The three D’s is a common expression in health of older people. Standing for Dementia, Depression, and Delirium. These are all separate conditions, they can co-exist in any combination, an older person can have all three conditions at a single time.
Delirium is possibly the least talked about condition. Delirium in older people can be a serious and rapidly progressing condition, it requires prompt medical attention.
Dementia
What is Dementia?
Dementia is an umbrella term for a collection of brain conditions that affect thinking, problem solving, decision-making, behaviour, emotion, and memory, (more than 400 different types of Dementia are known, currently Alzheimer’s is the most common type of Dementia). People with dementia can also experience anxiety, depression, paranoia, delirium, and a wide range of other conditions.
Dementia generally develops slowly over several years, once deterioration steps up the decline is also usually gradual, over months and years. The executive functions of daily living generally are affected first, (e.g., the functions that require planning and making decisions such as paying bills, food shopping, etc); then the personal care functions of daily living become affected (e.g., cooking, remembering to eat, showering, toileting, etc).
Commonly the changes include any one or more of the following (this is not a complete list): increasingly giving less thought to matters; deteriorating poor judgement; increasingly it is hard to ‘find’ common words, resulting in disjointed conversation; previous memory may become significantly impaired; may wander with no sense of intent or regard for their personal or others safety; they may shadow (follow closely behind) their key family/whānau carer; get out of bed in the night and be active inside the house (e.g. trying to cook, turning on lights /TV; making a lot of noise; etc). People with high intelligence can mask these factors for a long period of time, but those closest to them may notice distinct changes in their patterns and behaviours.
Dementia has a significant impact on individuals, families, and communities. People with dementia and their key family/whānau carer may experience the effects of stigma and social ‘demotion’ – not being treated the same way by people. Effects on health, financial circumstances, employment status and relationships with those around them may also have a negative impact on self-esteem.
Who develops Dementia?
In any country around the world, most people with dementia live in the community, and most are undiagnosed. Currently the cause of dementia has not been discovered, in some cases it runs in families but that is not most cases. Research to find the cause of dementia is happening across the world, including the New Zealand Brain Research Centre (for more information https://www.brainresearch.co.nz).
Alzheimer’s Disease International (ADI) is the global voice about dementia, they commission several studies across the world to research the various factors of dementia. One such study is regularly conducted by the Lancet Commission; on 31 July 2024 they published an amended list of modifiable risk factors for developing dementia. This is an increase from 12 to 14 risk factors (amendment to 2020 list). Evidence shows if these factors are ‘corrected’ it may prevent or delay up to 40% of dementia cases globally, to date no priority order of the risk factors has been proven.
The 14 Modifiable Risks of Dementia |
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Physical inactivity |
Smoking |
Excessive alcohol consumption |
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Air pollution |
Head injury |
Infrequent social contact |
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Less education |
Obesity |
Hypertension (high blood pressure) |
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Diabetes |
Depression |
Hearing impairment |
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High LDL Cholesterol |
Vision loss |
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How many people in New Zealand have Dementia?
The University of Auckland study, ‘Dementia Economic Impact Report 2020 (DEIR, 2020 and reviewed in 2022), by lead author Dr Etuini Ma’u, a Psychiatrist of Older Adults and other dementia experts in New Zealand, estimated 70,000 New Zealanders had dementia, that is projected to rise to 100,000 by 2030, and to 170,000 by 2050.
People with dementia and their families/whānau face significant financial impact from the cost of health and social care, and from the reduction of income. The DEIR (2020) review in 2022 shows the economic cost of dementia to New Zealand increased by 43% between 2016 and 2020, the total cost was $1.7b in 2016, $2.5b in 2020, and assuming no increase in healthcare costs, the economic cost of dementia is estimated to increase to $3.5b in 2030, and to $5.9b by 2050.
Professor Lynette Tippett (New Zealand Brain Research Centre) says “if the onset of dementia could be delayed by five years, then by 2050 the prevalence of the disease would be lowered by 50%.”
Depression
What is Depression?
Depression researchers now say there isn’t much evidence to support the previous claim that it results simply from a chemical imbalance in the brain. Clinical Psychologist Dr Jacqui Maguire says, “one prevalent misconception is that depression is merely a phase, or a sign of personal weakness, when in reality, it’s a complex mental health disorder influenced by various factors beyond an individuals’ control.”
Different types of depression exist, with a wide range of symptoms. Generally, depression does not result from a single event, but from a mix of events and factors. Besides the more common symptoms of sadness; a loss of interest in doing and/or enjoying their normal activities; 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. The person may also experience feelings of helplessness; irritability; guilt; or they may feel numb, not feeling anything at all; may have suicidal thoughts; and many other symptoms too.
If the older person has a long history of depression the onset of a new episode of depression may progressively happen over weeks to months. Later-life Depression is the first episode of depression happening at any age from 65+ years onward; or after several years of no depression an episode of depression happens at any age from 65+ years onward.
Later-life Depression can have an abrupt onset, but generally that rate of onset is associated with life changes; the symptoms are like those noted above. Changes in sleep patterns are common in Later-life Depression, as is short term memory being affected (memory of recent happenings).
More than 50% of the people who develop Later-life Depression have never previously had depression. It may be associated with age-related factors such as other medical conditions, declining physical health, cognitive changes (thinking, memory, emotional and behavioural changes), and structural changes in the brain. Also, psychological and social factors can be closely associated with Later-life Depression, such as: retirement from paid work and the resulting changes in life; reduced participation in enjoyable physical or social activities; death of a partner; or admission to 24/7 Age Residential Care.