Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008

Introduction Surgical patient population has changed..

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.

Dementia Definitions and Epidemiology  Dementia

Dementia Definitions and Epidemiology  Dementia: “acquired loss of cognitive function due to an abnormal brain condition”

Dementia Definitions and Epidemiology  Dementia: “acquired loss of cognitive function due to an abnormal brain condition” Usually progressive Includes functional decline

Dementia Definitions 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!

Dementia Definitions and Epidemiology  Prevalence of all dementias in the >65 yr population is 6-8%

Dementia Definitions and Epidemiology  Prevalence of all dementias in the >65 yr population is 6-8%  Prevalence in >85yr population is 30%

Dementia Definitions 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

Dementia Definitions 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

Types of Dementia  At least 50-60% of people with dementia have Alzheimer’s Disease

Types of Dementia  At least 50-60% of people with dementia have Alzheimer’s Disease  Commonest types of dementia include:

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)

Alzheimer’s Disease Neurodegenerative disease associated with:

Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits

Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)

Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)  Functional impairment

Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)  Functional impairment  Clear consciousness*

Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)  Functional impairment  Clear consciousness*  Change from previous level (>6 months duration)

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

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*

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

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 CT/MRI may be normal or show generalized atrophy/ focal atrophy in medial temporal lobe *correlates with disease severity

Alzheimer’s Disease Clinical Features:

Alzheimer’s Disease Clinical Features: Cognitive

 Amnesia

Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.

Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia

Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties

Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia

Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair

Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair  Agnosia

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

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

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)

Alzheimer’s Disease Clinical Features: Non-Cognitive

 Psychotic symptoms

Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations

Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems

Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes

Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes Apathy Overactivity/ agitation (wandering) Aggression Personality changes

Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes Apathy Overactivity/ agitation (wandering) Aggression Personality changes  Abnormal sleep

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

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

Management of Alzheimer’s Disease and Dementias

 Biological

Management of Alzheimer’s Disease and Dementias  Biological  Social

Management of Alzheimer’s Disease and Dementias  Biological  Social  Psychological

Management of Alzheimer’s Disease and Dementias Depends on stage of disease Multifactorial and multidisciplinary

Management of Alzheimer’s Disease and Dementias Day therapy/ day hospital Day centres Respite careSocial worker Alzheimer’s Association Community (Silver Chain) support PsychologistPsychiatrist GeriatricianGP DieticianOT Physiotherapy Depends on stage of disease Multifactorial and multidisciplinar y

Care for Patients with Dementia Admitted for Surgery

 Admission Assessment

Care for Patients with Dementia Admitted for Surgery  Admission Assessment  Implementation of Care

Care for Patients with Dementia Admitted for Surgery  Admission Assessment  Implementation of Care  Discharge considerations

Care for Patients with Dementia: Admission Assessment

 Take history from patient and carer

Care for Patients with Dementia: Admission Assessment  Take history from patient and carer  What is patient’s usual level of function? (ADLs)

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

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?

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?)

Care for Patients with Dementia: Implementation of Care

Environmental

Care for Patients with Dementia: Implementation of Care Environmental  Patient orientation

Care for Patients with Dementia: Implementation of Care Environmental  Patient orientation  Day/ night cycle

Care for Patients with Dementia: Implementation of Care Environmental  Patient orientation  Day/ night cycle  Remind patient of day/ time/ place/ why here

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

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..”

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

Care for Patients with Dementia: Implementation of Care Physical

Care for Patients with Dementia: Implementation of Care Physical  Ensure patient receives usual medications

Care for Patients with Dementia: Implementation of Care Physical  Ensure patient receives usual medications  Beware of increased effects of abnormal physiology causing agitation/ drowsiness

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)

Care for Patients with Dementia: Discharge considerations

 Attention to function (ADLs) and ability to return to previous environment

 If not sure: arrange OT, physiotherapy, geriatric medicine review

 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

 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

 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)