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
...elirium...
Key Poi...
...s a medical emergency – it may be the...
...ecognitio...
...: Identify who is at risk for developing...
...osing Factors or Vulnerability3Having t...
...ble 2. Precipitating Factors or Noxious Ins...
...y risk factors if possible...
...use of the Anticholinergic Cognitive Bur...
...Medications Commonly Associated with Deli...
...e routine multi-component non-pharmacologic...
...er Life Program (HELP) was originally designe...
...Pharmacologic Delirium Prevention (based on the...
Assessment
...n for delirium with a validated instru...
...has a sensitivity of 94–100% and a speci...
...ing trouble viewing table? Expand...
...dentify the potential causes of deliriu...
...could be a medical emergency; myocard...
...rmine the urgency of the situation – can the p...
...ostic Test Options to Help Assess the Causes of...
Treatment
...ement multi-component non-pharmacologi...
...efer to Table 4....
STEP 8: Manage sleep/wake c...
...3–5 mg PO QHS or ramelteon 8 mg...
...eat the underlying causes (e.g. the medical illne...
STEP 10: Utilize non-pharmacologic approache...
...For management of severe agitation or psychosis be...
...diazepines (BZDs) except in BZD or a...
...onitoring
...2: Reevaluate for delirium with the CAM frequent...
STEP 13: Minimize complications o...
...Aspiration pneumonitis or pneumonia P...
...: Adjust non-pharmacologic treatments...
...mation regarding PRN antipsychotic and P...
Dementia
...mentia...
...Points...
...nagement of dementia in the PALTC setting involve...
...ognition...
...: Recognize disorders in which cogn...
...le 1. Neurological Conditions in Whic...
...view symptoms that may suggest unde...
...2. Behaviors That May Suggest DementiaHav...
STEP 3: Appreciate differences among the most...
...heimer’s Disease, Vascular Dementia, and...
...le 4. Dementia with Lewy Bodies vs...
...4: Recognize frequency of common typ...
...er’s dementia: 55-75% Vascular dementia: 13-1...
Assessm...
...Gather history and perform complete physical ex...
...llateral family/caregiver history. Avoid "carry...
...ble 5. Common Types of DementiaHaving trouble v...
...sess functional capacity...
...6. Activities of Daily LivingHaving t...
...7: Perform a mental status e...
...ted yearly to document progression in long-ter...
...Selected Screening Tools for Cognitiv...
...: Perform limited laboratory testing...
...aboratory testing (CBC, basic metabolic...
...Consider neuro-imagi...
...CT or MRI to be performed at least onc...
...10: Screen for depressio...
...nize that depression can coexist in de...
...Consider formal neuropsychological testing in ca...
...12: Assess stage of dementia...
...Consider FAST scale (refer to Table 8). Reme...
...tional Assessment Staging Scale (FAST)...
...13: Assess for behavioral and psychologica...
...ese symptoms can include agitation,...
...DICE ApproachHaving trouble viewing tab...
...reatment...
...14: Use patient-centered approach t...
...ptimize function and quality of life. Capital...
...ize the environmental aspect of care to imp...
...alize the environment to provide a more home-...
...16: Manage any BPSD15...
...rior to instituting any treatments, rule out...
...sider appropriate pharmacological management...
...able 10. Pharmacologic Treatment of De...
Monitori...
...regular re-assessment of mental s...
...If treatment target is functional...
...or for adverse effects of antipsychotics...
...endix A and B; pay particular atten...
Depression
...pression...
...Points...
...pression among nursing home residents is common a...
...cognition...
...oes the patient have any risk factors?18...
...Chronic medical illness, such as cancer, diabet...
STEP 2: Does the patient have any signs or...
...ms Suggestive of Depression Patient...
...ssessme...
STEP 3: Does the patient screen positive...
...Screening Tools: Geriatric Depression Sc...
...EP 4: Perform a medical eva...
...ating depression in older adults, c...
...termine type of depressive disorder...
...of Depression Major Depressive Dis...
...es the patient require psychiatric care?...
...al ideation or plan Dangerous to self or other...
...reatmen...
...7: Determine most appropriate treatment...
...sychotherapy vs. Psychosocial Treatmen...
...: Prescribe Pharmacologic Treatment for Depre...
SSRIs are advised as first line treatment for...
...able 2. Classes of Anti-depressants wi...
...ly Used Antidepressant DosingHaving troubl...
Monitoring
...r response to treatment plan for depression...
...milar screening/diagnostic tools to mo...
...e 4. Phases of Major Depression DisorderHav...
Appendices
Appendice...
Appendix A: Antipsychotic AgentsHaving...
...pendix B: Side-Effect Profile of Co...
...Pharmacological Management of AgitationHaving tro...
...ppendix D: 3D’s Quality Performance M...
...E: Cornell Scale For Depression In...
...endix F: Patient Health Questionna...
...ix G: CMS Regulations Regarding PRN use of...
...ndix H: PHQ-9-OV...
References
...rences American Psychiatric Asso...
Sources
...AMDA - The Society for Post-Acute and Long-Term...
Acknowledgements
...entsAMDA – The Society for Post-Acute...