Quality of Life:
Dementia, Delirium & Other
Co-Morbid Conditions
A Crash Course Guide to
Awareness of Elder Care
Shawn A. Berkowitz, MD, CMD
AAFP, CAQ Geriatrics
Shawn_Berkowitz@uhs.org
Objectives
• Explain the predisposing or precipitating
RISK FACTORS for DEMENTIA and DELIRIUM
in older patients.
• Identify the types and prevalence of
MEDICAL CO-MORBIDITY associated with
mental health problems.
• Review and Explain the impacts of
Co-Morbid conditions on QUALITY OF LIFE in
older persons.
• “This project is/was supported by funds from the
Bureau of Health Professions (BHPr), Health
Resources and Services Administration (HRSA),
Department of Health and Human Services
(DHHS), Prevention and Public Health Fund
under grant number UB4HP19194A0
Alzheimer’s Disease interprofessional training
for $134,906. This information or content and
conclusions are those of the author and should
not be construed as the official position or policy
of, nor should any endorsements be inferred by
the BHPr, HRSA, DHHS or the U.S.
Government.”
The Wooden Bowl
Geriatric Medicine
Background Thoughts
• Increasingly important to recognize the
differences between
Adult and Geriatric Medicine…
• Children are not younger, smaller adults;
and
• Elders are not just older, smaller adults.
-SAB
Elder Care
• Elders are More Vulnerable (knock down)
- To Disease and Injuries
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Have Less Physiologic Reserves (bounce back)
Have Unique Diagnoses
Have Different Clinical Presentations.
Need More Multi-Functional Assessments
Have More Involved Families.
- J. Crosby
Overview
• Capacity vs Competence
• Medical Ethics –
Autonomy, Beneficence, Non-Maleficence, Social Justice.
• Right to Self-Determination – Advanced Directives, Living Wills.
Choosing One’s own care / QUALITY OF LIFE Issues.
• THE 3 “D”s :
DEMENTIA, DELIRIUM, and DEPRESSION.
How to tell them apart and
Why you need to know to do something about them.
• Other CO-MORBID CONDITIONS and QUALITY OF LIFE
• Comfort from a BIO-PSYCHO-SOCIAL-SPIRITUAL Perspective
Definitions ?
• Capacity vs Competence
• Capacity –
– Medical term
• Ability to UNDERSTAND what is being explained.
• Ability to PROCESS the risks and benefits of a treatment
intervention.
• Ability to EXPRESS a decision clearly and consistently.
- J.Crosby
• Competence –
– Legal term, decided by the courts.
Definitions ?
• Autonomy – Right to Self-Determination of care
• Beneficence – “Do Good for the patient”
• Nonmaleficence – “Do No Harm to the patient”
» Quality of Life is KEY
• Social Justice – Benefit as many people as possible
with limited resources.
HOW DO THESE RELATE TO QUALITY OF LIFE ?
-SAB
Definitions ?
• Advance Directives – written or oral directives
stating what care the patient would want in
various situations.
• Living Wills – A more specific written form with
directives for specific interventions.
• Health Care Proxy – An assigned surrogate
who can make health care decisions on the
patients behalf when the patient lacks Capacity.
-SAB
Case Study 1 - Dementia ?
Elaine
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88 y/o woman taken from home by APS.
APS requested by niece for fear of safety.
Elder would not leave the Home.
Food delivered nightly by neighbors.
Niece entered home on false pretense.
Niece found Hoarding and soiled food in
furniture. Unclean kitchen and bath.
Elder brought by APS to CPEP.
CS1 Hospital
• Misdiagnosed with UTI, Foley placed.
• Sedated with medications due to behavior
problems with agitation.
Anti-psychotics and anti-depressants.
• Confused and sedated with medications.
• Lost control of Bladder muscle and Foley
unable to be removed.
• Transferred to Nursing Home.
CS1 Nursing Home
• Medication burden was reduced due to excess sedation.
• All labs were found to be within normal limits, including
no evidence of malnutrition, no evidence of skin
breakdown, no rashes, …in short – no evidence of poor
self care on physical medical exam and lab work.
• Patient awoke and states “I just wanted to die at home,
why couldn’t they just let me die at home ?”
• Diagnosed at Nursing home with severe depression by
Geriatric Psychiatrist.
• Decision to pursue aggressive treatment with ECT and
inpatient Psych admission and feeding tube for
demonstrated anorexia (refusal to eat).
CS1 Intervention
• PCP intervened and spoke with Elder and discussed the
above concerns and plan.
• Elder expressed horror at feeding tube and ECT then
stated “It doesn’t matter what I want, you are going to do
what you want to me anyway.”
• Elder reassured that she had ability and right to make
her own decisions.
• Chart notes amended with PCP discussion noting
patients wishes for NO ECT, NO inpatient Psych
admission, and NO feeding tube. – per patient
expressed wishes with capacity as determined by PCP.
• Collaborating evidence from niece noting patient has
always been a loner and would not want feeding tube,
inpatient admission nor ECT.
CS1 Outcome
• Elder avoided unwanted treatment plan and is
now settled into facility and eating is improved
with modest weight gain.
• She is still very unhappy about not being
allowed to die in her own home and is agitated
at times with the staff during her care needs.
• Foley now removed with further bladder training
at nursing home.
• Elder has some good days and some bad days.
Attempt to have living will completed by elder on
a day she is more conversant and amenable to
discussion.
CS1 Thoughts ?
• How well did we address Elaine’s
autonomy ?
• How well did we address “Quality of Life”
issues for Elaine ?
• What Co-Morbid conditions might have
contributed to Elaine’s treatment and care
decisions ?
Dementia Syndrome
• Yes, Virginia there are different types.
• “Multiple acquired cognitive deficits that occur in
the absence of acute confusion, that causes
dysfunction and have no other medical cause.” –
• Domains –
memory, orientation,
language, visual-spatial,
executive decision-making.
*DSM IV
Dementia Types
• ALZHEIMER’s Disease –
– 50%+ of diagnosed dementia
– Gradual and progressive decline
– Genetic and Environmental ? Risk factors
»Biggest Risk Factor is OLDER AGE.
• VASCULAR Dementia –
– 20-35%+ of diagnosed dementias
– Abrupt deterioration post Stroke / CVA
or stepwise decline with multiple TIAs.
- Risk factors – DM, HTN, Lipids.
– Often coincides with Alzheimer’s as well.
*DSM IV, Up-To-Date 2007
•
CONFUSION !
»
What to do ???
Dementia Tips and Tools for QOL
• Don’t Blame patients; they “can’t”, not “won’t”.
• Do assess hearing if paranoia; hearing loss
worsens or causes.
• Don’t talk “about” the patient with family in
presence of the patient.
• Be patient: many troublesome symptoms
resolve with time.
• Be aware of 2 potential problem caregivers:
over-involved daughters and
denying / under-involved sons.
-J. Crosby
Dementia Tips and Tools for QOL
• Do advice reminder notebooks to compensate
for short-term loss.
• Don’t ask IF they want to do something;
Rather ask, WHEN it is time to do something.
• Don’t argue about delusions and hallucinations;
don’t nurture either.
• Don’t warn much about upcoming event.
• Don’t favor family wishes over patients
(whether expressed now or in the past).
-J Crosby
Case Study 2 - Delirium
Florence
• 75 y/o woman living at an assisted living facility.
• Brother actively involved in care and visits often.
• Medical problem complaints led to more and
more medications added by various specialists.
• Patient with worsening neuropathic pain from
trigeminal facial nerve. Patient and brother
insistent on “something to help her…”
CS2 Poly-Pharmacy
• Eventually patient taking 3 anti-seizure meds,
multiple pain medications, and several other
meds for her pain syndrome and other medical
problems.
• “Medical Desperation Syndrome” – S. Berkowitz
• Patient began having episodes of worsening
confusion and intermittent violent episodes.
• Brother reports her “Rage Episodes”, throwing
things and destroying her personal possessions.
• Patient had no memory of these events.
CS2 Outcome
• Patient admitted to Inpatient Psychiatry
• 2 week stay for Detox and returned to assisted
living with much reduced med burden and did
well for several more months.
• Eventually, patient needed to be moved to
nursing home due to increased confusion and
inappropriate behaviors.
• Patient doing much better at nursing home with
appropriate cueing and support.
CS2 Thoughts ?
• How well did we address Florence’s
autonomy ?
• How well did we address “Quality of Life”
issues for Florence ?
• What Co-Morbid conditions might have
contributed to Florence’s treatment and
care decisions ?
Delirium
1)[acute] change in cognition, altered LOC
2) short-term, fluctuating course
3) change in consciousness (inattention)
4) medically caused condition or substance
* DSM IV
• 30% of elders during hospitalization
(70% in ICU – ICU psychosis)
* Up to date 2007
Delirium is an Acute Problem
• Prolonged hospital stays and functional decline,
increased likelihood SNF placement,
increased mortality 2x age-matched controls.
• Quiet Delirium– sedated, withdrawn, distant.
• Active Delirium – agitated, calls out, tries to get OOB,
wandering, generally unhappy nurses.
• May be subtle at first, typically more severe in evenings and
nights (may be fine during Day Shift).
• May not “look sick” – apart from behavior change…so look
for acute illness as cause.
* Geriatric Review Syllabus
A COUPLE CASES
• Active Delirium –
87 y/o man on 80mg Prednisone 3x a day
Daughter upset and Nurse tells Pharmacist.
Passive Delirium
80 y/o man with million dollar work-up
Poly-pharmacy concerns.
Delirium Causes 1
• DELIRIUM
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Drugs(#1  30% of cases)
Endocrine / Metabolic issues
Location Change
Infections
Respiratory / Cardiac disease
Impaction (constipation)
Unrelieved Pain
Malignancy
*Geriatric Review Syllabus
Delirium Causes 2
• SAD MATES
– Stroke
– Alcohol
– Depression
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Malnutrition
Anemia
Trauma
Epilepsy
Sensory Deprivation
*Geriatric Review Syllabus
• FRUSTRATION !
What to do ???
Work-up of Delirium
• History, History, History –
– What happened to the patient ? Any Acute Cause ?
• Refer to Causes: DELIRIUM / SAD MATES
– How can we Reduce or Eliminate causal factors ?
• Med Review – any new or high risk meds ?
• Basic Labs – usu indicated.
• XRays and other studies- as indicated by Hx and PE
* Swanson’s Family Practice Review 2005
* Geriatric Review Syllabus
Treatment of Delirium
Non pharmacologic – AVOID CAUSING !!!
All Generally QUALITY Of LIFE issues !
Stop High Risk Meds
Re-orient, Nutrition, Hydration,
Consistent Care-Givers,
Sense of Control, Adjust schedules
Environment Lighting, Auditory Stimuli,
Augment Vision and Hearing,
“Sitters”/Company, Undisturbed Night Sleep.
Walk / Exercise
Cognitive Activities / Word Games
Annals of Long Term Care, April 2008
Clinical Geriatrics, June 2008
UNMC Geriatric website 2009
American Geriatrics Society, Inouye, 2010.
Treatment of Delirium 2
Pharmacologic – FIRST TREAT ACUTE ILLNESS !
And Stop High Risk Meds !
Pain ? –
Tylenol Routine  Narcotics (Use Step Therapy)
Alcohol Withdrawal ? – Ativan / Lorazepam
All Else ?– Haldol / Haloperidol
to control behavior that places patient or others at risk for harm.
Annals of Long Term Care, April 2008
Clinical Geriatrics, June 2008
UNMC Geriatric website
Treatment of Delirium 3
Parkinsons Sx – Quetiapine (Seroquel)
Long term Olanzapine (Zyprexa)
Risperidone (Risperdal)
Orthostatic Hypotension – Haloperidol (Haldol)
ICU Delirium Prevention - Quetiapine (Seroquel)
Note there now exist a black box warning for all anti-psychotics.
Be careful to document rationale carefully, and consider tapering when stable.
Annals of Long Term Care, April 2008
Clinical Geriatrics, June 2008
UNMC Geriatric website
Street, J et al. Arch Gen Psychiatry 57 :2000
Tariot P et al, Am J Ger Psychiatry 14: 2006
Case Study 3 – Depression
Rosemarie
• 82 year old woman living with her son and
daughter in law and her grand-daughter.
• Increasingly distant and less communicative
• Less interaction with family and friends.
• More often refusing to go out
• Eating less and sleeping more
• Increasing memory problems and confusion
CS3 – Misdiagnosis ?
• Taken to her PCP who diagnoses Alzheimer’s
Dementia and starts meds
• Family notes no difference over several weeks
• Family increasingly concerned and questions
diagnosis.
• Taken for a Comprehensive Geriatric
Assessment for second opinion.
CS-3 CGA
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A home visit with social work team leader
Cognitive and Depression screens done
Home safety eval completed
Caregivers interviewed for burnout
An office visit for PE with geriatrician
Review of all materials as team
Inter-professional discussion
Determination of No clear signs of dementia, that
more likely Pseudo-dementia
• Recommendation for CBT counseling and SSRI.
CS-3 Outcome
• Reccomendations sent to PCP and family
• PCP states “His depression is my dementia” and
refuses to treat for depression.
• Family switches to new PCP and med changes
made
• Patient improves significantly within 4 weeks
becoming more active and alert and with much
improved cognition
• More smiling, more family engagement and more
enjoyment of activities
CS-3 Thoughts ?
• How well did we address Rosemarie’s
autonomy ?
• How well did we address “Quality of Life”
issues for Rosemarie ?
• What Co-Morbid conditions might have
contributed to Rosemarie’s treatment and
care decisions ?
Depression
Step 1- Diagnose Depression
Pseudo-dementia, behavior change –agitation.
Scales - Geriatric Depression Scale, Cornell Scale of Depression in Dementia.
Step 2 – Correct Diagnosis
Differentiate other mood disorders like Bipolar dz, and psychotic depression.
History from family, chart, psychiatric history ?
Step 3 – Evaluate for cause - Screening lab tests and
/ Evaluate Co-morbid medical or neurologic conditions
Consider Thyroid, Malnutrition, Sleep Apnea, Vision and Hearing Problems.…
Step 4 – Treat and monitor
Follow Target symptoms. - Eating, Sleeping, Agitation outburts, etc.
AND Use Non-Pharmacologic Methods –
Care-giving, Increased Activity, Psychotherapy,
Enhance sensory input - hearing and vision.
* UNMC geriatric website
Age-Related Changes
• “Most significant problems of the elderly are
caused by disease, not by normal aging. If there
is loss of function, assume there is underlying
disease that potentially can be treated.”
– Neil Hall, MD.
• This is also true for Psychiatric changes
• Cognitive Ability and Mood.
• So look for Medical Illness first.
* Geriatric Clerkship Manual 2004
Co-Morbid Conditions
that may effect Cognition and Mood
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Neuro – Stroke, Parkinsons, Huntingtons
Respiratory – Asthma, COPD, Pneumonia
Cardio-Vascular – HTN, CHF, PVD-Edema
Gastrointestinal – Constipation, Diarrhea, Pain
Endocrine – Diabetes, Thyroid
Special – Vision and Hearing Loss
M/S – Rheumatoid and OsteoArthritis, Fractures
Substance - Alcohol and Drug Abuse
-SAB
Quality of Life
How do these effect people ?
• Independent Care - Can help yourself vs Need to get Help
• Mobility – Can go where you want to go on your own
• Diet Choices – Eat what you Like when you like
• Sense of Safety – Awareness of Surroundings
and Potential for Self-Defense
• Comfort – Pain, Anxiety, Breathing, Loneliness
• Poly-pharmacy – Excess Meds and Side Effects
-SAB
POLY-PHARMACY
• “The high incidence of adverse drug reactions in
geriatric patients is caused by the number of
drugs taken, not by unusual sensitivity to drug
effects.”
– Neil Hall M.D.
• Is this drug really needed ?
• Can we decrease or discontinue this drug ?
– Benefit vs Risk // Efficacy vs Side Effects ?
– if yes, Rx safest effective form at lowest effective dose.
* Geriatric Clerkship Manual 2004
….Swimming with the sharks !!
High Risk Meds
CAN NSAIDS
• Cardiovascular drugs
• Anticholingerics
• Narcotics
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NSAIDS
Sedatives
Anticoagulants
Insulin
Diabetes meds
pSychoactives
» SAB 2007
The Beers List
American Geriatrics Society (AGS)
http://www.americangeriatrics.org/files/
documents/beers/2012BeersCriteria_
JAGS.pdf
Journal of the American Geriatrics Society –
From The American Geriatrics Society, New York, New York.
Address correspondence to Christine M. Campanelli, The American
Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038.
E-mail: ccampanelli@americangeriatrics.org
DOI: 10.1111/j.1532-5415.2012.03923.x
JAGS 2012
© 2012, Copyright the Authors
Journal compilation © 2012, The American Geriatrics Society
Common QUALITY OF LIFE Concerns
• CONSTIPATION
• AGITATION
• PAIN
• SLEEP
CAPS
SAB 2007
conSTOPation
• Generally Try to avoid first ! Harder to treat.
• FOS – Full of Stool
– Fiber  Osmotic  Stimulant
• If Rx Iron – then trial Colace or Osmotic
• If Rx Opiod – then trial Osmotic w/ Stimulant
• Better to order meds and “Hold for loose stools”
then wait for symptoms to occur.
*UNMC Geriatric website
aGiTaTiOn
Discussed earlier with Dementia / Delerium topics.
Non pharmacologic –
AVOID CAUSING !!!
Re-orient, Nutrition, Hydration, Consistent Care-Givers, Sense of
Control, Environment Lighting, Auditory Stimuli, “Sitters”/Company,
Undisturbed Night Sleep, Augment Vision and Hearing,
Exercise, Cognitive Activities.
Pharmacologic –
FIRST TREAT ACUTE ILLNESS !
Pain ? – Tylenol RTC  Narcotics
Withdrawal ? – Lorazepam
All Else ?– Haloperidol
to control behavior that places patient or others at risk for harm.
*UNMC Geriatric website
Pain - Guiding Principles
1- Use Non-Pharmacologic methods too
2- Scheduled Dosing for Chronic Pain
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–
PRN = “Pain Relief Never”
Ex. Tylenol Routine plus PRN
3- Limit Side Effects / Step therapy –
Acetaminophen (Tylenol)  Codeine /
Hydrocodone  Morphine
4- Consider Neuropathic / Anxiety / Social Pain –
and treat as appropriate.
*UNMC Geriatric website
Sllleeeeeppppppp…
• Can we move room from noisy roommate ?
• Do you really have to wake them up before sunrise everyday ?
• Pharmaceuticals –
– Trazodone – a good alternative sleep agent in low doses.
– Zolpidem (Ambien) – more risky and more effective.
Start low dose, and avoid CR form unless careful and needed.
Next day grogginess, slow get-up and go, hypotension.
– Avoid Benzos – generally inc. risk of delirium due to confusion + agitation
and worsens sleep hygeine long term with less REM.
– Avoid Diphenhydramine (Benadryl) – anticholinergic effect, with increased
risk delerium esp after surgery.
*UNMC Geriatric website / Epocrates
Geriatric May 2006.
Other Hazards that reduce
QUALITY OF LIFE
• IMMOBILITY -Inc. Risk of DVT, Sores, Infections,
Delirium, Prolonged Recovery.
• PRESSURE ULCERS- “SORES”
– Sensory loss, Ooze (moisture), Restricted Mobility,
– Eating poor, Shear friction
• ACQUIRED INFECTIONS –
– Wash your hands before, after, and often.
– Follow patient isolation signs on doors.
* UNMC geriatric website
• LOST !
What to do ???
COMFORT
Bio-Psycho-Social + Spiritual
• BIO- Appropriate Meds and Treatments.
– Give and Take Away / “START” + “STOP” Meds
• PSYCHO- Counseling for Patient and Family
– Cognitive, Behavioral, Supportive, Reflective
• SOCIAL- Activities and Interaction with Others
– Food / Meals and Interesting Distractions, Trips
• SPIRITUAL- Church, Clergy visits,
– Also Music, Personal Reflection, Outdoor Gardens.
Serenity and Balance
Review
• Capacity and Medical Ethics, Right to Self-Determination.
• THE 3 “D”s: DEMENTIA, DELIRIUM, DEPRESSION.
• Explained the risk factors for DEMENTIA and DELIRIUM
in older patients.
• Reviewed QUALITY OF LIFE concerns in older persons with
CO-MORBID conditions // With Poly-Pharmacy Awareness.
• Identified some types and prevalence of medical CO-MORBIDITIES
associated with mental health problems.
– COMMONLY ENCOUNTERED PROBLEMS IN ELDERS
When an old lady died in the geriatric ward of a small hospital near Dundee,
Scotland, it was felt that she had nothing left of any value. Later, as the nurses
were going through her meager possessions, they found this poem. It's quality
and content so impressed the staff that copies were made and distributed to
every nurse in the hospital. One nurse took her copy to Ireland. The old lady's
sole bequest to posterity has since appeared in the Christmas edition of the
News Magazine of the North Ireland Association for Mental Health.
What do you see, nurses, what do you see?
What are you thinking when you're looking at me?
A crabby old woman, not very wise
Uncertain of habit, with faraway eyes?
Who dribbles her food and makes no reply
When you say in a loud voice, "I do wish you'd
try!"
Who seems not to notice the things that you do
And forever is losing a stocking or shoe
Who, resisting or not, lets you do as you will,
With bathing and feeding, and giving me pills!
Is that what you're thinking? Is that what you see?
Then open your eyes, nurse; you're not looking at
me.
I'll tell you who I am as I sit here so still
As I do at your bidding, as I eat at your will.
I'm a small child of ten...with a father and mother
Brothers and sisters, who love one another
A young girl of sixteen, with wings on her feet
Dreaming that soon now a lover she'll meet.
A bride soon at twenty -- my heart gives a leap
Remembering the vows that I promised to
keep
At twenty-five now, I have young of my own
Who need me to provide them a secure happy
home.
A woman of thirty, my young now growing fast,
Bound to each other with ties that should last.
At forty, my young sons have grown and are
gone
But my man's beside me to see I don't mourn.
At sixty once more, babies play round my knee
Again we know children, my loved one and me
Dark days are upon me, my husband is dead
I look at the future and I shudder with dread
For my young are all rearing young of their own
And I think of the years and the love that I've
known.
I'm now an old woman...and nature is cruel
'Tis jest to make old people look like a fool.
The body, it crumbles, grace and vigor depart
There is now a stone where I once had a heart.
But inside this old carcass a young girl still dwells
And now and again my battered heart swells.
I remember the joys
I remember the pain
And I'm loving and living life over again.
I think of the years...all too few, gone too fast
And accept the stark fact that nothing can last
So open your eyes, people, open and see
Not a crabby old woman; look closer.....
Remember this poem when you next meet an old person
who you might brush aside without looking at the young soul within...
Lord willing we will one day be there too!