The vital 3 Ds of psychotherapy with older people

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Counselling with older people would take place in different contexts. Whatever the environment or location, there are three diagnoses of sets of symptoms and behaviours that it is vitally important to recognise accurately - vital in the sense that it can be life-changing or life-saving. These are delirium, dementia and depression. ​

  1. Delirium is a relatively frequently occurring confusional state, which, if it is truly delirium, represents a medical emergency that requires immediate medical attention and action. It is different from depression, dementia and psychosis. The key symptoms are inattention,  an acute onset, and fluctuation within the day. It means an instant onset of cognitive impairment or deterioration that is different from anything that has taken place before, longer-term. ​It can feel like an altered state of consciousness. It is often externally triggered, which are not part of diagnosing it, but show that there are risks in the life of most older people. Possible triggers are drugs, alcohol, trauma, pain, stroke, heart attack, or even a complete change of situation / environment. Statistically the death rate after delirium is 25% in 3 months time, and 50% in one year.
  2. Depression has the usual meaning and symptoms that it has at all ages. It is independent of and more common than the dementias. Because of the chance of confusing dementia and depression, attention to their differences is very important. Depression can be influenced better, including by psychotherapeutic means, than dementia! Depression as such can cause cognitive impairment, which would lift if the depression is dealt with - unlike dementia in general.
  3. There is a range of dementias, which it is generally impossible to differentiate on the basis of symptoms. Only specialists can do this, and even they are often shown wrong when an autopsy is done. Hence the focus is on the general accurate recognition of dementias as a group. The modern view is to combine memory problems with cognitive impairment. (The new name of "neurocognitive disorders" is gaining currency for "dementias + amnesia"). Dementias mean: a significant worsening of cognitive or memory performance that interferes with independence. This includes attention, perception, language and social functioning. Usually only specific parts of the memory and cognitive systems are affected. It is only dementia if it can be clearly differentiated from major depression, delirium or schizophrenia. There used to be a tendency to diagnose dementia only after at least 6 months of symptoms, but there is a more recent view that it is better to diagnose early, and to distinguish between mild and severe forms of dementia.

The difficulty and importance of making the distinctions between the 3 Ds contribute to the responsibility of whoever is caring for or working with older people. Hence I thought it useful to contribute this short summary of what to look for, culled from the literature.​

Does any reader want to contribute their experience with any of these in the comments?