AAre there Snakes under my Bed:Depression, Delirium & Dementia

Sandy Yochem R.N. B.S Judy Tivnan RN BC MABluestone Physician Services Oakmonte Assisted LivingFlorida Market Director Director of Resident Care

ObjectivesDescribe the presentation of depression in older adultsDescribe the presentation of delirium in older adultsDescribe the presentation of dementia in older adults

Review the sign & symptoms of each condition andtreatment options

What will you Do?• 84

• 16

Depression

Geriatric Depression Definition

iatric depression is a mental and emotional order affecting senior citizens. Feelings of ness and occasional “blue” moods are normal.

wever, lasting depression is not a typical part aging.

Subsyndrominal Depression Definition

illion elderly suffer from this type of depression depressed mood, or in ability to experience

asure:rference with social interactions or so that others e noticed 10 codes F32.3-F33.9, F40.1-F43.*

Prevalence of Geriatric Depression6 Million affected but 10% receive treatment

15% to 20% of U.S. families are caring for an older relative.

58% Adult Caregivers showed clinically significant depressive symptoms

8%-15% of community- dwelling older adults

30% among institutionalized older adults

2%-10% over 65 year old

Signs & Symptoms of Geriatric Depressiong sad, anxious, or emptyg hopeless or pessimisticg guilty, worthless, or helplessjoying things you used to enjoye with concentration, memory, or making decisionsg too much or too little

te changesrawal Spellsg or losing weight

g restless or irritableal Aches and Painshts of suicide or deathsion is often the cause of physical pain in the elderly that is not explained by other medical conditions (Lapid & s, 2003).

Causes of Depression

•Psychological•Biological•Genetic Factors•Environmental risks•Prolonged Stress•Chronic Illness

Medications that cause Depression

Depression SIG-E-CAPS• S SSleep disturbance

I • InterestsG • GuiltE • Energy

• C Concentration• A Appetite Changes• P Psychomotor changes• S Suicide

*The John A. Hartford Foundation

Institute for Geriatric Nursing

Depression SituationYour elderly mother is widowed and lives alone. She complains ofsleep disturbances, weight loss, stomach ache and a constant headache.

The Doctor can’t find anything wrong

What could be wrong:A- Wants AttentionB- Possible DepressionC- Looking for a Date

Depression AssessmentThe Yesavage Geriatric Depression Scale (GDS)= screen

Used by all health care providers

Mini Mental Status Exam (MMSE): differential diagnosis

Cornell Scale for Depression in Dementia

Depression Scales

Treatment Options for Depression

Treatment options for DepressionSelective Serotonin Reuptake Inhibitors (SSRI)- Celexa, Lexapro, Prozac, Paxil, Zoloft, LuvoxSerotonin and Norepinephrine Reuptake Inhibitors (SSNI)- Effexor Cymbalta, PristiqTricyclic Antidepressants (TCA)- Pamelor, Elavil, Sinequan, Imipramine, NorpraminMonoamine oxidase inhibitors (MAOI)- Nardil, ParnateCombined reuptake inhibitors and receptor blockers- Desyrel (Trazodone)Noradrenergic and Specific Serotonergic Antidepressants (NASSA’s)- RemeronNorepinephrine and Dopamine Reuptake Inhibitors (NDRI)- Wellbutrin

Avoid:avil, Asendin, Sinequan, Tofranil, St. John’s Wart, Sumontril

Treatment options for Depression

estyle changes used to treat depression include:

ncreasing physical activityfinding a new hobby or interesthaving regular visits with family and friendsgetting enough sleep dailyeating a well-balanced diet

Delirium in the Elderly

a) deleriumb) delleriumc) deliriumd) dileriume) dillirium

If we can’t spell it then how can webe expected to know what it means?

Definition of DeliriumDDelirium is a state of mental confusion that develops quickly and usuallyy fluctuates in intensity.

An altered state of consciousness, consisting of confusion, distractibility,, disorientation, disordered thinking and memory, defective perception (illusions and hallucinations), prominent hyperactivity, agitation, and autonomic nervous system overactivity; caused by a number of toxic structural and metabolic disorders.

Definition of Delirium (part 2)

DDelirium, also known as acute confusional state, is an organically causedd decline from a previous baseline level of mental function. It often has a fluctuating course, attentional deficits, and disorganization of behavior.

Delirium itself is not a disease but rather a set of symptoms. It may result from an underlying disease, overconsumption of alcohol, drugs administered during treatment of a disease, or any number of health factors.

Delirium may be caused by a disease process outside the brain that nonetheless affects the brain, such as an infection.

Prevalence of Delirium 114-56% of hospitalized older adults experience delirium3 out of 10 are diagnosed33% of elderly affected by delirium will die from effects20-40% caused by metabolic disorderPostoperative delirium occurs in 15–53% of surgical patients over the age of 65 years, and among elderly patients admitted to an intensive care unit (ICU) the delirium incidence can reach 70–87%Medical Emergency

Signs & Symptoms of DeliriumSSudden onset (Hours to Days)Fluctuations in Alertness, Cognition, Perceptions, ThinkingPsychotic Feature: Misperceptions and illusionsSleep: Disturbed but with no set patternMood: Fluctuations in Emotions- outbursts, anger, crying, fearfulPsycho-Motor: Hyperactive: Agitation, restless, hallucinations

Hypoactive: Unarousable, very sleepyMixed: Combination

Poor thinking skillsThese may appear as:

• Poor memory, particularly of recent events • Disorientation, not knowing who or where you are• Difficulty speaking or recalling words• Rambling or nonsense speech• Trouble understanding speech• Difficulty reading or writing

Poor thinking skillsThese may appear as:

• Poor memory, particularly of recent events • Disorientation, not knowing who or where you are• Difficulty speaking or recalling words• Rambling or nonsense speech• Trouble understanding speech• Difficulty reading or writing

Reduced awareness of environment

This may result in:• Inability to stay focused on a topic or to switch topics• Getting stuck on an idea rather than responding to

questions• Being easily distracted by unimportant things• Being withdrawn, little response to environment• Little or no activity

Behavior changesThis may include:

• Seeing things that don’t exist• Restlessness, agitation, or combative behavior• Calling out• Being quiet or withdrawn• Slowed movement or lethargy• Disturbed sleep habits• Day-night reversal

Emotional disturbancesThese may appear as:

• Anxiety, fear or paranoia• Depression• Irritability or anger• A sense of feeling elated-euphoria• Apathy• Rapid mood shifts• Personality changes

DeliriumD DDrug UseE Electrolyte imbalanceL Lack of drugsI InfectionR Reduced sensory inputI Intracranial problemsU Urinary / Fecal impactionM Myocardial / Heart Failure

Delirium Diagnosis

•• blood chemistry test• head scans• drug and alcohol tests• thyroid tests• liver tests• chest X-ray• urine tests

Delirium Assessment

Focus on ability to maintain Attention and ConcentrationAsk to count backward from 20 by 3’sCopy a drawing of intersecting pentagons

Confusion Assessment Method (CAM)

Part one: assessment instrument that screens for overall cognitive impairment

Part two: includes four features that distinguish delirium or reversible confusion from other types of cognitive impairment

Delirium Assessment Tool

Scoring the CAM (Confusion Assessment Method)

Hospital use – less than 5 minutesPresence or absence of Delirium, not severitySerious and persistent lack of recognition of delirium in hospitalized EldersSystematic changes for our hospitalized Elders

Delirium Treatment

FFailure to treat delays recovery and can worsen the older persons health and functionPsychiatric ManagementEnvironmental and Supportive interventions

Medications for DeliriumAAntipsychoticsHaloperidol 0.5–1 mg PO or IM; can repeat every 4 hours for extrapyramidal syndrome (Surgery cases may reduce delirium)Atypical antipsychotics a Risperidone 0.5 mg BID Extrapyramidal syndrome,Olanzapine 2.5–5 mg daily Quetiapine 25 mg BID Benzodiazepines b (limited improvement in condition)Lorazepam 0.5–1 mg PO; can repeat for 4hrs paradoxical excitation, Resp depression, excessive sedation, confusionCholinesterase inhibitors Donepezil 5 mg QD Nausea, vomiting, diarrhea. Prevention studies have not demonstrated

Dementia

Dementia Definition

Prevalence of DementiaTThe elderly population (those aged 65 years or older) in the USA is expected to double from approximately 35 million today to more than 700 million by 2030The prevalence of dementia among individuals aged 71 and older was 13.9%, comprising about 3.4 million individuals in the USA in 2002. Dementia prevalence increased with age, from 5.0% of those aged 71–79 years to 37.4% of those aged 90 and older.“1 in 8 at 68, half of all 85 year olds”

Testing for Dementia

NormalScore: 10

MildCognitiveImpairment(Numberserror andplacementof hands)Score: 8

MildCognitiveImpairmentScore: 4

SeveCognImpaScorReversible

-Depression-Infections-Medication/Drug Interaction-Hydrocephalus-Vitamin/Mineral Deficiencies-Hypo/Hyperglycemia

Irreversible-Alzheimer’s Disease-Vascular Dementia or

Multi-Infarct-Frontotemporal Dementia-Parkinson’s Disease-Creutzfeldt-Jakob Disease-Lewy Body Disease-Huntington’s Disease

Types of Dementia

Types of DementiaAlzheimer's DiseaseVascular DementiaTraumatic Brain InjuryFrontotemporal DementiaLewy Body DementiaCreutzfeldt-Jakob Disease

• Mixed Dementia• Normal Pressure Hydrocephalus• Alcoholic Dementia- Korsakoff• Huntington’s Disease

Dementia Diagnosis

Alzheimer's Disease

Dementia vs. Alzheimer’s

Test AnxietyNot designed to differentiate between dementiasNot “pass vs fail”Practice will skew resultsWrong answers do not make you stupidOnly if “help is needed”Objectify and quantify something of concern

MMSENot well suited for mild cognitive impairment1975 created by DR Folstein Orientation, word recall, language abilities, attention and calculation, and visualspacial abilityIf the patient has minimal complaints and questions whether it isaffecting them functionally – choose MoCAIf the patient is clearly functionally impaired no need for that highly sensitive test.

MMSE

Mini-Mental State Examination (MMSE)

me: Date:

s: Score one point for each correct response within each question or activity.

Patient’sScore Questions

“What is the year? Season? Date? Day? Month?”

“Where are we now? State? County? Town/city? Hospital? Floor?”

The examiner names three unrelated objects clearly and slowly, then theinstructor asks the patient to name all three of them. The patient’s response is used for scoring. The examiner repeats them until patient learns all of them, if possible.

“I would like you to count backward from 100 by sevens.” (93, 86, 79,72, 65, …)Alternative: “Spell WORLD backwards.” (D-L-R-O-W)

“Earlier I told you the names of three things. Can you tell me what those were?”

Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them.

“Repeat the phrase: ‘No ifs, ands, or buts.’”

“Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper.)

“Please read this and do what it says.” (Written instruction is “Close your eyes.”)

“Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.)

“Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10angles must be present and two must intersect.)

TOTAL

MMSE formInterpretation of the MMSE:

Method Score Interpretation

Single Cutoff <24 Abnormal

Range<21

>25

Increased odds of dementia

Decreased odds of dementia

Education

21

<23

<24

Abnormal for 8th grade education

Abnormal for high school education

Abnormal for college education

Severity

24-30

18-23

0-17

No cognitive impairment

Mild cognitive impairment

Severe cognitive impairment

Interpretation of MMSE Scores:

Score Degree of

ImpairmentFormal PsychometricAssessment

Day-to-Day Functionin

25-30

Questionably

significant

If clinical signs of cognitive impairment are present, formal assessment of cognition may be valuable.

May have clinically significdeficits. Likely to affect ondemanding activities of da

20-25

Mild

Formal assessment may be helpful to better determine pattern and extent of deficits.

Significant effect. May reqsupervision, support and a

10-20

Moderate Formal assessment may be helpful if

there are specific clinical indications.Clear impairment. May resupervision.

0-10

Severe

Patient not likely to be testable.

Marked impairment. Likel24-hour supervision and awith ADL.

Mini- Cog Assessment

Mini COG0-2 positive

3-5 negative

Not used for mild cognitive impairment

Might detect using the cut score but insufficient evidence

Less affected by education and language skills

Clock Drawing Test or CDTClock drawing included in many testing forms. Visual special neglect being the diagnostic aim for dementia diagnosis. Unilateral neglect and focal brain damage visualized.

Normal CLOCK drawing reasonably excludes cognitive impairment.

Easy to administer. Non threatening.

SLUMSSaint Louis University Mental Status ExamDesigned as alternative to MMSE“more sensitive”Aim is “mild Cognitive”Based on education level for cut off.Attention and working memory, cognition, Ex Function, Language, Mental health, reasoning and problem solving.Contains items assessing logical memory and size differentiation

SLUMS form

MoCA : Montreal Cognitive Assessment

Both the SLUMS and MoCA have excellent convergent validity when given to community dwelling elders and within the LTC facility (Feliaciano et al,2013)One page 30 questionsAttention and concentration, Ex functioning, memory, language, visualspacial skills, concept thinking, calculations, and orientation.Validated in patients who are at risk of getting worse.

MoCA form

Delirium -vs- Dementia -vs- Depressionures Delirium Dementia Depression

et Hours to days Months to years Weeks to mon

rse Fluctuating Progressive May be long t

ation Hours to weeks Months to years Months to Yea

sciousness Altered Usually clear Clear

ntion Impaired Normal (except in late May be decrelate stage)

chomotor Increased or Late stages May be slowenges decreasedersibility Usually Irreversible Usually

TEST TIME

Delirium -or- Dementia -or- DepressionWhich one will you choose?

Q1: How old are you?

• Who is asking?

• Who cares?

• 46 ?

Q2: How was lunch?

Did I have any?

I don’t eat lunch, and neither should you.

It was great, I ate it all.

ReferencesKrucik, George. "Geriatric Depression (Depression in the Elderly)." Healthline. N.p., 04 Sept. 2012. Web. 22 Jan. 2017.

Bulter,R.N., Lewis, M/I., & Sunderland, T. (1992). Aging and mental health: Postitive psychosocial and biomedical approaches. (4th ed.). Columbus, OH: Charles E. Merrill.

Izal,M., & Montorio. I. Adaptation of the geriatric depression scale in Spain: A preliminary study. Clinical Gerontologist, 13, 83-91

Weeks, S.K., McGann, P.E., Michaels, T.K., Penninx, B.W.( 2003, Second Quarter). Comparing various short-form geriatric depression scales leads to the GDS-5/15. Journal of Nursing Scholarship, 133-137

Holroyd, S., & Clayton, A.H. (2000). Measuring depression in the elderly: Which scale is best? Medscape General Medicine, 2(4). Retrieved April 30, 2004 from http://www.Medscape.com/viewarticle/430554

Peters, James J. Geriatrics, Palliative Care and Interprofessional Teamwork Curriculum. Module #8. N.p.: n.p., n.d. James J. Peters VA BronxMedical Center Geriatric Research, Education & Clinical Center/Mount Sinai School of Medicine Brookdale Department of Geriatrics and Adult Development. Web. 14 Jan. 2017.

For The American Heritage® Medical Dictionary: "Delirium." The American Heritage® Medical Dictionary. 2007. Houghton Mifflin Company22 Jan. 2017 http://medical-dictionary.thefreedictionary.com/delirium

Van Son, Catherine. "The Three D's of Confusion." N.p.: n.p., n.d. Catherine Van Son, Ph.D., R.N., for the Older Adult Focus Project/ OHSU School of Nutsing. Web. 14 Jan. 2017.

Alagiakrishnan, Kannayiram. "Delirium Treatment & Management." Delirium Treatment & Management: Medical Care, Consultations. MedScape, 22 Sept. 2016. Web. 22 Jan. 2017.

Taylor, Dannette C. "Dementia, Alzheimer's and the Aging Brain." Dementia. MedicineNet.com, n.d. Web. 22 Jan. 2017.

Plassman, BL. "Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study." Karger.com. Neuroepidemiology, 29 Oct. 2007. Web. 22 Jan. 2017.

"2016 Alzheimers Disease Facts and Figures." Alzheimers Association. Alzheimers Association, n.d. Web. 21 Jan. 2017.

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