Delirium Dementia and Depression spr 2011-1

8/7/2019 Delirium Dementia and Depression spr 2011-1

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Delirium, Dementia andDepression


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DementiaMultiple cognitive deficits including: 1. Memory impairment 2. At least one of the following:

AphasiaApraxia

AgnosiaDisturbance in executive functioning


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Dementia contOnset: insidious

Duration: months to yearsUsually alertAffect: labile

Orientation: may get near miss answers


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DSM-IV criteria DementiaCriteria A 1. Memory impairment ( Asseen on MMSE)Criteria B 2. A,A,A, Impairment ExecutivefunctioningCriteriaC: Both memory impairment and

cognitive disturbances must be significantenough to cause a serious impairment insocial, or occupational functioning


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Types of Dementia

Senile dementia/ Alzheimers T ype (SDA T ) A. NF T 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 medicalconditions: PD can lead to irreversible dementia secondary

to dopamine insufficiency Huntingtons disease

B1 vitamin deficiencies usually secondary toET OH


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Differentiating Acute Deliriumfrom Chronic Dementia

Feature Delirium Dementia

Onset Acute InsidiousDuration Brief Chronic, unless

reversibleConsciousness fluctuates static

Orientation Abnormal Normal in mildcases

Memory Recent defective Recent/later lossInitial S T loss


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Delirium vs dementia contAttention Always

impairedMay be intact

Perception Freq. Disturbed Flat empty talk T hinking Disorganized,

contents richImpaired,contents empty

Judgement Poor poor Insight Present in lucid

intervalsMay be absent

Sleep Alwaysdisturbed

Variable


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Assessment toolsMMSE: Further eval if score < 25/30


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Assessment toolsPfeiffer Short Portable Mental StatusQuestionnaire: Further evaluation necessary if score is


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Assessment contFAST Functional Assessment Staging of Alzheimers Disease Identifies other causes of regression


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More AssessmentFunctional Rating Scale for Sx of Dementia T his questionnaire predicts clients appropriate

for NH placement. 83% of those appropriate have:

Incontinence of B&B Inability to speak coherently Inability to bathe and groom self


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Some stats1.5-2.3 million persons have mild to moddementiaCognitive impairment affects > 5% of thoseover 65 years., ~20% of those over 75Approximately 50% of nursing home

residents have irreversible dementia~70% of primary medical pt.s presentingwith cognitive deficits may have SDA T


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Intervention with confused pt.sValidation techniques should be employedBeliefs and values of validation: People are unique T here are reasons for disruptive behaviors Behavior reflects physical,social and psych

changes across the lifespan not just anatomicchanges

Behaviors can be changed only if a personwants 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 retrievingearlier memories

When a trusted listener acknowledges pain, pain diminishes

Empathy builds trust, reduces anxiety andrestores dignity


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DepressionDef: Alteration or disturbance of mood.Onset: recentDuration variableAlertness: diminished ability tocommunicateOrientation: Dont know answersAffect: Flat


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Depressive Disorders common inthe elderly

Major Depressive Disorder Dysthymic Disorder Mood disorder Due to General MedicalConditionAdjustment disorder with Depressive Mood

Depressive Disorder Not OtherwiseSpecified


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Differentiating Dementia fromDepression

Feature OrganicDementia

Depression

Onset Slow Rapid

Course Slow, worse atnight

Rapid anduneven same at

nightMemory Greater loss

recentApathetic Idont know

Orientation Approximate, perserverant

Apathetic asabove


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Affect Inappropriate Constricted

Neurovegetative signs

None Possiblesleep,appetite,

bowel or bladder, sex dys


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Factors leading to depression1. Grief/ bereavement2. Change in support network 3. Change in physical function


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Medical disorders causingdepressed mood

Occult malignancyInfectious processHypothyroidismApathetichyperthyroidism

Cushings syndromeAddisons disease

PanhypothyroidismParkinsonsDementing illnessCHFCRF

COPD


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Meds Asc. With depressed moodAntihypertensivesReserpineMethyldopaBeta blockersHydralazine

Histamine type IIReceptors/BlockersDigoxin

Oral hypoglycemicsCNS depressantsBarbituatesNeurolepticsOpiates

AlcoholSteroidsCytotoxics


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Depression Assessment toolsBeck- Long form cut off score of 10indicates depression. Short form is just asgood and takes just 5 minutes.Zung- self report. T he greater the score thegreater the depression. Not the best for

elderly since it was validated on collegestudents. 80 is the highest score and mostindicative of depression.


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Depression assessment toolscont

Geriatric Depression scale: a score of >8 is90%sensitive,80%specific 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 SocialAdjustment Scale


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Why is the identification of depression so important?

Hip fracture outcomes, have been shown todepend on the absence or presence of depression.

~13-18% of the community dwelling elderly havedepressionElderly medical pts. ~ 20% are depressed!Suicide rates are disproportionately high among

the elderlyReport your potential findings to the team so thatthis disorder can be treated.

Documents

Delirium Dementia and Depression spr 2011-1