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Geriatric Population the 3 D's Geriatric Dementia, Delirium and Depression 2015


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Michelle Peck | Legal Nurse Consultant | Adult & Geriatric Nurse Practitioner | Health Care | Consultant | Professional Speaker | Educator | Researcher

Enjoy your journey through this slide deck!

During your journey through Geriatric Dementia, Delirium and Depression, you will experience how to:
• Differentiate delirium, depression & dementia.
• Describe the etiology & signs and symptoms of delirium, depression, and dementia.
• Identify risk factors for delirium, depression, and dementia.
• Identify types of medications that may cause depression.
• Communicate and care for people experiencing delirium.
• Explain non-pharmacologic interventions for treating dementia.

In order to minimize risk and customize interventions, we have to know where and how our clients are living.

The picture on the first slide is from geriatric simulation lab, where nursing students practice administering geriatric assessment scales to identify areas of risk. What risks and hazards can you see in this picture?

What you can't see is that the V8 Splash bottle is actually whiskey, medications and incontinence briefs are scattered all over the floor and our client is using oxygen via nasal cannula while smoking. Would picking up the trash and organizing the house fix the problem? Fifty percent of the students verbalized wanting to clean up during their assessment visit and some asked if they could tidy up upsetting the client.

Every problem deserves a viable solution. A comprehensive geriatric assessment is in order and interventions need to follow by assembling the geriatric team.

Our client's assessment findings were all high risk.
View the geriatric assessment scales with how to administer articles & videos at

What do we do next? We need to assemble the geriatric team to intervene.
View assembling the geriatric team "Assessments and Referrals" at

Hopefully at minimum the discharging physician ordered the home health care services necessary to bridge our client's hospital to home care.

If the geriatric assessment scales were performed prior to hospital discharge the physician should have recognized that with all her high risk findings she should not have been discharged home alone. At minimum she requires 24 hour supervision for safety.

The students all felt our client was confused and attributed it to her whiskey drinking, but after performing her Mini Cog they realized she was screening positive for dementia. How many clients slip through the cracks because of lack of assessment?

Our client confabulated and was quite convincing until the students saw her clock draw. Now they knew environmental observations were much more important than client self-report.

A picture is worth a thousand words. We fail our clients until we learn the assessment skills required to paint an accurate picture.

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Geriatric Population the 3 D's Geriatric Dementia, Delirium and Depression 2015

  1. 1. LET’S DISCUSS HOW TO Differentiate delirium, depression & dementia. Describe the etiology and signs and symptoms of delirium, depression, and dementia. Identify risk factors for delirium, depression, and dementia.
  2. 2. LET’S DISCUSS HOW TO Identify types of medications that may cause depression. Communicate and care for people experiencing delirium. Explain non-pharmacologic interventions for treating dementia.
  3. 3. DELIRIUM Cholinergic/dopaminergic excess Cascade of events Complicates hospitalizations Is a medical emergency Durso, S. C. & et al. (2010). Sometimes preventable by minimizing medication use and adequate hydration
  4. 4. Glutamate Activation GABA Activation Reduced GABA Activity Cholinergic Inhibition Dopamine Activation Cytokine Excess Serotonin Activation Serotonin Deficiency Cortisol Excess Hepatic Failure & Alcohol Withdrawal Benzo’s & Hepatic Failure Benzo’s & ETOH Withdrawal Medications Surgical & Medical Illness Cholinergic Activation Medications Alcohol Withdrawal Medications Substance Withdrawal Glucocorticoids Stroke Surgery Surgical & Medical Illness Medications Stroke
  5. 5. COMMUNICATION IN DELIRIUM Know the person’s patterns Look at nonverbal signs Speak slowly Explain all actions Be calm Face the person keep eye contact Get to the level of the person, don’t stand over them Touhy, T. & Jett, K. (2012).
  6. 6. COMMUNICATION IN DELIRIUM Smile Use simple familiar words Allow adequate time for response Repeat if needed BE Consistent Tell the person what you want them to do One-step directions Reassure safety Do not assume they cannot understand Touhy, T. & Jett, K. (2012).
  7. 7. REVERSIBLE FACTORS Drugs Electrolyte imbalance Lack of drugs Infection Reduced sensory input Intracranial Urinary retention/fecal impaction Myocardial/Pulmonary
  8. 8. DEPRESSION Not a normal part of aging Most common mental health problem of late life Among the most treatable Often co-occurs illness “unwanted cotraveler” Up to 1 in 4 primary care clients suffer from depression Touhy, T. & Jett, K. (2012).
  9. 9. MEDICATIONS MAY RESULT IN DEPRESSIVE SYMPTOMS Antihypertensives Angiotensin- Converting Enzyme Inhibitors Antidysrhythmics Anticholesteremics Antibiotics Analgesics Corticosteroids Touhy, T. & Jett, K. (2012).
  10. 10. DEPRESSION Two simple questions effectively screen: Over the past 2 weeks, have you felt down, depressed or hopeless? Have you experienced a loss of interest or pleasure in most things? Durso, S. C. & et al. (2010).
  11. 11. DEPRESSION Supportive treatment Counseling, relief of loneliness Treat physical symptoms and pain Address anxiety, financial, dependency Consider stopping contributory drugs Psychotherapy effective as antidepressants Cognitive-behavioral therapy
  12. 12. comprehension DEMENTIA The term dementia describes a syndrome Chronic and progressive brain disease Affects higher cortical functions memory language judgment learning capacity thinking orientation calculation Bereczki, D. & Szatmári, S. (2009).
  13. 13. IMPACT 35.6 million with dementia Nearly doubles every 20 years Alzheimer’s in the USA will ALMOST TRIPLE BY 2050 World Alzheimer Report 2011.
  14. 14. 28 million of the world’s 35.6 million people with dementia have yet to receive a diagnosis… World Alzheimer Report 2011.
  15. 15. A Quality Dementia Diagnosis Changes Everything …
  16. 16. Annual dementia care costs $32,865 per person With a quality dementia diagnosis annual dementia cost decreases to $5,000 per person Improved health & quality of life even more cost-effective Impact of a Quality Dementia Diagnosis World Alzheimer Report 2011.
  17. 17. Earlier diagnosis allows people with dementia to… plan ahead while they still have the capacity, receive timely practical information, advice and support get access to available drug and non-drug therapies participate in research for the benefit of future generations World Alzheimer Report 2011.
  18. 18. 7.7 million new cases yearly. New case of dementia every? A. 18 minutes B. 23 hours C. 4 seconds D. 23 minutes E. 30 seconds C. 4 seconds
  19. 19. WORLD’S 18TH LARGEST ECONOMY D E M E N T I A de Vugt, M. E. & Verhey, F. (2013).
  20. 20. 0 1 2 3 4 5 6 DEMENTIA WAL-MART EXXON MOBIL 100 BILLION US DOLLARS Dementia Costs More Than 1% Gross Domestic Product Borson, S. & et al. (2013). If dementia were a company, it would be the world’s largest by annual revenue.
  21. 21. RISK Age Family history and genetics Psychiatric disorders Cardiovascular disease – related factors Head trauma Alcohol, drugs & toxins Vasculitis, Endocrine & Infectious disorders Neoplastic & Respiratory disorders Brain lesions, normal pressure hydrocephalus Fillit, H. M. & et al. (2010) & Patterson, C. & et al. (2007).
  22. 22. MILD COGNITIVE IMPAIRMENT NOT the result of normal aging Forgetfulness is hallmark symptom Sometimes called a transitional phase Conversion rate 2 - 15% per year Up to 80% conversion at 6 years Fillit, H. M. & et al. (2010).
  23. 23. MAJOR DEMENTIA TYPES AD Alzheimer’s disease VaD Vascular dementia FTD Frontotemporal dementia PDD Parkinson’s disease dementia DLB Dementia with Lewy bodies Others: SD Semantic dementia, Progressive nonfluent aphasia, etc.
  24. 24. NEUROPSYCHOLOGICAL DOMAINS Premorbid ability: review of educational, occupation Verbal memory: verbal and memory learning tests Visual memory: visual reproduction, figure drawing Simple attention: digit span Language: animal naming, oral word association test Executive function: card sort test, similarities Visuospatial: digit symbol test, clock drawing Motor: finger tapping Cognitive screening: MMSE, SLUMS, MoCA, etc. Fillit, H. M. & et al. (2010).
  25. 25. OTHER DOMAINS Function Katz Index of Activities of Daily Living ADL Lawton Instrumental Activities of Daily Living Scale IADL Get-up and go Caregiver Input Depression Hamilton Depression Rating Scale HDRS Geriatric Depression Scale GDS Fillit, H. M. & et al. (2010).
  26. 26. DIAGNOSTIC LABORATORY CBC, CMP, Thyroid, B12, Folate, CRP, RPR, Lipids, HIV, SED rate, etc. May need to rule out delirium urine sample, blood cultures, chest x-ray, CSF Neuroimaging MRI or CT - Choice depends on availability, cost, patient acceptability, contraindication MRI is preferred. SPECT & PET scanning, Pittsburgh Compound-B ligand for PET Fillit, H. M. & et al. (2010).
  27. 27. Reports of progressive change in cognition or ADL Clinical assessment Is cognitive impairment confirmed on formal testing? Is ADL impaired Is onset relatively sudden with disturbed attention? Investigations, including neuroimaging Is a non-vascular etiology for dementia identified? Is a vascular etiology for dementia identified? Is parkinsonism, visual hallucinations or fluctuating cognition present? Is presentation with isolated language and/or executive deficits? Is episodic memory deficit prominent? Consider depression, anxiety, normal agingNO NO Mild Cognitive Impairment YES Delirium Is cognitive impairment persistent despite appropriate treatment YES YES Toxic, NPH, tumor, Huntington, head injury, MS, HIV, Neurosyphilis, CJD, metabolic – thyroid, B12 deficiency YES Vascular dementia, SDH, vasculitis YES Dementia with Lewy bodies, Parkinson’s disease dementia YES Frontotemporal dementia YES Alzheimer’s disease DIAGNOSTIC PROCESSFillit,H.M.&etal.(2010).
  28. 28. ALZHEIMER’S DISEASE Impairment in memory Functional impairment social or vocational And impairment in one other cognitive area Agnosia - impaired ability recognize objects Aphasia - language disturbances in expressing, understanding Apraxia - inability to carry out motor activities Attention Executive function Visuospatial ability Other criteria: Progression is insidious and other diseases that could cause cognitive decline have been ruled out, diagnosis is primarily based on clinical judgment. Fillit, H. M. & et al. (2010).
  29. 29. AD - Damage to plaque and neurofibrillary tangles, synapse loss, atrophy starts medial temporal lobe SIGNS AND SYMPTOMS Understanding Language Processing Auditory Information Organizing Information Memory Learning
  30. 30. JILL, 86 YO CAUCASIAN FEMALE, COMPLETED SOME COLLEGE CAM: negative ADLs: Independent in eating & transfer IADLs: Dependent in ALL GDS: 4/15, negative Labs: not remarkable Brain Imaging: Diffuse atrophy PMH: HTN, DM II, CAD Physical Exam: Confabulates Increasingly more forgetful for the past 6 months…
  31. 31. CAM - negative No Feature 1: Acute Onset or Fluctuating Course No Feature 2: Inattention No Feature 3: Disorganized thinking No Feature 4: Altered Level of consciousness The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4. Inouye, S. & et al. (1990).
  33. 33. Feature Delirium Dementia Depression Onset Sudden Insidious Recent Course over 24 Hours Fluctuates, often worse at night Fairly stable Fairly stable, may be worse in the morning Consciousness Reduced Clear Clear Alertness Variable Normal Normal Psychomotor Activity Variable, mixed Normal Variable, mixed Attention Concentration Disordered Normal Little Impairment Orientation Impaired, fluctuates Impaired, tries to answer, confabulates Usually normal, “I don’t know” may try not to answer Speech Often incoherent, slow or raid Word finding, perseveration May be slow Touhy, T. & Jett, K. (2012).
  34. 34. VASCULAR DEMENTIA Second most prevalent dementia 1/3 Also know as multi- infarct dementia The brain has multiple vascular lesions in the cortex and subcortical areas, sometimes called “small strokes” Memory loss most common complaint The cognitive changes that occur are directly related to the location of the lesions Working memory more likely to be impaired more than delayed recall Fillit, H. M. & et al. (2010).
  35. 35. VASCULAR DEMENTIA Cued recall recognition previously learned material generally intact Executive dysfunction more commonly reported than in AD Depression common Fillit, H. M. & et al. (2010).
  36. 36. JOHN, 70 YO CAUCASIAN MALE, RETIRED PHARMACIST CAM: negative ADLs: Independent in ALL IADLs: Dependent in ALL GDS: 3/15, negative Labs: ESRD PMH: Insulin dependent diabetic Physical Exam: gait imbalance, due worsening vision/peripheral neuropathy Reports he trusts his wife to make all his decisions as he no longer can, “I do whatever she wants…”
  37. 37. JOHN’S MRI MRI Brain: Small punctate acute ischemic lesion in the right hippocampus, diffuse extensive chronic white matter microvascular ischemic changes and volume loss advanced for age.
  38. 38. Functional Assessment Staging (FAST) Stage 1 Normal adult. No functional decline. Stage 2 Normal older adult. Personal awareness of some functional decline. Stage 3 Early AD. Noticeable deficits in demanding job situations. Stage 4 Mild AD. Requires assistance in complicated tasks such as handling finances, planning parties, etc. Stage 5 Moderate AD. Requires assistance in choosing proper attire. Stage 6 Moderately Severe AD. Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence. Stage 7 Severe AD. Speech ability declines to about a half- dozen intelligible words. Progressive loss of the ability to walk, sit-up, smile, and hold head up.
  39. 39. maintaining reestablishing independence Improving and stabilizing cognitive ability and mood TREATMENT GOALS effective future planning symptom management orientating redirecting pharmacologic therapies daily care safety as needed Fillit, H. M. & et al. (2010) & Bereczki, D. & Szatmári, S. (2009). caregiver interventions nonpharmacologic promoting autonomy
  40. 40. NON-PHARMACOLOGIC INTERVENTIONS DEMENTIA Person-Centered Care Structure the environment and relationships to maintain stability – Stable & Predictable Establish a caring relationship Provide unconditional positive regard Find causes of behavior, identify triggers Provide as much control as possible Touhy, T. & Jett, K. (2012).
  41. 41. NON-PHARMACOLOGIC INTERVENTIONS DEMENTIA Reduce environmental distractions Approach from the front, make eye contact, address person by name, speak in calm voice To reduce sense of threat, talk first, then touch Avoid verbal testing or questioning beyond the person’s ability Do not argue or insist they accept your reality
  42. 42. PHARMACOLOGIC INTERVENTIONS Considerable variation in clinical practice regarding pharmacological treatment of dementias Bereczki, D. & Szatmári, S. (2009).
  43. 43. DEMENTIA KEY FINDINGS Most people wish to be told of their diagnosis Improving the likelihood of earlier diagnosis: medical practice-based educational programs, introduction of accessible dementia care services, promoting effective interaction in the health system Early therapeutic interventions: improving cognitive function, treating depression, improving caregiver mood, delaying institutionalization World Alzheimer Report 2011
  44. 44. What’s Your Story? "ElderlyWomanInGlasses". Licensed under CC BY-SA 3.0 via Wikimedia Commons - /File:ElderlyWomanInGlasses.jpg
  45. 45. Bereczki D, Szatmári S. Treatment of dementia and cognitive impairment: What can we learn from the Cochrane library. J Neurol Sci [Internet]. 2009 8/15;283(1–2):207-10. Borson S, Frank L, Bayley PJ, Boustani M, Dean M, Lin P, McCarten JR, Morris JC, Salmon DP, Schmitt FA, Stefanacci RG, Mendiondo MS, Peschin S, Hall EJ, Fillit H, Ashford JW. Improving dementia care: The role of screening and detection of cognitive impairment. Alzheimer's & Dementia [Internet]. 2013 3;9(2):151-9. de Vugt ME, Verhey FRJ. The impact of early dementia diagnosis and intervention on informal caregivers. Prog Neurobiol [Internet]. 2013 In Press. Durso, S. C., Bowker, L. K., Price, J. D., & Smith, S. C. (Eds.). (2010). Oxford American handbook of geriatric medicine (First ed.). New York, New York: Oxford University Press Inc. REFERENCES
  46. 46. Fillit HM, Rockwood K, Woodhouse K. The nervous system In: Brocklehurst's textbook of geriatric medicine and gerontology. 7th ed. Philadelphia: Elsevier; 2010; p. 385-432. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948. Patterson C, Feightner J, Garcia A, MacKnight C. General risk factors for dementia: A systematic evidence review. Alzheimer's & Dementia [Internet]. 2007 10;3(4):341-7. Touhy, T. & Jett, K. (2012). Ebersole & Hess’ Toward healthy aging: Human needs and nursing response, 8th edition. St. Louis: Elsevier Mosby. Special Thank You: Department of Veterans Affairs, Saint Louis University, SLUMS Examination. World Alzheimer Report 2009 & 2011. REFERENCES