DementiaWiseTM

Monthly Webinar Series

Delirium and Dementia: Do You Know This

Serious Risk?

Deborah Bier, PhDCreator, DementiaWiseTM

Welcome & Introductions

Deborah Bier, PhD

Delirium and Dementia: Do You Know This Serious Risk?

• What is hospital delirium?

• How are delirium and dementia related?

• Delirium in the hospital

• Delirium prevention, early detection

• Tools and resources

What is Hospital Delirium?

• It is a surprisingly common, dangerous condition.• Approximately 30% of patients in the hospital experience

delirium.• More than 40% of seniors in the hospital experience delirium.• Fewer than 25% of cases are diagnosed in the hospital.• U.S. hospitals and providers are behind regarding prevention,

detection and treatment, but it is now on their radar.• Few patients/family members know about the condition.• It causes sudden, serious deterioration in mental status.

Common Symptoms of Delirium

• Presents as an altered state of consciousness• Develops rapidly (hours, days)• Indicated by new and/or increased symptoms:

• Can cycle in and out of delirium: hypo/hyper delirium

Confusion Memory problems Personality changes

Language problems Changing emotions Hallucinations

HYPER Delirium: Agitation Acting out

HYPO Delirium: Withdrawal Unresponsiveness

How Serious is Delirium?

“Delirium is one of the absolutely most prevalent forms of harm that befall people in the hospital.”

Fred Rubin, MD, FACP Geriatrician, Chief of Medicine,

University of Pittsburgh Medical Center

Focus on Hospital Delirium

• AKA: Intensive Care Syndrome

• A sign of an underlying, undertreated medical crisis

• Indicates organ dysfunction, infection, serious illness and/or brain failure

• Can cause long-term (even permanent) cognitive impairment and/or muscle weakness

• Leads to longer hospital stays — up to 10 days more

• May cause increased rehab and home care services

• In the hospital, it is more serious because patients are so ill

Have You Already Seen Delirium?

Delirium can also happen outside the hospital:

• Happens quickly

• New or worsening dementia symptoms (confusion, language)

• Falls, sleep issues (too much, too little), hallucinations

• Infection or electrolyte imbalance common

• Treat UTI, low sodium, etc. = eliminate symptoms!

Delirium and Dementia

• These conditions are not the same!

• More than 50% of hospitalized patients with dementia experience delirium.

• Seniors without dementia who experience delirium in the hospital have an eight-fold risk of developing dementia.

Confusion Between Dementia and Delirium

• There is significant risk of not recognizing delirium if there is pre-existing dementia.

• Emerging delirium symptoms can be quickly attributed to the patient’s dementia, yet, these are distinctly different conditions.

• Both the public and health care professionals are confused about this!

Harm from Hospital Delirium

• There is a 25-70% higher chance of dying during that hospital stay.

• There is a 62% higher risk of death in the following year.

• Patients in intensive care with delirium have a three-times higher risk of dying over the next 12 months.

• Patients might be discharged with worse cognitive and physical functioning than when they were admitted.

• It is one of the most costly complications.

Harm from Hospital Delirium

• There is a 25-70% higher chance of dying during that hospital stay.

• There is a 62% higher risk of death in the following year.

• Patients in intensive care with delirium have a three-times higher risk of dying over the next 12 months.

• Patients might be discharged with worse cognitive and physical functioning than when they were admitted.

• It is one of the most costly complications.

Highest Risk Factors for Developing Hospital Delirium

• Increased age

• Dementia present

• Infection

• Surgery

• Multiple medications

• Chronic physical illness …and more!

Hospitals need to assess and respond to each patient’s risk level.

If Delirium Happens in the Hospital

• Only 30-40% of delirium is preventable through what we currently understand.

• The underlying cause(s) – infection, infection, medication problem, etc. – must be determined and treated.

• Delirium symptoms must be managed and allowed to run their course.

Need for a “Pre-Admission Functional Baseline”

• A pre-admission functional baseline is needed to distinguish emerging delirium from pre-existing dementia.

• If a patient has dementia, it is vital that hospital staff understands the patient’s abilities/losses.

• This baseline is typically missing from the admissions process and this is the likely cause of many missed delirium cases.

14-Point Functional Baseline

Confusion Judgment, planning, sequencing

Fine and gross motor coordination

Orientation Balance, gait Continence

Language abilities

Ability to follow directions

And more… (14 areas total)

Our dementia/delirium nurse assessmentcreates a functional baseline, including:

Post-Discharge to Rehab or Home Following Delirium

Delirium can result in increased home care needs:

• Cognitive impairmento DementiaWiseTM care methods

• Muscle weaknesso Encourage and cue PT exerciseso Get more activeo Help with transfers, ADLs, IADLs

Prevention of Delirium is the Only Direct Treatment

• 30-40% of delirium cases can be prevented.

• Once delirium starts, it cannot be stopped.

• Prevention is best treatment.

• The underlying medical issue(s) must be determined and treated.

• Delirium symptoms must be managed and allowed to run their course.

Delirium Prevention Best Practices

Hospital Elder Life Program (HELP) Team• Multi-disciplinary delirium prevention team

• From the Yale University School of Medicine

• HELP Team goals:

o Maintaining cognitive and physical functioning of high-risk, older adults throughout hospitalization

o Maximizing independence at discharge

o Assisting with the transition from hospital to home

o Preventing unplanned hospital readmissions

Early Detection is Vital

• Delirium is a sign of an underlying medical issue(s).

• 75% of hospital delirium cases are missed.

• This means developing medical issues are undetected until they become full-blown crises.

• Early delirium detection means early treatment of underlying medical issues.

• This can help reduce harm, including death.

Prevention = Medicine, Behavioral, Environmental Interventions

• Hospital staff must review medication choices.

• Multiple medications = increased risk

• Non-drug interventions = behavioral and environmental best practices = DementiaWise

TM

care methods

• Similar prevention methods, regardless of whether or not a patient has dementia

Non-Drug Delirium Prevention Best Practices

• Quiet environment

• Dark and quiet at night

• Personal belongings, familiar objects

• Daytime activity, three times/day

• Socialization opportunities

• Glasses, dentures, hearing aids (fresh batteries)

• Favorite foods

• Feeding assistance, companionship during meals

• Sufficient sleep

• Soothing massage

• Favorite music

• Bedsitter

• Avoidance of restraints (both chemical and physical – intubation acts as a restraint)

With dementia patients, use dementia care best practices: keep oriented, stimulated.

Monitoring for Delirium

• Cognitive function: e.g., worsened concentration, slow responses, confusion

• Perception: e.g., visual or auditory hallucinations• Physical function: e.g., reduced mobility, reduced

movement, restlessness, agitation, changes in appetite, sleep disturbance

• Social behavior: e.g., lack of cooperation with reasonable requests, withdrawal, or alterations in communication, mood and/or attitude

(National Institute for Health and Care Excellence, UK criteria)

• Any new or changed symptoms

Bedsitter - Main Recommendation from Johns Hopkins for Prevention

• Bedsitting (awake) 24/7 at bedside of a patient in hospital

• Observe, interact, engage, stimulate, amuse, calm and comfort the patient

• Monitor for changes specifically related to delirium

• Communicate with hospital staff about problems and/or changes witnessed

• Best practice dementia care interactions and methods

American Geriatrics Society Choosing Wisely® Recommendation

• Restraints should not be used on hospitalized delirium patients – behavioral interventions should be used instead

• Includes both physical and chemical restraints

• Behavioral interventions are the same as DementiaWiseTM care methods

(Issued 2013-14)

Delirium Nursing Best Practice Guidelines

Socialization Activity Adaptive aids

Appropriate sensory stimulation

Maintaining dark/light, day/night cycle

Dementia care best practices, if dementia is present

Calming interventions

Orientation aids Quiet environment

Behavioral interventions for delirium patients include:

All interventions are included in DementiaWiseTM care methods.

Tools Available

• Admission Information/Patient with Dementia • Strategies for Hospital Admissions • Making Hospital Stays and Discharge Easier• ComForcare’s Dementia Care Program• ComForcare/At Your Side bedsitter services• Dementia Care Tips for Families

• Supplemental Staffing information

• Professional and Family Confusion Assessment Method manuals (Harvard Medical School)

How Can We Help You?

• Are you a family member of someone with dementia or delirium?

• Are you a health care professional who wants to manage dementia and delirium care more effectively?

• Contact your local ComForcare/At Your Side office for information about dementia care services.

www.ComForcare.com 800-886-4044

www.AtYourSideHomeCare.com 888-518-1584 (Houston area)

Upcoming Free DementiaWiseTM Webinars

Held Monthly (3rd Tuesday) at 7 p.m. & 9:30 pm Eastern Time

• July 15 - The Difference Between Normal Age-Related Forgetfulness and Dementia

• August 19 - Handling Difficult Dementia Behaviors • September 16 - Home Safety Issues and Dementia• October 21 - Medications That Can Make Dementia Worse

Register online www.ComForcare.com or AtYourSideHomeCare.com

Hospital Delirium Recap

• About delirium and how it could impact your family

• Variety of tools to understand, advocate, report

• DementiaWiseTM delivers best practices in dementia care that include skills and interventions for hospital delirium:

o Preventiono Monitoringo Care (if delirium develops)o Post-discharge care

Questionsand

Answers

Thank you for joining us today!