Dementia, Delirium, and Depression in the Older Adult

Care of the Individual

Learning Objectives:
Identify DSM IV-TR criteria for dementia and delirium. Discuss etiology of some forms of dementia. Differentiate between primary symptoms of dementia and delirium. Identify the unique variations in depressive symptoms specific to older adults. Apply the nursing process to the care of older adults with dementia, delirium, and depression. Describe the five stages of the assault cycle. Explain verbal nursing interventions for anger and aggression. Describe the nursing care for patients in seclusion and restraints.

Growth trends in the geriatric population

Increasing life span in the US population The old-old (persons over 85) is the fastest growing segment Almost 1/4th of persons over 85 require nursing home care Most elderly will have at least one chronic medical problem and/or a combination with some type of cognitive disorder

Definitions of terms
Cognition: Process by which a person knows the world and interacts with it. Cognitive disorder: Characterized by disturbances/deficits in cognitive functions such as memory, learning ability, orientation, judgment, concentration, perception, and problem solving. Amnestic disorder: Characterized by memory impairment in the absence of other significant cognitive impairments.

Dementia DSM IV-TR Criteria

AMNESIA (memory impairment) At least one of the following:
APHASIA (language disturbance) APRAXIA (inability to carry out motor activities despite intact motor function) AGNOSIA (failure to recognize or identify objects in spite of intact sensory function) Disturbance in executive functioning (planning, organizing, abstracting, sequencing)

Dementias
Alzheimers Disease/Dementia of Alzheimers Type (DAT) Multi-infarct Dementia (MID)/Vascular Dementia DAT and MID combined Parkinsons Disease Diffuse Lewy Body Disease (DLBD) Huntingtons Disease Picks Disease (frontal lobe) Creutzfeldt-Jacob Disease (CJD) AIDS ETOH related: Wernicke-Korsakoff syndrome

Alzheimers Disease Etiology

Senile/amyloid plaques Neurofibrillary tangles (dead neurons) Overall decreased brain mass, increased lateral ventricle Diagnosing criteria:
Neuropsychiatric evaluation Brain imaging Definitive dx. only on autopsy/brain biopsy

AD Causation Theories
Genetic model (chromosomes 1, 14, 19, 21; protein Apo-E4 linked to development of amyolid plaques) Toxin model Infection model Cholinergic deficit model

AD Progression
Insidious, irreversible, progressive deterioration affecting all spheres of functioning (average course up to 10 years) Stages: mild, moderate, severe (p. 413) Alterations in memory (short/remote) Confabulation Alterations in perception Hallucinations Delusions Illusions Space/depth

AD Progression (contd)
Alterations in mood Dysphoria (malaise, anguish)/depression Alterations in behavior Physical/verbal aggression Persistent/repetitious behavior Uninhibited behavior Alterations in judgment

AD Progression (contd)
Incontinence Total dependence/bedridden Body systems/immune system fail Frequent cause of death: infections/pneumonia

Assessment
Complex, thorough, over time Rule out other possible reversible causes (Vitamin B12 deficiency, hypo/hyperthyroidism) Team approach (geriatric team) Assess caregivers ability to carry on Tools: The Mini Mental State Exam (MMSE)/Folstein et al. (see p. 413)

Treatment
Remain flexible and creative Address behavioral symptoms to maintain both client and caregiver safe Milieu management Educate caregiver Maintain optimal level of functioning

Treatment (contd)
Alzheimers specific medication:
AChE inhibitors, enhance cholinergic function Recommended only for early stage or mild to moderate AD Does not stop the progression of the disease itself Modest improvements

Treatment (contd)
AChE inhibitors:
tacrine (Cognex) (S/E: hepatotoxicity) donepezil (Aricept) (S/E; GI upset) rivastigmine (Exelon) (S/E: GI upset, fatigue, wt. loss) galantamine (Reminyl) (S/E: decreased appetite, wt. loss, GI upset)

Treatment (contd)
Drug approved by FDA in Nov. 2003: Memantine (Axura, Ebixa) Slows down mental/physical deterioration in moderate to severe cases of AD by blocking glutamate. No active metabolites Possible S/E: dizziness, constipation, hallucinations (rarely) Should not be combined w. antiparkinsonian agents (psychosis) Study published in the New England Journal of Medicine (April, 2003)

Treatment (contd)
Antipsychotics: 1. Traditional/typical (sedative, anticholinergic S/E)
Haldol (close monitoring of EPS)

2. Novel/atypical (fewer S/E)

risperidone (Risperdal) olanzapine (Zyprexa) clozapine (Clozaril) aripiprazole (Abilify) ziprasidone (Geodon)

Treatment (contd)
Antidepressants Antianxiety agents Alternative therapies:
Vitamin E Ginko biloba - Randomized, double-blind, placebo-controlled study (N=130) revealed that Ginko did not facilitate performance on neuropsych testing, memory, attention, and concentration. (JAMA, Aug., 2002)

Delirium
DSM IV-TR Criteria:
Disturbances in consciousness/reduced ability to focus, sustain/shift attention Change in cognition: memory deficit, disorientation, perceptual and language disturbance Development over a short period of time (hours/days) with tendency to fluctuate during course of the day

Delirium: Etiology
Prescription drug intoxication/polipharmacy: (tricyclic antidepressants, antihistamines, analgesics, steroids, sedatives, cardiovascular drugs) Dehydration Infections (pneumonia) CHF, CVAs, malnutrition

Delirium: clinical features

Sudden onset with rapidly fluctuating course/brief duration/reversible Restlessness, anxiety, irritability Decreased attention span, disorganized thinking Disorientation Impaired memory

Clinical features (contd)

Altered perceptions (illusions, delusions, hallucinations) Motor abnormalities Neurological abnormalities (apraxia, aphasia) Disturbed sleep-wake cycle EEG abnormalities

Treatment
Identify and treat the underlying condition Address behavioral symptoms Maintain environment/client safe Attend to basic physiological needs

Delirium and Dementia

Refer to box 32-1 on p. 407 in your text for a comparison of the two

Depression
Depression in the elderly does not always fit DSM IV-TR criteria The depressed elderly tend to display more somatic complaints Difficult to detect especially when cognitive symptoms are involved (poor memory, disorientation, agitation or motor retardation)

Depression (contd)
Pseudodementia = depression that mimics dementia Suicide is a major concern with the depressed elderly (group with highest suicide rate) Elderly white males x3 more likely to commit suicide than other older adults

Depression/Suicide
Older women attempt more often than men (overdose), but men are more successful in completing suicide because they use more lethal ways (firearms, CO suffocation) Prevention of suicide depends on thorough evaluation of predictors (box 43-3,p. 605) and assessment

Assessment and Treatment

The Geriatric Depression Scale - Appendix C, p. 650 Antidepressants Electroconvulsive therapy (ECT)
effective tx. For severely depressed elderly tx. of choice in emergency cases (suicidal clients)

Treatment (contd)
Nursing role:
maintain client and milieu safety monitor for medication S/Es educate client/family about medication S/E educate client/family about ECT (benefits vs. S/E)

Nursing Interventions for Anger and Aggression*

Sources:
Patient - past hx. of aggression, perceived lack of control, frustration, mental status, admitting diagnoses. Milieu - overstimulation, lack of structure, lack of diversional activities, lack of personnel. * See Table 13-2, p. 137

Nursing Interventions (contd)

Target:
Person inside/outside inpatient setting Situation

Likelihood of escalation:
Outward - verbal, physical Inward - depression, suicidal thoughts

Nursing Interventions (contd)

Triggering phase:
Facilitate ventilation: What is bothering you?; You seem pretty upset, Im here to helpIm listening Remove source/from source. Offer alternative ways to express anger: journaling, clay molding, exercising

Nursing Interventions (contd)

Escalating phase:
Give verbal directions - calm but firm: John, I can see you are becoming really upset. Please step outside (meeting room) and meet me in your room. I will bring your medication immediately.

Crisis phase:
Explain intervention is done to protect patient from harming self/others: John, your behavior is becoming dangerous, we are going to place restraints on you so you wont hurt yourself and others.

 Recovery phase: Process incident with staff/other patients Assess potential staff/patients/other patients injuries Evaluate patients progress toward self-control: John, you were very angry and out of control an hour ago, how are you feeling right now? Post crisis phase: Process crisis with patient: I wonder what is it like for you to lose control the way you did this morning?; Reduce restraints progressively. Facilitate reentry: John, are you feeling ready to join your peers?

Nursing Interventions (contd)