Dementia and Delirium - the unrecognised connection

1. Dementia and Delirium - the unrecognised connection Julia L. Poole CNC Aged Care Royal North Shore Hospital Sydney

2. 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 Julia Poole CNC Aged Care RNSH

3. Case Example The ACAT receives a very distressed call from Mrs TW - - requesting anursing 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 Julia Poole CNC Aged Care RNSH

4. 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. Julia Poole CNC Aged Care RNSH

5. Disorders that cause dementia • Alzheimer’s Disease • Vascular Dementia • Diffuse Lewy Body Disease • Fronto-temporal disorder • Huntington’s Disease • Creutzfelt-Jacob Disease • Etc Julia Poole CNC Aged Care RNSH

6. What is Delirium? • often known as Acute Confusion • Acute confusional states occur in 30-50% of hospitalised geriatric patients: patients with dementia are particularly vulnerable(Isselbacher et al.1998) Julia Poole CNC Aged Care RNSH

7. 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) Julia Poole CNC Aged Care RNSH

8. 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. Julia Poole CNC Aged Care RNSH

9. 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 Julia Poole CNC Aged Care RNSH

10. DeliriumClinical 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 Julia Poole CNC Aged Care RNSH

11. DeliriumClinical 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 Julia Poole CNC Aged Care RNSH

12. 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. Julia Poole CNC Aged Care RNSH

13. 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. Julia Poole CNC Aged Care RNSH

14. 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. Julia Poole CNC Aged Care RNSH

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16. 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) Julia Poole CNC Aged Care RNSH

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18. 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. AustralianJournal of Advanced Nursing. 20(3):38-43. Julia Poole CNC Aged Care RNSH

19. 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 Julia Poole CNC Aged Care RNSH

20. 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 Julia Poole CNC Aged Care RNSH

21. 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 Julia Poole CNC Aged Care RNSH

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26. Acute Care responsesN = 99 mostly RNs Julia Poole CNC Aged Care RNSH

27. 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’. Julia Poole CNC Aged Care RNSH

28. 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. Julia Poole CNC Aged Care RNSH

29. 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 Julia Poole CNC Aged Care RNSH

30. 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 Julia Poole CNC Aged Care RNSH

31. Case Example The ACAT receives a very distressed call from Mrs TW - - requesting anursing 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 Julia Poole CNC Aged Care RNSH

32. Solution to Mr & Mrs TW’s Problem • Consider safety - informed careful approach • Seek medical assessment as soon as possible Julia Poole CNC Aged Care RNSH

33. Julia Poole CNC Aged Care RNSH