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An Oncologist ’ s guide to Dementia & Delirium Dr. Mark Kinirons,

An Oncologist ’ s guide to Dementia & Delirium Dr. Mark Kinirons, Trust Lead for Dementia and Delirium Clinical Adviser to NHS London Dementia Pathway. A 70-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months.

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An Oncologist ’ s guide to Dementia & Delirium Dr. Mark Kinirons,

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  1. An Oncologist’s guide to Dementia & Delirium Dr. Mark Kinirons, Trust Lead for Dementia and Delirium Clinical Adviser to NHS London Dementia Pathway

  2. A 70-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep track of appointments and recent telephone calls, but the process has been insidious. She lives independently in the community; she drives a car, pays her bills, and is normal in appearance. A mental status examination revealed reduced score from previous. Does the patient have mild cognitive impairment? How should her case be managed? Case Vignette

  3. Specialty training in older people Kalsi et al 2013

  4. MCI and dementia Cognitive function SCD ‘Normal’ ‘MCI’ Decline noticed | | + + + | | ‘Dementia’ Loss of insight Time Rob Stewart, IOP

  5. Alzheimer’s Society, March, 2012

  6. Alzheimer’s Society, March , 2012

  7. Introduction General hospitals are challenging environments for people with dementia and delirium: People with dementia & delirium have worse outcomes in terms of:

  8. Dementia & Delirium Very common Poorly taught Poorly recognised & poorly responded Poorly cared for

  9. More public expectation National Dementia Strategy DH Review of antipsychotic use CQUIN Frances Report Jan 2013

  10. Dementia CQUIN 2013-4 National Screening and assessment London Training Reducing inappropriate antipsychotic prescribing

  11. Recognition and Response to memory, dementia and delirium

  12. Alzheimer’s Society, March , 2012

  13. PRIMARY CARE Full blood count ESR if less than 60 yr Renal, liver, bone, thyroid, lipids Glucose B12 & folate MSU – simple infection screen HIV SECONDARY CARE MRI & SPECT EEG Auto-immune screen HIV & Syphilis serology Neuropsychological testing CSF tau etc Test to order for memory work up

  14. Coronal MRI Scans from Patients with Normal Cognition, Mild Cognitive Impairment, and Alzheimer's Disease.

  15. Axial Scans of the Brain Obtained with Positron-Emission Tomography and the Use of Amyloid-Binding Carbon 11–Labelled Pittsburgh Compound B.

  16. Management • Medication review • Driving • Social services referral • Community mental health referral • Financial / Will / Power of Attorney • Patient information and voluntary sector information – www.alzheimers.org.uk • Research • Patient & carer forum • CPR / End of Life /Adv planning

  17. Mean Scores on the Standardized Mini–Mental State Examination (SMMSE) and the Bristol Activities of Daily Living Scale (BADLS), According to Visit Week and Treatment Group. Howard R et al. N Engl J Med 2012;366:893-903

  18. Delirium • Inpatient mortality 22-76% • One year mortality 35-40% • 60% resolve in 6 days • 5% delirious >1 month • 38% may have >=1 symptom still at discharge • Higher rates of other complications and institutionalisation • Accelerated cognitive decline

  19. Diagnosis: CAM Based on DSM-III-R criteria Condensed to four key features 1)Acute onset and fluctuating course 2)Inattention 3)Disorganized thinking 4)Altered level of consciousness 1 and 2 plus 3 or 4 diagnose delirium Inouye et al Annals Int Med 1990;113(12):949-948

  20. Risk factors for delirium: Old age Dementia Infection Dehydration Malnutrition Multiple medications Surgery Change of environment Hip fracture Severe illness Sleep deprivation Constipation Bladder catheterisation Visual or hearing impairment Immobility Alcohol abuse

  21. The patient lacks capacity if Stage 1. The patient has an impairment /disturbance of brain function □ Stage 2 Any of the following are true; Patient is unable to UNDERSTAND □ Patient is unable to USE and weigh □ Patient is unable to RETAIN □ the information required to make this decision Patient is unable to COMMUNICATE their decision (whether by talking, using sign language or other means) □ Presumption of capacity Necessity of intervention Least restrictive Involve patient , nominated representatives IMCA Mental capacity & Best interests MC Act 2005

  22. Questions • Email mark.kinirons@gstt.nhs.uk

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