Dementia & Delirium

1. Dementia & Delirium Dr Zoe Barron GP Yarm Medical Practice

2. https://www.dementiafriends.org.uk/DF_WEBC_PartnerVideos?page=videos-for-organisationshttps://www.dementiafriends.org.uk/DF_WEBC_PartnerVideos?page=videos-for-organisations

3. Overview of the session • Dementia • facts & stuff • practical bits • Delirium • facts & stuff • practical bits • gain a qualification • end with a song….. • ANYTHING ELSE?

4. What is dementia? ‘Dementia describes a clinical syndrome that encompasses difficulties in memory, language cognitive processing and behaviour that leads to impairment in activities of daily living’ (BMJ2015;350;h029)

5. The bookcase Analogy….. https://www.youtube.com/watch?v=kkvyGrOEIfA

6. Decline in memory Problems Decline in other cognitive functions affecting ADL Challenging behaviour

7. Incidence • 5% people over 65 are affected • 20% of people over 80 • Prevalence expected to double by 2040 • Estimated 50% undiagnosed • Contributes 1 in 4 hospital admissions • Health and social cost more than stroke, heart disease and cancer combined • In 2013 • healthcare cost of dementia £4.3 billion • Social care cost £10.3 billion

8. Risk factors • Alcohol • Smoking (AD) • Obesity • Hypertension • Head injury • Educational stimulation • Modifiable risk • Non-modifiable risk • Age • Learning disability • Sex

9. Alzheimer’s Disease (60%) Vascular Dementia Dementia with Lewy bodies Parkinson’s Disease Dementia Mixed (AD + Vascular) Frontotemporal dementia Types of dementia

10. Diagnosis of Dementia • National Dementia Strategy encourages early diagnosis • Dementia does not fulfil criteria for population screening • Case finding in high-risk groups, which are... • >60 with CVD, DM, COPD, obesity, alcohol, smoking • >40 with Down’s syndrome • >50 with learning disability • Patients with neurodegenerative diseases • Any patient who presents with memory loss

11. NICE guidance NG97 • Published June 18 • Dementia; assessment, management and support for people living with dementia and their carers • https://www.nice.org.uk/guidance/ng97

12. Diagnosis • Primary Care -History (Carer assessment) -Examination (Cognitive Assessment) -Blood screen ?which • Referral to Old Age Psychiatry -Neuropsychological testing -Imaging (MRI, CT) -Sub-type differentiation

13. Assessment Tools • MMSE (Gold Standard, 8mins) • GP-COG (for GPs, 4mins) www.patient.co.uk (e-copy/printable)

14. GP-COG • Name and address: for subsequent recall test • Time/Orientation: what is the date? • Clock Drawing – mark in numbers; mark hands to show 11:10 • Information: Can you tell me something that has happened in the news recently? • Recall: What was the name and address I asked you to remember?

15. Benefits Disadvantages Early Diagnosis

16. Benefits: • Relief; • End to uncertainty; • Label for symptoms; • Better understanding; • Focus on positive; • Cognitive and coping skills training; • Drug treatments; • Psychosocial support; • Family support; • Autonomy; • Advanced planning and financial planning

17. Disadvantages: • Distress; • Depression; • Social isolation; • Lack of cure; • Stigma; • Wrong diagnosis; • Negative effect on function; • Invalid role

18. Diagnosis....Shared responsibility • Preparing the ground...before diagnosis -Ideas, concerns... What are you worried this might be? -Discuss possible diagnosis... Exploring the D word -Explain the assessment process… realistic expectations -Highlight complexity of diagnostic process

19. Post diagnostic support - Review understanding of diagnosis and provide written information - Information – Alzheimer’s Society - Practical support: cognitive training/rehabilitation - Psychological therapy: difficulty adjusting to diagnosis -Discuss medico-legal issues eg. Driving -Information regarding financial and legal advice

21. What about the carers? • Carers of People with Dementia: higher ‘burden’ Worsening mental and physical health Living bereavement • Educational resources/support for carers www.carersuk.org • NICE suggesting health checks for dementia carers • Flu jab • Carers register

22. Behavioural & psychological symps. In dementia (BPSD) Behavioural • restlessness • physical aggression • screaming, agitation • wandering • sexual disinhibition • shadowing • Psychological • anxiety • depressed mood • delusions • hallucinations

23. Contributory Factors Physical (infection, pain, constipation) Activity-related (washing, dressing) Iatrogenic (drug side-effects) Noise (loud environment) Exclude delirium - more of this later….

24. Teepa Snow……. • https://www.youtube.com/watch?v=u5QMeQpkPhA

25. Non-Pharmacological Treatment • Environment • Safe environment for wandering • Calm • Music therapy • Rummage boxes • Behaviour therapy • Reminiscence therapy

28. a positive approach • stop at 6ft • “Hi” • Handshake • go slowly • calm conversation • more info - Teepa Snow

29. EOLC in dementia • terminal illness • recognition is important • unable to walk without help • doubly incontinent • no communication • decreased ability to do ADLs • 10% wgt loss over 6m • recurrent UTIs, pneumonia, pressure sores

30. stand up & have a shuffle….. DELIRIUM

31. What is delirium? • https://www.youtube.com/watch?v=BPfZgBmcQB8

32. Risk factors • old age • dementia • male • dehydration • sensory impairment • polypharmacy • smoking • alcohol • change in environment • general anaesthetic

33. causes • pain - don’t forget the mouth. • infection - look everywhere, ask carers • nutrition • constipation • hydration - can they get a drink? • medication - more regular than usual? • environment - familiar or not? • sensory impairment

34. How are you going to start investigating the cause? • what next? • who else?

35. Other bits… • Driving • Mental Capacity Act 2005 • Lasting Power of Attorney • Advanced Decisions to Refuse Treatment • Emergency Healthcare Plans

36. Driving • ? A danger to themselves and others. • Hx of frequent bumps/near misses/getting lost • Would a relative allow themselves or a grandchild to be driven by the patient? • Dementia diagnosis – legally has to inform DVLA • GP may have to inform if patient refuses to stop. • Driving assessment at mobility centre

37. MCA 2005 • Can a person take in the information, retain it for sufficient time, use it to help make a decision and then express that decision? • Not as simple as it sounds. • Capacity varies over time and is issue specific • People have the right to make unwise decisions - capacity assessment is about the process of decision making, not about the decision itself.

38. Lasting Power of Attorney • A legal arrangement to allow someone to appoint another person to make decisions on their behalf, in the event of them losing relevant capacity. • Health & Wellbeing, Finance & Property • Either one or both areas can be covered by the appointed person. • Form of advance planning.  • Once a patient loses capacity, it is too late.  • A lawyer isn’t needed to organise a LPoA, forms are available on the internet and Alzheimer’s Society has some useful information.

39. Advanced Decisions to Refuse Treatment • Under the Mental Capacity Act, any patient can write one. • As long as they retain capacity they can rescind the document at any point. • The patient can only dictate what medical care is NOT to be done in the event of them losing capacity e.g not to be resuscitated, ventilated or artificially fed.

40. Dementia Friends • Alzheimer’s Society’s Dementia Friends programme is the biggest ever initiative to change people’s perceptions of dementia. It aims to transform the way the nation thinks, acts and talks about the condition. • https://www.dementiafriends.org.uk/DF_WEBC_PartnerVideos?page=videos-for-organisations

41. Let’s end on something positive! • https://www.youtube.com/watch?v=qT22tFsPPUA

42. THANK YOU, ANY QUESTIONS?