Mental Health Services For Older People

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Mental Health Services For Older People

• UNDERSTANDING AGITATION CONFUSION AND THE
  POSSIBLE CAUSES IN OLDER PERSONS

Stephen Merrett - Oct 2001
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Older Person Presents With Agitation And Confusion
Is It A Delirium ?
Investigate And Treat Physical Causes First
Maintain Safety Of Client And Others
Physically Clear ?
Observe/Gather Information To Clarify Cause
? Depressive Disorder
? Dementia Syndrome
? Delusional Disorder
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INTRODUCTION
UNDERSTANDING AGITATION CONFUSION AND THE
POSSIBLE CAUSES IN OLDER PERSONS
Definition of Key Terms AGITATIONCONFUSIONHALLUC
INATIONSORIENTATION
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NB
Agitation and confusion should be viewed as
symptoms of an underlying cause, with
interventions aimed at establishing a diagnosis
and addressing the underlying cause/s
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AGITATION - Definition

• Acute restlessness both physically and
  mentally. Examples of behaviours that may be
  observed include
• Pacing
• Hand wringing
• Inability to remain seated or still for even a
  short period of time
• Inability to maintain a conversation.
• Shifting or poor eye contact
• Seem uncomfortable or have difficulty getting
  comfortable
• Short tempered or easily frustrated
• Anxious and/or preoccupied

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CONFUSION - Definition

• A complex presentation including, perplexity,
  bewilderment, failing memory and a clouding of
  consciousness.
• Examples of behaviours that may be observed
  include
• Appear perplexed, bewildered or uncertain
• Difficult to engage in conversation
• Unable to remain focused on a task
• Difficulty understanding what is said to them
  (answers only partially related to questions)
• Inappropriate behaviour (eg. voiding in
  inappropriate places)

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HALLUCINATIONS - Definition

• A false perception in the absence of external
  stimuli. The patient believes he/she sees,
  smells, hears, tastes or feels an object or
  person when there is no basis in the external
  environment for this belief. Examples of
  behaviours that may be observed include
• Responding to something not seen, felt or heard
  by others
• Answering/responding to sounds or voices that no
  one else can hear
• Unusual attention focused on an ordinary object
• Attempting to get away from something not seen by
  others
• Unusual appearance (dress) or behaviour

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ORIENTATION - Definition

• Awareness of self, place, time and situation.
  Examples of behaviours that may be observed when
  someone is disorientated include
• Getting lost in familiar surroundings
• Continually seeking information from others to
  assist with orientation (where am I, what day is
  it)
• Missing appointments
• Behaviour out of context with time and place (eg.
  getting dressed at 0200 hrs)

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DELIRIUM
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DELIRIUM

• DEFINITION
• KEY FEATURES
• USEFUL SCREENS
• STANDARD TESTS
• VULNERABILTY
• MANAGEMENT
• ALERTS

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DELIRIUM - DEFINITION

• A clinical state characterized by an acute,
  fluctuating change in mental status, with
  inattention and altered levels of consciousness.

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DELIRIUM - KEY EATURES

• Acute, rapid onset over minutes to days.
• Consciousness is clouded
• Usually rapid or slow speech
• Enhanced startle response
• Disturbed sleep/wake cycle with insomnia
• Confusion worsens toward evening
• Nightmares and/or visual hallucinations and/or
  delusions
• Symptoms fluctuate over the course of a day or
  even over minutes

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DELIRIUM - KEY EATURES Cont.

• Distressing and unpleasant for the sufferer
• Frightened, irrational and unpredictable
  behaviour
• Awareness of the surrounding environment is
  reduced
• Impaired ability to focus, shift or sustain
  attention
• Impaired immediate recall and short term memory
• Disorientation in time, place or person
• Rapid shifts from under to over activity
• Slowed reactions

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DELIRIUM - USEFUL SCREENS

• Exclude physical causes eg
• Infections
• Respiratory function
• Cardiac function
• Hydration / Nutrition
• Constipation
• Serum levels

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DELIRIUM - STANDARD TESTS

• Related to suspected causes identified from
  screens listed previously and may include
• MSSU (Urine Culture)
• Full Blood Count (ESR)
• B12 and Folate
• Biochem (LFT)
• Medication serum levels
• Chest X-ray
• CT Head
• TFT
• Others as appropriate

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DELIRIUM - STANDARD TESTS Cont.

• Usual Dementia screens are
• CBP
• TFT
• B12 Folate
• Biochem
• Syphilis serology
• CT Head
• Chest X-Ray
• ECG
• Mini Mental State Examination

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DELIRIUM - VULNERABILTY

• Most common causes are Medications and Infections
• The elderly
• Older people post GA
• Dementia sufferers
• Older persons with
• Strokes and Transient Ischaemic attacks
• Cardiac failure/arhthymias
• Anaemia
• Hypoxia from respiratory failure

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DELIRIUM - VULNERABILTY Cont.

• Uraemia
• Liver or kidney failure
• Electrolyte imbalance
• Acidosis or alkalosis
• Pre or post epileptic seizure
• Hypo or hyper Thyroidism
• Hypo or hyperglycaemia
• Concussion or sub-dural haematoma following a
  fall
• Blood loss

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DELIRIUM - MANAGEMENT

• Diagnosis and treatment of underlying disorders,
  removal of contributing factors, behavioural and
  environmental strategies, and support of the
  patient and family.
• Cautious use of medications to minimize
  challenging behaviours

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DELIRIUM - ALERTS

• Is associated with significantly increased
  resource utilization, morbidity, and mortality.
• Attempting to manage challenging behaviours with
  certain medications will lead to a worsening of
  the Delirium
• If mistaken for a non reversible dementia then
  premature placement in a residential care
  facility may occur
• Unresolved Delirium can result in death

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DELIRIUM MANAGEMENT GUIDE

• Useful Strategies Include
• Simple, but firm communication
• Adequate lighting
• Reduction of intense stimulation
• Unit-wide noise reduction
• Diurnal variation in noise and lighting
• Reality orientation

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DELIRIUM MANAGEMENT GUIDE

• Cont.
• Presence of a relative
• Hydration and nutritional support
• Use of sensory aids
• Use of single room
• Maintain activity levels
• Medication - as a last resort

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OBSERVATIONS AND INFORMATION GATHERING
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Observations/Information Gathering

• SCREENS
• MEDICATIONS
• HISTORY
• PRESENTATION
• NEUROVEGETATIVE FEATURES
• COGNITION

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SCREENS

• May Include
• Full Blood Count (ESR)
• MSSU (Urine Culture)
• TFT
• B12 and Folate
• Biochem (LFT)
• Medication serum levels
• Chest X-ray
• CT Head
• Others as appropriate

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MEDICATIONS

• Obtain a full list of current medications
  actually taken by client including over the
  counter medications
• Note recent medication changes including
• medications ceased
• doses changed
• brand change
• timing of dose
• Consider compliance issues, interactions , etc

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HISTORY

• Obtain a full history from both client and carer
  about
• Presenting problem/s - description of symptoms
• Personal/Social History - significant events
• Alcohol or substance abuse
• Onset, progression and duration of symptoms
• Previous medical and/or psychiatric history
• Daily living skills
• Functional abilities/limitations vision,
  hearing, mobility 

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PRESENTATION

• Appearance
• Behaviour
• Affect
• Mental State
• Perception
• Thought processes
• Conversation

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NEUROVEGETATIVE FEATURES

• Sleep
• Appetite/weight/bowels
• Motivation/energy
• Libido
• Diurnal mood variations
• Use Geriatric Depression Scale (Short Form) if
  thought useful

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COGNITION

• Level of awareness/consciousness, note any
  clouding.
• Memory immediate, recent, remote
• Orientation time, place, person, situation.
• Attention and concentration.
• Fund of information.
• Abstract or concrete thinking.
• Judgment and insight
• Use Mini Mental State Examination (MMSE)

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DEPRESSION
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DEPRESSION

• DEFINITION
• KEY FEATURES
• USEFUL SCREENS
• STANDARD TESTS
• VULNERABILTY
• MANAGEMENT
• ALERTS

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DEPRESSION - DEFINITION

• A pervasive and persistent change in mood
  characterised by depressed mood and loss of
  interest or pleasure in life.

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DEPRESSION - KEY FEATURES

• Depressed mood
• Loss of interest
• Loss of energy
• Reduced concentration
• Reduced self esteem
• Guilt
• Pessimism
• Tendency to underestimate cognitive functioning
• Altered sleep
• Decreased appetite
• Self harm/suicide
• Psychotic features

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DEPRESSION - SCREENS

• Possible use of Depression Scales eg.
• Geriatric Depression Scale
• Montgomery-Asberg Depression Scale (MADRS)
• Hamilton Depression Scale

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DEPRESSION - TESTS

• Exclude physical changes
• Biochem
• CBP
• B12 Folate
• Thyroid studies
• Chest Xray

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DEPRESSION - VULNERABILTY

• History of depression
• Social isolation
• Chronic health problems
• Chronic pain
• Losses

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DEPRESSION - MANAGEMENT

• Medical assessment
• Supportive psychotherapy
• Exploration of family and social circumstances
• Management anxiety
• Medication

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DEPRESSION - ALERTS

• Self harm
• Psychotic features
• Marked weight loss/ refusal sustenance
• MAD BLUE (high risk group)
• Male
• Alcohol
• Depressed
• Bereaved
• Lonely
• Unwell
• Elderly

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DEMENTIA
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DEMENTIA

• DEFINITION
• KEY FEATURES
• USEFUL SCREENS
• STANDARD TESTS
• VULNERABILITY
• MANAGAMENT
• ALERTS

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DEMENTIA - DEFINITION

• Not a single disease but a syndrome of which
  there are many causes.
• The development of multiple cognitive deficits
  including memory impairment and one or more of
  the following,
• Aphasia loss of the ability to use/understand
  words
• Apraxia loss of the ability to execute or carry
  out learned (familiar) movements
• Agnosia a failure of recognition, visual,
  auditory or tactile
• Disturbance in executive functioning problem
  solving, planning skills

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DEMENTIA - KEY FEATURES

• Decline in memory and other areas of thinking
• Tendency to over estimate cognitive functioning
• Decline in social domestic occupational
  functioning
• Changes in personality
• Changes in behaviour

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DEMENTIA - USEFUL SCREENS

• Mini Mental State Examination (MMSE)
• Lawton Instrumental Activities of Daily Living
  (IADL) Scale
• Alzheimer Disease Assessment Scale Cognitive
  sub Set (ADAS-Cog)

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DEMENTIA - STANDARD TESTS

• Biochem
• CBP
• TFT
• B12 and Folate
• Syphilis Serology
• CT Head
• Chest X-ray
• ECG

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DEMENTIA - VULNERABILTY

• Age
• Gender (female)
• Education
• Circulatory illness

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DEMENTIA - MANAGEMENT

• Medical referral to diagnose and treat reversible
  causes
• Possible referral to specialist for medication
  (Alzheimers )
• Care and education to individual referral to
  support services
• Education and support to family
• Planning for the future

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DEMENTIA - ALERTS

• Depression may occur / coexist
• Safety needs to be considered
• Psychotic and behavioural issues are common
•  

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DELUSIONAL DISORDER
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DELUSIONAL DISORDER

• DEFINITION
• KEY FEATURES
• USEFUL SCREENS
• STANDARD TESTS
• VULNERABILITY
• MANAGEMENT
• ALERTS

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DELUSIONAL DISORDER - DEFINITION

• A delusion is a false belief which is
  inconsistent with the patient's sociocultural
  background and held with absolute and unshakeable
  conviction.

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DELUSIONAL DISORDER - KEY FEATURES

• The nature of the disorder ensures that sufferers
  are quite insightless and cannot be talked out of
  their peculiar beliefs, which they are often keen
  to share and may include
• Persecutory delusions are most common eg.
• Being watched by others
• Punished or treated badly by others
• Possessions are being stolen
• Jealous preoccupation with presumed infidelity of
  a spouse
• Grandiose delusions are less common but can occur
• Convictions that some physical disease or defect
  is present
• Are often bound up with the persons home
  environment

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DELUSIONAL DISORDER - USEFUL SCREENS

• Exclude underlying physical causes
• Mini Mental State Examination to gauge cognitive
  functioning
• History of symptoms

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DELUSIONAL DISORDER - STANDARD TESTS

• Dementia screens i.e. CBP, TFT, B12 Folate,
  Biochem, Syphyliss serology, Chest X-ray, ECG
• MSSU
• Medication serum levels

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DELUSIONAL DISORDER - VULNERABILTY

• Female with the following
• Socially isolated
• Have impaired hearing
• Have had a suspicious, sensitive premorbid
  personality
• Dementia sufferers ( Lewy Body)
• Those with Depression
• Past history of a psychotic disorder eg.
• Schizophrenia
• Bipolar Affective Disorder

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DELUSIONAL DISORDER - MANAGEMENT

• Establish differential diagnosis
• Treat underlying causes
• Maintain safety of client and others - person may
  act on their delusional beliefs
• Rather than confronting the beliefs directly it
  is preferable to concentrate on the distress
  experienced by the sufferer

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DELUSIONAL DISORDER - ALERTS

• Person may act in a way that is appropriate to
  their delusional beliefs and can include
• self harm
• harming others
• making decisions based on delusional beliefs
• If not correctly diagnosed then a depressive
  disorder or dementia may be left untreated
• If not correctly diagnosed, the medications
  selected can lead to a worsening of the
  situation. E.g. Lewy Body Dementia
•  

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SUMMARY
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SUMMARY

• DELIRIUM
• DEPRESSION
• DEMENTIA
• DELUSIONAL DISORDER

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DELIRIUM - Suspect If -

• Rapid onset of symptoms, i.e. over hours, days or
  weeks
• Fluctuating level of consciousness, may vary hour
  to hour
• Difficulty in engaging and maintaining the
  persons attention
• Disturbed sleepwake cycle
• Recent history of physical illness, medication
  changes, trauma

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DEPRESSION - Suspect If -

• A person looks or acts sad
• Looses interest in activities
• Complains of loss of energy
• Expresses suicidal ideas or thoughts of life not
  being worth living
• Makes frequent complaints of physical problems
  with no physical basis.

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DEMENTIA - Suspect If -

• Loss of memory, particularly short term memory
• Confusion,
• Disorientation
• Change in ADL or Executive functioning

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DELUSIONAL DISORDERS

• A belief system which is inconsistent with the
  patient's sociocultural background, (i.e. it
  seems highly unlikely that the belief is true)
  and guides and determines behaviour.
• Is held with absolute and unshakeable conviction,
  i.e. the person refuses to consider alternative
  explanations.
• Delusions may be a feature of Depression or
  Dementia
• In dementia, delusions are most often of theft
  and suspicion.
• In Depression, delusions are most often of
  poverty, guilt, nihilistic ideas that bodily
  parts are absent, rotting or shrinking

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NB

• Purposefully exclude a Depressive Pseudo Dementia