MODULE 6.

DEPRESSION/DELIRIUM/DEMENTIA

Module 6. Depression/Delirium/Dementia
Mary Shelkey, RN, PhD Editor: Conchita Rader, MA, RN

Staff De elopment Partners Edition Instru!tor "uide

T#IS MODULE IN$LUDES% 1. Expected Staff Cognitive Competencies 2. Expected Staff Clinical Competencies 3. Content Outline including Learning Activities a. E!"#$E %O "#S% &C%O ' ead activities in "nstructor (uide and prepare materials for activities in advance ). Scripted Po*erPoint Presentation +. 1,-item Post %est 6. esources

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA E&PE$TED STA'' ($o)niti e* $OMPETEN$IES 1. 2. 3. ). +. 6. 4. $escri.e t/e prevalence of depression in older adults. &se an assessment instrument for depression in older adults 0see !odule +. Cognitive 1 !ental Status Assessment of Older Adults2 $iscuss s3mptoms and treatment strategies for depression in older adults. $escri.e t/e prevalence of delirium and dementia in older adults. $iscuss t/e s3mptoms of delirium and dementia. $iscuss t/e assessment and treatment strategies for delirium and dementia. Contrast criteria for differentiating depression5 delirium5 and dementia in older adults.

E&PE$TED STA'' ($lini!al* $OMPETEN$IES

+e,a iors #o- alidated
No i!e Ad an!ed +e)inner $ompetent Profi!ient E.pert

1. Accuratel3 assess for depression in an older adult client using a relia.le assessment instrument 2. ecogni6e manifestations of depression5 delirium5 and dementia in older adults

$irect o.servation of use of instrument5 and revie* of documented evidence of findings $irect o.servation of assessment evie* 1 discuss findings and documentation7 actions ta8en $irect o.servation of follo*-up and use of assessment tool to monitor for c/anges over time $irect o.servation of assessment tec/ni9ues and strategies7 revie* of documentation $irect o.servation of implemented measures and patient outcomes

3. Evaluate patient responses to treatment for depression5 delirium5 and dementia ). "mplement an individuali6ed plan for depression5 delirium5 and dementia +. Accuratel3 assess depression5 dementia5 and delirium5 .ased on clinical parameters 6. "mplement care environment alterations and nonp/armacologic interventions to encourage pro.lem solving .e/aviors in patients *it/ dementia.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA $ompeten!/ 0. Des!ri1e t,e pre alen!e of depression in older adults. $epression constitutes t/e most common emotional disorder found in older people.1 Estimates of t/e prevalence of ma:or depressive disorder in t/e elderl3 range from 2; to 1,; of t/ose 6+ and older.

A.

<. $epression in older adults /as .een associated *it/ and is closel3 related to t/e aging process. %/e accumulation of a lifetime of depressing events5 suc/ as .ereavement5 painful illness5 etc.5 coupled *it/ t/e effects of p/3sical illness5 decreasing mental5 and diminis/ed p/3sical energ35 place older adults at ris8 for depressive s3mptoms. <ecause /omicidal and suicidal ideation ma3 occur5 patients s/ould .e assessed for ris8 of dangerousness. Suicide ris8 factors and related conditions t/at older adults ma3 experience include' <.1. ps3c/iatric illness <.2. serious medical illness <.3. living alone <.). recent .ereavement5 divorce5 or separation <.+. personal or famil3 /istor3 of suicide attempt or completed suicide <.6. unemplo3ment or retirement <.4. advanced age <.=. su.stance a.use
C.

%/e causes are so common t/at t/e3 appear as t/oug/ a part of t/e normal aging process5 and to t/e clinician5 ma3 lead to misdiagnosis or undetected depression.2 Accepting t/e vie* t/at depression is a normal function in t/e life c3cle5 specificall3 during t/e aging 3ears5 is fla*ed and unet/ical5 leading to disparities in care deliver3 for t/is vulnera.le population.

$. $epression is defined as a clinical s3ndrome c/aracteri6ed .3 lo*er mood tone5 difficult3 t/in8ing5 and somatic c/anges precipitated .3 feelings of loss and 1 or guilt. $iagnostic la.els include' minor depression5 ma:or depression5 ad:ustment disorder *it/ depressed mood5 d3st/3mia5 .ipolar depression5 seasonal affective disorder5 and ot/ers. E. Clinicall3 depressed s3mptoms range from =; > 1+; among communit3-d*elling older persons and 3,; among institutionali6ed older persons. %/e s3mptoms are often associated *it/ c/ronic illness and pain.
F.

"t is important to identif3 patients */o ma3 .e experiencing depressed s3mptoms as a side effect of medication. !an3 prescription or over-t/e counter 0O%C2 drugs contri.ute to depression. Alt/oug/ t/ere is little pu.lis/ed information on alternative medicines causing depression5 consideration s/ould .e given to /er.al5 nutritional5 vitamins and supplements5 particularl3 */en consumed in large doses. Some medications t/at ma3 cause s3mptoms of depression in older adults include' anti/3pertensives5 antips3c/otics5 .en6odia6epines5 analgesics5 antipar8inson5 antiarr/3t/mic5 #SA"$s5 ot/er drugs suc/ steroids5 and

<utler5 . #.5 Le*is5 !. ".5 ? Sunderland5 %. 01@@22. Aging and mental health: Positive psychosocial and biomedical approaches. 0)t/ ed.2. Colum.us5 OA' C/arles E. !errill. 2 Anderson5 A. B. 02,,22. %reatment of depression in older adults. International Journal of Psychosocial Rehabilitation, 65 6@-4=.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA c/emot/erap3 drugs.3 (. !a:or depressive disorders occur less often in older adults compared to 3ounger adults7 /o*ever5 24; of older adults experience depressive s3mptoms. A. %/e /ig/est rate of completed suicide of an3 age5 gender5 or et/nic group is among older */ite men. %/e ris8 of suicide is /ig/er in older adults t/an t/e rate for 3ounger people 0up to six times more fre9uent in older */ite men over =+ 3ears of age2. ". C/ronic depression in older adults occurs in 4; to 3,; of all cases of depression5 *it/ a t/ird of t/ose */o recover relapsing in t/e first 3ear. B. As 3ounger persons *it/ t/eir /ig/er prevalence of depression age5 t/e incidence of depression in older adults is expected to increase over t/e next 2, to 3, 3ears.

$ompeten!/ 2. Use an assessment instrument for depression in older adults ('or a re ie-3 see Module 4. $o)niti e / Mental Status E.am of Older Adults* A. Assessing depression in t/e older adult client is difficult .ecause depression ma3 /ave at3pical presentations. <. Several depression scales are *ere descri.ed .3 Aolro3d and Cla3ton 02,,,2 offering information a.out t/e uses and validit3 of t/e tools listed /ere' ) <.1. #amilton Ratin) S!ale for Depression is a 21-item rating scale used to measure treatment outcome rat/er t/an a screening or diagnostic tool for depression. Alt/oug/ it *as not designed to diagnose depression it is used as a screening scale in t/e context of clinical trials to identif3 participants *it/ depressive disorders. <.2. 5un) Self6Ratin) Depression S!ale5 a 2,-item rating scale5 .ut /as .een noted to /ave little validation in depressed older adult populations5 especiall3 if depression ta8es t/e form of multiple somatic complaints. <.3. Mont)omer/6As1er) Depression Ratin) S!ale is sensitive to measuring c/ange in s3mptoms *it/ treatment over time5 .ut /as not .een validated sufficientl3 in t/e geriatric population. C. evie* *it/ t/e participants5 t/ree instruments used to s!reen and assess depression and dementia in older adults. C.1. emind t/em of t/e !ini-!ental Status Examination5 */ic/ is used to 9uantif3 !o)niti e a1ilit/ and measure !,an)es in !o)nition o er time. Patients */o score .elo* 23 on !!SE 0mild cognitive impairment2 s/ould .e referred for

3 4

!a3nard5 C. C. $ifferentiate depression from dementia. The urse Practitioner, !"0325 1=-24. Aolro3d5 S.5 ? Cla3ton5 A. A. 02,,,2. !easuring depression in t/e elderl3' D/ic/ scale is .estE #edscape $eneral #edicine, !0)2. etrieved April 3,5 2,,) from /ttp'11***.medscape.com1vie*article1)3,++)

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA follo*-up.

C.2. %/e

Fesavage (eriatric $epression Scale 0($S2 is used to s!reen for depression in older adults. A score of greater t/an + is suggestive of depression and s/ould *arrant a follo*-up intervie*. %/is ta8es approximatel3 + minutes to administer and /as .een validated and extensivel3 used *it/ medicall3 ill older adults5 and includes fe* somatic items t/at ma3 .e confounded *it/ p/3sical illness. %/is tool /as .een found to .e t/e .est tool and is availa.le in several languages. +6

C.3. %/e Cornell Scale for $epression in $ementia is used to assess for depression in !lients -it, ad an!ed dementia and used to follo* up *it/ t/ose */o scored less t/an 1+ 0severe cognitive impairment2 on t/e !!SE.

$ompeten!/ 7. Dis!uss s/mptoms and treatment strate)ies for depression in older adults. Clinical manifestations of depression in older adults4 A.1. $epressed mood'
5

A.

!a3 den3 sad mood and complain of pain or somatic distress Cr3ing spells 0or complaining of ina.ilit3 to cr3 or experience emotion2 Persistent G1) da3s eduction in gratification5 loss of pleasure in normall3 pleasura.le activities 0an/edonia25 loss of attac/ments 5 social *it/dra*al #egative expectations' feelings of guilt5 /opelessness5 and /elplessness7 lac8 of self-confidence5 lo* self-esteem5 self-reproac/ Poor concentration or memor3 pro.lems !or.id t/in8ing to include recurrent t/oug/ts of deat/ and suicidal t/oug/ts Persistent appetite c/anges and *eig/t loss or gain Significant altered sleep 0too muc/ or not enoug/2 or earl3 morning a*a8ening Ps3c/omotor retardation or agitation > common s3mptom in an older person

A.2. Associated ps3c/ological s3mptoms'

A.3. Somatic manifestations

"6al5 !.5 ? !ontorio5 ". Adaptation of t/e geriatric depression scale in Spain' A preliminar3 stud3. %linical $erontologist, &', =3-@1. 6 Dee8s5 S. C.5 !c(ann5 P. E.5 !ic/aels5 %. C.5 Penninx5 <. D. 02,,35 Second Huarter2. Comparing various s/ort-form geriatric depression scales leads to t/e ($S-+11+. Journal of ursing (cholarship5 133-134. 7 <eers5 !. A. ? <er8o*5 . 0Eds.2 02,,,2. The merc) manual of geriatrics. 03rd Ed.2. D/ite/ouse Station5 #B' &sed .3 permission.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA A.2. Ps3c/otic s3mptoms $elusions of *ort/lessness and sinfulness $elusions of ill /ealt/ $elusions of povert3 0Evaluate delusions as 3,; of elderl3 *omen alread3 are at t/e povert3 level.2
!a8e diagnosis

<. %reatment strategies for depression in older adults' see algorit/m for depression=

Select and initiate treatment

!onitor acute treatment ever3 1-2 *ee8s. Assess ad/erence and side effects

Assess response 0Dee8 ) - 62

Clearl3 .etter Continue treatment for 6 more *ee8s

Some*/at .etter Continue %reatment 0Ad:ust dosage2

#ot .etter at all Augment or c/ange treatment

!onitor treatment 0ever3 1-2 *ee8s2

Clearl3 .etter

Assess response 0Dee8 122

Complete remissionE #o Fes elapseE

#ot .etter

!edication continued for ) > @ mont/s Consider maintenance treatment

efer or consult a ps3c/iatrist or ot/er mental /ealt/ professional

C/ange %reatment

Source' Agenc3 for /ealt/ Care esearc/ and Hualit350AA H25 *epression in Primary %are 01@@325 volume 25 2@.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA %reatment strategies for depression in older adults include' <.1. P,arma!olo)i!' Patients s/ould receive antidepressant medication for 012 moderate or severe s3mptoms of depression7 0.2 significant impairment in social or occupational functioning due to depression7 and 0c2 suicidal ideation5 including 0d2 t/ose *it/ a famil3 /istor3 of depression5 0e2 recurrent depressive episodes5 and 0f2 t/ose *it/ a past /istor3 of positive response to medications. %/ere are t/ree ma:or classifications of antidepressants. Selective serotonin reupta8e in/i.itors 0SS "2 . %/ese drugs increase t/e .rainIs level of serotonin5 conse9uentl3 improving t/e patientIs mood. %/ese are first line drug t/erap3 and t/e most commonl3 prescri.ed antidepressants5 especiall3 for older adults. Examples are' antips3c/otics5 .eta-.loc8ers5 calcium c/annel .loc8ers5 codeine5 and *arfarin. Jluoxetine 20Pro6ac2and paroxetine 0Paxil2 /ave .een 8no*n to create toxicit3 */en used *it/ ot/er common drugs meta.oli6ed .3 t/e liver. Sertraline 0Koloft2 and escitalopram A<r 0Lexapro2 are examples of SS ".. %ric3clic antidepressants. $rugs in t/is class are t/oug/t to *or8 .3 affecting t/e levels of t/e .rainLs natural c/emical messengers 0called neurotransmitters25 and ad:usting t/e .rainLs response to t/em. %/ese drugs ma3 exacer.ate existing pro.lems common in older adults5 suc/ as constipation5 cognitive impairment5 dr3 mout/ arr/3t/mias5 and ort/ostatic /3potension. Examples are' Amitript3line 0Elavil25 $esipramine ACl 0#orpramine2 !onoamine oxidase in/i.itors 0!AO"s2 are used less fre9uentl3 .ecause .etter drugs /ave .ecome availa.le. #o antidepressant medication is more effective t/an anot/er. #o single medication results in remission for all patients. Patient factors and drug side effect profiles ma3 favor one antidepressant over anot/er for a specific patient. Consideration must .e given to t/e 012 patientIs ot/er medical conditions7 022 t/e rate of response 0*/ic/ could .e as /ig/ as 6, > 4,;7 032 targeted s3mptoms7 0)2 degree of close monitoring for medication compliance5 and 0+2 patient and famil3 education a.out t/e course and nature of depressive illness5 treatment and potential side effects5 and t/e importance of treatment compliance. %/e principle regarding dosing t/e older adult is' MStart Lo*5 (o Slo*N. Carefull3 monitor for side effects5 suc/ as falls and loss of appetite.

<.2. Ele!tro!on ulsi e T,erap/. %/is is t/e treatment of c/oice for older persons *it/ severe depression. "mprovement rate in older persons */o do not respond to antidepressant drugs is =,; 0same as 3ounger persons2. Primar3 EC% is :ustifia.le as a first line of t/erap3 for t/e follo*ing indications' 012 need for rapid5 definitive treatment response on eit/er medical or ps3c/iatric grounds7 0.2 ris8s of ot/er treatments out*eig/ t/e ris8s of EC%7 0c2 a /istor3 of poor drug response5 0d2 patient preference.@ <.3. Ps/!,ot,erap/ (Indi idual and "roup*. Ps3c/ot/erap3 is generall3 appropriate
9

OAA1$O$ clinical practice guideline for t/e management of ma:or depressive disorder in adults. Das/ington 0$C2' $epartment of Oeterans Affairs 0&.S.27 2,,,.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA for all forms of depression. (enerall35 t/is approac/ aims to /elp depressed individuals to t/oug/tfull3 examine t/eir .e/avior5 .eliefs5 emotions5 stressors5 and personal relations/ips in order to lead to lasting c/ange in factors t/at ma3 /ave contri.uted to t/e development of depression. <ecause t/ere are no demonstrated differences in outcome .et*een patients treated *it/ ps3c/ot/erap3 or p/armacot/erap35 patient c/oice s/ould .e strongl3 considered in planning treatment. %/e availa.ilit3 of a competent ps3c/ot/erapist is a prere9uisite for t/e ps3c/ot/erap3 option. "t /as .een s/o*n t/at t/e competenc3 affects treatment effectiveness. %/is is especiall3 effective in preventing relapses of episodic depression 03,; relapse rate of depression in older persons2. One must consider t/at t/e older adult ma3 /ave a negative attitude a.out ps3c/ot/erap3.

Pro.lem-Solving %/erap3 is used to /elp depressed older adults to develop effective means of coping *it/ stressful life events.1, eminiscence t/erap3 0 %2 is .ased on t/e premise t/at life revie* constitutes a normal developmental process .roug/t a.out .3 increasing a*areness of oneIs mortalit3.11

C. Points to Consider in %reatment Strategies'

C.1. Consider

comor.idities12 Patients */o /ave depression and anxiet3 comor.idities /ave /ig/er severit3 of illness5 /ig/er c/ronicit35 and greater impairment in *or8 functioning5 ps3c/osocial functioning5 and 9ualit3 of life t/an t/ose not suffering from comor.idities. Some medications ma3 not *or8 in patients *it/ several comor.id conditions5 re9uiring a different dosing5 different response time5 and effectiveness of t/e medications.

C.2. !onitor treatment ever3 1 to 2 *ee8s to assess ad/erence and side effects to SS " and ot/er medications. Ad/erence to medications ma3 .e influenced .3 t/e dosing. %/e patient is more li8el3 to compl3 *it/ medications */en using sustained release medication. C.3. Assess response in ) to 6 *ee8s to ensure t/at t/e patient remains on treatment *it/ desired outcome. C.). emission is defined as a return to full pre-mor.id functioning accompanied .3 a su.stantial reduction of depressive s3mptoms. &se depression scales to monitor s3mptom remission. Assess MS"(-E-CAPSN s3mptoms.13 $ata suggest t/at measuring s3mptom response .ased on clinicianLs glo.al impression ma3 .e ade9uate. S Sleep distur.ance 0insomnia or /3persomnia2
10

C.5.

#e6u5 A. !.5 ? #e6u5 C. !5 ? Perri5 !. (. 01@=@2. Problem+solving therapy for depression: theory, research, and clinical guidelines. #e* For8' Dile3. 11 <utler5 . 01@4)2. Successful aging and t/e role of life revie*. Journal of the American $eriatric (ociety, !! 5 +2@-+3+. 12 Airsc/feld5 . !. 02,,12. The comorbidity of ma,or depression and an-iety disorders: Recognition and management in primary care. '0625 2))-2+). 13 OAA1$O$ clinical practice guideline for t/e management of ma:or depressive disorder in adults. Das/ington 0$C2' $epartment of Oeterans Affairs 0&.S.27 2,,,. Oarious p. etrieved !a3 25 2,,) from /ttp'11***.guideline.gov1summar31summar3.aspxEssP1+?docQidP2+=+?n.rP1=11?stringPdepression

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA I "nterests 0an/edonia or loss of interest in usuall3 pleasura.le activities2 " (uilt and1or lo* self-esteem E Energ3 0loss of energ35 lo* energ35 or fatigue2 $ Concentration 0poor concentration5 forgetful2 A Appetite c/anges 0loss of appetite or increased appetite2 P Ps3c/omotor c/anges 0agitation or slo*ing1retardation2 S Suicide 0mor.id or suicidal ideation2 E. Jor all levels of depression5 develop an individuali6ed plan integrating t/e follo*ing nursing interventions' E.1. E.2. E.3. E.). E.+. E.6. "nstitute safet3 precautions for suicide ris8 per institutional polic3. emove or control etiologic agents t/at ma3 include correcting or treatment meta.olic and s3stemic distur.ances5 and altering depressogenic medications. !onitor and promote nutrition5 elimination5 sleep1rest patterns5 and p/3sical comfort5 especiall3 pain control. En/ance p/3sical function. En/ance social support. !aximi6e autonom3 1 personal control 1 self-efficac3. Jor example5 include patient in active participation in ma8ing dail3 sc/edules and setting s/ort-term goals. Structure and encourage dail3 participation in relaxation t/erapies5 and pleasant activities !onitor and document responses to medication and ot/er t/erapies5 readminister depression screening tool. Provide practical assistance5 suc/ as *it/ pro.lem-solving. Provide emotional support7 empat/ic5 supportive listening5 encourage expression of feelings and /ope instillation5 support adaptive coping5 and encourage pleasant reminiscences. Provide information a.out t/e p/3sical illness and treatment. Educate patient a.out t/e importance of ad/erence to prescri.ed treatment regimen Ensure mental /ealt/ communit3 lin8up7 consider ps3c/iatric5 nursing /ome care intervention.

E.4. E.=. E.@. E.1,.

E.11. E.12. E.13.

Learnin) A!ti it/. Case Stud3 on $epression !s. ( is a 4+-3ear old female living alone in /er apartment in #e* For8 Cit3. Aer /us.and died

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA suddenl3 t*o 3ears ago of a /eart attac8. %/eir t*o c/ildren are alive and living out-of-state. <ot/ of /er sons maintain *ee8l3 p/one contact *it/ !s. ( and visit usuall3 once a 3ear. !s. ( /as .een doing *ell until a.out 6 *ee8s ago */en s/e fell in /er apartment and sustained .ruises .ut did not re9uire a /ospital visit. Since t/en5 s/e /as .een preoccupied *it/ /er failing e3esig/t and decreased am.ulation. S/e does not go s/opping as often5 stating s/e doesnIt en:o3 going out an3more and feels Mver3 sad and tear3.N !s. ( states t/at /er s/opping needs are less5 since s/e is not as /ungr3 as s/e used to .e and M.esides "Im getting too old to coo8 for one person onl3.N Huestion. D/at ris8 factors mig/t account for !s. (Is s3mptoms of depressionE Ans*er' living alone5 minimal social support5 advancing age5 pain5 loss of independence5 and loss of spouse Huestion' D/at are !s. (Is depressive s3mptomsE Ans*er' sustained sad mood 0G1) da3s25 lac8 of en:o3ment in previousl3 pleasura.le activities 0going out25 social isolation5 decreased nutritional inta8e5 expressions of selfnegation 0M"Im getting too oldN2. Huestion' D/at mig/t .e some treatment strategies for !s. (E Ans*er' P/armacologic5 famil3 involvement 0mig/t increase visits and1or p/one contacts25 friendl3 visitor contacts 0communit3 or religious groups25 /ome-delivered meals5 ps3c/ot/erap3 0at t/e clinic *it/ transport or /ome2.

$ompeten!/ 8. Des!ri1e t,e pre alen!e of delirium and dementia in older adults. A. Jour to five million persons 0a.out 2; of all ages and 1+; of t/ose over age 6+2 are estimated to /ave cognitive disorders5 suc/ as delirium or dementia. 1,; of persons over 6+ and up to +,; over =+ are t/oug/t to /ave dementia. <. $ementia is a s3ndrome of progressive decline t/at relentlessl3 erodes intellectual a.ilities5 causing cognitive and functional deterioration leading to impairment of social and occupational functioning. $. $elirium or t/e development of acute confusional states occurs in 1,; to ),; of patients over 6+ 3ears old upon admission. 2+; to 6,; develop delirium after /ospitali6ation. !ost at ris8 are older persons */o /ave fallen and sustained a /ip fracture. 08 $. Al6/eimerIs diseases accounts for +,; to 6,; of all dementia in t/e &nited States5 affecting an estimated ) million adults over age 6+. Ot/er causes of dementia are vascular dementia and Par8insonIs disease. E. $eteriorating intellectual capacit3 ma3 .e caused .3 a variet3 of diseases and disorders. %/e #ational "nstitute on Aging states t/at some 1,, conditions */ic/ mimic serious disorders are
14

"nsel5 C. C.5 ? <adger5 %. S. 02,,22. $ecip/ering t/e ) $Is' cognitive decline5 delirium5 depression and dementia > a revie*. Journal of Advanced ursing, '"0)25 36,-36=.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA actuall3 reversi.le. %/ese are called MpseudodementiasN and are often treata.le. Examples are' E.1. E.2. E.3. E.). E.+. E.6. E.4. E.=. E.@. E.1,. E.11. eactions to medications Emotional distress !eta.olic distur.ances Oision and /earing pro.lems #utritional deficiencies Endocrine a.normalities "nfections Su.dural /ematoma #ormal Pressure A3drocep/alus <rain tumors At/erosclerosis 0/ardening of t/e arteries2

J. Certain conditions */ic/ cause irreversi.le cognitive impairment are' traumatic .rain in:ur35 and cere.ral degenerative diseases5 t/e most common of */ic/ is Al6/eimerIs disease.

$ompeten!/ 4. Dis!uss t,e s/mptoms of delirium and dementia in older adults. A. $elirium is defined as mental distur.ances c/aracteri6ed .3 acute onset5 distur.ed consciousness5 impaired cognition5 and an identifia.le underl3ing medical cause 0medications5 anest/esia5 sleep distur.ance5 electrol3te im.alance5 etc.2. $elirium is a re ersi1le !onfusional state. <. $ementia is a s3ndrome of ac9uired impairment of mental function5 not t/e result of an impaired level of arousal5 *it/ compromise in at least t/ree of t/e follo*ing areas of mental activit3' 012 language5 022 memor35 032 visuospatial s8ills5 0)2 personalit3 or emotional state5 and 0+2 executive function 0a.straction5 :udgment2. $ementia is usuall3 an irre ersi1le !onfusional state. C. Age-associated cognitive decline and Al6/eimerIs disease /ave t/e follo*ing clinical c/aracteristics .ased on t/e p/ase'1+ Normal P,ase 0#o Cognitive $ecline2 #o su.:ective complaints of memor3 deficit #o memor3 deficit evident on clinical intervie*

15

%/e (lo.al $eterioration scale for assessment of primar3 degenerative dementia. American Journal of Psychiatry, &'. 1136-113@. 1@=2. Cop3rig/t 1@=2. %/e American Ps3c/iatric Association. eprinted .3 permission.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA Earl/ $onfusional P,ase 0!ild Cognitive $ecline2 Earl/ Dementia P,ase 0!oderatel3 Severe Cognitive $ecline2 Late Dementia P,ase 0Severe Cognitive $ecline2 "ncreased forgetfulness $ecreased performance in emplo3ment and social settings O.:ective evidence of memor3 deficit o.tained *it/ an intensive intervie* !ild to moderate anxiet3 accompan3ing s3mptoms Can no longer survive *it/out assistance Cannot recall ma:or relevant aspects of t/eir current lives Some difficult3 c/oosing proper clot/ing to *ear A.le to retain 8no*ledge of ma:or facts 0name5 famil3Is names5 etc.2 !a3 re9uire some assistance *it/ A$L #o ver.al a.ilities "ncontinent of urine Loss of .asic ps3c/omotor s8ills e9uires assistance toileting and feeding

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA $. $epression5 $ementia5 and $elirium are differentiated .ased on specific parameters'16
Parameter
Onset

Depression
Coincides *it/ ma:or life c/anges5 relativel3 rapid progressing from *ee8s to mont/s Jlat affect5 /3poc/ondriasis5 focuses on s3mptoms5 apat/35 little effort to perform tas8s

Dementia
"nsidious and gradual7 mont/s to 3ears

Delirium
S/ort 1 rapid5 a.rupt7 /ours 1 da3s

"nitial Presentation

Oague s3mptoms5 loss of intellect5 great effort to perform tas8s5 agitated5 aggressive or apat/etic5 *andering5 famil3 more concerned t/an patient. Slo* and continuous decline. S3mptoms progressive 3et relativel3 sta.le over time

$isorientation5 clouded consciousness5 fluctuating moods5 disordered t/oug/ts5 fails to understand tas8s. Aours5 *ee8s5 or longer5 depending on t/e causes of delirium5 and t/e speed *it/ */ic/ t/e causes can .e resolved. S/ort diurnal fluctuations in s3mptoms5 *orse at nig/t in dar8ness5 and on a*a8ening7 s/o*s da3 dro*siness5 nig/ttime /allucinations5 insomnia5 nig/tmares. Aours to less t/an 1 mont/5 seldom longer educed La.ile varia.le5 fear 1 panic5 eup/oria5 distur.ed

Course

Self-limiting5 recurrent or c/ronic *it/out treatment. Often /as a period of improvement. $iurnal effect t3picall3 *orse in t/e morning5 situational fluctuations5 .ut less t/an delirium. Sleep impaired

Sleep 1 Da8e C3cle

#o diurnal effect5. Dorse in evening7 Msundo*ningN5 reversed sleep

$uration A*areness Affect

At least 6 *ee8s5 can .e several mont/s to 3ears Clear Pervasive sadness5 */ic/ precedes dementia5 *it/dra*n5 constricted5 apat/35 /opeless5 distressed #ormal Cognitive impairment inconsistent. #ormal of recent 1 past .ot/ altered. Slo*ed recall. Often s/ort-term memor3 deficits. "ntact "ntact $elusions in severe depressive disorders Poor :udgment5 man3 M" donIt 8no*N ans*ers

!ont/ to 3ears Clear Easil3 distracted7 s/allo*5 la.ile5 inappropriate anxiet35 depression5 or possi.le a.sence of depression. Suspiciousness. La.ile progressing to apat/3. (enerall3 normal S/ort term memor3 deficit in earl3 course of disease progresses to long-term deficits7 confa.ulation5 perseveration. $isoriented "ntact !isperceived people and events as t/reatening7 late delusions5 /allucinations "mpaired5 .ad 1 inappropriate decisions5 denies pro.lem

Alertness ecent !emor3

Jluctuates5 let/argic or /3pervigilant "mpaired5 remote intact

Orientation Level of Consciousness Ps3c/otic s3mptoms Budgment

$isoriented .ut not to person7 periods of lucidit3 $istur.ed $elusions

"mpaired7 difficult3 separating facts and /allucinations

$ompeten!/ 6. Dis!uss t,e assessment and treatment strate)ies for delirium and dementia.
16

Joreman5 !. $.5 Jletc/er5 C.5 !ion5 L. C.5 %r3gstad5 L. B.5 ? t/e #"CAE Jacult3. 01@@@2. Assessing cognitive function. "n A.ra/am5 ".5 <ottrell5 !. !.5 Julmer5 %. ? !e6e35 !. $.5 0Eds.2. $eriatric nursing protocols for best practice 5 0pp. +3-+)2. #e* For8' Springer Pu.lis/ing Compan3.

Page 13 of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA

A.

Delirium A.1. Assessment of delirium' A.1.1. Compre/ensive /istor3 and p/3sical examination 0t/ere ma3 .e more t/an one pro.lem2 A.1.2. evie* all current medications A.1.3. Evaluate tests in t/e routine evaluation 0.lood c/emistries' electrol3tes glucose5 calcium5 al.umin5 S(O%5 S(P%5 .iliru.in5 al8aline p/osp/atase5 magnesium5 p/osp/orus5 complete .lood cell count5 EC(5 CR 5 A<(s5 or O2 Saturation5 urinal3sis5 <&#1Creatinine5 Serum <12 levels5 and liver function tests5 t/3roid function tests5 depression screening2. A.1.). Ot/er tests t/at s/ould not .e included in t/e routine evaluation5 .ut could .e used on t/e .asis of results of la. studies and response to initial t/erap3. %/ese are c/est radiograp/35 cultures5 drug levels5 and folate levels5 pulse oximetr35 electrocardiogram5 .rain imaging5 lum.ar puncture5 and electroencep/galogram 0EE(2.
A.2.

Treatment of delirium' %/e treatment of patients *it/ delirium re9uires t/e consideration of man3 factors. %/e c/oice of treatment s/ould .e guided .3 a careful assessment of t/e patientIs clinical condition5 etiolog35 and comor.id conditions. Jailure to treat dela3s recover3 and can *orsen t/e older personIs /ealt/ and function.14 A.2.1. Ps3c/iatric management. "t is important to coordinate t/e care of t/e patient *it/ ot/er clinicians5 identif3ing t/e underl3ing causes of t/e delirium7 initiating immediate interventions for urgent medical conditions5 providing treatments t/at address underl3ing etiolog35 assessing and ensuring t/e safet3 of t/e patient and ot/er7 assessing t/e patientIs ps3c/iatric status and monitoring it on an ongoing .asis7 providing a supportive t/erapeutic stance *it/ t/e patient5 famil3 and ot/er clinicians5 educating t/e patient5 famil3 and ot/er clinicians regarding t/e illness5 and providing post delirium management to support t/e patient and famil3. A.2.2. Environmental and supportive interventions. educe or eliminate environmental factors t/at exacer.ate delirium' provide optimal level of environmental stimulation7 reduce sensor3 impairment7 ma8e environment more familiar and provide environmental cues t/at facilitate orientation. Cognitive-emotional supportive measures include reorientation5 reassurance5 and information concerning delirium t/at ma3 reduce fear or demorali6ation. A.2.3. Somatic interventions. %/e c/oice of somatic interventions *ill depend on t/e patientIs clinical condition and t/e underl3ing etiolog3 and associated comor.idities. Antips3c/otic medications5 .en6odia6epines5 and c/olinergic

17

American Ps3c/iatric Association. 01@@@5 !a32. Practice guideline for t/e treatment of patients *it/ delirium. American Psychiatric Association. American Journal of Psychiatry. &/6. 1-2,.

Page 1) of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA drugs are used. +. Dementia

B.1.

Assessment of Dementia. Studies /ave indicated t/at t/ere are several tests t/at can .e used to detect dementia1= <.1.1. Jolstein !ini-!ental Status Examination 0!!SE2 0see !odule +. Cognitive 1 !ental Status Assessment of Older Adults2 <.1.2. Co8men S/ort %est of !ental Status. D/en t/e !!SE score is S 2)5 or */en a patientIs famil3 mem.er suspects a memor3 impairment5 t/is tool /as an =6; sensitivit3 for detecting dementia. <.1.3. 4-minute screen comprising en/anced cued recall5 categor3 fluenc35 t/e <enton %emporal Orientation test5 and Cloc8 $ra*ing %est.

B.2.

Treatment of Dementia1@ <.2.1. P/armacological %reatment of Al6/eimerIs disease. %reat cognitive s3mptoms. <.2.1..1. C/olinesterase in/i.itors ma3 improve t/e 9ualit3 of life and cognitive functions including memor35 t/oug/t and reasoning. %/e3 are proven effective for t/ose */o are mildl3 to moderatel3 affected .3 t/e disease and under evaluation. <.2.1..2. Oitamin E > to slo* progression of disease <.2.1..3. (ing8o <ilo.a > some patients *it/ unspecified dementia ma3 .enefit from t/is .ut efficac3 data are lac8ing. <.2.1..). Stro8e Prevention for vascular dementia' Aspirin5 %iclopidine5 Plavix <.2.2. %reatment of <e/avioral $istur.ances <.2.2..1. Antips3c/otics are used to treat agitation or ps3c/osis */ere environmental manipulation fails' Aaloperidol 0Aaldol27 %/iorda6ine 0!ellaril27 Perp/ena6ine 0%rilafon27 isperidone 0 isperdal27 Olan6apine <.2.2..2. <en6odia6epines' Ativan <.2.2..3. Selected tric3clics5 !AO-< in/i.itors5 SS " Antidepressants' #efa6odone5 #ortript3line5 Paroxetine5 Sertaline5 %ra6adone. <.2.3. Educational "nterventions' s/ort term programs to educate famil3 caregivers5 and improve caregiver satisfaction7 intensive long-term education and support services to caregivers7 staff education to reduce use

18

Petersen5 . C.5 Stevens5 B. C.5 (anguli5 !.5 %angalos5 E. (.5 Cummings5 B. L.5 ? $eCos835 S. %. 02,,12. Practice parameter' Earl3 detection of dementia' !ild cognitive impairment 0an evidence-.ased revie*2. American Academy of eurology, /65 1133-11)2. 19 $ood35 . S.5 Stevens5 B. C.5 <ec85 C. et al. 02,,15 !a32. Practice parameter' !anagement of dementia 0an evidence-.ased revie*2. Report of the 0uality (tandards (ubcommittee of the American Academy of eurology. eurology, "0+62. 11+)-1166.

Page 1+ of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA of unnecessar3 antips3c/otics. <.2.). "nterventions to "mprove Junctional Performance' .e/avior modification5 sc/eduling toileting5 prompted voiding7 grade assistance5 practice and positive reinforcement7 lo* lig/ting levels5 music5 and simulated nature sounds <.2.+. #onp/armacologic "nterventions for Pro.lem <e/aviors Activit3 t/erapies5 including intergenerational and pet <rig/t lig/t5 */ite noise Cognitive emediation ealit3 orientation in earl3 stages Commands issued at t/e patientIs compre/ension level Compre/ensive ps3c/osocial care programs Environmental design 1 modifications for safet3 !assage !ilieu t/erap3 Occupational and p/3sical t/erap3 Prost/eses for sensor3 impairments Simulated presence t/erap35 suc/ as use of videotaped or audiotaped famil3 Structured5 routine dail3 activities Oalidation t/erap3 in later stages

<.2.6. Care Environment Alterations' %/e follo*ing environments ma3 .e considered for patient *it/ dementia' special care units7 /omeli8e p/3sical setting *it/ small groups5 s/ort-term planned /ospitali6ation of 1 > 3 *ee8s5 provide exterior space5 remodeling corridors to simulate natural or /ome settings5 and c/anges in t/e .at/ing environment <.2.4. "nterventions for Caregivers. %/e da3-to-da3 responsi.ilit3 of caring for a person *it/ dementia creates an emotional5 p/3sical5 social5 and financial toll on t/e caregiver. <ecause caregivers are stressed5 t/e3 ma3 find it /ard to maintain appropriate care. "t is vital to assess for caregiver depression. <.2.4..1. Compre/ensive ps3c/oeducational caregiver training <.2.4..2. Support groups <.2.4..3. Additional patient and caregiver .enefits ma3 .e o.tained .3 use of computer net*or8s to provide education to caregivers5 telep/one support programs5 and adult da3 care for patients and ot/er respite services. C. Al9,eimer $are. Alt/oug/ t/ere are no treatments to reverse t/e progression of

Page 16 of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA Al6/eimerIs disease5 strategies to support and sustain individuals *it/ t/e disease exist. %/e primar3 o.:ective of care is to /elp t/e person use as man3 retained a.ilities as possi.le. Successful management of Al6/eimerIs disease must address t/e cognitive5 functional5 and .e/avioral s3mptoms of t/is disease. Careful attention to factors t/at create excess disa.ilit3 0more disa.ilit3 t/an can .e attri.uted to t/e disease itself2 is criticall3 important. Persons *it/ Al6/eimerIs diseases graduall3 lose t/eir a.ilit3 to understand our s/ared realit3. As a result5 t/e3 misinterpret previousl3 understood events and o.:ects in t/eir p/3sical and social environment. Simple ad:ustments in routine /elp t/e person understand5 and function at as /ig/ a level as possi.le. As t/e disease progresses5 increasing .e/avioral distur.ances ma3 lead to placement in a nursing /ome. %/e follo*ing suggestions from t/e Al6/eimerIs Association ma3 /elp' C.1. &se personal /istor35 life experiences5 and /a.its as a .asis for self-care and leisure activities. Jor example5 if t/e individual en:o3ed gardening .efore developing Al6/eimerIs disease5 caregivers can /elp t/em participate in gardening activities as t/e3 are currentl3 a.le. !aintain a familiar and comforta.le routine t/at alternates activit3 *it/ rest to avoid fatigue and d3sfunction. Slo* do*n5 spea8 clearl35 ma8e e3e contact5 and sta3 in t/e personIs field of vision. Promote independence .3 cuing t/e person to do as muc/ for /im or /erself as possi.le. Limit c/oices to ones t/e individual can ma8e .3 using close-ended 9uestions. Jor example5 if t/e individual is confused .3 dressing independentl35 t/e caregiver mig/t c/oose t*o outfits and as8 t/e individual to pic8 .et*een t/em. !odif3 t/e p/3sical environment to reduce misinterpretation of real-life o.:ects or events. edirect or distract t/e person */o is delusional instead of correcting or confronting /im or /er. !onitor t/e individual for s3mptoms of personal distress suc/ as pain5 /unger5 or over1under stimulation. Pain assessment s/ould .e included in t/e ongoing plan or approac/ to caregiving. &se .e/avioral s3mptoms as a source of communication to guide .ot/ assessment and intervention. Jor example5 individuals ma3 .e/ave as if t/e3 are .eing violated during a .at/ .ecause t/e3 feel violated. Jraming .at/ time as a spa visit could c/ange t/e .e/avior.

C.2. C.3. C.). C.+.

C.6. C.4. C.=.

C.@.

C.1,. Promote independence5 autonom35 and self-directed meaningful activities *it/in a safe5 secure setting. Learnin) A!ti it/.

$ase Stud/ on Delirium

!r. % is a 4,-3ear-old male admitted to t/e ort/opedic unit in a large ur.an /ospital. !r. % fractured /is rig/t an8le in a golf outing and /ad an open reduction *it/ internal fixation t/is

Page 14 of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA morning. As 3ou ta8e report at 3 p.m.5 t/e da3 s/ift c/arge nurse tells 3ou t/at !r. % is insisting on going /ome and 8eeps getting out of .ed. !ultiple attempts to explain t/at /e is una.le to *al8 safel3 in t/e cast /ave not convinced /im and /e is no* 3elling5 distur.ing ot/er patients on t/e floor. 1. (iven t/e a.ove information5 3ou suspect t/at !r. %Is condition is caused .3' a. .. !. d. a. .. a. .. c. Post-operative infection $ementia Delirium (!orre!t ans-er* $epression True (!orre!t ans-er* Jalse "nfection A3poxia !edications

2. $elirium re9uires acute assessment.

3. $elirium is caused .3'

d. All of t,e a1o e (!orre!t ans-er* ). Some strategies to assist in carr3ing for !r. % *ould include' 0mar8 all t/at appl32 a. c. d. Realit/ orientation offered in a !alm3 non:ud)mental manner (!orre!t ans-er* %elling t/e patient to relax and /is an8le *ill /eal #one of t/e a.ove 1. $allin) famil/ to isit t,e patient (!orre!t ans-er*

Page 1= of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA

$ase Stud/ on Dementia

!s. $ is a @=-3ear-old female in a s8illed nursing facilit3 *it/ a diagnosis of Al6/eimerIs disease. !s. $ comes to t/e nursing station and appears ver3 upset. S/e tells 3ou t/at s/e is loo8ing for /er mot/er and as8s 3ou to /elp /er. Fou start *al8ing *it/ !s. $. D/ic/ of t/e follo*ing strategies *ould .e /elpful in assisting !s. $E
1. %elling /er t/at /er mot/er died a long time ago a. 1. 2. a. .. a. .. a. 1. a. .. a. .. %rue 'alse (!orre!t ans-er* True (!orre!t ans-er* Jalse True (!orre!t ans-er* Jalse %rue 'alse (!orre!t ans-er* True (!orre!t ans-er* Jalse True (!orre!t ans-er* Jalse

eassuring /er t/at ever3t/ing is o8a3 and t/at 3ou *ill /elp /er

3. Attempting to distract 1 redirect /er into a pleasura.le activit3 0eating5 singing2

). &sing realit3 orientation /oping to reverse /er cognitive losses.

+. As8ing /er to /elp 3ou *it/ a small tas8 and later 3ou *ill loo8 for /er mot/er toget/er

6. Cognitive losses related to Al6/eimerIs diseases are irreversi.le

4. Alt/oug/ p/armacologic agents ma3 .e /elpful 0in t/e presence of distur.ing delusions 1 /allucinations25 .e/avioral approac/es to treatment are t/e first-line in treating dementia. a. .. a. 1. True (!orre!t ans-er* Jalse %rue 'alse (!orre!t ans-er*

=. Promoting dependence 0*it/ feeding5 dressing5 toileting2 is advantageous for persons *it/ dementia.

@. Compensating for sensor3 impairments 0glasses5 /earing aides2 ma3 /elp minimi6e distur.ing illusions1 delusions. a. .. True (!orre!t ans-er* Jalse

$ompeten!/ 6. $ontrast !riteria for differentiatin) depression3 delirium3 and dementia in

Page 1@ of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA older adults.; Often depression5 delirium5 and dementia can co-exist so t/e follo*ing protocol s/ould .e follo*ed' A. <. C. $elirium assessment and treatment 1st $epression assessment and treatment 2nd $ementia assessment and treatment 3rd

Page 2, of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA RESOUR$ES Agenc3 for Aealt/ Care Polic3 and esearc/. 01@@62. Earl3 identification of Al1heimer2s disease and related dementias. Aut/or. Agenc3 for Aealt/ Care Polic3 and esearc/. 01@@32. *epression in primary care: Treatment of ma,or depression. Aut/or. American Ps3c/iatric Association. 01@@@5 !a32. Practice guideline for t/e treatment of patients *it/ delirium. American Psychiatric Association. American Journal of Psychiatry. &/6. 1-2,. Anderson5 A. B. 02,,22. %reatment of depression in older adults. International Journal of Psychosocial Rehabilitation, 65 6@-4=. <eers5 !. ? <er8o*5 . 02,,,2. The merc) manual of geriatrics. 03rd ed.2. D/ite/ouse Station5 #B' !erc8 and Co. <utler5 . 01@4)2. Successful aging and t/e role of life revie*. Journal of the American $eriatric (ociety, !!5 +2@-+3+. <utler5 . #.5 Le*is5 !. ".5 ? Sunderland5 %. 01@@22. Aging and mental health: Positive psychosocial and biomedical approaches. 0)t/ ed.2. Colum.us5 OA' C/arles E. !errill. $ood35 . S.5 Stevens5 B. C.5 <ec85 C. et al. 02,,15 !a32. Practice parameter' !anagement of dementia 0an evidence-.ased revie*2. Report of the 0uality (tandards (ubcommittee of the American Academy of eurology. eurology, "0+62. 11+)-1166. Jeil5 #. 01@@32. 3alidation brea)through: (imple techni4ues for communicating 5ith people 5ith Al1heimer2s type dementia. <altimore' Aealt/ Professions Press. Joreman5 !. $.5 !ion5 L. C.5 %r3gstad5 L. B.5 Jletc/er5 C.5 and t/e #"CAE Jacult3. 01@@@2. Acute confusion1delirium' Strategies for assessing and treating. "n ". A.ra/am5 !. <ottrell5 %. Julmer5 ? !. !e6e3. 0Eds.2. $eriatric nursing protocols for best practice 0pp. 63-462. #e* For8' Springer Pu.lis/ing Compan3. Aam5 . B.5 ? Sloane5 P. $. 01@@42. Primary care geriatrics: A case+based approach 03rd ed.2. #e* For8' !os.3. Aolro3d5 S.5 ? Cla3ton5 A. A. 02,,,2. !easuring depression in t/e elderl3' D/ic/ scale is .estE #edscape $eneral #edicine, !0)2. etrieved April 3,5 2,,) from /ttp'11***.medscape.com1vie*article1)3,++) Ao3ert5 $. L.5 Coc/ane85 C. $.5 ? !urp/35 S. L. 01@@@2. $eat/s' Jinal data for 1@@4. ational 3ital (tatistics Report "nsel5 C. C.5 ? <adger5 %. S. 02,,22. $ecip/ering t/e ) $Is' cognitive decline5 delirium5 depression and dementia > a revie*5 Journal of Advanced ursing, '"0)25 36,-36=.

Page 21 of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA Coenig5 A. (.5 !eador5 C. (.5 Co/en5 B. B.5 ? <la6er5 $. (. 01@==2. Self-rated depression scales and screening for ma:or depression in t/e older /ospitali6ed patient *it/ mental illness. Journal of the American $eriatrics (ociety, 6@@-4,6. Curlo*ic65 L. 01@@@5 !a32. %/e geriatric depression scale. Try this: best practices in nursing care to older adults. &01)2. #e* For8' Aartford "nstitute for (eriatric #ursing. #e* For8 &niversit35 $ivision of #ursing. Curlo*ic65 L. A.5 ? t/e #"CAE Jacult3. 01@@@2. $epression in elderl3 patients. pp. 111-13,. ". !. A.ra/am5 !. <ottrell5 %. Julmer5 ? !. !e6e3 0Eds.2. $eriatric nursing protocols for best practice. #e* For8' Springer Pu.lis/ing Compan3. Luggen5 A. S. 01@@62. %ore curriculum for gerontological nursing. St. Louis5 !O' !os.3-Fear <oo8. !addox5 (.5 et al. 0Eds.2. 02,,12. The encyclopedia of aging. 03rd ed.2. #e* For8' Springer Pu.lis/ing Compan3. !e6e35 !. et al. 0Eds.2. 02,,12. The encyclopedia of elder care. #e* For8' Springer Pu.lis/ing Compan3. #e6u5 A. !.5 ? #e6u5 C. !5 ? Perri5 !. (. 01@=@2. Problem+solving therapy for depression: theory, research, and clinical guidelines. #e* For8' Dile3. #"A Consensus $evelopment Panel. 01@@22. $iagnosis and treatment of depression in late life. Journal of the American #edical Association, !6", 1,1= > 1,2). Petersen5 . C.5 Stevens5 B. C.5 (anguli5 !.5 %angalos5 E. (.5 Cummings5 B. L.5 ? $eCos835 S. %. 02,,12. Practice parameter' Earl3 detection of dementia' !ild cognitive impairment 0an evidence-.ased revie*2. American Academy of eurology, /65 1133-11)2. ader5 B. ? %orn9uist5 E. 01@@+2. Individuali1ed dementia care: %reative, compassionate approaches. #e* For8' Springer. eis.erg5 <.5 Jerris5 S. A.5 de Leon5 !. B.5 ? Croo85 %. 01@=22. %/e glo.al deterioration scale for assessment of primar3 degenerative dementia. American Journal of Psychiatry, &'.5 1136-113@. S/ei8/5 . L.5 ? Fesavage5 B. A. 01@=62. (eriatric depression scale 0($S2. ecent evidence and development of a s/orter version. %linical $erontologist, /, 16+-143. Fesavage5 B. A.5 <rin85 %. L.5 ose5 %. L.5 Lum5 O.5 Auang5 O.5 Ade35 !.5 ? Leirer5 O. O. 01@=32. $evelopment and validation of a geriatric depression screening scale' A preliminar3 report. Journal of Psychiatric research, &6, 34-)@. Fos/i8a*a5 %. %.5 Co..s5 E. L.5 ? <rummel-Smit/5 C. 01@@=2. Practical ambulatory geriatrics. 02nd ed.2. #e* For8' !os.3.

Page 22 of 26

MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA Ot,er Resour!es

1. 2.

Al6/eimerIs Association /ttp'11***.al6.org1 Administration on Aging/ttp'11***.aoa.d//s.gov /ttp'11***.nia.ni/.gov

3. #ational "nstitute on Aging

DELIRIUM SPE$I'I$ TOPI$ RESOUR$ES <ournal Arti!les American Ps3c/iatric Association. 02,,,2. *iagnostic and statistical manual of mental disorders 0)t/ Ed. %ext ev.2. Das/ington5 $C. C/an5 $.5 ? <rennan5 #. 01@@@2. $elirium' !a8ing t/e diagnosis5 improving t/e prognosis. $eriatrics, /70325 2=-)2. Jla/ert35 B. A. 01@@=2. Ps3c/ot/erapeutic agents in older adults. Commonl3 prescri.ed and overt/e-counter remedies' causes of confusion. %linics in $eriatric #edicine, &70125 1,1-124. "nou3e5 S. C.5 <ogardus5 S. %. Br.5 C/arpentier5 P. A.5 Leo-Summers5 L.5 Acampora5 $.5 Aolford5 %. .5 ? Coone35 L. !.5 Br. 01@@@2. A multicomponent intervention to prevent delirium in /ospitali6ed older patients. e5 8ngland Journal of #edicine, '795 66@-646. "nou3e5 S. C.5 van $3c85 C. A.5 Alessi5 C. A.5 <al8in5 S.5 Siegal5 A. P.5 ? Aor*it65 . ". 01@@,2. Clarif3ing confusion' %/e confusion assessment met/od. A ne* met/od for detection of delirium. Annals of Internal #edicine, &&'01225 @)1-@)=. app5 C.5 Da8efield5 <.5 Cundrat5 !.5 !entes5 B.5 %ripp- eimer5 %.5 Culp5 C.5 !o.il35 P.5 A8ins5 B.5 ? Onega5 L. 02,,,2. Acute confusion assessment instruments' Clinical versus researc/ usa.ilit3. Applied ursing Research, &'012, 34-)+. Segatore5 !.5 ? Adams5 $. 02,,12. !anaging delirium and agitation in elderl3 /ospitali6ed ort/opaedic patients' Part "-%/eoretical aspects. :rthopaedic ursing, !9;125 31-)+.

+oo=s Joreman5 J. $.5 !ion5 L. C.5 %r3gstad5 L.5 ? Jletc/er5 C. 02,,32. $elirium' Strategies for Assessing and %reating. "n !. !e6e35 %. Julmer5 ". A.ra/am 0Eds.25 $. K*ic8er 0!anaging Ed.25 $eriatric nursing protocols for best practice 02nd ed.5 pp. 116-1),2. #e* For8' Springer Pu.lis/ing Compan35 "nc. Jla/ert35 E.5 Julmer5 %.5 ? !e6e35 !. 02,,32. $eriatric nursing revie5 syllabus: A core curriculum in advanced practice geriatric nursing. #e* For8' American (eriatrics Societ3. Cotter5 O. %. ? Strumpf5 #. E. 02,,12. Advance practice pursing 5ith older adults: %linical guidelines. #e* For8' !c(ra* Aill.

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA A(S Panel. 0&pdated annuall32. $eriatrics at your fingertips. American (eriatrics Societ3. <lac8*ell Pu.lis/ing. <eers5 !.5 ? <er8o*5 . 02,,,2. The merc) manual of geriatrics 03rd ed.2. D/ite/ouse Station5 #B' !erc8 and Compan3. !e6e35 !. $. 0Editor in C/ief25 <er8man5 <. B.5 Calla/an5 C. !.5 Julmer5 %. %5 !itt35 E. L.5 Pave6a5 (. B.5 Siegler5 E. L.5 ? Strumpf5 #. E. 0Eds.27 <ottrell5 !. !. 0!anaging Ed.2. 02,,12. The encyclopedia of elder care. #e* For8' Springer Pu.lis/ing Compan35 "nc. Assessment1Screening %ools Das63ns8i5 C. !. 0#ov 2,,12. Try this: <est practices in nursing care to older adults: %onfusion assessment method, Issue =&' . etrieved Bune 65 2,,)5 from %/e Bo/n A. Aartford "nstitute for (eriatric #ursing5 $ivision of #ursing5 Sc/ool of Education5 #e* For8 &niversit3 De. site' /ttp'11***./artfordign.org1pu.lications1tr3t/is1issue13.pdf Curlo*it65 L5 ? Dallace5 !. 0Ban 1@@@2. Try this: <est practices in nursing care to older adults: The mini mental state e-amination ;##(8>, Issue =' . etrieved Bune 65 2,,)5 from %/e Bo/n A. Aartford "nstitute for (eriatric #ursing5 $ivision of #ursing5 Sc/ool of Education5 #e* For8 &niversit3 De. site' /ttp'11***./artfordign.org1pu.lications1tr3t/is1issue,3.pdf %/e egistered #urses Association of Ontario 0 #AO2 #ursing <est Practice (uidelines 0#<P(2 Pro:ect. <est practice guideline: (creening for delirium, dementia and depression in older adults. etrieved Bune 65 2,,)5 from /ttp'11***.rnao.org1.estpractices1completedQguidelines1<P(Q(uideQC3Qddd.asp

Related Professional Or)ani9ations A(S (eriatrics At Four Jingertips Online Edition - /ttp'11***.geriatricsat3ourfingertips.org1 #urse Competence in Aging 0#CA2' /ttp'11***.geronurseonline.org1 Oregon Aealt/ Sciences &niversit3 Sc/ool of #ursing' %/e Bo/n A. Aartford Joundation Center of (eriatric #ursing Excellence' /ttp'11***.o/su.edu1/artfordcgne1 %/e Bo/n A. Aartford Joundation "nstitute for (eriatric #ursing' (eriatric De. Sites' /ttp'11***./artfordign.org %/e !erc8 "nstitute of Aging and Aealt/ Aome Page' /ttp'11***.mia/online.org1index./tml Evidence-<ased $elirium "nformation. etrieved Bune 65 2,,)5 from /ttp'11***.mia/online.org1mia/1servlet1<ro*se!"AAElaPen?9pP?9tP;2<topics;3A ;22$elirium;22?resourcesP?topicsP;2<topics;3A;22$elirium;22?xP1)?3P) %/e egistered #urses Association of Ontario 0 #AO2 #ursing <est Practice (uidelines 0#<P(2 Pro:ect. etrieved Bune 65 2,,)5 from /ttp'11***.rnao.org1.estpractices1a.out1.estPracticeQovervie*.asp

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA

&niversit3 of "o*a College of #ursing' %/e Bo/n A. Aartford Center of #ursing Excellence' /ttp'11***.nursing.uio*a.edu1/artford1index./tm &niversit3 of Penns3lvania Sc/ool of #ursing' Aartford Center of (eriatric #ursing Excellence' /ttp'11***.nursing.upenn.edu1centers1/cgne1a.out./tm "o ernment Information A)en!ies #ational (uideline Clearing/ouse1Agenc3 for Aealt/care esearc/ and Hualit3. 02,,35 !odified !a3 315 2,,)2. *elirium: (trategies for assessing and treating. etrieved Bune 65 2,,)5 from /ttp'11***.guideline.gov1summar31summar3.aspxEdocQidP3+,@?n.rP243+?stringPdelirium &nited States $epartment of Aealt/ and Auman Services' Aging' /ttp'11***.//s.gov1aging1index.s/tml Re)ulator//Aut,oritati e Sites 6 S!opes and Standards3 Position Papers3 et! American (eriatrics Societ3. 02,,12. (uidelines and Position Statements' /ttp'11***.americangeriatrics.org1products1positionpapers1 American !edical $irectors Association 0A!$A2. 02,,)2. Resour!e Li1rar/% /ttp'11***.amda.com1li.rar31 #ational Conference of (erontological #urse Practitioners' Aome Page' /ttp'11***.ncgnp.org #ational (erontological #ursing Association' Aome Page' /ttp'11***.ngna.org1 %/e (erontological Societ3 of America' Aome Page' /ttp'11***.geron.org1 &nited States $epartment of Aealt/ and Auman Services' Aome Page' /ttp'11***.//s.gov1 $ontinuin) Edu!ation Opportunities A$OA#CE #e*smaga6ines' Aome Page' /ttp'11***.advance*e..com1 A$OA#CE Continuing Education De.site' /ttp'11***.advance*e..com1ce.asp A#A Continuing Ed Online Education' /ttp'11nursing*orld.org1ce1ce/ome.cfm !edcom-%rainex - Oarious (erontological #ursing topics' /ttp'11***.medcominc.com1 !edscape from De.!$' #urses CE Center' /ttp'11***.medscape.com1cmecenterdirector31nursesEsrcP/dr #ational Association of (eriatric Education Centers' /ttp'11***./coa.org1nagec1 #e* For8 &niversit35 Stein/ardt Sc/ool of Education5 $ivision of #ursing5 Center for Continuing Education' /ttp'11***.n3u.edu1education1nursingne*1institutes./tml

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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA Online ceuIs' A director3 for nurses. (eriatric Classes Online' /ttp'11***.nurseceu.com1geri./tm Sigma %/eta %au "nternational Aonor Societ3 of #ursing' Continuing Education' /ttp'11***.nursingsociet3.org1education1ceonlineQactivities./tml %/e Bo/n A. Aartford Joundation "nstitute for (eriatric #ursing' (erontological #ursing Certification evie* Course /ttp'11***.n3u.edu1education1nursing1/artford.institute1course1 &niversit3 of "o*a College of #ursing' Continuing Education' /ttp'11***.nursing.uio*a.edu1conted1conferences./tmT1 &niversit3 of Penns3lvania Sc/ool of #ursing' Continuing Education' /ttp'11***.nursing.upenn.edu1ce1 Nurse trainin) materials (i.e. ideos3 self6stud/ materials* (eriatric Oideo Productions' ***.geriatricvideo.com #ursing Spectrum Education1CE' Self-Stud3 !odules' /ttp'11***.nursingspectrum.com1ContinuingEducation1#SSelfStud31index.cfm %/e Bo/n A. Aartford Joundation "nstitute for (eriatric #ursing' <est #ursing Practices in Care of Older Adults' /ttp'11***./artfordign.org1resources1education1curriculum(uide./tml %/e Bo/n A. Aartford Joundation "nstitute for (eriatric #ursing 02,,32. Partners for $issemination of <est #ursing Practices in Care of Older Adults. /ttp'11***./artfordign.org1resources1education1.snPartners./tml

$onsumer (patient and or famil/* related resour!es %/e egistered #urses Association of Ontario 0 #AO2 #ursing <est Practice (uidelines 0#<P(2 Pro:ect. 0Site in progress2' %aregiving strategies for older adults 5ith delirium, dementia, and depression. etrieved Bune 65 2,,)5 from /ttp'11***.rnao.org1.estpractices1inQprogressQguidelines1.estPracticeQfourt/C3cle.aspTddd $epartment of Aealt/ and Auman Services5 Centers for $isease Control and Prevention' Aome Page' /ttp'11***.cdc.gov1 #ational "nstitutes of Aealt/' Aealt/ "nformation' /ttp'11/ealt/.ni/.gov1 &.S. #ational Li.rar3 of !edicine and #ational "nstitutes of Aealt/' !edline Plus Lin8s to multiple governmental5 private5 and professional *e. sites' /ttp'11***.nlm.ni/.gov1medlineplus1 &nited States $epartment of Aealt/ and Auman Services' Aome Page' /ttp'11***.//s.gov1

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