Depression, Dementia or Delirium: Which "D" is it?

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Cheryl Swann
Cheryl Swann

Mr. Andrews was listless this morning, staring at his food as if he didn't know what to do with it. Normally he eats a big breakfast and jokes with the staff about his ability to eat a lot and not gain weight. He urinated in the bed, something he has never done. His caregivers wonder what could be going on with Mr. Andrews. Is he depressed?  He did lose his wife 3 months ago. Is he starting to get dementia? He did have a medication change, maybe he has delirium?

Depression, dementia, and delirium, sometimes called “The 3 Ds,” are often mistaken for one another due to the similarity of and overlap in symptoms. It is crucial to understand the difference as elders with dementia can experience delirium and depression. In the recently released white paper A Puzzle of Prevention: Recognizing the Role of Delirium in Preventing Rehospitalization, we explored delirium, its critical role in rehospitalization and the difficulty in assessing delirium.

Early detection is the key to recognizing and differentiating delirium from depression and dementia is critical to resolve its root cause before an acute hospitalization is required. This process begins by getting to know your residents, understanding their base level of functioning and their propensity for infection and illness. For this reason, consistent assignments can be critical when diagnosing delirium.  Learning the habits, nature, and normal behavior of each resident before delirium develops will allow staff members to pick up on even subtle clues.

Getting to know the difference

Onset: Delirium comes on suddenly and is usually caused by an acute illness, such as infection, heart attack, dehydration, and fecal impaction; a change in the elder's environment; or a medication reaction. Depression and dementia usually develop more gradually.  

Misperceptions: Residents with delirium may have delusions and visual hallucinations, such as seeing bugs crawling on the wall. These misperceptions are usually absent in both depression and dementia.  

Variability: Residents with delirium typically have fluctuating levels of awareness throughout the day. Residents who have depression or dementia tend to remain at their level of awareness, whether that is oriented or disoriented. Residents with dementia may become more agitated in the evening due to the predictable “sundowning” syndrome, but will generally maintain the same level of behavior during the day. Additionally, attention span will fluctuate in the resident with delirium, not with residents with depression or dementia.

Communication: Residents with dementia will have difficulty finding words, have impaired judgment, and be unable to think abstractly. Resident with delirium will have distorted, fragmented, and disorganized thinking and speech may be incoherent. 

It is crucial that staff differentiate between the 3 Ds in order to provide the care that is needed and understand the true medical emergency that might be the difference between life and death for residents. 

To learn more about the differences between the 3 Ds, down load the white paper or try Relias Learning's free online course Delirium, Dementia, and Depression.


Cheryl Swann, RN-BC,BSN,WCC,LNHA, is the vice president of content at Relias Learning. 

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