The Three Ds of Confusion Delirium, Depression, Dementia

1. The Three Ds of ConfusionDelirium, Depression, Dementia

2. Confusion • Is not a normal part of aging • Delirium and Depression are treatable • Dementia is manageable

3. Delirium • More common than fever or pain in older adults • About 50% of hospitalized older adults experience delirium • Only 3 out of 10 older adults with delirium are diagnosed by health care personnel • As many as 1/3 of those affected by delirium will die • Is a medical emergency and should be treated as such St. Pierre, J. (1996). Delirium in hospitalized elderly patients. Critical Care Nursing, 8(1), 53-60.

4. Delirium • Onset: hours to days • Causes: • medications • fluid and electrolyte imbalances (What is a common fluid imbalance that also begins with the letter “D”?) • infection (rule out urinary and respiratory infections) • elimination (urinary retention / constipation) • changes in chronic illness • newly-developed disease process • psychosocial / environmental issues

5. Delirium: Diagnosis • need to repeat questions • perseveration (What does this term mean?) • disorganized thinking • reduced LOC (level of consciousness) • perceptual disturbances • sleep-wake disturbance or psychomotor activity • disorientation to time, place, person • memory impairment

6. Delirium : Assessment • Person, place and time are the least sensitive markers for delirium • Focus on aspects of Attention and Concentration • Ask client to count backward from 20 by 3’s • Ask client to copy a drawing of intersecting pentagons

7. Delirium: Interventions • Rule out drug-related causes and infections first • Urinary tract and respiratory infections are the most common • Obtain data about the individual’s baseline cognitive functioning • Provide orienting cues and support • Eye glasses, hearing aids, calendar, clock, etc.

8. Depression • Onset: weeks to months • Causes: • heredity • biochemical changes • drugs • illness • sensory deficits • stress • seasons (seasonal affective disorder, frequently seen in the Northwest)

9. Losses with Aging • biological • psychological • personal • social • identity • possessions • religious Sometimes the cumulative effect of several losses can predispose an individual to a depressive episode. Think of some examples of how these losses may be experienced.

10. Depression: Diagnosis Symptoms include… • loss of interest or pleasure in activities • persistent depressed mood, including feelings of sadness or emptiness • feeling slowed down or restless, can’t sit still • feeling worthless or guilty • increase or decrease in appetite or weight • thoughts of death or suicide • problems thinking, concentrating, or making decisions • trouble sleeping, or sleeping too much • loss of energy or feeling tired all of the time; constant fatigue

11. Depression: Assessment • Geriatric Depression Scale • Self-administered • Well tested and used by all health care providers • Cornell Scale for Depression in Dementia • Useful in assessing depression in individuals with dementia • Can be used by family members or caregivers to articulate their observations, as some individuals may minimize the severity of their symptoms

12. The risk of suicide is high in older adults. Health care providers must intervene if an individual makes statements related to the taking of his or her own life. male significant loss poor health isolation feeling hopeless previous attempt drug / alcohol abuse family history financial insecurity Risk Factors for Late in Life Suicide

13. Depression: Interventions • Antidepressants • Monitor for side effects • Encourage and support counseling • Recommend a referral to Medical Social Worker (MSW) • May be able to link individual with resources and community support

14. Dementia • Onset: months to years • Causes: • Alzheimer’s Disease (AD) (most common) • Vascular Dementia (multi-infarct; MID) • Mixture of AD & MID • Pick’s, Parkinson’s, AIDS To learn more about AD, see the booklet Alzheimer’s Disease: Unraveling The Mystery, produced by the National Institute on Aging.

15. Delirium + Dementia Individuals with dementia still have acute illnesses such as pneumonia, UTI’s, medication side effects, and electrolyte imbalances. This means that they can have a delirium superimposed on their dementia. If an client with AD is more confused than usual (within hours to days) and experiencing the s/s of delirium as discussed earlier, you must intervene. Therefore, your assessment must include information about the client’s baseline cognitive functioning. Family members and caregivers must be included in the assessment process.

16. Dementia: Interventions • Obtain client’s baseline cognitive functioning. • Observe for potential delirium and/or depression that may magnify cognitive impairment (both of these conditions are treatable even in the individual with dementia). • Provide and encourage an environment that supports the individual’s highest level of functioning.

17. The Three Ds of Confusion was prepared by Catherine Van Son, Ph.D., R.N., for the Older Adult Focus Project, OHSU School of Nursing.