The Three D's

Updated: Aug 10, 2019

Dementia, Depression and Delirium

Known as the “three D’s”, the symptoms of dementia, depression and delirium often mirror each other. When working or living with older adults, it is important to be aware of the ways in which these three diagnoses present themselves.

Why is it important? It is important because a wrong diagnosis can lead to ineffective treatment that can, in some cases, be life threatening. Many older adults in our lives rely on their families or medical professionals for guidance and direct care. When accurately diagnosed, our elders are able to get the help they need to live their best life. In a time when most primary care visits last for 15 minutes and check ups are often only 6-12 months, many needs or symptoms can easily be overlooked.

Let’s explore some case studies together:


Archie, in tears, shares that his wife has been exhibiting signs of being down and depressed for months. She has stopped going to her weekly art group with friends, which she has done for the last eight years. She has also started missing her daily exercise group at the YMCA. He shares that not only has she withdrawn from her social life, including turning down offers to go to dinner with other couples, but she has also stopped reading, which was her favorite past time for over fifty years. Archie is clearly disturbed and concerned enough to reach out for support and guidance. “I just wish she was back to her old self, it is like someone has flipped off a switch. She is up at night, I can see she is bothered by something, yet there is nothing I can do to bring her out of it. I just wish she wasn’t so depressed”.

Archie is noticing a change as his wife is withdrawing from those things that usually bring her joy, such as participating in her regular social activities. As we examine her situation more closely, we find that these changes did not begin suddenly, but began to show over a period of time. His wife appears to have little difficulty answering questions and participating in conversation. However, upon further exploration, we find that it takes a tremendous amount of effort for her to present so well. This leaves her exhausted and avoiding social interactions. She admits that she has trouble tracking things and Archie notes that he has begun to make decisions for both of them about what to eat, when to go out, etc. She agrees to participate in a memory screening tool, which shows indication of cognitive impairment. It is also important to note that her low score on the memory tool can also be impacted by her mood if she does, indeed, have depression. She agrees to meet with her PCP to rule out memory impairment and we later learn that she has been diagnosed with dementia.


Susan is convinced that she is losing her memory. “My mother and grandmother both had Alzheimer’s Disease and I am convinced that it is now my turn. I can’t retain anything, I forget where I park the car, I forget things if I don’t write them down and I can’t even tell you what I did yesterday. The other day, someone asked me for my phone number and I couldn’t tell them what it is. I’ve had the same number for over twenty years!” Susan is clearly scared and her family history of dementia is impacting her on a deep level. She expresses fear about the unknown and a feeling of helplessness about her future.

Susan shares these concerns with her friend who encourages her to talk to someone about her fears. Susan agrees and schedules to meet with a counselor who will support her as she navigates the world of testing and receiving a diagnosis. During her first counseling session, she shares that she has experienced several significant loss over the last two years. She was a family caregiver for her mother, who passed away about six months ago. Prior to that, she and her husband separated and because she was so consumed by her mother’s care, Susan reports that she didn’t have time to process the separation. She is unsure where she will live, as she had moved into her mother’s house to provide her care while allowing her mother to remain at home. Her financial situation is unclear due to the marital separation and her mother’s recent death. During her session, her counselor talks about the signs of depression and that often, stress, grief and loss can have an impact on one’s memory. Her counselor encourages her to follow up with her primary care provider, to address health concerns that were put on the back burner. As Susan and her counselor work together, she learns about the importance of self-care, how healing from grief/loss can look different for different people, and how to adequately address the immediate concerns that have a direct impact on her well-being such as her housing and financial situation.


Robert schedules an appointment to explore the option of moving his wife to a memory care facility. “My wife is beginning to be too much care for me and as much as I want her to stay home until the end, I just can’t take it anymore”. As we explore the challenges he is facing, it becomes clear that his wife has had a sudden change. He shares that she has become combative and irritable. While she does have a diagnosis of Alzheimer’s type dementia, she has had a drastic change in her condition as evidenced by her challenging behavior over the last ten days. She started to experience visual and auditory hallucinations. “She will point out things that aren’t there, like telling me there are horses on the hill outside our window, or asking me to make the kids outside stop yelling and playing. She can get very upset about these things. I just don’t think I can handle the stress anymore”.

While Robert is personally familiar with Alzheimer’s, his knowledge is based on his daily experience in caring for his wife. He admits that he doesn’t know what to expect as the disease progresses. We talk about the gradual decline of Alzheimer’s disease and that it is rare for folks to experience a sudden change in condition. He understands that his wife is not experiencing a normal set of symptoms related to her disease, but could be experiencing the symptoms of an infection that has begun to spread. He agrees to have her evaluated immediately by her doctor. They discover that she has a UTI that has been untreated for some time. Many older adults begin to lose the ability to recognize the discomfort of a urinary tract infection. And because people with dementia are often not able to communicate their pain, many older folks, with or without dementia, are at risk of having a simple UTI spread and even become septic. It is important to note that this is a life threatening condition and needs to be treated right away.

One may be surprised to find that many people with a dementia diagnosis also suffer from depression and can also be at higher risk of developing delirium. It can be extremely important to tease out these symptoms so that appropriate treatment is offered.

Here are some common signs and symptoms of the “three D’s”:

Dementia: The more obvious signs of dementia include memory loss, confusion and changes in behavior. It is interesting to note that people with dementia can also experience anxiety, depression and paranoia.

Depression: Besides the more common symptoms of sadness, feelings of helplessness, and a lack of interest in doing things, people can also experience having too much or too little sleep, eating too much or too little, being easily distracted, interference in memory, and lack of focus.

Delirium: Delirium is often presented as either hyperactive, which includes restlessness, agitation and/or hallucinations; or hypoactive, with marked inactivity, slow moving, and sleepy/drowsy; and sometimes both hyper and hypoactive. Delirium can be caused by several events: infection, surgery, lack of sleep, and reaction to medication are not uncommon. It is important to understand that delirium can be a life threatening condition and if it is suspected, immediate medical intervention is recommended.

On the surface, these diagnoses can seem very different from each other. But upon further examination, and especially when working with older adults, one may see the intricacies and nuances of their similar symptoms. It is especially important for family members, professional caregivers and medical providers to take the time to ask questions and look deeper when assessing our clients and loved ones. Seeking professional guidance and educating yourself and others about the signs of depression, dementia, and delirium can potentially save the life of someone you care about.

Laura Vaillancourt, LMHC, GMHS, is a Licensed Mental Health Counselor and Geriatric Mental Health Specialist in Olympia, WA. She owns Eldercare Counseling and Guidance Services, a company that provides consulting, counseling and coaching support for family caregivers, professional caregivers and older adults. Her team is passionate about working with issues related to aging and are available to answer questions and provide guidance. They can be reached at:, or by calling 360-259-0078.

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