Confusion among

elderly
Delirium,
Depression,
Dementia
S.Sathees BscN,Mphil.

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 Confusion
• Depression, dementia, and delirium are the three most
common mental health conditions among older adults.

• Is not a normal part of aging

• Delirium and Depression are treatable

• Dementia is manageable

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 Depression, Dementia, and Delirium

 These conditions are complex and multi-faceted in older

individuals and often:
 Are unrecognized and untreated.
 Occur simultaneously and overlapping symptoms are
difficult to distinguish.
 Negatively impact health, well-being, and quality of life.
Depression in Older Adults
Depression
Onset: weeks to months

Causes:
 heredity

 biochemical changes

 drugs

 illness

 sensory deficits

 stress
SAD

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Losses with Aging
• Biological
• Psychological
• Personal
• Social
• Identity
• Possessions
• Religious

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Depression: Symptoms

• What are the symptoms of depression …

• However, depression manifests differently in older adults

than it does in younger populations.
Depression: Symptoms

Three types of symptoms:

 Mood
 Physical
 Cognitive
Depression: Mood Symptoms

 Sadness
 In older adults, sadness may be denied -- many complain of bodily
aches and pains, rather than admitting to their true feelings of
sadness.
 Loss of interest and pleasure in usual activities.
 Irritability
 This is especially common in older adults.
Depression: Physical Symptoms

Abnormal appetite with weight loss or weight gain.

Abnormal sleep
 Difficulty falling asleep, frequent awakenings during the
night or very early morning awakening.

Fatigue or loss of energy.

Psychomotor retardation or agitation.

Depression: Cognitive Symptoms

• Abnormal self-criticism or inappropriate guilt.

• Abnormal poor concentration or indecisiveness.

• Morbid thoughts of death (not just fear of dying or thoughts

about death) or suicide.
 Depression- Epidemiology

• The proportion of the global population with depression in 2015 is 4.4%.

• Depression is more common among females (5.1%) than males (3.6%).

• The estimated total cases in Sri Lanka is 802,321 and 4.1% of total
population.

• Prevalence rates vary by age, peaking in older adulthood (above 7.5% among
females aged 55-74 years, and above 5.5% among males).

• Depression also occurs in children and adolescents below the age of 15

years, but at a lower level than older age groups.

• the incidence of depression is higher among older adults in clinical settings

Depression: Epidemiology

 Among older adults:

 Depression is associated with increased mortality and morbidity rates.
 The incidence of depression increases in conjunction with medical conditions
 Depression can lead to increased mortality from other diseases such as heart disease,
myocardial infarction, and cancer

 Among older adults untreated depression may also result in:

 Increased substance abuse.
 Slowed recovery from medical illness or surgery.
 Malnutrition.
 Social isolation
Depression: Diagnosis

Symptoms include…
• loss of interest or pleasure in activities
• persistent low mood, including feelings of sadness or emptiness
• feeling slowed down or restless
• feeling worthless or guilty
• increase or decrease in appetite or weight
• thoughts of death or suicide
• problems thinking, concentrating, or making decisions
• trouble sleeping, or sleeping too much
• loss of energy or feeling tired all of the time; constant fatigue

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 Depression: Assessment

• Geriatric Depression Scale

• Self-administered
• Well tested and used by all health care providers

• Cornell Scale for Depression in Dementia

• Useful in assessing depression in individuals with dementia
• Can be used by family members or caregivers to articulate their
observations, as some individuals may minimize the severity of their
symptoms
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Late in Life Suicide
 One of the most problematic outcomes of depression is elder suicide.
 Older adults have the highest risk of suicide of any age group.
Risk Factors for
Late in Life Suicide
• The risk of suicide is high in older adults.

• Health care providers must intervene if an individual makes statements related to the
taking of his or her own life.

• Risk factors include

• male
• significant loss
• poor health
• isolation
• feeling hopeless
• previous attempt
• drug / alcohol abuse
• family history
• financial insecurity

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Depression: Interventions

• Antidepressants
• Monitor for side effects

• Encourage and support counseling

• Recommend a referral to Medical Social Worker

• May be able to link individual with resources and community support

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Dementia and Older Adults
 Dementia
A chronic and progressive loss of intellectual functions severe enough to interfere
with everyday life.
Onset: months to years
Causes:
Alzheimer’s Disease (AD) (most common)
Vascular Dementia (multi-infarct; MID)
Mixture of AD & MID
Parkinsons

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Dementia: Symptoms

 Include disturbances of multiple higher functions of the brain including:

 Memory
 Thinking
 Orientation
 Comprehension
 Calculation
 Learning capacity
 Language and judgment.

 Symptoms frequently cause changes in mood, behavior, and personality.

Warning Signs of Dementia

 Memory loss  Problems with abstract

 Difficulty performing familiar thinking

tasks  Misplacing things

 Problems with language  Changes in mood or behavior

 Disorientation to time and  Changes in personality

place  Loss of initiative
 Poor or decreased judgment
Most Common Types of Dementia

• Types of dementia
• Alzheimer’s disease
• Vascular dementia
• Lewy body dementia
• Frontotemporal degeneration
Alzheimer’s

• Not a normal part of aging, but the prevalence of

Alzheimer’s increases with age.
• risk doubles every 5 years after age 65:
• Currently the prevalence in Sri Lanka is 3.98%.
What is Alzheimer’s Disease?

 Like all dementias, it is a disease of the brain causing

progressive declines in memory.

 Results in the loss of intellectual functions severe enough to

interfere with everyday life specifically related to:
 Thinking
 Remembering
 Reasoning
What is Alzheimer’s Disease?

• Begins gradually with individual variation in the rate of progression.

• Symptoms:
• Forget recent events
• Have difficulty performing familiar tasks
• Confusion
• Personality and behavioral changes
• Impaired judgment
• Communication difficulties
• In late stages, the individual is totally unable to care for him or herself.
 Difference Between Alzheimer’s and Normal
Memory Difficulties?

• Many older adults fear that minor memory problems they

experience may signify Alzheimer’s dementia.

• Memory problems related to Alzheimer’s dementia is

different with the minor memory problems sometimes
associated with aging …
Difference Between Alzheimer’s and Normal
Memory Difficulties?

Activity Alzheimer’s Age-associated

Disease Memory Problems

Forgets Whole experiences Parts of an

experience

Remembers later Rarely Often

Can follow written or Gradually unable Usually able

spoken directions

Can use notes Gradually unable Usually able

Can care for self Gradually unable Usually able

Stages of Alzheimer’s

Alzheimer’s disease has recognizable stages:

1. No cognitive impairment
2. Very mild decline
3. Mild cognitive decline
4. Moderate cognitive decline
5. Moderately severe cognitive decline
6. Severe cognitive decline
7. Very severe cognitive decline
Alzheimer’s: Assessment

• There is no absolute method for diagnosing Alzheimer’s

dementia other than autopsy.

• The clinical diagnosis of this condition is accomplished by

ruling out other potential causes of cognitive decline.
Alzheimer’s: Assessment
• Assessment tools that help determine an individual’s stage of Alzheimer’s dementia:
• Global Deterioration Scale
• Brief Cognitive Rating Scale
• Functional Assessment Staging Tool

• Mini Mental Status Exam (MMSE)

• Cannot diagnosis Alzheimer’s dementia, but it can help identify an individual’s
cognitive strengths and limitations.
• Often used as a screening tool.

• Other cognitive tests: Clock test, SLUMS exam, Brief Portable Mental Status Questionnaire.
Self-Awareness of People With Dementia

• Perception of person with dementia having little insight to no

awareness of their cognitive deficits

• Anosognosia: diagnostic term for lack of awareness

• Research showing persons with dementia are aware of deficits

• Awareness associated with higher levels of anxiety and depression

Personal Experiences of Dementia

• Early stage of disease

• Awareness of initial changes
• May withdraw from complex tasks for protection
• Disease progress less able to conceal or compensate

• Common emotions and behaviours

• Loss, fear, shame, anger, sadness, anxiety, frustration, loneliness,
depression, uncertainty, sense of uselessness, self-blame, diminished affect
and withdrawal from challenging activities
Behavioural and Psychological Symptoms of
Dementia

• BPSD (behavioural and psychological symptoms of dementia)

• Agitation
• Psychiatric symptoms
• Personality changes
• Mood disturbances
• Aberrant motor movements
• Changes in sleep, eating and appetite
• Hypersexual behaviour
Behavioural and Psychological Symptoms of
Dementia….

• Sun-downing
• Fatigue, overstimulation, fear of darkness, altered circadian rhythm
• Aggression and agitation
• Major nursing responsibility
• Look for contributing causes and implement strategies to prevent issues or
minimize effects.
• Person-centred approach
Nursing Assessment of Dementia in Older
Adults

• Assessment is an ongoing process: Focus on identification of

conditions that cause negative consequences during course of illness.

• Factors that influence the assessment of dementia

• Attitudes, myths, lack of information—risk factors
• Cultural factors

• Initial assessment

• Ongoing assessment of consequences

Nursing Diagnoses

• Chronic confusion: irreversible, long-standing and progressive

• Fear

• Anxiety

• Risk for compromised human dignity

• Impaired memory

• Impaired social interaction

• Self-esteem disturbance

• Ineffective coping
Nursing Diagnoses…

• Address needs of caregiver/care partner.

• Stress overload
• Compromised family coping
• Caregiver role strain or risk for caregiver role strain
• Anticipatory grieving
 Planning for Wellness Outcomes
• Nursing care directed at highest level of function

• Nursing Outcome Classification (NOC)

• Agitation level
• Mood equilibrium
• Cognition
• Memory
• Leisure participation
• Quality of life
• Nutritional status
• Self-care status
• Sleep
• Social interaction skills
Nursing Interventions to Address Dementia #1

• Address nursing interventions in context of comprehensive,

interprofessional and person centred.
• Reassurance for anxiety and confusion with redirection
• Exercise and nutrition
• Address Behavioral and Psycho Social issues.
• Address needs of caregivers/care partners.
• Teaching about medications for dementia
• Nonpharmaceutical interventions for promoting wellness in people with
dementia
Nursing Interventions to Address Dementia

• Teaching about medications for dementia

• Nonpharmaceutical interventions for promoting wellness in people with

dementia

• Improving safety and function through environmental modifications

• Communicating with older adults with dementia

• Interventions for dementia-related behaviours

• Addressing needs of caregivers

Evaluating the Effectiveness of Nursing
Interventions
• Maintaining dignity and quality of life

• Evaluate quality of life in regard to life satisfaction.

• Feedback from caregivers/care partners

• Person free from pain, fear, anxiety

• Evaluate needs of caregivers/care partners.

Delirium in Older Adults
 Delirium
• A mental disturbance characterized by sudden changes in mental
functioning or acute confusion and fluctuating levels of
consciousness.
• Delirium is the most acute condition and is a true medical emergency.

• More common than fever or pain in older adults

• Most of hospitalized older adults experience delirium

• Fewer older adults with delirium are diagnosed by health care

personnel

• Is a medical emergency and should be treated immediately

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 Delirium
• Onset: hours to days
• Causes:
• The primary causes are underlying medical conditions, medications, or drug withdrawal:
• Reaction to prescribed medications or illicit drugs
• fluid and electrolyte imbalances
• Alcohol withdrawal
• Sensory deprivation
• infection (rule out urinary and respiratory infections)
• elimination (urinary retention / constipation)
• changes in chronic illness
• newly-developed disease process
• psychosocial / environmental issues
• Head injuries or falls
• Low
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 Delirium
• Functional consequences

• Longer hospital stays

• Increase mortality

• Increase dependency

• Short/long-term functional impairment

 Delirium: Diagnosis
• Perseveration
• Disorganized thinking
• Reduced LOC
• Perceptual disturbances
• Sleep-wake disturbance or psychomotor activity
• Disorientation to time, place, person
• Memory impairment
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Delirium : Assessment
 Because delirium is an emergency medical condition, medical
assessment and intervention is mandatory.
 However, delirium is one of the most under-recognized conditions in
older adults

• Assess the orientation

• Person, place and time

• Focus on aspects of Attention and Concentration

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Delirium: Symptoms

 Disorganized thinking

 Disorientation to time and place

 Reduced level of attention (drowsiness)

 Client may fall asleep during an interview.

 Increased or decreased psychomotor activity

 Or apathy, which is sometimes mistaken for depression

 Increased agitation

 Disturbances in sleep cycle

Delirium: Symptoms

 Three Types:
 Hyperactive: Features of this type of delirium include psychomotor
agitation, increased arousal and delusions. The degree of cognitive
impairment may be variable and even minimal in some instances.
 Hypoactive: Features of this type of delirium include withdrawal,
lethargy and reduced arousal.
 Mixed: Characteristics of both hyperactive and hypoactive delirium.

 The hypoactive form is the most frequently overlooked because

patients present with less problematic behavioral symptoms.
Delirium: Symptoms

 Four criteria are assessed in diagnosing delirium:

 Acute onset and fluctuating course

 Inattention

 Disorganized thinking

 Altered level of consciousness

 The diagnosis of delirium requires the presence of criteria 1 and 2

and either 3 or 4.
Delirium: Interventions
• Rule out drug-related causes and infections first
• Urinary tract and respiratory infections are the most common

• Obtain data about the individual’s baseline cognitive functioning

• Provide orienting cues and support

• Eye glasses, hearing aids, calendar, clock, etc.

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Delirium: Interventions
Nurses responsibility
• Prevention and early detection and treatment
• Nonpharmacologic interventions
• Avoidance of medications such as benzodiazepines
• Staff education
• Comprehensive geriatric assessment
• Treatment of all contributing factors
• Orientation interventions
• Environmental modification
• Nutritional interventions
 Depression in Dementia: Difficult to
Diagnose

 Difficult to Diagnose
 Some symptoms of dementia mimic those of depression
 Apathy
 Loss of interest
 Social withdrawal
 Cognitive deficits obstruct verbalization of sadness, hopelessness, guilt and other
feelings associated with depression.

 Combination of Depression and dementia 20-40 percent incidence rate; equal

across men and women.

 In the nursing home setting, rates may be as high as 50 to 75 percent.

Delirium and Dementia
 The prevalence of delirium superimposed on dementia among elderly

 Delirium is even more likely to be overlooked in the context of dementia; predictors for under-
recognition:
 Presence of the hypoactive form of delirium
 Age 80 and older
 Vision impairment
 Dementia diagnosis

 Results of untreated delirium in persons with dementia:

 Accelerated and long-term cognitive and functional decline
 Need for institutionalization
 Rehospitalization
 Increased mortality
 Delirium and Dementia
Is it Delirium or Dementia?
Delirium
Onset Rapid (hours/days); rapid
decrease in MMSE score.
Symptoms Fluctuate over the course of
the day.
Duration Days to weeks.
Orientation Disorientation and disturbed
thinking are intermittent.
Level of consciousness Fluctuates, with inability to
concentrate.
Sleep/wake cycle Sleep/wake cycle may be
reversed.
Dementia
Slow (months, years); slow
decline of 2 to 3 MMSE points
over a period of years.
Relatively stable.
Years.
Persistent disorientation.
Alert, stable.
Sleep may be fragmented.
Thank you