PRIMARY CARE O LDER A DULT PRIMARY CARE O LDER A DULT DELIRIUM + 2D S COMPARISON T ABLE 1 DELIRIUM + 2D S COMPARISON T ABLE 3 Delirium Dementia Depression Delirium Dementia Depression Delirium is a Dementia is a gradual Depression is a term Impaired Clear Clear medical and progressive used when a cluster Consciousness Fluctuates until late in the Unimpaired Definition emergency which decline in mental of depressive /Awareness Reduced course of the illness is characterized by processing ability that symptoms is present an acute and affects short term on most days, for fluctuating onset memory, communication, most of the time, for Stability Variable hour to hour Fairly stable Some variability of confusion, language, judgment, at least 2 weeks and Fluctuates Generally normal Normal disturbances in attention, reasoning, and abstract thinking. when the symptoms are of such intensity Alertness Lethargic or disorganized that they are out of hypervigilant Dementia eventually thinking and/or affects long-term the ordinary for that Inattentive Generally normal Difficulty decline in level of memory and the individual. Attention Fluctuates concentrating consciousness ability to perform Depression is a Minimal impairment Impaired Delirium cannot be familiar tasks. biologically based Distractable accounted for by a Sometimes there are illness that affects a preexisting changes in mood and person’s thoughts, Poor memory Poor memory Intact dementia; behaviour. feelings, behaviour, Recent and Recent and Minimally impaired however, can co- Common types include: and even physical Memory immediate remote impaired Selective or patchy exist with • Alzheimer disease(40-60%) health. impaired dementia. • Vascular dementia(10-20%) “Islands” of intact • Lewy Body dementia(15-20%) memory 2008 October RGPc: ML van der Horst VIHA: Delirium in the Older Person 2008 October RGPc: ML van der Horst VIHA: Delirium in the Older Person Primary Care Version www.rgpc.ca www.viha.ca Primary Care Version www.rgpc.ca www.viha.ca PRIMARY CARE O LDER A DULT PRIMARY CARE O LDER A DULT DELIRIUM + 2D S COMPARISON T ABLE 2 DELIRIUM + 2D S COMPARISON T ABLE 4 Delirium Dementia Depression Delirium Dementia Depression Acute Insidious Variable Variable Variable Depressed Subacute Chronic Often abrupt Onset Irritable Apathetic Loss of interest and Depends on cause Coincides with life changes Affect Aggressive Labile pleasure in usual Often at twilight /Emotions Fearful Irritable activities Hours to days to Months to years Variable Flat, unresponsive, Duration weeks and less At least 2 weeks but sad than 1 month can be months to May be irritable Seldom longer years Disorganized Difficulty with Intact with themes of Fluctuating Slowly progressive Diurnal variation Distorted abstractions hopelessness, Short, diurnal Relatively stable Worse in morning, Thinking Fragmented Thoughts helplessness, Course variations in over time improves during day Slow or impoverished indecisiveness, or symptoms, worse self-deprecation Situational accelerated Make poor at night, in the dark fluctuations but less Incoherent judgments and on awakening than acute confusion Words often Abrupt Slow but even Variable, rapid-slow difficult to find Progression but uneven PRIMARY CARE O LDER A DULT PRIMARY CARE O LDER A DULT DELIRIUM + 2D S COMPARISON T ABLE 5 DELIRIUM + 2D S COMPARISON T ABLE 7 Delirium Dementia Depression Delirium Dementia Depression Distorted: illusions, Misperceptions Intact A. Disturbance of A. The development Five (or more) of the delusions and/or often absent In severe cases may DSM-IV consciousness (i.e., of multiple cognitive following symptoms Diagnostic reduced clarity of deficits manifested have been present Perception hallucinations Lewy body experience delusions awareness of the by both during the same two- Difficulty dementia will have and hallucinations Criteria environment) with 1. memory impairment: week period and distinguishing hallucinations reduced ability to impaired ability to represent a change between reality, present focus, sustain or shift learn new information from previous func- misperceptions attention. or to recall previously tioning; at least one Disturbed Normal to Disturbed B. A change in cognition learned information of the symptoms is fragmented (such as memory 2. one or more of the either (1) depressed Nocturnal confusion Usually early deficit, disorientation, Sleep-Wake Reversed: up at night, Nocturnal morning awakening language disturbance) following cognitive disturbances: mood or (2) loss of interest or pleasure. Cycle very sleepy or nonre- wandering and Hypersomnia or the development a) aphasia (language 1. depressed mood sponsive during day confusion of a perceptual disturbance) most of the day, nearly disturbance that is b) apraxia (impaired every day Mental Testing is variable Attempts to answer and not Capable of giving correct answers not better accounted ability to carry out 2. marked diminished interest or pleasure in Status Dependent on cognition aware of mistakes Often states for by a preexisting, established or motor activities normal activities Testing fluctuations “I don’t know” evolving dementia. despite intact motor function) 3. significant weight loss or gain 2008 October RGPc: ML van der Horst VIHA: Delirium in the Older Person 2008 October RGPc: ML van der Horst VIHA: Delirium in the Older Person Primary Care Version www.rgpc.ca www.viha.ca Primary Care Version www.rgpc.ca www.viha.ca PRIMARY CARE O LDER A DULT PRIMARY CARE O LDER A DULT DELIRIUM + 2D S COMPARISON T ABLE 6 DELIRIUM + 2D S COMPARISON T ABLE 8 Delirium Dementia Depression C. The disturbance c) agnosia (failure to 4. insomnia or Delirium Dementia Depression DSM-IV develops over a recognize or identify objects despite intact hypersomnia nearly every day CAM MMSE (Folstein) Geriatric Depression Diagnostic short period of time (usually hours to sensory function) 5. psychomotor (Confusion Assessment (Mini-Mental Status Exam) Scale (without dementia) Standardized Method) MOCA Criteria days) and tends to d) disturbance in agitation or retardation Cornell Depression executive functioning nearly every day (Montreal Cognitive fluctuate during the Tests Assessment) Scale (with dementia) …continued course of the day. (e.g., organizing, planning, sequencing, 6. fatigue or loss of energy nearly every day Clock Drawing Test D. There is evidence abstracting) 7. feelings of Treatable and Treatments in early Treatable and from the history, B. The cognitive worthlessness or physical deficits in the above excessive guilt reversible stages may slow reversible condition criteria (Criteria A1 8. diminished ability to Prognosis condition progression examination or laboratory findings and A2) each cause think or concentrate, or Medical Non-reversible significant impair- indecisiveness that the disturbance ment in social or emergency condition 9. recurrent thought of is caused by the occupational function - death or suicidal Increased risk of direct physiological ing and represent a thoughts/actions relapse, morbidity consequences of a significant decline and mortality general medical from a previous level condition. of functioning. Other Other physical disease may not Past history of mood disorder Features be obvious Canadian Coalition for Seniors’ Mental Health (CCSMH) (2006). National Guidelines for Seniors’ Mental Health. The Assessment and Treatment of Delirium. Toronto, ON: Author/Baycrest. Registered Nurses Association of Ontario (RNAO) (2003). Screening for Delirium, Dementia and Depression in Older Adults. Nursing Best Practice Guideline. Toronto, ON: Author. The Royal Australian College of General Practitioners (2006). “The Silver Book “: Medical Care of Older Persons in Residential Aged Care Facilities (4th ed.). South Melbourne, Australia: Author.