Dementia and Delirium - the unrecognised connection

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Dementia and Delirium - the unrecognised connection. Julia L. Poole CNC Aged Care Royal North Shore Hospital Sydney. Sponsors. RNSH Department of Aged Care & Rehabilitation Medicine NSW Department of Health - Dementia Action Plan Eli Lilly Australia Ltd - unrestricted education grant - PowerPoint PPT Presentation

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  • Dementia and Delirium - the unrecognised connection

    Julia L. Poole CNC Aged Care Royal North Shore Hospital Sydney

    Julia Poole CNC Aged Care RNSH

  • SponsorsRNSH 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

    Julia Poole CNC Aged Care RNSH

  • 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 oldosteoarthritis, hypertension, cardiac failure, varicose ulcers, early dementia is now aggressive when approachedhas eaten little in the last two dayshis dog died last month

    Julia Poole CNC Aged Care RNSH

  • What is Dementia?a clinical syndrome of organic origincharacterised 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.

    Julia Poole CNC Aged Care RNSH

  • Disorders that cause dementiaAlzheimers DiseaseVascular DementiaDiffuse Lewy Body DiseaseFronto-temporal disorderHuntingtons DiseaseCreutzfelt-Jacob DiseaseEtc

    Julia Poole CNC Aged Care RNSH

  • 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)

    Julia Poole CNC Aged Care RNSH

  • 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)

    Julia Poole CNC Aged Care RNSH

  • DSM-IV 1994Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of timeDelirium due to a general medical conditionSubstance induced deliriumDelirium due to multiple etiologiesDelirium not otherwise specified

    American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington: American Psychiatric Association.

    Julia Poole CNC Aged Care RNSH

  • ICD-10-AM Diseases Tabular 2003F05 - Delirium, not induced by alcohol and other psychoactive substancesnon 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

    Julia Poole CNC Aged Care RNSH

  • Delirium Clinical FeaturesMost causes affect neuronal function diffusely - all aspects of intellectual functionCardinal feature - clouding of consciousness impaired alertness, awareness, attentionvariability in state of arousalreduced responsiveness is interspersed with periods of excited outburstssleep / wake cycle disrupted

    Isselbacher et al.1998. Harrisons Principles of Internal Medicine

    Julia Poole CNC Aged Care RNSH

  • Delirium Clinical Features (contd)Impaired perceptionmisperceives surrounding & attendantshallucinations Disturbance of emotionagitation, fear, depression, anxiety Psychomotor changeshyperactivity, restlessness, repetitive (plucking, tossing)

    Isselbacher et al.1998. Harrisons Principles of Internal Medicine

    Julia Poole CNC Aged Care RNSH

  • Causes of DeliriumPredisposingBrain disease - dementia, stroke, past severe head injuryUse of brain-active drugs - sedatives, anticholinergicsImpairments of special senses - sight, hearingMultiple severe illnessesMalnutritionPrecipitatingIatrogenic - unpleasant environmental change, invasive procedures, new medications, trauma, dehydration, ongoing malnutrition, elimination malfunctionIllnesses - 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.

    Julia Poole CNC Aged Care RNSH

  • Pathophysiology of deliriumPoorly understood decreased cerebral oxidative metabolism causing altered neurotransmitter levels &/orstress-induced increased plasma cortisol levels causing altered neurotransmitter activityMoran, 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 cortexYokata, H. et al. (2003) Regional cerebral blood flow in delirious patients. Psychiarty and Clinical Neurosciences.75(3):337-339.

    Julia Poole CNC Aged Care RNSH

  • DeliriumIs a medical emergencyIncidence of up to 56% in hospitalised older peopleIndependent predictor of adverse outcomesincreased falls incontinencepressure sores increased LOS in acute care decreased functional levelsincreased mortality Maher, S. and Almeida, O. (2002) Delirium in the elderly - another medical emergency. Current Therapeutics. March:39-43.

    Julia Poole CNC Aged Care RNSH

  • Julia Poole CNC Aged Care RNSH

    CONFUSION ASSESSMENT METHOD (CAM)

    Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present

    1. Acute and fluctuating course

    Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behaviour fluctuate during the day, that is, come and go, or increase and decrease in severity?

    No

    Yes

    Uncertain (please specify) .

    3. Disorganised thinking

    Was the patients thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from one subject to another?

    No

    Yes

    Uncertain (please specify) ..

    2. Inattention.

    Did the patient have difficulty focussing attention during the interview, e.g. being easily distractible, or having difficulty keeping track of what was being said?

    No

    Yes

    Uncertain (please specify) .

    4. Altered level of consciousness

    Overall, how would you rate this patients level of consciousness?

    Alert (normal)

    Altered

    Vigilant (hyperalert, easily startled, overly sensitive to stimuli)

    Lethargic (drowsy but easily aroused)

    Stupor (difficult to arouse)

    Coma (unrousable)

    Uncertain

    Delirium symptoms present

    Delirium symptoms NOT present

    N/A

    DATE:

    Signature of assessor & designation:

    Medical Officer's signature ..

    Royal North Shore and Ryde Health Service

    Inouye, S.K. van Dyck, C.H. Alessi, C.A. Balkin, S. Siegal, A.P. Horwitz, R.I. (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. 113(12):941-948.

  • A Good Modelhelps us see more clearlycreates a simple language for a complicated processpresents the whole or all of its partsis 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)

    Julia Poole CNC Aged Care RNSH

  • Julia Poole CNC Aged Care RNSH

  • 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.

    Julia Poole CNC Aged Care RNSH

  • MethodEthics approval Train-the-trainer sessions for senior ACF staffTraining sessions in their own facilities over three monthsEvaluation pre and post knowledge questionnairesfocus groups at the end of the 3 months

    Julia Poole CNC Aged Care RNSH

  • Pre & Post Knowledge QuestionnaireTick the three most common causes of disturbed behaviour in older people in your facility Personality disorder Anxiety disorder Delirium Dementia Senility Depression

    Julia Poole CNC Aged Care RNSH

  • Pre & Post Knowledge QuestionnaireTick the three most common causes of disturbed behaviour in older people in your facility Personality disorder Anxiety disorder Delirium Dementia Senility Depression

    Julia Poole CNC Aged Care RNSH

  • Julia Poole CNC Aged Care RNSH

    Table 1. Trainer-the-trainer and focus group participants

    Train-the-trainer

    Focus Groups

    Number

    %

    Number

    %

    Directors of Nursing

    8

    7.7

    3

    8.3

    Deputy Directors of Nursing

    18

    17.3

    4

    11.1

    Directors of Care

    3

    2.9

    -

    -

    Registered Nurses

    45

    43.3

    16

    44.4

    Enrolled Nurses