dementia & delirium in surgical patients damian harding department of geriatric medicine...

Dementia & Delirium in Surgical Patients

Damian HardingDepartment of Geriatric MedicineFebruary 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.

DementiaDefinitions and Epidemiology

Dementia


Dementia: “acquired loss of cognitive function due to an abnormal brain condition”


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


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!


Prevalence of all dementias in the >65 yr population is 6-8%



Prevalence in >85yr population is 30%



Prevalence in >85yr population is 30%

Estimated annual cost reaches US$100 billion (2001) Direct care to individual Lost wages by caregivers



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


Commonest types of dementia include:

Types of Dementia


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:



Cognitive deficits



Cognitive deficits (including memory loss)




Functional impairment




Functional impairment Clear consciousness*




Functional impairment Clear consciousness* Change from previous level

(>6 months duration)


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*




Multifactorial genetic component




Multifactorial genetic componentCT/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


Amnesia Misplace/ lose objects. Repeat same question.



Aphasia



Aphasia Word-finding difficulties




Apraxia




Apraxia Brush teeth, dress, comb hair





Agnosia





Agnosia Failure to recognise objects/ familiar faces






Frontal executive dysfunction






Frontal executive dysfunction (Capacity to consent for treatment)

Alzheimer’s Disease Clinical Features: Non-Cognitive


Psychotic symptoms


Psychotic symptoms Delusions, hallucinations



Mood problems



Mood problems Behavioural changes




Apathy Overactivity/ agitation (wandering) Aggression Personality changes





Abnormal sleep





Abnormal sleep Reduced appetite





Abnormal sleep Reduced appetite Incontinence

Management of Alzheimer’s Disease and Dementias


Biological


Biological Social


Biological Social Psychological


Depends on stage of disease Multifactorial and

multidisciplinary


Day therapy/ day hospital

Day centres

Respite care Social worker

Alzheimer’s Association

Community (Silver Chain) support

Psychologist Psychiatrist

Geriatrician GP

Dietician OT

Physiotherapy

Depends on stage of disease

•Multifactorial and multidisciplinary

Care for Patients with Dementia Admitted for Surgery


Admission Assessment


Admission Assessment Implementation of Care


Admission Assessment Implementation of Care Discharge considerations

Care for Patients with Dementia: Admission Assessment


Take history from patient and carer


Take history from patient and carer What is patient’s usual level of

function? (ADLs)



function? (ADLs) Patient’s usual daily routine



function? (ADLs) Patient’s usual daily routine Are patient and carer currently

coping at home?



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


Environmental Patient orientation


Environmental Patient orientation Day/ night cycle


Environmental Patient orientation Day/ night cycle Remind patient of day/ time/ place/ why

here



here Allow family/ carers to stay longer/ use of

phone/ photograph prompts




phone/ photograph prompts Consider use of visual prompts “This is

the bathroom”/ “I had knee surgery 2 days ago”/ “My nurse is..”




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


Physical


Physical Ensure patient receives usual medications


Physical Ensure patient receives usual medications Beware of increased effects of abnormal

physiology causing agitation/ drowsiness


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



Patient may benefit from ongoing restorative care




Patient may require increased long term level of care




Patient may require increased long term level of care

Ensure good communication to patient and carers (reduce stress and confusion)

dementia & delirium in surgical patients damian harding department of geriatric medicine...

Documents

epidemiology dementia

dementia definitions

alzheimers disease slide

pseudodementia slide

dementia delirium

cognitive deficits slide

memory loss slide

functional decline slide