Dementia: acute care

1
Dementia acute care risks and issues

• Primary Care Dementia Summit
• 24th November 2009

2
Case history acute admission to hospital

• 3am saturday morning
• 87 year old female
• brought to Emergency Department by ambulance
• limited history
• paramedic notes found on floor at care home,
  not moving left side

3
Information available

• lives in Uplands nursing home
• dementia
• HTN
• arthritis
• ? previous stroke
• usual level of functioning/mobility - unknown
• medications - unknown

4
History and examination

• no information available from patient
• chattering, pleasantly confused, ?dysphasic
• attempted phone calls to NH for further history
  no answer repeatedly
• On Examination
• AMTS 3/10
• mildly dysphasic
• left sided weakness
• examination, obs - otherwise normal
• catheterised in emergency department due to
  incontinence

5
Diagnosis Plan

• Stroke (L hemiplegia)
• ? UTI (incontinent)

• MSU
• Trimethoprim
• Aspirin 300mg
• CT head
• NBM pending SALT assessment
• collateral history from NH
• establish regular medications
• get old notes
• transfer to stroke unit

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On stroke unit (day 1)

• CT Head old infarct
• Collateral history from daughter
• left sided weakness is longstanding
• collapsed getting off toilet
• Uplands NH is a RH!! usually mobile with ZF
• normally incontinent of urine
• unsure of usual meds
• mother not her usual self much more confused
• SU PTWR plan - not a stroke!
• transfer to
  general elderly care ward
• speak to GP/RH
  re-usual meds
• further
  background info

7
Moved to EC ward (day 2 3)

• agitated (by ward moves), prescribed lorazepam
• failed SALT assessment as drowsy continued
  NBM
• NGT passed for medications/ feeding
• BP low
• Bloods ?Na 124, ? K 5.9
• started on fluid restriction for hyponatraemia by
  SHO
• MSU no infection
• increasingly drowsy
• renal function deteriorating
• GP/RH not contacted weekend, busy

8
Old Notes Arrive! (monday morning)

• Medications
• Aspirin 75mg od
• Donepezil 5mg od
• Simvastatin 40mg nocte
• Prednisolone 5mg od
• Calcichew D3 forte 1 bd
• Alendronate 70mg /week
• Tolterodine XL 4mg od
• on Prednisolone for 20 years for Rheumatoid
  Arthritis!
• given stat Hydrocortisone, Pred restarted
• IV fluids

9
On EC ward (days 4 5)

• drowsiness resolved
• BP improved
• renal function and electrolytes improved
• reassessed by SALT and passed
• NGT removed
• catheter removed
• Plan - ?discharge home after physiotherapy
  assessment

10
Day 6 ? 35!!

• R/v by physio unable to wt bear, left leg
  painful
• X-ray fractured NOF!!
• discharge cancelled
• referred to Orthopaedics ? transferred to Ortho
  ward
• went to theatre
• lots of post-op complications exacerbated by
  delirium
• never regained prior level of physical or
  cognitive functioning
• on discharge to new NH fully dependent, hoisted

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Summary of issues

• Significant delay to diagnosis of hip fracture
• Wrong diagnosis of stroke (old)
• Inappropriate catherisation for incontinence
• NBM and NGT unnecessary
• Multiple unnecessary ward moves (4)
• Inappropriate sedative and other medications
• Undiagnosed pain
• Not given usual meds
• Hypotensive, low Na and renal failure
  (dehydration) due to steroid withdrawal and
  inappropriate fluid restriction
• Multiple iatrogenic illness due to misdiagnosis
  and inappropriate treatments - mainly as result
  of inadequate information, poor understanding
  training

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What are the risks for cognitively impaired
patients admitted to hospital?
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What are the risks for cognitively impaired
patients admitted to hospital?

• Inability to communicate symptoms
• Information gathering difficult for staff
  sometimes relies heavily on external source that
  may not be readily available, particularly out
  of hours
• Mismanagement due to lack of information, poor
  understanding, time and bed pressures, inadequate
  training
• Environmental changes - multiple ward moves,
  patients and staff
• Cluttered ward layouts, poor signage, other
  hazards
• Inappropriate prescribing
• Inadequate pain recognition and control
• Procedures e.g. catheter, NGT, blood tests, IV
  lines
• Poor supervision on the ward

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Leads to -

• Delay to diagnosis
• ? incidence of - delirium
• falls and
  fractures
• iatrogenic illness
• malnutrition
• dehydration
• hospital acquired
  infections
• ? length of stay
• ? subsequent institutionalisation
• ? mortality

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National Dementia Strategy

• Objective 8 improved quality of care for people
  with dementia in
• general hospitals
• 70 acute hospital beds occupied by older people
• Up to 50 of these have cognitive impairment
• Majority undiagnosed and not known to dementia
  services
• Challenging environment
• Worse outcomes LOS, mortality,
  institutionalisation
• Malnutrition and dehydration
• Not appreciated by clinicians, managers,
  commissioners
• Lack of leadership
• Insufficient staff knowledge
• Insufficient information gained from
  carers/families
• Poor discharge planning

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How do we go about improving services in general
hospitals for those with cognitive impairment?
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How do we go about improving services in general
hospitals for those with cognitive impairment?

• Better access to appropriate information i.e.
  communication! acute trust, primary care, care
  homes, family - IT
• Safer environment
• Avoid unnecessary ward moves
• Dementia link nurse community and hospital
• Mental health liaison team
• Improve prescribing sedative avoidance, pain
  recognition etc - pharmacist
• Training doctors, health professionals, medical
  school
• Promoting awareness families, professional
  bodies, experts, government, champions
• Policies/guidelines
• Better discharge planning with MDT and family
  involvement
• Audit research
• Financial support

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National Dementia Strategy

• Objective 8 improved quality of care for people
  
• with dementia in general hospitals
• To deliver improvement -
• Identification of senior clinician to take the
  lead for quality improvement in dementia in the
  hospital
• Development of an explicit pathway for the
  management and care of people with dementia in
  hospital
• Commissioning of specialist liaison older
  peoples mental health teams to work in general
  hospitals

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Falls and Dementia the risks

• 60 people with dementia fall, 2 that of cog
  normal peers
• 25 fallers with dementia fracture
• Poorer prognosis
• 70 6 month mortality after NOF
• Higher incidence of gait and balance disorders
• Medications sedatives, neuroleptics,
  anti-depressants, higher falls syncope risk
• Higher incidence of autonomic dysfunction, CSH,
  OH
• Parkinsonism drug SEs, lewy-body, vascular
• More co-morbidities

• Incontinence
• Wandering
• Reduced ability to observe environmental hazards
  and show caution
• Poor compliance with mobility aids
• Decreased ability to communicate symptoms
• Diagnostic challenges
• Difficulties with obtaining investigations
• Inability to comply with falls advice,
  interventions or treatment
• Evidence suggesting no benefit of falls
  interventions in patients with dementia

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Thank you