Depression, Dementia, Delirium

1
Depression, Dementia, Delirium

• A nursing primer on how to approach cognitively
  compromised patients.

2
Depression Defined

• Depression is a common mental disorder that
  presents with unusual or extreme changes in mood,
  loss of interest or pleasure, feelings of guilt
  or low self-worth, disturbed sleep or appetite,
  low energy, and poor concentration.

3
Depression Defined

• These problems can become chronic or recurrent
  and lead to substantial impairments in an
  individual's ability to manage their social,
  financial, employment, and relationship needs.
• At its worst, depression can lead to suicide

4
Causes and Risk Factors

• Genetics and Family Hx
• Predisposition vs Family environment Doesnt
  matter.
• Traumatic life events
• Drug Abuse
• Certain medications
• Major life change
• Stress and conflict
• Serious illness

5
Depression Treatments

• -Pharmocological Psychoactive Meds
• Depression rarely occurs alone. Depressive ssx
  can often be part of a much larger, complex
  psychiatric picture. In many cases patients will
  be placed on several medications to treat and
  alleviate several selected symptoms. Such as
• Trazadone or Ambien for sleep
• Zoloft for depressed mood
• Risperdal for psychosis
• Xanax for anxiety-related discomfort.

6
Depression Treatments

• Psychotherapy and counseling
• Cognitive Behavioral Therapy (CBT) is often used
  to assist patients in managing their depressive
  ssx.
• This approach works to help the patient
  understand how their depressive/distorted thought
  processes lead to the behavioral outcomes.
• Treatment of symptoms to relieve crisis
• Assist in diet changes
• Assist in increasing activity
• Help patient improve sleep hygiene

7
Sleep Hygiene

• Sleep Hygiene
• Timing of sleep
• Comfort level during sleep
• Use of stimulants/depressants
• Activity level during the day
• Visual and auditory stimulation prior to bed
  time.
• Quality of diet prior to sleep

8
Dementia Defined

• Dementia is a progressive decline in memory and
  at least one other cognitive area in an alert
  person.  These cognitive areas include attention,
  orientation, judgment, abstract thinking and
  personality. 

9
Causes and Risk Factors

• Age
• Genetics
• Downs Syndrome
• Head injury
• Fewer years of education
• Female

10
Age as a factor

• Dementia is rare in under 50 years of age and the
  incidence increases with age 8 in gt65 and 30
  in gt85 years of age.

11
Genetics as a factor

• Genetics Early onset of mutations in chromosome
  1, 14, and 21
• Late onset of mutations in chromosome 19    
  -apolipoprotein E gen (APOE 2, 3, and 4)     4/4
  greatest risk (3 of population)     3/4 next
  risk (20 of population)    

12
Disease Processes

• Dementia results from brain damage.  The causes
  include the following
• Alzheimers Disease
• Stroke
• Picks disease
• Huntingtons
• Downs Syndrome
• Creutzfeldt-Jacob
• AIDS
• alcoholism
• Parkinsons disease
• other neurodegenerations.

13
Diagnosis

• DiagnosisThere are three purposes why diagnosing
  dementia is essential. 
• 1. By determining the probable cause, treatable
  disorders can be identified, such as medication
  toxicity (benzos, H2 blockers and
  anticholinergics), and thyroid disease.

14
Diagnosis

• There are symptoms and comorbidities that are
  treatable, such as depression, delirium,
  delusions, hallucinations, and agitation.
• Caregivers must be identified and environmental
  issues taken into consideration.

15
Criteria

• A diagnosis of dementia is based onmemory loss
  - both in short and long-term, plus one or more
  of the following
• aphasia language problems
• apraxia organizational problems
• agnosia unable to recognize objects or tell
  their purpose
• disturbed executive function personality and
  inhibition

16
Treatment

• There are both pharmacologic and
  non-pharmacologic interventions that may be
  beneficial for patients with dementia.
• Non-pharmacologic Interventions 
• Social activities
• Adequate sleep
• Adherence to a strict schedule
• Maintenance of a proper stimulation level
• Adequate hydration
• Reformatting task (occupation therapy)
• Support caregivers

17
Treatment

• Pharmacologic Interventions (course is typically
  10 years, but 2-20 possible)
• Prevention       Vitamin E, and cognitive
  stimulation such as education
• Memory/attention
• Acetylcholinesterase Inhibitors       Tacrine  
       Donepezil hydrochloride       Rivastigmine
  tartrate       Galantamine hydrochloride
• NMDA antagonists       Memantine       Others
  (Ginkgo biloba, caffeine, nicotine,
  methylphenidate, NSAIDs)

18
Treatment

• Memory/attention
• Acetylcholinesterase Inhibitors       Tacrine  
       Donepezil hydrochloride       Rivastigmine
  tartrate       Galantamine hydrochloride
• NMDA antagonists       Memantine       Others
  (Ginkgo biloba, caffeine, nicotine,
  methylphenidate, NSAIDs)

19
Treatment

• Behavioral
• Antipsychotics Risperdal, Zyprexa
• Antidepressants Zoloft, Celexa
• Mood Stabilizers Seroquel, Geodon

20
Dementia vs Delirium

• In order to make a diagnosis of Dementia,
  Delirium must be ruled out.  However, patients
  with dementia are at increased risk of delirium
  and may have both.  Delirium is an acute disorder
  of attention and global cognition (memory and
  perception) and is treatable. 

21
Delerium

• The diagnosis is missed in more than 50 of
  cases. 
• The risk factors for delirium include age,
  pre-existing brain disease, and medications. 

22
Causes

• There are many causes, the most common are
•    D   Dementia   E   Electrolyte disorders  
  L   Lung, liver, heart, kidney, brain   I   
  Infection   R   Rx Drugs   I    Injury, Pain,
  Stress   U   Unfamiliar enviroment   M  
  Metobolic

23
Prevention

• Prevention of delirium includes
• avoidance of psychoactive drugs
• quiet environment
• daytime activity
• dark and quiet at night
• visual and hearing assistive devices
• orientation devices
• avoidance of restraints

24
Diagnosis

• Diagnosis of delirium is based on clinical
  observation no diagnostic tests are available. 
  The essential features of delirium include
• Acute onset (hours/days) and a fluctuating course
  
• Inattention or distraction
• Disorganized thinking or a altered level of
  consciousness

25
Treatment

• Treatment of delirium, like dementia, is managed
  both pharmacologically and non-pharmacologically.

26
Treatment

• Non-pharmacologic management
• Optimize environment
• Personal belonging photographs
• Quiet
• Sitter

27
Treatment

• Pharmacologic management
• Neuroleptics may be needed if the patient is
  having distressing hallucinations/delusions
  or   the patient is very agitated
• High potency with low anti-cholinergic activity
• Low dose
• Haloperidol or risperdone
• Benzodiazepine if delirium is secondary to benzo
  or alcohol withdrawal

28
Managing the depressed patient

• It can be very distressing to have a patient with
  depression.
• They often have needs that cannot be met.
• They do not fix.
• Cognitive/mood difficulties respond slowly, at
  best, to interventions.
• They often act irrationally and difficult to
  redirect.

29
Managing the depressed patient

• Embrace your complete lack of control over this
  persons mood.
• These kind of patients remind us that we cannot
  save the world. We are human. Much of their
  progress will depend on their own motivation and
  inner fortitude. Inner strength and insight do
  not come in pill form.

30
Managing the depressed patient

• Do not overestimate your effect on the patient.
• A single misstep in a conversation will not
  trigger a suicidal act. Today is one many days
  that the patient has endured these feelings.
  Being overcautious can make the patient feel more
  alienated.

31
Managing the depressed patient

• Be OK with not talking about it.
• The patient may have no motivation to talk about
  it. Give them the space they need.
• Take care of their physical needs and enlist the
  proper trained professional to handle mental
  health needs.

32
Managing the depressed patient

• Depression cannot be argued with.
• Its not a completely rational experience.
• Sufferers often make irrational/non-logical
  statements. Do not argue the point unless it
  deals with a physical/medical need. This is not
  a battle you will win.

33
Managing the depressed patient

• Suicidality is a symptom, not a discussion.
• Do not attempt to address suicide triggers with a
  patient. Ask for help from Canyon View.
• Do not list all of the wonderful things that the
  patient has to live for. Shaming a patient
  simply strengthens their feelings of low
  self-worth.
• Be an active listener.
• If you are feeling some judgment toward the
  patient, trade patients or get over it.

34
Managing Altered Cognition

• Be content to simply make the patient as
  comfortable as possible.
• In the end, thats all you really can do.

35
Managing Altered Cognition

• Stay in the present.
• With cognitive impairment, patients struggle to
  maintain memory and linear thought processes.
• Stick with what the patient can internalize right
  now, in the room, with their five senses.
• Do not assume that memory is intact.

36
Managing Altered Cognition

• Stick with what they can sense
• Use concrete references.
• Avoid referring to persons not in the room.
• Avoid referencing yesterdays conversations.
• Future and other time concepts may not be
  usable.
• Do not expect the patient to think abstractly.

37
Managing Altered Cognition

• Watch for patterns
• Watch for and share and patterns that you see the
  patient engage in with your staff.
• Routines allow cognitively impaired patients to
  feel more calm.
• If you come across triggers for anxiety or
  acting-out, share them with your staff.

38
Managing Altered Cognition

• Approach with caution
• If a patient has impaired cognitive function,
  their decision-making process is faulty.
• They may act aggressively without warning.
• If they are responding to internal stimuli, make
  certain that you have their attention prior to
  making physical contact. Require a head nod or
  verbal confirmation that they see you, before
  approaching.

39
Managing Altered Cognition

• Keep the noise down
• Reduce stimuli to a bare minimum where possible.
• Speak in a low, calm voice.
• Do not use dramatic body movements.
• Police the noise level outside the patients room

40
Managing Altered Cognition

• Paranoia can occur
• Many patients with this disorder can become
  paranoid.
• Avoid this by not giving report right outside the
  patients room.
• Everyone who enters the patients room should
  identify themselves.
• Avoid giving the patient a reason to worry.

41
Wrapping up

• Know your limits.
• Do what you can and move on.
• Dont personalize it. The patients mental state
  exists regardless of you.
• Dont get sucked in. Maintain a professional
  distance.
• Remember your training. You are not a counselor
  or a therapist. No one expects you to be.