Assessing Physical Health Needs of People with Dementia Trudi Marshall Nurse Consultant Older People NHS Lanarkshire November 2015 Assessing Physical Health Needs of People with Dementia

Session Overview Disease / illness/ disability/ handicap Challenges in assessment Frailty Comprehensive Geriatric Assessment ( CGA)

World Health Organization definitions of disability. • Disease—an intrinsic pathology or disorder . . . [which] may or may not make [itself] evident clinically • Impairment—a loss or abnormality of structure or function at the organ system level • Disability—a restriction or lack of ability to perform an activity in a normal manner, a disturbance in the performance of daily tasks • Handicap—a disadvantage resulting from impairment or disability that limits or prevents fulfillment of a role that is normal

PATHOLOGY (DISEASE) IMPAIRMENT (SYMPTOMS & SIGNS) DISABILITY (FUNCTIONAL LOSS) HANDICAP (SOCIAL CONSEQUENCES)

Challenges in assessing physical health needs Multiple co-morbidities Polypharmacy Variable ADL functioning – disability and handicap Recognition, memory and communication of new symptoms – collateral history Over dependency on investigation , clinical findings Under recognised and under treated pain Management of frailty

Frailty Frailty is defined as "a state of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care, and mortality." (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004)

Frailty Frailty varies in severity (individuals should not be labelled as being frail or not frail but simply that they have frailty). The frailty state for an individual is not static; it can be made better and worse. Frailty is not an inevitable part of ageing; it is a long term condition in the same sense that diabetes or Alzheimer’s disease is.

Frailty Syndromes  Frailty syndromes can mask serious underlying illness and the response to a crisis call from a person with frailty should reflect the potential underlying illness and not the symptom itself.

Frailty Syndromes Falls (e.g. collapse, legs gave way, ‘found lying on floor’). Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’). Delirium (e.g. acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss). Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence). Susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).

Is it reversible ? Transitional frailty – eg hip fracture optimising protein intake and correcting vitamin D insufficiency  Strength and balance training Testosterone improves muscle strength but is also associated with adverse effects Growth hormone improves mass more than function angiotensin-converting enzyme inhibitors which appear to improve the structure and function of skeletal muscle

June Andrews Story https://www.youtube.com/watch?v=Fj_9HG_TWEM

Marjory Warren – “the mother of British Geriatrics”

Marjory Warren Medical director West Middlesex Hospital Responsible for 714 bed poor law workhouse infirmary when it merged with the hospital Patients described as “Incontinent, seizures, dementia, bed ridden, elderly sick, unmoved muscles” “For proper care, they require the full facilities of the general hospital” Created specialised geriatric assessment unit – the first in the UK Systematically assessed neglected, bedridden patients Determined capacity to improve Re-mobilised most. & returned many to own homes Pioneer of discharge planning (a revolutionary idea!!) And Comprehensive Geriatric Assessment Warren MW. Care of chronic sick. A case for treating chronic sick in blocks in a general hospital. BMJ 1943;ii:822–3. BMJ 1943 Warren MW. Care of the chronic aged sick. Lancet 1946;i:841–3.

Comprehensive Geriatric Assessment (CGA) “a multidimensional and usually interdisciplinary diagnostic process designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances in order to provide a coordinated and integrated plan for treatment and follow up.” Brittish Geriatric Society (BGS)2015

20 RCTs (10 427 participants) of in-patient CGA. Comprehensive geriatric assessment for older hospital patients systematic review and meta-analysis G Ellis, P Langhorne British Medical Bulletin 2005 71(1) 20 RCTs (10 427 participants) of in-patient CGA. In-patient comprehensive geriatric assessment (CGA) may reduce short-term mortality, increase the chances of living at home at 1 year and improve physical and cognitive function For every 100 patients undergoing CGA, 3 more will be alive and in their own homes compared with usual care Most of the benefit was seen for ward-based management units CGA does not reduce long-term mortality.

Aim of modern CGA The restoration of healthy function and independence, where possible, as well as minimising disability and distress. It is not just about initial assessment!

Multi-disciplinary team family Community support nurses Speech therapist pharmacist dietician Multi-disciplinary team Multi-disciplinary team geriatrician physiotherapist Local doctor Occupational therapist psychologist

Domains of CGA Delirium Medical Co-morbid conditions and disease severity Medication Review Nutritional status Pain Problem list Mental Health Cognition Delirium Mood and anxiety Fears Functional capacity Basic activities of daily living Gait and balance Activity/exercise status Instrumental activities of daily living

Social circumstances Informal support available from family or friends Social network such a visitors or daytime activities Eligibility for being offered care resources Environment Home comfort, facilities and safety Use or potential use of telehealth technology etc Transport facilities Accessibility to local resources

What should we be doing? Why is the patient here and who recognised the problem? What is the present functional level? What was the previous functional level and can we corroborate? Is there a medically reversible reason for the loss of function? If we cannot reverse all medical pathology, what can be modified?

What should we be doing? Which problems should be prioritised for intervention and what is the risk-benefit balance involved in acting on each? If not, can each be reversed by rehabilitation? If not, can the disability be overcome with equipment or services? If we cannot reverse all medical pathology, what can be modified? If the illness trajectory is irreversible, what can we do to optimise comfort, dignity and quality of life

ACP/ Ceiling of Treatment Is ACP in place ? Treatment plan to follow persons wishes What is persons short/ long term outcome ? If no action don't investigate

Questions