Dementia Delirium in Surgical Patients Damian Harding Department

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

Introduction Surgical patient population has changed. .

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.

Dementia Definitions and Epidemiology ¡ Dementia

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

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

Dementia Definitions and Epidemiology ¡ Dementia: “acquired loss of cognitive function due to an abnormal brain condition” l l ¡ Usually progressive Includes functional decline Memory loss and cognitive impairment are NOT features of normal aging!

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

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

Dementia Definitions and Epidemiology Prevalence of all dementias in the >65 yr population is 6 -8% ¡ Prevalence in >85 yr population is 30% ¡ Estimated annual cost reaches US$100 billion (2001) ¡ l l Direct care to individual Lost wages by caregivers

Dementia Definitions and Epidemiology ¡ ¡ ¡ Prevalence of all dementias in the >65 yr population is 6 -8% Prevalence in >85 yr population is 30% Estimated annual cost reaches US$100 billion (2001) l l ¡ Direct care to individual Lost wages by caregivers Significant emotional and personal costs

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

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

Types of Dementia At least 50 -60% of people with dementia have Alzheimer’s Disease ¡ Commonest types of dementia include: ¡ l l l Alzheimer’s Disease Vascular (multi-infarct) dementia Lewy body Dementia Alcoholic dementia (depression and pseudo-dementia)

Alzheimer’s Disease Neurodegenerative disease associated with:

Alzheimer’s Disease Neurodegenerative disease associated with: ¡ Cognitive deficits

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

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

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

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

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

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

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*

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

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

Alzheimer’s Disease Clinical Features:

Alzheimer’s Disease Clinical Features: Cognitive

Alzheimer’s Disease Clinical Features: Cognitive ¡ Amnesia

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

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

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

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

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

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

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

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

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

Alzheimer’s Disease Clinical Features: Non-Cognitive

Alzheimer’s Disease Clinical Features: Non-Cognitive ¡ Psychotic symptoms

Alzheimer’s Disease Clinical Features: Non-Cognitive ¡ Psychotic symptoms l Delusions, hallucinations

Alzheimer’s Disease Clinical Features: Non-Cognitive ¡ Psychotic symptoms l ¡ Delusions, hallucinations Mood problems

Alzheimer’s Disease Clinical Features: Non-Cognitive ¡ Psychotic symptoms l ¡ ¡ Delusions, hallucinations Mood problems Behavioural changes

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

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

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

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

Management of Alzheimer’s Disease and Dementias

Management of Alzheimer’s Disease and Dementias ¡ Biological

Management of Alzheimer’s Disease and Dementias Biological ¡ Social ¡

Management of Alzheimer’s Disease and Dementias Biological ¡ Social ¡ Psychological ¡

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

Management of Alzheimer’s Disease and Dementias Depends on stage of disease • Multifactorial and multidisciplinar y Day therapy/ day hospital Day centres Respite care Social worker Alzheimer’s Association Community (Silver Chain) support Psychologist Psychiatrist Geriatrician GP Dietician OT Physiotherapy

Care for Patients with Dementia Admitted for Surgery

Care for Patients with Dementia Admitted for Surgery ¡ Admission Assessment

Care for Patients with Dementia Admitted for Surgery Admission Assessment ¡ Implementation of Care ¡

Care for Patients with Dementia Admitted for Surgery Admission Assessment ¡ Implementation of Care ¡ Discharge considerations ¡

Care for Patients with Dementia: Admission Assessment

Care for Patients with Dementia: Admission Assessment ¡ Take history from patient and carer

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

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 ¡

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? ¡

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? ) ¡

Care for Patients with Dementia: Implementation of Care

Care for Patients with Dementia: Implementation of Care Environmental

Care for Patients with Dementia: Implementation of Care Environmental ¡ Patient orientation

Care for Patients with Dementia: Implementation of Care Environmental ¡ ¡ Patient orientation Day/ night cycle

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

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

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. . ”

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

Care for Patients with Dementia: Implementation of Care Physical

Care for Patients with Dementia: Implementation of Care Physical ¡ Ensure patient receives usual medications

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

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: l l Anaesthesia Analgesia (and bowels) Anti-emetics Fluids (and electrolytes)

Care for Patients with Dementia: Discharge considerations

¡ Attention to function (ADLs) and ability to return to previous environment

Attention to function (ADLs) and ability to return to previous environment ¡ If not sure: arrange OT, physiotherapy, geriatric medicine review ¡

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 ¡

¡ ¡ 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

¡ ¡ ¡ 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)