1. Dementia, Depression, & Delirium
3D Day
Dementia, Depression, & Delirium
Presented by: Mia Yang, MD & Antonio Graham, DO
Dec 2015

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11/8/2018

3. Outline Communicating with patients with cognitive impairment
Dementia review
MMSE & Mini-Cog
How to communicate with patients with cognitive impairment
Delirium review
4AT test
Depression & how it differs from dementia

4. Communication techniques
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5. Communication deficits experienced by people with memory loss
Problems finding the right words
Lack of coherence or logic in speech
Repetition of ideas
Decreased attention span
Regularly forgetting recent events, names, and faces
May have hearing or vision loss
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Alzheimer’s Association 2013

6. Ten communication strategies
Eliminate distractions, ie TV or radio
Approach the person slowly and from the front; establish & maintain eye contact
Use short, simple sentences
Speak slowly
Ask one question or give one instruction at a time
Use “yes” or “no” rather than open-ended questions
Repeat messages using the same wording
Paraphrase repeated messages
Avoid interrupting the person; allow plenty of time to respond
Encourage the person to “talk around” or describe the word he/she is searching for
Small et al. Journal of Speech, Language, and Hearing Research. 46, 2, , 2003
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7. DEMENTIA
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8. Why learn about dementia?
1 in 3 seniors dies with Alzheimer’s or another dementia
Alzheimer’s disease is the 6th leading cause of death in the U.S.
In 2015, Alzheimer’s and other dementias will cost the nation $226 billion
By 2050, cost could rise as high as $1.1 trillion

9. Dementia
Dementia is a disorder characterized by problems with cognition + functional impairment
Cognition components: learning/recall, reasoning, language, spatial ability/orientation, and executive function/handling complex tasks
Functional impairments:
Activities of Daily Living (ADLs): eating, dressing, toileting, etc
Instrumental Activities of Daily Living (IADLs): grocery shopping, cooking, finances, medications, driving, etc.

10. Dementia subtypes
Alzheimer's disease being the most common subtype prevalence (50%)
Prominent memory impairment
Gradual decline
Vascular Dementia is the second most common subtype.
tends to have white matter changes on brain imaging & history of strokes or CAD
“step wise” decline over time
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11. Dementia subtypes Lewy Body dementia: prevalence around 15%
cognitive impairment, hallucinations, & Parkinson-like symptoms such as shuffling gait, falls, rigidity & tremors
Cognitive & hallucinations may occur before or at the same time as Parkinson-like symptoms.
Parkinson’s dementia - must have motor symptoms before cognitive impairment by 1 year
Fronto-temporal dementia: usually younger patients, with executive and language dysfunction and often behavioral changes such as disinhibition & impulsivity.
Memory impairment less prominent.
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12. Dementia subtypes Other dementia: 5% Rule out reversible causes:
head trauma, HIV disease, Huntington's chorea, Pick's disease (a type of fronto-temporal dementia), Creutzfeldt-Jakob disease.
Rule out reversible causes:
B12 deficiency, hypothyroidism, neurosyphilis, substance abuse such as alcohol, depression, and delirium
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13. Dementia Screening
Mini Mental Status Exam: measures global cognitive function by examining memory/recall, language, orientation, and executive function.
Interpretation of scores depend on level of education (eg. 26/30 would be abnormal in someone with a PhD). MOCA (Montreal Cognitive Assessment) may be used in someone with higher education status.
25-30=normal or mild cognitive impairment
20-24 = dementia, mild
10-20 = dementia, moderate
<10 = dementia, severe

14. Mini-Cog- dementia screen
Ask patient to repeat three words: banana, sunrise, chair
Ask patient to draw face of a clock, then draw hands to read “ten past eleven”
Ask the patient to recall the three words

15. How to communicate with patients with cognitive impairment?
Make direct eye contact with patient.
Use close ended questions that require a yes or no answer.
Speak slowly and use simple sentences.
Ask one question at a time, allow patient to respond.
Repeat messages using the same wording.
Avoid distractions such as television or radio.

16. DELIRIUM
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17. Delirium
Delirium is an acute or fluctuating onset of confusion disturbances in attention, disorganized thinking, and/or decline in level of consciousness.
Often reversible with treatment, wax and wane throughout the day

18. Delirium Causes
Differential Diagnosis include the following but not limited to:
Medications, infections, withdrawal, acute metabolic toxins, CNS pathology, hypoxia, trauma, constipation, urinary retention
Most important predisposing factor: baseline cognitive impairment
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19. Delirium subtypes
Hyperactive Delirium: agitation, aggression, restlessness and hallucinations
Hypoactive Delirium: usually sedated, can be un-arousable
Mixed Delirium: both hypoactive and hyperactive behavior
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20. Delirium Predisposing factors
Advance age
Cognitive impairment/Dementia
Hearing and/or visual impairment
Polypharmacy: benzodiazepines, narcotics, anticholinergics
Chronic kidney disease (CKD)
Substance use such as alcohol
Anesthesia
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21. Delirium Screening
Screen is positive if the person has 1& 2 plus either 3 or 4 of the following:
(1) Presence of acute onset and fluctuating course.
(2) Inattention
(3) Disorganized thinking
(4) Altered level of consciousness
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22. 4-AT test A key component of screening for delirium is inattention.
AMT4 are questions regarding orientation

23. CAM- Confusion Assessment Method

24. Delirium Treatment Treat underlying cause: Rule out infection
Check medications
Rule out constipation, urinary retention, dehydration
Provide adequate sensory input, ie give glasses or hearing aids from home
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25. Non-Pharmacologic Treatment of Delirium
Setting a defined sleep wake cycle for patients .
Minimizing extraneous environmental noise such alarms or a disruptive roommate.
Having a family member, caregiver or sitter present to re-orient patient.
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26. DEPRESSION
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27. Recognizing depression: Why it is so difficult in older patients
Medical co-morbidity
Harder to recognize symptoms of depression
“Vegetative symptoms” may have multiple etiologies
Somatic complaints often prominent
May not complain of low mood
Executive dysfunction mimics dementia
Impairs daily functioning

28. Symptoms of late-life depression
Changes in sleep pattern and appetite
Diminished sex drive
Lack of energy and/or motivation
Feelings of worthlessness or guilt
Difficulty concentrating and making decisions
Irritability, restlessness
Social withdrawal
Recurrent thoughts of death, suicidal ideation
Memory problems and confusion
Vague, multiple somatic complaints

29. Distinguishing depression from dementia
Interests
Anhedonia, loss of pleasure
Apathy, loss of interest
Self-attitude
Diminished
Diminished or intact
Cognitive testing
Give up, won’t try to answer some questions
Wrong answers
Cognition
Executive dysfunction: impaired planning, organizing, prioritizing
Memory impairment prominent
Onset of symptoms
Can be abrupt or gradual
Gradual, progressive
Symptoms variability
Diurnal variation: better in the evening
“Sundowning”: worse cognition in the evening

30. Depression Screen- PHQ-9
PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression

31. For more info: Alzheimer’s Association: www.alz.org
MOCA (Montreal Cognitive Assessment):
Mini-Cog:
4AT test:
CAM (Confusion Assessment Method):
Depression in older adults:
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