Dementia and Delirium the unrecognised connection

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Dementia and Delirium - the unrecognised
connection

• Julia L. Poole CNC Aged Care
• Royal North Shore Hospital
• Sydney

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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

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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

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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.

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Disorders that cause dementia

• Alzheimers Disease
• Vascular Dementia
• Diffuse Lewy Body Disease
• Fronto-temporal disorder
• Huntingtons Disease
• Creutzfelt-Jacob Disease
• Etc

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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)

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What is Delirium ?(contd)

• 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)

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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.

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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

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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. Harrisons Principles of
  Internal Medicine

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Delirium Clinical Features (contd)

• Impaired perception
• misperceives surrounding attendants
• hallucinations
• Disturbance of emotion
• agitation, fear, depression, anxiety
• Psychomotor changes
• hyperactivity, restlessness, repetitive
  (plucking, tossing)
• Isselbacher et al.1998. Harrisons Principles of
  Internal Medicine

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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.
• August21-26.

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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.

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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. March39-43.

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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. (Mosbys Dictionary 1990)

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Poole, J.L. and McMahon, C. (2005) An Evaluation
of the Response to Pooles 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) Pooles algorithm Nursing
management of disturbed behaviour in older people
- the evidence. Australian Journal of Advanced
Nursing. 20(3)38-43.
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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

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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

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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

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Acute Care responsesN 99 mostly RNs
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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
• Im more inclined to look for reasons for the
  behaviourmore inclined to do something about
  it start to investigate all the clinical
  signs he had a UTI
• theres a haste to it ( to assess) lets
  start assessing the situation . understanding
  that its not just dementia.

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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 its not the person,
  its an illness or something thats causing the
  behaviour, not the actual resident being nasty to
  me
• more ordered, less panicky, more peaceful, more
  tolerant, more forgiving, less judgemental
  responses.

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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

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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

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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

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Solution to Mr Mrs TWs Problem

• Consider safety - informed careful approach
• Seek medical assessment as soon as possible

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