3 D's Flashcards
at a glance differntiate
delirum
depression
dementia
Delirium
- acue onset
- waxing and waining confusional state
- reversible with short duration
Depression
- mood disorder
- underrecognized and under diagnosed in eldery
Dementia
- organic mental syndrome
- neurodegenerative
- slow progression but fatal
Depression
DSM Criteria for diagnosis
how will older pt. present
Depression
- mood disorder with the following symptoms at least 5 of the symptoms nearly everyday for a 2-week consectutive period
SIG E CAPS
S: sleep disturbances
I: interest decreased
G: guilt or feelings of worthlessness
E: Energy decreased
C: concentration issues
A: appetite/weight changes
P: psychomotor agitation
S: suicidal ideation
Older Adult Presentation
- less outward appearance of mood disorder: they present differently
- somatic complaints (fatigue, weight loss, pain, memory changes)
- social withdrawal
- refused to eat/drink or take meds
- lack of self care
how to screen geriatrics for depression
- role of co-morbidities
- screening tools
Co-Morbidities
- concurrent conditions can mask/mimic depression signs
- medications can overlap signs (fatgiue, etc.)
- impaired communication (hearing loss, speaking loss) can make recognizing the signs diffiult
- reluctant to communicate: stigma for mental health in older adults high
Screening tools
USPSTF : anyone should be screened if resources can be provided
american geri society : screen for depression during dementia work up (overlapping signs)
geriatric Depression Scale : more in depth & most widely accepted tool for elderly
PHQ-2 or 9 good for depression but geri depression scale is more questions for elderly tailored
Treatment of depression in the eldery
historically, we undertreat, dont treat or treat too short
Treatment of depression
Psychotherapy
- very effective (especially mild depression)
- equally effective as meds & even better in concurrence with meds
Pharmacothearpy
- SSRIs: first line
- start low go slow mentality
- full response in elderly may take 16 weeks
ECT: electroconvusive thearpy
- good for unresponsive pts.
- well tolerated: mild transient short term memory loss may occur
Pharmacothearpy of Depression in Elderly
med classes and key pearls
SSRI: first line medications
- escitalopram, citalopram, sertraline, fluoxitene (paroxetine last option: antichol. SE)
SNRI: Venlafaxine, Duloxetine
- good for concominant depression + neuropathic pain
Atypicals (list = concominant conditions it helps)
-Mirtazipine: insomniam agitation, anorexia (helps weight gain)
Trazadone: insomnia
Buproprion: added on as adjuct treatment
AVOID TCAS!!!!: too many side effects and arrythmic and anticholenergic risks
Delirium
what is it & what does it signal
symptoms of hyperactive & hypoactive
Delirum
- neuropsychiatric syndrome
- commonly in elderly pt. with multple medical conditions
- these pts. are sick!!! this suggests an underlying acute illness
define
- acute change in mental status that fluctuates
- a reversible condition if underlying problem can be addressed : lasting days, weeks, months
- can have complete loss of function in a specific neurologic condition
Types of Delirium + symptoms
Hyperactive
- agitataed
- incoherant speech
- disoriented
- hallucinations
- delusions
Hypoactive
- sluggish and drowsy
- less reactive
- withdrawn
can be mixed presentation
Delirium
patho
risk factors
possible underlying conditions
Patho
- not well understood
- abnormal depolarizations + inflammation
Risk factors & Underlying Conditions
D: dementia, drugs
E: eye, ears & sensory deprivation
L: low O2 state (HF, COPD, MI, PE)
I: Infection
R: retention (urine or stool)
I: ictal state
U: undernutrtion/hydrated
M: Metabolic Upst: dernged, DM, electrolytes
S: subdural, sleep deprivation
ICU: 70% of pts.
General inpt: 30%
ER: 10%
Delirium
Evaulation
Testings
Diagnosing
when in doubt: presume delirium and rule out other common things
- < 1/3 ICU physicians cannot recognize delirum without a screening toold
Testing
- no specific testing : do a workup to rule out other things
- CBC,CMP,drug levlels, US, alchol, ABG, cultures
- CRX, cerebral imaing rarely helpful (unless acute change in neurologic fndings or head trauma)
- EEG and LP rarely helpful (unless r/o seizure or meningitis)
Diagnosis of Delirum
- acute onset or fluctuation findings
- inattention
- and either…
- disorganized thinking
- or
- altered level of consciousness
- using the CAM-ICU score to determine if inattention, etc. through specific tests
- exampple: inattention = SAVEAHAART test
Delirium
prevention & treatment
prevention is the best treatment!
Treatment
- identify the underlying cause & treat
- modifity the Risk Factors
- environmentla modifications: help get more sleep
- adequate nutrtion/hydration
- early mobilization
- avoid restraints
Psychotropic Medication can be used (use caution with these)
- only as needed basis
- Haloperidol: low doses (avoid in parkinsons and LB dementia)
- Benzos: good for alcohol abuse pt.
In normal Aging…. what remains stable or minimally changed in terms of cognition
- temperman remains stable
- routine memory, skills and knowledge stable
- ability to FUNCTION: society/workplace and home remain in tact
what is cognitive impairment
any change in which an individual has trouble remembering old information, learning new things, concentrating or making life decisions which can impact their everyday life
we break cognitive impairment diagnoses into two categories
- Mild Cognitive Impairment
- Major Cognitive Impairement (in which dementia, AD< LB, etc. all fall)
Define Minor/Mild Cognitive Impairment
symptoms to diagnosis
workup
outcomes
Mild Cognitive Impairment
Symptoms & Diagnosis
Impairment in an individuals cognition in one or more of these cognitive domains
- learning and memory
- complex attention
- exeucitve function
- language
- perceptual-motor control
- social cognition
AND
- NO SIGNS OF FUNCTIONAL IMPAIRMENT: like ADLs or iADLS (may require great effort but not deficient)
Workup
- this is common; increases with age but is NOT a normal process of aging
- MMSE and MOCA can be done to assess cognition
- neurpsychiatric testing (the cornersone) of the workup
Outcomes
- 1/3 of pt. willrevert back to original baseline
- 1/3 will stay at this level
- 1/3 will progress to worsening cognition
Major Cognitive Impairment
Major Cognitive Impairment
Diagnosis and Symptoms
- cogntive decline from previous in the areas of (1+) leraning/memory, complex attention, exeuctive function, langugae, perception/motor control & social cognition
AND
- the cognitive deficts IMPACT THE ADLS and iADLS
Criteria for dx.
- this cannot be better explained by another disorder
- this cannot exclusively occur during a setting of delirium
Dementia
sub-types
Risk Factors (the road….)
Dementia
- an umbrella term for a cluster of specific diagnoses which each include some component of memory loss, impaired judgment, personality changes and teh inability to perform daily activites
Alzheimers Disease the majority
Vasacular Dementia
Frontotemporal Dementia
Lewy Body Dementia
Risk Factors
Early on…
- less education
- hearing loss
- TBI
- hypertension, obesity
- alcohol ( > 21 a week) , smoking
- DM
- air pollution
- inactiity
- etc.
- 60% is unknown
Alzheimer’s Disease
- prevelene & onset
- pathology
- assoicated features (characteristic lost first & last)
- mediations
- life expectancy
AD : most common dementia
Prevelence
- 70% of cases
- typically > 65 y/o
- gradual, slower onset
Life expectancy
- a terminal illness; 8-10 years of slow neurological regression
Pathology
- Amyloid palques & neurofibiliary tangles
Features
- first lost: memory
- verbal fluency is preserved until the very end
Medications
- acetylcholinesterase inhibitors (first)
- NMDA-antagonists (second)
