Dementia Ppt and Delirum

Assessing and Treating Dementia with Delirium and Depression

Cathleen Carney, M.A., CCC-SLPSpeech Language Pathologist, Rehab America, Arlington TN

Susan Chapman, M.A., CCC-SLPSpeech Language Pathologist/Clinical ManagerGenesis Rehabilitation Services, Territory 4

ASHA 20062

“The geriatric patient with dementia who also presents with delirium or depression has specific challenges and needs that must be addressed by all members of the interdisciplinary team.”

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Objectives:

The participant will be able to: identify the symptoms, behaviors, and

characteristics of dementia, delirium and depression.

determine the appropriate assessment protocol for evaluation of the patient with dementia and its comorbidities.

provide functional goals and appropriate treatment techniques based on assessment objectives.

ASHA 20064

Definitions from DSM

Delirium Is a major mental disorder that is a direct

physiological consequence of a medical condition.

Usually characterized by disruptions in consciousness and change in cognitive abilities or perceptual difficulties that are not due to a dementia.

Develops over a short period of time (usually within hours or a day) and fluctuates over the course of a day.

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Delirium

Direct physiological consequence of a medical condition that is characterized by disruptions in consciousness which can include difficulty in focusing, maintaining or shifting attention and a change in cognitive abilities or the development of perceptual difficulties that are not due to a dementia.

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Delirium

Acute confusion and dementia: Used interchangeably

Acute confusion is a disturbance in information processing and attention characterized by disordered cognition as well as disturbances in perception, thinking, memory, attention and wakefulness – characterized by global impairment.

Characterized by: Acute onset Marked fluctuations in cognitive impairment over course of

the day Disruptions in consciousness and attention Alterations in sleep cycle. Hallucination and delusion are common. Infection or drug toxicity typically cause acute confusion.

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Definition from DSM

DepressionThe most common psychiatric

disorder among older people; it can vary in duration and degree and show psychological as well as

physiological manifestations.

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Depression: Situations associated with Depression Retirement Multiple role losses Bereavement Deaths of family members and friends Loneliness and isolation Responsibility for care of an older person with a

disability Residence in a nursing home Elder abuse Neglect Substance abuse

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Medical conditions associated with late life depression

Cardiac and vascular conditions Myocardial infarction Cerebrovascular

accident Neurological conditions

Dementia Parkinson’s disease Cancer

Sensory impairments Vision Impairments Hearing decrements

Physical disabilities Hip fracture Loss of mobility Trauma

Other medical conditions Acute pain Chronic pain

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Depression

The most common mental health problem confronting older adults.

Symptoms of a major depressive disorder:1. Depressed mood2. Diminished interest in / pleasure in activities3. Weight loss or weight gain of 5% within a month4. Insomnia or hypersomnia5. Psychomotor retardation or agitation6. Fatigue or loss of energy7. Feelings of worthlessness or guilt8. Diminished ability to concentrate or indecisiveness9. Recurrent thoughts of death or suicidal ideation

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Classification of Depression

5 or more of the symptoms One, of which must be depressed mood or diminished

interest. Symptoms have to have lasted for greater than two weeks. Symptoms represent a departure from previous

functionality. Symptoms result in impaired social and/or occupational

functioning.

Risk = 20-25%Risk factors include being female, unmarried, widowed or

recently bereaved, experiencing stressful life events, lower levels of social support, serious physical illness

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Classification of Depression

50% of older adults who have a chronic physical illness may also have major depressive disorder.

Depression results in “excess disability”, negatively impacting:

• quality of life, • functionality, • physical health status, • longevity, • relationships.

Depression results in resistance to care, inconsistency of course and negativity, excess pain and suffering.

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What Is Dementia?

The onset is usually insidious Cognitive deficits are losses of memory, language,

executive function, visuospatial ability. Compartmental changes are alterations in personality,

insight and judgment - functions which help a person behave appropriately in

social situations, make reasonable decisions and plan, organize and follow logical sequence to reach goals

Changes in cognition eventually impair IADL and ADL performance

Changes in social psychological environment and patterns of relationships and interaction may also evident

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DSM-IV, Dementia

Characterized by memory impairment and at least one of the following cognitive difficulties – aphasia, apraxia, agnosia, disruption in executive function.

Gradual onset of symptoms with continuing decline – representing a significant decline from previous level of functioning,

Severe enough to impair social and or occupational functioning.

Must not occur during course of delirium. Lifetime risk, 14-16% - higher risk for females, African

Americans

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Definition from DSM

Dementia A major mental disorder characterized

by memory impairment (which can include either difficulty learning new material or recalling previously learned material) and

difficulty with at least one of the following cognitive capacities: language, recognition, and organization and/or performance of motor activities.

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Dementia: Changes in appearance

Newly stooped posture Slowing of movement Slowing of thought processes Unexplained weight loss or weight gain Clothing that does not fit Poor grooming Poor maintenance of clothing Poor hygiene Diminished energy level Unexplained fatigue Sad affect

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Dementia: Changes in Behavior & Activity Level Decrease in social

participation Increase in isolation

and social withdrawal Decreased interest in

things Difficulty with decision

making Difficulty concentrating Unusual negativism Hopelessness

Inconsistency Newly poor hygiene Unexplained anger Increased anxiety level Increased complaints

of pain Complaints of sleep

difficulties Changes in appetite or

eating habits Noncompliance with

medications

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Early Symptoms of Dementia:Alzheimer’s DiseaseSlow, widespread, progressive symptoms

Neurological/Cognitive Short-term memory

impairments Inability to focus attention

and recall events Progressive disorientation

(time and place) Difficulty in word finding

and impaired naming Impaired language

comprehension and calculation

Visual and spatial deficits

Behavioral/Psychosocial Personality changes

(passivity to hostility) Decreased emotional

expression Diminished initiative Depression and anxiety Greater suspiciousness Visual hallucinations Delusions (accusations of

theft, infidelity, persecution) Wandering

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Early Symptoms of Dementia:Vascular Dementia

Neurological/cognitive Acute unilateral motor or

sensory dysfunction Urinary dysfunction Gait disturbance Mask like facial

expression and rigidity Aphasia

Behavioral/psychosocial Sudden, affective

changes Depression Delusions Psychotic symptoms

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Early Symptoms of Dementia:Dementia of the frontal lobe type

& Pick’s disease Neurological/cognitive

Apathy Language impairments

(unfocused speech, spontaneous compulsive repetition of words/phrases

Normal short-term memory

Normal or minimally affected cognitive testing

Normal visual and spatial abilities

Behavioral/psychosocial Prominent alterations in

emotion, affect, and behavior

Disordered executive function (initiation, goal setting, planning)

Little awareness of changes (denies any problems)

Disinhibited behavior Personality changes Withdrawal

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Early Symptoms of Dementia: Dementia with Parkinsonism

Neurological/cognitive Rigidity and postural

instability General slowing of

thought and action

Behavioral/psychosocial Disordered executive

function Delusions Hallucinations

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Early Symptoms of Dementia: Hydrocephalus

Neurological/cognitive Gait disorder Urinary incontinence Cognitive decline

(psychomotor slowing, impaired ability to concentrate, and mild memory difficulties

Behavioral/psychosocial Irritability Change in behavior

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Criteria for determining Dementia

Syndrome:Decline in cognitive functions in

comparison with client’s previous level of function

Decline severe enough to interfere with social and occupational functioning

Decline confirmed by clinical examination and neuropsychological tests

No disturbance of consciousnessDiagnosis based on behavior.

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Criteria for determining probable Alzheimer’s disease

MMSE, Blessed Dementia Scale Deficits in 2 or more areas of cognition Progressive worsening of cognitive

functions No disturbance of consciousness Onset between 40 & 90, most often after

age 65

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Medical Workup for Dementia

TESTS RATIONALE – rule out…

Urinalysis Kidney dysfunction, toxic encephalopathy

CBC, sedimentation rate, electrolytes

Anemia, electrolyte imbalance

Blood Urea Nitrogen (BUN)/creatinine, liver function test

Liver dysfunction

Thyroid function Thyroid dysfunction

Serum B 12 Vitamin deficiency

Syphilis serology Syphilis

HIV test AIDS dementia

Neuroimaging studies: CT or MRI Tumor, subdural hematomas, abscess, stroke, or hydrocephalus

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Symptoms of Depression & Dementia

Depression Dementia

Affect/mood/

demeanor

Pervasive sadness, dourness, negativity

Blank matter of fact expression,

Possible overlay of sadness

Memory Poor concentration and temporary memory decrease

Progressive impairment of short-term memory, eventually long term memory

Function Functional ability diminished by lack of motivation

Functional ability (activities of daily living and instrumental activities of daily living) diminished by declining abilities

Organization Impaired decision making Impaired executive function (e.g. organization, prioritization)

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Depression Dementia

Orientation Intact or impaired orientation

Impaired orientation

Language Slowed language Trouble finding words and naming things

Motivation Impaired motivation Possible impaired motivation

Appetite/weight Either decreased appetite and weight or increased appetite and weight

Trouble remembering to eat

Decrease in weight with no obvious explanation

Sleep Possible problems falling asleep, staying asleep, or waking up

Possible sleep problems or no sleep problems/impairment

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Depression Dementia

Thinking/reasoning/ability to learn

Slow thinking and reasoning, Ability to learn is retained

Impairment

Danger Possible suicide Safety concerns because of impaired judgment

Somatic complaints/pain Possible multiple or exaggerated somatic complaints

Fatigue

Complaints that are underreported or perseverated upon

Fatigue

Depression screening tool Possible high scores Possible high scores or low scores

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Depression and Dementia

Symptoms of depression and dementia may overlap or occur as co-morbidities with other medical conditions as well as with each other.

Vitamin deficiencies may present with depression as well as dementia.

Hyperthyroidism may present with symptoms of decreased energy and interest, symptoms common to both dementia and depression.

Sad affect of depressed individual may often be confused with the blank affect of an individual with dementia.

The lack of response to questions or slow responsiveness of depression due to poor concentration may appear to be similar to the loss of memory of the individual with dementia.

Poor hygiene and self neglect may be common to both conditions.

Evaluation and treatment of both dementia and depression is often warranted.

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Cognitive decline becomes increasingly common with advancing age.

5-15% of persons over 65 and 20-50% of persons over 85 are reported to be affected.

Mental impairment, including depression and dementia, is frequently under diagnosed in the geriatric population.

Cognitive decline affects every aspect of a client’s life and imposes major psychological and economic burdens on family and caregivers.

Cognitive decline may produce an overlay of depressive symptoms, or depression may be misdiagnosed as cognitive impairment.

Major depression is present in 20-40% of older person’s with Alzheimer’s disease.

Multiple “I don’t know” answers are a clue that an older person may be depressed.

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Tests that differentiate between cognitive impairment and depression should be administered.

Inconsistent performance on mental exam also suggest that depression may be present.

Assessing orientation by inquiring about name, place and date is ineffective as a screening tool.

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The presence of physical illness in later life increases the likelihood of emotional problems.

Severe emotional problems can be found in 10-25% of hospitalized older patients.

Emotional reactions to illness include depression, anxiety, problems in regards to pain, decline in body functions.

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Diagnostic Workup for Late Life Depression

Psychological history Mental Status (cognitive) screen Depression screen Assessment of activities of daily living and instrumental activities of

daily living Assessment of sleep and activity patterns Assessment of severity of depressive symptoms Assessment of suicidal ideation and history of prior attempts Medical history Review of prescription and over-the-counter medications Physical examination Routine diagnostic tests (e.g. electrocardiograms), laboratory tests,

or imaging (computed tomography scan or magnetic resonance imaging), if indicated to clarify diagnosis

Psychiatric consultation, if needed for clarification Neuropsychological testing, if needed for clarification

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Statements That May Be Indicative Of Depression

I’m not the person I used to be. I can’t manage to get anything done. I’m awake all night and then get to sleep in the morning. Nobody can do anything for me. I don’t care if I die. Things are hopeless. I don’t want to be a burden to anyone. I’ve heard that medicines have too many side effects,

so I don’t want any. I may be nervous, but I’m not mental. Who’s to care? Nobody wants me. I’m too poor to afford that.

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Alterations in thought processes: characteristics of client behavior -

Disorientation to time, place, personAltered ability to think abstractlyDisorders of memoryMisinterpretation of environmental stimuliChanges in problem-solving abilitiesChanges in behavior patterns, including regressionIrritabilityExpression of fear of others or of losing controlHallucinationsDelusional thoughtsInappropriate responses to commandsInaccurate interpretation of the environment

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Dementia, Depression, Delirium

Depression Dementia Delirium

Onset Usually within a period of weeks

Slow, insidious, over a period of months/years

Abrupt, may be within hours or days

Symptoms Pervasive sadness or loss of pleasure, plus vegetative signs

Gradual decline in functioning, including recent memory loss

Fluctuation in consciousness and attention

Possible hallucinations, delusions

Course Episodic, treatable, resolvable

Progressive, manageable

Treatable, usually resolvable

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Dementia, Depression, Delirium

Depression Dementia DeliriumConsequences May complicate course

of other illnesses

May lead to decrease in self-care

May lead to suicide and various safety problems

Results in decrease in ability to perform activities of daily living, poor judgment, and decreased ability to learn

May be harbinger of medical illness

Can flag life-threatening emergency

Requires prompt medical intervention

Phenomenology Can coexist with other Dx, causing “excess disability,” and may complicate course of other illnesses

May make depression and delirium harder to recognize

Is more prevalent in persons with dementia and hospitalized patients

Treatment Multiple simultaneous interventions

Multiple simultaneous interventions

Medical intervention first, to address underlying illness

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Assessment Tools

Be familiar with the strengths, weaknesses and accuracy of any tool.

Determine the goals of assessment. Be aware that older persons often view

mental and neuropsychological testing negatively.

Fatigue, frustration and anxiety may compromise the test scores.

Sensory loss, disorientation and medication may lower test scores.

Be observant. Take a complete history.

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Mini Mental State Examination

MMSE Used by 90% of physicians Recommended by the National Institute of

Neurological and Communicative Disorders 23 or lower out of 30 is indicative of cognitive

impairment 85% or better sensitivity to clients with

dementia Can distinguish between depressed clients,

clients with dementia and clients with both depression and dementia.

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Mini Mental Status Exam (MMSE)

Section 1: Orientation What is the day of the week? What building are we in?

Section 2: Memory, Part 1 Immediate recall: remember 3 words

Section 3: Attention and Calculation Ability to concentrate on a tricky task, serial 7’s – subtract from 100

Section 4: Memory, Part 2 Delayed recall; recall 3 words from section 2

Section 5: Language, writing and drawing Name common objects, Follow 3 stage command Read and follow directions Copying Write a complete sentence

Copies of the complete test are available from the Psychological Assessment Resources (PAR) website: http://www.parinc.com

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Short Portable Mental Status Questionnaire

SPMSQ Less than 2 errors, normal mental function 8 or greater error, severe mental impairment

Sensitivity of 95% when used as a screening tool for dementia in the 60 years and older population

Assesses short narrow range of basic functions including memory, attention, orientation, capable of detecting gross cognitive dysfunction only.

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THE SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE

1. What are the date, month, and year? 2. What is the day of the week? 3. What is the name of this place? 4. What is your phone number? 5. How old are you? 6. When were you born? 7. Who is the current president? 8. Who was the president before him? 9. What was your mother's maiden name? 10. Can you count backward from 20 by 3's?Ê

SCORING:* 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment *One more error is allowed in the scoring if a patient has had a grade school education or

less. *One less error is allowed if the patient has had education beyond the high school level. Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in

elderly patients. Journal of American Geriatrics Society. 23, 433-41.

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Cognitive Functioning Instruments

MMSE will not detect mild cognitive impairment Not designed to grade progression of

impairment Clients with expressive aphasia may appear

more impaired

SPMSQ Too insensitive to small changes

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Functional Assessment Staging Tool

FAST-Is for distribution to the familyProvides specific information on the

order in which various functions are lost

Provides time frame estimate on how long given level of function will last.

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Wechsler Memory Scale

Broad range of memory functionsSensitive to more subtle changesToo long to administerInadequate norms for older population

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Global Deterioration Scale (GDS)

Gives overall picture of the disease process

Able to appropriately stage dementiaLanguage performance is not usedIs used primarily with patients who’s

dementia is the Alzheimer’s type Will provide information on general

progression of disease but does not take into account individual variations.

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Global Deterioration Scale (GDS)

GDS Stage 1: Normal Phase GDS Stage 2: Forgetful Phase GDS Stage 3: Early Confusional Phase GDS Stage 4: Late Confusional Phase GDS Stage 5: Early Dementia GDS Stage 6: Middle Dementia GDS Stage 7: Late Dementia

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Some other commonly used cognitive assessment instruments Arizona Battery of Communication Disorders Brief Cognitive Rating Scale Cognitive Performance Test Clock Drawing FROMAJE Functional Linguistic Communication Inventory Rating Scale of Communication in Cognitive Decline Rehabilitation Institute of Chicago Evaluation of

Communication Problems on Right Hemisphere Dysfunction (RICE)

Ross Test of Higher Cognitive Processing Test of Problem Solving Token Test Rivermead Behavioral Memory Test

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Depression Instruments

Tools do not establish a diagnosis of depression but are important in identifying clients for further evaluation.

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Geriatric Depression Scale

Includes a broad range of depression mood questions

Quick and reliableAvoids excess physical symptom

questions

Weakness is it’s limitations and usefulness in clients with severe dementia.

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GERIATRIC DEPRESSION SCALE (GDS, SHORT FORM)

Choose the best answer for how you felt over the past week. 1. Are you basically satisfied with your life? 2. Have you dropped many of your activities and interests? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 9. Do you prefer to stay at home, rather than going out and doing new things? 10. Do you feel you have more problems with memory than most? 11. Do you think it is wonderful to be alive now? 12. Do you feel pretty worthless the way you are now? 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? 15. Do you think that most people are better off than you are? Score 1 point for each bolded answer. Cut-off: normal (0-5), above 5 suggests

depression. Source: Courtesy of Jerome A. Yesavage, MD.

Clinical Toolbox for Geriatric Care © 2004 Society of Hospital Medicine 2 of 2

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Hamilton Depression Scale

Assesses objective symptomsCan estimate severity of depression

Weakness is it’s reliability on physical symptoms thus making it less useful in older adults.

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Beck Depression Inventory

Self Rating scale Assesses symptoms of depression Includes a broad range of questions Validated in older adults and medical

patients

Weakness is that it relies too heavily on physical symptoms,

Also difficult for cognitively impaired clients to use.

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www.americangeriatrics.org/education/depression.shtml

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Treatment of Delirium

Identify and treat the underlying cause Provide a stable environment Perform a head-to-toe systems approach Perform a medication review

Check for side effects, use of outdated medication, interactions

Understanding of and adherence to prescribed medication administration

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Treatment of Depression

Social treatment therapy

PsychopharmacologicalAntidepressants

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Treatment of Depression Communication Strategies:

Listen. Recognize changes – trust your eyes, ears, sense of

smell, and general intuition. Remain calm – do not panic. Acknowledge the person’s feeling. Do not try to talk

the person out of the feelings. If the person expresses suicidal ideas, refer the

person for immediate psychiatric evaluation and treatment.

Be reassuring. The person is ill, and things will get better.

Don’t be judgmental. Depression is an illness and not something the person has chosen.

Provide positive reinforcement, as appropriate. Acknowledge positive steps toward recovery.

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Treatment of Dementia

Behavioral & Environmental Encourage appropriate behavior Minimize inappropriate behavior Maintain current level of functioning Ensure safety

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Treatment of Dementia

Patient, Family, Caregiver education and support

Assess for and manage depression and delirium

Supportive therapies Psychopharmacologic treatment

ASHA 200660

Clinicians working in nursing homes and retirement communities, where the population is generally over the age of 65 years of age, should be observant for symptoms of dementia, depression and delirium. In these settings, caregivers and family often overlook the onset of dementia, attributing cognitive and behavioral changes of residents to “aging”.

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Our challenge…

Facilitate communication. Slow the progression or impact of

functional decline. Modify the environment. Teach caregivers about the diseases

and impact on functional abilities.

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Questions

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Documents

Dementia Ppt and Delirum