Geriatric Nursing & the Three Ds

Delirium, dementia and depression, commonly known as “the three Ds” are multifaceted disorders that are often confused by caregivers.

Mutually exclusive disorders, all three can befall patients concurrently. It is common that one or all three components of the three D’s may be present in a patient at the same time.

Although they can be present together nurses must not forget that delirium, dementia and depression are disease states that are commonly seen interwoven in elderly patients.

Three Definitions

Delirium is defined as a reversible state of confusion, characterized by changes in orientation, perception, intellectually functioning and mood, usually of short duration with rapid onset and is common in the older post surgical patient.

Dementia is an organic mental syndrome, defined by short term or long term memory impairments encompassing an other aspect of intellectual functioning such as abstract thinking, judgment aphasia or personality changes, which has a slow progression.

Depression is a mood disorder, often unrecognized and under diagnosed in the elderly is characterized by feelings of loss, sadness, guilt and low self esteem where the patient exhibits cognitive, physical and mood changes.1,2,3

Three Differentiations

Delirium

Delirium is primarily caused by an acute medical condition affecting brain function by altering the neurotransmitters in the brain producing a confused like state. It is commonly caused by infections such as a urinary tract infection, pneumonia and meningitis.

In addition to infections, delirium can be caused by cardiac disorders that cause hypoxemia, diabetes related hypoglycemia, and electrolyte imbalances. Other conditions causing delirium include: medication interactions causing drug related delirium, substance abuse or intoxication, head trauma and falls.

Common symptoms of delirium include: disturbances in consciousness or loss of awareness of ones surroundings. Patients may exhibit cognitive changes such as memory impairment, disorientation to person place or time (not caused by dementia) and hallucinations and delusions (Saxena, 2009; Somes, 2010).1-2

Dementia

Condition can be classified as primary or secondary.

Primary dementia is related to organic brain disease that is not associated with any other organic illness. Secondary dementia is a direct result of another condition or related disease.

The most common dementias are Alzheimer’s disease, vascular dementia and lewy body dementia.

Alzheimer’s dementia is characterized by memory disorders, language disturbances, indifferent mood, agitation and delusions. Vascular dementia is of abrupt onset, a slow progressive deterioration with motor difficulties and aphasia. Patients with Lewy body dementia is present with extrapyramidal symptoms, alterations in mental status, hallucinations and delusions.4

Dementia is a chronic illness usually progressing over years; it is irreversible and leads to disorientation as the disease progresses. Memory impairment while fully alert is the most common and pronounced symptom.

Memory impairment begins with the loss of recent memory; as the dementia progresses, long-term memory becomes impaired recognition of family members declines to eventually absent.

Dementia patients are usually without psychomotor changes unless depression develops. Patients with dementia usually have a change in their sleep wake cycle early and late in the disease, which presents as day-night reversal. Alterations in abstract thinking, judgment, attention deficits, and aphasia can also be present.2-4 (Somes, 2010; NINDS)

Depression

A change in cognitive impairment, depression is a mood disorder, thought to have its origin in a blend of biological and psychosocial factors.

This combination of biopsychosocial changes indicates that chemical and anatomical changes in the brain may be present; however a disturbed thought process, a stressful psychosocial event and lack of social interactions can be implicated in causing depression.

The elderly have an altered presentation of depression. In the elderly, the common presenting symptom maybe anxiety, rather than the usual identified symptom of “depressed mood” may not be as prominent. In addition to anxiety, complaints of psychosis, cognitive impairment and soma are more common in elderly patients (Hunziker, 2011; Somes, 2010).2-3

A common acronym used in the identification of depression symptoms is known as SIGECAPS: (Hunziker, 2011)

is for sleep disturbance
is for interest or pleasure reduction
G indicates guilt or feelings of worthlessness
is energy changes or fatigue
indicates concentration or attention impairment
appetite and weight
psychomotor disturbance
suicidal thoughts or ideation3

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Recognizing the Differences

Delirium and dementia are often seen together in the older hospitalized patient.

The distinguishing characteristics of delirium that sets it apart form dementia are that dementia is of acute onset with alterations in cognitive functioning lasting over days and hours.

Delirium presents with impaired consciousness, attention and sleep dysfunction. The patient with dementia is initially is fully alert with memory impairment, this is often impaired in the delirious patient. (Saxena, Somes NINDS)1,2,4

Delirium and depression can also occur together, however in patients with primary depression, patients present with decreased motivation with cognitive testing and report cognitive complaints beyond measured deficits and patients with depression contain to maintain motor and language skills. (Hunziker, Somes and Saxena)1-3

Diagnosing depression and dementia can be difficult. One of the key factors to differentiate depression from dementia is affect. Patients with dementia often have an apathetic affect while patients with depression report loss of interest or reduction of pleasure. (Hunziker somes NINDS).2-4

Assessment & Evaluation

Critical evaluation and history of onset of symptoms is key in identifying the differences between these diagnoses. In addition, medical evaluation and mental status evaluation are needed to confirm and clarify findings.

The assessment approach should include physical examination, assessment of change in cognitive function, functional decline, cognitive testing and medical investigations that have reversible causes. Health assessment inquiry should focus on medical history, including past psychiatric history, substance abuse, family history and history of present illness including premorbid cognitive and functional status.

Specific diagnostic testing and screening tests are available to help identify cognitive deficits, mental status changes and depression.

Depression Screening

Patients without dementia can be screened with the Geriatric Depression Scale and the Cornell Depression Scale. The Geriatric Depression scale is a basic screening tool to assess for the presence of depression in adults. The Cornell Depression Scale is designed to assess signs and symptoms of depression in patients with dementia by interviewing the patient and an informant.5-6

Dementia Screening

Screening for dementia patients should include the Folstein Mini Mental Status Examination (MMSE) and the Clock Drawing Test. The Folstein MMSE is quick and easy test of cognitive function. The Clock Drawing Test is a test of higher level functioning to screen for dementia by having the patient draw a clock face. A clock that is abnormally drawn signifies problems requiring further evaluation7

Delirium Screening

Patients with Delirium can be screened with the Confusion Assessment Method (CAM). The CAM identifies 4 areas for the presence of delirium: 1) acute onset and fluctuating course, 2) inattention, 3) disorganized thinking and 4) altered level of consciousness. The diagnosis of delirium includes items 1 and 2 and 3 or 4.8

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Interventions for the Three D’s

There are multitudes of interventions recommended for treating the myriad symptoms of delirium, dementia and depression. Among some of the most commonly employed are these:

  • Provide reality orientation measures
  • Maximize autonomy
  • Maintain and establish a consistent schedule and routine
  • Speak and communicate clearly and slowly and do not rush
  • Maintain a calm and quiet environment
  • Post clock, calendar and pictures in view
  • Allow time for responses
  • Limit choices
  • Avoid contradiction and confrontation
  • Promote relaxation
  • Correct misperceptions calmly
  • Administer medications as ordered
  • Monitor intake: food and fluids, both intake and output1,9

Whether a patient has delirium, dementia or depression, staff caring for these patients should implement these interventions when needed to decrease the risk of the 3 D’s.

Nurses are in a crucial position to assess and inform team members of changes in a patient’s mood or cognitive level to ensure prompt and adequate treatment thereby improving the health outcomes of older adults.

References for this article can be accessed by clicking here.

Scott J. Saccomano is an assistant professor at Herbert H. Lehman College, Bronx, N.Y.

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