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
Complications/risks of delirium
- Increased mortality
- Prolonged hospital stay
- Higher complication rates
- Instiutionalisation
- Increase risk of developing dementia
Management delirium
- Supportive care
- Treat underlying cause
- Orientate to time and place always
When to use pharmacological management delirium?
Extreme cases where patient is at risk to themselves or others
What does 4AT assessment involve?
- Alertness - sleepy or alert
- AMT4 - age, DOB, place, current year
- Attention - please tell me months of year backwards from december
- Acute change or fluctuating - over last 2 weeks has cognition fluctuated
Pharamcological management - ONLY IF AT RISK - for delirium
- Haloperidol - oral and then IM if not
- Lorazepam if have dementia
Types of delirium
- Hyperactive - agitated and confused
- Hypoactive - withdrawn and drowsy
- Mixed
How to distinguish between delirium and dementia?
Collateral history
4AT test useful too
What is dementia?
Progressive decline in cognitive function usually ocurring over several months
Affects different areas inc:
* retention of new information
* managing complex tasks
* language and word finding difficulty
* behaviour
* orientation
* recognition
* ability to self care
* reasoning
Types of dementia
- Alzheimers
- Vascular
- Dementia with Lewy body
- Parkinsons disease with dementia
- Frontotemporal
- Mixed - Alzheimers and Vascular
Alzheimers dementia presention
- Most common cause
- Insidious onset (slowly)
- Slow progression
- Behavioural problems common
- Diagnosed with history but brain imaging may show hippocampal atrophy
Vascular dementia presentation
- 2nd most common
- Suggested by vascular RF
- Imaging suggests vascular disease (ischaemic damage?)
- Step wise progression
Dementia with Lewy body presentation
- Gradually progressive
- Prominent auditory or visual hallucinations
- Delusions are well formed and persistent
- Parkinsonism commonly present but not severe
Presentation or parkinsons with dementia
- Parkinsons disease features are present and precede confusion for over a year
Frontotemporal dementia presentation
- Onset early
- Complex behavioural problems
- Language dysfunction may occur
Treatment for dementia
- Cholinesterase inhibitors for Alzheimers to slow progression eg donepezil rivastigmine
- For vascular - reduce risk factors
