DELIRIUM ELDERLY AT-RISK INSTRUMENTNora McPherson, APRN, CNS, GeriatricsJill Tusing MS, RN, BC Service Line: Behavioral Health

SBAR: DELIRIUM IDENTIFYING HIGH RISK PATIENTSSituation: Delirium (acute

confusion) a common, under recognized, post-operative complication in elective orthopaedic patients (10%-40%); manifests as acute impairment in cognition and attention.

Background: Post-operative

delirium is associated with poor outcomes, greater costs, longer lengths of stays, poor recovery, institutionalization, and mortality.

Assessment:

Currently, HE does not have process to screen patient pre-op for risk

Screening pts. may allow for early interventions to reduce severity

Recommendation:Trial delirium risk

assessment tool (DEAR) with elective total joint population age 65 and older to identify high risk for delirium.

Phase 2 (future plans): On care units, patient screening every shift with use of Confusion Assessment Method (CAM)

Yes NoPatient age Age > 80

Sensory Impairment Patient uses hearing aid and/or has very low vision

Functional Dependence Patient requires assistance with any of the following:Bathing, dressing toileting, grooming, or feeding

Substance Use Patient consumes >3 drinks of alcohol per week and/orPatient takes benzodiazepine >3 times/week

Cognition Previous post-op delirium/confusionorFailed Clock-drawing Score

A DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium.

Delirium Elderly At-Risk (DEAR) instrument is used to assess risk for developing post-operative delirium. 5 scoring domains are listed below:

DEAR INSTRUMENT INSTRUCTIONSThe circle is a clock face. Ask your patient to place numbers and hands (small and large) on the face so the time reads 10 minutes after three o’clock. The instructions: May be repeated as often as requested No other directions or assistance should be

given Do not cover up or conceal any time pieces in

the roomAfter your patient has completed this task, you may score their efforts as pass or fail. Please review the following examples displaying pass and fail clocks.

SCORING GUIDELINES : PASS OR FAIL PASS:Hands and numbers are all present in correct positions. Patient corrects without prompting are acceptable. There are slight errorsin placement of hands OROne missing number without number spacingerrors. Moderate errors in placement of hands, confusion with small and large hands ORNumber spacing errors alone.

Guidelines:Placement of hands is significantly off course ORNumber spacing is inappropriate.

Example:Even though there is bunching, distortion not grossly inappropriate. Typically seen in those who are cued to spatial mistakes once they get to the 6 (because they know it is supposed to be at the bottom), and make correction only to commit same error in subsequent numbers.

Scoring Passed

Guidelines: Clock hands are used inappropriately ORThere is use of a digital displayCircling of numbers ORPerseveration in writing of numbers

Example:The clock hands are clearly pointing inward. This is scored 6, even though the 2 and 3 are correctly indicated, because there is clear evidence that problem solving how to correctly draw in the hands is lacking.

Score Fail

Example:Here is perseveration of numbers (3's and 8's). Only one example of perseverated numbers is needed for a score of 6. The hands are not included in this sample to focus on illustrating number perseveration.

Score Fail

Example:

A digital representation of 3:10 is drawn. This is often drawn in the middle of the clock face, or even well outside of it.

Score Fail

Example:

The numbers are circled to indicate 3:10.

Score Fail

Example:

This is an inappropriate use of clock hands, where a straight line is drawn from the 3 to the 2, without use of the center of the clock.

Score Fail

Guidelines:Numbers are crowded to one end of the clock.Reversed in order or absent.Example:

Numbers are reversed.

Score Fail

Example:

All of the numbers are crowded into to one end of the clock face.

Score Fail

Guidelines:There is significant distortion in number sequences. Counterclockwise order many missing numbers ORNumber placed outside of clock face border.Example:

There are many added numbers. This tends to occur when the patient loses track of the task at hand (drawing the numbers for the clock) and continues to add numbers until they run out of space.

Score Fail

Example:

Some numbers fall outside of the border

Score Fail

Example:

Numbers placed outside of the clock face. Even if all other criteria are met.

Score Fail

Example:

Prompting needed.This is a fairly common presentation of "drawing in the numbers". When this is seen, prompt the patient to put in numbers instead of dashes, allowing them to erase. This should not be scored unless the patient is unable to place the numbers at all, or is significantly confused by the directions.

Score Fail

Only vague representation of a clock or irrelevant spatial representation exist.Numbers and clock face are no longer connected in the drawing.

Score Fail

Result cannot be interpreted

OR

No attempt is made to draw a clock

Score Fail

Yes NoPatient age Age > 80 XSensory Impairment Patient uses hearing aid

and/or has very low vision

X

Functional Dependence Patient requires assistance with any of the following:Bathing, dressing toileting, grooming, or feeding

X

Substance Use Patient consumes >3 drinks of alcohol per week and/orPatient takes benzodiazepine >3 times/week

X

Cognition Previous post-op delirium/confusionorFailed Clock-drawing Score

X

A DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium. 2

DEAR scores >1 indicate patient is at higher risk for developing delirium. :

Add up all of the yes scores on the left side of the tool and place score on bottom.

Scores of over 1 are considered high risk. If a patient is scored to be at high risk for

delirium, communicate this risk with the medical team.

Place High risk for delirium sticker on patient Care Plan (or write it yourself).

Scoring DEAR Tool

REFERENCES Feter, S., Dunbar, M., MacLeod, H., Morrison,

M., MacKnight, C., et al. (2005) Predicting post-operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age and Ageing, 34(2), 169-184.

HealthEast A3 team: Joe Clubb, Director Behavior Health, Dr. David Frenz; Dr. Alvin Holm, Jill Tusing RN Education, Nora McPherson, APRN, CNS.