Improving acute-care for people with cognitive

impairment

Fred Graham CNC02/11/2012

I am not an orthopaedic or surgical Nurse!!! –sorry…

• Differentiating delirium from dementia helps

determine type of care approach

• Introduce a methodology for assessing pain in

hospitalised people with cognitive impairment

(tools & process)

• Special environment with a focus model of care

(PAH – HCR our experience)

Cognitive Impairment in Acute Care

• Delirium – acute confusional state – sepsis, metabolic conditions, brain trauma,

• Dementia – Alzheimer’s, Vascular, Fronto-temporal, Parkinson’s, Dementia with Lewy

Bodies, Korssakoff’s and Alcohol-related

• Delirium superimposed on dementia (DsD)

• Intellectual impairment

• Brain injury

• Dementia or delirium superimposed on a psychiatric condition

• Mild Cognitive Impairment (MCI) - pre-dementia

Care is often seen as difficult & challenging

• High risk behaviours - restlessness, agitation, elopement, removing indwelling devices, aggressiveness & falls

• Adverse events causing injury to self or others

• Risk of staff frustration, burnout & helplessness, negative attitudes toward patients with impairment

Current management

• Specials (AIN 1:1)

• Psychotropic medication/sedation

• Physical restraint

• Falls Rooms (AIN with group of pts)

• Do these reduce agitation?

• Only if they deliver therapeutic care

Literature suggests

• Specials not used well – The therapeutic opportunities afforded by 1:1 care are not taken1

• Knowledge deficits about delirium, dementia and delirium superimposed on dementia2

• Few models of care tested in acute-care3

• Overuse of antipsychotics 1st line behavioural management (risk of stroke, delirium, EPSE)4

1. Moyle et al (2010) Acute care management of older people with dementia: a qualitative perpspective. Journal of Critical Care Nursing, 20, 420-428

2. Fick, D. M., Hodo, D. M., Lawrence, F., & Inouye, S. K. (2007). Recognizing delirium superimposed on dementia. Journal of Gerontological Nursing, 33(2), 40-47.

3. Moyle et al (2008) Best practice for the management of older people with dementia in the acute acre setting: a review of the literature. International Journal

of Older People Nursing, 3(2), 121-130

4. Banerjee, S. (2009) The Use of Antipsychotic Medication for People with Dementia: Time for Action (pp 63) United Kingdom: UK Department of Health (DH)

Cognitive impairment - ‘core’ business

• 60-70% of all hospital patients are older people (chronic illnesses) 1

• Older people - high risk of delirium (10-15 admitted, 5-40% developed) 2

• Dementia increases risk of delirium (22-89% superimposed) 3

• Dementia increasing (289,000 now to 900,000 by 2050), 4

• Poor outcomes – falls, malnutrition, functional decline, incontinence 5

• Up 6 x LOS than people without cognitive impairment 4

1. Tadd et al (2011) Right place – wrong person: dignity in the acute care of older people. Quality in Ageing & Older Adults, 12(1), 33-43

2. Tropea et al (2008) Clinical practice guidelines for the management of delirium in older people in Australia. Australasian Journal on Ageing, 27(3) 150-156

3. Fick, D. M., Agostini, J.V., & Inouye (2002) Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society,

50(10), 1723-1732

4. Australian Institute of Health and Welfare. (2012). Dementia in Australia (Vol. Cat. no. AGE 70). Canberra: AIHW.

5. Naylor et al (2007) Care coordination for cognitively impaired older adults and their caregivers, Home Health care Services Quarterly 26(4), 57-78

Orthopaedic Context - fractured hip

• Incidence of delirium 40.5% - 55.9% over 60yrs 1,2

• Dementia is a risk factor for delirium in hip fracture3 with reports of up to 66% of patient DsD 4

• Prevalence of dementia in hip fracture is common 19.3%,5 while others report as high as 30-50% of all fractures 6

1. Santana Santos, F., et al (2005). Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures.

Dementia and Geriatric Cognitive Disorders, 20(4), 231-237.

2. Galanakis, P., et al. (2001). Acute confusional state in the elderly following hip surgery: incidence, risk factors and complications. [Article].

International Journal of Geriatric Psychiatry, 16(4), 349-355.

3. Juliebø, V., et al. (2009). Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. Journal of the

American Geriatrics Society, 57(8), 1354-1361.

4. Marcantonio et al (2001) Reducing deliium after hip farcture: A randomized trial. JAG 49, 516-522

5. Seitz, D. P., Adunuri, N., Gill, S. S., & Rochon, P. A. (2011). Prevalence of Dementia and Cognitive Impairment Among Older Adults With

Hip Fractures. Journal of the American Medical Directors Association, 12(8), 556-564.

6. Sttenvall, M., et al (2012). A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia--

subgroup analyses of a randomized controlled trial. Archives Of Gerontology And Geriatrics, 54(3), e284-e289.

Cognitive impairment in orthopaedics

• Poor staff knowledge of delirium 1

• Presence of Behavioural agitation and symptoms 2

• Poor staff knowledge of dementia3,4

– How well are nurses skilled to manage BPSD?

1. Meako, M. E Thompson, H.J., & Cochrane, B.B (2011) Orthopaedic nurses’ knowledge of delirium in older hospitalised patients. Orthopaedic Nursing,

30(4), 241-248

2. McGilton, K., et al. (2007). Rehabilitating patients with dementia who have had a hip fracture: part II: cognitive symptoms that influence care. Topics in

Geriatric Rehabilitation, 23(2), 174-182.

3. Borbasi, S., Jones, J., Lockwood, C., & Emden, C. (2006). Health Professionals' Perspectives of Providing Care to People with Dementia in the Acute Setting: Toward Better Practice. Geriatric Nursing, 27(5), 300-308.

4. Eriksson, C., & Saveman, B. (2002). Nurses' experiences of abusive/non-abusive caring for demented patients in acute care settings. Scandinavian

Journal of Caring Sciences, 16(1), 79-85

Behavioural disturbances from two differing conditions or mixture of these

• Delirium

• Dementia

• Delirium superimposed on dementia

What is delirium?

• Acute confusional state with alterations in sleep-wake cycles and psychomotor behaviour appearing as hyper-alert or hypo-alert

• Develops rapidly (hrs to days) and usually resolves within a relatively short time (days or sometimes months)

• Tendency toward visual hallucination/misperception and nocturnal exacerbation

• Characterised by reduced ability to maintain attentionoften leading to disoriented and disorganised thinking

Feature Delirium Dementia

Onset Acute, often at night Insidious

Course Fluctuating, with lucid intervals during the day; worse at

night

Stable over the course of the day

Duration Hours to weeks Months to years

Awareness Reduced Clear

Alertness Abnormally low or high Usually normal

Attention Impaired, causing distractibility; fluctuation over the

course of the day

Relatively unaffected; impaired in DLB and

vascular dementia

Orientation Usually impaired for time; tendency to mistake

unfamiliar places and persons

Impaired in later stages

Short-term (working)

memory

Always impaired Normal in early stages

Episodic memory Impaired Impaired

Thinking Disorganised; delusional Impoverished

Perception Illusions and hallucinations, usually visual and common Absent in earlier stages, common later; common

in DLB

Speech Incoherent, hesitant, slow or rapid Difficulty in word finding

Sleep-wake cycle Always disrupted Usually normal

John R Hodges (2007), Cognitive Assessment for Clinicians pp.54

CAM – Confusion Assessment Method

1. Acute onset and fluctuating course

2. Inattention

3. Disorganised thinking

4. Altered level of consciousness

+ve screen = 1 + 2 and 3 or 4

Semi-formal interview with Mini-Cog + digit span

Inouye S.K. et al (1990) Clarifying confusion: The Confusion assessment method. Anew method for detection of delirium. Ann. Intern. Med 113, 941-8

Risk Factors for Delirium in Hospital (medical and nursing care may modify these)

Precipitating insults

� Severe medical illness

� Metabolic disturbances especially from

abnormal sodium, dehydration, constipation

� Exposure to pethidine

� Exposure to benzodiazepine

� Exposure to narcotic analgesics preoperatively

� Addition of ≥ 3 medications during

hospitalisation

� Withdrawal syndromes

� Intoxication with alcohol or illicit drugs

� Infections

� Anaemia

� Head trauma & focal brain lesions

� Pain & discomfort

� Sleep deprivation

� Use of physical restraint

� Use of indwelling catheters

� Emotional stress and unfamiliar surroundings

Pre-disposing vulnerability

� Age ≥ 70 years

� Pre-existing cognitive impairment including

dementia

� Pre-existing neurological disorders (e.g. Parkinson’s

disease)

� Depression

� History of delirium

� Sensory deficits – e.g. visual or hearing impairment

� Immobility

� Pre-existing drug treatments/ dependencies such as

benzodiazepines

� Alcohol-related health concerns

� Chronic sleep deprivation/disorders (≤ 4 hours per

night)

Source: adapted from – Clinical practice guidelines for the management of delirium in older people. 2006. http://www.health.vic.gov.au/acute-agedcare/.

High level of vulnerability

Low level of insult

� Moderate to high risk of developing

delirium

High level of vulnerability

High Level of insult

� Very high risk of developing

delirium

Low level of vulnerability

Low level of insult

� Low risk of developing delirium

Low level of vulnerability

High level of insult

� Moderate to high risk of

developing delirium

Level of

Vulnerability

Low Level of Insult High

High

The interrelationship between patient vulnerability and precipitating insult

Delirium management priorities

• Eliminate or treat underlying cause (precipitating factor)

• Intervene to reduce or modify the effect of predisposing

factors 1

• Attempt to settle distressful symptoms for the patient

• Optimise patient safety (environment and staffing)

1. Inouye, S. K., et al (1999). A Multicomponent Interventin to Prevent Delirium in Hospitalised Older Patients. The New England

Journal of Medicine, 340(9), 669-676.

Environmental Psychosocial Physical

Provide adequate supervisionEducate client & family/carers and

involve in care

Wear vision & hearing aids & dentures:

keep within reach

Provide consistent care-giving staffUse reorientation strategies (clocks,

calendar, photos)Ensure adequate hydration

Provide access to sunlight (if available)

during the day

Ensure good communication: speak in

clear, short, simple phrasesEnsure adequate pain relief

Create a calm soothing atmosphere &

decrease sensory input: eliminate

unnecessary noise

Validate fears and concerns

Promote regular toileting: bowel meds

(softeners, stimulants may be

necessary)

Minimise sudden changes in

environment

Provide reassurance: inform that this is

short-term condition

Ensure prompt attention & treatment of

infections

Ensure safety and prevent

complicationsEncourage relaxation techniques Encourage activity: mobility & ADL’s

Have familiar possessions from home Normalise sleep patterns

Have a low set bed & bed rails down Maintain normal oxygenation

Source: J. McCrow, 2011 accessed from http://www.learnaboutdelirium

What is dementia?

• Syndrome caused by over100 different diseases

which all structural and chemical changes in the

brain leading to brain tissue death

• Progressive decline in memory, reasoning,

communication skills affecting daily activities

leading to extreme functional decline and death

Types of Dementia (many causes)

• Alzheimer’s

• Vascular

• Fronto-temporal (Pick’s disease)

• Parkinson’s

• Dementia with Lewy bodies

• Alcoholic related dementia & korsakoff’s

Behavioural symptoms and psychological symptoms of dementia (BPSD)

Behavioural:

• Agitation

• Aggression

• Wandering

• Vocalisations

• Repeated questioning

Psychological:

• Depression

• Psychosis

• Sleep disturbances

Biomedical understanding - Damage to brain affects certain abilities and behaviours

Frontal LobePlanning, impulse control, social &

behavioural control, co-ordination,

initiative,

Occipital LobeVisual processing

Temporal LobeMemory, emotions,

language

Parietal LobeLanguage, speech, calculation, spatial

reasoning, movement, recognition

Limbic system / hippocampusMemory formation & recall, emotions,

consciousness, sleep

RASArousal & attention

Psychosocial model – Person Centred Care1

Inclusion, Attachment, Occupation, Identity, Comfort, (Love),

• Valuing the person

• Know the person – their likes and dislikes (biography)

• Respect the person

• Holding the persons identity for them

• Mutuality

Kitwood (1997) , The experience of dementia. Aging & Mental Health, Vol 1, no 1, p 13-22

Need-driven Dementia-compromised Behaviour Model – unmet needs

• Behavioural symptoms are a person’s best attempts at communicating unmet physical, social and emotional needs.

– Drawing on all their preserved abilities & personality

albeit constrained by the limitations of a dementia

related illness

• Involves an interaction between background and proximal factors

Theoretical approach to behavioural management (NDB model)

Neurological factors

Specific regional brain involvement

Neurotransmitter imbalance levels

Circadian rhythm deterioration

Motor ability

Cognitive factors

Attention -

Memory

Visuo-spatial ability

Language skills

Health status

General health

Functional ability

Affective state (anxiety, depression)

Psychosocial factors

Gender

Education

Occupation

Personality type

History of psychological stress

Behavioural response to stress

Personal factors

Emotions

Physiological needs (Pain, thirst)

Functional performance

Physical environment

Light level

Noise level

Temperature

Social environment

Ward ambience

Staff stability

Staff mix

BACKGROUND FACTORS PROXIMAL FACTORS BEHAVIOUR

Dimension of

BehaviourFrequency

Duration

inetnsity

Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. and Beattie, E. (1996) Need-driven dementia-compromised behaviour: an

alternative view of disruptive behaviour, American Journal of Alzheimer’s Disease and Other Dementias, vol 11:10

Assessing unmet needs and consequences of unmet needs

• Discomfort – Pain, constipation, thirst,

treatments, ailments – itchy skin

• Sleep disturbances

• Toileting

• Nutrition – hunger & thirst

• Emotional responses/needs

• Loss of control

• Loss of independence or routines

Needs Specialised Assessment

• Measurement of behaviour

– Antecedent, behaviour, consequence - ABC method

– Cohen Mansfield Agitation Inventory - CMAI (30 domain behavioural assessment)

– Behavioural observation chart (PAH) – Pittsburgh Agitation scale + Verbal descriptor scale + PAINAD

• Graphical system, Pain assessment, Intervention grid

Therapeutic responses to aggression in dementia & brain injury (different to managing MH)

Nursing Reponses

Entering the patients world:

• Normalization

• Person-centred care

• Nurse-patient mutuality

• Downplaying negativity

• Thoughtful creativity

Patient

• Decreased aggression

Nurse

• Nurse satisfaction

Finfgeld-Connett, D. (2009). Management of aggression among demented or brain-injured patients. Clinical Nursing Research, 18(3), 272-287.

Non-Therapeutic responses to aggressive behaviours in dementia or brain injured patients

Nursing Reponses

Utilitarian care:

• Inflexible routines

Patient

• Persistent aggression

Nurse

• Negative physical, psychosocial, and professional consequences

Nursing Reponses

Authentic engagement (MH):

• Grounding interactions within reality

• Setting contextually based limits

Finfgeld-Connett, D. (2009). Management of aggression among demented or brain-injured patients. Clinical Nursing Research, 18(3), 272-287.

Assess & treat discomfort

Avoid or minimise psychotropic, sedative, hypnotic medications

Avoid restraint

Monitor for overstimulation

Reduce environmental stressors

Increase level of supervision

Provide non-pharmacological sleep aids

Provide & encourage recreational, occupational and social activity

Promote and maintain physical function

Schedule regular visits to toilet or prompted voiding

Monitor hydration, nutrition and swallowing

Provide sensory aids

Provide orientation aids

Provide reassurance

Remove or camouflage invasive devices

Provide low-set bed with bed-rails down

Document behaviour

Assess & ensure prompt attention & treatment of causes

Normalise sleep patterns

Prevent injury and delirium complications

Ensures adequate hydration

Provide cognitively stimulating activity

Provide access to sunlight

Maintain normal oxygenation

Promote regular toileting

Search for unmet needs

Use ‘Life Story’ information to communicate & plan person-centred care

Hygiene routines – consider time of day with least distractions

Provide dementia-specific recreational resources

Promote mealtime routines

Delirium Dementia

Search for unmet needs

Use ‘Life Story’ information to communicate & plan person-centred care

Hygiene routines – consider time of day with least distractions

Provide dementia-specific recreational resources

Promote mealtime routines

Some approaches that will work for both delirium and dementia

PAIN

Pain a contributor to delirium in hip fracture?

• Under treatment of postoperative pain in general has been associated with increased risk of delirium 1

• High opioid use may also increase risk of delirium 2

• Inadequate doses of opioids in hip fracture may increase risk of delirium however low dose opioids matching pain showed no increase 3,4

• Insufficient evidence on harms and benefits of anlagesia5

• Studies also report lower use of analgesics by people with dementia 3

1. Lynch et al (1998) The impact of Postoperative pain in the development of postoperative delirium. Regional Aesthesia and Pain management.

2. Leung et al (2009) anaesthesiology< vol. 111, 625-631

3. Sieber, F. E., Mears, S., Lee, H., & Gottschalk. (2011). Postoperative Opioid Consumption and Its Relationship to Cognitive Function in Older Adults Fracture. JAGS, 59, 2256-2262.

4. Morrison et al (2003) Relationship Between Pain and Opioid Analgesics on the Development of Delirium Following Hip Fracture. Journals of Gerontology Series

A: Biological Sciences and Medical Sciences, 58(1), M76-M76.

5. Abou-Setta et al (2011) Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Annals of Internal Medicine, 155(4), 234-245

Why is pain undertreated in cognitive impairment

• 1/3 less analgesia postoperatively than for cognitively intact 1

• Painful conditions

• Inability to self report

• Staff knowledge deficit

• Behaviours not linked to pain

• Lack of assessment tools

• Growing body of knowledge, still being defined

IStockphoto.com

1. Morrisson, s. R & Siu, A.L. (2000). A comparison of pain and its treatment in advanced dementia and cognitively intact Patients with hip fracture. Vol.

19, No. 4. 240-248

Difficulties of assessing pain in cognitive impairment, especially dementia

• Loss of ability to communicate pain (Is self-report reliable now?)

• Interpretation of non-verbal behaviours (which behaviours are pain related - BPSD broad range can we distinguish?)

• Availability of psychometrically validated observational tools?

• Reliability of only using these?

• What are best practice protocols & procedures?

Kaassalainen, S (2007). Pain Assessment in Older Adults with Dementia – using behavioural observation methods in clinical practice. Journal of Gerontological Nursing,

Observational tools focused on non-verbal behaviours

• Facial expressions

• Paralinguistic vocalisations (eg moaning)

• Guarding

• Bracing

• Sleep disturbances

• Aggressive behaviour

• Changes in psychomotor activity

Review of Observational Instruments

Herr, K., Bursch, H. & Black, B. (2008). State of the Art Review of tools for Assessment of Pain in Nonverbal Older Adults. University of Iowa. Retrieved, 27 October, 2009 from

http://prc.coh.org/pain_assessment.asp

What Tool to use?

• Expert consensus for RACFs – PAINAD (daily) & PACSLAC or Doloplus (weekly)1

• Many of the best psychometric tools are bulky –PACSLAC (4 subs 60 items) & Doloplus-2 (3 subs 10 items) - questionable as to whether they will be readily used by acute care nurses

• PAINAD – simpler, quicker and recommended to use alongside self report in acute care with hip fracture2

1. Herr, K., et al (2010). Use of pain-behavioral assessment tools in the nursing home: expert consensus recommendations for practice. Journal

of Gerontological Nursing, 36(3), 18-31.

2. DeWaters, et al (2008). Comparison of Self-Reported Pain and PAINAD Scale in Hospitalised Cognitively Impaired and Intact Older Adults After Hip Fracture Surgery. Orthopaedic Nursing, 27(1), 21-28

VERBAL PAIN SCALE

Verbal Descriptor Scale – Mild to moderate dementia may reliably self-report pain. Always try self report first.

No pain Mild Pain Moderate Pain Severe Pain Worst Pain

PAINAD SCALE

Pain Assessment in Advanced Dementia. Observational Pain Assessment Tool – scores from 0-10. Only use if patient cannot self report pain.

ITEMS 0 1 2 SCORE

Breathing independent of vocalisation

Normal Occasional laboured breathing. Short period of hyperventalion.

Noisy laboured breathing Long period of hyperventilation. Cheyne-stokes respirations

(0-2)

Negative vocalisation None Occasional moan or groan. Low level speech with negative or disapproving quality.

Repeated troubled calling out. Loud moaning or groaning. Crying.

(0-2)

Facial experession Smiling or inexpressive

Sad, frightened, frowning Facial grimacing. (0-2)

Body language Relaxed Tense, distressed pacing, fidgeting Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out

(0-2)

Consolability No need to console Distracted or reassured by voice or touch.

Unable to console, distract or reassure.

(0-2)

RECORD SCORES ON REVERSE PAGE

TOTAL (0-10)

Record over page

© PAINAD developed by Warden, V., Hurley, A. C., & Volicer, L., (2003)

Graphical system & hourly

VERBAL

PAIN

SCALE

Worst

Severe

Moderate

Mild

No Pain

PAINAD

Only use if unable

to self report pain

10

8

6

4

2

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Diversion (D)

PRN (PO, S/C, IM)

Restraint (X)

Baseline Continue to observe. Explore patient’s life story. Consider delirium reduction strategies & activities for persons with dementia.

Escalation 1st line: Address needs – consider pain, toileting, position, emotion. Problem solve within person’s reality. Try distraction & diversion.

2nd line: (Use if 1st line ineffective). Consider PRN medications. Reduce stimuli. Remove potential missiles & dangers.

Crisis Keep calm. Take action to ensure others safety. Remove dangers. Consider – calling for assistance from security, IM sedation, restraint.

Date: Day:

© PAH Behavioural Observation Chart developed by The Internal Medicine Unit, 5th floor Princess Alexandra Hospital, 07-12-2009 incorporating the Pittsburgh Agitation scale, Verbal Descriptor Scale & PAINAD.

Pain in dementia patients with co-morbid delirium and/or depression

• Caution – potential to inflate pain score when co-morbid delirium, depression, dementia due to overlapping behavioural symptoms1

• Clinicians should place an emphasis on behaviours not confounded by co-morbid diagnosis – e.g. protective body postures, protection score areas1

• Best practice - Assessment should triangulate information from a variety of sources 1-3

1. Hadjistavropolous et al, (2008) Assessing Pain in Patients with Co-morbid Delirium and/or Depression. Pain Management Nursing, Vol 9, No 2, pp48-54

2. Kaassalainen, S (2007). Pain Assessment in Older Adults with Dementia – using behavioural observation methods in clinical practice. Journal of

Gerontological Nursing

3. Kovach et al (2006) Effects of the serial trail inetrvention on discomfort and behvaiour of nursing home rseidents with dementia. American Journal of

Alzheimer’s Dsease and Other Dementias, 21 (3), 147-155

Guiding principles for Assessing Pain in Cognitive Impairment2006 American Society for Pain Management Nursing

• Self report– Always attempt to elicit self report and record why self report is not possible

• Painful conditions or treatments– Search for conditions or treatments that may cause pain

• Observe behaviours– Use a validated observational tool that measures distress

• Surrogate reporting– Interview family/carers to establish the nature of any new changes in

behaviour

• Analgesic trial– Rule out pain by attempting a time-limited analgesic trial and evaluate– Regular analgesia needed, – PRN not suitable

1. Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., . . . Wild, L. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice. Pain Management Nursing, 7(2), 44-52. doi: 10.1016/j.pmn.2006.02.003

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4

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PR N ( PO, S/ C , IM )

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4

3

2

1

0

4

3

2

1

0

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4

T D D

s/ c s/ c

R est raint ( X )

Only use if unable to

self report pain

0

4

2

D iversion ( D )

PR N ( PO, S/ C , IM )

M eal M eds. Shower

#

Mild

No pain

P A IN A D 8

6

HOURLY OBSERVATIONSTime in HoursP ITTSB U R GH

A GITA T ION S C A LE

Aberrant

Vocalisation

Moderat e

6hr scor e

6hr scor e

6hr scor e

Resisting Cares

Aggressiveness

M oto r Agitation

V ER B A L

P A IN

S C A LE

Worst

Severe

M eal Recor d act i v i t y & 6hr scor e

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4

4

3

2

1

0

4

3

2

1

0

4

3

2

1

0

4

3

2

1

0

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4

T D D

s/ c s/ c PO

Worst

Severe

M eal Recor d act i v i ty & 6hr scor e

Moderat e

6hr scor e

6hr scor e

6hr scor e

Resisting Cares

Aggressiveness

M otor Agitation

V ER B A L

P A IN

S C A LE

HOURLY OBSERVATIONSTime in HoursP IT T SB U R GH

A GIT A T ION S C A LE

Aberrant

Vocalisation

#

Mild

No pain

P A IN A D 8

6

M eal M eds. Shower

R est raint ( X )

Only use if unable to

self report pain

0

4

2

D iversio n ( D )

PR N ( PO, S/ C , IM )

Model of Care High Care Room/delirium room/ACE

• Several projects suggest specific environmental

adjustments and models of care for delirium

management1-3

• An observational study has reported LOS equal

to cognitively intact people and no more adverse

outcomes4

1. Niam, D. M. W. T., Geddes, J. A., & Inderjeeth, C. A. (2009). Delirium unit: our experience. Australasian Journal of Ageing, 28(4), 206-210.

2. Zieschang, T., et al (2010). Improving care for patients with dementia hospitalized for acute somatic illness in a specialized care unit: a feasibility study. International Psychogeriatrics, 22(1), 139-146.

3. Soto, M. E., et al. (2008). Special acute care unit for older adults with Alzheimer's disease. International Journal of Geriatric Psychiatry, 23(2), 215-219.

4. Flaherty, J. H., et al (2010). An ACE unit with a delirium room may improve function and equalize length of stay among older delirious medical inpatients. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 65A(12), 1387-1392

Started in Internal medicine - problem in 2007

• IMU found 70% of falls were in cognitive

impairment

• Falls & aggressive events were still occurring

despite 1:1 nursing specials (expensive!)

• Negative reputation affecting recruitment and

retention due to increased falls & aggressive

events

STRATEGY

• A high care unit with specialised interventions

was developed to increase quality of care,

reduce patient agitation and provide a safer

environment

• High risk patients were relocated from IMU

wards to 8 bed environment staffed by specialist

nurses and situated within the treating unit

W5B

High Care Unit

W5CW5AAcute Medical (1 & 3)Eye surgical wardImmunology & rheumatology

Acute Medical (2 & 5)Endocrine5D overflow (isolation)

Acute Medical (4, 6 & 7)High risk patientsHypertension

Wanderer

Alarms

Lif

ts

Lif

ts

Wanderer

Alarms

Glass doors

ENVIRONMENT

• Geographically located to least busy area with fewest exits• Located within medical unit facilitates timely access to treating teams • Double glazed doors to offer quieter environment

W5A

Patient Flow

• Admission & discharge criteria developed – falls

risks or behavioural risks with acute/chronic

cognitive impairment

• Relocation of patients with high risk to high care

environment

• Streamlined referral & assessment process –

nursing driven.

Multidisciplinary involvement including geriatric team

• Geriatric Assessment Team (referral based

service)

• Physio, Social work, Community Health nurses

(discharge nurses), Occupational Therapy

Increased staffing

• 4 staff (2 unlicensed) to 8 patients morning

• 4 staff (2 unlicensed) to 8 patients evening

• 2 staff (1-2 unlicensed) to 8 patients overnight

with CN support

Training

• Specialised training in dementia & delirium care

for licensed and unlicensed clinicians

• Education program delivered utilising ward-

based computer workstations

• Geographic location of unit facilitated focused

training to a localised (W5A) group of nurses

rather then whole IMU

Distraction Devices

• IVC Decoys

• IDC Decoy – apron

• Fiddle Blankets

Psychosocial understanding of behaviours: Biographical approach to knowing the person

Tolerate, anticipate and don’t agitate approach1

• Person centred communication

• Mobilisation, socialisation and engagement in

activity2

• Creativity and flexibility

1. Flaherty, J., & Little, M. (2011). Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium. JAGS, 59, S295-S300

2. Richards, K. C., Lambert, C., Beck, C. K., et al. (2011). Strength training, walking, and social activity improve sleep in nursing home and assisted living residents: randomized controlled trial. Journal of the American Geriatrics Society, 59(2), 214-223.

MODEL OF CARE

• Increased staffing

• Constant Supervision for high falls risk

• Person Centred Care (Kitwood, 1997)

biography, creativity, flexibility, choice

• Communication

• Emotional support

PATIENT LIFE STORY CHART Obtain collateral information from family & carers

KEEP UP TO DATE

LIFE STORY

BORN: INTERESTS:

(Place, year) (Hobbies, talking points)

CHILDHOOD:

(Where, hobbies, schooling)

FAMILY:

(Partners, children) FAVOURITE THINGS:

(Pets, objects, favourite activities)

OCCUPATIONS:

(Jobs, volunteers, armed service)

GAMES:

(Board games, puzzles)

SIGNIFICANT LIFE EVENTS:

(Achievements, accidents, marriages, births) MUSIC:

(Favourite songs & styles)

SPORTS:

(Sports played and favourites now)

URN: Family Name: Given Name: Date of Birth:

Theoretical approach to behavioural management (NDB model)

Neurological factors

Specific regional brain involvement

Neurotransmitter imbalance levels

Circadian rhythm deterioration

Motor ability

Cognitive factors

Attention -

Memory

Visuo-spatial ability

Language skills

Health status

General health

Functional ability

Affective state (anxiety, depression)

Psychosocial factors

Gender

Education

Occupation

Personality type

History of psychological stress

Behavioural response to stress

Personal factors

Emotions

Physiological needs (Pain, thirst)

Functional performance

Physical environment

Light level

Noise level

Temperature

Social environment

Ward ambience

Staff stability

Staff mix

BACKGROUND FACTORS PROXIMAL FACTORS BEHAVIOUR

Dimension of

BehaviourFrequency

Duration

inetnsity

Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. and Beattie, E.l (1996) Need-driven

dementia-compromised behaviour: an alternative view of disruptive behaviour, American Journal of Alzheimer’s

Disease and Other Dementias, vol 11:10

Mobility - physio

Medical history/diagnosis

mental health

MMSE

RUDAS

Verbal Fluency

Recreational Activities

Aims:

Provide distraction & interest

Relieve boredom

Involve family in care

Sorting activities

Aims:

Cognitive stimulation

Reduce boredom

Supply variety of meaningful tasks

Activities relevant to past occupations

or personality

Themed Fiddle Boxes

Aims:

Reminiscence

Explore stories with familiar

items

Textural exploration

Outcomes

• Reduced falls by 30%

• Increased staff retention

• Increased staff morale, improved BPA workplace culture

• Reduced workforce costs due to reduced external & internal casual staff use

– 62.7% reduction in 1:1 special use

– Less staff leave & vacancy due to improved workplace

• Improved quality of care is often an outcome of reduced transient and casual workforce

REDUCED FALLS BY 30%

0

20

40

60

80

100

120

140

160

2006-2007 2007-2008 2008-2009 2009-2010

YEARS

FA

LL

S

Post Implementation

Reduced External & Internal Casual FTE

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

2006/2007 2007/2008 2008/2009 2009/2010

Years

FT

E Internal

External

Post Implementation

The PAH Journey

Education (3 modules)

Module 1

• Cognition & brain anatomy

• Delirium (CAM embedded)

Module 2

• Dementia

• Models of Dementia Care

Module 3

• Behavioural Observations

• Pain in Dementia

• Pharmacological Management of Behaviours

• Patients with High-risk Behaviours

Workshop – interactive group work

• Practice CAM & Video Vignette's

• Case studies – develop care plans for patient with delirium and patient with dementia

Conclusion – can the following can be set up on orthopaedic wards?

• Specialised care environment

• Delirium assessment tools (a must for nurses)

• Pain assessment tools and method for cognitive

impairment (a must)

• Education

• Models of care and person centred care

• Environment that allows creativity and flexibility