30 January 2023
Article from January 2023 edition of INPractice
A Nurse Practitioner and her team are helping to break down the confusion over two skyrocketing afflictions of ageing.
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Nurse Practitioner Kathryn Resili at work.
‘Imagine if you woke up in bed next to your wife, but didn’t recognise her, didn’t know who she was in the morning. Very frightening’
Advancements in health care and improved lifestyle factors have contributed to people living longer. On the very unfortunate flipside is a surge in the number of people suffering from dementia, delirium and other conditions that come with older age.
“Fifty years ago, very few people lived into their 90s or 100s. People died in their 70s or even earlier, but now people are routinely living longer and so we are seeing these diseases of age,’’ says Nurse Practitioner Kathryn Resili.
“The tsunami of dementia is already here. The biggest group of people living in Australia are the Baby Boomers, they are in that age bracket now, and so that is why we are very busy here.’’
The ‘here’ Ms Resili refers to is the Hampstead Rehabilitation Centre-based Multi-Disciplinary Community Geriatric Service, assisting older people to stay in their own homes and in the process easing the strain on hospitals and aged care facilities.
Run by the Central Adelaide Local Health Network, this is a free service for people experiencing age-related health problems including cognitive impairment and memory loss.
“We see people in their homes or in residential care. We look at things like geriatric syndromes, so we would assess them for a cognitive decline, falls or provide a dementia diagnosis,’’ Ms Resili says.
“I guess the beauty of our team is that we don’t need a medical referral, we don’t have to have a patient go to the GP, sometimes it’s difficult for families to convince their loved ones to go to the GP.
“Families can ring us and say ‘Look, there’s something clearly wrong with my father, mother, could you please come and see them’. And we do. So it could be a family referral, it could be partner, husband or wife, it could be the care providers, they can refer to us.
“We complete a comprehensive geriatric assessment which looks at how they do everything, who pays the bills, who manages the finances, can they strip the sheets of the bed, do they need help with that, who does the washing, cooking, shopping, all of those things called Activities of Daily Living. We look at how they manage those and if they are not managing we will put services in to assist them.
According to Dementia Australia, 30 per cent of people aged over 85 have dementia, the second leading cause of deaths for Australians behind coronary heart disease.
And given our ageing population, University of Canberra modelling has found that cases of Alzheimer’s disease, the leading dementia, are estimated to almost double in Australia by 2041, costing the national economy $26.6 billion annually.
“There are over 100 types of diseases that cause dementia, the most common is Alzheimer’s dementia because that’s a dementia of age and people living longer now,’’ Ms Resili said.
A guest speaker at the ANMF (SA Branch)’s Delirium, Dementia and Depression Workshop, which attracted over 250 participants in November, Ms Resili’s talk focused specifically on delirium – a change in cognitive abilities often confused with dementia. While people with dementia often have delirium the latter can occur independently of dementia.
The prevalence of delirium in aged care homes, she says, is probably beyond 70 per cent of residents, and contrary to what people may believe, delirium and dementia are two very different conditions.
“Dementia is completely different from delirium. We don’t really know the exact cause of delirium, but the most accepted theory is a multifactorial one which seems to be associated with the vulnerability of the brain.
“So people that have dementia, people who are elderly, people who are on a lot of medication, they already have a brain that is vulnerable, so when they become unwell for some other reason, whether it’s an infection in the bladder, or post-operatively or that they’re constipated or just a change in the environment like going into hospital, they become confused and often agitated or withdrawn.’’
Ms Resili’s workshop presentation was titled Delirium: The Good, the Bad and the Ugly.
“The good thing about it is we’re getting better at recognising delirium. The bad thing is the prevalence of it - it’s quite high in elderly people that come into hospital - and the ugly thing about it is that some people never recover and there is a high death rate associated with delirium,’’ Ms Resili says.
Delirium has three sub types. “There’s hyperactive, where the person has their cane and they are coming at you, and they’re agitated and they’re pacing and they can’t settle.
“And then there’s hypoactive. The hypoactive delirium is someone who’s withdrawn. They don’t ring the bell, they don’t want anything, they just sit there and they stare out of the room, don’t really participate in a conversation, probably not eating or drinking and they’re high risk because they go unnoticed.’’
The third type is mixed delirium which includes symptoms of both hyperactive and hypoactive delirium.
“Delirium even 10 years ago was not diagnosed well and so people who had an extended delirium often had very poor outcomes and people can die with delirium,’’ Ms Resili says.
The difference between delirium and dementia is the former can occur within just hours or days, triggered by an underlying medical condition or change in stimuli such as a hospital setting, resulting in confusion, lack of awareness, lack of focus, anxiety, and/or changes in mood, behaviour and personality.
Dementia is the more insidious of the two. Brought on by damage to the brain or loss of brain cells, it can take months and even years to manifest.
One of the best ways to differentiate between the two conditions is to talk with the families of patients. They are the source of knowledge for people.
“The collateral history we take is to ask what changes have you noticed, have these changes you’ve noticed happened over months to years, how long ago did you first notice memory changes perhaps?,’’ Ms Resili says.
“And if the answer is six months, 12 months, two years, three years ago, well then that’s not delirium. If it’s mum or dad have been really good but in the last couple of days I don’t know what’s happened to them, they’ve just gone nuts. Well, that’s likely delirium.
“And so an elderly person whose living at home with a partner or family, they may have a delirium with a urine infection but the family may recognise this is not what mum or dad is usually like, there’s something wrong. Take them to the doctor, treat the infection, the delirium resolves in a couple of days.
“If the person’s living alone at home that doesn’t happen and they may go a week before someone sees them, they may not be eating or drinking. They may require hospitalisation.’’
Ms Resili says about 80 per cent of elderly patients who come through an ICU would have developed a delirium. “The lights being on 24 hours a day and the noise associated with being in an ICU is enough to cause delirium in an elderly person.
“Poor sleep, all of those types of things that we see in hospitals, cause delirium and the people that are more likely to develop it are the people who have a more vulnerable brain. So people who have an underlying dementia are more likely to develop delirium when they come into hospital or as a cause that would send them to hospital.
“The good news is that we are getting better at diagnosing it.
“With delirium in the majority of cases, once you recognise and treat the cause, such as a bladder infection or a chest infection, it’s the bugs that grow that are able to cross the brain blood barrier that cause the confusion.
“Delirium resolves itself in a couple of days. Once we give the person correct sleep, once we correct their constipation, once we make sure they are hydrated and eating, delirium tends to resolve pretty quickly.
“But in some cases it extends. With the COVID epidemic that we’ve had people that were in hospital in ICU or very unwell or with multiple pneumonias, they can have a prolonged delirium that lasts months, it can take months and months to recover. Some people never get back to their baseline.’’
Deaths are “probably” the result of a combination of things, including the cause of delirium.
“Say there was a 90-year-old man who came into hospital, had a chest infection, developed a hyperactive delirium, so he’s pacing, aggressive toward staff, they’ve called Code Black, which is a personal threat. He may be medicated and because he’s in his 90s he has poor renal function so he’s not clearing those drugs we are giving him and he may die.’’
Ms Resili provides staff education on dementia, delirium, changed behaviours and medication management. She says in most medical and surgical wards it is now common protocol for anyone aged over 65 coming into hospital to be screened for delirium.
Left undiagnosed it can increase their length of stay in hospital. “Better to recognise and treat it quickly and resolve it than have it develop further and then you’ve got a longer road to recovery.
“What happens in dementia, it’s really a type of brain failure, it’s progressive and we don’t have a cure,’’ Ms Resili says.
“Unfortunately people die with dementia and the changes that occur in the brain produces changed behaviours that we see in the person so they may not recognise their family anymore, they may not recognise where they are.
“They may feel that they are back in their childhood home, they may regress and think ‘I’m 10, I’ve just got off the bus and I’m looking for my mum’ and they will be going around their home or residential facility calling out for mum and it may be that they’re just hungry and mum always has food or they’re a bit anxious and mum’s always that safe place.
“People can become aggressive with confusion and it’s usually how we approach the person that determines the outcome of every interaction.
“If we approach the person correctly then we’ll get a better outcome without medication, so the best form of behaviour management is the non-pharmacological way.
“People with an Alzheimer’s diagnosis, they tend to end up with binocular vision. So if I approached from the side and said ‘Oh hi’, and touched them unexpectedly they may react to protect themselves.’’
While there is no cure for dementia, Ms Resili says “there’s always hope”.
“There’s actually been quite a bit on television recently about new developments and treatments that will be developing in the future.
“At the moment there is nothing we can do to stop it. If you have a look at slices of the brain, part of the work up would be a brain scan. And in someone that has dementia the slices of the brain which are usually nice and plump end up looking like Swiss cheese because as the brain cells die the brain shrinks.
“And then what happens is because our bodies are trying to protect us it sits in our skull, which is solid. If our brain shrinks every time we go like this (shaking her head), which is what happens to a boxer, our brain sloshes around and hits the side.
“This brain failure causes the changes that we see in behaviour.
“Imagine if you woke up in bed next to your wife, but didn’t recognise her, didn’t know who she was in the morning.
Very frightening.
“Or your son comes in the backdoor to bring you dinner because he visits every night and you don’t know who he is and you attack him because you are trying to protect yourself. All of those things happen. Again, very frightening.
“In nursing education there historically was little information given, little around dementia and delirium, but this has improved.
“We have delirium guidelines now, we have dementia guidelines to follow and so we are bringing it to the forefront and making people think about it. Is this a delirium, is this a dementia? What’s the difference between them and how’s our management differ?’’
Click here to read the January 2023 edition of INPractice.