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Delirium & Dementia in Hackney misc. observations

Delirium & Dementia in Hackney misc. observations. Dr Cianán O’Sullivan, Geriatrician (“Keen-on”, or “key- nawn ”, O’Sullivan). Dementia, Delirium. Dementia – neglected, overlooked, now hardly out of the news (e.g. Daily Mail, today) National Dementia Strategy

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Delirium & Dementia in Hackney misc. observations

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  1. Delirium & Dementia in Hackneymisc. observations Dr Cianán O’Sullivan, Geriatrician (“Keen-on”, or “key-nawn”, O’Sullivan)

  2. Dementia, Delirium • Dementia – neglected, overlooked, now hardly out of the news (e.g. Daily Mail, today) • National Dementia Strategy • Prime Minister’s Challenge on Dementia • Drive to increase diagnosis • Diagnosis • In ‘crisis’ vs early • Overdiagnosis? ‘pre-dementia’, mild cognitive impairment • When & Where to diagnose • “Screening” for Dementia in general, in GP, in acute care; CQUIN for dementia • Letters to GP, “Please (consider) referral to Memory Clinic” • “Dementia screening blood tests”. Hmm…..

  3. Dementia, Delirium • Brain Imaging • GP requested MRI, In-Health • ‘cerebrovascular disease’ • MRI very sensitive for subcortical, white matter changes • Normal ageing change vs ‘disease’ • Hypertension = 141/90 or 211/70 • Post-diagnosis • Education, support – family, living alone, alzheimerssoc, social services (20% cuts), • Anti-dementia drugs, (original 6month trials, donepezil cheap now) • Mental Capacity – what decision • Crisis, 999 = Homerton admission,length of stay

  4. Delirium • What is it? • Why is it important? • How common? • Underdiagnosed? • Preventable

  5. Case • HM, 87 yo woman, fall • Fractured forearm • Seems confused, • Speaks little English • Urea / creat 10 / 126, Hb 10, WBC 16, CRP 102 • CXR poor insp film

  6. Case • Day 2, Febrile, treated with antibiotics for chest infection • Agitation & drowsiness, sedation, analgesia • Collateral hx daughter • Day 2-21 Variable oral intake / drowsiness / poor mobility / dehydration / parenteral fluids • Day 22 -

  7. Delirium Delirium is a clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course It is a common but serious and complex clinical syndrome associated with poor outcomes Older people and people with dementia, severe illness or a current hip fracture are more at risk of delirium Delirium is preventable and treatable if dealt with urgently

  8. Addressing these clinical factors in a patient at risk of delirium can prevent delirium cognitive impairment and/or disorientation dehydration and/or constipation hypoxia infection immobility or limited mobility pain multiple drugs (CO’S: guidelines = ever more drugs) poor nutrition sensory impairment poor sleep patterns and sleep hygiene Clinical factors contributingto delirium (NICE slide)

  9. Diagnosis – CAM, (Confusion Assessment method) 1. Acute onset and fluctuating course 2. Inattention 3. Disorganised thinking 4. Altered level of consciousness The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.

  10. Acute onset and fluctuating course Inattention Is there evidence of an acute change in mental functioning from the patient’s usual? Does the (abnormal) behaviour vary in severity . NB Collateral Does the patient have difficulty focusing attention – for example, are they easily distracted, or do they have difficulty keeping track of what was being said CAM, 1 and 2

  11. 3. Disorganised thinking 4. Altered level of consciousness Is the patient’s thinking disorganised or incoherent,rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. Overall how would you rate this patient’s level of consciousness? Alert, vigilant/agitated, lethargic (drowsy, easily roused), stupor CAM, 3 or 4

  12. Year Age Address for recall DOB Time (nearest hour) Place Recognition of 2 people 20-1 backwards Monarch World War 2 (1) Abbreviated Mental Test (AMT)

  13. Tests of attention • 20- 1 backwards • Days of week backwards • Months of year backwards • Serial 7s - education • “World” backwards

  14. Onset - Hours, days Fluctuates over 24hrs Attention impaired Altered level of consciousness Physiological abnormality Reversible (not always) If in doubt treat as delirium Months, years Stable (decline) Attention preserved Normal level of consciousness Normal physiology Progressive Delirium vs Dementia

  15. Causes of delirium • Any acute medical condition, drug adverse effect or drug withdrawal • Common causes include… • Any medical a condition except don’t mention UTI!

  16. Typical patterns • Cortical and subcortical • AD short term memory first (ex Terry Pratchet) visuospatial, later language, praxis, agnosia • VaD, mental slowing, attention, executive/planning, gait / falls, or acute post stroke • DLB, visual halluc (not distressed), fluctuations, parkinsonism (25% absent) • FTD (younger), language, behaviour, executive function

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