1. “You can Observe a Lot by Watching!”
-Yogi Berra
CIRAC : The Reasons, the Research, and the Ramping Up
Shirley M. Neitch, MD, FACP
Maier Professor of Clinical Research Chief, Section of Geriatrics
Department of Internal Medicine Marshall University/Joan C. Edwards School of Medicine

2. Cognitive Impairment Recognition in Acute Care
Goal: Improving of the care of patients in acute care settings who have delirium or dementia
Objectives:
Define the problem of unrecognized cognitive impairment
How often it happens
Why it happens
Delineate difference between recognition, screening, and diagnosis
Outline a program of “Universal Observation” to be a part of every patient encounter
Empower non-clinical as well as clinical personnel to report observations: “See something/Say something”™

3. CIRAC: What is Cognition
Cognition = thinking, knowing, perceiving
Orientation Language
Attention Learning
Memory Calculation
Abstraction “Executive” function
Judgment/Insight Social interaction

4. Can be impaired temporarily or permanently by medical illness
Cognition
Can be impaired temporarily or permanently by medical illness
Temporary = delirium
Medical illness (esp. infection, metabolic disorders), brain injury (trauma, stroke, etc.), intoxication (alcohol, drugs), withdrawal from intoxicants
Permanent = dementia
Degenerative diseases, late effect of infections or deficiencies, structural disorders, etc.
Can be impaired in psychiatric illness

5. CIRAC: Why must impairment be recognized?
Delirium:
Can be caused by very serious, even life-threatening, problems that can usually be treated and often cured
Dementia:
Knowledge of its presence is hugely important for proper care, transitions of care, and discharge planning

6. CIRAC: Surely we don’t miss cognitive impairment in acute care?
40+% of elderly patients in hospitals have Cognitive Impairment
Up to 50% of them have no notation of CI in chart
Shenkin, et al, Screening for Dementia and Other Causes of Cognitive Impairment in General Hospital Inpatients. Age Ageing 2014; 43(2):
Recent review of discharges from a British hospital:
Of those > 75yo, 75% had some level of CI, and for 37%, it was a new dx
Shermon, et al, Cognitive Assessment of Elderly Inpatients. Dement Geriatr Cogn Disord Extra 2015; 5: 25-31

7. 60% of pts > 60 yo had undx’d CI
Missing CI in AC
60% of pts > 60 yo had undx’d CI
Partridge, et al. The prevalence and impact of undiagnosed cognitive impairment in older vascular surgery patients. J Vasc Surg 2014 Oct; 60(4):
Hanon, et al. Prevalence of memory disorders in ambulatory patients aged >70 years with chronic heart failure (from the EFICARE study). Am J Cardiol Apr 1; 113(7):
291 cardiologists; 912 patients
Cardiologists suspected memory impairment in 109 persons – 12%.
All patients tested and memory impairment found in 46%; severe in 23%.

8. How/why is Cognitive Impairment missed?
System-caused reasons
Patient-related reasons

9. Healthcare system reasons why CI may be missed
“Fog is more dangerous than dark, as it gives the illusion of seeing.” Aleksandra Ninkovic
Fog production in healthcare:
Shortened LOS
More procedures during a shortened LOS
Fragmented care teams
EHR
Even….architecture and design

10. Healthcare System reasons why Cognitive impairment may be missed
Shortened LOS:
Average LOS by age group: 1980 vs 2010
(All ages – Avg. LOS 4.8 days)
Age
1980
2010
65+
10.7
5.6
75+
11.4
5.7
85+
12.0

11. More procedures during a shortened LOS(Procedures done in 63% of hospitalizations)
Increase rate of proc
Indwelling catheter
213%
Vaccinations
185%
Blood transfusion
126%
Spinal fusion
115%
Paracentesis
99%
I&D skin
97%
Arthroplasty knee
96%
Parenteral nutrition
95%
A-gram or venogram
76%
Hemodialysis
58%
Intubation/Mech. Vent.
57%

12. Healthcare System reasons why Cognitive impairment may be missed
Fragmented care teams:
Old model – One patient → One attending physician (who was also the pt’s outpatient doctor), and one nurse per shift.
New model – One patient → One hospitalist, one nocturnalist, several specialists, resident physician teams, students, PCP by phone only (if at all), one nurse per shift, one CNA per shift for VS cks., a pharmacist, and a navigator.
~2 ½ days → 2 hospitalists/one gastroenterologist/two general surgeons/one surgical PA with a PA student/one 4th year med student/one resident on GI +…

13. Healthcare System reasons why Cognitive impairment may be missed
Electronic Health Record
Carrington, J. and Effken, J. Strengths and limitations of the EHR for documenting clinical events. Computers, Informatics, and Nursing, June (6):
Identified important clinical events which can lead to “failure to rescue”. Ex: ∆ in MS, hypoxia, drop in H&H. ∆ in MS most common.
100% of the nurses reported the EHR was a “barrier” to communicating the events
50% - lack of efficiency
31% - lack of relevance of documentation

14. Healthcare System reasons why Cognitive impairment may be missed
Other miscellaneous issues
New hospital design –
No more roommates = fewer observers per patient
More isolation from staff
Restrictions on payment for certain testing as inpatient
Concentration of clinical efforts on the “Hospital Never” events

15. Patient-related reasons why CI may be missed
The clinical nature of disorders causing cognitive impairment
Delirium
Dementia
Delirium-on-dementia

16. Delirium – Altered mental status which:
The clinical nature of disorders causing cognitive impairment to be missed: Delirium
Delirium – Altered mental status which:
Develops rapidly
Fluctuates over time
Need frequently repeated observations!
Patient looks like:

17. Agitated
Fearful/paranoid
Psychomotor
activity increased
Picking at things
Hallucinating
May be febrile,
tachypneic, and
tachycardic
Hyperactive

18. Unusually
subdued
Sleeping
excessively
“Listless”
Weak
VS may be
normal
Hypoactive #1

19. Dementia – Altered mental status which:
The clinical nature of disorders causing cognitive impairment to be missed: Dementia
Dementia – Altered mental status which:
Develops very slowly (usually years)
In acute care, you will rarely have a baseline frame of reference
May cause pts to be quite non-communicative
Need medical hx information from family or records

20. Dementia – Altered mental status which:
The clinical nature of disorders causing cognitive impairment to be missed: Dementia
Dementia – Altered mental status which:
Causes patients to “perform” better at some times than at others
Need frequently repeated observations
Usually allows patients to maintain superficial social intactness
Need to specifically “challenge” with standardized questioning #1

21. Delirium-on-dementia
The clinical nature of disorders causing cognitive impairment to be missed: Delirium-on-Dementia
Delirium-on-dementia
Acute illness in persons with dementia can cause delirium as it can in otherwise cognitively intact persons
Just as important to identify and treat the delirium
Missed because of assumption that the altered MS is the dementia
Need detailed and specific clinical history of acute change

22. Cognitive Impairment Recognition in Acute Care
Objectives:
Delineate difference between recognition, screening, and diagnosis
Recognition vs Screening vs Diagnosis
Are there Dementia Care Best Practices to guide Recognition to Screening to Diagnosis?

23. Best Practices – Recognition of CI
Alzheimer’s Association - Ten Warning Signs
10 warning sx of AD. Many of these signs are not directly relevant to an acute care setting, and/or would not be detectable by anyone unfamiliar with the patient, and are not directly relevant to delirium.

24. Best Practices – Recognition of CI
The Hartford Institute for Geriatric Nursing and the Alzheimer’s Association – “try this: Best Practices in Nursing Care for Hospitalized Older Adults” (vol.1, #5, 2004)
Suggests 4 Best Practices:
Ask the person and family if they have severe memory problems
Ask if a doctor has ever said they have AD or dementia
- if “no” -
Administer family questionnaire
Record patient behaviors
Undeservedly obscure!
1 & 2, should be in hx but? 3- unlikely to be done in acute care unless mandated 4- similar to our proposal. Only “4” relevant to delirium.

25. Best Practices – Recognition of CI
WV Chapter Alzheimer’s Association

26. WV Chapter Alzheimer’s Assoc.

28. Best Practices – Recognition of CI
Literature search:
Almost all articles, regardless of title, referred to screening and diagnosis, not recognition
200+ references describing screening tools
Mass screening is not recommended for the general public nor for any specific demographic group.
A couple of on-going projects identified; no published results available
Listening sessions:
Acute care staff
Families

29. Best Practices – Recognition of CI
Listening sessions:
Acute care staff say they know when CI is present “most of the time”, but say they hear “in report” or otherwise verbally, not found documented in chart
Staff often do not proceed to document themselves
Families consistently report that patients are not approached as if they have any CI.
Questioning may border on harassment
Instructions not tailored
Observation insufficient, especially when transported off their floor

31. Cognitive Impairment Recognition in Acute Care
There is much literature about screening for and/or diagnosing CI.
However, an error (the failure to recognize) is often made before
the screening step is reached. Evidence of cognitive lapses must be
recognized before screening/diagnosing can be done.
In the current inpatient climate, speedy diagnosis and treatment of acute
problems takes precedence over comprehensiveness of care. Subtle signs
of cognitive change may never recognized as problematic.

32. MMSE, MoCA, Mini-Cog, CAM, etc. Diagnosis
Delineate the difference between Recognition, Screening, and Diagnosis – Specifics of CIRAC
Recognition
CIRAC
Screening
MMSE, MoCA, Mini-Cog, CAM, etc.
Diagnosis
History and Physical, Imaging, Lab tests, Additional memory tests, ….

33. “Light is good from whatever lamp it shines.”
The CIRAC Program
“Light is good from whatever lamp it shines.” 
~Author Unknown
Therefore , first cornerstone principle for CIRAC is “Universal Observations”

34. Universal Observations
Taken directly from the “Universal Precautions” concept, defined by US Department of Labor/OSHA as :
Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other blood borne pathogens. (Blood borne Pathogens Standard 29 CFR (b)

35. Universal Observations
Universal Observations is an approach to recognition of cognitive impairment.
According to the concept of Universal Observations, all patients should be looked upon, by all staff, as being at risk for, and possibly having, cognitive impairment.

36. Universal Observations
ALL Hospital/Acute Care staff members observe patients.
Registration, nursing, laboratory and radiology, housekeeping, security, dietary…
Behaviors and appearances possibly indicative of CI are reported to clinical staff who can follow up.
If you See Something, Say Something.

37. “Red Flags” What should trigger a report to a clinical staff member?
Some abnormal behaviors are fairly obvious:
Patient has fallen
Pt. is screaming or crying
Pt. throws something at a staff member
Pt. cannot be awakened
Pt. acts paranoid, is having hallucinations, talks “out of their head”

38. “Red Flags” Some behaviors are equally important but not as obvious:
Pt. described as “Poor Historian”
Pt. is given food tray but makes no attempt to eat, especially if more than one meal
Repeatedly fails to follow instructions or answer questions
Appears “bewildered”
Unexpectedly wets or soils bed
Becomes extremely agitated over a small matter
Others

39. See something/Say something
See something / say something means:
You (whomever you are) see something (a red flag behavior), and you say something (verbal or written) to a clinical person who knows the patient (a nurse, midlevel provider, doctor)
No one has to do a screening test, such as MMSE or MoCA, except a clinical person who knows the patient, and then only if needed for an individual patient
No one has to make a diagnosis except the doctor

40. See something/Say something
See something / say something does NOT:
Label the patient
Cause a diagnosis to be entered in the chart
But it should:
Lead to further inquiry
And if pt. confirmed as cognitively impaired, can allow them to be identified.
Identification leads to allowing pt’s status to be known to others and evaluation as needed

41. See something/Say something
Reporting to nursing staff
Verbal is acceptable, especially nurse-to-nurse
Other staff to nurse – written observation
Notebooks provided

42. Next Step
Communication of patient’s Cognitive Impairment to others in the Acute Care setting

43. Communication of CI Status
Confirm it:
See something/say something leads to clinician recognition of CI
Chart it:
Nurse/clinical provider documents CI and/or a diagnosis in patient’s chart
Convey the information:
Identify patient to others in the Acute Care setting

44. Communication of Status
Identifying the impaired patient to others in Acute Care
Symbolized by something which must be recognizable to all staff, but non- stigmatizing
Not easily recognizable to non-staff
Armband or armband attachment
Individual
Always with patient

45. What can a Cirac program accomplish?

46. What CIRAC can accomplish
Diminished patient agitation
Proper approach to cognitively impaired person is crucial
More appropriate testing
Delirious patient may not tolerate, and demented patients sometimes should not have, certain tests
Better diagnostic decisions
Irritability may be due to delirium, not to being a mean old woman!
Patients adequately nourished and hydrated

47. What CIRAC can accomplish
More appropriate treatment (of the primary condition and the CI)
Patients with dementia may not be candidates for certain treatments regimens
Delirium must be seen to be treated
Improved patient and family satisfaction
More attention to individuals – POSITIVE!
Improved discharge planning and fewer readmissions
Accommodations made for cognitive impairment = better med adherence, better f/u, better home care, etc.!

48. Summary: CIRAC
“Fog is more dangerous than dark, as it gives the illusion of seeing.”
We miss CI in far too many patients
“You can Observe a Lot by Watching!”
Universal Observations
“Light is good from whatever lamp it shines.”
See Something/Say Something

49. Summary: CIRAC
Universal Observations →
See Something/Say Something →
Cognitive Impairment recognized when present →
Improved patient care →
Improved outcomes