The Three Ds of
Confusion
Delirium,
Depression,
Dementia
Confusion
Is
not a normal part of aging
Delirium and Depression are
treatable
Dementia is manageable
Delirium





More common than fever or pain in older
adults
About 50% of hospitalized older adults
experience delirium
Only 3 out of 10 older adults with delirium are
diagnosed by health care personnel
As many as 1/3 of those affected by delirium
will die
Is a medical emergency and should be
treated as such
St. Pierre, J. (1996). Delirium in hospitalized elderly patients. Critical Care Nursing, 8(1), 53-60.
Delirium

Onset: hours to days
 Causes:
• medications
• fluid and electrolyte imbalances (What is a
common fluid imbalance that also begins with the
letter “D”?)
•
•
•
•
•
infection (rule out urinary and respiratory infections)
elimination (urinary retention / constipation)
changes in chronic illness
newly-developed disease process
psychosocial / environmental issues
Delirium: Diagnosis








need to repeat questions
perseveration (What does this term mean?)
disorganized thinking
reduced LOC (level of consciousness)
perceptual disturbances
sleep-wake disturbance or psychomotor
activity
disorientation to time, place, person
memory impairment
Delirium : Assessment


Person, place and time are the least
sensitive markers for delirium
Focus on aspects of Attention and
Concentration
• Ask client to count backward from 20 by 3’s
• Ask client to copy a drawing of intersecting
pentagons
Delirium: Interventions

Rule out drug-related causes and
infections first
• Urinary tract and respiratory infections are
the most common


Obtain data about the individual’s
baseline cognitive functioning
Provide orienting cues and support
• Eye glasses, hearing aids, calendar, clock,
etc.
Depression

Onset: weeks to months
 Causes:







heredity
biochemical changes
drugs
illness
sensory deficits
stress
seasons (seasonal affective disorder,
frequently seen in the Northwest)
Losses with Aging







biological
psychological
personal
social
identity
possessions
religious
Sometimes the
cumulative effect
of several losses can
predispose an individual
to a depressive
episode.
Think of some examples of
how these losses may be
experienced.
Depression: Diagnosis
Symptoms include…
• loss of interest or pleasure in activities
• persistent depressed mood, including feelings of sadness or
emptiness
• feeling slowed down or restless, can’t sit still
• feeling worthless or guilty
• increase or decrease in appetite or weight
• thoughts of death or suicide
• problems thinking, concentrating, or making decisions
• trouble sleeping, or sleeping too much
• loss of energy or feeling tired all of the time; constant fatigue
Depression: Assessment

Geriatric Depression Scale
• Self-administered
• Well tested and used by all health care providers

Cornell Scale for Depression in Dementia
• Useful in assessing depression in individuals with
dementia
• Can be used by family members or caregivers to
articulate their observations, as some individuals
may minimize the severity of their symptoms
Risk Factors for
Late in Life Suicide

The risk of suicide is
high in older adults.
Health care providers
must intervene if an
individual makes
statements related to
the taking of his or her
own life.
male
 significant loss
 poor health
 isolation
 feeling hopeless
 previous attempt
 drug / alcohol abuse
 family history
 financial insecurity
Depression: Interventions

Antidepressants
• Monitor for side effects


Encourage and support counseling
Recommend a referral to Medical Social
Worker (MSW)
• May be able to link individual with
resources and community support
Dementia
 Onset:
months to years
 Causes:
Alzheimer’s Disease (AD) (most common)
Vascular Dementia (multi-infarct; MID)
Mixture of AD & MID
Pick’s, Parkinson’s, AIDS
To learn more about AD, see the booklet
Alzheimer’s Disease: Unraveling
The Mystery, produced by the National
Institute on Aging.
Delirium + Dementia
Individuals with dementia still have acute illnesses
such as pneumonia, UTI’s, medication side effects,
and electrolyte imbalances. This means that they can
have a delirium superimposed on their dementia. If
an client with AD is more confused than usual (within
hours to days) and experiencing the s/s of delirium as
discussed earlier, you must intervene.
Therefore, your assessment must include
information about the client’s baseline cognitive
functioning. Family members and caregivers must be
included in the assessment process.
Dementia: Interventions


Obtain client’s baseline cognitive
functioning.
Observe for potential delirium and/or
depression that may magnify cognitive
impairment (both of these conditions are treatable
even in the individual with dementia).

Provide and encourage an environment
that supports the individual’s highest
level of functioning.
The Three Ds of Confusion was
prepared by Catherine Van Son,
Ph.D., R.N., for the Older Adult
Focus Project, OHSU School of
Nursing.