After reading this article, the learner will be able to:
1. Differentiate between dementia and delirium, and understand appropriate screening tools for cognitive impairment.
2. Gain knowledge in nonpharmacologic interventions to manage challenging behaviors in cognitively impaired older adults in the acute care setting.
3. Understand how to manage safety in the confused older adult while providing restraint-free care.
Dementia is defined as a chronic change in memory and thinking sufficient to interfere with daily functioning. Delirium is an acute confusional state that includes inattention and global cognitive dysfunction. Bedside nurses commonly encounter hospitalized older adults with cognitive impairment, and in 29% to 64% of these patients, delirium is present.1 Delirium is particularly prevalent among patients with preexisting cognitive impairment.2
In contrast to dementia, delirium is diagnosed based on clinical findings that include an acute onset and fluctuating course of symptoms; inattention; impaired level of consciousness; and alteration in cognition.3 Symptoms are often classified into hypoactive, hyperactive or mixed types.4 The hypoactive variant is most common in older adults, yet it is commonly missed by clinicians.4 The hyperactive patient may be clearly recognized as confused and in need of additional nursing time, while the patient with hypoactive delirium may be "easier" to care for, yet is just as clinically concerning. Patients with delirium may also exhibit features such as delusions, hallucinations, change in sleep-wake cycle, inappropriate behavior, or emotional lability.3
In addition to underlying dementia, known nonmodifiable risk factors for delirium in hospitalized patients include age older than 65, history of neurologic disease, multiple comorbidities including chronic renal or hepatic disease, and male sex.4 Delirium has repercussions on patient outcomes, including increased risk for falls, functional decline, long-term institutionalization and future development of dementia.1,5
Dementia is not a diagnosis but rather a descriptive term to explain a progressive change in memory and thinking sufficient to interfere with social and/or occupational functioning. Dementia is common and is the leading cause of dependence and disability in older adults.6 More than 70 known causes of dementia have been identified; the most common is Alzheimer's disease (AD), which affects 5 million Americans.7 In the acute care setting, dementia is often underestimated and underdiagnosed,8 so it is not uncommon for nurses to encounter patients with cognitive impairment who do not have a formal diagnosis in the medical record. This phenomenon further reinforces the important role of the nurse in gathering baseline cognitive information from families and caregivers, understanding and defining whether the patient exhibits an acute change from baseline, and using this information to provide individualized interventions to manage cognitive and behavioral phenomena.
Behavioral and psychological symptoms of dementia (BPSD) are common and encompass many features: agitation, motor behavior, anxiety, irritability, depression, apathy, disinhibition, appetite changes, sleep-wake disturbance, delusions, and hallucinations. Over the course of a dementing illness, BPSD occur in 90% of patients and can create a significant level of burden for patients, caregivers and nurses at the bedside.9
Multiple causes for BPSD may be present in hospitalized older adults, such as pain or discomfort; inability to verbalize unmet needs; environmental disturbances; impaired nutrition and hydration; medication side effects; sleep deprivation, and use of tethering devices to assure that medical care is provided. It can be difficult for nurses to balance safety concerns with management of acute medical concerns. Additionally, the hospital environment is focused on disease management and set to be efficient for healthcare providers-but not ideal for confused older adults.
Screening for Cognitive Impairment
Given the significant increased risk of older adults developing delirium while hospitalized, particularly when underlying dementia is present, it is critical that nurses understand how to assess for delirium and dementia. Multidimensional cognitive assessment has been recognized as a metric to measure high-quality care of older hospitalized patients. Utilizing screening tools to assess for cognitive impairment early in the admission process can help identify patients at risk for developing delirium and allow for the implementation of appropriate preventive interventions.10 It is critical for nurses to identify delirium because in older adults, it is often a symptom of a serious underlying disease.
Screening Tools for Delirium
The most well-known delirium assessment tool is the Confusion Assessment Method (CAM).11 The CAM includes four criteria: 1. acute onset and fluctuating course; 2. inattention; 3. disorganized thinking; and 4. altered level of consciousness. Delirium can be diagnosed with the presence of features 1 and 2 and either 3 or 4. The CAM is widely known and validated. It is relatively easy to use, can be completed in less than 5 minutes, and is available in at least 12 languages.5
Associated with the CAM is the Family Confusion Assessment Method (FAM-CAM), which utilizes reports from families and caregivers to identify delirium symptoms.12 The CAM-ICU was designed for delirium diagnosis in critically ill ICU patients13and patients who are nonverbal mechanically ventilated.
A two-item delirium screen in hospitalized older adults has been proposed: naming the months of the year in reverse order (one error allowed for scoring) and orientation to the day of the week. These two questions have been associated with a greater than 90 % sensitivity for delirium.14
The Delirium-O-Meter (DOM) was developed by nurses as a 12-item rating scale to measure the severity of hypoactive and hyperactive delirium. Twelve items are assessed using a severity scale of 0 to 3, with features including sustained attention; shifting attention; orientation; consciousness; apathy; hypokinetic/psychomotor retardation; incoherence; fluctuations in functioning; restlessness; delusions; hallucinations; and anxiety/fear. It is not a screening test, but it can still be useful to help differentiate among patients with and without delirium (score greater than 5 correctly classified 92.9% of delirium).15 An advantage of the DOM is that it is completed via direct observation by the nursing staff member providing care to the patient and can easily be done on each shift or at more frequent intervals.15
Screening Tools for Dementia
Multiple screening tools for dementia exist, but a clear consensus on the best option in the hospitalized older adults does not. Clinicians often familiarize themselves with one or two options and utilize them depending on the patient's level of cognitive impairment, educational attainment and the availability of an informant.
The Mini-Cog includes three steps: three-word registration; clock drawing task with hands of the clock at 11:10; and recall of the three words. Scoring is out of 5 points (0-3 points for word recall, and 0 or 2 points for clock). A score of less than 3/5 has been validated for dementia screening, but a score of less than 4 may also indicate a need for more investigation into cognitive abilities.16
The Montreal Cognitive Assessment (MoCA) is a longer and more detailed test. It is helpful for better characterization of performance across multiple cognitive domains and in detecting mild cognitive impairment (i.e., cognitive impairment not sufficient to interfere with functioning). It takes approximately 10 minutes to complete, and it includes verbal and written sections. Administering the MoCA requires training. The instruction manual is available on mocatest.org.17
Cognitive screening tests can be performance-based (e.g., Mini-Cog and MoCA) or informant-based, such as the 8-item Interview to Differentiate Aging and Dementia (AD8). The benefit of an informant-based screening tool is that information can be collected from a reliable source, which can be helpful if a patient is unwilling or unable to participate in cognitive screening. The AD8 was designed to distinguish between normal aging and mild dementia by assessing for intra-individual change. Informants answer eight questions. A score of 2 or greater suggests cognitive impairment is likely. The AD8 takes only 3 minutes to complete and is available in multiple languages. The AD8 can be combined with other tools such as the Mini-Cog and MoCA to increase the likelihood of finding early cognitive changes.18
Thorough screening for dementia and delirium requires consideration of all potential causes:
Alcohol abuse. Alcohol abuse is often underreported and misdiagnosed in older adults, and screening tools are geared toward a younger population.19 Older adults may present with alcohol use disorders and other geriatric syndromes, such as falls, confusion or depression. Consideration of the signs and symptoms associated with alcohol withdrawal are particularly critical to evaluate in hospitalized older adults, and standardized scales are available. These include the Clinical Institute Withdrawal Assessment of Alcohol Scale.20 During the admission history, the patient and/or family should be asked about other substance use that can contribute to delirium, such as nicotine, cocaine, benzodiazepines, narcotics or other illicit drugs.21
Pain. Pain is a known risk factor for delirium and is often the cause of agitation in cognitively impaired older adults. Pain may be under- or overtreated in the hospital, particularly after hip fracture repair.22 Pain treatment for older adults should start with the lowest effective dose of medication,23 generally non-narcotic options. Consideration should be given to standing doses for cognitively impaired older adults who cannot request PRN medications. Older adults with dementia who may not be verbally able to respond to pain assessment questions should have their pain evaluated using observation tools such as the Pain Assessment in Advanced Dementia Scale.24
Medication Assessment and Review. Medication review and reconciliation should be performed at admission and include recent medication changes and OTC or herbal medications. Nurses can collaborate with pharmacy colleagues to consider the anticholinergic burden of medications and/or drug-drug interactions that may be causing symptoms as well as direct drug side effects. For every anticholinergic medication a patient takes, his or her risk of developing cognitive impairment may increase by 46% over 6 years.25 Nurses can refer to sources such as the Beers criteria26 to identify potentially inappropriate medications for older adults.
Nurses spend the most time with hospitalized patients and as such provide critically important information about changes in cognition and behavior that might be indicative of delirium or worsening of baseline cognitive function. Any changes in the patient should be communicated across shifts and in team reporting. The overall management of older adults with cognitive impairment requires input from families and caregivers as well as the multidisciplinary team.
Communicating with older adults with cognitive impairment should be clear. Directions and instructions should be provided in simple one-step commands. A patient who is aggressive can have a need for personal space that is four times greater than the average person; thus it is best to avoid touch or crowding.27 In situations when the patient is aggressive and agitated, it is helpful to assure that he or she is safe and then to provide some time alone to allow the aggression to dissipate.
Certain nursing interventions may worsen BPSD or hyperactive delirium, such as trying to convince the patient that a delusion (i.e., "a nurse stole my walker") is untrue. Instead, try to distract and redirect the patient by using techniques such as telling him or her that the physical therapist found another walker and "now you can go for a walk." When the patient is agitated by medical interventions and tethering (e.g., pulse oximetry), work with the healthcare team to evaluate whether discontinuation is possible.
Evaluate the patient for a simple solution to his or behavior. For example, restless behavior may be due to a treatable symptom such as constipation, hunger, pain or urinary retention. Obtain history from families or caregivers about home routines to follow a similar pattern to the extent possible. Explore the situation from the patient's perspective. Is the environment too loud and noisy? Has the patient missed meals because he or she has gone from test to test? Anticipate periods in which it is likely that patients with confusion will become agitated, such as shift change and high unit activity periods. Utilize whiteboards, familiar objects from home, or calendars for reorientation. Ensure sensory impairments are optimized by assuring that the patient has access to dentures, glasses and/or hearing aids.
Sleep-wake disturbance is often a highly disturbing symptom in patients with cognitive impairment, and it is magnified by reduced staffing and less senior staff overnight. Pharmacologic interventions for sleep should be avoided, including benzodiazepines, antihistamines or antispasmodics. Benzodiazepines can worsen delirium and increase the risk of cognitive impairment, falls and fractures.26 Nonpharmacologic interventions for sleep should include encouraging physical activity during waking hours; establishing a routine for bedtime (i.e., oral care, toileting and dimming or turning off lights); encouraging time out of bed during the day; managing pain; and eliminating noise to the extent possible.
Physically restraining a patient is not an effective fall prevention intervention.28 Furthermore, restraints are associated with deconditioning, pressure ulcers, agitation, confusion, and even death.28 Specific alternatives to restraint use in the acute care setting should be individualized to the patient. Bed/chair alarms can be considered with assessment to ensure the noise of the alarm does not worsen agitation and does not limit mobility. However, some evidence suggests bed alarms increase the risk of developing delirium and may not reduce the risk of restraint use or improve clinical outcomes.29 Visualization of the patient with cognitive impairment is critical, and it may be helpful to work with family, caregivers, hospital staff and volunteers to have constant observation of the patient.
Another way to facilitate patient safety, particularly when resources are limited, is grouping patients with similar symptoms when possible and placing patients who are impulsive and/or agitated near the main nursing station.30 Pod nursing is another option.30 In pod nursing, the workflow encourages teamwork and allows nurses to be close to their patient assignment.30 Environmental changes may also be helpful, such as lowering the bed closer to the floor; assuring that clear pathways exist in the patient's room and hallway; appropriate safety bars in the bathroom; and raised toilet seats if needed.
Models to Improve Management
The Hospital Elder Life Program (HELP) incorporates an evidenced-based approach to manage delirium risk factors such as orientation, early mobilization, therapeutic activities, hydration, nutrition, sleep, and hearing and vision adaptations. HELP utilizes a multidisciplinary team and trained volunteers to provide interventions to address delirium risk factors. It has prevented delirium and functional decline, therefore providing cost savings.31
NICHE (Nurses Improving Care for Health system Elders) is available in more than 680 hospitals and healthcare facilities and includes a geriatric resource nurse model (GRN) to help transition geriatric evidence-based knowledge into practice.32 GRNs serve as geriatric experts on their respective nursing units and help address geriatric syndromes. NICHE provides hospitals with e-learning tools and training resources, project management, and other clinical resources.
Hospital-based models such as the Acute Care for Elders (ACE) include geriatric units or adaptations of the model on regular hospital units to promote mobility and activities of daily living (ADL) independence and reduce hospital associated complications in older adults. ACE includes protocols to manage syndromes such as delirium, and provides interdisciplinary rounds and discharge planning. Acute geriatric unit care can be effective in reducing falls, delirium and functional decline while also impacting length of hospital stay, improving discharges to home rather than nursing home, and with cost reductions.33
A Senior-Friendly Hospital (SFH) framework has been used in Canadian hospitals. It incorporates organizational support, processes of care, emotional and behavioral environment, ethics, and the physical environment to provide better hospital care to older adults. A health system in Canada evaluated hospitals across its system based on this framework and noted decreased incidences of delirium and less functional decline when the SFH toolkit was implemented.34
Higher Level of Care
Nurses can provide a higher level of care when armed with tools to assess for, and respond to, cognitive impairment. Nurses are uniquely positioned to serve as champions in eliminating potentially harmful interventions such as restraint use and inappropriate use of antipsychotic medication. Nonpharmacologic interventions for challenging behaviors can be difficult to implement in the fast-paced acute care setting, yet are crucial to ensuring improved patient outcomes.
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Yael Zweig is an adult and gerontologic primary care nurse practitioner who practices in the geriatric consultation service at New York University Langone Medical Center in New York City.