1. “3 D’s” of Geriatrics Dementia, Delirium, and Depression These common disorders can look alike. GAI often helps uncover or differentiate them. All are associated with elder mistreatment.

2. Scope of the Issues Dementia Population trends. 8% of patients over 65 years old have dementia. Incidence doubles every 5 years: 2% at 65 and 32% at 85 years. 3.5 million cases in 1999 will be 14 million in 40 years. Cost of Alzheimer’s Disease alone is $90−100 billion per year.

3. Dementia Dementia is a progressive decline in cognitive and functional abilities with associated psychiatric disturbances. Normal aging leads to a slowing of performance but not decreased cognition.

4. Differential Diagnosis: General Dementia Depression Delirium

5. Differential Diagnosis: Specific Alzheimer’s Diffuse Lewy Body Vascular Parkinson’s Ethanol abuse Normal Pressure Hydrocephalus Huntington’s Frontal Lobe Shy Drager/ Progressive Supranuclear Palsy CJ

6. Delirium 1. Acute change in mental status and 2. Inattention With either: 3. Disorganized thinking or 4. Altered level of consciousness

7. Delirium It is a medical emergency. 15−20% of medical patients are delirious upon admission. 25−60% of patients over 65 years old develop delirium after admission. 32−67% of physicians fail to recognize the disease.

8. Differential Diagnosis Always consider dementia and depression as competing diagnoses. Other: post-ictal state, psychiatric disorders, nonconvulsive epilepsy. Three types of delirium Organic (medical) Post-operative Terminal restlessness The initial evaluation is primarily an acute workup in search of the underlying cause(s). Use of the Confusion Assessment Method (CAM) is essential in identifying delirium.

9. Dementia vs. Delirium Chronic Irreversible Long course Day to day Vague onset Acute Reversible Short course Hour to hour Precise onset

10. Dementia and Depression Pseudo-dementia: patients with complete recovery of high intellectual functioning will develop irreversible dementia at 20% per year. Late-onset depression has a higher prevalence of dementing disorders. Demented elderly develop depression at a higher rate.

11. Depression Prevalence in older adults: Community 1% (27%)* Inpatients11%(40%)* Nursing home 10−25% (45%)* * Inflated numbers due to inclusion of patients with less severe symptoms.

12. Depression Duration 31−50 years 9−18 months >50 years3−5 years Recurrence 50% after first episode 70% after second episode 90% after third episode Depression Treatable in 75% of cases. Untreated cases associated with 15% mortality. Suicide rate in elderly is double the rate for all other age groups. Workup is identical for that of dementia. Dementia and depression often coexist.