Dementia: acute care – risks and issues

Primary Care Dementia Summit

24th November 2009

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

Information available

• lives in Uplands nursing home• ‘dementia’• HTN• arthritis• ? previous stroke

• usual level of functioning/mobility - unknown

• medications - unknown

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

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

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

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’

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

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

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

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

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

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

Leads to -

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

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

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

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

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 people’s mental health teams to work in general hospitals

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 SE’s, 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

Thank you