Charles Bernick, MD, MPH Cleveland Clinic Lou Ruvo Center for Brain Health June 2, 2018

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1 Charles Bernick, MD, MPH Cleveland Clinic Lou Ruvo Center for Brain Health June 2, 2018

2 Delirium common Prolongs hospitalization Worsens dementia ( if you survive) Increased risk of institutionalization Death

3 UTI and other infections Falls/Fractures Others ( Dehydration, vascular) Not if, but when

4 Risk 3 X greater than others >65 25% of hospitalized patients > 65 have dementia ( at least!!) 1/3 of dementia patients are hospitalized/year

5 Unintended injury due to medical management Leads to: Prolonged hospitalization Temp or permanent disability Death

6 GENERAL Procedure related Hospital acquired infxn Drug reaction GERIATRIC SYNDROMES Delirium Falls Incontinence Immobility Poor nutrition Decubitus ulcers Agitation/Behavioral

7 Acute confusional state Reversible Fluctuating attention/alertness Sleep-wake dysfunction May include: Hallucinations Disorganized thinking Behavioral changes Hypo or hyper active

8 Present in 1/3 Worsens cognitive function Under recognized Under investigated Inappropriately treated

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10 Dementia (OR 6.6) Age Severity of medical illness High risk medications Sensory impairment Malnutrition Urinary catheter Immobility

11 Dementia patients more vulnerable to: Pain Thirst Fear Over-stimulation Agitation May be expression of pain/thirst

12 Hospital is not respite Rarely asked for information from staff Not provided with updates Not provided with amenities ( sleeper chairs, refreshments, etc. 77% of caregivers dissatisfied

13 12-39% of dementia patients had dx noted Not primary problem for admission Hospitals/staff generally don t have dementia protocols/training

14 Rapid Pace/Tech focus of hospital Pts unable to communicate ( informant not utilized optimally) Multiple handoffs Info gets lost/altered Adverse drug events Sleep deprivation Restraints (physical or kept in bed) Hospital acquired pneumonia Thromboembolism Decubitus

15 Meds: anticholinergics, opiates, benzo s Urinary catheters Unnecessary tests

16 Spend less time Lack of staffing 1 on 1 needed for nutrition/fluid/hygeine Lack of training in communication

17 Procedures to detect cognitive impairment/possible dementia Procedures to communicate information to hospital staff members about dementia symptoms that are likely to impact care Staff training, initial and ongoing Better planning for discharge / linkage to community care and support

18 Recognize sxs early ( often nonspecific) Caregiver training Physician assessment No current system to help caregiver manage illness as outpatient

19 Obtaining history Need informant Completing testing Choice of tests Need for sedation

20 Related to disease or superimposed delirium Frequent symptoms Agitation Psychosis Sleep disorder Non pharmacological approaches Medications

21 Room by nurses station (but quiet) Keep TV off (may try familiar music) Attempt same staffing Sitter or family member Identify sensory loss (hearing, vision) Care plan noticeable by all providers

22 No good drug choice for sleep But avoid benzo s and opiates Maintain CR cues Keep testing and checks during the daytime Keep mobile

23 Eliminate exacerbating drugs Benzodiazepines Narcotics Anticholinergics. but watch for withdrawal

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25 Non pharmacologic Stop deliriogenic agents Restore circadian rhythm Non-rx sleep promotion e.g. Melatonin Adequate stimulation no TV Pharmacologic Antipsychotics (literature is mixed) Hyperactive: haloperidol, quetiapine, risperidone Hypoactive: aripiprazole, risperidone VPA for non-responsive hyperactive delirium CEI should be continued if on before

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27 Push fluids Attend during meal time Assist in diet selection ( determine food likes from informant)

28 Sitter ( could be family) Avoid restraints Maintain day/night cues

29 Hospital patients with dementia are significantly less likely than other older patients to regain their preadmission functional (ADL) abilities at one month, three months, and one year after discharge Among older hospital patients admitted from home, patients with dementia are 2-4 times more likely than other older patients to be discharged to a nursing home and 3-7 times more likely to be living in a nursing home three months after discharge.

30 Should begin at time of admission Home with assistance if possible

31 Recognition of dementia Avoiding restraints Assessing and managing delirium Assessing pain Evaluating executive dysfunction Therapeutic activity kits Wandering Communication difficulties Decision making Eating and Feeding, Part 1 Eating and Feeding, Part 2 Working with Families

32 Massachusetts Dept. of Health: Recommendations from the Alzheimer s and Related Dementias Acute Care Advisory Committee University of California San Francisco, Partner With Me, training guidelines and resources Dementia Friendly America, Dementia Friendly Hospitals Updated Try This, Brief Training Documents for Nurses Caring for Hospital Patients with Dementia