1. The Three D’s an overview
SESSION 9
The Three D’s an overview

2. Objectives
To review the definitions of Dementia, Depression, and Delirium.
To understand in what ways these cognitive disorders are similar
To understand which features help define or distinguish one from the other.

3. Definitions DEMENTIA DEPRESSION
cognitive decline due to brain disease.
change in mood with feelings of worthlessness.
DELIRIUM
acute change in mental status

4. Common Presentation DEPRESSION DEMENTIA DELIRIUM Need a volunteer…
EX 1: Can you fill in the center red area---what are the common presenting signs and symptoms?
DELIRIUM

5. Case A
75F widowed 1 year ago, now living with her son, increasingly more forgetful, increasingly dependent with IADLs, losing weight and getting weaker over the past year, sustained a fall and hip fracture 2 weeks ago, but now not eating well, sleeps all day, restless at night, and not participating well in rehabilitation efforts.
The son is upset about this and wants to know why she is not improving and what you are doing about it.

6. Distinguishing Features
Associated Symptoms
Time
Course
Delirium
Dementia
Depression

7. Case A
75F widowed 1 year ago, now living with her son, increasingly more forgetful, increasingly dependent with IADLs, losing weight and getting weaker over the past year, sustained a fall and hip fracture 2 weeks ago, but now not eating well, sleeps all day, restless at night, and not participating well in rehabilitation efforts.

8. DELIRIUM: The Acute History
The son says…
Mother confusing him for her deceased husband
Picks in the air
Falls asleep while he’s trying to talk to her
New behavior since the surgery
The nurse says…
Restless at night
Placed in hallway by nurses station because trying to climb out of bed
Pulled out foley and IV once already
Only new med is Acetaminophen

9. DEMENTIA: a Chronic and Progressive History
The son says…
More forgetful during past year, but not THIS bad!
Previously independent in all ADLs
Dependent in Shopping, Transportation, Finances (husband used to do this before)
Cooks basic meals (less frequent, less fancy)
Complains of fatigue, naps a lot, TV, dosen’t leave house anymore.

10. DEPRESSION: episodic, recurrent
The son says…
History of depression in past, on antidepresants intermittently in her lifetime.
On Zoloft 75mg since death of her husband one year ago.
Longtime insomnia, takes ativan 2 mg qhs prn (average 3x per week), awakens 4am
Appetite fair in past year
No longer reads books
Feelings of despair, thoughts of dying, no suicidal
GDS score 7/15

11. PMH MEDICATIONS HTN Depression Insomnia B Knee Arthritis
Lisinopril 10 mg qd
Zoloft 75 mg qd
Ativan 2 mg qhs prn
Tylenol 650 mg q4h prn pain
Celebrex 100 mg po qd
Percocet one tablet po q4h prn severe pain
NEW

12. Physical Exam

13. Mini-mental Status Exam
Orientation: 2/5
Date: 0/5
Registration: 1/3
Attention: serial sevens 0/5, WORLD backwards 2/5
Naming: 2/2
Short-term memory: 0/3
3-step command: 1/3
Read and Obey: 1/1
Sentence: 1/1
Visualspatial: 0/1
SCORE=10/30

14. Clock-Drawing Task

15. Assessment and Plan DX: Delirium Depression maybe Dementia PLAN:
Nonpharmacologic
Pharmacologic