The 3 ds delirium dementia depression
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The document discusses the 3 D's of geriatric care - delirium, dementia, and depression. It provides information on recognizing, differentiating, and diagnosing each condition. For delirium, it describes potential causes and emphasizes the importance of recognizing it as it can be medical emergency. For dementia, it outlines diagnostic criteria for Alzheimer's disease and discusses assessment tools. Treatment goals for dementia include maintaining independence and cognitive ability. Non-pharmacological interventions for dementia focus on person-centered care.
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The 3 ds delirium dementia depression
- 1. THE 3 D’S Nursing Management of the 3 D’s: Depression, Dementia, & Delirium Michelle Peck, MPH, MSN, RN, AGPCNP-BC
- 2. OBJECTIVES Recognize, Differentiate and Diagnose Delirium, Depression & Dementia Discuss Evaluation & Assessment Tools Treatment & Management Options Evidence-Based Nursing Interventions
- 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. 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. Management requires recognition of the delirium http://www.gerisage.com/modules/delirium_module/index.htm SAGE Delirium Practice Site
- 6. Communication in Delirium Know the person’s patterns Look at nonverbal signs Speak slowly Explain all actions Remain calm Body language Touhy, T. & Jett, K. (2016).
- 7. Face the person keep eye contact Get to their level, don’t stand over them Smile Use simple familiar words Allow adequate time for response Be Consistent Communication in Delirium Touhy, T. & Jett, K. (2016).
- 8. Tell the person what you want them to do One-step directions Reassure safety Do not assume they cannot understand Repeat if needed Communication in Delirium Touhy, T. & Jett, K. (2016).
- 9. Reversible Factors Drugs Electrolyte imbalance Lack of drugs Infection Reduced sensory input Intracranial Urinary retention / Fecal impaction Myocardial / Pulmonary
- 10. Depression http://blausen.com/en/video/depression/ This Photo by Unknown Author is licensed under CC BY-ND
- 11. Depression, Older Adults • Not a normal part of aging • Influence of late-life stressors • Beliefs of older people, society, and health professionals may have about depression • Hispanics aged > 50 more depression • For older women the depression rate is twice that of older men 11 Touhy, T. & Jett, K. (2016).
- 12. Depression, Older Adults • Depression underdiagnosed and undertreated • 4th leading cause of disease burden globally • Prevalence rates likely underestimate • Stigma may be more prevalent • Health professionals often expect older people to be depressed • May not take appropriate action assess/treat 12 Touhy, T. & Jett, K. (2016).
- 13. Medications may result in depressive symptoms Antihypertensives ACE Inhibitors Beta Blockers Antidysrhythmics Anticholesteremics Antibiotics Analgesics Corticosteroids
- 14. Depression 2 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).
- 15. Depression Treatment • 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 Touhy, T. & Jett, K. (2016).
- 16. The goals of depression treatment in the older adult include which of the following? A. Reduce health care costs B. Improve quality of life C. Improve function and reduce relapse D. All of the above
- 17. This Photo by Unknown Author is licensed under CC BY-SA Dementia http://blausen.com/en/video/alzheimers-disease/
- 18. 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
- 19. 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 A Quality Dementia Diagnosis Changes Everything … World Alzheimer Report, 2011.
- 20. 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 lesion/normal pressure hydrocephalus Fillit HM, et al., 2010.
- 21. Mild Cognitive Impairment NOT the result of normal aging Forgetfulness is hallmark symptom
- 22. 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.
- 23. 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: Mini Cog, MMSE, SLUMS, MoCA, etc.
- 24. 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
- 25. Diagnostics 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
- 26. ALZHEIMER’S DISEASE Most prevalent 60% to 80% of US dementias This Photo by Unknown Author is licensed under CC BY-SA-NC
- 27. 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 activity Attention, Executive function, Visuospatial 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).
- 28. 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
- 29. Jill age 86 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… This Photo by Unknown Author is licensed under CC BY-SA
- 30. Confusion Assessment Method (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.
- 35. 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 & hold head up.
- 36. What is Jill’s FAST Stage? a. Stage 2 b. Stage 3 c. Stage 5 d. Stage 6 e. Stage 7 This Photo by Unknown Author is licensed under CC BY-SA
- 37. 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” • Depression Common • 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 HM, et al., 2010.
- 38. maintaining reestablishing independence improving and stabilizing cognitive ability and mood Treatment Goals effective future planning symptom management reorienting redirecting pharmacologic therapies daily care safety as needed caregiver interventions nonpharmacologic promoting autonomy
- 40. Non-Pharmacologic Dementia Interventions Person-Centered Care (favorite music) https://youtu.be/fyZQf0p73QM 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. (2016).
- 41. 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 Non-Pharmacologic Dementia Interventions Touhy, T. & Jett, K. (2016).
- 42. Key Findings Most people wish to be told of diagnosis. Improving the likelihood of earlier diagnosis: medical practice-based educational programs, introduction of accessible care services, and effective interactions in the health system. Early therapeutic interventions: improving cognitive function, treating depression, improving caregiver mood, and delaying institutionalization. World Alzheimer’s Report 2011.
- 43. 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
- 44. References 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. 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. Touhy, T. & Jett, K. (2016). Ebersole & Hess’ Toward healthy aging: Human needs and nursing response, 9th edition. St. Louis: Elsevier Mosby.