Delirium, Dementia And Depression In The Long-Term Care Setting
Definitions1
Definitions1
Clinical Frailty Scale
- Delirium is a sudden change in mental status (inattention and disorganized thinking) that develops over hours or days and has a fluctuating course.
- Dementia is a significant change in cognitive performance from a previous level of performance in one or more cognitive domains that interferes with activities of daily living (ADL) which do not occur in conjunction with delirium or depression.
- Depression is a spectrum of mood disorders characterized by a sustained disturbance in emotional, cognitive, behavioral, or somatic regulation that is associated with a change of previous level of functioning or clinically significant distress.
Delirium
- A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
- The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
- An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
- The disturbances in Criteria 1 and 3 (listed above) are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
- There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.
Dementia, “Major Neurocognitive Disorder”
- Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
- Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and
- A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
- The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).
- The cognitive deficits do not occur exclusively in the context of a delirium.
- The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).
Depression, "Major Depressive Episode"
- Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: Criteria 1–3 represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. - The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
- There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
Distinguishing the 3D’s
| Delirium | Dementia | Depression | |
|---|---|---|---|
| Onset | Acute (hours to days) | Gradual (months to years) | Gradual (weeks to months) |
| Course | Fluctuating | Slowly progressive or chronic | Usually reversible with treatment |
| Consciousness | Commonly altered | Clear except in advanced stages | Clear |
| Attention | Impaired | Intact except in advanced stages | Generally intact |
| Mood | Variable | Variable | Low |
| Apathy | Present or Absent | Present or Absent | Present or Absent |
| Hallucinations | Common in hyperactive delirium | Usually absent, except in Lewy body dementia | Absent except in depression with psychotic features |
| Psychomotor Changes | Hypoactive or hyperacitve | Wandering, agitated, or withdrawn in some cases | Hypoactive or hyperactive |
| Reversibility | Usually reversible | Not reversible | Usually reversible |
| Signs of other medical condition | Present | Absent | Usually absent |
Delirium
...eliriu...
Key Poin...
...um is a medical emergency – it may...
...cognitio...
...y who is at risk for developing delir...
Table 1. Predisposing Factors or Vulnerability3Ha...
Table 2. Precipitating Factors or No...
...dify risk factors if possible...
...the Anticholinergic Cognitive Burde...
...able 3. Medications Commonly Associa...
...nstitute routine multi-component non-pha...
...der Life Program (HELP) was originally desi...
...le 4. Non-Pharmacologic Delirium Preve...
...essment...
...4: Screen for delirium with a validated...
...AM9 has a sensitivity of 94–100% a...
...CAMHaving trouble viewing table? E...
...Identify the potential causes of del...
...ould be a medical emergency; myocar...
...ine the urgency of the situation â€...
...gnostic Test Options to Help Assess...
...reatment
...mplement multi-component non-pharmac...
...efer to Table 4...
...anage sleep/wake cycle...
...onin 3–5 mg PO QHS or ramelteon...
...e underlying causes (e.g. the medical illness, p...
...P 10: Utilize non-pharmacologic app...
...11: For management of severe agitation or psyc...
...Avoid benzodiazepines (BZDs) except in BZD or...
...onitorin...
...P 12: Reevaluate for delirium with t...
...Minimize complications of deliri...
...Falls Aspiration pneumonitis or pneumon...
...P 14: Adjust non-pharmacologic treatmen...
...n regarding PRN antipsychotic and PRN psychotrop...
Dementia
...mentia...
...Points...
...of dementia in the PALTC setting invol...
...ognition...
...TEP 1: Recognize disorders in which cog...
Table 1. Neurological Conditions in...
...symptoms that may suggest underlyi...
...e 2. Behaviors That May Suggest Demen...
...3: Appreciate differences among the most...
...imer’s Disease, Vascular Dementia, an...
...ntia with Lewy Bodies vs. Parkinson’s d...
...Recognize frequency of common types of de...
...zheimer’s dementia: 55-75% Vascular deme...
...essment
...history and perform complete physical exam...
...de collateral family/caregiver history. Av...
...5. Common Types of DementiaHaving trouble viewing...
STEP 6: Assess functional capacity
Table 6. Activities of Daily LivingHavi...
...erform a mental status evaluation...
...epeated yearly to document progression...
...e 7. Selected Screening Tools for Cognit...
...rm limited laboratory testing...
...boratory testing (CBC, basic metabol...
...EP 9: Consider neuro-...
...be performed at least once since onset of...
...10: Screen for depression...
...Recognize that depression can coexist in de...
...1: Consider formal neuropsychological te...
...: Assess stage of dementia...
...Consider FAST scale (refer to Table...
...nal Assessment Staging Scale (FAST) – 7 stage...
...for behavioral and psychological symptoms o...
...oms can include agitation, anxiety, confusion,...
...E ApproachHaving trouble viewing table? Ex...
...atment...
...ient-centered approach to manage dementia...
...function and quality of life. Capitalize o...
...e the environmental aspect of care to i...
...sonalize the environment to provide a mor...
...EP 16: Manage any BP...
...Prior to instituting any treatments, rule...
...Consider appropriate pharmacological man...
...10. Pharmacologic Treatment of DementiaH...
...onitori...
STEP 18: Perform regular re-assessment of mental...
...f treatment target is functional improvem...
...itor for adverse effects of antipsych...
...Review Appendix A and B; pay particu...
Depression
...epression...
...ey Poin...
...ession among nursing home residents is comm...
Recognitio...
...P 1: Does the patient have any risk factors?18...
...male Chronic medical illness, such as...
STEP 2: Does the patient have any signs or symptom...
...ms Suggestive of Depression Patie...
...essment...
...oes the patient screen positive for depression?...
...ening Tools: Geriatric Depression...
...orm a medical evaluation...
...hen evaluating depression in older adults,...
...5: Determine type of depressive disorde...
...ssion Major Depressive Disorder (MD...
...oes the patient require psychiatric care?...
...uicidal ideation or plan Dangerous to...
Treatmen...
...: Determine most appropriate treatment...
.... Psychotherapy vs. Psychosocial Treatment Modal...
...ibe Pharmacologic Treatment for Depression...
...dvised as first line treatment for...
...s of Anti-depressants with Potential Side E...
...mmonly Used Antidepressant DosingHavin...
...onitoring...
...EP 9: Monitor response to treatment plan for de...
...imilar screening/diagnostic tools to m...
...ases of Major Depression DisorderHaving t...
Appendices
...pendices...
...ndix A: Antipsychotic AgentsHaving trouble vie...
...e-Effect Profile of Common Antipsychotic M...
...: Non-Pharmacological Management of AgitationH...
...: 3D’s Quality Performance MeasuresHaving troubl...
...E: Cornell Scale For Depression In...
...Patient Health Questionnaire (PHQ-9)...
...dix G: CMS Regulations Regarding PRN use of...
...ppendix H: PHQ...
References
...nces American Psychiatric Association...
Sources
...MDA - The Society for Post-Acute and L...
Acknowledgements
...entsAMDA – The Society for Post-Acute and...