Dementia and Delirium - the

unrecognised connection

Julia L. Poole CNC Aged Care

Royal North Shore Hospital
Sydney

Sponsors
RNSH Department of Aged Care & Rehabilitation Medicine

NSW Department of Health - Dementia Action Plan

Eli Lilly Australia Ltd - unrestricted education grant

Illawarra Area Health Service - Commonwealth Funded

Psychogeriatric Project

Northern Sydney Home Nursing Service

Julia Poole CNC Aged Care RNSH

Case Example
The ACAT receives a very distressed call from Mrs TW - requesting a nursing home placement for her husband
because
he has been very confused and wandering about the house the
last two nights and she can no longer care him

Mr TW:
87 years old
osteoarthritis, hypertension, cardiac failure, varicose ulcers,
early dementia
is now aggressive when approached
has eaten little in the last two days
his dog died last month
Julia Poole CNC Aged Care RNSH

What is Dementia?
a clinical syndrome of organic origin
characterised by slow onset of decline in
multiple cognitive functions
particularly intellect and memory,

occur in clear consciousness and

causes dysfunction in daily living
Burns, A. and Hope, T. Clinical aspects of the dementias of old age, in Jacoby, R. and
Oppenheimer, C. (eds) (1997) Psychiatry in the Elderly. Oxford: Oxford university
Press.
Julia Poole CNC Aged Care RNSH

Disorders that cause dementia

Alzheimers Disease
Vascular Dementia
Diffuse Lewy Body Disease
Fronto-temporal disorder
Huntingtons Disease
Creutzfelt-Jacob Disease
Etc
Julia Poole CNC Aged Care RNSH

What is Delirium?
often known as Acute Confusion

Acute confusional states occur in 3050% of hospitalised geriatric patients:

patients with dementia are particularly
vulnerable (Isselbacher et al.1998)
Julia Poole CNC Aged Care RNSH

What is Delirium ?(contd)

an acute organic mental disorder
characterised by confusion, restlessness,
incoherence, inattention, anxiety or
hallucinations which may be reversible with
treatment

Inouye (1998); Gelder, Mayou & Geddes (1999); Moran & Dorevitch (2001)

Julia Poole CNC Aged Care RNSH

DSM-IV 1994
Delirium is characterised by a
disturbance of consciousness and a
change in cognition that develop over a
short period of time
Delirium due to a general medical condition
Substance induced delirium
Delirium due to multiple etiologies
Delirium not otherwise specified
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental
Disorders (4th Ed).Washington: American Psychiatric Association.
Julia Poole CNC Aged Care RNSH

ICD-10-AM Diseases Tabular

2003
F05 - Delirium, not induced by alcohol
and other psychoactive substances
non specific organic cerebral syndrome
concurrent disturbances of consciousness and
attention, perception, thinking, memory, psychomotor
behaviour, emotion, and the sleep-wake schedule.

F05.1 Delirium superimposed on dementia

Julia Poole CNC Aged Care RNSH

Delirium
Clinical Features
Most causes affect neuronal function diffusely all aspects of intellectual function
Cardinal feature - clouding of consciousness
impaired alertness, awareness, attention
variability in state of arousal
reduced responsiveness is interspersed with periods
of excited outbursts
sleep / wake cycle disrupted
Isselbacher et al.1998. Harrisons Principles of Internal Medicine
Julia Poole CNC Aged Care RNSH

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Delirium
Clinical Features (contd)
Impaired perception
misperceives surrounding & attendants
hallucinations

Disturbance of emotion
agitation, fear, depression, anxiety

Psychomotor changes
hyperactivity, restlessness, repetitive (plucking, tossing)
Isselbacher et al.1998. Harrisons Principles of Internal Medicine
Julia Poole CNC Aged Care RNSH

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Causes of Delirium

Predisposing

Brain disease - dementia, stroke, past severe head injury

Use of brain-active drugs - sedatives, anticholinergics
Impairments of special senses - sight, hearing
Multiple severe illnesses
Malnutrition

Precipitating
Iatrogenic - unpleasant environmental change, invasive
procedures, new medications, trauma, dehydration, ongoing
malnutrition, elimination malfunction
Illnesses - infections, intracranial pathologies, impaired organ
function, abnormal metabolite function, pain, drug withdrawal
Creasey, H. (1996) Acute confusion in the elderly. Current Therapeutics.
August:21-26.
Julia Poole CNC Aged Care RNSH

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Pathophysiology of delirium
Poorly understood
decreased cerebral oxidative metabolism causing altered
neurotransmitter levels
&/or
stress-induced increased plasma cortisol levels causing
altered neurotransmitter activity
Moran, J. & Dorevitch, M (2001) Delirium in the hospitalised elderly. The Australian
Journal of Hospital Pharmacy. 31(1):35-40.

cerebral hypo-perfusion in the frontal, temporal & occipital

cortex
Yokata, H. et al. (2003) Regional cerebral blood flow in delirious patients. Psychiarty and
Clinical Neurosciences.75(3):337-339.

Julia Poole CNC Aged Care RNSH

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Delirium
Is a medical emergency
Incidence of up to 56% in hospitalised older
people
Independent predictor of adverse outcomes
increased falls
incontinence
pressure sores
increased LOS in acute care
decreased functional levels
increased mortality
Maher, S. and Almeida, O. (2002) Delirium in the elderly - another medical emergency. Current Therapeutics. March:39-43.

Julia Poole CNC Aged Care RNSH

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CONFUSION ASSESSMENT METHOD (CAM)

R o y al N o rth S h o re an d R y d e H ealth S erv ice

Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present
1. Acute and fluctuating course
Is there evidence of an acute change in mental
status from the patient's baseline? Did the
(abnormal) behaviour fluctuate during the day,
that is, come and go, or increase and decrease
in severity?
No
Yes
Uncertain (please specify) .

2. Inattention.
Did the patient have difficulty focussing attention
during the interview, e.g. being easily
distractible, or having difficulty keeping track of
what was being said?
No
Yes
Uncertain (please specify) .

Delirium symptoms present

Delirium symptoms NOT present

N/A

3. Disorganised thinking
Was the patients thinking disorganised or
incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas,
or unpredictable switching from one subject to
another?
No
Yes
Uncertain (please specify) ..

4. Altered level of consciousness

Overall, how would you rate this patients level
of consciousness?
Alert (normal)
Altered
Vigilant (hyperalert, easily startled,
overly sensitive to stimuli)
Lethargic (drowsy but easily aroused)
Stupor (difficult to arouse)
Coma (unrousable)
Uncertain

DATE:
Signature of assessor & designation:
Medical Officer's signature ..

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Inouye, S.K. van Dyck, C.H. Alessi, C.A. Balkin, S. Siegal, A.P. Horwitz, R.I. (1990) Clarifying confusion: the confusion assessment method. A new method for detection
of delirium. Annals of Internal Medicine. 113(12):941-948.

A Good Model
helps us see more clearly
creates a simple language for a
complicated process
presents the whole or all of its parts
is stable and generalizable (McCarthy 1996)

ALGORITHM
- an explicit protocol with well- defined
rules to be followed in solving a health
care problem. (Mosbys Dictionary 1990)
Julia Poole CNC Aged Care RNSH

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Poole, J.L. and McMahon, C. (2005) An Evaluation of the

Response to Pooles Algorithm Education Programme by Aged
Care Facility Staff. Australian Journal of Advanced Nursing.
22(3):15-20.

AIM
a descriptive study instigated to seek
evidence of a change in knowledge and
care practices in staff who had participated
in the education programme
Poole, J. (2003) Pooles algorithm: Nursing management of disturbed behaviour in older
people - the evidence. Australian Journal of Advanced Nursing. 20(3):38-43.
Julia Poole CNC Aged Care RNSH

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Method
Ethics approval
Train-the-trainer sessions for senior ACF
staff
Training sessions in their own facilities
over three months
Evaluation
pre and post knowledge questionnaires
focus groups at the end of the 3 months
Julia Poole CNC Aged Care RNSH

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Pre & Post Knowledge

Questionnaire
Tick the three most common causes of
disturbed behaviour in older people in
your facility
Personality disorder
Anxiety disorder
Delirium
Dementia
Senility
Depression
Julia Poole CNC Aged Care RNSH

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Pre & Post Knowledge

Questionnaire
Tick the three most common causes of
disturbed behaviour in older people in
your facility
Personality disorder
Anxiety disorder
Delirium
Dementia
Senility
Depression
Julia Poole CNC Aged Care RNSH

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Table 1. Trainer-the-trainer and focus group participants

Train-the-trainer

Focus Groups

Number

Number

Directors of Nursing

7.7

8.3

Deputy Directors of Nursing

18

17.3

11.1

Directors of Care

2.9

Registered Nurses

45

43.3

16

Enrolled Nurses

1.9

Diversional Therapists

1.9

2.8

Personal Care Assistants (PCA) or Assistants

in Nursing (AIN)

4.8

2.8

Others (e.g.Allied Health, Managers)

21

20.2

11

30.6

Total

104

100

36

100

Julia Poole CNC Ag

44.4

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Table 3. Trainers Pre & Post Knowledge Test Results - Opinions of the three
major causes of disturbed behaviour from the given list (%). n = 104
Pretest
%

Posttest
%

Difference
%

* Chisquare
with 1 df

P value

95% CI of
difference

Delirium, depression and

dementia
Delirium

19.2

91.3

71.1

73.01

<0.001

63.5 - 80.7

39.4

97.1

57.7

58.02

<0.001

43.6 - 71.8

Depression

78.8

100

21.2

20.05

<0.001

71.0 - 86.7

Dementia

90.4

98.1

7.7

4.08

0.043

1.3 - 14.1

Personality Disorders

17.3

17.3

84.01

<0.001

10.0 - 24.6

Anxiety Disorder

62.5

8.7

53.9

54.02

<0.001

44.3 - 63.4

Senility

10.6

10.6

9.09

<0.003

4.7 - 16.5

* McNemars Test

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Table 2. Staff trained by the trainers.

Number

Registered Nurses

63

33.2

Enrolled Nurses

3.2

Diversional Therapists

4.2

Personal Care Assistants (PCA) or Assistants

in Nursing (AIN)

104

54.7

Others (e.g.kitchen or cleaning staff)

4.7

Total

190

100

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Table 5. Aged Care Facility Staff Pre & Post Knowledge Test Results Breakdown of the opinions of the three major causes of disturbed behaviour
from the given list (%). n = 190
Pretest
%

Posttest
%

Difference
%

* Chisquare
with 1 df

P value

95% CI of
difference

Delirium, depression and

dementia
Delirium

12.6

59.5

46.8

72.37

<0 001

38.7 - 55.0

24.7

75.2

50.5

80.58

<0 001

46.3 - 58.8

Depression

78.4

89.5

11.1

10.81

<0.001

5.0 - 17.1

Dementia

91.6

91.1

0.5

Personality Disorders

25.8

16.3

9.5

6.02

0.014

2.5 - 16.5

Anxiety Disorder

64.7

23.2

41.6

62.72

<0.001

34.0 - 49.2

Senility

20.0.

8.4

11.6

12.25

<0.001

5.6 - 17.5

McNemars Test

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Acute Care responses

N = 99 mostly RNs
What are the 3 most common causes of disturbed
behaviour in older patients in ACUTE care
Causes of disturbed
behaviour

Personality Disorder
Anxiety Disorder
Delirium
Dementia
Senility
Depression
0

20

40

60

80

100

Numbers of answers

Julia Poole CNC Ag

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5. Can you give me an instance of

you or your staff using the
knowledge in your workplace?

now I feel so guilty because I told Mrs So-and-so that she

was just being whingy, and now I understand;
Im more inclined to look for reasons for the behaviour
more inclined to do something about it; start to investigate
all the clinical signs he had a UTI;

theres a haste to it ( to assess); lets start assessing the

situation . understanding that its not just dementia.

Julia Poole CNC Aged Care RNSH

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7. Has this new knowledge altered the

way you or your staff feel about
difficult situations and behaviours?
I think a lot of the staff, particularly the AINs, are
understanding that its not the person, its an illness or
something thats causing the behaviour, not the actual
resident being nasty to me
more ordered, less panicky, more peaceful, more tolerant,
more forgiving, less judgemental responses.

Julia Poole CNC Aged Care RNSH

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Limitations
post knowledge questionnaires applied directly
after the training
small number of trainers returned for the focus
groups
those that returned may have particularly wanted
to report good results
difficulties finding time to complete all the staff
training
staff language and cultural diversity
Julia Poole CNC Aged Care RNSH

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Conclusions &
Recommendations
Delirium is poorly understood
Negative attitudes & practices are fuelled by
ignorance about mental health and medical
issues
Ongoing accurate training is essential
Expansion of this study in the acute and
community sectors is recommended
Julia Poole CNC Aged Care RNSH

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Case Example
The ACAT receives a very distressed call from Mrs TW - requesting a nursing home placement for her husband
because
he has been very confused and wandering about the house the
last two nights and she can no longer care him

Mr TW:
87 years old
osteoarthritis, hypertension, cardiac failure, varicose ulcers,
early dementia
is now aggressive when approached
has eaten little in the last two days
his dog died last month
Julia Poole CNC Aged Care RNSH

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Solution to
Mr & Mrs TWs Problem
Consider safety - informed careful
approach
Seek medical assessment as soon
as possible
Julia Poole CNC Aged Care RNSH

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