Transcript CIRAC - Alzheimer`s Association

“YOU CAN OBSERVE A LOT BY
WATCHING!”
Yogi Berra
CIRAC : The Reasons, the Research, and the Ramping Up
Shirley M. Neitch, MD, FACP
Maier Professor of Clinical Research
Department of Internal Medicine
Chief, Section of Geriatrics
Marshall University/Joan C. Edwards School of Medicine
COGNITIVE IMPAIRMENT RECOGNITION in ACUTE CARE
• Goal: Improving of the care of patients in acute care settings who
have delirium or dementia
• Objectives:
• Define the problem of unrecognized cognitive impairment
• How often it happens
• Why it happens
• Delineate difference between recognition, screening, and diagnosis
• Outline a program of “Universal Observation” to be a part of every
patient encounter
• Empower non-clinical as well as clinical personnel to report
observations: “See something/Say something”™
CIRAC:
WHAT IS COGNITION
• Cognition = thinking, knowing, perceiving
Orientation
Language
Attention
Learning
Memory
Calculation
Abstraction
“Executive” function
Judgment/Insight
Social interaction
COGNITION
• Can be impaired temporarily or permanently by medical illness
• Temporary = delirium
• Medical illness (esp. infection, metabolic disorders), brain injury (trauma, stroke,
etc.), intoxication (alcohol, drugs), withdrawal from intoxicants
• Permanent = dementia
• Degenerative diseases, late effect of infections or deficiencies, structural disorders,
etc.
• Can be impaired in psychiatric illness
CIRAC:
WHY MUST IMPAIRMENT BE RECOGNIZED?
• Delirium:
• Can be caused by very serious, even life-threatening,
problems that can usually be treated and often cured
• Dementia:
• Knowledge of its presence is hugely important for proper
care, transitions of care, and discharge planning
CIRAC:
SURELY WE DON’T MISS COGNITIVE IMPAIRMENT IN
ACUTE CARE?
• 40+% of elderly patients in hospitals have Cognitive
Impairment
• Up to 50% of them have no notation of CI in chart
• Shenkin, et al, Screening for Dementia and Other Causes of Cognitive Impairment in General
Hospital Inpatients. Age Ageing 2014; 43(2):166-168.
• Recent review of discharges from a British hospital:
• Of those > 75yo, 75% had some level of CI, and for 37%, it
was a new dx
• Shermon, et al, Cognitive Assessment of Elderly Inpatients. Dement Geriatr Cogn Disord
Extra 2015; 5: 25-31
MISSING CI IN AC
• 60% of pts > 60 yo had undx’d CI
• Partridge, et al. The prevalence and impact of undiagnosed cognitive impairment in older
vascular surgery patients. J Vasc Surg 2014 Oct; 60(4): 1002-11.
• Hanon, et al. Prevalence of memory disorders in ambulatory patients aged >70 years
with chronic heart failure (from the EFICARE study). Am J Cardiol. 2014 Apr 1;
113(7): 1205-10.
• 291 cardiologists; 912 patients
• Cardiologists suspected memory impairment in 109
persons – 12%.
• All patients tested and memory impairment found in 46%;
severe in 23%.
HOW/WHY IS COGNITIVE IMPAIRMENT MISSED?
• System-caused reasons
• Patient-related reasons
HEALTHCARE SYSTEM REASONS WHY CI MAY BE MISSED
• “Fog is more dangerous than dark, as it gives the illusion
of seeing.”
Aleksandra Ninkovic
• Fog production in healthcare:
• Shortened LOS
• More procedures during a shortened LOS
• Fragmented care teams
• EHR
• Even….architecture and design
HEALTHCARE SYSTEM REASONS WHY COGNITIVE IMPAIRMENT MAY BE MISSED
• Shortened LOS:
Average LOS by age group: 1980 vs 2010
Age
1980
2010
65+
10.7
5.6
75+
11.4
5.7
85+
12.0
5.6
• (All ages – Avg. LOS 4.8 days)
• More procedures during a shortened LOS (Procedures done in 63% of hospitalizations)
Procedure
Increase rate of proc. 1997-2010
Indwelling catheter
213%
Vaccinations
185%
Blood transfusion
126%
Spinal fusion
115%
Paracentesis
99%
I&D skin
97%
Arthroplasty knee
96%
Parenteral nutrition
95%
A-gram or venogram
76%
Hemodialysis
58%
Intubation/Mech. Vent.
57%
HEALTHCARE SYSTEM REASONS WHY COGNITIVE IMPAIRMENT MAY BE MISSED
• Fragmented care teams:
• Old model –
One patient → One attending physician
outpatient doctor), and one nurse per shift.
(who was also the pt’s
• New model –
One patient → One hospitalist, one nocturnalist, several
specialists, resident physician teams, students, PCP by
phone only (if at all), one nurse per shift, one CNA per shift
for VS cks., a pharmacist, and a navigator.
• ~2 ½ days → 2 hospitalists/one gastroenterologist/two general surgeons/one
surgical PA with a PA student/one 4 th year med student/one resident on GI +…
HEALTHCARE SYSTEM REASONS WHY COGNITIVE IMPAIRMENT MAY BE MISSED
• Electronic Health Record
• Carrington, J. and Effken, J. Strengths and limitations of the EHR for documenting
clinical events. Computers, Informatics, and Nursing, June 2011. 29(6):360-367.
• Identified important clinical events which can lead to “failure to rescue”.
Ex: ∆ in MS, hypoxia, drop in H&H. ∆ in MS most common.
• 100% of the nurses reported the EHR was a “barrier” to
communicating the events
• 50% - lack of efficiency
• 31% - lack of relevance of documentation
HEALTHCARE SYSTEM REASONS WHY COGNITIVE IMPAIRMENT MAY BE MISSED
• Other miscellaneous issues
• New hospital design –
• No more roommates = fewer observers per patient
• More isolation from staff
• Restrictions on payment for certain testing as inpatient
• Concentration of clinical efforts on the “Hospital Never”
events
PATIENT-RELATED REASONS WHY CI MAY BE MISSED
• The clinical nature of disorders causing cognitive
impairment
• Delirium
• Dementia
• Delirium-on-dementia
THE CLINICAL NATURE OF DISORDERS CAUSING COGNITIVE IMPAIRMENT TO
BE MISSED: DELIRIUM
• Delirium – Altered mental status which:
• Develops rapidly
• Fluctuates over time
• Need frequently repeated observations!
• Patient looks like:
Agitated
Fearful/paranoid
Psychomotor
activity increased
Picking at things
Hallucinating
May be febrile,
tachypneic, and
tachycardic
Hyperactive
Unusually
subdued
Sleeping
excessively
“Listless”
Weak
VS may be
normal
Hypoactive #1
THE CLINICAL NATURE OF DISORDERS CAUSING COGNITIVE IMPAIRMENT TO BE
MISSED: DEMENTIA
• Dementia – Altered mental status which:
• Develops very slowly (usually years)
• In acute care, you will rarely have a baseline frame of
reference
• May cause pts to be quite non-communicative
• Need medical hx information from family or records
THE CLINICAL NATURE OF DISORDERS CAUSING COGNITIVE IMPAIRMENT TO BE
MISSED: DEMENTIA
• Dementia – Altered mental status which:
• Causes patients to “perform” better at some times than at
others
• Need frequently repeated observations
• Usually allows patients to maintain superficial social
intactness
• Need to specifically “challenge” with standardized
questioning #1
THE CLINICAL NATURE OF DISORDERS CAUSING COGNITIVE IMPAIRMENT TO BE
MISSED: DELIRIUM-ON-DEMENTIA
• Delirium-on-dementia
• Acute illness in persons with dementia can cause delirium
as it can in otherwise cognitively intact persons
• Just as important to identify and treat the delirium
• Missed because of assumption that the altered MS is the
dementia
• Need detailed and specific clinical history of acute
change
COGNITIVE IMPAIRMENT RECOGNITION in ACUTE CARE
• Objectives:
• Delineate difference between recognition, screening, and diagnosis
• Recognition vs Screening vs Diagnosis
• Are there Dementia Care Best Practices to guide
Recognition to Screening to Diagnosis?
BEST PRACTICES – RECOGNITION OF CI
• Alzheimer’s Association - Ten Warning Signs
BEST PRACTICES – RECOGNITION OF CI
• The Hartford Institute for Geriatric Nursing and the Alzheimer’s
Association – “try this: Best Practices in Nursing Care for Hospitalized
Older Adults” (vol.1, #5, 2004)
• Suggests 4 Best Practices:
• Ask the person and family if they have severe memory problems
• Ask if a doctor has ever said they have AD or dementia
- if “no” • Administer family questionnaire
• Record patient behaviors
BEST PRACTICES – RECOGNITION OF CI
National Alzheimer’s Project Act - Jan. 2011
WV Chapter Alzheimer’s
Association
Alzheimer’s Association State Plans program
MAP –Make a Plan for WV - Feb. 2011
[Facilitated by WV PEL]
WV Senate Concurrent
Resolution 38 - 2011 Session
Workgroups
Care Systems
LTC
Education and Training
Feb. 2011
Home & Community Based
Research & QI
Acute Care
MAP Recommendations 1.7 & 1.8
WV Chapter Alz. Assooc.
Benedum Foundation
CIRAC
National Alzheimer’s Project Act - Jan. 2011
WV Chapter
Alzheimer’s
Assoc.
Alzheimer’s Association State Plans program
MAP –Make a Plan for WV - Feb. 2011
[Facilitated by WV PEL]
WV Senate Concurrent
Resolution 38 - 2011 Session
Workgroups
Care Systems
Education and Training
Feb. 2011
Research & QI
Care Systems
LTC
Education and Training
Home & Community Based
Research & QI
Acute Care
MAP Recommendations 1.7 & 1.8
WV Chapter Alz. Assooc.
Benedum Foundation
CIRAC
BEST PRACTICES – RECOGNITION OF CI
• Literature search:
• Almost all articles, regardless of title, referred to screening and diagnosis,
not recognition
• 200+ references describing screening tools
• Mass screening is not recommended for the general public nor for any specific
demographic group.
• A couple of on-going projects identified; no published results available
• Listening sessions:
• Acute care staff
• Families
BEST PRACTICES – RECOGNITION OF CI
• Listening sessions:
• Acute care staff say they know when CI is present “most of the time”,
but say they hear “in report” or otherwise verbally, not found
documented in chart
• Staff often do not proceed to document themselves
• Families consistently report that patients are not approached as if
they have any CI.
• Questioning may border on harassment
• Instructions not tailored
• Observation insufficient, especially when transported off their floor
COGNITIVE IMPAIRMENT RECOGNITION in ACUTE CARE
• There is much literature about screening for and/or diagnosing CI.
However, an error (the failure to recognize) is often made before
the screening step is reached. Evidence of cognitive lapses must be
recognized before screening/diagnosing can be done.
In the current inpatient climate, speedy diagnosis and treatment of acute
problems takes precedence over comprehensiveness of care. Subtle signs
of cognitive change may never recognized as problematic.
Delineate the difference between Recognition, Screening,
and Diagnosis – Specifics of CIRAC
• Recognition
• CIRAC
• Screening
• MMSE, MoCA, Mini-Cog, CAM, etc.
• Diagnosis
• History and Physical, Imaging, Lab tests, Additional
memory tests, ….
THE CIRAC PROGRAM
• “Light is good from whatever lamp it shines.”
~Author Unknown
• Therefore , first cornerstone principle for CIRAC is
“Universal Observations”
UNIVERSAL OBSERVATIONS
• Taken directly from the “Universal Precautions” concept,
defined by US Department of Labor/OSHA as :
Universal Precautions is an approach to infection control.
According to the concept of Universal Precautions, all human
blood and certain human body fluids are treated as if known to
be infectious for HIV, HBV, and other blood borne pathogens.
(Blood borne Pathogens Standard 29 CFR 1910.1030(b)
UNIVERSAL OBSERVATIONS
• Universal Observations is an approach to recognition of
cognitive impairment.
• According to the concept of Universal Observations, all
patients should be looked upon, by all staff, as being at risk
for, and possibly having, cognitive impairment.
UNIVERSAL OBSERVATIONS
• ALL Hospital/Acute Care staff members observe patients.
• Registration, nursing, laboratory and radiology,
housekeeping, security, dietary…
• Behaviors and appearances possibly indicative of CI are
reported to clinical staff who can follow up.
• If you See Something, Say Something.
“RED FLAGS”
• What should trigger a report to a clinical staff member?
• Some abnormal behaviors are fairly obvious:
• Patient has fallen
• Pt. is screaming or crying
• Pt. throws something at a staff member
• Pt. cannot be awakened
• Pt. acts paranoid, is having hallucinations, talks “out of
their head”
“RED FLAGS”
• Some behaviors are equally important but not as obvious:
• Pt. described as “Poor Historian”
• Pt. is given food tray but makes no attempt to eat,
especially if more than one meal
• Repeatedly fails to follow instructions or answer questions
• Appears “bewildered”
• Unexpectedly wets or soils bed
• Becomes extremely agitated over a small matter
• Others
SEE SOMETHING/SAY SOMETHING
• See something / say something means:
• You (whomever you are) see something (a red flag
behavior), and you say something (verbal or written)
to a clinical person who knows the patient (a
nurse, midlevel provider, doctor)
• No one has to do a screening test, such as MMSE or MoCA,
except a clinical person who knows the patient, and then
only if needed for an individual patient
• No one has to make a diagnosis except the doctor
SEE SOMETHING/SAY SOMETHING
• See something / say something does NOT:
• Label the patient
• Cause a diagnosis to be entered in the chart
• But it should:
• Lead to further inquiry
• And if pt. confirmed as cognitively impaired, can allow them
to be identified.
• Identification leads to allowing pt’s status to be known to
others and evaluation as needed
SEE SOMETHING/SAY SOMETHING
• Reporting to nursing staff
• Verbal is acceptable, especially nurse-to-nurse
• Other staff to nurse – written observation
• Notebooks provided
NEXT STEP
• Communication of patient’s Cognitive Impairment to
others in the Acute Care setting
COMMUNICATION OF CI STATUS
• Confirm it:
• See something/say something leads to clinician recognition
of CI
• Chart it:
• Nurse/clinical provider documents CI and/or a diagnosis in
patient’s chart
• Convey the information:
• Identify patient to others in the Acute Care setting
COMMUNICATION OF STATUS
• Identifying the impaired patient to others in Acute Care
• Symbolized by something which must be recognizable to all
staff, but non- stigmatizing
• Not easily recognizable to non-staff
• Armband or armband attachment
• Individual
• Always with patient
WHAT CAN A CIRAC PROGRAM ACCOMPLISH?
WHAT CIRAC CAN ACCOMPLISH
• Diminished patient agitation
• Proper approach to cognitively impaired person is crucia l
• More appropriate testing
• Delirious patient may not tolerate, and demented patients
sometimes should not have, certain tests
• Better diagnostic decisions
• Irritability may be due to delirium, not to being a mean old
woman!
• Patients adequately nourished and hydrated
WHAT CIRAC CAN ACCOMPLISH
• More appropriate treatment (of the primary condition and the
CI)
• Patients with dementia may not be candidates for certain
treatments regimens
• Delirium must be seen to be treated
• Improved patient and family satisfaction
• More attention to individuals – POSITIVE!
• Improved discharge planning and fewer readmissions
• Accommodations made for cognitive impairment = better
med adherence, better f/u, better home care, etc.!
SUMMARY:
CIRAC
• “Fog is more dangerous than dark, as it gives the illusion
of seeing.”
• We miss CI in far too many patients
• “You can Observe a Lot by Watching!”
• Universal Observations
• “Light is good from whatever lamp it shines.”
• See Something/Say Something
SUMMARY: CIRAC
• Universal Observations →
• See Something/Say Something →
• Cognitive Impairment recognized when present →
• Improved patient care →
• Improved outcomes