CAP Problem Goals Triggers Guidelines Physical Activities increase hours of exercises Reports less than 2 hours Personal choice Promotion and physical activity activity in last 3 days Instrumental Activities of Daily living IADLs Persons who engage in less than 2 hours of physical activity over a 3 day period Improve IADL self performance and capacity prevent loss of independent function in IADLs and ADL s and mobility develop goals and strategies to address potential barriers Preserve current independence or improve performance if possible Monitor for acute events e.g. pain that are influencing Independent with mobility Believes he/she could be more independent Good prospect of recovery from current condition IADL capacity 7 or higher ADL Hierarchy score of 3 or less CPS 2 or less Consider options for good level of physical and cognitive function Options for people with IADL/ADL problems Monitor for acute health problem or flare up of chronic problem Identify strengths e.g strong motivation Activities of Daily Living ADLs (Facilitate Improvement) Persons identified who assistance with tasks such as dressing/bathing/eating And appear to have some acute even t which could be reversible Those people who receive assistance with ADLs and not likely to be reversible Monitor interventions such as medications/motivation/mood on functioning Preserve current level of independence as long as possible Address acute problems to reverse functional loss Improve performance if functioning below capacity Target ADLs where improved capacity is possible (Facilitate improvement) Receive help in some ADLs but not totally dependent CPS less than 6 2 or more indicators of an acute event Same as above but less than 2 indicators for acute event Address functional problems if able or address driving problem e.g. falls/pain/ SOB (Facilitate Improvement) Manage the acute onset problem and work to return the person to their preacute functioning level if possible Develop a plan that maintains current level of independence Watch for acute health problems and treat as soon as possible Assessment Instruments Version 9.1 Page 1
CAP Problem Goals Triggers Guidelines Home Environment Safety Issues in relation to Optimization the home environment Institutional Risk CAP Physical Restraints This group have an increased risk of entering a Aged Residential Care Facility in the coming months is issues are not addressed or managed Risk of negative physical and psychosocial outcomes for persons who are restrained Improve the safety of the environment in which the person lives Avoid premature admission to an ARC setting by supporting family efforts and providing community intervention Identify and treat symptoms related to use of restraints, try alternative approaches and evaluate the outcome of this on an ongoing manner Need to have one or more of the following issues -lighting, flooring, bathroom or toilet, kitchen, heating or cooling, significant disrepair, squalid condition And Two or more of the following indicators or frailty Not able to climb stairs, less than 2 hrs activity in last 3 days, unsteady gait, poor health, conditions that make the person unstable, difficult to access the home or rooms in the home, DRS 3 or higher or mental health symptoms Four or more of the following coded Any stay in ARC in past 5 years, STM problem, decision making problem Alzheimer s, problems with communication, any behavior issues, help with transferring/mobility/personal hygiene, decline in past 90 days wheeled by others, not going out of the house, falls, urinary incontinence Triggered to remove in those people in restraints that have ability to perform Some ADLs Triggered to remove in those with little or no ability to perform ADLs Education to remove or reduce hazards in the home e.g. removing mats, having smoke alarms checked Referral for home alterations e.g. walk in shower/ ramp Self neglect cases with squalid conditions require intervention from specialist services Address all relevant CAPs triggered Work with family to monitor if issues worsen Carer relief and HBSS may be appropriate Consider a person s reversibility and rehabilitation potential Referral to OT to look at appropriate seating There must be a detailed documented plan for the use of the restraint Assessment Instruments Version 9.1 Page 2
If related to falls/wandering/behaviour has everything been done to reduce the risk of this indicator Cognitive Loss Delirium At risk of losing cognitive ability At risk of potential health complication if cause not treated. Optimise the ability to perform ADLs and participate in an active social life, to prevent further cognitive/physical decline and encourage safe and independent decision making Identify and treat underlying cause, monitor and care for symptoms, prevent secondary complications and recurrence CPS is 0,1 or 2 and two or more the following clinical risk factors are present: Diagnosis Alzheimer s/dementia, poor communication, mood indicators, wandering, physically abusive, easily distracted, disorganized speech, mental function varying over the day, decline in cognition in last 3 months, 6 or fewer months to live Triggers if behavior in the following areas are different from usual functioning, easily distracted, disorganized speech, mental function varies over the day If related to risk of removal of a medical device e.g. tube what other interventions could be put in place Refer for a clinical investigation if no diagnosis present Consider reversible causes for cognitive loss e.g. delirium, medication side effect Maximize opportunities for independent activity Refer for medical assessment and intervention Consider a medication review Are environmental or psychosocial factors contributing Communication Risk of non effective communication with others Prevent avoidable loss of communication skills, monitor (Facilitate Improvement) if a person has both Assess the issues that can impact on communication Assessment Instruments Version 9.1 Page 3
Mood Mood disorders are often under diagosed and untreated in the Elderly and can contribute to high mortality, functional decline and unnecessary suffering causal factors and treat as appropriate, work with families and caregivers to ensure effective communication Identify and address threats to the persons or others safety, treat any underlying conditions, implement a treatment program and monitor for response moderate to severe shortfalls in expression and comprehension and some ability to engage in daily decision making Those with better communication skills and worse cognition. Triggers by the calculation of the DRS from indicators in the mood section and if they are present daily or less DRS 3 or higher high risk DRS 1 or 2 med risk such as mood/ oral motor function Assess the components of communication such as hearing/ non verbal communication could be done by audiologist or SLT Review medications Referral for assessment and treatment Determine the nature and cause of the mood disorder Provide ongoing monitoring Review medication Behaviour Behaviour is disruptive to both the person and others who they come in contact with Eliminate underlying conditions or stressors that contribute to behaviour s, decrease the frequency or intensity or the behavior, prevent secondary complications arising and help staff and caregivers cope with behaviours Triggered reduce daily behaviours or triggers to prevent behaviours from occurring daily Could it be related to a change in another medical condition What is the nature of the behavior is it a type of communication Identify the causative or exacerbating factors e.g. flare up of a health condition or side effect of a new medication Build on a person s strengths e.g. when positive behavior is present what could be replicated to make this occur Assessment Instruments Version 9.1 Page 4
Abusive Relationship Persons who experience abuse may be at immediate risk or injury or other serious health problems and can affect all aspects of daily life and wellbeing Determine the level of risk and need for immediate intervention, evaluate the person s ability to decision make about their own welfare, monitor for long term mental health complications related to abuse High risk - if abuse indicators are present and two or more stressors are present, DRS 3 or higher, low BMI, Anger or conflict, non compliance with medicating, caregiver distress, social isolation Moderate risk if indicators of abuse are present more often Refer for assessment and intervention follow up and monitoring Could an increase in services assist with caregiver distress If a person is in immediate danger an emergency response is required Informal Support The person will put themselves at risk if there is no one to assist with IADL tasks that are necessary for daily functioning and is unable to do the task safely. Develop an informal support plan to meet the needs of the person s needs if they are available, consider what formal supports can assist, short term help may be required for those with acute needs Triggered if not independent with one or more IADL areas and have two of the following: are alone for long period lives alone or no primary informal helper present Carefully assess care needs and identify support systems that cannot fully compensate Establish reasons why the informal support cannot continue Social Relationships Decreases in a person s social relationships may affect psychological wellbeing and have an impact on mood, behavior and physical activity Engaging the person with other people, addressing conflicts, identify reasons for withdrawal, identify methods of increasing an persons engagement in social activities while keeping in mind preferred level Feels lonely CPS 3 or lower Has the ability to understand others Review other triggered CAPs to see in what areas the person might be able to improve e.g. pain Determine what their preferences are What factors are impinging on social exchanges Treatment involves offering age appropriate options/ treating mood issues, build upon strengths Assessment Instruments Version 9.1 Page 5
Falls Pain Falls are a leading cause of morbidity and mortality as people age and are an important cause of injury The presence of pain along with being an unpleasant sensory and emotional experience can lead to a increased sense of helplessness, anxiety, depression, decreased activity and appetite and disrupted sleep. Identify and change underlying risk factors for falls, promote activity safely Identify and treat underlying reasons for pain, optimize the ability to perform activities of daily living and to live an active social life, relieve suffering, monitor treatment efficacy nd adverse effects, recognize the associating between pain and other psychosocial factors. High Risk 2 or more falls in the past 90 days Moderate Risk 1 fall in the past 90 days High Risk any severe, horrible or excruciating pain Medium Risk daily pain described as mild or moderate. Complete assessment of the fall including medical conditions, symptoms, visual impairment, cognitive impairment, environmental factors Complete an in depth assessment of pain including frequency, intensity, determine location, type and response Manage the pain using pharmacological and non pharmacological intervention Pressure Ulcer Cardio respiratory Conditions Pressure Ulcers have negative outcomes including pain and suffering, increased risk of infection and mortality ( a person with a pressure ulcer has a three times the mortality risk of a person without an ulcer) All Cardio respiratory problems can severely restrict a person s lifestyle Prevent ulcers from occurring, optimise wound healing, achieve a clean ulcer with granulation, maintain moist local skin environment, monitor progress of healing, prevent development of more severe or new pressure ulcers, monitor skin for emerging pressure ulcers Help non physicians working with older adults to identify potiential symptoms and refer to a physician or other health Triggered Stage 2 ulcer present Triggered - no ulcer but at risk due to stage 1 ulcer or has risk factors present such as dependent with bed mobility, history of ulcers, IDC, venous ulcer or is receiving wound care Triggered if a person displays any of the following symptoms; chest pain, shortness of breath. Irregular Look to see where other CAPs may be triggering due to pain Assessment of the wound looking for necrotic tissue, signs of infection, presence of granulation If wound not healing look for complicating factors e.g. infection, under nutrition Relieve pressure/ maceration and friction for those people with risk factors Despite previous treatment or investigation those people displaying these symptoms should be reassessed Assessment Instruments Version 9.1 Page 6
Under nutrition Adverse consequences of under nutrition include placing the person at risk of premature death, continued weight loss, functional decline, heart, skin problems and risk of infection professional those who exhibit those signs and symptoms. Address underlying disease, condition s or medications that contribute to under nutrition or risk of it, implement a treatment plan to ensure adequate caloric intact to prevent further weight loss. pulse, dizziness High risk BMI lower than 19 and no terminal prognosis Medium Risk BMI 19-21 and no terminal prognosis Referral to exercise and educational programs may be appropriate Assessment of current eating patterns Assessment of food preferences, swallowing problems, dental problems, dry mouth, need for assistance with eating, special diets Dehydration Prevention Appropriate Medications Complications include drop in Blood Pressure, increased pulse rate and electrolyte imbalances, falls, delirium and constipation If not all screening tests are completed a person is at greater risk of preventable illness or early diagnosis Problems occur if medications interact, or are at too higher a dose or are not reviewed regularly Identify and treat the underlying cause of dehydration, rehydrate, establish suitable monitoring, prevent complications, provide comfort Identify people who have not completed all screening and outline benefits. Promote the management of each person neither over treating or under treating, appropriate dose, timing and length of use, promote adherence to the medication schedule High Risk identified as having been dehydrated or taking insufficient fluids and have one or more causes or complications of dehydration Low Risk identified as being dehydrated but no complicating factors present. Triggered Level 1 visited a GP but not all screening done Triggered Level 2 no visit to GP Triggered 9 or more medications with two or more of the following symptoms: chest pain, dizziness, Odema, SOB, Poor Health and recent deterioration Monitoring of eating to assess for changes. Assessment is required to determine cause and treatment plan Promotion of attendance to screening Promotion of attendance to GP regularly. Refer for a medication review If PRN medication charted but hasn t been taken for some time Assessment Instruments Version 9.1 Page 7
Tobacco and Alcohol use Urinary Incontinence Bowel Conditions Both Tobacco and Alcohol use have adverse effects for the older person Causes many problems including skin rashes, falls, isolation, pressure ulcers, infection Looks for the presence of constipation, diarrhoea and faecal incontinence. Most bowel conditions impact on social functioning and have varying degrees of potential harm Ensure those who some are provided with appropriate advice and support for smoking cessation, offer appropriate advice, support and treatment to reduce alcohol consumption if needed to reduce harm in persons who consume high levels of alcohol Recognize incontinence and establish cause, improve bladder function in those who could improve by appropriate diagnosis tic and therapeutic interventions, prevent increasing degrees of incontinence in persons who are already incontinent and may benefit from a treatment program Recognize the existence of one or more of these three conditions and establish a cause, address each in a way that the person is able to function as normally as possible and be able to monitor bowl function over time Triggered if smoking daily or person who has had 5 or more drinks at a single sitting in the last 14 days Facilitate Improvement recurring episodes of incontinence with cognitive ability, mobility and indicators of an acute condition Prevent Decline recurring episodes of incontinence, some cognitive function, and no acute indicators. Those with very poor cognition with incontinence do not trigger the CAP Facilitate Improvement has a some risk of decline but also some ability to improve and the person has some level of bowel incontinence Prevent Decline - triggers if is at higher risk of declining and has some bowel incontinence. Any non-adherence should be notified to the prescriber Assessment of tobacco and or alcohol use Treatment options should be explored with a specialist service Assessment of incontinence identify the type e.g stress, urge, mixed, overflow, look for modifiable factors and contributing factors including mobility, use of pads Assessment of bowel problems, patterns, contributing and modifiable factors. Depending on the cause different care planning options are available. Assessment Instruments Version 9.1 Page 8