Transcript No Slide Title - Alzheimer`s Australia

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
• Illawarra Area Health Service - Commonwealth Funded
Psychogeriatric Project
• Northern Sydney Home Nursing Service
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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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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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Disorders that cause dementia
•
•
•
•
•
•
•
Alzheimer’s Disease
Vascular Dementia
Diffuse Lewy Body Disease
Fronto-temporal disorder
Huntington’s Disease
Creutzfelt-Jacob Disease
Etc
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What is Delirium?
• often known as Acute Confusion
• Acute confusional states occur in 3050% of hospitalised geriatric patients:
patients with dementia are particularly
vulnerable (Isselbacher et al.1998)
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What is Delirium ?(cont’d)
• 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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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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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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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. Harrison’s Principles of Internal Medicine
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Delirium
Clinical Features (cont’d)
• Impaired perception
– misperceives surrounding & attendants
– hallucinations
• Disturbance of emotion
– agitation, fear, depression, anxiety
•
Psychomotor changes
– hyperactivity, restlessness, repetitive (plucking, tossing)
Isselbacher et al.1998. Harrison’s Principles of Internal Medicine
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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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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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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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CONFUSION ASSESSMENT METHOD (CAM)
Royal North Shore and Ryde Health Service
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) ……………….
………………………………………………
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) ……………….
 ………………………………………………

Delirium symptoms present

Delirium symptoms NOT present

N/A
3. Disorganised thinking
Was the patient’s 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) ……………..
………………………………………………
4. Altered level of consciousness
Overall, how would you rate this patient’s 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
DATE: ……………………………………
Signature of assessor & designation:………………………………………………………………
Medical Officer's signature ………………………………………………………………………..
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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 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. (Mosby’s Dictionary 1990)
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Poole, J.L. and McMahon, C. (2005) An Evaluation of the
Response to Poole’s 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) Poole’s algorithm: Nursing management of disturbed behaviour in older people
- the evidence. Australian Journal of Advanced Nursing. 20(3):38-43.
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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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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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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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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
Enrolled Nurses
2
1.9
-
-
Diversional Therapists
2
1.9
1
2.8
Personal Care Assistants (PCA) or Assistants
in Nursing (AIN)
5
4.8
1
2.8
Others (e.g.Allied Health, Managers)
21
20.2
11
30.6
Total
104
100
36
100
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22
Table 3. Trainers Pre & Post Knowledge Test Results - Opinions of the three
major causes of disturbed behaviour from the given list (%). n = 104
Pretest
%
Posttest
%
Difference
%
* Chisquare
with 1 df
P value
95% CI of
difference
Delirium, depression and
dementia
Delirium
19.2
91.3
71.1
73.01
<0.001
63.5 - 80.7
39.4
97.1
57.7
58.02
<0.001
43.6 - 71.8
Depression
78.8
100
21.2
20.05
<0.001
71.0 - 86.7
Dementia
90.4
98.1
7.7
4.08
0.043
1.3 - 14.1
Personality Disorders
17.3
0
17.3
84.01
<0.001
10.0 - 24.6
Anxiety Disorder
62.5
8.7
53.9
54.02
<0.001
44.3 - 63.4
Senility
10.6
0
10.6
9.09
<0.003
4.7 - 16.5
* McNemar’s Test
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Table 2. Staff trained by the trainers.
Number
%
Registered Nurses
63
33.2
Enrolled Nurses
6
3.2
Diversional Therapists
8
4.2
Personal Care Assistants (PCA) or Assistants
in Nursing (AIN)
104
54.7
Others (e.g.kitchen or cleaning staff)
9
4.7
Total
190
100
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Table 5. Aged Care Facility Staff Pre & Post Knowledge Test Results Breakdown of the opinions of the three major causes of disturbed behaviour
from the given list (%). n = 190
Pretest
%
Posttest
%
Difference
%
* Chisquare
with 1 df
P value
95% CI of
difference
Delirium, depression and
dementia
Delirium
12.6
59.5
46.8
72.37
<0 001
38.7 - 55.0
24.7
75.2
50.5
80.58
<0 001
46.3 - 58.8
Depression
78.4
89.5
11.1
10.81
<0.001
5.0 - 17.1
Dementia
91.6
91.1
0.5
0
-
-
Personality Disorders
25.8
16.3
9.5
6.02
0.014
2.5 - 16.5
Anxiety Disorder
64.7
23.2
41.6
62.72
<0.001
34.0 - 49.2
Senility
20.0.
8.4
11.6
12.25
<0.001
5.6 - 17.5
McNemar’s Test
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Acute Care responses
N = 99 mostly RNs
What are the 3 most common causes of disturbed
behaviour in older patients in ACUTE care
Causes of disturbed
behaviour
Personality Disorder
Anxiety Disorder
Delirium
Dementia
Senility
Depression
0
20
40
60
80
100
Numbers of answers
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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’;
• ‘… I’m more inclined to look for reasons for the
behaviour…more inclined to do something about it’; ‘… start to
investigate all the clinical signs … he had a UTI’;
•
‘there’s a haste to it ( to assess)’; ‘let’s start assessing the
situation …. understanding that it’s not just dementia’.
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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 it’s not the person, it’s an illness or
something that’s 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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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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Conclusions &
Recommendations
• Delirium is poorly understood
• Negative attitudes & practices are fuelled by
ignorance about mental health and medical
issues
• Ongoing accurate training is essential
• Expansion of this study in the acute and
community sectors is recommended
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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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Solution to
Mr & Mrs TW’s Problem
• Consider safety - informed careful
approach
• Seek medical assessment as soon
as possible
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