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Dementia Delirium Julia Poole
 

Dementia Delirium Julia Poole

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    Dementia Delirium Julia Poole Dementia Delirium Julia Poole Presentation Transcript

    • Dementia and Delirium - the unrecognised connection Julia L. Poole CNC Aged Care Royal North Shore Hospital Sydney
    • 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
    • Case Example
      • The ACAT receives a very distressed call from Mrs TW -
        • - requesting a nursing 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
    • 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.
    • Disorders that cause dementia
      • Alzheimer’s Disease
      • Vascular Dementia
      • Diffuse Lewy Body Disease
      • Fronto-temporal disorder
      • Huntington’s Disease
      • Creutzfelt-Jacob Disease
      • Etc
    • 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)
    • 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)
    • 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.
    • 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
    • Delirium Clinical 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
    • Delirium Clinical 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
    • 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.
    • 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 .
    • 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 .
    •  
    • 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)
    •  
    • 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. Australian Journal of Advanced Nursing. 20(3):38-43.
    • 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
    • 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
    • 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
    •  
    •  
    •  
    •  
    • Acute Care responses N = 99 mostly RNs
    • 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’.
    • 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.
    • 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
    • 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
    • Case Example
      • The ACAT receives a very distressed call from Mrs TW -
        • - requesting a nursing 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
    • Solution to Mr & Mrs TW’s Problem
      • Consider safety - informed careful approach
      • Seek medical assessment as soon as possible
    •