Download Dementia & Delirium in Surgical Patients - E-Ageing: E

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
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
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


Aphasia


Misplace/ lose objects. Repeat same question.
Word-finding difficulties
Apraxia
Alzheimer’s Disease Clinical Features:
Cognitive

Amnesia


Aphasia


Misplace/ lose objects. Repeat same question.
Word-finding difficulties
Apraxia

Brush teeth, dress, comb hair
Alzheimer’s Disease Clinical Features:
Cognitive

Amnesia


Aphasia


Word-finding difficulties
Apraxia


Misplace/ lose objects. Repeat same question.
Brush teeth, dress, comb hair
Agnosia
Alzheimer’s Disease Clinical Features:
Cognitive

Amnesia


Aphasia


Word-finding difficulties
Apraxia


Misplace/ lose objects. Repeat same question.
Brush teeth, dress, comb hair
Agnosia

Failure to recognise objects/ familiar faces
Alzheimer’s Disease Clinical Features:
Cognitive

Amnesia


Aphasia


Brush teeth, dress, comb hair
Agnosia


Word-finding difficulties
Apraxia


Misplace/ lose objects. Repeat same question.
Failure to recognise objects/ familiar faces
Frontal executive dysfunction
Alzheimer’s Disease Clinical Features:
Cognitive

Amnesia


Aphasia


Brush teeth, dress, comb hair
Agnosia


Word-finding difficulties
Apraxia


Misplace/ lose objects. Repeat same question.
Failure to recognise objects/ familiar faces
Frontal executive dysfunction

(Capacity to consent for treatment)
Alzheimer’s Disease Clinical Features:
Non-Cognitive
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



Mood problems
Behavioural changes





Delusions, hallucinations
Apathy
Overactivity/ agitation (wandering)
Aggression
Personality changes
Abnormal sleep
Alzheimer’s Disease Clinical Features:
Non-Cognitive

Psychotic symptoms



Mood problems
Behavioural changes






Delusions, hallucinations
Apathy
Overactivity/ agitation (wandering)
Aggression
Personality changes
Abnormal sleep
Reduced appetite
Alzheimer’s Disease Clinical Features:
Non-Cognitive

Psychotic symptoms



Mood problems
Behavioural changes







Delusions, hallucinations
Apathy
Overactivity/ agitation (wandering)
Aggression
Personality changes
Abnormal sleep
Reduced appetite
Incontinence
Management of Alzheimer’s Disease
and Dementias
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
Depends on
stage of
disease
•Multifactorial
and
multidisciplinar
y
Day therapy/ day
hospital
Day centres
Respite care
Social worker
Alzheimer’s
Association
Community (Silver
Chain) support
Psychologist
Psychiatrist
Geriatrician
GP
Dietician
OT
Physiotherapy
Care for Patients with Dementia
Admitted for Surgery
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
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
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


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)