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Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person
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Acute-care nursing of patients with cognitive impairment: Managing agitated behaviours in the confused older person

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Frederick Graham, CNC Dementia & Delirium, Princess Alexandra Hospital delivered this presentation at the 2012 Hip Fracture Management conference in Australia. The only regional event to discuss …

Frederick Graham, CNC Dementia & Delirium, Princess Alexandra Hospital delivered this presentation at the 2012 Hip Fracture Management conference in Australia. The only regional event to discuss practical innovations and improvement processes for the management of hip fractures in the hospital setting. For more information on the annual conference, please visit the website: http://bit.ly/14lcuVY

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  • 1. Improving acute-care for people with cognitive impairment Fred Graham CNC 02/11/2012
  • 2. I am not an orthopaedic or surgical Nurse!!! – sorry… • Differentiating delirium from dementia helps determine type of care approach • Introduce a methodology for assessing pain in hospitalised people with cognitive impairment (tools & process) • Special environment with a focus model of care (PAH – HCR our experience)
  • 3. Cognitive Impairment in Acute Care • Delirium – acute confusional state – sepsis, metabolic conditions, brain trauma, • Dementia – Alzheimer’s, Vascular, Fronto-temporal, Parkinson’s, Dementia with Lewy Bodies, Korssakoff’s and Alcohol-related • Delirium superimposed on dementia (DsD) • Intellectual impairment • Brain injury • Dementia or delirium superimposed on a psychiatric condition • Mild Cognitive Impairment (MCI) - pre-dementia
  • 4. Care is often seen as difficult & challenging • High risk behaviours - restlessness, agitation, elopement, removing indwelling devices, aggressiveness & falls • Adverse events causing injury to self or others • Risk of staff frustration, burnout & helplessness, negative attitudes toward patients with impairment
  • 5. Current management • Specials (AIN 1:1) • Psychotropic medication/sedation • Physical restraint • Falls Rooms (AIN with group of pts) • Do these reduce agitation? • Only if they deliver therapeutic care
  • 6. Literature suggests • Specials not used well – The therapeutic opportunities afforded by 1:1 care are not taken1 • Knowledge deficits about delirium, dementia and delirium superimposed on dementia2 • Few models of care tested in acute-care3 • Overuse of antipsychotics 1st line behavioural management (risk of stroke, delirium, EPSE)4 1. Moyle et al (2010) Acute care management of older people with dementia: a qualitative perpspective. Journal of Critical Care Nursing, 20, 420-428 2. Fick, D. M., Hodo, D. M., Lawrence, F., & Inouye, S. K. (2007). Recognizing delirium superimposed on dementia. Journal of Gerontological Nursing, 33(2), 40-47. 3. Moyle et al (2008) Best practice for the management of older people with dementia in the acute acre setting: a review of the literature. International Journal of Older People Nursing, 3(2), 121-130 4. Banerjee, S. (2009) The Use of Antipsychotic Medication for People with Dementia: Time for Action (pp 63) United Kingdom: UK Department of Health (DH)
  • 7. Cognitive impairment - ‘core’ business • 60-70% of all hospital patients are older people (chronic illnesses) 1 • Older people - high risk of delirium (10-15 admitted, 5-40% developed) 2 • Dementia increases risk of delirium (22-89% superimposed) 3 • Dementia increasing (289,000 now to 900,000 by 2050), 4 • Poor outcomes – falls, malnutrition, functional decline, incontinence 5 • Up 6 x LOS than people without cognitive impairment 4 1. Tadd et al (2011) Right place – wrong person: dignity in the acute care of older people. Quality in Ageing & Older Adults, 12(1), 33-43 2. Tropea et al (2008) Clinical practice guidelines for the management of delirium in older people in Australia. Australasian Journal on Ageing, 27(3) 150- 156 3. Fick, D. M., Agostini, J.V., & Inouye (2002) Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 50(10), 1723-1732 4. Australian Institute of Health and Welfare. (2012). Dementia in Australia (Vol. Cat. no. AGE 70). Canberra: AIHW. 5. Naylor et al (2007) Care coordination for cognitively impaired older adults and their caregivers, Home Health care Services Quarterly 26(4), 57-78
  • 8. Orthopaedic Context - fractured hip • Incidence of delirium 40.5% - 55.9% over 60yrs 1,2 • Dementia is a risk factor for delirium in hip fracture3 with reports of up to 66% of patient DsD 4 • Prevalence of dementia in hip fracture is common 19.3%,5 while others report as high as 30-50% of all fractures 6 1. Santana Santos, F., et al (2005). Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures. Dementia and Geriatric Cognitive Disorders, 20(4), 231-237. 2. Galanakis, P., et al. (2001). Acute confusional state in the elderly following hip surgery: incidence, risk factors and complications. [Article]. International Journal of Geriatric Psychiatry, 16(4), 349-355. 3. Juliebø, V., et al. (2009). Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. Journal of the American Geriatrics Society, 57(8), 1354-1361. 4. Marcantonio et al (2001) Reducing deliium after hip farcture: A randomized trial. JAG 49, 516-522 5. Seitz, D. P., Adunuri, N., Gill, S. S., & Rochon, P. A. (2011). Prevalence of Dementia and Cognitive Impairment Among Older Adults With Hip Fractures. Journal of the American Medical Directors Association, 12(8), 556-564. 6. Sttenvall, M., et al (2012). A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia-- subgroup analyses of a randomized controlled trial. Archives Of Gerontology And Geriatrics, 54(3), e284-e289.
  • 9. Cognitive impairment in orthopaedics • Poor staff knowledge of delirium 1 • Presence of Behavioural agitation and symptoms 2 • Poor staff knowledge of dementia3,4 – How well are nurses skilled to manage BPSD? 1. Meako, M. E Thompson, H.J., & Cochrane, B.B (2011) Orthopaedic nurses’ knowledge of delirium in older hospitalised patients. Orthopaedic Nursing, 30(4), 241-248 2. McGilton, K., et al. (2007). Rehabilitating patients with dementia who have had a hip fracture: part II: cognitive symptoms that influence care. Topics in Geriatric Rehabilitation, 23(2), 174-182. 3. Borbasi, S., Jones, J., Lockwood, C., & Emden, C. (2006). Health Professionals' Perspectives of Providing Care to People with Dementia in the Acute Setting: Toward Better Practice. Geriatric Nursing, 27(5), 300-308. 4. Eriksson, C., & Saveman, B. (2002). Nurses' experiences of abusive/non-abusive caring for demented patients in acute care settings. Scandinavian Journal of Caring Sciences, 16(1), 79-85
  • 10. Behavioural disturbances from two differing conditions or mixture of these • Delirium • Dementia • Delirium superimposed on dementia
  • 11. What is delirium? • Acute confusional state with alterations in sleep-wake cycles and psychomotor behaviour appearing as hyper- alert or hypo-alert • Develops rapidly (hrs to days) and usually resolves within a relatively short time (days or sometimes months) • Tendency toward visual hallucination/misperception and nocturnal exacerbation • Characterised by reduced ability to maintain attention often leading to disoriented and disorganised thinking
  • 12. Feature Delirium Dementia Onset Acute, often at night Insidious Course Fluctuating, with lucid intervals during the day; worse at night Stable over the course of the day Duration Hours to weeks Months to years Awareness Reduced Clear Alertness Abnormally low or high Usually normal Attention Impaired, causing distractibility; fluctuation over the course of the day Relatively unaffected; impaired in DLB and vascular dementia Orientation Usually impaired for time; tendency to mistake unfamiliar places and persons Impaired in later stages Short-term (working) memory Always impaired Normal in early stages Episodic memory Impaired Impaired Thinking Disorganised; delusional Impoverished Perception Illusions and hallucinations, usually visual and common Absent in earlier stages, common later; common in DLB Speech Incoherent, hesitant, slow or rapid Difficulty in word finding Sleep-wake cycle Always disrupted Usually normal John R Hodges (2007), Cognitive Assessment for Clinicians pp.54
  • 13. CAM – Confusion Assessment Method 1. Acute onset and fluctuating course 2. Inattention 3. Disorganised thinking 4. Altered level of consciousness +ve screen = 1 + 2 and 3 or 4 Semi-formal interview with Mini-Cog + digit span Inouye S.K. et al (1990) Clarifying confusion: The Confusion assessment method. Anew method for detection of delirium. Ann. Intern. Med 113, 941-8
  • 14. Risk Factors for Delirium in Hospital (medical and nursing care may modify these) Precipitating insults Severe medical illness Metabolic disturbances especially from abnormal sodium, dehydration, constipation Exposure to pethidine Exposure to benzodiazepine Exposure to narcotic analgesics preoperatively Addition of ≥ 3 medications during hospitalisation Withdrawal syndromes Intoxication with alcohol or illicit drugs Infections Anaemia Head trauma & focal brain lesions Pain & discomfort Sleep deprivation Use of physical restraint Use of indwelling catheters Emotional stress and unfamiliar surroundings Pre-disposing vulnerability Age ≥ 70 years Pre-existing cognitive impairment including dementia Pre-existing neurological disorders (e.g. Parkinson’s disease) Depression History of delirium Sensory deficits – e.g. visual or hearing impairment Immobility Pre-existing drug treatments/ dependencies such as benzodiazepines Alcohol-related health concerns Chronic sleep deprivation/disorders (≤ 4 hours per night)
  • 15. Source: adapted from – Clinical practice guidelines for the management of delirium in older people. 2006. http://www.health.vic.gov.au/acute-agedcare/. High level of vulnerability Low level of insult Moderate to high risk of developing delirium High level of vulnerability High Level of insult Very high risk of developing delirium Low level of vulnerability Low level of insult Low risk of developing delirium Low level of vulnerability High level of insult Moderate to high risk of developing delirium Level of Vulnerability Low Level of Insult High High The interrelationship between patient vulnerability and precipitating insult
  • 16. Delirium management priorities • Eliminate or treat underlying cause (precipitating factor) • Intervene to reduce or modify the effect of predisposing factors 1 • Attempt to settle distressful symptoms for the patient • Optimise patient safety (environment and staffing) 1. Inouye, S. K., et al (1999). A Multicomponent Interventin to Prevent Delirium in Hospitalised Older Patients. The New England Journal of Medicine, 340(9), 669-676.
  • 17. Environmental Psychosocial Physical Provide adequate supervision Educate client & family/carers and involve in care Wear vision & hearing aids & dentures: keep within reach Provide consistent care-giving staff Use reorientation strategies (clocks, calendar, photos) Ensure adequate hydration Provide access to sunlight (if available) during the day Ensure good communication: speak in clear, short, simple phrases Ensure adequate pain relief Create a calm soothing atmosphere & decrease sensory input: eliminate unnecessary noise Validate fears and concerns Promote regular toileting: bowel meds (softeners, stimulants may be necessary) Minimise sudden changes in environment Provide reassurance: inform that this is short-term condition Ensure prompt attention & treatment of infections Ensure safety and prevent complications Encourage relaxation techniques Encourage activity: mobility & ADL’s Have familiar possessions from home Normalise sleep patterns Have a low set bed & bed rails down Maintain normal oxygenation Source: J. McCrow, 2011 accessed from http://www.learnaboutdelirium
  • 18. What is dementia? • Syndrome caused by over100 different diseases which all structural and chemical changes in the brain leading to brain tissue death • Progressive decline in memory, reasoning, communication skills affecting daily activities leading to extreme functional decline and death
  • 19. Types of Dementia (many causes) • Alzheimer’s • Vascular • Fronto-temporal (Pick’s disease) • Parkinson’s • Dementia with Lewy bodies • Alcoholic related dementia & korsakoff’s
  • 20. Behavioural symptoms and psychological symptoms of dementia (BPSD) Behavioural: • Agitation • Aggression • Wandering • Vocalisations • Repeated questioning Psychological: • Depression • Psychosis • Sleep disturbances
  • 21. Biomedical understanding - Damage to brain affects certain abilities and behaviours Frontal Lobe Planning, impulse control, social & behavioural control, co-ordination, initiative, Occipital Lobe Visual processing Temporal Lobe Memory, emotions, language Parietal Lobe Language, speech, calculation, spatial reasoning, movement, recognition Limbic system / hippocampus Memory formation & recall, emotions, consciousness, sleep RAS Arousal & attention
  • 22. Psychosocial model – Person Centred Care1 Inclusion, Attachment, Occupation, Identity, Comfort, (Love), • Valuing the person • Know the person – their likes and dislikes (biography) • Respect the person • Holding the persons identity for them • Mutuality Kitwood (1997) , The experience of dementia. Aging & Mental Health, Vol 1, no 1, p 13-22
  • 23. Need-driven Dementia-compromised Behaviour Model – unmet needs • Behavioural symptoms are a person’s best attempts at communicating unmet physical, social and emotional needs. – Drawing on all their preserved abilities & personality albeit constrained by the limitations of a dementia related illness • Involves an interaction between background and proximal factors
  • 24. Theoretical approach to behavioural management (NDB model) Neurological factors Specific regional brain involvement Neurotransmitter imbalance levels Circadian rhythm deterioration Motor ability Cognitive factors Attention - Memory Visuo-spatial ability Language skills Health status General health Functional ability Affective state (anxiety, depression) Psychosocial factors Gender Education Occupation Personality type History of psychological stress Behavioural response to stress Personal factors Emotions Physiological needs (Pain, thirst) Functional performance Physical environment Light level Noise level Temperature Social environment Ward ambience Staff stability Staff mix BACKGROUND FACTORS PROXIMAL FACTORS BEHAVIOUR Dimension of Behaviour Frequency Duration inetnsity Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. and Beattie, E. (1996) Need-driven dementia-compromised behaviour: an alternative view of disruptive behaviour, American Journal of Alzheimer’s Disease and Other Dementias, vol 11:10
  • 25. Assessing unmet needs and consequences of unmet needs • Discomfort – Pain, constipation, thirst, treatments, ailments – itchy skin • Sleep disturbances • Toileting • Nutrition – hunger & thirst • Emotional responses/needs • Loss of control • Loss of independence or routines
  • 26. Needs Specialised Assessment • Measurement of behaviour – Antecedent, behaviour, consequence - ABC method – Cohen Mansfield Agitation Inventory - CMAI (30 domain behavioural assessment) – Behavioural observation chart (PAH) – Pittsburgh Agitation scale + Verbal descriptor scale + PAINAD • Graphical system, Pain assessment, Intervention grid
  • 27. Therapeutic responses to aggression in dementia & brain injury (different to managing MH) Nursing Reponses Entering the patients world: • Normalization • Person-centred care • Nurse-patient mutuality • Downplaying negativity • Thoughtful creativity Patient • Decreased aggression Nurse • Nurse satisfaction Finfgeld-Connett, D. (2009). Management of aggression among demented or brain-injured patients. Clinical Nursing Research, 18(3), 272-287.
  • 28. Non-Therapeutic responses to aggressive behaviours in dementia or brain injured patients Nursing Reponses Utilitarian care: • Inflexible routines Patient • Persistent aggression Nurse • Negative physical, psychosocial, and professional consequences Nursing Reponses Authentic engagement (MH): • Grounding interactions within reality • Setting contextually based limits Finfgeld-Connett, D. (2009). Management of aggression among demented or brain-injured patients. Clinical Nursing Research, 18(3), 272-287.
  • 29. Assess & treat discomfort Avoid or minimise psychotropic, sedative, hypnotic medications Avoid restraint Monitor for overstimulation Reduce environmental stressors Increase level of supervision Provide non-pharmacological sleep aids Provide & encourage recreational, occupational and social activity Promote and maintain physical function Schedule regular visits to toilet or prompted voiding Monitor hydration, nutrition and swallowing Provide sensory aids Provide orientation aids Provide reassurance Remove or camouflage invasive devices Provide low-set bed with bed-rails down Document behaviour Assess & ensure prompt attention & treatment of causes Normalise sleep patterns Prevent injury and delirium complications Ensures adequate hydration Provide cognitively stimulating activity Provide access to sunlight Maintain normal oxygenation Promote regular toileting Search for unmet needs Use ‘Life Story’ information to communicate & plan person- centred care Hygiene routines – consider time of day with least distractions Provide dementia-specific recreational resources Promote mealtime routines Delirium Dementia Search for unmet needs Use ‘Life Story’ information to communicate & plan person- centred care Hygiene routines – consider time of day with least distractions Provide dementia-specific recreational resources Promote mealtime routines Some approaches that will work for both delirium and dementia PAIN
  • 30. Pain a contributor to delirium in hip fracture? • Under treatment of postoperative pain in general has been associated with increased risk of delirium 1 • High opioid use may also increase risk of delirium 2 • Inadequate doses of opioids in hip fracture may increase risk of delirium however low dose opioids matching pain showed no increase 3,4 • Insufficient evidence on harms and benefits of anlagesia5 • Studies also report lower use of analgesics by people with dementia 3 1. Lynch et al (1998) The impact of Postoperative pain in the development of postoperative delirium. Regional Aesthesia and Pain management. 2. Leung et al (2009) anaesthesiology< vol. 111, 625-631 3. Sieber, F. E., Mears, S., Lee, H., & Gottschalk. (2011). Postoperative Opioid Consumption and Its Relationship to Cognitive Function in Older Adults Fracture. JAGS, 59, 2256-2262. 4. Morrison et al (2003) Relationship Between Pain and Opioid Analgesics on the Development of Delirium Following Hip Fracture. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58(1), M76-M76. 5. Abou-Setta et al (2011) Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Annals of Internal Medicine, 155(4), 234-245
  • 31. Why is pain undertreated in cognitive impairment • 1/3 less analgesia postoperatively than for cognitively intact 1 • Painful conditions • Inability to self report • Staff knowledge deficit • Behaviours not linked to pain • Lack of assessment tools • Growing body of knowledge, still being defined IStockphoto.com 1. Morrisson, s. R & Siu, A.L. (2000). A comparison of pain and its treatment in advanced dementia and cognitively intact Patients with hip fracture. Vol. 19, No. 4. 240-248
  • 32. Difficulties of assessing pain in cognitive impairment, especially dementia • Loss of ability to communicate pain (Is self-report reliable now?) • Interpretation of non-verbal behaviours (which behaviours are pain related - BPSD broad range can we distinguish?) • Availability of psychometrically validated observational tools? • Reliability of only using these? • What are best practice protocols & procedures? Kaassalainen, S (2007). Pain Assessment in Older Adults with Dementia – using behavioural observation methods in clinical practice. Journal of Gerontological Nursing,
  • 33. Observational tools focused on non-verbal behaviours • Facial expressions • Paralinguistic vocalisations (eg moaning) • Guarding • Bracing • Sleep disturbances • Aggressive behaviour • Changes in psychomotor activity
  • 34. Review of Observational Instruments Herr, K., Bursch, H. & Black, B. (2008). State of the Art Review of tools for Assessment of Pain in Nonverbal Older Adults. University of Iowa. Retrieved, 27 October, 2009 from http://prc.coh.org/pain_assessment.asp
  • 35. What Tool to use? • Expert consensus for RACFs – PAINAD (daily) & PACSLAC or Doloplus (weekly)1 • Many of the best psychometric tools are bulky – PACSLAC (4 subs 60 items) & Doloplus-2 (3 subs 10 items) - questionable as to whether they will be readily used by acute care nurses • PAINAD – simpler, quicker and recommended to use alongside self report in acute care with hip fracture2 1. Herr, K., et al (2010). Use of pain-behavioral assessment tools in the nursing home: expert consensus recommendations for practice. Journal of Gerontological Nursing, 36(3), 18-31. 2. DeWaters, et al (2008). Comparison of Self-Reported Pain and PAINAD Scale in Hospitalised Cognitively Impaired and Intact Older Adults After Hip Fracture Surgery. Orthopaedic Nursing, 27(1), 21-28
  • 36. VERBAL PAIN SCALE Verbal Descriptor Scale – Mild to moderate dementia may reliably self-report pain. Always try self report first. No pain Mild Pain Moderate Pain Severe Pain Worst Pain PAINAD SCALE Pain Assessment in Advanced Dementia. Observational Pain Assessment Tool – scores from 0-10. Only use if patient cannot self report pain. ITEMS 0 1 2 SCORE Breathing independent of vocalisation Normal Occasional laboured breathing. Short period of hyperventalion. Noisy laboured breathing Long period of hyperventilation. Cheyne-stokes respirations (0-2) Negative vocalisation None Occasional moan or groan. Low level speech with negative or disapproving quality. Repeated troubled calling out. Loud moaning or groaning. Crying. (0-2) Facial experession Smiling or inexpressive Sad, frightened, frowning Facial grimacing. (0-2) Body language Relaxed Tense, distressed pacing, fidgeting Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out (0-2) Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract or reassure. (0-2) RECORD SCORES ON REVERSE PAGE TOTAL (0-10) Record over page © PAINAD developed by Warden, V., Hurley, A. C., & Volicer, L., (2003)
  • 37. Graphical system & hourly VERBAL PAIN SCALE Worst Severe Moderate Mild No Pain PAINAD Only use if unable to self report pain 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Diversion (D) PRN (PO, S/C, IM) Restraint (X) Baseline Continue to observe. Explore patient’s life story. Consider delirium reduction strategies & activities for persons with dementia. Escalation 1st line: Address needs – consider pain, toileting, position, emotion. Problem solve within person’s reality. Try distraction & diversion. 2nd line: (Use if 1st line ineffective). Consider PRN medications. Reduce stimuli. Remove potential missiles & dangers. Crisis Keep calm. Take action to ensure others safety. Remove dangers. Consider – calling for assistance from security, IM sedation, restraint. Date: Day: © PAH Behavioural Observation Chart developed by The Internal Medicine Unit, 5th floor Princess Alexandra Hospital, 07-12-2009 incorporating the Pittsburgh Agitation scale, Verbal Descriptor Scale & PAINAD.
  • 38. Pain in dementia patients with co-morbid delirium and/or depression • Caution – potential to inflate pain score when co-morbid delirium, depression, dementia due to overlapping behavioural symptoms1 • Clinicians should place an emphasis on behaviours not confounded by co-morbid diagnosis – e.g. protective body postures, protection score areas1 • Best practice - Assessment should triangulate information from a variety of sources 1-3 1. Hadjistavropolous et al, (2008) Assessing Pain in Patients with Co-morbid Delirium and/or Depression. Pain Management Nursing, Vol 9, No 2, pp48-54 2. Kaassalainen, S (2007). Pain Assessment in Older Adults with Dementia – using behavioural observation methods in clinical practice. Journal of Gerontological Nursing 3. Kovach et al (2006) Effects of the serial trail inetrvention on discomfort and behvaiour of nursing home rseidents with dementia. American Journal of Alzheimer’s Dsease and Other Dementias, 21 (3), 147-155
  • 39. Guiding principles for Assessing Pain in Cognitive Impairment 2006 American Society for Pain Management Nursing • Self report – Always attempt to elicit self report and record why self report is not possible • Painful conditions or treatments – Search for conditions or treatments that may cause pain • Observe behaviours – Use a validated observational tool that measures distress • Surrogate reporting – Interview family/carers to establish the nature of any new changes in behaviour • Analgesic trial – Rule out pain by attempting a time-limited analgesic trial and evaluate – Regular analgesia needed, – PRN not suitable 1. Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., . . . Wild, L. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice. Pain Management Nursing, 7(2), 44-52. doi: 10.1016/j.pmn.2006.02.003
  • 40. 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 R est raint ( X ) Only use if unable to self report pain 0 4 2 D iversion ( D ) PR N ( PO, S/ C , IM ) # Mild Nopain P A IN A D 8 6 HOURLY OBSERVATIONS Time in HoursP ITTSB U R GH A GITA TION S C A LE Aberrant Vocalisation Moderate 6hr scor e 6hr scor e 6hr scor e Resisting Cares Aggressiveness M otor Agitation V ER B A L P A IN S C A LE Worst Severe Recor d acti vi ty &6hr scor e
  • 41. 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 Worst Severe Recor d acti vi ty &6hr scor e Moderate 6hr scor e 6hr scor e 6hr scor e Resisting Cares Aggressiveness M otor Agitation V ER B A L P A IN S C A LE HOURLY OBSERVATIONS Time in HoursP ITTSB U R GH A GITA TION S C A LE Aberrant Vocalisation # Mild Nopain P A IN A D 8 6 R est raint ( X ) Only use if unable to self report pain 0 4 2 D iversion ( D ) PR N ( PO, S/ C , IM )
  • 42. 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 s/ cPR N ( PO, S/ C , IM ) R est raint ( X ) Only use if unable to self report pain 0 4 2 D iversion ( D ) # Mild Nopain P A IN A D 8 6 HOURLY OBSERVATIONS Time in HoursP ITTSB U R GH A GITA TION S C A LE Aberrant Vocalisation Moderate 6hr scor e 6hr scor e 6hr scor e Resisting Cares Aggressiveness M otor Agitation V ER B A L P A IN S C A LE Worst Severe Recor d acti vi ty &6hr scor e
  • 43. 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 T s/ c s/ c R est raint ( X ) Only use if unable to self report pain 0 4 2 D iversion ( D ) PR N ( PO, S/ C , IM ) M eal M eds. Shower # Mild Nopain P A IN A D 8 6 HOURLY OBSERVATIONS Time in HoursP ITTSB U R GH A GITA TION S C A LE Aberrant Vocalisation Moderate 6hr scor e 6hr scor e 6hr scor e Resisting Cares Aggressiveness M otor Agitation V ER B A L P A IN S C A LE Worst Severe Recor d acti vi ty &6hr scor e 5
  • 44. 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 T D D s/ c s/ c R est raint ( X ) Only use if unable to self report pain 0 4 2 D iversion ( D ) PR N ( PO, S/ C , IM ) M eal M eds. Shower # Mild Nopain P A IN A D 8 6 HOURLY OBSERVATIONS Time in HoursP ITTSB U R GH A GITA TION S C A LE Aberrant Vocalisation Moderate 6hr scor e 6hr scor e 6hr scor e Resisting Cares Aggressiveness M otor Agitation V ER B A L P A IN S C A LE Worst Severe M ealRecor d acti vi ty &6hr scor e
  • 45. 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 T D D s/ c s/ c PO Worst Severe M ealRecor d act i vi ty & 6hr scor e Moderat e 6hr scor e 6hr scor e 6hr scor e Resisting Cares Aggressiveness M otor Agitation V ER B A L P A IN S C A LE HOURLY OBSERVATIONS Time in HoursP IT T SB U R GH A GIT A T ION S C A LE Aberrant Vocalisation # Mild No pain P A IN A D 8 6 M eal M eds. Shower R est raint ( X ) Only use if unable to self report pain 0 4 2 D iversio n ( D ) PR N ( PO, S/ C , IM )
  • 46. Model of Care High Care Room/delirium room/ACE • Several projects suggest specific environmental adjustments and models of care for delirium management1-3 • An observational study has reported LOS equal to cognitively intact people and no more adverse outcomes4 1. Niam, D. M. W. T., Geddes, J. A., & Inderjeeth, C. A. (2009). Delirium unit: our experience. Australasian Journal of Ageing, 28(4), 206-210. 2. Zieschang, T., et al (2010). Improving care for patients with dementia hospitalized for acute somatic illness in a specialized care unit: a feasibility study. International Psychogeriatrics, 22(1), 139-146. 3. Soto, M. E., et al. (2008). Special acute care unit for older adults with Alzheimer's disease. International Journal of Geriatric Psychiatry, 23(2), 215-219. 4. Flaherty, J. H., et al (2010). An ACE unit with a delirium room may improve function and equalize length of stay among older delirious medical inpatients. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 65A(12), 1387-1392
  • 47. Started in Internal medicine - problem in 2007 • IMU found 70% of falls were in cognitive impairment • Falls & aggressive events were still occurring despite 1:1 nursing specials (expensive!) • Negative reputation affecting recruitment and retention due to increased falls & aggressive events
  • 48. STRATEGY • A high care unit with specialised interventions was developed to increase quality of care, reduce patient agitation and provide a safer environment • High risk patients were relocated from IMU wards to 8 bed environment staffed by specialist nurses and situated within the treating unit
  • 49. W5B High Care Unit W5CW5A Acute Medical (1 & 3) Eye surgical ward Immunology & rheumatology Acute Medical (2 & 5) Endocrine 5D overflow (isolation) Acute Medical (4, 6 & 7) High risk patients Hypertension Wanderer Alarms Lifts Lifts Wanderer Alarms Glass doors ENVIRONMENT • Geographically located to least busy area with fewest exits • Located within medical unit facilitates timely access to treating teams • Double glazed doors to offer quieter environment
  • 50. W5A
  • 51. Patient Flow • Admission & discharge criteria developed – falls risks or behavioural risks with acute/chronic cognitive impairment • Relocation of patients with high risk to high care environment • Streamlined referral & assessment process – nursing driven.
  • 52. Multidisciplinary involvement including geriatric team • Geriatric Assessment Team (referral based service) • Physio, Social work, Community Health nurses (discharge nurses), Occupational Therapy
  • 53. Increased staffing • 4 staff (2 unlicensed) to 8 patients morning • 4 staff (2 unlicensed) to 8 patients evening • 2 staff (1-2 unlicensed) to 8 patients overnight with CN support
  • 54. Training • Specialised training in dementia & delirium care for licensed and unlicensed clinicians • Education program delivered utilising ward- based computer workstations • Geographic location of unit facilitated focused training to a localised (W5A) group of nurses rather then whole IMU
  • 55. Distraction Devices • IVC Decoys • IDC Decoy – apron • Fiddle Blankets
  • 56. Psychosocial understanding of behaviours: Biographical approach to knowing the person
  • 57. Tolerate, anticipate and don’t agitate approach1 • Person centred communication • Mobilisation, socialisation and engagement in activity2 • Creativity and flexibility 1. Flaherty, J., & Little, M. (2011). Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium. JAGS, 59, S295-S300 2. Richards, K. C., Lambert, C., Beck, C. K., et al. (2011). Strength training, walking, and social activity improve sleep in nursing home and assisted living residents: randomized controlled trial. Journal of the American Geriatrics Society, 59(2), 214-223.
  • 58. MODEL OF CARE • Increased staffing • Constant Supervision for high falls risk • Person Centred Care (Kitwood, 1997) biography, creativity, flexibility, choice • Communication • Emotional support PATIENT LIFE STORY CHART Obtain collateral information from family & carers KEEP UP TO DATE LIFE STORY BORN: INTERESTS: (Place, year) (Hobbies, talking points) CHILDHOOD: (Where, hobbies, schooling) FAMILY: (Partners, children) FAVOURITE THINGS: (Pets, objects, favourite activities) OCCUPATIONS: (Jobs, volunteers, armed service) GAMES: (Board games, puzzles) SIGNIFICANT LIFE EVENTS: (Achievements, accidents, marriages, births) MUSIC: (Favourite songs & styles) SPORTS: (Sports played and favourites now) URN: Family Name: Given Name: Date of Birth:
  • 59. Theoretical approach to behavioural management (NDB model) Neurological factors Specific regional brain involvement Neurotransmitter imbalance levels Circadian rhythm deterioration Motor ability Cognitive factors Attention - Memory Visuo-spatial ability Language skills Health status General health Functional ability Affective state (anxiety, depression) Psychosocial factors Gender Education Occupation Personality type History of psychological stress Behavioural response to stress Personal factors Emotions Physiological needs (Pain, thirst) Functional performance Physical environment Light level Noise level Temperature Social environment Ward ambience Staff stability Staff mix BACKGROUND FACTORS PROXIMAL FACTORS BEHAVIOUR Dimension of Behaviour Frequency Duration inetnsity Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. and Beattie, E.l (1996) Need-driven dementia-compromised behaviour: an alternative view of disruptive behaviour, American Journal of Alzheimer’s Disease and Other Dementias, vol 11:10 Mobility - physio Medical history/diagnosis mental health MMSE RUDAS Verbal Fluency
  • 60. Recreational Activities Aims: Provide distraction & interest Relieve boredom Involve family in care
  • 61. Sorting activities Aims: Cognitive stimulation Reduce boredom Supply variety of meaningful tasks
  • 62. Activities relevant to past occupations or personality
  • 63. Themed Fiddle Boxes Aims: Reminiscence Explore stories with familiar items Textural exploration
  • 64. Outcomes • Reduced falls by 30% • Increased staff retention • Increased staff morale, improved BPA workplace culture • Reduced workforce costs due to reduced external & internal casual staff use – 62.7% reduction in 1:1 special use – Less staff leave & vacancy due to improved workplace • Improved quality of care is often an outcome of reduced transient and casual workforce
  • 65. REDUCED FALLS BY 30% 0 20 40 60 80 100 120 140 160 2006-2007 2007-2008 2008-2009 2009-2010 YEARS FALLS Post Implementation
  • 66. Reduced External & Internal Casual FTE 0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 2006/2007 2007/2008 2008/2009 2009/2010 Years FTE Internal External Post Implementation
  • 67. The PAH Journey
  • 68. Education (3 modules) Module 1 • Cognition & brain anatomy • Delirium (CAM embedded) Module 2 • Dementia • Models of Dementia Care Module 3 • Behavioural Observations • Pain in Dementia • Pharmacological Management of Behaviours • Patients with High-risk Behaviours Workshop – interactive group work • Practice CAM & Video Vignette's • Case studies – develop care plans for patient with delirium and patient with dementia
  • 69. Conclusion – can the following can be set up on orthopaedic wards? • Specialised care environment • Delirium assessment tools (a must for nurses) • Pain assessment tools and method for cognitive impairment (a must) • Education • Models of care and person centred care • Environment that allows creativity and flexibility

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