Assessing and

Treating Dementia
with Delirium and
Depression
Cathleen Carney, M.A., CCC-SLP
Speech Language Pathologist, Rehab America, Arlington TN
Susan Chapman, M.A., CCC-SLP
Speech Language Pathologist/Clinical Manager
Genesis Rehabilitation Services, Territory 4
 “The geriatric patient with dementia
who also presents with delirium or
depression has specific challenges
and needs that must be addressed by
all members of the interdisciplinary
team.”

2 ASHA 2006
Objectives:
 The participant will be able to:
 identify the symptoms, behaviors, and
characteristics of dementia, delirium and
depression.
 determine the appropriate assessment
protocol for evaluation of the patient with
dementia and its comorbidities.
 provide functional goals and appropriate
treatment techniques based on
assessment objectives.

3 ASHA 2006
Definitions from DSM
 Delirium
 Is a major mental disorder that is a direct
physiological consequence of a medical
condition.
 Usually characterized by disruptions in
consciousness and change in cognitive abilities
or perceptual difficulties that are not due to a
dementia.
 Develops over a short period of time (usually
within hours or a day) and fluctuates over the
course of a day.

4 ASHA 2006
 Delirium

 Direct physiological consequence of a

medical condition that is characterized
by disruptions in consciousness which
can include difficulty in focusing,
maintaining or shifting attention and a
change in cognitive abilities or the
development of perceptual difficulties
that are not due to a dementia.

5 ASHA 2006
 Delirium
 Acute confusion and dementia:
 Used interchangeably
 Acute confusion is a disturbance in information processing
and attention characterized by disordered cognition as well
as disturbances in perception, thinking, memory, attention
and wakefulness – characterized by global impairment.
 Characterized by:
 Acute onset
 Marked fluctuations in cognitive impairment over course of
the day
 Disruptions in consciousness and attention
 Alterations in sleep cycle.
 Hallucination and delusion are common.
 Infection or drug toxicity typically cause acute confusion.

6 ASHA 2006
Definition from DSM

 Depression
 The most common psychiatric
disorder among older people;
 it can vary in duration and degree and
 show psychological as well as
physiological manifestations.

7 ASHA 2006
Depression: Situations
associated with Depression
 Retirement
 Multiple role losses
 Bereavement
 Deaths of family members and friends
 Loneliness and isolation
 Responsibility for care of an older person with a
disability
 Residence in a nursing home
 Elder abuse
 Neglect
 Substance abuse

8 ASHA 2006
 Medical conditions associated
with late life depression
 Cardiac and vascular  Physical disabilities
conditions  Hip fracture
 Myocardial infarction  Loss of mobility
 Cerebrovascular  Trauma
accident
 Neurological conditions  Other medical
 Dementia conditions
 Parkinson’s disease  Acute pain
 Cancer  Chronic pain
 Sensory impairments
 Vision Impairments
 Hearing decrements

9 ASHA 2006
 Depression
 The most common mental health problem confronting
older adults.
 Symptoms of a major depressive disorder:
1. Depressed mood
2. Diminished interest in / pleasure in activities
3. Weight loss or weight gain of 5% within a month
4. Insomnia or hypersomnia
5. Psychomotor retardation or agitation
6. Fatigue or loss of energy
7. Feelings of worthlessness or guilt
8. Diminished ability to concentrate or indecisiveness
9. Recurrent thoughts of death or suicidal ideation

10 ASHA 2006
Classification of Depression

 5 or more of the symptoms

 One, of which must be depressed mood or diminished
interest.
 Symptoms have to have lasted for greater than two weeks.
 Symptoms represent a departure from previous
functionality.
 Symptoms result in impaired social and/or occupational
functioning.

Risk = 20-25%
Risk factors include being female, unmarried, widowed or
recently bereaved, experiencing stressful life events, lower
levels of social support, serious physical illness

11 ASHA 2006
 Classification of Depression

 50% of older adults who have a chronic physical

illness may also have major depressive disorder.
 Depression results in “excess disability”, negatively
impacting:
• quality of life,
• functionality,
• physical health status,
• longevity,
• relationships.
 Depression results in resistance to care,
inconsistency of course and negativity, excess
pain and suffering.

12 ASHA 2006
What Is Dementia?
 The onset is usually insidious
 Cognitive deficits are losses of memory, language,
executive function, visuospatial ability.
 Compartmental changes are alterations in personality,
insight and judgment -
 functions which help a person behave appropriately in
social situations, make reasonable decisions and
plan, organize and follow logical sequence to reach
goals
 Changes in cognition eventually impair IADL and ADL
performance
 Changes in social psychological environment and
patterns of relationships and interaction may also
evident

13 ASHA 2006
DSM-IV, Dementia
 Characterized by memory impairment and at least one
of the following cognitive difficulties – aphasia, apraxia,
agnosia, disruption in executive function.
 Gradual onset of symptoms with continuing decline –
representing a significant decline from previous level
of functioning,
 Severe enough to impair social and or occupational
functioning.
 Must not occur during course of delirium.
 Lifetime risk, 14-16% - higher risk for females, African
Americans

14 ASHA 2006
Definition from DSM
 Dementia
 A major mental disorder characterized by
memory impairment (which can include
either difficulty learning new material or
recalling previously learned material) and
 difficulty with at least one of the following
cognitive capacities: language, recognition,
and organization and/or performance of
motor activities.

15 ASHA 2006
Dementia: Changes in
appearance
 Newly stooped posture
 Slowing of movement
 Slowing of thought processes
 Unexplained weight loss or weight gain
 Clothing that does not fit
 Poor grooming
 Poor maintenance of clothing
 Poor hygiene
 Diminished energy level
 Unexplained fatigue
 Sad affect
16 ASHA 2006
Dementia: Changes in
Behavior & Activity Level
 Decrease in social
participation
 Increase in isolation
and social withdrawal
 Decreased interest in
things
 Difficulty with decision
making
 Difficulty concentrating
 Unusual negativism
 Hopelessness
17 ASHA 2006
 Inconsistency
 Newly poor hygiene
 Unexplained anger
 Increased anxiety level
 Increased complaints
of pain
 Complaints of sleep
difficulties
 Changes in appetite or
eating habits
 Noncompliance with
medications
 Early Symptoms of Dementia:
Alzheimer’s Disease
Slow, widespread, progressive symptoms
 Neurological/Cognitive  Behavioral/Psychosocial
 Short-term memory  Personality changes
impairments (passivity to hostility)
 Inability to focus attention  Decreased emotional
and recall events expression
 Progressive disorientation  Diminished initiative
(time and place)  Depression and anxiety
 Difficulty in word finding  Greater suspiciousness
and impaired naming  Visual hallucinations
 Impaired language  Delusions (accusations of
comprehension and theft, infidelity, persecution)
calculation  Wandering
 Visual and spatial deficits
18 ASHA 2006
 Early Symptoms of Dementia:
Vascular Dementia
 Neurological/cognitive  Behavioral/psychosocial
 Acute unilateral motor or  Sudden, affective
sensory dysfunction changes
 Urinary dysfunction  Depression
 Gait disturbance  Delusions
 Mask like facial  Psychotic symptoms
expression and rigidity
 Aphasia

19 ASHA 2006
 Early Symptoms of Dementia:
Dementia of the frontal lobe type
& Pick’s disease
 Neurological/cognitive  Behavioral/psychosocial
 Apathy  Prominent alterations in

 Language impairments
emotion, affect, and
behavior
(unfocused speech,
 Disordered executive
spontaneous compulsive
repetition of function (initiation, goal
words/phrases setting, planning)
 Normal short-term  Little awareness of
memory changes (denies any
 Normal or minimally
problems)
 Disinhibited behavior
affected cognitive testing
 Normal visual and  Personality changes
spatial abilities  Withdrawal
20 ASHA 2006
 Early Symptoms of Dementia:
Dementia with Parkinsonism
 Neurological/cognitive  Behavioral/psychosocial
 Rigidity and postural  Disordered executive
instability function
 General slowing of  Delusions
thought and action  Hallucinations

21 ASHA 2006
 Early Symptoms of Dementia:
Hydrocephalus
 Neurological/cognitive  Behavioral/psychosocial
 Gait disorder  Irritability
 Urinary incontinence  Change in behavior
 Cognitive decline
(psychomotor
slowing, impaired
ability to concentrate,
and mild memory
difficulties

22 ASHA 2006
 Criteria for determining Dementia
 Syndrome:
 Decline in cognitive functions in
comparison with client’s previous level of
function
 Decline severe enough to interfere with
social and occupational functioning
 Decline confirmed by clinical examination
and neuropsychological tests
 No disturbance of consciousness
 Diagnosis based on behavior.
23 ASHA 2006
 Criteria for determining probable
Alzheimer’s disease
 MMSE,
 Blessed Dementia Scale
 Deficits in 2 or more areas of cognition
 Progressive worsening of cognitive
functions
 No disturbance of consciousness
 Onset between 40 & 90, most often after
age 65

24 ASHA 2006
 Medical Workup for Dementia
TESTS RATIONALE – rule out…
Urinalysis Kidney dysfunction, toxic
encephalopathy
CBC, sedimentation rate, Anemia, electrolyte imbalance
electrolytes
Blood Urea Nitrogen Liver dysfunction
(BUN)/creatinine, liver function test
Thyroid function Thyroid dysfunction

Serum B 12 Vitamin deficiency

Syphilis serology Syphilis

HIV test AIDS dementia

Neuroimaging studies: CT or MRI Tumor, subdural hematomas,

25 abscess,
ASHA 2006 stroke, or hydrocephalus
 Symptoms of Depression & Dementia

Depression Dementia
Affect/mood/ Pervasive sadness, Blank matter of fact
demeanor dourness, negativity expression,
Possible overlay of sadness
Memory Poor concentration and Progressive impairment of
temporary memory decrease short-term memory, eventually
long term memory
Function Functional ability diminished Functional ability (activities of
by lack of motivation daily living and instrumental
activities of daily living)
diminished by declining
abilities
Organization Impaired decision making Impaired executive function
(e.g. organization,
prioritization)
26 ASHA 2006
 Symptoms of Depression & Dementia

Depression Dementia
Orientation Intact or impaired Impaired orientation
orientation
Language Slowed language Trouble finding words and
naming things
Motivation Impaired motivation Possible impaired motivation

Appetite/weight Either decreased appetite Trouble remembering to eat

and weight or increased Decrease in weight with no
appetite and weight obvious explanation
Sleep Possible problems falling Possible sleep problems or no
asleep, staying asleep, or sleep problems/impairment
waking up
27 ASHA 2006
 Symptoms of Depression & Dementia
Depression
Thinking/reasoning/ability to Slow thinking and
learn reasoning, Ability to learn
is retained
Danger Possible suicide
Somatic complaints/pain Possible multiple or
exaggerated somatic
complaints
Fatigue
Depression screening tool Possible high scores
28 ASHA 2006
Dementia
Impairment
Safety concerns because
of impaired judgment
Complaints that are
underreported or
perseverated upon
Fatigue
Possible high scores or
low scores
Depression and Dementia

 Symptoms of depression and dementia may overlap

or occur as co-morbidities with other medical
conditions as well as with each other.
 Vitamin deficiencies may present with depression as well as
dementia.
 Hyperthyroidism may present with symptoms of decreased energy
and interest, symptoms common to both dementia and depression.
 Sad affect of depressed individual may often be confused with the
blank affect of an individual with dementia.
 The lack of response to questions or slow responsiveness of
depression due to poor concentration may appear to be similar to
the loss of memory of the individual with dementia.
 Poor hygiene and self neglect may be common to both conditions.

 Evaluation and treatment of both dementia and

depression is often warranted.

29 ASHA 2006
 Depression and Dementia
 Cognitive decline becomes increasingly common with
advancing age.
 5-15% of persons over 65 and
 20-50% of persons over 85 are reported to be affected.
 Mental impairment, including depression and dementia, is
frequently under diagnosed in the geriatric population.
 Cognitive decline affects every aspect of a client’s life and
imposes major psychological and economic burdens on
family and caregivers.
 Cognitive decline may produce an overlay of depressive
symptoms, or depression may be misdiagnosed as cognitive
impairment.
 Major depression is present in 20-40% of older person’s with
Alzheimer’s disease.
 Multiple “I don’t know” answers are a clue that an older
person may be depressed.
30 ASHA 2006
Depression and Dementia

 Tests that differentiate between cognitive

impairment and depression should be
administered.
 Inconsistent performance on mental
exam also suggest that depression may
be present.
 Assessing orientation by inquiring about
name, place and date is ineffective as a
screening tool.

31 ASHA 2006
 Depression and Dementia

 The presence of physical illness in later life

increases the likelihood of emotional
problems.
 Severe emotional problems can be found
in 10-25% of hospitalized older patients.
 Emotional reactions to illness include
depression, anxiety, problems in regards to
pain, decline in body functions.

32 ASHA 2006
 Diagnostic Workup for Late Life
Depression
 Psychological history
 Mental Status (cognitive) screen
 Depression screen
 Assessment of activities of daily living and instrumental activities of
daily living
 Assessment of sleep and activity patterns
 Assessment of severity of depressive symptoms
 Assessment of suicidal ideation and history of prior attempts
 Medical history
 Review of prescription and over-the-counter medications
 Physical examination
 Routine diagnostic tests (e.g. electrocardiograms), laboratory tests,
or imaging (computed tomography scan or magnetic resonance
imaging), if indicated to clarify diagnosis
 Psychiatric consultation, if needed for clarification
 Neuropsychological testing, if needed for clarification
33 ASHA 2006
 Statements That May Be
Indicative Of Depression
 I’m not the person I used to be.
 I can’t manage to get anything done.
 I’m awake all night and then get to sleep in the morning.
 Nobody can do anything for me.
 I don’t care if I die.
 Things are hopeless.
 I don’t want to be a burden to anyone.
 I’ve heard that medicines have too many side effects, so
I don’t want any.
 I may be nervous, but I’m not mental.
 Who’s to care?
 Nobody wants me.
 I’m too poor to afford that.

34 ASHA 2006
Alterations in thought processes:
characteristics of client behavior -
Disorientation to time, place, person
Altered ability to think abstractly
Disorders of memory
Misinterpretation of environmental stimuli
Changes in problem-solving abilities
Changes in behavior patterns, including regression
Irritability
Expression of fear of others or of losing control
Hallucinations
Delusional thoughts
Inappropriate responses to commands
Inaccurate interpretation of the environment

35 ASHA 2006
 Dementia, Depression, Delirium

Depression Dementia Delirium

Onset Usually within a period of Slow, insidious, over a Abrupt, may be within
weeks period of months/years hours or days

Symptoms Pervasive sadness or loss Gradual decline in Fluctuation in

of pleasure, plus vegetative functioning, including consciousness and
signs recent memory loss attention
Possible hallucinations,
delusions

Course Episodic, treatable, Progressive, manageable Treatable, usually

resolvable resolvable

36 ASHA 2006
 Dementia, Depression, Delirium

Depression Dementia Delirium

Consequences May complicate course of Results in decrease in May be harbinger of
other illnesses ability to perform activities medical illness
May lead to decrease in of daily living, poor Can flag life-threatening
self-care judgment, and decreased emergency
May lead to suicide and ability to learn Requires prompt medical
various safety problems intervention
Phenomenology Can coexist with other May make depression and Is more prevalent in
Dx, causing “excess delirium harder to persons with dementia
disability,” and may recognize and hospitalized patients
complicate course of
other illnesses
Treatment Multiple simultaneous Multiple simultaneous Medical intervention first,
interventions interventions to address underlying
illness
37 ASHA 2006
 Assessment Tools
 Be familiar with the strengths, weaknesses
and accuracy of any tool.
 Determine the goals of assessment.
 Be aware that older persons often view
mental and neuropsychological testing
negatively.
 Fatigue, frustration and anxiety may
compromise the test scores.
 Sensory loss, disorientation and medication
may lower test scores.
 Be observant. Take a complete history.

38 ASHA 2006
Mini Mental State Examination

 MMSE
 Used by 90% of physicians
 Recommended by the National Institute of
Neurological and Communicative Disorders
 23 or lower out of 30 is indicative of cognitive
impairment
 85% or better sensitivity to clients with
dementia
 Can distinguish between depressed clients,
clients with dementia and clients with both
depression and dementia.
39 ASHA 2006
 Mini Mental Status Exam
(MMSE)
 Section 1: Orientation
 What is the day of the week?
 What building are we in?
 Section 2: Memory, Part 1
 Immediate recall: remember 3 words
 Section 3: Attention and Calculation
 Ability to concentrate on a tricky task, serial 7’s – subtract from 100
 Section 4: Memory, Part 2
 Delayed recall; recall 3 words from section 2
 Section 5: Language, writing and drawing
 Name common objects,
 Follow 3 stage command
 Read and follow directions
 Copying
 Write a complete sentence

 Copies of the complete test are available from the Psychological Assessment
Resources (PAR) website: http://www.parinc.com

40 ASHA 2006
 Short Portable Mental Status
Questionnaire

 SPMSQ
 Less than 2 errors, normal mental function
 8 or greater error, severe mental impairment

 Sensitivity of 95% when used as a screening tool for

dementia in the 60 years and older population

 Assesses short narrow range of basic functions

including memory, attention, orientation, capable of
detecting gross cognitive dysfunction only.
41 ASHA 2006
 THE SHORT PORTABLE MENTAL STATUS
QUESTIONNAIRE

 1. What are the date, month, and year?

 2. What is the day of the week?
 3. What is the name of this place?
 4. What is your phone number?
 5. How old are you?
 6. When were you born?
 7. Who is the current president?
 8. Who was the president before him?
 9. What was your mother's maiden name?
 10. Can you count backward from 20 by 3's?Ê

 SCORING:*
 0-2 errors: normal mental functioning
 3-4 errors: mild cognitive impairment
 5-7 errors: moderate cognitive impairment
 8 or more errors: severe cognitive impairment
 *One more error is allowed in the scoring if a patient has had a grade school education or less.
 *One less error is allowed if the patient has had education beyond the high school level.
 Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in
elderly patients. Journal of American Geriatrics Society. 23, 433-41.

42 ASHA 2006
Cognitive Functioning Instruments

 MMSE
 will not detect mild cognitive impairment
 Not designed to grade progression of
impairment
 Clients with expressive aphasia may appear
more impaired

 SPMSQ
 Too insensitive to small changes

43 ASHA 2006
Functional Assessment Staging Tool

 FAST-
 Is for distribution to the family
 Provides specific information on the
order in which various functions are
lost
 Provides time frame estimate on how
long given level of function will last.

44 ASHA 2006
Wechsler Memory Scale

 Broad range of memory functions

 Sensitive to more subtle changes
 Too long to administer
 Inadequate norms for older population

45 ASHA 2006
Global Deterioration Scale (GDS)

 Gives overall picture of the disease

process
 Able to appropriately stage dementia
 Language performance is not used
 Is used primarily with patients who’s
dementia is the Alzheimer’s type
 Will provide information on general
progression of disease but does not
take into account individual variations.

46 ASHA 2006
Global Deterioration Scale
(GDS)
 GDS Stage 1: Normal Phase
 GDS Stage 2: Forgetful Phase
 GDS Stage 3: Early Confusional Phase
 GDS Stage 4: Late Confusional Phase
 GDS Stage 5: Early Dementia
 GDS Stage 6: Middle Dementia
 GDS Stage 7: Late Dementia

47 ASHA 2006
Some other commonly used
cognitive assessment instruments
 Arizona Battery of Communication Disorders
 Brief Cognitive Rating Scale
 Cognitive Performance Test
 Clock Drawing
 FROMAJE
 Functional Linguistic Communication Inventory
 Rating Scale of Communication in Cognitive Decline
 Rehabilitation Institute of Chicago Evaluation of
Communication Problems on Right Hemisphere
Dysfunction (RICE)
 Ross Test of Higher Cognitive Processing
 Test of Problem Solving
 Token Test
 Rivermead Behavioral Memory Test

48 ASHA 2006
 Depression Instruments
 Tools do not establish a diagnosis of
depression but are important in identifying
clients for further evaluation.

49 ASHA 2006
Geriatric Depression Scale
 Includes a broad range of depression
mood questions
 Quick and reliable
 Avoids excess physical symptom
questions

 Weakness is it’s limitations and

usefulness in clients with severe
dementia.

50 ASHA 2006
 GERIATRIC DEPRESSION SCALE (GDS, SHORT FORM)
 Choose the best answer for how you felt over the past week.
 1. Are you basically satisfied with your life?
 2. Have you dropped many of your activities and interests?
 3. Do you feel that your life is empty?
 4. Do you often get bored?
 5. Are you in good spirits most of the time?
 6. Are you afraid that something bad is going to happen to you?
 7. Do you feel happy most of the time?
 8. Do you often feel helpless?
 9. Do you prefer to stay at home, rather than going out and doing new things?
 10. Do you feel you have more problems with memory than most?
 11. Do you think it is wonderful to be alive now?
 12. Do you feel pretty worthless the way you are now?
 13. Do you feel full of energy?
 14. Do you feel that your situation is hopeless?
 15. Do you think that most people are better off than you are?
 Score 1 point for each bolded answer. Cut-off: normal (0-5), above 5 suggests
depression.
 Source: Courtesy of Jerome A. Yesavage, MD.

 Clinical Toolbox for Geriatric Care © 2004 Society of Hospital Medicine 2 of 2

51 ASHA 2006
Hamilton Depression Scale

 Assesses objective symptoms

 Can estimate severity of depression

 Weakness is it’s reliability on physical

symptoms thus making it less useful in
older adults.

52 ASHA 2006
Beck Depression Inventory
 Self Rating scale
 Assesses symptoms of depression
 Includes a broad range of questions
 Validated in older adults and medical
patients

 Weakness is that it relies too heavily on

physical symptoms,
 Also difficult for cognitively impaired clients
to use.

53 ASHA 2006
www.americangeriatrics.org/education/depression.shtml

54 ASHA 2006
 Treatment of Delirium

 Identify and treat the underlying cause

 Provide a stable environment
 Perform a head-to-toe systems approach
 Perform a medication review
 Check for side effects, use of outdated
medication, interactions
 Understanding of and adherence to
prescribed medication administration

55 ASHA 2006
Treatment of Depression

 Social treatment
 therapy
 Psychopharmacological
 Antidepressants

56 ASHA 2006
Treatment of Depression
 Communication Strategies:
 Listen.
 Recognize changes – trust your eyes, ears, sense of
smell, and general intuition.
 Remain calm – do not panic.
 Acknowledge the person’s feeling. Do not try to talk
the person out of the feelings.
 If the person expresses suicidal ideas, refer the
person for immediate psychiatric evaluation and
treatment.
 Be reassuring. The person is ill, and things will get
better.
 Don’t be judgmental. Depression is an illness and not
something the person has chosen.
 Provide positive reinforcement, as appropriate.
 Acknowledge positive steps toward recovery.
57 ASHA 2006
Treatment of Dementia

Behavioral & Environmental

 Encourage appropriate behavior

 Minimize inappropriate behavior

 Maintain current level of functioning

 Ensure safety

58 ASHA 2006
Treatment of Dementia

 Patient, Family, Caregiver education

and support
 Assess for and manage depression
and delirium
 Supportive therapies

 Psychopharmacologic treatment

59 ASHA 2006
 Clinicians working in nursing homes
and retirement communities, where the
population is generally over the age of
65 years of age, should be observant
for symptoms of dementia, depression
and delirium. In these settings,
caregivers and family often overlook
the onset of dementia, attributing
cognitive and behavioral changes of
residents to “aging”.

60 ASHA 2006
Our challenge…

 Facilitate communication.
 Slow the progression or impact of
functional decline.
 Modify the environment.

 Teach caregivers about the diseases

and impact on functional abilities.

61 ASHA 2006
Questions

62 ASHA 2006
63 ASHA 2006