LET’S DISCUSS HOW TO

Differentiate delirium, depression &

dementia.

Describe the etiology and signs and

symptoms of delirium, depression, and

dementia.

Identify risk factors for delirium,

depression, and dementia.

LET’S DISCUSS HOW TO

Identify types of medications that may

cause depression.

Communicate and care for people

experiencing delirium.

Explain non-pharmacologic interventions

for treating dementia.

DELIRIUM

Cholinergic/dopaminergic excess

Cascade of events

Complicates hospitalizations

Is a medical emergency

Durso, S. C. & et al. (2010).

Sometimes preventable by minimizing medication use and adequate hydration

Glutamate

Activation

GABA

Activation

Reduced

GABA

Activity

Cholinergic Inhibition

Dopamine

Activation

Cytokine Excess

Serotonin

Activation

Serotonin

Deficiency

Cortisol

ExcessHepatic

Failure

&

Alcohol

Withdrawal

Benzo’s

&

Hepatic

Failure

Benzo’s &

ETOH

Withdrawal

Medications

Surgical &

Medical Illness

Cholinergic Activation

Medications

Alcohol

Withdrawal

Medications

Substance

Withdrawal

Glucocorticoids

Stroke

Surgery

Surgical &

Medical Illness

Medications

Stroke

http://www.gerisage.com/modules/delirium_module/index.htm

COMMUNICATION IN DELIRIUM

Know the person’s

patterns

Look at nonverbal

signs

Speak slowly

Explain all actions

Be calm

Face the person

keep eye contact

Get to the level of

the person, don’t

stand over them

Touhy, T. & Jett, K. (2012).

COMMUNICATION IN DELIRIUM

Smile

Use simple familiar

words

Allow adequate time

for response

Repeat if needed

BE Consistent

Tell the person what

you want them to do

One-step directions

Reassure safety

Do not assume they

cannot understand

Touhy, T. & Jett, K. (2012).

http://www.youtube.com/watch?v=jZ_-13ww9hM&feature=youtu.be

REVERSIBLE FACTORS

Drugs

Electrolyte imbalance

Lack of drugs

Infection

Reduced sensory input

Intracranial

Urinary retention/fecal impaction

Myocardial/Pulmonary

DEPRESSION

Not a normal part of aging

Most common mental health problem of late life

Among the most treatable

Often co-occurs illness “unwanted cotraveler”

Up to 1 in 4 primary care clients suffer from

depression

Touhy, T. & Jett, K. (2012).

MEDICATIONS MAY RESULT IN DEPRESSIVE SYMPTOMS

Antihypertensives

Angiotensin-

Converting Enzyme

Inhibitors

Antidysrhythmics

Anticholesteremics

Antibiotics

Analgesics

Corticosteroids

Touhy, T. & Jett, K. (2012).

DEPRESSION

Two simple questions effectively

screen:

Over the past 2 weeks, have you felt

down, depressed or hopeless?

Have you experienced a loss of

interest or pleasure in most things?

Durso, S. C. & et al. (2010).

DEPRESSIONSupportive treatment

Counseling, relief of loneliness

Treat physical symptoms and pain

Address anxiety, financial, dependency

Consider stopping contributory drugs

Psychotherapy effective as antidepressants

Cognitive-behavioral therapy

comprehension

DEMENTIA

The term dementia describes a syndrome

Chronic and progressive brain disease

Affects higher cortical functions

memory

language

judgment

learning

capacity

thinking orientation

calculation

Bereczki, D. & Szatmári, S. (2009).

IMPACT

35.6 million with dementia

Nearly doubles every 20 years

Alzheimer’s in the USA will

ALMOST TRIPLE BY 2050

World Alzheimer Report 2011.

28 million of the world’s 35.6 million people with

dementia have yet to receive a

diagnosis…

World Alzheimer Report 2011.

A Quality Dementia Diagnosis Changes

Everything …

Annual dementia

care costs

$32,865

per person

With a quality

dementia diagnosis

annual dementia cost

decreases to $5,000

per person

Improved health & quality of life

even more cost-effective

Impact of a Quality Dementia Diagnosis

World Alzheimer Report 2011.

Earlier diagnosis allows people with dementia to…

plan ahead while

they still have the

capacity, receive

timely practical

information, advice

and support

get access to available

drug and non-drug

therapies

participate in

research for the

benefit of future

generations

World Alzheimer Report 2011.

7.7 million new cases yearly.New case of dementia every?

A. 18 minutes

B. 23 hours

C. 4 seconds

D. 23 minutes

E. 30 seconds

C. 4 seconds

WORLD’S 18TH LARGEST ECONOMY

D

E

M

E

N

T

I

A

de Vugt, M. E. & Verhey, F. (2013).

0 1 2 3 4 5 6

DEMENTIA

WAL-MART

EXXON MOBIL

100 BILLION US DOLLARS

Dementia Costs More Than 1% Gross Domestic Product

Borson, S. & et al. (2013).

If dementia were a company, it would be the world’s largest by annual revenue.

RISKAge

Family history and genetics

Psychiatric disorders

Cardiovascular disease – related factors

Head trauma

Alcohol, drugs & toxins

Vasculitis, Endocrine & Infectious disorders

Neoplastic & Respiratory disorders

Brain lesions, normal pressure hydrocephalus

Fillit, H. M. & et al. (2010) & Patterson, C. & et al. (2007).

MILD COGNITIVE IMPAIRMENT

NOT the result of normal aging

Forgetfulness is hallmark symptom

Sometimes called a transitional phase

Conversion rate 2 - 15% per year

Up to 80% conversion at 6 years

Fillit, H. M. & et al. (2010).

MAJOR DEMENTIA TYPES

AD Alzheimer’s disease

VaD Vascular dementia

FTD Frontotemporal dementia

PDD Parkinson’s disease dementia

DLB Dementia with Lewy bodies

Others: SD Semantic dementia, Progressive

nonfluent aphasia, etc.

NEUROPSYCHOLOGICAL DOMAINS

Premorbid ability: review of

educational, occupation

Verbal memory: verbal and

memory learning tests

Visual memory: visual

reproduction, figure drawing

Simple attention: digit span

Language: animal naming, oral

word association test

Executive function: card

sort test, similarities

Visuospatial: digit symbol

test, clock drawing

Motor: finger tapping

Cognitive screening:

MMSE, SLUMS, MoCA, etc.

Fillit, H. M. & et al. (2010).

OTHER DOMAINS

FunctionKatz Index of Activities of Daily Living ADL

Lawton Instrumental Activities of Daily Living Scale IADL

Get-up and go

Caregiver Input

DepressionHamilton Depression Rating Scale HDRS

Geriatric Depression Scale GDS

Fillit, H. M. & et al. (2010).

DIAGNOSTIC

LABORATORYCBC, CMP, Thyroid, B12, Folate, CRP, RPR, Lipids, HIV, SED rate, etc.

May need to rule out delirium urine sample, blood cultures, chest x-ray, CSF

NeuroimagingMRI or CT - Choice depends on availability, cost, patient acceptability, contraindicationMRI is preferred. SPECT & PET scanning, Pittsburgh Compound-B ligand for PET

Fillit, H. M. & et al. (2010).

Reports of progressive

change in cognition or ADL

Clinical assessment

Is cognitive impairment

confirmed on formal testing?

Is ADL impaired

Is onset relatively sudden

with disturbed attention?

Investigations, including

neuroimaging

Is a non-vascular etiology for

dementia identified?

Is a vascular etiology for

dementia identified?

Is parkinsonism, visual hallucinations

or fluctuating cognition present?

Is presentation with isolated

language and/or executive deficits?

Is episodic memory deficit prominent?

Consider depression,

anxiety, normal agingNO

NOMild Cognitive

Impairment

YES Delirium

Is cognitive impairment

persistent despite

appropriate treatment YES

YESToxic, NPH, tumor, Huntington, head

injury, MS, HIV, Neurosyphilis, CJD,

metabolic – thyroid, B12 deficiency

YESVascular dementia,

SDH, vasculitis

YESDementia with Lewy bodies,

Parkinson’s disease dementia

YES Frontotemporal dementia

YES Alzheimer’s disease

DIAGNOSTIC PROCESS F

illi

t, H

. M

. &

et

al.

(2

010

).

ALZHEIMER’S DISEASEImpairment in memory

Functional impairment social

or vocational

And impairment in one other

cognitive areaAgnosia - impaired ability recognize objects

Aphasia - language disturbances in expressing,

understanding

Apraxia - inability to carry out motor activities

Attention

Executive function

Visuospatial ability

Other criteria:

Progression is

insidious and

other diseases that

could cause

cognitive decline

have been ruled

out, diagnosis is

primarily based on

clinical judgment.

Fillit, H. M. & et al. (2010).

AD - Damage to plaque and neurofibrillary tangles, synapse

loss, atrophy starts medial temporal lobe

SIGNS AND SYMPTOMSUnderstanding Language

Processing Auditory Information

Organizing InformationMemory Learning

JILL, 86 YO CAUCASIAN FEMALE, COMPLETED SOME COLLEGE

CAM: negative

ADLs: Independent in eating & transfer

IADLs: Dependent in ALL

GDS: 4/15, negative

Labs: not remarkable

Brain Imaging: Diffuse atrophy

PMH: HTN, DM II, CAD

Physical Exam: Confabulates

Increasingly more forgetful for the past 6 months…

CAM - negative

No Feature 1: Acute Onset or Fluctuating Course

No Feature 2: Inattention

No Feature 3: Disorganized thinking

No Feature 4: Altered Level of consciousness

The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.

Inouye, S. & et al. (1990).

DEPENDENT

DEPENDENT

DEPENDENT

INDEPENDENT

DEPENDENT

INDEPENDENT

Feature Delirium Dementia Depression

Onset Sudden Insidious Recent

Course over 24 Hours

Fluctuates, often worse at night

Fairly stable Fairly stable, may be worse in

the morning

Consciousness Reduced Clear Clear

Alertness Variable Normal Normal

Psychomotor Activity

Variable, mixed Normal Variable, mixed

Attention Concentration

Disordered Normal LittleImpairment

Orientation Impaired, fluctuates

Impaired, tries to answer,

confabulates

Usually normal,“I don’t know” may try not to

answer

Speech Often incoherent, slow

or raid

Word finding, perseveration

May be slow

Touhy, T. & Jett, K. (2012).

VASCULAR DEMENTIA

Second most prevalent dementia 1/3

Also know as multi-infarct dementia

The brain has multiple vascular lesions in the cortex and subcortical areas, sometimes called “small strokes”

Memory loss most common complaint

The cognitive changes that occur are directly related to the location of the lesions

Working memory more likely to be impaired more than delayed recall

Fillit, H. M. & et al. (2010).

VASCULAR DEMENTIA

Cued recall

recognition

previously

learned

material

generally

intact

Executive

dysfunction

more

commonly

reported than

in AD

Depression

common

Fillit, H. M. & et al. (2010).

JOHN, 70 YO CAUCASIAN MALE, RETIRED PHARMACIST

CAM: negative

ADLs: Independent in ALL

IADLs: Dependent in ALL

GDS: 3/15, negative

Labs: ESRD

PMH: Insulin dependent diabetic

Physical Exam: gait imbalance, due

worsening vision/peripheral neuropathy

Reports he trusts his wife to make all his decisions as he no longer can, “I do whatever

she wants…”

JOHN’S MRI

MRI Brain:

Small punctate acute ischemic lesion

in the right hippocampus, diffuse

extensive chronic white matter

microvascular ischemic changes and

volume loss advanced for age.

Functional Assessment Staging (FAST)

Stage 1 Normal adult.

No functional decline.

Stage 2 Normal older adult.

Personal awareness of some functional

decline.

Stage 3 Early AD. Noticeable deficits

in demanding job situations.

Stage 4 Mild AD. Requires assistance

in complicated tasks such as handling

finances, planning parties, etc.

Stage 5 Moderate AD.

Requires assistance in choosing proper attire.

Stage 6 Moderately Severe AD.

Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.

Stage 7 Severe AD.

Speech ability declines to about a half-dozen intelligible words. Progressive loss of the ability to walk, sit-up, smile, and hold head up.

maintaining reestablishing independence

Improving andstabilizing cognitive

ability and mood

TREATMENT GOALS

effective future planning

symptom management

orientating redirecting

pharmacologic therapies

daily caresafety as needed

Fillit, H. M. & et al. (2010) & Bereczki, D. & Szatmári, S. (2009).

caregiver interventions

nonpharmacologic

promoting autonomy

NON-PHARMACOLOGIC INTERVENTIONS

DEMENTIAPerson-Centered Care

Structure the environment and relationships to

maintain stability – Stable & Predictable

Establish a caring relationship

Provide unconditional positive regard

Find causes of behavior, identify triggers

Provide as much control as possible

Touhy, T. & Jett, K. (2012).

NON-PHARMACOLOGIC INTERVENTIONS

DEMENTIAReduce environmental distractions

Approach from the front, make eye contact,

address person by name, speak in calm voice

To reduce sense of threat, talk first, then touch

Avoid verbal testing or questioning beyond the

person’s ability

Do not argue or insist they accept your reality

PHARMACOLOGIC INTERVENTIONS

Considerable

variation in clinical

practice regarding

pharmacological

treatment of

dementias

Bereczki, D. & Szatmári, S. (2009).

DEMENTIA KEY FINDINGS

Most people wish to be told of their diagnosis

Improving the likelihood of earlier diagnosis:

medical practice-based educational programs,

introduction of accessible dementia care services,

promoting effective interaction in the health system

Early therapeutic interventions:

improving cognitive function, treating depression,

improving caregiver mood, delaying

institutionalization

World Alzheimer Report 2011

What’s Your Story?"ElderlyWomanInGlasses". Licensed under CC BY-SA 3.0 via Wikimedia Commons -http://commons.wikimedia.org/wiki/File:ElderlyWomanInGlasses.jpg#mediaviewer

/File:ElderlyWomanInGlasses.jpg

Bereczki D, Szatmári S. Treatment of dementia and cognitive impairment:

What can we learn from the Cochrane library. J Neurol Sci [Internet]. 2009

8/15;283(1–2):207-10.

Borson S, Frank L, Bayley PJ, Boustani M, Dean M, Lin P, McCarten JR,

Morris JC, Salmon DP, Schmitt FA, Stefanacci RG, Mendiondo MS, Peschin S,

Hall EJ, Fillit H, Ashford JW. Improving dementia care: The role of screening

and detection of cognitive impairment. Alzheimer's & Dementia [Internet].

2013 3;9(2):151-9.

de Vugt ME, Verhey FRJ. The impact of early dementia diagnosis and

intervention on informal caregivers. Prog Neurobiol [Internet]. 2013 In Press.

Durso, S. C., Bowker, L. K., Price, J. D., & Smith, S. C. (Eds.). (2010). Oxford

American handbook of geriatric medicine (First ed.). New York, New York:

Oxford University Press Inc.

REFERENCES

Fillit HM, Rockwood K, Woodhouse K. The nervous system In:

Brocklehurst's textbook of geriatric medicine and gerontology. 7th ed.

Philadelphia: Elsevier; 2010; p. 385-432.

Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990).

Clarifying confusion: The confusion assessment method. Annals of

Internal Medicine, 113(12), 941-948.

Patterson C, Feightner J, Garcia A, MacKnight C. General risk factors for

dementia: A systematic evidence review. Alzheimer's & Dementia [Internet].

2007 10;3(4):341-7.

Touhy, T. & Jett, K. (2012). Ebersole & Hess’ Toward healthy aging: Human

needs and nursing response, 8th edition. St. Louis: Elsevier Mosby.

Special Thank You: Department of Veterans Affairs, Saint Louis University, SLUMS Examination. World Alzheimer Report 2009 & 2011.

REFERENCES