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Delirium Worsens prognosis- significant mortality rate Lengthens stay in hospital- longer in bed, falls, pneumonia Increased rates of institutionalisation.

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Presentation on theme: "Delirium Worsens prognosis- significant mortality rate Lengthens stay in hospital- longer in bed, falls, pneumonia Increased rates of institutionalisation."— Presentation transcript:

1 Delirium Worsens prognosis- significant mortality rate Lengthens stay in hospital- longer in bed, falls, pneumonia Increased rates of institutionalisation Potentially treatable Up to 2/3 not detected

2 Delirium: Clinical Features Clouding of consciousness, attention, memory, executive function all affected 2 types Apathetic Active, psychotic, behavioural symptoms Symptoms worse at night

3 Delirium:Risk Factors Increasing age Dementia Sensory deficits Previous episode Severe comorbidity Immobility Sleep Disturbance Alcohol Consumption Operation Dehdration Low albumin

4 Delirium-Medication Risk factors Benzodiazepines Anticholinergics Opiates Digoxin Warfarin

5 Delirium Causes Almost anything in combination with risk factors

6 Delirium-Tips Sudden deterioration in mental state consider delirium The greater the number of risk factors the more delirium is likely Sometimes delirium can go on for weeks

7 Delirium:Treatment Identify and treat cause Modify risk factors Infections, metabolic, malignancy, cardiac, vascular Consider hospital admission

8 Delirium:Treatment The eight ates or Nice Coat Noise abate Illuminate Communicate Environment manipulate Carer participate Orientate Ambulate Thermoregulate

9 Delirium:Medication If hyperactive and psychotic Antipsychotic-haloperidol Olanzapine, quetiapine Lorazepam

10 The Dementias Normal Ageing Mild Cognitive Impairment (MCI) Dementia

11 The Dementias: Clinical Features Progressive Impairment of cognition, personality and intellect Orientation, Memory, Language(dysphasia) Ability to carry out tasks(praxias) Recognition (agnosia)

12 The Dementias-Executive Function Impairment Planning Organising Abstract thinking Multi tasking

13 The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Why are they important? Predict carer distress and breakdown of supportive network Predict institutionalisation Nearly 90% of admissions to Larch

14 The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Mood Anxiety as a presentation Anxiety as a concomitant Depression Elation- often pre existing bipolar disorder

15 The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Psychosis Delusions Phantom lodger Misidentifications e.g.Capgras Persecutory

16 The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD-Psychosis Hallucinations Auditory- music, voices Visual-people, animals

17 The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Wandering Agitation Day night reversal Verbal Aggression Physical Aggression Disinhibition Apathy

18 The Dementias: Causes Subdural Brain tumour Normal pressure hydrocephalus Hypothyroidism Low B12/folate Syphilis Diabetes Chronic infection Uraemia

19 The Dementias: Causes Alzheimer’s Disease(AD) 50% Vascular Dementia(VaD) 10% Mixed Dementia-Alzheimer’s with cerebrovascular disease AD/VaD 25% Dementia with Lewy Bodies(DLB) 10% Fronto Temporal Dementia (FTD) 2%

20 Alzheimer’s disease Plaques, tangles Insidious onset Gradual decline Memory orientation difficulties early on Executive function impairment Later on dyshasia, dyspraxia, agnosia

21 Vascular Dementia Pure form not that common Single large infarct Multi infarct dementia Subcortical dementia RISK FACTORS Male Stroke/TIA

22 Alzheimer’s with Cerebrovascular disease Gradual deterioration RISK FACTORS 1.Family history dementia 2.Increasing age 3.Atrial fibrillation 4.Hypertension 5.Hypercholesterolaemia 6.Diabetes 7.Homocysteine 8.?Lack of Exercise

23 Modifying Risk NB long latency(10+ years) between modifying risk factor and seeing effect on disease ANTIOXIDANTS Vitamins C & E in combination ?Vitamin E delaying institutionalisation ANTIANFLAMMATORIES Non steroidal antiinflammatory agents ?Some benefit if taken over many years

24 Modifying Risk Tobacco- risk not reduced-stimulation of nicotinic receptors offset by other deleterious effects Alcohol- mild drinking up to 3 units of wine per day benefit Statins- beneficial in TIAs, stroke, hypercholesterolaemia, dementia-mixed results. May increase alpha secretase B12 & folate long term to reduce homocysteine? Oestrogen? Increased exercise? Mental stimulation?

25 Modifying Risk Fish 3x/week Curry-turmeric Smart drugs? Bandolier’s 10 Tips10 Tips

26 Dementia and Parkinson’s Disease(PD) PD and subcortical dementia PD and AD PD and hallucinations from treatment Dementia with Lewy Bodies(DLB)

27 Dementia with Lewy Bodies Fluctuating course Visual hallucinations Spontaneous features of Parkinsonism

28 Dementia with Lewy Bodies Falls Syncope Systemised delusions Hallucinations in other modalities Neuroleptic sensitivity

29 Fronto Temporal Dementia 30% of younger onset dementia(45-65yrs) Duration 8yrs 1.Overactive-disinhibted, lack of concern(orbitomedial frontal, anterior temporal) 2.Apathetic-perseveration, rigid thinking, lack of volition(pan frontal) 3.Stereotyped ritualistic behaviour(striatum) 4.Semantic dementia-unable to understand meaning of words, objects, sensations 5.Progressive non fluent dyshasia

30 Fronto Temporal Dementia Liking for sweet things Emotional blunting Striking loss of insight Ability may be enhanced-artistic or musical Tip-frontal lobe symptoms often precede memory problems

31 Other Dementias Subdural haematoma-history of fall Creutzfeld-Jacob Disease-Classical-rapid decline, myoclonus, abnormal EEG, death in < 1 yr Normal pressure hydrocephalus- cognitive change, gait abnormality, urinary incontinence

32 The Dementias: Identify and Diagnose History Cognitive testing Primary Care 6CIT MMSE6CITMMSE Physical examination

33 The Dementias: Dementia Screen FBC ESR U&Es LFT’s, Calcium, protein Blood Sugar Lipids B12&folate TFTs Serological Tests for syphilis ECG

34 Referral to Old Age Psychiatry Early for diagnosis, comprehensive assesment

35 Treatment With A Cholinesterase Inhibitor (CHEI) Mild to moderate AD, Mixed AD/VaD, DLB Secondary Care Shared Care Protocol

36 Dementias:Treatment Memory clinic History Examination Investigation Diagnosis Treatment

37 Memory Clinic Patient and carer(s) Detailed assessment and review Mini Mental State Examination Clock Drawing Test Demtect Executive Function Bristol Activities of Daily Living Peripatetic

38 NICE Guidelines(2001) Mild to moderate Alzheimer’s Disease >12 MMSE Diagnosis in specialist clinic Treatment initiated by specialist but may be continued by primary care under shared care protocol Seek carers’ views Assess 2-4/12 after maintenance dose. Continue only if improvement in MMSE score or no deterioration and behavioural or functional improvement Review every 6/12- MMSE must remain >12 and worthwhile effect on global functional and behavioural condition

39 Goals of Treatment Enhance Cognition Increase autonomy Decrease behavioural symptoms Slow or arrest progression of the disease Primary prevention in the presymptomatic stage

40 Memory Clinic- Indications for CHEIs Dementia screen ECG Neuropsychological testing-if MMSE>19 CT Brain scan with medial temporal lobe views One hit

41 Memory Clinic If AD, mixed dementia or DLB MMSE >12 Compliance with medication Regular observation of patient No contraindications

42 Memory Clinic Prescribe CHEI Patient and carer information Support or care at home Monitoring and treatment of BPSD Review 3/12 after stabilisation

43 Memory Clinic Review Usually every 6/12 MMSE, CDT, EF, BADL? Continue if evidence of benefit- not so easy to decide!

44 Memory Clinic Stopping CHEIs MMSE <12 Marked deterioration Withdraw over 2/52 Often severe relapse- need to restart within 4/52

45 The Dementias:CHEIs Side effects-cholinergic-nausea, headache,sweating, bradycardia dizziness Cautions-asthma, sick sinus syndrome Outcome-actual improvement in behaviour cognition, function, psychosis Slowing of deterioration Up to 18/12 Stopping

46 The Dementias: Treatment Memantine Licensed for moderate to severe dementia Not supported by Priorities Committee in W Berks Modest evidence of benefit in cognition, ADL, behaviour

47 Other Treatments NSAIDs-Low rates of AD in patients with RA. Insufficient evidence HRT- no effect in established disease, possibly preventative

48 Other Treatments: Antioxidants Vitamin E ? Delays institutionalisation. Dose 1000 IU/day Gingko Biloba- some benefit reported from German studies May interact with anticoagulants

49 Possible FutureTreatments Prevent plaque formation Vaccination –Beta amyloid Nerve growth factor Stem cells

50 The Dementias: Other Pharmacological Treatments Agitation, irritability, anxiety and verbal aggression Trazodone 50mgs/day up to 250mgs day Sedation, anticholinergic Citalopram 10-20mgs/day up to 40mgs/day palpitations., postural hypotension, confusion Depression- antidepressant

51 The Dementias: Other Pharmacological Treatments Acute severe anxiety or agitation Lorazepam 0.5 mgs up to tds Respiratory depression, sedation, paradoxical agitation Chronic agitation and restlessness- clomethiazole

52 The Dementias: Other Pharmacological Treatments Agitation, aggression-mood stabilisers Sodium valproate 200mgs up to 1200mgs Liver impairment, GI side effects, drowsiness or aggression Carbamazapine 50mgs bd up to 1g/day AV conduction defects,blurred vision. Dizziness, unstaediness GI side effects, confusion, agitation,, rash(Stevens Johnson), blood dyscrasia

53 The Dementias: Other Pharmacological Treatments Agitation & psychosis CHEIs

54 The Dementias: Antipsychotics Psychotic symptoms, agitation, sexual disinhibition Typicals; haloperidol 0.5mgs up to tds Sedation, EPS, Benperidol: sexual disinhibition

55 The Dementias: Antipsychotics Atypicals Quetiapine 25mgs/day up to 400mgs/day sedation Amisulpride 25mgs/day up to 300mgs/day hypotension, sedation Olanzapine 2.5mgs/day up to 20mgs/day sedation weight gain, cves, mortality Risperidone 0.5mg/day up to 2mgs/day EPS,sedation, agitation, cves Aripiprazole?-dopamine stabiliser

56 The Dementias: Non Pharmacological treatments Behaviour therapy- antecedents, behaviour, consequences Individuals preferences Context of behaviour Reinforcement strategies to reduce the behaviour Limited application

57 The Dementias: Non Pharmacological Treatments - Reality orientation Signposts Notices Memory aids effective

58 The Dementias: Validation therapy Retreat into inner world to avoid stress, boredom & loneliness Validation-empathy with feelings and hidden meanings behind the confusion ?Effective

59 The Dementias:Reminiscence May help social interaction, motivation, self care and reduce behavioural symptoms At all severities of dementia

60 The Dementias: Art Therapy Self expression through painting not relying on language Stimulation, communication, social interaction

61 The Dementias:Music Therapy Active participation or listening Social interaction Can help those with abnormal vocalisations Reductions in agitation for music tailored to individual

62 The Dementias: Activity Therapy Dance, drama. Sport Physical activity, reduces falls, improves sleep, mood and confidence Day time activity-reductions in agitaion and restlessness at night

63 The Dementias:Complementary Therapies Massage, Reflexology, Herbal medicine Efficacy not known

64 The Dementias: Aromatherapy Lavandula augustifolia melissa officianalis Inhalation, bathing or topical Reductions in agitation Well tolerated

65 The Dementias: Light and Multisensory BrightLight Therapy Beneficial in sleep disturbance MultiSensory Approaches Fibreoptics, cushions& vibrating pads, liquid wheels ?improvements in agitation

66 The Dementias: Cognitive Behaviour Therapy Early dementia Misinterpretations, biases, distortions, erroneous problem solving strategies, communication problems Benefit reported

67 The Dementias: Interpersonal Therapy Individual distress within their own context Person Centred Approach Disputes, personality difficulties, bereavements, life evenst/changes Little used in dementia

68 The Dementias: Vascular risk factors Diabetes Hypertension Hypercholesterolaemia

69 Prevention Treat vascular risk factors energetically in Middle Age Exercise Diet Early life educational achievement Use it or lose it Reduce chronic stress?

70 Single Assessment Process (SAP) Contact Overview Specialist Comprehensive

71 Old Age Psychiatry Services Acute treatment Rehabilitation Prevention

72 Old Age Psychiatry Services Consultant and other psychiatrists CPNs, Occupational therapy, psycchology, speech and languauge therapy, physiotherapy, dietetcis, support workers Home treatment Team Memory Clinic Day Hospital

73 Old Age Psychiatry Services Inpatients OutPatients Domiciliary and Home visits Carer Support and training Individual and Group therapies Liaison Service

74 Old Age Psychiatry Services-Model Early intervention Treatment in the community Prevent admission where possible Work closely with primary care Joint working with Social services Resource Centre of Knowledge and expertise

75 Supporting the Carers Listening Informing Involving Training-problem solving Cognitive analytical therapy- dichotomies, ethical & moral considerations

76 Changing the Environment Housing for cognitively impaired Safety issues Aids and adaptations Smart technology Levels of sheltered accomodation

77 Social Care Social services Voluntary Sector Private Sector

78 Social Care Support for personal care Help with shopping, housework Financial support- Enduring power of attorney Court of Protection Allowances Clubs, day care

79 Care Respite Care-at home or away Long term care Care homes DE Nursing Homes DE

80 Depressive Disorder: Risk Factors Disability Handicap Stroke Parkinson’s disease VaD Heart Disease COPD

81 Depressive Disorder- causative Physical Disorders Endocrine/Metabolic Thyroid disorder Cushings syndrome Hypercalcaemia Pernicious anaemia Folate deficiency

82 Depressive Disorder- causative Physical Disorders Organic Brain disease Cerebrovascular disease CNS tumours PD AD SLE Occult Carcinoma Pancreas Lung Chronic Infections Neurosyphilis Brucellosis Herpes Zoster

83 Depressive Disorder-Medication causing Depression Antihypertensives:Beta blockers, methyl dopa, calcium channel blockers Prednisolone Analgesics: Codeine, opioids, COX2 inhibitors AntiParkinsonian: L Dopa, amantadine, tetrabenazine Psychotropics: antipsychotocs, benzodiazepines

84 Depressive Disorder-Detection History Anorexia, weight loss and anergia difficult to interpret Examination GDS

85 Depressive Disorders- Treatment Remission of all residual symptoms Provide appropriate Rx- NICE guidelines antidepressants, psychological ECT Provide info & support for patient/carers

86 Depressive Disorders- Treatment Optimise Function- Rx physical conditions, Attend to sensory deficits Review medication Enable Practical support Sign posting to appropriate agencies

87 Depressive Disorders- Treatment Prevention of Relapse and Recurrence Continue medication during recovery Stay on medication for at least 1 yr after recovery Maintenance treatment

88 Depressive Disorders- Treatment Antidepressants- NNT of 4 SSRI-under 80yrs, avoid if patient taking aspirin NSAIDs, history of peptic ulcer Over 80s-mirtazapine( sedation), venlafaxine (hypo or hypertension, cardiac disease), lofepramine Moclobamide=MAOI B reversible Phenelzine All –low sodium-inappropriate ADH secretion Discontinuation reactions- possible after 8 weeks

89 Depressive Disorders- Treatment Efficacy TCA=venlafaxine> SSRIs Often difficult to obtain a therapeutic dose of TCA

90 Depressive Disorders- Psychological Treatment Work in older people CBT Interpersonal therapy-relapse prevention Problem solving Psychoeducational techniques Family therapy In major depression-antidepressant + psychological Rx

91 Depressive Disorders- Treatment ECT Severe depression80% recover Well tolerated Broader spectrum of use Not within 3/12 of stroke or heart attack Memory imapirment

92 Depressive Disorders- Treatment Rapid transcranial magnetic stimulation- ? Less effective in older patients Exercise in prevention Enhanced or stepped care- case mangement, antidepressants+ problem solving+ close links between primary & 2o care

93 Depressive Disorders- Treatment Resistant Depression Medical cause for depression Patient tolerates med Compliance with medication Proper dose For long enough up to 8-12 weeks However recovery unlikely if no response within 4 weeks

94 Depressive Disorders- Treatment Resistance Substitute with another antidepressant (fewer interactions, easier to attribute success or failure or side effects) Augmentation-( do not need to withdraw, possible synergy) TCA with SSRI SSRI+Mirtazapine Antidepressant + Lithium Up to 300mgs of venlafaxine

95 Depressive Disorders- MaintainanceTreatment Single episode major depression-1 yr after recovery > 3episodes continue indefinitely at therapeutic dose TCA, citalopram Antidepressant+ psychological Rx

96 Depressive Disorders- Prognosis Thirds- 1/3 got better, 1.3 had relapses, 1/3 continuing sympotms Better than this with active intervention- OAP-2/3 got better Psychotic depression lethal- excess mortality from physical conditions Increased risk of heart attacks and stroke Vascular depression poor prognosis

97 Communication ROAPI Emails Template e referral Web site:

98 Final Thoughts Prepare for old age Have good relationships with others Eat well Plenty of mental stimulation Physical exercise Earn enough money When you Retire Don’t stop

99 Si jeunesse savait; si vieillesse pouvait. [If only youth knew; if only age could.] H. Estienne, Les Prémices

100 Picture

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