Transcript Acute Care Dementia

Dementia: acute care – risks
and issues
Primary Care Dementia Summit
24th November 2009
Case history
acute admission to hospital
• 3am saturday morning
• 87 year old female
• brought to Emergency Department by
ambulance
• limited history
• paramedic notes – found on floor at care home,
not moving left side
Information available
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lives in Uplands nursing home
‘dementia’
HTN
arthritis
? previous stroke
• usual level of functioning/mobility - unknown
• medications - unknown
History and examination
• ‘no information available from patient’
• chattering, pleasantly confused, ?dysphasic
• attempted phone calls to NH for further history – no
answer repeatedly
On Examination
• AMTS 3/10
• mildly dysphasic
• left sided weakness
• examination, obs - otherwise normal
• catheterised in emergency department due to
incontinence
Diagnosis & Plan
• Stroke (L hemiplegia)
• ? UTI (incontinent)
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MSU
Trimethoprim
Aspirin 300mg
CT head
NBM pending SALT
assessment
collateral history from NH
establish regular
medications
get old notes
transfer to stroke unit
On stroke unit (day 1)
• CT Head – old infarct
• Collateral history from daughter
– left sided weakness is longstanding
– collapsed getting off toilet
– Uplands NH is a RH!! – usually mobile with ZF
– normally incontinent of urine
– unsure of usual meds
– mother not her usual self: much more confused
• SU PTWR plan - not a stroke!
transfer to general elderly care ward
speak to GP/RH re-usual meds &
further background info
Moved to EC ward (day 2 & 3)
• agitated++ (by ward moves), prescribed lorazepam
• failed SALT assessment as ‘drowsy’ – continued NBM
• NGT passed for medications/ feeding
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BP low
Bloods – ↓Na 124, ↑ K 5.9
started on fluid restriction for hyponatraemia by SHO
MSU – no infection
• increasingly drowsy
• renal function deteriorating
• GP/RH not contacted – weekend, ‘busy’
Old Notes Arrive! (monday morning)
Medications –
• Aspirin 75mg od
• Donepezil 5mg od
• Simvastatin 40mg nocte
• Prednisolone 5mg od
• Calcichew D3 forte 1 bd
• Alendronate 70mg /week
• Tolterodine XL 4mg od
• on Prednisolone for 20 years for Rheumatoid Arthritis!
• given stat Hydrocortisone, Pred restarted
• IV fluids
On EC ward (days 4 & 5)
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drowsiness resolved
BP improved
renal function and electrolytes improved
reassessed by SALT and passed
NGT removed
catheter removed
• Plan - ?discharge home after physiotherapy
assessment
Day 6  35!!
• R/v by physio – unable to wt bear, left leg painful++
• X-ray = fractured NOF!!
• discharge cancelled
• referred to Orthopaedics → transferred to Ortho ward
• went to theatre
• lots of post-op complications exacerbated by delirium
• never regained prior level of physical or cognitive
functioning
• on discharge to new NH – fully dependent, hoisted
Summary of issues
• Significant delay to diagnosis of hip fracture
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Wrong diagnosis of stroke (old)
Inappropriate catherisation for incontinence
NBM and NGT – unnecessary
Multiple unnecessary ward moves (4)
Inappropriate sedative and other medications
Undiagnosed pain
Not given usual meds
Hypotensive, low Na and renal failure (dehydration) due to steroid
withdrawal and inappropriate fluid restriction
• Multiple iatrogenic illness due to misdiagnosis and inappropriate
treatments - mainly as result of inadequate information, poor
understanding & training
What are the risks for cognitively impaired
patients admitted to hospital?
What are the risks for cognitively impaired
patients admitted to hospital?
• Inability to communicate symptoms
• Information gathering difficult for staff – sometimes relies
heavily on external source that may not be readily
available, particularly ‘out of hours’
• Mismanagement due to lack of information, poor
understanding, time and bed pressures, inadequate
training
• Environmental changes - multiple ward moves, patients
and staff
• Cluttered ward layouts, poor signage, other hazards
• Inappropriate prescribing
• Inadequate pain recognition and control
• Procedures – e.g. catheter, NGT, blood tests, IV lines
• Poor supervision on the ward
Leads to • Delay to diagnosis
•  incidence of - delirium
falls and fractures
iatrogenic illness
malnutrition
dehydration
hospital acquired infections
•  length of stay
•  subsequent institutionalisation
•  mortality
National Dementia Strategy
Objective 8 – improved quality of care for people with dementia in
general hospitals
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70% acute hospital beds occupied by older people
Up to 50% of these have cognitive impairment
Majority undiagnosed and not known to dementia services
Challenging environment
Worse outcomes – LOS, mortality, institutionalisation
Malnutrition and dehydration
Not appreciated by clinicians, managers, commissioners
Lack of leadership
Insufficient staff knowledge
Insufficient information gained from carers/families
Poor discharge planning
How do we go about improving services in general
hospitals for those with cognitive impairment?
How do we go about improving services in general
hospitals for those with cognitive impairment?
• Better access to appropriate information i.e. communication! –
acute trust, primary care, care homes, family - IT
• Safer environment
• Avoid unnecessary ward moves
• Dementia link nurse – community and hospital
• Mental health liaison team
• Improve prescribing – sedative avoidance, pain recognition etc pharmacist
• Training – doctors, health professionals, medical school
• Promoting awareness – families, professional bodies, experts,
government, ‘champions’
• Policies/guidelines
• Better discharge planning with MDT and family involvement
• Audit & research
• Financial support
National Dementia Strategy
Objective 8 – improved quality of care for people
with dementia in general hospitals
To deliver improvement • Identification of senior clinician to take the lead for
quality improvement in dementia in the hospital
• Development of an explicit pathway for the management
and care of people with dementia in hospital
• Commissioning of specialist liaison older people’s mental
health teams to work in general hospitals
Falls and Dementia – the risks
• 60% people with dementia fall,
×2 that of cog normal peers
• 25% fallers with dementia
fracture
• Poorer prognosis
• 70% 6 month mortality after
#NOF
• Higher incidence of gait and
balance disorders
• Medications: sedatives,
neuroleptics, anti-depressants,
– higher falls & syncope risk
• Higher incidence of autonomic
dysfunction, CSH, OH
• Parkinsonism – drug SE’s,
lewy-body, vascular
• More co-morbidities
• Incontinence
• Wandering
• Reduced ability to observe
environmental hazards and
show caution
• Poor compliance with mobility
aids
• Decreased ability to
communicate symptoms
• Diagnostic challenges
• Difficulties with obtaining
investigations
• Inability to comply with falls
advice, interventions or
treatment
• Evidence suggesting no
benefit of falls interventions in
patients with dementia
Thank you