Case 2 - Dementia and Delirium/poor swallow/care planning Flashcards
How to establish baseline of pt and trajectory over last 12 months?
- Collateral history
- Abbreviated mental test
- Mental state examination - anxiety, depression
- Medication review
- RF review
- 4AT test for delirium
Likely causes of poor oral intake in elderly
- Dementia - forgetting to eat
- Immobility - cannot cook, rely on others
- End of life?
- Choking/poor swallow - unpleasant
- Pain
- N + V
- Decreased taste
- Dentures/poor chewing
- Slower gastric emptying
- Depression
Types of fluid consistencies recommended by SALT
- Thin
- Slightly thick
- Mildly thick
- Moderately thick (same as liquidised food)
- Extremely thick (same as pureed food)
Types of food consistencies recommended by SALT
- Liquidised
- Pureed
- Minced and moist
- Soft and bitesize
- Regular
Are alternative feeding methods eg NG tube or PEG recommended in dementia and why?
No
* Risk of aspirational pneumonia higher
* Unpleasant to have NG tube
* PEG needs sedative/anaesthesia - risk
* Infection risk PEG
* Sores around tubes can result in pt trying to pull out
* Into hopsital for PEG insertion - distressing and may not recover to baseline
What does feed at risk mean?
- Continue to eat and drink despite risk of choking/aspiration
- QoL is priority - eg advanced illness, swallowing unlikely to improve, tube feeding declined or unsuitable
What is mental capacity?
- Ability to understand, retain, weigh up and communicate information
- Determines if pt can make decision or if we need to act in best interests
What is a best interest decision?
- Decision made when pt does not have capacity
- Takes into account patients previous and present wishes, beliefs, history and social history
- Consult others and act in a way which is best for the patient
What is an advance care plan?
- Plan for future care and support inc medical treatment
- For people at risk of losing capacity or those who have fluctuating capacity
- Takes into account feelings, wishes history, ceiling of care, place to be treated etc
- Ask if informed family
What is a RESPECT form?
- Recommended summary plan emergency care and treatment
- Takes into account patient preferences of care - priorities over preserving life vs comfort
- Clinical recommendations
- DNACPR?
- Discuss current health and how this may change and treatments which won’t probably work etc
What is delirium?
- Acute confusional state
- Sudden onset
- Fluctuating symptoms
- Develops over 1-2 days
- Hyper or hypoalert and inattention
Cause of delirium
- Underlying medical problem
- Substance intoxication
- Substance withdrawal
- Or combination
Who is delirium common in?
- Older persons admitted to hopsital
- Frailer
- Sensory impairment
- Cognitive impairment
- Surgery
- Hip fractures
- Severe infections
Important things to exclude as causes of delirium
- Infection
- Electrolyte imbalance
- Hypoxia
- Drugs inc opiates
- Urinary retention
- Constipation
- Uncontrolled pain
How long does delirium take to resolve?
- Anywhere up to 3 months
- Some people do not get back to baseline