Transcript The 3 Ds of Geriatric Care

The 3 Ds of
Geriatric Care
Depression, Dementia and Delirium
Dementia
 Average delay from 1st symptom to diagnosis 2-3
years.
 Family recognition is usually how it gets diagnosed.
Caregiver complaints, high suspicion of dementia
 Post CVA (30% develop within 3 months)
 Post-delirium (30% develop within 3 years)
 Post first onset depression (30% develop within 3
years)
 Family history – every first degree relative
 Age (2% at age 65) Every five years doubles risk of
dementia
 Every vascular burden/risk factor doubles the risk
Dementia
Risk calculator
Age
 65
2%
 70
4%
 75
8%
 80
16%
 85
32%
http://www.memantine.com/image
s/disease_progression.gif
Dementia Quick Screen
 Say three words, repeat back
 1 minute to name as many 4 legged animals (20 times
odd ratio)
If Animals are low – Alzheimer’s
 List year (37 times odds ratio)
 Draw clock 10 after 11 o’clock (24 times odd ratio)
Specificity 94%
Large enough circle, joined
Numbers evenly spaced
Time correct – hand placement
 Remember and repeat the three words from the
beginning
MMSE
Gold standard
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Needed for prescribing of cholinesterase inhibitors
<26 is dementia
Not sensitive for mild cognitive impairment
Deceptive: low educational/economic status, poor
language, illiteracy, impaired vision
 Scoring:
27-30 Normal
20-26 Mild AD – Independent
(advance care planning)
10-19 Moderate AD – Supervision
<10 Severe AD - Total dependence
MoCA
 Meant to assess mild cognitive impairment
(score <26)
 Clock draw – visual spatial and executive
function
 Rhino becomes a hippo
 Lewy Bodies – attention deficit present
 Less than 11 f words –
 frontal or vascular dementia – will see inappropriate
words come up first
Peterson Criteria:
Diagnosing MCI
 Memory complaint
 Memory impairment for age and
education
 Largely intact general cognitive function
 Present ADLs – no functional loss.
 Not demented
Diagnosing AD
 Memory impairment
 Impairment in function
 One of
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Aphasia (language)
Apraxia (motor)
Agnosia (recognition, identification)
Disturbance in executive function (planning organizing)
 Significant decline from previous level of function
 Impairment in social or occupational functioning
 Gradual onset – sudden onset is delirium until proven
otherwise
 Not due to other causes.
Delirium
 Commonly under-diagnosed, particularly
in residents who have a pre-existing
dementia.
 Acute and fluctuating onset
 Medical emergency
 Confusion, disturbances in attention,
disorganized thinking and/or decline in
level of consciousness
CAM
Confusion Assessment Method – Delirium
Sensitivity 94-100%, Specificity 90-95%
20% deliriums never clear
 Acute onset and fluctuating course
 Inattention
 Disorganized thinking
 Altered level of consciousness
 Diagnoses required the presences of features
of 1 and 2 and either 3 or 4.
Meet Mrs. G.
 Pneumonia, treated 1 month ago.
 Productive cough
 Calling out, worse in evening. Staff
reports that behaviours are most
challenging between 3pm and 7pm. Staff
refer to it as “Sundowning”.
 Worries about her son, recognizes him but
no longer knows he is her son. Worried
about having to pay for being in the LTC
home.
Mrs. G.
 Lethargy – change in sleep pattern that is
worse over the last week. Sleeping more
in the morning and wakes up around
3pm.
 Recently moved to LTC from hospital (1
month). Prior to that was living at home.
 Falls in hospital and 2 at the LTC home
since admission.
PMHx
Bilateral glaucoma
Mild hearing loss
Depression & anxiety
Alzheimer’s Disease
Past history of delirium
Past history of LRIs and UTIs
Hypothyroidism
Hypotension
COPD
Graves Disease
Osteoporosis
Osteoarthritis
Past smoker (quit 5 years ago)
Left hip fracture and bilateral wrist fractures
Bilateral leg edema
Bowel resection, prone to constipation - malignant polyps
Recent Diagnostics
 TSH 14.87
From admission bloodwork drawn but not
yet reviewed.
 CXR 2 days ago is negative for active
process
Medications
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Lasix 20mg PO daily
Xalatan and Timolol gtts
L-Thyroxine 0.15mg PO daily
Celexa 40mg PO daily (recently decreased from 60mg)
Spiriva and short acting PRN bronchodilator for COPD
Seroquel 50mg PO BID at 0800 and 2000
Clonazepam 0.5mg PO at 0800 and 1200; 2mg PO at 1600 and
2mg PO once daily PRN
 Colace QHS
 Lactulose PRN
 Tylenol PRN (PO or PR)
Had tried Aricept in the past but did not tolerate it.
Neuro Ax
 Difficult to rouse, sternal rub required to rouse
Mrs. G. Speech slurred and difficult to
understand. Family states that this is new and
unusual for her. Able to converse for 3-4
minutes before falling back asleep. Able to
follow directions but shows inattention.
Bilateral grip equal. Unable to assess pupils
d/t glaucoma.
 CAM score + for delirium (Feature 1, 2 and 4
present)
Resp Ax
 RRR, 16. No wheezing. Fine bilateral
rales audible. No SOB. Congested
cough, w upper airway secretions.
Afebrile.
CV Ax
 No murmurs, HR 76, S1, S2. No
peripheral edema noted. Recent BP
readings by staff stable.
Integument Ax
 Very dry skin. Mucous membranes dry.
Bruising present to lower legs.
GU Ax
 No specific signs of UTI. Small temp
change from baseline T 37.0 (baseline
36.2).
 Chronically positive C&S
Abdominal Ax
 BS present x 4 quadrants. No rebound
tenderness noted. Resident up in W/C,
therefore not assessed fully. Voiding well
into brief. No reports of dysuria, frq,
urgency, changes in continence. T 37.0
(baseline 36.2). Recent bowel
movements have been regular and
soft/formed in consistency.
Pain Ax
 Vague self-report. Behavioural indicators of
pain in staff reports. Kyphotic in appearance.
Recent loss of mobility (past 6 months).
Family reports that she used to be on regular
Tylenol in the retirement home but this was
discontinued in hospital. Family reports that
Mrs. A would never be one to ask for help with
pain. Recent falls. No spinal x-rays taken. Is
not on Vit D or Calcium.
Impression?
Delirium co-existing w dementia and depression!
Risk Factors:
Age, CI, Hx delirium, Hx depression, sleep
disturbance, vision and hearing loss, recent
relocation, hx fractures, unrelieved pain,
hypotension, recent infection, polypharmacy,
benzodiazepine use, antidepressant use,
antipsychotic use.
Now What? What is
causing her delirium?
Differentials:
 Dehydration
 Pain
 Hypothyroidism
 Polypharmacy
Other Considerations
 High risk of fractures, affecting QOL. Spinal x-ray not
feasible for her. Recent falls and posture combined
with behaviours make vertebral fractures highly likely.
 Prob UTI at this point seems low given the non-specific
nature of her symptoms. Will always test positive – no
need to treat unless symptomatic.
 Recent CXR negative. Rales could be some residual
post-infection atalectasis.
What’s our plan?
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Increase L-Thyroxine and recheck TSH in 1
week
Discontinue PRN Tylenol
Tylenol 325mg 2 tablets (total 650mg) PO
QID x 2 weeks then reassess. She is opiate
naïve – if we want to try these go low and
slow
Encourage oral fluids.
Dietitian to assess re: fluid intake.
Vitamin D 1000iu PO daily
Taper Clonazepam slowly.
Depression vs. Dementia or
Depression with Dementia
 For the most part, these two conditions coexist.
Depression looks different in older adults.
 Feelings of guilt/worthlessness
 Hopelessness, death wishes, suicidal
 Frequent crying spells
 Resident overstates impairments
 Greater problems with attention, concentration, speed
of processing and retrieval
 Constructional apraxia, agnosia and aphasia are rare
 Usually performs well on memory tasks
Questions?