Dementia in the acute
care setting
The CLAHRC CP & DeNDRoN meeting Sept 2011
Dr Claire G Nicholl
Consultant geriatrician, Addenbrookes
Declaration of interests
• Honoraria for lectures (Shire and Novartis)
• Sponsorship to attend the International
Psychogeriatric Association 2007 meeting
(Shire) and British Geriatrics Society meeting
2010.
What will be covered?
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In-patients (frail older people)
Delirium, usually on background of dementia
Organisation – Dementia Strategy Group
Results from the National Audit of Dementia
Specific projects: delirium unit, SHAPED, HIEC
funding
• Overlap areas: management of vulnerable
adults, pain management, falls prevention,
feeding issues
Acute care pathway
• Patient arrives in ED
RECOGNITION & ASSESSMENT
4 hours
• Destination ward
MULTIDISCIPLINARY
MANAGEMENT & CARE
• Leaves hospital
DISCHARGE PLANNING
Arrows show ideal patient flow in hospital
Acute care pathway
• Patient arrives in ED
RECOGNITION & ASSESSMENT
• Destination ward
MULTIDISCIPLINARY CARE
• Leave hospital
DISCHARGE PLANNING
Additional arrows show major information flows that need optimising
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Why is it hard to get basic information in dementia?
• Dementia / previous delirium not recognised or omitted
from admission information
• Lack of detail from patient
• Something plausible
• Lack of detail from carer – distant or care setting
• Problem not apparent
routine disrupted
acute presentation
• Whether the person with dementia presents depends on
the interaction brain
environment (maze)
National Audit of Dementia 2010
Core audit (206/238 sites)
• Hospital organisational
checklist (governance, care,
mental health needs, discharge policy,
information, recognition, training,
resources, liaison psychiatry)
• Retrospective case-note
audit (n=40)
61-98 years, mean 82 (83)
75% from care of the elderly (44%)
2.5% from general medicine (33%)
Median LoS 17 days (15)
ie a huge challenge ahead!
Acute care pathway
• Patient arrives in ED
• Destination ward
RECOGNITION & ASSESSMENT
MULTIDISCIPLINARY CARE
Delirium unit
• Leave hospital
DISCHARGE PLANNING
SHAPED pilot
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£
Recognition - cognitive tests
length
sensitivity
• AMT
• Mini Mental State Examination (MMSE)
• Way forward?
– Has Mrs Smith become more confused in the last year?
– Has Mrs Smith become more confused in the last few
days?
– Are you / do you think Mrs Smith is depressed?
• What are we testing?
• What does the result mean?
MMSE of 24/30
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Education
Dementia
Delirium
Depression
Deafness
Poor vision
English as a second language
Dysphasia
Limited cooperation
Addenbrooke’s initiatives
Delirium unit
• thanks to Duncan Forsyth and his team
• Images showing use of colour to identify bays, clear signage using pictures and
words visible from the bedside, red toilet seats, ‘café seating area, appropriate
paintings etc
– (see information from University of Stirling about design for dementia)
• Role of education for staff and carers
• Role of activities
SHAPED
• see afternoon session (Gareth Peters and Clare Wai)
• Supported home assessment for people with dementia
• Scheme to allow elderly patients with dementia and delirium in hospital for whom
discharge is considered ‘risky’ the opportunity to return home with live-in care for
a 2 week period to see if their confusion decreases on discharge to a familiar
environment.
HIEC funding for improved education about dementia for all grades of hospital staff
Is the dementia the main problem?
diseases
ageing physiology
fitness
social factors
Management
What gets overlooked in dementia?
Huge individual variation, stage and support
• General health: eyes, ears, feet
• Mood
• Other drugs
• The need to check – examine / tests
• The carer
• The plot
Feeding issues
• All frail older people in hospital need support to maintain
hydration and nutrition (appropriate food, well cooked and
served, in reach, appropriate utensils, help to eat and drink,
encouragement to continue etc)
– skill, time and resources
• People with dementia who are nearing the end of their life
stop eating and drinking enough to meet their needs
– education for carers, staff at all levels, evidence base,
emotional support, feeding issues MDT. Tube feeding is
rarely appropriate, nor is ‘nil-by-mouth’; comfort feeding
is usually the aim. Mitchell SL. N Engl J Med 2009;361:1529-38.
Sampson EL. Cochrane Database Syst Rev 2009;2:CD007209.