1. CNS R OLE A PPLICATION

2. E LDER L IFE CNS R OLE – SPHERES OF CARE INFLUENCE Patient level – comprehensive geriatric assessment, protocol driven, follow up assessment and interventions, education for patients and families Staff level – coaching and education on delirium prevention and functional decline; participation in care rounds System level – program operation, quality assurance, identification of care gaps and interventions

3. HELP N URSING P ROTOCOLS Targeted Risk Factor Approach using protocols Evaluation of Cognitive Status Delirium Protocol Dementia Protocol Psychoactive Medications Protocol Sleep Enhancement Protocol Early Mobilization Protocol

4. M ORE HELP N URSING P ROTOCOLS Hearing Protocol Fluid Repletion Protocol Discharge Planning Protocol Optimizing Length of Stay Protocol Additional Areas –

5. E XAMPLE : D ELIRIUM P ROTOCOL Assessmen t establishes baseline, cognitive tool plus CAM and collateral history psychoactive medications and ETOH use bloodwork then daily- structured cognitive tool plus the CAM and ongoing staff, family and volunteer inputs

6. IF PATIENT CHANGES SUDDENLY …. Review medication list for potentially contributory medications or potentially harmful interactions Search for occult infection, e.g., urinary tract infection (UTI) Rule out drug or alcohol withdrawal Support referrals to geriatrics, pharmacy, internal medicine

7. M ORE D ELIRIUM I NTERVENTIONS Non-Pharmacological Management Education for staff, involve family Strategies to decrease agitation and improve sleep Communication techniques

8. A T HHS, THE HELP NURSE ……. Follows HELP delirium protocols Structured cognitive assessment is not carried out daily but on admission and as indicated No discharge sMMSE is completed

9. A DHERENCE -W HAT DOSE OF HELP IS ENOUGH ? The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions Higher levels of adherence resulted in reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group. Inouye SK. Arch Intern Med. 2003;163:958-964

10. A T HHS…… 2005 A DHERENCE 68%-best for orientation, vision and hearing, therapeutic activities and feeding protocol 34% -lowest for mobility and sleep protocol

11. W HAT FACTORS AFFECT ADHERENCE ? A RE THEY MODIFIABLE ?

12. C OGNITIVE SCREENING I NSTRUMENTS InstrumentAdmin timeComments Sweet 163-5 minsPublished Nov 2010- on HELP website Mini-Cog3-5 minBrief, validated Short portable status questionnaire 3-5 minutesBrief 3MS10-15 minsMMSE plus remote memory, verbal fluency and abstraction sMMSE/Folstein10-15Copyright requires authors permission- per use fee with Folstein Montreal Cognitive Assessment (MoCA) 10-20 minutesOpen access-

13. T HE S WEET 16 PURPOSE: screening tool for cognitive impairment Why another tool? Length, burden,copyright ADVANTAGES : simple, rapid, paperless, validated against the MMSE, open access CONSTRAINTS : early days of testing Fong,T. Arch Intern Med. 2010 Nov 8

14. C ASE S TUDY M RS. S MITH IS A 91 YEARS OLD LADY ADMITTED FROM R.H. WITH LOW BACK PAIN

15. H ISTORY OF PRESENTING ILLNESS Sudden increase in low back pain 3 days ago; unable to walk, new onset of urinary incontinence. GP started Lorazepam 1 mg Q HS 5 days ago for poor sleep. Confusion over 48 hours –disoriented to time, not consistently recognizing family

16. P AST M EDICAL H ISTORY Hypothyroidism Dyslipidemia Hearing loss Macular degeneration Hypertension ?TIA Arthritis Chronic Low Back Pain Degenerative Disc Disease, Scoliosis

17. S OCIAL HISTORY Widowed, 3 children, 9 grandchildren Retired teacher – grade school and ESL Enjoys listening to music, attending socials and visiting with families

18. B ASELINE F UNCTION Walks with walker independently to D/R Toilets independently; no history of incontinence Assisted with bath 2 X per week 1 year history of short term memory loss, repeats stories, forgets family visits

19. I NVESTIGATIONS CT scan: no obvious fracture except for possibly a displaced right transverse process fracture of L3 Labs Lab FindingsNormal Range urea 11.2 Creat 115 TSH 18 WBC 13,3 Hgb 130

20. M EDICATIONS Aspirin 81 mg OD Lorazepam 1 mg Q HS Baclofen 10 mg TID Levothyroxine 0.125 mg OD Hydrochlorothiazide 25 mg OD Lipitor 20 mg OD Fosinopril 20 mg OD Colace 100mg BID Senokot 2 tabs Q HS Tylenol # 3 1-2 Q 4 H PRN