Evaluating Delirium, Dementia, and Depression in Older Adults: Clinical Use of the 5D Pocket Card

1. Evaluating Delirium, Dementia, and Depression in Older Adults: Clinical Use of the 5D Pocket Card Stephen Thielke Puget Sound VA GRECC

2. Learning Objectives • Characterize delirium, dementia, and depression • Identify key similarities and differences between them • Discuss steps in the clinical evaluation of these conditions • Review instruments contained in the 5D Pocket Card which can be used to evaluate and monitor delirium, dementia, and depression

3. Will not address • Management of delirium, dementia, and depression • General geriatric assessment • Suicide risk assessment and management

4. Project Timeline • 2007-2008: Needs assessment delineates challenges around differential diagnosis of dementia in primary care • Mid-2008: GRECC Dementia Education Workgroup begins discussing ways of improving the differential diagnosis and management of common geriatric cognitive symptoms in clinical settings • Mid-2009: First draft of pocket card and assessment guide trialed and evaluated • Mid-2010: Final pocket card and guide to be disseminated through the GRECCs

5. Key Contributors • Julie Moorer, Puget Sound GRECC • Suzanne Craft, Puget Sound GRECC • Kathy Horvath, New England GRECC • Theressa Burns, Minneapolis GRECC • Michelle Rossi, Pittsburgh GRECC • Terri Huh, Palo Alto GRECC • Nina Tumosa, St Louis GRECC • Byron Bair, Salt Lake City GRECC • Susan Cooley, Office of Geriatrics and Extended Care • Malva Rashid, Cleveland GRECC • RivkahLindenfeld, Northport EERC • Ken Shay, Office of Geriatrics and Extended Care

6. What Delirium IS • “Acute Brain Failure” • “Toxic Metabolic Encephalopathy” • “Acute Confusional State” • A medical condition: • Rapid onset • Deficits in attention and concentration • Waxing and waning mental status • Infections, medications, metabolic abnormalities are the most common causes • Mental status changes often precede objective signs of illness • Often multifactorial

7. What Delirium IS NOT • A psychological problem • An insignificant condition (over 25% of patients with delirium die within 6 months) • Dementia – slow onset, slow steady decline, little fluctuation • Rapidly resolving, even when cause corrected • A normal part of aging

8. What Dementia IS • A significant chronic loss in memory and/or mental functions, involving structural damage to the brain • Significant─ functional consequences • Chronic ─ not a rapid onset (comes on over years) • Loss ─ new impairments (not lifelong) • Structural Damage ─ neurons die

9. What Dementia IS NOT • Delirium─ acute onset, attention and concentration problems • Depression – anhedonia, distraction; subjective cognitive deficits which are not apparent on neuropsychological testing • Sensory deficits or communication problems • A normal part of aging

10. What Depression IS • A syndrome of psychological and bodily symptoms • Low mood or anhedonia (lack of pleasure), plus: • Problems with sleep (too little or too much) • Problems with appetite (too high or too low) • Trouble concentrating • Decreased interests • Feelings of guilt or having done something wrong • Low energy • Slowed movements • Suicidal thoughts • Unreal experiences: “my mind playing tricks on me” (hearing voices or feeling paranoid)

11. What Depression IS NOT • A bad day, week, or month • Grief • A natural reaction to medical illness or loss • A cause of dementia • A normal part of aging

12. Delirium, Dementia and Depression

13. Delirium

14. Delirium Prevalence • 15-40% of older hospitalized patients • Up to 70% of ICU patients • Roughly 80% of patients pre-death • 14% of patients 65 years and older in the emergency room • Patients with underlying cognitive impairments are more likely to develop delirium Inouye et al, 1999; McNiccoll et al, 2003; Hustey & Meldon, 2002 Rahkonen et al, 2002

15. Recognizing Delirium • Confusion that develops over days or weeks • Trouble with attention, focus, & concentration • Waxing and waning • Fluctuating sleep disturbances • Erratic, uncharacteristic, inappropriate behavior • Hallucinations (especially visual), paranoia

16. Recognizing Delirium (cont’d) • Can be hyperactive (agitated) or hypoactive (sedated) • Delirium often goes unrecognized • Acting “normal” during one assessment does not rule out delirium • Falling asleep during interview strongly suggests delirium

17. Working Up Delirium • Do not assume that patients are just having a “bad thinking day” • Use collateral sources of information • Consider the whole clinical picture • Apply a broad differential • I nfections • W ithdrawal • A cute metabolic • T rauma • C NS pathology • H ypoxia D eficiencies E ndocrinopathies A cute vascular T oxins or drugs H eavy metals

18. Delirium Evaluation: CAM The Confusion Assessment Method (Inouye 1993, 2000) Feature 1: Acute Onset and Fluctuating Course Usually obtained from family member or caregiver: rapid change from baseline, and fluctuating severity during the day. Feature 2: Inattention Trouble with attention, being distractible, or having difficulty keeping track of what was said.Example: recite months of the year backwards. Feature 3: Disorganized Thinking Rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. Feature 4: Altered Level of Consciousness Anything other than alert on scale of (Normal [alert], Vigilant [hyperalert], Lethargic [drowsy, easily aroused], Stupor [difficult to arouse], or Coma [unarousable]). Delirium is diagnosed with the presence of feature 1 and 2, and either 3 or 4.

19. Delirium Evaluation (cont) • Consider delirium FIRST in any patient who shows cognitive impairments • Identifying delirium is only the first step • Strive to determine and correct the cause

20. Dementia

21. Dementia Prevalence Plassman et al, 2007

22. Recognizing Dementia • Common warning signs are problems with: • Short-term memory, judgment • Word finding (language) • Taking medication incorrectly (executive function) • Driving (visuospatial) • Balancing checkbook (calculation) • Memory problems are often not the chief complaint

23. Recognizing Dementia (cont’d) • Spouses or children are often more concerned than patients • Good verbal skills and living independently should not preclude evaluation of cognition • Conduct additional workup whenever patient or family describe problems or when cognitive problems are observed • Routine screening of the asymptomatic is not recommended (USPSTF)

24. Working Up Dementia • History ─ use collateral sources • Rule out delirium and reversible causes • Labs: • TSH, CBC, Chem-7, Calcium, LFTs, B12, Folate, Urinalysis • Cognitive testing: • BOMC, Mini-Cog, GPCOG, STMS, SLUMS, MoCA, FAST • Complex cases: refer for neuropsychological evaluation • Neuroimaging is not routinely indicated; order if • Rapid decline • Unexplained focal neurological symptoms

25. DSM-IV Criteria for Alzheimer’s Dementia A. The development of multiple cognitive deficits manifested by: 1. Memory Impairment 2. One or more of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia (impaired ability to carry out motor activities) (c) agnosia (failure to recognize or identify objects) (d) disturbances in executive functioning ( i.e., planning, organizing, sequencing, abstracting) B. The cognitive deficits in A1 and A2 each cause significant impairment in social or occupational functioning. C. The course is characterized by gradual onset and continuing cognitive decline. D. The cognitive deficits are not due to other neurological or systemic conditions, or to substance use. E. The deficits do not occur exclusively during the course of a delirium.

26. Mini-Cog • 1. Ask the patient to remember 3 words. Repeat them until the patient is able to state all 3 without errors. • 2. Ask the patient to draw a clock and include all the numbers. Then ask the patient to place the hands on the clock to make the time be “One Ten”. • 3. Ask the patient to recall the 3 words you asked before. • Unscored • 2 points for a clock without errors, 0 for any error • 1 point per word (max 3) • A brief assessment; does not diagnose dementia • Scoring:None of the 3 words: Cognitively impaired • All 3 of the words: Not cognitively impaired • 1 – 2 words recalled  Abnormal clock: Cognitively impaired •  Normal clock: Not cognitively impaired

27. AD-8 • Assesses functional status, based on report of a spouse, caregiver, or close family member • Focuses on change in the last several years: 1. Problems with judgment (e.g. falls for scams, bad financial decisions, buys gifts inappropriate for recipients) 2. Reduced interest in hobbies/activities 3. Repeats questions, stories or statements 4. Trouble learning how to use a tool, appliance or gadget (e.g. VCR, computer, microwave, remote control) 5. Forgets correct month or year 6. Difficulty handling complicated financial affairs (e.g. balancing checkbook, income taxes, paying bills) 7. Difficulty remembering appointments 8. Consistent problems with thinking and/or memory • Scoring:One point per item • Score of 2 or greater suggests significant cognitive impairment

28. SLUMS • St Louis University Mental Status Exam • Used to assess cognitive changes and to track clinical changes over time • Better psychometric properties than the MMSE • Scoring:Total 30 points • Normed for education level (high school or more; high school or less)

29. FAST • Functional Assessment Staging Tool • Information provided by knowledgeable informant, and supplemented by clinical observation • Used to guide appropriateness of dementia medication therapy 1-2 No functional deficit (Normal). Subjective word difficulties (Normal Aging) 3-4 Decreased function in demanding settings or decreased ability to handle complex tasks ( i.e. finances or planning dinner.) 5. Requires assistance in choosing proper clothing 6. Difficulty with dressing, bathing, toileting. Urinary and/or fecal incontinence. 7a Can speak only about half a dozen intelligible different words or fewer 7b Speech ability limited to the use of a single intelligible word 7c Unable to talk without assistance 7d Cannot sit up without assistance 7e Loss of ability to smile 7f Loss of ability to hold up head independently • Scoring:The highest consecutive disability noted

30. Depression

31. Depression Prevalence Thielke et al, Aging and Mental Health 2010

32. Recognizing Depression • Often presents as nonspecific physical symptoms • Fatigue • Pain • GI problems • Older patients less likely than younger to admit to being “depressed” • Depression is stigmatized, especially in older adults • Patients often more willing to endorse mental health symptoms in writing than in person

33. Working Up Depression • All patients with mood symptoms or history of depression, mood disorders, or PTSD should be assessed for suicidal thoughts • Ask about mood symptoms in patients of all ages • Use structured scales when possible • Consider the mutual effects of depression and medical illness

34. PHQ-2 • A screening tool; does not diagnose depression • Self-report “Over the past two weeks, how often have you been bothered by these problems?”

35. PHQ-9 All questions use 0 – 3 scale (as on PHQ-2) A suicide risk evaluation is required within 24 hours if: 1. Total score is less than 10 and response to question #9 is 1, 2 or 3. 2. Total score is greater than 10. Depression is likely if the total score is greater than 10

36. How to approach a patient with cognitive problems 1. Is this patient delirious? 2. Is this patient depressed? 3. Does this patient have dementia? All three conditions frequently occur together.

37. Feel free to contact me • Stephen Thielke • Geriatric Research, Education, and Clinical Center, Seattle VAMC • (206) 764-2815 • Stephen.Thielke@va.gov For paper or electronic copies of the 5D Pocket Card or Guide: • Julie.Moorer@va.gov