CHOPSCare 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

• Expected outcomes include;

• Improved patient outcomes• Decrease length of stay• Increase staff awareness• Accuracy of coding for Delirium DRG’s

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 000Delirium in Hospital

▲ 30% of admissions ▲ Up to 60% frail elderly patients

Key Focus areas

• Understanding Cognitive assessment• Delirium Risk and Prevention• Identification and management• Communication

Referral pathway Carer Discharge

Cognitive AssessmentPresentation 1

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.

 

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

facilitiesIs the presentation different from this?

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.

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 risk

Six-Item Screener

Three items to remember, I will say them, then you repeat them.

AppleTableCar

What is the year?What is the month?What is the day of the week?

After 3 minutes ask to repeat the itemsAppleTableCar

Clock Drawing TestAssesses 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 score

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 impairment

3MSThe 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 administer

RUDASDeveloped 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 impairment

CAM Confusion Assessment Method

Feature 1. Acute Onset of Mental Status changes or fluctuating course

Feature 2. InattentionFeature 3. Disorganised ThinkingFeature 4. Altered level of consciousness

Delirium is diagnosed when both 1 and 2 are positive along with either 3 or 4

CAM Criteria DELIRIUM DEMENTIA DEPRESSION

Acute onset & fluctuating course

Hours to days Months to yearsDecline with no fluctuation

Weeks to monthsDay 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 Depression

What next?