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

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.

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

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

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.

Distinguishing Features Associated Symptoms Time Course Delirium Dementia Depression

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.

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

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.

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

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

Physical Exam

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

Clock-Drawing Task

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