Vol. 9 Issue 6
The Learning Scope
Dementia, Delirium & Depression
Through prompt recognition, nurses can improve health outcomes in these common, chronic problems in the geriatric population
This offering expires in 2 years: February 26, 2009
The goal of this CE offering is to provide nurses with information about dementia, delirium and depression they can apply to practice. After you have completed reading this article, you will be able to:
1. Differentiate between dementia, delirium and depression in older adults.
2. Identify three symptoms of delirium and three precipitating causes.
3. Discuss three appropriate treatment options for dementia, delirium and depression in older adults.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the PA State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Southeastern States Board of Nursing (No. 3298).
Dementia, delirium and depression referred to as the "3 D's" are common acute and chronic problems in the older adult. While it is possible for older adults to have more than one of these disorders, the three differ in both diagnosis and management among healthcare providers, including nurses. In fact, nurses are often the first people to identify the possibility of these significant and debilitating problems in older adults.
Knowing how to recognize the conditions and differentiate one from the other will help nurses caring for older adults improve health outcomes through more prompt recognition and initiation of treatment.
The First D: Dementia
Dementia is a general term to describe a collection of disorders. While there are several causes and types of dementia, all result in a persistent change in cognitive function with memory loss and one other deficit.
The diagnosis of dementia requires evidence of memory impairment and one of the following:
a deficit in ability to plan or organize (executive function);
a language disturbance such as problems finding the right words (aphasia);
impaired motor abilities (apraxia); and/or
impaired ability to identify objects (agnosia).1
These characteristics must be a change from the person's previous abilities and affect her ability to function in everyday life and work. It does not affect all parts of the brain at one time, and the change cannot be explained in any other way. Dementia does not cause a change in the person's level of consciousness; the person remains alert, but will become disoriented.
Dementia is a slow, persistent loss of intellectual function that occurs over months to years. In the past, we used the words "senile" or "organic brain disease" to label what we did not understand.
Categories of Dementia
The three categories of dementias are based on what area of the brain is affected (see Table 1). The most common type is Alzheimer's disease, affecting more than 4.5 million people in the U.S. in 2003, having doubled since 1980 and expected to reach 11.3 million to 16 million by 2050.2 While the data are just coming to light, African-Americans appear to have significantly higher risk for Alzheimer's disease than their European-American counterparts.3 The second most common has been vascular dementia (formerly called multi-infarct dementia), but the more recently recognized Lewy body dementia appears to be common as well.
Some people meet only some of the criteria for dementia and still have trouble fully functioning. A new category has been created for these individuals: minimally cognitively impaired (MCI). These people have been found to be at high risk for the development of dementia.4 In one study of people diagnosed with MCI, more than 55 percent of them developed dementia within 3-4 years after diagnosis.5
Dementia Signs & Symptoms
While all people with dementias have memory loss and one of the other symptoms listed above, the signs and symptoms displayed depend on the part of the brain affected. Individuals with cortical dementias often are disoriented and have impaired insight and judgment. In general, they have no motor or sensory problems until very late in the disease, when the brain failure is extensive.
People with subcortical dementias have signs and symptoms consistent with damage to and failure of the frontal lobe of the brain. Signs include slowing of cognition and impaired ability to organize and retrieve information. The person has difficulty with movement and control of movement. While individuals may be able to find the right words to say, their speech is slowed (hypophonic) or garbled (dysarthric). The person also may become less inhibited.
Some people have both cortical and subcortical dementias at the same time. These individuals usually have focal neurologic symptoms, such as hyperreflexia and extensor plantar responses, gait abnormality, incontinence, dysarthria, dysphagia and emotional lability.
As the dementia progresses, the brain's structure and chemistry are altered, leading to the death of brain cells. Behavioral manifestations become more pronounced and this may be particularly troubling to the nurse and the family. Individuals in more advanced stages of dementia have signs that include psychotic, paranoid or disruptive behavior, as well as denial, wandering, apathy, restlessness, depression, emotional lability, disrupted sleep/wake cycle, repetitive actions and questions, and inappropriate social and sexual actions.
The Second D: Delirium
On the surface, delirium and dementia look similar. People with delirium often are mistaken for people with dementia. However, the two conditions are very different, and nurses should be especially careful to differentiate between the two.
While dementia is progressive and irreversible, delirium is usually very treatable, especially when recognized early. Delirium is the result of brain dysfunction from an underlying health problem, such as infection, MI, heart failure, electrolyte disturbance, emotional shock, or acute alcohol or drug intoxication. Dehydration, often found among older adults in institutional settings, is a common cause of delirium; an adverse drug effect or interaction is another common cause of delirium.
A person in a noisy environment, such as an ICU, who is sensory and sleep deprived, is at high risk for delirium, commonly referred to as "ICU psychosis." Delirium may occur, for example, in a patient with underlying cognitive or sensory impairment who has an acute illness. Alternatively, delirium may occur in an individual who is relatively resilient but is exposed to multiple noxious insults such as anesthesia, major surgery, multiple psychoactive medication, infection, decreased oxygen saturation or sleep deprivation.
Delirium Signs & Symptoms
Delirium is characterized as an acute disorder of attention and global cognitive functioning. This means the changes appear to be in overall cognitive functioning instead of the discrete areas seen in dementia. It is commonly associated with acute illnesses and in hospitalization of the older adult.
The patient may appear to be easily distracted by things in the environment, have trouble maintaining a conversation or following a command, and may repeat answers and questions over and over. Disorganized thinking, demonstrated by the presence of incoherent or disorganized speech, may occur. While people with dementia usually are considered alert but disoriented, those with delirium are more likely to have psychomotor agitation or lethargy, as well as perceptual disturbances such as hallucinations, paranoid delusions, emotional lability and a sleep/wake cycle reversal.
The onset of delirium often can differentiate it from either dementia or depression (see Table 2). While dementia develops relatively slowly and insidiously, the onset of delirium may be quite abrupt, such as when a patient awakens with a low blood sugar. Delirium can come and go, depending on the underlying cause, and even changes over the course of a day. For example, the condition referred to as "sundowners" may actually be a type of delirium superimposed on dementia, triggered by afternoon fatigue and sensory overload.
The most important nursing response to delirium is prompt identification so the underlying cause can be treated. When this occurs, the delirium should resolve on its own and may do so very quickly. To facilitate the identification and diagnosis of delirium, the delirium assessment method can be used (see Table 3).
The Third D: Depression
In later life, depression often is mistaken for dementia. Unfortunately, this leads to either incorrect treatment or, more likely, a complete lack of treatment of a reversible health problem. Lack of treatment can have fatal outcomes.
Depression is the most common mood disorder seen in older adults and affects more than 20 percent of the 35 million people over age 65.7 Depression is now recognized as a medical condition on its own and has been found to coexist in many disorders common in later life, such as Parkinson's disease, stroke or following an MI.
Depression also is the side effect of a significant number of medications frequently prescribed to older adults. These medications can include:
chemotherapeutic agents; and
As with the term dementia, the term "depression," is used loosely and could describe several related mood disorders, such as adjustment disorders with depressed affect, dysthymia and, the most significant one, major depressive disorder. Bereavement often is misdiagnosed as depression.
In addition, several normal changes with aging and many symptoms of chronic medical problems look like those of depression but in reality are not. Other chronic diseases have a high rate of concurrent depression.9 The accurate diagnosis of depression, is a major challenge for healthcare providers.
Depression Signs & Symptoms
The signs and symptoms of depression are more variable and individual than those of dementia and delirium (see Table 2). Sleep may be increased or decreased, but rarely the same from the predepressed state. The same range is found in motor activity, appetite and weight. Specific symptoms of a major depressive episode are uncommon in dementia or delirium; that is, a sense of hopelessness and loss of pleasure in usually pleasurable activities (anhedonia).
In comparison to younger adults, depression in older adults is more likely to be expressed in somatic complaints. The patient may complain of fatigue, malaise or "just not feeling well," which when evaluated, no somatic cause can be determined. In the current cohort of older adults, it still is common for people to deny depressive feelings due to the historical shame and stigma of what were thought of as mental deficiencies. Older adult men have the highest suicide rate in the world.10
Dementia, while not reversible, is best treated using a variety of management strategies, such as avoiding medication that might worsen cognitive function; maintaining a safe, nonrestrictive environment to facilitate functional performance; and incorporating behavioral interventions. Strong evidence shows the use of cholinesterase inhibitors (e.g., Aricept, Exelon, Reminyl and Cognex), or the newer drug Namenda, may be effective in slowing the decline in function and minimizing the development of behavioral disturbances in people with dementia. However, in late stages, antipsychotics and anxiolytics are used to treat psychological and behavioral disturbances.
Treatment for delirium involves identifying and treating the underlying cause, such as infection, while keeping the person safe until the delirium resolves. In extreme cases, short courses of antipsychotics and anxiolytics are necessary. Ideally, interventions should be implemented to prevent delirium in older adults by identifying those at risk and avoiding precipitating factors.
Similarly, the treatment of depression always begins with the evaluation of possible causative effects, such as medications. However, the use of pharmacological interventions should not be delayed. For those with endogenous depression (not caused by other factors), the use of medications has been highly effective when prescribed appropriately. The group of drugs known as selective serotonin reuptake inhibitors such as Zoloft or Celexa is now the first-line drug treatment method. It is best when pharmacologic intervention is accompanied by psychosocial intervention, especially provided by professionals prepared in geropsychiatry.
Dementia, delirium and depression are common problems of late life. The incidence of Alzheimer's disease, in particular, significantly increases with age. Nurses working with these individuals should be vigilant in implementing interventions to decrease the risk of delirium or depression particularly in older adults who have an underlying dementia and continually evaluating individuals for each of these problems. The nurse is in a key position to alert other team members of changes in the person's cognitive functioning and mood and assuring the initiation of prompt and adequate treatment. By doing this, nurses are in the front line for improving health outcomes among older adults.
1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
2. Hebert, L.E., et al. (2003). Alzheimer disease in the U.S. population: Prevalence estimates using the 2000 census. Archives of Neurology, 60(8), 1119-1122.
3. Alzheimer's Association. African-Americans and Alzheimer's disease. Retrieved Feb. 15, 2007 from the World Wide Web: http://www.alz.org/living_with_alzheimers_african_americans.asp
4. Levey, A., et al. (2006). Mild cognitive impairment: An opportunity to identify patients at high risk for progression to Alzheimer's disease. Clinical Therapeutics, 28(7), 991-1001.
5. Meyer, J., et al. (2002). Is mild cognitive impairment prodromal for vascular dementia like Alzheimer's disease? Stroke, 33(8), 1981-1985.
6. Inouye, S. (1998). Delirium in hospitalized older patients recognition and risk factors. Journal of Geriatric Psychiatry and Neurology, 11(3), 118-125.
7. National Institute of Mental Health. (2003). Older adults: Depression and suicide facts. Retrieved Jan. 30, 2007 from the World Wide Web: http://www.nimh.nih.gov/publicat/depression.cfm
8. Semia, T.P., Beizer, J., & Higbee, J. (2006). Geriatric dosage handbook (10th ed.). Hudson, OH: Lexi-Comp.
9. Johansson, P., Dahlstrom, U., & Brostrom, A. (2006). Consequences and predictors of depression in patients with heart failure: Implications for nursing care and future research. Progress in Cardiovascular Nursing, 21(4), 202-211.
10. World Health Organization. (2002). Suicide prevention (SUPRE). Retrieved Jan. 30, 2007 from the World Wide Web: http://www.who.int/mental_health/en
Kathleen F. Jett is an associate professor and gerontology coordinator at the Christine E. Lynn College of Nursing at Florida Atlantic University, Boca Raton. This article is based on "Dementia, Delirium and Depression in Older Adults" by Barbara Resnick, PhD, CRNP, FAAN.