course materials

1. Patient Medical History Assessment Tool By Confusion Assessment
Method
Patient Medical History Assessment Tool By Confusion Assessment Method ON Patient
Medical History Assessment Tool By Confusion Assessment MethodOlder Adult Simulation
Scenarios. In order to get the most out of the experience, please make sure to read all of the
scenarios so that you are familiar with the patients that you will be caring for.Please write
out your responses and submit to the simulation faculty at the start of the simulation
experience:What considerations from the patient’s history could have an impact in the plan
of care for these patients?Consider the assessment tools that you learned about in the
classroom; which would be applicable in the scenarios and explain why? Review SPICES,
PAIN AD and the Confusion Assessment Method (CAM) tools.Background for Scenario
1:Lucy is an 80 year old female admitted three days ago after sustaining a left femoral neck
hip fracture from a fall at home. She lives alone and reported that she was going outside to
grab the mail when her legs gave out. Neighbors witnessed the fall and called 911. Upon
arrival to the Emergency Department she was in a lot of pain and unable to bear weight on
the left side. During the fall she also sustained an abrasion to the left elbow and forearm.
She was admitted under Dr. Spencer from Orthopaedic surgery who repaired the hip with a
total hip arthroplasty two days ago. Lucy has a medical history of HTN, CAD, HF,
Osteoarthritis and early onset dementia. She is 5’3’’ and weighed 145 pounds on admission.
She has an allergy to Penicillin and Morphine Patient Medical History Assessment Tool By
Confusion Assessment MethodBackground for Scenario 2Harold is a 73 year old male
admitted two days ago with hyperglycemia; his blood sugar was 480mg/dl on arrival. He
lives alone, but was complaining to a family member over the phone that he felt lightheaded
and weak, so they called 911. Paramedics brought him to the closest ED, but since his
primary care provider is not associated with our hospital, his admitting physician is Dr.
Shah. He was initially admitted to the ICU and put on an insulin drip, but has been
transitioned to subcutaneous insulin and transferred to our medical surgical floor yesterday
afternoon. Harold has a medical history of Type II DM, retinopathy, peripheral neuropathy,
HTN, osteoarthritis and an appendectomy when he was 23. He is 5’9’’ and weighed 215
pounds yesterday. He has no allergies to medication..Background for Scenario 3Emily is an
80-year-old female being admitted thru the emergency department with a diagnosis of rule
out urinary tract infection.She lives at home with her son who called 911 because the
patient had become more lethargic and confused over the past 2 days.Emily has a history of

2. a left –sided mastectomy with left axillary node dissection 10 years ago and lymphedema to
her left arm.She also has a history of dementia with episodes of delirium during past
hospitalizations.Emily is 5’6” tall and weighs 102 pounds.She is alert to person but is
disoriented to place and time.Her lungs sounds were clear and she cannot remember the
last time she had a bowel movement.Patient Medical History Assessment Tool By Confusion
Assessment Methodattachment_1attachment_2attachment_3Unformatted Attachment
Previewgeneral assessment series Best Practices in Nursing Care to Older Adults From The
Hartford Institute for Geriatric Nursing, New York University, College of Nursing Issue
Number 1, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c), MSN, GNP-BC New
York University College of Nursing Fulmer SPICES: An Overall Assessment Tool for Older
Adults By: Terry Fulmer, PhD, APRN, GNP, FAAN, Bouve College of Health Sciences,
Northeastern University and Meredith Wallace, PhD, APRN, CS, Fairfield University School
of Nursing WHY: Normal aging brings about inevitable and irreversible changes. These
normal aging changes are partially responsible for the increased risk of developing health-
related problems within the elderly population. Prevalent problems experienced by older
adults include: sleep disorders, problems with eating or feeding, incontinence, confusion,
evidence of falls, and skin breakdown. Familiarity with these commonly-occurring disorders
helps the nurse prevent unnecessary iatrogenesis and promote optimal function of the
aging patient. Flagging conditions for further assessment allows the nurse to implement
preventative and therapeutic interventions (Fulmer, 1991; Fulmer, 1991). BEST TOOL:
Fulmer SPICES is an efficient and effective instrument for obtaining the information
necessary to prevent health alterations in the older adult patient (Fulmer, 1991; Fulmer,
1991; Fulmer, 2001). SPICES is an acronym for the common syndromes of the elderly
requiring nursing intervention: S is for Sleep Disorders P is for Problems with Eating or
Feeding I is for Incontinence C is for Confusion E is for Evidence of Falls S is for Skin
Breakdown TARGET POPULATION: The problems assessed through SPICES occur
commonly among the entire older adult population. Therefore, the instrument may be used
for both healthy and frail older adults. VALIDITY AND RELIABILITY: The instrument has
been used extensively to assess older adults in the hospital setting, to prevent and detect
the most common complications (Fulmer, 2001; Lopez et al., 2002; Pfaff, 2002; Turner, J. et
al., 2001; NICHE). Patient Medical History Assessment Tool By Confusion Assessment
MethodPsychometric testing has not been done. STRENGTHS AND LIMITATIONS: The
SPICES acronym is easily remembered and may be used to recall the common problems of
the elderly population in all clinical settings. It provides a simple system for flagging areas
in need of further assessment and provides a basis for standardizing quality of care around
certain parameters. SPICES is an alert system and refers to only the most frequently-
occurring health problems of older adults. Through this initial screen, more complete
assessments are triggered. It should not be used as a replacement for a complete nursing
assessment. Permission is hereby granted to reproduce, post, download, and/or distribute,
this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited
as the source. This material may be downloaded and/or distributed in electronic format,
including PDA format. Available on the internet at www.hartfordign.org and/or

3. www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu. MORE ON
THE TOPIC: Best practice information on care of older adults: www.ConsultGeriRN.org.
Fulmer, T. (2007). How to try this: Fulmer SPICES. AJN, 107(10), 40-48. Fulmer, T. (1991).
The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93.
Fulmer, T. (1991). Grow Your Own Experts in Hospital Elder Care. Geriatric Nursing,
March/April 1991, 64-66. Fulmer, T. (2001). The geriatric resource nurse: A model of caring
for older patients. American Journal of Nursing, 102, 62. Kagan, S.H. (2010). Geriatric
syndromes in practice: Delirium is not the only thing. Geriatric Nursing, 31(4), 299-304.
Lopez, M., Delmore, B., Ake, J., Kim, Y., Golden, P., Bier, J., & Fulmer, T. (2002). Implementing
a Geriatric Resource Nurse Model. Journal of Nursing Administration, 32(11), 577-585.
Nurses Improving Care for Healthsystem Elders (NICHE) Program at the Hartford Institute
for Geriatric Nursing, http://www.nicheprogram.org/. Pfaff, J. (2002). The Geriatric
Resource Nurse Model: A culture change. Geriatric Nursing, 23(3), 140-144. Turner, J. T.,
Lee, V., Fletcher, K., Hudson, K., & Barton, D. (2001). Measuring quality of care with an
inpatient elderly population: The geriatric resource nurse model. Journal of Gerontological
Nursing, 27(3), 8-18. Fulmer SPICES: An Overall Assessment Tool for Older Adults Patient
Name: Date: SPICES EVIDENCE Yes No Sleep Disorders Problems with Eating or Feeding
Incontinence Confusion Evidence of Falls Skin Breakdown Adapted from Fulmer, T. (1991).
The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93. ©
Copyright Lippincott Williams & Wilkins, http://lww.com. general assessment series Best
Practices in Nursing Care to Older Adults A series provided by The Hartford Institute for
Geriatric Nursing, New York University, College of Nursing EMAIL hartford.ign@nyu.edu
HARTFORD INSTITUTE WEBSITE www.hartfordign.org www.ConsultGeriRN.org CLINICAL
NURSING WEBSITE general assessment series Best Practices in Nursing Care to Older
Adults From The Hartford Institute for Geriatric Nursing, New York University, College of
Nursing Issue Number 13, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN,
GNP-BC New York University College of Nursing The Confusion Assessment Method (CAM)
By: Christine M. Waszynski, MSN, APRN, BC, Hartford Hospital WHY: Delirium is present in
10%-31% of older medical inpatients upon hospital admission and 11%-42% of older
adults develop delirium during hospitalization (Siddiqi, House, & Holmes, 2006; Tullmann,
Fletcher, & Foreman, 2012). Delirium is associated with negative consequences including
prolonged hospitalization, functional decline, increased use of chemical and physical
restraints, prolonged delirium post hospitalization, and increased mortality. Patient Medical
History Assessment Tool By Confusion Assessment MethodDelirium may also have lasting
negative effects including the development of dementia within two years (Ehlenbach et al.,
2010) and the need for long term nursing home care (Inouye, 2006). Predisposing risk
factors for delirium include older age, dementia, severe illness, multiple comorbidities,
alcoholism, vision impairment, hearing impairment, and a history of delirium. Precipitating
risk factors include acute illness, surgery, pain, dehydration, sepsis, electrolyte disturbance,
urinary retention, fecal impaction, and exposure to high risk medications. Delirium is often
unrecognized and undocumented by clinicians. Early recognition and treatment can
improve outcomes. Therefore, patients should be assessed frequently using a standardized
tool to facilitate prompt identification and management of delirium and underlying etiology.

4. BEST TOOL: The Confusion Assessment Method (CAM) is a standardized evidence-based
tool that enables non-psychiatrically trained clinicians to identify and recognize delirium
quickly and accurately in both clinical and research settings. The CAM includes four features
found to have the greatest ability to distinguish delirium from other types of cognitive
impairment. There is also a CAM-ICU version for use with non-verbal mechanically
ventilated patients (See Try This:® CAM-ICU). VALIDITY AND RELIABILITY: Both the CAM
and the CAM–ICU have demonstrated sensitivity of 94-100%, specificity of 89-95% and high
inter-rater reliability (Wei, Fearing, Eliezer, Sternberg, & Inouye, 2008). Several studies
have been done to validate clinical usefulness. STRENGTHS AND LIMITATIONS: The CAM
can be incorporated into routine assessment and has been translated into several
languages. The CAM was designed and validated to be scored based on observations made
during brief but formal cognitive testing, such as brief mental status evaluations. Training to
administer and score the tool is necessary to obtain valid results. The tool identifies the
presence or absence of delirium but does not assess the severity of the condition, making it
less useful to detect clinical improvement or deterioration. FOLLOW-UP: The presence of
delirium warrants prompt intervention to identify and treat underlying causes and provide
supportive care. Vigilant efforts need to continue across the healthcare continuum to
preserve and restore baseline mental status. MORE ON THE TOPIC: Best practice
information on care of older adults: www.ConsultGeriRN.org. The Hospital Elder Life
Program (HELP), Yale University School of Medicine. Home Page:
www.hospitalelderlifeprogram.org/ CAM Disclaimer:
www.hospitalelderlifeprogram.org/private/cam-disclaimer. Useful websites for clinicians
including the CAM Training Manual:
www.hospitalelderlifeprogram.org/pdf/TheConfusionAssessmentMethodTrainingManual.p
df Cole, M.G., Ciampi, A., Belzile, E., & Zhong, L. (2009). Persistent delirium in older hospital
patients: A systematic review of frequency and prognosis. Age and Ageing, 38(1), 19-26.
Ehlenbach, W.J., Hough, C.L., Crane, P.K., Haneuse, S.J.P.A., Carson, S.S., Randall Curtis, J., &
Larson, E.B. (2010). Association between acute care and critical illness hospitalization and
cognitive function in older adults. JAMA, 303(8), 763-770. Inouye, S.K. (2006). Patient
Medical History Assessment Tool By Confusion Assessment MethodDelirium in older
persons. NEJM, 354, 1157-65. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. &
Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of
Internal Medicine, 113(12), 941-948. Maldonado, J.R. (2008). Delirium in the acute care
setting: Characteristics, diagnosis and treatment. Critical Care Clinics, 24(4), 657-722. Rice,
K.L., Bennett, M., Gomez, M., Theall, K.P., Knight, M., & Foreman, M.D. (2011, Nov/Dec).
Nurses’ recognition of delirium in the hospitalized older adult. Clinical Nurse Specialist,
25(6), 299-311. Siddiqi, N., House, A.O., & Holmes, J.D. (2006). Occurrence and outcome of
delirium in medical in-patients: A systematic literature review. Age and Aging, 35(4), 350-
364. Tullmann, D.F., Fletcher, K., & Foreman, M.D. (2012). Delirium. In M. Boltz, E. Capezuti,
T.T. Fulmer, & D. Zwicker (Eds.), A. O’Meara (Managing Ed.), Evidencebased geriatric
nursing protocols for best practice (4th ed., pp 186-199). NY: Springer Publishing Company,
LLC. Vasilevskis, E.E., Morandi, A., Boehm, L., Pandharipande, P.P., Girard, T.D., Jackson, J.C.,
Thompson, J.L., Shintani, A., Gordon, S.M., Pun, B.T., & Ely, E.W. (2011). Delirium and

5. sedation recognition using validated instruments: Reliability of bedside intensive care unit
nursing assessments from 2007 to 2010. JAGS, 59(Supplement s2), S249-S255. Wei, L.A.,
Fearing, M.A., Eliezer, J., Sternberg, E.J., & Inouye, S.K. (2008). The confusion assessment
method (CAM): A systematic review of current usage. JAGS, 56(5), 823-830. Permission is
hereby granted to reproduce, post, download, and/or distribute, this material in its entirety
only for not-for-profit educational purposes only, provided that The Hartford Institute for
Geriatric Nursing, New York University, College of Nursing is cited as the source. This
material may be downloaded and/or distributed in electronic format, including PDA format.
Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail
notification of usage to: hartford.ign@nyu.edu. The Confusion Assessment Method
Instrument: 1. [Acute Onset] Is there evidence of an acute change in mental status from the
patient’s baseline? 2A. [Inattention] Did the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty keeping track of what was being said?
2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to
come and go or increase and decrease in severity? 3. [Disorganized thinking] Was the
patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation,
unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4.
[Altered level of consciousness] Overall, how would you rate this patient’s level of
consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental
stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse];
Coma; [unarousable]; Uncertain) 5. [Disorientation] Was the patient disoriented at any
time during the interview, such as thinking that he or she was somewhere other than the
hospital, using the wrong bed, or misjudging the time of day? 6. [Memory impairment] Did
the patient demonstrate any memory problems during the interview, such as inability to
remember events in the hospital or difficulty remembering instructions? 7. [Perceptual
disturbances] Did the patient have any evidence of perceptual disturbances, for example,
hallucinations, illusions or misinterpretations (such as thinking something was moving
when it was not)? 8A. [Psychomotor agitation] At any time during the interview did the
patient have an unusually increased level of motor activity such as restlessness, picking at
bedclothes, tapping fingers or making frequent sudden changes of position? 8B.
[Psychomotor retardation] At any time during the interview did the patient have an
unusually decreased level of motor activity such as sluggishness, staring into space, staying
in one position for a long time or moving very slowly? 9. [ Altered sleep-wake cycle] Did the
patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime
sleepiness with insomnia at night? The Confusion Assessment Method (CAM) Diagnostic
Algorithm Feature 1: Acute Onset or Fluctuating Course This feature is usually obtained
from a family member or nurse and is shown by positive responses to the following
questions: Is there evidence of an acute change in mental status from the patient’s baseline?
Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or
increase and decrease in severity? Feature 2: Inattention This feature is shown by a positive
response to the following question: Did the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty keeping track of what was being said?
Patient Medical History Assessment Tool By Confusion Assessment MethodFeature 3:

6. Disorganized thinking This feature is shown by a positive response to the following
question: Was the patient’s thinking disorganized or incoherent, such as rambling or
irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from
subject to subject? Feature 4: Altered Level of consciousness This feature is shown by any
answer other than “alert” to the following question: Overall, how would you rate this
patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy,
easily aroused], stupor [difficult to arouse], or coma [unarousable]) The diagnosis of
delirium by CAM requires the presence of features 1 and 2 and either 3 or 4. © 2003 Sharon
K. Inouye, MD, MPH Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.
(1990). Clarifying confusion: The confusion assessment method. Annals of Internal
Medicine, 113(12), 941-948. general assessment series Best Practices in Nursing Care to
Older Adults A series provided by The Hartford Institute for Geriatric Nursing, New York
University, College of Nursing EMAIL hartford.ign@nyu.edu HARTFORD INSTITUTE
WEBSITE www.hartfordign.org www.ConsultGeriRN.org CLINICAL NURSING WEBSITE
dementia series Best Practices in Nursing Care to Older Adults with dementia From The
Hartford Institute for Geriatric Nursing, New York University, College of Nursing, and the
Alzheimer’s Association Issue Number D2, Revised 2012 Editor-in-Chief: Sherry A.
Greenberg, PhD(c) MSN, GNP-BC New York University College of Nursing Assessing Pain in
Older Adults with Dementia By: Ann L. Horgas, RN, PhD, FGSA, FAAN, University of Florida
College of Nursing WHY: Pain in older adults is very often undertreated, and it may be
especially so in older adults with severe dementia. Changes in a patient’s ability to
communicate verbally present special challenges in treating pain, since self-report is
considered the gold standard of pain assessment. As with all older adults, those with
dementia are at risk for multiple sources and types of pain, including chronic pain from
conditions such as osteoarthritis and acute pain from surgery, injury, and infection.
Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and
activity patterns, reduce function, reduce quality of life, and prolong hospitalization. BEST
TOOLS: Several tools are available to measure pain in older adults with dementia. Each has
strengths and limitations (Herr, Decker, & Bjoro, 2006). The American Medical Directors
Association has endorsed the Pain Assessment in Advanced Dementia Scale (PAINAD)
(Warden, Hurley, & Volicer, 2003). The American Society for Pain Management Nursing’s
Task Force on Pain Assessment in the Nonverbal Patient recommends a comprehensive,
hierarchical approach to pain assessment that incorporates the following steps: • Ask older
adults with dementia about their pain. Even older adults with mild to moderate dementia
can respond to simple questions about their pain. • Use a standardized tool to assess pain
intensity, such as the numerical rating scale (NRS) (0-10) or a verbal descriptor scale (VDS)
(Herr, Coyne, et al., 2006). The VDS asks participants to select a word that best describes
their present pain (e.g., no pain to worst pain imaginable) and may be more reliable than
the NRS in older adults with dementia. • Use an observational tool (e.g., PAINAD) to
measure the presence of pain in older adults with dementia. • Ask family or usual caregivers
as to whether the patient’s current behavior (e.g., crying out, restlessness) is different from
their customary behavior. This change in behavior may signal pain. • If pain is suspected,
consider a time-limited trial of an appropriate type and dose of an analgesic agent.

7. Thoroughly investigate behavior changes to rule out other causes. Use self report and
observational pain measures to evaluate the pain before and after administering the
analgesic. TARGET POPULATION: Older adults with cognitive impairment who cannot be
assessed for pain using standardized pain assessment instruments. Pain assessment in
older adults with cognitive impairment is essential for both planned or emergent
hospitalization. VALIDITY AND RELIABILITY: The PAINAD has an internal consistency
reliability ranging from .50 (for behavior assessed at rest) to .67 (for behaviors assessed
during unpleasant caregiving activities). Interrater reliability is high (r = .82 – .97). The
PAINAD scale is reported to have moderate to high concurrent validity, depending on
whether the patient was at rest or involved in pleasant or unpleasant activities (r = .76 –
.95). STRENGTHS AND LIMITATIONS: Pain is a subjective experience and there are no
definitive, universal tests for pain. For patients with dementia, it is particularly important to
know the patient and to consult with family and usual caregivers. BARRIERS to PAIN
MANAGEMENT in OLDER ADULTS with DEMENTIA: There are many barriers to effective
pain management in this population. Some common myths are: pain is a normal part of
aging; if a person doesn’t verbalize that they have pain, they must not be experiencing it;
and that strong analgesics (e.g., opioids) must be avoided. There are also some barriers to
using the PAINAD to assess pain in this population. First, the PAINAD has not been
evaluated for use in people with mild to moderate dementia. Second, some of the PAINAD
scale behaviors, such as breathing, may be difficult to assess. Third, some studies have
reported that the brevity of the PAINAD (only 5 items) makes it easy to complete, but limits
its utility by restr …Patient Medical History Assessment Tool By Confusion Assessment
Method