Live webinar recorded June 26, 2012 featuring Tracey L. Gendron and Dr. Andrew L. Heck - discussion moderated by Dr. E. Ayn Welleford. View details at www.alzpossible.org
TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
Differentiating depression and dementia gendron and heck
1. Community Training on
Depression and Dementia
Tracey Gendron, MSG Andrew L. Heck, Psy.D., ABPP
Gerontologist Licensed Clinical Psychologist
Assistant Professor Clinical Director
Virginia Commonwealth University Piedmont Geriatric Hospital
2. Why is it important for
YOU
to know the differences between
depression
dementia
3. A CASE STUDY
George is a 70-year-old physically healthy retiree
• Hobbies: working in the shop, target shooting
Recently began having memory problems
• Family history of Alzheimer’s disease (sister)
• Family physician diagnosed George with Alzheimer’s
too
THEN:
• Son and grandsons removed ammunition from
house
• Nursing home admission months later
• Occasional passes to visit home
• Wife hears screen door “slam”…
Fatal suicide attempt with handgun
Note revealed George had hidden one bullet back
from family, was afraid of becoming a burden
4. QUICK FACTS
Major depressive disorder affects 1-2% of older
adults 65+ in the community
Significant depressive symptoms affect
up to 20% of older adults
Dementia affects 5% of people 65+ and
about 40% of adults over 85
5. OUR RESEARCH SHOWS
Type of job influences knowledge
about depression and
differentiation of depression and
dementia symptoms
However,
it did not influence knowledge of dementia
6. WHAT PERCENTAGE OF RESIDENTS IN YOUR
FACILITY HAVE DEMENTIA AND DEPRESSION?
PROFESSIONAL PARAPROFESSIONAL
74
66
37
33
Dementia Depression
8. Short-term memory loss that disrupts
daily life
Word-finding difficulty
SYMPTOMS of AD
Get lost in familiar places
Following a plan or
recipe
Challenges with planning or solving
problems
Paying bills
Misplacing things and losing ability to
retrace steps
Trouble understanding visual images
and spatial relationships
Withdrawal from work or social ADLs
activities
Begin to be unable to care for self Meals
Changes in mood or personality Safety
May begin to lose track of place and
time (orientation)
9. 10% of medically hospitalized and 12-20% of Long Term Care (LTC)
residents have a full diagnosis of major depression
Between 20-25% of older adults in LTC have clinically significant signs and
DEPRESSION
symptoms of depression
10-15% of older adults in the community have signs and symptoms of
depression
Rates of diagnosed major depression in older adults are lower than rates for
younger adults
Older adults report that they would be most likely to tell their primary care
doctors about emotional difficulties
Depression can be treated as successfully in older adults as it can be in
younger persons!
10. DEPRESSION – DSM IV*
depressed
mood
loss of interest or
feelings of
pleasure in
worthlessness
activities
Five (5) or more of
the following
signs/symptoms
significant
fatigue weight loss
or gain
psychomotor
agitation or sleep disturbance
retardation
*Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition
11. DEPRESSION –NON-DSM
Hypochondriasis
Irritability Sleep difficulties
Depression
(Non-
DSM) Reduced
Apathy
appetite
A lack of positive
feelings (rather than Fatigue
active negative
feelings)
12. DID YOU KNOW??
Patients diagnosed
with depression
actually develop
dementia at As many as 10-
30% of patients
2.5 - 6 presenting with
times dementia also
the rate of the HAVE depression
general population
13. SO, HOW DO YOU KNOW…
IF IT IS
DEPRESSION or DEMENTIA?
14. What type of
What do we complaints arise
know about the from the
person’s history? individual? From
the family?
How did What does the
symptoms behavior look
develop? TAKING like?
A
CLOSER
LOOK
15. THE FAMILY
PERSPECTIVE
1. The symptoms progressed very
quickly after they first appeared.
2. The onset of symptoms are dated with
accuracy
MIGHT THIS BE DEPRESSION OR
DEMENTIA??
17. SIDE BY SIDE COMPARISON
DEPRESSION DEMENTIA
• Symptoms develop • Symptoms develop
QUICKLY after onset SLOWLY after onset and
• The onset of symptoms is throughout the course of
DATED WITH ACCURACY the illness
• Family is AWARE of a • The onset of symptoms is
problem and that it is only KNOWN WITHIN
severe BROAD LIMITS
• Medical help is sought • Family is often UNAWARE
SHORTLY after symptoms that there is a problem and
begin of its severity
• Medical help is usually
sought a LONG TIME after
symptoms develop
18. COMPLAINTS
1. The individual isn’t complaining much about
their cognitive problems.
2. They actually try to hide their disability.
IS THIS DEPRESSION OR DEMENTIA??
20. SIDE BY SIDE COMPARISON
DEPRESSION DEMENTIA
• Person usually • Person usually
complains MUCH complains LITTLE
about cognitive loss about cognitive loss
• Complaints about • Complaints about
cognitive dysfunction cognitive problems
is usually DETAILED are usually VAGUE
• Person • Person CONCEALS
EMPHASIZES disability
disability
21. BEHAVIOR
1. The individual makes very little effort to
perform even simple tasks
2. They usually communicate a strong level of
distress
IS THIS DEPRESSION OR DEMENTIA??
23. SIDE BY SIDE COMPARISON
DEPRESSION DEMENTIA
• Person makes very • Person STRUGGLES
LITTLE effort to to perform tasks
perform even simple • Person often appears
tasks UNCONCERNED
• Person usually • Person delights in
communicates a strong ACCOMPLISHMENTS
sense of DISTRESS
• Person highlights
FAILURES
24. BEHAVIOR
1. The individual still behaves appropriately in
social situations
2. Behavioral problems are clearly worse at
nighttime
DEPRESSION OR DEMENTIA??
26. SIDE BY SIDE COMPARISON
DEPRESSION DEMENTIA
• LOSS of social skills • Social skills are often
often early and RETAINED
prominent • Mood is LABILE and
• Change in mood is shallow
PERVASIVE • TYPICAL to
• NOT TYPICAL to experience
experience accentuated
accentuated problems at night
problems at night
27. WHAT DOES ALL OF THIS MEAN FOR YOU??
• Watch the individual’s behavior
In making a good diagnosis carefully, especially for anything out of
(which is crucial), treatment the ordinary;
providers are truly counting on• Ask about how he or she is feeling now
and how they’ve been feeling
good information from lately, and ask their family or
caregivers; caregivers’ the same thing about them;
• Listen for increased complaints about
health, pain, memory/cognition, or
anything else;
• Look closely for changes in eating
habits, sleep patterns, level of activity;
Report your observations to
someone from the treatment
team immediately;
Realize that your observations
may lead to life-changing
treatment!!
28. PRE-EVENT SURVEY
It is normal to become depressed as individuals get older and live in long-term care
FALSE
facilities.
Depressed residents should be able to "snap out of it" (i.e. use their willpower to get
FALSE
better).
Family members can be helpful when working with depressed residents. TRUE
Older adults do not change; therefore, there is no need to treat their depression. FALSE
Weight loss, difficulties falling asleep and concentration problems can be signs of TRUE
depression in older adults.
If a resident reports guilt about the past he or she might be depressed. TRUE
Agitation can be a sign of depression. TRUE
Confusion and memory lapses in older people can sometimes be due to physical TRUE
conditions that doctors can treat so that these symptoms go away over time.
Becoming disoriented (such as getting lost or losing track of what day it is) happens to FALSE
persons with Alzheimer’s disease, but only in the later stages of the disease.
TRUE
Memory loss that disrupts daily life can be a symptom of dementia.
TRUE
Confusion with time or place can be a symptom of dementia.
Alzheimer’s disease is the only illness that leads to confusion and memory problems in FALSE
older adults.
29. PRE-EVENT SURVEY
Symptoms develop slowly after onset and throughout the course of the illness in a person
DEMENTIA
with…
Social skills are often maintained in a person with … DEMENTIA
Difficulties with behavior and symptoms at night are typically of patients with… DEMENTIA
A person with ________ makes very little effort to perform basic tasks. DEPRESSION
A person with _______ complains very little about cognitive loss. DEMENTIA
30. QUESTIONS? COMMENTS?
For additional information about this training
please contact:
Tracey Gendron
tlgendro@vcu.edu
Virginia Commonwealth University
(804) 828-1565
Or
Dr. Andrew Heck
andrew.heck@dbhds.virginia.gov
Piedmont Geriatric Hospital
(434) 767-4582
Notas do Editor
Implications ofmis-diagnosis, under and over diagnosingHow this can lead to excess disability
George was a 70-year-old married man in reasonably good physical health. He lived with his wife of 45 years in a small country house flanked by farmland on all sides. Long retired from his blue-collar career, he spent his days either tinkering in his metal shop or taking target practice with his extensive and meticulously maintained rifle and handgun collection. His wife noticed he had been recently begun experiencing memory problems and grew concerned—especially since they had both watched his sister suffer and decline through a long course of Alzheimer’s disease a few years back. After a 20-minute interview and examination by his family physician, the doctor indeed diagnosed him with Alzheimer’s disease. Devastated, George and his wife began anticipating his inevitable decline.
Major depressive disorder – 1-2% of older adults which is generally lower than for younger adults (2-3%)This number is much higher for adults living in long-term care communities, which we will address later in the presentation.
Study of 159 staff members working in LTC who attended this presentation. Type of job influenced knowledge about depression and differentiation. Paraprofessional staff scored lower on depression and differentiation knowledge than professional staff. Interestingly the difference in knowledge did not have anything to do with level of education, which calls for more on the job training
In addition, paraprofessional staff perceived that it is normal to become depressed as you are getting older significantly more often than professional staff
Speaker note: Consider directly addressing the fallacy that “Alzheimer’s” and “Dementia” are entirely separate. Emphasize that Alzheimer’s is one form of dementia, and that there are several others. (e.g., “His doctor says he either has dementia or Alzheimer’s” is a common example of this misconception)Dementia is a term for a group of diseases that affect cognition and memory. Alzheimer’s Disease is the most common form of dementia and is typically associated with the gradual loss of memory, reasoning, orientation and judgment along with the progression of a number of behavioral disorders including confusion, depression and aggression.
Short-Term Memory:Most affected individuals have problems remembering recently learned information. Some may forget important dates or events or ask the same information over and overPlanning: Affected individuals have problems concentrating and seeing a task to completion that used to requires less thought. As a result, people with Alzheimer's often find it hard to complete daily tasks. Early places this becomes evident might include managing a budget at work or remembering the rules of a favorite game.Misplacing: Persons with Alzheimer's disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time.
Speaker: differentiate “signs and symptoms” from “full [DSM] diagnosis”Worth mentioning – Suicide - Older adults have greater attempts to completion ratio (4:1) than younger adults (30:1)Completion rates – likely due to using more lethal means. Also probably due to inability to recover from failed attempts (overdoses, injuries, etc)
DSM-IV (pronounced D-S-M Four) stands for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. It is the book that contains psychiatric diagnoses and the criteria that determine whether or not someone may have a mental illness.In order for an individual to be diagnosed with Major Depression, he or she must exhibit 5 or more of the following signs as listed within the DSM-IV DSM-IV criteria, however, are NOT a good index of depression in older adults. Speaker note: point out how DSM criteria can be confused with other possible explanations for “symptoms”Example: Discuss sleep changes in older adulthood and how they may be mistaken for sleep difficulties or insomnia (i.e., why this is a bad index criteria for older adults).
These are clinically recognized symptoms specific to older adults. These can often be difficult to separate from normal age-related changes which further complicates diagnosis.Highlight how these differences can lead to a misdiagnosis of either depression and/or dementia. Highlight how direct care staff play an important role in understanding symptoms from daily interaction with resident/patient/older adult. Also talking to family members and caregivers in order to get background and history of development and progression on symptoms
Introduce the concept of differential diagnosis between depression and dementia. Stress how important it is to understand the subtle differences in how they present in order to assure accurate diagnosis and treatment.This slide is followed by a series of slides that go step by step through examples of how depression and dementia present differently
Do you think that this is someone with depression or dementia?Additional information about this case…The individual’s family has always beenvery aware of a problem and exactly how serious it is.Medical help was sought very shortly after symptoms began.
Symptom development: point out how sudden and noticeable symptoms appear in depression, versus the more insidious and subtle (i.e., less likely to be noticed) development of dementia symptomsSymptom onset: point out that often times family members or caregivers can identify when symptoms began within even a specific month (e.g., “It seemed to start about 2 months ago…” versus a much broader estimate as to when dementia symptoms began (e.g., “I think it was around 2009 that he started having problems with his memory…”Family awareness: point out that family is much more likely to be aware (and more quickly becomes so) of depression than early dementiaSeeking help: point out that families and caregivers see depressive symptoms as being more urgent than the manner in which dementia symptoms manifest, and will therefore seek medical help faster even if they don’t know it’s depression
Additional information: Any complaints about memory or other thinking problems are vague and unclear.
Additional information:The individual highlights their failures rather than emphasizing their successes.
Additional information:Mood changes are labile and shallow (i.e., short-lived and quick-to-change)