Dementia Care at UHCW Dr Ray Rose O’Malley Liz Kiernan.
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Transcript of Dementia Care at UHCW Dr Ray Rose 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
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.