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Delirium, Dementia and Polypharmacy (Delirium: acute confusional state
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Delirium, Dementia and Polypharmacy
Delirium: acute confusional state
- De Litra = furrow = go out of track
- prevalence: range from 1%-85% (general population vs. post op and ICU)
- criteria according to DSM5
Diagnostic Criteria: DSM 5
- A) A disturbance in attention (focus, sustain, and shift attention) and awareness (reduced orientation to the environment)
- B) The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day
- C) An additional disturbance in cognition (ex. memory deficit, disorientation, language, visuospatial ability, or perception)
- D) The disturbances in Criteria A and C are not better explained by another preexisting, established, or disorder and do not occur in the context of a severely reduced level of arousal, such as coma
- E) The disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal
Associated Features:
- sleep disturbance: sleep - wake cycle and night - day
- emotional disturbances: anxiety, fear, depression, irritability, anger, euphoria, apathy
Types:
- Acute (hours-day) vs. Persistence (weeks - months)
- Hyperactive: psychomotor activity, mood lability, agitation, and/or refusal to cooperate with medical care
- Hypoactive: sluggishness and lethargy that approaches stupor
- mixed type
Risk Factors/ Causes:
- CNS disorders
- metabolic disorders
- systemic illness (failure, infection, trauma, pain, constipation)
- endocrine
- medications (interactions, side effects, complicaitons)
- drugs (intoxication, withdrawal)
- sensory impairment
Diagnosis:
- History
- Physical Exam
- Investigation (Blood work, drug screen, images, EEG)
- Diff. Diagnoses:
- Psychotic disorders (Schizo.,Bipolar, Depression with Psychosis.)
- Dementia
- Malingering, Factitious
Treatment:
- underlining causes
- nonpharmacological:
- nursing care / medical team: safety, orientation, appropriate stimulation, education toward pt. and family, vital signs, fluid intake and output, careful feeding to avoid aspiration)
- environment
- restraints
- sleep hygiene
- pharmacological approach:
- underlining medical causes (alcohol with., drug intoxication, medications’ side effects)
- antipsychotic meds. For agitation and / or psychosis
- ECT : shock therapy
Dementia:
- prevalence: 1% at 65 years old - 30% at 85 years old
- criteria in DSM5 (dementia in DSM4 is largely congruent with major NCD (neurocognitive disorder); mild cognitive impairment is congruent with mild NCD
Diagnostic Criteria: DSM 5
- Diagnostic Criteria (major NCD )
- A) Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains based on: concern of the individual/family/clinician; documented by standardized neuropsychological testing
- B) The cognitive deficits interfere with independence in everyday activities
- C) The cognitive deficits do not occur exclusively in the context of a delirium
- D) The cognitive deficits are not better explained by another mental disorders (was not in DSM 4)
Types/Specify:
- without behavioral disturbance
- with Behavioral Disturbance ( Psychosis, Mood disorders, agitation, apathy)
- Mild: difficulties with instrumental activities
- Moderate: difficulties with basic activities of daily living
- Severe: fully dependent
Etiological Subtypes:
- Alzheimer’s disease:
- gradual/insidious progression; family and physicians dismiss memory loss as normal aging; memory impairment, visuospatial problems, language impairment, executive dysfunction, social functioning and no personality change intact in early stage
- Lewy body disease:
- second most common form after AD, Parkinsonism concurrently with Dementia, fluctuation in cognitive impairment, visual hallucinations, sensitivity to antipsychotics, subcortical types vs. cortical
- Frontotemporal lobar degeneration (FTD):
- early onset at young age; behavioural variant (Picks disease) - hyperphagia, hypersexuality, personality changes (early), MMSE (mini-mental state examination) could be normal in early stage
- Vascular Dementia:
- onset after a stroke, sudden onset faster progress, mini-stroke is hard to detect, it usually comes with AD
- Traumatic brain injury
- Substance/medication use
- HIV infection
- Prion disease
- Parkinson’s disease
- Huntington’s disease
- Another medical condition Multiple etiologies
- Unspecified
Diagnostic Tools:
- History
- taking it from patients first
- is essential but can be not accurate or difficult
- focus on onset of cognitive deficits (ex. memory loss or others)
- symptoms / psychiatric features
- safety issues
- ADLs and IADLs
- medical illness, medications
- Examination
- physical exam
- mental status examination
- screening tests: MMSE, MOCA (montreal cognitive assessment), MINI COG
- Lab and Images
- neuropsychological testing
- Kohlman Evaluation of living skills
- genetic testing
- Differential Diagnosis
- 3 D's (depression, delirium, dementia)
- Medications (anticholinergic side effects, Benzodiazepine)
- Vitamin B12 deficiency
- Alcohol abuse
Treatment:
- Not curable but reduce progression of the illness
- Pharmacological approaches: cognitive impairment (cholinesterase inhibitors, mamantine for moderate – severe)
- Behavior problems antipsychotics, antidepressant, mood stabilizers
- Non-pharmacological Approaches: activity planning; social activity (Alzheimer society), family education, environment and safety; caregiver frustration
Agitation:
- Common problem with Delirium and Dementia
- resistance to care
- verbal outburst
- physical aggression
- due to: frustration, difficult to be understood, poor communications, psychotic, medication side effects, etc
5 W's of Pharmacists
- WHO: pharmacists are regulated healthcare professionals who have graduated from a four year undergraduate degree in pharmacy [BSc(Pharm) or PharmD] and successfully completed a national licensing exam (PEBC and OSCE) and provincial law exam
- WHAT: pharmacists are responsible for medication distribution and medication therapy management
- WHEN: pharmacist services are available 365 days per year 24 hours per day
- WHERE: community pharmacies, hospitals, primary care, government, pharmaceutical industry and academia
- WHY: to protect the public by ensuring the safe and effective use of medications
General:
- Frailty is defined as a progressive decline involving multiple body systems marked by a loss of physiologic reserve
- Overall frailty and physiologic age should be considered over chronological age when caring for older adults
Polypharmacy:
- the use of multiple medications (5 or more medications concurrently; inappropriate or more medications than clinically indicated)
- older adults typically have more chronic medical conditions that require treatment than younger adults
- on average elderly patients receive prescriptions from 3 different prescribers
- 65% of seniors were taking more than 5 medications and 30 of those over 85 were taking 10
- multiple medications/prescribers increase the clients risk of adverse drug reactions and drug interactions
- Nonprescription, dietary supplements and natural health products (NHPs) are commonly used - patients often don't consider these to be medications since they are natural; but still have potential ADRs and drug reactions
Pharmacokinetics:
- the study of how the body handles a medication
- A (absorption)
- D (distribution)
- M (metabolism)
- E (elimination)
Absorption:
- oral is most common route of drug administration
- reduced acid production in the stomach (higher pH) may lead to reduced drug absorption (age related versus drug induced)
- reduced gastric motility can affected reliability of absorption for certain medications
- reduced first pass metabolism (reduced liver mass and blood flow) may lead to increased bioavailability of some drugs
Distribution:
- Hydrophilic drugs: distribute into the plasma or muscle tissue
- Total body water declines with age as does lean muscle mass
- Hydrophilic drugs are more concentrated with age as the volume of distribution is smaller
- BOTTOM LINE: smaller doses will be effective
- Lipophilic drugs: distribute into fat tissue
- Percentage of body fat tends to increase with age
- Lipophilic drugs can take longer to reach steady state and can accumulate in fat tissue leading to a prolonged therapeutic effect
- BOTTOM LINE: start low and go slow
- Protein binding: drugs may bind to proteins such as albumin and alpha1-acid glycoprotein (AAG)
- Albumin may decrease with age as a result of poor nutritional status
- AAG may slightly increase or remain the same with age
- BOTTOM LINE: drugs that are highly protein bound maybe affected transiently
Metabolism:
- Liver is the main site of drug metabolism
- Drugs are most commonly metabolized by the CYP450 family of isoenzymes
- Hepatic blood flow is reduced with age resulting in reduced rates of drug metabolism
- BOTTOM LINE: reduced drug clearance increases drug concentrations, the duration of action and potential ADRs
Elimination:
- Kidneys are a major route of drug elimination
- Kidney function generally declines with age
- Drugs that are eliminated by the kidneys can accumulate in the body
- BOTTOM LINE: drugs that are eliminated by the kidney may require dose adjustment in the elderly
Pharmacodynamics
- physiological response of the body to a drug
- helps understand the relationship between drug dose and response
- older adults tend to be more sensitive to therapeutic as well as adverse effects of medications
- BOTTOM LINE: smaller doses are often required in the elderly to elicit the same therapeutic effects
Changes with Aging and Clinical Effects:
- Increased receptor sensitivity == Increased sedative effects from benzodiazepines, antidepressants, opioids, CNS depressants
- Decreased receptor sensitivity == Decreased number of beta receptors; decreased heart rate response to beta blockers
- Decreased baroreceptor function == Increased risk of orthostatic hypotension with blood pressure medcations
- Increased response to medications == Increased anti-cholinergic effects; increased response to warfarin and hypoglycaemic agents
BPMH vs. Med Rec:
- Best possible medication history (BPMH): a systematic process of interviewing a patient and/or caregiver using at least one other reliable source of information (medication vials, blister packages, community pharmacy medication list or nursing home MAR) to verify all of the patients medications (prescribed and not) and document how the patient is actually taking their medications including the name, dosage, route of administration and frequency for each
- Medication reconciliation (Med Rec): a formal process in which healthcare providers work together with patients, families, and care providers to ensure that accurate, comprehensive medication information is communicated consistently across transitions of care; requires a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed, or discontinued are carefully evaluated; component of medication management, medication reconciliation informs and enables prescribers to make the most appropriate prescribing decisions for the patient
Drug Therapy Problems:
- an event or circumstance involving drug therapy that actually or potentially interferes with an outcome of therapy
- the top two questions asked by a pharmacist:
- Can this be caused by a drug?
- Can this be cured or treated with a drug?
- 8 categories of DTPs are defined
- Untreated condition: the client has a medical condition that requires drug therapy but is not receiving drug therapy for that indication (client may not seek treatment; client may self medicate without knowledge of provider; omission of therapy- maybe intentional)
- Improper drug selection: client has a reason for taking the drug however a different drug is warranted because of safety or effectiveness (harms may outweigh potential benefits in older adults; evidence based therapies)
- Dose is too low: client has medical condition that is being treated with too little of the correct drug (dose not titrated to therapeutic effect)
- Failure to receive a medication: client has medical condition that is result of not receiving a drug; reasons for not receiving medication (drug interaction, economic, non adherence, chooses to to take due to perceived lack of efficacy or concerns regarding ADRs)
- Dose is too high: client has medical condition that is being treated with too much of the correct drug (excessive dosing very common DTP in older adults; failure to reassess medications as patient ages)
- Adverse Drug Reactions: any harmful or unintended response to a drug that occurs with normal doses, can be dose related (tend to be predictable extensions of drugs known pharmacological effects) or dose independent (tend to be unpredictable and unrelated to pharmacological effects)
- Drug Interactions: drugs can interact with one another or with clients disease state; interactions can be pharmacokinetic or pharmacodynamic
- Drug without Indication: client is taking a med for which there is no indication and can increase risk of interactions
High Risk Medications:
- have an increased risk of ADRs in the elderly
- these classes of medications have been associated with an increased risk of ER visits or hospitalizations
- Includes drugs that increase: bleeding risk, risk of hypoglycemia, falls risk, risk of memory loss, anticholingergic activity
- most common medication classes: CV agents, anticoagulants/antiplatelets; analesigcs; opioids; antihyperglycemics; anticholinergics; antipsychotics
Criteria for Medication Use:
- Beers Criteria 2015: developed for use in a frail nursing home population; benchmark to address inappropriate prescribing in the elderly; lists diseases or condition for which certain medications should be avoided to prevent exacerbations
- STOPP and START Criteria: developed in Europe to address “weaknesses” of the Beers criteria; STOPP screening tool for potentially inappropriate medications in older persons; START tool addresses prescribing omissions in older adults; separate criteria for end or life or palliative care
-3 R's of Medication Assessment: Recognize reduced life expectancy; Re-examine once appropriate treatment; Reconsider medication use
Role of Nurses in Safe Medication Use:
- Perform BPMH and medication reconciliation at transitions of care or as clinically indicated
- Encourage patients to keep an up-to-date list of medications and bring it to all medication appointments
- Educate on medication adherence and advocate for the use of adherence tools
- Work with the interdisciplinary team to ensure medications are taken in a safe and effective manner
- Liaise with the patient’s physician or pharmacist as required
Take Home Messages:
- Nurses:
- Play an important role in identifying polypharmacy in older adults
- Help identify patients who are at risk or actively experiencing medication related ADRs
- Identify medication non-adherence and offer strategies to assist with medication use
- Liaise with physicians and pharmacists to ensure the safe and effective use of medications