Elena Loomis MSN APRN AGNPC CDP CCRN Discussion
![Elena Loomis, MSN, APRN, A-GNP-C, CDP, CCRN Elena Loomis, MSN, APRN, A-GNP-C, CDP, CCRN](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-1.jpg)
![• Discussion of the importance of identification and assessment of depression, delirium, and • Discussion of the importance of identification and assessment of depression, delirium, and](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-2.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-3.jpg)
![� Clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and � Clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-4.jpg)
![Hopkins Frailty Assessment CSHA Clinical Frailty Scale Hopkins Frailty Assessment CSHA Clinical Frailty Scale](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-5.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-6.jpg)
![Cognitive function is the process to perceive, registering, store information and use information � Cognitive function is the process to perceive, registering, store information and use information �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-7.jpg)
![MUST ASSESS COGNITIVE FUNCTION & DETERMINE BASELINE ABILITY TO FUNCTION ADLs & IADLs MUST ASSESS COGNITIVE FUNCTION & DETERMINE BASELINE ABILITY TO FUNCTION ADLs & IADLs](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-8.jpg)
![Late Life Depression Late Life Depression](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-9.jpg)
![� 1. 2 -1. 8 million >65 years with depressive disorders � Elderly are � 1. 2 -1. 8 million >65 years with depressive disorders � Elderly are](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-10.jpg)
![� DSM-5 � Most of day over 2 week period criteria includes at least � DSM-5 � Most of day over 2 week period criteria includes at least](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-11.jpg)
![� Concurrent medical diagnosis � 80% of elderly have 1 chronic illness � 50% � Concurrent medical diagnosis � 80% of elderly have 1 chronic illness � 50%](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-12.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-13.jpg)
![� Stroke � 25 -50% � CV post CVA events � 65% following AMI � Stroke � 25 -50% � CV post CVA events � 65% following AMI](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-14.jpg)
![Late life depression � Major depressive episode occurring for first time in an older Late life depression � Major depressive episode occurring for first time in an older](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-15.jpg)
![� Similar to Adult s/s but could include � More Somatic or physical c/c � Similar to Adult s/s but could include � More Somatic or physical c/c](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-16.jpg)
![“Do you often feel sad or depressed? ” “Do you often feel sad or depressed? ”](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-17.jpg)
![92% Sensitivity 81% Specificity 93% Sensitivity 97% Specificity 92% Sensitivity 81% Specificity 93% Sensitivity 97% Specificity](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-18.jpg)
![“I think I’m blue” “I’m fine, just a little to much thinking” 1. 2. “I think I’m blue” “I’m fine, just a little to much thinking” 1. 2.](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-19.jpg)
![Talk Therapy/Group RX � � SSRI � � Escitalopram Start 5 mg PO daily Talk Therapy/Group RX � � SSRI � � Escitalopram Start 5 mg PO daily](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-20.jpg)
![� Late Life Depression � Rx �Patient specific �Use recommended �Mo. CA �Prodromal � � Late Life Depression � Rx �Patient specific �Use recommended �Mo. CA �Prodromal �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-21.jpg)
![� Portion of Executive Function � Lack of ambition or drive � Lack in � Portion of Executive Function � Lack of ambition or drive � Lack in](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-22.jpg)
![� Psychological distress that involves hopelessness, helplessness, loss of purpose and meaning, and existential � Psychological distress that involves hopelessness, helplessness, loss of purpose and meaning, and existential](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-23.jpg)
![� Increased Morbidity � Increase Mortality � Slow recovery from surgery/illness/falls � Malnutrition � � Increased Morbidity � Increase Mortality � Slow recovery from surgery/illness/falls � Malnutrition �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-24.jpg)
![� >65 years make up 12% of population � But � are 18% of � >65 years make up 12% of population � But � are 18% of](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-25.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-26.jpg)
![� Syndrome of sudden deterioration of mental function � Triggered by illness �Body �Brain � Syndrome of sudden deterioration of mental function � Triggered by illness �Body �Brain](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-27.jpg)
![Mortality rates 22 -76% as high as MI or sepsis!!! Up to 75% will Mortality rates 22 -76% as high as MI or sepsis!!! Up to 75% will](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-28.jpg)
![Old School Thinking New Research Ach Deficiency Abnormal Immune Physiologic Stress Acute s/s Treatment Old School Thinking New Research Ach Deficiency Abnormal Immune Physiologic Stress Acute s/s Treatment](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-29.jpg)
![� Male � Advanced � Whose age >60 � Cognitive Impairment � Depression � � Male � Advanced � Whose age >60 � Cognitive Impairment � Depression �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-30.jpg)
![Predisposing Precipitating Perpetuating MCI Sepsis Increase sedation Dementia Surgery Restraints Comorbidities Drugs Age Hospitalization Predisposing Precipitating Perpetuating MCI Sepsis Increase sedation Dementia Surgery Restraints Comorbidities Drugs Age Hospitalization](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-31.jpg)
![�Dehydration �Malnutrition �Immobility �Infection �Constipation �Psychoactive medications �Disorienting environment �Acute metabolic disturbance �Trauma �Hypoxia �Dehydration �Malnutrition �Immobility �Infection �Constipation �Psychoactive medications �Disorienting environment �Acute metabolic disturbance �Trauma �Hypoxia](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-32.jpg)
![� Acute onset �Within hours or days � Fluctuating course � Poor attention � � Acute onset �Within hours or days � Fluctuating course � Poor attention �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-33.jpg)
![Hyperactive Mixed Hypoactive Most Overlooked MOST DEADLY 30% 10% 60% Hyperactive Mixed Hypoactive Most Overlooked MOST DEADLY 30% 10% 60%](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-34.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-35.jpg)
![“Say the months of the year backwards? ” SAVEAHAART Alert Vigilant Lethargic Stuporous Will “Say the months of the year backwards? ” SAVEAHAART Alert Vigilant Lethargic Stuporous Will](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-36.jpg)
![� Out Patient �Restorative care �Treat pain minimize opioids �Hunger �Thirst �Sensory aids �Safety � Out Patient �Restorative care �Treat pain minimize opioids �Hunger �Thirst �Sensory aids �Safety](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-37.jpg)
![� Identify treat acute illness � Hyperactive � � � Use medication only if � Identify treat acute illness � Hyperactive � � � Use medication only if](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-38.jpg)
![� Upon hospital discharge : � 47% still meet criteria of delirium � 1 � Upon hospital discharge : � 47% still meet criteria of delirium � 1](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-39.jpg)
![� Increase risk of dementia in prolonged states � Death � Earlier LTC admission � Increase risk of dementia in prolonged states � Death � Earlier LTC admission](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-40.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-41.jpg)
![11%-28% >65 years old � 50% >80 years old � AD is 60 -80% 11%-28% >65 years old � 50% >80 years old � AD is 60 -80%](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-42.jpg)
![� MCI=more likely to develop AD or other dementia � 15 -20% � >65 � MCI=more likely to develop AD or other dementia � 15 -20% � >65](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-43.jpg)
![� 15% may convert to dementia � FORD �Finances �Orientation �Repeat questions �Direction � 15% may convert to dementia � FORD �Finances �Orientation �Repeat questions �Direction](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-44.jpg)
![Normal Aging � Harder to recall info � Forget names � New acquaintances � Normal Aging � Harder to recall info � Forget names � New acquaintances �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-45.jpg)
![� Decline in Brain function leading to disruption in daily functioning Deficits � Memory � Decline in Brain function leading to disruption in daily functioning Deficits � Memory](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-46.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-47.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-48.jpg)
![� Cognitive disability before memory impairment � Cognitive disability before memory impairment](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-49.jpg)
![� Age � HTN � HLD � T 2 DM � Obesity � Elevated � Age � HTN � HLD � T 2 DM � Obesity � Elevated](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-50.jpg)
![� Ask Patient � Memory Worse? � Lost? � Repeat? � Help with ADLs? � Ask Patient � Memory Worse? � Lost? � Repeat? � Help with ADLs?](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-51.jpg)
![� � � � � CMP CBC CT/MRI TSH FT 4 Folate Vitamin B � � � � � CMP CBC CT/MRI TSH FT 4 Folate Vitamin B](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-52.jpg)
![� Symptomatic � Behavioral disturbances � Support function � Provide for safety � Exercise � Symptomatic � Behavioral disturbances � Support function � Provide for safety � Exercise](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-53.jpg)
![� ACh. EI � Prevent breakdown of acetylcholine �Donepezil start 5 mg PO HS � ACh. EI � Prevent breakdown of acetylcholine �Donepezil start 5 mg PO HS](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-54.jpg)
![� ASA � Women � Estrogen replacement � No � � Unconvincing evidence Bleeding � ASA � Women � Estrogen replacement � No � � Unconvincing evidence Bleeding](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-55.jpg)
![� Agitation � Aberrant motor behavior � Anxiety � Elation � Irritability � Depression � Agitation � Aberrant motor behavior � Anxiety � Elation � Irritability � Depression](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-56.jpg)
![� Cognitive/emotion-oriented interventions � reminiscence therapy � validation therapy � Sensory stimulation interventions � � Cognitive/emotion-oriented interventions � reminiscence therapy � validation therapy � Sensory stimulation interventions �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-57.jpg)
![CNS Depression CNS Depression](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-58.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-59.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-60.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-61.jpg)
![� Akgün, K. M. , Crothers, K. , & Pisani, M. (2012). Epidemiology and � Akgün, K. M. , Crothers, K. , & Pisani, M. (2012). Epidemiology and](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-62.jpg)
- Slides: 62
![Elena Loomis MSN APRN AGNPC CDP CCRN Elena Loomis, MSN, APRN, A-GNP-C, CDP, CCRN](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-1.jpg)
Elena Loomis, MSN, APRN, A-GNP-C, CDP, CCRN
![Discussion of the importance of identification and assessment of depression delirium and • Discussion of the importance of identification and assessment of depression, delirium, and](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-2.jpg)
• Discussion of the importance of identification and assessment of depression, delirium, and dementia • Frailty Syndrome • Discuss Late Life Depression • Discuss Delirium • Discuss Dementia • BPSD • Use of validated tools and assessments to differentiate between the 3 D’s in order to initiate appropriate treatment
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-3.jpg)
![Clinically recognizable state of increased vulnerability resulting from agingassociated decline in reserve and � Clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-4.jpg)
� Clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is comprised. � Phenotypic Criteria �Must Meet 3/5 Low grip strength Low energy Slowed waking speed Low physical activity Unintentional weight loss
![Hopkins Frailty Assessment CSHA Clinical Frailty Scale Hopkins Frailty Assessment CSHA Clinical Frailty Scale](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-5.jpg)
Hopkins Frailty Assessment CSHA Clinical Frailty Scale
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-6.jpg)
![Cognitive function is the process to perceive registering store information and use information Cognitive function is the process to perceive, registering, store information and use information �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-7.jpg)
Cognitive function is the process to perceive, registering, store information and use information � Physiological �Loss of recent memory �Response time is delayed �Diminished ability to learn complex information � Pathologic �Depression �Delirium �Dementia
![MUST ASSESS COGNITIVE FUNCTION DETERMINE BASELINE ABILITY TO FUNCTION ADLs IADLs MUST ASSESS COGNITIVE FUNCTION & DETERMINE BASELINE ABILITY TO FUNCTION ADLs & IADLs](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-8.jpg)
MUST ASSESS COGNITIVE FUNCTION & DETERMINE BASELINE ABILITY TO FUNCTION ADLs & IADLs
![Late Life Depression Late Life Depression](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-9.jpg)
Late Life Depression
![1 2 1 8 million 65 years with depressive disorders Elderly are � 1. 2 -1. 8 million >65 years with depressive disorders � Elderly are](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-10.jpg)
� 1. 2 -1. 8 million >65 years with depressive disorders � Elderly are fastest growing suicide group � 40 -50% with AD develop depression � 50% of LTC � MDD Prevalence � 1 -3% Community � 10% Primary Care � 15% Medical Inpatients � 15% Long-Term Care
![DSM5 Most of day over 2 week period criteria includes at least � DSM-5 � Most of day over 2 week period criteria includes at least](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-11.jpg)
� DSM-5 � Most of day over 2 week period criteria includes at least 5 with 2 including � Depressed mode most of day for over 2 weeks � Anhedonia � Weight Loss/Gain � Sleep disturbance � Psychomotor changes � Diminished ability to think/concentration � Recurrent thoughts of death SIG-E-CAPS � Sleep disturbance � Interests � Guilt low self-esteem � Energy � Appetite � Psychomotor � Suicide
![Concurrent medical diagnosis 80 of elderly have 1 chronic illness 50 � Concurrent medical diagnosis � 80% of elderly have 1 chronic illness � 50%](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-12.jpg)
� Concurrent medical diagnosis � 80% of elderly have 1 chronic illness � 50% have at least 2 chronic illnesses Most Common Comorbidities HTN 58% Chronic Pain/Arthritis 56% Cancer 57% CAD 48% Pulmonary Disease 42% Parkinson/Disease 1 -2%
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-13.jpg)
![Stroke 25 50 CV post CVA events 65 following AMI � Stroke � 25 -50% � CV post CVA events � 65% following AMI](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-14.jpg)
� Stroke � 25 -50% � CV post CVA events � 65% following AMI � 50% s/p CABG � Orthopedic Surgeries � 20% s/p THR � 28% s/p TKA
![Late life depression Major depressive episode occurring for first time in an older Late life depression � Major depressive episode occurring for first time in an older](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-15.jpg)
Late life depression � Major depressive episode occurring for first time in an older person � Usually >50 or 60 years of age � Consider degree of impairment � Concurrent medical problems � Lower functional expectations
![Similar to Adult ss but could include More Somatic or physical cc � Similar to Adult s/s but could include � More Somatic or physical c/c](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-16.jpg)
� Similar to Adult s/s but could include � More Somatic or physical c/c GI most frequent � More likely to accept “unhappiness” “I’m old. . what do you except” � Irritability � Increasing fatigue or loss of energy Symptoms � Affective �State of mind � Cognitive �Slow and Low � Somatic �Either side of normal
![Do you often feel sad or depressed “Do you often feel sad or depressed? ”](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-17.jpg)
“Do you often feel sad or depressed? ”
![92 Sensitivity 81 Specificity 93 Sensitivity 97 Specificity 92% Sensitivity 81% Specificity 93% Sensitivity 97% Specificity](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-18.jpg)
92% Sensitivity 81% Specificity 93% Sensitivity 97% Specificity
![I think Im blue Im fine just a little to much thinking 1 2 “I think I’m blue” “I’m fine, just a little to much thinking” 1. 2.](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-19.jpg)
“I think I’m blue” “I’m fine, just a little to much thinking” 1. 2. 3. 4. Hx of Dysthymia Is this the First Episode Abulia Demoralization
![Talk TherapyGroup RX SSRI Escitalopram Start 5 mg PO daily Talk Therapy/Group RX � � SSRI � � Escitalopram Start 5 mg PO daily](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-20.jpg)
Talk Therapy/Group RX � � SSRI � � Escitalopram Start 5 mg PO daily Max 10 mg PO daily � Mild-Mod Renal no adjustments Citalopram Start 10 mg PO daily Max 20 mg PO daily � Mild-Mod Renal no adjustments � p. QTi Hyponatremia SNRI � If Chronic pain priority Venlafaxine � Start 37. 5 mg � Max 225 mg severe 375 mg � � Cr. CL 10 -70 25 -50% Cr. CL <10 by 50% Other � If sleep and appetite are priority Miratazpine � Start 7. 5 mg at HS � Max 150 mg at HS � � � Renal not defined Do not use concurrent with benzos If SSRI are contraindicated or can use in addition Buproprion SR � Start 75 mg PO daily � Max 150 mg in divided doses � � Seizure Renal How long? The treatment that gets someone well is the treatment that will keep that person well.
![Late Life Depression Rx Patient specific Use recommended Mo CA Prodromal � Late Life Depression � Rx �Patient specific �Use recommended �Mo. CA �Prodromal �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-21.jpg)
� Late Life Depression � Rx �Patient specific �Use recommended �Mo. CA �Prodromal � Medication to AD Review � H&P � Sensory Evaluation � Pain Evaluation � Risk vs Benefit � Metanaylsis �Many studies=good efficacy of 55 & older (P=0. 0001) �When mean age >65 years decreased efficacy (P=0. 265)
![Portion of Executive Function Lack of ambition or drive Lack in � Portion of Executive Function � Lack of ambition or drive � Lack in](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-22.jpg)
� Portion of Executive Function � Lack of ambition or drive � Lack in ability to be a self starter � Research has found that no amount of antidepressant medications makes a meaningful amount of improvement �most time using max dose with increase s/e � Some research in buproprion � Keep busy �Hobbies �Adult Daycares �Volunteer positions
![Psychological distress that involves hopelessness helplessness loss of purpose and meaning and existential � Psychological distress that involves hopelessness, helplessness, loss of purpose and meaning, and existential](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-23.jpg)
� Psychological distress that involves hopelessness, helplessness, loss of purpose and meaning, and existential distress � Progressive � Cancer Disease � Approximately 71% with demoralization did not meet criteria for depression � Cancer � High Spirituality � Anxiety � Loneliness � Must thoroughly � Talk Therapy � CBT assess for depression
![Increased Morbidity Increase Mortality Slow recovery from surgeryillnessfalls Malnutrition � Increased Morbidity � Increase Mortality � Slow recovery from surgery/illness/falls � Malnutrition �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-24.jpg)
� Increased Morbidity � Increase Mortality � Slow recovery from surgery/illness/falls � Malnutrition � Social isolation � Increase substance abuse � Suicide
![65 years make up 12 of population But are 18 of � >65 years make up 12% of population � But � are 18% of](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-25.jpg)
� >65 years make up 12% of population � But � are 18% of all suicides 15 : 100, 000 >65 years attempted suicide � 75. 4 million baby boomers � 11, 000 lives lost from suicide � 20% provider the day they die 40% the week they die 70% in the month they die � Depression is TREATABLE � � � 80% clinical dx can be effectively treated
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-26.jpg)
![Syndrome of sudden deterioration of mental function Triggered by illness Body Brain � Syndrome of sudden deterioration of mental function � Triggered by illness �Body �Brain](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-27.jpg)
� Syndrome of sudden deterioration of mental function � Triggered by illness �Body �Brain �Acute injury �Drug intoxication
![Mortality rates 22 76 as high as MI or sepsis Up to 75 will Mortality rates 22 -76% as high as MI or sepsis!!! Up to 75% will](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-28.jpg)
Mortality rates 22 -76% as high as MI or sepsis!!! Up to 75% will die within 3 years of delirium Misdiagnosed 66%
![Old School Thinking New Research Ach Deficiency Abnormal Immune Physiologic Stress Acute ss Treatment Old School Thinking New Research Ach Deficiency Abnormal Immune Physiologic Stress Acute s/s Treatment](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-29.jpg)
Old School Thinking New Research Ach Deficiency Abnormal Immune Physiologic Stress Acute s/s Treatment Resolve Resume Life Unhealthy Brain in Unhealthy Body Acute BUT Can be prolonged And segway into dementia
![Male Advanced Whose age 60 Cognitive Impairment Depression � Male � Advanced � Whose age >60 � Cognitive Impairment � Depression �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-30.jpg)
� Male � Advanced � Whose age >60 � Cognitive Impairment � Depression � Vision & Hearing impairments at risk? �Community 8 -17% dwellers �LTC 60% residents >75 yrs �Hospitalization 50% will develop � 15 -53% post op � 70 -80% ICU
![Predisposing Precipitating Perpetuating MCI Sepsis Increase sedation Dementia Surgery Restraints Comorbidities Drugs Age Hospitalization Predisposing Precipitating Perpetuating MCI Sepsis Increase sedation Dementia Surgery Restraints Comorbidities Drugs Age Hospitalization](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-31.jpg)
Predisposing Precipitating Perpetuating MCI Sepsis Increase sedation Dementia Surgery Restraints Comorbidities Drugs Age Hospitalization Frailty Foley IV
![Dehydration Malnutrition Immobility Infection Constipation Psychoactive medications Disorienting environment Acute metabolic disturbance Trauma Hypoxia �Dehydration �Malnutrition �Immobility �Infection �Constipation �Psychoactive medications �Disorienting environment �Acute metabolic disturbance �Trauma �Hypoxia](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-32.jpg)
�Dehydration �Malnutrition �Immobility �Infection �Constipation �Psychoactive medications �Disorienting environment �Acute metabolic disturbance �Trauma �Hypoxia �ETOH/drug w/d
![Acute onset Within hours or days Fluctuating course Poor attention � Acute onset �Within hours or days � Fluctuating course � Poor attention �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-33.jpg)
� Acute onset �Within hours or days � Fluctuating course � Poor attention � Disorganized thinking � Alerted LOC
![Hyperactive Mixed Hypoactive Most Overlooked MOST DEADLY 30 10 60 Hyperactive Mixed Hypoactive Most Overlooked MOST DEADLY 30% 10% 60%](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-34.jpg)
Hyperactive Mixed Hypoactive Most Overlooked MOST DEADLY 30% 10% 60%
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-35.jpg)
![Say the months of the year backwards SAVEAHAART Alert Vigilant Lethargic Stuporous Will “Say the months of the year backwards? ” SAVEAHAART Alert Vigilant Lethargic Stuporous Will](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-36.jpg)
“Say the months of the year backwards? ” SAVEAHAART Alert Vigilant Lethargic Stuporous Will a stone float on water? Are there fish in the sea? Do 2 lbs weigh more than 1 lb? Can you use a hammer to cut wood? 94% sensitivity 89% specificity
![Out Patient Restorative care Treat pain minimize opioids Hunger Thirst Sensory aids Safety � Out Patient �Restorative care �Treat pain minimize opioids �Hunger �Thirst �Sensory aids �Safety](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-37.jpg)
� Out Patient �Restorative care �Treat pain minimize opioids �Hunger �Thirst �Sensory aids �Safety in Environment �Medicine reviews 30 -40% cases can be prevented Opioids Cholinergic drugs �Cognitive � Hospitals protocols Stimulation now have http: //www. americangeriatrics. org/files /documents/beers/Printable. Beers Pocket. Card. pdf
![Identify treat acute illness Hyperactive Use medication only if � Identify treat acute illness � Hyperactive � � � Use medication only if](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-38.jpg)
� Identify treat acute illness � Hyperactive � � � Use medication only if safety is compromised Low & Short � Start low � Use for short periods of time Haloperidol 0. 5 mg PO or IM � � Can repeat PO q 4 hrs IM q 1 Quetiapine 25 mg HS � PD � dementia
![Upon hospital discharge 47 still meet criteria of delirium 1 � Upon hospital discharge : � 47% still meet criteria of delirium � 1](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-39.jpg)
� Upon hospital discharge : � 47% still meet criteria of delirium � 1 month 33% � 3 months 26% � 6 months 21% � 2 years 55% of community dwellers will have dementia dx
![Increase risk of dementia in prolonged states Death Earlier LTC admission � Increase risk of dementia in prolonged states � Death � Earlier LTC admission](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-40.jpg)
� Increase risk of dementia in prolonged states � Death � Earlier LTC admission � Increase length of hospital stay �Progression to Dementia 65% vs 10% �Risk of not staying in home 33% vs 10% �Progression 38% vs 26% to death
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-41.jpg)
![1128 65 years old 50 80 years old AD is 60 80 11%-28% >65 years old � 50% >80 years old � AD is 60 -80%](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-42.jpg)
11%-28% >65 years old � 50% >80 years old � AD is 60 -80% of dementias � 2017 5. 5 mil Americans � Every 66 seconds some is dx with AD � 6 th leading cause of death � 1: 3 will seniors die from AD or other dementias � AD kills more than breast and prostate cancer combined � 35% of caregivers report their own worsening health after caring for their loved one with AD compared to 19% of loved ones w/o AD �
![MCImore likely to develop AD or other dementia 15 20 65 � MCI=more likely to develop AD or other dementia � 15 -20% � >65](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-43.jpg)
� MCI=more likely to develop AD or other dementia � 15 -20% � >65 years MCI does not always lead to dementia.
![15 may convert to dementia FORD Finances Orientation Repeat questions Direction � 15% may convert to dementia � FORD �Finances �Orientation �Repeat questions �Direction](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-44.jpg)
� 15% may convert to dementia � FORD �Finances �Orientation �Repeat questions �Direction
![Normal Aging Harder to recall info Forget names New acquaintances Normal Aging � Harder to recall info � Forget names � New acquaintances �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-45.jpg)
Normal Aging � Harder to recall info � Forget names � New acquaintances � Unable � Will � Walk to recall word remember later into room…. what did I come for � Forget were you put things Dementia � Memory impairs ability to function
![Decline in Brain function leading to disruption in daily functioning Deficits Memory � Decline in Brain function leading to disruption in daily functioning Deficits � Memory](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-46.jpg)
� Decline in Brain function leading to disruption in daily functioning Deficits � Memory impairment � Language � Visuospatial � Executive function � Lack of insight � Decline in social function
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-47.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-48.jpg)
![Cognitive disability before memory impairment � Cognitive disability before memory impairment](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-49.jpg)
� Cognitive disability before memory impairment
![Age HTN HLD T 2 DM Obesity Elevated � Age � HTN � HLD � T 2 DM � Obesity � Elevated](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-50.jpg)
� Age � HTN � HLD � T 2 DM � Obesity � Elevated levels of inflammatory markers � MCI � 50% Down Syndrome
![Ask Patient Memory Worse Lost Repeat Help with ADLs � Ask Patient � Memory Worse? � Lost? � Repeat? � Help with ADLs?](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-51.jpg)
� Ask Patient � Memory Worse? � Lost? � Repeat? � Help with ADLs? � Animal recall 60 secs 15 animals 4 items recall & read � <21 Insensitive to short-term memory 87% sensitive 82% specificity Ask Caregivers � What Boo’s? Has there been any consequences for memory loss? � Would you feel comfortable leaving your loved one for 1 month? � What are your doing now that you were not doing 6 mths ago? 24 -26/30 88 -100% Sensitivity 86% Specificity
![CMP CBC CTMRI TSH FT 4 Folate Vitamin B � � � � � CMP CBC CT/MRI TSH FT 4 Folate Vitamin B](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-52.jpg)
� � � � � CMP CBC CT/MRI TSH FT 4 Folate Vitamin B 12 UA/culture Vitamin D 25 -OH Patient specific according to risks RPR � HIV � LP if suspicious for meningitis or Ca � CSF tap for NPH �
![Symptomatic Behavioral disturbances Support function Provide for safety Exercise � Symptomatic � Behavioral disturbances � Support function � Provide for safety � Exercise](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-53.jpg)
� Symptomatic � Behavioral disturbances � Support function � Provide for safety � Exercise � OT � Discuss palliative/hospice care � Try to maintain normality � Teach family � Do not try to reorient not argue � Community Resources � GPS tracker Educate!!!! Communicate!!!
![ACh EI Prevent breakdown of acetylcholine Donepezil start 5 mg PO HS � ACh. EI � Prevent breakdown of acetylcholine �Donepezil start 5 mg PO HS](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-54.jpg)
� ACh. EI � Prevent breakdown of acetylcholine �Donepezil start 5 mg PO HS and titrate up to 10 mg �Rivastigmine 1. 5 mg PO BID 3 mg careful with titration in <50 kg 4. 6 mg/24 hrs Every 4 weeks max 9. 5 mg/24 h � NMDA-receptor antagonist � Selectively block excitotixic effects of abnormal transmission of glutamate �Memantine When Ch. EI contraindicated 5 mp PO daily Weekly titration to 20 mg in divided doses � Combinations �ACh. EI +Memantine advanced disease �MMSE <14 Mo. CA <14
![ASA Women Estrogen replacement No Unconvincing evidence Bleeding � ASA � Women � Estrogen replacement � No � � Unconvincing evidence Bleeding](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-55.jpg)
� ASA � Women � Estrogen replacement � No � � Unconvincing evidence Bleeding Vitamin B and D � Medical food no clear evidence Ginkgo biloba � No benefit Axona � effect may increase incidence of dementia Cox-2 inhibitors � less cognitive decline ? Conflicting evidence for Testosterone Omeg-3 fatty Not effective
![Agitation Aberrant motor behavior Anxiety Elation Irritability Depression � Agitation � Aberrant motor behavior � Anxiety � Elation � Irritability � Depression](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-56.jpg)
� Agitation � Aberrant motor behavior � Anxiety � Elation � Irritability � Depression � Apathy � Disinhibition � Delusions & hallucinations � Sleep or appetite changes.
![Cognitiveemotionoriented interventions reminiscence therapy validation therapy Sensory stimulation interventions � Cognitive/emotion-oriented interventions � reminiscence therapy � validation therapy � Sensory stimulation interventions �](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-57.jpg)
� Cognitive/emotion-oriented interventions � reminiscence therapy � validation therapy � Sensory stimulation interventions � Acupuncture � Aromatherapy � light therapy � massage/touch � music therapy � Behavior management techniques � Other psychosocial interventions � animal-assisted � exercise. therapy
![CNS Depression CNS Depression](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-58.jpg)
CNS Depression
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-59.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-60.jpg)
![](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-61.jpg)
![Akgün K M Crothers K Pisani M 2012 Epidemiology and � Akgün, K. M. , Crothers, K. , & Pisani, M. (2012). Epidemiology and](https://slidetodoc.com/presentation_image/2af4ad42a15117bfb47b05061749e95b/image-62.jpg)
� Akgün, K. M. , Crothers, K. , & Pisani, M. (2012). Epidemiology and Management of Common Pulmonary Diseases in Older Persons. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 67 A(3), 276– 291. http: //doi. org/10. 1093/gerona/glr 251 � Alz. org. Alzheimers Association. (2018). 2017 AD facts and figures. https: //www. alz. org/facts/ � Cerejeira, J. , Lagarto, L. , & Mukaetova-Ladinska, E. B. (2012). Behavioral and Psychological Symptoms of Dementia. Frontiers in Neurology, 3, 73. http: //doi. org/10. 3389/fneur. 2012. 00073 � Conwell, Y. , Van Orden, K. , & Caine, E. D. (2011). Suicide in Older Adults. The Psychiatric Clinics of North America, 34(2), 451– 468. http: //doi. org/10. 1016/j. psc. 2011. 02. 002 � Drummond, D. (2014). The Aging Brain: Dementia, Delirium and Depression. https: //www. youtube. com/watch? v=Aj. QQkx-zw 4 A � D'Souza, G. , Kakoullis, A. , Hegde, N. , Tadros, G. (2010). Recognition and management of abulia in the elderly. � Fiske, A. , Wetherell, J. L. , & Gatz, M. (2009). Depression in Older Adults. Annual Review of Clinical Psychology, 5, 363– 389. http: //doi. org/10. 1146/annurev. clinpsy. 032408. 153621 � Fong, T. G. , Tulebaev, S. R. , & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews. Neurology, 5(4), 210– 220. http: //doi. org/10. 1038/nrneurol. 2009. 24 � Frank, Christopher. (2014). Pharmacologic treatment of depression in the elderly. Canadian Family Physician, 60, 121 -126. � Leth-Møller, K. B. , Hansen, A. H. , Torstensson, M. , Andersen, S. E. , Ødum, L. , Gislasson, G. , … Holm, E. A. (2016). Antidepressants and the risk of hyponatremia: a Danish register-based population study. BMJ Open, 6(5), e 011200. http: //doi. org/10. 1136/bmjopen-2016 -011200 � Manning, et al. (2013). Delirium. (2 nd ed. ) Stiriling: University of Striling/Hammond Press � National Alliance on Mental Health. (2009). Depression in Older Persons. https: //www. ncoa. org/wpcontent/uploads/Depression_Older_Persons_Fact. Sheet_2009. pdf � Tedeschini E. , Levkovitz, Y. , Lovieno, N. , Ameral, V. E. , Nelson, J. C. , Papkostas, G. I. (2011). Efficacy of antidepressants for late-life depression: a meta-analysis and meta-regression of placebo-controlled randomized trials. Journal of Clinical Psychiatry. Dec; 72(12 ): 1660 -8. doi: 10. 4088/JCP. 10 r 06531. � Robinson, S, , BPsych(Hons), Kissane, D. , Franz, C. P. , Brooker, J. , Burney, S. (2015) Systematic Review of the Demoralization Syndrome in Individuals With Progressive Disease and Cancer: A Decade of Research. Journal of Pain Symptom Management. (49)3, 595 -610. � Swaffer, K. (2016). Living beyond dementia. https: //livingbeyonddementia. com/tag/author-kate-swaffer 2016/ � Xue, Q. -L. (2011). The Frailty Syndrome: Definition and Natural History. Clinics in Geriatric Medicine, 27(1), 1– 15. http: //doi. org/10. 1016/j. cger. 2010. 08. 009 Progression in Neurology and Psychiatrics, Volume 14, Issue 6, November/December, p. 4– 28. DOI: 10. 1002/pnp. 178
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