Transcript General tips – time management, ward rounds and forms

Dr Carol Chong
Geriatrician and Supervisor of Intern Training
The Northern Hospital
October 19th 2012
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You need to be aware of aged care issues.
 Older patients are everywhere!
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Dementia
Delirium (… wait for Dr Holbeach’s talk!)
Falls in hospital
Functional decline
Polypharmacy
Incontinence
Aged Care Services (and all the acronyms!)
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1) Look out for patients with dementia
2) Liaise with families whenever possible
3) Know the patient’s premorbid functional
status
4) If someone has fallen, you need to work
out why
5) Beware the confused patient, they can do
badly
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Know which patients have cognitive
impairment or dementia
You’ll have to liaise more closely with family
members eg. for consent, letting them know
what’s happening
Prone to delirium and other complications
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Will save a lot of heartache later…
Should liase with the family asap (particularly
if patient has memory problems)
◦ - you are available and care
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Speaking to the family will help you gather
important info, gain rapport and save you
time later.
Communication breakdown is a major cause
of complaints. Your consultant will love you
if you are a communicator!
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Impairment of memory
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Another cognitive domain (aphasia, apraxia,
agnosia, executive dysfunction)
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**Functional impairment (decline from
previous level of function, severe enough to
interfere with daily function (versus mild
cognitive impairment)
Not reversible, not due to psych illness.
Often diagnosed as an outpatient. Need to
exclude delirium.
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Alzheimer’s 60-80%
Lewy Body 10-20%
Vascular 10-20%
Mixed Alzheimer’s and Vascular Dementia
Fronto-temporal
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Other – Alcohol related, CJD, Huntington’s
etc
“Reversible” dementia
pseudodementia Depression
Alcohol related (intoxication, withdrawal)
Normal pressure hydrocephalus
Medication related (opiates, sedatives,
antipsychotics)
◦ Metabolic disorders
◦ CNS: tumors, subdurals etc.
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Mild Cognitive Impairment
Current Spectrum of Dementia
Frontotemporal Hippocampal
Sclerosis
Dementia
Pure Vascular
1%
4%
Dementia
3%
Mixed Dementia
42%
Dementia With
Lewy Bodies
8%
Alzheimer's
Disease
42%
N = 382
Barker WW, et al. Alzheimer Dis Assoc Disord. 2002;16:203-212.
Barker WW, et al. Alzheimer Dis Assoc Disord. 2002;16:203-212.
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Commonest dementia
Median survival from time to diagnosis in
one study 4.2 years for men, 5.7 years for
women
A clinical diagnosis
Gold standard– pathological correlation of
senile plaques and neurofibrillary tangles.
AUTOPSY (but not practical!)
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Clinical – early and accurate diagnosis is
important so patients and families can plan
for the future.
Insidious onset, gradual decline
Symptoms: forgetful, repetitive, misplace
things
Collateral history is important. Patient’s
often feel their memory is okay. Family
notice STM loss.
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Rule out reversible causes.
FBE, U+E, LFTS, Ca, PO4, B12, folate, TFTS.
CT or MRI Brain – shrunken hippocampi
MMSE – A must! - short term memory usually
impaired first. If not consider differentials.
Neuropsychological tests if diagnosis
uncertain.
Other Ix – SPECT scan, PET scan, in research
Amyloid scans.
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Cholinesterase Inhibitors for mild-moderate
AD
◦ Small degree of benefit
◦ Cost-benefit ratio remains controversial
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Donepezil (Aricept), Galantamine (Reminyl) ,
Rivastigmine (Exelon)
In Australia PBS indication – MMSE between
10 – 24 or can start at higher MMSE scores
now. 2 point improvement within 6 months
for continuation.
Small improvements on cognitive and global
function.
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Loss of cholinergic neurons
Reduced cerebral production of choline acetyl
transferase  decreased acetylcholine
Cholinesterase inhibitors delay breakdown of
acetylcholine relased into synaptic clefts and
enhance cholinergic neurotransmission
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Treatment for periods of 6M to 1 year
produced improvements in cognitive function
1.37 points (95%CI 1.13-1.61) in MMSE
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Benefits on measurements of ADLS, behaviour
and global clinical state but benefits are not
large.
Efficacious for mild-mod dementia
Cochrane review 2006 (13 trials)
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80 year old lady commenced donepezil 5mg
o daily 2 days ago for Alzheimer’s Disease –
presents to ED with vomiting and diarrhoea?
Can donepezil cause these symptoms?
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80 year old man commenced donepezil 5mg
o daily yesterday, presents with collapse
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o/e b.p 90/60 pulse 40
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Can donepezil cause this problem?
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Usually mild and transient S.E (20%), generally
well tolerated but can cause…
Nausea and vomiting (start low dose)
Anorexia
Diarrhoea
Bradycardia (If bradycardic on examination –
check ECG and ensure no heart block)
Urinary incontinence
Confusion
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Less GI side effects
Minimal skin irritation
Convenient to patients and caregivers
Start with the Exelon 5 patch, increase to the
Exelon 10 patch in a month if tolerated
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Case Scenario – Pt goes back to Geriatrician
since donepezil is stopped and is commenced
on memantine instead…
But comes into ED 3 days later complaining of
dizziness.
Can this be from menantine?
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Memantine (Ebixa) – for moderate to severe
AD. MMSE score between 10-14 for PBS
approval
◦ NMDA receptor antagnoist
◦ NMDA receptor involved in learning and memory
◦ Postulated to inhibit cytotoxic overstimulation of
glutamatergic neurons.
◦ Neuroprotective
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S.E: generally well tolerated. Dizziness
most common SE. Worsening delusions and
hallucinations in some.
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Vitamin E (antioxidant)–
 No evidence from RCTs
 increased mortality at high dose
Selegiline
Estrogen
NSAIDS and COX2 inhibitors– side effects
+CV mortality
Gingko biloba – questionable efficacy
Prevention: Lifestyle factors unproven but
useful to try.
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50 year old man presents to ED after crashing
his car into a tree. Police find him confused
and disorientated. Family rush to the scene
and say his personality has changed over 6
months. Very aggressive verbally, dishevelled,
impulsive and does things without thinking…
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Characterised by frontotemporal lobar
degeneration.
In individuals aged less than 65, FTD is 2nd
most common after AD
Mean age of onset 58.5 years.
Family history in 20-40%, assoc with tau gene
mutation.
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Presentation: behavioural problems, language
difficulties (NB only a small % have memory
problems initially)
Changes in personality or social conduct
(90%), memory impairment (57%), language
problems (56%), dysexecutive symptoms
(54%)
Often mistaken as a psychiatric illness
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At least 6 month history of change in
personality and behaviour sufficient to
interfere with interpersonal relationships
◦ Disinhibition, Impulsivity, Social withdrawal,
emotional lability, apathy, reduced concern for
others, poor personal hygeine,
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LOSS OF INSIGHT
O/E Look for frontal signs
Ix: MMSE – not great at picking up frontal
impairment.
Frontal Assessment Battery
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Radiology – Frontal and temporal lobe
atrophy may be present.
Treatment: Supportive.
Patient’s often admitted to a secure ward due
to behavioural disturbance.
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Associated with parkinsonism. 2nd most
common neurodegenerative dementia.
CORE features
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Gradually progressive dementia
Fluctuating cognition
Visual hallucinations
Motor features of parkinsonism
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Repeated falls
Syncopy
Sensitivity to neuroleptics
REM sleep disorder
Supportive feature
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Beware of these patients.
Can’t give regular antipsychotics for
behavioural disturbance
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Parkinsonism
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◦ Avoid antipsychotics (except can trial quetiapine)
◦ *Consider benzodiazepines to treat behavioural
disturbance
◦ *Avoid Metoclopramide for vomiting
 Give domperidone instead
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Pathology= presence of lewy bodies in
brainstem and cortex
Treatment: Cholinesterase inhibitors (some
evidence that cholinergic deficit is greater
than in Alzheimer’s)
Rivastigmine found to be of benefit in 1
multicentre trial.
Beware of neuroleptic sensitivity – difficulty
in avoiding in patients with psychosis
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Post-stroke cognitive deficits
Stepwise deterioration, less predictable
course
Diverse manifestations
◦ Cognitive deficits depending on which part of the
brain is affected.
◦ MMSE variable
0/E neurological deficits
Imaging shows infarcts
Treatment: Stroke risk factors. Antiplatelet
agent. No conclusive evidence for
cholinesterase inhibitors
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Very useful
Should be first line before anti-psychotics.
Activity groups
Carer’s groups
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For behavioural and psychological
symptoms of dementia where nonpharmacological measures have not
worked.
Judicious use, short term use.
Risperidone (Riserdal) * only one on PBS for
BPSD. S
Olanzapine (Zyprexia)
Quetiapine (Seroquel)
Side effects: Somnolence, Parkinsonism,
gait disturbance, postural hypotenstion
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Med Reg asks you to admit an 88 year old
lady with pneumonia. Has multiple other
medical problems including IHD, CCF, AF.
Not sure of home situation…
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It’s up to you to take a history
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This helps with discharge planning!
Where do they live?
◦ Home alone vs with family vs residential care
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Ask about ADLs
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Personal ADLs
Domestic ADLs
Community ALDLs
Cognition
Mobility, gait aids
Allied health team can help you gather info
◦ Your best friends!
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Physiotherapist – premorbid mobility is
important
◦ Use of a gait aid, frame, steps in and out
the house
Occupational therapist
- home set up, daily activities
Social worker – what’s really happening,
can the patient manage at home?
Speech Pathologist – swallowing or
speech difficulties
Dietician – supplements are useful
Podiatrist – ulcers, diabetic feet etc
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Low or high level?
D/c planning is often easier
Aged care unit often looks after these
patients
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In general, need to be able to walk 50 metres
independently (can use an aid eg. frame)
Be able to self toilet or manage continence
aid
Will get assistance with showering/dressing
and medication management
Dementia specific hostels – secure ward
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Full nursing care
Assistance with showering, dressing,
toileting, feeding, walking
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Thinking of sending someone to GEM or
Rehab or placement (hostel or nursing home)
Help to liaise with allied health and nursing
staff
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HLC –
LLC –
ACAS –
PAG –
HH –
MOW –
PCA –
CAPS –
EACH –
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HLC – High level care
LLC – Low level care
ACAS – Aged Care Assessment Service – for level of
care paperwork,respite case management
PAG – planned activity group
HH – Home help usually fortnightly
MOW – Meals on wheals
PCA – Personal care assistance
CAPS – Community Aged Care Package
EACH – Extended Aged Care at Home Package
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A common cause of admission into hospital
Older people who fall are more likely to fall
again
Be more detailed than just saying a
“mechanical fall” – this phrase has little
meaning.
◦ Eg. tripped, slipped, lost balance
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Think of the cause of the fall
◦ Intrinsic vs Extrinsic causes
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Impaired balance, reduced mobility, muscle
weakness and lack of exercise
Cognitive impairment
Continence
Feet and footwear
Syncope and dizziness
Medications
Vision
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Hospitals are foreign places!
Common places where falls occur in hospital
◦ Near the bed – getting out of bed
◦ In the bathroom
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Try to prevent falls where possible
If your patient has fallen or is at high risk –
you can
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Ask for a high-low bed
Chair alarms
1:1 nursing for agitated patients
Do a thorough medical review to look for a cause
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Need to document the fall in the history
Circumstances surrounding the fall
Mechanism of fall – eg. slipped in the
bathroom.
Any injuries sustained –minor, major
◦ Document any bruising, sites of pain so this can be
followed up.
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If there is pain – low threshold for ordering
x-rays
◦ Osteoporosis is common in the elderly
◦ Minimal trauma fractures can occur
◦ CT Brain – if head strike particularly if on warfarin
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Work with nursing and allied health staff on a
plan to prevent further falls
Engage the team, be a leader!
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Dr Holbeach will tell you more….
Delirium is common
Often distressing to family members
Recognition is important
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Be aware of aged care issues
You can help the older patient in hospital by
being proactive, speak to families early and
engage the allied health team
Aged care is rewarding, as small things can
make a big difference!!