Download The Two Faces of Depression: Withdrawn or Aggressive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