Transcript Cognitive screening Instruments

The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
HELP Project Planning Tool
In this section think about….
 Will you start with some or all of the HELP
interventions?
 What HELP interventions will your system find most
challenging?
 What strategies will you use to support their
introduction?
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
ELS & CNS Protocols
RISK FACTORS
ELS PROTOCOL
NURSING PROTOCOL
Cognitive Impairment
Daily Visitor
/Orientation/
Therapeutic Activities
Delirium/Dementia/
Psychoactive Medications
Sleep Deprivation
Sleep Enhancement
Sleep Enhancement
Immobility
Early Mobilization
Early Mobilization
Vision Impairment
Vision
Same
Hearing Impairment
Hearing
Same
Dehydration
Meal Assistance/ Fluid
Repletion
Fluid Repletion Protocol
Orientation/Daily
Visitor/Therapeutic Activities
 Criteria- all patients are enrolled
 Intervention-Orient 1 time per day if SMMSE >20, orient 3 times
per day if SMMSE <20
-Explore patient’s interests and possible
therapeutic activities
-Discuss current events, structured reminiscence,
word games
(Inouye et al. N. Engl. J. Med. 1999, March 4 340 (9): 669-676)
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Delirium Protocol
 Assessment methods: pt. interview, chart review,
interview with nursing staff and families, reports from
volunteers, CAM assessment
• Interventions: medication review, occult infection,
drug/alcohol withdrawal; occult illness; nonpharmacological management; optimal environment,
behavioral management techniques, family
involvement, delirium order sets, referrals
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
More Delirium Interventions
Non-Pharmacological Management
 Education for staff, involve family
 Optimal environment
 Strategies to decrease agitation and
improve sleep
 Communication techniques
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Dementia Protocol
• Baseline cognitive status
• Baseline screening information (social
situation/caregiving needs/ADLs/IADLs/ nutrition,
sleep)
• Interventions (medical workup, effective behavioral
management strategies, nursing education, avoiding
psychoactive medications)
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Psychoactive Medication Protocol
 Past and current medication use
 Screening for medications associated with delirium
 Anticholinergic Cognitive Burden scale
 Nursing staff education
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Healthy Vision/Healthy Hearing
Vision
Criteria- if near vision in both eyes <20/70
Intervention
- Eyeglasses clean and on
- Magnifying glass
Hearing
Criteria-<3 whispers from each ear on whisper
test
Intervention
-Hearing aids in and turned on
-Consider use of hearing amplifier
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Healthy Eating/Fluid Repletion
Criteria-appetite rated as poor
InterventionAssist with set-up of meals
Encourage food intake
Ensure regular mouth care
Assist with menu completion
Criteria-clinical evidence of
dehydration and
Urea X10/Creatinine> 0.7
Intervention- Encourage fluids
if not contraindicated
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Fluid Repletion Protocol
 Assessment: criter; risk factors, postural hypotension
 Interventions: patient/family education re: fluid
intake and postural hypotension; collaboration with
nursing and medical staff; direction for volunteers,
patient preference ; collaboration with physician if
symptoms persist
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Poor Appetite
Further assessment by CNS:
 Physical appearance
 Weight loss
 Weight loss etiology
 Weight loss markers
CNS’ Interventions:
 Referrals to RD, OT, MD
 Communication with nursing staff
 Communication with families
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Early Mobilization
 Criteria- all patients assessed for early
mobilization
 Intervention-
ELS/CNS consults with Physiotherapist
to determine appropriate mobilization
protocol:
 Active range of motion exercises 3
times per day
 Supervised walking 3 times per day
according to PT guidelines
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Early Mobilization –CNS role
 Assessment: patient’s self-report of functional
abilities, direct mobility assessment, physician order,
hospital staff assessment, pain and pain management
assessment
 Intervention: referral to Physiotherapist/OT,
patient/family education,
staff education (deconditioning,
falls prevention)
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Sleep Enhancement
 Criteria- difficulty falling asleep or sleeps poorly at home or in hospital
 Intervention
 Avoid sleeping pills
 Instead:




Back rub/ hand rub (if not contraindicated)
Warm blanket
Warm drink such as herbal tea or warm milk
Soft music
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
Sleep protocol –CNS role
 Risk factors
 Medication
 Patient/family education on sleep hygiene practices:
Increase physical activity during the day
Avoid naps
Limit caffeine, nicotine intake
Have light snack before going to bed
No TV before going to bed
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
At HHS, the HELP nurse …….
 Follows HELP delirium protocols
 Structured cognitive assessment is not carried out
daily but on admission and as indicated
 SMMSE is not done prior to discharge
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
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
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
At HHS…… Start Up Adherence
68%-best for orientation, vision and
hearing , therapeutic activities and
feeding protocol
34% -lowest for mobility and sleep
protocol
Followed up with more training
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
What factors affect adherence?
Are they modifiable?
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH
HELP Project Planning Tool
 Will you start with some or all of the HELP
interventions?
 What HELP interventions will your system find most
challenging?
 What strategies will you use to support their
introduction?
The Hospital Elder Life Program © 2000, Sharon
K. Inouye, MD, MPH