Delirium, Dementia and Depression

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Delirium, Dementia and Depression
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Dementia

• Multiple cognitive deficits including
• 1. Memory impairment
• 2. At least one of the following
• Aphasia
• Apraxia
• Agnosia
• Disturbance in executive functioning

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Dementia cont

• Onset insidious
• Duration months to years
• Usually alert
• Affect labile
• Orientation may get near miss answers

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DSM-IV criteria Dementia

• Criteria A 1. Memory impairment ( As seen on
  MMSE)
• Criteria B 2. A,A,A, Impairment Executive
  functioning
• CriteriaC Both memory impairment and cognitive
  disturbances must be significant enough to cause
  a serious impairment in social, or occupational
  functioning

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Types of Dementia

• Senile dementia/ Alzheimers Type (SDAT)
• A. NFT are characteristic
• B. Dx confirmed post mortum
• C. Progressive slow decline
• D. 3X as many women than men

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• Multi Infarct Dementia Vascular Dementia
• A. Muliplt mini strokes
• B. Atherosclerotic plaques in bv, Diabetic
  deterioration of bl vessels
• C. Stepwise progressive decline
• D. Affects twice as many men as women

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• Dementia secondary to other medical conditions
• PD can lead to irreversible dementia secondary to
  dopamine insufficiency
• Huntingtons disease
• B1 vitamin deficiencies usually secondary to ETOH
  

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Differentiating Acute Delirium from Chronic
Dementia
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Delirium vs dementia cont
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Assessment tools

• MMSE
• Further eval if score lt 25/30

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Assessment tools

• Pfeiffer Short Portable Mental Status
  Questionnaire
• Further evaluation necessary if score is lt8/10

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Assessment cont

• FAST Functional Assessment Staging of Alzheimers
  Disease
• Identifies other causes of regression

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More Assessment

• Functional Rating Scale for Sx of Dementia
• This questionnaire predicts clients appropriate
  for NH placement.
• 83 of those appropriate have
• Incontinence of BB
• Inability to speak coherently
• Inability to bathe and groom self

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Some stats

• 1.5-2.3 million persons have mild to mod dementia
• Cognitive impairment affects gt 5 of those over
  65 years., 20 of those over 75
• Approximately 50 of nursing home residents have
  irreversible dementia
• 70 of primary medical pt.s presenting with
  cognitive deficits may have SDAT

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Intervention with confused pt.s

• Validation techniques should be employed
• Beliefs and values of validation
• People are unique
• There are reasons for disruptive behaviors
• Behavior reflects physical,social and psych
  changes across the lifespan not just anatomic
  changes
• Behaviors can be changed only if a person wants
  to change

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Validation cont

• People must be accepted non-judgmentally
• When more recent memory fails, elders try to
  restore balance to their lives by retrieving
  earlier memories
• When a trusted listener acknowledges pain, pain
  diminishes
• Empathy builds trust, reduces anxiety and
  restores dignity

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Depression

• Def Alteration or disturbance of mood.
• Onset recent
• Duration variable
• Alertness diminished ability to communicate
• Orientation Dont know answers
• Affect Flat

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Depressive Disorders common in the elderly

• Major Depressive Disorder
• Dysthymic Disorder
• Mood disorder Due to General Medical Condition
• Adjustment disorder with Depressive Mood
• Depressive Disorder Not Otherwise Specified

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Differentiating Dementia from Depression
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Factors leading to depression

• 1. Grief/ bereavement
• 2. Change in support network
• 3. Change in physical function

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Medical disorders causing depressed mood

• Occult malignancy
• Infectious process
• Hypothyroidism
• Apathetic hyperthyroidism
• Cushings syndrome
• Addisons disease

• Panhypothyroidism
• Parkinsons
• Dementing illness
• CHF
• CRF
• COPD

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Meds Asc. With depressed mood

• Antihypertensives
• Reserpine
• Methyldopa
• Beta blockers
• Hydralazine
• Histamine type II Receptors/Blockers
• Digoxin

• Oral hypoglycemics
• CNS depressants
• Barbituates
• Neuroleptics
• Opiates
• Alcohol
• Steroids
• Cytotoxics

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Depression Assessment tools

• Beck- Long form cut off score of 10 indicates
  depression. Short form is just as good and
  takes just 5 minutes.
• Zung- self report. The greater the score the
  greater the depression. Not the best for elderly
  since it was validated on college students. 80
  is the highest score and most indicative of
  depression.

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Depression assessment tools cont

• Geriatric Depression scale a score of gt8 is
  90sensitive,80specific for depression. A score
  of over 5 may indicate depression. Of the 30
  items, one point is awarded for each response
  that matches the yes or no at the end of the
  question.

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Holmes and Rahe Social Adjustment Scale
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Why is the identification of depression so
important?

• Hip fracture outcomes, have been shown to depend
  on the absence or presence of depression.
• 13-18 of the community dwelling elderly have
  depression
• Elderly medical pts. 20 are depressed!
• Suicide rates are disproportionately high among
  the elderly
• Report your potential findings to the team so
  that this disorder can be treated.