Two thirds of NHS beds are occupied by people aged 65 yrs and over. 60% of general hospital admissions in this age group will have, or develop a mental disorder during their stay. (Lets Respect 2006)

The 3 D’s Dementia, Delirium, Depression Delirium - A sudden, temporary state of mental confusion and fluctuating consciousness resulting from high fever, intoxication, shock, or other causes. It is characterized by anxiety, disorientation, hallucinations, delusions, and incoherent speech.

Causes of Delirium Infection Prescribed medication Toxicity Alcohol intoxication and/or withdrawal Heart circulation/problems Metabolic – hypoxia, electrolyte imbalance Dehydration Trauma, shock, pain, Operations Poorly controlled diabetes Liver Problems Kidney Problems Vitamin Deficiency Thyroid problems Trauma – head injury Epilepsy Cancer

MOST COMMON REASONS INFECTION CONSTIPATION CHANGE OF ENVIRONMENT/ROUTINE

Other features of Delirium Altered Perception - visual hallucinations and illusions Disturbed behaviour – always search for the meaning Restlessness – especially at night – trying to make sense of things Agitation and fear Shouting and the possibility of aggression AVOIDABLE IN MANY CASES LACK OF AWARENESS LEADS TO HIGH MORTALITY AND MORBIDITY

Reversibility If you can treat the reason for delirium the confusion will clear N.B. confusion is not progressive unless the cause is progressive. Acute confusion is therefore a medical problem requiring rapid and accurate diagnosis with treatment of the cause being a matter of urgency with the hope of recovery

Depression: Persistent sadness/low mood Loss of interest/pleasure Fatigue or low energy Change in appetite – weight loss Change in sleep pattern

Poor concentration Feelings of guilt / worthlessness Exaggerated beliefs Suicidal ideas Agitation

REMEMBER THE 3 D’S- Delirium, Dementia and Depression DeliriumDementiaDepression Sudden OnsetGradual OnsetVariable – either gradual or after specific event Clouding of Consciousness Clear Consciousness Variable – depending upon severity of depression Underlying Illness Deteriorating Dementia is Primary Condition May be related to physical health issues Potentially reversibleNeurodegenerative Condition Reversible

‘Challenging Behaviour’  Pain is positively associated with screaming, aggression and verbal agitation in dementia. (Cohen-Mansfield et al., 1990)  Primary response to ‘challenging behaviours’ is treatment with anti-psychotic medication (Balfour and O’Rourke, 2003; Elenchenny, 2001)  This could mask symptoms related to pain and its treatment (Kovach et al., 1999)

Challenging Behaviour’ ‘Challenging Behaviour’  Growing evidence that use and type of medication is related to staff attitudes and practices and less to the diagnosis of dementia and associated symptoms and behaviours (Jones et al 2004; Wills et al )  ‘There is a link between staffing levels and a high level of sedative medication’ (Carlisle 1997)

The Consequence  People with dementia are prescribed and given less analgesia than other older people (Horgas and Tsai 1998)  Even when analgesia is prescribed to a person with dementia 83% did not receive their medication (Dawson 1998)  76% of people with dementia did not receive regular analgesia post operative hip repair, despite 42% expected to be in severe pain ( Morrison and Sui 2000)