Johnston: Materials for Norcal GEC Faculty Development Program 4-04 DRAFT

Johnston: Materials for NorCal GEC Faculty Development Program 4-04 DRAFT

Dementia, Depression, and Delirium

Learning Objectives By the end of this session, participants will be able to: 1. Describe normal changes of cognition with aging

2. Describe the risk factors, prevalence and clinical course of delirium, dementia, and depression.

3. Compare and contrast the clinical features of delirium, dementia, and depression

4. List and describe common screening and diagnostic tools for delirium, dementia, and depression

5. Describe management techniques for the above syndromes, with a focus on your own discipline

Resources

1. The Clock Draw Test 2. The Geriatric depression scale (short form) 3. Hamilton Psychiatric Rating Scale for Depression 4. The CAM (confusion assessment method) 5. MMSE and MMSE norms 8. The global deterioration scale (GDS) for dementia 9. The Cornell Scale for Depression in Dementia

This session will use a case based, small group discussion format to explore the above topics. Johnston: Materials for NorCal GEC Faculty Development Program 4-04 DRAFT

Dementia, Delirium, and Depression

Part One

Mr. Garcia is an 85-year-old Latino farmer from Modesto who is your new patient. He comes in today because he is finding that he feels “awkward” at his longstanding poker club, and can no longer think of “conversation”. He is concerned that he might be losing his memory. He also finds that he now gets no enjoyment out of getting together with his friends.

Mr. Garcia lives alone on a farm, and his wife of many years died 2 years ago. He drives to get to the church and the grocery, but is not getting out much otherwise. He also has mild osteoarthritis, for which he takes acetaminophen.

1. What cognitive changes of aging are “normal”? Abnormal?

2. What do you think is going on?

3. How would you explore this further?

Part Two

You discuss the situation with Mr. Garcia and agree that you need to explore his memory further. He tells you that his primary language was Spanish, but he is now equally comfortable in English or Spanish. He completed the ninth grade and is able to read.

You do a MMSE (in English) and he scores 26/30, missing two of three objects at five minutes and two letters of “world” backwards, saying “I was never good at spelling”.

1. How do you interpret his MMSE?

2. Does education and language influence the results?

3. What other tests might you administer?

Part Three

His GDS (short form) is 7/15. He says he has dropped most of his activities and interests, his life is empty, he is bored, and has no energy for things. He is worried that his real life is over and he is worried that he will become a burden to his children. He currently stays at home most of the time, and worries that his memory is “shot”. He is not satisfied with his life, (“who would be?”) but denies that he is depressed (“I am not the type to feel sorry for myself”).

1. Do you think he is depressed? Johnston: Materials for NorCal GEC Faculty Development Program 4-04 DRAFT

2. What else would you want to know?

3. What risk factors does he have for depression?

4. How can you help differentiate depression from dementia in this setting? Johnston: Materials for NorCal GEC Faculty Development Program 4-04 DRAFT

Part Four

After discussion, Mr. Garcia agrees to take an antidepressant. He is started on sertraline 50mg nightly and notes improvement.

Mr. Garcia did well for over a year, however, now he is back with his son, who noted that Mr. Garcia’s phone was disconnected after Mr. Garcia failed to pay a bill. Mr. Garcia denies any problems, and says he has been “ok” since you started him on the new pill.

1. What do you think is going on?

2. What do you do now?

Part Five

You repeat a MMSE and a GDS on Mr. Garcia. His MMSE is now 21/30, with Mr. Garcia missing the date, 3/3 objects, 4 letters of WORLD, and the overlapping pentagons. His GDS is now 3/15.

1. What do think is going on now? Why?

2. What other evaluation would you perform?

3. How can you differentiate between depression and dementia?

4. What risk factors does Mr. Garcia have for dementia?

5. What interventions would you make at this point?

6. Would you tell him that he has dementia? Why or why not?

7. What are your legal obligations (this will vary from state to state)?

Part Six

Mr. Garcia has done relatively well for three months after moving in with his son. However, now Mr. Garcia is in the hospital with a hip fracture. When you go to see him, he is picking at the air and is moaning. Now his MMSE is only 7/30, and Mr. Garcia seems to drift off during the test without answering questions.

1. Now what do you think is going on? Why?

2. What other evaluation would you perform?

3. What risk factors does Mr. Garcia have for delirium? Johnston: Materials for NorCal GEC Faculty Development Program 4-04 DRAFT

4. How can you differentiate between delirium and dementia? Delirium and depression?

5. What interventions would you make at this point? SCHEDULE Objectives Covered

1-1:15 Introduction and Review of Learning Objectives

1:15-2:00 Discussion of case parts I & II 1, 2, 3, 4

2:00-2:45 Discussion of case parts III & IV 2, 3 ,4 , 5

2:45-3:00 Break

3:00-3:45 Discussion of case parts V and VI` 2, 3, 4, 5

3:45-4:30 Review each of the syndromes individually 3:45-4:00 Depression 2,3,4,5 4:00-4:15 Dementia 2,3,4,5 4:15-4:30 Delirium 2,3,4,5

4:30-4:50 Discuss educational strategies applied to this session 6

Readings 1. Current Geriatric Diagnosis and Treatment, Chapter 10, Chapter 11, and pages 100-107 of Chapter 14.

Additional References

Alexopoulos GS et al. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988: 23: 261- 270.

Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003 Oct;51(10):1451-4.

Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993 May 12;269(18):2386-91.

Wolf-Klein GP et al. Screening for Alzheimer’s disease by clock drawing. JAGS. 1989; 37: 730-734.

Yesavage JA. Geriatric depression scale. Psychopharmacol Bull 1988: 24: 709. Johnston: Materials for NorCal GEC Faculty Development Program 4-04 DRAFT