Dementia: acute care – risks and issues

1. Dementia: acute care – risks and issues Primary Care Dementia Summit 24th November 2009

2. Case historyacute admission to hospital • 3am saturday morning • 87 year old female • brought to Emergency Department by ambulance • limited history • paramedic notes – found on floor at care home, not moving left side

3. Information available • lives in Uplands nursing home • ‘dementia’ • HTN • arthritis • ? previous stroke • usual level of functioning/mobility - unknown • medications - unknown

4. History and examination • ‘no information available from patient’ • chattering, pleasantly confused, ?dysphasic • attempted phone calls to NH for further history – no answer repeatedly On Examination • AMTS 3/10 • mildly dysphasic • left sided weakness • examination, obs - otherwise normal • catheterised in emergency department due to incontinence

5. Stroke (L hemiplegia) ? UTI (incontinent) MSU Trimethoprim Aspirin 300mg CT head NBM pending SALT assessment collateral history from NH establish regular medications get old notes transfer to stroke unit Diagnosis & Plan

6. On stroke unit (day 1) • CT Head – old infarct • Collateral history from daughter • left sided weakness is longstanding • collapsed getting off toilet • Uplands NH is a RH!! – usually mobile with ZF • normally incontinent of urine • unsure of usual meds • mother not her usual self: much more confused • SU PTWR plan - not a stroke! transfer to general elderly care ward speak to GP/RH re-usual meds & further background info

7. Moved to EC ward (day 2 & 3) • agitated++ (by ward moves), prescribed lorazepam • failed SALT assessment as ‘drowsy’ – continued NBM • NGT passed for medications/ feeding • BP low • Bloods – ↓Na 124, ↑ K 5.9 • started on fluid restriction for hyponatraemia by SHO • MSU – no infection • increasingly drowsy • renal function deteriorating • GP/RH not contacted – weekend, ‘busy’

8. Old Notes Arrive! (monday morning) Medications – • Aspirin 75mg od • Donepezil 5mg od • Simvastatin 40mg nocte • Prednisolone 5mg od • Calcichew D3 forte 1 bd • Alendronate 70mg /week • Tolterodine XL 4mg od • on Prednisolone for 20 years for Rheumatoid Arthritis! • given stat Hydrocortisone, Pred restarted • IV fluids

9. On EC ward (days 4 & 5) • drowsiness resolved • BP improved • renal function and electrolytes improved • reassessed by SALT and passed • NGT removed • catheter removed • Plan - ?discharge home after physiotherapy assessment

10. Day 6  35!! • R/v by physio – unable to wt bear, left leg painful++ • X-ray = fractured NOF!! • discharge cancelled • referred to Orthopaedics → transferred to Ortho ward • went to theatre • lots of post-op complications exacerbated by delirium • never regained prior level of physical or cognitive functioning • on discharge to new NH – fully dependent, hoisted

11. Significant delay to diagnosis of hip fracture Wrong diagnosis of stroke (old) Inappropriate catherisation for incontinence NBM and NGT – unnecessary Multiple unnecessary ward moves (4) Inappropriate sedative and other medications Undiagnosed pain Not given usual meds Hypotensive, low Na and renal failure (dehydration) due to steroid withdrawal and inappropriate fluid restriction Multiple iatrogenic illness due to misdiagnosis and inappropriate treatments - mainly as result of inadequate information, poor understanding & training Summary of issues

12. What are the risks for cognitively impaired patients admitted to hospital?

13. What are the risks for cognitively impaired patients admitted to hospital? • Inability to communicate symptoms • Information gathering difficult for staff – sometimes relies heavily on external source that may not be readily available, particularly ‘out of hours’ • Mismanagement due to lack of information, poor understanding, time and bed pressures, inadequate training • Environmental changes - multiple ward moves, patients and staff • Cluttered ward layouts, poor signage, other hazards • Inappropriate prescribing • Inadequate pain recognition and control • Procedures – e.g. catheter, NGT, blood tests, IV lines • Poor supervision on the ward

14. Leads to - • Delay to diagnosis •  incidence of - delirium falls and fractures iatrogenic illness malnutrition dehydration hospital acquired infections •  length of stay •  subsequent institutionalisation •  mortality

15. National Dementia Strategy Objective 8 – improved quality of care for people with dementia in general hospitals • 70% acute hospital beds occupied by older people • Up to 50% of these have cognitive impairment • Majority undiagnosed and not known to dementia services • Challenging environment • Worse outcomes – LOS, mortality, institutionalisation • Malnutrition and dehydration • Not appreciated by clinicians, managers, commissioners • Lack of leadership • Insufficient staff knowledge • Insufficient information gained from carers/families • Poor discharge planning

16. How do we go about improving services in general hospitals for those with cognitive impairment?

17. How do we go about improving services in general hospitals for those with cognitive impairment? • Better access to appropriate information i.e. communication! – acute trust, primary care, care homes, family - IT • Safer environment • Avoid unnecessary ward moves • Dementia link nurse – community and hospital • Mental health liaison team • Improve prescribing – sedative avoidance, pain recognition etc - pharmacist • Training – doctors, health professionals, medical school • Promoting awareness – families, professional bodies, experts, government, ‘champions’ • Policies/guidelines • Better discharge planning with MDT and family involvement • Audit & research • Financial support

18. National Dementia Strategy Objective 8 – improved quality of care for people with dementia in general hospitals To deliver improvement - • Identification of senior clinician to take the lead for quality improvement in dementia in the hospital • Development of an explicit pathway for the management and care of people with dementia in hospital • Commissioning of specialist liaison older people’s mental health teams to work in general hospitals

19. 60% people with dementia fall, ×2 that of cog normal peers 25% fallers with dementia fracture Poorer prognosis 70% 6 month mortality after #NOF Higher incidence of gait and balance disorders Medications: sedatives, neuroleptics, anti-depressants, – higher falls & syncope risk Higher incidence of autonomic dysfunction, CSH, OH Parkinsonism – drug SE’s, lewy-body, vascular More co-morbidities Incontinence Wandering Reduced ability to observe environmental hazards and show caution Poor compliance with mobility aids Decreased ability to communicate symptoms Diagnostic challenges Difficulties with obtaining investigations Inability to comply with falls advice, interventions or treatment Evidence suggesting no benefit of falls interventions in patients with dementia Falls and Dementia – the risks

20. Thank you