CHHS18/204 Canberra Hospital and Health Services Clinical Procedure Cognitive Impairment (CI) Contents Contents..................................................... 1 Purpose...................................................... 3 Scope........................................................ 3 Section 1 – Screening for Cognitive Impairment...............3 Why is screening for Cognitive Impairment required?........3 Who needs to be screened for Cognitive Impairment?.........3 When should screening for Cognitive Impairment occur?......4 Which screening for Cognitive Impairment tools can be used? 4 Where to document the screening for Cognitive Impairment tools?.....................................................4 Section 2 – Use of the Cognitive Impairment Identifier.......5 Section 3 – Patients with CI Require Further Assessment......6 Nursing assessment required................................6 Nutritional assessment required............................7 Occupational therapy assessment required...................7 Pharmacy assessment required...............................7 Social work assessment required............................7 Section 4 – Care Planning and Management of Patients with CI. 8 Section 5 – Patients with CI on Discharge....................8 Implementation............................................... 9 Related Policies, Procedures, Guidelines and Legislation.....9 References.................................................. 10 Definition of Terms.........................................10 Doc Number Version Issued Review Date Area Responsible Page CHHS18/204 1.0 12/07/2018 01/06/2020 RACC 1 of 27 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript
CHHS18/204
Canberra Hospital and Health ServicesClinical Procedure Cognitive Impairment (CI)Contents
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Attachment 5: Management of CI.....................................................................................17
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Purpose
The purpose of this procedure is to: Provide direction to all clinical staff to improve the safety of patients, through early
recognition, adequate assessment and appropriate management of CI, and Establish a consistent approach to the planning and delivery of care for patients with CI
that is in accordance with Australian best practice guidelines.
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Scope
This procedure applies to all ACT Health staff providing care or support to adult patients aged 65 years or more (45 years or more for Aboriginal and Torres Strait Islander peoples 6) who are admitted to the Canberra Hospital.
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Section 1 – Screening for Cognitive Impairment
Why is screening for Cognitive Impairment required? Patients with CI (delirium or dementia) are at a significantly higher risk of adverse events and preventable complications. Falls, pressure injuries, accelerated functional decline, prolonged hospital stay, premature entry to residential care and death are potentially preventable complications. Despite being a common condition amongst patients, CI is commonly undiagnosed, under-reported and inadequately managed in hospital settings.
Screening for CI assists in early identification and appropriate management of conditions like delirium and dementia. This could potentially reduce the risk of complications and improve health care outcomes for patients during hospital admission.
Note:Screening provides a baseline of the patient’s cognitive function and identifies patients at a greater risk of complications. It does not provide a diagnosis of dementia or delirium, which requires further assessment, in patients screened positive for CI.
Who needs to be screened for Cognitive Impairment? ACT Health staff must screen every patient admitted to Canberra Hospital and is aged 65 years or more, (45 years or more in Aboriginal and Torres Strait Islander peoples) for CI as part of the Patient Care and Accountability Plan (PCAP). The screening for CI process is illustrated in Attachment 1.
Patients with a known cognitive impairment (e.g. diagnosis of dementia) should still be screened to obtain an objective assessment of their current cognitive function. This will assist in identification of any fluctuations and potentially reversible conditions like delirium.
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When should screening for Cognitive Impairment occur?ACT Health staff should complete screening for CI when a patient is being admitted to hospital. The assessment may be deferred until the tests can be attempted at a time when the patient is more stable and/or responsive, but it is recommended that this is done within 24 hours of admission.
Appropriate clinical reasoning must apply to the decision of when to attempt the screening tests. Consideration is needed for patients who are: Medically unstable Unresponsive Non-verbal In the terminal phase of a life limiting illness Visually or physically impaired and unable to complete the screening for CI.
Note: The cognition section of the PCAP must not be left blank and the reason for non-completion must be recorded on both the PCAP and medical record (including pre-existing diagnosis of CI). Document any future plan for screening. This information should be handed over to the next shift.
Which screening for Cognitive Impairment tools can be used?ACT Health staff are to screen for CI using two validated tools: the 4 Item Abbreviated Mental Test (AMT4) and the Clock Drawing Test (CDT).
The screening requires both tests to be completed. Please see Attachment 2 for details.
If there has been CI identified using the screening tools, it is important to contact patient’s family or carer/s; general practitioner (GP); or current service providers e.g. residential aged care facilities or home care providers, to obtain information about the patient’s baseline level of functioning. This should be then documented in the patient's clinical record. Where to document the screening for Cognitive Impairment tools?The results of the screening assessments must be documented on the PCAP, and in the patient’s clinical record. A numeric score is recorded for the AMT4 test. A notation of “Yes” or “No” is required to indicate whether the CDT was completed correctly.
Further medical assessment should be undertaken to determine the cause (delirium, dementia etc.) of the CI. Please see Attachment 3.
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Section 2 – Use of the Cognitive Impairment Identifier
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For patients screening positive for CI a Cognitive Impairment Identifier (CII) must be placed at the patient’s bedside, as shown below, to facilitate appropriate care for patients with CI wherever possible:
The CII sign and symbol are copyright material of Ballarat Health Services.
Patients who screen positive for CI using the AMT4 (scores less than 4) and/or CDT (incorrect clock face), and/or who have an existing diagnosis of delirium/dementia / CI must have the CII placed above the bed and documented in the patient’s clinical record.
The staff member placing the CII must offer information/education about the CII to the patient and family/carers by providing the Cognitive Impairment Identifier – Information for Patients, Families and Carers consumer handout, found on the policy register, when appropriate.
If the patient or family/carers request removal of the CII, this must be documented in the patient’s medical notes.
A patient with a CII bedside sign will have the following patient carer engagement strategies utilised: Introduction of staff at every contact. Maintenance of eye contact while communicating at all times (if culturally appropriate). Calm approach and the use of simple factual explanations. Involvement of family and/or carers. The use of short and simple sentences when speaking to the patient. The patient will be given only one instruction at a time. The patient will be given time to respond. The information will be repeated as needed (staff members are not to assume they have
been understood). The patient will be a given one choice at a time.
These strategies are relevant to all staff who interact with the patient and family, including support staff e.g. Wards Persons, Hospital Assistants, Ward Clerks, Food Services and Cleaning staff.
A stock of CIIs is maintained in a nominated place on each ward.
Please ask the Clinical Nurse Consultant or Clinical Development Nurse where they are located on wards.
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The CII must be removed, cleaned and returned to the nominated storage area when the patient is reassessed as having no cognitive impairment, transferred to another ward or discharged from hospital. If transferred to another ward detailed handover is to be provided and reassessment of cognition is to be attended by the admitting ward.
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Section 3 – Patients with CI Require Further Assessment
Increased risk of Delirium Patients with CI are at increased risk of delirium. However, patients without CI may also be at risk of delirium, and this risk must also be assessed.
The key risk factors for delirium are: Age ≥ 65 years (≥ 45 years for Aboriginal and Torres Strait Islander peoples 3,6) Known cognitive impairment/dementia Severe medical illness or at the end phase of a life limiting disease Current hip fracture.
Patients who screen positive for CI and those at high risk of delirium as listed above must be further assessed for delirium from a multidisciplinary approach.
Medical Assessment requiredThe Confusion Assessment Method (CAM) is a validated tool used to determine whether a patient’s CI is due to delirium. ACT Health medical staff must use the CAM Delirium Screen Clinical Forms accessible from the Clinical Records Form Register (please see Attachment 4 for sample). The CAM should be undertaken in conjunction with clinical assessment of the patient. Attachment 3 provides further medical background information in relation to factors likely to precipitate delirium, potential causes and further assessments and investigations which may need to be considered, where clinically appropriate.
Nursing assessment requiredAs per the Patient Care and Accountability Plan (PCAP), for patients with CI, ACT Health nursing staff must regularly assess patients with CI, with special emphasis on assessment of: Pain Supportive aids used (visual, mobility and hearing) Orientation cues (may need to seek information from carers/family if available) Need for assistance with eating Need for 1 on 1 nursing care. Risk of falls and pressure injury
Physiotherapy assessment requiredThe following must be considered within 24 hours: Mobility Pain
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Nutritional assessment requiredThe following must be considered within 24 hours: Nutritional status Need for nutritional supplements.
Occupational therapy assessment requiredThe following must be considered within 24 hours: Premorbid and current functional status. Need for assistive equipment
Pharmacy assessment requiredThe following must be considered within 24 hours: Current medications contributing to delirium New medications contributing to delirium Potential medication interactions Any adverse effects of medication prescribed to manage behaviours secondary to
delirium.
Social work assessment required The following must be considered within 24 hours: Patient and family counselling Patient and family education Existence of Enduring Power of Attorney and/or Advance Care Plan.
Ongoing Assessment requiredThe patient’s cognitive function must be appropriately monitored during the admission and any change in cognition assessed further.
Cognition screening and delirium risk assessment should be repeated as clinically indicated or if there are changes in the patient’s condition, either an improvement or deterioration in cognitive status.
Patients who have screened positive for CI where delirium has not been identified must have the cause of CI investigated further to determine the cause (including mental health issues) and appropriate management strategies instituted.
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Section 4 – Care Planning and Management of Patients with CI
Management of patients with CI/delirium is the responsibility of the treating team. Where possible, patients with CI must be offered a set of interventions to treat the identified underlying causes.
An individualised and integrated prevention and management plan should be developed in partnership with the patient and family/carers. This plan should consider non-pharmacological and pharmacological management strategies as detailed in Attachment 5 where clinically appropriate.
The plan must be communicated to the multidisciplinary team and documented in the patient’s clinical record. The patient’s cognitive function must be appropriately monitored during the admission.
ReferralsReferral to the Aged Care Nurse Practitioner for assessment and management is recommended for elderly patients with an episode of delirium in hospital. Referral can be made by any member of the MDT team. Contact can be made via switch or a Fax can be sent to the geriatric outpatient’s clinic Fax No 61745600.
Referral to Geriatric Medicine is appropriate only for older patient’s ≥ 80 years of age when there are significant behavioural and psychological symptoms that cannot be managed by the treating team.
Note:All staff have a role to play in the care of patients with cognitive impairment. Non-clinical support staff can make an important contribution to the patient’s care through an awareness of CI, good communication skills, and understanding of non-medical strategies for the management of behavioural and psychological symptoms.
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Section 5 – Patients with CI on Discharge
The identification of CI and any episodes of delirium during hospital admission must be documented in the patient’s discharge summary and a recommendation provided to the GP regarding further monitoring of cognitive state.
If on discharge, the patient continues to meet criteria suggestive of CI (not delirium) and this CI has not previously been diagnosed, likelihood of dementia needs to be considered. This should be documented in the discharge summary and recommendation made to the GP regarding further investigation, and/or referral to a geriatrician for follow up, after discharge, should be considered.
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Implementation
Information contained in this document will be disseminated to staff via educational forums, workshops, and e-learning.
This document will be available to all staff on the policy register.
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Related Policies, Procedures, Guidelines and Legislation
Policies Consent and Treatment Restraint of a Person – Adults Only Clinical Records Management
Procedures Falls Prevention and Management Increased Patient Care Supervision Advanced Care Planning Language Services Interpreters Policy and Procedure
National Guidelines A better way to care: Safe and high-quality care for patients with cognitive impairment
(dementia and delirium) in hospital, Australian Commission on Safety and Quality in Health Care, 2014.
Delirium Clinical Care Standard, Australian Commission on Safety and Quality in Health Care, 2016.
Clinical Practice Guidelines and Principles of Care for People with Dementia, Cognitive Decline Partnership Centre, 2016.
Legislation Human Rights Act (2004) Patient Health and Safety Act (2003) Health Act 1993 Health Records (Privacy and Access) Act 1997 Mental Health Act 2015
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2. Agrell, B and Dehlin, O. The clock-drawing test. Age and Ageing. 1998; 27: 399-4033. Australian Commission for Safety and Quality in Health Care. Delirium Clinical Care
Standard. 2016.4. Australian Commission for Safety and Quality in Health Care. Caring for Cognitive
Impairment http://cognitivecare.gov.au 2014 5. Bellelli G, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a
study in 234 hospitalised older people. Age Ageing. 2014 Mar 14. [Epub ahead of print]6. Care of Confused Hospitalised Older Persons (CHOPS), NSW Health
http://www.aci.health.nsw.gov.au/chops 2015 7. Clinical Epidemiology and Health Service Evaluation Unit. Clinical Practice Guidelines for
the Management of Delirium in Older People. Melbourne: Victorian Government Department of Human Services on behalf of AHMAC; 2006. http://docs.health.vic.gov.au/docs/doc/A9F4D074829CD75ACA25785200120044/$FILE/delirium-cpg.pdf
8. Dementia Care in Hospitals Program, Ballarat Health Service. https://www.bhs.org.au/node/130 2017
9. Inouye S, Westendorp R, Saczynski J. Delirium in elderly people. The Lancet. 2014; 383(9920):911-22.
10. Inouye S. The Short Confusion Assessment Method (Short CAM): Training Manual and Coding Guide. 2014; Boston: Hospital Elder Life Program.
11. National Institute for Health and Clinical Excellence. Delirium: diagnosis, prevention and management; Clinical Guideline 103. London: NICE, 2010.
12. Shulman, K. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry. 2000 Jun; 15(6):548-61.
13. Schofield I, Stott DJ, Tolson D, McFadyen A, Monaghan J, Nelson D. Screening for cognitive impairment in older people attending accident and emergency using the 4-item Abbreviated Mental Test. Eur J Emerg Med. 2010 Dec; 17(6):340-2.
14. World Health Organization Dementia Fact Sheet http://www.who.int/mediacentre/factsheets/fs362/en/ 2017
15. Therapeutic Guidelines. Treatment of Benzodiazepine Poisoning 2015. https://tgldcdp.tg.org.au/viewTopic?topicfile=toxicology-benzodiazepines&guidelineName=Toxicology%20and%20Wilderness#toc_d1e100 Accessed on 12 July 2018.
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Definition of Terms
Cognitive Impairment: An umbrella term for difficulties in memory and thinking, which may include, but is not limited to dementia and delirium.
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Dementia: A syndrome –usually of a chronic or progressive nature in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing. It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected.
Delirium: An acute change in mental status that is common among older patients in hospital. Delirium is characterised by a disturbance of consciousness, attention, cognition and perception that develops over a short period of time (usually hours to a few days). Patients with delirium may be agitated and restless (hyperactive delirium), quiet and withdrawn (hypoactive delirium), or move between these two subtypes (mixed delirium).
Inpatient: Any person, client or consumer admitted to Canberra Hospital for at least 24 hours or overnight.
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Search Terms
Cognition, Cognitive Impairment, Delirium, Dementia, CI
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Attachments
Attachment 1: Pathway for Management of Cognitive Impairment Attachment 2: Screening tools for CI and their interpretations.Attachment 3: Medical assessment of CI Medical assessment of CI Attachment 4: Confusion Assessment Method (CAM) Attachment 5: Management of CI
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 16 May 18 New Document Paul Dugdale, ED RACC CHHS Policy Committee
This document supersedes the following: Document Number Document Name
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Attachment 1: Pathway for Management of Cognitive Impairment
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Attachment 2: Screening tools for CI and their interpretations.
The AMT4 consists of the following 4 questions:
1. What is your age?2. What is your date of birth?3. Can you tell me where you are? Or: What is the name of this place?4. Can you tell me what year it is?
A numeric score of 1 is recorded for each correct answer.
A score of less than 4 on AMT4 is considered positive screen for CI.
To perform the CDT, the patient is given the following verbal instructions: I want you to draw a clock face showing the time of 10 minutes past five o’clock. Draw the outline of a clock face. Put in all the numbers. Set the hands at ten past five.
The specific time of 10 minutes past five o’clock must be used. The time must be expressed to the patient as “10 minutes past five o’clock”, not “5:10”. The instructions may be repeated but the patient must not be prompted.
Interpreters for patients from culturally and linguistically diverse backgrounds must be offered in accordance with the Language Services Interpreters policy and procedure, found on the policy register. Patients must be offered their reading glasses and/or hearing aids, if they normally use these aids, before attempting the assessment. Patients who are unable to use their dominant hand can still attempt the CDT, as it is an assessment of cognition and not coordination or drawing ability. Patients under contact precautions can complete the CDT using a separate piece of paper, with the result (correct/incorrect) noted by ticking the appropriate box on the PCAP.
A correct CDT has all of the following features: A reasonable circle All numbers included and well distributed Both hands are well drawn, different lengths and placed on the correct numbers
An incorrect clock face is considered a positive screen for CI
(Ref: Agrell, B and Dehlin, O. Age and Ageing. 1998; 27: 399-403)
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Attachment 3: Medical assessment of CI Medical assessment of CI
Factors likely to precipitate delirium should be identified. These include: Mechanical restraint Under nutrition and/or dehydration Polypharmacy and adding more than three new medications during hospitalisation Indwelling catheters An iatrogenic event (such as surgery, a procedure, infection, complication). Symptom instability e.g. pain
Potential Causes of Delirium:The following possible aetiologies must be considered: Sepsis Medications Constipation Urinary retention Electrolyte imbalance Intracerebral event Hypoxia/Hypercapnia Hyperglycaemia/Hypoglycaemia/Ketosis Intoxication/Withdrawal Other.
Further assessment: Medication review (particularly of opioids, benzodiazepines, antipsychotics) Clinical examination to rule out infections, urinary retention, constipation etc. Identify triggers likely to precipitate delirium/ agitation (loud noise, bright light, lack of
sleep, changes in physical environment, poor symptom management e.g pain) Changes in behaviour should be recorded in the Behaviour Chart – geriatric (35150). If patient is agitated, Agitation Scale – geriatric (35151), should be used to record and
monitor the extent of agitation.
Investigations:The following investigations must be considered, where clinically appropriate: Full blood count (FBC), electrolytes urea and creatinine (EUC), liver function test (LFT),
Calcium Phosphate Magnesium , C-reactive protein (CRP), blood glucose level (BGL), blood cultures, thyroid function test (TFT)
Urine analysis via Multistix urinalysis test strip and Midstream urine culture Bladder scan Chest x-ray (Posterior anterior and lateral) Abdominal x-ray (if suspected faecal loading / obstruction) Electrocardiogram (ECG) Arterial blood gas/venous blood gas (if suspected hypercapnia) Computed tomography (CT) brain – if focal neurology or head injury or on anticoagulants Electroencephalography (EEG) – if seizures a possibility
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Lumbar puncture – if need to exclude Central Nervous System infection and other specific diagnoses.
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Attachment 4: Confusion Assessment Method (CAM)
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Sample
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Attachment 5: Management of CI
Alert:All staff have a role to play in the care of patients with cognitive impairment. Non-clinical support staff can make an important contribution to the patient’s care through awareness of CI, good communication skills, and understanding of non-medical strategies for the management of behavioural and psychological symptoms.
The management plan must be communicated to the multidisciplinary team and documented in the patient clinical record. The patient’s cognitive function must be appropriately monitored during the admission.
Non- Pharmacological interventionsAn individualised and integrated prevention and management plan should be developed in partnership with the patient and family/carers.
The following interventions should be considered to minimise delirium: Ensure wearing of glasses or hearing aids as needed Reorientation and reassurance strategies Encourage participation in activities of daily living Normalise sleep patterns Ensure and monitor adequate hydration and nutrition intake Bowel and bladder management to minimize complications. Remove catheters and cannulas, if not needed Address risk of harm from falls and pressure injuries Reduce medication but ensure adequate, appropriate pain relief Ensure continuity of care (familiar staff), if possible
Supportive strategies/ interventions: Good communication with patient, family/carer/s and multidisciplinary team Family/carer/s involvement where appropriate Education and support for the patient, family and carer/s Assess need for increase in care and/or supervision
Pharmacological Management: Pharmacological management with an antipsychotic medication is considered only if a patient with CI is severely distressed or there is an immediate risk of harm to the patient or others.
Medications are prescribed only if non-pharmacological strategies have failed to manage the cause of the patient’s behaviour and ease their symptoms.
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Alert:Haloperidol or Risperidone must not be used in patients with Parkinson’s disease or Lewy Body Dementia.
For agitated patients:1. Haloperidol 0.25 – 0.5mg oral/subcutaneous (up to 1mg)
If needed, repeat in 2-4 hours (Max 3mg/24 hours)(Not if Parkinsonism or Lewy Body Dementia is present)
OR2. Risperidone 0.25 – 0.5mg oral
Max 2mg/ 24hr(Not if Parkinsonism or Lewy Body Dementia is present).
OR3. Quetiapine 12.5 – 25mg oral (If Parkinsonism or Lewy Body Dementia present)
If needed, repeat 4 hourly (Max 100mg/24hr)
4. Midazolam 1mg subcutaneous (for excessive agitation)Monitor response and give additional dose, if required (Maximum 5mg/24 hours)
5. If no response with above, seek Geriatric/ Psychiatric input. If potentially close to dying seek specialist palliative care input.
Alert:When administering midazolam in the elderly additional monitoring for respiratory depression is required. This often presents as decreased respiratory rate. Monitor the patient’s respiratory rate more frequently and act according to the Vital Signs and Early Warning Scores Procedure.
Alert:Management of patients with CI/delirium is the responsibility of the treating team. Referral to Geriatric Medicine is appropriate only for older patient’s ≥ 80 years of age when there are significant behavioural and psychological symptoms that cannot be managed by the treating team.
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