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 Julia Poole CNC Aged Care RNSH 2 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 Julia Poole CNC Aged Care RNSH 3 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. Julia Poole CNC Aged Care RNSH 4 Disorders that cause dementia • • • • • • • Alzheimer’s Disease Vascular Dementia Diffuse Lewy Body Disease Fronto-temporal disorder Huntington’s Disease Creutzfelt-Jacob Disease Etc Julia Poole CNC Aged Care RNSH 5 What is Delirium? • often known as Acute Confusion • Acute confusional states occur in 3050% of hospitalised geriatric patients: patients with dementia are particularly vulnerable (Isselbacher et al.1998) Julia Poole CNC Aged Care RNSH 6 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) Julia Poole CNC Aged Care RNSH 7 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. Julia Poole CNC Aged Care RNSH 8 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 Julia Poole CNC Aged Care RNSH 9 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 Julia Poole CNC Aged Care RNSH 10 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 Julia Poole CNC Aged Care RNSH 11 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. Julia Poole CNC Aged Care RNSH 12 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. Julia Poole CNC Aged Care RNSH 13 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. Julia Poole CNC Aged Care RNSH 14 CONFUSION ASSESSMENT METHOD (CAM) Royal North Shore and Ryde Health Service Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present 1. Acute and fluctuating course Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behaviour fluctuate during the day, that is, come and go, or increase and decrease in severity? No Yes Uncertain (please specify) ………………. ……………………………………………… 2. Inattention. Did the patient have difficulty focussing attention during the interview, e.g. being easily distractible, or having difficulty keeping track of what was being said? No Yes Uncertain (please specify) ………………. ……………………………………………… Delirium symptoms present Delirium symptoms NOT present N/A 3. Disorganised thinking Was the patient’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from one subject to another? No Yes Uncertain (please specify) …………….. ……………………………………………… 4. Altered level of consciousness Overall, how would you rate this patient’s level of consciousness? Alert (normal) Altered Vigilant (hyperalert, easily startled, overly sensitive to stimuli) Lethargic (drowsy but easily aroused) Stupor (difficult to arouse) Coma (unrousable) Uncertain DATE: …………………………………… Signature of assessor & designation:……………………………………………………………… Medical Officer's signature ……………………………………………………………………….. Julia Poole CNC Aged Care RNSH 15 Inouye, S.K. van Dyck, C.H. Alessi, C.A. Balkin, S. Siegal, A.P. Horwitz, R.I. (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. 113(12):941-948. 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) Julia Poole CNC Aged Care RNSH 16 Julia Poole CNC Aged Care RNSH 17 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. Julia Poole CNC Aged Care RNSH 18 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 Julia Poole CNC Aged Care RNSH 19 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 Julia Poole CNC Aged Care RNSH 20 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 Julia Poole CNC Aged Care RNSH 21 Table 1. Trainer-the-trainer and focus group participants Train-the-trainer Focus Groups Number % Number % Directors of Nursing 8 7.7 3 8.3 Deputy Directors of Nursing 18 17.3 4 11.1 Directors of Care 3 2.9 - - Registered Nurses 45 43.3 16 Enrolled Nurses 2 1.9 - - Diversional Therapists 2 1.9 1 2.8 Personal Care Assistants (PCA) or Assistants in Nursing (AIN) 5 4.8 1 2.8 Others (e.g.Allied Health, Managers) 21 20.2 11 30.6 Total 104 100 36 100 Julia Poole CNC Aged Care RNSH 44.4 22 Table 3. Trainers Pre & Post Knowledge Test Results - Opinions of the three major causes of disturbed behaviour from the given list (%). n = 104 Pretest % Posttest % Difference % * Chisquare with 1 df P value 95% CI of difference Delirium, depression and dementia Delirium 19.2 91.3 71.1 73.01 <0.001 63.5 - 80.7 39.4 97.1 57.7 58.02 <0.001 43.6 - 71.8 Depression 78.8 100 21.2 20.05 <0.001 71.0 - 86.7 Dementia 90.4 98.1 7.7 4.08 0.043 1.3 - 14.1 Personality Disorders 17.3 0 17.3 84.01 <0.001 10.0 - 24.6 Anxiety Disorder 62.5 8.7 53.9 54.02 <0.001 44.3 - 63.4 Senility 10.6 0 10.6 9.09 <0.003 4.7 - 16.5 * McNemar’s Test Julia Poole CNC Aged Care RNSH 23 Table 2. Staff trained by the trainers. Number % Registered Nurses 63 33.2 Enrolled Nurses 6 3.2 Diversional Therapists 8 4.2 Personal Care Assistants (PCA) or Assistants in Nursing (AIN) 104 54.7 Others (e.g.kitchen or cleaning staff) 9 4.7 Total 190 100 Julia Poole CNC Aged Care RNSH 24 Table 5. Aged Care Facility Staff Pre & Post Knowledge Test Results Breakdown of the opinions of the three major causes of disturbed behaviour from the given list (%). n = 190 Pretest % Posttest % Difference % * Chisquare with 1 df P value 95% CI of difference Delirium, depression and dementia Delirium 12.6 59.5 46.8 72.37 <0 001 38.7 - 55.0 24.7 75.2 50.5 80.58 <0 001 46.3 - 58.8 Depression 78.4 89.5 11.1 10.81 <0.001 5.0 - 17.1 Dementia 91.6 91.1 0.5 0 - - Personality Disorders 25.8 16.3 9.5 6.02 0.014 2.5 - 16.5 Anxiety Disorder 64.7 23.2 41.6 62.72 <0.001 34.0 - 49.2 Senility 20.0. 8.4 11.6 12.25 <0.001 5.6 - 17.5 McNemar’s Test Julia Poole CNC Aged Care RNSH 25 Acute Care responses N = 99 mostly RNs What are the 3 most common causes of disturbed behaviour in older patients in ACUTE care Causes of disturbed behaviour Personality Disorder Anxiety Disorder Delirium Dementia Senility Depression 0 20 40 60 80 100 Numbers of answers Julia Poole CNC Aged Care RNSH 26 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’. Julia Poole CNC Aged Care RNSH 27 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. Julia Poole CNC Aged Care RNSH 28 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 Julia Poole CNC Aged Care RNSH 29 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 Julia Poole CNC Aged Care RNSH 30 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 Julia Poole CNC Aged Care RNSH 31 Solution to Mr & Mrs TW’s Problem • Consider safety - informed careful approach • Seek medical assessment as soon as possible Julia Poole CNC Aged Care RNSH 32 Julia Poole CNC Aged Care RNSH 33