Frailty, Alzheimer’s Disease, Delirium and Negative Health Outcomes

1. Frailty, Alzheimer’s Disease, Delirium and Negative Health Outcomes L. Jaime Fitten, MD Professor, Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA

2. Alzheimer’s, Frailty and Delirium • Frailty is part of normal advanced age and is distinct from diseases of aging • Frailty complicates Alzheimer’s disease (AD) • Delirium is frequent in AD and in frail persons worsening health outcomes and increasing dependence • Risk of delirium can be reduced

3. Frailty Max Func Perform Reserve N. Aging Functional Impairment Disability + Disease 20 30 40 50 60 70 80 Age in Years

4. Modes of Cognitive Decline Max Cog Perform NormalAging Functional Impairment AD FEO-AD 20 30 40 50 60 70 80 Age in Years

5. Cognitive Decline and Delirium in AD and Normal Aging Max Cog Perform Cognitive reserve ? NA Functional Impairment Negative Outcomes Delirium AD 20 30 40 50 60 70 80 Age in Years

6. Delirium • High prevalence in hospitalized elders (~30%) • Dementia increases risk 2 to 5 times • 50% of patients with delirium have dementia • Increases hospital stays by 20% • Increases hospital costs by $ 2500/pt. • Leads to increased negative outcomes: • Functional decline • More co-morbidities • Increase dependence • Institutionalization • Death

7. Dementia Severe Illness Depression Sensorial impairment Immobility Dehydration Chronic renal insuff. Anemia: Hct < 30% Previous CVA History of ethanol abuse History of falls Psychotropic drug use Poor nutrition Advanced age Male Predisposing Risk Factors for Delirium

8. Psychoactive meds Use of restraints Immobilization Dehydration Major surgery Major med illness Poor nutritional status Metabolic imbalances Indwelling catheters Infections Hypoxia/anemia Sensory stress Pain Sleep deprivation Precipitating Factors

9. Patient- Centered Prevention • Pre-Hospitalization Protocols • Identify predisposing factors • Frailty, Low MMSE, Male gender • Co-morbidities, e.g. anemia, hypoxia, infection • Dehydration • Malnutition • Deliriogenic medications • Chronic renal insufficiency • Sensorial impairment • Reduce modifiable factors before hospitalization

10. In-Hospital Protocols 1 • AVOID: • Deliriogenic medications e.g. anticholinergics, hypnotics • Restraints • Dehydration • Prolonged sleep deprivation, overstimulation • Prolonged bladder catheterization

11. In-Hospital Protocols 2 • Provide: • Daily orientation, interaction • Early mobilization • Appropriate sensorial stimulation • Judicious pain relief

12. In-Hospital Protocols 3 • Manage and / or Treat: • Psychoactive medications, e.g. antidepressants, anxiolytics • Nutritional status • Medical and neuro co-mobidities especially • Metabolic derangements • Infection, hypoxia and anemia Hct. > 30%

13. Treatment Team-Centered Prevention • Early geriatric, nutritional, and rehabilitation consultation for high risk patients • Delirium education and training for the team, education for patients’ families • Use of risk assessment protocols and use of prevention protocols for high risk patients

14. Summary • AD patient at high risk for in-hospital delirium • Delirium produces many negative health and cost outcomes • Prevention methods work before and after hospitalization • Team approach, education of staff and family for better outcomes • Develop systemic policies for delirium awareness, risk assessment and prevention