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...assessment is everything!
Many conditions share symptoms in common Stereotyping of the older person can lead to incorrect assumptions regarding presentation/condition Reduced ability of the unwell client to communicate what is wrong can impede assessment An immediate, thorough, longitudinal patient history and mental state examination minimises the risk of misdiagnosis
kerry.miller@avondale.edu.au Created 2011

SameSame-same but different!

...assessment is everything!
Information must be sought from the client and a variety of other sources, whilst considering the issues of consent and privacy Begin with the client alone, where possible (?why)
Family and carers, other health workers (doctors, nurses, ambulance officers), medical and other health records, pharmacists, neighbours, Police and other community organisations (ie Meals on Wheels, community transport) can all be helpful sources of information.

...assessment is everything!
Presentation and History are both part of the picture, with presentation being the point of first response. If presentation and history dont match up, further investigation will be urgently required Physical investigations should always be undertaken to rule out organic causes (ie trauma, infection, dehydration, poisoning, heart attack, stroke etc) even if history matches presentation Physical observations provide a perfect opportunity to engage and create rapport with a client, whilst ascertaining their level of orientation and cooperation
kerry.miller@avondale.edu.au Created 2011

Document all information as part of the assessment

kerry.miller@avondale.edu.au Created 2011

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Delirium
An organic, acute and relatively sudden decline in focus and attention, perception and cognition Can be life-threatening and should be viewed as an emergency Most common acute disorder of adults in hospital Changed cognition (memory deficit, disorientation, altered language skills) and development of perceptual disturbances must not be due to evolving dementia rapid (delirium) versus gradual (dementia) development of symptoms over time helps to differentiate between the two
kerry.miller@avondale.edu.au Created 2011

Delirium
Causes may include: Infection (such as respiratory or urinary tract) Anaesthesia/surgery Medication toxicity and/or side effects Allergic response Brain injury Withdrawal from substances Poisoning/intoxication Electrolyte or other body chemistry changes

kerry.miller@avondale.edu.au Created 2011

Delirium
Onset Progression Duration Alertness Orientation Memory Cognition Perception Sleep Acute/subacute; Depends on cause Abrupt Hours to 1 Month (seldom longer) Fluctuates: Lethargic - Hypervigilant Fluctuates based on severity. Generally impaired Recent AND Immediate memory impaired Disorganised, slow, distorted, fragmented, or accelerated, incoherent Distorted. Illusions and delusions and hallucinations. Difficulty distinguishing real and imagined Nocturnal confusion. twilight syndrome or sundowners

kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

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Dementia
Is an acquired organic progressive decline in cognitive function Describes a set of symptoms that may have multiple causes Is not a disease May or may not be reversible, based on cause Remember that a diagnosis of dementia does NOT rule out delirium (and/or depression)!

Dementia
Affects areas of brain function including memory, attention, language and problem solving, with higher functions affected first ie complex problem solving Disorientation to time, place and person evident in later stages behavioural and psychological Sx include psychosis, depression and anxiety, agitation, aggression and disinhibition in the later stages It is very easy to stop looking for a reason for an older persons presentation once a diagnosis of dementia has been given. This doesnt allow for co-morbidity, and can represent a missed opportunity to prevent re-presentation to care
kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

Dementia
Alzheimers Disease is the leading cause of progressive dementia Vascular dementia is caused by interruption of blood supply to the brain (such as in stroke or frequent TIAs, and associated with cardiovascular disease) Other diseases such as Wernicke-Korsakoff Syndrome, Huntingtons Chorea, Picks Disease and Creutzfeldt-Jakob Disease may also contribute to developing dementia

Dementia
Onset Progression Duration Alertness Orientation Memory Cognition Perception Sleep Chronic, insidious; Depends on cause Slow but even Months to years Generally normal May be impaired, especially in later stages Recent & Remote memory impaired Difficulty with abstraction, impoverished thought stream, poor judgement, searching for words May be absent or altered (misperception) Often disturbed. Nocturnal confusion and wandering

kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

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Depression and Anxiety

Depression is one of the most common of all mental health problems. One in five people experience depression at some stage of their lives. Anxiety is often overlooked, especially in older people. While everyone feels anxious from time to time, some people experience these feelings so often and/or so strongly that it can affect their everyday lives. These two issues are now considered to be part of the same disorder, with most people showing stronger symptoms of one or the other
www.beyondblue.org.au
kerry.miller@avondale.edu.au Created 2011

Depression and the older person

Older people tend to under-report depressive symptoms, which may lead to misdiagnosis Physical illness, chronic pain and mobility problems, visual and auditory decline (causing isolation and fear), social changes and grief and loss can all be the cause of, or result in, depression. Alcohol and other drug misuse can contribute to symptoms, mask symptoms, or prevent the person from seeking help. Why? Consider the range of physical, social, and emotional changes faced by an older person moving from independence in to care. How do you feel about ageing?
kerry.miller@avondale.edu.au Created 2011

Depression and the older person

Onset Progression Duration Alertness Orientation Memory Cognition Perception Sleep Often abrupt, coinciding with life changes Variable, uneven At least two weeks, but can last for months or even years Minimal impairment. Distractible Selective disorientation Selective or patchy impairment Intact. Hopeless/Helpless themes and self-depreciation Intact. Delusions and hallucinations only in severe cases Early morning awakening. May sleep less or more than usual

kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

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Alcohol and the older person

Community perception is that older people have less alcoholand other substance-related problems, but this is not true Ageing populations worldwide mean the total number of older people with alcohol- and other substance-related problems is on the rise Screening tools for alcohol dependence and/or abuse may not adequately assess older people, and are less likely to be used by clinicians Why?

Alcohol and the older person

Symptoms of alcohol intoxication are very similar to delirium of other sorts. Misdiagnosis can work both ways be careful not to jump to conclusions! Long-term alcohol abuse can cause alcoholic dementia, lead to depression, and permanently impact cognitive function Many contemporary studies suggest alcohol (wine) consumption may provide some protective factors consider these in a comparative lifestyle framework!

kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

Suicide and the older person

Australian research shows that for older men, the rate of suicide increases as age increases
Men (2008) Suicides per 100,000 65-74 years old 17.3 Over 75 years old 21.3

Suicide and the older person

Risk factors for suicide are similar across all ages and genders Loss and grief (widowhood, death of peers) A sense of loss of purpose (retirement can trigger) Hopeless and helpless themes Isolation Depression Acute and Chronic health problems/pain/disability

There is often less warning, higher lethality, less history of previous attempts, and a greater prevalence of physical illness and depression. Older people are less likely to contact mental health services for help. Why? Consider changing attitudes to psychiatric illness and treatment.
kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

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Summary
Delirium, Dementia and Depression share many similar symptoms Differentiating between the three through comprehensive assessment will reduce the risk of delayed, inadequate, or inappropriate treatment It is possible for one person to have one, two, or all of these conditions at the same time, and require appropriate treatment for each

Compare
Delirium
Onset Progression Duration Alertness Orientation Memory Cognition
Acute/subacute; Depends on cause Abrupt Hours to 1 Month (seldom longer) Fluctuates: Lethargic - Hypervigilant Fluctuates based on severity Generally impaired Recent AND Immediate memory impaired Disorganised, slow, distorted, fragmented, or accelerated, incoherent Distorted. Illusions and delusions and hallucinations. Difficulty distinguishing real and imagined Nocturnal confusion. twilight syndrome or sundowners

Dementia
Chronic, insidious; Depends on cause Slow but even Months to years Generally normal May be impaired, especially in later stages Recent & Remote memory impaired Difficulty with abstraction, impoverished thought stream, poor judgement, searching for words May be absent or altered (misperception) Often disturbed. Nocturnal confusion and wandering

Depression
Often abrupt, coinciding with life changes Variable, uneven At least two weeks, but can last for months or even years Minimal impairment Distractible Selective disorientation Selective or patchy impairment Intact. Hopeless/Helpless themes and self-depreciation

Perception Sleep

Intact. Delusions and hallucinations only in severe cases Early morning awakening May sleep less or more than usual

http://dementia.uow.edu.au/understandingdementiacare/module2/dementia.html

kerry.miller@avondale.edu.au Created 2011

kerry.miller@avondale.edu.au Created 2011

Terminology
Confusion Illusions alteration or distortion of sensory perception (ie coat in the dark perceived as a person) Delusions firmly-held beliefs not supported by evidence (including Grandiose, Paranoid, Religious, Persecutory, Somatic, Thought Insertion, Thought Broadcasting) Hallucinations false sensory perception without external or objective stimuli (including Auditory, Visual, Olfactory, Gustatory, Tactile) Misinterpretation drawing unusual conclusions from information or interactions Psychosis cluster of symptoms resulting in loss of contact with reality due to thought disturbance/s, disorganised thought processes and unusual behaviour Thought Disorder expression and flow of thought interrupted, with illogical and confused speech and thinking
kerry.miller@avondale.edu.au Created 2011

References
Brown, D., & Edwards, H. (2008). Lewiss Medical-surgical nursing: Assessment and management of clinical problems (2nd ed.). Marrickville, Australia: Elsevier. Byrne, G., & Neville, C. (2010). Community mental health for older people. Chatswood, Australia: Churchill Livingstone. VEA (Distributor). (2010). Delirium, Dementia and Depression. (DVD). Available from VEA Australia. 111A Mitchell Street, Bendigo, VIC 3550: Australia. Dementia Training Study Centre. (2011). Dementia training online. Retrieved March 31, 2011, from http://dementia. uow.edu.au/understandingdementiacare/module2/dementia.html Elder, R., Evans, K., & Nizette, D. (2009). Psychiatric and mental health nursing (2nd ed.). Chatswood, Australia: Mosby. Happell, B., Cowin, L., Roper, C., Foster, K., & McMaster, R. (2008). Introduction to mental health nursing: A consumerorientated approach. Crows Nest, Australia: Allen & Unwin. International Centre for Alcohol Policies. (1995-2011). Alcohol and the Elderly. Retrieved March 31, 2011, from http:// www.icap.org/PolicyTools/ICAPBlueBook/BlueBookModules/23AlcoholandtheElderly/tabid/181/ Default.aspx McMurray, A. (2007). Community health and wellness: A socio-ecological approach (3rd ed.). Sydney, Australia: Elsevier.

kerry.miller@avondale.edu.au Created 2011