Delirium and Falls. Falls in the Community. Ontario Stratify. Literature - delirium. Risk factors. Falls Risk Screening Tool.

Transcription

1 NORTHERN SYDNEY CENTRAL COAST HEALTH Falls Risk Screening - Ontario STRATIFY Please read instructions for use MR Number. Surname.. Date of Birth.. Please fill in if no patient label available Date: / / Item Falls Risk Screening Assessment Value Score Delirium and Falls Julia Poole CNC Aged Care RNSH Did the patient present to hospital with a fall or have they fallen since admission? 1. History of falls. If not, has the patient fallen within the last 2 months? Is the patient confused? (i.e., unable to make purposeful decisions, disorganised thinking and memory impairment). Is the patient disorientated? (i.e. lacking awareness, being 2.Mental status mistaken about time, place or person). Is the patient agitated? (i.e., fearful, affect, frequent movements, and anxious) Does the patient require eyeglasses continually? Does the patient report blurred vision? 3. Vision Does the patient have glaucoma, cataracts or macular degeneration? Are there any alterations in urination? (i.e., frequency urgency, 4. Toileting. incontinence, nocturia). Unable no sitting balance; mechanical lift. 5. Transfer score Major help one strong skilled helper or two normal people; (TS) [ means from physical can sit. bed to chair and Minor help one person easily or needs supervision for safety. back]. Independent use of aids to be independent is allowed. Immobile. Yes to any = 6 Yes to any = 14 Yes to any = 1 Yes = 2 0 Add Transfer 1 score (TS) and Mobility score(ms) 2 3 If value total between 0-3, then score = 7 0 ( Score totalled) Falls Risk Screening Tool Ontario STRATIFY Falls Risk Screening Tool Ontario Stratify 6. Mobility score (MS). Wheelchair independent including corners, etc. Walks with help of one person (verbal or physical). Independent (but may use any aid, e.g., cane) If values total between 4-6, then score = 0 Action: total score and follow risk recommendations as per level of risk (As validated tool patient at risk -If Total score 9) = At Risk 0-5 Low risk 6-16 Medium risk High risk Total Score = With acknowledgement to SWAHS & GSAHS. Falls in the Community Risk factors Balance Gait Eyesight Tactile sensation Certain medications Environment / footwear Impaired cognition Literature - delirium Delirium in older persons (Inouye NEJM.354:11) Common, life threatening, potentially preventable and reversible In hosp prevalence 14-24%; incidence 6-56% Correlates with lower quality of hospital care Delirium in elderly general medical inpatients: a prospective study (Isel 2007 Int Med J.37(12):806) >49% of all USA hospital bed days on care for delirium Melbourne study all patients eligible >65 (n=104) general med ward Prevalent del 18%: incident 2% Pre existing cognitive impairment strong predictor In particular, the prevention of, or appropriate management of delirium can save up to $2.5 million per 1000 cases (Lipski, P White Paper on Geriatric Medical Services on The NSW Central Coast 2007). Delirium Sometimes known as: Acute Confusion Acute Confusional State Acute Brain Disorder Acute Brain Syndrome

2 Delirium Definition Disturbance of consciousness, attention, cognition, and perception that develops over a short period of time (usually hours or days) and tends to fluctuate during the course of the day DSM-IV 1994 Delirium is characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time Delirium due to a general medical condition Substance induced Delirium Delirium due to multiple etiologies AHMAC Clinical Practice Guidelines for the Management of Delirium in Older People. Vic. Govt Dept Human Services. If Delirium not otherwise specified American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington: American Psychiatric Association. ICD-10-AM Disease Tabular 2003 F05 -Delirium, not induced by alcohol and other psychoactive substances non specific organic cerebral syndrome concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behavior, emotion, and the sleep-wake schedule. F05.1 Delirium superimposed on dementia Pathophysiology of Delirium Poorly understood &/or decreased cerebral oxidative metabolism causing altered neurotransmitter levels stress-induced increased plasma cortisol levels causing altered neurotransmitter activity Moran, J. & Dorevitch, M (2001) Delirium in the hospitalised elderly. The Australian Journal of Hospital Pharmacy. 31(1): cerebral hypo-perfusion in the frontal, temporal & occipital cortex Yokata, H. et al. (2003) Regional cerebral blood flow in delirious patients. Psychiarty and Clinical Neurosciences.75(3): PREDISPOSING CAUSES OF DELIRIUM - Brain disease - dementia, stroke, past severe head injury - Use of brain-active drugs - sedatives, anticholinergics - Impairments of special senses - sight, hearing - Multiple severe illnesses - Malnutrition PRECIPITATNG CAUSES OF DELIRIUM - Iatrogenic - unpleasant environmental change, invasive procedures, new medications, trauma, dehydration, ongoing malnutrition, elimination malfunction - Illnesses - infections, intracranial pathologies, impaired organ function, abnormal metabolite function, pain, drug withdrawal Delirium Risk Assessment Predisposing Visual impairment Severe illness Cognitive deficit (AMTS <7/10; MMSE < 25/30) Dehydration Precipitating mechanical restraint malnutrition 3 new medications IDC Unpleasant event (eg surgical procedure, med. toxicity, falls, infections, faecal impaction etc) Weber, J. Coverdale, J and Kunik, M (2004) Delirium: current trends in prevention and treatment. Internal Medicine Journal. 34: Creasey, C. (1996) Acute confusion in the elderly. Current Therapautics. August:

3 Royal North Shore and Ryde Health Service CONFUSION ASSESSMENT METHOD (CAM) Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present 1. Acute and fluctuating course 3. Disorganised thinking Is there evidence of an acute change in mental Was the patient s thinking disorganised or status from the patient's baseline? Did the incoherent, such as rambling or irrelevant (abnormal) behaviour fluctuate during the day, conversation, unclear or illogical flow of ideas, that is, come and go, or increase and decrease or unpredictable switching from one subject to in severity? another? No No Yes Yes Uncertain (please specify). Uncertain (please specify).. 2. Inattention. Did the patient have difficulty focussing attention during the interview, e.g. being easily distractible, or having difficulty keeping track of what was being said? No Yes Uncertain (please specify). 4. Altered level of consciousness Overall, how would you rate this patient s level of consciousness? Alert (normal) Altered Vigilant (hyperalert, easily startled, overly sensitive to stimuli) Lethargic (drowsy but easily aroused) Stupor (difficult to arouse) Coma (unrousable) Uncertain Delirium symptoms present Delirium symptoms NOT present N/A DATE: Signature of assessor & designation: Medical Officer's signature.. Delirium: What does it mean for the patient? Trapped in incomprehensible experiences a turmoil of past & present being in borderland being a victim & not in control feeling threatened Quotes NOTE: Inouye, S. K The Confusion Assessment Method CAM). Training Manual and Coding Guide. Yale University School of Medicine. Anderrson, E. M. Hallberg, I. R. Norberg, A. and Edberg, Anna-Karin. (2002) The meaning of acute confusional state Delirium: What does it mean for the staff? Recognising Protecting Strain feelings of adequacy / inadequacy Follow up care Hallberg, I. R Impact of Delirium on Professionals. Dementia & Geriatric Cognitive Disorders. 10(5): Factors associated with delirium severity among older patients (Voyer, McCusker, Cole et al J Clin Nurs. 16: ) Aim: investigate factors associated with severity of delirium Method: secondary analysis of instit. older patients admitted to acute care n = 104 Results: nurses have important role in preventing mild severe delirium reassuring/supporting environment reducing severe delirium role of pain management important Cognitive Impairment Immobility Sensory impairment Dehydration Prevention of Delirium Sleep deprivation Inouye et al NEJM 340(9): Orientation, therapeutic activities Pain relief, nonpharmacological sleep enhancement protocol early mobilisation, minimal use of immobilising equipment vision & hearing protocols volume repletion Delirium Is a medical emergency Incidence of up to 56% in hospitalized elderly Independent predictor of adverse outcomes increased falls incontinence pressure sores increased LOS in acute care decreased functional levels increased mortality Maher, S. and Almeida, O. (2002) Delirium in the elderly - another medical emergency. Current Therapeutics. March:39-43.

4 1. How do you know? (state how you came to this decision in the Integrated Notes) 4 question AMTS SIS 3 item recall, day, month, year. MiniCog 3 item recall, Clock AMTS CLOCK MMSE GCS questions RUDAS Other (state).. 2. Why are they confused? can t speak the language can t speak or express themselves can t hear can t see delirium (CAM) and/or dementia? 3. What is causing the confusion? e.g. UTI, pneumonia, pain, cellulitis, constipation, medications, ETOH withdrawal, changed environment, hyponatraemia, unknown, etc? 4. What are you doing to try to reduce the confusion (delirium, dementia, other)? Treat cause Ask family to visit often and filled in the Communication & Care Cues form bring in toiletries, dressing gown, slippers bring in reassuring/orienting mementos photos, books, music, cuddly things, etc Talk with patient often & referred to the information in the Communications Cues form including: time / day / month / season etc eg Mary is looking after Rover your dog you must miss him I bet you would much rather be going fishing now its autumn Fred knows you are here and will be here soon to see you etc 5. How have you made sure that the staff can continue these actions? Noted cause and gave instructions at handover Placed CCC form in end of bed notes Noted the CCC form in the patient notes and care plan Role modelled reassuring, orientating communication skills Displayed reassuring information on the bed notice boards

5 SIS (Six Item Screen) [Callahan 2002 Medical Care 40(9): ] 1. Say to your patient I am going to name 3 objects remember what they are because I am going to ask you to name them again in a few minutes. Please say the 3 items after me. (Say clearly & slowly 1 second for each word) APPLE TABLE PENNY Keep giving trials for the 3 words until the patient has said all 3 (up to 6 trials) 2. Then ask the patient to name the current day month year Give 1 point for each correct answer 3. Say Now what were the 3 objects I asked you to remember? Give 1 point for each correct answer 1. Say to your patient I am going to name 3 objects. After I have said them I want you to repeat them. Remember what they are because I am going to ask you to name them again in a few minutes. Please say the 3 items for me. (Say clearly & slowly 1 second for each word) APPLE TABLE PENNY Keep giving trials for the 3 words until the patient has said all 3 (up to 6 trials) Mini-Cog (Borson et al Int J Geri Psych : ) 2. Clock Drawing Test Say to the subject :"Put the numbers on the clock and set the hands at ten minutes past eleven 3. Say Now what were the 3 objects I asked you to remember? Give 1 point for each correct answer 3 = impairment - needs further investigation) Normal [ ] Abnormal [ ] All numbers present in correct sequence & position and hands readably displayed the requested time Total / 6 ( 4 = impairment - needs further investigation) Abbreviated Mental Test Score (AMTS) Hodkinson, H. (1972) Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and Ageing. 1: Each correct answer = I mark Date Date Royal North Shore and Ryde Health Services 1. What is your age? 2. What is the time (to the nearest hour)? 3. Address for recall at the end of the test this should be repeated by the patient to ensure it has been heard correctly 42 West St. 4. What is the year? 5. What is the name of this hospital? 6. Can you recognise two people here (Dr, Nurse, carer etc) 7. What is your date of birth? 8. What is the year of the 1st World War (1914 &/or 1918)? 9. What is the name of the present Prime Minister? 10. Please count backwards from 20-1? (Remember to ask for the address stated in Q 3. TOTAL Equal to or less than 7 = possible cognitive impairment DATE: Signature assessor & designation:. Medications: review for all patients Strategies For Preventing Falls In Hospital These can increase falls risk: Antihypertensives Aperients Opioids Anticonvulsants Antiparkinsonians Diuretic Benzodiazepines Psychotropics Hypoglycaemics Ontario Stratify Score Low Risk 0-5 points Medium Risk 6-16 points High Risk Points 1. Orientation to the bed area and ward facilities, ward routine and staff 2. Lower bed if possible, except during direct clinical care. Ensure brakes are on. 3. Keep bedrails lowered except at appropriate patient request. 4. Place call bell and side table within reach, and instruct patient to call for assistance as required 5. Clear area of hazards-spills, clutter, unstable furniture 6. Ensure safe footwear when mobilising ie well-fitted shoes or non-slip socks. Provide safe footwear brochure to patient and carer 7. Place walking aids within reach 8. Clothing to be good fitting and of appropriate length 9. Fall prevention brochure provided to patient/carer 10. Ensure patient has access to adequate nutrition and hydration 11. Medication review 12. Ensure patient has glasses and hearing aid if required All of the above plus (if available) 13. Orange falls identifiers used: sign and sticker, as appropriate 14. Supervise patient during mobilisation 15. Supervise patient during self care and toileting 16. Regular, individualised toileting plan and prior to settling for the evening 17. Referral to physiotherapy for mobility disorders, and occupational therapy for difficulties in ADL, as per facility policy 18. For over 65 s- consider bone protection medication review: consider vitamin D and calcium supplementation All of the above plus (if available) 19. Use orange falls bracelet identifier to denote High Risk, as appropriate 20. Do not leave patient unattended during planned toileting, self care or mobilising. 21. Locate patient close to the nurses station 22. Use lo-lo/hi-lo bed for patient where available. Ensure bed is near/on the ground if patient is unattended 23. Consider use of IPS (independent patient specials), sitter or family to increase frequency of observation particularly if confused/delirious 24. Consider use of hip protectors

6 Behaviour is a means of communication Any sudden change in behaviour warrants a careful medical review AND a review of the FALL RISK