Delirium, Dementia, Depression Flashcards
Delirium
A serious acute neuropsychiatric syndrome characterized by inattention and acute cognitive dysfunction
- a symptom of an underlying condition
- life threatening
- 30-40% preventable and reversable
Why is diagnosis of delirium important?
May be the ONLY SIGN of significant medical illness such as:
- pneumonia
- sepsis
- abdominal infection
- intra-cerebral event
Consequences of Delirium
- functional impairment
- prolonged hospitalization
- institutionalization
- psychological stress
- death
- full recovery
Risk Factors for Delirium
Non-modifiable
- dementia
- multiple comorbidities
- advancing age >65
- hx of delirium, stroke, neuro disease, falls or gait disorder
- chronic renal or hepatic disease
Potentially modifiable
- sensory impairment
- medications
- acute neurological diseases
- sustained sleep deprivation
- environment
- pain
- emotional distress
Causes of Delirium
Multifactorial, almost any medical illness, intoxication or medication can cause delirium
I WATCH DEATH
infection, withdrawal, acute metabolic (sedatives), toxins, CNS pathology, hypoxia
deficiencies (b12), endocrine (thyroid), acute vascular (shock), trauma, heavy metals
DELIRIUM
dementia, electrolyte, lung liver heart kidney brain, infection, Rx, injury, unfamiliar environment, metabolic
Clinical Presentations of Delirium
a. Hyperactive “agitated”
b. Hypoactive “sleepy, difficult to rouse”
c. Mixed
Key Clinical Features of Delirium (3 core + 5)
- inattention
- disorganized thinking
- altered LOC
- cognitive deficits
- perceptual disturbances
- psychomotor disturbances
- altered sleep cycle
- emotional states (rapid change)
Delirium Superimposed on Dementia (DSD)
Occurs when an individual with a pre-existing dementia develops delirium
assumed to be worsening dementia
Delirium Assessment
- hx or dx of dementia or chronic cognitive decline
- hx of cognitive impairment
- gather details
a. symptoms/behaviours - types, frequency, course
b. onset
c. duration - assessment q 8-12 hrs
Confusion Assessment Method (CAM)
C1 and C2 both present + C3 or C4
Criteria 1: acute onsent and fluctuating course
Criteria 2: inattention
Criteria 3: disorganized thinking
Criteria 4: altered LOC
Warning words during assessment
"not feeling/acting right" "weak" "just not himself/herself "vague complaints" "pleasantly confused"
Q 8-12 Hr Assessment of Delirium
- LOC
- Attention
- Orientation
- Thought process
- Memory
- Perception (hallucinations/illusions)
- Sleep/wake cycle
- Affect
Behaviours:
- Motor
- Verbal or physical aggression
- Resistance to care
- Wandering/exit seeking
Delirium Treatment
- Treat cause
INVESTIGATE: collateral help, review EMR, routine bw, ECG, Xrays/CT, urine analysis - Non-pharmacologic
therapeutic communication, reduce internal/external stressors, involve family, diversion activities - Pharmacologic
medication review, treat agitation?
Prevention of Delirium
(HELP program)
Consider:
a. continuation of care
b. sleep deprivation
c. immobility
d. sensory impairment
e. dehydration
f. cognitive impairment
Nursing Care to Prevent Delirium
- orientation and therapeutic activities
- early mobilization
- minimize use of psychoactive drugs
- prevent sleep deprivation
- adaptive methods (glasses and hearing aids)
- early tx of volume depletion
Dementia (DSM5)
- significant cognitive decline in one or more cognitive domains
(attention, executive functioning, learning, memory, language, perceptual-motor, social cognition)
a. concern from informant
b. neuropsychological testing - interference with independence in everyday activities
- don’t occur in context of delirium and not explained by other mental disorders
cannot be diagnosed in patient with delirium
Normal age related changes in memory
- modest increase in processing time
- increase emphasis on relevance
- increased distractibility
Risk Factors of Dementia
- increasing age
- family hx
- smoking
- high cholesterol
- diabetes
- untreated depression
- alcohol
10 Warning Signs of Dementia
- memory loss affecting day to day
- difficulty performing familiar tasks
- problems with language
- disorientation in time
- impaired judgment
- problems with abstract thinking
- misplacing things
- changes in mood and behaviour
- changes in personality
- loss of initiative
Types of Dementia
a. Alzheimer dementia (gradual onset)
b. Vascular dementia (often after stroke)
c. Parkinson dementia (motor)
d. Frontotemporal dementia (judgment and control)
e. Lewy body dementia (hallucinations)
f. Mixed dementia (or related to HIV or alcohol)
Stages of Dementia
Mild: forgetfulness and misplacing things, word finding difficulty, impaired judgment
Moderate: increased confusion, greater memory loss and worsening judgment, changes in personality and behaviour, help with ADLs
Severe: unable to communicate meaningfully, decline in physical capabilities, incontinence, immobility
Screening Tools for Dementia
- Mini-cog + clock drawing
- 3 word recall and clock drawing
- step 1 words, step 2 clock, step 3 recall words - Mini-Mental State Examination (MMSE)
- out of 30
- screening not diagnostic
- memory, language and perception but not executive functioning - Montreal Cognitive Assessment (MoCA)
- reliable screening for Alzheimer
- measures executive function
- takes longer than MMSE
7 A’s of Dementia
- Amnesia: loss of memory
- Aphasia: loss of language
- Agnosia: loss of recognition
- Apraxia: loss of purposeful movement
- Altered perception: loss of visual acuity
- Apathy: loss of initiation
- Anosognosia: no knowledge of disease
Responsive Behaviours in Dementia
over 90% experience responsive behaviours, aka behavioural and psychological symptoms of dementia (BPSD)
verbal and physical aggression with psychosis
refusing care, refusing meds, refusing to bath
Investigate the Behaviour (The ABCs)
Activator
(what happened just before B?)
Behaviour
(what is the behaviour, who is present, where and where?)
Consequence
(what happened just after B?)
Managing BPSD
Apply person-centred care principles
- relationship
- environment
- abilities
- personhood
Prioritize non-pharmacological options
Pleasant events can be a distractor
Sundowning in Dementia
Confusion/agitation gets worse as day progresses
hypothesis: decision fatigue over course of day and less resilience to control behaviours
Nursing Interventions for Dementia
- follow a set routine
- don’t rush and provide extra time for communication or tasks
- keep instructions simple
- reduce distraction, offer snack
- don’t argue or correct
- be flexible
- caution the use of prn meds for agitation, behavioural interventions work best
Depression
Mood disorder characterized by a pervasive low mood or a loss of interest in activities and difficulty with:
sleep, appetite, energy, concentration, worthlessness, motor slowing, suicidal ideation
Lasting > 2 weeks
Most misdiagnosed, under-diagnosed and underrated illness
Risk Factors for Depression
Physical
- chronic disease
- acute heart attack
- organic brain disease
- endocrine/metabolic disease
- malignancy
- chronic pain and disability
Psychosocial
- social isolation
- change in financial
- being a carer
- change in role and loss of social status
- bereavement and loss
- difficulty adapting to illness/pain/disability
- history of depression
- institutionalization
Depression in older adults
Not a normal part of aging
Endorse physical complains but deny sadness
Worsens other illnesses
Assessment for Depression
a. Geriatric Depression Scale
b. ED-Depression Screen
(Sad? Helpless? Blue?)
*exploring suicidal ideation is important if depression is likely!
Interventions for Depression
Depression is treatable!
a. Medications
- antidepressants
- meds for associated agitation and psychosis
b. Supportive Care Strategies
c. Electroconvulsive Therapy (ECT) - most effective!
Interaction/Supportive Care
Support the person by:
- understanding that behaviour is due to an illness and recovery is more complicated than just “trying harder”
- offering reassurance, don’t push beyond what the person is capable of doing at the time
- listening
Three D’s
Common Features:
- Confusion
- Irritability
- Disrupted sleep
Differentiating Features:
a. time course
b. causes
c. interventions
