The 3Ds

1. The 3Ds Lisa Zaynab Killinger, DC Healthy Aging

2. What are the 3Ds?

3. D’s: There are 3 • Depression-A mental state characterized by dejection, lack of hope, and absence of cheerfulness. • Delirium-A state of mental confusion, with disorientation to time and place. • Dementia-Irrecoverable deteriorative mental state, the common end of many health conditions or scenarios.

4. Depression A treatable illness that involves the body, moods, and thoughts; characterized by persistent sad, anxious, or empty mood or feelings of hopelessness.

5. Depression • 10% of population suffers from depression annually • Nearly 19 million Americans suffer from depression • Much more common in women (2-3x) • Cause: Familial, genetic, hormonal, stress, pain, life events, self-esteem, etc. • Signs: Just don’t care, disengaged.

6. Depression • Acute or chronic • Often precipitate by life events, chronic pain, or chemical imbalance (drugs/alcohol) • 80% of depressions are totally reversed with treatment • Important to detect/screen for to prevent suicide (the worst outcome of depression) • Often confused with dementia; can’t focus

7. Suicide • 4 X as many men commit suicide than women, although women attempt suicide more than men • Highest rate of suicide is elderly males • Suicide is one of the leading causes of death in people over 65!!

8. Meds • MAOIs-mono-amine oxidase inhibitors • SSRIs-selective seratonin reuptake inhibitors (affect neurotransmitters such as dopamine or norepinephrine) • Tricyclics- caution with side effects • Most antidepressives have to be taken for 3-8 weeks to get full benefit (and stay on them for 4-18 months) • Withdrawl is rough!

9. St. John’s Wort-Hypericum p. • Several clinical trials • May be as effective as some traditional approaches in the care of patients with mild to moderate depression • Best to use multifaceted approach- counseling, support network, physical activity, laughter, setting realistic goals and expectations, etc.

10. Assessment/Management • Mini-mental status exam • Geriatric Depression Scale-score > 8 • Ask about life events, trauma, drugs/alcohol • Drink more than 6 alcoholic bev/day? ! • Management: Adjust, identify support network, refer for care/support, drug therapies (prevent suicide !) • Address patient pain-esp. chronic pain

11. Depression Resources: • National Institute of Mental Health (NIMH): www.nimh.nih.gov (1-301-443-4514) • Local suicide prevention hotlines: Here = Robert Young Center • Nat’l foundation for Depressive Illness: www.depression.org (1-800-239-1265) • National Mental Health Assoc (NMHA) www.nmha.org or (1-800-969-6942)

12. Dementia An irrecoverable deteriorative mental state. Affects mostly the parts of the brain that control thought, language, and memory.

13. Dementia • Chronic confusion, esp about time, people, places • Loss of memory, language, judgement • Alzheimer’s is most common type • Slow, gradual onset (years to decades) • Changes in behavior and personality • No known cure (So, is it hopeless??)

14. Dementias (Besides Alzheimer’s) • Alcoholic or toxic • Epileptic or apoplectic-w/ hemorrhage/tumors • Paralytica-pt becomes paralyzed • Syphilitic-secondary to syph. Infection • Post-febrile

15. Dementia (Alzheimer’s) • Causes: Unknown • Cure: None • Signs: Amyloid plaques in brain, neurofibrillary tangles • Prevalence: 4 Million people have Alz. (3% of people 65-74 and nearly 50% of people who are 85+) • Prognosis: Most people with Alz live ave. of 8-10 years (some up to 20 years)

16. Assessment/Management • Mini-Mental Status Exam • Review history-ask new questions • Management: Adjust, refer for further eval, • Reminiscence….remember when • Prevention: Regular interaction with people, and physical activity! • Also: Mental exercises, crosswords, math, brain teasers, puzzles

17. Alzheimer’s Resources: • Www.Alz.org-Alzheimer’s Assoc. (1-800-272-3900) • Www.alzheimers.org- ADEAR: Alz. Disease Ed. And Referral site (National Inst. On Aging) Ph: 1-800-438-4380 • Combined Health Info Database: CHID www.chid.nih.gov Click on Alzheimer’s

18. Delirium An acute state of mental confusion, characterized by disorientation to time and place.

19. Delirium • Acute confusion • Sudden, rapid onset • Cause: Drug reaction, infection, trauma • Difficulties w/attention, thinking, memory • Disturbances in sleep, psychomotor activity • Often confused with Alzheimer’s • Completely reversible if treated

20. Delirium-Types • Alcoholic or drug induced (polypharmacy) • Febrile • Traumatic • Delirium Tremens-hallucinations, suicidal tendencies,(pt needs constant supervision) Restraints?

21. Assessment/Management • Mini-mental status exam • Physical exam-check for fever/infection • Medication evaluation (drugs are confusing) • Ask about alcohol-More than 6 drinks/day? • Manage: adjust, care for infection, refer for reconsideration of drugs, alcohol rehab.

22. Ramifications of Misclassification

23. Florence, 75, a long standing pt of yours comes to you after a 6 month break from care, and has trouble filling out the intake forms. She seems to have slowed since you saw her last, and doesn’t seem to care about the missing answers on the form.What do you suspect/do?

24. Harry, an 83 yr old patient, has always been sharp as a tack. This time, his daughter, who drives him to his appointment, tells you she’s very worried. She states that Harry has been very confused for a couple of days. He just recently saw his MD. What do you do?

25. You are worried about Charlie. He has been a patient of yours for almost a decade. You have observed a gradual decline in his memory. He states that he got lost coming to your office, even though his been there hundreds of times. He has no living family members;he’s a loner.What do you do?

26. TAKE HOME MESSAGES:1. Some of your patients will experience confusion2. Know the different types, and differentials3. Have a plan of action, some resources, and another health professional to confer with4. Don’t be afraid/keep your pts safe!

27. Thank you for your attention!