ࡱ> x( }/ 0DTimes New Roman(0(z[ 0 DArialNew Roman(0(z[ 0  DMarlettw Roman(0(z[ 0  C0.  @n?" dd@  @@``  X$!      !"#%'&)(+*-,/.12547698;:=<?>ABEDGFIHKJMLONQPSTWVYX[Z]\_^a`cbefihkjmlonqpsrutwx{z}~0@Rdv3CUgyc AA1?@/g4HdHd@z[ 08ppp@ <4BdBdl 0$3 <4!d!dl< 0mS ʚ;q8ʚ;<4ddddl|- 0X0___PPT10 ppl___PPT9N/ 02(     F||F(8 8!"#$F%&('8()*+,-./*0123456&789? %O =q'Mental Health Services For Older People(' LUNDERSTANDING AGITATION & CONFUSION AND THE POSSIBLE CAUSES IN OLDER PERSONSMM",<  2   INTRODUCTION     NB  AGITATION - Definition& $  Acute restlessness both physically and mentally. Examples of behaviours that may be observed include; Pacing Hand wringing Inability to remain seated or still for even a short period of time Inability to maintain a conversation. Shifting or poor eye contact Seem uncomfortable or have difficulty getting comfortable Short tempered or easily frustrated Anxious and/or preoccupied zj0Z04ZZ&1"5" ~  CONFUSION - Definition:   $   A complex presentation including, perplexity, bewilderment, failing memory and a clouding of consciousness. Examples of behaviours that may be observed include; Appear perplexed, bewildered or uncertain Difficult to engage in conversation Unable to remain focused on a task Difficulty understanding what is said to them (answers only partially related to questions) Inappropriate behaviour (eg. voiding in inappropriate places) VZ 4ZZ" "Fl  "  HALLUCINATIONS - Definition:   $   A false perception in the absence of external stimuli. The patient believes he/she sees, smells, hears, tastes or feels an object or person when there is no basis in the external environment for this belief. Examples of behaviours that may be observed include; Responding to something not seen, felt or heard by others Answering/responding to sounds or voices that no one else can hear Unusual attention focused on an ordinary object Attempting to get away from something not seen by others Unusual appearance (dress) or behaviour J Z4Z " "( D ORIENTATION - Definition& $ oAwareness of self, place, time and situation. Examples of behaviours that may be observed when someone is disorientated include; Getting lost in familiar surroundings Continually seeking information from others to assist with orientation (where am I, what day is it) Missing appointments Behaviour out of context with time and place (eg. getting dressed at 0200 hrs) <Z4Zn"*N  w:DELIRIUM 0  DELIRIUM  UDEFINITION KEY FEATURES USEFUL SCREENS STANDARD TESTS VULNERABILTY MANAGEMENT ALERTS 2U8U  I  DELIRIUM - DEFINITION $   A clinical state characterized by an acute, fluctuating change in mental status, with inattention and altered levels of consciousness. J4     DELIRIUM - KEY EATURES $  =Acute, rapid onset over minutes to days. Consciousness is clouded Usually rapid or slow speech Enhanced startle response Disturbed sleep/wake cycle with insomnia Confusion worsens toward evening Nightmares and/or visual hallucinations and/or delusions Symptoms fluctuate over the course of a day or even over minutes @)444> >  DELIRIUM - KEY EATURES Cont. $ \Distressing and unpleasant for the sufferer Frightened, irrational and unpredictable behaviour Awareness of the surrounding environment is reduced Impaired ability to focus, shift or sustain attention Impaired immediate recall and short term memory Disorientation in time, place or person Rapid shifts from under to over activity Slowed reactions r,4344^(^    DELIRIUM - USEFUL SCREENS  }Exclude physical causes eg; Infections Respiratory function Cardiac function Hydration / Nutrition Constipation Serum levels N4Za4ZZ$a (L # DELIRIUM - STANDARD TESTS  Related to suspected causes identified from screens listed previously and may include; MSSU (Urine Culture) Full Blood Count (ESR) B12 and Folate Biochem (LFT) Medication serum levels Chest X-ray CT Head TFT Others as appropriate W4Z4Z4Z4ZW  " ,              DELIRIUM - STANDARD TESTS Cont.  $   Usual Dementia screens are; CBP TFT B12 & Folate Biochem Syphilis serology CT Head Chest X-Ray ECG Mini Mental State Examination H4g4$g       H DELIRIUM - VULNERABILTY $  Most common causes are Medications and Infections The elderly Older people post GA Dementia sufferers Older persons with ; Strokes and Transient Ischaemic attacks Cardiac failure/arhthymias Anaemia Hypoxia from respiratory failure f{4l4{R.  * DELIRIUM - VULNERABILTY Cont.0 $   Uraemia Liver or kidney failure Electrolyte imbalance Acidosis or alkalosis Pre or post epileptic seizure Hypo or hyper Thyroidism Hypo or hyperglycaemia Concussion or sub-dural haematoma following a fall Blood loss ^44 DELIRIUM - MANAGEMENT $  Diagnosis and treatment of underlying disorders, removal of contributing factors, behavioural and environmental strategies, and support of the patient and family. Cautious use of medications to minimize challenging behaviours 04 @*  DELIRIUM - ALERTS $  ^Is associated with significantly increased resource utilization, morbidity, and mortality. Attempting to manage challenging behaviours with certain medications will lead to a worsening of the Delirium If mistaken for a non reversible dementia then premature placement in a residential care facility may occur Unresolved Delirium can result in death @]4^ 6DELIRIUM  MANAGEMENT GUIDE $ Useful Strategies Include; Simple, but firm communication Adequate lighting Reduction of intense stimulation Unit-wide noise reduction Diurnal variation in noise and lighting Reality orientation 4Z4Z4Z4ZZ$l"  ' "  "    $  3  (  6DELIRIUM  MANAGEMENT GUIDE $ FCont& . Presence of a relative Hydration and nutritional support Use of sensory aids Use of single room Maintain activity levels Medication - as a last resort 4Z4Z4Z4ZZ$"  ! "  @"    $R  c  x;&OBSERVATIONS AND INFORMATION GATHERING'&0 "Observations/Information Gathering##" MSCREENS MEDICATIONS HISTORY PRESENTATION NEUROVEGETATIVE FEATURES COGNITION LN4)` ` (A  SCREENS May Include Full Blood Count (ESR) MSSU (Urine Culture) TFT B12 and Folate Biochem (LFT) Medication serum levels Chest X-ray CT Head Others as appropriate  Z4Z "/bb b b bbb b  $b$(b(,b,008DI  MEDICATIONS    Obtain a full list of current medications actually taken by client including over the counter medications Note recent medication changes including; medications ceased doses changed brand change timing of dose Consider compliance issues, interactions , etc kZ+4ZA4Z04Zk"+"A ." HISTORY $ `@ Obtain a full history from both client and carer about: Presenting problem/s - description of symptoms Personal/Social History - significant events Alcohol or substance abuse Onset, progression and duration of symptoms Previous medical and/or psychiatric history Daily living skills Functional abilities/limitations  vision, hearing, mobility 8Z!4ZZ7""." " ,""""+ " $"$+("(,",0"04"4=8"8<"<&+)   PRESENTATION $ `@  RAppearance Behaviour Affect Mental State Perception Thought processes Conversation>)4*4)*R !NEUROVEGETATIVE FEATURES $b( Sleep Appetite/weight/bowels Motivation/energy Libido Diurnal mood variations Use Geriatric Depression Scale (Short Form) if thought useful O4?4       = " $$(M > " COGNITION $  `@  Level of awareness/consciousness, note any clouding. Memory : immediate, recent, remote Orientation: time, place, person, situation. Attention and concentration. Fund of information. Abstract or concrete thinking. Judgment and insight Use Mini Mental State Examination (MMSE) 4*44"""" " ,"""" " $"$("(,",0"044(8"8<<( ) y< DEPRESSION 0 # DEPRESSION  UDEFINITION KEY FEATURES USEFUL SCREENS STANDARD TESTS VULNERABILTY MANAGEMENT ALERTS 2U8U ( I  $DEPRESSION - DEFINITION  $tA pervasive and persistent change in mood characterised by depressed mood and loss of interest or pleasure in life. 4t8t  u %DEPRESSION - KEY FEATURES $Depressed mood Loss of interest Loss of energy Reduced concentration Reduced self esteem Guilt Pessimism Tendency to underestimate cognitive functioning Altered sleep Decreased appetite Self harm/suicide Psychotic features J8Zi"/G"    & DEPRESSION - SCREENS $Possible use of Depression Scales eg. Geriatric Depression Scale Montgomery-Asberg Depression Scale (MADRS) Hamilton Depression Scale &4`444& ` "  `  5 '!DEPRESSION - TESTS $MExclude physical changes Biochem CBP B12 & Folate Thyroid studies Chest Xray \444"4"@  (   ("DEPRESSION - VULNERABILTY $SHistory of depression Social isolation Chronic health problems Chronic pain Losses 6S4S  T )#DEPRESSION - MANAGEMENT $yMedical assessment Supportive psychotherapy Exploration of family and social circumstances Management anxiety Medication *z4x  m   *$DEPRESSION - ALERTS $Self harm Psychotic features Marked weight loss/ refusal sustenance MAD & BLUE (high risk group) Male Alcohol Depressed & Bereaved Lonely Unwell Elderly b4Z4Z4Z4Z4ZC    D \ z=DEMENTIA 0 +%DEMENTIA  UDEFINITION KEY FEATURES USEFUL SCREENS STANDARD TESTS VULNERABILITY MANAGAMENT ALERTSV4V U ,&DEMENTIA - DEFINITION  $Not a single disease but a syndrome of which there are many causes. The development of multiple cognitive deficits including memory impairment and one or more of the following, Aphasia = loss of the ability to use/understand words Apraxia = loss of the ability to execute or carry out learned (familiar) movements Agnosia = a failure of recognition, visual, auditory or tactile Disturbance in executive functioning = problem solving, planning skills d44Cn""  -'DEMENTIA - KEY FEATURES $Decline in memory and other areas of thinking Tendency to over estimate cognitive functioning Decline in social domestic occupational functioning Changes in personality Changes in behaviour D4."/`"   .(DEMENTIA - USEFUL SCREENS $FMini Mental State Examination (MMSE) Lawton Instrumental Activities of Daily Living (IADL) Scale Alzheimer Disease Assessment Scale  Cognitive sub Set (ADAS-Cog) .4" $  /)DEMENTIA - STANDARD TESTS $JBiochem CBP TFT B12 and Folate Syphilis Serology CT Head Chest X-ray ECG 4J4J  D 0*DEMENTIA - VULNERABILTY $2Age Gender (female) Education Circulatory illness *341    1+DEMENTIA - MANAGEMENT $Medical referral to diagnose and treat reversible causes Possible referral to specialist for medication (Alzheimer s ) Care and education to individual  referral to support services Education and support to family Planning for the future 44   2,DEMENTIA - ALERTS $lDepression may occur / coexist Safety needs to be considered Psychotic and behavioural issues are common >j4l  m {>DELUSIONAL DISORDER0 3-DELUSIONAL DISORDERUDEFINITION KEY FEATURES USEFUL SCREENS STANDARD TESTS VULNERABILITY MANAGEMENT ALERTSV4V U 4. DELUSIONAL DISORDER - DEFINITION(!   A delusion is a false belief which is inconsistent with the patient's sociocultural background and held with absolute and unshakeable conviction. 4F @5/"DELUSIONAL DISORDER - KEY FEATURES(#   The nature of the disorder ensures that sufferers are quite insightless and cannot be talked out of their peculiar beliefs, which they are often keen to share and may include; Persecutory delusions are most common eg. Being watched by others Punished or treated badly by others Possessions are being stolen Jealous preoccupation with presumed infidelity of a spouse Grandiose delusions are less common but can occur Convictions that some physical disease or defect is present Are often bound up with the persons home environment `4Z94Z"+"7"&<   60$DELUSIONAL DISORDER - USEFUL SCREENS(% tExclude underlying physical causes Mini Mental State Examination to gauge cognitive functioning History of symptoms (u4s  u 71$DELUSIONAL DISORDER - STANDARD TESTS%%zDementia screens i.e.: CBP, TFT, B12 & Folate, Biochem, Syphyliss serology, Chest X-ray, ECG MSSU Medication serum levels 4{4l  @/    : 82"DELUSIONAL DISORDER - VULNERABILTY(#  Female with the following; Socially isolated Have impaired hearing Have had a suspicious, sensitive premorbid personality Dementia sufferers ( Lewy Body) Those with Depression Past history of a psychotic disorder eg. Schizophrenia Bipolar Affective Disorder t4Za4Z4Z"a""  93 DELUSIONAL DISORDER - MANAGEMENT(!   Establish differential diagnosis Treat underlying causes Maintain safety of client and others - person may act on their delusional beliefs Rather than confronting the beliefs directly it is preferable to concentrate on the distress experienced by the sufferer 24   :4DELUSIONAL DISORDER - ALERTS&  qPerson may act in a way that is appropriate to their delusional beliefs and can include; self harm harming others making decisions based on delusional beliefs If not correctly diagnosed then a depressive disorder or dementia may be left untreated If not correctly diagnosed, the medications selected can lead to a worsening of the situation. E.g. Lewy Body Dementia Y4ZG4Z4ZZZY" ""&"" r |?SUMMARY0 ;5 SUMMARY   0DELIRIUM DEPRESSION DEMENTIA DELUSIONAL DISORDER 141 0 <6DELIRIUM - Suspect If :-" $  Rapid onset of symptoms, i.e. over hours, days or weeks Fluctuating level of consciousness, may vary hour to hour Difficulty in engaging and maintaining the persons attention Disturbed sleepwake cycle Recent history of physical illness, medication changes, trauma TZ 4ZZ "  =7DEPRESSION - Suspect If :-" $A person looks or acts sad Looses interest in activities Complains of loss of energy Expresses suicidal ideas or thoughts of life not being worth living Makes frequent complaints of physical problems with no physical basis. .4" >8DEMENTIA - Suspect If :- *  $rLoss of memory, particularly short term memory Confusion, Disorientation Change in ADL or Executive functioning 2r4r r ?9DELUSIONAL DISORDERSA belief system which is inconsistent with the patient's sociocultural background, (i.e. it seems highly unlikely that the belief is true) and guides and determines behaviour. Is held with absolute and unshakeable conviction, i.e. the person refuses to consider alternative explanations. Delusions may be a feature of Depression or Dementia In dementia, delusions are most often of theft and suspicion. In Depression, delusions are most often of poverty, guilt, nihilistic ideas that bodily parts are absent, rotting or shrinking `U4Z4ZZU""&9  @NB1Purposefully exclude a Depressive Pseudo Dementia22,/@ABCDEFGH I J K L MNOPQRSTUVWXYZ[\]^_ `!a"b#c$d%e&f'g(h)i*j+k,l-m.n/o0p1q2r3s4t5u6v7~89:;<=>?Pv  ` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> ` 4(      6 " `}  X Click to edit Master title style!! (   0( " `  RClick to edit Master text styles Second level Third level Fourth level Fifth level!    S    0Ԡ "^ `  f*0     0 "^   l* 0      0થ "^ `  l* 0   H   0޽h ? 3380___PPT10.pp*;  1_Default Design 0 ` (      f1 ?P    P*     f1 ?    R*  d  c $ ?  L   f1 ? @  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  # lt`1 ?`P   P*    # lLe1 ?`   R*  H  0޽h ? ̙3380___PPT10.p˔9 0((    0̴ P    `*     0˴     b*     6Ӵ `P   `*     6Dٴ `   b*   H  0޽h ? ̙3380___PPT10.pkT=_ 8PK0 0 ( w    s *  `}<$  0     s *  `<$ 0     f<1? @  UStephen Merrett - Oct 2001 2H  0޽h ? ̙33u8`lK0 RJ@ ( 34L   033o L$D 0U 0 2Older Person Presents With Agitation And Confusion 322 U 02U 0232  0jJ@ L$D 0U 0  c $33oP0 p,$D 0 [Is It A Delirium ? ,  c $33o`P ,$D 0 -Investigate And Treat Physical Causes First 6.+   c $` 33o` ,$D 0 s%Maintain Safety Of Client And Others 2&$ 2  c $jJp@ ,$D 0z2  S jJ@ ,$D 0   c $ 33o ( ,$D  0 QPhysically Clear ? "z2   S jJ @  ,$D  0   c $33op 0` ,$D  0 }+Observe/Gather Information To Clarify Cause",+ ,    S  33o ``,$D  0 i? Depressive Disorder 6    S " 33o 0 6`,$D 0 g? Dementia Syndrome 6   S <(33o @`,$D 0 _? Delusional Disorder , z2  S jJ`  ,$D 0z2  S jJ` X ,$D 0z2  S jJ`   ,$D  0R  0jJ ,$D 0B  s *g޽h ? ̙33))___PPT10)+4Dw'' = @B D2'' = @BA?%,( < +O%,( < +DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<* %(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(++0+ ++0+ ++0+ ++0+ ++0+  ++0+  ++0+  ++0+  ++0+ +H  $(  $ $ s *X  `}<$  0   T $  fLY1?P LUNDERSTANDING AGITATION & CONFUSION AND THE POSSIBLE CAUSES IN OLDER PERSONSMM"$4  3 B $  f^1?`  FDefinition of Key Terms AGITATION CONFUSION HALLUCINATIONS ORIENTATION. 2/ 2/F H $ 0޽h ? f33  ZR,(  , , s *m  `}<$  0    ,  f(o1?@  jAgitation and confusion should be viewed as symptoms of an underlying cause, with interventions aimed at establishing a diagnosis and addressing the underlying cause/s "$          H , 0޽h ? f33j  4(  4 4 s *~  `}<$  0    4 s *|  `<$ 0  "H 4 0޽h ? f33N  <(  < < s *L  `}<$  0    < c $H  <$ 0  H < 0޽h ? f33N   D( @ D D s *  `}<$  0    D c $  <$ 0  H D 0޽h ? f33T  @L(  L L s *|ö  `}<$  0    L s * Ķ  `<$ 0  H L 0޽h ? f33v9 &`(     0P׶33 >  B  s *޽h ? f33l `)K0 T(  T T s *%  `}<$D  0    T s *)  `<$  0  H T 0޽h ? ̙33l K0 \(  \ \ s *   `}<$D  0    \ s *  `<$  0  H \ 0޽h ? ̙33f  ;K0 d(  d d c $T P<$D  0    d s *P  `<$  0  H d 0޽h ? ̙33f  3K0 l(  l l s * = `<$  0    l c $ p<$  0  H l 0޽h ? f33f  /K0 t(  t t c $X' P<$D  0    t s *T(  `<$  0  H t 0޽h ? ̙33`  K0  |(  | | c $: P<$D  0    | c $; P<$  0  H | 0޽h ? ̙332  K0 @Z( ޽h   c $ P<$D  0     c $ԧ <$  0    Z331?@U 0U 0H  0޽h ? ̙33l K0 `( @   s *^  `}<$D  0     s *  `<$  0  H  0޽h ? ̙33f K0 (    c $,s P<$  0     s *(t  `<$  0  H  0޽h ? ̙33f K0 ( @   s *4  `}<$D  0     c $0  <$  0  H  0޽h ? ̙33l K0 ( @   s *t  `}<$D  0     s *p  `<$  0  H  0޽h ? ̙33` K0 (    c $ P<$D  0     c $ Pp<$  0  H  0޽h ? ̙33` K0 (    c $¸ P<$D  0     c $ø Pp<$  0  H  0޽h ? ̙33v: & (  H    0ظ33 0   B  s *޽h ? f33` `)K0 @( {   c $  P<$  0     c $ <$  0  H  0޽h ? ̙33j  `(    s *ײ  `}<$  0     s *@  `<$ 0  "P@08XH  0޽h ? f33T  (    s *  `}<$  0     s *  `<$ 0  H  0޽h ? f33N  (    s *޲  `}<$  0     c $߲ <$ 0  H  0޽h ? f33T  ( @   s *  `}<$  0     s *xֳ  `<$ 0  H  0޽h ? f33N  ( 0   c $; P<$  0     s *<  `<$ 0  H  0޽h ? f33N  (    s *tJ  `}<$  0     c $pK <$ 0  H  0޽h ? f33|; ,$ ( w    6]33 >  B  s *޽h ? f33T  @( '   s *g  `}<$  0     s * h  `<$ 0  H  0޽h ? ̙33T  `( ,ԍ   s *Ds  `}<$  0     s *@t  `<$ 0  H  0޽h ? ̙33H  (    c $U P<$  0     c $T  <$ 0  H  0޽h ? ̙33N   (      s *(  `}<$  0      c $$ <$ 0  H   0޽h ? ̙33N  (    s *  `}<$  0     c $  <$ 0  H  0޽h ? ̙33N   ( 0   c $ P<$  0     s *  `<$ 0  H  0޽h ? ̙33H ! $( H0, $ $ c $ P<$  0    $ c $º <$ 0  H $ 0޽h ? ̙33N "  ,(  , , s *Xκ  `}<$  0    , c $TϺ <$ 0  H , 0޽h ? ̙33|< ,$@( w    6x33 >  B  s *޽h ? f33T # `4(  4 4 s *  `}<$  0    4 s *  `<$ 0  H 4 0޽h ? ̙33N $ <( *5 < < s *,  `}<$  0    < c $(  <$ 0  H < 0޽h ? ̙33N % D( 8h(^ D D s *  `}<$  0    D c $ <$ 0  H D 0޽h ? ̙33T & L(  L L s *,-  `}<$  0    L s *(.  `<$ 0  H L 0޽h ? ̙33T ' T(  T T s *,  `}<$  0    T s *  `<$ 0  H T 0޽h ? ̙33T ( \(   \ \ s *M  `}<$  0    \ s *N  `<$ 0  H \ 0޽h ? ̙33  )  d`(  d d s *[  `}<$  0    d c $\ <$ 0   d Z331?@U 0U 0H d 0޽h ? ̙33N * @l(   l l s *h  `}<$  0    l c $i <$ 0  H l 0޽h ? ̙33|= ,$`( w    6 x33 >  B  s *޽h ? f33T + t(   t t s *  `}<$  0    t s *  `<$ 0  H t 0޽h ? ̙33N , |(  | | c $Ԏ P<$  0    | s *  `<$ 0  H | 0޽h ? ̙33H - ( Odw8   c $8 P<$  0     c $4 <$ 0  H  0޽h ? ̙33N . 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Oh+'0H hp    ((Mental Health Services For Older People MHSOP-CLSltHSOStekmer18kMicrosoft PowerPoints F@`spT@`;n)M@qezGg  B  Y-- @ !Y--'@Arial-. B2 A$'Mental Health Services For Older People   ."Systemhi-@Arial-. 2 UNDERSTANDING   .-@Arial-. 2 M AGITATIOND  .-@Arial-.  2 !&.-@Arial-. 2 F CONFUSION   .-@Arial-. !2 AND THE POSSIBLE     .-@Arial-. 2 CAUSES IN OLDER    .-@Arial-. 2 @PERSONS1.-@Times New Roman-. !2 BStephen Merrett  .-@Times New Roman-.  2 -.-@Times New Roman-. 2 Oct 2001 .-