Depression Delirium and Dementia in Older Adults Objectives

Depression, Delirium, and Dementia in Older Adults

Objectives Describe the prevalence of depression in older adults n Use an assessment instrument for depression in older adults n Discuss symptoms and treatment strategies for depression in older adults n Describe the prevalence of delirium and dementia in older adults n 2

Objectives n Discuss the symptoms of delirium and dementia n Discuss the assessment and treatment strategies for delirium and dementia n Contrast criteria for differentiating depression, delirium, and dementia in older adults. 3

Definition of Depression n Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and / or guilt. n Diagnostic labels: minor depression, major depression, adjustment disorder with depressed mood, dysthymia, bipolar depression, seasonal affective disorder 4

Prevalence of Depression The most common emotional disorder found in older people (2% - 10%) n 8% to 15% of community-dwelling older adults n 30% among institutionalized older persons n Suicide risk factors: - psychiatric illness, serious medical illness, living along, recent bereavement, divorce, or separation, unemployment or retirement, advanced age, and substance abuse n 5

Prevalence of Depression n Herbal, nutritional, vitamins, and supplement consumed in large doses n Highest rate of completed suicide is among older white men. n Risk of suicide is higher in older adults than in younger people. 6

Assessment Instruments for Depression n Hamilton Rating Scale for Depression n Zung Self-rating Depression Scale n Montgomery-Asberg Depression Rating Scale n Yesavage Geriatric Depression Scale n Cornell Scale for Depression in Dementia 7

Symptoms of Depression n Depressed mood n Associated psychological symptoms n Somatic manifestations n Psychotic symptoms 8

Treatment Strategies for Depression n Pharmacologic – SSRI, Tricyclic antidepressants, MAO inhibitors n Electroconvulsive Therapy n Group and Individual Psychotherapy 9

Points to consider…… n Comorbidities n Monitor every 1 – 2 weeks n Assess response every 4 – 6 weeks n Assess “SIG-E-CAPS” symptoms 10

Depression: “SIG-E-CAPS” is the acronym used for evaluating the patient’s progress over time n n n n S Sleep disturbance (insomnia or hypersomnia) I Interests (anhedonia or loss of interest in usually pleasurable activities) G Guilt and/or low self-esteem E Energy (loss of energy, low energy, or fatigue) C Concentration (poor concentration, forgetful) A Appetite changes (loss of appetite or increased appetite) P Psychomotor changes (agitation or slowing/retardation) S Suicide (morbid or suicidal ideation) 11

Interventions n n Institute safety precautions for suicide risk Monitor / promote nutrition, elimination, sleep, rest, comfort, pain control Enhance physical function and social support Maximize autonomy n n Structure and encourage daily participation in therapies Remove etiologic agents n Monitor / document responses Provide practical assistance, such as problem -solving n Provide emotional support n 12

Case Study Ms. G is a 75 -year old female living alone in her apartment in New York City. Her husband died suddenly two years ago of a heart attack. Their two children are alive and living out-of-state. Both of her sons maintain weekly phone contact with Ms. G and visit usually once a year. Ms. G has been doing well until about 6 weeks ago when she fell in her apartment and sustained bruises but did not require a hospital visit. Since then, she has been preoccupied with her failing eyesight and decreased ambulation. She does not go shopping as often, stating she doesn’t enjoy going out anymore and feels “very sad and teary. ” Ms. G states that her shopping needs are less, since she is not as hungry as she used to be and “besides I’m getting too old to cook for one person only. ” 13

Questions 1. What risk factors might account for Ms. G’s symptoms of depression? 2. What are Ms. G’s depressive symptoms? 3. What might be some treatment strategies for Ms. G? 14

Prevalence of Delirium and Dementia n n Delirium – a reversible confusional state, a mental disturbance characterized by acute onset, disturbed consciousness, impaired cognition, and an identifiable underlying medical cause (medications, anesthesia, sleep disturbance, electrolyte imbalance, etc. ) Dementia – an irreversible confusional state, , acquired impairment of mental function, not the result of impaired level of arousal, with compromise in at least three areas of mental activity. 15

Prevalence of Delirium and Dementia n 4 to 5 million are estimated to have cognitive disorders (dementia or delirium) n Alzheimer’s disease accounts for 50% to 60% of all dementias in the U. S. n Incidence of dementia will increase to 14 million by 2050 16

Symptoms Parameter Delirium Onset Short, rapid, hours/days Insidious and gradual Presentation Disoriented, fluctuating Vague symptoms, loss of moods intellect, agitated, aggressive Hours, weeks, or longer Slow and continuous Course Sleep/Wake Duration Affect Dementia Worse at night in darkness and on awakening, insomnia Hours to < month Worse in evening; “sundowning”, reversed sleep Month to years Labile variable; fear / panic, euphoria, disturbed Easily distracted, inappropriate anxiety, labile to apathy 17

Symptoms Parameter Delirium Dementia Judgment Impaired; difficulty separating facts and hallucinations Impaired, bad / inappropriate decisions, denies problems Psychotic symptoms Delusions Misperceives people and events as threatening; late delusions, hallucinations Level of Disturbed Consciousness Intact Recent Memory Short term memory deficit in early course, progresses to long-term deficits, confabulation, perseveration Impaired, but remote memory is intact 18

Assessment of Delirium n History and Physical n Current medication n Tests: chemistries, EKG, CXR, ABGs, oxygen saturation, u/a, thyroid function tests, cultures, drug levels, folate levels, pulse oximetry, EEG, lumbar puncture, serum B 12 19

Treatment of Delirium n Failure to treat delays recovery and can worsen the older person’s health and function. n Psychiatric Management: identify and treat underlying etiology, intervene immediately for urgent medical conditions; ongoing monitoring of psychiatric status n Environmental and supportive interventions: all environmental factors that exacerbate delirium; make environment more familiar; reorient; reassure, and inform to fear or demoralization n Somatic Interventions: antipsychotic; benzodiazepines 20

Assessment of Dementia n Folstein Mini-Mental Status Examination (MMSE) n Kokmen Short Test of Mental Status n 7 -minute screen: cued recall, category fluency, Benton Temporal Orientation Test, Clock Drawing Test 21

Try This Dementia Series at www. hartfordign. org n n n Developed by The Hartford Institute for Geriatric Nursing in collaboration with The National Alzheimer’s Association Assessment tool that can be administered in 20 minutes or less Topics include: n Brief Evaluation of Executive Dysfunction n Recognition of Dementia in Hospitalized Older Adults n Assessing Pain in Persons with Dementia n Assessing and Managing Delirium in Persons with 22 Dementia

Brief Evaluation of Executive Dysfunction: An Essential Refinement in the Assessment of Cognitive Impairment 23

Treatment of Dementia n Treat cognitive symptoms: cholinesterase inhibitors; Vitamin E; Gingko Biloba; stroke prevention n Treatment of Behavioral Disturbances: antipsychotics; benzodiazepines; selected tricyclics n Educational interventions: family caregivers and staff 24

Treatment of Dementia n Improve functional performance: low lighting level, music, behavior modification n Nonpharmacologic Interventions for Problem Behaviors: cognitive remediation, massage, pet therapy, occupational and physical therapy, validation therapy n Care Environment Alterations: homelike setting, special care unit n Interventions for Caregivers: assess for caregiver depression 25

Alzheimer Care Use personal history, life experiences, and habits n Maintain a familiar and comfortable routine n Slow down, speak clearly, make eye contact, in field of vision n Cue the person to do as much for him or herself as possible n Modify physical environment – reduce misinterpretation n Monitor for symptoms of personal distress n 26

Case Study: Dementia Ms. D is a 98 -year-old female in a skilled nursing facility with a diagnosis of Alzheimer’s disease. Ms. D comes to the nursing station and appears very upset. She tells you that she is looking for her mother and asks you to help her. You start walking with Ms. D. 27

Which strategies would be helpful in assisting Ms. D. ? 1. Using reality orientation in the hope of reversing her cognitive loss 2. Telling her that her mother died a long time ago 3. Attempt to distract / redirect her into a pleasurable activity, such as eating or singing 4. Ask her to help you with a small task and that later you will look for her mother together. 28

Summary n Prevalence, symptoms and treatment strategies for depression, delirium, and dementia. n Assessment tools n Interventions for behavior problems n Case Studies to reinforce knowledge 29