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 Points...
...s a medical emergency – it may be the only...
Recognition
...1: Identify who is at risk for developing deli...
...e 1. Predisposing Factors or Vulnerability3Havin...
...le 2. Precipitating Factors or Noxious Insults...
...Modify risk factors if possible...
Consider use of the Anticholinergi...
Table 3. Medications Commonly Assoc...
...stitute routine multi-component non-pharmacologic...
...lder Life Program (HELP) was originally designed...
...on-Pharmacologic Delirium Prevention (based on th...
...sessment...
...Screen for delirium with a validated instrument s...
CAM9 has a sensitivity of 94–100% and...
...e 5. CAMHaving trouble viewing table?...
...the potential causes of delirium...
...uld be a medical emergency; myocardial infarc...
...mine the urgency of the situation – can th...
...6. Diagnostic Test Options to Help Assess th...
...reatment
...nt multi-component non-pharmacologic interventio...
...Refer to Table 4.
...: Manage sleep/wake cycle...
...atonin 3–5 mg PO QHS or ramelteon...
...the underlying causes (e.g. the medical i...
...Utilize non-pharmacologic approac...
...management of severe agitation or ps...
...benzodiazepines (BZDs) except in BZD or alco...
...onitoring
...2: Reevaluate for delirium with the CAM...
...3: Minimize complications of delirium...
...Aspiration pneumonitis or pneumonia Pressure...
...just non-pharmacologic treatments and me...
...regarding PRN antipsychotic and PRN psycho...
Dementia
...mentia...
...ey Point...
...anagement of dementia in the PALTC setting i...
...ecognitio...
...cognize disorders in which cognitive functi...
...rological Conditions in Which Cogniti...
...2: Review symptoms that may suggest underly...
...e 2. Behaviors That May Suggest DementiaHaving...
...reciate differences among the most common...
...mer’s Disease, Vascular Dementia...
...4. Dementia with Lewy Bodies vs. Parkinsonâ€...
STEP 4: Recognize frequency of common types of d...
...€™s dementia: 55-75% Vascular deme...
...ssessmen...
...Gather history and perform complete...
...lateral family/caregiver history. Avoid "carr...
...ble 5. Common Types of DementiaHaving tro...
...6: Assess functional capaci...
...6. Activities of Daily LivingHaving trouble view...
STEP 7: Perform a mental status eva...
...Can be repeated yearly to document pro...
...ted Screening Tools for Cognitive ImpairmentHav...
...Perform limited laboratory te...
...atory testing (CBC, basic metabolic panel...
...Consider neuro-imaging...
...CT or MRI to be performed at lea...
...: Screen for depression...
...Recognize that depression can coex...
...er formal neuropsychological testing in cases...
STEP 12: Assess stage of dementia
...Consider FAST scale (refer to Ta...
...onal Assessment Staging Scale (FAST) – 7 stagesH...
...P 13: Assess for behavioral and psy...
...se symptoms can include agitation, anxiety, confus...
...ICE ApproachHaving trouble viewing...
...eatmen...
...P 14: Use patient-centered approac...
...Optimize function and quality of life. Capit...
STEP 15: Optimize the environmental aspect of car...
...e the environment to provide a more home-like a...
...P 16: Manage any BPSD15
...Prior to instituting any treatments, rule out...
...Consider appropriate pharmacological ma...
...able 10. Pharmacologic Treatment of DementiaHa...
...onitori...
...rform regular re-assessment of mental stat...
If treatment target is functional improvement...
STEP 19: Monitor for adverse effec...
...ppendix A and B; pay particular attention to m...
Depression
Depressio...
Key Poin...
...ion among nursing home residents is common and i...
...cognition
...EP 1: Does the patient have any ri...
...ronic medical illness, such as canc...
...: Does the patient have any signs...
...stive of Depression Patients with several of the...
Assessment
...Does the patient screen positive for depr...
...Screening Tools: Geriatric Depression Scale...
...: Perform a medical evaluation...
...valuating depression in older adults, co...
...ne type of depressive disorder...
Types of Depression Major Depres...
...patient require psychiatric care?...
...cidal ideation or plan Dangerous to self or o...
...reatment
...P 7: Determine most appropriate tr...
Table 1. Psychotherapy vs. Psychosoci...
...EP 8: Prescribe Pharmacologic Treatmen...
...advised as first line treatment for older...
...able 2. Classes of Anti-depressants wit...
...ommonly Used Antidepressant DosingHaving troub...
...nitoring
...P 9: Monitor response to treatment pl...
...creening/diagnostic tools to monitor for...
...Phases of Major Depression DisorderHaving trouble...
Appendices
Appendic...
...tipsychotic AgentsHaving trouble viewing table...
...B: Side-Effect Profile of Common Antipsych...
...x C: Non-Pharmacological Management of Agit...
...€™s Quality Performance MeasuresHa...
...nell Scale For Depression In Dementia...
Appendix F: Patient Health Questionnaire (PHQ...
...dix G: CMS Regulations Regarding PRN use of...
...ndix H: PHQ-9-...
References
...eferences American Psychiatric Association. (...
Sources
...e Society for Post-Acute and Long-Term...
Acknowledgements
...owledgementsAMDA – The Society for Po...