Assessing and Treating Dementia with Delirium and Depression Cathleen Carney, M.A., CCC-SLP Speech Language Pathologist, R...
<ul><li>“ The geriatric patient with dementia who also presents with delirium or depression has specific challenges and ne...
Objectives: <ul><li>The participant will be able to: </li></ul><ul><ul><li>identify the symptoms, behaviors, and character...
Definitions from DSM <ul><li>Delirium </li></ul><ul><ul><li>Is a major mental disorder that is a direct physiological cons...
Delirium <ul><li>Direct physiological consequence of a medical condition that is characterized by disruptions in conscious...
Delirium <ul><li>Acute confusion and dementia: </li></ul><ul><ul><li>Used interchangeably </li></ul></ul><ul><li>Acute con...
Definition from DSM <ul><li>Depression </li></ul><ul><ul><li>The most common psychiatric disorder among older people;  </l...
Depression: Situations associated with Depression <ul><li>Retirement </li></ul><ul><li>Multiple role losses </li></ul><ul>...
Medical conditions associated with late life depression <ul><li>Cardiac and vascular conditions </li></ul><ul><ul><li>Myoc...
Depression <ul><li>The most common mental health problem confronting older adults. </li></ul><ul><li>Symptoms of a major d...
Classification of Depression <ul><li>5 or more of the symptoms </li></ul><ul><ul><li>One, of which must be depressed mood ...
Classification of Depression <ul><li>50% of older adults who have a chronic physical illness may also have major depressiv...
What Is Dementia? <ul><li>The onset is usually insidious </li></ul><ul><li>Cognitive deficits are losses of memory, langua...
DSM-IV, Dementia <ul><li>Characterized by memory impairment and at least one of the following cognitive difficulties – aph...
Definition from DSM <ul><li>Dementia </li></ul><ul><ul><li>A major mental disorder characterized by memory impairment (whi...
Dementia: Changes in appearance <ul><ul><li>Newly stooped posture </li></ul></ul><ul><ul><li>Slowing of movement </li></ul...
Dementia: Changes in Behavior & Activity Level <ul><li>Decrease in social participation </li></ul><ul><li>Increase in isol...
Early Symptoms of Dementia: Alzheimer’s Disease Slow, widespread, progressive symptoms <ul><li>Neurological/Cognitive </li...
Early Symptoms of Dementia: Vascular Dementia <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Acute unilateral motor ...
Early Symptoms of Dementia: Dementia of the frontal lobe type  & Pick’s disease <ul><li>Neurological/cognitive </li></ul><...
Early Symptoms of Dementia:  Dementia with Parkinsonism <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Rigidity and ...
Early Symptoms of Dementia:  Hydrocephalus <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Gait disorder </li></ul></...
Criteria for determining Dementia <ul><li>Syndrome: </li></ul><ul><ul><li>Decline in cognitive functions in comparison wit...
Criteria for determining probable Alzheimer’s disease <ul><li>MMSE,  </li></ul><ul><li>Blessed Dementia Scale </li></ul><u...
Medical Workup for Dementia Tumor, subdural hematomas, abscess, stroke, or hydrocephalus Neuroimaging studies: CT or MRI A...
Symptoms of Depression & Dementia Impaired executive function (e.g. organization, prioritization) Impaired decision making...
Symptoms of Depression & Dementia Impaired orientation Intact or impaired orientation Orientation Trouble finding words an...
Symptoms of Depression & Dementia Dementia Depression Possible high scores or low scores Possible high scores Depression s...
Depression and Dementia <ul><li>Symptoms of depression and dementia may overlap or occur as co-morbidities with other medi...
Depression and Dementia <ul><li>Cognitive decline becomes increasingly common with advancing age. </li></ul><ul><ul><li>5-...
Depression and Dementia <ul><li>Tests that differentiate between cognitive impairment and depression should be administere...
Depression and Dementia <ul><li>The presence of physical illness in later life increases the likelihood of emotional probl...
Diagnostic Workup for Late Life Depression <ul><li>Psychological history </li></ul><ul><li>Mental Status (cognitive) scree...
Statements That May Be Indicative Of Depression <ul><li>I’m not the person I used to be. </li></ul><ul><li>I can’t manage ...
Alterations in thought processes: characteristics of client behavior - <ul><li>Disorientation to time, place, person </li>...
Dementia, Depression, Delirium Treatable, usually resolvable Progressive, manageable Episodic, treatable, resolvable Cours...
Dementia, Depression, Delirium May be harbinger of medical illness Can flag life-threatening emergency Requires prompt med...
Assessment Tools <ul><li>Be familiar with the strengths, weaknesses and accuracy of any tool. </li></ul><ul><li>Determine ...
Mini Mental State Examination <ul><li>MMSE </li></ul><ul><ul><li>Used by 90% of physicians </li></ul></ul><ul><ul><li>Reco...
Mini Mental Status Exam (MMSE) <ul><li>Section 1: Orientation </li></ul><ul><ul><li>What is the day of the week? </li></ul...
Short Portable Mental Status Questionnaire <ul><li>SPMSQ </li></ul><ul><ul><li>Less than 2 errors, normal mental function ...
THE SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE  <ul><li>1. What are the date, month, and year?  </li></ul><ul><li>2. What ...
Cognitive Functioning Instruments <ul><li>MMSE </li></ul><ul><ul><li>will not detect mild cognitive impairment </li></ul><...
Functional Assessment Staging Tool <ul><li>FAST- </li></ul><ul><ul><li>Is for distribution to the family </li></ul></ul><u...
Wechsler Memory Scale <ul><ul><li>Broad range of memory functions </li></ul></ul><ul><ul><li>Sensitive to more subtle chan...
Global Deterioration Scale (GDS) <ul><ul><li>Gives overall picture of the disease process </li></ul></ul><ul><ul><li>Able ...
Global Deterioration Scale (GDS) <ul><li>GDS Stage 1:  Normal Phase  </li></ul><ul><li>GDS Stage 2:  Forgetful Phase </li>...
Some other commonly used  cognitive assessment instruments <ul><li>Arizona Battery of Communication Disorders </li></ul><u...
Depression Instruments <ul><ul><li>Tools do not establish a diagnosis of depression but are important in identifying clien...
Geriatric Depression Scale <ul><ul><li>Includes a broad range of depression mood questions </li></ul></ul><ul><ul><li>Quic...
<ul><li>GERIATRIC DEPRESSION SCALE (GDS, SHORT FORM)   </li></ul><ul><li>Choose the best answer for how you felt over the ...
Hamilton Depression Scale <ul><ul><li>Assesses objective symptoms </li></ul></ul><ul><ul><li>Can estimate severity of depr...
Beck Depression Inventory <ul><ul><li>Self Rating scale </li></ul></ul><ul><ul><li>Assesses symptoms of depression </li></...
www.americangeriatrics.org/education/depression.shtml
Treatment of Delirium <ul><li>Identify and treat the underlying cause </li></ul><ul><li>Provide a stable environment </li>...
Treatment of Depression <ul><li>Social treatment  </li></ul><ul><ul><li>therapy </li></ul></ul><ul><li>Psychopharmacologic...
Treatment of Depression <ul><li>Communication Strategies: </li></ul><ul><ul><li>Listen. </li></ul></ul><ul><ul><li>Recogni...
Treatment of Dementia <ul><li>Behavioral & Environmental </li></ul><ul><li>Encourage appropriate behavior </li></ul><ul><l...
Treatment of Dementia <ul><li>Patient, Family, Caregiver education and support </li></ul><ul><li>Assess for and manage dep...
<ul><li>Clinicians working in nursing homes and retirement communities, where the population is generally over the age of ...
Our challenge… <ul><li>Facilitate communication. </li></ul><ul><li>Slow the progression or impact of functional decline. <...
Questions ???
 
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  • Depression is often related to life event changes, such as: 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
  • Depression is the most common mental health problem confronting older adults. DSM-IV criteria for depression vary as a function of the severity and frequency of the symptoms. Symptoms of major depressive disorder: Depressed mood that is either reported by the individual or observed by others Diminished interest in/pleasure in activities Weight loss or weight gain of 5 percent of body weight within a month without trying to lose/gain Insomnia or hypersomnia Psychomotor retardation or agitation that is observable by others. Fatigue or loss of energy Feelings of worthlessness or guilt Diminished ability to concentrate or indecisiveness Recurrent thoughts of death or a suicidal ideation In order to be classified as a major depressive disorder, the individual must exhibit 5 or more of the symptoms – one of which must be depressed mood or diminished interest. The symptoms have to have lasted for greater than two weeks – represent an departure from previous functioning and result in impaired social, occupational functioning. There must be no evidence that the symptoms are due to the physiological effects of a substance, a general medical condition or bereavement over the loss of a loved one.
  • In order to be classified as a major depressive disorder, the individual must exhibit 5 or more of the symptoms – one of which must be depressed mood or diminished interest. The symptoms have to have lasted for greater than two weeks – represent a departure from previous functioning and result in impaired social, occupational functioning. There must be no evidence that the symptoms are due to the physiological effects of a substance, a general medical condition or bereavement over the loss of a loved one. The lifetime risk for developing depression is 20 to 25% The risk factor of depression include being female, being unmarried, widowed or recently bereaved; experiencing various stressful life events, and having lower levels of support socially. A serious physical illness also increases the risk. 50% of older adults who have a chronic physical illness may also have major depressive disorder.
  • Depression negatively impacts quality of life, functionality, physical health status, longevity, relationships. Depression causes “excess disability” complicating the illness, slowing the recovery, compromising rehabilitation and other interventions. Depression is often responsible for resistance to care, inconsistency of course and negativity. It also causes excess pain and suffering.
  • The onset of dementia is usually insidious Cognitive deficits are losses of memory, language, executive function, visuospatial ability Compartmental changes are alterations in personality, insight, judgment. Compartmental functions help person behave appropriately in social settings, make reasonable decisions and plan, organize and follow a logical sequence of steps to reach goals. These changes eventually impair IADLS and ADL skills – in addition to decline in brain function there may be changed in social psychological environment and patterns of relationship and interaction.
  • According to the DSM-IV, dementia is characterized by memory impairment and at least one of the following cognitive difficulties: aphasia, apraxia, agnosia, disruption in executive function Additional criteria to meet diagnosis and that these symptoms must be characterized by gradual onset and continuing decline, represent a significant decline from previous levels of functioning and be severe enough to impair social and or occupational functioning. Thee symptoms must not occur during course of a delirium. The lifetime risk for developing dementia is 14 to 16%. Females are at greater risk than males and African Americans are at greater risk than whites (Caucasians?) .
  • Dementia is characterized by 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
  • Dementia is also characterized by changes in Behavior: Decrease in social participation Increase in isolation and social withdrawal Decreased interest in things Difficulty with decision making Difficulty concentrating Unusual negativism Hopelessness and Activity level: 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
  • Should be familiar with the strengths, weaknesses and accuracy of any tool. Prior to choosing which instrument to use, it is necessary to determine what the goals of the assessment are.
  • The most commonly used and most thoroughly researched screening test for dementia is the Mini Mental State Examination (MMSE). It is used by 90% of the physicians and is recommended by the National Institute of Neurological and Communicative Disorders. It is the test against which other cognitive assessment tools are compared in validation tests. It is relatively quick to administer and requires no special equipment other than pencil and paper. - A brief, quantitative measure of cognitive status in adults. A score of 23 or lower out of 30 possible is indicative of cognitive impairment. Test, re-test reliability ranges from 0.80 to .90. The MMSE has been found to have convergent validity with other cognitive tests and with functional measures. Sensitivity of 85% or better has been found in clients with dementia. Research has shown that the MMSE can distinguish between depressed clients, clients with dementia and clients with both depression and dementia.
  • The MMSE is copyrighted and now available from the Psychological Assessment Resources.
  • Short Portable Mental Status Questionnaire (SPMSQ) asks 10 questions with each error scored as one point. Intact mental function is indicated by less than 2 errors and severe mental impairment by 8 to 10 errors. Scoring is adjusted for educational level. When used as a screening tool for dementia in 60 years and older population, the questionnaire has sensitivity of 95% and a specificity of 88% accuracy.
  • The Functional Assessment Staging Tool (FAST) is for distribution to the family. It provides specific information on the order in which various functions are lost. It also provides time frame estimates so they can have an approximate idea of how long given level of function will last.
  • The Global Deterioration Scale defines 7 stages in the course of dementia with observational criteria. This is a familiar tool to many therapists and most nurses. It allows the entire interdisciplinary team to speak the same language regarding the patient’s cognitive status. Developed by Barry Reisberg, MD Dementia is a process that spans over approximately 8 to 10 years.
  • GDS Stage 1: Normal Phase – no subjective complaints of memory deficit. Most of us are normal, follow multiple directions, complete a task following a sequence. GDS Stage 2: Forgetful Phase – Subjective complaints of memory deficit. Similar to you and I when we’re having a bad day or we’re under a lot of stress. GDS Stage 3: Early Confusional Phase – Earliest clear cut deficits. Decreased performance in demanding employment and social setting. Objective evidence of memory deficit obtained only with an intensive interview – Mild to moderate anxiety GDS Stage 4: Late Confusional Phase – clear cut deficit on clinical interview. Inability to perform complex tasks – Denial is dominant defense mechanism. Flattening affect and withdrawal from challenging situations. – the last stage where we can continue to gain new knowledge. Difficulty concentrating, poor historian, may encounter a lot of refusals in therapy. GDS Stage 5: Early Dementia – Persons can no longer survive without some assistance. Persons are unable to recall a major relevant aspect of their current lives. Persons retain knowledge of many major facts regarding themselves and others - They know their spouses and children’s names. They require no assistance with toileting or eating but may have difficulty choosing the proper clothing to wear. – live in the immediate GDS Stage 6: Middle Dementia – May occasionally forget the name of the spouse – Will be largely unaware of all recent events and experiences. Will require some assistance with ADLS. Personal and emotional changes occur. They search for the familiar, resist unfamiliar. 20-505 will have delusions or hallucinations. May be able to respond to simple yes/no ?s regarding comfort, Will need to teach caregivers to be observant of behaviors, facial expression, body language, etc. Loss of peripheral vision – attend to what is in front. GDS Stage 7: Late Dementia – All verbal abilities are lost. May be not speech at all, just grunting – perhaps with expression . Incontinent of urine, requires assistance toileting and feeding. Loses basis psychomotor skills. These patients are dependent on others for survival. Dysphagia issues – advance directives will determine the approaches at this level – a patient may require tube feeding.
  • Check out the exhibit hall where you can find most of these tools and many others.
  • The primary treatment strategy is to identify and treat the underlying cause and provide a predictable stable environment for the person who suffers from delirium. Minimize excessive sensory stimulation (sound, light). A physical condition may present as confusion or dementia rather than the symptoms commonly seen in the younger age groups. For this reason, no matter what the presentation, a head to toe systems approach is necessary when physically assessing the older person. Also an RN or medical professional needs to perform a medication review, checking for side affects, use of outdated medications, interactions of over the counter medications or prescriptions from multiple physicians. Also, need for ascertain if medications are being taken as prescribed or if client is forgetting or making changes in the frequency of medications because they do not understand the directions, medications are expensive or because medication has side affects.
  • It’s always important when working with someone with dementia to monitor/assess for depression and delirium. If the dementia is related to the depression or delirium, once you treat that, the dementia clears. Treatment for dementia will follow different patterns specific to the disease resulting in the dementia (HIV, substance abuse, Alzheimer’s type, etc,) Treatment approaches will change throughout the progression of the disease. Because there is no cure for dementia, one of the treatment strategies typically centers on behavioral and environmental. Interventions are designed to encourage appropriate behavior, minimize the inappropriate behavior, maintain current levels of functioning, and ensure the safety of the individual with the diagnosis. When treating the patient with dementia, or any patient for that matter, it’s important to know their cognitive capacities and limitations and to identify the environmental factors that can be modified to enable successful participation in life’s activities. Treatment strategies also revolve around providing family caregivers with the educational and emotional support necessary for them to sustain care giving efforts.
  • Pharmacologic treatment might include medications such as antidepressants, Benzodiazepines (which may have an adverse effect), cholinesterase inhibitors – such as aricept, nemenda (which prolong the ability to function but do not cure the disease).
  • ???
  • PPT

    1. 1. 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
    2. 2. <ul><li>“ 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.” </li></ul>
    3. 3. Objectives: <ul><li>The participant will be able to: </li></ul><ul><ul><li>identify the symptoms, behaviors, and characteristics of dementia, delirium and depression. </li></ul></ul><ul><ul><li>determine the appropriate assessment protocol for evaluation of the patient with dementia and its comorbidities. </li></ul></ul><ul><ul><li>provide functional goals and appropriate treatment techniques based on assessment objectives. </li></ul></ul>
    4. 4. Definitions from DSM <ul><li>Delirium </li></ul><ul><ul><li>Is a major mental disorder that is a direct physiological consequence of a medical condition. </li></ul></ul><ul><ul><li>Usually characterized by disruptions in consciousness and change in cognitive abilities or perceptual difficulties that are not due to a dementia. </li></ul></ul><ul><ul><li>Develops over a short period of time (usually within hours or a day) and fluctuates over the course of a day. </li></ul></ul>
    5. 5. Delirium <ul><li>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. </li></ul>
    6. 6. Delirium <ul><li>Acute confusion and dementia: </li></ul><ul><ul><li>Used interchangeably </li></ul></ul><ul><li>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. </li></ul><ul><li>Characterized by: </li></ul><ul><ul><li>Acute onset </li></ul></ul><ul><ul><li>Marked fluctuations in cognitive impairment over course of the day </li></ul></ul><ul><ul><li>Disruptions in consciousness and attention </li></ul></ul><ul><ul><li>Alterations in sleep cycle. </li></ul></ul><ul><ul><li>Hallucination and delusion are common. </li></ul></ul><ul><ul><li>Infection or drug toxicity typically cause acute confusion. </li></ul></ul>
    7. 7. Definition from DSM <ul><li>Depression </li></ul><ul><ul><li>The most common psychiatric disorder among older people; </li></ul></ul><ul><ul><li>it can vary in duration and degree and </li></ul></ul><ul><ul><li>show psychological as well as physiological manifestations. </li></ul></ul>
    8. 8. Depression: Situations associated with Depression <ul><li>Retirement </li></ul><ul><li>Multiple role losses </li></ul><ul><li>Bereavement </li></ul><ul><li>Deaths of family members and friends </li></ul><ul><li>Loneliness and isolation </li></ul><ul><li>Responsibility for care of an older person with a disability </li></ul><ul><li>Residence in a nursing home </li></ul><ul><li>Elder abuse </li></ul><ul><li>Neglect </li></ul><ul><li>Substance abuse </li></ul>
    9. 9. Medical conditions associated with late life depression <ul><li>Cardiac and vascular conditions </li></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Cerebrovascular accident </li></ul></ul><ul><li>Neurological conditions </li></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Parkinson’s disease </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><li>Sensory impairments </li></ul><ul><ul><li>Vision Impairments </li></ul></ul><ul><ul><li>Hearing decrements </li></ul></ul><ul><li>Physical disabilities </li></ul><ul><ul><li>Hip fracture </li></ul></ul><ul><ul><li>Loss of mobility </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><li>Other medical conditions </li></ul><ul><ul><li>Acute pain </li></ul></ul><ul><ul><li>Chronic pain </li></ul></ul>
    10. 10. Depression <ul><li>The most common mental health problem confronting older adults. </li></ul><ul><li>Symptoms of a major depressive disorder: </li></ul><ul><ul><ul><li>Depressed mood </li></ul></ul></ul><ul><ul><ul><li>Diminished interest in / pleasure in activities </li></ul></ul></ul><ul><ul><ul><li>Weight loss or weight gain of 5% within a month </li></ul></ul></ul><ul><ul><ul><li>Insomnia or hypersomnia </li></ul></ul></ul><ul><ul><ul><li>Psychomotor retardation or agitation </li></ul></ul></ul><ul><ul><ul><li>Fatigue or loss of energy </li></ul></ul></ul><ul><ul><ul><li>Feelings of worthlessness or guilt </li></ul></ul></ul><ul><ul><ul><li>Diminished ability to concentrate or indecisiveness </li></ul></ul></ul><ul><ul><ul><li>Recurrent thoughts of death or suicidal ideation </li></ul></ul></ul>
    11. 11. Classification of Depression <ul><li>5 or more of the symptoms </li></ul><ul><ul><li>One, of which must be depressed mood or diminished interest. </li></ul></ul><ul><ul><li>Symptoms have to have lasted for greater than two weeks. </li></ul></ul><ul><ul><li>Symptoms represent a departure from previous functionality. </li></ul></ul><ul><ul><li>Symptoms result in impaired social and/or occupational functioning. </li></ul></ul><ul><ul><li>Risk = 20-25% </li></ul></ul><ul><ul><li>Risk factors include being female, unmarried, widowed or recently bereaved, experiencing stressful life events, lower levels of social support, serious physical illness </li></ul></ul>
    12. 12. Classification of Depression <ul><li>50% of older adults who have a chronic physical illness may also have major depressive disorder. </li></ul><ul><li>Depression results in “excess disability”, negatively impacting: </li></ul><ul><ul><ul><li>quality of life, </li></ul></ul></ul><ul><ul><ul><li>functionality, </li></ul></ul></ul><ul><ul><ul><li>physical health status, </li></ul></ul></ul><ul><ul><ul><li>longevity, </li></ul></ul></ul><ul><ul><ul><li>relationships. </li></ul></ul></ul><ul><li>Depression results in resistance to care, inconsistency of course and negativity, excess pain and suffering. </li></ul>
    13. 13. What Is Dementia? <ul><li>The onset is usually insidious </li></ul><ul><li>Cognitive deficits are losses of memory, language, executive function, visuospatial ability. </li></ul><ul><li>Compartmental changes are alterations in personality, insight and judgment - </li></ul><ul><ul><li>functions which help a person behave appropriately in social situations, make reasonable decisions and plan, organize and follow logical sequence to reach goals </li></ul></ul><ul><li>Changes in cognition eventually impair IADL and ADL performance </li></ul><ul><li>Changes in social psychological environment and patterns of relationships and interaction may also evident </li></ul>
    14. 14. DSM-IV, Dementia <ul><li>Characterized by memory impairment and at least one of the following cognitive difficulties – aphasia, apraxia, agnosia, disruption in executive function. </li></ul><ul><li>Gradual onset of symptoms with continuing decline – representing a significant decline from previous level of functioning, </li></ul><ul><li>Severe enough to impair social and or occupational functioning. </li></ul><ul><li>Must not occur during course of delirium. </li></ul><ul><li>Lifetime risk, 14-16% - higher risk for females, African Americans </li></ul>
    15. 15. Definition from DSM <ul><li>Dementia </li></ul><ul><ul><li>A major mental disorder characterized by memory impairment (which can include either difficulty learning new material or recalling previously learned material) and </li></ul></ul><ul><ul><li>difficulty with at least one of the following cognitive capacities: language, recognition, and organization and/or performance of motor activities. </li></ul></ul>
    16. 16. Dementia: Changes in appearance <ul><ul><li>Newly stooped posture </li></ul></ul><ul><ul><li>Slowing of movement </li></ul></ul><ul><ul><li>Slowing of thought processes </li></ul></ul><ul><ul><li>Unexplained weight loss or weight gain </li></ul></ul><ul><ul><li>Clothing that does not fit </li></ul></ul><ul><ul><li>Poor grooming </li></ul></ul><ul><ul><li>Poor maintenance of clothing </li></ul></ul><ul><ul><li>Poor hygiene </li></ul></ul><ul><ul><li>Diminished energy level </li></ul></ul><ul><ul><li>Unexplained fatigue </li></ul></ul><ul><ul><li>Sad affect </li></ul></ul>
    17. 17. Dementia: Changes in Behavior & Activity Level <ul><li>Decrease in social participation </li></ul><ul><li>Increase in isolation and social withdrawal </li></ul><ul><li>Decreased interest in things </li></ul><ul><li>Difficulty with decision making </li></ul><ul><li>Difficulty concentrating </li></ul><ul><li>Unusual negativism </li></ul><ul><li>Hopelessness </li></ul><ul><li>Inconsistency </li></ul><ul><li>Newly poor hygiene </li></ul><ul><li>Unexplained anger </li></ul><ul><li>Increased anxiety level </li></ul><ul><li>Increased complaints of pain </li></ul><ul><li>Complaints of sleep difficulties </li></ul><ul><li>Changes in appetite or eating habits </li></ul><ul><li>Noncompliance with medications </li></ul>
    18. 18. Early Symptoms of Dementia: Alzheimer’s Disease Slow, widespread, progressive symptoms <ul><li>Neurological/Cognitive </li></ul><ul><ul><li>Short-term memory impairments </li></ul></ul><ul><ul><li>Inability to focus attention and recall events </li></ul></ul><ul><ul><li>Progressive disorientation (time and place) </li></ul></ul><ul><ul><li>Difficulty in word finding and impaired naming </li></ul></ul><ul><ul><li>Impaired language comprehension and calculation </li></ul></ul><ul><ul><li>Visual and spatial deficits </li></ul></ul><ul><li>Behavioral/Psychosocial </li></ul><ul><ul><li>Personality changes (passivity to hostility) </li></ul></ul><ul><ul><li>Decreased emotional expression </li></ul></ul><ul><ul><li>Diminished initiative </li></ul></ul><ul><ul><li>Depression and anxiety </li></ul></ul><ul><ul><li>Greater suspiciousness </li></ul></ul><ul><ul><li>Visual hallucinations </li></ul></ul><ul><ul><li>Delusions (accusations of theft, infidelity, persecution) </li></ul></ul><ul><ul><li>Wandering </li></ul></ul>
    19. 19. Early Symptoms of Dementia: Vascular Dementia <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Acute unilateral motor or sensory dysfunction </li></ul></ul><ul><ul><li>Urinary dysfunction </li></ul></ul><ul><ul><li>Gait disturbance </li></ul></ul><ul><ul><li>Mask like facial expression and rigidity </li></ul></ul><ul><ul><li>Aphasia </li></ul></ul><ul><li>Behavioral/psychosocial </li></ul><ul><ul><li>Sudden, affective changes </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Delusions </li></ul></ul><ul><ul><li>Psychotic symptoms </li></ul></ul>
    20. 20. Early Symptoms of Dementia: Dementia of the frontal lobe type & Pick’s disease <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Apathy </li></ul></ul><ul><ul><li>Language impairments (unfocused speech, spontaneous compulsive repetition of words/phrases </li></ul></ul><ul><ul><li>Normal short-term memory </li></ul></ul><ul><ul><li>Normal or minimally affected cognitive testing </li></ul></ul><ul><ul><li>Normal visual and spatial abilities </li></ul></ul><ul><li>Behavioral/psychosocial </li></ul><ul><ul><li>Prominent alterations in emotion, affect, and behavior </li></ul></ul><ul><ul><li>Disordered executive function (initiation, goal setting, planning) </li></ul></ul><ul><ul><li>Little awareness of changes (denies any problems) </li></ul></ul><ul><ul><li>Disinhibited behavior </li></ul></ul><ul><ul><li>Personality changes </li></ul></ul><ul><ul><li>Withdrawal </li></ul></ul>
    21. 21. Early Symptoms of Dementia: Dementia with Parkinsonism <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Rigidity and postural instability </li></ul></ul><ul><ul><li>General slowing of thought and action </li></ul></ul><ul><li>Behavioral/psychosocial </li></ul><ul><ul><li>Disordered executive function </li></ul></ul><ul><ul><li>Delusions </li></ul></ul><ul><ul><li>Hallucinations </li></ul></ul>
    22. 22. Early Symptoms of Dementia: Hydrocephalus <ul><li>Neurological/cognitive </li></ul><ul><ul><li>Gait disorder </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><ul><li>Cognitive decline (psychomotor slowing, impaired ability to concentrate, and mild memory difficulties </li></ul></ul><ul><li>Behavioral/psychosocial </li></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Change in behavior </li></ul></ul>
    23. 23. Criteria for determining Dementia <ul><li>Syndrome: </li></ul><ul><ul><li>Decline in cognitive functions in comparison with client’s previous level of function </li></ul></ul><ul><ul><li>Decline severe enough to interfere with social and occupational functioning </li></ul></ul><ul><ul><li>Decline confirmed by clinical examination and neuropsychological tests </li></ul></ul><ul><ul><li>No disturbance of consciousness </li></ul></ul><ul><ul><li>Diagnosis based on behavior. </li></ul></ul>
    24. 24. Criteria for determining probable Alzheimer’s disease <ul><li>MMSE, </li></ul><ul><li>Blessed Dementia Scale </li></ul><ul><li>Deficits in 2 or more areas of cognition </li></ul><ul><li>Progressive worsening of cognitive functions </li></ul><ul><li>No disturbance of consciousness </li></ul><ul><li>Onset between 40 & 90, most often after age 65 </li></ul>
    25. 25. Medical Workup for Dementia Tumor, subdural hematomas, abscess, stroke, or hydrocephalus Neuroimaging studies: CT or MRI AIDS dementia HIV test Syphilis Syphilis serology Vitamin deficiency Serum B 12 Thyroid dysfunction Thyroid function Liver dysfunction Blood Urea Nitrogen (BUN)/creatinine, liver function test Anemia, electrolyte imbalance CBC, sedimentation rate, electrolytes Kidney dysfunction, toxic encephalopathy Urinalysis RATIONALE – rule out… TESTS
    26. 26. Symptoms of Depression & Dementia Impaired executive function (e.g. organization, prioritization) Impaired decision making Organization Functional ability (activities of daily living and instrumental activities of daily living) diminished by declining abilities Functional ability diminished by lack of motivation Function Progressive impairment of short-term memory, eventually long term memory Poor concentration and temporary memory decrease Memory Blank matter of fact expression, Possible overlay of sadness Pervasive sadness, dourness, negativity Affect/mood/ demeanor Dementia Depression
    27. 27. Symptoms of Depression & Dementia Impaired orientation Intact or impaired orientation Orientation Trouble finding words and naming things Slowed language Language Dementia Depression Possible sleep problems or no sleep problems/impairment Possible problems falling asleep, staying asleep, or waking up Sleep Trouble remembering to eat Decrease in weight with no obvious explanation Either decreased appetite and weight or increased appetite and weight Appetite/weight Possible impaired motivation Impaired motivation Motivation
    28. 28. Symptoms of Depression & Dementia Dementia Depression Possible high scores or low scores Possible high scores Depression screening tool Complaints that are underreported or perseverated upon Fatigue Possible multiple or exaggerated somatic complaints Fatigue Somatic complaints/pain Safety concerns because of impaired judgment Possible suicide Danger Impairment Slow thinking and reasoning, Ability to learn is retained Thinking/reasoning/ability to learn
    29. 29. Depression and Dementia <ul><li>Symptoms of depression and dementia may overlap or occur as co-morbidities with other medical conditions as well as with each other. </li></ul><ul><ul><li>Vitamin deficiencies may present with depression as well as dementia. </li></ul></ul><ul><ul><li>Hyperthyroidism may present with symptoms of decreased energy and interest, symptoms common to both dementia and depression. </li></ul></ul><ul><ul><li>Sad affect of depressed individual may often be confused with the blank affect of an individual with dementia. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Poor hygiene and self neglect may be common to both conditions. </li></ul></ul><ul><li>Evaluation and treatment of both dementia and depression is often warranted. </li></ul>
    30. 30. Depression and Dementia <ul><li>Cognitive decline becomes increasingly common with advancing age. </li></ul><ul><ul><li>5-15% of persons over 65 and </li></ul></ul><ul><ul><li>20-50% of persons over 85 are reported to be affected. </li></ul></ul><ul><li>Mental impairment, including depression and dementia, is frequently under diagnosed in the geriatric population. </li></ul><ul><li>Cognitive decline affects every aspect of a client’s life and imposes major psychological and economic burdens on family and caregivers. </li></ul><ul><li>Cognitive decline may produce an overlay of depressive symptoms, or depression may be misdiagnosed as cognitive impairment. </li></ul><ul><li>Major depression is present in 20-40% of older person’s with Alzheimer’s disease. </li></ul><ul><li>Multiple “I don’t know” answers are a clue that an older person may be depressed. </li></ul>
    31. 31. Depression and Dementia <ul><li>Tests that differentiate between cognitive impairment and depression should be administered. </li></ul><ul><li>Inconsistent performance on mental exam also suggest that depression may be present. </li></ul><ul><li>Assessing orientation by inquiring about name, place and date is ineffective as a screening tool. </li></ul>
    32. 32. Depression and Dementia <ul><li>The presence of physical illness in later life increases the likelihood of emotional problems. </li></ul><ul><li>Severe emotional problems can be found in 10-25% of hospitalized older patients. </li></ul><ul><li>Emotional reactions to illness include depression, anxiety, problems in regards to pain, decline in body functions. </li></ul>
    33. 33. Diagnostic Workup for Late Life Depression <ul><li>Psychological history </li></ul><ul><li>Mental Status (cognitive) screen </li></ul><ul><li>Depression screen </li></ul><ul><li>Assessment of activities of daily living and instrumental activities of daily living </li></ul><ul><li>Assessment of sleep and activity patterns </li></ul><ul><li>Assessment of severity of depressive symptoms </li></ul><ul><li>Assessment of suicidal ideation and history of prior attempts </li></ul><ul><li>Medical history </li></ul><ul><li>Review of prescription and over-the-counter medications </li></ul><ul><li>Physical examination </li></ul><ul><li>Routine diagnostic tests (e.g. electrocardiograms), laboratory tests, or imaging (computed tomography scan or magnetic resonance imaging), if indicated to clarify diagnosis </li></ul><ul><li>Psychiatric consultation, if needed for clarification </li></ul><ul><li>Neuropsychological testing, if needed for clarification </li></ul>
    34. 34. Statements That May Be Indicative Of Depression <ul><li>I’m not the person I used to be. </li></ul><ul><li>I can’t manage to get anything done. </li></ul><ul><li>I’m awake all night and then get to sleep in the morning. </li></ul><ul><li>Nobody can do anything for me. </li></ul><ul><li>I don’t care if I die. </li></ul><ul><li>Things are hopeless. </li></ul><ul><li>I don’t want to be a burden to anyone. </li></ul><ul><li>I’ve heard that medicines have too many side effects, so I don’t want any. </li></ul><ul><li>I may be nervous, but I’m not mental. </li></ul><ul><li>Who’s to care? </li></ul><ul><li>Nobody wants me. </li></ul><ul><li>I’m too poor to afford that. </li></ul>
    35. 35. Alterations in thought processes: characteristics of client behavior - <ul><li>Disorientation to time, place, person </li></ul><ul><li>Altered ability to think abstractly </li></ul><ul><li>Disorders of memory </li></ul><ul><li>Misinterpretation of environmental stimuli </li></ul><ul><li>Changes in problem-solving abilities </li></ul><ul><li>Changes in behavior patterns, including regression </li></ul><ul><li>Irritability </li></ul><ul><li>Expression of fear of others or of losing control </li></ul><ul><li>Hallucinations </li></ul><ul><li>Delusional thoughts </li></ul><ul><li>Inappropriate responses to commands </li></ul><ul><li>Inaccurate interpretation of the environment </li></ul>
    36. 36. Dementia, Depression, Delirium Treatable, usually resolvable Progressive, manageable Episodic, treatable, resolvable Course Fluctuation in consciousness and attention Possible hallucinations, delusions Gradual decline in functioning, including recent memory loss Pervasive sadness or loss of pleasure, plus vegetative signs Symptoms Abrupt, may be within hours or days Slow, insidious, over a period of months/years Usually within a period of weeks Onset Delirium Dementia Depression
    37. 37. Dementia, Depression, Delirium May be harbinger of medical illness Can flag life-threatening emergency Requires prompt medical intervention Results in decrease in ability to perform activities of daily living, poor judgment, and decreased ability to learn May complicate course of other illnesses May lead to decrease in self-care May lead to suicide and various safety problems Consequences Is more prevalent in persons with dementia and hospitalized patients May make depression and delirium harder to recognize Can coexist with other Dx, causing “excess disability,” and may complicate course of other illnesses Phenomenology Medical intervention first, to address underlying illness Multiple simultaneous interventions Multiple simultaneous interventions Treatment Delirium Dementia Depression
    38. 38. Assessment Tools <ul><li>Be familiar with the strengths, weaknesses and accuracy of any tool. </li></ul><ul><li>Determine the goals of assessment. </li></ul><ul><li>Be aware that older persons often view mental and neuropsychological testing negatively. </li></ul><ul><li>Fatigue, frustration and anxiety may compromise the test scores. </li></ul><ul><li>Sensory loss, disorientation and medication may lower test scores. </li></ul><ul><li>Be observant. Take a complete history. </li></ul>
    39. 39. Mini Mental State Examination <ul><li>MMSE </li></ul><ul><ul><li>Used by 90% of physicians </li></ul></ul><ul><ul><li>Recommended by the National Institute of Neurological and Communicative Disorders </li></ul></ul><ul><ul><li>23 or lower out of 30 is indicative of cognitive impairment </li></ul></ul><ul><ul><li>85% or better sensitivity to clients with dementia </li></ul></ul><ul><ul><li>Can distinguish between depressed clients, clients with dementia and clients with both depression and dementia. </li></ul></ul>
    40. 40. Mini Mental Status Exam (MMSE) <ul><li>Section 1: Orientation </li></ul><ul><ul><li>What is the day of the week? </li></ul></ul><ul><ul><li>What building are we in? </li></ul></ul><ul><li>Section 2: Memory, Part 1 </li></ul><ul><ul><li>Immediate recall: remember 3 words </li></ul></ul><ul><li>Section 3: Attention and Calculation </li></ul><ul><ul><li>Ability to concentrate on a tricky task, serial 7’s – subtract from 100 </li></ul></ul><ul><li>Section 4: Memory, Part 2 </li></ul><ul><ul><li>Delayed recall; recall 3 words from section 2 </li></ul></ul><ul><li>Section 5: Language, writing and drawing </li></ul><ul><ul><li>Name common objects, </li></ul></ul><ul><ul><li>Follow 3 stage command </li></ul></ul><ul><ul><li>Read and follow directions </li></ul></ul><ul><ul><li>Copying </li></ul></ul><ul><ul><li>Write a complete sentence </li></ul></ul><ul><li>Copies of the complete test are available from the Psychological Assessment Resources (PAR) website: http://www.parinc.com </li></ul>
    41. 41. Short Portable Mental Status Questionnaire <ul><li>SPMSQ </li></ul><ul><ul><li>Less than 2 errors, normal mental function </li></ul></ul><ul><ul><li>8 or greater error, severe mental impairment </li></ul></ul><ul><li>Sensitivity of 95% when used as a screening tool for dementia in the 60 years and older population </li></ul><ul><li>Assesses short narrow range of basic functions including memory, attention, orientation, capable of detecting gross cognitive dysfunction only. </li></ul>
    42. 42. THE SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE <ul><li>1. What are the date, month, and year? </li></ul><ul><li>2. What is the day of the week? </li></ul><ul><li>3. What is the name of this place? </li></ul><ul><li>4. What is your phone number? </li></ul><ul><li>5. How old are you? </li></ul><ul><li>6. When were you born? </li></ul><ul><li>7. Who is the current president? </li></ul><ul><li>8. Who was the president before him? </li></ul><ul><li>9. What was your mother's maiden name? </li></ul><ul><li>10. Can you count backward from 20 by 3's?Ê </li></ul><ul><li>SCORING:* </li></ul><ul><li>0-2 errors: normal mental functioning </li></ul><ul><li>3-4 errors: mild cognitive impairment </li></ul><ul><li>5-7 errors: moderate cognitive impairment </li></ul><ul><li>8 or more errors: severe cognitive impairment </li></ul><ul><li>*One more error is allowed in the scoring if a patient has had a grade school education or less. </li></ul><ul><li>*One less error is allowed if the patient has had education beyond the high school level. </li></ul><ul><li>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. </li></ul>
    43. 43. Cognitive Functioning Instruments <ul><li>MMSE </li></ul><ul><ul><li>will not detect mild cognitive impairment </li></ul></ul><ul><ul><li>Not designed to grade progression of impairment </li></ul></ul><ul><ul><li>Clients with expressive aphasia may appear more impaired </li></ul></ul><ul><li>SPMSQ </li></ul><ul><ul><li>Too insensitive to small changes </li></ul></ul>
    44. 44. Functional Assessment Staging Tool <ul><li>FAST- </li></ul><ul><ul><li>Is for distribution to the family </li></ul></ul><ul><ul><li>Provides specific information on the order in which various functions are lost </li></ul></ul><ul><ul><li>Provides time frame estimate on how long given level of function will last. </li></ul></ul>
    45. 45. Wechsler Memory Scale <ul><ul><li>Broad range of memory functions </li></ul></ul><ul><ul><li>Sensitive to more subtle changes </li></ul></ul><ul><ul><li>Too long to administer </li></ul></ul><ul><ul><li>Inadequate norms for older population </li></ul></ul>
    46. 46. Global Deterioration Scale (GDS) <ul><ul><li>Gives overall picture of the disease process </li></ul></ul><ul><ul><li>Able to appropriately stage dementia </li></ul></ul><ul><ul><li>Language performance is not used </li></ul></ul><ul><ul><li>Is used primarily with patients who’s dementia is the Alzheimer’s type </li></ul></ul><ul><ul><li>Will provide information on general progression of disease but does not take into account individual variations. </li></ul></ul>
    47. 47. Global Deterioration Scale (GDS) <ul><li>GDS Stage 1: Normal Phase </li></ul><ul><li>GDS Stage 2: Forgetful Phase </li></ul><ul><li>GDS Stage 3: Early Confusional Phase </li></ul><ul><li>GDS Stage 4: Late Confusional Phase </li></ul><ul><li>GDS Stage 5: Early Dementia </li></ul><ul><li>GDS Stage 6: Middle Dementia </li></ul><ul><li>GDS Stage 7: Late Dementia </li></ul>
    48. 48. Some other commonly used cognitive assessment instruments <ul><li>Arizona Battery of Communication Disorders </li></ul><ul><li>Brief Cognitive Rating Scale </li></ul><ul><li>Cognitive Performance Test </li></ul><ul><li>Clock Drawing </li></ul><ul><li>FROMAJE </li></ul><ul><li>Functional Linguistic Communication Inventory </li></ul><ul><li>Rating Scale of Communication in Cognitive Decline </li></ul><ul><li>Rehabilitation Institute of Chicago Evaluation of Communication Problems on Right Hemisphere Dysfunction (RICE) </li></ul><ul><li>Ross Test of Higher Cognitive Processing </li></ul><ul><li>Test of Problem Solving </li></ul><ul><li>Token Test </li></ul><ul><li>Rivermead Behavioral Memory Test </li></ul>
    49. 49. Depression Instruments <ul><ul><li>Tools do not establish a diagnosis of depression but are important in identifying clients for further evaluation. </li></ul></ul>
    50. 50. Geriatric Depression Scale <ul><ul><li>Includes a broad range of depression mood questions </li></ul></ul><ul><ul><li>Quick and reliable </li></ul></ul><ul><ul><li>Avoids excess physical symptom questions </li></ul></ul><ul><ul><li>Weakness is it’s limitations and usefulness in clients with severe dementia. </li></ul></ul>
    51. 51. <ul><li>GERIATRIC DEPRESSION SCALE (GDS, SHORT FORM) </li></ul><ul><li>Choose the best answer for how you felt over the past week. </li></ul><ul><li>1. Are you basically satisfied with your life? </li></ul><ul><li>2. Have you dropped many of your activities and interests? </li></ul><ul><li>3. Do you feel that your life is empty? </li></ul><ul><li>4. Do you often get bored? </li></ul><ul><li>5. Are you in good spirits most of the time? </li></ul><ul><li>6. Are you afraid that something bad is going to happen to you? </li></ul><ul><li>7. Do you feel happy most of the time? </li></ul><ul><li>8. Do you often feel helpless? </li></ul><ul><li>9. Do you prefer to stay at home, rather than going out and doing new things? </li></ul><ul><li>10. Do you feel you have more problems with memory than most? </li></ul><ul><li>11. Do you think it is wonderful to be alive now? </li></ul><ul><li>12. Do you feel pretty worthless the way you are now? </li></ul><ul><li>13. Do you feel full of energy? </li></ul><ul><li>14. Do you feel that your situation is hopeless? </li></ul><ul><li>15. Do you think that most people are better off than you are? </li></ul><ul><li>Score 1 point for each bolded answer. Cut-off: normal (0-5), above 5 suggests depression. </li></ul><ul><li>Source: Courtesy of Jerome A. Yesavage, MD. </li></ul><ul><li>Clinical Toolbox for Geriatric Care © 2004 Society of Hospital Medicine 2 of 2 </li></ul>
    52. 52. Hamilton Depression Scale <ul><ul><li>Assesses objective symptoms </li></ul></ul><ul><ul><li>Can estimate severity of depression </li></ul></ul><ul><ul><li>Weakness is it’s reliability on physical symptoms thus making it less useful in older adults. </li></ul></ul>
    53. 53. Beck Depression Inventory <ul><ul><li>Self Rating scale </li></ul></ul><ul><ul><li>Assesses symptoms of depression </li></ul></ul><ul><ul><li>Includes a broad range of questions </li></ul></ul><ul><ul><li>Validated in older adults and medical patients </li></ul></ul><ul><ul><li>Weakness is that it relies too heavily on physical symptoms, </li></ul></ul><ul><ul><li>Also difficult for cognitively impaired clients to use. </li></ul></ul>
    54. 54. www.americangeriatrics.org/education/depression.shtml
    55. 55. Treatment of Delirium <ul><li>Identify and treat the underlying cause </li></ul><ul><li>Provide a stable environment </li></ul><ul><li>Perform a head-to-toe systems approach </li></ul><ul><li>Perform a medication review </li></ul><ul><ul><li>Check for side effects, use of outdated medication, interactions </li></ul></ul><ul><ul><li>Understanding of and adherence to prescribed medication administration </li></ul></ul>
    56. 56. Treatment of Depression <ul><li>Social treatment </li></ul><ul><ul><li>therapy </li></ul></ul><ul><li>Psychopharmacological </li></ul><ul><ul><li>Antidepressants </li></ul></ul>
    57. 57. Treatment of Depression <ul><li>Communication Strategies: </li></ul><ul><ul><li>Listen. </li></ul></ul><ul><ul><li>Recognize changes – trust your eyes, ears, sense of smell, and general intuition. </li></ul></ul><ul><ul><li>Remain calm – do not panic. </li></ul></ul><ul><ul><li>Acknowledge the person’s feeling. Do not try to talk the person out of the feelings. </li></ul></ul><ul><ul><li>If the person expresses suicidal ideas, refer the person for immediate psychiatric evaluation and treatment. </li></ul></ul><ul><ul><li>Be reassuring. The person is ill, and things will get better. </li></ul></ul><ul><ul><li>Don’t be judgmental. Depression is an illness and not something the person has chosen. </li></ul></ul><ul><ul><li>Provide positive reinforcement, as appropriate. </li></ul></ul><ul><ul><li>Acknowledge positive steps toward recovery. </li></ul></ul>
    58. 58. Treatment of Dementia <ul><li>Behavioral & Environmental </li></ul><ul><li>Encourage appropriate behavior </li></ul><ul><li>Minimize inappropriate behavior </li></ul><ul><li>Maintain current level of functioning </li></ul><ul><li>Ensure safety </li></ul>
    59. 59. Treatment of Dementia <ul><li>Patient, Family, Caregiver education and support </li></ul><ul><li>Assess for and manage depression and delirium </li></ul><ul><li>Supportive therapies </li></ul><ul><li>Psychopharmacologic treatment </li></ul>
    60. 60. <ul><li>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”. </li></ul>
    61. 61. Our challenge… <ul><li>Facilitate communication. </li></ul><ul><li>Slow the progression or impact of functional decline. </li></ul><ul><li>Modify the environment. </li></ul><ul><li>Teach caregivers about the diseases and impact on functional abilities. </li></ul>
    62. 62. Questions ???
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