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

Last updated December 18, 2021

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. 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...

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


...Recognition...

...STEP 1: Ident...

.... Predisposing Factors or Vulnerability3 Ag...

...able 2. Precipitating Factors or N...

...STEP 2: Modify ri...

Consider use of the Anticholinergic Co...

...edications Commonly Associated with Del...

...STEP 3: I...

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

...on-Pharmacologic Delirium Prevention (based on...


Assessm...

...ST...

...nsitivity of 94–100% and a specif...

...To diagnose delirium b...

...STEP 5: Ident...

...could be a medical emergency; myoca...

...STEP...

...6. Diagnostic Test Options to Help Asse...


...Tr...

...STEP 7: Implement...

...Refer to Table 4....

...STEP 8: Ma...

...latonin 3–5 mg PO QHS or ramelteo...

...ST...

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


...Monit...

STEP 12:...

...STEP 13: Mini...

...Falls  Aspiration pneumonitis or pneum...

...STEP 14: Adj...

...garding PRN antipsychotic and PRN psychotropic me...


Dementia

...Key Points...

...ent of dementia in the PALTC setting inv...


...Recog...

...ST...

...ological Conditions in Which Cognitive...

...STEP 2:...

...haviors That May Suggest Dementia ...

...STEP 3: Appreciate d...

...zheimer’s Disease, Vascular Deme...

...able 4. Dementia with Lewy Bodies vs. Parkinso...

...STEP...

...heimer’s dementia: 55-75% Vascu...


...Assessm...

...STEP 5: Gather his...

...teral family/caregiver history. Avo...

...ommon Types of Dementia   History...

...STEP 6: Assess...

...ctivities of Daily Living ADLs IADL...

...STEP 7: Perfo...

...repeated yearly to document progressio...

...elected Screening Tools for Cognitive Impairm...

...STEP...

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

...STEP 9:...

...MRI to be performed at least once si...

...STEP 10: Screen for de...

...ecognize that depression can coexist in dementia....

...STEP 11...

...STEP 12: Asse...

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

...8. Functional Assessment Staging Scale (FAST)...

...STEP 13...

...ptoms can include agitation, anxiety, confusion...

.... DICE Approach D De...


...Treatme...

...STEP 14: Use...

...ction and quality of life. Capital...

...ST...

...Personalize the environment to provi...

...STEP 16: Man...

...tituting any treatments, rule out reversible...

...Step 17: Consider appro...

...10. Pharmacologic Treatment of Dem...


...Monitorin...

...STEP...

...eatment target is functional improvement with cho...

...STEP 19...

...w Appendix A and B; pay particular attention to...


Depression

...Depression...

...Key Points...

...among nursing home residents is com...


Reco...

...STEP 1: Does the patien...

...hronic medical illness, such as cancer, dia...

...s Suggestive of Depression Patients with s...


...Assessment...

...STEP 3: Does th...

...Screening Tools: Geriatric Depression Scale...

...STEP 4...

...When evaluating depression in older ad...

...S...

...f Depression Major Depressive Diso...

...STEP...

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


...Treatment...

...STEP 7: Det...

...otherapy vs. Psychosocial Treatment Mod...

...STEP 8: Pr...

...dvised as first line treatment for older ad...

...asses of Anti-depressants with Potential Side E...

...Commonly Used Antidepressant Dosing...


...Monitoring...

...STE...

...similar screening/diagnostic tools to monito...

...4. Phases of Major Depression Disorder...


Appendices

...Appendices...

...ntipsychotic Agents Antipsyc...


...de-Effect Profile of Common Antipsychotic Medicati...


...endix C: Non-Pharmacological Management...


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


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


Appendix F: Patient Health Question...


...G: CMS Regulations Regarding PRN use...


...dix H: PHQ-9-OV...


References

...es American Psychiatric Associat...

Sources

SourcesAMDA - The Society for Post-Acute...

Acknowledgements

...sAMDA – The Society for Post-Acute and L...