Delirium, Dementia and

Depression
 Dementia
• Multiple cognitive deficits including:
– 1. Memory impairment
– 2. At least one of the following:
• Aphasia
• Apraxia
• Agnosia
• Disturbance in executive functioning
 Dementia con’t
• Onset: insidious
• Duration: months to years
• Usually alert
• Affect: labile
• Orientation: may get near miss answers
 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
 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
• 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
• Dementia secondary to other medical
conditions:
– PD can lead to irreversible dementia secondary
to dopamine insufficiency
– Huntington’s disease
– B1 vitamin deficiencies usually secondary to
ETOH
 Differentiating Acute Delirium
from Chronic Dementia
Feature Delirium Dementia
Onset Acute Insidious
Duration Brief Chronic, unless
reversible
Consciousness fluctuates static
Orientation Abnormal Normal in mild
cases
Memory Recent defective Recent/later loss
Initial ST loss
 Delirium vs dementia con’t
Attention Always May be intact
impaired
Perception Freq. Disturbed Flat empty talk
Thinking Disorganized, Impaired,
contents rich contents empty
Judgement Poor poor
Insight Present in lucid May be absent
intervals
Sleep Always Variable
disturbed
 Assessment tools
• MMSE:
– Further eval if score < 25/30
 Assessment tools
• Pfeiffer Short Portable Mental Status
Questionnaire:
– Further evaluation necessary if score is <8/10
 Assessment con’t
• FAST Functional Assessment Staging of
Alzheimer’s Disease
– Identifies other causes of regression
 More Assessment
• Functional Rating Scale for Sx of Dementia
– This 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
 Some stats
• 1.5-2.3 million persons have mild to mod
dementia
• Cognitive impairment affects > 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
 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
 Validation con’t
– 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
 Depression
• Def: Alteration or disturbance of mood.
• Onset: recent
• Duration variable
• Alertness: diminished ability to
communicate
• Orientation: “Don’t know answers”
• Affect: Flat
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
 Differentiating Dementia from
Depression
Feature Organic Depression
Dementia
Onset Slow Rapid
Course Slow, worse at Rapid and
night uneven same at
night
Memory Greater loss Apathetic I
recent don’t know
Orientation Approximate, Apathetic as
perserverant above
Affect Inappropriate Constricted
Neuro None Possible
vegetative signs sleep,appetite,
bowel or
bladder, sex dys
 Factors leading to depression
• 1. Grief/ bereavement
• 2. Change in support network
• 3. Change in physical function
 Medical disorders causing
depressed mood
• Occult malignancy • Panhypothyroidism
• Infectious process • Parkinsons
• Hypothyroidism • Dementing illness
• Apathetic • CHF
hyperthyroidism • CRF
• Cushing’s syndrome • COPD
• Addison’s disease
Meds Asc. With depressed mood
• Antihypertensives • Oral hypoglycemics
• Reserpine • CNS depressants
• Methyldopa • Barbituates
• Beta blockers • Neuroleptics
• Hydralazine • Opiates
• Histamine type II • Alcohol
Receptors/Blockers • Steroids
• Digoxin • Cytotoxics
 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.
 Depression assessment tools
con’t
• Geriatric Depression scale: a score of >8 is
90%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.
Holmes and Rahe Social
Adjustment Scale
 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.