The Two Faces of Depression: Withdrawn or Aggressive
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Transcript The Two Faces of Depression: Withdrawn or Aggressive
Mental Health Challenges that CoOccur with Dementia
Marianne Smith, PhD, RN, FAAN
Associate Professor, University of Iowa
College of Nursing
Goals for Today
List 3 mental disorders that overlap with
dementia
Discuss the role of long-standing history in
the expression of behavioral and
psychological symptoms in dementia (BPSD)
Identify key signs and symptoms of
overlapping and potentially treatable mental
disorders
Discuss the role of assessment, referral and
treatment in the treatment in BPS
But first a quick review!!
Chronic vs. Acute Confusion
CHRONIC confusion
Irreversible course; often progressive
Associated with DEMENTIA
ACUTE confusion
Reversible course; often short-term
Associated with DELIRIUM, DEPRESSION
and ANXIETY
Why we care . . .
Broad terms defy subtle but important
differences
Confusion too often equated with
dementia
“Irreversible” = “Nothing can be done”
Treatable conditions overlooked
Risk: permanent disability; loss of comfort,
function, quality of life; unnecessary
placement in more restrictive care settings
But first a brief review!!
The first step is
to identify,
assess, and treat
contributing
factors
Physical
Psychological
Environmental
Psychiatric
. . . and
Psychiatric
causes often
include
Depression
Anxiety
Delirium
Psychosis
Many factors interact!
Longstanding
traits and
habits
Level of
social
support,
activity
involvement
Environment
limits or
facilitates
Type of
dementia
Other health
problems
Changes: Name & Criteria
DSM-IV (2000)
MEMORY impairment
AND one or more of the following
Agnosia: recognition of common objects
Apraxia: ability to move
Aphasia: use of language
Disturbance in executive functioning: ability to
organize, plan, sequence, abstract
Gradual onset; impaired function
Criteria updated in DSM-5 (2013)
Neurocognitive disorders: DSM-5
Language & criteria changed
Category of dementia replaced with Major
Neurocognitive disorder (NCD)
Minor Neurocognitive disorder was added
(formerly called MCI)
Term “dementia” is retained in DSM-5; not
precluded from use in clinical practice
Point is that NCD is now preferred!
Major NCD: Criteria
Evidence of significant cognitive decline from
previous level of performance in one or more
domains:
Complex attention
Executive function
Learning and memory
Language
Perceptual motor
Social cognition
Interfere with independence in everyday
activities (IADLs)
(-) Cognitive & functional abilities (+)
Dementia: Course
Early
Confused Ambulatory
Months to years
Late
NCD due to . . .
Types
Alzheimer’s disease
HIV disease
Vascular disease
Prion disease
Frontotemporal lobar
degeneration
Lewy-Body disease
Traumatic brain
injury
Parkinson’s disease
Huntington’s disease
Substance/
medication use
Another medical
condition
Multiple etiologies
Unspecified
Non-Cognitive Symptoms
Behavioral & psychological symptoms of
dementia (BPSD) Common focus of care,
but not part of diagnosis!
Delusions, hallucinations, illusions
Anxiety, depression, apathy, paranoia
Irritability, agitation, pacing/wandering
Sleep-wake, appetite/eating disturbances
ALL considered treatable!
Two domains interact
Background/
Individual factors
Cognitive function
Physical function
Longstanding
personality
Habits, traits
Proximal/
Environmental
factors
Physical needs
Psychological needs
Social environment
Physical environment
Behavioral & Psychological
Symptoms
Personality Traits
Coping, managing,
ways of interacting
with others may be
magnified
*#!*&#@*@!!!
What’s
WRONG with
you people!?!
Blame, criticize, hard
to please?
Kind, patient, quiet?
Social, out-going, wants
to be involved?
Tendencies often persist!!
ASK: What’s going on?
Physical needs?
Pain? Infection/illness? Sensory impairment?
Psychological needs?
Loneliness, boredom? Fear, worry?
Social environmental?
Too many people, too much noise?
Too little to do? Expectation are unrealistic?
Physical environment?
Physical surroundings are not “understandable”?
Psychiatric illness?
Depression, anxiety, delirium, psychosis?
Delirium
DEMENTIA
DELIRIUM
DELIRIUM
Acute confusion Alone or overlapping
with dementia
Key Differences
DELIRIUM
Onset
Hours to days
Course
Fluctuating
Reversible Potentially
Affects
Attention
Cognitive Focal
Cause
Illness, drugs
Tx
Immediate
DEMENTIA
Months to years
Slow, progressive
Not reversible
Memory
Global
AD, vascular
Ongoing
Delirium: Criteria
Disturbance in ATTENTION and
awareness (reduced orientation to the
environment)
RAPID ONSET of symptoms representing
a change from baseline attention &
awareness
Symptoms tend to FLUCTUATE in
severity during the course of the day
Delirium: Criteria
COGNITION disturbance
Memory deficit
Disorientation
Language disturbance
Visuospatial disturbance
Perception (hallucinations, delusions,
illusions)
Consequence of medical condition, substance,
toxin, or multiple etiologies
Delirium: Fluctuating course
(-)
Symptoms (+)
De Lira = Latin for “Off the track”
Morning
Afternoon
Night
Causes: I-WATCH-DEATH
I nfections
W ithdrawal
Acute metabolic
T rama
C entral nervous
system pathology
H ypoxia
D eficiencies
E ndocrinopathies
A cute vascular
T oxins/drugs
H eavy metals
Assessment
Confusion Assessment Method (CAM)
Items reflect diagnostic criteria
Try This
Delirium Observation Scale
Checklist format preferred by UIHC nurses
Goal is to understand how to use the scale
and use it consistently!!
Try this: CAM
http://consultgerirn.org/resources
Delirium Observation Scale (DOS)
27
13 items observed each of 3 shifts: day, evening, night:
Dozes off during conversation or activities
Is easily distracted by stimuli from the environment
Maintains attention to conversation or action**
Does not finish question or answer
Gives answers that do not fit the question
Reacts slowly to instructions
Thinks he/she is somewhere else
Knows which part of the day it is **
Remembers recent events **
Is picking, disorderly, restless
Pulls IV tubes, feeding tubes, catheters etc.
Is easily or suddenly emotional (frightened, angry, irritated)
Sees/hears things which are not there
Scoring:
Never = 0 points; Sometimes or always = 1 point. ** items are reverse scored
A total score of three or more points indicate a delirium
Growing evidence for 1 question
Is the person more
confused today than
USUAL?
If Yes, then use CAM!!!
Delirium Interventions
First and Foremost . . .
Identify & treat
any reversible
UNDERLYING
CAUSES!!
Refer for assessment/treatment
Assure SAFETY
Delirium Interventions
REASSURE
Provide information to patient & family
Re-ORIENT
Gently “correct” misperceptions, misbeliefs
Provide environmental cues (e.g., calendar,
clock, other items) to help stay “on track”
Promote accurate SENSORY INPUT
Increase lighting, glasses, hearing aides
Delirium Interventions
Reduce potential MISPERCEPTIONS
Clutter, reflections, pictures
Noise, sounds that aren’t understood
TV, radio
Conversations
Increase AMBULATION
Promote HYDRATION
Depression
DEMENTIA
DEPRESSION
DEPRESSION
30% with both!
Depressive Disorder Alone or
overlapping with dementia
Key Differences
DEPRESSION
Onset
Weeks/months
Course
Persistent1
Reversible Most (80%)
Affects
Mood
Cognitive Focal
Cause
Stress, genetics
Tx
Immediate2
DEMENTIA
Months to years
Slow, progressive
Not reversible
Memory
Global
AD, vascular
Ongoing
1. Often chronic in the absence of treatment
2. May be ongoing for those with severe/recurrent episodes
Dementia & Depression
Problems that are common to both
Loss of interest in once-enjoyable activities
and hobbies
Social withdrawal
DEMENTIA
Memory problems
Sleep disturbance
Impaired concentration
DEPRESSION
(30%)
Depression
The most common
psychiatric illness for
people of all ages
Under- and misdiagnosed in older
adults
Mistaken for
“problems of aging”
Masked & misunderstood
Who wouldn’t feel that way?
Being sad is understandable –
I mean, after all…
Goodness, you have every RIGHT to be
depressed!
Often UN-recognized and UN-treated!
Major Depressive Disorder: Criteria
Two “hallmark” symptoms
Depressed mood
Sadness, discouragement, crying
“Down in the dumps” – “Blues”
OR
Loss of ability to experience pleasure
(a.k.a. anhedonia)
Withdrawal, inactivity, isolation
“Nothing is fun” – “Don’t care”
Major Depressive Disorder: Criteria
Four additional symptoms
Weight loss or gain
Sleep disturbance Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue, loss of energy
Feelings of worthlessness, inappropriate guilt
Loss of ability to think, concentrate, make
decisions [seems “confused”]
Recurrent thoughts of death, suicidal ideation
Depression “Without Sadness”
Anhedonia present, but sadness is NOT
Loss of ability to experience pleasure =
loss of interest, apathy, withdrawal,
indifference, low motivation
Additional symptoms
Physical: Sleep, appetite, energy, motor activity =
PHYSICAL ILLNESS
Psychological: Concentration, worthlessness =
CONFUSION/DEMENTIA
Often overlooked AS depression!!
Minor depression
Same 9 criteria as MDD
2 to 4 symptoms and one is hallmark
2 – 4 times more common than MDD
Associated with:
Reduced physical and social functioning
Loss of quality of life
Greater use of health services
(+)
Symptoms (-)
Depression: Course
Weeks to Months (up to 2 years)
Medical Comorbidities=Higher risk!
Stroke
Diabetes
Heart disease
Chronic pain
Parkinson’s disease
Cancer
Low vision
Osteoporosis
Source: NIMH
Depression: Contributing factors
Many factors to consider . . .
Co-morbid medical illness
Cognitive impairment / dementia
Anxiety
Pain
Social function
Physical function
Loss/change/stress
Resources & abilities
Pain is a key issue!
Depression
Increases perception of
pain symptoms
Makes pain more
difficult to treat
Pain
Increases risk of
becoming depressed
Makes depression
more difficult to treat
Bi-directional relationship is well-established!
Depression Screening Tools
Geriatric Depression
Rating Scale: 15-30
yes/no items
(Try This series)
Cornell Scale for
Depression in
Dementia: 19 items
Patient Health
Questionnaire: 9 item
OR 2-item
Patient Health Questionnaire
1.
2.
3.
4.
5.
6.
7.
8.
9.
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, feeling like a failure
Trouble concentrating on things, such as reading the
newspaper or watching television
Moving or speaking slowly, or being restless and
moving around more than usual
Thoughts that you would be better off dead or of
hurting yourself in some way
PHQ-9 Scoring
Score each item:
0=Not at all
1=Several days
2=More than half the
days
3=Nearly every day
Total each column
(0 to 3)
Add across columns
to get a total score:
0 to 27
Apply cut-points:
0 to 4 – depression is
not significant
5 to 9 – mild
depression
10 to 14 – moderate
depression; any score
over 10 is considered
clinically significant/
worthy of treatment
15 or greater – severe
depression
Depression Interventions
Behavioral/non-drug therapies
Behavioral activation
Talking therapy
Physical activity/exercise
Self-care
Anti-depressant medication
Many choices; selection based on symptoms
Support to use consistently is critical!
Behavioral Activation
Schedule pleasant events just like we do
health care appointments!
Reestablish healthy routines
Increase positive experiences
Overcome avoidance patterns
Leads to improved mood
AND better functioning
Individual, social, physical activities
Keep it simple! (failure free~!)
Physical Activity/Exercise
Do less
Feel Worse
Engaging in physical activity for 20
minutes a day, 5x each week, decreases
depression and improves health!
Self-Care in daily life
In addition to social, physical activities . . .
Nutrition/weight maintenance
Elimination
Sleep/rest patterns
Energy level
Concentration
Pain management
Antidepressant medications
Same drugs different approach
with elders
Common prescribing “rules”
Start low, go slow, but keep going until
symptoms resolve!
Select drugs based on their side-effect profile
Irritable, psychomotor agitation, insomnia drug
with sedating qualities (e.g., mirtazepine)
Fatigue, apathy, psychomotor retardation drug
with activating qualities (e.g., bupropion)
Avoid TCAs & MAOs
Promote adherence!
TO DO:
Antidepressants . . .
1. Outcomes
2. Side-effects
Do NOT work immediately
3. Education
Are NOT addicting
Will not make you “high”
or impair thinking
Need to be taken every day
May take 12 weeks to get the full benefit
Side-effects may occur & should be reported
Just another “illness treatment”
Anxiety
DEMENTIA
ANXIETY
ANXIETY
Anxiety Disorder Alone or overlapping
with dementia
Anxiety
A “normal” reaction social stress
A symptom of
psychiatric illness
physical illness
medication reactions
The PRIMARY symptom
of anxiety disorders
Generalized anxiety disorder
Phobia
Anxious depression
Like depression, anxiety causes many physical symptoms!!!
Anxiety AND . . .
Anxiety commonly
co-occurs with
Dementia
Depression
Delirium
Paranoia
Difficult to
distinguish from
physical health conditions
Anxiety Assessment
Generalized Anxiety
Disorder
Signs and symptoms overlap with dementia
Consider pre-existing issues/conditions
Anxiety one of many BPSD
Signs and symptoms are the same
Consider environment/other factors
AVOID anti-anxiety drugs!
(benzodiazepines)
Depression & Anxiety GAD-7
Over the last 2 weeks, how often have you
been bothered by the following problems?
Not at all
Several
day
Over half
the days
Nearly
every day
1. Feeling nervous, anxious, or on edge
0
1
3
3
2. Not being able to stop or control
worrying
0
1
3
3
3. Worrying too much about different
things
0
1
3
3
4. Trouble relaxing
0
1
3
3
5. Being so restless that it’s hard to sit
still
0
1
3
3
6. Becoming easily annoyed or irritable
0
1
2
3
7. Feeling afraid as if something awful
might happen
0
1
2
3
Add columns: ______+ ______+
Total:
______
_________________________
Anxiety Interventions
Staff approaches
Ask: Is worry “real” or exaggerated?
Assist with problem-solving
Distract with pleasant activities
Apply depression care interventions
Address anxiety-related problems
Engage in pleasant activities
Persisting MI
DEMENTIA
Pre-Existing
Psychiatric
illnesss
Pre-Existing
Psychiatric
illness
Pre-Existing Psychiatric illness Alone or
overlapping with dementia
Serious & Persistent MI
Diagnosis early in life
Persistent course of illness/disability
extends into later life
May confuse symptom presentation
Common goals of care
Evaluate BPSD in the context of earlier Dx
Enhance function, socialization, engagement
Select antipsychotics based on history
Summary
Lots of overlap in symptom presentation
and treatments!
Primary goals
IDENTIFY problems
Conduct ASSESSMENTS
Refer for EVALUATION & TREATMENT
Provide SUPPORTIVE care & interventions
MONITOR outcomes and start again!!!
References/Resources
Delirium Observation Scale:
http://thepracticalpsychosomaticist.com/
tag/delirium-observation-screening-scaledoss/
Try This (Hartford Institute) Series:
http://consultgerirn.org/resources
Patient Health Questionnaire:
http://www.phqscreeners.com/
[Or Google PHQ-9; many pdf files!]
References/Resources
Iowa Geriatric Education Center: Free
training on dementia, many other topics
http://www.healthcare.uiowa.edu/igec/
Hartford/Csomay Center for Geriatric
Nursing Excellence: Free training on
dementia, delirium, depression, other
topics
http://www.nursing.uiowa.edu/hartford
/geriatric-mental-health-trainingdescription