CHOPS
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
• 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 341 000
Delirium 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 Assessment
Presentation 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
facilities
Is 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.
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
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 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
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 administer
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 impairment
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
Comparison of CAM Criteria for Delirium, Dementia and Depression
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
Not present
Not present
Altered level of Present
consciousness
What next?