Transcript Dementia - MEDICAL EDUCATION at University Hospitals Coventry

Dementia Care at UHCW
Dr Ray
Rose O’Malley
Liz Kiernan
Changing times
•
•
•
•
•
Increase in life expectancy.
Change in the age balance in society.
People living longer with frailty.
People living longer with dementia.
Increased number of people with dementia
coming into hospital.
University Hospital Coventry and
Warwickshire.
•
•
•
•
Large new PFI build.
1200 beds.
75% of patients over 75.
25% of patients who have a have
diagnosis or an undiagnosed dementia.
A real commitment to enhancing
the environment.
•
•
•
•
Forget-me-not lounge.
Forget-me-not shrub.
Memory Lane.
Activity organisers
Forget-Me-Not Lounge and
Memory Lane
Forget-Me-Not Lounge and
Memory Lane
Dementia Screening
•
•
•
•
•
Used VTE model
Computer based tool
Memory question
6 item test
Some temporary exclusions and one permanent
dementia diagnosis
Benefits of the screening.
• Diagnosis of dementia becomes known.
• Data base of patients with dementia and
one of patients with delirium.
• Previous assessment available on
computer with clinical results.
• Increased awareness.
Forget-me-not Care Bundle
• Knowing key personalised information about the patient
within 24 hours of admission
• Personalised regular communication
• Adequate nutrition and hydration geared to patient
preferences and capability
• A safe and orientating environment
Getting to know me form.
This form stays with the person while they are in hospital. It has been designed to
help staff understand your loved one and consequently help staff care for your
loved one while they are in hospital.
What do you like to be know as?________________________________________
What type of things make me happy?__________________________
What helps me to walk?_______________________________________
What helps me to eat and drink?________________________________
Important events in my life _____________________________________
People and pets closest to me (start with those closest and describe relationship).
People _____________________________________________________
Pets _______________________________________________________
What helps me manage through the day?_________________________
What helps me manage during the night?_________________________
What helps you to feel calm?__________________________________
What activities do you enjoy?
__________________
Patient admitted with
confusion
Is it a new
or increased confusion?
YES
Treat for acute
cause of delirium/
Use care plan and
screening tool
NO
Seek information from
Family/GP/Caludon/Carers/
Fill in getting to know me form
Start discharge
planning
YES
Has patient got
diagnosis of
dementia?
Use Care plan
Read old notes/
Treat cause of
admission/
Start discharge planning
NO
Involve family/
Treat cause of
admission/
Start discharge planning
Assess patient for discharge
Is patient safe for
discharge?
If Delirium
GP to monitor
for recurrent
cause
If Known Dementia
YES
GP &
Keyworker to
review/monitor
Possible New
Ask GP to refer
to memory
clinic
Involve Social worker/
CHAAT/AMHAT
Seek advice from
Dementia/Older
People Lead
NO
Confusion? Agitation? Withdrawal?
Falls?
Think DELIRIUM!
DIAGNOSE DELIRIUM BY CAM (CONFUSION ASSESSMENT
METHOD)
1. Acute onset and fluctuating course obtain collateral history
2. Inattention easily distracted or difficulty keeping track of what is being said
3. Disorganised thinking rambling or irrelevant unclear speech
4. Altered level of consciousness agitated, hyperalert, lethargic, drowsy, stuporose
POSITIVE CAM REQUIRES 1 AND 2 PLUS EITHER 3. OR 4
SEARCH FOR PRECIPITANTS AND TREAT URGENTLY
Drugs (prescribed or illicit, alcohol withdrawal) and Dehydration
Electrolyte disturbance (e.g. hyponatraemia, hypercalcaemia)
Level of pain
Infection (sepsis) or Inflammation (e.g. post-trauma or surgery)
Respiratory failure (hypoxia, hypercapnia)
Impaction of faeces (constipation)
Urinary retention
Metabolic (hepatic/renal failure, hypoglycaemia, hypo/hyperthyroidism)
or MI
HIGH RISK PATIENTS
•
•
•
•
•
•
•
•
Age >65
Severe illness e.g. sepsis
Pre-existing dementia
Current hip fracture
Multiple comorbidities
Physical frailty
Polypharmacy
Alcohol or drug abuse
DON’T FORGET TO
DOCUMENT
DIAGNOSIS OF
DELIRIUM IN
MEDICAL NOTES
AND ON DISCHARGE
LETTER
Management of
Delirium
DO
All MDT Staff
• Orientate frequently using verbal
and visible clues e.g. clocks, signs
• Provide repeated reassurance
and explanations using short
sentences
• Use calming speech/manner
• Encourage visits from
family/friends
• Use familiar staff when possible
• Ensure glasses/hearing aids are
worn/working
• Follow falls prevention guidance
• Consider single room or small
bay close to nurses station
• Eliminate unnecessary noise e.g.
pump alarms
• Ensure appropriate lighting levels
• Ensure adequate hydration/diet
• Establish regular sleep pattern
• Encourage early mobilisation
DON’T
Medical and Nursing Staff
• Screen for and treat infection
and other precipitants urgently
• Review all prescribed
medications
• Ensure regular adequate pain
relief
• Monitor for and treat
constipation
• Correct hypoxia and hypotension
• Explain diagnosis to family
• Avoid sedation where possible
• Delay treatment – delirium has a
•
•
•
•
•
high mortality!
Argue with or confront patient
Frequently move bed or wards
Catheterise unnecessarily
Perform unnecessary procedures
e.g. CT, bloods
Routinely use sedative drugs or
physical restraint
PHARMACOTHERAPY may be considered if other measures fail, to reduce
risk to patient/others or permit essential
investigations/procedures/treatment
Use PO rather than IM/IV if possible, start at low doses and gradually titrate
HALOPERIDOL 0.5-1mg PO every 1-2h PRN or 0.5-1mg IM every 2h PRN
(maximum daily dose 5-10mg in the elderly, up to 30mg in young patients)
OLANZAPINE 2.5-5mg PO every 2h PRN (maximum daily dose 10-20mg)
If antipsychotics are contraindicated (QTc>470ms, Parkinsonism, Lewy body
dementia) use LORAZEPAM 0.5-1mg PO every 1-2h PRN or 0.5-1mg IM
What doctors can do to help people
with Dementia.
•
•
•
•
Have a positive attitude.
Talk to family- they are the experts.
Understand dementia and delirium.
See Challenging behaviour as an
expression of need.
• Promote the Forget-me-not Care Bundle
rather than drugs.
• Use drugs with real caution, small and
slow!
Getting support
• If new cognitive problem but safe to
discharge ask GP to follow up.
• AMHAT- Adult Mental Health Assessment
Team- for mental illness 18 years plus.
• Frail Older Peoples Team- problems
related to people with frailty very much
including delirium and dementia.
Questions please.