Depression, Delirium, and Dementia in Older Adults Depression, Delirium, and Dementia in Older Adults Steve Bartels, MD, MS Steve Bartels, MD, MS Professor of Psychiatry & Professor of Psychiatry & Community and Family Medicine Community and Family Medicine Co Co - - Director Dartmouth Center for the Aging Director Dartmouth Center for the Aging
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Depression, Delirium, and Dementia in Older Adults Delirium, and Dementia in Older Adults Steve Bartels, MD, MS Professor of Psychiatry & Community and Family Medicine Co-Director
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Depression, Delirium, and Dementia in Older Adults
Depression, Delirium, and Dementia in Older Adults
Steve Bartels, MD, MSSteve Bartels, MD, MSProfessor of Psychiatry & Professor of Psychiatry &
Community and Family MedicineCommunity and Family MedicineCoCo--Director Dartmouth Center for the AgingDirector Dartmouth Center for the Aging
ObjectivesObjectives
Describe the prevalence of depression in older adultsUse an assessment instrument for depression in older adultsDiscuss symptoms and treatment strategies for depression in older adultsDescribe the prevalence of delirium and dementia in older adults
Describe the prevalence of depression in older Describe the prevalence of depression in older adultsadultsUse an assessment instrument for depression in Use an assessment instrument for depression in older adultsolder adultsDiscuss symptoms and treatment strategies for Discuss symptoms and treatment strategies for depression in older adultsdepression in older adultsDescribe the prevalence of delirium and Describe the prevalence of delirium and dementia in older adultsdementia in older adults
ObjectivesObjectives
Discuss the symptoms of delirium and dementia
Discuss the assessment and treatment strategies for delirium and dementia
Contrast criteria for differentiating depression, delirium, and dementia in older adults.
Discuss the symptoms of delirium and dementiaDiscuss the symptoms of delirium and dementia
Discuss the assessment and treatment strategies Discuss the assessment and treatment strategies for delirium and dementiafor delirium and dementia
Contrast criteria for differentiating depression, Contrast criteria for differentiating depression, delirium, and dementia in older adults.delirium, and dementia in older adults.
Long term Care ResidentsLong term Care Residents (Katz 1989, (Katz 1989, Rovner Rovner 1991, 1991, Parmelee Parmelee 1992; Ashby1991; 1992; Ashby1991; Shah 1993, Samuels 1997)Shah 1993, Samuels 1997)
Depression Is a Medical Illness Depression Is a Medical Illness with Poor Health Outcomeswith Poor Health Outcomes
Depression and Mortality in Older Women Following Hip Fracture
Depression and Mortality in Older Women Following Hip Fracture
65+: highest suicide rate of any age group65+: highest suicide rate of any age group85+: 2X the national average 85+: 2X the national average (CDC 1999)(CDC 1999)
Suicide rate goes up continuously for men Suicide rate goes up continuously for men Peaks at midlife for women, then declines Peaks at midlife for women, then declines
20% older men saw PCP on day of suicide20% older men saw PCP on day of suicide40% older men saw PCP on week of suicide40% older men saw PCP on week of suicide70% older men saw PCP on month of suicide70% older men saw PCP on month of suicide
Suicide risk factorsSuicide risk factors
Depression, HopelessnessSerious medical illnessLiving aloneRecent bereavement, divorce, or separation,Unemployment or retirementSubstance abuse (alcohol and medication misuse
Risk Factors for Late Life DepressionRisk Factors for Late Life Depression
Medical IllnessMedical IllnessSelfSelf--report of poor health and disabilityreport of poor health and disabilityPain; Use of pain medicationPain; Use of pain medicationCognitive ImpairmentCognitive ImpairmentMedications; Substance AbuseMedications; Substance AbusePrior Depressive EpisodePrior Depressive EpisodeFinancial difficultiesFinancial difficultiesBereavementBereavementIsolation; dissatisfaction with social networkIsolation; dissatisfaction with social networkPhysiological changes associated with agingPhysiological changes associated with aging
What We KnowWhat We Know
Depression is complex and can be difficult to Depression is complex and can be difficult to identify (identify (““depression without sadnessdepression without sadness””))Treatments are pretty goodTreatments are pretty goodEffects of treatment may be slowed and Effects of treatment may be slowed and incomplete (incomplete (““response but not remissionresponse but not remission””))LongLong--term approaches are needed to keep people term approaches are needed to keep people wellwellWe know what to doWe know what to do
Definition of DepressionDefinition of Depression
Clinical syndrome characterized by low mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and / or guilt.
Diagnostic labels: minor depression, major depression, adjustment disorder with depressed mood, dysthymia, bipolar depression, seasonal affective disorder
MAKING THE DIAGNOSIS:ANHEDONIAMAKING THE DIAGNOSIS:ANHEDONIA
Loss of interest or pleasure in things that you normally enjoy.
May be the most important and useful symptom.
Loss of interest or pleasure in things that Loss of interest or pleasure in things that you normally enjoy.you normally enjoy.
May be the most important and useful May be the most important and useful symptom.symptom.
MAKING THE DIAGNOSIS:PHYSICAL SYMPTOMSMAKING THE DIAGNOSIS:PHYSICAL SYMPTOMS
Sleep disturbance.
Appetite or weight change.
Low energy or fatigue .
Psychomotor retardation or agitation.
Sleep disturbance.Sleep disturbance.
Appetite or weight change.Appetite or weight change.
Low energy or fatigue .Low energy or fatigue .
Psychomotor retardation or agitation.Psychomotor retardation or agitation.
MAKING THE DIAGNOSIS:PSYCHOLOGICAL SYMPTOMSMAKING THE DIAGNOSIS:PSYCHOLOGICAL SYMPTOMS
Low self-esteem or guilt.
Poor concentration.
Suicidal ideation or persistent thoughts of death.
Low selfLow self--esteem or guilt.esteem or guilt.
Poor concentration.Poor concentration.
Suicidal ideation or persistent Suicidal ideation or persistent thoughts of death.thoughts of death.
Depression: “SIG-E-CAPS”Depression: “SIG-E-CAPS”
SS Sleep disturbance (insomnia or hypersomnia)Sleep disturbance (insomnia or hypersomnia)II Interests (anhedonia or loss of interest in usually pleasurableInterests (anhedonia or loss of interest in usually pleasurableactivities)activities)GG Guilt and/or low selfGuilt and/or low self--esteemesteemEE Energy (loss of energy, low energy, or fatigue)Energy (loss of energy, low energy, or fatigue)CC Concentration (poor concentration, forgetful)Concentration (poor concentration, forgetful)AA Appetite changes (loss of appetite or increased appetite)Appetite changes (loss of appetite or increased appetite)PP Psychomotor changes (agitation or slowing/retardation)Psychomotor changes (agitation or slowing/retardation)SS Suicide (morbid or suicidal ideation)Suicide (morbid or suicidal ideation)
Depression Screening and MonitoringDepression Screening and Monitoring
PHQPHQ--9: Nine Item Patient Health9: Nine Item Patient HealthQuestionnaireQuestionnaire
Can be effective as medication for mild to moderate major depression or dysthymia
Should be offered as option .
Also useful adjunct to medication.
Particularly useful with underlying psychosocial issues, abuse issues, family dysfunction, life transitions
Can be effective as medication for mild to moderate Can be effective as medication for mild to moderate major depression or major depression or dysthymiadysthymia
Should be offered as option .Should be offered as option .
Also useful adjunct to medication.Also useful adjunct to medication.
Particularly useful with underlying psychosocial Particularly useful with underlying psychosocial issues, abuse issues, family dysfunction, life transitionsissues, abuse issues, family dysfunction, life transitions
ANTIDEPRESSANTSANTIDEPRESSANTS
Tricyclics (e.g. elavil, sinequan)Side effects, but less expensive.
The Key to Successful Rx: FOLLOW UP!The Key to Successful Rx: FOLLOW UP!
Time
Seve
rity
Normalacy
Symptoms
SyndromeAcutePhase
ContinuationPhase
MaintenancePhase
Response
RemissionRemission
Relapse
RelapseRecurrence
> 50% STOP
Rx
65 to 70%STOPRx
Only 25%Have ≥ 3Visits
RecoveryRecovery
Points to consider……Points to consider……
Comorbidities
Monitor every 1 – 2 weeks
Assess response every 4 – 6 weeks
Care Manager
Encourage AdherenceProblem Solve Barriers
Measure Treatment Response
Monitor Remission
Com
mun
i ca t
e w
i th C
li ni c
i an s
Nursing InterventionsNursing Interventions
Institute safety precautions Institute safety precautions for suicide riskfor suicide riskMonitor / promote nutrition, Monitor / promote nutrition, elimination, sleep, rest, elimination, sleep, rest, comfort, pain controlcomfort, pain controlEnhance physical function Enhance physical function and social supportand social supportMaximize autonomyMaximize autonomy
Structure and encourage daily Structure and encourage daily participation in therapiesparticipation in therapiesRemove etiologic agentsRemove etiologic agents
Monitor / document responsesMonitor / document responsesProvide practical assistance, Provide practical assistance, such as problemsuch as problem--solvingsolving
Provide emotional supportProvide emotional support
Case StudyCase StudyMs. G is a 75Ms. G is a 75--year old female living alone in her apartment in year old female living alone in her apartment in New York City. Her husband died suddenly two years ago of a New York City. Her husband died suddenly two years ago of a heart attack. Their two children are alive and living outheart attack. Their two children are alive and living out--ofof--state. Both of her sons maintain weekly phone contact with Ms. state. Both of her sons maintain weekly phone contact with Ms. G and visit usually once a year. Ms. G has been doing well G and visit usually once a year. Ms. G has been doing well until about 6 weeks ago when she fell in her apartment and until about 6 weeks ago when she fell in her apartment and sustained bruises but did not require a hospital visit. Since tsustained bruises but did not require a hospital visit. Since then, hen, she has been preoccupied with her failing eyesight and she has been preoccupied with her failing eyesight and decreased ambulation. She does not go shopping as often, decreased ambulation. She does not go shopping as often, stating she doesnstating she doesn’’t enjoy going out anymore and feels t enjoy going out anymore and feels ““very sad very sad and teary.and teary.”” Ms. G states that her shopping needs are less, since Ms. G states that her shopping needs are less, since she is not as hungry as she used to be and she is not as hungry as she used to be and ““besides Ibesides I’’m getting m getting too old to cook for one person only.too old to cook for one person only.””
QuestionsQuestions
1. What risk factors might account for Ms. G’s symptoms of depression?
2. What are Ms. G’s depressive symptoms?
3. What might be some treatment strategies for Ms. G?
1. What risk factors might account for Ms. G’s symptoms of depression?
2. What are Ms. G’s depressive symptoms?
3. What might be some treatment strategies for Ms. G?
Delirium and DementiaDelirium and Dementia
Delirium Delirium –– a a reversible confusional statereversible confusional state, a mental , a mental disturbance characterized by acute onset, disturbed disturbance characterized by acute onset, disturbed consciousness, impaired cognition, and an identifiable consciousness, impaired cognition, and an identifiable underlying medical cause (medications, anesthesia, underlying medical cause (medications, anesthesia, sleep disturbance, electrolyte imbalance, etc.)sleep disturbance, electrolyte imbalance, etc.)Dementia Dementia –– an an irreversible confusional stateirreversible confusional state,, acquired acquired impairment of mental function, not the result of impairment of mental function, not the result of impaired level of arousal, with compromise in at least impaired level of arousal, with compromise in at least three areas of mental activity.three areas of mental activity.
DeliriumDelirium
35% of U.S. population aged ≥ 65 years hospitalized each year accounting for nearly 50% of inpatient days.
Delirium: 14% - 56% of elderly hospitalized patients
Mortality: 10% - 65%.
Prevalence of Alzheimer’s Disease by AgePrevalence of Alzheimer’s Disease by Age
05
101520253035404550
%
65-74 75-84 85+
65-7475-8485+
SOURCE: Evans, D.A. et al. (1989). Journal of the American Medical Association. Vol. 262: 2251-2256.
PresentationPresentationInsidious and gradualInsidious and gradualShort, rapid, hours/daysShort, rapid, hours/daysOnsetOnsetDementiaDementiaDeliriumDeliriumParameterParameter
SymptomsSymptoms
Short term memory deficit in Short term memory deficit in early course, progresses to early course, progresses to longlong--term deficits, term deficits, confabulation, perseverationconfabulation, perseveration
Impaired, but remote Impaired, but remote memory is intactmemory is intact
Recent MemoryRecent Memory
Intact Intact DisturbedDisturbedLevel of Level of ConsciousnessConsciousness
Misperceives people and Misperceives people and events as threatening; late events as threatening; late delusions, hallucinationsdelusions, hallucinations
Amyloid Plaques and Neurofibrillary Tangles in Alzheimer’s Disease vs. Normal AgingAmyloid Plaques and Neurofibrillary Tangles in Alzheimer’s Disease vs. Normal Aging
AlzheimerAlzheimer’’ss NormalNormal
TanglesTangles
PlaquesPlaques
Courtesy of Harry Courtesy of Harry VintersVinters, MD., MD.
Treatment of DeliriumTreatment of DeliriumFailure to treat delays recovery and can worsen the older person’s health and function.
Psychiatric Management: identify and treat underlying etiology, intervene immediately for urgent medical conditions; ongoing monitoring of psychiatric status
Environmental and supportive interventions: all environmental factors that exacerbate delirium; make environment more familiar; reorient; reassure, and inform to fear or demoralization
MiniCogMiniCog: 3 object recall and Clock Drawing Test: 3 object recall and Clock Drawing Test
Min
i-Men
tal S
tate
E
xam
(MM
SE
)
Source: Folstein, 1975
Minicog Dementia Screen
1) Name 3 unrelated objects (e.g. “apple, house, book” or “pony, qua rter, orange”)2) Draw a large circle and ask the individual to put the numbers on the face of the clockand then to put the hands of the clock to indicated the time 11:203) Ask for the individual to repeat the names of the 3 objects
__ No or very mild Cognitive Impairment/No Dementia___Score =1 or 2 (one or 2 objects recalled ) and normal clock drawing test)___Score =3 (regardless of clock drawing test)
__ Significant Cognitive Impairment/Dementia___Score= 0 (none of the 3 objects recalled)___Score= 1 or 2 (one or 2 objects recalled) and abnormal clock drawing test)
Nonpharmacologic Interventions for Problem Behaviors: Nonpharmacologic Interventions for Problem Behaviors: cognitive remediation, massage, pet therapy, occupational cognitive remediation, massage, pet therapy, occupational and physical therapy, validation therapyand physical therapy, validation therapy
Care Environment Alterations: homelike setting, special Care Environment Alterations: homelike setting, special care unitcare unit
Interventions for Caregivers: assess for caregiver Interventions for Caregivers: assess for caregiver depressiondepression
Alzheimer CareAlzheimer Care
Use personal history, life experiences, and habitsUse personal history, life experiences, and habitsMaintain a familiar and comfortable routineMaintain a familiar and comfortable routineSlow down, speak clearly, make eye contact, in field of Slow down, speak clearly, make eye contact, in field of visionvisionCue the person to do as much for him or herself as Cue the person to do as much for him or herself as possiblepossibleModify physical environment Modify physical environment –– reduce misinterpretationreduce misinterpretationMonitor for symptoms of personal distressMonitor for symptoms of personal distress
Ms. D is a 98-year-old female in a skilled nursing facility with a diagnosis of Alzheimer’s disease. Ms. D comes to the nursing station and appears very upset. She tells you that she is looking for her mother and asks you to help her. You start walking with Ms. D.
Ms. D is a 98Ms. D is a 98--yearyear--old female in a old female in a skilled nursing facility with a skilled nursing facility with a diagnosis of Alzheimerdiagnosis of Alzheimer’’s disease. s disease. Ms. D comes to the nursing station Ms. D comes to the nursing station and appears very upset. She tells and appears very upset. She tells you that she is looking for her you that she is looking for her mother and asks you to help her. mother and asks you to help her. You start walking with Ms. D. You start walking with Ms. D.
Case Study: DementiaCase Study: Dementia
Which strategies would be helpful in assisting Ms. D.?Which strategies would be helpful in assisting Ms. D.?
1.1. Using reality orientation in the hope of reversing Using reality orientation in the hope of reversing her cognitive lossher cognitive loss
2.2. Telling her that her mother died a long time agoTelling her that her mother died a long time ago
3.3. Attempt to distract / redirect her into a pleasurable Attempt to distract / redirect her into a pleasurable activity, such as eating or singingactivity, such as eating or singing
4.4. Ask her to help you with a small task and that Ask her to help you with a small task and that later you will look for her mother together.later you will look for her mother together.
Resources: Try This Dementia Seriesat www.hartfordign.org
Resources: Try This Dementia Seriesat www.hartfordign.org
Developed by The Hartford Institute for Geriatric Nursing in Developed by The Hartford Institute for Geriatric Nursing in collaboration with The National Alzheimercollaboration with The National Alzheimer’’s Associations AssociationAssessment tool that can be administered in 20 minutes or less Assessment tool that can be administered in 20 minutes or less Topics include:Topics include:
Brief Evaluation of Executive DysfunctionBrief Evaluation of Executive DysfunctionRecognition of Dementia in Hospitalized Older AdultsRecognition of Dementia in Hospitalized Older AdultsAssessing Pain in Persons with Dementia Assessing Pain in Persons with Dementia Assessing and Managing Delirium in Persons with DementiaAssessing and Managing Delirium in Persons with Dementia
Brief Evaluation of Executive Dysfunction: An Essential Brief Evaluation of Executive Dysfunction: An Essential Refinement in the Assessment of Cognitive ImpairmentRefinement in the Assessment of Cognitive Impairment
SummarySummary
Prevalence, symptoms and treatment strategies Prevalence, symptoms and treatment strategies for depression, delirium, and dementia.for depression, delirium, and dementia.
Assessment toolsAssessment tools
Interventions for behavior problemsInterventions for behavior problems
Case Studies to reinforce knowledgeCase Studies to reinforce knowledge