The Three Ds of Confusion Delirium, Depression, Dementia

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The Three Ds of ConfusionDelirium,
Depression, Dementia
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Confusion

• Is not a normal part of aging
• Delirium and Depression are treatable
• Dementia is manageable

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Delirium

• More common than fever or pain in older adults
• About 50 of hospitalized older adults experience
  delirium
• Only 3 out of 10 older adults with delirium are
  diagnosed by health care personnel
• As many as 1/3 of those affected by delirium will
  die
• Is a medical emergency and should be treated as
  such

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Delirium

• Onset hours to days
• Causes
• medications
• fluid and electrolyte imbalances (What is a
  common fluid imbalance that also begins with the
  letter D?)
• infection (rule out urinary and respiratory
  infections)
• elimination (urinary retention / constipation)
• changes in chronic illness
• newly-developed disease process
• psychosocial / environmental issues

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Delirium Diagnosis

• need to repeat questions
• perseveration (What does this term mean?)
• disorganized thinking
• reduced LOC (level of consciousness)
• perceptual disturbances
• sleep-wake disturbance or psychomotor activity
• disorientation to time, place, person
• memory impairment

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Delirium Assessment

• Person, place and time are the least sensitive
  markers for delirium
• Focus on aspects of Attention and Concentration
• Ask client to count backward from 20 by 3s
• Ask client to copy a drawing of intersecting
  pentagons

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Delirium Interventions

• Rule out drug-related causes and infections first
  
• Urinary tract and respiratory infections are the
  most common
• Obtain data about the individuals baseline
  cognitive functioning
• Provide orienting cues and support
• Eye glasses, hearing aids, calendar, clock, etc.

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Depression

• Onset weeks to months
• Causes
• heredity
• biochemical changes
• drugs
• illness
• sensory deficits
• stress
• seasons (seasonal affective disorder,
• frequently seen in the Northwest)

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Losses with Aging

• biological
• psychological
• personal
• social
• identity
• possessions
• religious

Sometimes the cumulative effect of several
losses can predispose an individual to a
depressive episode.
Think of some examples of how these losses may be
experienced.
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Depression Diagnosis

• Symptoms include
• loss of interest or pleasure in activities
• persistent depressed mood, including feelings of
  sadness or emptiness
• feeling slowed down or restless, cant sit still
• feeling worthless or guilty
• increase or decrease in appetite or weight
• thoughts of death or suicide
• problems thinking, concentrating, or making
  decisions
• trouble sleeping, or sleeping too much
• loss of energy or feeling tired all of the time
  constant fatigue

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Depression Assessment

• Geriatric Depression Scale
• Self-administered
• Well tested and used by all health care providers
• Cornell Scale for Depression in Dementia
• Useful in assessing depression in individuals
  with dementia
• Can be used by family members or caregivers to
  articulate their observations, as some
  individuals may minimize the severity of their
  symptoms

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Risk Factors for Late in Life Suicide

• male
• significant loss
• poor health
• isolation
• feeling hopeless
• previous attempt
• drug / alcohol abuse
• family history
• financial insecurity

• The risk of suicide is high in older adults.
• Health care providers must intervene if an
  individual makes statements related to the taking
  of his or her own life.

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Depression Interventions

• Antidepressants
• Monitor for side effects
• Encourage and support counseling
• Recommend a referral to Medical Social Worker
  (MSW)
• May be able to link individual with resources and
  community support

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Dementia

• Onset months to years
• Causes
• Alzheimers Disease (AD) (most common)
• Vascular Dementia (multi-infarct MID)
• Mixture of AD MID
• Picks, Parkinsons, AIDS

To learn more about AD, see the booklet
Alzheimers Disease Unraveling The Mystery,
produced by the National Institute on Aging.
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Delirium Dementia

• Individuals with dementia still have acute
  illnesses such as pneumonia, UTIs, medication
  side effects, and electrolyte imbalances. This
  means that they can have a delirium superimposed
  on their dementia. If an client with AD is more
  confused than usual (within hours to days) and
  experiencing the s/s of delirium as discussed
  earlier, you must intervene.
• Therefore, your assessment must include
  information about the clients baseline cognitive
  functioning. Family members and caregivers must
  be included in the assessment process.

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Dementia Interventions

• Obtain clients baseline cognitive functioning.
• Observe for potential delirium and/or depression
  that may magnify cognitive impairment (both of
  these conditions are treatable even in the
  individual with dementia).
• Provide and encourage an environment that
  supports the individuals highest level of
  functioning.

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The Three Ds of Confusion was prepared by
Catherine Van Son, Ph.D., R.N., for the Older
Adult Focus Project, OHSU School of Nursing.