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Integrating Depression, Dementia, and
Delirium in the Older Adult
“Annotated Bibliography”

Gwendolyn de Geest RN, BSN, MA

Introduction

It is the intention of this annotated bibliography to differentiate between the concepts of dementia, delirium, and depression in the older adult, and to illustrate the clinical significance of each of these conditions. The literature will identify needs of these individuals, as well as the needs of their caregivers. It will be especially useful for formal as well as informal caregivers caring for individuals in the later stages of the disease process.

This annotated bibliography will include explanatory or critical notes, and will include a statement predicting the audience for which the work is most relevant. I have selected approximately ten articles for each concept.

Depression in the Older Adult

  • Dellasega, C., & Cutezo, E. (1994). Strategies used by home health nurses to assess the mental status of homebound elders. Journal of Community Health Nursing, vol. 11, no. 3, p. 129–138.

    These authors discuss methods whereby home health nurses assess elderly clients’ mental status. Accurate evaluation of the individual’s mental status is particularly important, for it indicates whether the individual will be able to survive in his or her home and thereby avoid institutionalization. However, previous studies suggest that nurses in a variety of settings use assessment criteria that result in inaccurate judgements about their client’s cognitive status. This study was undertaken to investigate specific strategies used by home health nurses to determine mental status. Findings showed that these nurses, like others, rely primarily on orientation to evaluate cognition. Particularly useful for formal as well as informal caregivers caring for older adults in the home.
  • Dreyfus, J. (1988). Depression assessment and interventions in the medically ill frail elderly, Journal of Gerontological Nursing, vo. 14, no. 9, p. 27–35.

    Depression is a very common syndrome in the medically ill elderly. The symptoms of depression may be the cause of nursing care problems and decreased functional ability for the elderly patient. Caregivers (both formal and informal) must be aware of behavior problems such as refusal to eat, decreased motivation for self care, and being critical of others. These may be symptoms of depression. This article identifies a Geriatric Depression Scale that can be used by nurses in assessment of depression. Nursing care problems and symptoms of depression are described which assists caregivers to understand the patient behavior. Nursing interventions for treatment of the depression are then offered, including psychotherapy and medication. The first step in dealing with depression is early nursing assessment of this complex and often hidden problem. This article will be most helpful for formal as well as informal caregivers.
  • Johnson, J. (1996). Depression and dementia in the elderly: A primary care perspective, Comprehensive Therapy, vol. 22, no. 5, p. 280–285.

    This author emphasizes the importance of accurate assessment that will assist in differentiating between depression and dementia. The first step is to recognize which of the syndromes is present. The article identifies the signs and symptoms of each condition, and offers methods of assessment, treatment, and evaluation of these conditions. Formal and informal caregivers must be made aware that depression is often treatable, whereas the course of dementia can be palliated by maintaining nutrition, social stimulation, and carefully treating concomitant illnesses. It is emphasized that with both diagnoses, the caregivers’ needs must be met as well as the patient. A must read for formal and informal caregivers.
  • Keane, S., & Sells, S. (1990). Recognizing depression in the elderly, Journal of Gerontological Nursing, vol. 16, no. 1, p. 21–25.

    Depression in late life is treatable and frequently is chronic only because adequate therapeutic intervention is not initiated earlier. These authors identify one major problem in managing depression in the elderly, concerning the adequacy of present diagnostic measures. Identification of elder perceptions is central to accurate assessment and the development of interventions enabling elders to regain a sense of control in decision making within their current living situations. Findings suggest that patient input may identify target areas for further exploration and enhance the elderly person’s sense of control through active participation in care. The increased health risks and the clinical, financial, and emotional benefits of early detection, support the potential usefulness of a depression screening instrument used in conjunction with a nursing assessment guide. An essential article for nurses.
  • Kurlowicz, L. & Niche Faculty (1997). Nursing standard of practice protocol: Depression in elderly patients, Geriatric Nursing, vol. 18, no. 5, p. 192–199.

    An excellent article depicting depression as a highly prevalent but underrecognized and undertreated mental health problem in community– dwelling, medically ill, and institutionalized older adults. Untreated depression is associated with serious negative consequences for the elderly patient. Nurses in various practice settings can reduce the negative effects of depression through early recognition, intervention, and referral of patients with depression. This article presents an overview of depression in late life with emphasis on age–related assessment considerations, clinical decision–making and nursing intervention strategies for elders with depression. A standard of practice protocol for use by nurses in a variety of practice settings is also presented. Highly recommended for formal as well as informal caregivers.
  • Nursing Standard, (1997). Depression in older people, April 2, vol. 11, no. 28.

    Although depression is more common than dementia in older people, it is frequently not detected and when it is, the only treatment offered is medication. This study reports that multiple bereavements, a loss of physical and perhaps mental abilities, loss of the family home, increasing social isolation, and loss of dignity and respect from others frequently accompany old age, any one of which can lead to depression. The author stresses the importance of the approach taken by health care professionals, and encourages nurses to ask themselves, “how much am I contributing to a person’s depression by the way that I deal with them?” Rather, nurses must be made aware of the effectiveness of psychotherapeutic and behavior therapy to assist with depressive disorders. This article will prove useful for family members as well as nurses caring for these individuals.
  • O’Connor, D., Pollitt, P., & Roth, M. (1990). Coexisting depression and dementia in a community survey of the elderly, International Psychogeriatrrics, vol. 2, no. 1, p. 45–53.

    This study reports on the coexistence of dementia and depression in a community population aged 75 years and older. Individuals suffering from both disorders were so markedly apathetic that their depression might easily have been overlooked had specific enquiries not been made. Depression was particularly associated with dementia secondary to multi–infarct and Parkinson’s disease. It is important for health care professionals and families as well to be alert to the behavior of the individual. This observation will greatly assist in disentangling depression, cognitive impairment, and dementia, both in clinical practice and community surveys. Particularly recommended for physicians and nurses caring for these individuals.
  • Rubin, E., Kinscherf, D., Grant, E., & Storandt, M. (1991). The influence of major depression on clinical and psychometric assessment of senile dementia of the Alzheimer type. American Journal of Psychiatry, vol. 148, no. 9, p. 1164–1171.

    These authors compare elderly individuals with major depression alone with those suffering depression plus mild senile dementia of the Alzheimer type. These individuals are then compared with nondepressed persons with mild dementia, and then compared with persons without dementia. The results reveal that the persons without dementia performed as well as the nondepressed persons without dementia on most clinical measures. The performance of the individuals with depression plus mild dementia was comparable to that of the nondepressed persons with mild dementia on most clinical and psychometric measures. Although depressed persons performed as well as persons without dementia on many clinical assessments, psychometric testing was not able to distinguish depressed persons from those with very mild dementia. This demonstrates to nurses the need for careful assessment before interpreting deficits on psychometric tests as indicating the presence of very mild dementia of the Alzheimer type. A useful article for nurses.
  • Ryan, M. (1995). Loneliness, social support, and depression as interactive variables with cognitive status: Testing Roy’s model, Nurse Science Quarterly, vol. 9, no. 3, p. 107–114.

    This study examines the relationship between and among the variables of loneliness, social support, depression, and cognitive functioning in adults over 60, living in senior housing in a metropolitan area. Other variables, namely life–satisfaction and ability to perform activities of daily living, were also measured. Although the research hypotheses were not supported, relationships between subjects’ health status, life satisfaction, and self–assessment of health were significant. Assessment of these variables by community and advanced practice nurses who work with community elderly, to effect positive client outcomes, is presented within the context of Roy’s adaptation model. An essential read for interdisciplinary caregivers.
  • Tueth, M. (1995). How to manage depression and psychosis in Alzheimer’s disease, Geriatrics, vol. 50, no. 1, p. 43–49.

    Depression and psychosis each occur in about 30–50% of patients with Alzheimer’s disease. Depressive syndromes range from grieving and mild depressive symptoms to major depression. Depression can also mimic the signs and symptoms of Alzheimer’s disease. The diagnosis of both depression and psychosis is based on a careful history and a mental status examination. Treatment includes psychosocial intervention and, when symptoms are severe, drug therapy. The newer antidepressants are recommended for depressive syndromes, whereas psychosis is treated with high– potency neuroleptics. Particularly recommended for physicians and nurses engaged with these topics.

Delirium in the Older Adult

  • Foreman, M., & Zane, D. (1996). Nursing strategies for acute confusion in elders, AJN, vol. 96, no. 4, p. 44–52.

    Acute confusion complicates and may jeopardize recovery, and though it’s common, it can often be prevented, eased, or abbreviated. This article offers key assessments and interventions that may apply in any setting. Also, a behavioral rating scale which is particularly useful for differentiating among acute confusion, dementia, and depression is identified. Highly recommended for nurses who must promptly identify those patients at risk for acute confusion or those presently confused.
  • Gupta, T.L., McGrath, P.N. (1996). Delirium in the oncology patient: A clinical dilemma, Canadian Oncology Nursing Journal, vol. 6, no. 2, p. 79–83.

    Delirium is a serious quality of life issue for which nurses are strategically positioned to prevent, identify, and provide intervention. However, a general lack of knowledge, an inability to distinguish varying manifestations and etiologies, and incomplete assessments have resulted in difficulty managing this phenomenon. This article reviews the literature on delirium, and examines the assessment and nursing interventions for care of the cancer patient. Recommendations for practice and research are made, emphasizing a holistic approach to enhance quality of life. This article is essential for nurses working in this area.
  • Hadley Vermeersch, P. (1990). The clinical assessment of confusion–A, Applied Nursing Research, vol. 3, no. 3, p. 128–133.

    Confusion in a hospitalized adult interferes with the patient’s understanding of medical and nursing therapies, may generate fear and anxiety in the patient and patient’s family, and may initiate unsafe patient behaviors. Confusion as diagnosed by nurses is a multidimensional concept assessed through observation of the patient’s behavior. The purpose of this study was to develop a clinically useful scale to measure the multiple dimensions of confusion in hospitalized adults as diagnosed by nurses based on observed patient behaviors. It is the hope of the author that the practice and research community will build on the work begun in this study and further nurses’ understanding of confusion, its measurement, and its management. Also, is a useful article for family caregivers.
  • Inouye, S.K. (1994). The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients, American Journal of Medicine, vol. 97, p. 278–288.

    Despite its clinical impact, delirium is often unrecognized by the clinicians caring for the patient. The purpose of this article is to highlight areas of controversy and discrepancies in our knowledge base that will need to be addressed before meaningful clinical guidelines for diagnosis and evaluation of delirium in hospitalized elderly patients can be developed. Current barriers to the recognition and diagnosis of delirium are addressed, including limitations in current diagnostic criteria and instruments. An overview of studies of the underlying etiology of delirium is presented, as well as the evaluation of the delirious patient. Finally, areas are highlighted in which research is needed to fully address the problem of delirium in the hospitalized elderly medical patient. Physicians must read this article.
  • Kelley, F. J. (1996). Planning care for acutely confused critically ill older persons, Critical Care Nursing Quarterly, vol. 19, no. 2, p. 41–46.

    The critically ill older patient is at increased risk for developing an acute confusional state or delirium. Critical care nurses must be aware of the risk factors, the clinical manifestations, and potential complications associated with delirium. Nursing strategies focus on prevention, comprehensive assessments, and interventions to manage agitated behavior and provide environmental support. An excellent article to enhance nurses’ understanding of the normal changes of aging and the unique needs of this group.
  • Matthiesen, V., Sivertsen, L., Foreman, M., Cronin–Stubbs, D. (1994). Acute confusion: Nursing intervention in older patients, Orthopaedic Nursing, vol. 13, no. 2, p. 21–29.

    Older patients are at high risk for developing acute confusion while hospitalized with an associated increased risk of morbidity and mortality. Causes for acute confusion include physiologic, psychosocial and environmental alterations. Often not recognized by nurses, acute confusion needs to be differentiated from depression and dementia. Nursing assessment of acute confusion should include baseline data on cognition, behavior, and functional status. Standard, routine, and systemic assessments of cognition, behavior, and functional status need to be ongoing during hospitalization, if nurses are to identify and manage acute confusion in hospitalized older patients. The interventions are particularly helpful for all nurses.
  • McCabe, M. (1990). From disease to delirium: managing the declining elderly patient, Geriatrics, vol. 45, no. 12, p. 28–31.

    Many geriatric patients have concurrent physical and psychiatric illnesses, but at times it may be difficult to determine which is primary. Delirium, a transcient syndrome that presents with psychiatric symptoms, is usually the manifestation of an organic disorder and, if undetected and untreated, can be fatal. Clinicians, therefore, must learn to recognize the syndrome, search diligently for the underlying etiology, and treat accordingly. Highly recommended for formal caregivers.
  • Morency, C.R., Levkoff, S.E., Dick, K.L. (1994). Research considerations: Delirium in hospitalized elders, Journal of Gerontological Nursing, vol. 20, no. 8, p.24–30.

    Nurses, as the front–line caregivers of patients 24 hours a day, are in an optimal position to observe and note changes in behavior of hospitalized elders that might be markers for the onset of delirium. Because delirium often occurs either as a prominent presenting feature of a life–threatening physical illness or a serious complication of disease, it is vitally important that nurses are skilled at its detection. This article reveals that undergraduate curriculums for nurses may cover only general assessment of the elderly, with little or no attention given to the complicated and potentially morbid condition of delirium. The data suggests that nurses need more education regarding the assessment of the recognition of symptoms of delirium in the elderly. The assessment of delirium should include more than simply questions about orientation, and should include the aspects of sleep–wake disturbances, perceptual and psychomotor manifestations. Essential article for nurses working in this area.
  • Morency, C.R. (1990). Mental status change in the elderly: recognizing and treating delirium, Journal of Professional Nursing, vol. 6, no. 6, p. 356–365.

    Delirium is a common cause of acute mental status change in hospitalized elderly people, yet the literature and the author’s clinical experience suggest that clinical nurses are often unaware of how the syndrome can present, how it differs from other types of mental status changes seen in the elderly, and what interventions are most appropriate in affected individuals. This article discusses these areas, presents original data from Beth Israel Hospital, Boston, MA, concerning nursing assessment of patients with delirium, and outlines a new educational module that nurse specialists, educators, and others can use to teach clinical nurses about delirium in elderly patients. An excellent article for nurses.
  • Palmieri, D.T., (1991). Clearing up the confusion: Adverse effects of medications in the elderly, Journal of Gerontological Nursing, vol. 17, no. 10, p. 32–35.

    Drugs have been clearly implicated in many episodes of confusion developed after hospitalization. This article reviews drug–related causes of confusion and discusses nursing interventions to prevent and identify this adverse effect. It discusses the effects of normal aging on drug action, and clearly classifies the medications that may cause confusion in the elderly. A high index of suspicion is indicated when the nurse observes mental status in the older adult after a new prescription is begun, when multiple medications are taken, and when some medications have been taken for extended periods. An excellent article for front–line caregivers, including physicians and nurses.
  • Trzepacz, P., Baker, R., & Greenhouse, J. (1987). A symptom rating scale for delirium, Psychiatry Research, vol. 23, p. 89–97.

    The authors present a 10–item clinician–rated symptom rating scale for delirium. Compared to demented, schizophrenic, and normal control groups, 20 delirious subjects scored significantly higher on the scale, which quantitates multiple parameters affected by delirium. The scale can be used alone or in conjunction with an electroencephalogram and bedside cognitive tests to assess the delirious subject. The study reveals the linkage between the diffuse slowing of the EEG background rhythm consistently, regardless of the etiology of the delirium. These explanations are very useful for all nurses working in this area.
  • Tueth, M.J., Cheong, J. (1993). Delirium: Diagnosis and treatment in the older patient, Geriatrics, vol. 48, no. 3, p. 75–80.

    Delirium is more common in older adults because of normal physiologic changes, increased incidence of medical illnesses, and increased medication use in this population. Older dementing patients are particularly predisposed to delirium because of associated neurologic abnormalities. Delirium is often superimposed on a dementing condition and may be difficult to differentiate from a typical dementia or a catastrophic reaction. Accurate diagnosis is essential, as is a thorough search for an underlying cause. The delirium will usually resolve if the underlying cause is properly treated. Treatment also requires maintaining a comfortable environment for the patient, and when necessary administering a high–potency neuroleptic. Highly recommended for physicians and nurses.
  • Yeaw, E.M., &Abbate, J.H. (1993). Identification of confusion among the elderly in an acute care setting, Clinical Nurse Specialist, vol. 7, no. 4, p. 192–197.

    This exploratory study investigates what indicators nurses use to establish a diagnosis of confusion among elderly patients in an acute care setting and which indicators are significant in arrival at a diagnosis of confusion, and what previous information from intershift report nurses rely upon in arriving at a diagnosis of confusion. The article reveals that nurses’ focus should be on how confusion interferes with patients’ ability to function rather than on interference with nurses’ function. This study provides data for better assessment of the confused, elderly patient in the acute care setting. An essential study for interdisciplinary caregivers.

Understanding Dementia

  • Bonnel, W.B. (1996). Not gone and not forgotten: A spouse’s experience of late–stage Alzheimer disease, Journal of Psychosocial Nursing and Mental Health Services, vol. 34, no.8, p. 23–27.

    Late–stage caregiving is different from earlier stages. This article deals with issues of ethical decision–making, supportive care, and discusses the concept of palliative care. A further assessment of current educational programs and family support groups is discussed. Further research is needed on helping families prepare for and cope with late stage caregiving. Particularly recommended for physicians and nurses.
  • Boyd, C., & Vernon, G. (1998). Primary care of the older adult with end–stage Alzheimer disease, The Nurse Practioner, vol. 23, no. 4, p. 63–83.

    End–of–life care is slowly being recognized as a dimension of primary care. A growing need for hospice/palliative care exists for end–stage Alzheimer patients. This article describes end–stage Alzheimer disease, and proposes ways a primary care provider may participate in the terminal care process. A patient education handout discussing end–stage Alzheimer disease issues and providing family resources is presented. This article is essential for formal as well as informal caregivers who are dealing with these issues.
  • Drachman, D., Friedland, R., Larson, E., & Williams, M. (1991). Making sure it’s really Alzheimer’s, Patient Care, vol. 11, p. 13–41.

    This article takes a three–phase approach to the diagnosis of Alzheimer’s disease: Watch for signs, confirm suspected dementia, then rule out potentially treatable causes. A table of criteria for clincal diagnosis of Alzheimer disease is offered, as well as practical suggestions in interviewing family members. An excellent review for formal as well as informal caregivers.
  • Farran, C., Keane–Hagerty, E., Tatarowicz, L., & Scorza, E. (1993). Dementia care–receiver needs and their impact on caregivers, Clinical Nursing Research, vol. 2, no. 1, p. 86–97.

    This study examines home–based persons with dementia, their needs associated with activities of daily living (ADL), cognitive impairment, and disruptive behaviors, and the relationship of these needs to caregiver distress and burden. Findings suggest that selective disruptive behaviors were most distressing to caregivers, and that when disruptive behaviors occurred more frequently, caregivers were significantly more distressed with these behaviors and reported higher levels of burden. The frequency of cognitive impairment behaviors and level of ADL impairment were not significantly related to caregiver burden, but caregiver distress with these needs was significantly related to caregiver burden. A particularly useful article for family caregivers.
  • Fisk, A., & Pannill, F. (1987). Assessment and care of the community–dwelling Alzheimer disease patient, JAGS, vol. 35, no. 4, p. 307–311.

    This article describes a two–year study of 159 community dwelling Alzheimer disease patients evaluated in a geriatric clinic. Isolation was a major concern for many of these patients. Management of Alzheimer disease patients, including medication use, day–care, education, and support for family caregivers, and nursing home placement is discussed. An excellent article for multidisciplinary caregivers.
  • Foreman, M., & Grabowski, R. (1992). Diagnostic dilemma: Cognitive impairment in the elderly, Journal of Gerontological Nursing, vol. 18, no. 9, p. 5–12.

    Cognitive impairment is a significant health problem for the elderly and is associated with severe negative consequences: higher morbidity and mortality and a diminished capacity to care for self. These authors compare the clinical features of acute confusion, dementia, and depression, and offer a behavioral rating scale which is particularly useful for differentiating among these conditions. An excellent article for physicians and nurses in assisting in assessment of the individual with cognitive impairment.
  • Golden, R. (1995). Dementia and Alzheimer’s disease: indications, diagnosis, and treatment, Minnesota Medicine, vol. 78, no. 1, p. 25–29.

    Reaching the diagnosis of Alzheimer’s disease is often difficult, since the accurate diagnosis can only be made after all other options are ruled out. The process is painstaking, but it’s also the crucial link in ensuring proper diagnosis and treatment. There’s no known cure for Alzheimer disease, but researchers are narrowing in on possible causes of the disease and identifying patients who may be predisposed to developing it. This article focuses on some of this research, including genetic testing and several drug studies. Community resources are offered to provide Alzheimer patients and their families with information on everything from support groups to assisted–living arrangements.
  • Hall, G., & Buckwalter, K. (1991). Whole disease care planning: Fitting the program to the client with Alzheimer disease, Journal of Gerontological Nursing, vol. 17, no. 3, p. 38–41. In this study, interventions are planned that will meet the needs of the person with Alzheimer disease throughout the disease process. A step by step guide is offered which assesses the functional level of the individual, and promotes as much independence as possible. This information can help nurses determine which intervention strategies to pursue based on the sociocultural background of clients and their level of functional loss. The desired outcomes at all levels of care include maximizing the potential for safe function by controlling for excess disability and providing appropriate levels of assistance; participation in activities as desired by the client; and minimizing discomfort and maximizing expressions of comfort. Particularly recommended for nurses who are caring for these individuals.
  • Mangino, M., & Middlemiss, C. (1997). Alzheimer’s disease: preventing and recognizing a misdiagnosis. The Nurse Practioner, vol. 10, p. 58–75.

    The diagnosis of Alzheimer’s disease is sometimes made prematurely and incorrectly. A significant number of conditions, ranging from the irreversible to the fully reversible, can produce cognitive impairment, and thus may be mistaken for Alzheimer’s disease. Knowledge of the most common of these conditions and their presenting symptoms and precipitating factors, combined with a thorough assessment, can prevent a misdiagnosis of Alzheimer’s disease. This article reviews several conditions that may be mistaken for Alzheimer’s disease. Actual case studies depict the typical presentation of some of them. Essential for interdisciplinary caregivers, particularly physicians.
  • McDaniel, L., Lukovits, T., & McDaniel, K. (1993). Alzheimer disease: The problem of incorrect clinical diagnosis, Journal of Geriatric Psychiatry and Neurology, vol. 6, p. 230–234.

    This report suggests that clinicians may not strictly follow diagnostic criteria and consequently inappropriately assign the diagnosis of probable Alzheimer disease. This study also suggests that additional clinical features not described in the established sets of criteria may be atypical for Alzheimer disease and that their inclusion in future criteria may be helpful in preventing misdiagnosis. Based on the clinical features of eight misdiagnosed patients and an extensive review of the literature, the authors have constructed a list of clinical red flags, intended to aid in preventing the erroneous diagnosis of Alzheimer disease in a patient with a non– Alzheimer cause of dementia. Highly recommended for physicians and nurses for refinement of diagnostic specificity of this individual.
  • Post, S., & Whitehouse, P. (1995). Fairhill guidelines on ethics of the care of people with Alzheimer disease: A clinical summary, JAGS, vol.43, no. 12, p. 1423–1429.

    This article summarizes the content of meeting of family caregivers and individuals with dementia of the Alzheimer type who identified and spoke on ethical issues in dementia care and who engaged in dialogue with an interdisciplinary and interprofessional group of individuals working in the field of Alzheimer disease. This inductive method begins with attentive listening to the voices of the affected population and family members, in contrast with a theoretical and deductive approach to ethics. These authors emphasize the importance of respecting human dignity through touch rather than through technology. This article is essential for formal as well as informal caregivers.
  • Rice, V., Beck, C., & Stevenson, J. (1997). Ethical issues relative to autonomy and personal control in independent and cognitively impaired elders. Nursing Outlook, vol. 45, no. 1, p. 27–34.

    For the past 20 years, the concept of autonomy has been central in biomedical ethics and a driving force behind some significant changes in health care practices for the elderly. This article suggests that definable sets of ethical issues and challenges to autonomy and personal control parallel levels of dependency in later adulthood. The authors discuss ethical issues that parallel the functional phases of independence, dependence with cognitive impairment, and dying. Each of these functional phases present ethical challenges for nursing; these explanations would be very helpful for all nurses.
  • Volicer, L., Volicer, B.J., & Hurley, A. (1993). Is hospice care appropriate for Alzheimer patients? Caring Magazine, vol.14, no. 11, p. 50–55.

    Hospice care can benefit late–stage Alzheimer patients, but caregivers and families must first be aware of the complications and treatment difficulties that often accompany Alzheimer disease. From this awareness they can determine whether and when hospice care is appropriate for their patients or loved ones. In this article, the authors discuss treatment limitations to consider before hospice, decision making and appointing proxies for medical care decisions, and offers a model for inclusion of patients with late–stage dementia in a hospice program. This review is particularly useful for families of patients who are struggling to keep their loved ones at home for as long as possible.

Comments: This annotated bibliography has proven to be a most useful task. As in the scholarly paper, the bibliography differentiates the concepts of dementia, depression, and delirium in the older adult and illustrates the clinical significance of each of these conditions. In exploring the literature, I have discovered a wealth of information discussing palliative care issues, caregiver issues, and ethical issues for the person with advanced dementia, but not for the person with delirium and/or depression. There is implication for future study in these areas. Therefore, I have created a matrix that will illustrate the gaps discovered in the literature. Although these gaps are limited to this annotated bibliography alone, this information is intended to provide future direction for my research and future knowledge development.

Gwendolyn welcomes your questions/comments at gwendolyn@LivingDementia.com

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