Post on 21-Dec-2015
Dementia & Delirium in Surgical Patients
Damian HardingDepartment of Geriatric MedicineFebruary 2008
Introduction
Surgical patient population has changed..
Introduction
Surgical patient population has changed..
More older patients Patients have more co-morbidities.. More likely to experience patients
with dementia, and to encounter delirium/ acute confusion in surgical patients.
DementiaDefinitions and Epidemiology
Dementia
DementiaDefinitions and Epidemiology
Dementia: “acquired loss of cognitive function due to an abnormal brain condition”
DementiaDefinitions and Epidemiology
Dementia: “acquired loss of cognitive function due to an abnormal brain condition” Usually progressive Includes functional decline
DementiaDefinitions and Epidemiology
Dementia: “acquired loss of cognitive function due to an abnormal brain condition” Usually progressive Includes functional decline
Memory loss and cognitive impairment are NOT features of normal aging!
DementiaDefinitions and Epidemiology
Prevalence of all dementias in the >65 yr population is 6-8%
DementiaDefinitions and Epidemiology
Prevalence of all dementias in the >65 yr population is 6-8%
Prevalence in >85yr population is 30%
DementiaDefinitions and Epidemiology
Prevalence of all dementias in the >65 yr population is 6-8%
Prevalence in >85yr population is 30%
Estimated annual cost reaches US$100 billion (2001) Direct care to individual Lost wages by caregivers
DementiaDefinitions and Epidemiology
Prevalence of all dementias in the >65 yr population is 6-8%
Prevalence in >85yr population is 30% Estimated annual cost reaches US$100
billion (2001) Direct care to individual Lost wages by caregivers
Significant emotional and personal costs
Types of Dementia
At least 50-60% of people with dementia have Alzheimer’s Disease
Types of Dementia
At least 50-60% of people with dementia have Alzheimer’s Disease
Commonest types of dementia include:
Types of Dementia
At least 50-60% of people with dementia have Alzheimer’s Disease
Commonest types of dementia include: Alzheimer’s Disease Vascular (multi-infarct) dementia Lewy body Dementia Alcoholic dementia (depression and pseudo-dementia)
Alzheimer’s Disease
Neurodegenerative disease associated with:
Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits
Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Functional impairment
Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Functional impairment Clear consciousness*
Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Functional impairment Clear consciousness* Change from previous level
(>6 months duration)
Alzheimer’s Disease
Neurodegenerative disease associated with: Cognitive deficits (including memory loss) Functional impairment Clear consciousness* Change from previous level
(>6 months duration) Median survival from diagnosis: 5-6 years
Alzheimer’s Disease is associated with specific changes in brain anatomy, chemistry and physiology
Alzheimer’s Disease is associated with specific changes in brain anatomy, chemistry and physiology
Neurofibrillary tangles* Amyloid plaques Loss of cortical choline acetyltransferase
activity and of cholinergic projection neurons in Nucleus basalis of Meynert*
Alzheimer’s Disease is associated with specific changes in brain anatomy, chemistry and physiology
Neurofibrillary tangles* Amyloid plaques Loss of cortical choline acetyltransferase
activity and of cholinergic projection neurons in Nucleus basalis of Meynert*
Multifactorial genetic component
Alzheimer’s Disease is associated with specific changes in brain anatomy, chemistry and physiology
Neurofibrillary tangles* Amyloid plaques Loss of cortical choline acetyltransferase
activity and of cholinergic projection neurons in Nucleus basalis of Meynert*
Multifactorial genetic componentCT/MRI may be normal or show generalized atrophy/
focal atrophy in medial temporal lobe
*correlates with disease severity
Alzheimer’s Disease Clinical Features:
Alzheimer’s Disease Clinical Features: Cognitive
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
Agnosia
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
Agnosia Failure to recognise objects/ familiar faces
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
Agnosia Failure to recognise objects/ familiar faces
Frontal executive dysfunction
Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
Agnosia Failure to recognise objects/ familiar faces
Frontal executive dysfunction (Capacity to consent for treatment)
Alzheimer’s Disease Clinical Features: Non-Cognitive
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Apathy Overactivity/ agitation (wandering) Aggression Personality changes
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Apathy Overactivity/ agitation (wandering) Aggression Personality changes
Abnormal sleep
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Apathy Overactivity/ agitation (wandering) Aggression Personality changes
Abnormal sleep Reduced appetite
Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Apathy Overactivity/ agitation (wandering) Aggression Personality changes
Abnormal sleep Reduced appetite Incontinence
Management of Alzheimer’s Disease and Dementias
Management of Alzheimer’s Disease and Dementias
Biological
Management of Alzheimer’s Disease and Dementias
Biological Social
Management of Alzheimer’s Disease and Dementias
Biological Social Psychological
Management of Alzheimer’s Disease and Dementias
Depends on stage of disease Multifactorial and
multidisciplinary
Management of Alzheimer’s Disease and Dementias
Day therapy/ day hospital
Day centres
Respite care Social worker
Alzheimer’s Association
Community (Silver Chain) support
Psychologist Psychiatrist
Geriatrician GP
Dietician OT
Physiotherapy
Depends on stage of disease
•Multifactorial and multidisciplinary
Care for Patients with Dementia Admitted for Surgery
Care for Patients with Dementia Admitted for Surgery
Admission Assessment
Care for Patients with Dementia Admitted for Surgery
Admission Assessment Implementation of Care
Care for Patients with Dementia Admitted for Surgery
Admission Assessment Implementation of Care Discharge considerations
Care for Patients with Dementia: Admission Assessment
Care for Patients with Dementia: Admission Assessment
Take history from patient and carer
Care for Patients with Dementia: Admission Assessment
Take history from patient and carer What is patient’s usual level of
function? (ADLs)
Care for Patients with Dementia: Admission Assessment
Take history from patient and carer What is patient’s usual level of
function? (ADLs) Patient’s usual daily routine
Care for Patients with Dementia: Admission Assessment
Take history from patient and carer What is patient’s usual level of
function? (ADLs) Patient’s usual daily routine Are patient and carer currently
coping at home?
Care for Patients with Dementia: Admission Assessment
Take history from patient and carer What is patient’s usual level of
function? (ADLs) Patient’s usual daily routine Are patient and carer currently
coping at home? (Is patient at risk of elder abuse?)
Care for Patients with Dementia: Implementation of Care
Care for Patients with Dementia: Implementation of Care
Environmental
Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation
Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle
Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle Remind patient of day/ time/ place/ why
here
Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle Remind patient of day/ time/ place/ why
here Allow family/ carers to stay longer/ use of
phone/ photograph prompts
Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle Remind patient of day/ time/ place/ why
here Allow family/ carers to stay longer/ use of
phone/ photograph prompts Consider use of visual prompts “This is
the bathroom”/ “I had knee surgery 2 days ago”/ “My nurse is..”
Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle Remind patient of day/ time/ place/ why
here Allow family/ carers to stay longer/ use of
phone/ photograph prompts Consider use of visual prompts “This is
the bathroom”/ “I had knee surgery 2 days ago”/ “My nurse is..”
Low level lighting at night
Care for Patients with Dementia: Implementation of Care
Physical
Care for Patients with Dementia: Implementation of Care
Physical Ensure patient receives usual medications
Care for Patients with Dementia: Implementation of Care
Physical Ensure patient receives usual medications Beware of increased effects of abnormal
physiology causing agitation/ drowsiness
Care for Patients with Dementia: Implementation of Care
Physical Ensure patient receives usual medications Beware of increased effects of abnormal
physiology causing agitation/ drowsiness Beware of new drugs and their doses:
Anaesthesia Analgesia (and bowels) Anti-emetics Fluids (and electrolytes)
Care for Patients with Dementia: Discharge considerations
Attention to function (ADLs) and ability to return to previous environment
Attention to function (ADLs) and ability to return to previous environment
If not sure: arrange OT, physiotherapy, geriatric medicine review
Attention to function (ADLs) and ability to return to previous environment
If not sure: arrange OT, physiotherapy, geriatric medicine review
Patient may benefit from ongoing restorative care
Attention to function (ADLs) and ability to return to previous environment
If not sure: arrange OT, physiotherapy, geriatric medicine review
Patient may benefit from ongoing restorative care
Patient may require increased long term level of care
Attention to function (ADLs) and ability to return to previous environment
If not sure: arrange OT, physiotherapy, geriatric medicine review
Patient may benefit from ongoing restorative care
Patient may require increased long term level of care
Ensure good communication to patient and carers (reduce stress and confusion)