

    contents richImpaired,contents empty

    Judgement Poor poor Insight Present in lucid

    intervalsMay be absent

    Sleep Alwaysdisturbed

    Variable

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    Assessment toolsMMSE: Further eval if score < 25/30

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    Assessment toolsPfeiffer Short Portable Mental StatusQuestionnaire: Further evaluation necessary if score is

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    Assessment contFAST Functional Assessment Staging of Alzheimers Disease Identifies other causes of regression

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    More AssessmentFunctional Rating Scale for Sx of Dementia T his 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

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    Some stats1.5-2.3 million persons have mild to moddementiaCognitive impairment affects > 5% of thoseover 65 years., ~20% of those over 75Approximately 50% of nursing home

    residents have irreversible dementia~70% of primary medical pt.s presentingwith cognitive deficits may have SDA T

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    Intervention with confused pt.sValidation techniques should be employedBeliefs and values of validation: People are unique T here are reasons for disruptive behaviors Behavior reflects physical,social and psych

    changes across the lifespan not just anatomicchanges

    Behaviors can be changed only if a personwants to change

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

    restore balance to their lives by retrievingearlier memories

    When a trusted listener acknowledges pain, pain diminishes

    Empathy builds trust, reduces anxiety andrestores dignity

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    DepressionDef: Alteration or disturbance of mood.Onset: recentDuration variableAlertness: diminished ability tocommunicateOrientation: Dont know answersAffect: Flat

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    Depressive Disorders common inthe elderly

    Major Depressive Disorder Dysthymic Disorder Mood disorder Due to General MedicalConditionAdjustment disorder with Depressive Mood

    Depressive Disorder Not OtherwiseSpecified

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    Differentiating Dementia fromDepression

    Feature OrganicDementia

    Depression

    Onset Slow Rapid

    Course Slow, worse atnight

    Rapid anduneven same at

    nightMemory Greater loss

    recentApathetic Idont know

    Orientation Approximate, perserverant

    Apathetic asabove

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    Affect Inappropriate Constricted

    Neurovegetative signs

    None Possiblesleep,appetite,

    bowel or bladder, sex dys

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    Factors leading to depression1. Grief/ bereavement2. Change in support network 3. Change in physical function

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    Medical disorders causingdepressed mood

    Occult malignancyInfectious processHypothyroidismApathetichyperthyroidism

    Cushings syndromeAddisons disease

    PanhypothyroidismParkinsonsDementing illnessCHFCRF

    COPD

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    Meds Asc. With depressed moodAntihypertensivesReserpineMethyldopaBeta blockersHydralazine

    Histamine type IIReceptors/BlockersDigoxin

    Oral hypoglycemicsCNS depressantsBarbituatesNeurolepticsOpiates

    AlcoholSteroidsCytotoxics

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    Depression Assessment toolsBeck- Long form cut off score of 10indicates depression. Short form is just asgood and takes just 5 minutes.Zung- self report. T he greater the score thegreater the depression. Not the best for

    elderly since it was validated on collegestudents. 80 is the highest score and mostindicative of depression.

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    Depression assessment toolscont

    Geriatric Depression scale: a score of >8 is90%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.

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    Holmes and Rahe SocialAdjustment Scale

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    Why is the identification of depression so important?

    Hip fracture outcomes, have been shown todepend on the absence or presence of depression.

    ~13-18% of the community dwelling elderly havedepressionElderly medical pts. ~ 20% are depressed!Suicide rates are disproportionately high among

    the elderlyReport your potential findings to the team so thatthis disorder can be treated.

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