Delirium is a common and serious syndrome among hospitalized patients, with an incidence of 10-15% on admission and 5-40% developing delirium during hospitalization. It is characterized by acute onset and fluctuating features including inattention, disorganized thinking, and altered level of consciousness. Delirium is associated with poor outcomes including prolonged hospitalization, increased mortality rates up to 33% in hospital and 39% after discharge, and persistent symptoms in some patients for months or longer. Non-pharmacological management focuses on treating underlying causes, supportive care, and minimizing risk factors through proper nutrition, hydration, safety measures, and a calm environment with clear communication.
Core slides from my presentation about the new DSM diagnostic system. The full presentation has more zing but I removed some to streamline and to whet the appetite.
Core slides from my presentation about the new DSM diagnostic system. The full presentation has more zing but I removed some to streamline and to whet the appetite.
Excessive daytime sleepiness
The most common causes of excessive daytime sleepiness are sleep deprivation, obstructive sleep apnea, and sedating medications. Other potential causes of excessive daytime sleepiness include certain medical and psychiatric conditions and sleep disorders, such as narcolepsy.
Presentation delivered by Dr. Carol Manning at the live webinar hosted by AlzPossible at www.alzpossible.org on the 17th of March, 2014.
www.alzpossible.org
Excessive daytime sleepiness
The most common causes of excessive daytime sleepiness are sleep deprivation, obstructive sleep apnea, and sedating medications. Other potential causes of excessive daytime sleepiness include certain medical and psychiatric conditions and sleep disorders, such as narcolepsy.
Presentation delivered by Dr. Carol Manning at the live webinar hosted by AlzPossible at www.alzpossible.org on the 17th of March, 2014.
www.alzpossible.org
This presentation JoAnne Nowak and I gave for NHPCO last spring addresses the prevention, assessment and treatment of delirium - particularly in hospice and palliative care settings.
Emergency Department and Outpatient Senior Healthcare Consultant Coursenomadicnurse
The one day course provided by Piedmont Hospital of ED and outpatient nursing staff on Geriatric Patient care issues. Funded by the HRSA Comprehensive Geriatric Education Grant.
Main topics about acute confusional state, including the following:
Definition
Pathophysiology
Epidemiology
History
Description and presentation, with short video about the essential features of delirium and approach procedures
Causes, toxic,drug-induced, infectious, central nervous system insults, respiratory conditions, endocrine disorders, cardiac problems, environmental effects, pregnancy complications
Differential diagnosis: all organic and some non organic diseases of central nervous system, endocrine disorders, metabolic disturbances,
Assessment
Lab studies, CBC, blood glucose, PT, PTT, INR, liver function, thyroid function, electrolytes, ABG, toxins assays, urinalysis
Imaging studies: CT brain. MRI brain, plain abdominal film
Emergency management, supportive measures, rapid sequence intubation,
Headache in children -indexforpaediatrics.comdr-nagi
Headache is one of the commonest neurological symptoms in children and young people who are
referred to doctors. Headache refers to pain involving the orbits, forehead, scalp and temples but not
the face or neck. The primary headache includes chronic or recurrent headache and migraine. The
prevalence of chronic or recurrent headaches in children occur in 60-69% by the age of 7-9 years
and 75% by the age of 15 years. The prevalence of migraine in children is up to 28% of older
teenagers. The most serious cause of the secondary headache is brain tumor and the prevalence of
brain tumours in children is 3 per 100,000 per annum.
https://indexforpaediatrics.com
hii guys this is my ongoing presentation from my speciality class i hope u guys lije that please so i hope it is been useful for u in ur specialities by getting little help with that
Audit of Appropriateness for Brain Scan Use for Paediatric Headache at the Em...Lyndon Woytuck
The purpose is to evaluate practice variation at the emergency department in comparison with best practice for brain imaging in children presenting with headache. The results of the study might be used to inform a clinical prediction rule in order to better stratify risk according to the American College of Radiology Appropriateness Criteria.
I created a poster for presentation and am currently working on a paper for publication in a scholarly journal.
How to Think Straight- Cognitive Debiasing Pat CroskerrySMACC Conference
"How to think straight: Cognitive de-biasing by Pat Croskerry
The number of preventable deaths of hospitalized patients in the US each year is estimated at 40,000- 80,000. The figure for the ICU alone is estimated at 40,000 so the death rate must be in the higher end of the range. When settings outside the hospital are taken into account (ED, primary care), the overall number must be considerably higher.
While many factors contribute to diagnostic failure, a variety of sources suggest that physician’s thinking has a lot to do with it. Dual Process Theory describes how the brain makes decisions in one of two modes: through fast, unconscious, intuitive processes (System 1) or through slower, conscious, analytical processes (System 2). Mental short-cuts (heuristics) and biases are predominantly located in the intuitive mode where we spend most of our conscious time, and this is where the majority of decision failures occur. Thinking straight essentially means achieving a good balance between System 1 and System 2 decision making, and much of our cognitive effort needs to go into monitoring what our unconscious brains are doing in System 1. This is referred to by a variety of terms: metacognition, reflection, mindfulness, and others. They all involve cognitive de-coupling from System 1 and characterize the process of cognitive de-biasing. This is not easily accomplished in the ED or any environment where decision density is often high, throughput pressure exists, resources may be limited, and where decision makers may be fatigued and/or sleep deprived.
While medicine has acquired a variety of strategies over the years for de-biasing clinicians, added benefits can be obtained by developing specific mindware to tackle particular biases. Clinicians need to be aware of the operating characteristics of the dual process model of decision making, of the prevalence and nature of biases, and of how to apply and sustain de-biasing mindware in their decision making.
"
Alex J Mitchell Alcohol Detection by Clinician (Aug2012)Alex J Mitchell
Powerpoint slides on detection and identification of alcohol problems (alcohol use disorder) by clinicians.
See related paper:
http://bjp.rcpsych.org/content/201/2/93.abstract
Royalty free for personal use, but please cite with credit to AJMitchell (Leicester)
Here are the most anticipated time-trial (triathlon) bikes of 2012. Carbon fibre masterpieces designed to go fast in a straight line. Image resolution 1600x1000 approx.
Illustration of Mental Health Clustering Calculator ajmitchellAlex J Mitchell
Our team has created a clustering calculator for mental health diagnoses. This is a preview of how it works. The idea is to allow clinicians to work out the correct cluster from the problem list inputs. The calculator is in MS excel and follows the suggested algorithms precisely
Weight diabetes and metabolic problems in patients taking atypical antipsycho...Alex J Mitchell
Free slide show on weight gain, diabetes and metabolic problems in those taking atypical antipsychotic medication in schizophrenia, bipolar disorder and related conditions. Image credits retained by original authors. Please give correct acknolwedgements if you present any material from here.
Photos from Tour of Britain London Stage (Sept11) taken by me (alex mitchell). Photos mostly used a sports panning technique to capture movement with some fill-in flash. Available to download.
POCOG - The Future of Psycho-Oncology (Aug 2011)Alex J Mitchell
This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.
This is a combined one page one side screener consisting of the PHQ9 and GAD7. Both are in the public domain seperately, but here I have simply combined the two. The PHQ9 includes the standard question on function.
patient health questionnaire, generalized anxiety disorder
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
Rcpsych Workshop - Depression in medical settings (Mar11)Alex J Mitchell
Rcpsych liaison faculty workshop on; depression in medical settings: symptoms and screening. This is an update on the latest on screening for depression in medical settings.
COH Online- The future of screening for distress in cancer settings (February11)Alex J Mitchell
This is a presentation I did at the us city of hope comprehensive cancer center in february 2011. The topic was future of screening for distress (and depression) in cancer; including an overview of recent screening findings.
Top 100 Most Cited People in Psychiatry (Mental Health) (Jan 2011) [aka Top 1...Alex J Mitchell
This is an uptodate list of the top 100 most highly cited people in psychiatry (mental health). List includes neuroscientists and psychologists publishing in this field. Note that to qualify an author must be listed on a peer reviewed paper on web of science; not necessarily the lead author. Current as of 31-Jan-2011. Presentation also known as list of Top 100 Psychiatrists
Top 100 Papers & People in Psychiatry (Jan2011)Alex J Mitchell
Short slideshow of the top100 people and papers in psychiatry as of january 2011 based on Web of science. British emphasis, worlwide list in preparation.
Organizational chart of NHS staffing ratios 1999-2009Alex J Mitchell
This is an illustrative chart of NHS staffing, normalized per hospital consultant. In other words...for every 1 hospital consultant in the NHS there are X nurses; X managers X ambulance drivers etc.
Prepared by Alex J Mitchell (ajm80@le.ac.uk) from public data.
In his public lecture, Christian Timmerer provides insights into the fascinating history of video streaming, starting from its humble beginnings before YouTube to the groundbreaking technologies that now dominate platforms like Netflix and ORF ON. Timmerer also presents provocative contributions of his own that have significantly influenced the industry. He concludes by looking at future challenges and invites the audience to join in a discussion.
Observability Concepts EVERY Developer Should Know -- DeveloperWeek Europe.pdfPaige Cruz
Monitoring and observability aren’t traditionally found in software curriculums and many of us cobble this knowledge together from whatever vendor or ecosystem we were first introduced to and whatever is a part of your current company’s observability stack.
While the dev and ops silo continues to crumble….many organizations still relegate monitoring & observability as the purview of ops, infra and SRE teams. This is a mistake - achieving a highly observable system requires collaboration up and down the stack.
I, a former op, would like to extend an invitation to all application developers to join the observability party will share these foundational concepts to build on:
GridMate - End to end testing is a critical piece to ensure quality and avoid...ThomasParaiso2
End to end testing is a critical piece to ensure quality and avoid regressions. In this session, we share our journey building an E2E testing pipeline for GridMate components (LWC and Aura) using Cypress, JSForce, FakerJS…
Alt. GDG Cloud Southlake #33: Boule & Rebala: Effective AppSec in SDLC using ...James Anderson
Effective Application Security in Software Delivery lifecycle using Deployment Firewall and DBOM
The modern software delivery process (or the CI/CD process) includes many tools, distributed teams, open-source code, and cloud platforms. Constant focus on speed to release software to market, along with the traditional slow and manual security checks has caused gaps in continuous security as an important piece in the software supply chain. Today organizations feel more susceptible to external and internal cyber threats due to the vast attack surface in their applications supply chain and the lack of end-to-end governance and risk management.
The software team must secure its software delivery process to avoid vulnerability and security breaches. This needs to be achieved with existing tool chains and without extensive rework of the delivery processes. This talk will present strategies and techniques for providing visibility into the true risk of the existing vulnerabilities, preventing the introduction of security issues in the software, resolving vulnerabilities in production environments quickly, and capturing the deployment bill of materials (DBOM).
Speakers:
Bob Boule
Robert Boule is a technology enthusiast with PASSION for technology and making things work along with a knack for helping others understand how things work. He comes with around 20 years of solution engineering experience in application security, software continuous delivery, and SaaS platforms. He is known for his dynamic presentations in CI/CD and application security integrated in software delivery lifecycle.
Gopinath Rebala
Gopinath Rebala is the CTO of OpsMx, where he has overall responsibility for the machine learning and data processing architectures for Secure Software Delivery. Gopi also has a strong connection with our customers, leading design and architecture for strategic implementations. Gopi is a frequent speaker and well-known leader in continuous delivery and integrating security into software delivery.
A tale of scale & speed: How the US Navy is enabling software delivery from l...sonjaschweigert1
Rapid and secure feature delivery is a goal across every application team and every branch of the DoD. The Navy’s DevSecOps platform, Party Barge, has achieved:
- Reduction in onboarding time from 5 weeks to 1 day
- Improved developer experience and productivity through actionable findings and reduction of false positives
- Maintenance of superior security standards and inherent policy enforcement with Authorization to Operate (ATO)
Development teams can ship efficiently and ensure applications are cyber ready for Navy Authorizing Officials (AOs). In this webinar, Sigma Defense and Anchore will give attendees a look behind the scenes and demo secure pipeline automation and security artifacts that speed up application ATO and time to production.
We will cover:
- How to remove silos in DevSecOps
- How to build efficient development pipeline roles and component templates
- How to deliver security artifacts that matter for ATO’s (SBOMs, vulnerability reports, and policy evidence)
- How to streamline operations with automated policy checks on container images
Removing Uninteresting Bytes in Software FuzzingAftab Hussain
Imagine a world where software fuzzing, the process of mutating bytes in test seeds to uncover hidden and erroneous program behaviors, becomes faster and more effective. A lot depends on the initial seeds, which can significantly dictate the trajectory of a fuzzing campaign, particularly in terms of how long it takes to uncover interesting behaviour in your code. We introduce DIAR, a technique designed to speedup fuzzing campaigns by pinpointing and eliminating those uninteresting bytes in the seeds. Picture this: instead of wasting valuable resources on meaningless mutations in large, bloated seeds, DIAR removes the unnecessary bytes, streamlining the entire process.
In this work, we equipped AFL, a popular fuzzer, with DIAR and examined two critical Linux libraries -- Libxml's xmllint, a tool for parsing xml documents, and Binutil's readelf, an essential debugging and security analysis command-line tool used to display detailed information about ELF (Executable and Linkable Format). Our preliminary results show that AFL+DIAR does not only discover new paths more quickly but also achieves higher coverage overall. This work thus showcases how starting with lean and optimized seeds can lead to faster, more comprehensive fuzzing campaigns -- and DIAR helps you find such seeds.
- These are slides of the talk given at IEEE International Conference on Software Testing Verification and Validation Workshop, ICSTW 2022.
In the rapidly evolving landscape of technologies, XML continues to play a vital role in structuring, storing, and transporting data across diverse systems. The recent advancements in artificial intelligence (AI) present new methodologies for enhancing XML development workflows, introducing efficiency, automation, and intelligent capabilities. This presentation will outline the scope and perspective of utilizing AI in XML development. The potential benefits and the possible pitfalls will be highlighted, providing a balanced view of the subject.
We will explore the capabilities of AI in understanding XML markup languages and autonomously creating structured XML content. Additionally, we will examine the capacity of AI to enrich plain text with appropriate XML markup. Practical examples and methodological guidelines will be provided to elucidate how AI can be effectively prompted to interpret and generate accurate XML markup.
Further emphasis will be placed on the role of AI in developing XSLT, or schemas such as XSD and Schematron. We will address the techniques and strategies adopted to create prompts for generating code, explaining code, or refactoring the code, and the results achieved.
The discussion will extend to how AI can be used to transform XML content. In particular, the focus will be on the use of AI XPath extension functions in XSLT, Schematron, Schematron Quick Fixes, or for XML content refactoring.
The presentation aims to deliver a comprehensive overview of AI usage in XML development, providing attendees with the necessary knowledge to make informed decisions. Whether you’re at the early stages of adopting AI or considering integrating it in advanced XML development, this presentation will cover all levels of expertise.
By highlighting the potential advantages and challenges of integrating AI with XML development tools and languages, the presentation seeks to inspire thoughtful conversation around the future of XML development. We’ll not only delve into the technical aspects of AI-powered XML development but also discuss practical implications and possible future directions.
Sudheer Mechineni, Head of Application Frameworks, Standard Chartered Bank
Discover how Standard Chartered Bank harnessed the power of Neo4j to transform complex data access challenges into a dynamic, scalable graph database solution. This keynote will cover their journey from initial adoption to deploying a fully automated, enterprise-grade causal cluster, highlighting key strategies for modelling organisational changes and ensuring robust disaster recovery. Learn how these innovations have not only enhanced Standard Chartered Bank’s data infrastructure but also positioned them as pioneers in the banking sector’s adoption of graph technology.
Generative AI Deep Dive: Advancing from Proof of Concept to ProductionAggregage
Join Maher Hanafi, VP of Engineering at Betterworks, in this new session where he'll share a practical framework to transform Gen AI prototypes into impactful products! He'll delve into the complexities of data collection and management, model selection and optimization, and ensuring security, scalability, and responsible use.
GDG Cloud Southlake #33: Boule & Rebala: Effective AppSec in SDLC using Deplo...James Anderson
Effective Application Security in Software Delivery lifecycle using Deployment Firewall and DBOM
The modern software delivery process (or the CI/CD process) includes many tools, distributed teams, open-source code, and cloud platforms. Constant focus on speed to release software to market, along with the traditional slow and manual security checks has caused gaps in continuous security as an important piece in the software supply chain. Today organizations feel more susceptible to external and internal cyber threats due to the vast attack surface in their applications supply chain and the lack of end-to-end governance and risk management.
The software team must secure its software delivery process to avoid vulnerability and security breaches. This needs to be achieved with existing tool chains and without extensive rework of the delivery processes. This talk will present strategies and techniques for providing visibility into the true risk of the existing vulnerabilities, preventing the introduction of security issues in the software, resolving vulnerabilities in production environments quickly, and capturing the deployment bill of materials (DBOM).
Speakers:
Bob Boule
Robert Boule is a technology enthusiast with PASSION for technology and making things work along with a knack for helping others understand how things work. He comes with around 20 years of solution engineering experience in application security, software continuous delivery, and SaaS platforms. He is known for his dynamic presentations in CI/CD and application security integrated in software delivery lifecycle.
Gopinath Rebala
Gopinath Rebala is the CTO of OpsMx, where he has overall responsibility for the machine learning and data processing architectures for Secure Software Delivery. Gopi also has a strong connection with our customers, leading design and architecture for strategic implementations. Gopi is a frequent speaker and well-known leader in continuous delivery and integrating security into software delivery.
GraphRAG is All You need? LLM & Knowledge GraphGuy Korland
Guy Korland, CEO and Co-founder of FalkorDB, will review two articles on the integration of language models with knowledge graphs.
1. Unifying Large Language Models and Knowledge Graphs: A Roadmap.
https://arxiv.org/abs/2306.08302
2. Microsoft Research's GraphRAG paper and a review paper on various uses of knowledge graphs:
https://www.microsoft.com/en-us/research/blog/graphrag-unlocking-llm-discovery-on-narrative-private-data/
Essentials of Automations: The Art of Triggers and Actions in FMESafe Software
In this second installment of our Essentials of Automations webinar series, we’ll explore the landscape of triggers and actions, guiding you through the nuances of authoring and adapting workspaces for seamless automations. Gain an understanding of the full spectrum of triggers and actions available in FME, empowering you to enhance your workspaces for efficient automation.
We’ll kick things off by showcasing the most commonly used event-based triggers, introducing you to various automation workflows like manual triggers, schedules, directory watchers, and more. Plus, see how these elements play out in real scenarios.
Whether you’re tweaking your current setup or building from the ground up, this session will arm you with the tools and insights needed to transform your FME usage into a powerhouse of productivity. Join us to discover effective strategies that simplify complex processes, enhancing your productivity and transforming your data management practices with FME. Let’s turn complexity into clarity and make your workspaces work wonders!
Goodbye Windows 11: Make Way for Nitrux Linux 3.5.0!SOFTTECHHUB
As the digital landscape continually evolves, operating systems play a critical role in shaping user experiences and productivity. The launch of Nitrux Linux 3.5.0 marks a significant milestone, offering a robust alternative to traditional systems such as Windows 11. This article delves into the essence of Nitrux Linux 3.5.0, exploring its unique features, advantages, and how it stands as a compelling choice for both casual users and tech enthusiasts.
Climate Impact of Software Testing at Nordic Testing DaysKari Kakkonen
My slides at Nordic Testing Days 6.6.2024
Climate impact / sustainability of software testing discussed on the talk. ICT and testing must carry their part of global responsibility to help with the climat warming. We can minimize the carbon footprint but we can also have a carbon handprint, a positive impact on the climate. Quality characteristics can be added with sustainability, and then measured continuously. Test environments can be used less, and in smaller scale and on demand. Test techniques can be used in optimizing or minimizing number of tests. Test automation can be used to speed up testing.
4. Scope of the Problem
• 10-15% delirious on admission (Inouye 1997, Lipowski 1987)
• 5-40% incident delirium in hospital (Francis 1992)
• Settings
– 11-43% post-operatively (Bryson 2006)
– 70-87% in the ICU (Pisani 2006)
– > 70% in terminal CA (Massie 1987)
5. Delirium: Outcomes - Duration
• More persistent than previously realised
• Up to one week in 60%
• two weeks in 20%
• four weeks in 15%
• more than four weeks in 5%
• Delirium still present at 6 months
– O'Keeffe S The prognostic significance of delirium in older hospital patients J of
the Am Geriatr Soc 1997;45(2):174-8
6. Delirium: Outcomes Mortality
• Delirium in hospital is associated with mortality rates
of 25 – 33%
• Most studies report higher mortality after discharge
eg 39% vs 23% at two years
– Francis J Prognosis after hospital discharge of older medical patients with
delirium. J Am Geriatr Soc 1992;40(6):601-6
• Hazard ratio of 2.11 at 1 year adjusted for
comorbidity, dementia and severity of illness
– McCusker et al Delirium predicts 12 month mortality. Arch Intern Med.
2002;162:457-463
13. A Case That Breaks the Rules
• Ms EM, a 27 y/o with Hodgkins, two months post-natal
• EM experienced disturbed sleep-wake cycle, disorientation, distractibility,
and a sub-acute onset of confusion over seven days. There was also mild
daytime somnolence but no changes in consciousness, no psychotic
symptoms or perceptual disturbance, and no convincing fluctuations. She
was not unduly agitated or over-aroused.
• She scored 6 out of 10 on the clock-drawing test (CDT), and 22/30 on the
mini-mental state examination (MMSE).
• On the Delirium Rating Scale she scored 11 out of a possible 32.
Functionally, she stopped working and driving, and required assistance
with everyday household tasks.
• At one year the symptoms had not changed.
14. QualifyingQualifyingNoCausative agent
EssentialQualifyingNoRapid onset and fluctuation of symptoms
Not requiredEssentialYesEmotional disturbance
Not requiredQualifyingYesImpairment of abstract thinking or comprehension
QualifyingQualifyingYesMemory impairment
QualifyingQualifyingYesDisorientation
Not requiredQualifyingNoIncreased or decreased motor activity
Not requiredQualifyingYesDisturbance of sleep-wake cycle
QualifyingNot requiredYesDisorganized thinking/incoherent speech
QualifyingQualifyingNoPerceptual disturbances
EssentialEssentialYesImpairment of attention
QualifyingEssentialNoClouding/disturbance of consciousness
DSM-IVICD-10This CaseCriteria
15. Laurila (2003) 425 patients hospital & nursing home
ICD 10
DSM IV
81 18
25
16. Prodromal Symptoms
• Prospective & descriptive observational study
• 6 hours before meeting DSM IV criteria
• Behavioural symptoms noticed
• Urgent calls for attention
• Anxiety
• Disorientation
• Decreased psychomotor activity
Other literature
– Altered sleep pattern
– Fatigue
Sorensen & Wickbald (2004), J of Clin Nursing, 13
21. Delirium: Detection
• Delirium often missed
• 32 – 67% of delirious patients are not diagnosed
• Cognitive assessment should be standard
– MMSE or AMTS
• Serial testing to monitor progress and to detect
delirium arising during an admission
• Mental status = a “vital sign”
22. Educational intervention => recognition
Rockwood et al (1994)
• Simple educational intervention at monthly
grand ward
• Diagnosed 3% pre intervention (187 pts)
• Diagnosed 9% post intervention (247 pts)
• Frequent comments on various aspects of
mental state (15.6% Vs. 8.5%)
Rockwood et al (1994) J of Am Ger Soc, 42
23. Delirium: Differential Diagnosis
Meagher, D J Delirium BMJ 2001; 322: 144 -149
Delirium Dementia Depression
Onset Acute Insidious Variable
Course Fluctuating Steadily progressive Diurnal variation
Consciousness and
orientation
Clouded;
disoriented
Clear until late
stages
Generally
unimpaired
Attention and
memory
Poor short term
memory; inattention
Poor short term
memory without
marked inattention
Poor attention but
memory intact
Psychosis present? Common (psychotic
ideas fleeting,
simple content)
Less common Occurs in small
number (psychotic
symptoms complex
and mood
congruent)
EEG Abnormal in 80-
90%; generalised
diffuse slowing in
80%
Abnormal in 80-
90%; generalised
diffuse slowing in
80%
Generally normal
29. The Clock Drawing Test
12
6
39
10
11 1
2
4
57
8
•Used extensively in assessment of cognitive
function, especially as a screen for dementia
•Administration is quick, easy and non-threatening
•Several studies assessing its validity as a screen
for delirium with conflicting results
•Multiple scoring methods, >12 reported in the
literature
J Geriatr Psychiatry Neurol 2005;18:129-133
Int J Geriatr Psychiatry 2000;15:548-561
Draw a clock face. Set the time at 10 past 11.
30. The Clock Drawing Interpretation Scale
1. There is an attempt to indicate a time in any way.
2. All marks or items can be classified as either part of a closure figure, a hand, or a symbol for clock
numbers.
3. There is a totally closed figure without gaps (closure figure).
4. A “2” is present and is pointed out in some way for the time.
5. Most symbols are distributed as a circle without major gaps.
6. Three or more clock quadrants have one or more appropriate numbers:12-3, 3-6 etc.
7. Most symbols are ordered in a clockwise or rightward direction.
8. All symbols are totally within a closure figure.
9. An “11” is present and is pointed out in some way for time.
10. All numbers 1-12 are indicated.
11. There are no repeated or duplicated number symbols.
12. There are no substitutions for Arabic or Roman numerals.
13. The numbers do not go beyond the number 12.
14. All symbols lie about equally adjacent to a closure figure edge.
15. Seven or more of the same symbol type are ordered sequentially.
16. All hands radiate from the direction of a closure figure center.
17. One hand is visibly longer than another hand.
18. There are exactly two distinct and separable hands.
19. All hands are totally within a closure figure.
20. There is an attempt to indicate a time with one or more hands.
(Score “1” per Item)
Score Only if Symbols for Clock Numbers are Present:
Score Only if One or More Hands are Present:
J Am Geriatr Soc 1992;40:1095-1099
36. Haloperidol
• Rosen H, (1979) Haloperidol Vs Thioridazine
• Tsuang M, (1971) Haloperidol Vs Thioridazine
• Thomas et al (1992) Haloperidol Vs Droperidol
• Brietbart et al (1996) Haloperidol, CPZ & Lorazepam
37. Delirium: Non Pharmacological Mx
• Correct sensory deficits (glasses and hearing aids)
• Communication, simple instructions, avoid jargo
• Re orientation (calendars, clocks, schedules)
• A quiet, stable environment (Minimise room and
staff changes)
38. Delirium: Non Pharmacological Tips
• Avoid sleep disruption
• Encourage mobility and self care
• Avoid restraints and bed rails
• Involve family where possible
• Meaningful personal items
• A view to the outside
41. Non Pharmacological Mx: Does it work?
• Cole et al found 227 with incident or prevalent
delirium amongst 1925 patients in 5 general medical
units
• Randomised to usual care or geriatrician and nurse
consultation & follow up
• No significant differences in LOS, time to
improvement, discharge, mortality!!
• Cole MG et al. Systematic detection and multidisciplinary care of delirium in older
medical inpatients: a randomized trial. CMAJ. 2002; 167(7):753-9.
42. Delirium: Prevention
• Prospective study involving 852 patients with 426
matched pairs compared usual care of elderly
general medical patients with those receiving
interventions
– Incidence of delirium lower in intervention vs usual
care group (9.9% vs 15%)
– Total days of delirium (105 vs 160)
– Number of episodes of delirium (62 vs 90)
– No difference in severity of delirium or recurrence
rates
– Major effect of interventions was to prevent the
primary episode of delirium
Inouye et al N Engl Med 1999;340:669-76
43. Delirium: Prevention
Hip Fracture
• Marcantonio et al. Pre-op and daily post-op geriatric
review 126 elderly patients (RCT)
• Oxygen, fluid/electrolytes
• pain, medication review/reduction
• bowel and bladder function
• nutrition, early mobilisation and rehabilitation
• prevent/detect/treat post op complications
• environmental stimuli
• treat delirium
44. • 126 patients > 65 y/o for hip fracture repair
• Pre-op and daily post-op geriatric review or
usual care
– Delirium: 32% vs 50% (NNT = 6) RR 0.6
– Severe delirium: 12% vs 29% (NNT = 6) RR0.4
– Those without dementia benefited most
– Marcantonio et al. Reducing Delirium after Hip Fracture J Am Geriatr
Soc 2001;49: 516-22
Delirium: Prevention Hip Fracture
46. Mental Capacity Act (2005)
• Premise: everyone can make their own decisions.
• Give the person all the support they can to help them
make decisions.
• No-one should be stopped from making a decision
just because someone else thinks it is wrong or bad.
• Anytime someone does something or decides for
someone who lacks capacity, it must be in the
person’s best interests
• When they do something or decide something for
another person, they must try to limit your own
freedom and rights as little as possible.
47. Advance (directives) Decisions
• An advance decision is when someone who has mental
capacity decides that they do not want a particular type of
treatment if they lack capacity in the future.
• A doctor must respect this decision.
• If the advance decision says no to treatment which may help
keep you alive, it must say this clearly and be signed by you.
Another person can sign an advance decision for you but
only if you agree and you can see them sign it.
• You are free to make an advance decision if you want to, but
no one should force you to make it.