low serum albumin multiple spit severe unstable medical problems dementia recognizance pyramid multiple medications metabolic disturbances alcohol remember your younger days when you drink too much that's a delirium you're confused your disoriented timers screwed up your using bad judgment to delirium you stop treating the alcohol a nuclear the whole nature of delirium issue go to remove the causative factor or what you've removed that you've treated sensory deprivation advanced age fractures bacterial infections especially here in track infections fever hypothermia visual and hearing impairments in trauma a recent study identified five other factors for delirium usa physical restraints use of more than three medications how i'm on six and my average patients on thirty two usable bladder catheter because it sets align right in the body the germs can just call operated the bladder malnutrition enemy i a trajectory that such a surgery page eight widest delirium get to be such a problem with older adults well number one and they're slower absorption of oral and i'd be medications we talked about that in that first section this morning there's decreased the city in the gi tract therefore medications are slower to absorb from the gi tract notes are patient says that they have pain we go some with the lord cap we follow up forty five minutes or our later and we say how's the pain the pill hasn't been absorbed yet they say oh it's still just as bad as it was so we we don't stop forty five minutes later they have no pain an hour later they think they're on jupiter okay we go deal with the lord there's also slower absorption of suppositories because there's decreased blood supply to the rectum and there's a lower court body temperature now once the pills are absorbed into the system their slower getting distributed throughout the body because there's a slowing of the active and passive transport systems that carry medications to all parts of the body there also tends to be a greater amount cycle pharmacologically active drug present an older adults because there's fewer plasma proteins available for binding and there's an increased concentration of the drug because there's decreased body mass and decrease surface area so it's slow to absorb these pills and the stomach once we do have them absorbed it's loaded distribute them but once we get in distributed throughout the body their power payrolls because we've got fewer plasma proteins we've got less body mass so the amount of pill they have on board is high now we just got to get a clear from the system right will pluck pluck breaks medications down in the system it's deliver in the kidneys so number six there's slower drug metabolism in a longer duration of action resulting from decreased liver enzyme production caused by decree circulation of the liver and there's less trek excretion because of decreased kidney function some patients may have normalcy admin ever normal serum creat men but abnormal creat an clearance the ability to clear nitrogen what xd now if you really want to get into political hot water with your position tried telling him to stop at the bottom of page eight and and you can't but i think you can be aware of the stuff on the bottom of page eight and when you don't see that happening don't be surprised for your patience have delirious reactions foreperson sixty five to eighty the starting dose of most medications should be reduced by half in order to account for all of that stuff that we just talked about for person to older than eighty years old the starting dosage should be reduced it to threats of the usual starting to us absolutely any medication can cause mental status change in an older adult i had a patient about a year and a half ago that we doubt on tap for cycling had a low-grade bronchitis i've been seeing him once a week in the office uh... sort of a hacking cough low-grade stuff not really infected goes disposition for an annual check-up position says you know i'm gonna get it does detect recycling clear that up so the plan puts a gun tetracycline from day three young kept recycling the sky was disoriented didn't have a good carryover learning just looked at out of it three or four days after he stopped taking these ten days of tetracycline declared he was flying weed out on the tough recycling i'm not used to seeing patients we gallon antibiotics but he did so you just have to be sensitive that any medication can cause any of these reactions people who take more than three or four medications including over the counter xx are at very high risk for drug drug interaction the larger the number of medications the higher the risk for drug interactions the tri cyclic anti-depressants in the benso die as a pains denso servers tranquilizers zen x valium librium very likely to cause confusion and older adults senate eat sleep medications and analgesics pain medications are the next groups most likely to cause confusion it also seems to me that when i call a physician and say my patients doing this and i wonder if it's this medication the standard answer that i get is i've never known that medication because that effect uh... and i'm not poking fun at physicians either positions are just like us there in the helping profession they don't want to believe that they've done something that potentially harm to someone but it's inevitable with pills i mean if if we all ever got prescription authority it's going to be the case that sometimes you're going to prescribe exactly the right medication for someone and it's going to mess them up you're having a little tiaa she's got high blood pressure okay uh... if i'm going to prescribe medication to you i'm going to push on it baby aspirin a day good preventive medicine so then you'd start bleeding out with her also okay it just happens ameen it's hard to get away from side effects of medications and do keep in mind that your position receives a mostly information regarding medications from the pharmacy rep did give some free samples pharmacy wraps do not like to come in the door talking about the side effects of the medication they talk about how wonderful the medications are the person that is really a student at drug interactions in drug side effects pitcher local pharmacist they are a wealth of information about drugs and in facilities consulting pharmacists have to come in every so often and review the medications that patients are on that consultant uh... pharmacist has been a real got sent to me on several occasions because you get with that person and say do you think that this medication is causing this effect in this patient nosair out we see it all the time all the time and then they'll write a note to the possessions saying please consider changing this medication to this very very effective way to do it that doesn't have you in the middle of the position saying sell you practicing medicine now okay and if i had prescription privileges and you didn't a new challenge something that i think that's probably what you hear from me too stay off my turkey some nurses to make those calls consulting uh... promises to make those calls and they're both very good source of information i had a physician about eight or nine months ago one of the sleeping medications we seem to love for older adults is ambient i took indian one-time the next day i felt like i was coming off of a four day drop i was so groggy i was so out of it and i just couldn't clear the cobwebs that i never retook the drug well sometimes my patient has that reaction to him i called a position summary months ago and said you know this patient has been very groggy since going on and be i was wondering if you would consider maybe switch into something else like restaurant or something that might not have that effect groggy i've never ever known and begin to have that effect on people religiously medication or it's supposed to do so you just sort of get defensiveness sometimes for positions or maybe it's on my approach that i get sits with us from physicians page nine page nine is a delirium rating scale there are some clinicians that fine the scale very very uh... effective for them in detecting delirium i have not found it very affective but i am cluded here because some clinicians have found an effective and it is a good review of symptoms as you look through this scale the highest numbers are the delirium pts affects and the uh... scoring key is on the next page delirious patients tend to average about twenty three on the scale demented patients average four five so it is a good review of symptoms you may find it helpful to use in your practice i've not found it helpful but a lot of people do page eighteen is diagnostic criteria for dementia development of multiple cognitive deficits manifested by both number one memory impairment and number two one or more of the following cognitive disturbances aphasia cracks the egg notion disturbance an executive functioning which is essentially everything the big criteria the cognitive deficits in a one in eight to caused significant paramount and represent a significant decline from a previous level of functioning see the course is characterized by a gradual onset and continuing cognitive decline d not due to sub girl hematoma normal pressure-cooker selfless brain tumor or systematic condition known to cause dementia and the deficits do not occur exclusively during the course of the delirium and a half not better accounted for by major depression or schizophrenia but as you say fairly easy to get the dementia diagnosis now if you truly have a case of dementia you will have six wide spread cognitive deficits that you'll have your choice of many if you really have to build a case for your patient on judgment ike i think you're set them up because of this is really at the dementia you're going to have a wide variety of cognitive deficits to choose from you know if you have to go with with uh... judgment kid no idea how many families have seen walk into nursing homes with clients check register set look at this check register 