Care of the Confused Hospitalised Older Persons Study CHOPS ACI in collaboration with CEC and GP NSW and funded through DVA Aims to improve care and reduce harm for confused older people in hospital ID: 191401
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Slide1
CHOPS
Care of the Confused Hospitalised Older Persons StudySlide2
CHOPS
ACI in collaboration with CEC and GP NSW and funded through DVA
Aims to improve care and reduce harm for confused older people in hospital
Expected outcomes include;
Improved patient outcomes
Decrease length of stay
Increase staff awareness
Accuracy of coding for Delirium DRG’sSlide3
The Confused Older Person
Dementia
Third leading cause of death after heart disease and stroke
26 000 new cases diagnosed annually
By 2033 its estimated total cases in NSW will be 341 000
Delirium in Hospital
30% of admissions
Up to 60% frail elderly patientsSlide4
Key Focus areas
Understanding Cognitive assessment
Delirium Risk and Prevention
Identification and management
Communication
Referral pathway
Carer
Discharge Slide5
Cognitive Assessment
Presentation 1Slide6
Cognitive assessment
Cognition assessment for older people is often overlooked in an initial admission process of assessments, thus assuming that any confusion during admission is related to dementia and missing the diagnosis of delirium.
By not identifying delirium, or missing those most at risk of delirium, increases the risk of poor outcomes such as falls, falls, pressure injury, inappropriate use of medications and mortality.
Slide7
Understanding Cognitive Assessment
Finding a baseline
Talking with significant others
GP
Old medical notes including previous assessments
(AMT, MMSE, RUDAS)
Assess premorbid level of functioning
ACAT, home care, residential Aged care facilities
Is the presentation different from this?Slide8
Understanding Cognitive Assessment
Formal Assessment of cognition should be completed before the CAM (confusion assessment method) is attempted
There are a number of assessment tools available that can take anywhere from
2 minutes to 3 hours
Some examples are given in the next slides.Slide9
AMT (Abbreviated Mental Test)
QUESTION
1.
How old are you
2.
What is the time (nearest hour)
Give the patient an address and ask them to repeat it at the end of the test
e.g
42 Market St
Queanbeyan
3.
What year is it?
4.
What is the name of this place
5.
Can the patient
recognise
two relevant persons (
eg
. Nurse/doctor
or relative)
6.
What is your date of birth?
7.
When did the second world war start? (1939)
8.
Who is the current Prime Minister?
9.
Count down backwards from 20 to 1
10
Can you remember the address I gave you?
TOTAL SCORE
If score 7 or less screen for delirium using the CAM ……
If score 8 or greater assess for delirium symptoms and riskSlide10
Six-Item Screener
Three items to remember, I will say them, then you repeat them.
Apple
Table
Car
What is the year?
What is the month?
What is the day of the week?
After 3 minutes ask to repeat the items
Apple
Table
Car Slide11
Clock Drawing Test
Assesses global cognitive function and reflects subtle changes in brain function
People with dementia have difficulty in both placing the digits and indicating correct positioning of the hands
People with Delirium have difficulty completing the task (inattention)
Assesses
Visuospatial
organisation
Integrative functions
Abstract thinking
Number of scoring systems
Watson – 0 perfect scoreSlide12
MMSE and SMMSE(Malloy)
Most commonly used tool – although recent questions over validity and copyright issues
Limits inc
CALD
Age
Socio-economic status
Education – not for those with less than 8 yrs ed.
Frontal impairment
5-10 min to perform
Score /30
24/30 indicates cognitive impairmentSlide13
3MS
The Modified Mini-Mental State (3MS) incorporates four added test items, more graded scoring, and some other minor changes.
These modifications are designed to sample a broader variety of cognitive functions, cover a wider range of difficulty levels, and enhance the reliability and the validity of the scores.
The range of scores from 0-100.
Greater sensitivities of the 3MS over the MMS have been demonstrated.
The 3Ms is thought to have greater validity
15min to administerSlide14
RUDAS
Developed for multi-cultural setting
Assesses wide range of domains including frontal lobe function
Limits
Bed bound or immobile patients
Not as familiar
Takes 8-10 min
Score /30
22/30 indicates cognitive impairmentSlide15
CAM
Confusion Assessment Method
Feature 1. Acute Onset of Mental Status changes or fluctuating course
Feature 2. Inattention
Feature 3.
Disorganised
Thinking
Feature 4. Altered level of consciousness
Delirium is diagnosed when both 1 and 2 are positive along with either 3 or 4 Slide16
CAM Criteria
DELIRIUM
DEMENTIA
DEPRESSION
Acute onset & fluctuating course
Hours to days
Months to years
Decline with no fluctuation
Weeks to months
Day to day fluctuation possible
Inattention
Present
Present in late stages
Possible present
Disorganised
thinking
Present
Memory Impairment
Present in severe cases
Altered level of
consciousness
Present
Not present
Not present
Comparison of CAM Criteria for Delirium, Dementia and DepressionSlide17
What next?