Transcript Delirium Depression Dementia - Aged Care Quality Association Inc.

Dementia
Delirium
Matt Kowald
Overview
What is Dementia
 What is Delirium
 Detecting Delirium
 Picking apart the 3Ds
 Dealing with Dementia and Delirium
 Drugs Drugs Drugs
 The future for management

What is Dementia

Umbrella term which groups a variety of
conditions such as
 Alzheimer's
 Vascular
 Frontal
 Lewy
bodies
Who cares about dementia?





In 2012 Garvin report more than 500 000 people
had dementia
In 2005 McCuser foundation estimated that 52
000 people are diagnosed every day
Projection to 2050 1,130 000 will have dementia
People living longer larger burden of disease
In UK 2012 1 in 4 beds of public hospitals
occupied by person with dementia
What are the common
misconceptions??
Don’t feel pain properly
 Don’t understand what your saying so no
point talking to them
 Best to lock them up so they don’t get
away
 Restraint and drugs are the only way that
they can be managed

BPSD


Behavioural and Psychological Symptoms of
Dementia
This is the term that is given to the cluster of
observable symptoms







Wandering - Pacing
Inappropriate behaviour - Calling out, Spitting
Agitation – Aggression
Sexually inappropriate behaviour
Delusions
Hallucinations
Anxiety
Delirium
Transient mental disorder
 Usually with an organic basis
 Key to management is addressing the
cause of the Delirium

Does delirium matter?
Yes!

Delirium is associated with increased risk of
 Prolonged hospitalisation
 Residential care placement
 Death (risk 38% over 2 years)
 Development of dementia (62.5% over 4 years)

Witlox 2010 JAMA
Prevalence
Common!
 Community: 1-2% (14% for >85 years)1
 Hospital
 On admission 10 – 24%2
 14-24% ED pts
 15-53% post-op
 70-87% ICU
 Hospice 42%
 Incident delirium up to 56%

Prevalence

Residential care
On admission to NH
 6.5% full delirium
 39.7% subsyndromal delirium


Post acute care
16 % full delirium
 53 % subsyndromal delirium

Management principles
Avoid / prevent known precipitants of
delirium
 Identify and treat underlying illness
 Supportive care
 Manage behavioural issues

ANAGRAM
Picking apart the 3 Ds
Delirium
Dementia
Depression
Onset
Acute or subacute
Insidious
Gradual
Duration
Hours/days/Weeks
Months/years
Weeks/months
Course
Fluctuates – worse at Stable and progressive Usually
worse
night
Lucid
periods, (unless
vascular morning, improves
usually during day
dementia
–
usually day goes on
stepwise
in
as
Activities of daily living Gradual decline in ability Sudden deterioration in Normal
(ADLs)
to do ADLs
ability to do ADLs
Alertness
Fluctuates
Usually normal,
until later stages
clear Normal
Orientation
Fluctuates,
but
will May be normal – usually Usually normal
always be impaired in impaired for time and
some
aspect:
time, place
place, person?
Memory
Recent impaired
Poor short term memory, Recent may be impaired
attention less affected
Remote intact
until severe
Delirium
Thoughts
Often
paranoid
grandiose
Dementia
and Slowed
?bizarre ideas and topics
?paranoid
Reduced interests
Perseverant
Depression
Usually slowed, and
preoccupied by sad and
hopeless themes
Delusions are common
Perception
Visual
and
auditory ?normal – hallucinations About 20% have mood
hallucinations common,
and
delusions
often congruent
auditory
absent
hallucinations
Delusions common
Emotions
Irritable
Aggressive
Shallow,
apathetic, Flat, unresponsive or sad
labile, ? irritable, careless and fearful
May be irritable
Fearful
Sleep
Nocturnal
confusion Often disturbed
Early morning wakening
and/or
“sundowning”
Nocturnal
wandering
common
common
Nocturnal confusion
Other features
Physical causes may not
be obvious
? past history of mood
disorder
Dealing with dementia
and delirium

Main issue is the person can not
comprehend the environment.
Re orientate.
 Explain in simple terms.
 Offer reassurance.
 If they are waiting for mum and dad and they
are 95 don’t be-little them.
 5 minutes spent one on one can lead to hours
of contentment for the person

Dealing with dementia
and delirium

Wont sleep
Bright light is needed at least 2-3hours per
day to make people realize the difference
between day and night.
 Not natural to be in a nighty or Pyjamas all
day, get them dressed
 ADLS use 80% of an older person energy
 Important to walk!

Dealing with dementia
and delirium

Wandering and pacing
Waiting for something to happen BOARD
 Pain behaviour
 Looking for someone to be nice to them

Dealing with dementia
and delirium

Aggression and agitation
UN MET NEEDS
 Not heard
 In Pain
 Need to go to the toilet and don’t want to poo
in a pad
 Hungry
 IT GOES ON

DRUGS DRUGS DRUGS











Haloperidol
Risperidone
Olazapine
Citralapram
Sodium Valproate
Quitiaprin
Sertraline
Propanalol
Lorazapam
Oxazapam
Diazapam
Place of Restraint

Chemical or physical restraint


MUST BE RISK ASSESSED
Restraint is not best practice and an
absolute last resort
NICE Guidelines
Familiar carers if possible
 Avoid room changes
 Clock and calendar
 Good lighting
 Reorientation
 Adequate hydration
 Assess for and treat infections
 Avoid catheterisation

NICE Guidelines








Encourage mobilisation
Monitor O2 sats
Assess and treat pain
Medication review if multiple drugs
Assess nutrition & refer if necessary
Ensure glasses worn
Ensure hearing aids worn and working
Promote good sleep patterns


Avoid medications / obs etc during sleep times
Minimise noise during sleep times
The Future
Need to design environments that are
suitable for people who are confused.
 Reduce the use of long term anti
psychotics and atypical anti psychotics
 Increase the education of all staff in
hospitals community and residential care
about the management of BPSD

Acknowledgment and
references
1.
2.
3.
4.
5.
6.
7.
8.
Opening picture Bright lights provided by Louise Kotz 2012
McCusker Fpundation http://www.alzheimers.com.au/alzheimers/incidence.php
Garvan Institute http://www.garvan.org.au/
Cohen-Mansfield, J. and A. Bester (2006). "Flexibility as a management principle in
dementia care: the Adards example." The Gerontologist 46(4): 540-544.
Commonwealth Department of Health and Human Services 1996. Dementia Kit.
Canberra: AGPS. In use by the Cairns Integrated Mental Health Program –
Consultation Liaison Team. Queensland Health.
Cohen-Mansfield, J. and B. Jensen (2008). "Assessment and Treatment
Approaches for Behavioral Disturbances Associated With Dementia in the Nursing
Home: Self-Reports of Physicians' Practices." Journal of the American Medical
Directors Association 9(6): 406-413.
Nay, R, Scherer, S, Pitcher, A, Kock, S, Browning, Ficker, L, Nugent, N, Ames, D,
Behaviours of concern among people living in residential aged care, La Trobe
University (Australia) March 2003 (Cited 7th August 2011) Available from
http://www.latrobe.edu.au/acebac/assets/documents/BehavioursReport.pdf
Roche 2003 Am J Med Sci 2. Inoyue 1998 Clin Geriatr Med
Questions