1. Cognitive Impairment in Patients Admitted to the Inpatient Unit: do we screen patients for it? Dr Clare Kendall Dr Rebecca Bhatia St Peter’s Hospice, Bristol

2. Background: incidence Common clinical problem in palliative care Common clinical problem in palliative care Incidence 26-44% in reported studies Incidence 26-44% in reported studies Prospective study at BHOC 54% Prospective study at BHOC 54% Incidence rises as patients deteriorate Incidence rises as patients deteriorate 83% in final days 83% in final days Potentially reversible in 50% Potentially reversible in 50% Not detected in 22-50% Not detected in 22-50% Comparison with baseline crucial Comparison with baseline crucial

3. Background: risk factors Increasing age Increasing age Cognitive status: dementia, depression Cognitive status: dementia, depression Functional status: immobility, falls Functional status: immobility, falls Sensory impairment Sensory impairment Decreased oral intake Decreased oral intake Drugs Drugs Co morbidities Co morbidities Precipitating factors: infection, anaemia, pain, sleep deprivation, neurological events etc.. Precipitating factors: infection, anaemia, pain, sleep deprivation, neurological events etc..

4. Screening Tools Mini-mental state examination Mini-mental state examination Abbreviated mental test score Abbreviated mental test score Confusion Assessment Method Confusion Assessment Method Memorial Delirium Assessment Scale Memorial Delirium Assessment Scale Confusion Rating Scale Confusion Rating Scale Clock Drawing Test Clock Drawing Test Vary in ease of use, operator training, time to complete Vary in ease of use, operator training, time to complete

5. Prevention of Delirium- HELP Programme Familiar objects Familiar objects Clock/newspapers/calendars Clock/newspapers/calendars Orienting conversation Orienting conversation Day/night clarity Day/night clarity Sleep enhancement Sleep enhancement Limit room and staff changes Limit room and staff changes Early mobilisation Early mobilisation Hearing aids and glasses Hearing aids and glasses Maintain usual routine for meals/medication Maintain usual routine for meals/medication Prevent dehydration Prevent dehydration Address reversible causes early Address reversible causes early

6. Audit Proposal A retrospective review of notes of all admissions to Brentry Inpatient Unit in October 2007 A retrospective review of notes of all admissions to Brentry Inpatient Unit in October 2007 Was there any evidence of screening for cognitive impairment using any recognised method? Was there any evidence of screening for cognitive impairment using any recognised method? Of those identified with cognitive impairment was there any evidence of implementation of a nursing care plan for confusion? Of those identified with cognitive impairment was there any evidence of implementation of a nursing care plan for confusion?

7. Standards 1. All patients admitted to the inpatient unit should have documented evidence of having been screened for cognitive impairment using a recognized screening tool, unless they are unable to complete this 2. All patients found to have cognitive impairment should have a confusion care plan followed

8. Justification for Standards No published guidelines but: No published guidelines but: Known high prevalence Known high prevalence Known poor detection rate Known poor detection rate Known associated high risk to patients Known associated high risk to patients Known associated high cost to providers Known associated high cost to providers Several papers recommending screening to compliment good practice Several papers recommending screening to compliment good practice

9. Methods Patients identified from admissions book Patients identified from admissions book Notes reviewed for evidence of: 1.Documented use of screening tool to identify cognitive impairment 2.Any entries to suggest cognitive impairment 3.Inclusion of completed confusion care plan in notes Notes reviewed for evidence of: 1.Documented use of screening tool to identify cognitive impairment 2.Any entries to suggest cognitive impairment 3.Inclusion of completed confusion care plan in notes

10. Results: Screening Tools 28 admissions to inpatient unit October 2007 1 patient had documented use of screening on admission (4%) 5 patients had evidence of modified screening tests (18%) 11 patients had comments on mental state in notes (39%) 6 patients had no evidence of screening (21%) 5 patients deemed too unwell to have coped with screening (18%)

11. Results: Cognitive Impairment Of the 4 with cognitive impairment, only 1 patient (25%) had evidence of a confusion care plan in notes 28 admissions in October 2007 4 cognitive impairment (14%) 19 nothing in notes to suggest cognitive impairment (68%) 5 patients too unwell to have coped with screening (18%)

12. Implement Change Discussion at Clinical forum: Screen all patients on admission Discussion at Clinical forum: Screen all patients on admission Include screening tool in admission notes Include screening tool in admission notes Which screening tool? Which screening tool? Clock drawing test chosen Clock drawing test chosen

13. Clock Drawing Test: Pros Quick Quick Simple Simple Validated in many settings Validated in many settings Correlates well with MMSE scores Correlates well with MMSE scores High specificity 0.96 High specificity 0.96 High sensitivity 0.86 High sensitivity 0.86 High negative predictive value 0.93 High negative predictive value 0.93 Not affected by IQ, language, mood, culture Not affected by IQ, language, mood, culture

14. Clock Drawing Test: Cons Many scoring systems available so need to be clear which system is in use Many scoring systems available so need to be clear which system is in use Unsuitable for those with upper limb dysfunction Unsuitable for those with upper limb dysfunction Unsuitable for those with marked visual impairment Unsuitable for those with marked visual impairment

15. Clock Drawing Test: Instructions Ask patient to draw face of clock Ask patient to draw face of clock Ask patient to draw in hands of clock showing a specified time eg 10 to 2 Ask patient to draw in hands of clock showing a specified time eg 10 to 2 Repeat instructions as needed UNTIL patient has started drawing Repeat instructions as needed UNTIL patient has started drawing Do not cover watches/clocks Do not cover watches/clocks Abnormal result is score of 3 or more as per Shulman scoring system Abnormal result is score of 3 or more as per Shulman scoring system

17. Re-Audit Proposal A retrospective review of notes of all admissions to Brentry Inpatient Unit in January 2008 A retrospective review of notes of all admissions to Brentry Inpatient Unit in January 2008 Was there any evidence of screening for cognitive impairment using Clock Drawing Test? Was there any evidence of screening for cognitive impairment using Clock Drawing Test? Of those identified with cognitive impairment was there any evidence of implementation of a nursing care plan for confusion? Of those identified with cognitive impairment was there any evidence of implementation of a nursing care plan for confusion?

18. Re-audit results: screening 30 admissions to inpatient unit January 2008 24 patients screened with Clock Drawing Test on admission (80%) 1 patient had no documented evidence of screening (3%) 0 patients had evidence of use of modified screening tools 5 patients unable to complete screening (17%)

19. Re-audit results: cognitive impairment 25 patients screened on admission to inpatient unit in January 2008 13 patients had abnormal Clock Drawing Test (CDT) (52%) 10 abnormal CDT and evidence of CI (77%) 3 abnormal CDT and no initial evidence of CI (23%) 12 patients had normal CDT and no evidence of cognitive impairment (48%)

20. Re-audit results: cognitive impairment 10 patients with evidence of cognitive impairment 3 patients had confusion care plan in notes (30%) 7 patients had no evidence of confusion care plan

21. Results versus standards CriteriaStandard Results – October 07 Results – January 08 100% of admissions not meeting exclusion criteria to be screened for cognitive impairment 100%4%96% 100% of those patients identified as being cognitively impaired to have a confusion care plan completed 100%25%30%

22. Further changes from re-audit Amended wording on CDT sheet Amended wording on CDT sheet SCORE: SCORE: If >3, initiate management plan to identify reversible causes If >3, initiate management plan to identify reversible causes If >3, inform nurses to implement confusion care plan If >3, inform nurses to implement confusion care plan Confusion care plan implemented Confusion care plan implemented