Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February...
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Dementia & Delirium in Surgical Patients
Damian HardingDepartment of Geriatric MedicineFebruary 2008
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Introduction
Surgical patient population has changed..
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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.
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DementiaDefinitions and Epidemiology
Dementia
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DementiaDefinitions and Epidemiology
Dementia: “acquired loss of cognitive function due to an abnormal brain condition”
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DementiaDefinitions and Epidemiology
Dementia: “acquired loss of cognitive function due to an abnormal brain condition” Usually progressive Includes functional decline
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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!
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DementiaDefinitions and Epidemiology
Prevalence of all dementias in the >65 yr population is 6-8%
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DementiaDefinitions and Epidemiology
Prevalence of all dementias in the >65 yr population is 6-8%
Prevalence in >85yr population is 30%
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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
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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
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Types of Dementia
At least 50-60% of people with dementia have Alzheimer’s Disease
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Types of Dementia
At least 50-60% of people with dementia have Alzheimer’s Disease
Commonest types of dementia include:
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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)
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Alzheimer’s Disease
Neurodegenerative disease associated with:
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Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits
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Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
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Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Functional impairment
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Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Functional impairment Clear consciousness*
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Alzheimer’s Disease
Neurodegenerative disease associated with:
Cognitive deficits (including memory loss)
Functional impairment Clear consciousness* Change from previous level
(>6 months duration)
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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
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Alzheimer’s Disease is associated with specific changes in brain anatomy, chemistry and physiology
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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*
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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
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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
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Alzheimer’s Disease Clinical Features:
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Alzheimer’s Disease Clinical Features: Cognitive
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
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Alzheimer’s Disease Clinical Features: Cognitive
Amnesia Misplace/ lose objects. Repeat same question.
Aphasia Word-finding difficulties
Apraxia Brush teeth, dress, comb hair
Agnosia
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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
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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
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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)
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Alzheimer’s Disease Clinical Features: Non-Cognitive
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Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms
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Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
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Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems
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Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
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Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Apathy Overactivity/ agitation (wandering) Aggression Personality changes
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Alzheimer’s Disease Clinical Features: Non-Cognitive
Psychotic symptoms Delusions, hallucinations
Mood problems Behavioural changes
Apathy Overactivity/ agitation (wandering) Aggression Personality changes
Abnormal sleep
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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
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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
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Management of Alzheimer’s Disease and Dementias
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Management of Alzheimer’s Disease and Dementias
Biological
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Management of Alzheimer’s Disease and Dementias
Biological Social
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Management of Alzheimer’s Disease and Dementias
Biological Social Psychological
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Management of Alzheimer’s Disease and Dementias
Depends on stage of disease Multifactorial and
multidisciplinary
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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
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Care for Patients with Dementia Admitted for Surgery
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Care for Patients with Dementia Admitted for Surgery
Admission Assessment
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Care for Patients with Dementia Admitted for Surgery
Admission Assessment Implementation of Care
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Care for Patients with Dementia Admitted for Surgery
Admission Assessment Implementation of Care Discharge considerations
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Care for Patients with Dementia: Admission Assessment
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Care for Patients with Dementia: Admission Assessment
Take history from patient and carer
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Care for Patients with Dementia: Admission Assessment
Take history from patient and carer What is patient’s usual level of
function? (ADLs)
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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
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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?
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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?)
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Care for Patients with Dementia: Implementation of Care
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Care for Patients with Dementia: Implementation of Care
Environmental
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Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation
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Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle
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Care for Patients with Dementia: Implementation of Care
Environmental Patient orientation Day/ night cycle Remind patient of day/ time/ place/ why
here
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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
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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..”
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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
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Care for Patients with Dementia: Implementation of Care
Physical
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Care for Patients with Dementia: Implementation of Care
Physical Ensure patient receives usual medications
![Page 73: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/73.jpg)
Care for Patients with Dementia: Implementation of Care
Physical Ensure patient receives usual medications Beware of increased effects of abnormal
physiology causing agitation/ drowsiness
![Page 74: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/74.jpg)
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)
![Page 75: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/75.jpg)
Care for Patients with Dementia: Discharge considerations
![Page 76: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/76.jpg)
Attention to function (ADLs) and ability to return to previous environment
![Page 77: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/77.jpg)
Attention to function (ADLs) and ability to return to previous environment
If not sure: arrange OT, physiotherapy, geriatric medicine review
![Page 78: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/78.jpg)
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
![Page 79: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/79.jpg)
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
![Page 80: Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649d5a5503460f94a3a2ea/html5/thumbnails/80.jpg)
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)