DEMENTIA:

• Prevention: There are 12 potentially modifiable risk factors that have been found to be associated with dementia. These include hypertension, diabetes, obesity and lack of physical activity, smoking, high alcohol consumption, unhealthy diet, depression, traumatic brain injury, social isolation, air pollution, and hearing loss. Research has found that lifestyle modification aimed at specific risk factors could decrease the incidence of dementia by 40%.

• Identification: There is insufficient evidence to support dementia screening among people who do not exhibit signs of dementia. But early identification is important and when changes in cognition, behavior, mood, and/or function are observed or reported, screening should occur. Earlier detection allows for improved brain health, better management symptoms, and early capture of their care preferences. Diagnosis can be made with cognitive/neurological tests, brain scans, psychiatric evaluation, genetic testing, and CSF and blood tests.
  • When signs/symptoms of dementia are observed or reported, screen patients age 65 and over. It is recommended to establish clinical workflow integration for documentation within your EMR. There are various screening tool options available:
    • Short BleSSed Test (SBT)
      • Weighted six-item instrument designed to identify dementia.
      • Evaluates orientation, registration, and attention.
    • Abbreviated Mental Test Score (AMTS)
      • Can be used to rapidly assess elderly patients for the possibility of dementia
      • Consists of 10 questions, each worth one point.
      • Score of 6 or less is suggestive of delirium or dementia. Further testing is necessary to confirm a diagnosis.
    • Rowland Universal Dementia Assessment Scale (RUDAS)
      • 6-item scale that assesses the cognitive domains of memory, praxis, language, judgement, drawing, and body orientation.
    • MiniCog
      • Considered a routine ‘cognitive vital sign’ measure.
      • A composite of three-item recall and clock-drawing

• Management: The overall goal for managing dementia is to reduce suffering caused by the cognitive and accompanying symptoms while delaying progressive cognitive decline. This is most often done by using both pharmacologic and non-pharmacologic approaches.  Ideas for these approaches are found below in the Interventions

• Interventions
  • Implement a geriatric specific order-set to highlight care considerations for patients with dementia. Consider including items like: a pain assessment scoring tool for dementia patients, non-pharmacological treatments including music therapy, massage, sensory stimulation, and aromatherapy. Also include development of personal care routines and assurance of effective communication practices.
  • If patients have not yet been started on medications aimed at symptomatic benefits for cognitive symptoms, ensure that they receive prompt follow-up after hospital discharge to be evaluated by their PCP.
  • Provide a 4M’s Educational Brochure to patients age 65 and over. 4M’s Provider Toolkit and 4M’s Patient Brochure
    • The four M’s include: what Matters, Mobility, Medication, and M The intent is to provide a guide for older adults and their families to evaluate how they think about the 4M’s and develop resources to help them proactively interact with their health care team.

• Other Considerations
  • Recommend follow-up with a PCP for further evaluation if concerns are noted.
  • Screening is only one small part of a comprehensive assessment and is not a conclusive diagnosis
  • If a person is acutely ill or is experiencing delirium, it is recommended that health-care providers postpone in-depth dementia assessments and a diagnosis until the person is stable and reversible causes are addressed.
  • Clinical guidelines suggest that depression be treated before a dementia diagnosis is made
  • Assessment for dementia should be conducted after delirium screening.

DEPRESSION:

• Prevention: The ability to prevent depression is unknown. However, it is necessary for health care providers to place their focus on identification.

• Identification: Health-care providers must be vigilant for depression among older adults, and assess for depression whenever risk factors or signs and symptoms are present. Unfortunately, depression is often not recognized, is under-diagnosed, and frequently goes untreated. Furthermore, few older adults actively seek treatment or see a mental health specialist to manage their depression. A detailed assessment for depression should occur when risk factors are present or when depression is suspected
  • When signs/symptoms of depression are observed or reported, screening should be completed. It is recommended to establish clinical workflow integration for documentation within your EMR. There are various screening tool options available:

• Geriatric Depression Scale
  • Provides a quantitative rating of depression
  • Available in 15-questions or 30-question All questions are YES/NO
• Patient Health Questionaire-2 (PHQ-2)
  • “First Step” approach with two-question screening regarding the frequency of depressed mood and anhedonia over the past two weeks
  • If the patient has a positive screen (3 or above), proceed to further screening with the PHQ-9.
• Patient Health Questionnaire-9 (PHQ-9)
  • Used for diagnosing, monitoring, and measuring the severity of depression
  • Nine question screening regarding the frequency of depressed mood and anhedonia over the past two weeks

• Management: Health-care providers should ensure that follow-up support and resources are available for older adults who are identified as having depression. Experts suggests that qualified health-care professionals may include a primary care practitioner, psychiatrist, or a psychogeriatric/geriatric mental health specialist. Other referrals to members of the health-care team may be necessary, especially to rule out or assess for co-morbid conditions that may mimic depression. If there is active suicidal ideation/risk of a person killing himself/herself, or if a person with depression presents a considerable immediate threat or harm to others, it is important to seek urgent attention from a qualified professional. A variety of pharmacological and non-pharmacological therapies with varying degrees of efficacy are available in clinical guidelines. When selecting treatment, health-care providers should start with the least invasive and most effective

• Interventions
  • Implement a Geriatric specific order-set to include screenings and referrals for those identified as high likelihood or at risk for depression.

• Other Considerations:
  • Due to the high prevalence of depression in people with dementia, health-care providers may need to consider the impact that co-morbid dementia has on individuals with depression. When these conditions co-exist, healthcare providers can offer many of the same interventions as they would for a person who only has depression, making any necessary adjustments to the approach and duration of the interventions.

DELIRIUM:

Delirium is defined as an abrupt change in the brain that causes mental confusion, emotional disruption, and/or perceptual disturbances.  Delirium increases a patient’s risk of morbidity and mortality, contributes to longer length of stays, and increases health care costs.  It develops over a short period (hours to days) and fluctuates over time.  Delirium is classified as: hyperactive, hypoactive, and mixed. Hypoactive delirium is often mistaken for depression or dementia.  Delirium is often underrecognized.

• Prevention (prevention and management interventions often overlap)
  • Pre-Op optimization (pain control, med management, education)
  • Post-Op mobility and pain management
  • Lighting: Soft light is recommended, but exposure to nature light is also shown to be beneficial for recovery times and decreasing delirium.
  • Acoustic Orientation Improvements: private rooms or acoustically enhanced drapes, if necessary, for better communication and decrease levels of anxiety and delirium.
  • Sleep hygiene – promote quiet and uninterrupted sleep
  • Provide sensory aids (hearing aids, dentures, glasses)
  • Provide frequent re-orientation
  • Limit physical restraints
  • Provide patient and family education brochure on delirium

• Identification
  • Implement routine screenings for injured patients age 65 and over. It is recommended to establish clinical workflow integration for documentation within your EMR.
    • 4AT
      • Include four items: Alertness – Abbreviated Mental Test-4 – Attention – Acute Change or Fluctuating Course
      • Scored from 0 to 12. Each of the four categories are assessed and scored. The sum of the 4 scores is the total.
      • Can be used on patient too drowsy to engage in testing or conversation since a score is provided instead of N/A or not-testable.
    • Confusion Assessment Measuring Instrument (CAM)
      • This is considered the “gold standard” for screening for delirium
      • Has sensitivity of 94-100%, specificity of 90-95% and high interobserver reliability
    • Nursing Delirium Screening Scale (Nu DESC)
      • Continuous, observational five-item scale
    • Recognizing Active Delirium As part of your Routine (RADAR) 18-19
      • Three-step process to identify delirium in the elderly population
      • Observation of three signs of altered LOC and inattention with each medication delivery.
    • There are also outpatient/Emergency Department screening options available:
      • Delirium Triage Screen
      • Brief Confusion Assessment Method Tool

• Management
  • It is important to treat delirium when it occurs. Prioritization must be given to the following items:
    • Pain assessment and management
      • Consider restlessness as an indicator of pain
      • Schedule acetaminophen
      • Utilize Ice/heat modalities
    • Activity and mobility
      • Providers need to place expectation of mobility on patient/staff/family
        • Up to chair for all meals
        • Walking 2-3 times per day
        • Update activity orders as needed – d/c bedrest orders
      • Sleep interventions and promotion
        • Shades open/lights on during day 8a-8p
        • Daytime activity/mobility to promote fatigue for sleep at night
        • Minimize nighttime interruptions (cluster cares)
      • Patient/Family education
      • Reduce lines/tethers
      • Sensory interventions
      • Cognitive stimulation/orientation
    • Upon diagnosis of acute delirium, attention should be paid to underlying causes including, but not limited to:
      • Infections: Commonly due to UTI or pneumonia
      • Medications: Including: Anti-cholinergic medications, sedative/hypnotics, narcotics, and any new medication, especially if multiple medications have been recently added
      • Electrolyte imbalances
      • Alcohol/drug use or withdrawal
    • Interventions
      • Implement a Geriatric specific order-set to include screenings and prevention measures, and precautions.
• Other considerations
  • New focal neurologic findings should guide an evaluation for stroke syndromes
  • Coordination of care, with special attention to directing interventions towards improving reversible causes and limiting factors that extend or cause delirium is the main goal.

As mental status changes wax and wane, delirium screening should be reevaluated on a regular basis.