Implications ofmis-diagnosis, under and over diagnosingHow this can lead to excess disability
George was a 70-year-old married man in reasonably good physical health. He lived with his wife of 45 years in a small country house flanked by farmland on all sides. Long retired from his blue-collar career, he spent his days either tinkering in his metal shop or taking target practice with his extensive and meticulously maintained rifle and handgun collection. His wife noticed he had been recently begun experiencing memory problems and grew concerned—especially since they had both watched his sister suffer and decline through a long course of Alzheimer’s disease a few years back. After a 20-minute interview and examination by his family physician, the doctor indeed diagnosed him with Alzheimer’s disease. Devastated, George and his wife began anticipating his inevitable decline.
Major depressive disorder – 1-2% of older adults which is generally lower than for younger adults (2-3%)This number is much higher for adults living in long-term care communities, which we will address later in the presentation.
Study of 159 staff members working in LTC who attended this presentation. Type of job influenced knowledge about depression and differentiation. Paraprofessional staff scored lower on depression and differentiation knowledge than professional staff. Interestingly the difference in knowledge did not have anything to do with level of education, which calls for more on the job training
In addition, paraprofessional staff perceived that it is normal to become depressed as you are getting older significantly more often than professional staff
Speaker note: Consider directly addressing the fallacy that “Alzheimer’s” and “Dementia” are entirely separate. Emphasize that Alzheimer’s is one form of dementia, and that there are several others. (e.g., “His doctor says he either has dementia or Alzheimer’s” is a common example of this misconception)Dementia is a term for a group of diseases that affect cognition and memory. Alzheimer’s Disease is the most common form of dementia and is typically associated with the gradual loss of memory, reasoning, orientation and judgment along with the progression of a number of behavioral disorders including confusion, depression and aggression.
Short-Term Memory:Most affected individuals have problems remembering recently learned information. Some may forget important dates or events or ask the same information over and overPlanning: Affected individuals have problems concentrating and seeing a task to completion that used to requires less thought. As a result, people with Alzheimer's often find it hard to complete daily tasks. Early places this becomes evident might include managing a budget at work or remembering the rules of a favorite game.Misplacing: Persons with Alzheimer's disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time.
Speaker: differentiate “signs and symptoms” from “full [DSM] diagnosis”Worth mentioning – Suicide - Older adults have greater attempts to completion ratio (4:1) than younger adults (30:1)Completion rates – likely due to using more lethal means. Also probably due to inability to recover from failed attempts (overdoses, injuries, etc)
DSM-IV (pronounced D-S-M Four) stands for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. It is the book that contains psychiatric diagnoses and the criteria that determine whether or not someone may have a mental illness.In order for an individual to be diagnosed with Major Depression, he or she must exhibit 5 or more of the following signs as listed within the DSM-IV DSM-IV criteria, however, are NOT a good index of depression in older adults. Speaker note: point out how DSM criteria can be confused with other possible explanations for “symptoms”Example: Discuss sleep changes in older adulthood and how they may be mistaken for sleep difficulties or insomnia (i.e., why this is a bad index criteria for older adults).
These are clinically recognized symptoms specific to older adults. These can often be difficult to separate from normal age-related changes which further complicates diagnosis.Highlight how these differences can lead to a misdiagnosis of either depression and/or dementia. Highlight how direct care staff play an important role in understanding symptoms from daily interaction with resident/patient/older adult. Also talking to family members and caregivers in order to get background and history of development and progression on symptoms
Introduce the concept of differential diagnosis between depression and dementia. Stress how important it is to understand the subtle differences in how they present in order to assure accurate diagnosis and treatment.This slide is followed by a series of slides that go step by step through examples of how depression and dementia present differently
Do you think that this is someone with depression or dementia?Additional information about this case…The individual’s family has always beenvery aware of a problem and exactly how serious it is.Medical help was sought very shortly after symptoms began.
Symptom development: point out how sudden and noticeable symptoms appear in depression, versus the more insidious and subtle (i.e., less likely to be noticed) development of dementia symptomsSymptom onset: point out that often times family members or caregivers can identify when symptoms began within even a specific month (e.g., “It seemed to start about 2 months ago…” versus a much broader estimate as to when dementia symptoms began (e.g., “I think it was around 2009 that he started having problems with his memory…”Family awareness: point out that family is much more likely to be aware (and more quickly becomes so) of depression than early dementiaSeeking help: point out that families and caregivers see depressive symptoms as being more urgent than the manner in which dementia symptoms manifest, and will therefore seek medical help faster even if they don’t know it’s depression
Additional information: Any complaints about memory or other thinking problems are vague and unclear.
Additional information:The individual highlights their failures rather than emphasizing their successes.
Additional information:Mood changes are labile and shallow (i.e., short-lived and quick-to-change)
Differentiating depression and dementia gendron and heck
Community Training onDepression and DementiaTracey Gendron, MSG Andrew L. Heck, Psy.D., ABPPGerontologist Licensed Clinical PsychologistAssistant Professor Clinical DirectorVirginia Commonwealth University Piedmont Geriatric Hospital
Why is it important for YOUto know the differences between depression dementia
A CASE STUDYGeorge is a 70-year-old physically healthy retiree• Hobbies: working in the shop, target shooting Recently began having memory problems • Family history of Alzheimer’s disease (sister) • Family physician diagnosed George with Alzheimer’s too THEN: • Son and grandsons removed ammunition from house • Nursing home admission months later • Occasional passes to visit home • Wife hears screen door “slam”… Fatal suicide attempt with handgun Note revealed George had hidden one bullet back from family, was afraid of becoming a burden
QUICK FACTS Major depressive disorder affects 1-2% of older adults 65+ in the community Significant depressive symptoms affect up to 20% of older adults Dementia affects 5% of people 65+ and about 40% of adults over 85
OUR RESEARCH SHOWS Type of job influences knowledge about depression and differentiation of depression and dementia symptoms However, it did not influence knowledge of dementia
WHAT PERCENTAGE OF RESIDENTS IN YOURFACILITY HAVE DEMENTIA AND DEPRESSION? PROFESSIONAL PARAPROFESSIONAL 74 66 37 33 Dementia Depression
Short-term memory loss that disrupts daily life Word-finding difficultySYMPTOMS of AD Get lost in familiar places Following a plan or recipe Challenges with planning or solving problems Paying bills Misplacing things and losing ability to retrace steps Trouble understanding visual images and spatial relationships Withdrawal from work or social ADLs activities Begin to be unable to care for self Meals Changes in mood or personality Safety May begin to lose track of place and time (orientation)
10% of medically hospitalized and 12-20% of Long Term Care (LTC) residents have a full diagnosis of major depression Between 20-25% of older adults in LTC have clinically significant signs andDEPRESSION symptoms of depression 10-15% of older adults in the community have signs and symptoms of depression Rates of diagnosed major depression in older adults are lower than rates for younger adults Older adults report that they would be most likely to tell their primary care doctors about emotional difficulties Depression can be treated as successfully in older adults as it can be in younger persons!
DEPRESSION – DSM IV* depressed mood loss of interest or feelings of pleasure in worthlessness activities Five (5) or more of the following signs/symptoms significant fatigue weight loss or gain psychomotor agitation or sleep disturbance retardation*Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition
DEPRESSION –NON-DSM Hypochondriasis Irritability Sleep difficulties Depression (Non- DSM) Reduced Apathy appetite A lack of positive feelings (rather than Fatigue active negative feelings)
DID YOU KNOW?? Patients diagnosed with depression actually develop dementia at As many as 10- 30% of patients 2.5 - 6 presenting with times dementia also the rate of the HAVE depression general population
SO, HOW DO YOU KNOW… IF IT IS DEPRESSION or DEMENTIA?
What type of What do we complaints arise know about the from the person’s history? individual? From the family? How did What does thesymptoms behavior lookdevelop? TAKING like? A CLOSER LOOK
THE FAMILY PERSPECTIVE1. The symptoms progressed very quickly after they first appeared.2. The onset of symptoms are dated with accuracy MIGHT THIS BE DEPRESSION OR DEMENTIA??
SIDE BY SIDE COMPARISON DEPRESSION DEMENTIA• Symptoms develop • Symptoms develop QUICKLY after onset SLOWLY after onset and• The onset of symptoms is throughout the course of DATED WITH ACCURACY the illness• Family is AWARE of a • The onset of symptoms is problem and that it is only KNOWN WITHIN severe BROAD LIMITS• Medical help is sought • Family is often UNAWARE SHORTLY after symptoms that there is a problem and begin of its severity • Medical help is usually sought a LONG TIME after symptoms develop
COMPLAINTS1. The individual isn’t complaining much about their cognitive problems.2. They actually try to hide their disability. IS THIS DEPRESSION OR DEMENTIA??
SIDE BY SIDE COMPARISON DEPRESSION DEMENTIA• Person usually • Person usually complains MUCH complains LITTLE about cognitive loss about cognitive loss• Complaints about • Complaints about cognitive dysfunction cognitive problems is usually DETAILED are usually VAGUE• Person • Person CONCEALS EMPHASIZES disability disability
BEHAVIOR1. The individual makes very little effort to perform even simple tasks2. They usually communicate a strong level of distress IS THIS DEPRESSION OR DEMENTIA??
SIDE BY SIDE COMPARISON DEPRESSION DEMENTIA• Person makes very • Person STRUGGLES LITTLE effort to to perform tasks perform even simple • Person often appears tasks UNCONCERNED• Person usually • Person delights in communicates a strong ACCOMPLISHMENTS sense of DISTRESS• Person highlights FAILURES
BEHAVIOR1. The individual still behaves appropriately in social situations2. Behavioral problems are clearly worse at nighttime DEPRESSION OR DEMENTIA??
SIDE BY SIDE COMPARISON DEPRESSION DEMENTIA• LOSS of social skills • Social skills are often often early and RETAINED prominent • Mood is LABILE and• Change in mood is shallow PERVASIVE • TYPICAL to• NOT TYPICAL to experience experience accentuated accentuated problems at night problems at night
WHAT DOES ALL OF THIS MEAN FOR YOU?? • Watch the individual’s behavior In making a good diagnosis carefully, especially for anything out of (which is crucial), treatment the ordinary; providers are truly counting on• Ask about how he or she is feeling now and how they’ve been feeling good information from lately, and ask their family or caregivers; caregivers’ the same thing about them; • Listen for increased complaints about health, pain, memory/cognition, or anything else; • Look closely for changes in eating habits, sleep patterns, level of activity; Report your observations to someone from the treatment team immediately; Realize that your observations may lead to life-changing treatment!!
PRE-EVENT SURVEYIt is normal to become depressed as individuals get older and live in long-term care FALSEfacilities.Depressed residents should be able to "snap out of it" (i.e. use their willpower to get FALSEbetter).Family members can be helpful when working with depressed residents. TRUEOlder adults do not change; therefore, there is no need to treat their depression. FALSEWeight loss, difficulties falling asleep and concentration problems can be signs of TRUEdepression in older adults.If a resident reports guilt about the past he or she might be depressed. TRUEAgitation can be a sign of depression. TRUEConfusion and memory lapses in older people can sometimes be due to physical TRUEconditions that doctors can treat so that these symptoms go away over time.Becoming disoriented (such as getting lost or losing track of what day it is) happens to FALSEpersons with Alzheimer’s disease, but only in the later stages of the disease. TRUEMemory loss that disrupts daily life can be a symptom of dementia. TRUEConfusion with time or place can be a symptom of dementia.Alzheimer’s disease is the only illness that leads to confusion and memory problems in FALSEolder adults.
PRE-EVENT SURVEYSymptoms develop slowly after onset and throughout the course of the illness in a person DEMENTIAwith…Social skills are often maintained in a person with … DEMENTIADifficulties with behavior and symptoms at night are typically of patients with… DEMENTIAA person with ________ makes very little effort to perform basic tasks. DEPRESSIONA person with _______ complains very little about cognitive loss. DEMENTIA
QUESTIONS? COMMENTS? For additional information about this training please contact: Tracey Gendron firstname.lastname@example.org Virginia Commonwealth University (804) 828-1565 Or Dr. Andrew Heck email@example.com Piedmont Geriatric Hospital (434) 767-4582