Dementia Training
Training support • Skills development • Competency • Assessment • Scholarships • Education
Training to care for people with dementia
Development of a brief delirium screen
for older patients in the Emergency
Department
Malcolm Hare,
Fremantle Hospital
PhD Candidate
Training to care for people with dementia
Background
•
•
•
•
•
Delirium is an episode of acute confusion, and signals a serious
physiological problem.
It occurs frequently in older hospitalised patients and is often present
on arrival in ED
Older patients with delirium are at high risk of a range of serious
adverse outcomes
Early recognition leads to early treatment and management with better
outcomes (↑ survival, ↓ LOS, ↓ falls, ↓ ‘specialling’,
↓ discharge to nursing home etc), BUT
Recognition of delirium by nurses and other health staff is poor
Training to care for people with dementia
Background
•
•
•
2006:
Investigated nurses’ knowledge of delirium and its risk factors
– Demonstrated that nurses knowledge is generally poor, especially
in relation to risk factors
– Questionnaire (or parts of it) now in use in Victoria, NSW,
Queensland, Ireland and the USA
Delirium prevalence by audit of in-patient notes
– Approx 10% prevalence
– Poor documentation, suggestive of poor understanding
– Many cases of probable delirium undiagnosed
Training to care for people with dementia
Background
• 2006:
• Delirium screening using CAM and AMT with patients aged 65
years and over in the ED
• Found to be time-consuming and problematic even with AMT
(which is briefer than the required / recommended MMSE)
• Published in International Emergency Nursing Journal 2008 –
– In top 10 most downloaded articles second half of 2008 and
first half of 2009
Training to care for people with dementia
Background
•
•
•
•
•
Tools to screen for cognitive deficit / delirium exist BUT
They need training to use
They take time to administer
They are often difficult or inappropriate to use in ED
Staff lack knowledge
Training to care for people with dementia
Project
• HREC approval (SMAHS and Curtin)
• Funding for new project from Office of the Chief nurse
• Permission and buy-in from ED research coordination
group and nursing management
Training to care for people with dementia
Developing a brief delirium screen
• Aim:
• To develop a brief delirium screen for
use by ED nurses
• Test whether incorporating risk factors
improves the sensitivity etc of the screen
• Compare brief screen with full CAM
(Confusion Assessment Method)
including MMSE
Training to care for people with dementia
Stage 1: Collect data
• Research nurse conducted CAM assessment including MMSE
on convenience sample of patients aged 65+
• Gathered data on risk factors (from the literature),
demographics etc
• Consent from patient/relative
• Conducted in-service education for ED nurses
Training to care for people with dementia
Stage 1: Analysis
•
•
•
•
•
325 patients assessed
23 with positive screen, 15 with delirium
Analysed which risk factors are likely to have
information available to the nurse (ie on
patient arrival)
Logistic regression to develop a 3 item risk
model
Developed preliminary assessment form with
the aim of having high negative predictive
value
Training to care for people with dementia
Stage 2: Process
• In-service sessions on delirium
• Nurses used assessment form to screen all patients aged 65+
over all shifts in the context of their initial assessment
• Research nurse collated data and conducted a full delirium
assessment and data collection for patients who had had an
ED nurse screen (only if they could assess the patient within 2
hours of the ED nurse screen)
• Preliminary assessment form developed into final form during
the stage
Training to care for people with dementia
Assessment form design
• Front page:
– AMT4 (4 questions abbreviated from AMT)
– Risk screen:
• Any evidence of acute onset of confusion
• and/or combination of risk factors:
– Dementia plus either or both depression and
abnormal cardiac rhythm
– If negative screen, no further assessment required, total
assessment time < 1 min
Training to care for people with dementia
Assessment form design
• Second page (only if positive risk screen):
– Elements from CAM, ignoring fluctuation:
• * Fluctuation is required for a diagnosis of delirium, but is not
required for a positive screen according to the developers of
the CAM. It is assumed that at the first assessment the ED
nurse will not have had enough time with the patient to
assess for this.
– “Delirium screen” score, linked to actions. Highest score =
probable delirium
Training to care for people with dementia
Assessment form design
• Second page (cont):
– “Delirium screen” score:
• 2 points for Inattention, 1 point each for disorganised
thinking and altered conscious state
– Score 3 or 4 = probable delirium
– Score 2 = high risk of delirium
– Score 0 or 1 = moderate risk (the patient was
already at risk from the front page screen or we
would not be on the back page)
Training to care for people with dementia
Final form development
•
•
•
•
Preliminary form designed (intended) to be simple to follow, quick to
use and require no reference to other information
Format of initial form redeveloped through iterative process, with
changes driven by:
– Inconsistent / contradictory results
– Feedback from research nurses
– Feedback from staff
– Readability (layout, wording to improve reliability, repeatability)
not core content
Final version released in August, data more consistent.
Stage 2 finalised in November
Training to care for people with dementia
Assess impact of in-service education
and use of form
• Questionnaire to nurses: impact on workload, patient
assessment, confidence and care of older patients
– Preliminary data from Stage 2:
• Time taken to complete each assessment times number
of patients = workload over 8 weeks:
1 minute per nurse per day if all patients aged 65 +
assessed
• Positive responses regarding improvement in knowledge
and assessment skills
• Mixed responses regarding workload impact
Training to care for people with dementia
Stage 3: Testing assessment form
• Funding from Nurses Memorial Trust Fund
• Break over Christmas (4 hour rule implementation, staffing
issues)
• Started last week with 1 week run-in
• To run for at least 16 weeks
• Further education & information to staff (turnover)
• Re-focus protocol: day shift only
Training to care for people with dementia
Questions?
Training to care for people with dementia
Acknowledgements and disclaimer
•
•
•
•
•
Fremantle Hospital
Curtin University
OCNO
WA DTSC
WA Nurses’ Memorial Trust
•
The Western Australian Dementia Training Study Centre (WA DTSC) has been established as part of the Australian
Government’s Dementia Initiative.
The WA DTSC is one of four Centres nationally that promote dementia studies in Australian graduate and
undergraduate curriculum as well as providing tertiary dementia career pathways.
The views expressed in this work are the views of its author(s) and not necessarily those of the Commonwealth of
Australia. Despite any permitted use of Graphic Design Guidelines for Training Partner and Projects copyright
material, the reader needs to be aware that the information contained in this work is not necessarily endorsed, and its
contents may not have been approved or reviewed, by the Australian Government Department of Health and Ageing.
•
•
Training to care for people with dementia