Mentation is about preventing, identifying,
treating, and appropriately managing the 3Ds in
geriatrics: dementia, delirium, and depression.
-Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN

“She’s just not right today”. When referring to an older adult, this simple phrase should be a signal to family and formal caregivers alike to begin to find out why. 

If a child “wasn’t right” one day, no one would ignore it – and we cannot ignore it in an older adult.

An altered mental state is a broad term for geriatric patients having issues with their cognitive level. Essentially, for older adults with altered mental states, early detection and diagnosis are essential, as the source could be life-threatening. 

In line with that, today’s episode of This Is Getting Old, will focus on continuing our special series on the Health Systems Initiative and the 4Ms Framework, explicitly talking about MENTATION. 

Dr. Tahira I. Lodhi joins us, and we’ll talk more about providing health care services to older adults with the limelight on the spheres of Mentation.

Also check out these related podcasts:

Part One of ‘The 4M’s Framework: MENTATION’.

THE SPHERES OF MENTATION

Mentation is about preventing, identifying, treating, and appropriately managing what is referred to as the 3D’s in geriatrics; dementia, delirium, and depression.

The 3D’s are a cornerstone of geriatrics, and it can be challenging to tease these three apart when providing care to an older adult. 

There are several characteristics in common with depression, dementia, and delirium. Apathy, detachment, and tearfulness can be present in both depression and delirium, especially hypoactive delirium. However, a reliable indicator lies with the onset and duration. 

The onset of dementia is slow and insidious. However, deterioration is progressive over time. Delirium develops unexpectedly (for hours or days), and manifestations appear to fluctuate during the day. While a change in mood persisting for at least two weeks characterizes the onset of depression. The duration may coincide with life changes and can last for months or years.

DELVING DEEPER INTO MENTATION

DEPRESSION

It is necessary to remember that depression is not an unavoidable aspect of becoming older, nor is it an indication of failure or character defects. Regardless of your history or past successes in life, it can happen to everyone, at any age. While life changes when you age, retirement, loved ones’ demise, deteriorating health may also induce depression.  

TOOLS FOR ASSESSING DEPRESSION

For health care providers, it’s essential to recognize depression. You can use several instruments, like PHQ-2, PHQ-9, and other Geriatric Depression Scales, to assess depression in older adults. 

PHQ-2 (Patient Health Questionnaire-2) uses a valid and reliable depression screening tool for all ages. In comparison, a PHQ-9 is a screening test that can also be used to follow-up on a promising PHQ-2 outcome and to track response to therapy.

You may find that a person who was once active in the long-term care setting is now just sitting on the sidelines, not talking to anybody and say that they just feel down. That’s the time to evaluate the person and make sure it’s not depression. -Tahira I. Lodhi, MD

SIGNS AND SYMPTOMS OF DEPRESSION IN OLDER ADULTS

Recognizing depression starts with getting familiar with the signs and symptoms. Red flags for depression include:

  • Sadness or feelings of hopelessness.
  • Unexplained aches and aggravated pains
  • Lack of interest in hobbies or socializing.
  • Loss of weight or appetite.
  • Feelings of desperation or helplessness.
  • Lack of encouragement and energy.
  • Sleep disruptions
  • Slowed movement or discourse.
  • Fixation on death; suicidal thoughts.
  • Problems with memory.
  • Neglecting personal treatment

WHAT TO DO: PREVENTIVE MEASURES AS FAMILY MEMBERS OR CAREGIVERS

To help older adults suffering from depression, you can evaluate psychological evaluation with or without starting SSRIs. Selective serotonin reuptake inhibitors (SSRIs) are prescribed for patients with mild to severe depression who initiate psychiatric treatment with an antidepressant. Among the countless antidepressants, SSRIs provide as much value in terms of efficacy and mitigating health risks.  Besides, SSRIs are the most commonly used antidepressants.

Daily exercise can even help avoid depression and lift an older adult’s mood. Let them do everything that they want to do. Also, being physically healthy and consuming a healthy diet will help reduce ailments that may contribute to depression among older adults.

Moreover, Psychotherapy, often referred to as “talk therapy,” can help those with depression. Talk therapy is used to mitigate depression, and it works by assisting older adults to do away with harmful thoughts and any habits that could exacerbate depression.

Part Two of ‘The 4M’s Framework: MENTATION’.

DELIRIUM

Delirium can be a medical urgency/emergency and can present as either hyperactive or hypoactive. Any sudden change in mental status should be considered delirium. The hallmark is in-attention. It can get tricky when a person already has a diagnosis of dementia – we refer to this as delirium superimposed on dementia. However, once we fix the delirium’s underlying cause, the person will typically return to the baseline mental status.

If you or a loved one are planning an elective surgery, be sure to review these considerations and discuss them with your provider and surgeon, in hopes of preventing postoperative delirium. Page 24 has a checklist of things that you and your provider should look for and many of the Confusion Assessment Methods (CAM), such as the CAM-ICU (p. 47).

RECOGNIZING HYPOACTIVE DELIRIUM  AND HYPERACTIVE DELIRIUM

Delirium progresses gradually, and the effects fluctuate throughout the day and worsen at night. 

Hyperactive delirium is distinguished by Increased muscle movement, restlessness, anxiety, hostility, roaming, hyper-alertness, hallucinations, delusions, and inappropriate behavior. 

On the other hand, Hypoactive delirium is characterized by reduced muscle movement, lethargy, withdrawal, drowsiness, and sleeping too much.

SCREENING TOOLS THAT CAN BE USED TO ASSESS DELIRIUM

Whether you’re a family or caregiver of older adults at risk of or healing from delirium, you should take precautions to enhance the well-being of the individual better.  Assessment tools that may be used to test instances of delirium.

  • Confusion Assessment Method (CAM)
  • CAM-ICU for intensive care units
  • 3D-CAM for medical-surgical units
  • bCAM for emergency departments

WHAT TO DO AS FAMILY MEMBERS

The best thing you can do as a family member is to provide encouragement and orientation.  Remind the individual where they are, who they are, and also what time it is.

It would also help if you alerted providers whenever delirium signs and symptoms are noticed in the patient. A matter of saying, “Mama just isn’t right today.” can make a difference. 

WHAT TO DO AS PROVIDERS: PREVENTION STRATEGIES

As a healthcare provider, you will play a critical part in having a positive and comforting presence during an older person’s delirium. 

Here are several straightforward steps to alleviate delirium and how you can help as a caregiver :

  • Convey and resolve sensory disability. Use simple sentences to ask individual questions, and use interpreters where available.
  • Minimizing the confusion of the patient.
  • Place a large-font clock, calendars, and signs.
  • Promote cognitive enhancement, such as learning about news or recalling.
  • Discourage napping throughout the day to help the patient relax at night.
  • Foster mobility and self-care
  • Promote autonomy in everyday life tasks and minimize the possibility of crashes.
  • Encourage patients to reduce the possibility of constipation, dehydration, and under-nutrition by eating and drinking.
  • Consider calming, music, or massage therapies (this may also help with sleep).
  • Stop using indwelling catheters because they can cause contamination.
  • It is advised to minimize, stop or prevent the usage of psychoactive medications as they can aggravate delirium.
  • Document the indications in the psychiatric background of the patient for the usage and stopping use of antipsychotic treatment
  • Ensure that pain control is available and that a protocol for pain treatment is in effect.
  • Keep the room silent, such as utilizing vibrating pagers instead of calling bells.

Recognizing delirium is the biggest thing. In some of the studies that I’ve seen, up to 60 to 75 % of health care providers don’t recognize delirium. -Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN

DEMENTIA

RECOGNIZING DEMENTIA

Dementia is not a particular illness; it’s a broad concept that encompasses a wide variety of serious medical issues, including Alzheimer’s disease.   Abnormal brain shifts are triggered by diseases clustered under the general word “dementia.”

These transitions cause a reduction in reasoning skills, which are incredibly severe to affect everyday life and autonomous functioning. They also influence actions, thoughts, and relationships.

Check out these related podcasts to learn more:

SCREENING TOOLS USED TO ASSESS DEMENTIA

A clinical evaluation, experimental testing, and the observation of the irregular shifts in thought, day-to-day function, and patient actions are needed by physicians to identify Alzheimer’s and other forms of dementia. 

But the precise form of dementia is more difficult to ascertain since the signs and brain alterations of multiple dementias may overlap. For health care providers, some of the screening tools that are commonly used are MMSE (Mini-Mental State Exam), MoCA (Montreal Cognitive Assessment for Dementia, and the SLUMS Test.

WHAT TO DO AS FAMILY MEMBERS AND HEALTHCARE PROVIDERS

You can take measures to improve cognitive health and reduce your loved one or patient’s risk of dementia. Please encourage them to maintain an active mind by playing word puzzles, memory games, and reading. Being physically active, exercising at least once a week, and making other positive lifestyle improvements will also lower the risk.

Lifestyle and dietary improvements include avoiding smoking and consuming a diet high in, Fatty Acids omega-3, Fruit, Vegetable, and whole grains.

About Tahira I. Lodhi MD

Tahira I. Lodhi, MD, is an assistant professor at the University of George Washington for Geriatrics and Palliative Care. In 1999, she graduated from medical school and received her Family Medicine training at Virginia Commonwealth University and her Geriatrics Fellowship Training at George Washington University.

Dr. Lodhi’s expertise is in the training and practice of primary care geriatrics. She’s often involved in developing workflows in healthcare systems and supporting her patients to receive streamlined, patient-centered services.

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About Melissa:

Melissa Batchelor, PhD, RN, FNP, FGSA, FAAN. I am a nurse, nurse practitioner, nurse educator and nurse researcher with over 25 years of experience in the aging and long-term care healthcare space. You can visit my website at MelissaBPhD.com to learn more about me, how you can work with me directly,
and/or support future episodes of the podcast. Within the first 18 months of launching this podcast, we reached a ranking of top 10% globally. I have all of you who’ve been with me on this journey so far to thank for that!

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