Stephen Thielke
Puget Sound VA GRECC
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Learning Objectives
 Characterize delirium, dementia, and depression
 Identify key similarities and differences between
them
 Discuss steps in the clinical evaluation of these
conditions
 Review instruments contained in the 5D Pocket
Card which can be used to evaluate and monitor
delirium, dementia, and depression
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Will not address
 Management of delirium, dementia, and
depression
 General geriatric assessment
 Suicide risk assessment and management
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Project Timeline
 2007-2008: Needs assessment delineates
challenges around differential diagnosis of
dementia in primary care
 Mid-2008: GRECC Dementia Education
Workgroup begins discussing ways of improving
the differential diagnosis and management of
common geriatric cognitive symptoms in clinical
settings
 Mid-2009: First draft of pocket card and
assessment guide trialed and evaluated
 Mid-2010: Final pocket card and guide to be
disseminated through the GRECCs
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Key Contributors
 Julie Moorer, Puget Sound GRECC
 Suzanne Craft, Puget Sound GRECC
 Kathy Horvath, New England GRECC
 Theressa Burns, Minneapolis GRECC
 Michelle Rossi, Pittsburgh GRECC
 Terri Huh, Palo Alto GRECC
 Nina Tumosa, St Louis GRECC
 Byron Bair, Salt Lake City GRECC
 Susan Cooley, Office of Geriatrics and Extended Care
 Malva Rashid, Cleveland GRECC
 Rivkah Lindenfeld, Northport EERC
 Ken Shay, Office of Geriatrics and Extended Care
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What Delirium IS
 “Acute Brain Failure”
 “Toxic Metabolic Encephalopathy”
 “Acute Confusional State”
 A medical condition:
 Rapid onset
 Deficits in attention and concentration
 Waxing and waning mental status
 Infections, medications, metabolic abnormalities are the
most common causes
 Mental status changes often precede objective
signs of illness
 Often multifactorial
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What Delirium IS NOT
 A psychological problem
 An insignificant condition (over 25% of
patients with delirium die within 6 months)
 Dementia – slow onset, slow steady
decline, little fluctuation
 Rapidly resolving, even when cause
corrected
 A normal part of aging
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What Dementia IS
 A significant chronic loss in memory and/or mental
functions, involving structural damage to the brain
 Significant ─ functional consequences
 Chronic ─ not a rapid onset (comes on over
years)
 Loss ─ new impairments (not lifelong)
 Structural Damage ─ neurons die
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What Dementia IS NOT
 Delirium ─ acute onset, attention and
concentration problems
 Depression – anhedonia, distraction; subjective
cognitive deficits which are not apparent on
neuropsychological testing
 Sensory deficits or communication problems
 A normal part of aging
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What Depression IS
 A syndrome of psychological and bodily symptoms
 Low mood or anhedonia (lack of pleasure), plus:
 Problems with sleep (too little or too much)
 Problems with appetite (too high or too low)
 Trouble concentrating
 Decreased interests
 Feelings of guilt or having done something wrong
 Low energy
 Slowed movements
 Suicidal thoughts
 Unreal experiences: “my mind playing tricks on me”
(hearing voices or feeling paranoid)
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What Depression IS NOT
 A bad day, week, or month
 Grief
 A natural reaction to medical illness or loss
 A cause of dementia
 A normal part of aging
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Delirium, Dementia and Depression
Common
Features
Delirium
Subjective
confusion
Difficulty
performing
tasks
Dementia
Depression
“Not right” on
interview
Hallmarks
Trouble with attention and
concentration
Rapid onset; waxing and waning
Due to a medical cause
Problems with memory plus problems
with speech, actions, recognition, or
executive functioning
Chronic and progressive, slow onset
Functional decline
Loved ones are Decreased concentration and interest
Sensorium is clear
worried
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Delirium Prevalence
 15-40% of older hospitalized patients
 Up to 70% of ICU patients
 Roughly 80% of patients pre-death
 14% of patients 65 years and older in the
emergency room
Inouye et al, 1999; McNiccoll et al, 2003; Hustey & Meldon, 2002
 Patients with underlying cognitive
impairments are more likely to develop
delirium
Rahkonen et al, 2002
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Recognizing Delirium
 Confusion that develops over days or weeks
 Trouble with attention, focus, & concentration
 Waxing and waning
 Fluctuating sleep disturbances
 Erratic, uncharacteristic, inappropriate
behavior
 Hallucinations (especially visual), paranoia
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Recognizing Delirium (cont’d)
 Can be hyperactive (agitated) or hypoactive
(sedated)
 Delirium often goes unrecognized
 Acting “normal” during one assessment
does not rule out delirium
 Falling asleep during interview strongly
suggests delirium
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Working Up Delirium
 Do not assume that patients are just having a “bad
thinking day”
 Use collateral sources of information
 Consider the whole clinical picture
 Apply a broad differential
I nfections
W ithdrawal
A cute metabolic
T rauma
C NS pathology
H ypoxia
D eficiencies
E ndocrinopathies
A cute vascular
T oxins or drugs
H eavy metals
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Delirium Evaluation: CAM
The Confusion Assessment Method (Inouye 1993, 2000)
Feature 1: Acute Onset and Fluctuating Course
Usually obtained from family member or caregiver: rapid change from baseline,
and fluctuating severity during the day.
Feature 2: Inattention
Trouble with attention, being distractible, or having difficulty keeping track of what
was said.
Example: recite months of the year backwards.
Feature 3: Disorganized Thinking
Rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject.
Feature 4: Altered Level of Consciousness
Anything other than alert on scale of (Normal [alert], Vigilant [hyperalert],
Lethargic [drowsy, easily aroused], Stupor [difficult to arouse], or Coma
[unarousable]).
Delirium is diagnosed with the presence of feature 1 and 2, and either 3 or 4.
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Delirium Evaluation (cont)
Consider delirium FIRST in any patient
who shows cognitive impairments
Identifying delirium is only the first step
Strive to determine and correct the
cause
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Dementia Prevalence
Age Range
% with
Dementia
71-79
5.0%
80-89
24.2%
90+
37.4%
Total (71+ yrs)
13.9%
Plassman et al, 2007
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Recognizing Dementia
 Common warning signs are problems with:
 Short-term memory, judgment
 Word finding (language)
 Taking medication incorrectly (executive function)
 Driving (visuospatial)
 Balancing checkbook (calculation)
 Memory problems are often not the chief complaint
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Recognizing Dementia (cont’d)
 Spouses or children are often more concerned
than patients
 Good verbal skills and living independently
should not preclude evaluation of cognition
 Conduct additional workup whenever patient or
family describe problems or when cognitive
problems are observed
 Routine screening of the asymptomatic is not
recommended (USPSTF)
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Working Up Dementia
 History ─ use collateral sources
 Rule out delirium and reversible causes
 Labs:
 TSH, CBC, Chem-7, Calcium, LFTs, B12, Folate, Urinalysis
 Cognitive testing:
 BOMC, Mini-Cog, GPCOG, STMS, SLUMS, MoCA, FAST
 Complex cases: refer for neuropsychological evaluation
 Neuroimaging is not routinely indicated; order if
 Rapid decline
 Unexplained focal neurological symptoms
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DSM-IV Criteria for Alzheimer’s Dementia
A. The development of multiple cognitive deficits manifested by:
1. Memory Impairment
2. One or more of the following cognitive disturbances: (a) aphasia
(language disturbance) (b) apraxia (impaired ability to carry out motor
activities) (c) agnosia (failure to recognize or identify objects) (d)
disturbances in executive functioning ( i.e., planning, organizing,
sequencing, abstracting)
B. The cognitive deficits in A1 and A2 each cause significant impairment in
social or occupational functioning.
C. The course is characterized by gradual onset and continuing cognitive
decline.
D. The cognitive deficits are not due to other neurological or systemic
conditions, or to substance use.
E. The deficits do not occur exclusively during the course of a delirium.
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Mini-Cog
 A brief assessment; does not diagnose dementia
1. Ask the patient to remember 3 words.
Repeat them until the patient is able to
state all 3 without errors.
2. Ask the patient to draw a clock and include
all the numbers. Then ask the patient to
place the hands on the clock to make the
time be “One Ten”.
3. Ask the patient to recall the 3 words you
asked before.
Unscored
2 points for a clock without
errors, 0 for any error
1 point per word (max 3)
Scoring: None of the 3 words: Cognitively impaired
All 3 of the words: Not cognitively impaired
1 – 2 words recalled  Abnormal clock: Cognitively impaired
 Normal clock: Not cognitively impaired
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AD-8
 Assesses functional status, based on report of a
spouse, caregiver, or close family member
 Focuses on change in the last several years:
1. Problems with judgment (e.g. falls for scams, bad financial decisions,
buys gifts inappropriate for recipients)
2. Reduced interest in hobbies/activities
3. Repeats questions, stories or statements
4. Trouble learning how to use a tool, appliance or gadget (e.g. VCR,
computer, microwave, remote control)
5. Forgets correct month or year
6. Difficulty handling complicated financial affairs (e.g. balancing
checkbook, income taxes, paying bills)
7. Difficulty remembering appointments
8. Consistent problems with thinking and/or memory
Scoring: One point per item
Score of 2 or greater suggests significant cognitive impairment
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SLUMS
 St Louis University
Mental Status Exam
 Used to assess cognitive
changes and to track
clinical changes over
time
 Better psychometric
properties than the
MMSE
Scoring: Total 30 points
Normed for education level (high school or more; high school or less)
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FAST
 Functional Assessment Staging Tool
 Information provided by knowledgeable informant, and
supplemented by clinical observation
 Used to guide appropriateness of dementia medication
therapy
1-2 No functional deficit (Normal).
Subjective word difficulties (Normal
Aging)
3-4 Decreased function in demanding
settings or decreased ability to
handle complex tasks ( i.e. finances
or planning dinner.)
5. Requires assistance in choosing
proper clothing
6. Difficulty with dressing, bathing,
toileting. Urinary and/or fecal
incontinence.
7a Can speak only about half a dozen
intelligible different words or fewer
7b Speech ability limited to the use of
a single intelligible word
7c Unable to talk without assistance
7d Cannot sit up without assistance
7e Loss of ability to smile
7f Loss of ability to hold up head
independently
Scoring: The highest consecutive
disability noted
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Depression Prevalence
Prevalence of Major Depressive Symptoms
0.45
0.4
0.35
0.3
Sick - Female
0.25
Sick - Male
0.2
Entire Group - Female
0.15
Entire Group - Male
0.1
Healthy - Female
0.05
Healthy - Male
0
Age
Thielke et al, Aging and Mental Health 2010
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Recognizing Depression
 Often presents as nonspecific physical symptoms
 Fatigue
 Pain
 GI problems
 Older patients less likely than younger to admit to
being “depressed”
 Depression is stigmatized, especially in older adults
 Patients often more willing to endorse mental
health symptoms in writing than in person
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Working Up Depression
 All patients with mood symptoms or history of
depression, mood disorders, or PTSD should
be assessed for suicidal thoughts
 Ask about mood symptoms in patients of all ages
 Use structured scales when possible
 Consider the mutual effects of depression and
medical illness
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PHQ-2
 A screening tool; does not diagnose depression
 Self-report
“Over the past two weeks, how often have you been
bothered by these problems?”
Not at
all
Several > Half of
days
the days
Nearly
every
day
1. Little or no interest or pleasure in doing
things?
0
1
2
3
2. Feeling down, depressed, or
hopeless?
0
1
2
3
A score of 3 or greater merits completing the PHQ-9, AND a suicide risk
evaluation should be completed within 24 hours
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PHQ-9
1. Little or no interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Feeling tired or having little energy?
5. Poor appetite or overeating?
6. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let
yourself or your family down?
7. Trouble concentrating on things such as reading the newspaper or watching
television?
8. Moving or speaking so slowly that others could have noticed, or being so fidgety and
restless that you have been moving around a lot more than usual?
9. Thinking that you would be better off dead or that you want to hurt yourself in some
way?
All questions use 0 – 3 scale (as on PHQ-2)
A suicide risk evaluation is required within 24 hours if:
1. Total score is less than 10 and response to question #9 is 1, 2 or 3.
2. Total score is greater than 10.
Depression is likely if the total score is greater than 10
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How to approach a patient with
cognitive problems
1. Is this patient delirious?
2. Is this patient depressed?
3. Does this patient have dementia?
All three conditions frequently occur
together.
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Feel free to contact me
 Stephen Thielke
 Geriatric Research, Education, and Clinical
Center, Seattle VAMC
 (206) 764-2815
 Stephen.Thielke@va.gov
For paper or electronic copies of the 5D
Pocket Card or Guide:
 Julie.Moorer@va.gov
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