Cognitive assessment and differentiating the 3 Ds (Dementia, Depression, Delirium)

Today, older people live longer. In the United States a 70-year-old person can expect to live another 14.7 years [114]. In Europe, the life expectancy at the age of 65 for men and women is on average 16 and 19 years, respectively [115]. Consequently, these individuals are more likely to be confronted and have to deal with an alteration in their cognitive functioning; however, to deal effectively and appropriately with this decline, it must be determined whether or not the decline is a benign consequence of aging or the result of a serious health problem. In this article, "cognitive decline" was clarified from a benign and generic label to one consisting of various types of impairments each with its specific representation, characteristics, and implications for care. As a result, failing to assess the cognitive abilities of an older individual should be unacceptable, unprofessional practice, and may even be considered professional neglect. At worst, failing to assess an older person's cognitive abilities contributes to ineffective and inappropriate care and treatment while relatives or significant others may be wrongly informed about the individual's prognosis (eg, the possible (ir)reversibility of the disorder). The older person easily is labeled "confused", "depressed," or "demented" without sound evidence to support this. Moreover, such labels profoundly influence how others interact with these people. At the least, many consider these people incompetent, and such labels are infrequently removed. Nurses play a pivotal role in the recognition, diagnosis, and prevention and care of cognitive decline in older people. Because nurses have significant, more frequent, and more continuous contact with older persons, and their relatives, nurses are the obvious person to gather and compare relevant details about the older person's cognitive and social functioning (eg, at home versus inhospital behavior); this can be easily accomplished using the informal, naturally occurring method of assessment discussed earlier. Furthermore, when integrating structured assessment into routine care, nurses can identify minor impairments easily and earlier and as a result have the potential to prevent or promptly reverse the impairment in cognitive functioning. To enable nurses to accomplish this, this article provides a description of the diagnostic dilemmas of dementia, depression, and delirium in the elderly along with current recommendations for the standardized assessment and systematic monitoring of cognition.