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

...elirium...

...Points

...Delirium is a medical emergency – i...


...cognitio...

...: Identify who is at risk for deve...

...disposing Factors or Vulnerability3Having tro...

...e 2. Precipitating Factors or Noxious Insult...

...y risk factors if possible...

...of the Anticholinergic Cognitive Burden Sc...

...ications Commonly Associated with Deliri...

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

...e Hospital Elder Life Program (HELP) was...

...4. Non-Pharmacologic Delirium Prevention (based...


...sessment

...en for delirium with a validated instrument...

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

...MHaving trouble viewing table? Expand...

...TEP 5: Identify the potential causes of d...

...m could be a medical emergency; myocardial inf...

...mine the urgency of the situation –...

...iagnostic Test Options to Help Assess t...


...eatment...

...TEP 7: Implement multi-component non-phar...

Refer to Table 4....

...nage sleep/wake cycle...

...Melatonin 3–5 mg PO QHS or ramelte...

...reat the underlying causes (e.g. the medical illne...

...10: Utilize non-pharmacologic approaches for...

...management of severe agitation or psy...

...Avoid benzodiazepines (BZDs) except in BZD or alco...


...itoring

...eevaluate for delirium with the CAM frequently...

...imize complications of delirium...

...piration pneumonitis or pneumonia Pressur...

...14: Adjust non-pharmacologic treatments an...

...rmation regarding PRN antipsychotic and PRN ps...


Dementia

Dementia

...ey Points

...Management of dementia in the PALTC...


...cognitio...

...ecognize disorders in which cognitive function i...

...Neurological Conditions in Which Cognit...

...TEP 2: Review symptoms that may suggest...

...able 2. Behaviors That May Suggest De...

STEP 3: Appreciate differences amo...

...lzheimer’s Disease, Vascular Dem...

...tia with Lewy Bodies vs. Parkinson...

...4: Recognize frequency of common types of dement...

...Alzheimer’s dementia: 55-75% Vas...


...essment...

...ather history and perform complete physical exam...

...collateral family/caregiver history....

...5. Common Types of DementiaHaving...

...ssess functional capacity...

...ies of Daily LivingHaving trouble viewing table? E...

...7: Perform a mental status evaluati...

...eated yearly to document progression in long...

Table 7. Selected Screening Tools fo...

...rform limited laboratory testin...

...aboratory testing (CBC, basic metabolic panel...

...Consider neuro-imaging...

...be performed at least once since onset of...

...EP 10: Screen for dep...

...ize that depression can coexist in dementia. A...

...Consider formal neuropsychological tes...

...ssess stage of dementia...

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

...onal Assessment Staging Scale (FAST) – 7 st...

...3: Assess for behavioral and psychological...

...se symptoms can include agitation, anxie...

...DICE ApproachHaving trouble viewing table? Expand...


...eatment

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

...imize function and quality of life. Capitalize...

...ize the environmental aspect of ca...

...onalize the environment to provide a...

STEP 16: Manage any BPS...

...or to instituting any treatments, rule out rev...

...17: Consider appropriate pharmacological managem...

...acologic Treatment of DementiaHaving trouble viewi...


...nitoring

...rform regular re-assessment of men...

...eatment target is functional improvement with ch...

...itor for adverse effects of antipsychotics...

...ix A and B; pay particular attention to movement d...


Depression

...pressio...

...y Points

...on among nursing home residents is common and i...


...cognitio...

...TEP 1: Does the patient have any risk fa...

...emale Chronic medical illness, such as c...

...TEP 2: Does the patient have any signs or...

...stive of Depression Patients wit...


...essment...

...oes the patient screen positive for d...

...on Screening Tools: Geriatric Dep...

...Perform a medical evaluation...

...uating depression in older adults, consi...

...ine type of depressive disorder...

...f Depression Major Depressive Disord...

...oes the patient require psychiatric care?...

...cidal ideation or plan Dangerous to self...


...eatment...

...EP 7: Determine most appropriate trea...

...ychotherapy vs. Psychosocial Treatment Modalit...

...TEP 8: Prescribe Pharmacologic Treatment for Depre...

...e advised as first line treatment for o...

...able 2. Classes of Anti-depressants...

...only Used Antidepressant DosingHaving troub...


Monitorin...

...9: Monitor response to treatment plan for depres...

...similar screening/diagnostic tools to moni...

...le 4. Phases of Major Depression DisorderHav...


Appendices

Appendice...

...A: Antipsychotic AgentsHaving trouble viewin...


...Side-Effect Profile of Common Anti...


...Pharmacological Management of AgitationHaving...


...pendix D: 3D’s Quality Performance Measure...


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


...ppendix F: Patient Health Questionnaire...


...S Regulations Regarding PRN use of Psychotrop...


...ndix H: PHQ-9-...


References

References American Psychiatric Associat...

Sources

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

Acknowledgements

...ementsAMDA – The Society for Pos...