Transcript Cognitive screening Instruments

The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
If patient changes suddenly ….
 Search for occult infection, e.g., urinary tract infection
(UTI)
 Review medication list for potentially contributory
medications or potentially harmful interactions
 Rule out drug or alcohol withdrawal
 Support referrals to geriatrics, pharmacy, internal
medicine
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Case Study
Mrs. Smith is a 91 years old lady admitted from R.H. with low back pain
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
History of presenting illness
 sudden increase in low back pain 3 days ago;
unable to walk
 new onset of urinary incontinence at home
 GP started Lorazepam 1 mg Q HS 5 days ago
for poor sleep
 confusion over 48 hours –disoriented to
time, not consistently recognizing family
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Course in the hospital
 indwelling Foley catheter inserted
 not sleeping well – she is awake during the night
and sleeping much of the day
 takes pain medication regularly due to low back
pain
 not drinking or eating much
 stays in bed most of the day
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Past Medical History
 Hypothyroidism
 Dyslipidemia
 Hearing loss
 Macular degeneration
 Hypertension
 ?TIA
 Arthritis
 Chronic Low Back Pain
 Degenerative Disc Disease, Scoliosis
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Social History
 Widowed, 3 children, 9 grandchildren
 Retired teacher – grade school and ESL
 Enjoys listening to music, attending socials and
visiting with families
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Baseline Function
 Walks with walker independently to D/Room
 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
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Investigations
 X Ray spine: no obvious fracture except for possibly a
displaced right transverse process fracture of L3
 Urine C & S: result pending
 CT Head: mild cerebral atrophy, moderate ischemic
change in the white matter, no acute infarct or
intracranial hemorrhage
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Blood work
Lab Findings
Normal Range
urea 11.2
3.0-6.5 mmol/L
Creat 115
60-115 umol/L
TSH 18
12-22 pmol/L
WBC 13,3
4.0 – 11.0 x 10 9/L
Hgb 130
130-180 g/L
Albumin 23
35 - 50 g/L
Medications
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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
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
What are Mrs. Smith’s risk factors for
delirium and functional decline?
a) Age
o True
o False
b) ADL impairment
o True
o False
c) Dehydration
o True
o False
d) Vision impairment
o True
o False
d) Hearing Impairment
o True
o False
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
What medications could contribute to her
confusion?
a) Baclofen 10 mg TID
o True
o False
b) Levothyroxine 0.125 mg OD
oTrue
o False
c)Lorazepam 1 mg Q HS
oTrue
o False
d) Tylenol # 3 1-2 Q 4 H PRN
oTrue
o False
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Based on the clinical presentation and blood work what would you suspect as
the most likely cause of Mrs. Smith’s cognitive and functional decline?
a) Displaced right transverse process fracture of L3
o True
o False
b) Arthritis flare up
o True
o False
c) Urinary Tract Infection
o True
o False
d) Hypothyroidism
o True
o False
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Based on Mrs. Smith’s history and her current clinical
presentation she is most likely experiencing…
a) Delirium
o True
o False
b) Dementia
o True
o False
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Distinguishing Delirium from Dementia
Delirium
Dementia
Onset
Hrs – days
Months
Fluctuations
Within a day
Within days
Attention
Impaired
Not until Severe
Disorganized thinking
Usually present
Memory Impairment
Level of Consciousness
Often impaired
Not until Severe
Adapted from Rudolph, J.L, Marcantonio, E.R.,
Geriatrics & Aging 2003: 6(10): 14 – 19.
I WATCH DEATH
I - Infections
W - Withdrawal
A – Acute Metabolic
T – Toxins
C – CNS Pathology
H – Hypoxia
D – Deficiencies
E – Endocrine
A – Acute Vascular
T – Trauma
H – Heavy Metals
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
HELP CNS Assessment
Cognitive Assessment
 SMMSE
 Mini-Cog
 Confusion Assessment
Method
 Digit Span Test
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
HELP CNS Assessment
Functional Assessment
 Mobility status
 Fall’s risk
 Continence
 Emotional Health
 Discharge barriers
 Nutritional status
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
HELP Interventions
Mrs. Smith
 Delirium Protocol (suggest to
D/C Lorazepam, Tylenol #3,
Baclofen; routine urinalysis done
on admission )
 Recommend more blood work(
B12, calcium, glucose, lytes)
 Early mobilization Protocol
 Fluid Repletion protocol
 Vision protocol
 Hearing Protocol
 Referrals to OT, PT, SW, RD,
Geriatrician
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
HELP Interventions
Mrs. Smith
 Remove catheter, check for
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voiding
Check for constipation
Regular Pain Assessment
Sleep Enhancement
Protocols
Discharge Planning
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH