Download 48-6 practice statement: cognitive functioning

48-6 PRACTICE STATEMENT: COGNITIVE FUNCTIONING
If, through the initial 48/6 screen, the senior (or a close family member or friend on their
behalf) reports or demonstrates any recent cognitive changes, the following practice statement
has been developed to help the care team assess and manage this aspect of care.
PURPOSE OF THIS PRACTICE STATEMENT:
 To support the senior to maintain optimal level of cognitive functioning through the
effective use of care strategies which promote functional independence, including the
senior with mild to moderate dementia.
 To prevent adverse conditions/events in hospital that create or exacerbate the onset of
delirium.
 To prevent, detect and manage delirium, both within hospital and at points of transitional
care, through:
o the early identification of common risk factors (social, environmental, etc.);
o planned targeted interventions;
o consistent monitoring and surveillance of client status (“Delirium Watch”); and
o evaluating the effectiveness of targeted interventions.
WHY COGNITIVE FUNCTIONING IS IMPORTANT TO SENIORS’ HEALTH:
By the time a person is 85 years old the probability of their having dementia is 30% – 40%, with
the majority of these people able to remain in their own home until well-advanced stages. The
prevalence of dementia is even higher amongst the residential care population.
The cognitively-impaired senior will demonstrate better outcomes when they are included in
decision-making by health care staff who anticipate and can mitigate the risks posed for the
senior being in the acute care environment. As well, health care professionals should adapt
their usual communication style and pace to ensure that with any level of cognitive impairment,
the senior will understand the care they are receiving.
Delirium is a medical emergency.
Any confused hospitalized senior should be assumed delirious until proven otherwise.
Delirium is under-recognized and preventable, and can develop in seniors with and without
prior cognitive loss. Approximately 10% of seniors come to the ED with delirium as part of their
symptoms and 14%-56% of seniors develop delirium while in hospital. Poor cognitive
functioning is related to poorer hospital outcomes and contributes to a deterioration in the
other 48/6 care areas.
Common precipitating factors that may impact cognition include: infection, medications, pain,
dehydration, immobility, constipation, urinary retention, sleep deprivation, vision and hearing
impairment, depression, dementia and sudden changes in environment, including
hospitalization.
While delirium is the most common form of cognitive impairment bringing seniors to hospital,
other forms of cognitive impairment should be considered: dementia, the impact of depression,
or some combination of all three.
RELEVANT GUIDELINES:
Existing Guideline and Protocols Advisory Committee (GPAC) and Health Authority clinical
practice guidelines, practice standards and policies pertinent to your regulated discipline (e.g.,
Delirium, Falls Prevention, Least Restraint, and appropriate Medication Protocols (e.g.,
antipsychotics), etc.).
TARGETED ASSESSMENTS INCLUDE:
 Assess baseline level of pre-hospital cognitive status.
 Assess the change between pre-hospital status and current cognitive status, including the
timeline of changes to differentiate between dementia, delirium or depression, or
combination.
 Selection and use of a valid and reliable cognitive screening tool for cognitive change:
 For delirium:
o Confusion Assessment Method (CAM)
o Pain/Retention-Restraints/Infection-Illness-Immobility/Sleep-SkinSensory/Mental Status-Medications-Metabolic/Environment (PRISME)
 For depression: Cornell Geriatric Depression Scale
 For dementia: standardized Mini Mental Status Examination (sMMSE)
 Assess family member’s willingness and/or ability to participate in delirium screening and
interventions.
 Support the senior’s safety by proactively managing their physical and social environments
to meet their assessed individual needs.
RECOMMENDED INTERVENTIONS, DEPENDENT ON THE RESULTS OF THE ASSESSMENT,
INCLUDING BUT NOT LIMITED TO:
Provider/Patient Level:
 Prevent delirium in hospital by early identification of the senior’s specific risk factors
(dementia, medication changes, dehydration, severe illness, vision impairment, and
environmental factors such as lighting and noise) and intervene to modify those risk factors
and monitor effectiveness of interventions.
 Screen for delirium on admission and minimum of once daily or as per local protocols, and
contact the primary physician immediately to seek rapid treatment for all seniors who
screen positive or with possible/probable delirium.
 If screened positive, further assess the client for underlying predisposing and precipitating
factors as possible causes of delirium and address reversible causes in the care plan.
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Communicate cognitive changes and their timelines through appropriate referrals to the
inter-professional health care team.
Educate and involve patient, family, and/or caregiver(s) in management of delirium.
Include management of the underlying precipitating causes of delirium (i.e. constipation,
malnutrition, dehydration, indwelling urinary catheter, polypharmacy, pain or elevated
glucose) in an individualized plan of care to which the interdisciplinary team can contribute.
Use non-pharmacological and environmental strategies as a first line of intervention to
address responsive behaviours for both delirium and dementia.
System-Level:
 Educate staff re: prevention of delirium, screening tools for cognitive impairment, early
identification of delirium, understanding of dementia and the effectiveness of interventions
for delirium.
 Develop a culture of avoiding the use of restraints (restraints contribute to agitation and
increase safety risks).
 Establish a timely communication process between hospital and the receiving community
care setting/service for the transfer of information contained within the care plan and the
discharge and/or transition plan to relay concerns the senior continues to experience in this
care area post-discharge.
REFERENCES:
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012).American
Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults. JAGS, 60:616–631.
Fick, D.M. & Semla, T.P. (2012). 2012 American Geriatrics Society Beers Criteria: New Year, New
Criteria, New Perspective. JAGS, 60,614–615.
British Columbia’s Provincial Dementia Action Plan (currently in press as at June 27, 2012)
Canadian Coalition for Seniors Mental Health: National Guidelines and practice support
documentation for each of delirium, depression and dementia, 2006.
British Columbia’s Dementia Services Framework (2007) unpublished.
American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders,
4th Edition. Retrieved 17 August 2012 at: http://www.dsmiv.net/
GPAC Guideline:
 Cognitive Impairment in the Elderly - Recognition, Diagnosis and Management
Resnick, B. & Pacala, J.T. (2012). 2012 Beers Criteria. JAGS, 60, 612–613.