Depression, Depression, Delirium, and Delirium, and Dementia in Dementia in Older AdultsOlder Adults

Depression, Depression, Delirium, and Delirium, and Dementia in Dementia in Older AdultsOlder Adults

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ObjectivesObjectives

Describe the prevalence of depression Describe the prevalence of depression in older adultsin older adults

Use an assessment instrument for Use an assessment instrument for depression in older adultsdepression in older adults

Discuss symptoms and treatment Discuss symptoms and treatment strategies for depression in older strategies for depression in older adultsadults

Describe the prevalence of delirium Describe the prevalence of delirium and dementia in older adultsand dementia in older adults

Describe the prevalence of depression Describe the prevalence of depression in older adultsin older adults

Use an assessment instrument for Use an assessment instrument for depression in older adultsdepression in older adults

Discuss symptoms and treatment Discuss symptoms and treatment strategies for depression in older strategies for depression in older adultsadults

Describe the prevalence of delirium Describe the prevalence of delirium and dementia in older adultsand dementia in older adults

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ObjectivesObjectives

Discuss the symptoms of delirium and Discuss the symptoms of delirium and dementiadementia

Discuss the assessment and treatment Discuss the assessment and treatment strategies for delirium and dementiastrategies for delirium and dementia

Contrast criteria for differentiating Contrast criteria for differentiating depression, delirium, and dementia in depression, delirium, and dementia in older adults.older adults.

Discuss the symptoms of delirium and Discuss the symptoms of delirium and dementiadementia

Discuss the assessment and treatment Discuss the assessment and treatment strategies for delirium and dementiastrategies for delirium and dementia

Contrast criteria for differentiating Contrast criteria for differentiating depression, delirium, and dementia in depression, delirium, and dementia in older adults.older adults.

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Definition of DepressionDefinition of Depression

Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and / or guilt.

Diagnostic labels: minor depression, major depression, adjustment disorder with depressed mood, dysthymia, bipolar depression, seasonal affective disorder

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Prevalence of DepressionPrevalence of Depression

The most common emotional disorder found in older people (2% - 10%)

8% to 15% of community-dwelling older adults

30% among institutionalized older persons Suicide risk factors: - psychiatric illness,

serious medical illness, living along, recent bereavement, divorce, or separation, unemployment or retirement, advanced age, and substance abuse

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Prevalence of DepressionPrevalence of Depression

Herbal, nutritional, vitamins, and Herbal, nutritional, vitamins, and supplement consumed in large dosessupplement consumed in large doses

Highest rate of completed suicide is Highest rate of completed suicide is among older white men.among older white men.

Risk of suicide is higher in older Risk of suicide is higher in older adults than in younger people.adults than in younger people.

Herbal, nutritional, vitamins, and Herbal, nutritional, vitamins, and supplement consumed in large dosessupplement consumed in large doses

Highest rate of completed suicide is Highest rate of completed suicide is among older white men.among older white men.

Risk of suicide is higher in older Risk of suicide is higher in older adults than in younger people.adults than in younger people.

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Assessment Instruments Assessment Instruments for Depressionfor Depression

Hamilton Rating Scale for DepressionHamilton Rating Scale for Depression

Zung Self-rating Depression ScaleZung Self-rating Depression Scale

Montgomery-Asberg Depression Montgomery-Asberg Depression Rating ScaleRating Scale

Yesavage Geriatric Depression ScaleYesavage Geriatric Depression Scale

Cornell Scale for Depression in Cornell Scale for Depression in DementiaDementia

Hamilton Rating Scale for DepressionHamilton Rating Scale for Depression

Zung Self-rating Depression ScaleZung Self-rating Depression Scale

Montgomery-Asberg Depression Montgomery-Asberg Depression Rating ScaleRating Scale

Yesavage Geriatric Depression ScaleYesavage Geriatric Depression Scale

Cornell Scale for Depression in Cornell Scale for Depression in DementiaDementia

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Symptoms of DepressionSymptoms of Depression

Symptoms of Depression

Depressed mood

Associated psychological symptoms

Somatic manifestations

Psychotic symptoms

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Treatment Strategies for Treatment Strategies for DepressionDepression

Pharmacologic – SSRI, Pharmacologic – SSRI, Tricyclic antidepressants, Tricyclic antidepressants, MAO inhibitorsMAO inhibitors

Electroconvulsive TherapyElectroconvulsive Therapy

Group and Individual Group and Individual PsychotherapyPsychotherapy

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Points to consider……Points to consider……

Comorbidities

Monitor every 1 – 2 weeks

Assess response every 4 – 6 weeks

Assess “SIG-E-CAPS” symptoms

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Depression: “SIG-E-Depression: “SIG-E-CAPS”CAPS”

““SIG-E-CAPS” is the acronym used for evaluating the SIG-E-CAPS” is the acronym used for evaluating the patient’s progress over timepatient’s progress over time

SS Sleep disturbance (insomnia or hypersomnia) Sleep disturbance (insomnia or hypersomnia) II Interests (anhedonia or loss of interest in usually Interests (anhedonia or loss of interest in usually

pleasurable activities)pleasurable activities) GG Guilt and/or low self-esteem Guilt and/or low self-esteem EE Energy (loss of energy, low energy, or fatigue) Energy (loss of energy, low energy, or fatigue) CC Concentration (poor concentration, forgetful) Concentration (poor concentration, forgetful) AA Appetite changes (loss of appetite or increased Appetite changes (loss of appetite or increased

appetite)appetite) PP Psychomotor changes (agitation or Psychomotor changes (agitation or

slowing/retardation)slowing/retardation) SS Suicide (morbid or suicidal ideation)Suicide (morbid or suicidal ideation)

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InterventionsInterventions Institute safety Institute safety

precautions for precautions for suicide risksuicide risk

Monitor / promote Monitor / promote nutrition, nutrition, elimination, sleep, elimination, sleep, rest, comfort, pain rest, comfort, pain controlcontrol

Enhance physical Enhance physical function and social function and social supportsupport

Maximize autonomyMaximize autonomy

Structure and encourage Structure and encourage daily participation in daily participation in therapiestherapies

Remove etiologic agentsRemove etiologic agents

Monitor / document Monitor / document responsesresponses

Provide practical Provide practical assistance, such as assistance, such as problem-solvingproblem-solving

Provide emotional Provide emotional supportsupport

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Case StudyCase Study Ms. G is a 75-year old female living alone in her Ms. G is a 75-year old female living alone in her

apartment in New York City. Her husband died apartment in New York City. Her husband died suddenly two years ago of a heart attack. Their two suddenly two years ago of a heart attack. Their two children are alive and living out-of-state. Both of children are alive and living out-of-state. Both of her sons maintain weekly phone contact with Ms. G her sons maintain weekly phone contact with Ms. G and visit usually once a year. Ms. G has been doing and visit usually once a year. Ms. G has been doing well until about 6 weeks ago when she fell in her well until about 6 weeks ago when she fell in her apartment and sustained bruises but did not require apartment and sustained bruises but did not require a hospital visit. Since then, she has been a hospital visit. Since then, she has been preoccupied with her failing eyesight and decreased preoccupied with her failing eyesight and decreased ambulation. She does not go shopping as often, ambulation. She does not go shopping as often, stating she doesn’t enjoy going out anymore and stating she doesn’t enjoy going out anymore and feels “very sad and teary.” Ms. G states that her feels “very sad and teary.” Ms. G states that her shopping needs are less, since she is not as hungry shopping needs are less, since she is not as hungry as she used to be and “besides I’m getting too old to as she used to be and “besides I’m getting too old to cook for one person only.”cook for one person only.”

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QuestionsQuestions

1. What risk factors might account for Ms. G’s symptoms of depression?

2. What are Ms. G’s depressive symptoms?

3. What might be some treatment strategies for Ms. G?

1. What risk factors might account for Ms. G’s symptoms of depression?

2. What are Ms. G’s depressive symptoms?

3. What might be some treatment strategies for Ms. G?

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Prevalence of Delirium and Prevalence of Delirium and DementiaDementia Delirium – a Delirium – a reversible confusional statereversible confusional state, a , a

mental disturbance characterized by acute mental disturbance characterized by acute onset, disturbed consciousness, impaired onset, disturbed consciousness, impaired cognition, and an identifiable underlying cognition, and an identifiable underlying medical cause (medications, anesthesia, sleep medical cause (medications, anesthesia, sleep disturbance, electrolyte imbalance, etc.)disturbance, electrolyte imbalance, etc.)

Dementia – an Dementia – an irreversible confusional irreversible confusional statestate, , acquired impairment of mental , , acquired impairment of mental function, not the result of impaired level of function, not the result of impaired level of arousal, with compromise in at least three arousal, with compromise in at least three areas of mental activity.areas of mental activity.

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Prevalence of Delirium and Prevalence of Delirium and DementiaDementia 4 to 5 million are estimated to have 4 to 5 million are estimated to have

cognitive disorders (dementia or cognitive disorders (dementia or delirium)delirium)

Alzheimer’s disease accounts for 50% Alzheimer’s disease accounts for 50% to 60% of all dementias in the U.S.to 60% of all dementias in the U.S.

Incidence of dementia will increase to Incidence of dementia will increase to 14 million by 205014 million by 2050

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SymptomsSymptoms

ParameterParameter DeliriumDelirium DementiaDementiaOnsetOnset Short, rapid, Short, rapid,

hours/dayshours/daysInsidious and Insidious and gradualgradual

PresentatioPresentationn

Disoriented, Disoriented, fluctuating moodsfluctuating moods

Vague symptoms, Vague symptoms, loss of intellect, loss of intellect, agitated, aggressiveagitated, aggressive

CourseCourse Hours, weeks, or Hours, weeks, or longerlonger

Slow and continuousSlow and continuous

Sleep/Sleep/WakeWake

Worse at night in Worse at night in darkness and on darkness and on awakening, awakening, insomniainsomnia

Worse in evening; Worse in evening; “sundowning”, “sundowning”, reversed sleepreversed sleep

DurationDuration Hours to < monthHours to < month Month to yearsMonth to yearsAffectAffect Labile variable; Labile variable;

fear / panic, fear / panic, euphoria, euphoria, disturbeddisturbed

Easily distracted, Easily distracted, inappropriate inappropriate anxiety, labile to anxiety, labile to apathyapathy

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SymptomsSymptoms

ParameterParameter DeliriumDelirium DementiaDementiaJudgmentJudgment Impaired; Impaired;

difficulty difficulty separating facts separating facts and hallucinationsand hallucinations

Impaired, bad / Impaired, bad / inappropriate inappropriate decisions, denies decisions, denies problemsproblems

Psychotic Psychotic symptomssymptoms

DelusionsDelusions Misperceives people Misperceives people and events as and events as threatening; late threatening; late delusions, delusions, hallucinationshallucinations

Level of Level of ConsciousnConsciousnessess

DisturbedDisturbed Intact Intact

Recent Recent MemoryMemory

Impaired, but Impaired, but remote memory is remote memory is intactintact

Short term memory Short term memory deficit in early deficit in early course, progresses course, progresses to long-term deficits, to long-term deficits, confabulation, confabulation, perseverationperseveration

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Assessment of DeliriumAssessment of Delirium History and PhysicalHistory and Physical

Current medicationCurrent medication

Tests: chemistries, EKG, CXR, Tests: chemistries, EKG, CXR, ABGs, oxygen saturation, u/a, ABGs, oxygen saturation, u/a, thyroid function tests, cultures, thyroid function tests, cultures, drug levels, folate levels, pulse drug levels, folate levels, pulse oximetry, EEG, lumbar puncture, oximetry, EEG, lumbar puncture, serum B12serum B12

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Treatment of DeliriumTreatment of Delirium Failure to treat delays recovery and can worsen

the older person’s health and function.

Psychiatric Management: identify and treat underlying etiology, intervene immediately for urgent medical conditions; ongoing monitoring of psychiatric status

Environmental and supportive interventions: all environmental factors that exacerbate delirium; make environment more familiar; reorient; reassure, and inform to fear or demoralization

Somatic Interventions: antipsychotic; benzodiazepines

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Assessment of DementiaAssessment of Dementia

Folstein Mini-Mental Status Folstein Mini-Mental Status Examination (MMSE)Examination (MMSE)

Kokmen Short Test of Mental StatusKokmen Short Test of Mental Status

7-minute screen: cued recall, 7-minute screen: cued recall, category fluency, Benton Temporal category fluency, Benton Temporal Orientation Test, Clock Drawing Orientation Test, Clock Drawing TestTest

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Try ThisTry This Dementia Series Dementia Seriesatat www.hartfordign.orgwww.hartfordign.org

Developed by The Hartford Institute for Geriatric Developed by The Hartford Institute for Geriatric Nursing in collaboration with The National Nursing in collaboration with The National Alzheimer’s AssociationAlzheimer’s Association

Assessment tool that can be administered in 20 Assessment tool that can be administered in 20 minutes or less minutes or less

Topics include:Topics include: Brief Evaluation of Executive DysfunctionBrief Evaluation of Executive Dysfunction Recognition of Dementia in Hospitalized Older Recognition of Dementia in Hospitalized Older

AdultsAdults Assessing Pain in Persons with Dementia Assessing Pain in Persons with Dementia Assessing and Managing Delirium in Persons Assessing and Managing Delirium in Persons

with Dementiawith Dementia

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Brief Evaluation of Executive Dysfunction: Brief Evaluation of Executive Dysfunction: An Essential Refinement in the Assessment An Essential Refinement in the Assessment of Cognitive Impairmentof Cognitive Impairment

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Treatment of DementiaTreatment of Dementia

Treat cognitive symptoms: Treat cognitive symptoms: cholinesterase inhibitors; Vitamin E; cholinesterase inhibitors; Vitamin E; Gingko Biloba; stroke preventionGingko Biloba; stroke prevention

Treatment of Behavioral Treatment of Behavioral Disturbances: antipsychotics; Disturbances: antipsychotics; benzodiazepines; selected tricyclicsbenzodiazepines; selected tricyclics

Educational interventions: family Educational interventions: family caregivers and staffcaregivers and staff

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Treatment of DementiaTreatment of Dementia Improve functional performance: low lighting Improve functional performance: low lighting

level, music, behavior modificationlevel, music, behavior modification

Nonpharmacologic Interventions for Problem Nonpharmacologic Interventions for Problem Behaviors: cognitive remediation, massage, Behaviors: cognitive remediation, massage, pet therapy, occupational and physical pet therapy, occupational and physical therapy, validation therapytherapy, validation therapy

Care Environment Alterations: homelike Care Environment Alterations: homelike setting, special care unitsetting, special care unit

Interventions for Caregivers: assess for Interventions for Caregivers: assess for caregiver depressioncaregiver depression

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Alzheimer CareAlzheimer Care Use personal history, life experiences, and Use personal history, life experiences, and

habitshabits Maintain a familiar and comfortable Maintain a familiar and comfortable

routineroutine Slow down, speak clearly, make eye Slow down, speak clearly, make eye

contact, in field of visioncontact, in field of vision Cue the person to do as much for him or Cue the person to do as much for him or

herself as possibleherself as possible Modify physical environment – reduce Modify physical environment – reduce

misinterpretationmisinterpretation Monitor for symptoms of personal distressMonitor for symptoms of personal distress

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Ms. D is a 98-year-old Ms. D is a 98-year-old female in a skilled nursing female in a skilled nursing facility with a diagnosis of facility with a diagnosis of Alzheimer’s disease. Ms. D Alzheimer’s disease. Ms. D comes to the nursing station comes to the nursing station and appears very upset. She and appears very upset. She tells you that she is looking tells you that she is looking for her mother and asks you for her mother and asks you to help her. You start to help her. You start walking with Ms. D. walking with Ms. D.

Ms. D is a 98-year-old Ms. D is a 98-year-old female in a skilled nursing female in a skilled nursing facility with a diagnosis of facility with a diagnosis of Alzheimer’s disease. Ms. D Alzheimer’s disease. Ms. D comes to the nursing station comes to the nursing station and appears very upset. She and appears very upset. She tells you that she is looking tells you that she is looking for her mother and asks you for her mother and asks you to help her. You start to help her. You start walking with Ms. D. walking with Ms. D.

Case Study: DementiaCase Study: Dementia

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Which strategies would be Which strategies would be helpful helpful

in assisting Ms. D.?in assisting Ms. D.?1.1. Using reality orientation in the hope of Using reality orientation in the hope of

reversing her cognitive lossreversing her cognitive loss

2.2. Telling her that her mother died a long Telling her that her mother died a long time agotime ago

3.3. Attempt to distract / redirect her into a Attempt to distract / redirect her into a pleasurable activity, such as eating or pleasurable activity, such as eating or singingsinging

4.4. Ask her to help you with a small task Ask her to help you with a small task and that later you will look for her and that later you will look for her mother together.mother together.

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SummarySummary

Prevalence, symptoms and Prevalence, symptoms and treatment strategies for depression, treatment strategies for depression, delirium, and dementia.delirium, and dementia.

Assessment toolsAssessment tools

Interventions for behavior problemsInterventions for behavior problems

Case Studies to reinforce knowledgeCase Studies to reinforce knowledge