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

2. 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.

3. 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.

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

5. Forget-Me-Not Lounge and Memory Lane

6. Forget-Me-Not Lounge and Memory Lane

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

8. 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.

10. 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

11. 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? __________________

12. 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

13. 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

14. Management of DeliriumDO
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)

15. 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!

16. 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.

17. Questions please.