This issue of Topics in Geriatric Rehabilitation takes a look at 3 conditions that significantly affect quality of life for older adults: delirium, depression, and dementia (3 Ds). These conditions interact with each other and even have similar symptoms. Across rehabilitation settings, therapists will treat older adult patients experiencing these conditions. Two of the conditions, delirium and dementia, show increased prevalence with aging, whereas depression, although prevalent with older age, is not a result of aging. The 3 Ds can result in challenging patient-therapist interactions. This issue aims to assist the therapist in understanding the underlying physical causes for these cognitive changes, develop strategies to overcome them, and finally to recognize the importance of therapeutic interventions for improving patient outcomes.

One difficulty with the 3 Ds is determining exactly what is causing the cognitive changes being displayed. Some symptoms can be attributed to any of the 3 Ds, this overlap of symptoms makes diagnosis difficult. For example, patients with a subtype of delirium (hypoactive) display similar behaviors to depression, that is, lack of interest in surroundings, excessive sleep, and so forth. Patients with dementia develop delirium or depression, but the underlying condition makes it more difficult to recognize these treatable disorders. The clinician may think the dementia is progressing when recovery is possible. A second issue is that delirium and depression are often underdiagnosed in older adults, thus preventing appropriate treatment. Therapists must be alert to the symptoms of delirium and depression. They must be willing to work with the rehabilitation team to identify those at risk or already with symptoms. In the first article, Nora Francis provides therapists with assessment tools that can be used in the clinic to identify patients who may need further definitive testing or treatment.

Patients with any of the 3 Ds can be challenging for the rehabilitation therapist. Knowledge of these conditions helps us to understand that there is an underlying pathology that may respond to treatment and that the behaviors demonstrated by a patient are not a personality characteristic of the patient. Reframing the patient's behaviors in the context of their condition helps us to provide the care the patient needs. Understanding the complex interaction of patient susceptibility and environmental stresses should help therapists seek strategies to manage these challenging patients. These topics are described in the article on delirium by Gail Huber. This syndrome can result in long-term debilitating outcomes and we must use all the tools at our disposal to identify and treat those at risk.

Early identification is also critical for those experiencing mild cognitive impairment, where the hope is that early treatment may slow or prevent a progression to dementia. William Healey describes this hot area of aging research. As physical activity and cognitive interventions provide a nonpharmacological treatment for mild cognitive impairment, a multidisciplinary approach may be required to improve outcomes. On the basis of recent results from a prospective, 4-year cohort study of 716 older adults, researchers in Chicago reported that a higher level of physical activity (subjects wore a wrist actigraph, which measured usual levels of daily physical activity) was associated with a reduced risk of Alzheimer's disease and cognitive decline.1 Older adults in clinical and community settings would benefit from therapists' recommendations and expertise on safely and effectively increasing physical activity at any level.

The knowledge and skill required to effectively treat older adults with these conditions are necessary, but there is an underlying imperative to treat the patient on the basis of a professions' code of ethics and clinical reasoning. The article by Jensen, Randall, and Wharton delves into the ethical aspects of treating these challenging patients. Their review of the ethical principles to be considered when determining appropriateness of treatment is critical to making decisions about providing treatment as well as discontinuing treatment. We must identify ways to work with the confused and uncooperative patient before we dismiss him or her as not appropriate for treatment.

Although therapists have professional responsibilities for older adults with delirium, depression, or dementia, those seniors still at home are largely cared for by family members. Etkin, Bright, and Krajci describe some of the issues surrounding caregiving. Health professionals must be aware of the stresses caregivers experience. A holistic approach to the family requires that we learn about the resources therapists can use to assist family members dealing with the daily stresses of caregiving.

With the growth of the aging population we will need to find new ways to prevent older adults from developing dementia, delirium, or depression. We start by understanding the problem, identifying the risks, and providing treatment to the best of our ability.

No matter what age you are, or what your circumstances might be, you are special, and you still have something unique to offer. Your life, because of who you are, has meaning (Barbara de Angelis).

-Gail M. Huber, PT, PhD, MHPE

Issue Editor

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