Confusion

Dementia
Dementia is a syndrome or set of symptoms and signs which usually occur at the same time and is due to a disease in the brain. It is usual y progressive or chronic and there is impairment of memory, thinking, orientation, learning capacity, language and judgement. These changes to cognition occur in a fully alert person and this feature distinguishes dementia from delirium in which there is an alteration of the individual’s level of consciousness. Changes in cognition in dementia are commonly accompanied and occasionally preceded by deterioration in the person’s emotional control, social behaviour or motivation. Cognitive decline that occurs in dementia represents a decline from the individual’s earlier functioning and is progressive over time. Signs and symptoms of dementia vary and this is not only due to individual differences but is also related to the specific type of dementia, the personality of the person experiencing the dementia, the presence of other problems (physical or psychiatric), and the environment, for example, in the nursing home context. Changes in behaviour often impinge significantly on relationships with others. Cognitive Signs and Symptoms of Dementia Memory is often the first behaviour to be affected in dementia and deterioration in short term or recent memory, in particular, causes the most difficulty. Long-term memory is not affected to the same extent until quite late in the disease. Changes may also affect the person’s orientation (to time, place and person), thinking (which becomes more concrete), comprehension, language, learning capacity, calculation and judgment. Changes in these behaviours will severely affect daily activities and overall functioning. Other cognitive changes often include apraxia, agnosia, and aphasia. Apraxia is the inability to perform specific movements at the request of others or by imitation and includes a loss of coordination thus affecting the person’s mobility and daily activities of living, such as dressing and eating. In agnosia the person fails to recognise or identify objects and their purpose due to sensory function changes, for example, where an older male resident with dementia tries to cut up his food using a fork. Aphasia relates to deterioration and disturbance of language, for example, the person with dementia may be unable to comprehend what is being asked of them and is therefore unable to Behaviour Changes Associated with Dementia Behaviour changes associated with dementia have been referred to as inappropriate, for example, an old man exposing himself in company; challenging, that is, the changes create difficulties for the nurse, for example, wandering and interfering with other residents’, problem behaviours (including delusions and hallucinations). Challenging behaviours refer to behaviours, associated with dementia, that cause difficulties for others. It is judged from the observer’s point of view (e.g. the nurse) as being challenging whilst the older person who is experiencing the behaviour may consider the behaviour as being appropriate (or even goal-directed, for example, trying to return to the original family home). Challenging behaviours include aimless wandering, pacing, cursing, screaming, biting, and fighting. Agitation is a common problem that people with dementia experience. It has been defined by Thomas & O’Brien, 2004, p.517, as “an inner tension associated with excessive motor activity” which disturbs others. It may follow aggression or abuse, be performed to excess, for example, in the form of repetitive mannerisms or questions, or may be inappropriate for the social situation, for example, taking clothes off in front of others. Challenging behaviours may be severe, unpredictable and frequent. It should be pointed out though, that there is not always a fixed relationship between behavioural changes and cognitive decline in Alzheimer’s disease and they can occur at all stages of Alzheimer’s disease. Various writers suggest that psychotic symptoms, for example, delusions and hallucinations, occur in 20% to 50% of cases of dementia. Common delusions in patients with Alzheimer’s disease include the belief that people are stealing their possessions and misidentification, for example, the person might state that her husband is a stranger. Moderate associations have been noted among paranoid delusions, mis-identification delusions and behavioural disturbance. Hallucinations are perceptions that occur in the absence of an external stimulus and affect al the senses. They are more common in severe dementia and more likely to be visual, for example, they might see children when there is no one else present. Also, with the progression of Alzheimer’s disease, there is a steady increase in the percentage of time spent awake which may suggest changes are Changes in memory, inability to coordinate activities, poor judgment and an inability to learn new skills, all affect the ability of the older person with dementia to carry out the physical demands of daily living. Generally, there is a pattern of decline that occurs beginning with Instrumental Activities of Daily Living (IADLs), progressing to Activities of Daily Living (ADLs) and during the end stage of dementia even the skil s associated with eating and speaking may be lost. Loss of mobility may cause persons with dementia to be unsteady, at risk of falls or other injury related to unstable gait, and eventually to become chair- or bed-bound. Diminished motivation and, therefore, physical activity will in turn lead to reduced muscle strength. Incontinence (urinary and bowel) often occurs Changes in Personality and Emotional Signs and Symptoms of Dementia Behavioural and emotional symptoms of dementia have been identified in several studies as the single greatest cause of formal stress. The person with dementia may experience changes in emotions and personality. Changes in personality may even be noticed in early stage dementia with the person becoming, for example, less spontaneously responsive to others. Alternatively, existing personality characteristics may become more pronounced. In end stage dementia many carers describe the care recipient’s original personality as ‘no longer being there’. Loss of emotional control often accompanies or precedes cognitive impairment associated with dementia. Mood changes in dementia can include depression, anxiety, irritability, agitation, restlessness, One system which usefully describes the changes in behaviour associated with the level or stage of severity of dementia is the Clinical Dementia Rating Scale (CDRS) developed by Berg and published in 1988. In the first stage, moderate memory loss (short term and for recent events), difficulty in orienting for time or place, moderate problem solving difficulties are more evident, whilst personal care may be unaffected. In Stage Two, severe memory loss is more pronounced although memory for past events may still be present and memory for new material rapidly lost. Disorientation to time and place is more pronounced and severe impairment in handling problems and judgment in social situations are often prominent features. Hobbies and interests are very restricted and poorly sustained with only the ability to carry out very basic tasks being retained. Personal care activities will require prompting and supervision. Stage Three is characterised by severe memory loss and disorientation to time and place, inability to make judgments or problem solve, and severe deterioration in the ability to carry out home chores or hobbies and personal care will require substantial help. Although it is sometimes useful to describe dementia as occurring in stages, from the presenter’s personal and professional experience, individual sufferers do not always fit neatly into a particular stage and hypothesises that a three stage model of dementia may be an over simplification of what is in fact a complex phenomenon. Sometimes, for example, it is not always clear where one stage ends and another begins. As other conditions may be mistaken for dementia, the importance of accurate assessment cannot be stressed too strongly as other causes may be amenable to treatment. Assessment involves establishing the likelihood of dementia, excluding other explanations for the clinical presentation, determining the type or cause of dementia, assessing any disability in daily living and identifying available resources. Assessment is a clinical approach that enables health professionals to recognise common disorders of old age, such as dementia, and improve outcomes for the individual and their quality of life. Assessment usual y involves multiple team members, for example, medical officers, nurses, occupational therapists, social workers, and psychologists. As for any investigation, an accurate history of the problems that the individual has been experiencing is important. This may include a medical and psychiatric history, identification of any medications that the person is taking, any changes in functioning, and areas of functioning that remain unchanged. The Mini-Mental State Examination (MMSE), a commonly used screening test for dementia, provides a useful initial impression about any changes in cognitive functioning. The MMSE comprises questions that test the person’s orientation, recall and language. A score of less than 23 (out of a total of 30) indicates that the person may have cognitive impairment (although those who are well educated may be dementing but perform well on this test, conversely, a person from a non-English speaking background may perform poorly but not have dementia). After confirming that the patient has dementia, the type of dementia needs to be identified. This may involve doing blood tests, for example, to rule out other reversible causes of dementia such as B12 deficiency, hypothyroidism, carrying out further clinical examinations and brain imaging, for example, Computerised Tomography Scan (CT) and Magnetic Resonance Imaging (MRI). However, CT and MRI imaging remain controversial and may not be helpful in identifying patients with a typical presentation of AD and where symptoms have been present for less than two years. In the late stages of AD a CT scan usually shows cerebral atrophy, however, many patients in the early stages will have a normal looking scan. Moreover, imaging studies for vascular dementia (VD) are also non-specific as many old people will have some degree of small vessel ischaemic disease on CT or MRI. However, where there is extensive ischaemic disease with multiple infarcts and a history of neuropsychological findings indicating probable VD, then imaging findings will probably be relevant. Positron Emission Tomography (PET) scans measure glucose metabolism in specific areas in the brain and show promise in the early diagnosis of AD. However, their role in the clinical diagnosis of AD is still largely unclear as they lack full sensitivity and specificity in diagnosing AD. Brain scans, such as Single Photon Emission Computed Tomography (SPECT), have also been developed to demonstrate any hypo perfusion in cerebral blood flow. As with all brain scan techniques, interpretation of findings may be affected by the overlap between normal ageing, age-related memory loss and cognitive impairment related to dementia, thus making diagnosis difficult. Evidence of cerebrovascular disease or focal brain damage, may suggest Vascular Dementia, whereas lack of such tel tale signs may by deduction lead to a diagnosis of Alzheimer’s Disease. Moreover, normal scan results do not mean that the older adult does not have AD, however, the majority of people with AD usual y show a loss of grey and white matter volume as demonstrated on CT scan. Dementia occurs in Alzheimer’s disease (AD), in some types of cerebrovascular disease (most common is Vascular dementia) and in other conditions such as Lewy Body disease (LBD), Frontotemporal dementia (FTD), Parkinson’s disease, and Acquired Immunodeficiency Syndrome (AIDS) that primarily or secondarily affect the brain. Various forms of dementia will now be described. Lewy Body (LBD) and Frontotemporal Dementia LBD is a dementia characterised by fluctuating symptoms, episodes of acute confusion, prominent hallucinations, Parkinsonian symptoms and neuroleptic sensitivity, for example, to antipsychotic medications. Recent studies indicate that LBD accounts for 15-25% of all cases of dementia. Alzheimer-Type changes are also to be found in the majority of patients with LBD and up to one third of patients with dementing illnesses will have a mixed pathology (both AD and LBD). It is not surprising, therefore, that there is an imprecise estimate of the proportion of cases of dementia due to LBD. LBD is characterised by the presence of ‘Lewy bodies’ and displays a different pattern of cognitive decline compared to other types of dementia, with patients performing worse n tests of visuospatial activity, initiation of behaviour, and perseveration (persistence of repetitive verbal response or motor activity). In addition, patients’ deterioration on the Mini-Mental State Examination is faster than for those patients with AD. Cholinergic deficits, for example, tremor, rigidity and bradykinesia, are more severe and occur earlier in LBD compared to those that occur in AD However, it is unclear whether LBD is a type of AD or is a disorder in its own right. It is possible that persons who are diagnosed with LBD are in fact suffering from AD and vice versa. Frontotemporal dementia (FTD) or Pick’s disease, is characterised by changes in the frontal and temporal lobes of the brain which control reasoning, personality, social behaviour, and speech thus resulting, among other things, in pronounced changes in affect and personal and social conduct. FTD is characterised by the presence of ‘Pick bodies’ that gave the disorder its original name, Pick’s disease. However, these are not always present on autopsy; therefore, the term frontotemporal dementia has been used. Unlike AD, onset of FTD over 75 years of age is rare. As stated earlier in this section, AD is the most common type of dementia. The following discussion addresses the signs and symptoms, pathological changes, molecular biological changes and describes the parts of the brain involved in this disorder. The most common type of AD is the late-onset form (LOFAD), mostly occurring after 75 years of age. LOFAD is associated with genes that increase the risk of AD and it occurs over 65 years of age. There is a less common form of AD that occurs before 65 years of age but this will not be described. Prevalence rates of AD vary and have been reported to occur in between 54% and 65% of all cases of dementia with over 80% of residents in residential care and nursing homes experiencing the disorder. As noted in relation to LBD, there is considerable variation in the proportion of cases of dementia attributed to AD. Comprehensive evaluations for AD are accurate 90% of the time but are sometimes not ful y accurate until a post- Of note is the fact that its pathology is not as yet precisely definable as its components al occur to some extent in normal ageing and there is still no clear agreement about where normal ageing ends and AD begins although general y it is agreed that the changes that occur are more numerous in AD. In AD, therefore, there are more senile plaques and neurofibrillary tangles to be found in the brain and it is thought that accumulation of plaques results in the formation of tangles (Coni et al., 2003). Accompanying these changes is a substantial loss of nerve cells and deficits in People with AD have difficulty incorporating present experiences into long-term memory. They may also experience speech difficulties, particularly in relation to finding an appropriate word to use in conversation. Language comprehension is also affected, resulting in further problems in comprehension, reading and writing. When neurons are lost from the parietal lobe, especially the right side, the individual with AD becomes increasingly disoriented and frequently gets lost. Trouble with dressing may also be experienced as they are unable to correlate the spatial arrangement of their clothing with their bodies. Damage to the nucleus basilis is associated with changes in emotional states and intellectual function. AD is characterised by an insidious or subtle onset and a gradual and progressive decline in function, for example, activities of daily living, although this is not always the case, and symptoms may fluctuate in presentation. Generally, life expectancy is shortened to a median life expectancy of 3-15 years. Significantly, there is an early, clinically silent phase spanning many years which is often only identified retrospectively, for example, by family carers. As noted earlier, the diagnosis of AD is only made after other causes are excluded. This can be achieved by taking a history, performing a clinical examination, carrying out special investigations including objective cognitive assessments, laboratory tests including biochemistry, complete blood picture, erythrocyte sedimentation rate, thyroid function, and neuroimaging (CT, SPECT, PET scans) to exclude other explanations for the clinical picture. A diagnosis of AD depends on clinically observable behaviours typical of dementia, and absence of evidence, either from the history and clinical examination or from laboratory tests, that the person’s mental state is due to other disorders of the brain (such as Parkinson’s disease or delirium) or other medical and psychiatric problems, for example, hypothyroidism, depression and drug reactions. The presence of AD in at least one first-degree relative (siblings and children) has been found to increase the risk of dementia at least three-fold (although figures vary between 2.5 to 7.2 times) (St.George-Hyslop, 2000; Jacoby & Oppenheimer, 2004). There is also an increase in cases of AD where there is a history of Parkinson’s disease and Down’s syndrome, suggesting that a mutation on chromosome 21 results in the same tangles and plaques in the brain as are found in people with AD (Jorm, 2004). A mutation on chromosome 19 accounts for up to 40% of cases of late-onset AD. Search for a viral infective aetiology for AD, for example, herpes zoster, or environmental neurotoxin, has not as yet produced any positive results (Thomas & O’Brien, 2004). It can be concluded that genetic mutations and an earlier head injury have been positively implicated in the development of some cases of AD. Another common cause of dementia is vascular dementia. This is discussed next, its causes and risk factors, prevalence and ways in which it differs in its presentation from AD As described earlier, AD is the most common cause of dementia and accounts for more than half of the cases. VD accounts for between 10% and 50% of all cases of dementia and where AD and VD occur together, they account for between 14-60% of all cases of dementia. Such a wide range of case estimates highlights that there are differences in the ways in which VD is defined and measured by clinicians who are using different classification systems and therefore criteria to make a diagnosis. As discussed earlier, AD is caused by an accumulation of tangles and plaques which interfere with protein utilisation within the brain. VD, on the other hand, is caused by cerebral tissue damage through large or small vessel disease, embolus or bleeding within the brain and is diagnosed when a person shows evidence of dementia and there is uneven deficits in memory, intellectual impairment and focal brain damage to various but specific parts of the brain, resulting from cerebrovascular disease and stroke that is likely to be related to dementia. In addition, high blood pressure, lability of mood, relative preservation of personality (though some may show a definite change, for example, apathy, disinhibited behaviour, accentuation of previous personality traits), are often present. Whilst the course of AD is insidious and progressive, the course of VD has been described as stepwise, that is, it is characterised by progressive episodes of deterioration. VD has several clinical syndromes. These syndromes are multi-infarct dementia (caused by a large number of small areas of infarction of the grey matter within the cortex of the brain), strategic infarct dementia (symptoms depend on location), and lesions in the There have been fewer investigations of risk factors for VD than for AD but direct risk factors include cerebral infarction, amyloid angiopathy, cerebral vasculitis, and intracranial haemorrhage. Indirect factors include essential hypertension, hyper-lipidemia, and a number of systemic diseases including diabetes mel itus. It may be noted that the incidence of VD increases with age and that where family members develop VD, the risk of close relatives also developing it increases. There is also some evidence that smokers are at increased risk of stroke and therefore VD. Table 1 identifies the essential differences between VD and AD although these differences are not always as clear as the table indicates and as noted previously sometimes it may not be possible to diagnose AD, for example, until an autopsy is conducted. Major Characteristics of Alzheimer’s Disease and Vascular Dementia
ALZHEIMER’S DISEASE
VASCULAR DEMENTIA
neurofibrillary tangles, loss of damage (weakness, brain cells, reduced levels of abnormal reflexes, gait neurotransmitters Progressive slow deterioration Stepwise, Age, family history, Down’s Stroke, age, family history syndrome, head trauma, Epidemiology of the Dementias in Later Life Dementing illnesses are emerging as major health problems facing Australian society and are competing with heart disease, cancer and stroke for medical attention. Disease burden refers to the range of effects dementia has on both the quality and length of life (AIHW, 2004, p.xiii). In Australia, dementia was the second leading cause of non-fatal disease burden for women in 1996 and the fourth for men (AIHW, 2000b.) and is projected to be the number one source of disease burden for women in 2016 and the fifth for men (Jorm, 2001). Burden in this context is the financial cost of services provided by State and Federal governments and private agencies, but does not include the costs to families who provide care. In Australia, Access Economics (2005) estimates that the cost of dementia in 2004 was $6.1 bil ion including $3.56 billion in direct health costs (mainly residential costs), around $1.96 billion in family carer costs, and the remainder in productivity costs, aids and modifications, for example, to the family home. As highlighted earlier in this chapter, dementia, and Alzheimer’s disease in particular, is the main disabling condition for 2.6% of those aged 65-79 years, and for 12% of those Prevalence refers to the number of new cases of disease that exist in a defined population at a particular point in time. Prevalence rates for mild dementia range between 2.4% and 12.7% and for severe or moderate dementia between 2% and 7.7% of older adults. Because of the difficulty associated with identifying people with mild or moderate dementia, no definite estimates of the number of people with various levels of dementia in Australia are available to date. In Australia, 51% of people with dementia were living at home and 49% in nursing homes, hostels and other institutions. Worldwide prevalence rates have also been examined by age and vary in their projected Prevalence Rates for Dementia
Age Group
Prevalence Rates
Even though there are variations in these figures, it is clear that the prevalence rate of dementia is much higher for the ‘old-old’ than for the ‘young-old’. Because the population in Australia and in many other countries is progressively ageing, more people are falling into the age groups where dementia prevalence is highest. In 2001, it was estimated that over 165,000 Australians had dementia and this was projected to increase to 460,000 in 2040 (Jorm & Jolley, 1998). By 2050, it is projected that there wil be over 420,000 Australian women with dementia (3.2% of all women), and over 310,000 Australian men (2.4% of men) (Access Economics, 2005, p.6). It is also clear that the number of people with dementia in Australia is well ahead of the increase in the population generally and for those aged 65 years and over (see Table 3). Table 3 demonstrates a steady increase in the overall population, pronounced increases in the elderly population and still more pronounced increases in the number of cases of dementia projected to 2005.
Table 3
Projected Increases in Dementia Cases, Elderly Population and Total Population of
Australia, 1989-2031
Total Population
Elderly Population
Australia
Dementia Cases
Increase
(Adapted from Access Economics, 2005, p.2) Treatment Approaches for Dementia Treatment approaches for dementia have included medical and non-medical interventions, however, there is currently no intervention that can halt or reverse the progression of dementia. Nevertheless, a variety of treatment strategies are aimed at slowing the progression of the disease and maximising the person’s quality of life. Interventions often include a combination of medication, medical, psychological, environmental, behavioural, supportive counselling, and service provision. Medical treatment of dementia involves the use of memory enhancing drugs that slow the onset of dementia. People with AD have less Acetylcholine, therefore, Cholinesterase (ChE) inhibitors are used in mild to moderate dementia to make more Acetylcholine available. ChE inhibitors include Donepezil, Rivastigmine, and Galantamine and these have met with varying success. Apart from cost, another issue associated with their use is that where patients discontinue taking them they will return to previous dementia-related cognitive levels. It has also been suggested that vitamin E, oestrogen, and anti-inflammatory agents show some promise in the treatment of Alzheimer’s disease but there is insufficient evidence to support their routine use. More recently, Memantine has been used to treat late-stage dementia and this medication regulates the activity of glutamate, a neurotransmitter, which is essential to learning and memory. Although it won’t reverse the disease there is some evidence to show that it may slow the process and improve awareness in some people. This finding highlights the need to diagnose dementia early so that drugs may be used more beneficially before the moderate to severe stage when they wil be less effective. No drug therapies have been specifically useful for VD. Treatment of stroke risk factors remains important, especially cessation of smoking, reduction of hyperlipidemia, and treatment of diabetes. A range of strategies include modification of diet, removing arterial blockages, aspirin, cholesterol and high blood pressure lowering agents. However, once dementia is present, mild hypertension (systolic readings in the 150s mmHg) may benefit cognitive function. Some data suggest that galantamine in VD may benefit cognition but more studies are needed. Psychological, Environmental and Behavioural Treatments for People with Dementia In psychological treatments the individual with dementia is encouraged to take part with others in activities, for example, reminiscence, reality orientation. These interventions are believed to improve cognitive function, mood and behaviour although the changes may be short term and may or may not prove to have any lasting consequences as the The psychosocial environment of the older adult with dementia should encourage interactions with others and be stimulating through a variety of experiences that call for some personal initiative or self-expression. It should provide opportunities for personal choice in relation to dress, privacy and personal possessions and reinforce a sense of personal dignity, discourage excessive sleep and allow a range of activities in safety and under appropriate supervision. At the same time, the physical environment should be structured to allow for predictability, calmness, and safe wandering. Although such an environment will not necessarily bring about any lasting cognitive benefits, it should assist the development of a better quality of life for people with dementia. The cause or causes of disturbed behaviour should be identified and where possible eliminated or modified. Environmental change may be implemented to effect change in behaviour, for example, use of colour coding for various rooms and signs or pictures on doors (for example, a picture of a toilet for the room that houses a toilet). A behavioural approach, for example, rewarding appropriate behaviours and ignoring inappropriate behaviours, may be effective if the person’s memory impairment is not too advanced. Nevertheless, change of any kind is unsettling for the person with dementia, since there is a sense of security in stable long term memories of activities, people and events. Sensory enhancement, for example, Snoezelen Therapy (multisensory therapy using music, colour, tactile, smell and touch), music, aromatherapy, simulated presence therapy, (SPT), and structured activities have also been utilised in clinical practice but may also be of use to family carers. Evidence of the effectiveness of Snoezelen is still unclear but there have been some reports of its usefulness in some people with dementia in residential settings. In SPT, it is thought that patients’ agitation is decreased and social interaction increased by audio-taping personal conversations and memories, and family anecdotes. Significant improvement in social isolation has been demonstrated in some studies but not for all participants. Music therapy may be effective in reducing challenging behaviours in older adults with dementia but results may depend on the importance that music had for them previously. Aromatherapy therapy has also been shown to be effective in reducing challenging behaviours in some patients particularly where it is used in combination with massage and touch therapy. However, a person’s response to aromatherapy will depend on the positive or negative memories the smells trigger. The use of structured recreational and physical activities is thought to al eviate boredom and therefore agitation but this will not be a very effective approach in patients with late-stage dementia. Supportive Counselling and Supports for Family Members Supportive counseling, on an individual or group basis will allow family members to ventilate feelings and deal with their own concerns and those of other family members. Family members may need advice, for example, about power of attorney and guardianship. Support group attendance often provides emotional sustenance and education. Carer support groups may facilitate institutional placement significantly. Determination of the level of disability and the identification of their needs and problems is important and has implications for the type of management plan that is developed. These determinations are often carried out by allied health professionals, for example, Occupational Therapists, Social Workers, Psychologists, who are members of the multidisciplinary team. The level of the person’s disability may be assessed using instruments which assess activities of daily living (ADLs), for example, drinking from a cup, eating, dressing, washing, bathing and grooming and instrumental activities of daily living (IADL), for example, ability to use a telephone, prepare food, carry out housekeeping routines and travel independently. Formal supports, for example, hospital services, informal supports, for example, family, friends, should also be identified and assessed for the level and quality of support that could be provided or has the potential to be provided. In summary, dementia is a significant, degenerative and irreversible disorder of brain function which eventually leads to death and may result from respiratory infection simply because the person with advanced dementia forgets how to cough. The incidence of dementia increases with age, and its highest incidence occurs in the seventh and later decades. Sufferers experience profound changes in thinking, memory, orientation, emotions, personality, judgment, IADLs and ADLs although the level of change in each area of behaviour may vary within and between individuals. Problem behaviours associated with these changes become worse as the disease progresses. Problems may also be related to the presence of psychiatric il ness, medical problems, the personality of the sufferer and the environment in which the family member is being cared for. Dementia results in an increasing number of disabilities over time. Common causes of dementia are Alzheimer’s disease and Vascular dementia and the number of people in the Australian population who develop these diseases wil continue to increase well into the future. Treatment approaches for both AD and VD do not halt or reverse the progress of these illnesses although memory enhancing drugs may assist cognition in some persons with dementia. Therefore, environmental and behavioural interventions for challenging behaviours take on increasing importance. Supportive counselling for family members allows them to deal with feelings and concerns associated with admission to care.
Case Study: Mrs. Diamond

Indicators of dementia for Mrs. Diamond include that she had begun to cook whole
cauliflowers with no water in the saucepan and she stated that she had “cooked the dinner”. She had also turned the stove on without cooking anything on it. This might suggest that she was experiencing apraxia and agnosia. There is also a statement that she is experiencing memory loss. Other symptoms suggest that she might be experiencing another depressive disorder or delirium. Of significance also is her recent admission, possible grief reaction (as we don’t know when her husband died), and separation from her wider family who had been providing care. Her eye problems could also have been impacting on her current problem state. Assessment includes identifying presence of infection or other medical problems, eye and hearing status, medication history and current medications.
Depression in Older Adults
Depression in older person has been under-researched. However, it is as common in old age as in other age groups. Where it occurs in the elderly, it is often due to a complex interplay between vascular factors, physical illness, disability, and socio-cultural risk factors. It is the most common mental illness that occurs in older adults. Risk factors include: female gender, divorced or separated, low economic status, poor social supports. Outcomes include unnecessary suffering (for both patient and others), excess physical, psychological and social disability, exacerbation of co-existing illness, overuse There are different types of depression. Major depression is a severe form of depression and often has a significant biological component. Older people with a Major depressive illness require anti-depressant medication and electro convulsant therapy. Features include experiencing a depressed mood or loss of interest or pleasure. Depressed mood is often present most of the day, nearly every day. Other features include feelings of worthlessness, a sense of inappropriate guilt, inability to think, difficulties making decisions and even recurrent thoughts of death. Melancholic depression also has biological features, depressed mood which is worse in the morning with early morning wakening. Psychomotor retardation or agitation may be a feature of the illness. Anorexia and weight loss and feelings of guilt (reaching delusional intensity) may be experienced. Older people with post-traumatic stress disorder may experience many depressive symptoms and fear, sense of helplessness may follow an upsetting event. Dysthymic disorder is characterized by depressive mood which has been present for at least two years. General y, it is not as severe as major depressive disorder. It doesn’t have as many biological features and doesn’t necessarily require anti-depressant medication or ECT. Depression is a human response when there is a failure to adapt to stress. It involves psychological and biological features and is commonly a normal response to ‘loss’ Sometimes it represents a failure to adapt to a ‘crisis’. A crisis can be a positive or negative event. It is a positive event where the older person learns from the situation. It is a negative event where the older person doesn’t adapt to the situation with which he or Depression in older people is a common experience with a significant number inadequately treated. What changes in function or behaviour may lead us to ‘suspect’ that the older adult has become depressed. Changes might include: • recent change in function or behaviour • past history of depression • depressed mood • decreased interest in pleasurable activities • loss of energy • feelings of worthlessness or guilt • difficulty concentrating • excessive health complaints But, don’t forget that physical illness may cause similar features and physical illness can trigger depression. Older adults’ responses to physical illness may need antidepressant treatment. When assessing older people for depression remember that what you are seeing may be a dementing illness not a depressive one. Additionally, an older person with dementia may also develop a depressive illness. Assessment will include assessment of the older person’s general health, medication regimen, level of activities, feelings about the past, present and future, level of thinking and movement. Consider, does the older person ‘look’ depressed (e.g. is their face expressionless?). To assess whether the older adult is contemplating suicide, don’t be afraid to ask (the issue here is when to ask and perhaps the timing is important, e.g. after a relationship has been established – look for the right moment!). You could ask “Do you sometimes feel that life is not worth living?” – If “Yes” try to explore further.
Case Study: Mr. Carpenter
It is possible that Mr. Carpenter has been depressed even since coming to residential care and even before that. It could have been a reaction to a diagnosis of diabetes and problems with its management. Depression may have affected his sleep and led to overeating. Additionally, he has become less social. He is experiencing cognitive impairment, forgetfulness and is unable to respond to staff requests. It is possible that he is worried about his wife’s condition and perceived loneliness. Problems prevent her from visiting.
Confusion

Confusion is a state of perplexity, muddled thinking, and lack of awareness and
understanding of one’s environment. Memory and judgment may also be affected and state of consciousness impaired. The older person who is confused may experience delusions (e.g. persecutory), hallucinations (e.g. auditory or visual) and will understandably be anxious. Confusion may worsen at night and the older person’s mood may be quite labile. Distraction and limited concentration and attention may also be Confusion is caused by impaired brain tissue function. It may be obvious or not so obvious (i.e., the older person may be ‘quietly’ confused). In the elderly it is also associated with age-related changes including progressive neuronal loss, decreased cholinergic function (in cortex and hippocampus), less physiologic reserve, higher levels of sensory impairment, free drug levels and co-existing illness. Acute confusion is referred to as delirium and chronic confusion is referred to as dementia. Delirium is often transitory in nature and is a response to systemic illness (occurring somewhere in the body and related to pneumonia, asthma, heart failure, hypoglycaemia) or cerebral disturbance (e.g. caused by cerebral tumour). Its onset is acute and its duration usually less than one month. Epidemiological studies of delirium are rare and data may be easily distorted as definitions and diagnosis may vary. Additionally, the research literature suggests that it may not be recognized by doctors and nurses and that they may too readily accept that the older person has developed a dementing illness. Understandably, it is important to recognize that the older person has a delirium rather than a dementia as otherwise it wil result in incorrect management, inappropriate and lengthy hospital stays, nursing or hostel placement, and higher mortality rates. Medications are a common cause of delirium in old age. A high proportion of older adults are on one or more medications and there are high number prescriptions rates for the elderly. Most commonly used drugs used by the elderly include analgesics, diuretics (may cause electrolyte imbalance), psychotrophics (e.g. Benzodiazipines – cause greater sedation in the elderly; anti-depressants – may have long half life), digoxin (elimination is prolonged in the elderly), non-steroidal inflammatory medications, laxatives. Medications may be extensively used in multiple amounts and sometimes are inappropriately ordered. Adverse drug effects are associated with polypharmacy. Patient non-compliance with medication regimes may also be problematic and cause a renewal of symptoms for which medications have been ordered. Over-the counter drugs may also cause problems. Don’t forget that constipation, malnutrition and dehydration may cause confusion. Moreover, there are also psychological causes of confusion, including stress, depression, anxiety, pain, fatigue, grief, sensory deficits. Environmental causes include unfamiliar environment, sensory deprivation or overload, immobility, sleep deprivation. Commonly used tests for delirium include taking the older person’s temperature, pulse and respiration, carrying out a urinalysis and blood glucose analysis to identify causative factors. Other tests could include ESR, ECG, chest-x-ray, ful blood count, urea and electrolytes, cultures (e.g. urine, sputum, blood). Thyroid function and B12 and folate tests should also be considered. Treatment includes medical, pharmacological, psychosocial, environment and nursing management. Nursing management includes:
a) Environmental
As far as possible the older person’s environment should be quiet and non-stimulating. Safety issues should be addressed but approached to ensuring resident safety should not be too restrictive. A night light may reduce confusion and misperception of stimuli and provide a broader perceptual field at night. If possible, objects should be removed which may be misinterpreted.
b) Physical needs should be attended to including nutritional needs (e.g. Vitamin B and
C, protein and complex carbohydrates). Fluids should be pushed unless there is a reason
not to do this (e.g. where an older person is experiencing circulatory overload). Regular oral hygiene is important as the older adult may not be able to attend to this. Regular care of the skin is recommended because of increased sweating, incontinence, friction due to restlessness. Constipation should be avoided. Regular observation of vital signs may be necessary. Observe fluid output. Attention to comfort needs include adequate and appropriate clothing. Analgesia for pain may be ordered. c) Protective needs include appropriate observations (e.g. vital signs), care in relation to
overactivity and exhaustion, care against self-injury, impulsive suicidal attempts, aggressive outbursts. Medications regimes and other treatments should be strictly adhered to and specialling may be necessary.
d) Orientation needs may include reality orientation, verbalizing orientation information
(name and purposes of persons providing care and an explanation for their activities of
care). Clocks and calendars may be helpful, also photos and personal possessions. If possible, the older person should be encouraged to wear their glasses and where appropriate hearing aids. The older person should be told about his condition during times of lucidity. It has been suggested that sustained nursing interaction and actions (10minutes of more) are to be encouraged. Explanation of the older adult’s condition for family and friends should be undertaken and they made need support and reassurance. However, visitors may need to be limited to one or two persons and should be encouraged to stay for as long as possible except where they are having a detrimental effect on the older person’s confused state. Educational programmes for nurses who are providing care should be organized on a regular basis. Programs should assist nurses to recognize the differences between acute and chronic confusion. Prevention of confusional states in older adults is to be encouraged and nurses should learn to recognize early signs and symptoms.
Case Study: Mr. Wang
Mr. Wang is experiencing multiple pathology. This suggests that he is most probably receiving multiple medications. He has a history of acute infection with resultant confusion. His behaviour resulted in staff not wanting to manage his care. There is a need to assess his eyesight and hearing and medications. Consider whether he has developed

Source: http://www.agedcarechannel.com.au/wp-content/uploads/2012/02/Dementia-Delirium-Depression-synopsis-Peter-Brown.pdf