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

Last updated May 27, 2022

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

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

...Delirium

...Key Points...

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


...Re...

...STEP 1:...

...osing Factors or Vulnerability3 Age 75 or older...

...recipitating Factors or Noxious Insults3...

...STEP 2: Modify...

...of the Anticholinergic Cognitive Bu...

...dications Commonly Associated with Delirium Ce...

STEP 3: In...

...Elder Life Program (HELP) was originally designed...

...n-Pharmacologic Delirium Prevention (based...


...Assessment...

...STEP 4:...

...AM9 has a sensitivity of 94–100% and a...

...CAM To diagnose deliri...

STEP 5: Ide...

...irium could be a medical emergency; myo...

...STEP 6:...

.... Diagnostic Test Options to Help Assess t...


...Treatment

...STEP 7: Implement mul...

...r to Table 4....

...STEP 8: Ma...

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

...STEP 9: Treat...

...STEP 10:...

...STE...

...d benzodiazepines (BZDs) except in BZD or alc...


...Monitoring...

...STEP 12...

...STEP 13: Minim...

...Falls Aspiration pneumonitis or pneumonia...

...STEP 14: Adjus...

Information regarding PRN antipsychotic and PRN p...


Dementia

...Key Points...

...ement of dementia in the PALTC setting involves...


...Recognition...

...Neurological Conditions in Which Cognitive F...

...ST...

...rs That May Suggest Dementia...

...STEP 3: Appreciate d...

...Alzheimer’s Disease, Vascular Dementia, an...

Table 4. Dementia with Lewy Bodies vs. P...

...STEP 4: Recog...

...eimer’s dementia: 55-75% Vascular dem...


...Assessment...

...ST...

...ateral family/caregiver history. Avoid "car...

...5. Common Types of Dementia H...

...STEP 6...

...vities of Daily Living AD...

...STEP...

...be repeated yearly to document progres...

...Selected Screening Tools for Cognitive Impai...

...STEP 8: Perform limit...

...aboratory testing (CBC, basic metab...

STEP...

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

...STEP 10:...

...Recognize that depression can coexist in demen...

...STEP 11:...

...STEP 12: Assess...

...T scale (refer to Table 8). Remembe...

...tional Assessment Staging Scale (FAST) ...

...STEP 13: Assess for...

...se symptoms can include agitation, anxiety, confus...

...le 9. DICE Approach D Desc...


...Trea...

...STEP 14...

...ize function and quality of life. Capitalize on re...

...STEP 1...

...the environment to provide a more...

...STEP 16...

...ituting any treatments, rule out reversible causes...

...Step 17: Consid...

...le 10. Pharmacologic Treatment of Dementia...


...STEP 18: Perform re...

...If treatment target is functional impr...

...STEP 19...

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


Depression

...Depression...

...Key Points...

...ssion among nursing home residents...


...STEP 1: Does the...

...emale Chronic medical illness, such as cancer, d...

...STEP 2: Does...

...ggestive of Depression Patients with severa...


...As...

...STEP 3:...

...ssion Screening Tools: Geriatric Depressio...

...STE...

...When evaluating depression in older adu...

...STEP 5...

...Depression Major Depressive Disorder (MDD):...

...STEP 6: Does the patie...

...Suicidal ideation or plan Dang...


...Treatment...

...hotherapy vs. Psychosocial Treatment Modalitie...

...STEP 8: Prescribe...

...s are advised as first line treatment for older a...

...Classes of Anti-depressants with Poten...

...3. Commonly Used Antidepressant Dosing...


...Monit...

...STEP 9: Moni...

...ar screening/diagnostic tools to monitor for r...

...ses of Major Depression Disorder Te...


Appendices

...Appendices...

...ppendix A: Antipsychotic Agents Antips...


...endix B: Side-Effect Profile of Commo...


...Non-Pharmacological Management of Agitati...


...ix D: 3D’s Quality Performance Measures...


...ppendix E: Cornell Scale For Depression In De...


...pendix F: Patient Health Questionnaire (PHQ-...


Appendix G: CMS Regulations Regarding PR...


...endix H: PHQ-9-OV...


References

...American Psychiatric Association...

Sources

...esAMDA - The Society for Post-Acute and...

Acknowledgements

...entsAMDA – The Society for Post-Acute and Lo...