Mental Health and Cognitive Changes in the Older Adult
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The document discusses mental health and cognitive changes in older adults, focusing on dementia and delirium, their definitions, symptoms, and screening tools such as the MMSE and the confusion assessment method. It highlights the prevalence of cognitive disorders in older adults, the importance of accurate diagnosis, and differences between dementia and delirium. Recommendations for clinical practice strategies to support older patients experiencing these cognitive changes are also provided.
![Clinical Practice Strategies [1]
Interpreter for culturally & linguistically
diverse (CALD) patients/clients
Indigenous Liaison Officer
Eating & Drinking
Hearing Aids?
Glasses?
Bowels – avoid constipation
Mobilisation](https://image.slidesharecdn.com/mentalhealthandcognitivechangesintheolderadult-161129044043/85/Mental-Health-and-Cognitive-Changes-in-the-Older-Adult-38-320.jpg)
![Clinical Practice Strategies [2]
Encourage independence in basic ADLs
Medication review
Promote sufficient sleep at night
Manage discomfort or pain
Provide orienting information
Minimise use of indwelling catheters
Avoid use of physical restraints
Avoid polypharmacy/psychoactive drugs](https://image.slidesharecdn.com/mentalhealthandcognitivechangesintheolderadult-161129044043/85/Mental-Health-and-Cognitive-Changes-in-the-Older-Adult-39-320.jpg)
Mental Health and Cognitive Changes in the Older Adult
- 1. Mental Health and Cognitive Changes in the Older Adult Paul McNamara RGN (RAH), RPN (SAMHS), BN (Flin.), MMHN (USQ), Cert IMH (WCHN), CMHN, FACMHN @meta4RN #Ausmed
- 2. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
- 3. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
- 4. Why it matters 25% of patients visiting a health service have at least one mental, neurological or behavioural disorder Cognitive problems more common amongst older persons Older persons a significant proportion of hospital patients
- 5. > 65 ~ 13% population > 65 ~ 39% hospital patients > 65 ~ 48% hospital bed days AIHW (2014) Australia's hospitals at a glance 2012-13 Why it matters
- 6. Cognition cognōscere “to know” the process of knowing thinking, thoughts capacity to understand / interpret information
- 7. Cognition processing of information memory + thoughts store, retrieve and manipulate information disruption to this process = cognitive disorder
- 8. Disorders of Cognition Sx impaired awareness reasoning memory judgment perception disorientation (time +/or place +/or person)
- 9. DSM IV (old speak) Delirium Dementia Amnesia Cognitive Disorder NOS DSM 5 (new speak) Delirium Unspecified Neurocognitive Disorder Neurocognitive Disorders due to…
- 11. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
- 12. Dementia “a progressive illness that involves cognitive and non-cognitive abnormalities and disorders of behaviour; presents as a gradual failure of brain function. It is not a normal part of life or aging.” Elder, Evans & Nizette (2013) pp 525
- 13. Dementia aka Neurocognitive Disorders due to… Alzheimer’s Disease Vascular Disease Lewy Bodies Prion Disease HIV Infection Traumatic Brain Injury Multiple Aetiologies
- 14. Dementia ~ 1.9% > 65 years ~ 8.4% > 75 years ~ 22.4% > 85 years Elder, Evans & Nizette (2013) pg 256 2009 ~ 1.1% Australian population 2050 ~ 3.2% Australian population
- 15. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
- 16. Delirium “go off the furrow” "off the track“ not a disease: a syndrome a medical emergency: associated with increased morbidity and mortality rates up to 56% of older people in hospital Inouye S, 1994. ‘The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium hospitalized elderly medical patients’ American Journal of Medicine 97(3):278–88.
- 17. Some Causes of Delirium Hyperthyroidism Hypothyroidism Hypercalcaemia Hyponatraemia Urinary Tract Infection Pneumonia Septicaemia Stroke Subarachnoid Haemorrhage Unmanaged Pain (esp. old age) Head Trauma Fractures (esp. Hip & Rib) Hypoglycaemia Vitamin B12 Deficiency Folate Deficiency Sedatives Antihistamines Alcohol Benzodiazepines Opiates Anticholinergics Urinary Retention Constipation Faecal Impaction Severe Diarrhoea Changes In Environment
- 18. Diagnosis Under-diagnosis common: up to 50% Contributing factors: Hypoactive delirium Old age Misdiagnosed as depression or dementia Important because: Worse prognosis Prevents detection and management of other sx Increases family’s distress
- 19. Communication between staff Fluctuating nature may lead to tension between different staff groups: Emphasise fluctuation as core symptom Use of validated scales Differences in pharmacological approaches Treat early but at low dose
- 20. Communication with the Family Valuable source of baseline data “Patrick seems to be having difficulty concentrating at times. How was he before he came into hospital?” Gagnon et al (2002): 60% of 124 caregivers hadn’t realised possibility of delirium All care-givers expressed distress
- 21. Compare & Contrast Dementia Delirium Onset Insidious Acute Duration Months/years Hours/days/ ??weeks Course Stable & progressive (unless vascular dementia – usually stepwise) Fluctuates – worse at night Lucid periods Orientation May be normal – usually impaired for time and place Fluctuates, but will always be impaired in some aspect: Time, Place, Person? Memory Impaired recent & sometimes remote memory Recent impaired
- 22. Compare & Contrast Dementia Delirium Thoughts Slowed Reduced interests Perserverant Delusions are common Often paranoid & grandiose ? bizarre ideas & topics ? paranoid Perception ? normal Visual & auditory hallucinations common Delusions are common Emotions Shallow, apathetic, labile, ? irritable, careless Irritable Aggressive Fearful Sleep Often disturbed. Nocturnal wandering common. Nocturnal confusion. Nocturnal confusion and/or “sundowning” common.
- 24. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
- 25. MHS-MINIMENTALSTATEEXAMINATION Instructions: • Before starting the questionnaire, try to get the consumer to sit facing you. •Ask the question a maximum of three times. If the consumer does not respond, score zero. •If the consumer answers incorrectly, score zero. Do not hint, prompt or ask the question again. I am going to ask you some questions and give you some problems to solve. Please try to answer as best you can. Orientation (allow 10 seconds for each response) Points ( = Pass) 1. a) What year is it? (accept exact answer only) b) What season is it? (last week of old season or first week of new season acceptable) c) What is today’s date? (accept previous or next day’s date) d) What day of the week is it? (accept exact answer only) e) What month of the year is it? (first day of new month or last day of previous month acceptable) 2. a) What state of Australia are we in? (accept exact answer only) b) What city are we in? (accept exact answer only) c) What suburb are we in? (accept exact answer only) d) What floor of the building are we on or what ward are we on? (accept exact answer only) e) What is the name of this place? (accept exact answer only) 1 1 1 1 1 1 1 1 1 1 Orientation sub-total: Registration 3. I am going to name three objects. After I have said them, I want you to repeat them. Remember what they are because I am going to ask you to name them in a few minutes. Say them slowly at about 1 second intervals APPLE TABLE PENNY Please repeat the three items for me. Score one point for each correct response on the first attempt. Allow 20 seconds for response; if consumer does not repeat all three, repeat until they do, or up to a maximum of five times. Maximum score three. 1 - Apple 1 - Table 1 - Penny Registration sub-total: Attention and Calculation 4. Can you subtract 7 from 100, and then subtract 7 from the answer you get, and keep subtracting 7 until I tell you to stop? OR 1 - 93 1 - 86 1 - 79 1 - 72 1 - 65 OR 5. I am going to spell a word forwards and I want you to spell it backwards. The word is WORLD – W – O – R – L – D. (You may help the person spell the word correctly). Now spell it backwards. Repeat if necessary. Allow 30 seconds to spell it backwards. If the consumer cannot spell “world” with assistance, score 0. Score one for each letter in correct order. Maximum score five. 1 - D 1 - L 1 - R 1 - O 1 - W Attention and Calculation sub-total: Recall 6. Now, what were the three objects I asked you to remember? Score one point for each correct response, regardless of order. Allow 10 seconds for response. Maximum score of three. 1 - Apple 1 - Table 1 - Penny Recall sub-total: Page 1 of 2 (Affix identification label here) URN: Family name: Given name(s): Address: Date of birth: Sex: M F I Mental Health Services Mini Mental State Examination (MMSE) Facility: ......................................................................................................... Clinician’s name (please print): Designation: Signature: Team: Date: Time:
- 26. Language Points ( = Pass) 7. Show the consumer a wrist watch. What is this called? Allow 10 seconds for response. Accept ‘wrist watch’ or ‘watch’. Do not accept ‘clock’ or ‘time’. Score one point. 1 8. Show the client a pencil. What is this called? Allow 10 seconds for response. Accept ‘pencil’ only, not ‘pen’. Score one point. 1 9. I would like you to repeat a phrase after me: “No ifs, ands or buts” Allow 10 seconds for response, score one point for correct repetition. Answer must be exact. 1 10. Read the words on this page and do what it says. Close your eyesIf consumer reads and does not close eyes, you may repeat it to a maximum of three times. Allow 10 seconds, score only one point only if consumer closes eyes. 11. Read the full statement below before handing respondent blank piece of paper. Do not repeat or coach. I am going to hand you a piece of paper. When I do, take the piece of paper in your right hand, fold the paper in half with both hands and put the paper down on your lap. Allow 30 seconds. Score one point for each instruction executed correctly. Takes the paper in correct hand Folds the paper in half Puts paper down on lap 1 1 1 1 12. Hand consumer a piece of paper. and a pencil. Write any complete sentence on that piece of paper. Allow 30 seconds. The sentence should have a subject and a verb, and make sense. Spelling and grammatical errors are okay. 1 13. Refer to diagram shown below. Here’s a drawing. Please copy the drawing on the same paper. Hand drawing to respondent. Correct if two convex, five-sided figures and intersection makes a four-sided figure. Score one point for a correctly copied diagram. Allow 1 minute maximum. 1 Language sub-total: Score best of question 4 or 5 to give a total out of 30. A score of 23 or less indicates cognitive impairment. Total Test Score: Adjusted Score: (Modified from Folstein, Folstein, McHugh, Psychiat. Res 1975, 12, 189–198, and Molloy et al, American Journal of Psychiatry, 1991; 148: 102– 105) Page 2 of 2 DONOTWRITEINTHISBINDINGMARGIN (Affix identification label here) URN: Family name: Given name(s): Address: Date of birth: Sex: M F I Mental Health Services Mini Mental State Examination (MMSE) Clinician’s name (please print): Designation: Signature: Team: Date: Time:
- 27. MMSE Screening tool not diagnostic tool Does not differentiate between dementia and delirium English literacy and numeracy Other considerations?
- 29. Clockface Drawing Test Brief screening tool not diagnostic tool More sensitive to frontal lobe impairment “Please draw the face of a clock with all the numbers on it. Make it large.” then “Show the time at 10 minutes past 11”
- 33. The Confusion Assessment Method (CAM) Diagnostic Algorithm 1: Acute Onset & Fluctuating Course 2: Inattention 3: Disorganised Thinking 4: Altered Level of Consciousness features 1 & 2 and either 3 or 4 = diagnosis of delirium Reference: Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the Confusion Assessment Method. Annals of Internal Medicine 113: 941-8
- 36. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
- 37. Environmental Strategies Lighting appropriate to time of day Low Stimulus Environment Clock & calendar that clients can see Encourage family to visit/stay Bring in client’s personal and familiar objects Avoid room changes
- 38. Clinical Practice Strategies [1] Interpreter for culturally & linguistically diverse (CALD) patients/clients Indigenous Liaison Officer Eating & Drinking Hearing Aids? Glasses? Bowels – avoid constipation Mobilisation
- 39. Clinical Practice Strategies [2] Encourage independence in basic ADLs Medication review Promote sufficient sleep at night Manage discomfort or pain Provide orienting information Minimise use of indwelling catheters Avoid use of physical restraints Avoid polypharmacy/psychoactive drugs
- 40. After Delirium Resolves Many patients remember being delirious Symptoms resolve, but the feelings remain Not always discussed: Fear of being thought mad Health professionals may assume no recall
- 41. dbmas.org.au Behavioural and Psychological Symptoms of Dementia (BPSD)
- 42. Veronica by Elvis Costello
- 44. Today’s Presentation Overview Dementia Delirium Screening Tools MMSE Clockface CAM Supporting
Editor's Notes
- #2: As we get older, the likelihood of undergoing alterations to brain function is high. This may include normal neurodegenerative changes as well as abnormal deteriorations. Separating normal from dysfunctional degeneration when screening and assessing an older adult is essential for quality nursing care planning. This session will look at: What are normal age-related changes to the brain and consequent behavioural signs? How are these changes different to the onset of mental health disorders such as schizophrenia, psychosis or bipolar disorder? Age appropriate assessment tools for effective mental health assessment Benefits of brief psychosocial interventions What practical behavioural strategies may improve outcomes for a person with a mental health disorder and cognitive changes?
- #3: This is what we’ll be working through over today’s session
- #4: This is what we’ll be working through over today’s session
- #5: 25% of patients visiting a health service have at least one mental, neurological or behavioural disorder Mental illnesses affect, & are affected by, physical conditions World Health Organisation 2006
- #6: In 2012–13, for overall admitted patient care: 39% of separations (think admissions) were for people aged 65 and over (who account for about 13% of the population), and these accounted for 48% of patient days. > 65 ~ 13% of Australia’s population > 65 ~ 39% of Australia’s hospital patients > 65 ~ 48% of Australia’s hospital bed days Australian Institute of Health and Welfare (AIWH) 2014. Australia's hospitals at a glance 2012-13. Health services series no. 55. Cat. no. HSE 146. Canberra: AIHW
- #7: Latin cognōscere “to know” Noun = the process of knowing Thinking, thoughts How you understand/ interpret information
- #8: Cognition involves the mental processing of information. Memory and thought combine to store, retrieve and manipulate this information When something goes wrong with this process, a cognitive disorder may result
- #9: Symptoms vary, but generally include
- #10: We’re at a time of transition from DSM-IV to DSM V. Amnesia = significant loss of memory, although there is no loss of other cognitive functions as there is in dementia Cognitive Disorder NOS = not otherwise stated. This is often a preliminary/provisional diagnosis while diagnostic testing is underway. Often, not always, secondary to a medical cause – a delirium. For the sake of clarity and simplicity, I‘m sticking with the old system for now.
- #11: 15 years ago in FNQ mental health would actively avoid getting involved with people who have cognitive problems. Psychiatry can not fix an irreversible condition like dementia. Delirium is a behavioural expression of an underlying medical or surgical problem – an admission to a mental health unit would be dangerous. Now major centres have small specialized teams to assist with the diagnosis and management of psychiatric and cogniotive problems that older persons experience.
- #12: This is what we’ll be working through over today’s session
- #13: A progressive deterioration of brain function that is marked by impairment of memory, confusion and inability to concentrate. Most common types : Alzheimer's disease (general cerebral atrophy) Parkinson's disease Huntington’s disease Vascular dementia Wernicke-Korsakoff (sever alcohol abuse HIV dementia
- #14: A progressive deterioration of brain function that is marked by impairment of memory, confusion and inability to concentrate. The due to… bit includes Alzheimer’s Disease Vascular Disease Lewy Bodies Prion Disease HIV Infection Traumatic Brain Injury Multiple Eitiologies Most common types : Alzheimer's disease (general cerebral atrophy) Parkinson's disease Huntington’s disease Vascular dementia Wernicke-Korsakoff (sever alcohol abuse HIV dementia
- #15: Not quite 1 in 50 at age 65 Nearly 1 in 12 at 75 Over 1 in 5 at age 85 Because our population is aging, so is the overall prevelance of dementia
- #16: This is what we’ll be working through over today’s session
- #17: Delirium is a Latin word for off the furrow (a ploughing metaphor)
- #18: The one’s I’ve highlighted in yellow are the ones I think we, at CBH, see the most. I haven’t got hard data on this, it’s just my perception.
- #19: Incidence of 26-44% of patients admitted to hospices Bruera: 47 pts in last 2 weeks of life, up to 83% have episode of delirium, half of these not recognised Hypoactive most common form of delirium Old age: ageist steotypes Sensory deficits Prognosis worse: shorter life expectancy, longer hospital stays, greater functional decline Yet can be treated: Gagnon et al 89 study patients admitted to a hospice (life expectation <2 months) 32 experinced delirium: significant sx improvement in 50% Partic pain
- #20: Day/night staff Nurses/doctors Community/hospital based staff Physios/Ots and others Validated scales: MMSE Confusion assessment method: 4 item instrument for clinicians with no psych training, takes approx 10 minutes acute onset mental status changes or fluctuating course; inattention; disorganised thinking; altered level of conbsciousness Confusion rating scale CRS: screening tool 0-2 takes <2 moinutes Disorientation Inappropriate behaviour Inappropriate communication Illusions/hallucinations Breitbart 30 pts with AIDS 24 haloperidol: 2.8 mg Chang-Su Han 28 pts with delirium dose 1.7 mg
- #21: Distress: loss of contact with relative before death Fear when pt is aggressive Feelings of guilt and powerlessness 15 bedded hospice in Canada Pamphlet drawn up in consultation with caregivers and professionals Discussion about whether it should be given to all or only to families where pt is delirious Families felt more confident that they were doing the right thing; found it reassuring, offered hope; able to discuss with other family members. Older caregivers more anxious.
- #24: So lets’ compare and contrast…
- #25: This is what we’ll be working through over today’s session
- #28: Brown, p.54, 2007 suggests Before commencing a cognitive assessment the nurse needs to consider: Does the client speak English? Has the client lived in the country for an extended period of time? Are there cultural implications that may affect the outcome? What is the literacy level of the client? Is the environment suitable? Has the client any vision impairment? Has the client any hearing impairment or speech deficits? Did the client complete the assessment with the assistance of family or friend? What measures were employed to allay fears the client may have? Were the physical needs of the client met before commencing the test, i.e. pain free, no bladder or bowel concerns, no hunger or thirst?
- #29: Rowland Universal Dementia Assessment Scale (RUDAS) Montreal Cognitive Assessment (MoCA) Kimberley Indigenous cognitive assessment (KICA) Frontal Assessment Battery (FAB)
- #30: I would like you to draw the face of a clock with all the numbers on it. Make it large. After completion: Now I would like you to set the time to 10 minutes past 11.
- #35: Key features of the 4AT: ♦ takes only 1-2 minutes ♦ suitable for use in normal clinical practice ♦ practical and simple ♦ no special training is required ♦ allows assessment of ‘untestable’ patients (that is, patients with severe drowsiness or agitation) ♦ includes brief cognitive tests
- #36: Why is important to detect delirium and dementia? Because it gives direction to how to effectively support the patient.
- #37: This is what we’ll be working through over today’s session
- #41: Minnick et al: 6/15 pts in ICU remember being restrained Breitbart: 53% of 101 pts recall episode of deluirium More common among people with mild-moderate delirium 43/54 pts reported severe distress both hypoalert qnd hyperalert More distress if perceptual abnormalities or delusions (altho’ less likely to remember if these were severe – prob because this reflects greater severity if delirium)
- #43: Also, watch and listen to “Veronica” by Elvis Costello
- #44: Also, watch and listen to “Veronica” by Elvis Costello
- #45: Any comments or questions?