572 Home Healthcare Nurse © 2006 Lippincott Williams & Wilkins, Inc. www.homehealthcarenurseonline.com

he number of old and very old patients that we encounter is significantly on the rise.

Never has the need been so great for nurses to view their older patient population

base as a true specialty. With the responsibility of caring for our older patients comes

the need and responsibility to know and use correct assessment parameters for this

unique group. A geriatric assessment is a comprehensive evaluation designed to

explore and gain information about the older person’s functional abilities or

limitations in order to help improve overall quality of life and enable him or her to live

independently for as long as possible. Such a comprehensive assessment includes

physical, psychological, and social dimensions.

As with other adult life cycles, the geriatric population is not immune to mental

health disorders such as depression or anxiety. Assessment and diagnosis of late-life

mental disorders are especially challenging for today’s home health nurse. The symp-

toms presented by older adults may be different from those found more commonly in

younger patients, making the disorder more difficult to determine. Additionally, many

older patients are reluctant to report symptoms, afraid of the social ramifications and

the stigmas attached to an aging mind. The elderly are more likely to seek medical at-

tention for physical symptoms than for feeling depressed. Comorbidity with other

medical disorders, and even the effects of normal aging, may result in misdiagnosis

and inappropriate plans of care. This article is intended to explore three distinctive dis-

orders in the elderly that often mimic each other, sharing some basic symptoms, and

to assist the home healthcare nurse to differentiate between the three: dementia, de-

pression, and delirium.

T

The Home Health Nurse’sRole in Geriatric Assessment

of Three Dimensions:

Detection of mental disorders inolder adults is complicated by high co-morbidity with other medical disor-ders. A complete and thorough physi-cal assessment is absolutely essentialbefore concluding that the symptomsof depression, delirium, or dementiaare present in the older patient. Nursesmust first understand the physiology ofnormal aging before distinguishing ab-normal findings. Also, the symptoms ofsomatic disorders may mimic or maskthe symptoms of dementia, depression,or delirium, making diagnosis more dif-ficult. When is a complete geriatric as-sessment needed? A request for a geri-atric assessment would be appropriatewhen there are persistent or intermit-tent symptoms such as memory loss,confusion, or other signs of possibledementia. Often, what looks likeAlzheimer’s disease or dementia couldbe the result of medication interactionsor other medical or psychiatric prob-lems. Because of the thoroughness ofthe geriatric assessment, it is one of thebest ways to determine the actualcause of the problem (Table 1).

Depression OverviewNurses specializing in the field of geri-atric nursing or home healthcarenurses with older patients can fre-quently expect to have patients pre-senting with clinically significant symp-toms of depression. It is estimated thatsymptoms of depression occur in morethan 30% to 50% of all older patients; itis the mental health problem of great-est frequency and magnitude in thispopulation (Tabloski, 2006). Symptomsof depression may include loss of en-ergy, variations in sleep patterns, lossof appetite, chronic headaches, rise insomatic complaints, and difficulty in

vol. 24 • no. 9 • October 2006 Home Healthcare Nurse 573

Jean T. Walker, RN, MSN, PhD,

Susan P. Lofton, RNC, CNS, PhD,

Lisa Haynie, RN, FNP, PhD, and

Tina Martin, RN, FNP, PhD

concentrating. Sometimes, older patients with de-pression also report excessive or inappropriatefeelings of guilt, suicidal ideation, or a preoccupa-tion with death. Unfortunately, because manymedical conditions that are present in the elderlyalso produce similar symptoms, depression mayexacerbate over time before the health team con-siders depression as a diagnosis. Additionally,many common medicines prescribed to the olderage group also produce similar symptoms. Theseinclude sedatives, corticosteroids, antihyperten-sives, anticonvulsants, anti-Parkinson drugs, andnonsteroidal anti-inflammatory drugs (NSAIDS)(http://www. pdrhealth.com, 2006).

All people feel sad or unhappy at times duringtheir lives, but persistent sadness may be depres-sion, a serious illness affecting 15 out of every 100adults older than 65 in the United States (Unutzeret al., 2002). Depression is not a normal part ofgrowing old but rather a treatable medical illnessthat impacts more than 6 million of the more than40 million Americans older than 65 (Center for El-derly Suicide Prevention, 2006). When depressionoccurs in late life, it may be a relapse of an earlierdepression. If it is a first-time occurrence, it may betriggered by another illness, hospitalization, orplacement in a nursing home. Unlike the onset ofdepression in nonelderly populations, depressionin the elderly is often triggered by specific stres-sors, such as medical illness or the death of a lovedone such as a spouse or friend (Gallo et al., 2006).

To assist in diagnosing depression, the nurseshould determine if the elderly patient has expe-rienced multiple signs of depression for morethan 2 weeks. Many clinicians consider a loss ofinterest or pleasure in daily activities to be the es-sential feature of depression. Depression is aprincipal risk factor for suicide in older adults.Often, the nurse can better assess the older pa-tient using a methodical, organized data collec-tion approach. There are several useful and re-spected tools that can assist the nurse in correctassessment, including the Geriatric DepressionScale (GDS), which is a self-report assessment de-veloped in 1982 by J.A. Yesavitch and coworkers.The GDS is a 30-item self-report assessment de-signed specifically to identify depression in theelderly. The items may be answered as yes or no,which is thought to be simpler than scales thatuse a five-category or Likert-like response set.However, a diagnosis of clinical depressionshould not be made on the basis of the GDS re-sults alone, but in conjunction with other clinical

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Table 1. Common PhysicalFindings of Normal Aging Cardiac Heart loses elasticity

Systolic murmurs common

Common presence of somearteriosclerosis

Significant increase in systolic pressure (at orabove 140 mm Hg), whichmay suggest hypertension

Integumentary

Loss of elasticity

Cooler extremities

Thinning hair distribution

Presence of multiple agespots

Musculoskeletal Bones are more porous

Loss of 2 inches in heightfrom young adulthood

Joints are less mobile, with limitations on range of motion

Posture changes, often with kyphosis

Gastrointestinal Decreased saliva production, making swallowing more difficult

Decreased peristalsis

Weaker anal sphincter control

Sensory Decreased peripheral vision

Yellowing of lens, causingdecreased discrimination of colors

Decreased tearing, causingdry eyes

Diminished sense of balance

Diminished thermal regulation

Diminished sense of taste

Note. Data from Gallo et al., 2006 and Ebersole et al., 2004.

findings (Sheikh & Yesavitch, 1986; Gale Encyclo-pedia, 2005).

Older people have the highest rates of suicidein the US population: suicide rates increase withage, with older white men having a rate of suicideup to six times that of the general population(Table 2). Eighty-five percent of all persons dyingfrom suicide are men older than 65 years (Centerfor Elderly Suicide Prevention, 2006). Despite theprevalence of depression and the risk it confersfor suicide, depression is neither well recognizednor treated in primary care settings, where mostolder adults seek and receive healthcare (Unutzeret al., 2002). Consider case study 1.

Case Study 1Joe Tubbs, an elderly male veteran, lives in a smallhome on Elm Street. Joe is 80 years old, with a his-

tory of congestive heart failureand diabetes. Daily medica-tions include Lasix, Glu-caphage, and Digoxin. Joe iscurrently battling gout. Sincethe death of his wife, Ethyl(then aged 53) 7 months ago,Joe spends his days alone, oc-casionally visited by one WWIIArmy buddy. Although Ethyl al-

ways prepared their meals around a strict AmericanDietetic Association diet, Joe finds he does not havemuch of an appetite these days, preferring to simplysnack on saltines, sardines, and eggs. For the past 10days, Joe has been unable to fall asleep, strugglingwith an overwhelming sense of loneliness and sor-row. Today, Joe awakes to find his first toe, or hal-lux, inflamed, stiff, and painful to touch. He coughsup an abundance of frothy sputum, and realizes heforgot to take yesterday’s Lasix. Rubbing his throb-bing toe, Joe remembers a previous episode of goutwhen he and Ethyl went to Niagara Falls on their sil-ver anniversary. As Joe sits down to look over an oldphoto album of that trip, his telephone rings withnews of his Army buddy’s death early this morning.Joe feels so alone in the world. He feels that his bodyis old and falling apart, with frequent bouts of con-gestion, and now this flare-up of gout. Thinking ofhow much he wishes to be with his wife and friend,Joe begins to form a plan...and thinks of a way to tellhis home healthcare nurse goodbye....

Points to Ponder• What are the clinical symptoms of depression

presented by Joe?

• Which of Joe’s medications may produce sim-ilar symptoms to depression?

• What comorbid physical findings should befurther assessed before a diagnosis of depres-sion is established?

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Table 2. Suicide Among the Elderly

n The highest suicide rates of any age groupoccur among persons aged 65 years andolder.

n There is an average of one suicide amongthe elderly every 90 minutes.

n Suicide disproportionately impacts the el-derly. In 1998, this group represented 13%of the population but suffered 19% of allsuicide deaths.

n Firearms (71%), overdose (liquids, pills, orgas, 11%), and suffocation (11%) were the 3most common methods of suicide used bypersons aged 65+ years.

n Risk factors for suicide among older personsdiffer from those among the young. In addi-tion to a higher prevalence of depression,older persons are more socially isolated andmore frequently use highly lethal methods.They also make fewer attempts per com-pleted suicide, have a higher male-to-femaleratio than other groups, have often visited ahealthcare provider before their suicide, andhave more physical illnesses.

n It is estimated that 20% of elderly (>65years) persons who commit suicide visiteda physician within 24 hours of their act, 41%visited within a week of their suicide, and75% have been seen by a physician within 1month of their suicide.

n Suicide rates among the elderly are highestfor those who are divorced or widowed.

n Several factors relative to those older than65 years will play a role in future suiciderates among the elderly, including growth inthe absolute and proportionate size of thatpopulation; health status; availability of ser-vices; and attitudes about aging and suicide.

Note. Data from National Strategy for Suicide Prevention,United States Department of Health & Human Services,2006.

• As a home healthcare nurse, if upon visitingJoe, he manifested the above clinical picture,how would you assess his risk for suicide?

• What steps would the home healthcare nursetake next?

Delirium OverviewThe term delirium is derived from the Latin wordsde lira meaning “off the path.” Delirium is charac-terized by disturbances in levels of consciousnessand cognition, and is often associated with an un-derlying medical condition (Life Steps, n.d.).Therefore, the causes of delirium may be re-versible. Patients with delirium frequently presentwith agitation, somnolence (fatigue), withdrawal,and psychosis. To determine dementia in an el-derly patient, it is important to obtain the historyof the onset and course of the condition from fam-ily members or caregivers. Although low doses ofantipsychotic drugs are often ordered to assist incontrolling symptoms of agitation, this strategyshould be used only when nonmedication strate-gies fail. Environmental interventions, includingfrequent reorientation of patients by nursing staffand education of patients and families, should befirst implemented rather than providing a quickfix through medications alone.

There are four basic tenets that help form thediagnosis of delirium:

• laboratory data, which confirm a problematicunderlying medical condition;

• change in baseline level of consciousness;• changes in cognition, such as acute memory

disturbance; and• fluctuations of cognition throughout a 24-

hour period.

Additionally, often there are changes in psy-chomotor activities, either obvious or subtle. Use-ful screening methods to identify attention prob-lems include asking patients to spell a wordbackwards or perform “serial 7s” (counting back-ward from 100 by sevens) (Folstein et al., 1975).Early diagnosis and resolution of symptoms arecritical to achieve the most favorable outcomes.Approximately 14% to 56% of elderly patients whoare hospitalized show symptoms of delirium (LifeSteps, n.d.). This may cause an increased length ofhospital stay, increased costs to the patient, andincreased medical complications.

Considering that patients with delirium oftenhave symptoms of confusion, the nursing assess-ment and corresponding documentation of pa-tients’ conditions are paramount to the interdisci-plinary plan of care. The home healthcare nurseshould routinely obtain a detailed history from fam-ily, caregivers, or other sources, and should care-fully and accurately document these baseline datain the patient’s clinical record. Episodes of halluci-nations, disorientation, or other abnormal behav-iors should be detailed. Patients with delirium oftenhave episodes of persecutory delusions and may beunwilling to share their feelings with the healthcareteam. Because of the high risk of suicidal behaviorsin persons with delirium, the patient should neverbe left alone or unattended, and the suicide riskshould always be considered (case study 2).

Case Study 2Maria Sanchez is a 71-year-old Hispanic female,who is accompanied to the community health

clinic by her daughter, Lucia,and great grandson, Juan.Maria has the following med-ical diagnoses: mild arthritis,hypertension, and peripheralvascular disease.

Lucia, the daughter, is 53years old with multiple healthproblems. She is trying to carefor her mother while working

full time as a nurse’s aide. Additionally, Lucia is car-ing for little Juan, who is an active 3-year-old toddler.Juan’s mother is deployed in Iraq on active dutywith the Marines. It is obvious that Lucia is irritableand tired and needs help with caregiver stress.

According to Lucia, who tends to do all of thetalking for the family, her mother is “out of con-trol” for the past 2 weeks. She states that hermother is not sleeping and is keeping the rest of

576 Home Healthcare Nurse www.homehealthcarenurseonline.com

Because patients with delirium

often have symptoms of confusion,

the nursing assessment and

corresponding documentation of

patients’ conditions are paramount

to the interdisciplinary plan of care.

the family up at night because of her “constantroaming through the house.” She states thatthough Maria has been very forgetful for the pastfew years, she has now forgotten the grandson’sname. She states that last night her motherburned the tortillas at supper, yet seemed un-aware of the danger when the burned tortillasfilled their little kitchen with smoke. Two daysago, her mother was bitten by “some bug” and hasa problem with her ankle since that time.

Maria presents to the clinic this morning withthe following symptoms: swollen left ankle with alarge area of cellulitis. Huge scratch marks arepresent around the site of the bite. Elevated tem-perature is at 100.4°F orally. Blood pressure is138/94. As you examine her ankle, Maria yells outthat she wants to go home now, as she needs toget breakfast for her husband, Manny. Lucia ex-plains that Manny has been dead for 12 years.Maria becomes very agitated at this time.

Points to Ponder• What are the clinical symptoms for delirium

that are presented by Maria?• How does the cellulitis influence the diagno-

sis of delirium?• What are some basic teaching points about

delirium that may be useful in reducingLucia’s stress?

• What are some home safety tips that could beeasily implemented to decrease risk of injuryto Maria?

Dementia OverviewDementia is defined as a loss of mental ability, se-vere enough to interfere with normal activities ofdaily living, lasting more than 6 months, not pre-sent since birth, and not associated with a loss ofalteration of consciousness (Life Steps, n.d.).Wold (2004) defines dementia as a slow, insidiousprocess that results in a progressive loss of cog-nitive function and may be caused by damage tothe cerebral cortex that is most commonly a re-sult of disease conditions. Alzheimer’s disease isthe most well-known form of dementia. The es-sential feature of this disease is impairment inshort-term and long-term memory.

In the elderly patient, delirium and dementiamay coexist owing to multiple medications andelectrolyte imbalance (Ebersole et al., 2004). Fiveto eight percent of all persons aged between 65and 74 and up to 20% of those older than 75 are af-fected by dementia (Life Steps, n.d.). Home health-care nurses should be aware that medications maycause side effects that simulate dementia. Theseinclude the drug categories of sedatives, hyp-notics, anticonvulsants, antiarrhythmics, anddrugs with anticholinergic effects (www.pdrhealth.com, 2006). Table 3 lists conditions thatmay cause or simulate confusion or dementia.

Three Levels of DementiaAlthough dementia does not progress through dis-tinct stages, there are some general levels of the dis-ease that have distinct features and symptomology.

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Table 3. Conditions That MayCause or Simulate Confusion or Dementia

n AIDS

n Parkinson’s disease

n Huntington’s disease

n Brain tumor

n Hydrocephalus

n Heat stroke

n Alcohol and drug abuse

n Thiamin, niacin, and vitamin B12 deficiencies

For Further ReadingArnold, E. (2005). Sorting out the 3 D’s:

Delirium, dementia, depression. HolisticNursing Practice, 19(3), 99-104.

Caregiving strategies for older adults withdelirium, dementia and depression. Na-tional Guideline Clearinghouse. Availableat: www.guideline.gov.

Depression in older adults guidelines. Avail-able at: www.guideline.gov.

Edwards, N. (2003). Differentiating the threeD’s: Delirium, dementia and depression.Medsurg Nursing, 12(6), 347-357.

Long, C. (n.d.). Dementia vs. depression.Neuropsychology & Behavioral Neuro-science. Retrieved April 2006, fromhttp://www.neuro.psyc.memphis.edu.

n Hyperthyroidism

n Hypercalcemia

n Liver failure

n Kidney failure

n Pernicious anemia

n Infection

n Dehydration

Level 1• Hallmarked by forgetfulness, poor judgment,

and loss of spontaneous emotional response.During this initial level, caregivers and familyoften notice decreased ability to perform sim-ple verbal and math skills commonly associ-ated with activities of daily living.

Level 2• Usually ushers in advanced episodes of for-

getfulness, significantly impaired judgment,and episodes of irritability and mild agitation.Family and caregivers may now notice someconfusion to place and time and bouts of in-continence.

Level 3• Patients often manifest a total inability to

communicate verbally and also experience aloss of contact with reality of their situation.Patients in the later levels are dependent oncaregivers for all physical needs. During thelater disease levels, patients are at high riskof infection, malnutrition, dehydration, falls,and skin breakdown and need close assess-ment and detailed care planning.

Home Care Nursing ImplicationsHome care nurses working with the elderly shouldbe familiar with normal aging changes and expec-tations. This allows the nurse to better separateabnormal symptoms that merit further assess-ment and scrutiny. Our geriatric patients are athigh risk to experience depression, delirium, anddementia at some point of the elder life span. Thehome healthcare nurse can play a pivotal role inrecognizing symptoms at their earliest stages andreferring the patient for further medical workupand treatment. Medication regimens should be as-sessed frequently to determine possible side ef-fects that may mimic clinical pictures of depres-sion, delirium, and dementia. Laboratory valuesshould also be closely monitored. The homehealthcare nurse’s complete, accurate, and de-tailed baseline history and physical examinationwill also assist the health team in determining anaccurate diagnosis and effective plan of care.Early intervention and treatment reduce morbid-ity and increase quality of life.

Jean T. Walker, RN, MSN, PhD, is Associate Profes-sor, The University of Mississippi Medical Center,School of Nursing, Jackson, Mississippi.

Susan P. Lofton, RNC, CNS, PhD, is Professor,The University of Mississippi Medical Center, Schoolof Nursing, Jackson, Mississippi.

Lisa Haynie, RN, FNP, PhD, is Assistant Professor,The University of Mississippi Medical Center, Schoolof Nursing, Jackson, Mississippi.

Tina Martin, RN, FNP, PhD, is Assistant Professor,The University of Mississippi Medical Center, Schoolof Nursing, Jackson, Mississippi.

Address for correspondence: Jean T. Walker, RN,MSN, PhD, The University of Mississippi MedicalCenter, School of Nursing, Jackson, Mississippi (e-mail: jwalker@son.umsmed.edu).

The authors of this article have no significantties, financial or otherwise, to any company thatmight have an interest in the publication of this ed-ucational activity.

REFERENCESCenter for Elderly Suicide Prevention. (2006). Retrieved

May 8, 2006, from http://www.ioaging.org.Ebersole, P., Hess, P., & Luggen, A. (2004). Toward health

aging: Human needs and nursing response (6th ed.).St. Louis: Mosby.

Folstein, M., Folstein, S., & McHugh, P. (1975). Mini-men-tal state. A practical method for grading the cogni-tive state of patients for the clinician. Journal of Psy-chiatric Residents, 12, 189-198.

Gale Encyclopedia of Mental Disorders. (2005). Geriatricdepression scale forum. Available at: http://www.minddisorders.com/Flu-Inv/Geriatric-Depression-Scale.html.2005-10-24; 13; 57; 47.0.

Gallo, J., Bogner, H., Fulmer, T., & Paveza, G. (2006).Handbook of geriatric assessment (4th ed.). Boston:Jones & Bartlett Publishers.

Life Steps. (n.d.). Dementia. Retrieved January 19, 2005,from http://www.lifesteps.com.

PDR Health (2006). Thompson Healthcare. RetrievedMay 17, 2006, from http://wwwpdrhealth.com.

Sheikh, J., & Yesavitch, J. (1986). Geriatric depressionscale (GDS): Recent evidence and development of ashorter version. In T. L. Brink (Ed.), Clinical gerontol-ogy: A guide to assessment and intervention. NewYork: Haworth Press.

Tabloski, P. (2006). Gerontological nursing. New Jersey:Prentice Hall.

United States Department of Health and Human Ser-vices. (2006). National strategy for suicide prevention.Retrieved May 2006, from http://www.mental-health.samhsa.gov.

Unutzer, J., Patrick, L., Marmon, T., Simon, G., & Katon,W. (2002). Depressive symptoms and mortality in aprospective study of 2,558 older adults. American As-sociation for Geriatric Psychiatry, 10, 521-530.

Wold, G. (2004). Basic geriatric nursing. New Jersey:Prentice Hall.

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