Dr Ray Rose O’Malley Liz Kiernan Dementia Care at UHCW Dr Ray Rose O’Malley Liz Kiernan

Changing times Increase in life expectancy. Change in the age balance in society. People living longer with frailty. People living longer with dementia. Increased number of people with dementia coming into hospital.

University Hospital Coventry and Warwickshire. Large new PFI build. 1200 beds. 75% of patients over 75. 25% of patients who have a have diagnosis or an undiagnosed dementia.

A real commitment to enhancing the environment. Forget-me-not lounge. Forget-me-not shrub. Memory Lane. Activity organisers

Forget-Me-Not Lounge and Memory Lane

Forget-Me-Not Lounge and Memory Lane

Dementia Screening Used VTE model Computer based tool Memory question 6 item test Some temporary exclusions and one permanent dementia diagnosis

Benefits of the screening. Diagnosis of dementia becomes known. Data base of patients with dementia and one of patients with delirium. Previous assessment available on computer with clinical results. Increased awareness.

Forget-me-not Care Bundle Knowing key personalised information about the patient within 24 hours of admission Personalised regular communication Adequate nutrition and hydration geared to patient preferences and capability A safe and orientating environment

Getting to know me form. This form stays with the person while they are in hospital. It has been designed to help staff understand your loved one and consequently help staff care for your loved one while they are in hospital. What do you like to be know as?________________________________________ What type of things make me happy?__________________________ What helps me to walk?_______________________________________ What helps me to eat and drink?________________________________ Important events in my life _____________________________________ People and pets closest to me (start with those closest and describe relationship). People _____________________________________________________ Pets _______________________________________________________ What helps me manage through the day?_________________________ What helps me manage during the night?_________________________ What helps you to feel calm?__________________________________ What activities do you enjoy? __________________

Patient admitted with confusion Is it a new or increased confusion? YES NO Treat for acute cause of delirium/ Use care plan and screening tool Seek information from Family/GP/Caludon/Carers/ Fill in getting to know me form Has patient got diagnosis of dementia? Start discharge planning YES NO Use Care plan Read old notes/ Treat cause of admission/ Start discharge planning Involve family/ Treat cause of admission/ Start discharge planning Assess patient for discharge Is patient safe for discharge? Involve Social worker/ CHAAT/AMHAT Seek advice from Dementia/Older People Lead Possible New If Delirium If Known Dementia YES NO GP & Keyworker to review/monitor GP to monitor for recurrent cause Ask GP to refer to memory clinic

Confusion? Agitation? Withdrawal? Falls? Think DELIRIUM! HIGH RISK PATIENTS 1. Acute onset and fluctuating course obtain collateral history 2. Inattention easily distracted or difficulty keeping track of what is being said 3. Disorganised thinking rambling or irrelevant unclear speech 4. Altered level of consciousness agitated, hyperalert, lethargic, drowsy, stuporose POSITIVE CAM REQUIRES 1 AND 2 PLUS EITHER 3. OR 4 DIAGNOSE DELIRIUM BY CAM (CONFUSION ASSESSMENT METHOD) Age >65 Severe illness e.g. sepsis Pre-existing dementia Current hip fracture Multiple comorbidities Physical frailty Polypharmacy Alcohol or drug abuse SEARCH FOR PRECIPITANTS AND TREAT URGENTLY Drugs (prescribed or illicit, alcohol withdrawal) and Dehydration Electrolyte disturbance (e.g. hyponatraemia, hypercalcaemia) Level of pain Infection (sepsis) or Inflammation (e.g. post-trauma or surgery) Respiratory failure (hypoxia, hypercapnia) Impaction of faeces (constipation) Urinary retention Metabolic (hepatic/renal failure, hypoglycaemia, hypo/hyperthyroidism) or MI DON’T FORGET TO DOCUMENT DIAGNOSIS OF DELIRIUM IN MEDICAL NOTES AND ON DISCHARGE LETTER

Management of Delirium DO DON’T All MDT Staff Orientate frequently using verbal and visible clues e.g. clocks, signs Provide repeated reassurance and explanations using short sentences Use calming speech/manner Encourage visits from family/friends Use familiar staff when possible Ensure glasses/hearing aids are worn/working Follow falls prevention guidance Consider single room or small bay close to nurses station Eliminate unnecessary noise e.g. pump alarms Ensure appropriate lighting levels Ensure adequate hydration/diet Establish regular sleep pattern Encourage early mobilisation Medical and Nursing Staff Screen for and treat infection and other precipitants urgently Review all prescribed medications Ensure regular adequate pain relief Monitor for and treat constipation Correct hypoxia and hypotension Explain diagnosis to family Avoid sedation where possible Delay treatment – delirium has a high mortality! Argue with or confront patient Frequently move bed or wards Catheterise unnecessarily Perform unnecessary procedures e.g. CT, bloods Routinely use sedative drugs or physical restraint PHARMACOTHERAPY may be considered if other measures fail, to reduce risk to patient/others or permit essential investigations/procedures/treatment Use PO rather than IM/IV if possible, start at low doses and gradually titrate HALOPERIDOL 0.5-1mg PO every 1-2h PRN or 0.5-1mg IM every 2h PRN (maximum daily dose 5-10mg in the elderly, up to 30mg in young patients) OLANZAPINE 2.5-5mg PO every 2h PRN (maximum daily dose 10-20mg) If antipsychotics are contraindicated (QTc>470ms, Parkinsonism, Lewy body dementia) use LORAZEPAM 0.5-1mg PO every 1-2h PRN or 0.5-1mg IM every 2h PRN (maximum daily dose 4mg in elderly)

What doctors can do to help people with Dementia. Have a positive attitude. Talk to family- they are the experts. Understand dementia and delirium. See Challenging behaviour as an expression of need. Promote the Forget-me-not Care Bundle rather than drugs. Use drugs with real caution, small and slow!

Getting support If new cognitive problem but safe to discharge ask GP to follow up. AMHAT- Adult Mental Health Assessment Team- for mental illness 18 years plus. Frail Older Peoples Team- problems related to people with frailty very much including delirium and dementia.

Questions please.