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
...elirium
...ey Points...
...Delirium is a medical emergency – it m...
Recognitio...
...1: Identify who is at risk for developing...
...posing Factors or Vulnerability3Having...
...2. Precipitating Factors or Noxious Insults3Havin...
...EP 2: Modify risk factors if possibl...
...of the Anticholinergic Cognitive Burden S...
...ications Commonly Associated with DeliriumHavi...
...te routine multi-component non-pha...
...ital Elder Life Program (HELP) was originally des...
...on-Pharmacologic Delirium Prevention (based...
Assessment
...EP 4: Screen for delirium with a va...
...sensitivity of 94–100% and a specificity of...
...able 5. CAMHaving trouble viewing table? Expand...
...dentify the potential causes of deliriu...
...d be a medical emergency; myocardial infarcti...
...6: Determine the urgency of the situation –...
...agnostic Test Options to Help Assess the Causes...
...atment
...Implement multi-component non-pharmacolo...
...Refer to Table 4....
...P 8: Manage sleep/wake...
...3–5 mg PO QHS or ramelteon 8 mg PO QHS....
...TEP 9: Treat the underlying causes (e.g. the...
...: Utilize non-pharmacologic approaches for a...
...P 11: For management of severe agitation or ps...
...benzodiazepines (BZDs) except in BZD...
...onitoring
...eevaluate for delirium with the CAM frequent...
STEP 13: Minimize complications...
...Aspiration pneumonitis or pneumonia...
...ust non-pharmacologic treatments and medi...
...ormation regarding PRN antipsychotic...
Dementia
...ementia...
...y Point...
...of dementia in the PALTC setting involves the...
...cognitio...
...e disorders in which cognitive function is a...
...1. Neurological Conditions in Which Co...
...symptoms that may suggest underlying...
...haviors That May Suggest DementiaHav...
...3: Appreciate differences among the most co...
...Alzheimer’s Disease, Vascular Dementia, an...
...entia with Lewy Bodies vs. Parkinson’s dis...
...4: Recognize frequency of common types of deme...
...€™s dementia: 55-75% Vascular dementia:...
...essment...
...r history and perform complete physical e...
...collateral family/caregiver history. Avoid...
...Types of DementiaHaving trouble viewing table? Ex...
...sess functional capacity...
...ivities of Daily LivingHaving trouble...
...Perform a mental status evaluation...
...ated yearly to document progression in long...
...7. Selected Screening Tools for Cognitive...
...TEP 8: Perform limited laboratory te...
...outine laboratory testing (CBC, basi...
...: Consider neuro-imaging...
CT or MRI to be performed at least once sin...
...0: Screen for depression...
...Recognize that depression can coexist...
STEP 11: Consider formal neuropsychologi...
...sess stage of dementia...
...der FAST scale (refer to Table 8). Re...
Table 8. Functional Assessment Stagin...
...for behavioral and psychological sympto...
...ms can include agitation, anxiety,...
...DICE ApproachHaving trouble viewing ta...
...atment
...: Use patient-centered approach to manage...
...ize function and quality of life. Capitalize o...
...mize the environmental aspect of care to impro...
...Personalize the environment to provide a more...
STEP 16: Manage any BPSD1...
...Prior to instituting any treatments, rule out r...
...: Consider appropriate pharmacological manage...
Table 10. Pharmacologic Treatment of De...
Monitorin...
...P 18: Perform regular re-assessment of mental st...
...atment target is functional improvement with...
...9: Monitor for adverse effects of antipsy...
...ndix A and B; pay particular attention to m...
Depression
...pression
Key Points
...ssion among nursing home residents is c...
...ecognition...
...s the patient have any risk factors?18
...Chronic medical illness, such a...
STEP 2: Does the patient have any signs or symp...
Symptoms Suggestive of Depression...
...essment
...oes the patient screen positive for dep...
...n Screening Tools: Geriatric Dep...
...Perform a medical evaluation
...ing depression in older adults, conside...
...5: Determine type of depressive disor...
...of Depression Major Depressive Disorder...
...es the patient require psychiatric care?...
...icidal ideation or plan Dangerous to self...
...reatmen...
...e most appropriate treatment...
...Psychotherapy vs. Psychosocial Treatment...
...Prescribe Pharmacologic Treatment for Depression...
...SSRIs are advised as first line treatment...
Table 2. Classes of Anti-depressants with P...
...3. Commonly Used Antidepressant DosingHaving trou...
...onitori...
...9: Monitor response to treatment plan for...
...Use similar screening/diagnostic too...
...of Major Depression DisorderHaving trouble...
Appendices
Appendice...
...Antipsychotic AgentsHaving trouble viewing...
...e-Effect Profile of Common Antipsychotic Med...
...on-Pharmacological Management of AgitationHaving...
...endix D: 3D’s Quality Performance MeasuresHavin...
...ornell Scale For Depression In Dementia (CS...
...F: Patient Health Questionnaire (PHQ-9)...
...ndix G: CMS Regulations Regarding PRN...
...endix H: PHQ-9-OV...
References
...merican Psychiatric Association. (2013). Dia...
Sources
...- The Society for Post-Acute and Long...
Acknowledgements
...ntsAMDA – The Society for Post-Acute and L...