1. The 3 Ds of Geriatric Care Depression, Dementia and Delirium

2. Dementia  Average delay from 1st symptom to diagnosis 2-3 years.  Family recognition is usually how it gets diagnosed. Caregiver complaints, high suspicion of dementia  Post CVA (30% develop within 3 months)  Post-delirium (30% develop within 3 years)  Post first onset depression (30% develop within 3 years)  Family history – every first degree relative  Age (2% at age 65) Every five years doubles risk of dementia  Every vascular burden/risk factor doubles the risk

3. Dementia Risk calculator Age  652%  704%  758%  8016%  8532%

4. http://www.memantine.com/image s/disease_progression.gif

5. Dementia Quick Screen  Say three words, repeat back  1 minute to name as many 4 legged animals (20 times odd ratio) If Animals are low – Alzheimer’s  List year (37 times odds ratio)  Draw clock 10 after 11 o’clock (24 times odd ratio) Specificity 94% Large enough circle, joined Numbers evenly spaced Time correct – hand placement  Remember and repeat the three words from the beginning

6. MMSE Gold standard  Needed for prescribing of cholinesterase inhibitors  <26 is dementia  Not sensitive for mild cognitive impairment  Deceptive: low educational/economic status, poor language, illiteracy, impaired vision  Scoring: 27-30Normal 20-26Mild AD – Independent (advance care planning) 10-19Moderate AD – Supervision <10Severe AD - Total dependence

7. MoCA  Meant to assess mild cognitive impairment (score <26)  Clock draw – visual spatial and executive function  Rhino becomes a hippo  Lewy Bodies – attention deficit present  Less than 11 f words –  frontal or vascular dementia – will see inappropriate words come up first

8. Peterson Criteria: Diagnosing MCI  Memory complaint  Memory impairment for age and education  Largely intact general cognitive function  Present ADLs – no functional loss.  Not demented

9. Diagnosing AD  Memory impairment  Impairment in function  One of  Aphasia (language)  Apraxia (motor)  Agnosia (recognition, identification)  Disturbance in executive function (planning organizing)  Significant decline from previous level of function  Impairment in social or occupational functioning  Gradual onset – sudden onset is delirium until proven otherwise  Not due to other causes.

10. Delirium  Commonly under-diagnosed, particularly in residents who have a pre-existing dementia.  Acute and fluctuating onset  Medical emergency  Confusion, disturbances in attention, disorganized thinking and/or decline in level of consciousness

11. CAM Confusion Assessment Method – Delirium Sensitivity 94-100%, Specificity 90-95% 20% deliriums never clear  Acute onset and fluctuating course  Inattention  Disorganized thinking  Altered level of consciousness  Diagnoses required the presences of features of 1 and 2 and either 3 or 4.

12. Meet Mrs. G.  Pneumonia, treated 1 month ago.  Productive cough  Calling out, worse in evening. Staff reports that behaviours are most challenging between 3pm and 7pm. Staff refer to it as “Sundowning”.  Worries about her son, recognizes him but no longer knows he is her son. Worried about having to pay for being in the LTC home.

13. Mrs. G.  Lethargy – change in sleep pattern that is worse over the last week. Sleeping more in the morning and wakes up around 3pm.  Recently moved to LTC from hospital (1 month). Prior to that was living at home.  Falls in hospital and 2 at the LTC home since admission.

14. PMHx Bilateral glaucoma Bilateral glaucoma Mild hearing loss Depression & anxiety Alzheimer’s Disease Past history of delirium Past history of LRIs and UTIs HypothyroidismHypotensionCOPD Graves Disease OsteoporosisOsteoarthritis Past smoker (quit 5 years ago) Left hip fracture and bilateral wrist fractures Left hip fracture and bilateral wrist fractures Bilateral leg edema Bilateral leg edema Bowel resection, prone to constipation - malignant polyps Bowel resection, prone to constipation - malignant polyps

15. Recent Diagnostics  TSH 14.87 From admission bloodwork drawn but not yet reviewed.  CXR 2 days ago is negative for active process

16. Medications  Lasix 20mg PO daily  Xalatan and Timolol gtts  L-Thyroxine 0.15mg PO daily  Celexa 40mg PO daily (recently decreased from 60mg)  Spiriva and short acting PRN bronchodilator for COPD  Seroquel 50mg PO BID at 0800 and 2000  Clonazepam 0.5mg PO at 0800 and 1200; 2mg PO at 1600 and 2mg PO once daily PRN  Colace QHS  Lactulose PRN  Tylenol PRN (PO or PR) Had tried Aricept in the past but did not tolerate it.

17. Neuro Ax  Difficult to rouse, sternal rub required to rouse Mrs. G. Speech slurred and difficult to understand. Family states that this is new and unusual for her. Able to converse for 3-4 minutes before falling back asleep. Able to follow directions but shows inattention. Bilateral grip equal. Unable to assess pupils d/t glaucoma.  CAM score + for delirium (Feature 1, 2 and 4 present)

18. Resp Ax  RRR, 16. No wheezing. Fine bilateral rales audible. No SOB. Congested cough, w upper airway secretions. Afebrile.

19. CV Ax  No murmurs, HR 76, S1, S2. No peripheral edema noted. Recent BP readings by staff stable.

20. Integument Ax  Very dry skin. Mucous membranes dry. Bruising present to lower legs.

21. GU Ax  No specific signs of UTI. Small temp change from baseline T 37.0 (baseline 36.2).  Chronically positive C&S

22. Abdominal Ax  BS present x 4 quadrants. No rebound tenderness noted. Resident up in W/C, therefore not assessed fully. Voiding well into brief. No reports of dysuria, frq, urgency, changes in continence. T 37.0 (baseline 36.2). Recent bowel movements have been regular and soft/formed in consistency.

23. Pain Ax  Vague self-report. Behavioural indicators of pain in staff reports. Kyphotic in appearance. Recent loss of mobility (past 6 months). Family reports that she used to be on regular Tylenol in the retirement home but this was discontinued in hospital. Family reports that Mrs. A would never be one to ask for help with pain. Recent falls. No spinal x-rays taken. Is not on Vit D or Calcium.

24. Impression? Delirium co-existing w dementia and depression! Risk Factors: Age, CI, Hx delirium, Hx depression, sleep disturbance, vision and hearing loss, recent relocation, hx fractures, unrelieved pain, hypotension, recent infection, polypharmacy, benzodiazepine use, antidepressant use, antipsychotic use. Age, CI, Hx delirium, Hx depression, sleep disturbance, vision and hearing loss, recent relocation, hx fractures, unrelieved pain, hypotension, recent infection, polypharmacy, benzodiazepine use, antidepressant use, antipsychotic use.

25. Now What? What is causing her delirium? Differentials:  Dehydration  Pain  Hypothyroidism  Polypharmacy

26. Other Considerations  High risk of fractures, affecting QOL. Spinal x-ray not feasible for her. Recent falls and posture combined with behaviours make vertebral fractures highly likely.  Prob UTI at this point seems low given the non-specific nature of her symptoms. Will always test positive – no need to treat unless symptomatic.  Recent CXR negative. Rales could be some residual post-infection atalectasis.

27. What’s our plan?  Increase L-Thyroxine and recheck TSH in 1 week  Discontinue PRN Tylenol  Tylenol 325mg 2 tablets (total 650mg) PO QID x 2 weeks then reassess. She is opiate naïve – if we want to try these go low and slow  Encourage oral fluids.  Dietitian to assess re: fluid intake.  Vitamin D 1000iu PO daily  Taper Clonazepam slowly.

28. Depression vs. Dementia or Depression with Dementia  For the most part, these two conditions coexist. Depression looks different in older adults.  Feelings of guilt/worthlessness  Hopelessness, death wishes, suicidal  Frequent crying spells  Resident overstates impairments  Greater problems with attention, concentration, speed of processing and retrieval  Constructional apraxia, agnosia and aphasia are rare  Usually performs well on memory tasks

29. Questions?