Dementia and Delirium - the unrecognised connection

Dementia and Delirium - the unrecognised connection

Julia L. Poole CNC Aged Care

Royal North Shore Hospital

Sydney

2Julia Poole CNC Aged Care RNSH

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 DeliriumPredisposing

– 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 deliriumPoorly understood

– decreased cerebral oxidative metabolism causing altered neurotransmitter levels

&/or– stress-induced increased plasma cortisol levels causing

altered neurotransmitter activityMoran, 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.

Julia Poole CNC Aged Care RNSH 15

CONFUSION ASSESSMENT METHOD (CAM)Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present1. Acute and fluctuating courseIs there evidence of an acute change in mentalstatus from the patient's baseline? Did the(abnormal) behaviour fluctuate during the day,that is, come and go, or increase and decreasein severity? No Yes Uncertain (please specify) ……………….………………………………………………

3. Disorganised thinkingWas the patient’s thinking disorganised orincoherent, such as rambling or irrelevantconversation, unclear or illogical flow of ideas,or unpredictable switching from one subject toanother? No Yes Uncertain (please specify) ……………..………………………………………………

2. Inattention.Did the patient have difficulty focussing attentionduring the interview, e.g. being easilydistractible, or having difficulty keeping track ofwhat was being said? No Yes Uncertain (please specify) ………………. ………………………………………………

4. Altered level of consciousnessOverall, how would you rate this patient’s levelof consciousness? Alert (normal) Altered

Vigilant (hyperalert, easily startled,overly sensitive to stimuli)

Lethargic (drowsy but easily aroused) Stupor (difficult to arouse) Coma (unrousable) Uncertain

Delirium symptoms present

Delirium symptoms NOT present

N/A

DATE: ……………………………………Signature of assessor & designation:………………………………………………………………Medical Officer's signature ………………………………………………………………………..

Roy

al N

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Sho

re a

nd R

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Hea

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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 detectionof 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)



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


Table 1. Trainer-the-trainer and focus group participantsTrain-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 44.4

Enrolled Nurses 2 1.9 - -

Diversional Therapists 2 1.9 1 2.8

Personal Care Assistants (PCA) or Assistantsin 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


Table 3. Trainers Pre & Post Knowledge Test Results - Opinions of the threemajor causes of disturbed behaviour from the given list (%). n = 104

Pre-test%

Post-test%

Difference%

* Chi-squarewith 1 df

P value 95% CI ofdifference

Delirium, depression anddementia

19.2 91.3 71.1 73.01 <0.001 63.5 - 80.7

Delirium 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


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 Assistantsin Nursing (AIN)

104 54.7

Others (e.g.kitchen or cleaning staff) 9 4.7

Total 190 100


Table 5. Aged Care Facility Staff Pre & Post Knowledge Test Results -Breakdown of the opinions of the three major causes of disturbed behaviourfrom the given list (%). n = 190

Pre-test%

Post-test%

Difference%

* Chi-squarewith 1 df

P value 95% CI ofdifference

Delirium, depression anddementia

12.6 59.5 46.8 72.37 <0 001 38.7 - 55.0

Delirium 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


Acute Care responsesN = 99 mostly RNs

What are the 3 most common causes of disturbed behaviour in older patients in ACUTE care

0 20 40 60 80 100

Depression

Senility

Dementia

Delirium

Anxiety Disorder

Personality Disorder

Ca

use

s o

f d

istu

rbe

d

be

ha

vio

ur

Numbers of answers


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


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Dementia and Delirium - the unrecognised connection

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