CNS ROLE APPLICATION

ELDER LIFE CNS ROLE –SPHERES OF CARE INFLUENCE

Patient level – comprehensive geriatric assessment, protocol driven, follow up assessment and interventions, education for patients and families

Staff level – coaching and education on delirium prevention and functional decline; participation in care rounds

System level – program operation, quality assurance, identification of care gaps and interventions

HELP NURSING PROTOCOLS

Targeted Risk Factor Approach using protocols

Evaluation of Cognitive Status• Delirium Protocol • Dementia Protocol • Psychoactive Medications Protocol

Sleep Enhancement Protocol Early Mobilization Protocol

MORE HELP NURSING PROTOCOLS Hearing Protocol

Fluid Repletion Protocol

Discharge Planning Protocol

Optimizing Length of Stay Protocol

Additional Areas –

EXAMPLE: DELIRIUM PROTOCOL

Assessment establishes baseline, cognitive tool plus

CAM and collateral history psychoactive medications and ETOH use bloodwork then daily- structured cognitive tool plus the

CAM and ongoing staff, family and volunteer inputs

IF PATIENT CHANGES SUDDENLY ….

Review medication list for potentially contributory medications or potentially harmful interactions

Search for occult infection, e.g., urinary tract infection (UTI)

Rule out drug or alcohol withdrawal Support referrals to geriatrics, pharmacy,

internal medicine

MORE DELIRIUM INTERVENTIONS

Non-Pharmacological Management

Education for staff, involve family

Strategies to decrease agitation and improve sleep

Communication techniques

AT HHS, THE HELP NURSE ……. Follows HELP delirium protocols

Structured cognitive assessment is not carried out daily but on admission and as indicated

No discharge sMMSE is completed

ADHERENCE-WHAT DOSE OF HELP IS ENOUGH ?

The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions

Higher levels of adherence resulted in

reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group.

Inouye SK. Arch Intern Med. 2003;163:958-964

AT HHS…… 2005 ADHERENCE

68%-best for orientation, vision and hearing , therapeutic activities and feeding protocol

34% -lowest for mobility and sleep protocol

WHAT FACTORS AFFECT ADHERENCE?

ARE THEY MODIFIABLE?

COGNITIVE SCREENING INSTRUMENTS

Instrument Admin time Comments

Sweet 16 3-5 mins Published Nov 2010- on HELP website

Mini-Cog 3-5 min Brief , validated

Short portable status questionnaire

3-5 minutes Brief

3MS 10-15 mins MMSE plus remote memory, verbal fluency and abstraction

sMMSE/Folstein 10-15 Copyright requires authors permission- per use fee with Folstein

Montreal Cognitive Assessment (MoCA)

10-20 minutes Open access-

THE SWEET 16

PURPOSE: screening tool for cognitive impairment

Why another tool? Length, burden ,copyright ADVANTAGES : simple, rapid, paperless, validated against the MMSE, open accessCONSTRAINTS : early days of testing

Fong,T. Arch Intern Med. 2010 Nov 8

CASE STUDYMRS. SMITH IS A 91 YEARS OLD LADY ADMITTED FROM

R.H. WITH LOW BACK PAIN

HISTORY OF PRESENTING ILLNESS

Sudden increase in low back pain 3 days ago; unable to walk, new onset of urinary incontinence. GP started Lorazepam 1 mg Q HS 5 days ago for poor sleep. Confusion over 48 hours –disoriented to time, not consistently recognizing family

PAST MEDICAL HISTORY

Hypothyroidism Dyslipidemia Hearing loss Macular degeneration Hypertension ?TIA Arthritis Chronic Low Back Pain Degenerative Disc Disease, Scoliosis

SOCIAL HISTORY

Widowed, 3 children, 9 grandchildren Retired teacher – grade school and ESL Enjoys listening to music, attending

socials and visiting with families

BASELINE FUNCTION

Walks with walker independently to D/R

Toilets independently; no history of incontinence

Assisted with bath 2 X per week 1 year history of short term memory

loss, repeats stories, forgets family visits

INVESTIGATIONS

CT scan: no obvious fracture except for possibly a displaced right transverse process fracture of L3

LabsLab Findings Normal Range

urea 11.2

Creat 115

TSH 18

WBC 13,3

Hgb 130

MEDICATIONS

Aspirin 81 mg OD Lorazepam 1 mg Q HS Baclofen 10 mg TID Levothyroxine 0.125 mg OD Hydrochlorothiazide 25 mg OD Lipitor 20 mg OD Fosinopril 20 mg OD Colace 100mg BID Senokot 2 tabs Q HS Tylenol # 3 1-2 Q 4 H PRN