The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient experiencing Dementia, Depression or Delirium in a convenient care setting.
The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with Cerumen Impaction in a convenience care setting.
The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with Cerumen Impaction in a convenience care setting.
GR AFHS Skin Infection-final 9-23 wo CE for ho.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with a skin infection in a convenient care setting.
GR AFHS Geriatric Syndromes- HO Version wo CE.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge of applying the Age-Friendly 4Ms Framework while caring for an older adult patient experiencing elements of Geriatric Syndrome in a convenient care setting.
GR AFHS Possible UTI.8.26.20 wo CE for ho.pptxAFHSResources
The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with a Possible UTI in a convenience care setting.
GR AFHS Shingles 4.22.21-ho version wo CH.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient with Shingles in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient with a Upper Respiratory Infection in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework in managing polypharmacy in the older adult patient seen in a convenient care setting.
The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with Cerumen Impaction in a convenience care setting.
The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with Cerumen Impaction in a convenience care setting.
GR AFHS Skin Infection-final 9-23 wo CE for ho.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with a skin infection in a convenient care setting.
GR AFHS Geriatric Syndromes- HO Version wo CE.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge of applying the Age-Friendly 4Ms Framework while caring for an older adult patient experiencing elements of Geriatric Syndrome in a convenient care setting.
GR AFHS Possible UTI.8.26.20 wo CE for ho.pptxAFHSResources
The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with a Possible UTI in a convenience care setting.
GR AFHS Shingles 4.22.21-ho version wo CH.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient with Shingles in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient with a Upper Respiratory Infection in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework in managing polypharmacy in the older adult patient seen in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient with Diabetes Mellitus in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with community-acquired pneumonia in a convenient care setting.
GR AFHS Diff Venous Stasis Derm from Cellulitis.-w-o CH.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with COPD in a convenient care setting.
GR AFHS COPD.7.8.2020 -FINAL wo CE for ho.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with COPD in a convenient care setting.
Join us as Eden Stotsky-Himelfarb, BSN, RN from Johns Hopkins Medicine discusses how to manage after a colorectal cancer diagnosis. In this session, she will cover understanding diagnoses, shared decision making, managing mental health, talking to family and colleagues, and more.
Senior Healthcare Consultant (Geriatric) class at Piedmont Hospitalsnomadicnurse
The first of a 2-day class on Geriatric issues for nursing staff at all 4 Piedmont hospitals funded by a HRSA Comprehensive Geriatric Education Grant 2009-2012.
How are advances in social science being used to improve HCAHPS scores? Join Carol Packard, PhD, for key actions you can take to improve patient satisfaction scores, while improving clinical outcomes and reducing costs.
98% of Patients Cannot Recall Their Surgical RisksJim Cucinotta
The vast majority of patients do not know the risks associated with their health conditions. In order to fix this, we need to bulk up on patient education- but in non-traditional ways. Catch the patient when they are ready to learn and we have a chance to succeed. Halo Health can help you do this.
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The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient with Diabetes Mellitus in a convenient care setting.
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with community-acquired pneumonia in a convenient care setting.
GR AFHS Diff Venous Stasis Derm from Cellulitis.-w-o CH.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with COPD in a convenient care setting.
GR AFHS COPD.7.8.2020 -FINAL wo CE for ho.pptxAFHSResources
The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with COPD in a convenient care setting.
Join us as Eden Stotsky-Himelfarb, BSN, RN from Johns Hopkins Medicine discusses how to manage after a colorectal cancer diagnosis. In this session, she will cover understanding diagnoses, shared decision making, managing mental health, talking to family and colleagues, and more.
Senior Healthcare Consultant (Geriatric) class at Piedmont Hospitalsnomadicnurse
The first of a 2-day class on Geriatric issues for nursing staff at all 4 Piedmont hospitals funded by a HRSA Comprehensive Geriatric Education Grant 2009-2012.
How are advances in social science being used to improve HCAHPS scores? Join Carol Packard, PhD, for key actions you can take to improve patient satisfaction scores, while improving clinical outcomes and reducing costs.
98% of Patients Cannot Recall Their Surgical RisksJim Cucinotta
The vast majority of patients do not know the risks associated with their health conditions. In order to fix this, we need to bulk up on patient education- but in non-traditional ways. Catch the patient when they are ready to learn and we have a chance to succeed. Halo Health can help you do this.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Grand Rounds
Siyang Li PharmD
Emily Zaragoza, MD
Topic: Age-Friendly Health Systems:
Dementia, Depression, and Delirium in the Older Adult
Feel free to chat in the chat box. Remember
to change your chat to ‘Everyone’ so we may
all benefit from your comments.
To Unmute your line: Click on your screen
and then the microphone at the top of screen.
Then click Unmute Call
2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Providing Age-Friendly Care
The goal is for all care with older adults to be Age-Friendly care, which:
• Follows an essential set of evidence-based practices;
• Causes no harm; and
• Aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each
case scenario. The 4Ms include:
• What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
• Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation,
and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the
older adult, Mobility, or Mentation
• Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
• Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that
older adults move safely in order to maintain function and do What Matters
5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
SBAR: Case Scenario
(S) Situation: Nina, a 86 year old female is accompanied by her daughter, Rita, to the clinic for right
shoulder pain. She reports that for the last 2-3 days her mother was complaining of right shoulder
pain and has been crying, restless, and not sleeping, which is different from her usual behavior. Her
mother has not been eating or drinking well.
Rita reports sometimes her mom says she hears their dad talking to her at night and sees him in the
corners of rooms. Nina’s husband passed away 1 year ago. It is near his birthday. Daughter reports
her mother is “stubborn” and still likes to garden though told by multiple providers not to climb the
stairs when watering her plants. Nina is Italian-speaking only and has recently had a caregiver come
to her house to help with daily needs. Rita denies witnessing any falls injuries.
(B) Background: PMH: Alzheimer's dementia, depression, stroke, MI, HTN, hyperlipidemia, and
osteoporosis.
Medications: donepezil 10 mg PO daily, sertraline 50 mg PO daily, metoprolol succinate 100 mg PO
daily, atorvastatin 20 mg PO daily, alendronate 70 mg tab PO once weekly, calcium 1 tab PO daily,
multivitamin 1 tab PO daily, Vitamin D2 1000U PO daily
6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
SBAR: Case Scenario (Cont.)
(A) Assessment: VS: BP 168/100 mmHg, repeat BP 170/96 mmHg, HR 90/min, RR 20/min, Temp 97.8F, SpO2
98% on room air
Patient reports it hurts in Italian, unable to provide numeric score from 1-10, facial grimacing noted, guarding
shoulder noted.
Mentation: Alert, oriented to person only. Language barrier for adequate mental status and mood screening.
Mobility: Patient walks in unassisted wearing appropriate footwear; slow walking speed
Skin: Clean, dry, some tenting. Skin intact with normal capillary refill.
Respiratory: CTA bilaterally, no wheezes, rhonchi, crackles
Cardiac: Regular rate and rhythm, harsh late peaking crescendo decrescendo systolic murmur and heard best at
the R 2nd ICS
Musculoskeletal: Moderate swelling on the right shoulder, no obvious deformity, no ecchymosis. Mild tenderness to
palpation, uncooperative with remainder of exam secondary to pain with movement.
Psych: Anxious and uncooperative during exam, swatting
(R): Recommendation: Let’s discuss…
7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Recommendations
If thought to be delirium with acute or emergent cause of pain and/or behavior, activate EMS.
Prepare patient demographic sheet and give report to medic when arrives. Update patient and
family regarding plan. Otherwise, consider further assessment for dementia and depression.
• What are some differences between dementia, depression, and delirium?
• What are some risk factors for developing depression and delirium?
Let’s learn more…
8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Screen for Delirium: Confusion Assessment Method
The CAM Diagnostic Algorithm
Feature 1: Acute change in mental status and fluctuating course
Feature 2: Inattention
Feature 3: Disorganized thinking
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
Source: 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.
Delirium instruments and training modules by Dr. Sharon Inouye and colleagues:
https://www.hospitalelderlifeprogram.org/delirium-instruments
9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Consider potential causes of delirium
D: Drugs, dehydration, detox, deficiencies, discomfort/pain
E: Electrolyte disturbance, elimination issues, environment
L: Lungs (hypoxia), liver, lack of sleep, long emergency department stay
I: Infection, iatrogenic events, infarction (cardiac, cerebral)
R: Restricted movement/mobility, renal failure
I: Impaired sensory issue, intoxication
U: Urinary tract infection, unfamiliar environment
M: Metabolic abnormalities (pancreas, thyroid), medications
10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Screen for Dementia: Mini-Cog™
Three-item recall and clock drawing test (CDT)
• Instruct patient to repeat 3 unrelated words (may be repeated; word registration not scored)
• Instruct patient to draw a clock and have it read 11:10 (10 past 11) (clock drawing test scored)
• Instruct patient to recall the 3 words (word recall scored)
Scoring
• Clock Drawing Test scoring: 2 points if normal clock; 0 (zero) points if abnormal clock. A normal clock must
include all numbers (1-12), each only once, in the correct order and direction (clockwise) with two hands
present, one pointing to the 11 and one pointing to 2. Hand length not scored.
• 3-Item recall scoring: 1 point for each word recalled without cues
Results
• 0-2: Positive screen for dementia
• 3-5: Negative screen for dementia; does not rule out some degree of cognitive impairment
For more information about the Mini-Cog, please refer to the AFHS intranet banner > Video podcast
13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Feature Depression Delirium Dementia
Onset Weeks to months Hours to days Months to years
Course Chronic; responds to
treatment
Acute; reversible Chronic, progressive
Orientation Intact Varies, fluctuates Impaired
Sleep Disturbed, hypersomnia Disturbed; not pattern;
Changes nightly
May be disturbed; may
have pattern at night
Mood Low; apathetic;
decreased pleasure in
activities; change in
appetite
Fluctuates Fluctuates; may be
depressed in early stage;
may demonstrate apathy
Self-awareness Likely concerned about
any memory impairment
May be aware of
cognitive changes;
fluctuates
Likely to hide or be
unaware of cognitive
deficits
Function May be unaffected or
impaired
May be unaffected or
impaired
Impairment progressive
Differentiating Depression, Delirium, Dementia
Adapted from: Gagliardi, J. P. (2008). Differentiating among depression, delirium, and dementia in elderly patients. Virtual Mentor, 10(6), 383-388.
Huang, J. (2016). Merck Manual: Professional Edition. Delirium and Dementia. Available at http://www.merckmanuals.com/professional/neurologic-
disorders/delirium-and-dementia/dementia
14. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Back to the case…
Summary: ASSESS and ACT ON the 4Ms as a set
What Matters: Know and act on each patient’s specific health outcome goals and care preferences
• Assessment is difficult, rely on patient’s daughter. Ask if daughter has durable power of attorney and if a health care proxy. If
acute or emergent, needs EMS; Based on history, patient likely enjoys gardening…pictures about gardening may help
behavioral symptoms
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what
matters
• Consider polypharmacy and possibility for deprescribing (e.g. Vitamin D, MVI, atorvastatin, calcium); https://deprescribing.org
Mentation: Focus on dementia and depression and delirium.
• What are reversible causes or possible delirium? Head injury with fall? Are dementia medications needed at this time (risk vs
benefit)? Could anniversary death of husband trigger depression? Consider possibility of dementia, depression, and delirium
concurrently.
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Encourage daily mobility. Consider use of assistive device, exercise program, PT when stable.
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider
15. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Interprofessional Team Discussion…
16. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Acknowledgements
Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare
Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health
Association of the United States (CHA).
MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A.
Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
17. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
References
Alagiakrishnan, K. (2019, April 26). What are the DSM-5 criteria for delirium? (G. L. Xiong & F. Talavera, Eds.). Retrieved August 19, 2019,
from https://www.medscape.com/answers/288890-31777/what-are-the-dsm-5-criteria-for-delirium
Delirium. (2018, June 27). Retrieved August 19, 2019, from https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-
causes/syc-20371386
Huang, J. (2019). Overview of Delirium and Dementia - Neurologic Disorders. Retrieved August 19, 2019, from
https://www.merckmanuals.com/professional/neurologic-disorders/delirium-and-dementia/overview-of-delirium-and-dementia
O'Sullivan, R., Inouye, S. K., & Meagher, D. (2014, September). Delirium and depression: Inter-relationship and clinical overlap in elderly
people. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338740/
Shin, R. D., H. A., & Shlamovitz, G. Z. (2019, July 16). Delirium, Dementia, and Amnesia in Emergency Medicine (F. Talavera & J. S. Huff,
Eds.). Retrieved August 19, 2019, from https://emedicine.medscape.com/article/793247-overview
Tampi, R. (2019). Evaluation of Dementia. Retrieved August 19, 2019, from https://online.epocrates.com/diseases/242/Evaluation-of-
dementia
18. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Thank You
Editor's Notes
Today’s topic is: Dementia, Depression and Delirium in the Older Adult
The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older.
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include:
What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation
Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
S: Situation: Nina, a 86 year old female is accompanied by her daughter, Rita, to the clinic for right shoulder pain. She reports that for the last 2-3 days her mother was complaining of right shoulder pain and has been crying, restless, and not sleeping, which is different from her usual behavior. Her mother has not been eating or drinking well.
Rita reports sometimes her mom says she hears their dad talking to her at night and sees him in the corners of rooms. Nina’s husband passed away 1 year ago. It is near his birthday. Daughter reports her mother is “stubborn” and still likes to garden though told by multiple providers not to climb the stairs when watering her plants. Nina is Italian-speaking only and has recently had a caregiver come to her house to help with daily needs. Rita denies witnessing any falls injuries.
B: Background: PMH: Alzheimer's dementia, depression, stroke, MI, HTN, hyperlipidemia, and osteoporosis.
Medications: donepezil 10 mg PO daily, sertraline 50 mg PO daily, metoprolol succinate100 mg PO daily, atorvastatin 20 mg PO daily, alendronate 70 mg tab PO once weekly, calcium 1 tab PO daily, multivitamin 1 tab PO daily, Vitamin D2 1000U PO daily
A: Assessment: VS: BP 168/100 mmHg, repeat BP 170/96 mmHg, HR 90/min, RR 20/min, Temp 97.8F, SpO2 98% on room air
Patient reports it hurts in Italian, unable to provide numeric score from 1-10, facial grimacing noted, guarding shoulder noted.
Mentation: Alert, oriented to person only. Language barrier for adequate mental status and mood screening.
Mobility: Patient walks in unassisted wearing usual footwear; slow walking speed
Skin: clean, dry, some tenting. Skin intact with normal capillary refill.
Respiratory: CTA bilaterally, no wheezes, rhonchi, crackles
Cardiac: RRR, harsh late peaking crescendo decrescendo systolic murmur and heard best at the R 2nd ICS
Musculoskeletal: Moderate swelling on the right shoulder, no obvious deformity, no ecchymosis. Mild tenderness to palpation, uncooperative with remainder of exam secondary to pain with movement
Psych: anxious and uncooperative during exam, swatting
R: Recommendation: Let’s discuss
If thought to be delirium with acute or emergent cause of pain and/or behavior, activate EMS. Prepare patient demographic sheet and give report to medic when arrives. Update patient and family regarding plan. Otherwise, consider further assessment for dementia and depression.
What are some differences between dementia, depression, and delirium?
What are some risk factors for developing depression and delirium?
We will discuss these.
In the case scenario, assuming delirium, EMS was activated. Patient was transferred to the hospital. Provider called to check on patient several days later and learned that the patient had been admitted with plans for discharge to a physical rehabilitation center prior to being discharged home.
Altered mental status can be divided into two major subgroups, acute (delirium or acute confusion) and chronic (dementia) as well as depression Disturbance of consciousness, reduced ability to focus, sustain, or shift in attention are DSM-5 diagnostic criteria for delirium. For dementia, the prevalence of dementia in older adults doubles every 5 years, to reach 30% to 50% by the age of 85. The patient, family, caregivers, and other knowledgeable sources should be interviewed to discover changes in cognition, function, personality, language skills, and behavior to ascertain the patient’s baseline.
Delirium is an acute change in mental status. Delirium affects mainly attention while dementia mainly affects memory. Delirium is typically caused by acute illness or drug toxicity and may be life threatening. Delirium is often reversible, but should be treated as a medical emergency.
The Confusion Assessment Method or CAM is a diagnostic algorithm for delirium and includes the following possible features:
Feature 1: Acute change in mental status and fluctuating course
Feature 2: Inattention
Feature 3: Disorganized thinking
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
There are many potential causes of delirium. The mnemonic “DELIRIUM” is a helpful way to remember these:
D: Drugs, dehydration, detox, deficiencies, discomfort/pain
E: Electrolyte disturbance, elimination issues, environment
L: Lungs (hypoxia), liver, lack of sleep, long emergency department stay
I: Infection, iatrogenic events, infarction (cardiac, cerebral)
R: Restricted movement/mobility, renal failure
I: Impaired sensory issue, intoxication
U: Urinary tract infection, unfamiliar environment
M: Metabolic abnormalities (pancreas, thyroid), medications
Dementia has slower onset and is generally irreversible, typically caused by physiological changes in the brain. Dementia is a progressive cognitive disorder and includes Alzheimer’s disease, Lewy body dementia, and vascular dementia. For persons with dementia, orientation to time and place is impaired; with delirium it varies.
It is important to target risk factors that may trigger an episode of delirium. Good sleep hygiene, helping the person to remain calm and oriented, and helping prevent medical issues and acuity is important. Risk factors for developing delirium include sleep deprivation, pain, presence of multiple medical issues, visual and hearing impairment, and emotional distress.
Mini-Cog™: The Mini-Cog is a 3-minute screening instrument that can increase detection of cognitive impairment in older adults. It begins with registration of 3 unrelated words that the person is asked to remember as they’ll be asked to state them again later. This word registration may be repeated up to 3 times to make sure the person registered the words. This word registration is not scored. Then, the Mini-Cog continues with two scored components, a clock drawing test and 3-item word recall test.
The Clock Drawing Test is scored as 2 points for a normal clock or 0 (zero) points for an abnormal clock drawing. A normal clock must include all numbers 1 through 12, each only once, in the correct order and direction which is clockwise. There must also be two hands present, one pointing to the 11 and one pointing to 2. Hand length is not scored in the Mini-Cog™ assessment.
The 3-Item word recall is scored 1 point for each word recalled without cues after the clock drawing test, for a 3-item recall score of 1, 2, or 3.
A total score of 3, 4, or 5 indicates lower likelihood of dementia but does not rule out some degree of cognitive impairment. The Mini-Cog™ is not a diagnostic test for Alzheimer’s disease or any other dementia or cause of cognitive impairment.
FOR MORE information about the Mini-Cog, please refer to the AFHS intranet banner>Video podcasts
Depression is a mood disorder common among older adults. In the case scenario, with the anniversary of husband’s death, depression may be another factor exacerbating baseline depression and dementia.
Screening tests may help differentiate depression, dementia and delirium and include the
PHQ-2 and/or PHQ-9: These are unreliable when a person experiences delirium, an acute change in mental status, such as in the case scenario.
In general however, use the Patient Health Questionnaire to screen for depression. The PHQ-2 may be used first to screen for depression. Ask: (1) Over the past 2 weeks, have you often been bothered by: Little interest or pleasure in doing things? (2) Feeling down, depressed or hopeless?
Not at all (0-1 day): 0 points
Several days (2-6 days): 1 point
More than half of the days (7-11 days): 2 points
Nearly every day (12-14 days): 3 points
A total PHQ-2 score ≥3 suggests elevated symptoms of depression.
If the PHQ-2 is positive, complete the PHQ-9.
Over the past 2 weeks, have you often been bothered by any of the following problems? Use the same scale as for the PHQ-2 for the rating or number of days reported and point scoring.
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself-or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that would be better off dead, or of hurting yourself
A total PHQ-9 score is interpreted as: 1-4 minimal depression; 5-9 mild depression; 10-14 moderate depression; 15-19 moderately severe depression; 20-27 severe depression
This slide shows a table differentiating dementia, depression, and delirium.
Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set.
What Matters-Include the daughter as a contact person when registering the baseline. Check to make sure they are durable power of attorney and a health care proxy.
Medication-Consider deprescribing medications that may no longer be needed and may increase risk of side effects. In terms of polypharmacy, may consider discontinuing Calcium and Vitamin D and encourage dietary intake instead. Consider reassessing Metoprolol use especially if concerned about fluid intake and orthostasis. Is there a need to continue the statin? The website for deprescribing.org is provided: https://deprescribing.org
Mentation-Utilize tools to assess mentation such as the Mini-Cog when appropriate. Delirium may be assessed with the Confusion Assessment Method. Screen for depression via PHQ-2/PHQ-9.
Mobility-Encourage daily mobility, decrease incidence of falls when patient is transferring, and when at home while in the garden.
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider
Team discussion: NP, pharmacist, physician, other
These are the references cited throughout the presentation:
Alagiakrishnan, K. (2019, April 26). What are the DSM-5 criteria for delirium? (G. L. Xiong & F. Talavera, Eds.). Retrieved August 19, 2019, from https://www.medscape.com/answers/288890-31777/what-are-the-dsm-5-criteria-for-delirium
Delirium. (2018, June 27). Retrieved August 19, 2019, from https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386
Huang, J. (2019). Overview of Delirium and Dementia - Neurologic Disorders. Retrieved August 19, 2019, from https://www.merckmanuals.com/professional/neurologic-disorders/delirium-and-dementia/overview-of-delirium-and-dementia
O'Sullivan, R., Inouye, S. K., & Meagher, D. (2014, September). Delirium and depression: Inter-relationship and clinical overlap in elderly people. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338740/
Shin, R. D., H. A., & Shlamovitz, G. Z. (2019, July 16). Delirium, Dementia, and Amnesia in Emergency Medicine (F. Talavera & J. S. Huff, Eds.). Retrieved August 19, 2019, from https://emedicine.medscape.com/article/793247-overview
Tampi, R. (2019). Evaluation of Dementia. Retrieved August 19, 2019, from https://online.epocrates.com/diseases/242/Evaluation-of-dementia