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...
...y Point...
...a medical emergency – it may be the only...
...ecognition
...ify who is at risk for developing del...
...le 1. Predisposing Factors or Vulnerability3H...
.... Precipitating Factors or Noxious Insults3Havi...
...Modify risk factors if possib...
...use of the Anticholinergic Cognit...
...e 3. Medications Commonly Associated with Deliri...
...e routine multi-component non-pharmac...
...Hospital Elder Life Program (HELP) was origi...
...able 4. Non-Pharmacologic Delirium Preven...
...sessment
STEP 4: Screen for delirium with a validated i...
...M9 has a sensitivity of 94–100% and a spec...
...MHaving trouble viewing table? Expand...
...dentify the potential causes of delirium...
...irium could be a medical emergency; myocardial i...
...Determine the urgency of the situation –...
...e 6. Diagnostic Test Options to Help Assess th...
Treatment
...lement multi-component non-pharmacologic interven...
...Refer to Tabl...
...P 8: Manage sleep/wake cycle...
...atonin 3–5 mg PO QHS or ramelteon 8 mg PO QH...
...Treat the underlying causes (e.g. the me...
...TEP 10: Utilize non-pharmacologic a...
...1: For management of severe agitati...
...odiazepines (BZDs) except in BZD or...
Monitoring
...2: Reevaluate for delirium with the C...
...3: Minimize complications of delirium...
...Falls Aspiration pneumonitis or pne...
...non-pharmacologic treatments and med...
...rmation regarding PRN antipsychotic...
Dementia
...mentia
...y Points...
...of dementia in the PALTC setting involves the...
Recognitio...
...ecognize disorders in which cognitive func...
...1. Neurological Conditions in Whic...
...P 2: Review symptoms that may suggest underlying...
.... Behaviors That May Suggest Dement...
...ciate differences among the most co...
...zheimer’s Disease, Vascular Dementi...
...tia with Lewy Bodies vs. Parkinson’s diseas...
...nize frequency of common types of dementia10...
...Alzheimer’s dementia: 55-75% Vascular de...
...sessment...
...r history and perform complete physical exam...
...lude collateral family/caregiver history....
.... Common Types of DementiaHaving troub...
...TEP 6: Assess functional capaci...
...vities of Daily LivingHaving troubl...
...m a mental status evaluation...
...ted yearly to document progression in long-term...
...ected Screening Tools for Cognitive Impairmen...
...Perform limited laboratory testin...
...ine laboratory testing (CBC, basic me...
...9: Consider neuro-imaging...
...o be performed at least once since onset of symp...
...P 10: Screen for depress...
...Recognize that depression can coexist in dementi...
...EP 11: Consider formal neuropsychological t...
...ssess stage of dementia...
...FAST scale (refer to Table 8). Remembe...
...unctional Assessment Staging Scale (FAS...
...: Assess for behavioral and psychologic...
...ms can include agitation, anxiety, confusi...
...able 9. DICE ApproachHaving trouble viewi...
...eatment...
...tient-centered approach to manage dementia...
...tion and quality of life. Capitalize on remai...
...e the environmental aspect of care to i...
...onalize the environment to provide a...
...16: Manage any BPSD15
...Prior to instituting any treatments...
...Consider appropriate pharmacological m...
Table 10. Pharmacologic Treatment o...
...itoring...
...8: Perform regular re-assessment of mental...
...nt target is functional improvement with choli...
...TEP 19: Monitor for adverse effects of ant...
...endix A and B; pay particular attentio...
Depression
...ression...
...ey Poin...
...ong nursing home residents is common a...
...ecognitio...
...TEP 1: Does the patient have any risk fa...
...emale Chronic medical illness, such as cancer,...
...EP 2: Does the patient have any signs or...
...ptoms Suggestive of Depression Pa...
...essment...
...he patient screen positive for depression?...
...reening Tools: Geriatric Depression Scal...
...rform a medical evaluation...
When evaluating depression in olde...
...termine type of depressive disorder...
...sion Major Depressive Disorder (MDD): Symp...
...oes the patient require psychiatric car...
...idal ideation or plan Dangerous to...
Treatment
...e most appropriate treatment...
...ble 1. Psychotherapy vs. Psychosocial Treatme...
...be Pharmacologic Treatment for Depression When App...
...s are advised as first line treatment for olde...
...s of Anti-depressants with Potential Side Eff...
...ly Used Antidepressant DosingHaving t...
...itoring
...itor response to treatment plan for...
...screening/diagnostic tools to monitor for...
...of Major Depression DisorderHaving t...
Appendices
...pendices...
...Antipsychotic AgentsHaving trouble viewing table...
...: Side-Effect Profile of Common Antips...
...Non-Pharmacological Management of Agitati...
...D: 3D’s Quality Performance MeasuresHa...
...ell Scale For Depression In Dementia...
...x F: Patient Health Questionnaire (P...
...dix G: CMS Regulations Regarding PRN use of Ps...
Appendix H: PHQ-9...
References
...es American Psychiatric Association....
Sources
SourcesAMDA - The Society for Post...
Acknowledgements
...mentsAMDA – The Society for Post-Acute and...