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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