1. The Three Ds of Confusion Delirium, Depression, Dementia

2. Confusion Is not a normal part of aging
Delirium and Depression are treatable
Dementia is manageable

3. Delirium More common than fever or pain in older adults
About 50% of hospitalized older adults experience delirium
Only 3 out of 10 older adults with delirium are diagnosed by health care personnel
As many as 1/3 of those affected by delirium will die
Is a medical emergency and should be treated as such
St. Pierre, J. (1996). Delirium in hospitalized elderly patients. Critical Care Nursing, 8(1),

4. Delirium Onset: hours to days Causes: medications
fluid and electrolyte imbalances (What is a common fluid imbalance that also begins with the letter “D”?)
infection (rule out urinary and respiratory infections)
elimination (urinary retention / constipation)
changes in chronic illness
newly-developed disease process
psychosocial / environmental issues

5. Delirium: Diagnosis need to repeat questions
perseveration (What does this term mean?)
disorganized thinking
reduced LOC (level of consciousness)
perceptual disturbances
sleep-wake disturbance or psychomotor activity
disorientation to time, place, person
memory impairment

6. Delirium : Assessment
Person, place and time are the least sensitive markers for delirium
Focus on aspects of Attention and Concentration
Ask client to count backward from 20 by 3’s
Ask client to copy a drawing of intersecting pentagons

7. Delirium: Interventions
Rule out drug-related causes and infections first
Urinary tract and respiratory infections are the most common
Obtain data about the individual’s baseline cognitive functioning
Provide orienting cues and support
Eye glasses, hearing aids, calendar, clock, etc.

8. Depression Onset: weeks to months Causes: heredity biochemical changes
drugs
illness
sensory deficits
stress
seasons (seasonal affective disorder,
frequently seen in the Northwest)

9. predispose an individual to a depressive
Losses with Aging
biological
psychological
personal
social
identity
possessions
religious
Sometimes the
cumulative effect
of several losses can
predispose an individual to a depressive
episode.
Think of some examples of how these losses may be experienced.

10. Depression: Diagnosis
Symptoms include…
loss of interest or pleasure in activities
persistent depressed mood, including feelings of sadness or emptiness
feeling slowed down or restless, can’t sit still
feeling worthless or guilty
increase or decrease in appetite or weight
thoughts of death or suicide
problems thinking, concentrating, or making decisions
trouble sleeping, or sleeping too much
loss of energy or feeling tired all of the time; constant fatigue

11. Depression: Assessment
Geriatric Depression Scale
Self-administered
Well tested and used by all health care providers
Cornell Scale for Depression in Dementia
Useful in assessing depression in individuals with dementia
Can be used by family members or caregivers to articulate their observations, as some individuals may minimize the severity of their symptoms

12. Risk Factors for Late in Life Suicide
male
significant loss
poor health
isolation
feeling hopeless
previous attempt
drug / alcohol abuse
family history
financial insecurity
The risk of suicide is high in older adults.
Health care providers must intervene if an individual makes statements related to the taking of his or her own life.

13. Depression: Interventions
Antidepressants
Monitor for side effects
Encourage and support counseling
Recommend a referral to Medical Social Worker (MSW)
May be able to link individual with resources and community support

14. Dementia Onset: months to years Causes:
Alzheimer’s Disease (AD) (most common)
Vascular Dementia (multi-infarct; MID)
Mixture of AD & MID
Pick’s, Parkinson’s, AIDS
To learn more about AD, see the booklet Alzheimer’s Disease: Unraveling
The Mystery, produced by the National
Institute on Aging.

15. Delirium + Dementia
Individuals with dementia still have acute illnesses such as pneumonia, UTI’s, medication side effects, and electrolyte imbalances. This means that they can have a delirium superimposed on their dementia. If an client with AD is more confused than usual (within hours to days) and experiencing the s/s of delirium as discussed earlier, you must intervene.
Therefore, your assessment must include information about the client’s baseline cognitive functioning. Family members and caregivers must be included in the assessment process.

16. Dementia: Interventions
Obtain client’s baseline cognitive functioning.
Observe for potential delirium and/or depression that may magnify cognitive impairment (both of these conditions are treatable even in the individual with dementia).
Provide and encourage an environment that supports the individual’s highest level of functioning.

17. The Three Ds of Confusion was prepared by Catherine Van Son, Ph.D., R.N., for the Older Adult Focus Project, OHSU School of Nursing.