Transcript Cognitive screening Instruments

CNS ROLE APPLICATION
ELDER LIFE CNS ROLE –SPHERES OF
CARE INFLUENCE

Patient level – comprehensive geriatric
assessment, protocol driven, follow up
assessment and interventions, education for
patients and families
Staff level – coaching and education on delirium
prevention and functional decline; participation
in care rounds
 System level – program operation, quality
assurance, identification of care gaps and
interventions

HELP NURSING PROTOCOLS
Targeted Risk Factor Approach using
protocols
Evaluation of Cognitive Status
• Delirium Protocol
• Dementia Protocol
• Psychoactive Medications Protocol
Sleep Enhancement Protocol
 Early Mobilization Protocol
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MORE HELP NURSING PROTOCOLS
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Hearing Protocol
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Fluid Repletion Protocol
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Discharge Planning Protocol
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Optimizing Length of Stay Protocol
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Additional Areas –
EXAMPLE: DELIRIUM PROTOCOL
Assessment
 establishes baseline, cognitive tool plus CAM
and collateral history
 psychoactive medications and ETOH use
 bloodwork
 then daily- structured cognitive tool plus the
CAM and ongoing staff, family and volunteer
inputs
IF PATIENT CHANGES SUDDENLY ….
Review medication list for potentially
contributory medications or potentially harmful
interactions
 Search for occult infection, e.g., urinary tract
infection (UTI)
 Rule out drug or alcohol withdrawal
 Support referrals to geriatrics, pharmacy,
internal medicine
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MORE DELIRIUM INTERVENTIONS
Non-Pharmacological Management
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Education for staff, involve family
Strategies to decrease agitation and
improve sleep
Communication techniques
AT HHS, THE HELP NURSE …….
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Follows HELP delirium protocols
Structured cognitive assessment is not carried out
daily but on admission and as indicated
No discharge sMMSE is completed
ADHERENCE-WHAT DOSE OF HELP IS ENOUGH
?
The Role of Adherence on the
Effectiveness of Nonpharmacologic
Interventions

Higher levels of adherence resulted in reduced
rates of delirium in a directly graded fashion,
with extremely low levels of delirium in the
highest adherence group.
Inouye SK. Arch Intern Med. 2003;163:958-964
AT HHS…… 2005 ADHERENCE
68%-best for orientation, vision and
hearing , therapeutic activities and
feeding protocol
34% -lowest for mobility and sleep
protocol
WHAT FACTORS AFFECT ADHERENCE?
ARE THEY MODIFIABLE?
COGNITIVE SCREENING INSTRUMENTS
Instrument
Admin time
Comments
Sweet 16
3-5 mins
Published Nov 2010on HELP website
Mini-Cog
3-5 min
Brief , validated
Short portable status
questionnaire
3-5 minutes
Brief
3MS
10-15 mins
MMSE plus remote
memory, verbal
fluency and
abstraction
sMMSE/Folstein
10-15
Copyright requires
authors permissionper use fee with
Folstein
Montreal Cognitive
Assessment (MoCA)
10-20 minutes
Open access-
THE SWEET 16
PURPOSE: screening tool for cognitive
impairment
Why another tool? Length, burden ,copyright
ADVANTAGES :
 simple, rapid, paperless,
 validated against the MMSE,
 open access
CONSTRAINTS :
 early days of testing
Fong,T. Arch Intern Med. 2010 Nov 8
CASE STUDY
MRS. SMITH IS A 91 YEARS OLD LADY ADMITTED FROM R.H.
WITH LOW BACK PAIN
HISTORY OF PRESENTING ILLNESS
 Sudden
increase in low back pain 3
days ago; unable to walk, new onset
of urinary incontinence. GP started
Lorazepam 1 mg Q HS 5 days ago for
poor sleep. Confusion over 48 hours
–disoriented to time, not consistently
recognizing family
PAST MEDICAL HISTORY
Hypothyroidism
 Dyslipidemia
 Hearing loss
 Macular degeneration
 Hypertension
 ?TIA
 Arthritis
 Chronic Low Back Pain
 Degenerative Disc Disease, Scoliosis
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SOCIAL HISTORY
 Widowed,
3 children, 9 grandchildren
 Retired teacher – grade school and ESL
 Enjoys listening to music, attending
socials and visiting with families
BASELINE FUNCTION
 Walks
with walker independently to D/R
 Toilets independently; no history of
incontinence
 Assisted with bath 2 X per week
 1 year history of short term memory loss,
repeats stories, forgets family visits
INVESTIGATIONS
CT scan: no obvious fracture except for possibly a
displaced right transverse process fracture of L3
 Labs Lab Findings
Normal Range
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urea 11.2
Creat 115
TSH 18
WBC 13,3
Hgb 130
MEDICATIONS
Aspirin 81 mg OD
 Lorazepam 1 mg Q HS
 Baclofen 10 mg TID
 Levothyroxine 0.125 mg OD
 Hydrochlorothiazide 25 mg OD
 Lipitor 20 mg OD
 Fosinopril 20 mg OD
 Colace 100mg BID
 Senokot 2 tabs Q HS
 Tylenol # 3 1-2 Q 4 H PRN
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