Older People with Cognitive Decline at home: Pushing the Limits

Dr Ronald Morgan

Some important facts

What is dementia? (cf delirium) How to diagnose Classification What tests should I carry out? How might it be managed

What is dementia?

Global impairment of memory, intelligence (attention, language, problem solving) and personality in the setting of clear consciousness and of greater than 3 months duration

Prevalence of dementia

Over 65s 5%

Over 80s 20%

What about delirium?

Recent onset of:

Fluctuating awareness Impairment of memory & attention Disorganised thinking

Delirium cont.

In addition there may be:

Hallucinations Disturbance of sleep – wake cycle

Confusion Assessment Method

1. Acute onset & fluctuating course

2. Inattention

3. Disorganised thinking

4. Altered level of consciousness

Diagnosis requires 1 and 2 plus either 3 or 4

How do you recognise dementia?

Abbreviated Mental Test Score (AMTS)

Mini Mental State Examination (MMSE)

Clock drawing test

AMTS

1. Age 6. Recall

2. Date of birth 7. Recognition 2 people

3. Year 8. Monarch

4. Time (nearest hr.) 9. WW1 or 2

5. Place 10. Count 20 to 1

AMTS interpretation

No half marks to be given

A score of 7 or less is abnormal, but is not diagnostic of any condition

MMSE

30 point score:

Orientation in time 5

Orientation in place5

Attention & calc. 5

Registration 3

Recall 3

MMSE continued

Language 9

naming 2

repetition 1

3 stage command 3

reading 1

writing 1

copying 1

MMSE interpretation

Greater than 24 is normal

Less than 20 is abnormal

20 – 24 may indicate dementia

NB Hearing, eyesight, education

Do serial tests if unsure

Clock drawing test

Draw in the numbers and hands on the clock face setting the time to 10 past 11

Clock test – simple interpretation

Circle 1

Numbers in correct order 1

Numbers in special order1

Hands 1

10 past 11 1

4 or 5 is normal

Types of dementia (1)

Common:

Alzheimers (35%) Vascular (20%) – many types Dementia with Lewy bodies (15%) Alcoholic

Types of dementia (2)

Less common: Creutzfeldt – Jakob (sporadic & new variant) Huntingdons AIDS related Parkinson’s disease Frontotemporal (Pick’s disease) – 5% Down’s syndrome Trauma or toxic injury

Types of dementia (3)

Treatable (about 5% of total): Hypothyroidism Vitamin B12 deficiency Folate deficiency Normal pressure hydrocephalus Tumour (1º, 2º or paraneoplastic) Depressive pseudodementia Syphilis

What tests should I carry out?

FBC, U & Es, LFTs, calcium, B12, folate, TSH, CRP

CXR

CT or MRI

(but do examine the patient first!)

Management

Pharmacological: Aspirin, statin, antihypertensive for vascular

Cholinesterase inhibitors for Alzheimers

(but see NICE guidelines)

Ethical issues

Capacity Right to self determine Patient’s rights versus rights of family & neighbours Advance directives (advance statements, living wills) Food & drink refusal – swallow normal

swallow abnormal Do not resuscitate Do not admit to hospital

Case study 1

1 MS, an 84 year old woman brought into hospital for emergency repair of strangulated hernia. Very confused both pre and post op. MMSE 5/30. Her short term memory is virtually non existent.

Transferred to Sydenham House for ‘rehab.’ Physically very well though has no recollection of operation or why

she isn’t at home.Wanders around the unit asking to be taken home.Family extremely concerned about her return home, saying she is

at risk.Questions1 Does she have capacity to determine her future?2 How would you assess her ability to manage at home ?

Case study 2

2 FH is an 86 year old woman who has suffered a left sided CVA which has left her with some expressive dysphasia. Her comprehension of language seems to be intact. She is physically well. She expresses a desire to go home but her 3 sons think she should go into Residential Care. ( 1 son in France, 1 in Yorkshire, 1 local but doesn’t drive). In the past she has refused carers

She is taken on a home visit (lives in sheltered housing) and becomes distressed at home as she equates home with the family home that she lived in for many years but hasn’t lived in for several years now.

1 Does she have capacity? 2 Should her wish to go home be honoured 3 Are her sons acting in her best interests?

Case study 3

3 You are asked to see an 80 year old woman resident at one of the local Care homes. She has a 5 year history of Alzheimer’s disease and remains physically quite well. The carers tell you that she is refusing to eat (& sometimes to drink), other than a few tea spoons. Mostly she just pushes away the person who tries to feed her.

When you see her she is very amiable and on examination there are no abnormalities. You perform routine bloods and all is normal. In particular, you watch her drinking a cup of tea and her swallow seems to be intact.

What do you do next? How will you manage the situation?

Case study 4

4 Albert is a 75 year old man who has vascular dementia. He retains some insight into his condition, but has become a bit disinhibited. He telephones his son who lives nearby, about 15 times during the evening and night. If the neighbours are a bit noisy (they have teenage daughters) he bangs on the wall with a broom and swears vociferously.

He regularly wanders in his garden in a state of undress and generally appears unkempt. His son ensures that he has food in the house but cannot provide more care as he looks after his own wife who has MS and their 2 teenage children.

Devise an action plan to deal with this man.

Criteria for decision making

P must be able to comprehend the information relevant to the decision

P must be able to retain this information P must be able to use and weigh the

information in order to arrive at a choice P must be able to communicate their choice

Capacity & Incapacity – general principles

There is a legal presumption that adults have capacity to make decisions unless the contrary is proven

Patients should not be regarded as incapable of making or communicating a decision unless all practical steps have been taken to maximise their ability to do so

Greater evidence of capacity will be required for decisions that have serious implications

Adults with Capacity

Assume P has capacity unless proven otherwise

Health teams not required to offer treatment that is inappropriate

Where P requests life prolonging treatment that is able to achieve its physiological aim, there is an expectation that it will be provided

Adults with capacity

If P refuses life prolonging treatment then that refusal must be respected

Requests for, or refusals of, artificial N & H should be respected

P may plan for future care by making an advance decision or in E, W & S by appointing a welfare attorney

Adults with capacity - communication

P should be given sufficient information to make an informed decision and should be encouraged to be involved in decision making

P’s preferences about treatment should form a central part of deciding care plans

Communication cont.

Efforts should be made to comply with reasonable requests from P about the provision of life prolonging treatment

Although health professionals may find it difficult when P refuses treatment, the decision of whether to accept or reject treatment offered rests with P

Adults who lack capacity

Incapacity relates to the time when a decision has to be made & on the particular matter to which the decision relates.

Incapacity can be partial, temporary or even fluctuate.

A person may lack capacity in relation to one matter but not another.

Adults who lack capacity – cont.

Incapacity must be caused by an impairment of or disturbance in functioning of the mind or brain.

Can be caused by psychiatric illness, learning disability, dementia, brain damage or delirium.

Determinations of a person’s capacity MUST NOT BE MADE merely on the basis of the person’s age, appearance or behaviour

Adults who lack capacity

In E & W an adult with capacity may appoint a welfare attorney to give or withhold consent to medical treatment on his or her behalf once capacity is lost.

Mental Capacity Act 2005 – in force from October 2007

Lasting Power of Attorney (LPA)

Welfare attorneys acting under an LPA are bound by general principles of Mental Capacity Act:

P is assumed to have capacity until proven otherwise

P is not to be treated as unable to make decision unless all practical steps to help him to do so have been taken without success

General principles cont.

P is not to be treated as unable to make a decision merely because he makes an unwise decision

A decision made under this Act for or on behalf of a person who lacks capacity must be in his best interests

Before decision is made it must be clear that the result cannot be as effectively achieved in a way that is less restrictive of P’s rights and freedom of action

Patients with an LPA

If P has appointed a welfare attorney with authority to make medical decisions, this person must be consulted & give consent before treatment is provided (except in emergencies)

The authority of welfare attorneys only extends to life prolonging treatment if that is specifically stated in the LPA

Where there is disagreement about best interests The Court of Protection may be involved

Advance decisions

Where P has lost decision making capacity but has a valid advance decision refusing life prolonging treatment (including ANH) this must be respected

Advance decisions - criteria for validity

P was 18 years or older when it was made P had capacity when it was made Advance decision sets specific treatments to

be refused and the circumstances in which the refusal is to apply

Advance decision has not been withdrawn After making advance decision, P has not

appointed an attorney to make the specified decision

Criteria cont.

P making the advance decision has not done anything clearly inconsistent with its terms

At the time the advance decision is invoked P lacks capacity to make contemporaneous decisions

Additional criteria for refusal of life prolonging treatment

Advance decision: Must be in writing Must be signed Must be witnessed Must contain a signed & witnessed statement

that it is to apply even where life is at risk

Patients without an LPA or advance decision

Clinician in charge of P’s care must decide whether treatment would be in P’s best interests

Discussion should take place with the family or Independent Mental Capacity Advocate (IMCA) in assessing P’s best interests

Where there is disagreement about best interests legal advice should be sought