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
...lirium...
...Points
...m is a medical emergency – it may be the only...
Recognitio...
...EP 1: Identify who is at risk for developing deli...
...osing Factors or Vulnerability3Hav...
...tating Factors or Noxious Insults3Having troub...
...2: Modify risk factors if po...
...sider use of the Anticholinergic Cognitive Bur...
...ations Commonly Associated with DeliriumHav...
...te routine multi-component non-pharmacologic...
...spital Elder Life Program (HELP) was originally...
...rmacologic Delirium Prevention (based on the HEL...
...sessment...
...: Screen for delirium with a validat...
...s a sensitivity of 94–100% and a specificity o...
...5. CAMHaving trouble viewing table? Expand...
...P 5: Identify the potential cause...
...irium could be a medical emergency; myocardial i...
...etermine the urgency of the situation – can the...
...gnostic Test Options to Help Assess the Causes o...
...eatment...
...lement multi-component non-pharmacologic interv...
...Refer to Table 4...
...anage sleep/wake cycle...
...“5 mg PO QHS or ramelteon 8 mg PO QHS....
...9: Treat the underlying causes (e.g. the medica...
...ize non-pharmacologic approaches for agitation...
...P 11: For management of severe agitation o...
Avoid benzodiazepines (BZDs) excep...
...onitori...
...TEP 12: Reevaluate for delirium with th...
...ize complications of delirium
...Falls Aspiration pneumonitis or pneumonia...
...ust non-pharmacologic treatments and med...
...garding PRN antipsychotic and PRN psych...
Dementia
...mentia...
...ey Point...
Management of dementia in the PALTC setting...
...ecogniti...
...cognize disorders in which cognitive functi...
...Neurological Conditions in Which Cognitive Fun...
...EP 2: Review symptoms that may suggest unde...
...2. Behaviors That May Suggest Dementia...
...: Appreciate differences among the...
...e 3. Alzheimer’s Disease, Vascular...
...entia with Lewy Bodies vs. Parkins...
...TEP 4: Recognize frequency of common types of d...
...€™s dementia: 55-75% Vascular dementia: 13-16%...
Assessment
...ather history and perform complete physical...
...collateral family/caregiver history....
...5. Common Types of DementiaHaving trouble...
...Assess functional capacity...
...ble 6. Activities of Daily LivingHaving...
...Perform a mental status evalu...
...be repeated yearly to document progression...
...able 7. Selected Screening Tools for...
...orm limited laboratory testing...
Routine laboratory testing (CBC, basic...
...nsider neuro-imaging...
...CT or MRI to be performed at least once since o...
...TEP 10: Screen for depre...
...at depression can coexist in dementia. A...
...11: Consider formal neuropsychological testing i...
...ssess stage of dementia...
...Consider FAST scale (refer to Table 8)....
...le 8. Functional Assessment Staging Scal...
...ess for behavioral and psychological symptoms...
...ptoms can include agitation, anxiety, confusion,...
...CE ApproachHaving trouble viewing table? Expand...
...eatment
...P 14: Use patient-centered approach to manage deme...
...tion and quality of life. Capitalize on remaining...
...ze the environmental aspect of care...
...onalize the environment to provide a more...
...EP 16: Manage any BPSD1...
...or to instituting any treatments, rule o...
...r appropriate pharmacological management...
...10. Pharmacologic Treatment of DementiaHavin...
...onitoring
...regular re-assessment of mental status, funct...
...ment target is functional improvement with...
...for adverse effects of antipsychotics...
...Review Appendix A and B; pay particular...
Depression
Depressio...
Key Poin...
...n among nursing home residents is common and is...
...ognition...
...the patient have any risk factors?18...
...hronic medical illness, such as ca...
...TEP 2: Does the patient have any s...
...stive of Depression Patients with several of...
Assessm...
...Does the patient screen positive for depressio...
...Screening Tools: Geriatric Depressi...
...P 4: Perform a medical evaluation...
...ng depression in older adults, consider checki...
...Determine type of depressive diso...
...ion Major Depressive Disorder (...
...patient require psychiatric care?...
...dal ideation or plan Dangerous to self or other...
...atment
...P 7: Determine most appropriate treatment...
...Psychotherapy vs. Psychosocial Treatment Moda...
...cribe Pharmacologic Treatment for Depression Wh...
...SSRIs are advised as first line trea...
...2. Classes of Anti-depressants with Potential S...
...Commonly Used Antidepressant DosingH...
...itoring...
...or response to treatment plan for depression...
Use similar screening/diagnosti...
...of Major Depression DisorderHaving tro...
Appendices
...endices...
...pendix A: Antipsychotic AgentsHaving troubl...
...ndix B: Side-Effect Profile of Common Antip...
...C: Non-Pharmacological Management of Agita...
...D: 3D’s Quality Performance MeasuresHaving trou...
...: Cornell Scale For Depression In Deme...
...endix F: Patient Health Questionnai...
...ndix G: CMS Regulations Regarding PR...
...dix H: PHQ-9-O...
References
...erences American Psychiatric Association. (...
Sources
...A - The Society for Post-Acute and Long-Ter...
Acknowledgements
...AMDA – The Society for Post-Acute and...