Dementia and Delirium - the unrecognised connection Julia L. Poole CNC Aged Care Royal North Shore...

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Transcript of Dementia and Delirium - the unrecognised connection Julia L. Poole CNC Aged Care Royal North Shore...

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  • Dementia and Delirium - the unrecognised connection Julia L. Poole CNC Aged Care Royal North Shore Hospital Sydney
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  • Julia Poole CNC Aged Care RNSH2 Sponsors RNSH Department of Aged Care & Rehabilitation Medicine NSW Department of Health - Dementia Action Plan Eli Lilly Australia Ltd - unrestricted education grant Illawarra Area Health Service - Commonwealth Funded Psychogeriatric Project Northern Sydney Home Nursing Service
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  • Julia Poole CNC Aged Care RNSH3 Case Example The ACAT receives a very distressed call from Mrs TW - - requesting a nursing home placement for her husband because he has been very confused and wandering about the house the last two nights and she can no longer care him Mr TW: 87 years old osteoarthritis, hypertension, cardiac failure, varicose ulcers, early dementia is now aggressive when approached has eaten little in the last two days his dog died last month
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  • Julia Poole CNC Aged Care RNSH4 What is Dementia? a clinical syndrome of organic origin characterised by slow onset of decline in multiple cognitive functions particularly intellect and memory, occur in clear consciousness and causes dysfunction in daily living Burns, A. and Hope, T. Clinical aspects of the dementias of old age, in Jacoby, R. and Oppenheimer, C. (eds) (1997) Psychiatry in the Elderly. Oxford: Oxford university Press.
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  • Julia Poole CNC Aged Care RNSH5 Disorders that cause dementia Alzheimers Disease Vascular Dementia Diffuse Lewy Body Disease Fronto-temporal disorder Huntingtons Disease Creutzfelt-Jacob Disease Etc
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  • Julia Poole CNC Aged Care RNSH6 What is Delirium? often known as Acute Confusion Acute confusional states occur in 30- 50% of hospitalised geriatric patients: patients with dementia are particularly vulnerable (Isselbacher et al.1998)
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  • Julia Poole CNC Aged Care RNSH7 What is Delirium ? (contd) an acute organic mental disorder characterised by confusion, restlessness, incoherence, inattention, anxiety or hallucinations which may be reversible with treatment Inouye (1998); Gelder, Mayou & Geddes (1999); Moran & Dorevitch (2001)
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  • Julia Poole CNC Aged Care RNSH8 DSM-IV 1994 Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time Delirium due to a general medical condition Substance induced delirium Delirium due to multiple etiologies Delirium not otherwise specified American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington: American Psychiatric Association.
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  • Julia Poole CNC Aged Care RNSH9 ICD-10-AM Diseases Tabular 2003 F05 - Delirium, not induced by alcohol and other psychoactive substances non specific organic cerebral syndrome concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. F05.1 Delirium superimposed on dementia
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  • Julia Poole CNC Aged Care RNSH10 Delirium Clinical Features Most causes affect neuronal function diffusely - all aspects of intellectual function Cardinal feature - clouding of consciousness impaired alertness, awareness, attention variability in state of arousal reduced responsiveness is interspersed with periods of excited outbursts sleep / wake cycle disrupted Isselbacher et al.1998. Harrisons Principles of Internal Medicine
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  • Julia Poole CNC Aged Care RNSH11 Delirium Clinical Features (contd) Impaired perception misperceives surrounding & attendants hallucinations Disturbance of emotion agitation, fear, depression, anxiety Psychomotor changes hyperactivity, restlessness, repetitive (plucking, tossing) Isselbacher et al.1998. Harrisons Principles of Internal Medicine
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  • Julia Poole CNC Aged Care RNSH12 Causes of Delirium Predisposing Brain disease - dementia, stroke, past severe head injury Use of brain-active drugs - sedatives, anticholinergics Impairments of special senses - sight, hearing Multiple severe illnesses Malnutrition Precipitating Iatrogenic - unpleasant environmental change, invasive procedures, new medications, trauma, dehydration, ongoing malnutrition, elimination malfunction Illnesses - infections, intracranial pathologies, impaired organ function, abnormal metabolite function, pain, drug withdrawal Creasey, H. (1996) Acute confusion in the elderly. Current Therapeutics. August:21-26.
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  • Julia Poole CNC Aged Care RNSH13 Pathophysiology of delirium Poorly understood decreased cerebral oxidative metabolism causing altered neurotransmitter levels &/or stress-induced increased plasma cortisol levels causing altered neurotransmitter activity Moran, J. & Dorevitch, M (2001) Delirium in the hospitalised elderly. The Australian Journal of Hospital Pharmacy. 31(1):35-40. cerebral hypo-perfusion in the frontal, temporal & occipital cortex Yokata, H. et al. (2003) Regional cerebral blood flow in delirious patients. Psychiarty and Clinical Neurosciences.75(3):337-339.
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  • Julia Poole CNC Aged Care RNSH14 Delirium Is a medical emergency Incidence of up to 56% in hospitalised older people Independent predictor of adverse outcomes increased falls incontinence pressure sores increased LOS in acute care decreased functional levels increased mortality Maher, S. and Almeida, O. (2002) Delirium in the elderly - another medical emergency. Current Therapeutics. March:39-43.
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  • Julia Poole CNC Aged Care RNSH16 A Good Model helps us see more clearly creates a simple language for a complicated process presents the whole or all of its parts is stable and generalizable (McCarthy 1996) ALGORITHM - an explicit protocol with well- defined rules to be followed in solving a health care problem. (Mosbys Dictionary 1990)
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  • Julia Poole CNC Aged Care RNSH18 Poole, J.L. and McMahon, C. (2005) An Evaluation of the Response to Pooles Algorithm Education Programme by Aged Care Facility Staff. Australian Journal of Advanced Nursing. 22(3):15-20. AIM a descriptive study instigated to seek evidence of a change in knowledge and care practices in staff who had participated in the education programme Poole, J. (2003) Pooles algorithm: Nursing management of disturbed behaviour in older people - the evidence. Australian Journal of Advanced Nursing. 20(3):38-43.
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  • Julia Poole CNC Aged Care RNSH19 Method Ethics approval Train-the-trainer sessions for senior ACF staff Training sessions in their own facilities over three months Evaluation pre and post knowledge questionnaires focus groups at the end of the 3 months
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  • Julia Poole CNC Aged Care RNSH20 Pre & Post Knowledge Questionnaire Tick the three most common causes of disturbed behaviour in older people in your facility Personality disorder Anxiety disorder Delirium Dementia Senility Depression
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  • Julia Poole CNC Aged Care RNSH21 Pre & Post Knowledge Questionnaire Tick the three most common causes of disturbed behaviour in older people in your facility Personality disorder Anxiety disorder Delirium Dementia Senility Depression
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  • Julia Poole CNC Aged Care RNSH26 Acute Care responses N = 99 mostly RNs
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  • Julia Poole CNC Aged Care RNSH27 5. Can you give me an instance of you or your staff using the knowledge in your workplace? now I feel so guilty because I told Mrs So-and-so that she was just being whingy, and now I understand; Im more inclined to look for reasons for the behaviourmore inclined to do something about it; start to investigate all the clinical signs he had a UTI; theres a haste to it ( to assess); lets start assessing the situation . understanding that its not just dementia.
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  • Julia Poole CNC Aged Care RNSH28 7. Has this new knowledge altered the way you or your staff feel about difficult situations and behaviours? I think a lot of the staff, particularly the AINs, are understanding that its not the person, its an illness or something thats causing the behaviour, not the actual resident being nasty to me more ordered, less panicky, more peaceful, more tolerant, more forgiving, less judgemental responses.
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  • Julia Poole CNC Aged Care RNSH29 Limitations post knowledge questionnaires applied directly after the training small number of trainers returned for the focus groups those that returned may have particularly wanted to report good results difficulties finding time to complete all the staff training staff language and cultural diversity
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  • Julia Poole CNC Aged Care RNSH30 Conclusions & Recommendations Delirium is poorly understood Negative attitudes & practices are fuelled by ignorance about mental health and medical issues Ongoing accurate training i