Evaluating Delirium, Dementia, and Depression in Older Adults: Clinical Use of the 5D Pocket Card

Stephen Thielke

Puget Sound VA GRECC

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Learning ObjectivesCharacterize delirium, dementia, and depressionIdentify key similarities and differences between

themDiscuss steps in the clinical evaluation of these

conditionsReview instruments contained in the 5D Pocket

Card which can be used to evaluate and monitor delirium, dementia, and depression

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Will not addressManagement of delirium, dementia, and

depressionGeneral geriatric assessmentSuicide risk assessment and management

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Project Timeline2007-2008: Needs assessment delineates

challenges around differential diagnosis of dementia in primary care

Mid-2008: GRECC Dementia Education Workgroup begins discussing ways of improving the differential diagnosis and management of common geriatric cognitive symptoms in clinical settings

Mid-2009: First draft of pocket card and assessment guide trialed and evaluated

Mid-2010: Final pocket card and guide to be disseminated through the GRECCs 4

Key Contributors Julie Moorer, Puget Sound GRECC Suzanne Craft, Puget Sound GRECC Kathy Horvath, New England GRECC Theressa Burns, Minneapolis GRECC Michelle Rossi, Pittsburgh GRECC Terri Huh, Palo Alto GRECC Nina Tumosa, St Louis GRECC Byron Bair, Salt Lake City GRECC Susan Cooley, Office of Geriatrics and Extended Care Malva Rashid, Cleveland GRECC Rivkah Lindenfeld, Northport EERC Ken Shay, Office of Geriatrics and Extended Care

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What Delirium IS“Acute Brain Failure”“Toxic Metabolic Encephalopathy”“Acute Confusional State”A medical condition:

Rapid onsetDeficits in attention and concentrationWaxing and waning mental statusInfections, medications, metabolic abnormalities are the

most common causes

Mental status changes often precede objective signs of illness

Often multifactorial6

What Delirium IS NOTA psychological problemAn insignificant condition (over 25% of

patients with delirium die within 6 months)Dementia – slow onset, slow steady

decline, little fluctuationRapidly resolving, even when cause

correctedA normal part of aging

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What Dementia ISA significant chronic loss in memory and/or

mental functions, involving structural damage to the brainSignificant ─ functional consequencesChronic ─ not a rapid onset (comes on over

years)Loss ─ new impairments (not lifelong)Structural Damage ─ neurons die

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What Dementia IS NOTDelirium ─ acute onset, attention and

concentration problemsDepression – anhedonia, distraction; subjective

cognitive deficits which are not apparent on neuropsychological testing

Sensory deficits or communication problemsA normal part of aging

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What Depression ISA syndrome of psychological and bodily symptomsLow mood or anhedonia (lack of pleasure), plus:

Problems with sleep (too little or too much)Problems with appetite (too high or too low)Trouble concentratingDecreased interestsFeelings of guilt or having done something wrongLow energySlowed movementsSuicidal thoughtsUnreal experiences: “my mind playing tricks on me”

(hearing voices or feeling paranoid)10

What Depression IS NOTA bad day, week, or monthGriefA natural reaction to medical illness or lossA cause of dementiaA normal part of aging

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Common Features Hallmarks

Delirium

Subjective confusion

Difficulty performing

tasks

“Not right” on interview

Loved ones are worried

Trouble with attention and concentration

Rapid onset; waxing and waningDue to a medical cause

Dementia

Problems with memory plus problems with speech, actions, recognition, or executive functioning

Chronic and progressive, slow onsetFunctional decline

DepressionDecreased concentration and interestSensorium is clear

Delirium, Dementia and Depression

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Delirium

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Delirium Prevalence15-40% of older hospitalized patientsUp to 70% of ICU patientsRoughly 80% of patients pre-death14% of patients 65 years and older in the

emergency room

Patients with underlying cognitive impairments are more likely to develop delirium

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Rahkonen et al, 2002

Inouye et al, 1999; McNiccoll et al, 2003; Hustey & Meldon, 2002

Recognizing DeliriumConfusion that develops over days or weeksTrouble with attention, focus, &

concentrationWaxing and waningFluctuating sleep disturbancesErratic, uncharacteristic, inappropriate

behaviorHallucinations (especially visual), paranoia

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Recognizing Delirium (cont’d)

Can be hyperactive (agitated) or hypoactive (sedated)

Delirium often goes unrecognizedActing “normal” during one assessment

does not rule out delirium

Falling asleep during interview strongly suggests delirium 16

Working Up DeliriumDo not assume that patients are just having a “bad

thinking day”Use collateral sources of informationConsider the whole clinical pictureApply a broad differential

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D eficienciesE ndocrinopathiesA cute vascularT oxins or drugsH eavy metals

I nfections

W ithdrawal

A cute metabolic

T rauma

C NS pathology

H ypoxia

Delirium Evaluation: CAMThe Confusion Assessment Method (Inouye 1993, 2000)

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Feature 1: Acute Onset and Fluctuating CourseUsually obtained from family member or caregiver: rapid change from baseline, and fluctuating severity during the day.Feature 2: InattentionTrouble with attention, being distractible, or having difficulty keeping track of what was said. Example: recite months of the year backwards.Feature 3: Disorganized ThinkingRambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject.Feature 4: Altered Level of ConsciousnessAnything other than alert on scale of (Normal [alert], Vigilant [hyperalert], Lethargic [drowsy, easily aroused], Stupor [difficult to arouse], or Coma [unarousable]).

Delirium is diagnosed with the presence of feature 1 and 2, and either 3 or 4.

Delirium Evaluation (cont)

Consider delirium FIRST in any patient who shows cognitive impairments

Identifying delirium is only the first stepStrive to determine and correct the

cause

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Dementia

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Dementia Prevalence

Age Range% with

Dementia

71-79 5.0%

80-89 24.2%

90+ 37.4%

Total (71+ yrs) 13.9%

21Plassman et al, 2007

Recognizing DementiaCommon warning signs are problems with:

Short-term memory, judgmentWord finding (language)Taking medication incorrectly (executive function)Driving (visuospatial)Balancing checkbook (calculation)

Memory problems are often not the chief complaint

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Recognizing Dementia (cont’d)Spouses or children are often more concerned

than patientsGood verbal skills and living independently

should not preclude evaluation of cognitionConduct additional workup whenever patient or

family describe problems or when cognitive problems are observed

Routine screening of the asymptomatic is not recommended (USPSTF)

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Working Up DementiaHistory ─ use collateral sourcesRule out delirium and reversible causesLabs:

TSH, CBC, Chem-7, Calcium, LFTs, B12, Folate, Urinalysis

Cognitive testing:BOMC, Mini-Cog, GPCOG, STMS, SLUMS, MoCA,

FASTComplex cases: refer for neuropsychological evaluation

Neuroimaging is not routinely indicated; order ifRapid declineUnexplained focal neurological symptoms

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DSM-IV Criteria for Alzheimer’s Dementia

A. The development of multiple cognitive deficits manifested by:

1. Memory Impairment

2. One or more of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia (impaired ability to carry out motor activities) (c) agnosia (failure to recognize or identify objects) (d) disturbances in executive functioning ( i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in A1 and A2 each cause significant impairment in social or occupational functioning.

C. The course is characterized by gradual onset and continuing cognitive decline.

D. The cognitive deficits are not due to other neurological or systemic conditions, or to substance use.

E. The deficits do not occur exclusively during the course of a delirium.

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Mini-CogA brief assessment; does not diagnose dementia

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1. Ask the patient to remember 3 words. Repeat them until the patient is able to state all 3 without errors.

2. Ask the patient to draw a clock and include all the numbers. Then ask the patient to place the hands on the clock to make the time be “One Ten”.

3. Ask the patient to recall the 3 words you asked before.

Unscored

2 points for a clock without errors, 0 for any error

1 point per word (max 3)

Scoring: None of the 3 words: Cognitively impaired

All 3 of the words: Not cognitively impaired

1 – 2 words recalled Abnormal clock: Cognitively impaired

Normal clock: Not cognitively impaired

AD-8Assesses functional status, based on report of a

spouse, caregiver, or close family memberFocuses on change in the last several years:

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1. Problems with judgment (e.g. falls for scams, bad financial decisions, buys gifts inappropriate for recipients)

2. Reduced interest in hobbies/activities3. Repeats questions, stories or statements4. Trouble learning how to use a tool, appliance or gadget (e.g. VCR,

computer, microwave, remote control)5. Forgets correct month or year6. Difficulty handling complicated financial affairs (e.g. balancing

checkbook, income taxes, paying bills)7. Difficulty remembering appointments8. Consistent problems with thinking and/or memory

Scoring: One point per item

Score of 2 or greater suggests significant cognitive impairment

SLUMSSt Louis University

Mental Status ExamUsed to assess cognitive

changes and to track clinical changes over time

Better psychometric properties than the MMSE

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Scoring: Total 30 points

Normed for education level (high school or more; high school or less)

FASTFunctional Assessment Staging ToolInformation provided by knowledgeable informant, and

supplemented by clinical observationUsed to guide appropriateness of dementia medication

therapy

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1-2 No functional deficit (Normal). Subjective word difficulties (Normal Aging)

3-4 Decreased function in demanding settings or decreased ability to handle complex tasks ( i.e. finances or planning dinner.)

5. Requires assistance in choosing proper clothing

6. Difficulty with dressing, bathing, toileting. Urinary and/or fecal incontinence.

7a Can speak only about half a dozen intelligible different words or fewer

7b Speech ability limited to the use of a single intelligible word

7c Unable to talk without assistance7d Cannot sit up without assistance7e Loss of ability to smile7f Loss of ability to hold up head

independently

Scoring: The highest consecutive disability noted

Depression

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Depression Prevalence

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66 68 70 72 74 76 78 80 82 84 86 88 900

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

Sick - Female

Sick - Male

Entire Group - Female

Entire Group - Male

Healthy - Female

Healthy - Male

Age

Pre

va

len

ce

of

Ma

jor

De

pre

ss

ive

Sy

mp

tom

s

Thielke et al, Aging and Mental Health 2010

Recognizing DepressionOften presents as nonspecific physical symptoms

FatiguePainGI problems

Older patients less likely than younger to admit to being “depressed”

Depression is stigmatized, especially in older adults

Patients often more willing to endorse mental health symptoms in writing than in person

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Working Up DepressionAll patients with mood symptoms or history of

depression, mood disorders, or PTSD should be assessed for suicidal thoughts

Ask about mood symptoms in patients of all ages

Use structured scales when possible

Consider the mutual effects of depression and medical illness

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PHQ-2A screening tool; does not diagnose depressionSelf-report

“Over the past two weeks, how often have you been bothered by these problems?”

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Not at all

Several days

> Half of the days

Nearly every day

1. Little or no interest or pleasure in doing things? 0 1 2 3

2. Feeling down, depressed, or hopeless?

0 1 2 3

A score of 3 or greater merits completing the PHQ-9, AND a suicide risk evaluation should be completed within 24 hours

PHQ-9

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All questions use 0 – 3 scale (as on PHQ-2)

A suicide risk evaluation is required within 24 hours if:

1. Total score is less than 10 and response to question #9 is 1, 2 or 3.

2. Total score is greater than 10.

Depression is likely if the total score is greater than 10

1. Little or no interest or pleasure in doing things?

2. Feeling down, depressed, or hopeless?

3. Trouble falling asleep, staying asleep, or sleeping too much?

4. Feeling tired or having little energy?

5. Poor appetite or overeating?

6. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down?

7. Trouble concentrating on things such as reading the newspaper or watching television?

8. Moving or speaking so slowly that others could have noticed, or being so fidgety and restless that you have been moving around a lot more than usual?

9. Thinking that you would be better off dead or that you want to hurt yourself in some way?

How to approach a patient with cognitive problems

1. Is this patient delirious?

2. Is this patient depressed?

3. Does this patient have dementia?

All three conditions frequently occur together.

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Feel free to contact meStephen ThielkeGeriatric Research, Education, and Clinical

Center, Seattle VAMC(206) 764-2815Stephen.Thielke@va.gov

For paper or electronic copies of the 5D Pocket Card or Guide:

Julie.Moorer@va.gov

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