Delirium, Dementia and Depression
Health Canada, Division of Aging and Seniors (2001)
estimates that by 2021, there will be about 7 million seniors who
will represent 19 per cent of the Canadian population over the age
of 65 years. Of this population, an increasing number will experience
some form of altered mental status. Canadian studies in the early
1990’s on the prevalence of dementia and/or some form of cognitive
impairment with no dementia (CIND) suggest that while 75.2 per cent
had no impairment, the largest group with impairment was the CIND
at 16.8 % followed by those diagnosed with dementia at 8 per cent
(Graham, et al., 1997). The health-care
system must anticipate an increase in the number of older adults
with cognitive impairment with or without dementia, and nurses must
be educated to case find and initiate care strategies.
To date, under-recognition of delirium, dementia and depression
remains an issue. The American College of Emergency Physicians (1999)
suggests that 40 per cent of clients over the age of 70 years and
presenting to emergencies have altered mental status; 25 per cent
with altered level of consciousness; 25 per cent with delirium;
and 50 per cent with cognitive impairment. Given that nurses are
providing care to an increasingly complex and older client population,
it is suggested that best practice guidelines to assist in anticipating
and managing delirium, dementia and depression be explored. These
care strategies offer nurses recommendations for practice that are
evidence-based and reviewed by clinical experts.
The RNAO Best Practice Guidelines
Screening for Delirium, Dementia and Depression in Older Adults,
and Caregiving
Strategies for Delirium. Dementia and Depression discuss the
three concepts, delirium, dementia, and depression. The following
discussion of these concepts is from the Screening guideline.
Delirium is a temporary disordered mental state,
characterized by acute and sudden onset of cognitive impairment,
disorientation, disturbances in attention, decline in level of consciousness
or perceptual disturbance. A prevalent disorder, it is estimated
that 14 to 80 per cent of all elderly clients hospitalized for the
treatment of acute physical illnesses experience an episode of delirium.
Studies have shown a marked variability in the epidemiology of delirium
results from the differences in study populations, diagnostic criteria,
case finding and research techniques.
Research findings have shown that delirium in older adults result
in:
- Greater in-hospital functional decline (Foreman
et al., 2001; Inouye, Rushing, Foreman,
Palmer & Pompei, 1998).
- Greater intensity of nursing care (Brannstrom,
Gustafson, Norberg & Winblad, 1989; Foreman et al., 2001).
- More frequent use of physical restraints (Foreman
et al., 2001; Ludwick, 1999; Sullivan-Marx, 1994).
- Increased length of hospitalization, and higher hospital mortality
rates (Foreman et al., 2001; Inouye et al.,
1998).
- Worse outcomes in severe delirium (e.g., ADL decline, ambulatory
decline, and nursing
home placement or death) than mild delirium, particularly at 6
months (Marcantonio, Ta,
Duthie & Resnick, 2002).
Dementia is a syndrome of progressive decline
in multiple areas of cognitive function eventually leading to a
significant inability to maintain occupational and social performance.
The estimates of the prevalence of dementia range from 2.4 percent
among persons aged 65-74 years, to 34.5 percent among those aged
85 and over (Loney, Chambers, Bennett, Roberts
& Stratford, 1998). Research shows there are presently
over 250,000 seniors with dementia in Canada, and it is estimated
to rise to 778,000 by 2031 (Canadian Study on
Health and Aging, 1994b; Patterson et al., 2001). The incidence
suggests that there will be approximately 60,150 new cases of dementia
in Canada each year. Patterson et al. (2001)
conclude that because of the increasing burden of suffering which
dementing disorders impose on individuals, their caregivers and
the health care system, recommendations on the assessment and management
of these conditions are both timely and important.
Depression is a syndrome comprised of a constellation
of affective, cognitive and somatic or physiological manifestations
in varying severity from mild to severe (Kurlowicz
& NICHE Faculty, 1997; National Institute of Health Consensus
Development Panel, 1992). Depressive symptoms occur in 15
to 20 per cent of community-based elders requiring clinical attention
and 37 per cent of elders in primary care settings.
Depression in late life is a major public health concern. Mortality
and morbidity rates increase in the older adult experiencing depression,
and there is a high incidence of comorbidity with medical conditions
(Conwell, 1994). It is widely known that
depression can lead to increased mortality from other diseases such
as heart disease, myocardial infarction, cancer and chronic depression
(U.S. Dept. of Health and Human Services, 1997).
Untreated depression may also result in increased substance abuse,
slowed recovery from medical illness or surgery, malnutrition and
social isolation (Katz, 1996). The most
troubling outcome of depression is elder suicide, and older adults
have the highest risk of suicide rates of any age group.
The suicide rate for individuals aged 85 and older is the highest
at about 21 suicides per 100,000 people, a 25 percent increase from
1980 to 1986 (Conwell, 1994). Studies
reveal that single, white, elderly males have the highest rate of
suicide and are more likely to succeed than their female counterparts.
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