Module 5: Geriatric Psychiatry - Depression, Delirium, Dementia

Which of the following are realities about older adults?

A) Age-associated changes in cognition are mild

B) Slower reaction time

C) Intelligence does not decline significantly

D) Short-term memory shows more noticeable changes than long-term memory

E) Reduced problem-solving skills

F) Creativity and wisdom continue till the end of life

G) Personality traits remain stable

H) Older adults are not set in their ways and demonstrate adaptability to change

I) The speed at which information is encoded, stored and retrieved slows

B) Slower reaction time

E) Reduced problem-solving skills

I) The speed at which information is encoded, stored and retrieved slows

What are the 3 Ds?

- Delirium

- Dementia

- Depression

What are some normal cognitive changes with aging?

slower reaction time, reduced problem solving skills, slower speed of encoding and storing and retrieving information

Is this a sign of dementia or normal aging related to memory loss?

- Difficulty remembering names, places or recent events

Signs of dementia

Is this a sign of dementia or normal aging related to memory loss?

- Temporarily forgets names, appointments or where they left their keys but remembers later

Normal aging

Is this a sign of dementia or normal aging related to disorientation?

- Losing track of days, months, season

- Getting lost on their own street or not knowing how to get home

Sign of dementia

Is this a sign of dementia or normal aging related to disorientation?

- Forgets the day of the week but later remembers, do not get lost in familiar places

Normal aging

Is this a sign of dementia or normal aging related to being challenged by mental tasks?

- Unable to complete familiar tasks, such as following a recipe

Sign of dementia

Is this a sign of dementia or normal aging related to being challenged by mental tasks?

- Makes mistakes when balancing a check book

Normal aging

Is this a sign of dementia or normal aging difficulty with ADL?

- Needs assistance with electronic devices, computers

Normal aging

Is this a sign of dementia or normal aging difficulty with ADL?

- Needs assistance getting dressed or using the phone

Sign of dementia

is this a sign of dementia or normal aging related to trouble using words?

- Difficulty completing sentences and following directions/ conversations

- Frequent word substitutions

Sign of dementia

Is this a sign of dementia or normal aging related to trouble using words?

- Occasionally struggles to find the right word

Normal aging

Is occasional poor decision making a sign of dementia or normal aging?

Normal aging

Is this a sign of dementia or normal aging related to poor decision making?

- Frequent poor judgment and decision-making

- Unsure how to dress for changing weather

Sign of dementia

Is this a sign of dementia or normal aging related to mood and personality?

- Increased suspicion, withdrawn, disinterested, behaving in socially inappropriate ways

Sign of dementia

Is this a sign of dementia or normal aging related to mood and personality?

- Irritable when routine is disrupted

Normal aging

Define the following:

Umbrella term for loss of memory and other thinking abilities severe enough to interfere with daily life

Dementia

All of the following are key characteristics of alzheimer's except?

A. Developmental deficit

B. Multifaceted cognitive impact (learning, memory, language, executive functioning and complex attraction)

C. Progressive and irreversible

D. Impaired social and occupational functioning

A. Acquired deficit, not developmental

Alzheimers is the ___ leading cause of death among Americans aged 65 or older

5th

Women make up ___ of those affected by Alzheimer's

2/3

Is Alzheimer's a normal part of aging?

No

Risk factors, modifiable factors, or protective factors for Alzheimer's Dementia?

- Age

- Genetics

- Family History

- Head Trauma

- Depression

- Hearing Loss

Risk factors

Risk factors, modifiable factors, or protective factors for Alzheimer's Dementia?

- Exercise

- Sleep

- Smoking

- Alcohol

- Diet

- Obesity

- Hypertension

- Diabetes

Modifiable factors

Risk factors, modifiable factors, or protective factors for Alzheimer's Dementia?

- Education

- Socioeconomic Status

- Social Engagement

- Cognitive Engagement

Protective factors

What are common causes of death for people with Alzheimer's Disease?

- Pneumonia

- Dehydration

- Malnutrition

- Falls

- Infection

What is the MOST common cause of death in late-stage Alzheimer's?

pneumonia

What are dental treatment recommendations in early stage of AD?

- Routine dental care with minor modification

- Caries identified and restored

- Proper function should be restored

What are dental treatment recommendations in middle stage of AD?

- Prevention and maintenance

- Short appointments

- Uncooperative behavior should be expected

- Issues around consent to treatment arise

What are dental treatment recommendations in late stage of AD?

Focus on maintaining oral comfort and provision of emergency treatment

If you see the following, what do you suspect?

- Refusal to eat (particularly hard or cold foods)

- Frequent pulling at the face or mouth

- Leaving previously worn dentures out of their mouth

- Increased restlessness, moaning or shouting

- Disturbed sleep

- Refusal to take part in daily activities

- Aggressive behavior

Signs of dental problems for a person with dementia

T/F: Medication can cause memory loss side effects

True

Mouth props can look like a restraint, so how can you help get the mouth opne?

- Invite a family member/caregiver to be present

- A slow, calm approach

- Say "Ahhhh"

- Introducing a toothbrush first

- Explain the use for the patient/observers

- Document in case note

What mouth prop?

- Adult or pedo sizes

- OK if patient is cooperative

- Must use floss attached to bite block

Rubber bite block

What mouth prop?

- More useful in less cooperative patients

Molt mouth prop

What should practitioners document when using a mouth prop?

A) The size of the prop used

B) The type of treatment provided

C) Any soft tissue trauma observed

D) The total time taken for the procedure

C) Any soft tissue trauma observed

What should you do if you cannot get in the mouth at all when trying to operate?

- Do not dismiss pt right away

- Ask caregiver/family member for suggestions

- Try brief visual inspection (EOE, IOE) for obvious problems: swelling, sinus tracts, loose teeth, large carious lesions

- Advise caregivers of situation and possible problems

- Place on 3-6 month recare to try again when behaviors settle down

- Document situation and plan of action

When do you know it is time to seek professional help for older adults with signs of the three D's?

When their behaviors disrupt daily activities

T/F: We frequently hear about the three symptoms and signs of COVID19: fever, cough and shortness of breath. Yet older adults can have difficulty mounting a fever response or have impaired cough reflex and they may not be able to report shortness of breath. Altered mental status (i.e., delirium) should be on the list of presenting signs.

True

Delirium or dementia?

- Caused by acute illness/ drug toxicity

Delirium

Delirium or dementia?

- Caused by changes in the brain

Dementia

Delirium or dementia?

- Rapid onset

Delirium

Delirium or dementia?

- Slow onset

Dementia

Delirium or dementia?

- Course: fluctuates, "sundowning"

Delirium

Delirium or dementia?

- Course: gradual progressive decline

Dementia

Delirium or dementia?

- Duration: hours to weeks

Delirium

Delirium or dementia?

- Duration: years

Dementia

Delirium or dementia?

- Consciousness: Altered

- Attention: Significant inattention and lack of concentration

- Orientation: Impaired

- Behavior: Agitated, withdrawn or depressed or combative

- Speech: Incoherent, rapid/slow

- Thoughts: Disorganized, delusional

- Perception: Hallucinations

- Sleep: Sleep wake reversal

Delirium

Delirium or dementia?

- Consciousness: Often normal

- Attention: Intact early, impaired late

- Orientation: Intact early, impaired late

- Behavior: Intact early

- Speech: Word finding

- Thoughts: Impoverished

- Perception: Intact early

- Sleep: Often normal

Dementia

Is delirium or dementia reversible?

Delirium

What are the following factors for delirium?

- Age > 65

- Male

- Dementia / cognitive impairment

- Sensory impairment (visual/hearing)

- Severe illness /comorbidities

- History of alcohol abuse

- Parkinson disease

Predisposing risk factors

What are precipitating factors for delirium?

- Anticholinergic, psychoactive drugs, opioids

- Dehydration

- Fever

- Pain

- Infections (pneumonia, sepsis, urinary tract)

- Prolonged immobilization

- Polypharmacy

- Hypoxia

- New acute medical/dental problem (include tooth pain, dental abscess, oral infection, extractions under sedation)

- Surgery / anesthesia

- Environmental change / relocation to nursing home

Is depression a normal part of the aging process?

No

What can all of the following cause in older adults?

- PAIN

- Upsetting life events

- Forced retirement

- Certain medical conditions: Dementia

- Loss of vision or hearing

- Biochemical factors

- Medications

- Alcohol

- Social isolation

- Lack of physical activity

Depression

What is the most common cause of depression in older adults?

Pain (affects energy, sleep, activity, mood)

What proportion of adults 65+ with depression and/or anxiety?

~20%

The connections between depression and poor oral health include all of the following, EXCEPT?

A) Decreases the immune system

B) Decrease infections and chronic inflammation

C) Disinterest in self care and oral hygiene

D) Increased risk of caries and periodontal disease

E) Adopt unhealthy behaviors (smoking, alcohol, drugs)

F) Cariogenic diet

G) Xerostomia

B) Decrease infections and chronic inflammation (increase)

You should limit local anesthetic to 2 carpules of epinephrine if a patient is taking ____ for depression

Tricyclic antidepressants (TCAs)

What type of symptoms of depression?

- Pain (arthritis)

- Headache

- Appetite/weight change

- Psychomotor agitation or retardation

- Lethargy/fatigue or loss of energy

- Sleeping too much or too little

Somatic symptoms

What type of symptoms of depression?

- Depressed mood (persistent sadness)

- Crying

- Diminished interest or pleasure in activities

- Feelings of hopelessness, worthless /guilt

- Difficulty concentrating/indecisiveness

- Constant worrying

- Anxiety

cognitive/psychological symptoms

Which of the following is a distinguishing feature of delirium compared to dementia?

A. Slow onset

B. Acute illness

C. Irreversible progression

D. Gradual decline

B. Acute illness

Which is a precipitating factor for delirium?

A. Gender

B. Tooth pain

C. Age > 65

D. Sensory impairment

B. Tooth pain

Which is a physical symptom of depression?

A. Hopelessness

B. Anxiety

C. Appetite changes

D. Difficulty concentrating

C. Appetite changes

Which is a cognitive symptom of depression?

A. Arthritis pain

B. Sleep disturbances

C. Persistent sadness

D. Fatigue

C. Persistent sadness