module 6 depression delirium and dementia
TRANSCRIPT
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
Module 6.Module 6.
Depression/Delirium/DementiaDepression/Delirium/DementiaMary Shelkey, RN, PhDMary Shelkey, RN, PhD
Editor: Conchita Rader, MA, RNEditor: Conchita Rader, MA, RN
Staff Deelopment Partners EditionInstru!tor "uide
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T#IS MODULE IN$LUDES%
1. Expected Staff Cognitive Competencies2. Expected Staff Clinical Competencies3. Content Outline including Learning Activities
a. E!"#$E %O "#S%&C%O ' ead activities in "nstructor(uide and prepare materials for activities in advance
). Scripted Po*erPoint Presentation+. 1,-item Post %est6. esources
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E&PE$TED STA'' ($o)nitie* $OMPETEN$IES
1. $escrie t/e prevalence of depression in older adults.
2. &se an assessment instrument for depression in older adults 0see !odule +. Cognitive !ental Status Assessment of Older Adults
3. $iscuss smptoms and treatment strategies for depression in older adults.). $escrie t/e prevalence of delirium and dementia in older adults.
+. $iscuss t/e smptoms of delirium and dementia.
6. $iscuss t/e assessment and treatment strategies for delirium and dementia.
4. Contrast criteria for differentiating depression5 delirium5 and dementia in older adults.
E&PE$TED STA'' ($lini!al* $OMPETEN$IES
+e,aiors #o- alidated Noi!e Adan!ed+e)inner
$ompetent Profi!ient Epert
1. Accuratel assess fordepression in an older adultclient using a relialeassessment instrument
$irect oservation of use
of instrument5 and revie*of documented evidence offindings
2. ecognie manifestations ofdepression5 delirium5 anddementia in older adults
$irect oservation of
assessment
3. Evaluate patient responses totreatment for depression5delirium5 and dementia
evie* discuss findings
and documentation7 actionsta8en
). "mplement an individualiedplan for depression5 delirium5and dementia
$irect oservation of
follo*-up and use ofassessment tool to monitorfor c/anges over time
+. Accuratel assessdepression5 dementia5 anddelirium5 ased on clinicalparameters
$irect oservation of
assessment tec/ni9ues andstrategies7 revie* ofdocumentation
6. "mplement care environmentalterations and
nonp/armacologicinterventions to encourageprolem solving e/aviors inpatients *it/ dementia.
$irect oservation of
implemented measures and
patient outcomes
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
$ompeten! 0. Des!ri1e t,e prealen!e of depression in older adults.
A. $epression constitutes t/e most common emotional disorder found in older people.1
Estimates of t/e prevalence of ma:or depressive disorder in t/e elderl range from 2; to 1,;
of t/ose 6+ and older.
1+; among communit-d*elling olderpersons and 3,; among institutionalied older persons. %/e smptoms are often associated*it/ c/ronic illness and pain.
F. "t is important to identif patients */o ma e experiencing depressed smptoms as a side
effect of medication. !an prescription or over-t/e counter 0O%C drugs contriute todepression. Alt/oug/ t/ere is little pulis/ed information on alternative medicines causingdepression5 consideration s/ould e given to /eral5 nutritional5 vitamins and supplements5
particularl */en consumed in large doses. Some medications t/at ma cause smptoms ofdepression in older adults include' anti/pertensives5 antipsc/otics5 enodiaepines5analgesics5 antipar8inson5 antiarr/t/mic5 #SA"$s5 ot/er drugs suc/ steroids5 and
1
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
c/emot/erap drugs.3
(. !a:or depressive disorders occur less often in older adults compared to ounger adults7/o*ever5 24; of older adults experience depressive smptoms.
. %/e /ig/est rate of completed suicide of an age5 gender5 or et/nic group is among older
*/ite men. %/e ris8 of suicide is /ig/er in older adults t/an t/e rate for ounger people 0up tosix times more fre9uent in older */ite men over =+ ears of age.
". C/ronic depression in older adults occurs in 4; to 3,; of all cases of depression5 *it/ a t/irdof t/ose */o recover relapsing in t/e first ear.
B. As ounger persons *it/ t/eir /ig/er prevalence of depression age5 t/e incidence ofdepression in older adults is expected to increase over t/e next 2, to 3, ears.
$ompeten! 2. Use an assessment instrument for depression in older adults ('or a reie-3see Module 4. $o)nitie / Mental Status Eam of Older Adults*
A. Assessing depression in t/e older adult client is difficult ecause depression ma /ave atpicalpresentations.
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follo*-up.
C.2.%/e Fesavage (eriatric $epression Scale 0($S is used to s!reen for depression
in older adults. A score of greater t/an + is suggestive of depression and s/ould*arrant a follo*-up intervie*. %/is ta8es approximatel + minutes to administerand /as een validated and extensivel used *it/ medicall ill older adults5 andincludes fe* somatic items t/at ma e confounded *it/ p/sical illness. %/is tool/as een found to e t/e est tool and is availale in several languages. +6
C.3. %/e Cornell Scale for $epression in $ementia is used to assess for depression in!lients -it, adan!ed dementiaand used to follo* up *it/ t/ose */o scoredless t/an 1+ 0severe cognitive impairment on t/e !!SE.
$ompeten! 7. Dis!uss smptoms and treatment strate)ies for depression in older adults.
A. Clinical manifestations of depression in older adults4
A.1. $epressed mood'
!a den sad mood and complain of pain or somatic distress
Cring spells 0or complaining of inailit to cr or experience emotion
Persistent G1) das
A.2. Associated psc/ological smptoms'
eduction in gratification5 loss of pleasure in normall pleasurale activities0an/edonia5 loss of attac/ments 5 social *it/dra*al
#egative expectations' feelings of guilt5 /opelessness5 and /elplessness7 lac8 of
self-confidence5 lo* self-esteem5 self-reproac/
Poor concentration or memor prolems
!orid t/in8ing to include recurrent t/oug/ts of deat/ and suicidal t/oug/ts
A.3. Somatic manifestations
Persistent appetite c/anges and *eig/t loss or gain
Significant altered sleep 0too muc/ or not enoug/ or earl morning a*a8ening
Psc/omotor retardation or agitation > common smptom in an older person
5"al5 !.5 ? !ontorio5 ". Adaptation of t/e geriatric depression scale in Spain' A preliminar stud. %linical
$erontologist, &', [email protected] S. .5 !c(ann5 P. E.5 !ic/aels5 %. .5 Penninx5
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
A.2. Psc/otic smptoms
$elusions of *ort/lessness and sinfulness
$elusions of ill /ealt/
$elusions of povert 0Evaluate delusions as 3,; of elderl *omen alread are
at t/e povert level.
@ mont/s
Consider maintenance treatment
elapse
efer or consult a psc/iatrist orot/er mental /ealt/ professional C/ange %reatment
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%reatment strategies for depression in older adults include'
4,;7 03 targetedsmptoms7 0) degree of close monitoring for medication compliance5 and 0+patient and famil education aout t/e course and nature of depressive illness5treatment and potential side effects5 and t/e importance of treatmentcompliance. %/e principle regarding dosing t/e older adult is' MStart Lo*5 (oSlo*N. Carefull monitor for side effects5 suc/ as falls and loss of appetite.
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for all forms of depression. (enerall5 t/is approac/ aims to /elp depressedindividuals to t/oug/tfull examine t/eir e/avior5 eliefs5 emotions5 stressors5 andpersonal relations/ips in order to lead to lasting c/ange in factors t/at ma /avecontriuted to t/e development of depression.
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I"nterests 0an/edonia or loss of interest in usuall pleasurale activities
"(uilt andor lo* self-esteem
EEnerg 0loss of energ5 lo* energ5 or fatigue
$Concentration 0poor concentration5 forgetful
AAppetite c/anges 0loss of appetite or increased appetite
PPsc/omotor c/anges 0agitation or slo*ingretardation
SSuicide 0morid or suicidal ideation
E. Jor all levels of depression5 develop an individualied plan integrating t/e follo*ing nursinginterventions'
E.1. "nstitute safet precautions for suicide ris8 per institutional polic.
E.2. emove or control etiologic agents t/at ma include correcting or treatmentmetaolic and sstemic disturances5 and altering depressogenic medications.
E.3. !onitor and promote nutrition5 elimination5 sleeprest patterns5 and p/sicalcomfort5 especiall pain control.
E.). En/ance p/sical function.
E.+. En/ance social support.
E.6. !aximie autonom personal control self-efficac. Jor example5 includepatient in active participation in ma8ing dail sc/edules and setting s/ort-termgoals.
E.4. Structure and encourage dail participation in relaxation t/erapies5 and pleasant
activities
E.=. !onitor and document responses to medication and ot/er t/erapies5readminister depression screening tool.
E.@. Provide practical assistance5 suc/ as *it/ prolem-solving.
E.1,. Provide emotional support7 empat/ic5 supportive listening5 encourageexpression of feelings and /ope instillation5 support adaptive coping5 andencourage pleasant reminiscences.
E.11. Provide information aout t/e p/sical illness and treatment.
E.12. Educate patient aout t/e importance of ad/erence to prescried treatment
regimen
E.13. Ensure mental /ealt/ communit lin8up7 consider psc/iatric5 nursing /omecare intervention.
Learnin) A!tiit.
Case Stud on $epression
!s. ( is a 4+-ear old female living alone in /er apartment in #e* For8 Cit. er /usand died
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suddenl t*o ears ago of a /eart attac8. %/eir t*o c/ildren are alive and living out-of-state.
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
actuall reversile. %/ese are called MpseudodementiasN and are often treatale. Examplesare'
E.1. eactions to medications
E.2. Emotional distress
E.3. !etaolic disturances
E.). ision and /earing prolems
E.+. #utritional deficiencies
E.6. Endocrine anormalities
E.4. "nfections
E.=. Sudural /ematoma
E.@. #ormal Pressure drocep/alus
E.1,.
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
Earl $onfusional P,ase0!ildCognitive $ecline
"ncreased forgetfulness
$ecreased performance in emploment and social
settings
O:ective evidence of memor deficit otained *it/ an
intensive intervie*
!ild to moderate anxiet accompaning smptoms
Earl Dementia P,ase0!oderatel Severe Cognitive$ecline
Can no longer survive *it/out assistance
Cannot recall ma:or relevant aspects of t/eir current
lives
Some difficult c/oosing proper clot/ing to *ear
Ale to retain 8no*ledge of ma:or facts 0name5familIs names5 etc.
!a re9uire some assistance *it/ A$L
Late Dementia P,ase0SevereCognitive $ecline
#o veral ailities
"ncontinent of urine
Loss of asic psc/omotor s8ills
e9uires assistance toileting and feeding
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
$. $epression5 $ementia5 and $elirium are differentiated ased on specific parameters'16
Parameter Depression Dementia Delirium
Onset Coincides *it/ ma:or lifec/anges5 relativel rapid
progressing from *ee8s to
mont/s
"nsidious and gradual7 mont/s toears
S/ort rapid5 arupt7 /ours das
"nitialPresentation
Jlat affect5 /poc/ondriasis5focuses on smptoms5 apat/5
little effort to perform tas8s
ague smptoms5 loss ofintellect5 great effort to perform
tas8s5 agitated5 aggressive orapat/etic5 *andering5 famil
more concerned t/an patient.
$isorientation5 cloudedconsciousness5 fluctuating
moods5 disordered t/oug/ts5fails to understand tas8s.
Course Self-limiting5 recurrent or
c/ronic *it/out treatment.Often /as a period of
improvement.
Slo* and continuous decline.
Smptoms progressive etrelativel stale over time
ours5 *ee8s5 or longer5
depending on t/e causes ofdelirium5 and t/e speed *it/
*/ic/ t/e causes can eresolved.
Sleep Da8eCcle
$iurnal effect tpicall *orse int/e morning5 situational
fluctuations5 ut less t/andelirium. Sleep impaired
#o diurnal effect5. Dorse inevening7 Msundo*ningN5
reversed sleep
S/ort diurnal fluctuations insmptoms5 *orse at nig/t in
dar8ness5 and on a*a8ening7s/o*s da dro*siness5
nig/ttime /allucinations5insomnia5 nig/tmares.
$uration At least 6 *ee8s5 can e severalmont/s to ears
!ont/ to ears ours to less t/an 1 mont/5seldom longer
A*areness Clear Clear educed
Affect Pervasive sadness5 */ic/
precedes dementia5 *it/dra*n5constricted5 apat/5 /opeless5
distressed
Easil distracted7 s/allo*5
laile5 inappropriate anxiet5depression5 or possile asence
of depression. Suspiciousness.
Laile progressing to apat/.
Laile variale5 fear panic5
eup/oria5 distured
Alertness #ormal (enerall normal Jluctuates5 let/argic or/pervigilant
ecent
!emor
Cognitive impairment
inconsistent. #ormal of recent
past ot/ altered. Slo*ed recall.Often s/ort-term memor
deficits.
S/ort term memor deficit in
earl course of disease
progresses to long-term deficits7confaulation5 perseveration.
"mpaired5 remote intact
Orientation "ntact $isoriented $isoriented ut not to person7periods of lucidit
Level of
Consciousness
"ntact "ntact $istured
Psc/otic
smptoms
$elusions in severe depressive
disorders
!isperceived people and events
as t/reatening7 late delusions5
/allucinations
$elusions
Budgment Poor :udgment5 man M" donIt
8no*N ans*ers
"mpaired5 ad inappropriate
decisions5 denies prolem
"mpaired7 difficult separating
facts and /allucinations
$ompeten! 6. Dis!uss t,e assessment and treatment strate)ies for delirium and dementia.
16Joreman5 !. $.5 Jletc/er5 .5 !ion5 L. C.5 %rgstad5 L. B.5 ? t/e #"CE Jacult. 01@@@. Assessing cognitive
function. "n Ara/am5 ".5
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A. Delirium
A.1. Assessment of delirium'
A.1.1. Compre/ensive /istor and p/sical examination 0t/ere ma e more t/anone prolem
A.1.2. evie* all current medications
A.1.3. Evaluate tests in t/e routine evaluation 0lood c/emistries' electroltesglucose5 calcium5 alumin5 S(O%5 S(P%5 iliruin5 al8aline p/osp/atase5magnesium5 p/osp/orus5 complete lood cell count5 E(5 CR5 A
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drugs are used.
+. Dementia
B.1. Assessment of Dementia. Studies /ave indicated t/at t/ere are several tests
t/at can e used to detect dementia1=
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of unnecessar antipsc/otics.
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Al/eimerIs disease5 strategies to support and sustain individuals *it/ t/e disease exist.%/e primar o:ective of care is to /elp t/e person use as man retained ailities aspossile. Successful management of Al/eimerIs disease must address t/e cognitive5functional5 and e/avioral smptoms of t/is disease. Careful attention to factors t/atcreate excess disailit 0more disailit t/an can e attriuted to t/e disease itself iscriticall important. Persons *it/ Al/eimerIs diseases graduall lose t/eir ailit tounderstand our s/ared realit. As a result5 t/e misinterpret previousl understood eventsand o:ects in t/eir p/sical and social environment. Simple ad:ustments in routine /elpt/e person understand5 and function at as /ig/ a level as possile. As t/e diseaseprogresses5 increasing e/avioral disturances ma lead to placement in a nursing /ome.%/e follo*ing suggestions from t/e Al/eimerIs Association ma /elp'
C.1. &se personal /istor5 life experiences5 and /aits as a asis for self-care and leisureactivities. Jor example5 if t/e individual en:oed gardening efore developingAl/eimerIs disease5 caregivers can /elp t/em participate in gardening activities ast/e are currentl ale.
C.2. !aintain a familiar and comfortale routine t/at alternates activit *it/ rest to
avoid fatigue and dsfunction.
C.3. Slo* do*n5 spea8 clearl5 ma8e ee contact5 and sta in t/e personIs field ofvision.
C.). Promote independence cuing t/e person to do as muc/ for /im or /erself aspossile.
C.+. Limit c/oices to ones t/e individual can ma8e using close-ended 9uestions. Jorexample5 if t/e individual is confused dressing independentl5 t/e caregivermig/t c/oose t*o outfits and as8 t/e individual to pic8 et*een t/em.
C.6. !odif t/e p/sical environment to reduce misinterpretation of real-life o:ects orevents.
C.4. edirect or distract t/e person */o is delusional instead of correcting orconfronting /im or /er.
C.=. !onitor t/e individual for smptoms of personal distress suc/ as pain5 /unger5 oroverunder stimulation. Pain assessment s/ould e included in t/e ongoing plan orapproac/ to caregiving.
C.@. &se e/avioral smptoms as a source of communication to guide ot/ assessmentand intervention. Jor example5 individuals ma e/ave as if t/e are eing violatedduring a at/ ecause t/e feel violated. Jraming at/ time as a spa visit couldc/ange t/e e/avior.
C.1,. Promote independence5 autonom5 and self-directed meaningful activities *it/in asafe5 secure setting.
Learnin) A!tiit.
$ase Stud on Delirium
!r. % is a 4,-ear-old male admitted to t/e ort/opedic unit in a large uran /ospital. !r. %fractured /is rig/t an8le in a golf outing and /ad an open reduction *it/ internal fixation t/is
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
morning. As ou ta8e report at 3 p.m.5 t/e da s/ift c/arge nurse tells ou t/at !r. % is insistingon going /ome and 8eeps getting out of ed. !ultiple attempts to explain t/at /e is unale to*al8 safel in t/e cast /ave not convinced /im and /e is no* elling5 disturing ot/er patients ont/e floor.
1. (iven t/e aove information5 ou suspect t/at !r. %Is condition is caused '
a. Post-operative infection
. $ementia
!. Delirium (!orre!t ans-er*
d. $epression
2. $elirium re9uires acute assessment.
a. True (!orre!t ans-er*
. Jalse
3. $elirium is caused '
a. "nfection
. poxia
c. !edications
d. All of t,e a1oe (!orre!t ans-er*
). Some strategies to assist in carring for !r. % *ould include' 0mar8 all t/at appl
a. Realit orientation offered in a !alm3 non:ud)mental manner (!orre!t ans-er*
1. $allin) famil to isit t,e patient (!orre!t ans-er*
c. %elling t/e patient to relax and /is an8le *ill /eal
d. #one of t/e aove
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$ase Stud on Dementia
!s. $ is a @=-ear-old female in a s8illed nursing facilit *it/ a diagnosis of Al/eimerIs disease.!s. $ comes to t/e nursing station and appears ver upset. S/e tells ou t/at s/e is loo8ing for/er mot/er and as8s ou to /elp /er. Fou start *al8ing *it/ !s. $.
D/ic/ of t/e follo*ing strategies *ould e /elpful in assisting !s. $
1. %elling /er t/at /er mot/er died a long time ago
a. %rue
1. 'alse (!orre!t ans-er*
2. eassuring /er t/at evert/ing is o8a and t/at ou *ill /elp /er
a. True (!orre!t ans-er*
. Jalse
3. Attempting to distract redirect /er into a pleasurale activit 0eating5 singing
a. True (!orre!t ans-er*. Jalse
). &sing realit orientation /oping to reverse /er cognitive losses.
a. %rue
1. 'alse (!orre!t ans-er*
+. As8ing /er to /elp ou *it/ a small tas8 and later ou *ill loo8 for /er mot/er toget/er
a. True (!orre!t ans-er*
. Jalse
6. Cognitive losses related to Al/eimerIs diseases are irreversile
a. True (!orre!t ans-er*
. Jalse
4. Alt/oug/ p/armacologic agents ma e /elpful 0in t/e presence of disturing delusions /allucinations5 e/avioral approac/es to treatment are t/e first-line in treating dementia.
a. True (!orre!t ans-er*
. Jalse
=. Promoting dependence 0*it/ feeding5 dressing5 toileting is advantageous for persons *it/ dementia.
a. %rue
1. 'alse (!orre!t ans-er*@. Compensating for sensor impairments 0glasses5 /earing aides ma /elp minimie disturing
illusions delusions.
a. True (!orre!t ans-er*
. Jalse
$ompeten! 6. $ontrast !riteria for differentiatin) depression3 delirium3 and dementia in
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
older adults.;
Often depression5 delirium5 and dementia can co-exist so t/e follo*ing protocol s/ould efollo*ed'
A. $elirium assessment and treatment 1st
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
RESOUR$ES
Agenc for ealt/ Care Polic and esearc/. 01@@6. Earlidentification of Al1heimer2s diseaseand related dementias. Aut/or.
Agenc for ealt/ Care Polic and esearc/. 01@@3.*epression in primary care: Treatment ofmaor depression. Aut/or.
American Psc/iatric Association. 01@@@5 !a. Practice guideline for t/e treatment of patients*it/ delirium.American Psychiatric Association. American Journal of Psychiatry. &/6.1-2,.
Anderson5 A. B. 02,,2. %reatment of depression in older adults.International Journal ofPsychosocial Rehabilitation, 65 6@-4=.
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
oenig5 . (.5 !eador5 . (.5 Co/en5 B. B.5 ? 1,2).
Petersen5 . C.5 Stevens5 B. C.5 (anguli5 !.5 %angalos5 E. (.5 Cummings5 B. L.5 ? $eos85 S. %.02,,1. Practice parameter' Earl detection of dementia' !ild cognitive impairment 0an
evidence-ased revie*.American Academy of eurology, /65 1133-11)2.
ader5 B. ? %orn9uist5 E. 01@@+.Individuali1ed dementia care: %reative, compassionateapproaches.#e* For8' Springer.
eiserg5
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
Ot,er Resour!es
1. Al/eimerIs Association /ttp'***.al.org
2. Administration on Aging/ttp'***.aoa.d//s.gov
3. #ational "nstitute on Aging /ttp'***.nia.ni/.gov
DELIRIUM SPE$I'I$ TOPI$ RESOUR$ES
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
A(S Panel. 0&pdated annuall. $eriatrics at your fingertips. American (eriatrics Societ.
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
&niversit of "o*a College of #ursing' %/e Bo/n A. artford Center of #ursing Excellence'/ttp'***.nursing.uio*a.edu/artfordindex./tm
&niversit of Pennslvania Sc/ool of #ursing' artford Center of (eriatric #ursing Excellence'/ttp'***.nursing.upenn.educenters/cgneaout./tm
"oernment Information A)en!ies#ational (uideline Clearing/ouseAgenc for ealt/care esearc/ and Hualit. 02,,35 !odified!a 315 2,,).*elirium: (trategies for assessing and treating. etrieved Bune 65 2,,)5 from/ttp'***.guideline.govsummarsummar.aspxdocQid3+,@?nr243+?stringdelirium
&nited States $epartment of ealt/ and uman Services' Aging'/ttp'***.//s.govagingindex.s/tml
Re)ulator/Aut,oritatie Sites S!opes and Standards3 Position Papers3 et!
American (eriatrics Societ. 02,,1. (uidelines and Position Statements'/ttp'***.americangeriatrics.orgproductspositionpapers
American !edical $irectors Association 0A!$A. 02,,). Resour!e Li1rar%/ttp'***.amda.comlirar
#ational Conference of (erontological #urse Practitioners' ome Page' /ttp'***.ncgnp.org
#ational (erontological #ursing Association' ome Page' /ttp'***.ngna.org
%/e (erontological Societ of America' ome Page' /ttp'***.geron.org
&nited States $epartment of ealt/ and uman Services' ome Page' /ttp'***.//s.gov
$ontinuin) Edu!ation Opportunities
A$A#CE #e*smagaines' ome Page' /ttp'***.advance*e.com
A$A#CE Continuing Education Desite'/ttp'***.advance*e.comce.asp
A#A Continuing Ed Online Education' /ttp'nursing*orld.orgcece/ome.cfm
!edcom-%rainex - arious (erontological #ursing topics' /ttp'***.medcominc.com
!edscape from De!$' #urses CE Center'/ttp'***.medscape.comcmecenterdirectornursessrc/dr
#ational Association of (eriatric Education Centers' /ttp'***./coa.orgnagec
#e* For8 &niversit5 Stein/ardt Sc/ool of Education5 $ivision of #ursing5 Center forContinuing Education' /ttp'***.nu.edueducationnursingne*institutes./tml
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http://www.nursing.uiowa.edu/hartford/index.htmhttp://www.nursing.upenn.edu/centers/hcgne/about.htmhttp://www.guideline.gov/summary/summary.aspx?doc_id=3509&nbr=2735&string=deliriumhttp://www.hhs.gov/aging/index.shtmlhttp://www.americangeriatrics.org/products/positionpapers/http://www.amda.com/library/http://www.ncgnp.org/http://www.ngna.org/http://www.geron.org/http://www.hhs.gov/http://www.advanceweb.com/http://www.advanceweb.com/ce.asphttp://www.advanceweb.com/ce.asphttp://nursingworld.org/ce/cehome.cfmhttp://www.medcominc.com/http://www.medscape.com/cmecenterdirectory/nurses?src=hdrhttp://www.hcoa.org/nagec/http://www.nyu.edu/education/nursingnew/institutes.htmlhttp://www.nursing.uiowa.edu/hartford/index.htmhttp://www.nursing.upenn.edu/centers/hcgne/about.htmhttp://www.guideline.gov/summary/summary.aspx?doc_id=3509&nbr=2735&string=deliriumhttp://www.hhs.gov/aging/index.shtmlhttp://www.americangeriatrics.org/products/positionpapers/http://www.amda.com/library/http://www.ncgnp.org/http://www.ngna.org/http://www.geron.org/http://www.hhs.gov/http://www.advanceweb.com/http://www.advanceweb.com/ce.asphttp://nursingworld.org/ce/cehome.cfmhttp://www.medcominc.com/http://www.medscape.com/cmecenterdirectory/nurses?src=hdrhttp://www.hcoa.org/nagec/http://www.nyu.edu/education/nursingnew/institutes.html -
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MODULE 6. DEPRESSION/DELIRIUM/DEMENTIA
Online ceuIs' A director for nurses. (eriatric Classes Online'/ttp'***.nurseceu.comgeri./tm
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%/e Bo/n A. artford Joundation "nstitute for (eriatric #ursing' (erontological #ursingCertification evie* Course /ttp'***.nu.edueducationnursing/artford.institutecourse
&niversit of "o*a College of #ursing' Continuing Education'/ttp'***.nursing.uio*a.educontedconferences./tmT1
&niversit of Pennslvania Sc/ool of #ursing' Continuing Education'/ttp'***.nursing.upenn.educe
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