Is It Depression, Delirium, or Dementia?
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Transcript Is It Depression, Delirium, or Dementia?
Sept 13, 2016
___________
Presented by
Sally King,
MSW, LCSW,
LSCSW, RYT
200
Is it Depression, Delirium, or
Dementia?
Depression
today is the
single most
underdiagnosed
and
undertreated of
all mental
illnesses . 1 in 4
Americans will
experience an
episode of
clinical
depression in
their lifetime.
It’s costly…
In terms of overall economic burden to
our society, clinical depression is the
second most costly disease there is. The
cost, in terms of direct treatment,
unnecessary medical care, lost
productivity, and shortened life span, is
estimated at over $44 billion annually.
It’s disabling…
Currently, the World Health
Organization ranks clinical
depression as one of the leading
causes of suffering and disability
worldwide.
A Startling Statistic
Caucasian males over
65 complete
suicide 4 times more
often than any other
age group in the
U.S.
The Mental disorder older adults
most frequently suffer from….
DEPRESSION
A Reminder of What Clinical Depression is
NOT
…
Passing sadness or the blues
Normal grieving
“Reactive or Situational” Depression
A normal part of aging
A moral or character weakness
Something you can “snap out of”
Major Depressive Disorder
(Must have 5 of these every day for 2 wks
or more.)
Depressed Mood (rarely admitted)
• Anhedonia (inability to experience joy)
• Weight changes (usually loss)
• Insomnia or hypersomnia
• Noticeable restlessness or noticeable
slowness of movement
• Fatigue or loss of energy
Criteria for Depression cont’d
Feelings of worthlessness (“nothing I do
matters anymore.”
Inappropriate guilt (rarely seen in seniors)
Diminished ability to think or concentrate
(pseudo-dementia)
Recurrent thoughts of death or suicidal
ideations, attempt or plan (not including
fear of dying or thinking about mortality
as a result of growing older).
---- DSM IV
Self Administered
and Good for
Community use:
•Geriatric Depression
Scale
•PHQ-9
Clinician
Administered/PCP
setting
•HaM-D
Cornell Scale for
Depression in
Dementia (CSDD)
Good Assessment tools
How to refer
Do the GDS if worried about safety to self or others.
Worried? Alert your supervisor or other mental
health professional.
Excellent resource for suicide-related screening tools
and education put out by the National Institute of
Mental Health:
www.endingsuicide.com
Remember, if client is having sudden mental or
mood status change, always rule out physical issues
first!
Why
Depression
Occurs
Areas in the brain
responsible for
regulation of
moods, thinking,
sleep, appetite,
and behavior fail
to function
properly and are
off-balance.
There are both
genetic AND
environmental
causes.
Comorbidity of Depression
Numerous
physical
conditions
can cause
depression in
adults and in
the elderly
Why it Gets Missed - How Depression
Differs in Seniors
Increased physical complaints often indicates
subsyndromal depression
More confusion and clouded thinking
Functional decline
Overlaps with medical issues such as diabetes, cancer, etc.
Agitation and irritability common
Behavioral regression
Psychotic features in 30%
May be early sign of dementia
Med side effects may be more pronounced
Depression with Psychosis
Fairly Common
40% of admits to geropsychiatric units
Get history of symptom development
Includes 1 or more:
*
*
*
Hallucinations
Delusions
Paranoia
Counseling
Successful if
motivated & early
stages of dementia
Best results with
medications
Patient education is
goal – working on loss
of autonomy, dignity,
etc.
Effective Therapeutic Techniques
Cognitive Behavioral Therapy/CBT
Problem Solving Therapy/PST
Interpersonal therapy/IPT
Support/self-help groups
Medication Treatment
Avoiding Relapse a major
goal
Newer classes have fewer
negative side-effects
Start dose low and go slow,
BUT GO.
Final dose may be as high as
younger
Avoid polypharmacy
Which is better for older adults? Meds or therapy or
both?
Studies say older adults do just as well as any
other population group when utilizing Cognitive
Behavioral Therapy – Combating stinkin’
thinkin’ !
SSRI and SNRIs do fairly well with this
population, SNRI’s especially if
energy/motivation is a problem.
BEST CLINICAL RESULTS= combo of
CBT+meds.
What also helps – support, continuity of roles,
sometimes 8-10 sessions of ECT for treatment
resistant cases.
“The Depression
Cure”
Dr. Stephen
Ilardi, KU
Psychologist
and Depression
Researcher
One wellness approach for depression….
TLC – Therapeutic Lifestyle Change for
Depression
Antidepressant Elements
of the Ancestral Environment
(Ilardi, 2009)
•EXERCISE
•LIGHT EXPOSURE
•SOCIAL SUPPORT
•SLEEP HYGIENE
•DIET
•BEHAVIORAL ACTIVATION
Social Networks
Social
Relationships
Linked to Improved
Survival (Lunstad,
2010)
UCLA Study on
Friendship in
Women and
Oxytocin (Klein,
3002)
Resiliency
One of the Keys to Resiliency in
your Older Adult Clients?
COPING SKILLS
Understanding Dementia and Behavior
Two
types of Alzheimer’s
EarlyLate-
onset- before age 65
onset- after age 65
What goes wrong in the AD brain
AD brain = smaller
overall
ventricles enlarge
cortex (blue) shrivels,
especially near
hippocampus
Understanding Dementia and Behavior
What about brain anatomy?
In the temporal lobe is the hippocampus, which is
believed to be where short-term memories are converted
to long-term memories.
In Alzheimer’s patients, this area of the brain is often
atrophied, and this area, along with other parts of the
brain which involve thinking and making decisions are
also filled with two types of abnormalities:
Beta-amyloid plaques
Neurofibrillary tangles
Understanding Dementia and Behavior
Things we take for granted:
Assessment skills
Ability to manage our environment
Stress management
Nutrition and hydration
Need for personal space/ alone time.
Ability to structure our time, activities and work.
10 Warning Signs
Difficulty with familiar
tasks
Slipping job performance
Language difficulties
Confusion of place &
time
Lack of Judgment
Problems with abstract
thinking
Misplacing objects
Mood fluctuations
Changes in personality
Lack of initiative
Overall Decline
Average life span 9 years
Declines to total care
No cure and so far, no known single cause
Treatments are around preventing decline in
acetylcholine by blocking the enzyme that breaks it
down
We have made more advances in HIV/AIDs than
Alzheimers
Other Causes of Dementia
Strokes
Parkinson’s Disease
Multiple Sclerosis
Tertiary syphilis
Heavy metal toxicity
Undiagnosed diabetes
Of over 100 causes worldwide Alzheimer’s is 70%
of all cases
Delirium
Symptoms for Delirium
Sudden onset – hours to days
Fluctuating level of consciousness over course of
24 hours
More confused and less alert
Can see & hear things that are not real
Always caused by something physical:
Infection, dehydration, pain, medication toxicity,
constipation, etc.
25% fatal if underlying caused not treated
Causes to consider . . .
Infections, sepsis
Medications, street drugs (including withdrawal)
Hypoxemia – Inadequate Oxygen in blood
Metabolic Issues
. . . Causes to consider
Vitamin deficiencies
Fecal impaction, urinary retention
Renal, Acute liver failure
Changes in environment
Miscellaneous Deliriums
Hypothyroidism
B12 & folate deficiency
Undiagnosed diabetes
Heavy metal toxicity
Neurosyphilis
Sub-dural hematomas
Drug toxicity ~ particularly inhalants
Psychosis
Seeing, hearing or believing things that are not true
Schizophrenia ~ never starts in old age
Bipolar Disease ~ never starts in old age
Dementia ~ common cause
Depression ~ common cause
Delirium ~ very common cause
Stroke ~ common immediately following
Some medications
Auditory & Visual Hallucinations
Can be faint sound or vision like a shadow or a
television talking in the background
OR…
Can be as real a sight or sound as you and I see and
hear
Voices can be telling them things that they believe
We cannot talk them out of these
Delusions
Fixed false belief
Easily confused with dementia when only long term
memory remains. An example of this would be, “I
have to go home now my mother is waiting for me.”
Delusions often associated with paranoia: the CIA is
outside watching us, etc.
Schizophrenia
Begins in late teens or early twenties with
first psychotic break
Life long illness
Not completely understood, but probably an
excess of dopamine
Lack of dopamine is cause of Parkinson’s Disease
Therefore, high doses of Sinemet can cause
psychosis
Medications used to treat schizophrenia can
cause Parkinsonism – tremors, shuffling gait,
drooling
When working with Older Adults,
Remember
“Resistant and uncooperative” may be anxiety
related to poor sight, hearing, speech, language,
incontinence, or medication management impacting
how an older person communicates.
Keep in mind when scheduling appointments Reaction time and speed, Time of day, Weather,
Adaptive equipment.
References
Agronin, Marc, MD, How We Age: A Doctor’s Journey Into the Heart of Growing Old, 1st edition. (Cambridge: Da Capo
Press, 2011).
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (text revision).
Washington, DC; Author.
Bonanno, George A, The Other Side of Sadness, 1st edition. (Basic Books, 2009).
Halpain, Maureen C.et al. (1999). Training in Geriatric Mental Health: Needs and Strategies. Psychiatric Services. 50:9,
1205-1208.
Ilardi, Stephen, PhD., “The Depression Cure.” Da Capo Press: Cambridge: 2009.
Jacobson, S. (1995). Overselling depression to the old folks. The Atlantic Monthly, April, 46-51.
Klein, Laura Cousin, PhD. “UCLA Study on Friendship Among Women.” 2002.
Lamberg L: "Treating Depression in Medical Conditions May Improve Quality of Life." JAMA 1996; 276(Dec. 18):857858.
Linehan, M. M. (1993). Skills Training Manual For Treatment of Borderline Personality Disorder. New York Guilford
Press.
Lunstad, Julianne Holt et al, “Social Relationships Are linked to Improved Survival.” PLoS Medicine, July 2010.
National Institute of Mental Health, "Co-occurrence of Depression with Heart Disease," Accessed July 1999. Netscape:
http.7/www.nimh.nih.gov/depression/co_occur/heart.htm.
National Institute of Mental Health, "Co-occurrence of Depression with Cancer," Accessed July 1999. Netscape:
http://www.nimh.nih.gov/depression/co_occur/cancer.htm.
Stroebe, Margaret, and Henk Schut. "The Dual Process Model of Coping with Bereavement: Rationale and Description."
Death Studies 23 (1999):197–224.
Warden, William J, Grief Counseling and Grief Therapy, 4th edition (New York: Springer Publishing Company, 2009).
Sally King, MSW, LCSW, LSCSW
816-226-8211
[email protected]
www.sallykingconsulting.com