Depression and Delirium

Depression

 * No. Personality is stable for the most part.  Life satisfaction, morale and overall adjustment do not decline as long as health status, living arrangements and income remain stable (but, don't these three things almost always change with aging, so isn't she just making an academic argument here???)

Symptoms of MDD:

 * Psychological: low mood, loss of interest, irritability and anxiety, difficulty making decisions, poor self-esteem, guilt, worthlessness, hopelessness, pessimism, helplessness, rumination, desire to die
 * Somatic: appetite change, sleep disturbance, abnormal psychomotor activity (slowing or agitation), decreased energy, apathy, decreased libido
 * Cognitive: poor executive function, distractibility
 * Functional: social, occupational, or other impairments

Clinical Presentation

 * Reluctance to seek psychiatric care
 * Usually seen for somatic complaints
 * Anxious and sleep disturbance
 * Delirium, frontal lobe disease, organic illnesses and emotional lability are not depression
 * Risk factors are:
 * Illness and disability
 * Brain injury
 * Medications
 * Other psychiatric disorders
 * Losses, stress
 * So...I think this means every elderly patient, right?
 * Suicide
 * ELDERLY WHITE MALES ARE AT AN ESPECIALLY HIGH RISK (6X THE GENERAL POPULATION)

Treatment

 * Treatment is successful with psychotherapy and antidepressants
 * But, age is a negative predictor for remission and a risk factor for relapse
 * Elderly more likely to need long term therapy
 * SSRIs are most common first line therapy
 * Mirtazepine often used as sleep aid and to improve appetite
 * Goals are to monitor risk of self harm, educate and then aim for complete remission

Definition

 * This is a transient organic mental syndrome
 * Has an acute onset, results in global impairment of cognitive function
 * Reduced level of consciousness and attentional abnormalities
 * Increased or decreased psychomotor activity
 * Disordered sleep-wake cycle
 * Hypoactive variant, hyperactive variant, or both

History of Illness

 * ALWAYS LINKED TO PHYSICAL ILLNESS
 * BRAIN DYSFUNCTION DUE TO SYSTEMIC ILLNESS
 * Always recognized as distinct from insanity

Clinical Features

 * Attention: loss of selective mental processes affecting all spheres of mental activity
 * Orientation: tested by month, year or place question; always abnormal if these are incorrect; delirious patients maybe oriented; present in dementia and other mental disorders
 * Psychomotor Activity: characterized by reaction time, speed and flow of speech. Can be hypo or hyperactive.
 * Emotions: fear, anxiety, lability, tearfullness, shame.
 * Arousal: waxing and waning of consciousness with periods of lethargy/somnolence common, but NOT NECESSARY FOR DIAGNOSIS.
 * Predispositions:
 * Age
 * Brain damage (particularly Alzheimer's)
 * Reduced homeostatic regulation capacity and resistance to stress
 * Impaired vision/hearing
 * Increased susceptibility to infections
 * High prevalence of chronic diseases and high incidence of acute diseases
 * Multiple diseases
 * Impaired mechanisms for drug distribution and metabolism
 * Malnutrition
 * Facilitating factors:
 * Psychological stress
 * Sleep deprivation
 * Sensory underload/overload
 * Immobilization
 * Outcomes
 * Full recovery
 * Progression to coma/death (~14% mortality in one month)
 * Transition to dementia, behavioral disorder, affective disorder, or psychosis
 * Treatment
 * TREAT THE UNDERLYING CAUSE!!!
 * There are no specific pharmacological treatment for disorder, but there are nonspecific treatments for the behavior (i.e. treating the symptoms)
 * Haloperidol is used if addressing agitation or psychosis in delirium
 * Anticholinergics (antidepressants, Benadryl (aka diphenhydramine), and low potency neuroleptics like thorazine) and long-acting benzodiazepines (except in EtOH or benzo withdrawal) have no place in treating delirium!

Prevalence

 * 10-15% of elderly at hospital admit
 * 5-30% subsequently develop
 * Reported at high levels after heart and hip surgeries
 * Bottom line is that it is grossly underreported (~5%)

Etiologies (aka the cheeriest acronym we have learned so far!)
I WATCH DEATH
 * Infection
 * Withdrawal (EtOH, sedatives)
 * Acute metabolic (hyponatremia, liver failure, hypo- hyperglycemia, electrolyte or acid-base abnormalities)
 * Trauma
 * CNS pathology
 * Hypoxia (Anemia, COPD, Cardiac, CO)
 * Deficiencies in cobalamine (B12), folate (B9)
 * Endocrinopathies
 * Acute vascular
 * Toxins or drugs
 * Heavy metals

Depression vs. Dementia

 * Mood
 * Depression = Sad
 * Dementia = apathetic
 * Mental Status Exam
 * Depression = variable performance
 * Dementia = consistently poor performance
 * Awareness
 * Depression = they know they have memory problems
 * Dementia = they are often not aware

Depression vs. Delirium

 * Mood
 * Depression: Intact/mildly impaired
 * Delirium: Impaired
 * Memory
 * Depression: Mildly impaired
 * Delirium: Impaired
 * Affect
 * Depression: Sad, rarely tearful
 * Delirium: Labile, tearful

Delirium vs. Dementia

 * Onset
 * Delirium: Days
 * Dementia: Weeks/years
 * Attention
 * Delirium: Impaired
 * Dementia: Intact
 * Awareness
 * Delirium: Decreased
 * Dementia: Intact
 * Thinking
 * Delirium: Disorganized
 * Dementia: Impoverished
 * Perception
 * Delirium: Hallucinations are common
 * Dementia: Hallucinations are rare

Delirium vs. Schizophrenia

 * Onset
 * Delirium: Days
 * SCZ: Weeks/years
 * Attention
 * Delirium: Impaired
 * SCZ: Intact
 * Perception
 * Delirium: Visual hallucinations more common
 * SCZ: Auditory hallucinations more common
 * Orientation
 * Delirium: Decreased
 * SCZ: Unimpaired