1. Duke GEC www.interprofessionalgeriatrics.duke.edu Lisa P. Gwyther, MSW, LCSW Duke Family Support Program Duke Center for Aging Delirium Teaching Rounds Duke Geriatric Education Center January 11, 2013 Preventing Delirium in the Hospitalized Patient with Dementia

2. Duke GEC www.interprofessionalgeriatrics.duke.edu Objectives Describe the prevalence of delirium in persons with dementia and its impact on the health of older patients Identify risk factors and key presenting features of delirium Describe Prevention and Management Strategies Identify resources for teams and families about delirium recognition and prevention

3. Duke GEC www.interprofessionalgeriatrics.duke.edu Case 92 year old AA female in own apt near son and his ex-wife 2009 GET Clinic dx of vascular dementia, emotional lability, occasional delusions May 2012: frequent tearful calls to son, fearful of being alone & wandered away at night, delusions of being attacked, son had to stay at night -.25mg. risperidone Nov 2012 Family considering placement Dec 2012 ED with complaints of abdominal pain, nausea, vomiting, fever and not eating one week.

4. Duke GEC www.interprofessionalgeriatrics.duke.edu Questions What are her risks for delirium? What can be done to reduce her risk of delirium/improve hospital care, given her dementia?

5. Duke GEC www.interprofessionalgeriatrics.duke.edu Common Risk Factors for Delirium Predisposing Advanced age Preexisting dementia History of stroke Parkinson disease Multiple comorbid conditions Impaired vision Impaired hearing Functional impairment Male sex History of alcohol abuse Precipitating New acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New psychoactive medication Acute stroke Pain Environmental change Urine retention/fecal impaction Electrolyte disturbances Dehydration Sepsis Marcantonio, 2011.

6. Duke GEC www.interprofessionalgeriatrics.duke.edu Hospital Course Pelvic abscess drained well, but persistent difficulty communicating symptoms and anxiety on day 4 Helpful Strategies - CNA sitter experienced in dementia and familiar with hospital unit - Out of bed every day - Effective pain control - Help with bowels - Attention to eating and drinking - Lights on, reassurance - Reduced tethering constraints - Risperidone

7. Duke GEC www.interprofessionalgeriatrics.duke.edu Hospital Course Day 5 developed C.dif colitis from antibiotics Delirious, aggressive, increased disorientation Delayed discharge to nursing home

8. Duke GEC www.interprofessionalgeriatrics.duke.edu An email to Lisa Gwyther, Jan, 2013 My geriatric care management client is 94. He is an active community leader, teacher and pastor who lives independently and drove until a recent UTI caused extreme confusion. He left the hospital with a new diagnosis of FTD. The family wants to know: 1) how to tell him the diagnosis and prognosis and 2) now that the UTI has improved over six weeks, can he resume driving?

9. Duke GEC www.interprofessionalgeriatrics.duke.edu What Dementia Families Tell Us Her dementia progressed much faster after she was hospitalized. It seems like one hospitalization led to many more and we never got the meds straight. When I saw how he was in the hospital, I knew I couldn’t take care of him at home any longer. I thought it was just her dementia progressing, but she was dehydrated and really sick. The ED was like an exhausting time capsule – when he finally got a room, we thought he was safe to sleep and we could finally get a break.

10. Duke GEC www.interprofessionalgeriatrics.duke.edu What Dementia Families Tell Us Shouldn’t they know the call light and the food containers were totally beyond her? She fell trying to find some food and a bathroom. The hospital staff are clueless – it didn’t help for them to keep telling him where he was. Why do we have to pay a private aid, given all that hospital charges? They either asked him impossible questions he couldn’t hear anyway, or talked about him like he wasn’t even there.

11. Duke GEC www.interprofessionalgeriatrics.duke.edu Risks for Patients with Dementia Delayed presentation to ED and delayed detection (Morandi,A et al, JAGS, 2012 review suggests limited evidence base for tools to detect delirium superimposed on dementia; and Thomas C et al, JAGS, 2012 found adding psychomotor change to the CAM algorithm improved specificity and diagnostic value against ICD-10 in hospitalized patients with dementia) If left alone, patients forget what they are waiting for and leave If left alone, patients are unreliable informants who may confabulate and sound reasonable to fill in holes in memory

12. Duke GEC www.interprofessionalgeriatrics.duke.edu Risks for Patients with Dementia Change is the enemy – any sudden change in routine can lead to delirium in someone with Alzheimer’s. Recent study estimate: 6% of deaths, 15% of placements and 21% of cognitive decline in hospitalized patients with AD can be attributed to delirium. (Fong et al, Annals of Internal Medicine 2012)

13. Duke GEC www.interprofessionalgeriatrics.duke.edu Risks for Patients with Dementia Dementia is the leading risk factor for delirium and two thirds of cases of delirium occur in patients with dementia (Inouye, 2006 NEJM) Delirium in hospitalized patients with dementia is associated with an 2.2-fold increase in the rate of cognitive decline over one year and 1.7 fold increased rate of cognitive deterioration maintained up to five years. (Weiner MF, Arch Neurol, 2012; Gross et al, Archives of Internal Medicine, 2012) “Results challenge the notion that delirium is transient and reversible in Alzheimer’s, making an even stronger case for prevention”

14. Duke GEC www.interprofessionalgeriatrics.duke.edu Risks of Delirium in Hospitalized Patients with Dementia Hospitalization alone results in poor outcomes for patients with Alzheimer’s, but hospitalization and delirium results in an even greater risk (Fong, 2012) “We have to prevent hospitalizations and delirium in patients with Alzheimer’s disease and prepare families for the risks of complications” Apostolova, UCLA, June, 2012

15. Duke GEC www.interprofessionalgeriatrics.duke.edu Home Alone: Family Caregivers Providing Complex Chronic Care 2012 46% of 1677 family caregivers in a recent United Hospital Fund survey say they have no choice but to perform a range of medical and nursing tasks, once only performed in hospitals or nursing homes, for family members with multiple chronic physical and cognitive conditions. Two-thirds had no home visit by a health care professional after hospital Unprepared, scared, stressed and depressed

16. Duke GEC www.interprofessionalgeriatrics.duke.edu Prevention of Delirium in Hospitalized Patients with Dementia Constant presence of familiar transitional person Reassuring communication: Identity props, reminders, something to do, sensory aids Eliminate wandering triggers – suitcase, coat, EXIT Adjust noise, temperature, view, TV risks Limit tethering, hide or use decoy Label and unclutter hospital room Increase mobility Nutrition and hydration

17. Duke GEC www.interprofessionalgeriatrics.duke.edu Talking with the Hospitalized Delirious Dementia Patient Limit background noise and stay visible One step directions and two choice questions I will help you – pause – proceed Use gestures but don’t patronize Don’t guess if you’re not sure – listen for key ideas and assess non-verbal cues Label and validate emotions, not facts Assess and anticipate unmet needs

18. Duke GEC www.interprofessionalgeriatrics.duke.edu Prevention: Talking to Families Teach family how to distinguish acute change vs. good days/bad days variability Re-establish preferred routines, soothers – favorite robe, pillow, newspaper, snack, iPad, Suggest they not ask pt. “who, what, where, when, why?” questions or extract promises. Help pt. start, sequence, organize tasks Affirm disorientation if re-orient doesn’t work

19. Duke GEC www.interprofessionalgeriatrics.duke.edu Prevention: Talking to Families Attention to pain and palliative care Soothing props, cues, touch – Seskovitch, The Anxiety Whisperer Discuss risks/benefits/effectiveness/costs of diagnostics and treatments What scares you the most about taking him home? Hospitalization is a choice - next time

20. Duke GEC www.interprofessionalgeriatrics.duke.edu Resources for Teams Try this: Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia (2013) 2pp. Consultgerirn.org/uploads/File/trythis/try_this_d7.pdf Try this: Assessing and Managing Delirium in Older Adults with Dementia (2013) 2pp. Consultgerirn.org/uploads/File/trythis/try_this_d8.pdf Try This: Working with Families of Hospitalized Older Adults with Dementia (2007) 2pp. Consultgerirn.org/uploads/File/trythis/try_this_d10.pdf Gitlin LN, Kales HC and Lyketsos, CG (2012) Nonpharmacologic Management of Behavioral Symptoms in Dementia. JAMA Care of the Aging Patient: From Evidence to Action. Flaherty JH & Milta MO, (2011) Matching the Environment to Patients with Delirium. JAGS

21. Duke GEC www.interprofessionalgeriatrics.duke.edu Resources for Families Hospitalization Happens (2009) nia.nih.gov/sites/default/files/hospitalization_happe ns.pdf REASSURE for DELIRIUM (Poer, 2011) Delirium: Unique to Older Adults (2012) Healthinaging.org Next Step in Care Family Caregiver Guide (2012): Emergency Room (ER) Visits: A Family Caregiver’s Guide from the United Hospital Fund. nextstepincare.org