Delirium, Dementia And Depression In The Long-Term Care Setting

Publication Date: January 1, 2019

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

  1. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
  2. 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.
  3. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
  4. 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.
  5. 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”

  1. 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.
  2. 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).
  3. The cognitive deficits do not occur exclusively in the context of a delirium.
  4. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Depression, "Major Depressive Episode"

  1. 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.
  2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  3. 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.

  4. 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.
  5. 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

Having trouble viewing table?

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

...lirium

...y Points...

...Delirium is a medical emergency – it may be the...


Recognit...

...entify who is at risk for developing deli...

...sposing Factors or Vulnerability3Having trouble v...

...recipitating Factors or Noxious In...

...: Modify risk factors if possible...

...r use of the Anticholinergic Cognitive B...

...ions Commonly Associated with DeliriumHaving t...

...P 3: Institute routine multi-component non-pharmac...

...lder Life Program (HELP) was originally desi...

...armacologic Delirium Prevention (b...


...essment

...Screen for delirium with a validated instrume...

...a sensitivity of 94–100% and a spe...

...aving trouble viewing table? Expand...

...P 5: Identify the potential causes of deliri...

Delirium could be a medical emergency; myocard...

...ine the urgency of the situation â€...

...nostic Test Options to Help Assess t...


...atment...

...Implement multi-component non-pharmacologic inter...

...Refer to Table 4...

...nage sleep/wake cycle...

...€“5 mg PO QHS or ramelteon 8 mg PO QHS....

STEP 9: Treat the underlying causes (e.g. the...

...lize non-pharmacologic approaches for agita...

...: For management of severe agitation o...

...nzodiazepines (BZDs) except in BZD or alcohol wi...


...itoring...

...P 12: Reevaluate for delirium with the C...

...P 13: Minimize complications of delirium...

...spiration pneumonitis or pneumonia Pressu...

...non-pharmacologic treatments and medicatio...

...regarding PRN antipsychotic and PRN psychotropic...


Dementia

...mentia...

...Points

...ent of dementia in the PALTC setting involves th...


Recognitio...

...ize disorders in which cognitive func...

...le 1. Neurological Conditions in Which Cognit...

STEP 2: Review symptoms that may suggest...

...haviors That May Suggest DementiaHaving trouble...

...Appreciate differences among the most...

...ble 3. Alzheimer’s Disease, Vasc...

...le 4. Dementia with Lewy Bodies vs. Parkinson...

...TEP 4: Recognize frequency of common types of de...

...imer’s dementia: 55-75% Vascular dementi...


Assessment

...TEP 5: Gather history and perform comple...

...ollateral family/caregiver history. Avoi...

...e 5. Common Types of DementiaHaving trouble viewi...

...6: Assess functional capa...

...ities of Daily LivingHaving trouble viewing...

...rm a mental status evaluation...

...Can be repeated yearly to document progr...

...lected Screening Tools for Cognitiv...

...orm limited laboratory testi...

...laboratory testing (CBC, basic metabolic panel [...

...EP 9: Consider neuro-imagi...

...r MRI to be performed at least once since onset...

...TEP 10: Screen for depression

Recognize that depression can coexist in deme...

...nsider formal neuropsychological test...

...Assess stage of dementia...

...FAST scale (refer to Table 8). Reme...

...unctional Assessment Staging Scale (FAS...

...sess for behavioral and psychological symptoms...

...symptoms can include agitation, anxiet...

...proachHaving trouble viewing table? Expand...


...atment...

...4: Use patient-centered approach to ma...

...unction and quality of life. Capitaliz...

...ize the environmental aspect of care to improve...

...e the environment to provide a more home-like...

...16: Manage any BPSD15...

...o instituting any treatments, rule...

...der appropriate pharmacological management...

...10. Pharmacologic Treatment of DementiaH...


...onitorin...

...Perform regular re-assessment of mental status,...

...treatment target is functional improvemen...

...Monitor for adverse effects of antipsychotics...

...Review Appendix A and B; pay particular attenti...


Depression

...pression...

...Points...

...ssion among nursing home residents is co...


...cognitio...

...the patient have any risk factor...

...e Chronic medical illness, such as cancer, diab...

...the patient have any signs or symptoms of depre...

...gestive of Depression Patients with several of...


...ssessment...

...EP 3: Does the patient screen positive f...

...creening Tools: Geriatric Depressi...

...4: Perform a medical evaluation

...ing depression in older adults, consider...

...Determine type of depressive disorder...

...pes of Depression Major Depressiv...

...he patient require psychiatric care?...

...Suicidal ideation or plan Dangerous to self...


...atment...

...rmine most appropriate treatment...

...ychotherapy vs. Psychosocial Treatment Modalities...

...: Prescribe Pharmacologic Treatment for Depre...

...RIs are advised as first line treatm...

...ses of Anti-depressants with Potential Sid...

...le 3. Commonly Used Antidepressant Dos...


...itoring...

...9: Monitor response to treatment plan f...

...screening/diagnostic tools to monitor for relie...

...ses of Major Depression DisorderHaving trouble v...


Appendices

...endices

...dix A: Antipsychotic AgentsHaving trouble vie...


...ppendix B: Side-Effect Profile of Com...


...ppendix C: Non-Pharmacological Management of Agi...


...D’s Quality Performance MeasuresHaving trouble...


...nell Scale For Depression In Dementia (...


...tient Health Questionnaire (PHQ-9)...


...dix G: CMS Regulations Regarding PRN use of Ps...


...dix H: PHQ-9-OV


References

...eferences American Psychiatric Association. (2...

Sources

...cesAMDA - The Society for Post-Acute and Long-...

Acknowledgements

...dgementsAMDA – The Society for Post-Acute and...