Geriatric & Palliative Medicine 2009-2010
Department of Geriatric Medicine, JABSOM, University of Hawai’i
Updated 6/24/09
Facilitator’s NotesSession 9
THE 3 D’S
Session Length:
20 / Supplemental
Teaching Materials:
3D’s Worksheet / Preliminary Notes:
Slide # / Notes / Facilitator Comments
2 / This objective of this session is to review the definitions of Dementia, Depression, and Delirium.
To understand in what ways these cognitive disorders are similar
And to understand which features help define or distinguish them from the other.
3 / To start of, lets review the basic definitions of these disorders. Read slide 3.
Dementia- cognitive decline due to brain disease.
Delirium- acute change in ms
Depression- change in mood with feelings of worthlessness.
4 / Its all very nice and good to talk about Dementia, Depression, and Delirium as separate topics- But the reality is—oftentimes symptoms and presentation of disease do overlap. They look very similar. And we are left to wonder what’s really going on here?….
CLICK—to get RED center. Its this RED part—that can be confusing: the common presenting signs and symptoms.
5 / To illustrate this point, I’ll give you a common scenario:
What if we have 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, with fall and hip fracture 2 weeks ago, now not eating well, tired and sleeps all day, restless at night, and not participating well in rehab…and if she keeps this up and doesn’t succeed in walking, she will likely need to be placed in a NH. And of course, there’s the son…
Draw 3 overlapping circles on the board. Draw an arrow to the center area.
Ask a student to come up to the board:
Ask: “Lets read through this case and see if we can find those common overlap signs and symptoms.” Refer to slide 6 for answers.
Answers:
Apathy, withdrawal
Anorexia / wt loss
Impaired cognition, attention
Cognitive and Functional Decline
Disturbed sleep wake cycle
Thank you…. You may sit down.
Slide # / Notes / Facilitator Comments
6-7 / n What are the distinguishing features that will help us differentiate the three and guide our history taking?
· To help us out. Lets fill out the following table. HAND OUT 3 D’s WORKSHEET.
> Show slide 7 (the case) while filling out the table.
Say: “As we fill this table out, I am going to encourage you to ask questions about the patient that might help clarify for you what is going on.” See below:
Ask:
Ø What is the distinguishing feature of delirium? Answer: fluctuating LOC
o Time course? Acute!
o Other features? Inattention. Hallucinations, agitation
Ø What is the distinguishing feature of dementia? Answer: memory impairment
o Time course? Chronic, slow, progressive? Stepwise?
o Other features? Disorientation. Agitation
Ø What is the distinguishing feature of depression? Ans: sadness, loss of interest
o Single episode? recurrent? Chronic?
o Other features? Concentration, hopelessness
COMPLETED 3 D’s WORKSHEET:
Fill in the WORKSHEET: Distinguishing Between Delirium, Dementia, Depression
Distinguishing Feature / Associated Sx / Course
Delirium / Fluct levels of consciousness / Disorientations, hallucination, apathy, withdrawal, impaired memory and attention,
Disturbed sleep cycle / Acute, remit with correction of underlying condition
Dementia / Memory impairment / Disorientation, agitation,
Disturbed sleep cycle / Chronic, slow, progressive
Depression / Sadness, loss of interest / Disturb sleep, appetite, concentration, energy, feelings of hopelessness, worthlessness, thoughts of suicide / Single episode or recurrent episodes, chronic
Slide # / Notes / Facilitator Comments
8 / Where are you going to get the history that will help clarify this? Answer: Need To talk to the family, nurses, anyone who interacts with her.
OK, pretend I’m the son—what are you going to ask me? What parts of the history are you interested in keying in on?
- ASK SON: What was she like before she came to the hospital?
o What kinds of things did she do? How did she spend her time? Eating? Memory? Sleep?
o What is she like in the hospital that is different?
-ASK NURSE: any agitated behaviors? Does she follow directions? Does she sleep at night? Is she asleep most of the day?
[ NOTE: If they ask about her other meds or PMH—tell them to hold the thought, we’ll get to it after we finish the table.]
Delirium: THE ACUTE HISTORY.
The patient has fluctuating levels of consciousness, difficulty with attention, and is noted by son that she is confusing him for her deceased husband, and picks in the air sometimes. The nurses notes say she is restless all night, and is place in the hallway by the nurses station. otherwise they’d have to restrain her to prevent her from pulling out her IV and foley, or climbing out of bed. This is all new, since her surgery. Only new meds is Tylenol. [She definitely has delirium!]
9 / Dementia: THE CHRONIC, PROGRESSIVE HISTORY. patient has memory impairment, and son has noted that she has been more and more forgetful in the past year, but not this bad! Her baseline before the surgery was that she was independent in all ADLs , including bathing. But dependent on her son for finances, shopping, and transportation. (She never did these things when her husband was alive anyway). Still was able to use the telephone, take her medications, and cook some basic meals for her son –although admittedly now less elaborate, and less frequently. She has been complaining of fatigue so actually, now hardly does any housework, either. She spends much of her day in bed taking naps or on the couch resting while watching TV. Doesn’t leave house. [She may or may not have a history of dementia- the story for memory impairment is not strong, deficits more dependent on fatigue affecting her function]
Her MMSE demonstrates 2/5 in orientation to location, 0/5 for date, 1/3 registration, difficulty with subtracting serial 7’s (0/5), and difficulty with spelling “WORLD” backwards (3/5). =poor attention, naming intact, Short-term memory 0/3, unable to follow 3 step command (1/3), able to read and obey, able to write 3 word sentence, unable to copy pentagons. SCORE=11/30
Clock Drawing: circle ok, numbers start at 1 and go around to 10. no hands.
Slide # / Notes / Facilitator Comments
10 / Depression: EPISODIC FLARES. Patient has a PMH of depression in the past and had been on antidepressants intermittently throughout her life. She has been on Zoloft 75mg po daily since the death of her husband. She has longstanding problems with insomnia and takes Ativan 2 mg at bedtime maybe 3x per week. Often awakens at 4am, unable to go back to sleep. Her appetite has been fair to poor in the past year. No longer reads books like she used to, saying its “hard to concentrate”. She has feelings of despair, and thinks about dying, but is not actively suicidal. No alcohol use. GDS score 7/15
11 / Discuss PMH
· h/o depression is impt
· insomnia may lead to fatigue
· arthritis may lead to deconditioning
Discuss Meds
· Note Ativan- can contribute to withdrawal or depression/fatigue
· Note new med is Tylenol at pretty toxic doses for elderly, also consider pain as factor for delirium, no opioids here, should there be?
· Celebrex-may contribute to dyspepsia/ anorexiam, HTN, CNS sedation?
12 / Does this physical exam help us? What’s missing?
13 / MMSE- Please emphasize that the final score is not as helpful as knowing where the deficit is.
14 / Clock drawing Task: showing 10 min after 11. (numbers wrong, no hands)
15 / Ask: What is your differential diagnosis?
Ans: Delirium with Depression…dementia not as likely.
Briefly review delirium and anorexia work-up:
*Rule out medical illness!!
- check TSH, vit B12, folate, rule out withdrawal from Etoh or bzd
-rule out GI problems as cause for anorexia (gastritis, ulcers, nausea, constipation)
-rule out dental pbm, diff preparing or getting foods—as source of wt loss.
*Rule out Drug effect!!
- Zoloft- activating? No recent changes. Ativan- excessive sedation, celebrex- may have some CNS side effects (dyspepsia, htn, somnolence).
CLICK…to get second part of Slide 15.
What should we tell the son about what we are doing about it?
Her poor performance cog and physical are likely due to both Delirium with and Depression. We can work-up for dementia once dust settles. Maybe if mild only MCI.
Slide # / Notes / Facilitator Comments
15
cont’d / And don’t forget that depression can present as psychosis=Psychotic depression…it has fooled many a practitioner! But the surrounding circumstances and time course don’t fit.
Tell him we will check her labs- rule out anemia, infection, electrolyte abnl, liver failure, renal failure, thyroid, Vitamin deficiencies…
Treat underlying medical conditions. Step-wise approach.
Non-pharmacologic: one-to-one, frequent reorientation, OOB to chair and bright lights in daytime, d/c foley, no restraints, heplock IV. Start ensure supplements BID.
Pharmacologic:
d/c Zoloft and ativan, switch to remeron 7.5mg qhs and titrate up in 1 week.
Can try seroquel 50 mg qhs and haldol 0.5 mg q4h prn
(Note: Seroquel is an 8hr drug, esp for day-night reversal, and if you want her to sleep better at night and get out of the hallway, and then be awake in the day. ideal if night is disruptive but daytime is not. Use risperdal or zyprexa if long acting drug needed. Haldol is for breakthrough agitation)
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9 THE 3 D’S
Geriatric & Palliative Medicine 2009-2010
Department of Geriatric Medicine, JABSOM, University of Hawai’i
Updated 6/24/09
3D’s Worksheet. Distinguishing Between Delirium, Dementia, Depression
DISTINGUISHING FEATURE / ASSOCIATED SYMPTOMS / TIME COURSEDELIRIUM
DEMENTIA
DEPRESSION
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9 THE 3 D’S