Standard 5: Comprehensive Care

Preventing delirium and managing cognitive impairment

Action 5.29

The health service organisation providing services to patients who have cognitive impairment or are at risk of developing delirium has a system for caring for patients with cognitive impairment to:

a. Incorporate best-practice strategies for early recognition, prevention, treatment and management of cognitive impairment in the care plan, including the Delirium Clinical Care Standard, where relevant

b. Manage the use of antipsychotics and other psychoactive medicines, in accordance with best practice and legislation

Intent

A system for caring for cognitive impairment is implemented that minimises the risk of harm for people with cognitive impairment or at risk of developing delirium. The use of antipsychotics and other psychoactive medicines is in line with best practice and legislation.

Reflective questions

What processes are in place to manage safety and quality issues for patients with, or at risk of, developing cognitive impairment?

How is the use of antipsychotics and other psychoactive medicines monitored, and how is feedback provided to clinicians?

What supports are available for clinicians to use non-pharmacological approaches in response to behavioural and psychological symptoms of dementia?

Key tasks

  • Review, revise or develop a system for providing high-quality care for patients with cognitive impairment.

  • Allocate roles, responsibilities and accountabilities for establishing or maintaining the system.

  • Implement a system for caring for cognitive impairment.

  • Regularly monitor the use of best-practice evidence-based strategies in the care plan, provide feedback and implement improvement strategies.

Strategies for improvement

Hospitals

Implement a system

A well-designed system for caring for patients with for cognitive impairment will support clinicians to:

  • Routinely screen for cognitive impairment1 in patients aged 65 years or over using a validated tool (Action 5.10)
  • Screen patients of any age at risk of delirium and when the patient, carer, family or other key informants raise concerns about cognitive impairment.

An initial screen provides a useful baseline for further monitoring. Note that a positive score on a screening tool is not a diagnosis but a prompt for further assessment, early intervention and early family involvement. Document the results and communicate them to patients and family, and the relevant members of the workforce who interact with patients, including primary care clinicians.

For all patients with cognitive impairment:

  • Assess for delirium and reassess with any changes in behaviour or thinking1 using validated delirium assessment tools applicable to the setting (see Action 8.5)
  • If delirium is detected, investigate and treat the causes of delirium; comprehensive history taking and physical examination can enable targeted investigations
  • Investigate (or refer for investigation) other causes of cognitive impairment – for example, a person may have developed cognitive impairment as a result of a recent acquired brain injury or an undiagnosed dementia, requiring further assessment, treatment and follow-up
  • Partner with patients, carers and family members who have a central role in the prevention, early recognition, assessment and management of cognitive impairment; develop systems for their early consultation and involvement
  • Comprehensively assess and develop an individualised plan (see Actions 5.12 and 5.13)
  • Provide relevant information to patients, carers and families in an easy-to-understand format, including information on delirium risk, delirium, and the roles of patients, carers and families; delirium may be a frightening experience for patients and families, and can be associated with feelings of remorse and shame2
  • Respond to other care needs, including assistance with nutrition3 and hydration (see Action 5.27), reorientation, safe mobilising, maintaining or restoring functioning, and providing meaningful activities4,5; these strategies also assist in prevention of delirium and other geriatric syndromes6, and a well-structured and well-supported volunteer program can assist in implementation7,8
  • Set goals of care based on the needs and preferences of the person with cognitive impairment; use processes for informed consent, shared and substitute decision-making, and advance care planning to set goals of care
  • Manage medication issues, including
    • treating pain and reducing sedation9
    • undertaking medication reconciliation, and reviewing to identify, reduce or stop medicines that can cause or exacerbate cognitive impairment (see Action 4.10)
    • providing accurate medicines lists (see Action 4.12)
    • consulting, informing and educating patients, carers and substitute decision-makers (as well as the patient’s general practitioner and care facility) about these processes
  • Communicate effectively10 and seek information to provide individualised care
  • Respond appropriately to behavioural symptoms (see ‘Manage the use of antipsychotic medicines’, below)
  • Provide a supportive environment– for example, implement evidence-based design principles in scheduled major capital works or refurbishments, as well as through simple, small-scale changes at the ward and room level (see Actions 1.29 and 1.30), and support carers and family members when they choose to be actively involved in a person’s care
  • Manage transitions effectively, including
    • information exchange and transfer of responsibilities among all relevant health service organisations and care providers, including seeking early primary care input (see Actions 6.7 and 6.8)
    • access to hospital substitution, outreach, fast-track or transition programs
    • referral for appropriate follow-up for undiagnosed cognitive impairment and after a delirium episode – for example, many patients who are identified with cognitive impairment or experience delirium may have undiagnosed dementia11
  • If a comprehensive diagnostic process is not appropriate during admission, arrangements must be put in place for post-discharge assessment12; ensure that referral pathways are in place for post-discharge assessment, and involve and inform patients and carers about ongoing care decisions.1

Note that these steps are not linear. For example, keeping a person safe through responding to other care needs should happen at the same time as investigating the possible cause of delirium, if detected.

For patients at risk of delirium, implement multi-component delirium prevention strategies1,13

Patients aged 65 years and over, and patients with a known cognitive impairment (such as dementia), severe medical illness or hip fracture are considered to be at greatest risk.1

Note that delirium prevention strategies are also useful delirium management strategies – for example, early treatment of dehydration, sepsis, metabolic imbalance, immobilisation, sensory impairment and sleep disturbance.9

Introduce protocols to prevent and treat pain, reduce sedation, enable safe early mobilisation and reduce sleep disturbance.9

Set up procedures to avoid or remove catheters in a timely manner.

For all patients, be alert to, and assess for, delirium when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (see Action 8.5)

To implement a system for caring for patients with cognitive impairment, use the screening, assessment and comprehensive care planning processes described in the Comprehensive Care Standard for guidance, including items that cover advance care plans.

Other relevant NSQHS Standards include the:

A Better Way to Care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital14 and the Delirium Clinical Care Standard1 set out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment. A Better Way to Care also provides links to further resources that are useful in implementing this action.

Manage the use of antipsychotic medicines

Incorporate best practice12 and legislation for the use of antipsychotics and other psychoactive medicines for people with cognitive impairment into policies and procedures. This includes:

  • Conducting a comprehensive, formal assessment of any behavioural symptoms or changes, including assessment of potential unmet needs
  • Communicating effectively and understanding the person
  • Involving carers and family members
  • Creating a supportive environment
  • Managing training and education of the workforce (see Action 5.30)
  • Avoiding physical restraint, if possible, and following guidance in Action 5.35 to minimise restraint
  • Trying non-pharmacological approaches in the first instance
  • Seeking behavioural management advice when required
  • Starting pharmacological treatment only if a patient is severely distressed, or is at immediate risk of harm to themselves or others, and non-pharmacological interventions have been ineffective1
  • If pharmacological interventions are prescribed
    • following ‘start low, go slow, time limit and review’
    • selecting the agent based on evidence according to diagnosis, severity and patient factors such as comorbidities
    • avoiding multiple agents
    • considering evidence and pharmacokinetics when selecting dose, frequency and timing
    • documenting indications for use and providing instructions for community prescribers15,16
  • Monitoring and collecting feedback on the use of antipsychotics and other psychoactive medicines.

Ensure that policies for preventing and responding to aggression include specific guidance on responding to acute behavioural disturbance in relation to cognitive impairment. Use non-pharmacological approaches in the first instance, involve carers and families, minimise sedation, and ensure that any medicine use is evidence based, including age-specific evidence. Over-sedation can have serious consequences, such as dehydration, falls, respiratory depression, pneumonia and death.17

Day Procedure Services

Implement a system

Pre-admission screening should identify patients with cognitive impairment or at risk of delirium, to trigger strategies to keep the patient safe and to minimise potential distress. Strategies include:

  • Reviewing communication systems to ensure that risk and identified cognitive impairment are flagged, communicated and documented during pre-admission and admission processes
  • Providing consumer information in an easy-to-understand format, including information about the risk of delirium
  • Involving family members or carers to support patients in pre-admission screening, or consulting with a substitute decision-maker
  • Communicating effectively with patients with cognitive impairment
  • Consulting with family members on strategies to minimise distress
  • Involving family members or carers in the care episode, including reporting any concerns they raise about the patient
  • Providing information to other health services (for example, referring clinician) regarding any delirium and further follow-up.

Pre-admission screening should include screening for risk factors for postoperative delirium, including age greater than 65 years, chronic cognitive decline or dementia, certain medicines or multiple medicines, and poor vision or hearing.18,19

A Better Way to Care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital20 and the Delirium Clinical Care Standard1 set out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment. A Better Way to Care also provides links to further resources that are useful in implementing this action.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline processes for
    • recognising, preventing, treating and managing cognitive impairment, including through pre-admission screening for cognitive impairment
    • obtaining early primary care input about a patient’s cognitive difficulties to aid diagnosis, treatment and ongoing management decisions
  • Validated tools and resources used to screen for, and assess, cognitive impairment
  • Training documents about communicating with, and providing support to, patients with cognitive impairment, and assessing and responding to distress
  • Examples of activities that have been implemented and evaluated to improve the environment for people with cognitive impairment
  • Examples of non-pharmacological approaches that have been implemented to respond to behavioural symptoms of dementia
  • Patient, carer and family information packages that provide information to enable them to participate in the system for caring for patients with cognitive impairment
  • Committee and meeting records that show the health service organisation’s involvement in dementia pathway initiatives to integrate primary, community and acute care.
MPS & Small Hospitals

Implement a system

A well-designed system for caring for patients with cognitive impairment will support clinicians to routinely screen for cognitive impairment1 in patients aged 65 years or over using a validated tool (Action 5.10). Also, at any age, screen patients at risk of delirium and when the patient, carer, family or other key informants raise cognitive concerns.

For all patients with cognitive impairment:

  • Assess for delirium and reassess with any changes in behaviour or thinking1 using validated delirium assessment tools applicable to the setting (see Action 8.5)
  • If delirium is detected, investigate and treat the causes of delirium; comprehensive history taking and physical examination can enable targeted investigations
  • Investigate (or refer for investigation) other causes of cognitive impairment–for example, a person may have developed cognitive impairment as a result of a recent acquired brain injury or an undiagnosed dementia, requiring further assessment, treatment and follow-up
  • Partner with patients, carers and family members who have a central role in the prevention, early recognition, assessment and management of cognitive impairment; develop systems for their early consultation and involvement
  • Provide relevant information to patients, carers and families in an easy-to-understand format, including information on delirium risk, delirium, and the roles of patients, carers and families
  • Comprehensively assess and develop an individualised plan (see Actions 5.12 and 5.13)
  • Respond to other care needs, including assistance with nutrition3 and hydration (see Action 5.27), reorientation, safe mobilising, maintaining or restoring functioning, and providing meaningful activities4,5
  • Set goals of care based on the needs and preferences of the person with cognitive impairment; use processes for informed consent, shared and substitute decision-making, and advance care planning to establish goals of care
  • Manage medication issues, including
    • treating pain and reducing sedation9
    • undertaking medication reconciliation, and reviewing to identify, reduce or stop medicines that can cause or exacerbate cognitive impairment (see Action 4.10)
  • Communicate effectively10 and seek information to provide individualised care; tools are included in the Resources section at the end of this standard
  • Respond appropriately to behavioural symptoms (see ‘Manage the use of antipsychotic medicines’, below)
  • Provide a supportive environment – for example, implement evidence-based design principles in scheduled major capital works or refurbishments, as well as through simple, small-scale changes at the ward and room level (see Actions 1.29 and 1.30), and support carers and family members when they choose to be actively involved in a person’s care
  • Manage transitions effectively, including referral for appropriate follow-up for undiagnosed cognitive impairment and after a delirium episode
  • Involve and inform patients and carers about ongoing care decisions.1

Note that these steps are not linear. For example, keeping a person safe by responding to other care needs should happen at the same time as investigating the possible cause of delirium, if detected.

For patients at risk of delirium, implement multi-component delirium prevention strategies1,13

Patients aged 65 years and over, and patients with a known cognitive impairment (such as dementia), severe medical illness or hip fracture are considered to be at greatest risk.1

Note that delirium prevention strategies are also useful delirium management strategies – for example, early treatment of dehydration, sepsis, metabolic imbalance, immobilisation, sensory impairment and sleep disturbance.9

Introduce protocols to prevent and treat pain, reduce sedation, enable safe early mobilisation and reduce sleep disturbance.9

Set up procedures to avoid or remove catheters in a timely manner.

For all patients, be alert to, and assess for, delirium when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (see Action 8.5)

Care of Confused Hospitalised Older Persons (CHOP) and the Dementia Care in Hospitals Program provide direction on implementing systems for caring for patients with cognitive impairment.

A Better Way to Care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital14 and the Delirium Clinical Care Standard1 set out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment. A Better Way to Care also provides links to further resources that are useful in implementing this action.

Manage the use of antipsychotic medicines

Incorporate best practice and legislation in the use of antipsychotics and other psychoactive medicines for people with cognitive impairment into policies and procedures. This includes:

  • Conducting a comprehensive, formal assessment of any behavioural symptoms or changes, including assessment of potential unmet needs
  • Communicating effectively and understanding the person
  • Involving carers and family members
  • Creating a supportive environment
  • Managing training and education of the workforce (see Action 5.30)
  • Avoiding physical restraint, if possible, and following guidance in Action 5.35 to minimise restraint
  • Trying non-pharmacological approaches in the first instance
  • Seeking behavioural management advice when required
  • Starting pharmacological treatment only if a patient is severely distressed, or is at immediate risk of harm to themselves or others, and non-pharmacological interventions have been ineffective1
  • If pharmacological interventions are prescribed
    • following ‘start low, go slow, time limit and review’
    • selecting the agent based on evidence according to diagnosis, severity and patient factors such as comorbidities
    • avoiding multiple agents
    • considering evidence and pharmacokinetics when selecting dose, frequency and timing
    • documenting indications for use and providing instructions for community prescribers15,16
  • Monitoring and collecting feedback on the use of antipsychotics and other psychoactive medicines.

Ensure that policies for preventing and responding to aggression include specific guidance on responding to acute behavioural disturbance in relation to cognitive impairment. Use non-pharmacological approaches in the first instance, involve carers and families, minimise sedation, and ensure that any medicine use is evidence based, including age-specific evidence. Over-sedation can have serious consequences, such as dehydration, falls, respiratory depression, pneumonia and death.14

Action 5.30

Clinicians providing care to patients who have cognitive impairment or are at risk of developing delirium use the system for caring for patients with cognitive impairment to:

a. Recognise, prevent, treat and manage cognitive impairment

b. Collaborate with patients, carers and families to understand the patient and implement individualised strategies that minimise any anxiety or distress while they are receiving care

Intent

Risks are minimised by undertaking strategies to recognise, prevent, treat and manage cognitive impairment. Clinicians, patients, carers and families work together to minimise anxiety or distress experienced by the person with cognitive impairment.

Reflective questions

How is the workforce supported to recognise, prevent, treat and manage cognitive impairment?

How is feedback from patients with cognitive impairment, and their carers and families collected and used to inform improvement strategies?

Key tasks

  • Review and, if necessary, revise the organisation’s education and training program to support implementation.

  • Provide access to education and training about the system that supports caring for patients with cognitive impairment, and agreed tools and responsibilities.

  • Work with clinicians and consumers to design and implement systems for working together and for implementing strategies to minimise anxiety and distress experienced by a person with cognitive impairment.

  • Use regular feedback from patients, carers and families to improve collaboration.

Strategies for improvement

Hospitals

The whole workforce has a role in providing care and creating a person-centred culture. This means that all levels of the workforce need access to continual, targeted education, information and training.

Provide orientation, education and training for the workforce to understand their individual roles, responsibilities and accountabilities in working with patients, carers and families to prevent and reduce the risk of harm for people with cognitive impairment or at risk of developing delirium.

Include information about forms of cognitive impairment other than dementia and delirium, because people with other forms of cognitive impairment also have poor experiences.21

Ensure that training and education programs cover the elements of the system for caring for cognitive impairment described in Action 5.29.

Multifaceted education programs that include enabling and reinforcing techniques can result in positive outcomes for patients.22 

Consider liaising with Dementia Training AustraliaDementia Behaviour Management Advisory Service and Dementia Australia.

Consider developing initiatives such as recruiting cognitive champions who can reinforce education, offer peer support to help clinicians improve their skills and confidence, and organise relevant resources for their wards.23

Consider implementing evidence-based programs, such as TOP 524, that assist clinicians and carers to work together to reduce a person’s distress. Well-structured and well-supported volunteer programs and modification of the environment (see Action 1.29) can also help to reduce a person’s distress.

Day Procedure Services

Pre-admission screening should identify patients with cognitive impairment or at risk of delirium, to trigger strategies to keep the patient safe and to minimise potential distress.

If the day procedure service admits patients who have cognitive impairment or are identified as being at risk of developing delirium, the service should have processes to ensure that clinicians are aware of the systems outlined in Action 5.29.

Refer to the hospitals tab for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

The whole workforce has a role in providing care and creating a person-centred culture. This means that all levels of the workforce need access to continual, targeted education, information and training.

Provide orientation, education and training for the workforce to understand their individual roles, responsibilities and accountabilities in working with patients, carers and families to prevent and reduce the risk of harm for people with cognitive impairment or at risk of developing delirium.

Include information about forms of cognitive impairment other than dementia and delirium, because people with other forms of cognitive impairment also have poor experiences.21

Consider liaising with Dementia Training AustraliaDementia Support Australia and Dementia Australia.

Consider developing initiatives such as recruiting cognitive champions who can reinforce education, offer peer support to help clinicians improve their skills and confidence, and organise relevant resources for their wards.23

Consider implementing evidence-based programs, such as TOP 5177, that assist clinicians and carers to work together to reduce a person’s distress. Well-structured and well-supported volunteer programs and modification of the environment (see Action 1.29) can also help to reduce a person’s distress.

Last updated 5th July, 2018 at 10:19pm
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References

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Pollard C, Fitzgerald M, Ford K. Delirium: the lived experience of older people who are delirious post-orthopaedic surgery. Int J Ment Health Nurs 2015;24(3):213–21.

Alzheimer’s Disease International. Nutrition and dementia: a review of available research. London: Alzheimer’s Disease International; 2014.

Royal College of Nursing. Improving quality of care for people with dementia in general hospitals: essential guide. Canberra: RCN; 2010.

Mudge AM, McRae P, Cruickshank M. Eat walk engage: an interdisciplinary collaborative model to improve care of hospitalized elders. Am J Med Qual 2015;30(1):5–13.

Caplan G, Coconis J, Board N, Sayers A, Woods J. Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age Ageing 2006;35(1):53–60.

Bateman C, Anderson K, Bird M, Hungerford C. Volunteers improving person-centred dementia and delirium care in a rural Australian hospital. Rur Rem Health 2016;16(2):3667.

Health Research & Educational Trust (US). Preventing iatrogenic delirium change package. Chicago (IL): Health Research & Educational Trust; 2016.

Alzheimer’s Australia. Caring for someone with dementia. Help sheet: communication. Canberra: Alzheimer’s Australia; 2012.

Jackson TA, MacLullich AM, Gladman JR, Lord JM, Sheehan B. Undiagnosed long-term cognitive impairment in acutely hospitalised older medical patients with delirium: a prospective cohort study. Age Ageing 2016;45(4):493–9.

Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Sydney: Guideline Adaptation Committee; 2016.

Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Internal Med 2013;158(5 Pt 2):375–80.

Australian Commission on Safety and Quality in Health Care. A better way to care: safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital. Sydney: ACSQHC; 2014.

Brunero S, Wand AP, Lamont S, John L. A point prevalence study of the use of psychotropic medication in an acute general hospital. Int Psychogeriatr 2016;28(6):967–75.

Herzig SJ, Rothberg MB, Guess JR, Stevens JP, Marshall J, Gurwitz JH, et al. Antipsychotic use in hospitalized adults: rates, indications, and predictors. J Am Geriatr Soc 2016;64(2):299–305.

Peisah C, Chan DK, McKay R, Kurrle SE, Reutens SG. Practical guidelines for the acute emergency sedation of the severely agitated older patient. Intern Med J 2011;41(9):651–7.

Inouye SK, Robinson T, Blaum C, Busby-Whitehead J, Boustani M, Chalian A, et al. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg 2015;220(2):136–48.e1.

Viswanath O, Kerner B, Jean Y-K, Soto R, Rosen G. Emergence delirium: a narrative review. J Anesthesiol Clin Sci 2015 2015;4(1):2.

Australian Commission on Safety and Quality in Health Care. A better way to care: safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital. Actions for clinicians. Sydney: ACSQHC; 2014.

Iacono T, Bigby C, Unsworth C, Douglas J, Fitzpatrick P. A systematic review of hospital experiences of people with intellectual disability. BMC Health Serv Res 2014;14:505.

Wand A. Evaluating the effectiveness of educational interventions to prevent delirium. Australas J Ageing 2011 Dec;30(4):175–85.

Graham F. A new frontier. J Nurs Admin 2015;45(12):589–91.