Transcript Key issues in dementia care in the acute hospital

An Oncologist’s guide to
Dementia & Delirium
Dr. Mark Kinirons,
Trust Lead for Dementia and Delirium
Clinical Adviser to NHS London Dementia Pathway
Case Vignette
• A 70-year-old woman has been noticing increasing
forgetfulness over the past 6 to 12 months.
• Although she has always had some difficulty recalling the
names of acquaintances, she is now finding it difficult to
keep track of appointments and recent telephone calls, but
the process has been insidious.
• She lives independently in the community; she drives a car,
pays her bills, and is normal in appearance.
• A mental status examination revealed reduced score from
previous.
• Does the patient have mild cognitive impairment?
• How should her case be managed?
Specialty training in older people
Kalsi et al 2013
MCI and dementia
Cognitive
function
SCD
|
‘Normal’
|
‘MCI’
+
Decline
noticed
| |
Loss of
insight
+ +
‘Dementia’
Time
Rob Stewart, IOP
Alzheimer’s Society, March, 2012
Alzheimer’s Society, March , 2012
Introduction
• General hospitals are challenging
environments for people with dementia
and delirium:
• People with dementia & delirium have
worse outcomes in terms of:
Dementia & Delirium
• Very common
• Poorly taught
• Poorly recognised & poorly responded
• Poorly cared for
More public expectation
• National Dementia Strategy
• DH Review of antipsychotic use
• CQUIN
• Frances Report Jan 2013
Dementia CQUIN 2013-4
National
• Screening and assessment
London
• Training
• Reducing inappropriate antipsychotic
prescribing
Dementia Screening January '13 - October '13
100.00%
80.00%
60.00%
40.00%
January
February
March
% screened in 72 hrs
April
May
June
% received 4AT
July
August
% received care plan
September
October
Recognition and Response to
memory, dementia and delirium
Number of activations of Sepsis bundle on EPR
Number of activations of Dementia and Delerium
bundle on EPR
Number of activations of Acute Kidney Injury bundle
on EPR
60
140
80
120
70
60
100
50
40
80
60
Sep-13
Jul-13
Aug-13
Jun-13
Apr-13
May-13
Mar-13
Feb-13
Sep-13
Jul-13
Aug-13
Jun-13
Apr-13
May-13
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
0
Aug-12
0
Sep-12
Sep-13
Jul-13
Aug-13
Jun-13
Apr-13
May-13
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
May-12
0
20
20
10
Jan-13
40
10
Dec-12
30
Oct-12
20
Nov-12
30
Sep-12
40
90
Aug-12
50
160
Alzheimer’s Society, March , 2012
Test to order for memory work up
PRIMARY CARE
• Full blood count
• ESR if less than 60 yr
• Renal, liver, bone,
thyroid, lipids
• Glucose
• B12 & folate
• MSU – simple infection
screen
• HIV
SECONDARY CARE
•
•
•
•
MRI & SPECT
EEG
Auto-immune screen
HIV & Syphilis serology
•
Neuropsychological testing
•
CSF tau etc
Coronal MRI Scans from Patients with Normal Cognition, Mild Cognitive Impairment, and
Alzheimer's Disease.
Axial Scans of the Brain Obtained with Positron-Emission Tomography and the Use of
Amyloid-Binding Carbon 11–Labelled Pittsburgh Compound B.
Management
•
•
•
•
•
•
Medication review
Driving
Social services referral
Community mental health referral
Financial / Will / Power of Attorney
Patient information and voluntary sector
information – www.alzheimers.org.uk
• Research
• Patient & carer forum
• CPR / End of Life /Adv planning
Mean Scores on the Standardized Mini–Mental State Examination (SMMSE) and the Bristol
Activities of Daily Living Scale (BADLS), According to Visit Week and Treatment Group.
Howard R et al. N Engl J Med 2012;366:893-903
Delirium
•
•
•
•
•
•
Inpatient mortality 22-76%
One year mortality 35-40%
60% resolve in 6 days
5% delirious >1 month
38% may have >=1 symptom still at discharge
Higher rates of other complications and
institutionalisation
• Accelerated cognitive decline
Diagnosis: CAM
• Based on DSM-III-R criteria
• Condensed to four key features
•
•
•
•
1)Acute onset and fluctuating course
2)Inattention
3)Disorganized thinking
4)Altered level of consciousness
• 1 and 2 plus 3 or 4 diagnose delirium
– Inouye et al Annals Int Med 1990;113(12):949-948
Risk factors for delirium:
• Old age
• Severe illness
• Dementia
•
•
•
•
• Infection
• Dehydration
• Malnutrition
• Multiple medications
• Surgery
• Change of environment
• Hip fracture
Sleep deprivation
Constipation
Bladder catheterisation
Visual or hearing
impairment
• Immobility
• Alcohol abuse
Mental capacity & Best interests
The patient lacks capacity if
•
Presumption of capacity
•
•
Necessity of intervention
•
Least restrictive
•
Involve patient , nominated
representatives
•
IMCA
Stage 1. The patient has an
impairment /disturbance of brain
function □
•
•
•
•
•
•
Stage 2
Any of the following are true;
Patient is unable to UNDERSTAND □
Patient is unable to USE and weigh □
Patient is unable to RETAIN □
the information required to make this
decision
•
Patient is unable to COMMUNICATE
their decision (whether by talking,
using sign language or other means)
□
MC Act 2005
Questions
• Email [email protected]