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Delirium, Dementia, and Considerations
of Medical Consent.
Melissa Sisco, MA & Gabriel Araujo, MA
Agenda
• Consent
• Altered States of Awareness
• Differential Diagnosis
– Key items to diagnosis (delirium v. dementia)
– Neuropsychological Case Study
• Legal & Ethical Considerations
– Medical Decision Makers (Illinois State Law)
– Documentation of Rationale
– Considerations of Undue Influence
Quick Facts
• 10-15% of hospitalizations result from delirium (Arnold, 2004)
• 13.9% of adults age 71+ have some form of dementia in the US
(Plassman et al, 2007).
• Delirium is often a sign of an emerging illness (Jackson et al, 2004)
and is often misdiagnosed as dementia (Rahkonen et al, 2000)
• Delirium increased the risk of dementia 323% (Rockwood, 1999)
• Delirium increased mortality rates 195% and institutionalization rates
by 241% (Witlox, 2010)
CONSENT
"Decisional capacity" means the ability to understand
and appreciate the nature and consequences of a
decision regarding medical treatment or forgoing
life-sustaining treatment and the ability to reach and
communicate an informed decision in the matter as
determined by the attending physician. (755 ILCS 40/25)
Decision Making Capacity
• Understanding
– Comprehension, learning, and remembering information about
diagnosis and treatment
• Appreciation
– Insight and judgment about treatment in consideration of one’s
health and values
• Reasoning
– Analysis and appropriate decision making among treatment
options
• Expressing a Choice
– Communicating clearly; free of duress
*Additional Considerations: Familial views,
previously expressed values, opinions of medical
staff, societal values (Buchanan, 2004)
Considerations with the Elderly
• Understanding- Use memory aids
and reasonable information chunks;
assessing consent is not a memory
test
• Appreciation- Be cautious of
acquiescence to medical staff
• Reasoning- Recognize the likelihood
of minimization of problems
• Expressing a Choice- E.g.,
survivors of WWII and the Great
Depression are less likely to
complain or view medical risk as
severe (Moye et al, 2004)
COMPROMISED STATE OF
AWARENESS
Delirium
Dementia
Pathology
Diffuse cortical dysfunction
or impairment in
susceptible areas of the
cortex
Varied per dementia type
(Alzheimer’s, Parkinson’s,
ALS, HIV, ongoing
cardiovascular insults)
Onset
Moments to days
Several weeks or months
Triggers
Infection, dehydration,
constipation, drug
interaction, poor diet,
insomnia, pain, toxins,
stress, metabolic changes
*Worsened by pain meds,
sedatives, & SSRIs
Biological disease, stroke,
long-term alcohol abuse,
vitamin deficiency
Hallmark
Signs
Fluctuation, severe
attention problems and
disorientation.
Chronic, may worsen in
Evenings, memory problems
Delirium First
• Delirium overshadows dementia when
present. Delirious symptoms are the same
with or without underlying dementia
(Meagher, 2010)
• Delirium, if resolved, should return the
client to baseline functioning
• Delirium if not resolve may lead to
dementia (Rockwood, 1999)
Delirium & Consent
• Use collateral sources to determine if
the person’s stated wishes are
commensurate with that of:
– Previous medical records
– Family and loved ones
• Mental Capacity Act (2005)
– Capacity is assumed unless
disproven
– Capacity should be supported in as
many domains as possible
– Individuals must retain the right to
eccentric or unwise decisions
*If capacity to consent is raised, it must be
evaluated and considered.
Dementia & Consent
• People with dementia represent the largest
single group of adults affected by incapacity.
• Sample: 88 mild to moderately demented elderly
compared to 88 controls (Moye et al, 2004)
• Maintenance of Ability to:
Mild Dementia
Moderate
Dementia
Understanding
78-89%
33-49%
Appreciation
78%
51%
Reasoning
83-87%
70-76%
Expressing Choice
89%
82%
NEUROPSYCHOLOGICAL
TESTING
Neuropsychological Assessment
• Role of neuropsychological assessment:
– Assisting with differential diagnosis
– Clarifying areas of cognitive strength and
weakness
• Assisting in determination of capacity
– Treatment recommendations
Delirium vs. Dementia
• Overlapping features complicate differential
diagnosis
• Temporal course and reversibility
• Delirium  inattention; Dementia  memory
disturbance
• Spatial span forward (basic attention)
differentiated dementia from delirium (Meagher
et al., 2011)
Determining Capacity
• Evaluation of reasoning and understanding
• Only 56% judgment agreement among
physicians assessing capacity based on clinical
interview alone (Moye et al., 2003)
– Decision-making capacity: understanding,
appreciation, reasoning, and expression of choice
Determining Capacity
• Evaluation of reasoning and understanding
• Multiple self- and informant-report measures to
assess capacity, independence, etc.
– However, self-report data may over- or underestimate abilities; informants may be unable to
determine, or lack observation (Barbas et al., 2001)
Determining Capacity
• Neuropsychological testing: provides objective
data on general cognitive impairment and
cognitive strengths and weaknesses to bolster
judgments
– NP performance predicted decisional abilities serving
capacity in patients with mild to moderate dementia
(Gurrera et al., 2006)
– Measures of global impairment less useful than
measures of basic attention (Bassett et al., 1999)
Determining Capacity
• Initial decisional abilities: problems in
understanding and reasoning; subsequent
declines: further decrements in reasoning (Moye
et al., 2005)
– Baseline naming and Trails B best classified impaired
decisional capacity at 9 month follow-up
Case Presentation
• Ms. X
– 80 year old
– Right Handed
– African American female
– 11 Years of education
– Retired (formerly occupied as a maid and
factory worker)
– Right frontal menigioma diagnosed in 2008
Reason for Referral
• Concerns that tumor may be negatively
affecting her ability to make informed
decisions
– Recognize dangerous situations
– Identify when she is being taken advantage of
– Take her medication
– Tend to personal hygiene
Present Concerns
• Ms. X’s living situation
• Family members (grandchildren, great
grandchildren) engaging in illegal activities
(fighting, drug use) and stealing in her home
– Money being taken by or used for occupants
• Police action not permitted by Ms. X
– Concern that her grandchildren will be arrested
Background Information
• Right frontal meningioma diagnosed in 2008
– gamma knife therapy and steroids ( dizzy
spells)
• Periodic MRI scans
– MRI August 2010: diffuse cortical atrophy, white
matter changes, sub acute lacunar infarct in left
basal ganglia
• Anosmia
• Medications: allopurinol, omeprazole,
metroprolol, prednisone, aspirin,
dipyridamole, captropril, and Dilantin
Medical History
•
•
•
•
High blood pressure
No alcohol use last 10 years
No significant psychiatric history
Family history: Hypertension (mom),
Alzheimer’s Disease (sister)
Cognitive Symptoms
• Ms. X: Unable to describe reason for
undergoing evaluation or information
about medical history or medications
• Was able to answer yes/no questions
– Reported memory impairment; denied
difficulties in other cognitive domains
• Ms. X’s son: memory problems, irritability,
difficulty planning or organizing, and
forgetful of names, conversations,
appointments, and time and date
Behavioral Observations
• Eye glasses, difficulty hearing
• No abnormalities in gait and posture,
conversational speech, affect, or mood
– Paraphasias only on confrontation naming
• Alert and attentive
• oriented to the city, day of week, and
season, but not to the purpose of the
evaluation, date, year, month, or place
Premorbid Abilities
• Estimated low average to average range
(Barona FSIQ SS = 91)
– Word reading and knowledge lower (WRAT-4
Reading SS= 71) likely due to educational
attainment
General Cognitive Function
• Moderately impaired on cognitive
screening measure (MMSE = 16/30)
• DRS-2: Some cognitive domains impaired
(i.e., visuospatial, memory) but low
average to average language, construction
and basic attention
• Overall performance below expectation
given estimated premorbid abilities
Attention and Processing Speed
• Variable
– Basic attention (e.g., digit span, visual search)
at expected levels
– However, impaired and below expectation on
tasks with greater demands on working
memory (digit span) and speeded processing
(Trails A)
Learning and Memory
• Consistently impaired performance in
learning, spontaneous recall, and
recognition
– Four and 12 item word list
– Four visual signs
– Two sentences
Executive Functioning
• Variable
– Unable to complete a test of switching (Trails
B)
• Perhaps reflective of educational attainment
– Low average performance on another test of
strategy and switching (WCST)
• 1 of 6 categories, but consistent with expectation
relative to others her age
Language
• Intact conversational skills and social
comportment with fluent speech and
normal volume and prosody
• However, considerable difficulty on tests of
expressive and receptive language and
retrieval of information from semantic
memory
– Borderline to severely impaired on COWA,
NAB Naming, PPVT-IV
Visuospatial
• Intact visuospatial abilities
• Low average performance on a test of
visual construction (DRS-2)
Functional Abilities and Emotion
• Mild depression (GDS = 9/30)
• Given measure of practical knowledge to
articulate solutions to everyday problems
– Adequate practical problem solving, but lack of
experience or detail in responses  impaired overall
performance
• Given measure of judgment related to safety,
medical, social, and finance issues
– Practical solutions on some but vague/insufficient
responses on other items  impaired overall
performance
Functional Abilities and Emotion
• Patient and her son completed questionnaires
rating her competency and ADL’s
– Ms. X:
• No difficulties in self-care activities
• Some decrease in household chores
• Complete capacity with the exception of controlling her
temper
– Patient’s son:
•
•
•
•
Decrease in self-care and household chores
Financial irresponsibility
Considerable competency problems
Unawareness of difficulties
Summary
• Low average intellectual abilities
• Prominent cognitive impairment in memory
functioning
– Impaired performance on measures of learning,
retaining, and retrieving information
• Preserved basic attention, alertness, and
practical reasoning
– Adequate basic attention and practical problem
solving abilities, but difficulty with more complex
executive tasks
– Adequate practical judgment despite lower scores on
tests
Summary
• Pattern of performance consistent with a dementia of
mild severity characterized by prominent memory
impairment
• Adequate reasoning abilities for making decisions and
determinations
• Concerns regarding her safety and being taken
advantage of by those in her home are likely complicated
by personal and psychological factors
– Reluctance to proactively protect herself not due to inability to
recognize threats and articulate wishes, but rather disinclination
due to potential interference in her relations with grandchildren
Recommendations
• Due to memory impairment, recommended that
Ms. X continue to receive assistance with daily
medications, cooking, finances, and traveling
outside of the home
• Recommended that patient’s son contact the
City of Chicago Family and Support Services to
request detailed assessment of Ms. X’s living
environment to evaluate safety and ability to
advocate for herself with members of her family.
Conclusions
• Intact basic attention, understanding, and
reasoning  consistent with research
findings (Bassett et al., 1999; Moye et al.,
2005)
• However, impaired naming and cognitive
switching (Trails B)  follow-up evaluation
may be warranted (Moye et al., 2005)
– Interventions to maximize understanding and
reasoning by supporting naming, memory,
and flexibility
LEGAL & ETHICAL
CONSIDERATIONS
755 ILCS 40/25
Who makes the decision
for the client?
Health Care Providers must:
1.Find the Health Care Agent (POA or legal
guardianship): Exhaustively search the person’s
personal effects, medical record, and other sources to
locate the health care agent and telephone the person
within 24 hours of the time the person was found to
lack decisional capacity.
2. Select a Surrogate Decision Maker: If there is ‘no
health care agent,’ medical treatment decisions can be
made including refraining from life-sustaining treatment
without judicial involvement by the following people in
order of priority: the patient's guardian, spouse,
child, parent, sibling, grandchild, close friend,
estate guardian
*If multiple, majority consensus makes decision.
**This lasts until the person regains capacity or dies.
3. Initiate Civil Proceeding. Court-appointed
guardian.
How is the decision
made?
In order of priority:
•Advance directives of the client
– Designation of a Health Care Surrogate- "health care proxy" or a
"durable power of attorney for health care”
– Living Will
•Decisions made by surrogate conforming to the patients wishes
and values
– Including advanced directive voided on technicality
•Logic based on that the client would use to weigh pros & cons
•If wishes remain unknown after great deliberation, client’s best
interest.
*Independent Mental Capacity Advocate (IMCA) are individuals who
advocate to the decision-maker about the client’s values or wishes
Illinois Care Documentation
Advance Directives of the Patient
•Each health care facility shall maintain any advance directives proffered
by the patient or other authorized person, including a do not resuscitate
order, a living will, a declaration for mental health treatment, a declaration
of a potential surrogate or surrogates should the person become
incapacitated or impaired, or a power of attorney for health care, in the
patient's medical records. This Act does apply to patients without a
qualifying condition.
Surrogate Decision Maker Selection
•What methods were utilized to discover a health agent and the exact
time and number used to contact this person if identified.
•What rationale was used to identify a surrogate decision maker if a
health agent was not available. After a surrogate has been identified, the
name, address, telephone number, and relationship of that person to the
patient shall be recorded in the patient's medical record.
Protecting the Altered Client:
Financial Undue Influence
•
•
•
•
Susceptible victim
Confidential relationship
Active perpetrator
Monetary gain
• This concept is defined as follows in Illinois: 750 ILC
60/103 "Exploitation”- The illegal, including tortious, use
of a high-risk adult with disabilities or…. the
misappropriation of assets or resources of a high-risk
adult with disabilities by undue influence, by breach of a
fiduciary relationship, by fraud, deception, or extortion, or
the use of such assets or resources in a manner contrary
to law.
Protecting the Altered
Client: Elder Abuse &
Neglect
• Monitoring and
documenting signs of fear
or unusual or recurrent
illness patterns
• Recognizing that the person
in closest proximity to the
client may not be there for
the appropriate reason
• Reporting all suspected
cases to Adult Protective
Services
Protecting the Altered Client:
Caring for the Caregiver
– Dementia care givers reported lower
well-being, more depression, and
greater guilt than other caregivers
(Clip & George, 1993; Rabins et al,
1990)
– 35% of caregivers reported felt more
positive than non-caregivers (Rabins
et al, 1990)
• social support, familial
cohesiveness, and strong faith,
lessened the caregiver’s emotional
distress
Thank You
Sources
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Arnold, E. (2004). Sorting out the 3 Ds. Nursing, 34(6), 36-41.
Bellelli, G. (2010). Diagnosing delirium. JAMA, 304(19), 2124-2125.
Bellelli, G., Frisoni, G.B., Turco, R., Lucchi, E., Magnifico, F., Trabucchi, M. (2007).
Delirium superimposed on dementia predicts 12-month survival in elderly patients
discharged from a postacute rehabilitation facility. Journal of Gerontology and Bioloical
Medical Sciences, 62(11), 1306-1309.
Belzile, E. (2003). The course of delirium in older medical inpatients. Journal of General
Internal Medicine, 18(9), 696-704.
Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment.
Journal of the Royal Society of Medicine, 97, 415-420.
•
Clip, E.C., & George, L.K. (1993). Dementia and cancer: A comparison of spouse
caregivers. The Gerontologist, 33(4), 534-541.
•
Featherstone, I., Hopton, A., Siddiqi, N., (2010). An intervention to reduce delirium in care
homes. Nursing Older People, 22(4), 16-21.
Fick, D., Agostini, J., Inouye, S. (2002). Delirium superimposed on dementia: A systematic
review. Journal of the American Geriatrics Society, 50(10), 1723-1732.
Jackson, J.C., Gordon, S.M., Hart, R.P., Hopkins, R.O., & Ely, E.W. (2004). The
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Sources (cont’d)
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Meagher, D., Leonard, M., Donnelly, S., Conroy, M., Saunders, J., & Trzepacz, P.T. (2010).
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