1. WELCOME TO
IS IT DEMENTIA,
DELIRIUM,
OR DEPRESSION?

2. IS IT DEMENTIA, DELIRIUM, OR DEPRESSION?
THIS IS A FUN INTERACTIVE GAME THAT TESTS YOUR KNOWLEDGE OF THE SIMILARITIES AND DIFFERENCES OF THIS TRIAD OF ISSUES THAT AFFECTS OLDER ADULTS.
CLICK TO ADVANCE THE SLIDE WHICH WILL REVEAL THE QUESTION.
DOUBLE CLICK TO REVEAL THE ANSWER SELECTIONS.
ONCE THE PARTICIPANT ANSWERS THE QUESTION CLICK TO REVEAL THE CORRECT ANSWER.
REPEAT FOR EACH SLIDE.
THE SPEAKER NOTES ADDED TO EACH SLIDE OFFER FURTHER INFORMATION ABOUT THE QUESTION TO ELICIT DISCUSSION.
LINKS ARE OFFERED IN SOME OF THE SLIDES FOR FURTHER INFORMATION ON USING TOOLS TO EVALUATE THE ISSUES HIGHLIGHTED IN THE QUESTION.

3. WHICH OF THE FOLLOWING HAS AN INSIDIOUS ONSET OF SYMPTOMS?
10 POINTS
WHICH OF THE FOLLOWING HAS AN INSIDIOUS ONSET OF SYMPTOMS?
A. DEMENTIA
A. DEMENTIA-
Alzheimer’s dementia has an insidious onset of symptoms often not noticeable in the beginning stages of the illness. Changes can occur in the brain (that are not evident on brain imaging) years before symptoms become evident. The beginning symptoms often go unnoticed or are attributed “aging.” Remember that the aging process begins at age 30, and memory issues are linked to increased difficulty retrieving information, in part due to the increased amount of information that needs to be managed as we age.
This of course is different from Alzheimer’s dementia where the information cannot be retrieved, and the disease progressively affects functioning. Those close to the individual in the early stages of Alzheimer’s disease are generally the first to catch a change in thinking. For example, judgment and reasoning may be impaired. The ability to manage finances, which are considered part of our executive functioning , become an issue (asking a question about managing finances, balancing a check book, is a good assessment tool to start understanding when early signs of Alzheimer’s dementia started. Of course, it is not a good indicator if the individual never did his or her finances.).
Another early sign is increased difficulty with driving; being able to take in all of the stimulation and the motor skills required to drive can become more difficult for the individual. However it is rare that insight will accompany this struggle. While the symptoms of dementia are insidious and often not recognized for quite some time, an acute issue such as a hospitalization can highlight the cognitive deficits. The acute episode likely did not cause the dementia to worsen drastically, but the change in environment and routine now makes functioning more difficult which of course will affect functioning.
Delirium has an acute onset (hours/days) with a marked change in cognition. This is sometimes evident with psychotic symptoms such as hallucinations or paranoia, or increased confusion. Knowing what the individual’s baseline status is can help to better delineate the change and better understand what cognition will look like once the delirium clears.
Depression is generally marked by a marked change in functioning that can often be isolated to a specific time.
B. DELIRIUM
C. DEPRESSION
D. DELIRIUM AND DEPRESSION

4. WHAT IS THE INCIDENCE OF
25 POINTS
WHAT IS THE INCIDENCE OF
OLDER ADULTS ADMITTED
TO AN ACUTE CARE UNIT
WITH DELIRIUM?
10-31 percent of older adults have delirium on admission to an acute care facility
11-42 percent of older adults develop delirium during hospitalization
Older patients presenting to ER: up to 30 percent
Long-term care home residents: 6-14 percent
General surgical patients: percent
Cardiac surgery patients: 30 percent
Hip fractures: 50 percent
Age >65 admitted to ICU: 70 percent
CAM Confusion Assessment Method
According to the National Institutes of Health, the mortality and morbidity rates are increased greatly in older adults with delirium.
Potentially Modifiable Risk Factors of Delirium
Sensory impairment (hearing or vision)
Immobilization (catheters or restraints)
Medications (for example, sedative hypnotics, narcotics, anticholinergic drugs, corticosteroids, polypharmacy, alcohol withdrawal
Metabolic instability
Surgery
Environment (for example, admission to an intensive care unit)
Pain
Emotional distress
Sleep deprivation
Nonmodifiable Risk Factors
Dementia
Advancing age (>65 years)
History of delirium, stroke, neurological disease, falls, or gait disorder
Multiple co-morbidities
Male sex
Chronic renal or hepatic disease
A. 8%
B. 30%
B. 30%
C. 40%10-30%nswer
D. 50%wer

5. 50 POINTS DEPRESSION IN OLDER ADULTS OFTEN PRESENTS IN AN ATYPICAL
MANNER WHEN COMPARED TO
YOUNGER ADULTS. WHAT IS AN
EXAMPLE OF THIS PRESENTATION?
Older adults frequently have an atypical presentation of depression (as well as delirium). Oftentimes older adults think of depression as a weakness and can become defensive when asked if they feel depressed. Asking questions like “how are your spirits?” or “do you feel blue?” can be less intimidating. They often present with symptoms such as irritability, difficulty processing information, somatic complaints, behavioral changes. It is important to stress that especially in terms of somatic complaints (which frequently come in the form of pains, gastrointestinal discomfort, constipation), older adults genuinely feel these symptoms; they are not making them up. It is also important that all physical complaints get assessed and addressed before assuming they are psychological in nature.
Also of note is that someone with cognitive slowing looks different than the person with dementia. For example, the person with dementia will attempt to answer the questions in a cognitive exam but will get them wrong. The person with cognitive slowing will say “I don’t know” as they often don’t have the energy to even try and answer the question. In terms of assessment asking a question such as “do you find things are getting on your nerves more,” can get to the irritability and behavioral change symptoms. It is sometimes also good to ask the client’s permission to talk with family members or friends about behavior or irritability as they may not have the awareness they are presenting in such a way.
A. -BEHAVIORAL ISSUES
B. COGNITIVE SLOWING
C. -SOMATIC COMPLAINTS
D.– ALL OF THE ABOVE
D. ALL OF THE ABOVE

6. 75 POINTS WHICH OF THE FOLLOWING EVALUATION TOOLS DIFFERENTIATES
DEMENTIA FROM DELIRIUM?
CAM - Confusion Assessment Model differentiates dementia and delirium.
Mini-Cog and MoCA evaluate cognition.
GDS Geriatric Depression Scale assesses for depression.
It is important to note that none of the tools are completely diagnostic. They collect information that needs to be correlated with other assessments and a history on the patient.
A. GDS
B. MINI-COG
C. CAM
C. CAM
D. MoCA

7. 100 POINTS SYMPTOMS OF DELIRIUM INCLUDE WHICH OF THE FOLLOWING?
Delirium onset is acute and the symptoms are reversible however an underlying cognitive deficit or delayed recognition of the delirium can compromise full return to baseline
The marked change in mental status is a hallmark symptom of delirium
Fluctuation or waxing and waning of symptoms
Inattention, distractibility, disorientation, perceptual changes, disturbed sleep-wake cycle are additional symptoms
The CAM tool further discusses the symptoms of delirium and the algorithm which differentiates symptoms from dementia
A. CHANGE IN MENTAL STATUS
B. IRREVERSIBLE SYMPTOMS
C. DISTRACTABILITY
D. BOTH A & C
D. BOTH A&C

8. 125 POINTS WHAT IS THE MOST IMPORTANT ASSESSMENT IN UNDERSTANDING
COGNITION?
Understanding how an individual functions at baseline is the key to being able to assess where they may be now. For example the expectation is that after clearing a delirium or being treated for depression the individual would return to their baseline status of functioning. Understanding what this baseline looks like helps to target an outcome. It is helpful to have a yearly updated cognitive evaluation tool on a chart (primary care provider, assisted living or long term care chart) in order to use as a comparison for when the mental status changes. Being able to communicate across the disciplines with the result of a mini cog or a mini mental status examination can give a clear picture of what the patient looks like cognitive. For example if a patient is admitted to the hospital and the their baseline mini cog was 5 or their baseline mini mental status examination was 27 and their current exam shows a mini cog of 2 or a mini mental status examination of 18 the examining practitioner clearly recognizes a marked change in mental status.
A. BASELINE LEVEL OF FUNCTIONING
A. BASELINE LEVEL OF FUNCTIONING
B. VITAL SIGNS
C. BRAIN IMAGING
D. FAMILY HISTORY OF DEMENTIA

9. 150 POINTS NAME THREE COMMON CAUSES FOR DELIRIUM IN OLDER ADULTS?
URINARY TRACT INFECTION
DEHYDRATION
MEDICATION
ELECTROLYTE IMBALANCES
PNEUMONIA
ALCOHOL WITHDRAWAL

10. CARING FOR AN OLDER ADULT
175 POINTS
WHICH OF THE FOLLOWING
IS THE PRIORITY IN
CARING FOR AN OLDER ADULT
WITH DELIRIUM?
The change in behavioral symptoms will often prompt a treatment of those symptoms by sedating or “calming” the patient. However best practices are to treat the underlying cause and subsequently symptoms will improve. Adding medication to the picture often clouds the issue and worsens behavioral symptoms. If medications are used, they should not sedate the patient and they should only be used for a short term and as the delirium clears. Overstimulation will add to confusion and behavioral disturbances in the delirious patient. Though pain should not be ignored and could worsen behavioral symptoms, treating the underlying cause of the delirium is the priority. It is also important to note that even when the underlying cause is treated, it could take weeks and even months for the delirium to resolve. Do not expect the delirium to clear as soon as a course of antibiotics is completed in treating the underlying infection.
A. KEEPING THE PATIENT SEDATED
B. TREATING THE UNDERLYING CAUSE
B. TREATING THE UNDERLYING CAUSE
C. KEEPING THE PATIENT STIMULATED
D. MEDICATING FOR PAIN

11. 200 POINTS
WHICH GROUP OF MEDICATIONS IS MORE LIKELY TO CONTRIBUTE TO A CHANGE IN MENTAL STATUS WITH OLDER ADULTS?
Sedative hypnotics, opioids, and anticholinergic medications can all contribute to confusion in older adults. The Beers Criteria outline medications that could be potentially dangerous to older adults and more likely to contribute to delirium:
A. – SEDATIVE HYPNOTICS
B. – ANTICHOLINERGIC MEDS
C. - OPIOIDS
D. – ALL OF THE ABOVE
D. ALL OF THE ABOVE

12. 225 POINTS
WHEN CARING FOR THE CLIENT DIAGNOSED WITH DELIRIUM, WHICH CONDITION IS THE MOST IMPORTANT FOR THE NURSE TO ASSESS FIRST?
A. CONCURRENT DIAGNOSIS OF CANCER
Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.
Beer Criteria for the evaluation of inappropriate medication use with older adults:
B. PRESCRIPTION DRUG INTOXICATION
B. PRESCRIPTION DRUG INTOXICATION
C. IMPAIRED HEARING
D. HEART FAILURE

13. 250 POINTS A. -RENAL FAILURE B. –ADVANCING DEMENTIA C. DEPRESSION
AN 87-YEAR-OLD WOMAN IS SEEN IN THE EMERGENCY DEPARTMENT WITH THE FOLLOWING LABS:
BUN: 20 mg/dL
Creatinine: 1.4 mg/dL
Serum potassium: 4.3 mEq/L
Serum sodium: 129 mEq/L
SHE HAS A DIAGNOSIS OF ALZHEIMER’S DEMENTIA, BUT HER DAUGHTER SAID SHE IS MORE AGITATED AND PARANOID ABOUT EATING OVER THE PAST WEEK. SHE IS LIKELY TO HAVE:
This patient is hyponatremic and is demonstrating an acute change in mental status consistent with delirium. Bun, Creatinine, and potassium levels are unremarkable. She has an underlying Alzheimer’s dementia which puts her at higher risk of developing a delirium. Dementia does not advance that quickly, and while agitation (behavioral changes) and appetite changes can occur as an atypical presentation of depression, the sodium level in the context of the behavioral changes is most likely to indicate a delirium.
Dehydration and medications (Selective Seratonin Reuptake Inhibitors) can contribute to hyponatremia.
A. -RENAL FAILURE
B. –ADVANCING DEMENTIA
C. DEPRESSION
D.- DELIRIUM
D. DELIRIUM

14. 275 POINTS A PATIENT LIVING INDEPENDENTLY AND BEING TREATED FOR
DEPRESSION COMPLAINS THAT SHE
FORGOT TWO OF HER APPOINTMENTS
THIS WEEK. SHE IS LIKELY TO HAVE
A CONCURRENT:
Expect cognitive slowing with depression in older adults. One of the differences between this cognitive slowing and cognitive impairment is that the patient will be aware (and often times upset) that he or she did not remember the appointments. The patient with dementia would most likely not remember that he or she forgot. Concurrently, a patient with delirium would most likely not be aware of the confusion he or she is exhibiting.
A. NONE OF THE BELOW
A.- NONE OF THE BELOW
B. - STROKE
C. - DELIRIUM
D. – DEMENTIA

15. 300 POINTS I’M 92 YEARS OLD AND I AM STUCK IN THIS PLACE.
THEY ARE KEEPING ME CAPTIVE. THEY CALL IT A
HOSPITAL. LOOK AT THE CHILDREN HIDING UNDER THE BED. CALL THE POLICE. YOU ARE THE NURSE RIGHT? HOW ARE YOU GOING TO HELP ME?
CAM
TALK WITH FAMILY ABOUT HER BASELINE LEVEL OF
FUNCTIONING.
EVALUATE HER LEVEL OF FEARFULNESS REGARDING
THE VISUAL HALLUCINATIONS.
SAFE AND REASSURING ENVIRONMENT
BETTER UNDERSTAND THE ETILOGY OF LIKELY DELIRIUM.

16. 400 POINTS CAN A PATIENT HAVE DEMENTIA, DELIRIUM,
AND DEPRESSION CONCURRENTLY? IF SO
HOW WOULD THEY PRESENT?
INCREASE IN CONFUSION FROM BASELINE
CHANGE IN SENSORIUM OR LEVEL OF
CONSIOUSLNESS USUALLY DELINIATES
DELIRIUM
CHANGES IN SLEEP, APPETITE, ENERGY,
AND BEHAVIOR MAY HAVE BEEN SEEN PRIOR
TO EMERGING DELIRIUM
BASELINE COGNITIVE DEFICITS CAUSED BY
DEMENTIA MAY WORSEN WITH CONCURRENT
DELIRIUM AND DEPRESSION.

17. CONGRATULATIONS!
YOU ARE NOW BETTER
PREPARED TO CARE FOR
OLDER ADULTS.
REMEMBER THE SIMILARITIES AND DIFFERENCES OF DEMENTIA, DELIRIUM AND DEPRESSION IN CARING FOR OLDER ADULTS