Delirium, dementia, and depression can coexist and are often difficult to diagnose in the older community-bound patient. Home healthcare clinicians need to understand symptoms of each of these conditions and remain astute in their assessment of these distinctly different entities. Failure to correctly identify delirium, dementia, and/or depression can delay treatment and result in poor quality of life.
Delirium
Delirium is considered an acute disturbance of mental status and behavior that can be reversed, and is common in both hospitalized and community-dwelling older patients. Delirium in the geriatric population is often misunderstood, undiagnosed, and can be responsible for unnecessary hospitalizations. Delirium presents as a constellation of symptoms, all related to an overall change in mental status (Halter, 2014). There are three types of delirium: hyperactive, hypoactive, and mixed. Patients may experience either hyper or hypoactive as well as a combination of both (mixed). Patients with delirium may present with rapid mood changes, agitation, restlessness, and/or hallucinations, or lethargy and sluggishness. Hyperactive delirium is often the most easily recognized due to the increased energy level as well as dramatic changes in behavior and mental status (Mayo Clinic Staff, 2015).
Conditions or diseases that put patients at higher risk of delirium include: advanced age (especially those who are postoperative), those with brain disorders, dementia, stroke, or Parkinson disease; patients with previous episodes of delirium; and those with hearing or visual disturbances. Clinicians should listen for and solicit feedback from family members regarding subtle changes in mental status and behavior to aid in diagnosing delirium (Mayo Clinic Staff, 2015).
Delirium can be related to one or several factors, which may include the presence of chronic or severe medical condition exacerbations, alcohol or drug withdrawal, infection or alterations in metabolic balance such as low sodium or calcium levels, malnutrition or dehydration, sleep deprivation or severe emotional distress, and exposure to toxins. Medications or combinations of medications can often trigger delirium, including: pain medications, hypnotics, antihistamines, and medications that treat mood disorders, asthma, Parkinson disease, or seizures.
Unlike dementia or depression, symptoms of delirium represent an acute change and occur over a period of a few hours or days. Symptoms can fluctuate and are often absent during the day, but worsen in the evening or when patients are exposed to unfamiliar environments (such as hospitals). Common symptoms of delirium are categorized into four areas: (1) Reduced awareness of their environment, which consists of an inability to stay focused on a topic or appropriately change topics along with an increased distraction. Patients will often become stuck on an idea, rather than engaging in a conversation appropriately. They can also become withdrawn with a decrease in activity level and newly noted decrease in response to their environment. (2) The second group of symptoms involves cognitive or thinking skills. Patients will display poor memory, most often of recent events, disorientation, and difficulty recalling words or speaking. There might be rambling or nonsense speech, and difficulty understanding speech or written directions. (3) Emotional changes and disturbances are another category of symptoms characteristic of delirium. Patients may experience anxiety, paranoia, fear, euphoria, apathy, irritability, or anger. They may also experience rapid and unpredictable mood changes and changes in personality. (4) Finally, behavioral changes characteristic of patients experiencing delirium include: restlessness, agitation or combative behavior, sleep disturbance with wakefulness at night and sleepiness during the day. Patients may moan or call out making sounds, or they may be quiet and withdrawn with slowed movement and lethargy (Mayo Clinic Staff, 2015).
Dementia
Dementia is an umbrella term assigned to a number of neurocognitive disorders that represent the progressive deterioration of global and cognitive functioning (Halter, 2014). Alzheimer disease (most common), Lewy body dementia, vascular dementia, frontotemporal lobe, mixed dementia, Parkinson disease, Creutzfeldt-Jakob disease, and Wernicke-Korsakoff syndrome all fall under the dementia umbrella. Dementia is not considered a normal part of aging.
Patients with dementia struggle with memory and executive function, self-care tasks related to toileting, bathing/grooming and taking medications accurately, and personal safety challenges such as driving, wandering, and falls. In later stages of dementia, most patients are faced with infections such as urinary tract infections and pneumonia (related to a limited ability to chew and swallow) as well as malnutrition and dehydration and physical trauma related to injuries from falls. Death in late-stage dementia is often from coma related to infection (Mayo Clinic Staff, 2016).
Clinicians should be aware that patients with dementia can also show signs and symptoms of depression and experience a higher incidence of delirium (Mayo clinic Staff, 2015). Due to the potentially co-occurring states of dementia, depression, and delirium, it is often difficult to determine what the patient is presenting with during an assessment. Note the onset of symptoms, the patient's level of attention, and the appearance of fluctuating symptoms.
The onset of delirium occurs over a short period of time (hours to days), whereas dementia begins with minor symptoms over months or years and becomes progressively more debilitating. The ability to stay focused and attentive is impaired for a patient suffering from delirium, whereas patients in the early stages of dementia are able to stay alert and focused. Finally, symptoms of delirium tend to fluctuate. Symptoms can fluctuate frequently and significantly throughout the day in delirium, whereas individuals with dementia remain relatively stable through a slow progression of the disease. Dementia patients may have periods of time during the day where they are better or worse, but their memory and thinking skills remain relatively consistent and without dramatic changes throughout the day (Mayo clinic Staff, 2015).
Depression
Depression is a mood disorder that impacts how the patient feels and behaves. Patients usually have difficulty performing day-to-day activities due to loss of interest and persistent feelings of sadness. In severe cases of depression, patients often express a lack of motivation and feel that life is not worth living (Mayo Clinic Staff, 2017). Individuals may socially withdraw, curtail normal activities, lose or gain weight, experience anxiety, and have difficulty with sleep disturbance. Depression can be treated with medications and psychotherapy and patients can fully recover to lead a better quality of life. Depression can be distinguished from dementia and delirium through depression assessment scales, such as the Geriatric Depression Scale and an assessment of the psychiatric history, patient's mood, and energy level. Depression is common and often untreated in the older individual; it can coexist with dementia and increases the risk for delirium. Patients with significant depression may exhibit poor memory and decreased energy levels, which may be mistaken for symptoms of dementia or delirium.
Home healthcare clinicians can significantly impact the quality of life of their patients by remaining vigilant to the acute symptoms of delirium, the progressive symptoms of dementia, and the emotionally debilitating symptoms of depression. Recognition and treatment can decrease the risk for hospitalization and improve the patient's and family's quality of life.
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