Cumbria Partnership NHS Foundation Trust Memory Matters Service Dementia, Depression and Delerium Cancer Awareness Toolkit Evaluation Event Andrew Milburn Occupational Therapy Clinical Lead, Dementia Pathways
Dementia The term dementia is used to describe conditions that result in the progressive loss of mental abilities. Dementia will often affect a person s ability to remember, learn, think and reason and will cause the global loss of social skills. There are many different types of dementia and not all result in permanent disability. Counsel and Care (1996)
Dementia Statistics There are an estimated 750,000 people with dementia in the UK Dementia affects one person in 20 aged over 65 years and one person in five over 80 years of age There are 16,000 younger people with dementia in the UK. This is likely to be a major underestimate by up to three times because of the way the data relies on referrals to services There will be over a million people with dementia by 2025. Two thirds of people with dementia are women. Two thirds of people with dementia live in the community 64% of people living in care homes have a form of dementia Applying the prevalence rates to latest mid 2009 population estimates in Cumbria, these indicate that there are: overall 7.300 people suffering from dementia 4.400 people with a diagnosis of Alzheimer s Disease 1.300 people with Vascular Dementia 150 young onset dementia
Numbers of people with dementia in Cumbria are expected to rise substantially from about 7,000 in 2010 to nearly 13,000 in 2030 as our population ages.
Cumbria Dementia Strategy
Dementia is everyone s business: With increasing numbers of people with dementia, innovative solutions are required to improve quality and thereby effectiveness of services. Improved integrated working and rapid access to specialist services equals improved outcome which equals less crisis
Key Areas from Cumbria Dementia strategy Need for improved early recognition, referral and diagnosis (Current QOF- 55%) Modernisation of Community Dementia services in line with strategy Challenges of service provision in rural settings by developing improved integrated approach with services working together around the individual s needs Need to meet carer and family needs-implement family intervention Need to continue building on collaborative working with other services and agencies Reduce reliance on anti-psychotic medication with use improved non pharmacological approaches Improve dementia awareness, access to specialist memory services and quality across multiple settings (including hospital and care homes)
Benefits of a modernised, locality-based dementia service: Enables equity of access to specialist Memory Services in each locality and within each natural community. Enables reduction in duplication, ease of access/rapid referral Improved awareness of dementia, depression & delirium Enables flexibility in response to differing communities needs Each practice has named link responsible for training, rapid access to memory assessment/diagnosis, advice/support Improved integrated working, joint training, opportunistic screening etc Pro-active- reduces incidence of crisis and use of time limited specialist services improves ability to cope with demographic demands Ability to develop Dementia friendly Communities Ensures implementation of Dementia Strategy, NICE and other key requirementsbut proactively engages with natural communities
Improved early recognition and diagnosis: Integrated approaches with dementia training and 3Ds screening tool developed for staff in Community services, Community Hospitals with links to Community Memory services Closer working with GPs & practice staff (training to practice nurses) Primary care protocol developed to encourage early referral Memory services developed to offer flexible diagnosis and support irrespective of setting (e.g. clinic based, home based, surgery based) Improved information packs Care Home Education and Support Service (CHESS) and Hospital Liaison
Integrated developments
Delirium, Depression and Dementia (3D s) Early symptoms of delirium are similar to symptoms of anxiety, anger, depression, and dementia. Delirium that causes the patient to be very inactive may appear to be depression. Delirium and dementia may be difficult to tell apart, since both may cause disorientation and impair memory, thinking, and judgment.
Memory Matters Improved early recognition Patient ID Label or RNN number: NHS number: Surname: Forename/s: Date of Birth: Memory Matters- Screening Form GPCOG Screening Test, PHQ-4 & Delirium Screen Unless specified, each question should only be asked once 1. Examination: Score 1. I am going to give you a name and address. After I have said it, I want you to repeat it. Remember this name and address because I am going to ask you to tell it to me again in a few minutes: John Brown, 42 West Street, Kensington. (Allow a maximum of 4 attempts). 2. What is the date? (exact only) correct- 1 incorrect -0 3D s screening tool 3. Clock Drawing: Ask patient to draw a clock face Please mark in all the numbers to indicate the hours of a clock (correct spacing required) correct- 1 incorrect -0 Please mark in hands to show 10 minutes past eleven o clock (11.10) correct- 1 incorrect -0 4. Information: Can you tell me something that happened in the news recently? (Recently = in the last week. If a general answer is given, eg war, lot of rain, ask for details. Only specific answer scores). correct- 1 incorrect -0 5. Recall: What was the name and address I asked you to remember (score one point for each correct answer) John Brown 42 West Street Kensington Total Score: (To get a total score, add the number of items answered correctly- total score out of 9) If patient scores 9, no significant cognitive impairment and further testing not necessary. If patient scores 5-8, more information required. Proceed with Step 2, informant questionnaire * If patient scores 0-4, cognitive impairment is indicated. Conduct standard investigations consider referral to Memory services
Dementia DEGENARITIVE VASCULAR Alzheimer s Multi Infarct Lewy Body Parkinson's Picks OTHERS INFECTIVE Huntington s chorea Alcoholism Creutzfelt -Jacob Frontal Lobe Vitamin deficiency Syphilis Acute Confusional State Aids Hyperthyroidism Depression
Treatment for dementia Drugs developed aim to improve or at least slowing the decline of cognitive function. Psycho-Social Interventions: family based interventions, consider impact of dementia on family- family coping skills, attributions and education, separate interventions for person and carer. Psychological interventions: Used to help enhance coping skills or treat psychological factors Behavioural Interventions: Seek to identify behaviours by means of analysing communication, behaviour, dynamics of interaction and environmental factors Cognitive Stimulation: series of exercises aiming to introduce regular stimulation of memory. Errorless learning: can be effective in early dementia to reduce negative impact of memory loss
Depression statistics 3% of people over 65 suffer from major depression 10-15% have substantial depressive symptoms No age related increase in prevalence Women are affected more than men. More severe in men. Under-diagnosis remains a problem High risk groups: Bereaved (30%), Physically Ill, Alzheimer's Disease (20%), Post stroke (30%), Parkinson s (40%) Research shows cancer patients at high risk of depression, e.g. lung cancer 11-44%, pancreatic 33-50% Death rates up to 25% higher for cancer patients showing symptoms of depression, 39% higher if major depression
Delirium What is it? Latin for Off track Hippocrates A syndrome characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycle. Acute Confusional State due to a general medical condition or drug withdrawal or drug intoxication. Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence from the history, examination or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication (DSM 1V)
The Signs and Symptoms Acute onset over short period of time (hours or days) Fluctuating levels of consciousness throughout the day Attention Impairment Memory Impairment & Disorientation Agitation Apathy and Withdrawal Sleep Disturbance Emotional Lability Perceptual Disturbances Neurological Signs
The Many Causes of Delirium Infection (e.g. Pneumonia, UTI) Neurological (e.g. Stroke, Subdural Haematoma, Epilepsy) Cardiological (e.g. myocardial infarction, heart failure) Respiratory ( e.g. Hypoxia) Electrolyte imbalance (e.g. dehydration, renal failure) Endocrine and Metabolic imbalances Drugs (particularly antidepressants, anti-parkisonian drugs) Poly pharmacy / Reaction to New Medication Drug and/or alcohol withdrawal Urinary retention Constipation / Faecal Impaction Severe Pain Multiple Contributing Causes Medical Interventions
Delirium may be due to Cancer direct effects that cancer has on the brain, the pressure of a growing tumour may also be caused by indirect effects of cancer or its treatment, including the following: organ failure. electrolyte imbalances: infection symptoms caused by the cancer but that occur apart from the local or distant spread of the tumour, such as inflammation of the brain. medication side effects: some cancer drugs have side effects that include delirium and confusion. Usually reversible Withdrawal from drugs that depress the CNS
Differences in the symptoms of delirium and dementia Patients with delirium often go in and out of consciousness. Patients who have dementia usually remain alert. Delirium may occur suddenly. Dementia appears gradually and gets worse over time. Sleeping and waking problems are more common with delirium than with dementia. In elderly patients who have cancer, dementia is often present along with delirium, making diagnosis difficult. The diagnosis is more likely dementia if symptoms continue after treatment for delirium is given. In patients aged 65 or older who have survived cancer for more than 5 years, the risk for cognitive disorders and dementia is increased, apart from the risk for delirium
Treating Delirium Locate and treat the causes. Symptoms may be treated at the same time. Identifying the causes of delirium will include a physical examination to check general signs of health, including checking for signs of disease. A medical history of the patient's past illnesses and treatments Treatment may include the following: Stopping or reducing medications that cause delirium. Giving fluids into the bloodstream to correct dehydration. Giving drugs to correct hypercalcemia (too much calcium in the blood). Giving antibiotics for infections
Memory Matters Memory Matters South Lakes Memory Service Advice; Support; Referral; Assessment; Intervention Are you worried about your memory? tel: 01539 715009 fax: 01539 715209