Dementia in the acute care setting The CLAHRC CP & DeNDRoN meeting Sept 2011 Dr Claire G Nicholl Consultant geriatrician, Addenbrookes

Declaration of interests Honoraria for lectures (Shire and Novartis) Sponsorship to attend the International Psychogeriatric Association 2007 meeting (Shire) and British Geriatrics Society meeting 2010.

What will be covered? In-patients (frail older people) Delirium, usually on background of dementia Organisation – Dementia Strategy Group Results from the National Audit of Dementia Specific projects: delirium unit, SHAPED, HIEC funding Overlap areas: management of vulnerable adults, pain management, falls prevention, feeding issues

Acute care pathway Patient arrives in ED RECOGNITION & ASSESSMENT Destination ward MULTIDISCIPLINARY MANAGEMENT & CARE Leaves hospital DISCHARGE PLANNING Arrows show ideal patient flow in hospital 4 hours

Acute care pathway Patient arrives in ED RECOGNITION & ASSESSMENT Destination ward MULTIDISCIPLINARY CARE Leave hospital DISCHARGE PLANNING Additional arrows show major information flows that need optimising HIECHIEC

Why is it hard to get basic information in dementia? Dementia / previous delirium not recognised or omitted from admission information Lack of detail from patient Something plausible Lack of detail from carer – distant or care setting Problem not apparent routine disrupted acute presentation Whether the person with dementia presents depends on the interaction brain environment (maze)

National Audit of Dementia 2010 Core audit (206/238 sites) Hospital organisational checklist (governance, care, mental health needs, discharge policy, information, recognition, training, resources, liaison psychiatry) Retrospective case-note audit (n=40) years, mean 82 (83) 75% from care of the elderly (44%) 2.5% from general medicine (33%) Median LoS 17 days (15) ie a huge challenge ahead!

Acute care pathway Patient arrives in ED RECOGNITION & ASSESSMENT Destination ward MULTIDISCIPLINARY CARE Leave hospital DISCHARGE PLANNING Delirium unit SHAPED pilot HIEC £HIEC £

Recognition - cognitive tests length sensitivity AMT Mini Mental State Examination (MMSE) Way forward? – Has Mrs Smith become more confused in the last year? – Has Mrs Smith become more confused in the last few days? – Are you / do you think Mrs Smith is depressed? What are we testing? What does the result mean?

MMSE of 24/30 Education Dementia Delirium Depression Deafness Poor vision English as a second language Dysphasia Limited cooperation

Addenbrooke’s initiatives Delirium unit thanks to Duncan Forsyth and his team Images showing use of colour to identify bays, clear signage using pictures and words visible from the bedside, red toilet seats, ‘café seating area, appropriate paintings etc – (see information from University of Stirling about design for dementia) Role of education for staff and carers Role of activities SHAPED see afternoon session (Gareth Peters and Clare Wai) Supported home assessment for people with dementia Scheme to allow elderly patients with dementia and delirium in hospital for whom discharge is considered ‘risky’ the opportunity to return home with live-in care for a 2 week period to see if their confusion decreases on discharge to a familiar environment. HIEC funding for improved education about dementia for all grades of hospital staff

Is the dementia the main problem? diseases fitness social factors ageing physiology

Management

What gets overlooked in dementia? Huge individual variation, stage and support General health: eyes, ears, feet Mood Other drugs The need to check – examine / tests The carer The plot

Feeding issues All frail older people in hospital need support to maintain hydration and nutrition (appropriate food, well cooked and served, in reach, appropriate utensils, help to eat and drink, encouragement to continue etc) – skill, time and resources People with dementia who are nearing the end of their life stop eating and drinking enough to meet their needs – education for carers, staff at all levels, evidence base, emotional support, feeding issues MDT. Tube feeding is rarely appropriate, nor is ‘nil-by-mouth’; comfort feeding is usually the aim. Mitchell SL. N Engl J Med 2009;361: Sampson EL. Cochrane Database Syst Rev 2009;2:CD