Old Peoples Care Flashcards
What are the effects of normal aging?
Difficulty finding words
Forgetting things and events
Not being able to remember the name of an acquaintance.
Family not worried about the memory.
Not remembering conversations which occurred > 1yr ago.
Dementia is different because of the affect on ADL.
What is dementia?
Syndrome caused by many brain disorders, leading to decline in cognitive functioning, memory AND activities of daily living (ADL).
Always progressive.
Likely to have clear consciousness.
What are the RF for developing dementia?
Ageing Genetics Mild cognitive impairment Parkinson's Cerebrovascular Cardiovascular Smoking DM Lack of exercise Obesity
How does a Px with dementia present?
1) Cognitive impairment relating to disturbance of higher cortical function, memory, thinking, judgement, planning, language, perception and visuospatial awareness. Px usually have a clear consciousness.
2) Psychiatric or behavioural disturbances: changes in personality, emotional control, and social behaviour; depression, agitation, hallucinations, and delusions.
3) Difficulties with ADL.
Need to have this presentation for >/= 6 months for a diagnosis.
What are the stages of dementia?
1) Early stage-
Forgetfulness and other memory symptoms. Usually short term memory affected i.e. lunch, shopping list, keys.
May get subtle mood changes and behaviour i.e. loss of motivation/interest
May be minimal intrusion day-day.
2) Mid stage-
More prominent memory problems
areas of cognition; visuospatial awareness, language. Higher order functioning i.e. sequencing, planning.
More prominent behavioural problems
More obvious problems with disabilities.
May lose insight, can downplay severity of their condition.
3) Severe- Global problems in all cognitive domains. Can't recognise family members. Severe disabilities- falling etc Requiring 24hr care
What are the common causes of dementia?
> 65yrs old- 2/3 is Alzheimer’s, the second most common is vascular.
<65yrs old- 1/3 Alzheimer’s (still most common), VD, alcohol, LB dementia, FTD.
What are the common subtypes of dementia?
Alzheimer’s
Vascular
LBD
FTD
What are the causes of Alzheimer’s disease?
Sporadic
Genetic
Increased risk with Downs syndrome
What are the features of Alzheimer’s disease?
Gradual onset and slow progression.
Presents early with memory impairment.
Mood and behavioural changes may be minimal but pre-existing anxiety may worsen.
On imaging see reduced volume in temporal lobe and posterior cingulate.
Macroscopic- cortex and hypothalamus atrophy.
Microscopic- tau tangles and amyloid plaques.
How is Alzheimer’s disease managed?
Non pharm- Tailored activities for pts Pharm- Acetylcholine-esterase inhibitors (donepezil, galantamine and rivastigmine) for mild to moderate. NMDA antagonists (memantine) of contraindicated, as add-on therapy in moderate or as monotherapy in severe Alzheimer’s.
Only use antipsychotics if at risk of self harm.
What is vascular dementia?
Stepwise deterioration in cognitive function by different mechanisms including ischaemia/haemorrhage secondary to cerebrovascular disease.
Imaging will show signs of infarct, bleeds, WM ischaemia.
What are the features of vascular dementia?
Progression speed varies. Emotional disturbance Gait disturbance Speech disturbance Memory disturbance Difficulty with attention and concentration Seizures Visual disturbances, sensory or motor symptoms
How is vascular dementia managed?
Treat symptoms and reduce cognitive decline
Manage challenging behaviours
Music/art therapy
Pharmacological interventions are not really useful.
What is Lewy Body dementia?
Lewy bodies in the substantia nigra, paralimbic and neocortical areas.
What are features of Lewy Body dementia?
Loss of memory, function and cognition early on.
Followed by Parkinsonism
Visual Hallucinations
Fluctuating episodes may be confused with delirium initially.
How is Lewy Body dementia managed?
Manage same as Alzheimer’s
AChE inhibitors and NMDA antagonists
Avoid neuroleptics in Lewy body dementia as very sensitive and can lead to irreversible Parkinsonism
Also consider rivastigmine in Parkinson’s disease.
What is frontotemporal dementia?
<65yrs
Insidious onset
Change in personality i.e. impulsivity (XS spending, sexual disinhibition, overeating, obsessions), loss of empathy, apathy (loss of interest), lack of insight.
Intact memory and visuospatial awareness
Gradual onset but may progress quickly in younger Px.
Imaging will show frontotemporal atrophy.
How is frontotemporal dementia managed?
NICE say do not treat with AChE inhibitors or NMDA antagonists.
How is dementia initially diagnosed?
Memory clinic with an MDT allows for a holistic approach in diagnosis. Includes OT, psychiatrist, community mental health professionals social, pharmacists etc.
Dementia is a clinical diagnosis made through personal and collateral Hx.
Important to talk to the Px initially alone.
Examinations include GPCOG, AMT, MMSE, 6-CIT, MOCA etc.
Must inquire about the Px functionality/impairment of ADL.
Also must ask about the risks i.e. risk to self (self harm, suicide, neglect, driving), risk to others (BPSD [Behavioral and psychological symptoms of dementia], driving), risk from others (vulnerability).
Important to explain interventions to promote cognition, independence and wellbeing. As well as discussing pharmacological interventions.
Diagnose first as dementia then subtype it.
Basic ADL- Essential for living i.e. eating/drinking, washing, dressing etc
Instrumental ADL- More difficult
If BPSD can have regular follow ups in the clinic.
What are the benefits of diagnosing dementia?
Relief from having a diagnosis. Optimising medical management Maximising decision making autonomy Access to care and services Risk reduction (driving) Clinical cost effectiveness A human right to know your own diagnosis
How is dementia investigated?
It rarely exists on its own and may be overlooked by diagnostic over shadowing.
Need to ensure that an underlying diagnosis is not missed; FBC, U+Es, LFTs, B12/folate, Ca, glucose, TFTs.
Confirm diagnosis with blood culture, CXR, MRI and psychometric tests.
CSF if considering CJD
Brain imaging- structural with CT, functional with dopamine, glucose metabolism.
EEG
How is all dementia managed non-pharmacologically?
Inform Px of their diagnosis and prognosis.
Provide psychological support to give positive outlook on life and allow engagement.
Early discussions to allow advance planning, i.e. regarding lasting power of attorney, preferred care plans etc.
Carer support
Px must inform the DVLA about their diagnosis.
Non-cognitive therapy involves music, dancing, art,, aromatherapy etc.
Px should be looked after in the community, but admitted if their own safety or the safety of others is at risk.
Palliative care in the cases of end stage. PEG is not really shown to have any added benefit so should not be used.
How can dementia be prevented?
1) Diet- Healthy and balanced can be preventative for dementia, i.e. CV RF will increase risk of developing vascular dementia.
2) Exercise- Large amount of CO goes to brain so exercise will help perfuse the brain.
3) Social interaction
4) Cognitive stimulation- Learning new skills, brain teasers.
What is BPSD?
Behavioural and psychological symptoms of dementia.
These are the presentations in the more later stages of dementia
Presenting with delusions, hallucinations, agitation, emotional lability, depression, anxiety, apathy, social or sexual disinhibition, motor disturbance (for example wandering or repetitive activity), and sleep disruption.
Increased care costs and prognosis. Very challenging, can impact individual cognitive of life. 4 main clusters; Affective Psychotic Hyperactive hk
UPDATE WHEN PPT UP
What are the different types of BPSD?
Affective- Low mood; agitated, anxious, pacing, wandering, anxiety.
Psychotic- delusions (fixed false beliefs- think body is breaking down, think the news is about you etc), hallucinations (false perception in absence of stimuli, nothing there but Px thinks there is.
Hyperactive- aggression, disinhibition irritability, lability, night disturbance.
Apathetic- indifference, appetite, eating problems.
How is BPSD managed?
Choose an appropriate setting
Treat any discomfort i.e. pain, constipation, retention etc
Non-pharmacological interventions i.e. music therapy, massage therapy.
Antipsychotic/antidepressant- use with caution.
UPDATE WHEN PPT UP
How is dementia different to other conditions?
Common cause of disability in later life, more than CVD, stroke, cancer
Even more costly than these.
Diagnosis is often missed
Its always a progressive disorder
Stressful for all members of the family
Those most dependent and vulnerable often have the least awareness of their disabilities.
What is delirium?
Impaired cognition.
Disturbed consciousness/attention (more common than memory problem).
Disturbed sleep-wake cycle (sleep in day but in night awake and wandering).
Abnormal psychomotor behaviors
Acute onset- can last hrs to days to a few months.
Visual hallucinations
Symptoms fluctuate- typically worse at night.
What are the two types of delirium?
1) Hypoactive- Most common form. Quiet, sleepy, inactive, unmotivated, easily overlooked.
2) Hyperactive- heightened arousal, restlessness, irritability, wandering, carphologia (picking at clothes). On acute wards this can lead to agitation towards staff, refusal of care/treatment, falls, may not engage in physical examinations- vicious cycle can’t manage the health issue causing delirium therefore the delirium gets worse and so does the underlying condition.
3) Mixed picture is also possible.
What are the RF for developing delirium?
Previous dementia Severe trauma (Hip fracture) >65yrs Polypharmacy Increased Frailty
What are the precipitants of delirium?
T- Trauma (head injury, intracranial event) H- Hypoxia (PE, CCF, MI, COPD, Pneumonia I- Increasing age/frailty N- NOF fracture K- smoKer or alcohol withdrawal.
D- Drugs
E- Environment (i.e. ward changes)
L- Lack of sleep, reversal of sleep-wake cycle.
I- Imbalanced electrolytes (renal failure, Na+, Ca2+, glucose, liver function
R- Retention (urinary/constipation)
I- Infection/sepsis
U- Uncontrolled pain
M- Medical conditions (dementia, Parkinson’s disease)
How is delirium diagnosed?
Hx, examination, collateral Hx, investigating a cause, along with:
1) CAM- Short confusion assessment method. Px is examined on the following;
a) Irritability (2)
b) Acute onset and fluctuating course (2)
c) Altered consciousness (1)
d) Disorganized thinking (1)
CAM >/= 5 THINK DELIRIUM
Need a + b + c/d for a diagnosis of delirium.
2)Meet the DSM-5 criteria
3) AMT- Abbreviated mental test, where the Px is asked the following;
a) How old are you?
b) What is your DOB?
c) Where are we right now?
d) What year is it?
If >65yrs with AMT<4 THINK DELIRIUM
Most Px will need admittance to hospital.
How can delirium present?
Early on- Inattention Clouding of consciousness Repetitive Rambling Speed of thinking is slower Drifting off point Distractible
Then can develop perceptual abnormality- usually transient visual hallucination i.e. seeing insects, lasting briefly, not causing much distress usually.
Which drugs could induce delirium?
Psychotropic drug i.e. antidepressants, antipsychotic, benzodiazepines.
Anti parkinsonian drugs
Anti cholinergic
Opiates
Diuretics
Recreational drug intoxication and withdrawal
What are the relevant scoring systems and scores for diagnosing delirium?
CAM >/= 5 THINK DELIRIUM
Age >65yrs and AMT<4 THINK DELIRIUM
How is delirium managed?
Manage underlying cause.
First line treatment is haloperidol unless Parkinson’s, where this can worsen the symptoms. Therefore consider reducing Parkinson’s medication dose.
What is the prognosis of delirium?
Not all Px get better
In acutely ill Px the prognosis is worse
Increased mortality
Can take >3months to full resolve, may get diagnosis of dementia.
Some evidence that certain delirium can precipitate/permanently worsen dementia.
What are the differences between dementia and delirium?
Delirium Acute onset Fluctuates more Change in consciousness Clouded consciousness Lack of attention Visual hallucinations Delusions Agitation/fear Delirium can resolve
What is mild cognitive impairment?
Mild cognitive impairment- is memory impairment more than should be expected for their normal, but no functional impairment on ADL therefore not a diagnosis of dementia.
It is a RF for developing dementia, therefore should be monitored.
MCI is a clinical diagnosis, may impact higher cognitive function; memory, problem solving, planning or language.
What are the differences in the types of dementia between <65yrs and >65yrs?
Both common cause is Alzheimer’s, but <65yrs only 1/3 compared to 2/3.
<65yrs also likely to get FTD and LBD.
Early onset dementia is more likely to present with language difficulties (grammar sounds odd), motor symptoms i.e. tremors/myoclonic jerks, visual symptoms w/o cause, behavioral symptoms.
Early- Prognosis can be between weeks to years.
Older- More likely to have prognosis of yrs.
What are the different causes of dementia?
Neurodegenerative- AD, vascular, FTD, Pakrinsons, LB
Infective- HIV, Herpes
Prion- CJD
Inflammatory- vasculopathies, autoimmune
Metabolic- diabetes poor controlled, vitamin deficiencies
Genetic- Presentalin gene, APP gene, Downs sydnrome and AD.
Others
What are the unique challenges of early onset dementia?
Working age
Px is not limited as much physically, so can wander further.
Driving
Stigma and poor understanding of others
They are a carer for someone else or their carer (wife/child/sibling) has other commitments
Multiple losses/bereavements
May not be accepted as much socially, i.e. people will think Px are drunk.
How is early onset dementia investigated?
Need to know the timeline- when did it start and how was the Px before?
Symptoms and how do they relate to each other.
MEMORY LANES
PMH or psychosis
DHx- Do they comply to their medications
SHx- Finances, job, support system, normal daily activities, alcohol, substance misuse, withdrawal.
FHx
Personal Hx
Assess the risk:
Self harm/suicide/aggression to others.
Wandering, found out at night, neglect, medication compliance (diabetes), carer strain, being left alone.
Mental state examination
Cognitive assessments- Mainly ACE-11, MMSE, GPCOG.
Physical examination concentrating on neurological aspect.
What are the symptoms of cognitive impairment in early onset dementia?
M- Memory (recent and far back)
E- Employment (what do they do i.e. quite skill/management, are they having trouble?)
M- Motor symptoms (tremors, falls, stiffness)
O- Overeating (esp sweet food- increased desire)
R- Risk (driving/wandering/cooking/impulsive)
Y- Usual self (aka personality/social etiquette)
L- Language (expression/comprehension) A- Accidents (continence) N- Night E Exclude other illnesses (ask about mood and psychosis) S- Sight (occipital lobes affected)
How is early onset dementia investigated?
Assessment:
MSE (Mental State Examination), Cognitive Assessments (MMSE, ACE-11, GPCOG, etc)
Investigations:
Baseline bloods
MRI for neurological changes/inflammatory processes
PET
ECG/EEG/OT functional assessment, CSF for genetics or clarifying diagnosis etc.
How is early onset dementia managed?
-Explain the diagnosis and prognosis
-Consider medication:
Cholinesterase inhibitor +/- memantine in Alzheimer’s
Rivastigmine in PD
Antipsychotic/antidepressant for BPSD- use with caution.
-Plan:
Referral to OT
Referred for FDG-PET Scan
Follow up with results
What is posterior cortical atrophy?
What is the common presentation of posterior cortical atrophy?
Onset between 50-65yrs old.
Potential variant of Alzheimer’s, where Alzheimer’s disease is also cortical atrophy, but this is specifically posterior.
Since the affected area is where the visual cortex exists, common symptoms include; difficulty judging distances, distinguishing between two points (moving/stationary), disorientation, some experience hallucinations. Px can also develop anxiety (because they know something is wrong- have insight).
It is a rare disease.
investiate with RO
How is posterior cortical atrophy investigated?
In the first instance the Px would present to the ophthalmologist because of what they perceive as visual changes. The vision tests would be normal.
There is no specific test but neuropsychological tests, blood tests, brain scans and a neurological examination can be used to diagnose the condition and rule out other potential explanations for symptoms.
How is posterior cortical atrophy managed?
Explain diagnosis and prognosis including driving and working. Cholinesterase inhibitors MDT- SALT, SS, CMHT Rare dementia groups Support for the carer
What are the mimics of dementia?
Delirium Other psychiatric illness Substance misuse Menopause Fibromylagia Normal pressure hydrocephalus Sensory deprivation
What is rapidly progressive dementia?
j
What are the causes of rapidly progressive dementia?
Delirium Other psychiatric illness Substancemisuse Menopause fibromyalisgia Sensory deprivation
DOnt miss
Raoidly progressive dementia- devellps wothin wks to mnths
Imp o get diangosis correct
CAuses include
carer strain
refer to social serviecs
r Hibbert believes Bill has carer strain
• You will hear more about this in the block
• Unpaid care is vital to support people in the community
• Nearly 3 quarters of carers in England have sufered mental ill
health such as stress and depression, while over 60% have
experienced physical ill health due to caring.
• Many have not had a carer’s assessment.
•
It is important to recognise and implement early assessments
to keep them well so that they are supported to care for their
loved ones
just for clarification - community hospitals are not for social admissions they are for step up care i.e. medical issues - they won’t accept pure social unless they need medical intervention. If pure social then this would be an urgent social care admission to a care facility or emergency care package
assessments from community team
aids home modifications walking aids assess bills look at relative too
What is a CGA?
Comprehensive geriatric assessment. Co morbidiites medicationas nutritional assessment functional assessmet
carried out by several health care professionals
Clincial frailty score
Need to know well fro exam
Gives accurate infromation about Px
Whta is a POA
Fill out when a person has the capacity
Only becomes active when the person has lost the capacity.
If dont fill in with capacity then family need to go tp courts (of protections?)
o be deemed as lacking capacity someone must have a
medical or mental health conditon that means they lack the
ability to undertake the following
– Understand informaton given to them about a partcular decision
– Retain that informaton long enough to be able to make the
decision
– Weigh up the informaton available to make the decision
– Communicate their decision.
• Capacity is decision specifc and is for that decision alone
and in that point of tme.
• Capacity can be fuctuant- during the day, throughout the condition, or with more complex topics.
What is safe guarding?
Is a term used to describe measures to protect
the health, well-being and human rights of
individuals, which allow people — especially
children, young people and vulnerable adults —
to live free from abuse, harm and neglect
• Safeguarding concerns can be raised to either
the locality safeguarding team or social services
• Where a crime has been commited and others
may be at risk police input may be required
what is risk feeding?
Px continues to eat/drink despite the risk of aspiration pneumonia.
This is more for enjoyment adn imrpoving QoL, as opposed to nutritional advancement.
Reasons:
dvanced stage of illness
• The person’s swallow safety is not likely to improve
• When the preference to eat and drink takes priority over swallow
safety
• Tube feeding optons are declined or inappropriate
How is dementia invesitgated?
Need to ensure that an underlying diagnosis is not missed; FBC, U+Es, LFTs, B12/folate,
Whta is a DTA bed?
What is
Continents assessment
Detailed contnence history • Review of bladder and bowel diary • Abdominal examinaton • Urine dipstck and MSU • PR examinaton including prostate assessment in a male • External genitalia review partcularly looking for atrophic vaginits in females • A post micturiton bladder scan
Managemtn of incontinence
Drug therapy or pads are not frst line management
• Switch to decafeinated drinks
• Good bowel habit
•
Improving oral intake
• Regular toiletng
• Pelvic foor exercises and bladder retraining
• Remember that antcholinergics are not good in older
people and oxybutynin whilst good for younger patents
is not good for older people.
• Many of the drugs used for bladder stabilisaton can also
cause postural hypotension leading to increased falls.
