Mental Health and Cognitive Changes in the

Older Adult

Paul McNamara RGN (RAH), RPN (SAMHS), BN (Flin.), MMHN (USQ), Cert IMH (WCHN), CMHN, FACMHN

@meta4RN

#Ausmed

Today’s Presentation

Overview

Dementia

Delirium Screening Tools

MMSE Clockface CAM

Supporting

Today’s Presentation

Overview

Dementia

Delirium Screening Tools

MMSE Clockface CAM

Supporting

Why it matters

25% of patients visiting a health service have at least one mental, neurological or behavioural disorder

Cognitive problems more common amongst older persons

Older persons a significant proportion of hospital patients

> 65 ~ 13% population > 65 ~ 39% hospital patients> 65 ~ 48% hospital bed days

AIHW (2014) Australia's hospitals at a glance 2012-13

Why it matters

Cognition

cognōscere “to know”

the process of knowing

thinking, thoughts

capacity to understand / interpret information

Cognition

processing of information

memory + thoughts

store, retrieve and manipulate information

disruption to this process = cognitive disorder

Disorders of Cognition Sx

impaired awareness

reasoning

memory

judgment

perception

disorientation (time +/or place +/or person)

DSM IV (old speak)DeliriumDementiaAmnesiaCognitive Disorder NOS

DSM 5 (new speak)DeliriumUnspecified Neurocognitive Disorder Neurocognitive Disorders due to…

OPMHS

Cairns Townsville

Today’s Presentation

Overview

Dementia

Delirium Screening Tools

MMSE Clockface CAM

Supporting

Dementia

“a progressive illness that involves cognitive and non-cognitive abnormalities and disorders of

behaviour; presents as a gradual failure of brain function. It is not a normal part of life or aging.”

Elder, Evans & Nizette (2013) pp 525

Dementia

aka Neurocognitive Disorders due to…

Alzheimer’s Disease

Vascular Disease

Lewy Bodies

Prion Disease

HIV Infection

Traumatic Brain Injury

Multiple Aetiologies

Dementia

~ 1.9% > 65 years

~ 8.4% > 75 years

~ 22.4% > 85 yearsElder, Evans & Nizette (2013) pg 256

2009 ~ 1.1% Australian population

2050 ~ 3.2% Australian population

Today’s Presentation

Overview Dementia

Delirium Screening Tools

MMSE Clockface CAM

Supporting

Delirium“go off the furrow”

"off the track“

not a disease: a syndrome

a medical emergency: associated with increased morbidity and mortality rates

up to 56% of older people in hospitalInouye S, 1994. ‘The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of

delirium hospitalized elderly medical patients’ American Journal of Medicine 97(3):278–88.

Some Causes of Delirium

Hyperthyroidism Hypothyroidism HypercalcaemiaHyponatraemia

Urinary Tract InfectionPneumonia

Septicaemia Stroke

Subarachnoid Haemorrhage Unmanaged Pain (esp. old age)

Head Trauma Fractures (esp. Hip & Rib)

Hypoglycaemia

Vitamin B12 DeficiencyFolate Deficiency

Sedatives Antihistamines

Alcohol Benzodiazepines

OpiatesAnticholinergics

Urinary RetentionConstipation

Faecal ImpactionSevere Diarrhoea

Changes In Environment

Diagnosis

Under-diagnosis common: up to 50%

Contributing factors:Hypoactive deliriumOld ageMisdiagnosed as depression or dementia

Important because:Worse prognosisPrevents detection and management of other sxIncreases family’s distress

Communication between staff

Fluctuating nature may lead to tension between different staff groups:

Emphasise fluctuation as core symptom

Use of validated scales

Differences in pharmacological approachesTreat early but at low dose

Communication with the Family

Valuable source of baseline data

“Patrick seems to be having difficulty concentrating at times. How was he before he

came into hospital?”

Gagnon et al (2002):60% of 124 caregivers hadn’t realised possibility of delirium

All care-givers expressed distress

Compare & ContrastDementia Delirium

Onset Insidious Acute

Duration Months/years Hours/days/ ??weeks

Course Stable & progressive (unless vascular dementia – usually stepwise)

Fluctuates – worse at nightLucid periods

Orientation May be normal – usually impaired for time and place

Fluctuates, but will always be impaired in some aspect: Time, Place, Person?

Memory Impaired recent & sometimes remote memory

Recent impaired

Compare & ContrastDementia Delirium

Thoughts Slowed Reduced interests Perserverant Delusions are common

Often paranoid & grandiose ? bizarre ideas & topics ? paranoid

Perception ? normal Visual & auditory hallucinations common Delusions are common

Emotions Shallow, apathetic, labile, ? irritable, careless

Irritable Aggressive Fearful

Sleep Often disturbed. Nocturnal wandering common. Nocturnal confusion.

Nocturnal confusion and/or “sundowning” common.

Today’s Presentation

Overview Dementia Delirium Screening Tools

MMSE Clockface CAM

Supporting

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Instructions: • Before starting the questionnaire, try to get the consumer to sit facing you.•Ask the question a maximum of three times. If the consumer does not respond, score zero.•If the consumer answers incorrectly, score zero. Do not hint, prompt or ask the question again.

I am going to ask you some questions and give you some problems to solve. Please try to answer as best you can.

Orientation (allow 10 seconds for each response)Points

( = Pass)

1. a) What year is it? (accept exact answer only)

b) What season is it? (last week of old season or first week of new season acceptable)

c) What is today’s date? (accept previous or next day’s date)

d) What day of the week is it? (accept exact answer only)

e) What month of the year is it? (first day of new month or last day of previous month acceptable)

2. a) What state of Australia are we in? (accept exact answer only)

b) What city are we in? (accept exact answer only)

c) What suburb are we in? (accept exact answer only)

d) What floor of the building are we on or what ward are we on? (accept exact answer only)

e) What is the name of this place? (accept exact answer only)

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Orientation sub-total:

Registration3. I am going to name three objects. After I have said them, I want you to repeat them. Remember what they are because I

am going to ask you to name them in a few minutes.

Say them slowly at about 1 second intervals

APPLE TABLE PENNY

Please repeat the three items for me.

Score one point for each correct response on the first attempt. Allow 20 seconds for response; if consumer does not repeat all three, repeat until they do, or up to a maximum of five times. Maximum score three.

1 - Apple

1 - Table

1 - Penny

Registration sub-total:

Attention and Calculation4. Can you subtract 7 from 100, and then subtract 7 from the answer you get, and keep subtracting 7 until I tell you to stop?

OR

1 - 93

1 - 86

1 - 79

1 - 72

1 - 65

OR5. I am going to spell a word forwards and I want you to spell it backwards.

The word is WORLD – W – O – R – L – D. (You may help the person spell the word correctly). Now spell it backwards.

Repeat if necessary. Allow 30 seconds to spell it backwards. If the consumer cannot spell “world” with assistance, score 0. Score one for each letter in correct order. Maximum score five.

1 - D

1 - L

1 - R

1 - O

1 - W

Attention and Calculation sub-total:

Recall6. Now, what were the three objects I asked you to remember?

Score one point for each correct response, regardless of order. Allow 10 seconds for response. Maximum score of three.

1 - Apple

1 - Table

1 - Penny

Recall sub-total:

Page 1 of 2

(Affix identification label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Mental Health Services

Mini Mental State Examination (MMSE)

Facility: .........................................................................................................

Clinician’s name (please print): Designation: Signature: Team: Date: Time:

LanguagePoints

( = Pass)

7. Show the consumer a wrist watch. What is this called?

Allow 10 seconds for response. Accept ‘wrist watch’ or ‘watch’. Do not accept ‘clock’ or ‘time’. Score one point.1

8. Show the client a pencil. What is this called?

Allow 10 seconds for response. Accept ‘pencil’ only, not ‘pen’. Score one point.1

9. I would like you to repeat a phrase after me: “No ifs, ands or buts”

Allow 10 seconds for response, score one point for correct repetition. Answer must be exact.1

10. Read the words on this page and do what it says.

Close your eyesIf consumer reads and does not close eyes, you may repeat it to a maximum of three times. Allow 10 seconds, score only one

point only if consumer closes eyes.

11. Read the full statement below before handing respondent blank piece of paper. Do not repeat or coach.

I am going to hand you a piece of paper. When I do, take the piece of paper in your right hand, fold the paper in half with both hands and put the paper down on your lap.

Allow 30 seconds. Score one point for each instruction executed correctly.

Takes the paper in correct hand

Folds the paper in half Puts paper down on lap

1

1

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12. Hand consumer a piece of paper. and a pencil. Write any complete sentence on that piece of paper.

Allow 30 seconds. The sentence should have a subject and a verb, and make sense. Spelling and grammatical errors are okay.1

13. Refer to diagram shown below. Here’s a drawing. Please copy the drawing on the same paper.

Hand drawing to respondent. Correct if two convex, five-sided figures and intersection makes a four-sided figure. Score one point for a correctly copied diagram. Allow 1 minute maximum.

1

Language sub-total:

Score best of question 4 or 5 to give a total out of 30. A score of 23 or less indicates cognitive impairment. Total Test Score:

Adjusted Score:

(Modified from Folstein, Folstein, McHugh, Psychiat. Res 1975, 12, 189–198, and Molloy et al, American Journal of Psychiatry, 1991; 148: 102–105)

Page 2 of 2

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(Affix identification label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Mental Health Services

Mini Mental State Examination (MMSE)

Clinician’s name (please print): Designation: Signature: Team: Date: Time:

MMSE

Screening tool not diagnostic tool

Does not differentiate between dementia and delirium

English literacy and numeracy

Other considerations?

MMSE alternatives

Clockface Drawing Test

Brief screening tool not diagnostic tool

More sensitive to frontal lobe impairment

“Please draw the face of a clock with all the numbers on it. Make it large.”

then

“Show the time at 10 minutes past 11”

The Confusion Assessment Method (CAM) Diagnostic Algorithm

1: Acute Onset & Fluctuating Course2: Inattention

3: Disorganised Thinking4: Altered Level of Consciousness

features 1 & 2 and either 3 or 4 = diagnosis of delirium

Reference:

Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the Confusion Assessment Method. Annals of Internal Medicine 113: 941-8

?CAM Alternative

AlertnessAge etcAttentionAcute

www.the4AT.com

Today’s Presentation

Overview Dementia Delirium Screening Tools

MMSE Clockface CAM

Supporting

Environmental Strategies

Lighting appropriate to time of day Low Stimulus Environment Clock & calendar that clients can see Encourage family to visit/stay Bring in client’s personal and familiar objects Avoid room changes

Clinical Practice Strategies [1]

Interpreter for culturally & linguistically diverse (CALD) patients/clients

Indigenous Liaison Officer Eating & Drinking Hearing Aids? Glasses? Bowels – avoid constipation Mobilisation

Clinical Practice Strategies [2]

Encourage independence in basic ADLs Medication review Promote sufficient sleep at night Manage discomfort or pain Provide orienting information Minimise use of indwelling catheters Avoid use of physical restraints Avoid polypharmacy/psychoactive drugs

After Delirium Resolves

Many patients remember being deliriousSymptoms resolve, but the feelings remain

Not always discussed:Fear of being thought mad

Health professionals may assume no recall

dbmas.org.au

Behavioural and Psychological Symptoms of Dementia (BPSD)

Veronica by Elvis Costello

https://youtu.be/zifeVbK8b-g

Today’s Presentation

Overview Dementia Delirium Screening Tools

MMSE Clockface CAM

Supporting