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CNS ROLE APPLICATION ELDER LIFE CNS ROLE –SPHERES OF CARE INFLUENCE Patient level – comprehensive geriatric assessment, protocol driven, follow up assessment and interventions, education for patients and families Staff level – coaching and education on delirium prevention and functional decline; participation in care rounds System level – program operation, quality assurance, identification of care gaps and interventions HELP NURSING PROTOCOLS Targeted Risk Factor Approach using protocols Evaluation of Cognitive Status • Delirium Protocol • Dementia Protocol • Psychoactive Medications Protocol Sleep Enhancement Protocol Early Mobilization Protocol MORE HELP NURSING PROTOCOLS Hearing Protocol Fluid Repletion Protocol Discharge Planning Protocol Optimizing Length of Stay Protocol Additional Areas – EXAMPLE: DELIRIUM PROTOCOL Assessment establishes baseline, cognitive tool plus CAM and collateral history psychoactive medications and ETOH use bloodwork then daily- structured cognitive tool plus the CAM and ongoing staff, family and volunteer inputs IF PATIENT CHANGES SUDDENLY …. Review medication list for potentially contributory medications or potentially harmful interactions Search for occult infection, e.g., urinary tract infection (UTI) Rule out drug or alcohol withdrawal Support referrals to geriatrics, pharmacy, internal medicine MORE DELIRIUM INTERVENTIONS Non-Pharmacological Management Education for staff, involve family Strategies to decrease agitation and improve sleep Communication techniques AT HHS, THE HELP NURSE ……. Follows HELP delirium protocols Structured cognitive assessment is not carried out daily but on admission and as indicated No discharge sMMSE is completed 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 AT HHS…… 2005 ADHERENCE 68%-best for orientation, vision and hearing , therapeutic activities and feeding protocol 34% -lowest for mobility and sleep protocol WHAT FACTORS AFFECT ADHERENCE? ARE THEY MODIFIABLE? COGNITIVE SCREENING INSTRUMENTS Instrument Admin time Comments Sweet 16 3-5 mins Published Nov 2010on HELP website Mini-Cog 3-5 min Brief , validated Short portable status questionnaire 3-5 minutes Brief 3MS 10-15 mins MMSE plus remote memory, verbal fluency and abstraction sMMSE/Folstein 10-15 Copyright requires authors permissionper use fee with Folstein Montreal Cognitive Assessment (MoCA) 10-20 minutes Open access- THE SWEET 16 PURPOSE: screening tool for cognitive impairment Why another tool? Length, burden ,copyright ADVANTAGES : simple, rapid, paperless, validated against the MMSE, open access CONSTRAINTS : early days of testing Fong,T. Arch Intern Med. 2010 Nov 8 CASE STUDY MRS. SMITH IS A 91 YEARS OLD LADY ADMITTED FROM R.H. WITH LOW BACK PAIN HISTORY OF PRESENTING ILLNESS Sudden increase in low back pain 3 days ago; unable to walk, new onset of urinary incontinence. GP started Lorazepam 1 mg Q HS 5 days ago for poor sleep. Confusion over 48 hours –disoriented to time, not consistently recognizing family PAST MEDICAL HISTORY Hypothyroidism Dyslipidemia Hearing loss Macular degeneration Hypertension ?TIA Arthritis Chronic Low Back Pain Degenerative Disc Disease, Scoliosis SOCIAL HISTORY Widowed, 3 children, 9 grandchildren Retired teacher – grade school and ESL Enjoys listening to music, attending socials and visiting with families BASELINE FUNCTION Walks with walker independently to D/R 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 INVESTIGATIONS CT scan: no obvious fracture except for possibly a displaced right transverse process fracture of L3 Labs Lab Findings Normal Range urea 11.2 Creat 115 TSH 18 WBC 13,3 Hgb 130 MEDICATIONS 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