Dementia Care at UHCW

Dr RayRose O’Malley

Liz Kiernan

Changing times

• Increase in life expectancy.

• Change in the age balance in society.

• People living longer with frailty.

• People living longer with dementia.

• Increased number of people with dementia coming into hospital.

University Hospital Coventry and Warwickshire.

• Large new PFI build.

• 1200 beds.

• 75% of patients over 75.

• 25% of patients who have a have diagnosis or an undiagnosed dementia.

A real commitment to enhancing the environment.

• Forget-me-not lounge.

• Forget-me-not shrub.

• Memory Lane.

• Activity organisers

Forget-Me-Not Lounge and Memory Lane

Forget-Me-Not Lounge and Memory Lane

Dementia Screening

• Used VTE model• Computer based tool• Memory question • 6 item test• Some temporary exclusions and one permanent

dementia diagnosis

Benefits of the screening.

• Diagnosis of dementia becomes known.

• Data base of patients with dementia and one of patients with delirium.

• Previous assessment available on computer with clinical results.

• Increased awareness.

Forget-me-not Care Bundle

• Knowing key personalised information about the patient within 24 hours of admission

• Personalised regular communication

• Adequate nutrition and hydration geared to patient preferences and capability

• A safe and orientating environment

Getting to know me form.This form stays with the person while they are in hospital. It has been designed to

help staff understand your loved one and consequently help staff care for your loved one while they are in hospital.

What do you like to be know as?________________________________________What type of things make me happy?__________________________What helps me to walk?_______________________________________What helps me to eat and drink?________________________________Important events in my life _____________________________________People and pets closest to me (start with those closest and describe relationship).People _____________________________________________________Pets _______________________________________________________What helps me manage through the day?_________________________What helps me manage during the night?_________________________What helps you to feel calm?__________________________________What activities do you enjoy? __________________

Is it a new or increased confusion?

Treat for acute cause of delirium/Use care plan and

screening tool

Use Care planRead old notes/Treat cause of

admission/Start discharge planning

YES NO

Patient admitted with confusion

Seek information from Family/GP/Caludon/Carers/

Fill in getting to know me form

Has patient got diagnosis of dementia?

Involve family/ Treat cause of

admission/Start discharge planning

NOYESStart discharge

planning

Is patient safe for discharge?

GP to monitor for recurrent

cause

Assess patient for discharge

YES

NO

If Delirium If Known DementiaPossible New

GP & Keyworker to

review/monitor

Ask GP to refer to memory

clinic

Involve Social worker/CHAAT/AMHAT

Seek advice from Dementia/Older

People Lead

Confusion? Agitation? Withdrawal? Falls?

Think DELIRIUM!

1. Acute onset and fluctuating course obtain collateral history2. Inattention easily distracted or difficulty keeping track of what is being said3. Disorganised thinking rambling or irrelevant unclear speech4. Altered level of consciousness agitated, hyperalert, lethargic, drowsy, stuporose

POSITIVE CAM REQUIRES 1 AND 2 PLUS EITHER 3. OR 4

DIAGNOSE DELIRIUM BY CAM (CONFUSION ASSESSMENT METHOD)

• Age >65• Severe illness e.g. sepsis• Pre-existing dementia• Current hip fracture• Multiple comorbidities• Physical frailty• Polypharmacy• Alcohol or drug abuse

HIGH RISK PATIENTS

DON’T FORGET TO DOCUMENT

DIAGNOSIS OF DELIRIUM IN

MEDICAL NOTES AND ON DISCHARGE

LETTER

SEARCH FOR PRECIPITANTS AND TREAT URGENTLYDrugs (prescribed or illicit, alcohol withdrawal) and DehydrationElectrolyte disturbance (e.g. hyponatraemia, hypercalcaemia)Level of painInfection (sepsis) or Inflammation (e.g. post-trauma or surgery) Respiratory failure (hypoxia, hypercapnia)Impaction of faeces (constipation)Urinary retention Metabolic (hepatic/renal failure, hypoglycaemia, hypo/hyperthyroidism) or MI

DO DON’T

All MDT Staff•Orientate frequently using verbal

and visible clues e.g. clocks, signs•Provide repeated reassurance

and explanations using short sentences

•Use calming speech/manner•Encourage visits from

family/friends•Use familiar staff when possible•Ensure glasses/hearing aids are

worn/working•Follow falls prevention guidance•Consider single room or small

bay close to nurses station•Eliminate unnecessary noise e.g.

pump alarms •Ensure appropriate lighting levels•Ensure adequate hydration/diet•Establish regular sleep pattern•Encourage early mobilisation

Medical and Nursing Staff•Screen for and treat infection

and other precipitants urgently•Review all prescribed

medications•Ensure regular adequate pain

relief•Monitor for and treat

constipation•Correct hypoxia and

hypotension•Explain diagnosis to family•Avoid sedation where possible

• Delay treatment – delirium has a high mortality!

• Argue with or confront patient• Frequently move bed or wards• Catheterise unnecessarily• Perform unnecessary

procedures e.g. CT, bloods• Routinely use sedative drugs or

physical restraint

PHARMACOTHERAPY may be considered if other measures fail, to reduce risk to patient/others or permit essential investigations/procedures/treatment Use PO rather than IM/IV if possible, start at low doses and gradually titrateHALOPERIDOL 0.5-1mg PO every 1-2h PRN or 0.5-1mg IM every 2h PRN (maximum daily dose 5-10mg in the elderly, up to 30mg in young patients) OLANZAPINE 2.5-5mg PO every 2h PRN (maximum daily dose 10-20mg)If antipsychotics are contraindicated (QTc>470ms, Parkinsonism, Lewy body dementia) use LORAZEPAM 0.5-1mg PO every 1-2h PRN or 0.5-1mg IM every 2h PRN (maximum daily dose 4mg in elderly)

Management of Delirium

What doctors can do to help people with Dementia.

• Have a positive attitude.• Talk to family- they are the experts.• Understand dementia and delirium. • See Challenging behaviour as an

expression of need.• Promote the Forget-me-not Care Bundle

rather than drugs.• Use drugs with real caution, small and

slow!

Getting support

• If new cognitive problem but safe to discharge ask GP to follow up.

• AMHAT- Adult Mental Health Assessment Team- for mental illness 18 years plus.

• Frail Older Peoples Team- problems related to people with frailty very much including delirium and dementia.

Questions please.