Dementia in General Hospitals

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Dementia in General Hospitals

• Dave Anderson
• Consultant Old Age Psychiatrist
• Mersey Care NHS Trust
• Liverpool
• E.mail helen.bickerton_at_merseycare.nhs.uk
• Conflict of Interest None

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Prevalence of Mental Disorder

• Systematic review (WCW) RLUH
• Dementia 31 7400
• Depression 29 7000
• Delirium 20 4800

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500 bed DGH

• 5000 elderly admissions p.a.
• 3000 episodes mental disorder
• Each day
• 330 elderly
• 220 mental disorder
• 102 dementia
• 96 depression
• 66 delirium
• 23 others

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Independent Predictor

• Increased mortality
• Increased LOS
• Loss of independent function
• Institutionalisation
• Readmission (depression)
• Cost (Upbeat)

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The effect of mental disorder on length of
hospital stay after hip fracture (Holmes House,
2000)
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Outcome
(Nightingale et al, 2001)
Numbers at risk Kaplan-Meler curves of survival
after hip fracture stratified by psychiatric
diagnosis
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Policy Position

• National Service Framework for Older People (DH,
  2001)
• ST 1 Within the NHS agreement a rolling programme
  to
• tackle areas of age discrimination which are
• identified including additional resources (both
• financial and human).
• ST 2 Health and social care professionals should
  be aware that patients may have needs beyond
  their
• immediate problem.
• ST 3 To provide integrated services to promote
  further recovery
• from illness, prevent unnecessary admissions,
  support timely discharge and maximise
  independent living.

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NSF - OP

• ST 4 Early specialist input to assessment
• is required, good management will
• involve attention to..
• Develop guidelines for specialist mental
• health services with training to
• recognise and manage mental disorder
• Early planning for discharge

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• ST 5 Stroke
• 25 major depression post stroke
• One third of elderly survivors develop
• vascular dementia
• 30,000 new cases of vascular dementia in the UK
• each year following stroke
• stroke teams should include clinical
  psychologist
• ST 6 - Falls
• ST 8 - Promote mental health and combat
• discrimination

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Discharge from (acute) hospital getting it
right for people with dementia. (DH, 2003) The
majority of people whose discharge from hospital
is delayed are older people with mental health
needs, especially dementia, but their special
needs are little understood. Reimbursement .
.the research itself contains a number of gaps.
Chief among these are Failure to draw specific
attention to the needs of older people with
mental health problems.. (Glasby et al, 2006)
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Who Cares Wins - Introduction The present
delivery of mental health services for older
people in general hospital is by the process of
consultation. The superior model of
multidisciplinary liaison is established for
working age adults as a developed speciality.
This approach should be established for older
people and a failure to do so represents an
ageist policy. Better management of these
(mental) disorders improves the outcome and this
has major implications for the care of older
people, the efficiency of acute hospitals and the
utilisation of health and social care resources.
We believe that any strategy to improve the
performance of acute hospitals is seriously
deficient if it ignores the mental health needs
of older people. We urge acute hospital
trusts, older peoples mental health services and
commissioners of health and social care to
regard carefully the care of mentally disordered
older people in general hospitals and work
together to improve their outcome.
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Everybodys Business (CSIP, 2005)

• Multidisciplinary team
• Base in general hospital
• Electronic database and good communication
• Direct access to specialist domiciliary and
  intermediate care
• Shared care ward
• Integrated management
• Raising the Standard (RCPsych, 2006)

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• Living Well in Later Life NSF Five Years On
  (DH, 2006)
• deep rooted cultural attitudes to ageing
• mental health services particularly poor
• A New Ambition for Old Age (DH, 2006)
• Programme 5 (4 Aims)
• HCC CSI benchmark Everybodys Business
• Improve skills/competencies to enhance
  detection and management
• of mental illness in non-specialised settings
  so wherever people are,
• they have their mental health needs managed
  well.
• Comprehensive specialist mental health services
  for older adults,
• particular emphasis CMHT, memory clinics and
  liaison services

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Supplementary guidance for older peoples mental
health services 10 high impact changes (CSIP,
2007) Do you have an Old Age Psychiatric Liaison
Service in the acute hospital? This can lead to
major improvements in discharge and outcome. Do
older people with mental health needs have
access to a range of services such as
intermediate care and psychiatric liaison?
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• Dementia UK (2007)
• 17 billion p.a.
• Demographic change and disease
• burden
• A national priority

• National Audit Office (2007)
• Improving services and support for people with
  dementia
• Theyre in acute hospitals
• 68 inappropriate
• 41 mental health assessment
• Diagnosis avoided?
• Lack of specialist Liaison Teams
• Excluded from long term conditions
• Case management OPMH central
• A national priority

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Age Concern Inquiry into Mental Health
(2007) Commissioning Framework NHS Funding
Continuing Care (DH, 2007) Human Rights of
Older People in Health Care (Joint Committee
on Human Rights, 2007) National Dementia
Strategy (DH, 2007) Academy of Royal
Colleges (2007)
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National Strategy for End of Life Care (DH,
2007) National Audit Office Study End of Life
Care (2008) Commissioning Guidance for
OPMHS (DH, 2008) Emergency Psychiatry
Guidance (DH/RCPsych, 2007) Health Care
Commission Audit Standards for
Dementia (2007)
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N.I.C.E. Dementia Guideline

• Liaison mental health teams for training
• All suspected/confirmed referred to
• specialist service
• Neuroimaging

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Dementia in General Hospitals

• Detection when?
• Common but appropriate?
• Loss of function
• Delirium
• BPSD
• Intermediate care/long term conditions
• Palliative care

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Results 1(LDP)

• Study period December 1999 October 2003
• Cohort n 2000
• RLUH Admissions 72429
• Referral Rate 2.76
• Known to psychiatric services 9
• Open to MCT 30
• Closed to MCT 12

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Results 3 (LDP)RLUH Admissions Liaison
ReferralsAge Band and Gender
RLUH
LIAISON
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Results 4 (LDP)Marital status by age
21 widowed all age bands (41 age 85-89)
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Results 6 (LDP)Marital Status by Gender
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Results 7 (LDP)Home Circumstances/Age
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Results 9 (LDP) Referral Source
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Results 12 (LDP)Capacity referrals

54 referrals for assessment of capacity across
all departments.
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Results 13 (LDP)Capacity Sub-Groups
Additional capacity outcomes Treatment 27 Placeme
nt 30 Finance 25 Discharge 14 Other 22
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DischargeConclusions 5 (LDP)

• To Home 56
• To R/N Home 17
• Died 18
• New OPMH 7
• Continued OPMH 11
• Inpatient OPMH 7

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Conclusions 7 (LDP)

• Seen Predicted
• Dementia 568 22,453 (7484)
• Delirium 197 14,486 (4829)
• Depression 283 21,004 (7001)
• Anxiety 25 5,794 (1931)
• Schizophrenia 52 290

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DEMENTIA PATHOLOGY

• Nurse Doctor
• (n415) (n95)
• Alzheimer 2 8
• Vascular 261 54
• Multi-infarct 9 12
• Huntingtons 1 1
• CJD 1 1
• Parkinsons 5 -
• Unspecified 136 19

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Delirium

• Dementia major risk factor (x5)
• 30-40 incident preventable
• HELP

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Delirium Prevention Strategy

• Focussed staff training with feedback
• Routine on admission screening for risk
• Cognitive impairment
• Sensory deficit
• Severe physical illness
• Urea/creatinine

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Delirium Prevention Strategy

• Care plans identify at risk and
• Avoid recognised precipitants
• Attend to environmental factors
• Employ protocol of prevention strategies
• Avoid anticholinergic drugs
• Alert to early signs of delirium
• (Any change or fluctuation of mental state
• or behaviour)

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Delirium Prevention Strategy

• Limit severity by
• Early recognition
• Prompt treatment underlying cause
• Avoid anticholinergic drugs
• Attend to environmental factors
• (Sensory input, orientation aids,
• reassuring human contact)

Audit and feedback
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Outcome
Mortality
Delirium 79 No delirium 43 Worse with
dementia 60 Delirium no dementia dem. (18.1
p.a.) 18.5 No del. No dem. dementia (5.6
p.a) Adjusted or 5.97 (CI 1.83 19.54) (Rockwood
et al, 1999)
In dementia More psychomotor agitation,
disorganised thinking, disorientation. (Cole et
al, 2002)
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All eligible patients in geriatric medical units
Mini Mental State Examination (MMSE) and CLOX1
An Executive Clock Drawing Task
MMSE 24/30 and CLOX1 11
MMSE lt24/30 or CLOX1 lt11
Exit Algorithm
Duration of cognitive impairment?
Confusion Assessment Method (CAM) Informant
Questionnaire on Cognitive Decline in the Elderly
(IQCODE)
Delirium (acute Confusional state)
CAMve IQCODE -ve
CAM ve IQCODE ve
CAM -ve IQCODE ve
Chronic impairment
Delirium and chronic impairment
Investigation and monitoring
Team assessment screen for depression, further
background information, appropriate
investigations according to BGS protocol
Possible dementia syndrome requiring
further Assessment and management
Put test results and diagnoses of delirium
and/or Cognitive impairment in discharge summary
Refer to memory clinic or other specialist service
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Dementia Decision Making Pathway
Comprehensive assessment from patient,
relatives/carers. Characteristic symptoms
recorded. Duration, progression, behaviour,
risk. Cognitive assessment completed. 6CIT,
MMSE, GDS
Diagnosis
Exclude treatable causes (infection, medication).
Complete B12, F01, Calcium, Glucose, CT scan,
LFT, FBC
Probable diagnosis irreversible Dementia
Lewy Body Check under specialist Review and refer
if not. Monitor hallucinations and physical
symptoms. Keep Parkinsons medication
to minimum. Avoid neuroleptics
Alzheimers Disease Consider Cholinesterase
inhibitors Need specialist review follow up
Vascular Dementia Consider Aspirin
Clopidogrel
Management/assessment
Causing problem at home or complex discharge
Develop behaviour disorder
Could this be super-imposed delirium?
No
Yes
Treatment as usual
No
Yes
Refer to MH Liaison
Refer to Old Age Psych OPD i.e., include on d/c
summary
Referral
Follow delirium pathway
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Intervention

• RCT hip fractures
• Reduce LOS (median 47 versus 147
• days
• Increased return to home 12 months
• Mild-moderate dementia
• (Huusko et al, 2000)
• 27 only diagnosed in hospital
• (Holmes, 1999)

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Palliative care

• Less likely to receive analgesia (1/3 hip)
• Sampson et al (2006)
• Religious faith recorded (40 v 63)
• Refer to palliative care ( 9 v 25)
• Palliative medicines (28 v 51)
• Arterial blood gasses (80 v 58)
• NG tube (40 v 23)
• Central line ( 3 v 20)
• Catheter (77 v 57)

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Could it be different?

• Reduce incident delirium 30-40 (1000 episodes
  p.a. (Inouye et al, 1999 Marcantonio et al,
  2001)
• Reduce LODS mild-moderate dementia (Huusko et al,
  2000)
• Increase return to independent living (Huusko et
  al, 2000 Cole et al, 1991)
• Improve recovery from depression (Evans et al,
  1997 Baldwin et al, 2007)
• Reduce health care utilisation, readmission and
  cost (Kominski et al, 2001 Wilson et al, 2007)
• Reduce LOS by routine liaison (2 days)
• (Strain et al, 1991)

? 24000 bed days RLUH (3 x 20 bed wards) ? 20
960 x 5 day admissions
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Liaison Mental Health Teams

• Increase specialist assessments
• Increase referrals with depression
• Increase diagnostic concordance
• Increase adherence
• Decrease LOS
• Increase return to independent living
• Decrease cost
• Education and training?

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Older Peoples Mental Health Liaison Teams

• Education and training
• Complex case management
• Link physical and mental health care
• Link hospital and community care
• Vehicle to quality improvement
• Need to be
• ? Multidisciplinary
• ? Integrated
• ? Commissioned

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Focus

• Prevention strategy
• Antidepressants
• Psychological awareness
• Contact with mental health services
• Case Management
• Alternatives to admission
• Collaborative emergency response (CRHT)
• Liaison Emergency Department
• Intermediate care services
• Prompt discharge
• Education
• Attitudes

• Delirium
• Depression
• Dementia
• General

Liaison Teams
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Personal Experience

• I just felt I had to write and plead with
  someone when anyone with dementia is admitted to
  please contact someone in your department.
• Please dont let anyone else be put through this
  indignity

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Dementia in General Hospitals Dr Dave
Anderson Consultant Old Age Psychiatrist E-mail
helen.bickerton_at_merseycare.nhs.uk Mersey Care
NHS Trust Liverpool Conflict of Interest None