Advocating for the Cognitively Impaired Older Adult with Traumatic Injuries

Suzanne Purvis, DNP, RN, GCNS-BCClinical Nurse Specialist, Geriatrics

University of Wisconsin Hospital and Clinics

Objectives

We will be discussing today:

• Role of the trauma nurse with the cognitively impaired

• Importance of an observational pain assessment tool for older adults with dementia

• Importance of sleep assessments in older adults with traumatic injuries

Nurses as Advocates

• Help older adults formulate their goals, and help to achieve them, especially with those with a cognitive impairment.

• Ensure that patients receive the care and education they need to avoid future traumatic injuries.

• Speak for vulnerable older adults who can’t speak for themselves, or do not understand the health care system

Geriatric Trauma Nurses

• You cannot advocate for those you do not understand

• All trauma nurses need to know the basics of geriatrics

• Dementia and delirium require specialized knowledge & skills

• Nurses are important advocates with older adults with cognitive impairments

Older Adults and Trauma:Focus on Cognitive Impairment

• Cognitive impairment: - Dementia - Delirium

- Traumatic brain Injury - Alcohol withdrawal

• Age related changes & Polypharmacy create extra challenges in caring for this population

Explaining Cognition to Families/Caregivers: Dementia/Delirium/Normal Aging

With normal cognitive aging, the current thought is that neurons do not die in large numbers, but there are decreases in synaptic function*****

Hippocampus & Early Alzheimer’s Dementia

Decreased neurons in the hippocampus leading to shrinkage

Dementia Capable Wisconsin*

• In 2010, it was estimated that 119,900 persons had dementia.

• By 2035, that number is expected to increase by 68% to 201,600.

• Because the chances of developing a dementia are one in three at age 85, it is anticipated that there will be a shortage of family caregivers

https://www.dhs.wisconsin.gov/dementia/demographics.htm

Symptoms of Dementia that Affect the Hospital Experience

• Can’t remember where they are, how they got there

• May not be able to understand or express pain, yet be restless, and moaning

• May forget they are ill, and weak, and keep trying to get out of bed on their own.

• Decreased ability to monitor their mood states, fear of losing control can cause a ‘catastrophic’ reaction

Preexisting Dementia Issues In Older Adults with Traumatic Injuries that can Result in Catastrophic

Reactions

• Identifying individuals with dementia who arrive alone!

• Lack of early access to resources can lead to accidents/falls

• Transfer trauma occurs when moved to unfamiliar hospital

• Challenges in assessing pain can increase delirium

• Safety issues: Difficulty following instructions, pulling at lines, neck collars, etc.

• Critical medications are sometimes withheld on admission

Nurses Advocating for Patients with Dementia

• Does the Plan of Care clearly state that the patient has dementia, so everyone entering the room knows?

- mild cognitive impairment - memory loss - altered mental status

• Is a family member/caregiver with them?

• Do you know the individuals baseline cognitive status?

Evidence Based Care: Baseline Functioning

• Questions to ask:

- problems with memory?

- recent change in behavior or activities?

- look for changes in their ability to perform activities of daily living

- assess for BPSD (Behavioral & Psychological Symptoms of Dementia)

BPSD on the Plan of Care?

• Wandering/elopement

• Hallucinations

• Anxiety

• Repetitive talking or movements

• Disrupted sleep/wake cycles

• Depression, loss of appetite, lethargy

• Aggression/paranoia

Steps to take: Any Change/worsening of Mental Status

• Go back and check medications that are being held: Especially: Pain, anxiety, antipsychotics

• Look on patient’s problem list for painful conditions!

• Investigate PRNs they have been taking and how much.

• If NPO due to trauma, patient in a neck collar, etc.

• Older spines with arthritic changes

Communicating with Older Adults with Dementia

• Remember, you may be a stranger no matter how many times they have seen you today.

• Be reassuring

• Protect the cognitively impaired patient from any tension/anxiety around them.

• Watch for signs of pain, rising anxiety, get medications early

• Avoid Elderspeak: Do not talk to older adults like they are children.

Remember, It is hard to advocate for someone you don’t know!

“Things to Know About Me” document

• Relatives• Pets• Interests• Food preferences• Hobbies• Likes/dislikes• Important considerations

Assessing Pain in the Cognitively Impaired

• Difficulties identifying and/or expressing pain

• Observational scales known to be valid - PAINAD - Checklist of Non-Verbal Pain Indicators (CNPI)

• Assess pain based on: - what patient tells you - physical expressions of pain like restlessness - and note the presence of a painful condition

Checklist of Non-Verbal Pain Indicators

Observe the patient for the following behaviors both at rest and during movement. • 1. Vocal complaints: nonverbal • 2. Facial Grimaces/Winces • 3. Bracing • 4. Restlessness • 5. Rubbing • 6. Vocal complaints: verbal

• Sources:Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nur 2000 Mar;1(1):13-21.

Checklist of NonVerbal Pain Indicators (CNPI) Audit by Geriatric & Pain Resource Nurses

• Audited 34 older adults with dementia & 34 without dementia (N = 68)

• Assessed their pain level with appropriate pain tool (numerical/mild-mod/CNPI)

• Evaluated use of pain tools throughout patients hospitalization, to see which ones were used, and did them seem appropriate to assess the patient’s pain level?

Older Adults age 60 and older with Dementia: Pain Scale Currently in use Reflects Current Level of Pain

Numeric CNPI Mild-Mod0

2

4

6

8

10

12

14

16

7

14

3

8

1 1

YesNo

CNPI Most accurate in

this population

CNPI QI Project: Goal: Increase Appropriate use of the CNPI

• September Pain Awareness Month

• Weekly puzzles (crossword,fill in the blank)

• Article on the CNPI distributed by email & in nurses’ break rooms

• Prizes

• Post-Audit

Geriatric Trauma & Delirium

• Delirium is common in elderly patients after injury and is associated with increased morbidity and mortality.

• Recent studies (Ely, http://www.icudelirium.org/) demonstrate long term cognitive impairments after delirium

• It is important to assess the patient’s baseline cognitive function, assess risk factors for delirium, and monitor for signs and symptoms of delirium every shift

Risk Factors for Delirium

• Use of benzodiazepines

• Prior episodes of delirium

• Positive blood alcohol level

• Current infection

• Increased age

• Preexisting cognitive impairment

Length of Stay in Delirium

FY '11 FY'12 FY'13 FY'14LOS by Fiscal Year for older adults age 65 and older

0

2

4

6

8

10

12

14

5.5 5.3 5.5 5.3

6.86.4

6.8

5.5

12.3

11.3

12.8

10.9

> age 65

> age 65 w/dx dementia*

> age 65 w/dx delirium

Delirium as a Complication of Trauma

Assess for: • Change in baseline• Waxing• Decreased attention• Disorganized thinking

• Confusion Assessment Method (CAM & CAM-ICU)

Assessing Attention

• Reverse-order months of the year

• Spell world backward

• Digit span (3-7-2) then add one (3-7-2-5)

• Normal digit span is 6 + 1 (5 in the elderly)

# Month1 January

2 February

3 March

4 April

5 May

6 June

7 July

8 August

9 September

10 October

11 November

12 December

Sleep Initiatives to Reduce Delirium

• Sleep habits & patterns important!!

• Keep awake during day

• Ambulate

• Sound reduction

Sleep & Delirium

• Studies show that prevention of sleep deprivation can prevent, slow or improve delirium and its consequences

• Sleep deprivation research (Weinhouse, 2009) has revealed many similarities clinically with delirium. These are characterized by poor thought processing, attention and memory deficits, and fluctuating mental status

Alcohol Withdrawal delirium and Older Adults

• Very little research on alcohol withdrawal in older adults

• Vital signs: In Older Adults, vital signs may not change until late….

• Alcohol withdrawal may switch to delirium after window of time for withdrawal is past

Antipsychotics & Dementia

• FDA warning: all antipsychotic medications carry a black box warning regarding their use in patients with psychotic symptoms related to dementia.

• 17 trials in patients with dementia related psychosis taking atypical antipsychotics

• risk of death in drug-treated patients between 1.6 to 1.7 times the risk of death in placebo-treated pts.

Resources to Help at the Bedside

• Nursing guidelines on caring for older adults with pain & delirium & dementia

• ‘Things to Know About Me’ (who are you advocating for?)

• Identify cognitively impaired, especially those that arrive alone

• Regular sleep and pain assessments

References

• American College of Surgeons ( 2013 ) Geriatric Trauma Management Guidelines, https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/geriatric%20guide%20tqip.ashx

• Bjoro K, Herr K. (2008). Assessment of pain in the nonverbal or cognitively impaired older adult. Clinical Geriatric Medicine, 24, 237-262.

• Grimm, D & Mion, L (2011). Falls resulting in traumatic injury among older adults. AACN Advanced Critical Care, 22 (2)m 161-168.

• Cutugno, CL (2011). The ‘Graying’ of trauma care: Addressing traumatice injury in older adults. American Journal of Nursing, 111 (11), 40-48.

• Horgas AL. Assessing pain in persons with dementia. In: Boltz M, series ed. Try This: Best Practices in Nursing Care for Hospitalized Older Adults with Dementia. 2003 Fall;1(2). The Hartford Institute for Geriatric Nursing. www.hartfordign.org

• Weinhouse, G.L., Schwab, R., Watson, P., Patil, N., Vaccaro, B., Pandharipande, P., Ely, E.W. (2009). Bench to bedside review: Delirium in ICU patients-importance of sleep deprivation, Critical Care, 13 (234).

References

• Resnick, B. (2011). Geriatric Trauma and the Impact of Nursing Care. Geriatric Nursing, 32 (4), 235-237.

• Bonne, S. & Schuerer, D. (2013). Trauma in the Older Adult: Epidemiology and Evolving Geriatric Trauma Principles. Clinics in Geriatric Medicine, 29, 137-150.

• Cognitive Assessment. Alzheimer’s Association. http://www.alz.org/