The 3 Ds of The 3 Ds of Geriatric CareGeriatric CareDepression, Dementia and DeliriumDepression, Dementia and Delirium

DementiaDementia

Average delay from 1st symptom to diagnosis 2-3 Average delay from 1st symptom to diagnosis 2-3 years.years.

Family recognition is usually how it gets diagnosed. Family recognition is usually how it gets diagnosed. Caregiver complaints, high suspicion of dementiaCaregiver complaints, high suspicion of dementia

Post CVA (30% develop within 3 months)Post CVA (30% develop within 3 months) Post-delirium (30% develop within 3 years)Post-delirium (30% develop within 3 years) Post first onset depression (30% develop within 3 Post first onset depression (30% develop within 3

years)years) Family history – every first degree relativeFamily history – every first degree relative Age (2% at age 65) Every five years doubles risk of Age (2% at age 65) Every five years doubles risk of

dementiadementia Every vascular burden/risk factor doubles the riskEvery vascular burden/risk factor doubles the risk

DementiaDementia

Risk calculatorRisk calculator

AgeAge 6565 2%2% 7070 4%4% 7575 8%8% 8080 16%16% 8585 32%32%

http://www.memantine.com/http://www.memantine.com/images/disease_progression.gifimages/disease_progression.gif

Dementia Quick ScreenDementia Quick Screen

Say three words, repeat backSay three words, repeat back 1 minute to name as many 4 legged animals (20 times 1 minute to name as many 4 legged animals (20 times

odd ratio)odd ratio)If If AAnimals are low – nimals are low – AAlzheimer’slzheimer’s

List year (37 times odds ratio)List year (37 times odds ratio) Draw clock 10 after 11 o’clock (24 times odd ratio) Draw clock 10 after 11 o’clock (24 times odd ratio)

Specificity 94%Specificity 94%Large enough circle, joinedLarge enough circle, joinedNumbers evenly spacedNumbers evenly spacedTime correct – hand placementTime correct – hand placement

Remember and repeat the three words from the Remember and repeat the three words from the beginningbeginning

MMSEMMSEGold standardGold standard

Needed for prescribing of cholinesterase inhibitorsNeeded for prescribing of cholinesterase inhibitors <26 is dementia<26 is dementia Not sensitive for mild cognitive impairmentNot sensitive for mild cognitive impairment Deceptive: low educational/economic status, poor Deceptive: low educational/economic status, poor

language, illiteracy, impaired visionlanguage, illiteracy, impaired vision Scoring:Scoring:

27-3027-30 NormalNormal20-2620-26 Mild AD – Independent Mild AD – Independent

(advance care planning)(advance care planning)10-1910-19 Moderate AD – SupervisionModerate AD – Supervision<10<10 Severe AD - Total dependence Severe AD - Total dependence

MoCAMoCA

Meant to assess mild cognitive impairment Meant to assess mild cognitive impairment (score <26)(score <26)

Clock draw – visual spatial and executive Clock draw – visual spatial and executive functionfunction

Rhino becomes a hippoRhino becomes a hippo Lewy Bodies – attention deficit presentLewy Bodies – attention deficit present Less than 11 f words – Less than 11 f words –

frontal or vascular dementia – will see inappropriate frontal or vascular dementia – will see inappropriate words come up firstwords come up first

Peterson Criteria: Peterson Criteria: Diagnosing MCIDiagnosing MCI

Memory complaintMemory complaint Memory impairment for age and Memory impairment for age and

educationeducation Largely intact general cognitive functionLargely intact general cognitive function Present ADLs – no functional loss.Present ADLs – no functional loss. Not dementedNot demented

Diagnosing ADDiagnosing AD

Memory impairmentMemory impairment Impairment in functionImpairment in function One ofOne of

Aphasia (language)Aphasia (language) Apraxia (motor)Apraxia (motor) Agnosia (recognition, identification)Agnosia (recognition, identification) Disturbance in executive function (planning organizing)Disturbance in executive function (planning organizing)

Significant decline from previous level of functionSignificant decline from previous level of function Impairment in social or occupational functioningImpairment in social or occupational functioning Gradual onset – sudden onset is Gradual onset – sudden onset is delirium delirium until proven until proven

otherwiseotherwise Not due to other causes.Not due to other causes.

DeliriumDelirium

Commonly under-diagnosed, particularly Commonly under-diagnosed, particularly in residents who have a pre-existing in residents who have a pre-existing dementia.dementia.

Acute and fluctuating onsetAcute and fluctuating onset Medical emergencyMedical emergency Confusion, disturbances in attention, Confusion, disturbances in attention,

disorganized thinking and/or decline in disorganized thinking and/or decline in level of consciousnesslevel of consciousness

CAMCAM

Confusion Assessment Method – DeliriumConfusion Assessment Method – DeliriumSensitivity 94-100%, Specificity 90-95%Sensitivity 94-100%, Specificity 90-95%

20% deliriums never clear20% deliriums never clear Acute onset and fluctuating courseAcute onset and fluctuating course InattentionInattention Disorganized thinkingDisorganized thinking Altered level of consciousnessAltered level of consciousness Diagnoses required the presences of features Diagnoses required the presences of features

of 1 and 2 and either 3 or 4.of 1 and 2 and either 3 or 4.

Meet Mrs. G.Meet Mrs. G. Pneumonia, treated 1 month ago.Pneumonia, treated 1 month ago. Productive coughProductive cough Calling out, worse in evening. Staff Calling out, worse in evening. Staff

reports that behaviours are most reports that behaviours are most challenging between 3pm and 7pm. Staff challenging between 3pm and 7pm. Staff refer to it as “Sundowning”. refer to it as “Sundowning”.

Worries about her son, recognizes him but Worries about her son, recognizes him but no longer knows he is her son. Worried no longer knows he is her son. Worried about having to pay for being in the LTC about having to pay for being in the LTC home.home.

Mrs. G.Mrs. G.

Lethargy – change in sleep pattern that is Lethargy – change in sleep pattern that is worse over the last week. Sleeping more worse over the last week. Sleeping more in the morning and wakes up around in the morning and wakes up around 3pm. 3pm.

Recently moved to LTC from hospital (1 Recently moved to LTC from hospital (1 month). Prior to that was living at home.month). Prior to that was living at home.

Falls in hospital and 2 at the LTC home Falls in hospital and 2 at the LTC home since admission.since admission.

PMHxPMHx Bilateral glaucomaBilateral glaucoma

Mild hearing lossMild hearing lossDepression & anxietyDepression & anxietyAlzheimer’s Disease Alzheimer’s Disease Past history of deliriumPast history of deliriumPast history of LRIs and UTIsPast history of LRIs and UTIsHypothyroidismHypothyroidismHypotensionHypotensionCOPDCOPDGraves DiseaseGraves DiseaseOsteoporosisOsteoporosisOsteoarthritisOsteoarthritisPast smoker (quit 5 years ago)Past smoker (quit 5 years ago)

Left hip fracture and bilateral wrist fracturesLeft hip fracture and bilateral wrist fractures Bilateral leg edemaBilateral leg edema Bowel resection, prone to constipation - malignant polypsBowel resection, prone to constipation - malignant polyps

Recent DiagnosticsRecent Diagnostics

TSH 14.87TSH 14.87

From admission bloodwork drawn but not From admission bloodwork drawn but not yet reviewed.yet reviewed.

CXR 2 days ago is negative for active CXR 2 days ago is negative for active process process

MedicationsMedications

Lasix 20mg PO dailyLasix 20mg PO daily Xalatan and Timolol gttsXalatan and Timolol gtts L-Thyroxine 0.15mg PO dailyL-Thyroxine 0.15mg PO daily Celexa 40mg PO daily (recently decreased from 60mg)Celexa 40mg PO daily (recently decreased from 60mg) Spiriva and short acting PRN bronchodilator for COPDSpiriva and short acting PRN bronchodilator for COPD Seroquel 50mg PO BID at 0800 and 2000Seroquel 50mg PO BID at 0800 and 2000 Clonazepam 0.5mg PO at 0800 and 1200; 2mg PO at 1600 and Clonazepam 0.5mg PO at 0800 and 1200; 2mg PO at 1600 and

2mg PO once daily PRN2mg PO once daily PRN Colace QHSColace QHS Lactulose PRNLactulose PRN Tylenol PRN (PO or PR)Tylenol PRN (PO or PR)

Had tried Aricept in the past but did not tolerate it.Had tried Aricept in the past but did not tolerate it.

Neuro AxNeuro Ax

Difficult to rouse, sternal rub required to rouse Difficult to rouse, sternal rub required to rouse Mrs. G. Speech slurred and difficult to Mrs. G. Speech slurred and difficult to understand. Family states that this is new and understand. Family states that this is new and unusual for her. Able to converse for 3-4 unusual for her. Able to converse for 3-4 minutes before falling back asleep. Able to minutes before falling back asleep. Able to follow directions but shows inattention. follow directions but shows inattention. Bilateral grip equal. Unable to assess pupils Bilateral grip equal. Unable to assess pupils d/t glaucoma.d/t glaucoma.

CAM score + for delirium (Feature 1, 2 and 4 CAM score + for delirium (Feature 1, 2 and 4 present)present)

Resp AxResp Ax

RRR, 16. No wheezing. Fine bilateral RRR, 16. No wheezing. Fine bilateral rales audible. No SOB. Congested rales audible. No SOB. Congested cough, w upper airway secretions. cough, w upper airway secretions. Afebrile. Afebrile.

CV AxCV Ax

No murmurs, HR 76, S1, S2. No No murmurs, HR 76, S1, S2. No peripheral edema noted. Recent BP peripheral edema noted. Recent BP readings by staff stable.readings by staff stable.

Integument AxIntegument Ax

Very dry skin. Mucous membranes dry. Very dry skin. Mucous membranes dry. Bruising present to lower legs. Bruising present to lower legs.

GU AxGU Ax

No specific signs of UTI. Small temp No specific signs of UTI. Small temp change from baseline T 37.0 (baseline change from baseline T 37.0 (baseline 36.2). 36.2).

Chronically positive C&SChronically positive C&S

Abdominal AxAbdominal Ax

BS present x 4 quadrants. No rebound BS present x 4 quadrants. No rebound tenderness noted. Resident up in W/C, tenderness noted. Resident up in W/C, therefore not assessed fully. Voiding well therefore not assessed fully. Voiding well into brief. No reports of dysuria, frq, into brief. No reports of dysuria, frq, urgency, changes in continence. T 37.0 urgency, changes in continence. T 37.0 (baseline 36.2). Recent bowel (baseline 36.2). Recent bowel movements have been regular and movements have been regular and soft/formed in consistency. soft/formed in consistency.

Pain AxPain Ax

Vague self-report. Behavioural indicators of Vague self-report. Behavioural indicators of pain in staff reports. Kyphotic in appearance. pain in staff reports. Kyphotic in appearance. Recent loss of mobility (past 6 months). Recent loss of mobility (past 6 months). Family reports that she used to be on regular Family reports that she used to be on regular Tylenol in the retirement home but this was Tylenol in the retirement home but this was discontinued in hospital. Family reports that discontinued in hospital. Family reports that Mrs. A would never be one to ask for help with Mrs. A would never be one to ask for help with pain. Recent falls. No spinal x-rays taken. Is pain. Recent falls. No spinal x-rays taken. Is not on Vit D or Calcium. not on Vit D or Calcium.

Impression?Impression?

Delirium co-existing w dementia and depression!Delirium co-existing w dementia and depression!Risk Factors:Risk Factors:

Age, CI, Hx delirium, Hx depression, sleep Age, CI, Hx delirium, Hx depression, sleep disturbance, vision and hearing loss, recent disturbance, vision and hearing loss, recent relocation, hx fractures, unrelieved pain, relocation, hx fractures, unrelieved pain, hypotension, recent infection, polypharmacy, hypotension, recent infection, polypharmacy, benzodiazepine use, antidepressant use, benzodiazepine use, antidepressant use, antipsychotic use.antipsychotic use.

Now What? What is Now What? What is causing her delirium?causing her delirium?

Differentials:Differentials: DehydrationDehydration Pain Pain HypothyroidismHypothyroidism PolypharmacyPolypharmacy

Other ConsiderationsOther Considerations

High risk of fractures, affecting QOL. Spinal x-ray not High risk of fractures, affecting QOL. Spinal x-ray not feasible for her. Recent falls and posture combined feasible for her. Recent falls and posture combined with behaviours make vertebral fractures highly likely.with behaviours make vertebral fractures highly likely.

Prob UTI at this point seems low given the non-specific Prob UTI at this point seems low given the non-specific nature of her symptoms. Will always test positive – no nature of her symptoms. Will always test positive – no need to treat unless symptomatic.need to treat unless symptomatic.

Recent CXR negative. Rales could be some residual Recent CXR negative. Rales could be some residual post-infection atalectasis.post-infection atalectasis.

What’s our plan?What’s our plan?

Increase L-Thyroxine and recheck TSH in 1 Increase L-Thyroxine and recheck TSH in 1 weekweek

Discontinue PRN TylenolDiscontinue PRN Tylenol Tylenol 325mg 2 tablets (total 650mg) PO Tylenol 325mg 2 tablets (total 650mg) PO

QID x 2 weeks then reassess. She is opiate QID x 2 weeks then reassess. She is opiate naïve – if we want to try these go low and naïve – if we want to try these go low and slowslow

Encourage oral fluids.Encourage oral fluids. Dietitian to assess re: fluid intake.Dietitian to assess re: fluid intake. Vitamin D 1000iu PO dailyVitamin D 1000iu PO daily Taper Clonazepam Taper Clonazepam slowlyslowly. .

Depression vs. Dementia or Depression vs. Dementia or Depression with DementiaDepression with Dementia

For the most part, these two conditions coexist. For the most part, these two conditions coexist. Depression looks different in older adults.Depression looks different in older adults.

Feelings of guilt/worthlessnessFeelings of guilt/worthlessness Hopelessness, death wishes, suicidalHopelessness, death wishes, suicidal Frequent crying spellsFrequent crying spells Resident overstates impairmentsResident overstates impairments Greater problems with attention, concentration, speed Greater problems with attention, concentration, speed

of processing and retrievalof processing and retrieval Constructional apraxia, agnosia and aphasia are rareConstructional apraxia, agnosia and aphasia are rare Usually performs well on memory tasksUsually performs well on memory tasks

Questions?Questions?