1. Dementia & Delirium in Surgical Patients Damian Harding Department of Geriatric Medicine February 2008

2. Introduction Surgical patient population has changed..

3. 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.

4. Dementia Definitions and Epidemiology  Dementia

5. Dementia Definitions and Epidemiology  Dementia: “acquired loss of cognitive function due to an abnormal brain condition”

6. Dementia Definitions and Epidemiology  Dementia: “acquired loss of cognitive function due to an abnormal brain condition” Usually progressive Includes functional decline

7. 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!

8. Dementia Definitions and Epidemiology  Prevalence of all dementias in the >65 yr population is 6-8%

9. Dementia Definitions and Epidemiology  Prevalence of all dementias in the >65 yr population is 6-8%  Prevalence in >85yr population is 30%

10. 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

11. 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

12. Types of Dementia  At least 50-60% of people with dementia have Alzheimer’s Disease

13. Types of Dementia  At least 50-60% of people with dementia have Alzheimer’s Disease  Commonest types of dementia include:

14. 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)

15. Alzheimer’s Disease Neurodegenerative disease associated with:

16. Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits

17. Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)

18. Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)  Functional impairment

19. Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)  Functional impairment  Clear consciousness*

20. Alzheimer’s Disease Neurodegenerative disease associated with:  Cognitive deficits (including memory loss)  Functional impairment  Clear consciousness*  Change from previous level (>6 months duration)

21. 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

22. Alzheimer’s Disease is associated with specific changes in brain anatomy, chemistry and physiology

23.  Neurofibrillary tangles*  Amyloid plaques  Loss of cortical choline acetyltransferase activity and of cholinergic projection neurons in Nucleus basalis of Meynert*

24. 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

25. 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

26. Alzheimer’s Disease Clinical Features:

27. Alzheimer’s Disease Clinical Features: Cognitive

28.  Amnesia

29. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.

30. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia

31. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties

32. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia

33. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair

34. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair  Agnosia

35. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair  Agnosia Failure to recognise objects/ familiar faces

36. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair  Agnosia Failure to recognise objects/ familiar faces  Frontal executive dysfunction

37. Alzheimer’s Disease Clinical Features: Cognitive  Amnesia Misplace/ lose objects. Repeat same question.  Aphasia Word-finding difficulties  Apraxia Brush teeth, dress, comb hair  Agnosia Failure to recognise objects/ familiar faces  Frontal executive dysfunction (Capacity to consent for treatment)

38. Alzheimer’s Disease Clinical Features: Non-Cognitive

39.  Psychotic symptoms

40. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations

41. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems

42. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes

43. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes Apathy Overactivity/ agitation (wandering) Aggression Personality changes

44. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes Apathy Overactivity/ agitation (wandering) Aggression Personality changes  Abnormal sleep

45. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes Apathy Overactivity/ agitation (wandering) Aggression Personality changes  Abnormal sleep  Reduced appetite

46. Alzheimer’s Disease Clinical Features: Non-Cognitive  Psychotic symptoms Delusions, hallucinations  Mood problems  Behavioural changes Apathy Overactivity/ agitation (wandering) Aggression Personality changes  Abnormal sleep  Reduced appetite  Incontinence

47. Management of Alzheimer’s Disease and Dementias

48.  Biological

49. Management of Alzheimer’s Disease and Dementias  Biological  Social

50. Management of Alzheimer’s Disease and Dementias  Biological  Social  Psychological

51. Management of Alzheimer’s Disease and Dementias Depends on stage of disease Multifactorial and multidisciplinary

52. Management of Alzheimer’s Disease and Dementias Day therapy/ day hospital Day centres Respite careSocial worker Alzheimer’s Association Community (Silver Chain) support PsychologistPsychiatrist GeriatricianGP DieticianOT Physiotherapy Depends on stage of disease Multifactorial and multidisciplinar y

53. Care for Patients with Dementia Admitted for Surgery

54.  Admission Assessment

55. Care for Patients with Dementia Admitted for Surgery  Admission Assessment  Implementation of Care

56. Care for Patients with Dementia Admitted for Surgery  Admission Assessment  Implementation of Care  Discharge considerations

57. Care for Patients with Dementia: Admission Assessment

58.  Take history from patient and carer

59. Care for Patients with Dementia: Admission Assessment  Take history from patient and carer  What is patient’s usual level of function? (ADLs)

60. 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

61. 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?

62. 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?)

63. Care for Patients with Dementia: Implementation of Care

64. Environmental

65. Care for Patients with Dementia: Implementation of Care Environmental  Patient orientation

66. Care for Patients with Dementia: Implementation of Care Environmental  Patient orientation  Day/ night cycle

67. Care for Patients with Dementia: Implementation of Care Environmental  Patient orientation  Day/ night cycle  Remind patient of day/ time/ place/ why here

68. 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

69. 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..”

70. 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

71. Care for Patients with Dementia: Implementation of Care Physical

72. Care for Patients with Dementia: Implementation of Care Physical  Ensure patient receives usual medications

73. Care for Patients with Dementia: Implementation of Care Physical  Ensure patient receives usual medications  Beware of increased effects of abnormal physiology causing agitation/ drowsiness

74. 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)

75. Care for Patients with Dementia: Discharge considerations

76.  Attention to function (ADLs) and ability to return to previous environment

77.  If not sure: arrange OT, physiotherapy, geriatric medicine review

78.  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

79.  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

80.  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)