Recognizing Dementia, Delirium and Depression in Older Adults

Dementia, depression, and delirium are among the most common psychiatric disorders seen with older adults and speak to the complexity of geriatrics. The overlap of symptoms prevalent in this triad is abundant. The ability to differentiate the subtle differences is vital to optimum outcomes to older adults. Understanding the differences and putting the proper interventions into place helps to ensure the best outcomes. Adding to the complexity of dementia, depression, and delirium is the very real possibility of having a combination of these issues, even all three concurrently. Mortality and morbidity rates increase with delirium with mortality rates from 22-76 percent in hospitalized patients and rates as high as 40 percent one year after diagnosis of delirium (Inouye, 2006). The possible cascade of negative outcomes, which can result from any combination of this trio, can cumulate into a significant alteration in the quality of life of an older adult.

This teaching strategy is designed to help students understand dementia, depression, and delirium. By better understanding this triad and developing a clearer understanding of the similarities and differences, the student will be better able to intervene to ensure the best outcomes. This strategy utilizes active learning to help students understand the content and to apply it to clinical practice.

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Recognizing Dementia, Delirium and Depression in Older Adults

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- Is It Dementia, Depression, or Delirium Game
Learning Objectives
Students will:
- Develop an understanding of behaviors associated with Alzheimer’s dementia
- Develop an understanding of the etiology of the behaviors
- Articulate an assessment of behavioral disturbances versus aggressive behaviors
- Recognize the risks associated with caregiver burnout with behavioral issues
- Create a tool box of approaches to intervening with the client with behavioral issues related to Alzheimer’s dementia
- Better understand the use of standardized tools in evaluating both behaviors and the etiology of behaviors
- Articulate possible safety concerns as they pertain to the behaviors discussed
Learner Pre-Work

Ask the students to review the following chart to differentiate Dementia, Depression and Delirium http://geropsychiatriceducation.vch.ca/docs/edu-downloads/dementia/3D_comparison_VIHA.pdf
Suggested Learning Activities
1.   Download the PowerPoint document labeled Is It Dementia, Depression, or Delirium Game. The document is a PowerPoint presentation of a game students can play, directed by a faculty facilitator. This strategy promotes active learning as the platform to discuss dementia, depression, and delirium. The speaker’s notes have additional information for the facilitator to continue the discussion. These notes also link to applicable tools that are pertinent to the content. It may be helpful to assign students a reading from their text books or prepare by reading an article such as:

Edwards, N. (2003). Differentiating the three D's: Delirium, dementia, and depression. Medsurg Nursing, 12(6), 347-57; quiz 358.

a.   The PowerPoint presentation needs to be viewed in slide show mode to play.
b.   Click to advance the slides to the next question, and double click to reveal the answer choices, then single click to reveal the correct answer. Repeat this to go through all fourteen questions.
c. There are points assigned to each question if the facilitator chooses to use the game in a competitive manner.
d.   The slides can be edited at the discretion of the facilitator to include any additional information.

2.   All of the ACE.Z unfolding cases - Ertha Williams, Judy Jones and George Palo - have elements of dementia, depression, and delirium and can be used in an active way to help students identify differences and interventions. These simulations can be utilized after the students play the Is It Dementia, Depression, or Delirium Game or independent of the game. In addition, any of the monologues could be used at the start of a lecture to spark discussion and have the students link the content to a first-person case study. These monologues can also be a dynamic part of an online discussion on dementia, delirium, and depression as the instructor can guide the learner to the audio clip of the case. In each case the patients have a level of confusion with an array of other symptoms that require the student to think about how they would further assess the patient and what interventions they would put into place based on the diagnosis and behavioral concerns.

a.   Judy Jones has an underlying dementia with a superimposed delirium resulting in an acute change in mental status and behavioral changes.
b.   George Palo has a mild cognitive impairment with worsening of cognitive impairment with a superimposed depression.
c.    Ertha has progressive Alzheimer’s dementia with worsening of her symptoms with time and transition.
d.   Utilize the Confusion Assessment Method in each of these simulation monologues to start the discussion on the differentiation between dementia and delirium.
e.   Utilize the following questions (Benner) to help further process the content in monologues:
- What are your concerns about this patient?
- What is the cause of the concern?
- What information do you need?
- What are you going to do about it?
- What is the patient experiencing?
Materials
- Recognition of Dementia in Hospitalized Older Adults
- Mental Status Assessment of Older Adults: The Mini-Cog™
- Assessing and Managing Delirium in Older Adults with Dementia
- Geriatric Depression Scale
- Mental Status Assessment in Older Adults: Montreal Cognitive Assessment MoCA
- The AD8: The Washington University Dementia Screening Test. Eight-Item Interview to Differentiate Aging and Dementia.
Suggested Reading

Benner, P., Sutphen, M., Leonard, V., Day, L., & Shulman, L. (2010). Paradigm case: Lisa Day, classroom and clinical instructor. In Educating nurses: A call for radical transformation (p. 133). San Francisco, CA: Jossey-Bass.

Bradway, C., Bixby, M. B., Hirschman, K. B., McCauley, K., & Naylor, M. D. (2013). Case study: Transitional care for a patient with benign prostatic hyperplasia and recurrent urinary tract infections. Urologic Nursing, 33(4), 177-179, 200.

Inouye, S. K. (2006). Delirium in older persons. New England Journal of. Medicine, 354(11),1157-1165. doi:10.1056/NEJMra052321

Steis, M. R., & Fick, D. M., (2012). Delirium superimposed on dementia: Accuracy of nurse documentation Journal of Gerontological Nursing, 38(1), 32-42. doi: 10.3928/00989134-20110706-01
Author Information

Laureen Tavolaro-Ryley, MSN, RN
Community College of Philadelphia
Philadelphia, PA