Organizational and Procedural Manual...MMSE SPMSQ score # of errors Application in HELP 24 8 2+ Risk...

PLEASE DO NOT USE THESE MATERIALS IF YOU OR YOUR INSTITUTION HAS NOT COMPLETED THE HELP

USER AGREEMENT LOCATED AT: http://hospitalelderlifeprogram.org.

Use of this document and the content herein is subject to the HELP User Agreement, including the limitations on liability set

forth therein. All material contained in the Hospital Elder Life Program (HELP) manuals and DVDs (including but not limited

to publications, citations, lectures, and presentations) is © 1999, Hospital Elder Life Program. All rights reserved. These

materials may not be reproduced, disseminated, or broadcast except pursuant to the HELP User Agreement located at

http://hospitalelderlifeprogram.org or other written consent.

All uses of HELP materials must acknowledge the Hospital Elder Life Program (HELP).

Organizational and

Procedural Manual

The Clinical Process

The Hospital Elder Life Program

Clinical Process Manual

Acknowledgments

Development of these dissemination materials was supported in part by The Commonwealth Fund (a New York City-based private independent foundation), The Fan Fox and Leslie R. Samuels Foundation, Inc., and The Retirement Research Foundation. The views presented are those of the authors and not necessarily those of the funders, their directors, or staff.

NOTICE: This program is protected by copyright under US and applicable international laws.

*NOTICE* This document is supplied by Hospital Elder Life Program, LLC (the “LLC”) for use by accredited hospitals in training individuals in the principles of the Hospital Elder Life Program (“HELP”). Use of this document and the content herein (the “Content”) is subject to the HELP User Agreement (the “Agreement”), located at http://hospitalelderlifeprogram.org. Individuals and organizations that have not executed the User Agreement are not authorized to view, copy, or disseminate these materials. This document is intended to be used in tandem with other HELP training materials. As with all HELP materials, this document supplements but does not replace the individualized personal instruction that is necessary to ensure the effectiveness of HELP and the safety of patients, volunteers, and staff. It provides general guidance, but does not address many situations that may arise in dealing with the hospitalized elderly. Persons using the HELP techniques must continue to exercise their independent judgment about such clinical situations. You agree that the Content does not address many situations that may arise in dealing with the hospitalized elderly, and that persons using the information and techniques described in the Content must continue to exercise their independent judgment about such clinical situations. Your use of the Content is at your sole risk. THE LLC DISCLAIMS ANY AND ALL PROMISES, REPRESENTATIONS, AND WARRANTIES, EXPRESS OR IMPLIED, EXCEPT AS EXPRESSLY SET FORTH IN THE AGREEMENT, WITH RESPECT TO THE CONTENT, OR ANY PORTION THEREOF, INCLUDING WITH RESPECT TO ITS CONDITION, CONFORMITY TO ANY REPRESENTATION OR DESCRIPTION, TITLE, AND MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE. In no event shall the LLC, Sharon K. Inouye, M.D., M.P.H. (“Dr. Inouye”) or Hebrew SeniorLife, Inc. (“HSL”) be liable to you or any third party for any loss of revenue, any incidental, special, exemplary, or consequential injury or damages, or any claims or demands brought against you related to the Content or your use of the Content, even if the LLC, Dr. Inouye or HSL has been advised of the possibility of such damages. You agree to indemnify and hold harmless the LLC, Dr. Inouye and HSL from and against any and all losses, claims, damages, suits, actions or liabilities of any kind resulting from your use of or reliance on the Content.

*NOTICE* updated: 11/15/2011 HELP POLICY ON MMSE

HELP was developed utilizing the Mini-Mental State Examination in 1993, prior to enforcement of the copyright protection and the MMSE is referenced in manuals. Currently, the instrument is copyrighted by Psychological Assessment Resources, Inc. (PAR), and as of 2001, a per use fee is required for any use of the MMSE using a printed version of the test. Thus, the HELP program does not advocate for use of any printed version of the MMSE. Many sites have decided to use alternative instruments. Our recommendations are outlined below. 1. For clinical use: The MMSE may be administered clinically as long as an

authorized version of the MMSE is used, or the MMSE is administered from memory without a printed version. Otherwise, a per use fee must be paid to PAR.

2. For use in research or for publication: The user must obtain permission from PAR, and pay a per use fee for the MMSE in this context.

3. Because of these restrictions, the HELP Program recommends use of alternative brief cognitive assessment instruments for research purposes. A wide variety of instruments are available which are not restricted by copyright restrictions. These should be chosen by the user depending on their specific goals. A brief review of some of these measures and recommendations are provided below. These can be used to rate the CAM and to evaluate for dementia. Each instrument has its own cutpoints, see attached references.

COGNITIVE SCREENING INSTRUMENTS

INSTRUMENT ADMINISTRATION TIME

COMMENTS

BRIEF INSTRUMENTS (<10 mins)

Short Portable Mental Status Questionnaire*

3-5 mins Recommended, validated brief screening tool

Mini-Cog 3-5 mins Recommended; validated brief screening tool.

LONGER INSTRUMENTS (>10 mins) FOR MORE COMPREHENSIVE ASSESSMENT

3MS 10-15 mins Recommended; includes the MMSE, plus remote memory, verbal fluency, and abstraction

Montreal Cognitive Assessment

10-15 mins Recommended; assesses similar domains to MMSE, and also verbal fluency and abstraction

These listings are NOT comprehensive. Many other effective instruments exist which should be considered; these may be very useful to individual sites depending on timeframes and domains for screening. *At this time we recommend the use of the SPMSQ combined with an attention task, as outlined below.

REFERENCES

1. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15: 1021–1027

2. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433- 441.

3. Teng EL, Chui HC. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry. 1987;48:314-8.

4. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-699.

Recommendation

At this time the HELP Program recommends that HELP sites use the Short Portable Mental Status Questionnaire combined with an attention task. A worksheet with the SPMSQ and scoring guidelines has been incorporated into the HELP manuals, along with the digits backwards and days of the week backwards attention tasks. These two assessments can be used to rate the CAM and evaluate for cognitive impairment.

Please note: any brief, validated cognitive assessment may be used with the HELP program as long as it is used consistently and patient scores are tracked.

Hospital Elder Life Program Brief Cognitive Evaluation

Short Portable Mental Status Questionnaire Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41. Copyright E. Pfeiffer 1994. Reproduced with permission.

Question Response Error?

What are the date, month, and year?* Date Month Year

What is the day of the week?

What is the name of this place?

What is your phone number?

How old are you?

When were you born?

Who is the current president?

Who was the president before him?

What was your mother’s maiden name?

Can you count backward from 20 by 3s?

*A mistake on ANY part of this question should be scored as an error

Total Errors:

Suggested Cutpoints for HELP MMSE SPMSQ

score # of errors Application in HELP

24 8 2+ Risk factor for cognitive decline— Enroll in HELP*

20 5 5+ Enrollment in orientation protocol 10 2 8+ Severe impairment; case by case

enrollment *Patients with fewer than 2 errors should also be enrolled in HELP if they have one or more of the additional risk factors outlined in the HELP manuals.


VOLUME II THE CLINICAL PROCESS

TABLE OF CONTENTS

Page INTRODUCTION 3 Section 1 SCREENING AND ENROLLMENT PROCEDURES

Screening Overview 4 Enrollment Criteria for HELP Patients 5 Screening Procedure 6 Guidelines for Patient Screening 7 Introduction Script 10

Section 2 ELDER LIFE SPECIALIST AND VOLUNTEER INTERVENTIONS

Intervention Overview 14 Patient Information Packet 15 Elder Life Specialist Protocols/Volunteer Interventions 18

1. Overview 2. Targeted Risk Factor Approach 3. Elder Life Specialist Daily Clinical Evaluation 4. Evaluation of Cognitive Status

Elder Life Specialist/Volunteer Intervention Summary Chart 24 Orientation Protocol 26 Therapeutic Activities Protocol 27 Sleep Enhancement Protocol 32 Early Mobilization Protocol 33 Vision Protocol 35 Vision Protocol – Blindness 36 Hearing Protocol 38 Feeding Assistance/Fluid Repletion Protocol 39

Section 3 GERIATRIC NURSING ASSESSMENT AND INTERVENTIONS

1. Overview 42 2. Targeted Risk Factor Approach 43 3. Elder Life Nurse Specialist Daily Clinical Reassessment 44 4. Evaluation of Cognitive Status 45

Elder Life Nurse Specialist: Patient Profile Sheet 49 Delirium Protocol 50 Dementia Protocol 53 Psychoactive Medications Protocol 55 Sleep Enhancement Protocol 57 Early Mobilization Protocol 59 Hearing Protocol 62


Fluid Repletion Protocol 63 Discharge Planning Protocol 65 Optimizing Length of Stay Protocol 68 Additional Areas of Elder Life Nurse Specialist Assessment and Interventions-Including Protocols based on NICE Guidelines 70 HELP Policy on MMSE/Cognitive Screening Instruments 95 Updating the Beers Criteria for Potentially Inappropriate Medication use in Older Adults 99 Top 10 Drug Interactions 109

Section 4 INTERDISCIPLINARY INTERVENTIONS

Interdisciplinary Interventions Summary Chart 114 Interdisciplinary Rounds and Consultation 115 Geriatrician Consultation 116 Community Linkages 116 HELP Interdisciplinary Rounds Form 117

Section 5 DISCHARGE AND POST-DISCHARGE PROCEDURES

Discharge Evaluation and Clinical Outcomes 119 1. Discharge Evaluation Procedure 2. Post Discharge Assistance and Evaluation

Elder Life Nurse Specialist: Telephone Follow-up Form 121 Hospital Elder Life Program: Patient-Family Satisfaction Survey 123

Section 6 EDUCATIONAL INTERVENTIONS TO IMPROVE GERIATRIC EXPERTISE

Provider Education Program 125 1. Nursing Education Program 2. Physician Education Program 3. Training Site

Elder Life Nurse Specialist: Gerontological Nursing Inservice Protocol 126

Section 7 REFERENCES AND SUGGESTED RESOURCES 129 Section 8 AFTERWORD

Customize Clinical Components To Match Facility Needs 139 1. Consulting Staff 2. Enrollment Criteria 3. Therapeutic Activities Elder Life Specialist: Chaplaincy Protocol 140


HOSPITAL ELDER LIFE PROGRAM VOLUME II

THE CLINICAL PROCESS

SECTION I

• SCREENING AND ENROLLMENT PROCEDURES

Page

o CLINCAL PROCESS CHART AND INTRODUCTION…………………2-3 o SCREENING OVERVIEW………………………………………………………… 4 o ENROLLMENT CRITERIA FOR HELP PATIENTS …………….………5 o SCREENING PROCEDURE……………………………………………………… 6 o GUIDELINES FOR PATIENT SCREENING……………………………… 7-9 o INTRODUCTION SCRIPT………………………………………………………. 10-11

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Patient admitted or transferred to unit

Screening and Enrollment Procedures by ELS (Complete within 48 hours)

1. Brief chart review to determine if patients have any exclusionary criteria. 2. Describe program to patients and complete Patient Enrollment Form. 3. Enroll appropriate patients.

Intervention Process Elder Life Specialist 1. Initially use Patient Enrollment

Form to derive appropriate ELS and volunteer interventions. • ELS Intervention Worksheet • Patient Care Plan • Volunteer Assignment Form

2. Review clinical status daily. Initiate, regularly update, and document appropriate ELS and volunteer interventions. • ELS Daily Evaluation Form • Volunteer Interventions • Master Tracking Log

Intervention Process Elder Life Nurse Specialist 1. Review Patient Enrollment Form;

complete Geriatric Vital Signs; initiate and document appropriate ELNS interventions. • ELNS Patient Profile Sheet • ELNS Interventions Master

Tracking Log 2. Review clinical status daily. Initiate,

regularly update, and document appropriate ELNS interventions. • ELNS Daily Evaluation Form

Intervention Process Interdisciplinary Interventions 1. Interdisciplinary Rounds and

Consultation. • HELP Interdisciplinary Rounds

Form 2. Geriatrician Consultation 3. Community Linkages

Discharge and Post Discharge Procedures

Discharge evaluation to track clinical outcomes related to program interventions. • Patient Discharge Form (ELS) • HELP Patient/Family Survey (ELS) • ELNS Telephone Follow-up Form


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INTRODUCTION The overall goal of this manual is to provide a detailed overview of the clinical components of the Hospital Elder Life Program as they relate to older patients. The manual has been arranged chronologically, i.e., the sections in the manual are presented in the order they relate to the patient throughout their hospitalization. First, the screening and enrollment process, performed by the Elder Life Specialist, is reviewed. The intervention process follows. The Elder Life Specialist initiates the Elder Life Specialist/volunteer interventions, which are predetermined via standing protocols. Simultaneously, the Elder Life Nurse Specialist expands on the screening completed by the Elder Life Specialist and implements geriatric nursing interventions. An important feature of this program is that the majority of the intervention protocols are targeted towards six major risk factors for cognitive and functional decline in hospitalized older patients (i.e., cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, and dehydration). Additional interdisciplinary program interventions are then described, i.e., interdisciplinary rounds and consultation, geriatrician consultation and community linkages. Then, the discharge evaluation and post-hospitalization follow-up are presented. Finally, educational interventions to improve geriatric expertise are included. This carefully designed and tested program has been demonstrated to decrease cognitive and functional decline in hospitalized older patients. When establishing the program, it is important for all HELP staff to become proficient with the clinical process and all protocols for which they are responsible. In addition, training and standardization sessions run by the program director and/or other HELP staff are encouraged to assure that all staff are executing procedures in the same fashion (e.g., patient screening, appropriate assignment to intervention protocols, completing interventions, etc.). (See “Quality Assurance Procedures” in Organizational and Procedural Manual I: Overview and Structure). HELP has expanded to many new sites around the country and the world. While all of the clinical protocols should be enacted as described in the manuals, we also realize that each site will need to customize the protocols to match the needs and resources available at their own facilities.


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SCREENING AND ENROLLMENT PROCEDURES

SCREENING OVERVIEW

Every patient aged 70 years and older admitted to the HELP unit(s) is screened for enrollment into the program. The purpose of screening is threefold. First, screening helps to verify that the patient has risk factors for cognitive or functional decline that will allow him/her to benefit from the program. Second, screening verifies that the patient does not have exclusion criteria that make interventions difficult or inappropriate. And third, the risk factors that are identified during screening trigger specific intervention protocols by the HELP team. The “Patient Enrollment Form” (see Database Manual) is the screening tool for enrollment into the program, and it is completed by the Elder Life Specialist, with assistance from the Elder Life Nurse Specialist as needed. Each patient is screened and enrolled within 24-48 hours of admission or transfer to a HELP unit. For the complete enrollment criteria, including inclusion and exclusion criteria, see the attached table “Enrollment Criteria for Hospital Elder Life Program Patients.” The inclusion criteria are intended to be as inclusive as possible, while assuring that patients will benefit from the program by having at least one targeted risk factor for cognitive or functional decline. The six targeted risk factors include: cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, and dehydration. The main reason for exclusion is inability to participate in the intervention protocols. Exclusions are minimized, and all reasons for exclusion are closely monitored at the HELP Working Groups. Each facility implementing the program will need to set its own enrollment cap based on staff availability and patient census. The purpose of the cap is to limit enrollment into the program at times when patient census is high, to ensure that staff have the capability to fully carry out all program intervention protocols.


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ENROLLMENT CRITERIA FOR HOSPITAL ELDER LIFE PROGRAM PATIENTS Inclusion Criteria:

Age 70 years and older and on HELP unit At least one risk factor for cognitive or functional decline. Risk factors

include: o Cognitive impairment – SPMSQ 2+ errors, equivalent to MMSE <24/30 o Any mobility or ADL impairment o Vision impairment: <20/70 best corrected vision o Hearing impairment: < 3 of 6 whispers in each ear on Whisper test or

unable to hear fingers lightly rubbed together 3-4 inches from their ear on the Finger Rub Test

o Dehydration: BUN/Cr ratio >18 Able to communicate verbally or in writing. Nonverbal patients who can

communicate in writing are included. Exclusion Criteria:

Coma Mechanical ventilation Aphasia (expressive and/or receptive) if communication ability severely

impaired Terminal condition with comfort care only, death imminent Combative or dangerous behavior Severe psychotic disorder that prevents patient from

understanding/participating in interventions Severe dementia (e.g., unable to communicate; SPMSQ 10 errors). For

patients with severe impairment (SPMSQ 8+ errors), decision to enroll will be made on a case-by-case basis depending on their ability to participate in interventions.

Airborne precautions (e.g., tuberculosis). Patients on contact isolation (e.g., vancomycin-resistant enterococcus) or droplet precautions (e.g., influenza) will be enrolled

Neutropenic precautions Discharge firmly anticipated within 48 hours of admission Refusal by patient, family member (if patient is incompetent), or physician

Capping Criteria: The enrollment cap is patients. (Customize to your site) If this cap is met and there are additional high-risk patients meeting many risk factors for the development of delirium, services to enrolled patients not fully meeting enrollment criteria (e.g., low risk patients without delirium risk factors) will be gradually discontinued so that high-risk patients can be enrolled.


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SCREENING PROCEDURE

Overview:

This screening procedure is designed to be carried out in a standardized fashion, using tested instruments, as included in the “Patient Enrollment Form”. While initially learning this process may take some time and effort, the advantages of this standardized process are many. First, this process will enable key clinical information to be obtained in a consistent and reliable fashion across all staff. This process greatly simplifies assignment to HELP interventions. In addition, this method will facilitate the tracking of selected clinical outcomes, which are crucial to tracking the effectiveness of the program. Finally, this method assures completeness in obtaining baseline information on the patients. Procedure:

• Daily, the Elder Life Specialist reviews a list of all patients on the unit(s) to identify patients > 70 years old newly admitted to the unit (within 48 hours).

• For each age-appropriate patient, the Elder Life Specialist performs a

brief chart review to determine if the patient has any excluding criteria. (See table: “Enrollment Criteria for Hospital Elder Life Program Patients”).

• The Elder Life Specialist proceeds to describe the program to eligible

patients and completes the Patient Enrollment Form (see Database Manual). The “Guidelines for Patient Screening” provides a general overview of interviewing techniques. The “Introduction Script” is used by the Elder Life Specialist as a guide for describing the program to the patient and completing the screening process.

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GUIDELINES FOR PATIENT SCREENING

A. Initial Contact

Put the respondent at ease: • Be calm, composed, pleasant and sincere • Convey confidence in ability to ask questions and listen carefully to

answers B. The Interview Setting

Conduct in quiet room with limited interruptions by staff and visitors by avoiding mealtimes, early morning nursing care time, etc.

C. Maintaining Rapport

Occasionally rapport may be broken during the interview because the respondent finds a particular question “too personal”. If this happens, take time to reassure the respondent that the information is confidential and is only used to help plan care.

D. The Interview – Asking the Questions

1. The information heard and recorded during an interview must be accurate and complete so as not to bias or distort the content.

2. The interviewer should have a thorough knowledge of the

questionnaire and the principles to follow in asking the questions:

• BECOME FAMILIAR WITH ALL TEST QUESTIONS. It is important that the interviewer feel at ease with the questions asked. The interviewer should practice asking all questions in a “matter of fact” way to avoid awkwardness or unfamiliarity about any questions asked.

• REMAIN NEUTRAL. The interviewer strives to create an atmosphere for patients to express themselves free of judgement. Toward that end, be careful that nothing in words or manner implies criticism, surprise, approval or disapproval of either the questions asked or of the respondent’s answers.

• ASK ALL QUESTIONS EXACTLY AS WORDED. Many times, a small change in wording can change the whole meaning of the question. Questions may be repeated if needed. Emphasize that there are no right or wrong answers.

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E. Probing

1. Technique used by the interviewer to stimulate discussion and obtain more information.

2. Used when a respondent’s answer is not meaningful or is incomplete,

that is, when it does not adequately answer the question.

3. Probing Methods Should Be Neutral. It is important to use neutral probes that do not imply to the respondent that a specific answer is expected, or suggest dissatisfaction with an answer.

4. Kinds of Probes: There are several neutral probes that appear as a

part of a normal conversation that can be used to stimulate a more clear and complete response.

• REPEAT THE QUESTION - Useful when the respondent does not

seem to understand the question, misinterprets it, seems unable to decide, or strays from the subject.

Example: Question: How much is religion a source of strength and comfort to you? Would you say none, a little, or great deal? Answer: Now and then I find it a great comfort, but not often.

Question: So as a source of strength and comfort to you, would you say religion is none, a little, or a great deal?

Answer: Oh, I’d say a little.

• GENERALIZE - Useful when the respondent reports that none of the

responses fit, or that under certain conditions he/she would choose one answer and under different conditions another.

Interviewer tries to get the respondent to generalize by repeating the question and saying, “Usually, is it this way or that?”, or “Most of the time,” or “In most cases,” etc. For example:

Example: Question: At home, do you need help from another person to get in and out of bed?

Answer: Well, sometimes I need help, but sometimes I can do it myself.

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Question: Usually, do you need help getting in and out of bed, or can you do it you yourself.

Answer: Usually, I can do it by myself.

F. The Don’t Know (DK) Response

• Do not automatically accept a “don’t know” reply. Instead, the interviewer should sit quietly and expectantly. The respondent will usually think of something further to say. Silence and waiting are useful probes for a “don’t know”.

• An alternative probe is, “Well, what do you think? I just want your own ideas on that.”

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ELDER LIFE SPECIALIST INTRODUCTION SCRIPT

Hello. My name is (your name) and I am an Elder Life Specialist here at (name of site) . I work with the Hospital Elder Life Program, and we help the doctors and nurses give you some extra care while you are here in the hospital. The goal of the program is to keep you as active and independent as possible during your hospitalization. The program is staffed by a geriatrician, geriatric nurse specialist, Elder Life Specialists (like me), and trained volunteers. We work together to provide you with the best possible care while you are here in the hospital. I need to ask you a few questions to see how you were doing before you came into the hospital, and how you are doing now. This will take about 15 minutes. This will help me to find out the best way to take care of you while you are here. (Proceed to Screening Tools. Suggested order:

• IADL/ADL Screening • Vision Screening • Hearing Screening • Cognitive Screening Assessment (i.e., SPMSQ or Mini Cog) • Therapeutic Activities Screening • Sleep Screening • Mobility Screening • Nutritional Screening • Spirituality Screening)

Now that I know a little bit more about you, I want to let you know what the Hospital Elder Life Program will do to help you while you are here. Every morning, I will put your schedule on the board and go over it with you so you will know what to expect each day. I am going to leave this pencil and paper here, so you can write down any questions you have for the nursing staff or for me to help you get answered each day. It is very important to make sure you get some exercise each day so you don’t lose strength, so we will either take a walk or do exercises three times a day. You will do this either with me or the volunteers who work with me. We will also do some enjoyable activities with you each day. (Describe activities based on Therapeutic Activities Screening. As needed, provide brief, one-line description of other protocols patient to be enrolled in, e.g.:

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• Feeding Assistance Program - A program providing company and

assistance at meals, if necessary • Sleep Enhancement Program – A program to help improve your sleep

in the hospital) (Name of next staff/volunteer) will be in to see you between and to do (list activities on board) with you. Here is some information about our program that you can look through at any time (give Patient Information Packet). Our program can also provide information to help you or your family begin to plan for your discharge. Do you have any questions? Can I get you anything?

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SECTION II

• ELDER LIFE SPECIALIST AND VOLUNTEER INTERVENTIONS

Page

o SCOPE OF RESPONSIBILITIES CHART……………………………… 13 o INTERVENTION OVERVIEW………………………………………………… 14 o PATIENT INFORMATION PACKET……………………………………… 15-17 o ELDER LIFE SPECIALIST PROTOCOLS/VOLUNTEER

INTERVENTIONS………………………………………………………………… 18-24 1. OVERVIEW 2. TARGETED RISK FACTOR APPROACH 3. ELDER LIFE SPECIALIST DAILY CLINICAL EVALUATION 4. EVALUATION OF COGNITIVE STATUS

o ELDER LIFE SPECIALIST/VOLUNTEER INTERVENTION SUMMARY CHART………………………………………………………………… 25-26

o ORIENTATION PROTOCOL…………………………………………………… 27 o THERAPEUTIC ACTIVITIES PROTOCOL……………………………….. 28-32 o SLEEP ENHANCEMENT PROTOCOL………………………………………. 33 o EARLY MOBILIZATION PROTOCOL………………………………………. 34-35 o VISION PROTOCOL………………………………………………………………..36 o VISION PROTOCOL – BLINDNESS……………………………………….. 37-38 o HEARING PROTOCOL……………………………………………………………. 39 o FEEDING ASSISTANCE/FLUID REPLETION PROTOCOL………. 40-41

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ELDER LIFE SPECIALIST SCOPE OF RESPONSIBILITIES

VOLUNTEER COORDINATION • Recruitment and screening • Volunteer training program • Volunteer schedules • Supervision & support • Quality assurance measures • Continuing education • Volunteer retention

PATIENT CARE • Patient screening & enrollment • Develop & update individualized care plans • Implement the ELS protocols and monitor

patients’ outcomes • Oversee Volunteers in:

• Daily Visitor Program • Therapeutic Activities Program • Early Mobilization Program • Feeding Assistance Program

• Provide appropriate equipment

PROGRAM OPERATIONS • Record and maintain volunteer/ELS

interventions progress reports • Measure and record program outcomes

via Patient-Family Satisfaction Survey and Patient Discharge Form

• Track and address quality assurance and adherence issues.

• Record and maintain program expenditures for equipment and supplies.

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ELDER LIFE SPECIALIST AND VOLUNTEER INTERVENTIONS

INTERVENTION OVERVIEW

After screening, eligible patients are enrolled:

A. Each patient is given a “Patient Information Packet” – a folder providing general information about the program, and more specific information about hospital and community services that are unique to each facility. Items and information to include in the packet: • General description of the program and program staff (see attached) • More detailed descriptions of specific program interventions, e.g.,

sleep enhancement protocol, relaxation exercises (see attached) • Useful hospital-specific information, e.g., telephone instructions,

visiting hours, additional services helpful to older patients and their families

• Description and pamphlets of community services available

B. The Patient Enrollment Form is reviewed by the Elder Life Specialist and Elder Life Nurse Specialist. It is then entered into the computer or abstracted to derive an assignment to appropriate staff and volunteer intervention protocols. While the intervention protocols are standardized, the menu of assigned interventions is individualized for each patient, based on the risk factors present at screening and regular reevaluations.

All staff and volunteer assignments, particularly mobility assignments, should be initiated within 24 hours of enrollment into the program.

C. Three Broad Categories of HELP Interventions:

There are three broad categories of HELP interventions. First, the Elder Life Specialist/volunteer interventions (described in following section); second, the geriatric nursing assessment and interventions (described in Section 3); and finally the interdisciplinary interventions (described in Section 4).

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THE HOSPITAL ELDER LIFE PROGRAM (HELP)

What is HELP?

OVERVIEW Patient Information Packet

The Hospital Elder Life Program is a new service provided by this facility to improve the hospital experience of older patients.

Who are we?

A team of staff who make sure that older adults get the special consideration they need to get the best results from their hospital stay. The team includes an Elder Life Specialist, Nurse Specialist, Geriatrician (physician), and carefully trained Volunteers. This team works with regular hospital staff in all departments to meet each older patient’s needs.

Elder Life Specialist(s): Nurse Specialist: Physician:

Why? Being in the hospital upsets normal routines of mental and physical activity just at the time a person is coping with illness. This disruption can cause older hospitalized people to lose their general mental and physical ability to function. The Hospital Elder Life Program helps keep the mind and body as active as possible in spite of illness. This benefits older patients and helps speed their full recovery.

What do we do? To help keep you in good shape, we provide the following services, free of charge, as part of your hospital care.

• Daily Visitor Program – Daily visits designed to keep you alert and oriented by providing you with your daily schedule and answering your questions.

• Feeding Assistance Program – Provides company and assistance at meals if necessary.

• Early Mobilization Program – Provides daily assistance with walking and exercises.

• Therapeutic Activities Program – Provides stimulating and enjoyable activities to help keep your mind and body active. Your volunteers can also assist you with relaxation exercises that can help reduce stress during your stay.

• Sleep Enhancement Program – Designed to assist you with sleep without the use of sleep medications that can have harmful side effects.

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SLEEP ENHANCEMENT PROGRAM Patient Information Packet

Briefly waking up during the night is common and normal for many older people. It is often difficult to sleep in the hospital. If you are having problems sleeping while you are here, we would like to offer you our Sleep Enhancement Program. This program has been tested and been found to be very effective.

Older patients are more likely than younger patients to experience complications from sleeping medications. Sleeping medications can cause memory loss, confusion, unsteadiness, falls, daytime drowsiness, and incontinence. In our sleep program, we want you to relax and rest normally, without taking sleeping medication, if possible.

Our Sleep Program Consists Of:

1. Individualized consideration of your normal routines. For example, can you think of something that might help you sleep which you do at home when you have trouble sleeping?

2. Offering you: • A warm drink (either milk or herbal tea) • A back-rub • Relaxation music played on a portable music player

Additional Sleep-Promoting Actions: • Avoid caffeine after 2 p.m. • Increase exercise and mobility during the day as much as possible • Avoid daytime napping • Maintain regular time for going to bed each night

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RELAXATION EXERCISES Patient Information Packet

Sometimes we cope with stress by holding our muscles tight. We may not realize the tension, but it increases discomfort and interferes with body relaxation needed for sleep. Relaxation exercises help us release tension anywhere in the body. By taking time out, we can also calm the mind. This helps the body get the good rest it needs to heal.

1. To begin relaxing, set a calm, relaxed mood. Turn the lights down or off, and make sure the room is as quiet and restful as possible. Quiet music may be playing in the background, if you prefer.

2. Begin breathing. Breathe in through the nose and out through the

mouth with counts of three between inhale and exhale. For example, inhale through your nose and count one, two, and three. Now exhale through your mouth and count one, two, and three.

Continue this pattern until your breathing is slowed and regular.

3. Go through each part of your body, squeezing and releasing muscle

areas. Begin at your toes, and travel up your body to your head.

• Squeeze and release toes (3 to 5 times) • Stretch and flex ankles (3 to 5 times) • Squeeze and release the muscles above your knees (3 to 5 times) • Feel the stress and discomfort leave your legs. • Squeeze and release your buttocks (3 to 5 times) • Arch and stretch your back (3 to 5 times) • Shrug your shoulders up and down (3 to 5 times) • Drop your chin to your chest and lift it to the ceiling (3 to 5 times) • Turn your head from side to side (3 to 5 times)

4. Remain quiet, concentrating on a relaxed, floating feeling for 5 to 10

minutes.

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ELDER LIFE SPECIALIST PROTOCOLS/VOLUNTEER INTERVENTIONS 1. Overview The Elder Life Nurse Specialist and Elder Life Specialist review the screening information obtained with the Patient Enrollment Form. This information is then used to derive appropriate Elder Life Specialist and volunteer interventions. The Elder Life Specialist’s interventions are designed to complement the volunteer interventions, and they are fully described in the Elder Life Specialist protocols, which follow. One of the clinical roles of the Elder Life Specialist is to work closely with the volunteers, overseeing the completion of the four volunteer intervention programs described fully in the Volunteer Training Manual and training videos, i.e., the Daily Visitor Program, the Therapeutic Activities Program, the Early Mobilization Program, and the Feeding Assistance Program. As part of the training for these programs, volunteers are also instructed in maximizing patients’ vision and hearing, sleep enhancement interventions, and fluid repletion interventions. The Elder Life Specialist (and other HELP staff) are ultimately responsible for the completion of all program interventions, including the volunteer interventions. The Elder Life Specialist or other program staff may need to carry out volunteer interventions if a volunteer is unable to; e.g., volunteer is absent, patient census is extremely high, etc. 2. Targeted Risk Factor Approach The Elder Life Specialist protocols were developed to target the six major risk factors for cognitive and functional decline in hospitalized older patients:

Risk Factor

Cognitive impairment

Sleep deprivation

Immobility

Vision impairment

Hearing impairment

Dehydration

Elder Life Specialist Protocol

Orientation Protocol Therapeutic Activities Protocol

Sleep Enhancement Protocol

Early Mobilization Protocol

Vision Protocol Vision Protocol - Blindness

Hearing Protocol

Feeding Assistance/Fluid Repletion Protocol

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3. Elder Life Specialist Daily Clinical Evaluation

An important role of the Elder Life Specialist is to methodically review each patient’s clinical status daily as outlined in each of the ELS protocols. The ELS determines if protocols should be initiated, continued or discontinued based on patient’s needs and outcomes, and updates assignments accordingly. For example, a patient may be assigned to the feeding assistance protocol upon admission due to a poor appetite and food intake. However, the patient’s appetite may improve during their hospital stay; subsequently, the ELS discontinues the feeding assistance protocol since assistance is no longer required. At other times, the ELS may determine that more patient assistance is needed during hospitalization. For example, a patient may obtain an SPMSQ score of 0 errors upon admission, thus meeting requirements to be oriented once daily. However, several days after admission, the patient becomes disoriented, and obtains a repeat SPMSQ score of 6 errors. The ELS revises the patient’s Daily Visitor assignment to provide orientation three times daily until the patient’s mental status improves. Thus, because a patient’s clinical status can change throughout his or her hospitalization, it is vital that the ELS continually reevaluate each patient’s needs and outcomes to ensure appropriate and beneficial patient assignments. The elements of the daily reevaluation should be recorded on the “ELS: Daily Evaluation Form”. (See Database Manual).

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4. Evaluation of Cognitive Status Careful and consistent evaluation of each patient’s cognitive status is a significant component of the HELP program. These evaluations determine recommended interventions and document patient outcomes. In addition to a baseline and discharge evaluation, we recommend that sites evaluate cognitive status on a daily basis, in one of two ways: 1. Daily delirium measurements:

In order to obtain daily delirium measurements, we recommend the use of daily patient interviews consisting of a cognitive assessment such as the SPMSQ or Mini Cog and the digit span test, which are then used to rate the short version (questions 1-4) Confusion Assessment Method (CAM rating). Daily chart reviews for written documentation of change in mental status should also be conducted.

To use these instruments reliably, HELP staff would need to undergo training for standardization on the instruments. Training materials for the CAM are located in Section 7. The staff time involved in daily delirium measurements is considerable - approximately 15-20 minutes per patient per day. These measurements would need to be carried out at least once daily in order to reliably detect delirium. It is also important to note that some patients become irritated with daily cognitive interviews. Because of the staff time involved, we understand that this level of surveillance will not be possible/feasible for most clinical sites.

The digit span test and the short version CAM are attached.

2. Daily chart review and patient observation for changes in mental status,

and cognitive assessment (i.e., SPMSQ or Mini Cog) change monitoring:

For many sites, it may not be feasible to perform daily delirium measurements. In this situation we recommend the following:

All HELP patients should have a cognitive assessment (i.e., SPMSQ or Mini Cog): 1. at baseline, 2. with any suspected mental status change during their hospitalization and 3. at time of discharge.

To determine a mental status change, we recommend daily chart reviews and daily patient observations by the HELP staff. Both HELP staff and floor staff should have ongoing education about cognitive assessment, and should be sensitized to observe and report changes. When notations

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in the chart describe changes in mental status (e.g., sudden onset of confusion, inattention, disorientation, lethargy, agitation, inappropriate behavior, "sundowning", etc.), or observations of the patient suggest mental status change, a cognitive assessment should be performed.

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SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ)

Patient’s Name: _________________________________ Date: ___________________ Instructions: Ask questions 1 to 10 on this list and record all answers. (Ask question 4a only if the patient does not have a telephone.) All responses must be given without reference to a calendar, newspaper, birth certificate, or other memory aid. Mark errors in the “Error?” column. Record the total number of errors based on the answers to the 10 questions.

Question Response Error? 1. What is the date today?

2. What day of the week is it?

3. What is the name of this place?

4. What is your telephone number? (4a. What is your street address?)

5. How old are you?

6. When were you born?

7. Who is the current president of the United States?

8. Who was president just before him?

9. What is your mother’s maiden name?

10. Please count backwards from 20 by 3s

Total number of errors: _______________ Scoring: 0-2 errors: normal cognitive functioning 3-4 errors: mild cognitive impairment 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment Suggested Cutpoints for HELP: 0-1 errors: Enroll in HELP if the patient has one or more of the additional risk factors outlined in the HELP manuals ≥2 errors: Risk factor for cognitive decline – Enroll in HELP ≥5 errors: Enrollment in orientation protocol ≥8 errors: Severe cognitive impairment; Case by case enrollment Source: Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23(10):433-41. Used with permission.

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DIGIT SPAN

Now I am going to say some numbers. Please repeat them back to me.

[SAY DIGITS AT RATE OF ONE PER SECOND]

Digits Response Correct Error Unable

6-2-9 - - 1 2 6 5-4-1-7 - - - 1 2 6 3-6-9-2-5 - - - - 1 2 6 9-1-8-4-2-7 - - - - - 1 2 6 1-2-8-5-3-4-6 - - - - - - 1 2 6

[Enter the numbers as repeated. Record as correct or error. If errors are made on 2 consecutive spans, discontinue test and record highest span performed correctly. If error on 3-digit and 4-digit spans (must do at least 2 spans), code as “2”. Each span can be repeated once if needed.

If patient is deaf, score as “unable”.]

Alternative Attention Tasks:

Days of the Week Backward

Day Sat. Fri. Thurs. Weds. Tues. Mon. Sun. Answer

Any error indicates impairment

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BOX 1

CONFUSION ASSESSMENT METHOD (CAM) SHORTENED VERSION WORKSHEET

EVALUATOR: DATE:

I. ACUTE ONSET AND FLUCTUATING COURSE BOX 1

a) Is there evidence of an acute change in mental No status from the patient’s baseline?

b) Did the (abnormal) behavior fluctuate during the No day, that is tend to come and go or increase and decrease in severity?

II. INATTENTION

Yes Yes

Did the patient have difficulty focusing attention, for No example, being easily distractible or having difficulty keeping track of what was being said?

III. DISORGANIZED THINKING

Yes

Was the patient ‘s thinking disorganized or incoherent, BOX 2 such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? No

IV. ALTERED LEVEL OF CONSCIOUSNESS

Yes

Overall, how would you rate the patient’s level of consciousness?

-- Alert (normal)

-- Vigilant (hyperalert) -- Lethargic (drowsy, easily aroused) -- Stupor (difficult to arouse) -- Coma (unarousable)

Do any checks appear in this box? No

Yes

If all items in Box 1 are checked and at least one item in Box 2 is checked a diagnosis of delirium is suggested. Adapted from Inouye SK et al, Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium. Ann Intern Med. 1990; 113:941-8. Copyright 2003 © Hospital Elder Life Program.

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ELS/Vol.

ELDER LIFE SPECIALIST/VOLUNTEER INTERVENTION SUMMARY CHART

Intervention Criteria Description of Intervention Intervention Orientation/Daily Visitor

• All patients are enrolled in the Daily Visitor/ Orientation Program

Orientation board with names of care team members and daily schedule; orienting communication

• Orientation Protocol: SPMSQ <5 errors Orient 1x/day SPMSQ 5+ errors

Orient 3x/day Therapeutic Activities • All patients are enrolled in the

Therapeutic Activities Program. • The Elder Life Specialist assigns

activities based on patients’

Cognitive stimulation activities three times daily (e.g., discussion of current events, structured reminiscence, word games)

interests and functional status Sleep Enhancement • Patients who have difficulty

falling asleep or sleep poorly at home or in the hospital are enrolled in The Sleep Protocol.

Nonpharmacologic sleep protocol: at bedtime, warm drink (milk or herbal tea), relaxation recordings or music, and back massage. Unit-wide noise- reduction strategies (e.g., silent pill crushers, vibrating beepers and quiet hallways) and schedule adjustments to allow uninterrupted sleep (e.g., rescheduling of medications and

procedures). Early Mobilization • All patients are enrolled in the

Early Mobilization Program • The Elder Life Specialist consults

with the Elder Life Nurse Specialist and hospital staff daily to determine the appropriate mobilization program for each patient based on: Patient’s self- report of functional abilities (per screening), direct mobility observation, chart review and physician order, and/or hospital staff assessment.

Vision Protocol • Patients are enrolled if near vision in both eyes <20/70 on near vision screener

Ambulation or active range-of-motion exercises three times daily; minimizing use of immobilizing equipment (e.g., bladder catheters, restraints)

Visual aids (e.g., glasses or magnifying lenses) and adaptive equipment (e.g., large illuminated telephone keypads, large print books, and fluorescent tape on call bell),

with daily reinforcement of their use Hearing Protocol • Patients are enrolled if they hear

<3 whispers from each ear on the Whisper Test or are unable to hear fingers lightly rubbed together 3-4 inches from their ear on the Finger Rub Test

Portable amplifying devices and special communication techniques, with daily reinforcement of these adaptations. Consider referral for earwax removal unless it is an acute problem to be addressed by the HELP team.

_______________________________

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ELDER LIFE SPECIALIST/VOLUNTEER

INTERVENTION SUMMARY CHART (cont.)

ELS/Vol. Intervention Intervention Criteria Description of Intervention Feeding Assistance • Patients who rate their

appetite as “poor” are enrolled into the Feeding Assistance Protocol. Level of feeding assistance is also determined by physical and cognitive impairment.

Fluid Repletion • As directed by the Elder Life Nurse Specialist: Patients with clinical evidence of dehydration and/or BUN/Cr

Feeding assistance and encouragement during meals Early recognition of dehydration and oral volume repletion, i.e., encouragement of oral intake of fluids

ratio ≥ 18.

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ELDER LIFE SPECIALIST ORIENTATION PROTOCOL

Patient Eligibility: All Evaluation:

1. A cognitive assessment (i.e., SPMSQ or Mini Cog) will be performed during screening and enrollment procedure.

2. The cognitive assessment will be repeated every seven days of hospitalization (at minimum).

3. Elder Life Specialist, in collaboration with Elder Life Nurse Specialist, will observe each patient daily for signs of new-onset confusion, and mental status improvement or deterioration. If a significant change is noted, the cognitive assessment will be repeated at that time.

Interventions:

1. Elder Life Specialist orients all patients on first day of enrollment into Hospital Elder Life Program, and orients confused patients daily, including: Patient Orientation Board, features of the room, and addressing patient’s concerns.

2. For patients scoring <5 errors on the SPMSQ:

• Elder Life Specialist and volunteers provide orienting information once daily in the morning.

• For patients exhibiting new-onset confusion or worsening mental status (SPMSQ 5+ errors), orientation will be done three times daily.

3. For patients scoring 5+errors on the SPMSQ:

• Elder Life Specialist and volunteers provide orienting information three times daily (morning, afternoon and early evening).

• For patients exhibiting improved mental status (SPMSQ <5 errors), orientation will be decreased to once daily.

4. Elder Life Specialist directs the Daily Visitor Program:

• Orients patients and families to the program. • Provides appropriate patient equipment and sensory aids (i.e.

hearing devices, pad and pencil, etc.) and ensures use of patients’ own adaptive equipment (i.e., glasses, hearing aid, etc.)

• Provides volunteers with appropriate patient assignments • Updates volunteer assignments based on patients’ needs and

outcomes • Monitors and records adherence to interventions

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ELDER LIFE SPECIALIST

THERAPEUTIC ACTIVITIES PROTOCOL Therapeutic activities are designed to maintain and stimulate cognitive and social function. In addition, certain activities are meant to provide physical and mental relaxation. Generally, the selection of therapeutic activities is geared toward patients’ reported leisure activities and interests. However, this may not always be possible due to patient factors, e.g., illness and impairment, and institution factors, e.g., unavailability of the activity. Additionally, some therapeutic activities may be used as a tool to meet goals of other program interventions. For example, playing soft music can make the eating experience more pleasurable, thereby encouraging a patient’s appetite. The Therapeutic Activities Chart (attached) lists categories of activities that we have used effectively with hospitalized older patients. The chart also includes the purpose and examples of each category. This chart is a useful tool when selecting activities that are interesting and meaningful to patients. Patient Eligibility: All Evaluation:

1. In addition to completing the Therapeutic Activities Screening, the Elder Life Specialist notes any cognitive, sensory or physical impairment that may interfere with the patients’ participation (using cognitive assessment results, vision and hearing, and ADL/IADL screenings). Patients with impairment(s) will benefit from adaptations of the general activities, as described below.

Interventions:

1. Daily, the Elder Life Specialist collaborates with patients and/or families to select activities of interest. After introducing the activities to the patient, the Elder Life Specialist directs the volunteers to provide the selected activities three times daily. A sample daily assignment for therapeutic activities may include:

• Morning shift activity: Current Events - Review newspaper articles • Afternoon shift activity: Trivia – Discuss Elder Trivia Cards: 1940’s • Evening shift activity: Reminisce – Discuss “How Things Have

Changed” pictures: Women’s jobs (modify as appropriate)

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2. Elder Life Specialist provides volunteers with appropriate supplies and

equipment, generally kept in a marked location on the nursing unit, e.g., in an Activity Closet.

3. Elder Life Specialist directs the Therapeutic Activities Program:

• Orients patients and families to the program • Provides appropriate patient equipment and sensory aids (e.g.,

glasses, hearing devices, etc.). • Updates therapeutic activity assignments based on patients’

interests, needs and outcomes • Monitors and records adherence to interventions

4. Elder Life Specialist encourages family participation in the Therapeutic

Activities Program. Families can participate by: • Hands-on participation • Giving encouragement • Sharing ideas

ADAPTED THERAPEUTIC ACTIVITIES

Adapted therapeutic activities are aimed towards patients with cognitive, sensory and/or physical impairments that interfere with or prevent full participation. Communication techniques, specific therapeutic activities, and modifications of general therapeutic activities can help diminish the impairment(s) and/or improve the underlying condition.

1. Patients with Cognitive Impairment • SPMSQ 5+ errors

A. Communication techniques to be used by Elder Life staff and

volunteers: 1. Acknowledge and validate patients’ feelings and concerns 2. Maintain a calm, pleasant manner 3. Gently reorient patient. Do not correct patient in a

confrontational manner, but take opportunities to provide correct information.

4. Use touch as much as possible 5. Reinforce detailed verbal instruction with physical action 6. Maximize use of physical props

B. Activities:

1. Reminisce activities 2. Trivia activities, such as “Finish the phrase” cards 3. Music - To promote relaxation and as a tool to meet goals of

other interventions, e.g., may use music while

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assisting/encouraging the patient to eat to maximize the eating experience

4. Current Events 5. Concrete Tasks – Such as simple arts and crafts, simple card

games, simple board games 2. Patients with Sensory Impairment

• Patients with severe visual impairment or who score less than 20/70 on the near-vision test, with their maximal corrected vision

• Patients with severe hearing loss who wear a hearing aid and/or hear three or less whispers from each ear on the Whisper Test and/or are unable to hear fingers lightly rubbed together 3-4 inches from their ear on the Finger Rub Test.

A. Activities for the Visually Impaired:

1. Fragrance Recognition Game 2. Read aloud/audio books 3. Tactile arts and crafts 4. Therapeutic activities using conversation – Such as “Finish the

Phrase” cards, verbal question and answer games 5. Music – To maximize other activities and experiences, e.g.,

during eating or exercises

B. Activities for the Hearing Impaired: 1. Therapeutic activities using printed materials – Books, cards,

puzzles, board games 2. Tactile arts and crafts

3. Patients with Physical Impairment

• Patients who require moderate/maximal assistance to participate in therapeutic activities secondary to physical impairment, i.e., paralysis, severe shortness of breath, pain

A. Activities:

1. Trivia, Reminisce, Current Events, and other activities requiring little or no physical involvement by the patient

2. Stationary arts and crafts 3. Board games 4. Music 5. Cards, using adapted card holders as necessary 6. Books, using adapted book holders as necessary

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THERAPEUTIC ACTIVITIES CHART CATEGORY PURPOSE EXAMPLES Sensory Stimulation

Trivia

Current Events

Reminisce

Music Appreciation

Cards

Board Games

Puzzles

Arts and Crafts

To produce a pleasurable sensory experience by bringing patients into contact with different objects To stimulate thought processes and memory recall To provide orienting information and encourage discussion of current events

To stimulate long-term memories, to encourage patients to reflect on information or events that have shaped their lives To promote relaxation; to use as entertainment; to use as a tool to meet the goals of other interventions, i.e., feeding assistance To provide cognitive stimulation and entertainment

To encourage socialization, problem solving, sequencing and other cognitive skills To encourage cognitive stimulation and problem solving

To allow individual expression and improve self-esteem

• Take off unit for change of scenery

• Arts and crafts • Fragrance Recognition Game • “Finish the Phrase” cards • Elder Trivia • Newspaper – Review daily local

newspaper and discuss specific details of an article or event

• News magazine • “How things Have Changed”

cards (Review pictures from 1900-1950)

• Photo cards/pictures • Magazine articles • Classical music • Music from different eras • Environmental sounds

• Uno • Gin Rummy • Double Solitaire • Checkers • Trivial Pursuit

• Crossword Puzzles • Finger Puzzles • Jigsaw Puzzles (small size) • Logic Puzzles • Search-a-Word Puzzles • Needlework (crocheting,

knitting, needlepoint) • Drawing

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THERAPEUTIC ACTIVITIES CHART

CATEGORY PURPOSE EXAMPLES Reading

Video

Hand Care

Spiritual

Special Events

To provide entertainment, cognitive stimulation and/or mental distraction

To produce a pleasurable experience by viewing “classic” familiar movies To engage patients in an activity which encourages socialization To provide spiritual resources and to help relax and manage stress

To increase the patients’ appreciation and knowledge about different leisure resources

Books, including audio books/large print books

Magazines Short stories

Classic movies, e.g., black

& white Therapeutic hand

massage and social interaction

Bibles (printed and audio

versions) Additional

spiritual/religious references, such as Torah

Spiritual/religious music Dog visits Musicians Visiting artists

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ELDER LIFE SPECIALIST SLEEP ENHANCEMENT PROTOCOL*

Patient Eligibility: All patients who request a sedative-hypnotic medication for sleep or complain of difficulty initiating sleep. Evaluation:

1. Sleep Screening will be performed during screening and enrollment procedure.

2. Daily, all patients will be asked quality of preceding night’s sleep. If sleep quality is reported as poor, patients will be asked perceived reason for poor sleep, e.g., hallway noise.

Interventions:

1. Elder Life Specialist maintains appropriate equipment in a marked location. Equipment includes: • Portable music players • Relaxation music or recordings • Herbal tea ** • Hospital lotion

2. Elder Life Specialist orients patients and families to the protocol.

3. Daily, Elder Life Specialist initiates nurse or volunteer to provide the

sleep enhancement protocol (as outlined in Volunteer Training Manual) to those patients who report poor sleep or who request a sedative- hypnotic medication. This includes: • Environmental modifications, i.e., noise reduction (see

ELNS – Sleep Enhancement Protocol), dim lights, etc. • Three-step guideline:

1. Herbal tea or milk 2. Relaxation music or recordings 3. Backrub

4. Elder Life Specialist monitors and records adherence to

and effectiveness of interventions.

* This protocol should be carried out in conjunction with the Elder Life Nurse Specialist Sleep Enhancement Protocol.

** To avoid any potential toxicities or drug interactions, we recommend only

the following herbal teas: mint or fruit-spice teas (e.g., orange spice, cinnamon apple) with no added herbs or sugar.

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ELDER LIFE SPECIALIST EARLY MOBILIZATION PROTOCOL*

Patient Eligibility: All HELP patients will be enrolled in the Early Mobilization Protocol unless medically contraindicated. Evaluation:

1. Baseline mobility screening will be performed during screening and enrollment procedure.

2. Elder Life Specialist consults with the Elder Life Nurse Specialist

and hospital staff daily to determine the appropriate mobilization program for each patient.

3. Note - When walking with patients or encouraging them to

exercise, volunteers may provide assistance with balance. For example, a volunteer may put his or her arm behind a patient’s back while walking in the hall. However, volunteers do not lift patients or the patient’s extremities. The patient must be encouraged to use their own energy to move their bodies and extremities. This is not the role of the volunteers. Thus:

• Patients on bedrest or who require more than supervision

by volunteers will be enrolled in the Daily Exercise Program.

• Patients who ambulate independently or who require only supervision will be enrolled in the Daily Ambulation Program.

• Patients who are not on bedrest, but who require minimal assistance with ambulation (e.g., patients with balance problems) will be enrolled in a combination Volunteer Exercise/Staff Ambulation Program.

Interventions:

1. Daily Exercise Program: Active range-of-motion exercises 3 times daily, coached by volunteers or the HELP staff. These 10 exercises are designed to: • Increase muscle tone and flexibility of the six major joints

(shoulder, elbow, wrist, hip, knee and ankle). • Reinforce physical therapy exercise programs. • Be performed bilaterally in sets of 10 repetitions each, unless

the patient is too weak or acutely ill.

2. Daily Ambulation Program: Patients are coached to walk 3 times daily by volunteers or the HELP staff.

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3. Volunteer Exercise/Staff Ambulation Program: This level of assistance is designed to safely increase the stamina for patients who are too weak to walk alone. Volunteers administer range-of-motion exercises and HELP staff provide hands-on assistance to ambulate.

4. Mobility Restrictions: Elder Life Specialist consults with the Elder

Life Nurse Specialist and hospital staff daily regarding specific mobility restrictions or limitations for all HELP patients (e.g., patient with acute left lower extremity deep vein thrombosis will receive no left lower extremity exercises). 5. Elder Life Specialist directs the Early Mobilization Program: • Orients patients and families to the program. • Provides appropriate patient equipment and sensory aids (i.e.,

hearing devices, non-skid footwear, canes, walkers, portable oxygen tanks and carriers, IV poles). Whenever possible, Elder Life Specialist facilitates use of the patients’ own equipment and sensory aids (e.g., family brings in sneakers from home).

• In collaboration with the Elder Life Nurse Specialist and hospital staff, updates mobility assignments based on patients’ needs and progress.

• Monitors and records adherence to interventions. * This protocol should be carried out in conjunction with the Elder Life Nurse

Specialist Early Mobilization Protocol.

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VISION PROTOCOL Patient Eligibility: Patients who score less than 20/70, using a hand-held near vision screening card, with their best-corrected vision. Patients can also be included if their corrective lenses are unavailable or needing repair, if uncorrected vision is less than 20/70. Evaluation:

1. Vision Screening will be performed during screening and enrollment procedure.

Interventions:

1. Elder Life Specialist facilitates obtaining corrective lenses from patients’ homes, as necessary. If corrective lenses are not available, Elder Life Specialist provides appropriate adaptive equipment and sensory aids and reinforces their regular use with patients, families, volunteers and nursing staff. Equipment includes: • Large button telephone • Fluorescent tape for water-jugs, nurse’s call bell, and bed controls • Large print books and periodicals • Lighted magnifier glass

2. Elder Life Specialist:

• Orients patients to room visually, including instruction in use of bedside lighting

• Cleans glasses as necessary • Monitors and records adherence to interventions

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VISION PROTOCOL - BLINDNESS Patient Eligibility: Patients with severe visual impairment (total blindness or shadow, light/dark vision only). Adapt standard HELP interventions as follows to maximize effectiveness:

1. Daily Visitor: All staff and volunteers: • Upon entering room, announce your presence, introduce self and

explain your role. • Read all Orientation Board information to patient on each shift. • Upon leaving room, be sure that all equipment (walkers, IV pole,

etc.) and other items (tray table, chairs, etc.) are returned to designated place, and that call bell is within reach.

Elder Life Specialist: • Provides patient with large call bell, if available. Call bell should be

clipped to hospital gown or placed on bed next to patient’s dominant hand. If helpful to patient, Elder Life Specialist applies fluorescent tape to bedrail denoting where call bell is located.

• Provides patient with large button phone and orients patient to the position and layout of the numbers. This information is reviewed routinely.

• Applies fluorescent tape to mark water pitcher and other items used frequently by the patient. Fluorescent tape is applied on the tray table to indicate where phone and meal tray should be regularly placed.

• Alerts hospital staff and volunteers as to uniform placement of patient equipment, and places sign over bed alerting staff and volunteers that patient is visually impaired.

2. Feeding Assistance:

• Provide Full Feeding Assistance if required, or Set-Up Meal Tray for patient following a “clockwise” approach. Describe the food that is being served and tell patient where items are located on the tray.

soup desert drink

salad entree

←utensils/napkin

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3. Early Mobilization: • If patient is to be walked, guide them by taking them by the arm to

locate doorways and avoid obstacles in the hallway. • If performing range of motion exercises, use hand-over-hand

guidance (that is, light touches of the hand on the patient’s hand or body to guide the motion).

4. Therapeutic Activities:

• Use modified activities that minimize use of vision (i.e., avoid activities that involve patient reading). Verbally, explain all activities in detail.

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HEARING PROTOCOL Patient Eligibility: Patients who: (1) wear a hearing aid; and/or (2) hear three or less whispers from each ear on the Whisper Test; and/or (3) are unable to hear fingers lightly rubbed together 3-4 inches from their ear on the Finger Rub Test. Evaluation:

1. Hearing Screening will be performed during screening and enrollment procedure.

Interventions:

1. For patients wearing hearing aids, Elder Life Specialist: • Assures hearing aid is clean, without cerumen obstruction, batteries

working and obtains new batteries as necessary. • Facilitates hearing aid repairs and servicing, as necessary • If hearing remains poor despite above efforts, offers patients use of

an amplified hearing device and encourages its regular use.

2. For patients who do not wear hearing aids, Elder Life Specialist: • Offers an amplified hearing device to use during hospitalization and

instructs patients on its use • Encourages regular use of amplified hearing device

3. Elder Life Specialist reinforces use of hearing-adaptive equipment with

patients, families, volunteers and nursing staff. Patients are encouraged to use hearing aids and amplified hearing devices at start of each conversation.

4. Elder Life Specialist reinforces use of communication techniques with

families, volunteers and nursing staff: • Speak slowly, clearly and firmly in a mid-range pitch. • Avoid exaggerating facial expressions and shouting, which distorts

language sounds. • Position self so that patient can read lips; direct conversation to

patient’s “better” ear, when possible.

5. Elder Life Specialist refers patients with hearing impairment to the Elder Life Nurse Specialist to evaluate for cerumen impaction.

6. Elder Life Specialist monitors and records adherence to interventions.

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FEEDING ASSISTANCE/FLUID REPLETION PROTOCOL Patient Eligibility: Patients with inadequate oral intake, physical impairment and/or cognitive impairment will be enrolled (see below). Evaluation:

1. Nutritional Screening will be performed during screening and enrollment procedure.

2. Elder Life Specialist, in collaboration with Elder Life Nurse Specialist and hospital staff, regularly observes each patient during mealtime for: • Inadequate oral intake – A decrease in intake due to a decreased

appetite or medical condition (e.g., nausea, vomiting, etc.). • Physical impairment – Specific physical problems preventing the

patient from feeding themselves (e.g., paralysis or fracture of dominant hand, etc.).

• Cognitive impairment – Cognitive dysfunction so severe that the patient cannot recognize the need to eat or carry out the act of feeding themselves.

Interventions:

1. Daily, the Elder Life Specialist determines level of feeding assistance required for each patient using information from the Patient Enrollment Form and daily observations:

• Encouragement: For patients with poor oral intake but without

physical or severe cognitive impairment.

• Set-up Meal Tray: For patients able to feed themselves independently but who require assistance opening cartons, unwrapping utensils, etc., due to physical, cognitive or visual limitations.

• Partial Feeding Assistance: For patients requiring assistance with

both tray preparation and eating due to physical and/or cognitive impairment.

• Full Feeding Assistance: For patients needing to be fed by another

person due to physical and/or cognitive impairment. 2. Elder Life Specialist oversees the volunteers provide feeding assistance

for two meals daily (lunch and dinner).

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3. Elder Life Specialist, in collaboration with Elder Life Nurse Specialist,

nursing staff, and dietitian, assists patients to receive foods that suit their preferences (within their prescribed diet) to maximize their nutritional intake.

4. Elder Life Specialist, in collaboration with Elder Life Nurse Specialist,

oversees volunteers in fluid repletion (re-hydration) strategies (see ELNS – Fluid Repletion Protocol). For this protocol, volunteers are usually asked to encourage two 8-ounce cups of fluid per shift.

5. Elder Life Specialist directs the Feeding Assistance/Fluid Repletion

Program: • Orients patients and families to the program • Provides and encourages the use of appropriate patient

equipment and sensory aids (e.g., glasses, hearing devices, dentures, etc.).

• Oversees volunteers’ recordings of food and fluid intake • Updates levels of feeding assistance requirements based on

patients’ needs and outcomes • Monitors and records adherence to interventions

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SECTION III

Page

• GERIATRIC NURSING ASSESSMENT AND INTERVENTIONS 1. OVERVIEW…………………………………………………………………………43-44 2. TARGETED RISK FACTOR APPROACH……………………………… 44-45 3. ELDER LIFE NURSE SPECIALIST DAILY CLINICAL

REASSESSMENT………………………………………………………………. 45 4. EVALUATION OF COGNITIVE STATUS…………………………… 46-50

o ELDER LIFE NURSE SPECIALIST: PATIENT PROFILE SHEET… 51 o DELIRIUM PROTOCOL……………………………………………………………… 52-54 o DEMENTIA PROTOCOL…………………………………………………………….. 55-56 o PSYCHOACTIVE MEDICATIONS PROTOCOL……………………………. 57-58 o SLEEP ENHANCEMENT PROTOCOL………………………………………….. 59-60 o EARLY MOBILIZATION PROTOCOL………………………………………….. 61-63 o HEARING PROTOCOL……………………………………………………………….. 64 o FLUID REPLETION PROTOCOL………………………………………………… 65-66 o DISCHARGE PLANNING PROTOCOL………………………………………… 67-69 o OPTIMIZING LENGTH OF STAY PROTOCOL…………………………….. 70-71 o ADDITIONAL AREAS OF ELDER LIFE NURSE SPECIALIST

ASSESSMENT AND INTERVENTIONS………………………………………. 72-73 o NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE TO HELP (NICE TO HELP) PROTOCOLS……………………………………………………..74-96 o HELP POLICY ON MMSE/COG. SCREENING INSTRUMENTS…… 97-99 o UPDATING THE BEERS CRITERIA FOR POTENTIALLY

INAPPROPRIATE MEDICATION USE IN OLDER ADULTS…… 100-108 o TOP 10 DRUG INTERACTIONS………………………………………………. 109-112

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ELDER LIFE NURSE SPECIALIST SCOPE OF RESPONSIBILITIES

PATIENT CARE Direct Patient Care

• Provide comprehensive geriatric assessment and interventions, with an emphasis on delirium risk factors

• Review and expand Patient Enrollment Form to complete Geriatric Vital Signs

• Round with nursing staff and review all patients enrolled in the program

• Implement the ELNS protocols and monitor patients’ outcomes

Interdisciplinary Interventions • Coordinate interdisciplinary geriatric team rounds • Assure prompt referrals to consulting staff

Discharge and Post-Discharge • Facilitate optimal, individualized discharge planning • Collaborate with hospital discharge planning staff and

community agencies to optimize care after discharge • Ensure prompt telephone call follow-up after

discharge

STAFF EDUCATION • Provide education, support and role modeling

to nursing and other staff as appropriate • Coordinate Provider Education Program and

Gerontological Nursing In-Services.

PROGRAM OPERATIONS • Record and maintain ELNS interventions

progress reports • Provide clinical and administrative support for

ELS and volunteers • Serve as a liaison between the program and

nursing administration • Track and address quality assurance and

adherence issues.

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GERIATRIC NURSING ASSESSMENT AND INTERVENTIONS 1. Overview

The Elder Life Nurse Specialist holds the central clinical role in the program, providing geriatric clinical assessment and interventions. In addition, the ELNS assures prompt referrals to consulting staff in the hospital and facilitates optimal, individualized discharge planning. Importantly, the ELNS provides education, support, and role modeling in care of older patients for staff nurses.

As the clinical resource to the Elder Life Specialist, the ELNS reviews the focused Patient Enrollment Form completed by the Elder Life Specialist. Areas of patient’s problems or concerns are expanded on as necessary by the ELNS. Ultimately, the ELNS builds on the Patient Enrollment Form to complete the “Geriatric Vital Signs” for each patient. This information is recorded on the “ELNS: Patient Profile Sheet” (attached). The Geriatric Vital Signs include:

• Cognition: Delirium, Dementia • Psychoactive Medication Use • Sleep • Functional Status: ADLs and IADLs • Mobility • Sensory Function: Vision and Hearing • Hydration/Nutrition • Incontinence and Elimination Issues • Skin • Emotional Health: Depression, Anxiety • Social Issues • Discharge Planning and Educational Needs

2. Targeted Risk Factor Approach

The targeted, focused nature of the intervention protocols has enhanced the success of the HELP model of care. However, while the specific ELNS protocols are targeted towards the six risk factors for cognitive and functional decline (i.e., cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, and dehydration) and to improve the transition from hospital to home, broader geriatric issues are regularly addressed by the ELNS. Although comprehensive presentation of clinical algorithms for geriatric medicine and nursing are beyond the scope of this manual, some general recommendations of other areas to assess and intervene, including potential screening tools, are provided.

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The six risk factors with their corresponding protocols include:

Risk Factor

Cognitive impairment

Sleep deprivation

Immobility

Vision impairment

Hearing impairment

Dehydration

Elder life Nurse Specialist Protocol Delirium Protocol Dementia Protocol Psychoactive Medications Protocol Sleep Enhancement Protocol

Early Mobilization Protocol

See ELS: Vision Protocol

Hearing Protocol

Fluid Repletion Protocol

In addition: Improving transition from hospital to home

Discharge Planning Protocol Optimizing Length of Stay Protocol

3. Elder Life Nurse Specialist Daily Clinical Reassessment

An important role of the Elder Life Nurse Specialist is to methodically review each patient’s clinical status daily, with an emphasis on the geriatric vital signs and the ELNS protocols. For example, the ELNS reviews daily each patient’s cognitive status, medication use, sleep status, etc.

Interventions outlined in the ELNS protocols are initiated based on the daily clinical assessments performed by the ELNS. For example, the ELNS may assign fluid repletion as an intervention based on a patient’s BUN/Cr and physical examination at time of admission. Daily, the ELNS reassesses the patient’s volume status to determine if fluid repletion continues to be necessary and/or to determine need for additional interventions.

It is also imperative for the ELNS to assess each patient’s mobility status daily, collaborating with the Elder Life Specialist and hospital staff to determine patients’ mobility assignments.

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4. Evaluation of Cognitive Status

Careful and consistent evaluation of each patient’s cognitive status is a significant component of the HELP program. These evaluations determine recommended interventions and document patient outcomes. In addition to a baseline and discharge evaluation, we recommend that sites evaluate cognitive status on a daily basis, in one of two ways:

1. Daily delirium measurements:

In order to obtain daily delirium measurements, we recommend the use of daily patient interviews consisting of a cognitive assessment (i.e., the SPMSQ or Mini Cog) and digit span test, which are then used to rate the short version (questions 1-4) Confusion Assessment Method (CAM rating). Daily chart reviews for written documentation of change in mental status should also be conducted.

To use these instruments reliably, HELP staff would need to undergo training for standardization on the instruments. Training materials for the CAM are located in Section 7. The staff time involved in daily delirium measurements is considerable - approximately 15-20 minutes per patient per day. These measurements would need to be carried out at least once daily in order to reliably detect delirium. It is also important to note that some patients become irritated with daily cognitive interviews. Because of the staff time involved, we understand that this level of surveillance will not be possible/feasible for most clinical sites.

The digit span test and the short version CAM are attached.

2. Daily chart review and patient observation for changes in mental status,

and cognitive assessment change monitoring:

For many sites, it may not be feasible to perform daily delirium measurements. In this situation we recommend the following:

All HELP patients should have a cognitive assessment: 1. at baseline, 2. with any suspected mental status change during their hospitalization and 3. at time of discharge.

To determine a mental status change, we recommend daily chart reviews and daily patient observations by the HELP staff. Both HELP staff and floor staff should have ongoing education about cognitive assessment, and should be sensitized to observe and report changes. When notations

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in the chart describe changes in mental status (e.g., sudden onset of confusion, inattention, disorientation, lethargy, agitation, inappropriate behavior, "sundowning", etc.), or observations of the patient suggest mental status change, a cognitive assessment should be performed.

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SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ)

Patient’s Name: _________________________________ Date: ___________________ Instructions: Ask questions 1 to 10 on this list and record all answers. (Ask question 4a only if the patient does not have a telephone.) All responses must be given without reference to a calendar, newspaper, birth certificate, or other memory aid. Mark errors in the “Error?” column. Record the total number of errors based on the answers to the 10 questions.

Question Response Error? 1. What is the date today?

2. What day of the week is it?

3. What is the name of this place?

4. What is your telephone number? (4a. What is your street address?)

5. How old are you?

6. When were you born?

7. Who is the current president of the United States?

8. Who was president just before him?

9. What is your mother’s maiden name?

10. Please count backwards from 20 by 3s

Total number of errors: _______________ Scoring: 0-2 errors: normal cognitive functioning 3-4 errors: mild cognitive impairment 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment Suggested Cutpoints for HELP: 0-1 errors: Enroll in HELP if the patient has one or more of the additional risk factors outlined in the HELP manuals ≥2 errors: Risk factor for cognitive decline – Enroll in HELP ≥5 errors: Enrollment in orientation protocol ≥8 errors: Severe cognitive impairment; Case by case enrollment Source: Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23(10):433-41. Used with permission.

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DIGIT SPAN

Now I am going to say some numbers. Please repeat them back to me.

[SAY DIGITS AT RATE OF ONE PER SECOND]

Digits Response Correct Error Unable

6-2-9 - - 1 2 6 5-4-1-7 - - - 1 2 6 3-6-9-2-6 - - - - 1 2 6 9-1-8-4-2-8 - - - - - 1 2 6 1-2-8-5-3-4-6 - - - - - - 1 2 6

[Enter the numbers as repeated. Record as correct or error. If errors are made on 2 consecutive spans, discontinue test and record highest span performed correctly. If error on 3-digit and 4-digit spans (must do at least 2 spans), code as “2”. Each span can be repeated once if needed.

If patient is deaf, score as “unable”.]

Alternative Attention Tasks:

Days of the Week Backward

Day Sat. Fri. Thurs. Weds. Tues. Mon. Sun. Answer

Any error indicates impairment

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CONFUSION ASSESSMENT METHOD (CAM) SHORTENED VERSION WORKSHEET

EVALUATOR: DATE:

I. ACUTE ONSET AND FLUCTUATING COURSE BOX 1

a. Is there evidence of an acute change in mental status from the patient’s baseline? No

Yes

b. Did the (abnormal) behavior fluctuate during the day, that is tend to come and go or increase and decrease in severity?

No

Yes

II. INATTENTION

Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

No

Yes

III. DISORGANIZED THINKING

Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

IV. ALTERED LEVEL OF CONSCIOUSNESS

Overall, how would you rate the patient’s level of consciousness? No

Yes

-- Alert (normal)

-- Vigilant (hyperalert)

-- Lethargic (drowsy, easily aroused)

-- Stupor (difficult to arouse)

-- Coma (unarousable)

Do any checks appear in this box? No Yes

If all items in Box 1 are checked and at least 1 item in Box 2 is checked, a diagnosis of delirium is suggested.

Adapted from Inouye, SK et al Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium. Ann Intern Med. 1990; 113:941-8. Copyright © 2003 Hospital Elder Life Program.

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ELDER LIFE NURSE SPECIALIST PATIENT PROFILE SHEET

Patient Name: Admission Date:

Room: Isolation: Discharge Date:

Medical Information: Hydration/Nutrition

Continence/Elimination

Skin

Cognition (Baseline, Recent changes) Emotional Health

Medications (Past/Current) Social Supports

Sleep Discharge Planning

Functional Status (ADL, IADL)

Mobility Other

Vision/Hearing

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Assessment:

ELDER LIFE NURSE SPECIALIST DELIRIUM PROTOCOL

1. Elder Life Nurse Specialist monitors the cognitive status of all patients

daily. Methods may include: personal interview, chart review, interviews with nursing staff and family, review of cognitive assessment (SPMSQ or Mini Cog) scores and report from the Elder Life Specialist and volunteers.

2. For patients with evidence of cognitive impairment, ELNS establishes

patient’s baseline cognitive status from family/caregivers. Information to review with the family/caregivers includes: • Onset and course of mental status problem (abrupt, or steady

downhill) • Use of psychoactive medications (including over-the-counter

medications) • Alcohol use

3. For patients with an acute change in mental status (over hours

or days), ELNS performs CAM assessment (see Section 7: Suggested Resources) and communicates findings to physician.

Interventions:

1. If patient develops an abrupt change in mental status: Elder Life Nurse Specialist collaborates with medical and nursing staff to investigate cause of change, and expedites appropriate medical work-up and management as necessary: • 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 • Rule out other occult illness/event, e.g., myocardial infarction (MI)

2. Non-Pharmacological Management: Patients with delirium frequently

have agitation and sleep disturbances. Their symptoms tend to fluctuate and are often worse at night. A crucial role of the Elder Life Nurse Specialist is to educate and reinforce with the nursing and hospital staff non-pharmacological methods to decrease patients’ agitation and improve their sleep patterns and overall symptoms.

* Pharmacologic management should be used only when the

patient poses a danger to themselves or to others.

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The following environmental and behavioral interventions are reviewed daily by the ELNS with the nursing staff, family and other hospital staff:

A. Creating an optimal environment: Interventions designed to create an appropriate calm, orienting environment (but not secluding) for all confused patients (particularly those with nighttime confusion and/or agitation at any time): • Create and post routine/schedule • Leave night light on • Limit patients’ intake of caffeine • Noise reduction strategies, limiting misleading stimuli and un-

needed noise (TV, paging system). Some patients appreciate soft, relaxing music.

• Relaxation techniques, Sleep Enhancement Protocol. • Keep room and staff changes to a minimum • Provide orienting influences (e.g., clock, calendar, personal effects

from home).

B. Communication techniques: Communication with the patient to prevent further confusion or “sundowning”, and to create a calm environment. Principles of this communication include: • Reality orientation (introduce self; orient patient to date, room,

what’s going on with their day’s schedule, etc.). Keep patients involved in their care.

• Speak in a calm, pleasant and unhurried manner, with frequent eye contact and calming touch.

• Give simple, one-step instructions. Limit choices to those the patient can make.

• Be sure patients wear glasses and hearing aides during conversation if needed.

• Be concrete, avoid arguing. • Avoid over-stimulation via rapid conversation and large groups of

people.

C. Behavioral management strategies: • Use of constant companions (i.e., “sitters”) or family members for

management of agitated patient • Transfer disruptive patient to a private room or bring to nurse’s

station for increased supervision • Avoid physical restraints: Elder Life Nurse Specialist expedites the

discontinuation of a restraint order when appropriate and educates medical and nursing staff on appropriate alternative methods to treat confused, agitated behavior. Restraints will increase agitation, and may cause injury.

D. Family involvement: In collaboration with the nursing staff, the Elder

Life Nurse Specialist involves family members in the patient’s care:

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• Educates the family members in orienting communication (as above for nurses) and relaxation techniques to use with the patients.

• Encourages family’s presence at the bedside, especially at night and for overnight stays, to enhance and maintain the patient’s cognitive status. Arranges schedule for family visits as appropriate (in some cases, 24 hour presence of family may be indicated to provide reorientation and minimize agitation).

3. Referrals: The Elder Life Nurse Specialist expedites the following

referrals, as appropriate: • Psychiatry – For comprehensive evaluation and/or treatment of

psychiatric symptoms and illnesses • Psychiatric Liaison Nurse – To evaluate psychiatric symptoms and

symptoms of stress, especially difficulty coping with disease and hospitalization, and for psychotherapeutic intervention

• Social Worker – For psychosocial and family/caregiver assessment to help formulate an effective treatment and discharge plan

• Discharge planner – For family/caregiver assessment to help formulate an effective discharge plan

Nursing Staff Education: The Elder Life Nurse Specialist provides regular inservices on the following, and introduces the Delirium Protocol.

• Evaluation of cognitive status • Delirium vs. dementia • Management of confused patients (including use of orienting

communication and nonpharmacologic behavioral management strategies).

Adherence: Elder Life Nurse Specialist monitors and records adherence to interventions.

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ELDER LIFE NURSE SPECIALIST DEMENTIA PROTOCOL

Assessment:

1. Elder Life Nurse Specialist monitors daily all patients’ cognitive status as described in the Delirium Protocol.

2. For patients with evidence of cognitive impairment, the Elder Life

Nurse Specialist establishes patient’s baseline cognitive status as described in the Delirium Protocol.

3. For patients with signs and symptoms consistent with a chronic, slowly

progressive cognitive impairment (dementia), ELNS reviews baseline screening information with family/caregivers, with emphasis on:

• Social situation/Caregiving needs • ADL/IADL • Nutrition • Sleep

Interventions:

1. If patient has a chronic cognitive impairment, the Elder Life Nurse Specialist: • Collaborates with medical staff to facilitate appropriate medical

work-up as necessary (i.e., lab tests to rule out reversible causes of cognitive impairment, etc.).

• Collaborates with family/caregivers about effective behavioral management strategies

2. Nursing staff education: The Elder Life Nurse Specialist notifies nursing

staff of observations consistent with dementia, and educates nursing and hospital staff in non-pharmacological methods to prevent further confusion (e.g., delirium, sundowning) and to create a calm environment. These interventions are described in the Delirium Protocol and include: • Creating an optimal environment • Communication techniques • Behavioral management strategies • Family involvement

3. Avoiding psychoactive medications: Elder Life Nurse Specialist

encourages the use of patient companions, family visits, communication techniques and relaxation strategies -- rather than psychoactive medications -- to manage agitation.

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*Pharmacologic management should be used only when the patient poses a danger to themselves or to others.

4. Referrals: The Elder Life Nurse Specialist expedites referrals as

described in the Delirium Protocol. Nursing Staff Education: The Elder Life Nurse Specialist provides regular inservices as described in the Delirium Protocol, and introduces the Dementia Protocol. Adherence: Elder Life Nurse Specialist monitors and records adherence to interventions.

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ELDER LIFE NURSE SPECIALIST PSYCHOACTIVE MEDICATIONS PROTOCOL

Assessment:

1. The Elder Life Nurse Specialist performs a past and current medication history on all patients at time of enrollment into HELP.

2. The Elder Life Nurse Specialist screens each patient’s daily medication

list for medications associated with delirium. See article “Some Drugs That Cause Psychiatric Symptoms” (Section 7) as resource.

Interventions:

1. Daily, after reviewing each patient’s medication list, the Elder Life Nurse Specialist collaborates with medical, nursing and pharmacy staff about potential and actual adverse medication outcomes, and makes recommendations. Recommendations may include medication dosage adjustment, discontinuation, and/or selection of an alternative medication.

Nursing Staff Education: The Elder Life Nurse Specialist collaborates with pharmacist to provide regular inservices on pharmacologic considerations in the elderly, and introduces the Psychoactive Medications Protocol. Education also includes:

• Changes with Aging - Pharmacokinetics/Pharmacodynamics • Adverse Drug Reactions • Medications Associated with Delirium in the Elderly


* Additional Recommended Intervention: Review of the Medication

Formulary

Adverse drug effects are common in the elderly, and psychoactive medication use is a well-recognized risk factor for cognitive and functional decline. During the start-up phase of implementing the Hospital Elder Life Program, it is recommended that the ELNS, geriatrician and pharmacist review their facility’s medication formulary and the prescribing habits of the physicians/other prescribing clinicians. Particular attention should be focused on medications with psychoactive effects, e.g., benzodiazepines, anticholinergic medications, narcotics, etc.

The ELNS, geriatrician and pharmacist can compile a complete list of these medications to be used with caution in older patients (particularly those

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with psychoactive effects) or an abbreviated list of these medications that are used frequently in their facility. Additional information to compile about selected medications may include: side effect profiles, interactions with other medications or concomitant illness, “geriatric” dose range or minimum effective dose (if known), normal range of serum drug concentration (if known), and “drug of choice” for selected conditions. This information can be used as a resource by the ELNS during daily patient medication list reviews to target potential or actual adverse medication effects. The ELNS can also use this information to educate nursing staff about pharmacologic considerations in the elderly.

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ELDER LIFE NURSE SPECIALIST SLEEP ENHANCEMENT PROTOCOL*

Eligible Patients: All patients who request a sedative-hypnotic medication for sleep or complain of difficulty initiating sleep. Assessment:

1. Elder Life Nurse Specialist reviews baseline and current sleep screening information.

2. Elder Life Nurse Specialist screens each patient's medication list daily, reviewing for the presence of sedative-hypnotic drugs (SHDs) (**) and time schedule of all medications.

Interventions:

1. In collaboration with medical and nursing staff and when medically appropriate, the Elder Life Nurse Specialist: • Rearranges medication timing so that patients are awakened the

minimum number of times during the night. • Coordinates the timing of medical/nursing treatments (e.g.,

catheterizations, dressing changes, and taking vital signs) so that the patient is allowed uninterrupted sleep for as long a time as possible.

• Makes recommendations which may include nonpharmacologic relaxation approaches, SHD dosage adjustment, discontinuation, and/or selection of an alternative medication.

2. Elder Life Nurse Specialist collaborates with the Elder Life Specialist to

initiate nurse or volunteer to provide the sleep enhancement protocol (as outlined in Volunteer Training Manual) to those patients who report poor sleep or who request a sedative-hypnotic medication. This includes:

A. Three-step guideline:

1. Herbal tea*** or milk 2. Relaxation music or recordings 3. Backrub

B. Environmental modifications:

• Noise reduction strategies: silent pill crushers, vibrating beepers and quiet hallways

• Dim lights

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Nursing Staff Education: The Elder Life Nurse Specialist provides regular inservices on sleep and sleep medications in the elderly, and introduces the Sleep Enhancement Protocol. Education will also include:

• Sleep disturbances in older patients • SHDs and their potential toxicity • General sleep enhancement strategies/sleep hygiene measures (e.g.,

avoiding caffeinated beverages and diuretics in the evening) • Detailed instructions on administration of the sleep protocol • Unit-wide nighttime noise reduction strategies


* This protocol should be carried out in conjunction with the Elder Life Specialist Sleep Enhancement Protocol.

** SHD is defined as any benzodiazepine, minor tranquilizer, or antihistamine

(e.g., diphenhydramine) administered for complaints of difficulty initiating sleep.

***To avoid any potential toxicities or drug interactions, we recommend only the

following herbal teas: mint or fruit-spice teas (e.g., orange spice, apple cinnamon) with no added herbs or sugar.

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ELDER LIFE NURSE SPECIALIST EARLY MOBILIZATION PROTOCOL*

Assessment:

1. Elder Life Nurse Specialist will: • Daily, determine each patient’s physical limitations and ability to

participate in mobility protocol, based on clinical assessment, which will include input from: patient’s self-report of functional abilities (per ADL/IADL screening), direct mobility assessment (see attached “Mobility Observation Guidelines”), chart review and physician order, and/or other hospital staff assessment.

2. In collaboration with hospital staff, the Elder Life Nurse Specialist

assesses each patient for physical difficulties that may indicate need for physical therapy consultation. Such factors may include: • Decline in range of motion (ROM), endurance, balance and strength

from baseline status and/or from effects of chronic and acute disease.

• Decline in physical ability to perform tasks necessary for daily function, i.e., bed mobility, transfers, gait/ambulation, and stair climbing.

3. In collaboration with hospital staff, the Elder Life Nurse Specialist

assesses each patient for functional difficulties that may indicate need for occupational therapy consultation. Such factors may include: • Difficulty with self care including bathing, dressing, grooming and

feeding • Difficulty with upper extremity strength/ROM/sensory function that

affects ability to perform activities of daily living • Difficulty with coordination • Need for instruction on work simplification and/or energy

conservation (i.e., patients with chronic lung disease) • Difficulty with cognitive/perceptual functioning, i.e., visual

disturbances, neglect, memory, safety and judgment deficits • Need for adaptive equipment

4. The Elder Life Nurse Specialist collaborates with home caregivers as

necessary to determine baseline mobility and functional status for patients unable to provide accurate information, i.e., confused patients.

5. The Elder Life Nurse Specialist assesses location and nature of pain, if

any, during movement.

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Interventions:

1. The goal of the Early Mobilization Program is for patients to regain their maximal level of functioning as quickly as is safe. The Elder Life Nurse Specialist provides constant surveillance of patients’ abilities and readiness to participate in the Early Mobilization Program and prompts hospital staff to update orders including: • Discontinuation of bedrest orders • Discontinuation of immobilizing equipment, e.g., restraints, catheters • Acquisition of equipment to enhance mobility, e.g., overbed trapeze,

walker, cane • Optimal pain regimen/pain control

2. The Elder Life Nurse Specialist provides education to patient/caregiver

to maximize mobility: a. Reinforces instructions provided to patient by rehabilitation

therapists regarding proper ways to perform exercises to minimize injury and maximize effectiveness, and safe transfer and ambulation techniques

b. Assists patient to choose activities consistent with physical capabilities c. Assists patient to focus on what he or she can do rather than deficits d. Assists patient/family to monitor own progress toward goal achievement e. Educates patient/family on hazards of immobility in the elderly, and

instructs on how to guard against orthostatic hypotension/make postural adjustments

3. Referrals: The Elder Life Nurse Specialist expedites physical

therapy/occupational therapy consults based on factors listed above. Nursing Staff Education: The Elder Life Nurse Specialist collaborates with rehabilitation therapists to provide regular inservices on hazards of immobility in the elderly, and introduces the Mobility Protocol. Education will also include:

• Aging, disuse and disease • Exercise and functional status with aging • Falls

Adherence: Monitors and records adherence to interventions * This protocol should be carried out in conjunction with the Elder Life Specialist

Early Mobilization Protocol.

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MOBILITY OBSERVATION GUIDELINES Overview: These guidelines have been developed in collaboration with physical therapists to assist the Elder Life Nurse Specialist in assessing patients’ mobility at the bedside.

1. Bed Mobility Watch for ability to roll onto side and sit up unassisted.

Disturbance of bed mobility:

• Body placement off center and/or too close to edge • Unable to reposition self while in supine position

2. Sitting Balance

Watch for ability to maintain trunk in upright posture.

Disturbance of sitting balance: • Leans off center to side, front or back

3. Sit and rise from a chair

Watch for ability to sit and rise to standing in a smooth, controlled manner using the strength of arms and legs without balance loss. Should not require more than two attempts or human help to accomplish movement

4. Standing balance

Watch for ability to maintain erect posture and stand steady, without human assistance (devices are allowed), without balance loss, unsteadiness or dizziness.

Disturbance of standing balance:

• Leans off center to side, front or back

5. Gait Walk in a straight line (about 15 feet), turn around, and walk back. Watch for ability to walk and turn around without hesitation, excessive veering from side to side, or shuffling of feet.

Disturbance of walking ability:

• Steps uneven, shuffling feet, missing steps, tripping or staggering gait, wide (>12 inch) base

• Lack of control while walking or during turns • Unsafe use of assistive devices

6. Stand to sit -

Watch for lack of control: dropping into chair or flopping back out of control

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ELDER LIFE NURSE SPECIALIST

HEARING PROTOCOL* Patient Eligibility: Patients who: (1) wear a hearing aid; and/or (2) hear three or less whispers from each ear on the Whisper Test; and/or (3) are unable to hear fingers lightly rubbed together 3-4 inches from their ear on the Finger Rub Test. Assessment:

1. Hearing Screening will be performed during screening and enrollment procedure.

Interventions:

1. For patients with decreased hearing, the Elder Life Nurse Specialist evaluates patients for cerumen impaction. If present, ELNS: • Facilitates carbamide peroxide 6.5% (Debrox) ear drops

prescription • Removes cerumen after softening of cerumen • Facilitates ENT consultation for complex and/or complicated cases

(e.g., history of perforated tympanic membrane)

2. Remaining interventions are overseen and completed by the Elder Life Specialist.

* This protocol should be carried out in conjunction with the Elder Life

Specialist Hearing Protocol.

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ELDER LIFE NURSE SPECIALIST FLUID REPLETION PROTOCOL

Eligible Patients: Patients with clinical evidence of dehydration (e.g., poor skin turgor, dry mucous membranes, postural hypotension) and/or BUN/Cr ratio > 18. Assessment:

1. Elder Life Nurse Specialist assesses each patient daily for dehydration.

Risk factors for dehydration may include: • Acute illness with increased insensible volume losses from fever,

diaphoresis, tachypnea, emesis or diarrhea • Decreased water access due to immobility, poor visual acuity,

altered mental status, etc. • Administration of diuretics • Uncontrolled hyperglycemia • Fear of urinary incontinence leading to diminished fluid intake • Administration of either intravenous radiographic contrast agents or

high protein enteral feedings causing an osmotic diuresis • Previous dehydration episodes • Anorexia

Interventions:

Initial Management:

If a patient is dehydrated, Elder Life Nurse Specialist:

1. Educates and reinforces with patient the importance of increasing fluid intake

2. Collaborates with medical and nursing staff about initiating

rehydration strategies, including volume repletion.

3. If appropriate, instructs nursing staff and oversee volunteers in rehydration strategies, i.e., push oral fluids as needed to replace losses.

Aim is 30cc/kg/day unless contraindicated (heart failure, cirrhosis, nephrotic syndrome). Additional fluid may be needed to replace losses (e.g., vomiting, diarrhea, insensible losses). Volunteers are usually asked to encourage two 8-ounce cups of fluid per shift.

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4. Strategies will also include: provide oral fluids that are patient’s preference, placed in easy reach, provide a straw, and provide fresh water.

5. Collaborates with pharmacist to evaluate medications/medication

dosages that may contribute to dehydration, e.g., diuretics

6. Assesses for postural hypotension. If present, instructs patient and caregivers in postural hypotension precautions including avoiding rapid position changes, especially from supine to sitting or standing.

Ongoing management:

1. Reassesses patient’s hydration status daily via chart review and

clinical reassessment.

2. Instructs and reinforces with nursing staff to obtain strict “Intakes and Outputs” and daily weights.

3. Collaborates with physician if signs and symptoms of poor fluid

intake and/or electrolyte imbalance persist or worsen. Nursing Staff Education: Elder Life Nurse Specialist provides regular inservices on dehydration in the elderly, and introduces the Fluid Repletion Protocol. Adherence: Elder Life Nurse Specialist monitors and records adherence to interventions.

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ELDER LIFE NURSE SPECIALIST DISCHARGE PLANNING PROTOCOL

Eligible Patients: All patients enrolled in the Hospital Elder Life Program will receive individualized discharge planning. Assessment: At the time of admission, Elder Life Nurse Specialist assesses each patient’s home environment and social supports for possible discharge needs. This assessment will include:

• Type and safety of living environment • Marital status • Primary caregiver • Social/family supports both in the home environment and in the

immediate area • Skilled nursing services being utilized • Need for assistance with transportation, chores, shopping, and/or

friendly visiting. Interventions:

A. Home Health Care Services

Types of patients to target: Patients with ADL limitations and for whom further teaching and observation are necessary to avoid a predictable exacerbation of a chronic or an acute condition that interferes with reasonable recovery.

Home Health Care Services offered: Disease management programs; nursing care and supervision; social work services; rehabilitation therapies; nutritional guidance; laboratory and radiology services; speech therapy; inhalation therapy; appliance, equipment and sterile supply services; and homemaker and home health aide services.

1. The Elder Life Nurse Specialist collaborates with appropriate

hospital staff (nurse, discharge planner, social worker) about patient and specific home care needs.

2. At time of discharge, Elder Life Nurse Specialist provides home care

agency with the “ELNS: Patient Communication Form” (attached) to supplement the W-10 (interfacility communication form). Information to assist agencies in planning patients’ care after hospitalization is provided and includes: precipitating hospital admitting factors, “geriatric vital signs”, and educational needs identified. When appropriate, Elder Life Nurse Specialist provides agency with a verbal report as well.

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B. Additional Services: Examples of Connecticut services funded by the Older Americans Act which have been useful to older adults living in the community are listed below. These services may vary by state. The Elder Life Nurse Specialist assesses patients’ needs and facilitates referrals to community agencies when appropriate.

1. Community Action Agency:

• Types of patients to target: Those patients living in the

geographic area served by the agency with limited social support, and who may require prompt assistance to facilitate optimal discharge from hospital to home. Also targeted will be those frail elderly who may have chronic need for services provided by the agency, i.e., have limited social support, limited financial resources, are homebound, or are functionally limited.

• Services offered: Energy assistance, fuel bank, weatherization, chore services, grocery delivery, food shopping and delivery, medical transportation, Meals-on-Wheels, and congregate meals.

2. Interfaith Volunteer Caregivers (IVC):

• Types of patients targeted: Frail elderly persons living alone,

with limited social support, and who are in need of assistance to continue living independently.

• Services offered: Friendly visiting, grocery shopping or other errands, transportation to medical appointments, telephone reassurance, help with banking, household and yard chores, minor home repairs, and family relief care.

3. SAGE Services: Offers chore assistance, housing information, and

other services to community-dwelling elders.

4. Other: • Community pharmacies that offer free delivery of medications

and medical supplies. • Senior Centers • Adult Daycare Centers

Nursing Staff Education: The Elder Life Nurse Specialist provides regular inservices on psychosocial assessment and discharge planning strategies in the hospitalized elderly, and introduces the Discharge Planning Protocol. Adherence: Elder Life Nurse Specialist monitors and records adherence to interventions.

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ELDER LIFE NURSE SPECIALIST PATIENT COMMUNICATION FORM

PATIENT NAME: DISCHARGE DATE: Precipitating Hospital Admitting Factors

Medication Concerns

Vision/Hearing

Elimination/Continence

Educational Needs Identified

Cognitive Status/Emotional Health (Including admit & discharge cognitive assessment, i.e., SPMSQ or Mini Cog)

Functional Status/Mobility

Hydration/Nutrition

Social Supports

Additional Comments/Concerns

Questions? Please call Elder Life Nurse Specialist (ELNS) at If this is an emergency, please page ELNS at

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ELDER LIFE NURSE SPECIALIST OPTIMIZING LENGTH OF STAY PROTOCOL

Overall Goals of Program:

• Early, ongoing, interdisciplinary assessments and interventions toward the goal of returning to independent, community living as early as possible.

• Maintenance or improvement of patients’ cognitive and functional abilities.

• Shortening length of stay by a mean of one day. Assessment:

1. At the time of admission, the Hospital Elder Life Team assesses for each patient: cognitive status, functional status, social/financial situation, environmental concerns, access to formal and informal services, and patient’s discharge needs.

2. Elder Life Nurse Specialist identifies risk factors that indicate a need

for intensive discharge planning, which may include:

• Frequent hospitalizations in past one to two years • Presence of unstable chronic medical conditions, i.e, diabetes, CHF • History of active alcohol use, or recent use of psychoactive

medications • Patients labeled “Failure to Thrive” • Community patients unable to transfer or ambulate independently • History of falls and/or injuries • Patients with new-onset confusion • Community patients with inadequate social supports

Interventions:

1. Communicates regularly with appropriate hospital staff (physician, nurse, rehabilitation specialists, discharge planner, social worker) about HELP patients and possible discharge needs.

2. Facilitates open communication between the health care team and patient/family to address issues related to discharge from the time of admission. Acts as patient advocate and liaison among caregivers when appropriate.

3. In collaboration with medical and nursing staff, ensures prompt access to necessary interventions such as dietitian consultation, physical therapy and occupational therapy.

4. Anticipates discharge needs and community services that may provide assistance. Utilizes knowledge of community resources to link patient and family to appropriate agencies and services. Communicates

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regularly with key clinicians in community agencies and facilitates two- way communication with community agencies to create viable, individualized plans for care after hospitalization.

Referrals

Elder Life Nurse Specialist facilitates referrals to home health care agencies, local Community Action Agencies, and other community resources as outlined in Discharge Planning Protocol.

Adherence

• Elder Life Nurse Specialist evaluates whether length of stay was prolonged for any reason.

• Elder Life Nurse Specialist evaluates whether any nursing home

placements were avoidable.

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ADDITIONAL AREAS OF ELNS ASSESSMENT AND INTERVENTIONS Emotional Health • Depression - Screen all patients for depression.

Suggested resources: 1. Case-finding instruments for depression: Two

questions are as good as many (Whooley, et al., 1997).

2. Geriatric Depression Scale For patients with positive responses for depression on screening, the ELNS communicates findings to medical team and facilitates further evaluation and/or treatment.

• Anxiety – The ELNS assesses patients daily for

anxiety. If present, a specific intervention that the ELNS discusses with the patient is Relaxation Exercises. Relaxation exercises are exercises designed to decrease anxiety and stress, assist with pain control, and assist with sleep by encouraging self-managed relaxation. The ELNS educates patient and/or family as to the purpose and process of the exercises. Volunteers are directed to provide them at least once daily, if indicated, and the ELNS monitors for effectiveness and continued need.

• The ELNS also assesses need for chaplain referral based on indicators described in “ELS: Chaplaincy Protocol”

• Refer to Resource List (Section 7) for additional information and resources on Emotional Health

Nutrition • Review and expand upon ELS: Patient Enrollment Form as necessary

• Facilitate dietitian referral as appropriate • Facilitate swallow evaluation/speech therapist

evaluation for patients demonstrating mechanical problems with feeding (i.e., choking, aspiration, etc).

• Facilitate occupational therapy evaluation for patients with upper extremity dysfunction, or visual- perceptual or sensory deficits

Functional Status, i.e., ADLs, IADLs

• Review and expand upon ELS: Patient Enrollment Form as necessary

• Facilitate referrals to improve function as appropriate, e.g., physical therapy, occupational therapy

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Additional Areas of ELNS Assessment and Interventions

(cont.) Incontinence and Elimination Issues

• Evaluate incontinence symptoms for transient cause (e.g., UTI, constipation/impaction, etc.), and to differentiate between types (e.g., stress, urge, overflow, functional, mixed). Use attached table as reference.

• If transient cause, facilitate further evaluation and treatment

• If chronic symptoms of urinary incontinence, assess patients’ willingness to pursue treatment. Facilitate further evaluation and treatment via referrals, as appropriate.

• Evaluate bowel symptoms such as constipation,

diarrhea • Maintain patients’ normal bowel routine, as able • Refer to Resource List for assessment and

management information

Skin • Evaluate all skin for pressure areas, rashes, etc. • Facilitate removal of pressure from pressure areas • Refer to Resource List for assessment and

management information

Social Issues • Review ELS: Baseline Screening Information. Additional information to obtain may include: - Educational level - Formal and informal supports - Income - Driving/transportation concerns - Surrogate information - Alcohol/Substance abuse (CAGE Questionnaire)

• Refer to ELNS: Discharge Planning Protocol and Optimizing Length of Stay Protocol

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These are optional protocols for the HELP program. These measures are suggested for optimal care, in accordance with NICE guidelines for delirium prevention. However, many hospitals already have existing guidelines in these areas, and the responsibilities may fall to other staff. Implementation of these protocols should be individualized at each HELP site.

GENERAL HELP PROGRAM HAND HYGIENE PROTOCOL

Note: This protocol applies to all HELP staff, volunteers, family members, and patients

Eligibility: All patients in HELP and all HELP staff /volunteers will participate in the hand hygiene protocol. Evaluation:

1. Indications for hand washing for HELP staff and volunteers: • Before and after every patient contact • After blowing nose, coughing or sneezing • Before and after eating a meal or handling another’s food • After using the toilet or assisting another with using the toilet • Before and after any medical procedure • After body fluid exposure (e.g., urine) • Before and after contact with any objects in patient’s environment

2. Indications for hand washing for patients: Patients should be encouraged to wash their

hands: • After using the toilet, bedpan, or commode • After coughing, sneezing, or touching nose or mouth • When returning to room after test or procedure • Before eating, drinking, taking medicine, or putting anything in the mouth • When visibly dirty • Before touching any breaks in the skin (e.g., wounds, dressing, tubes) • Before any medical procedures (e.g., dialysis, IV drug administration, injections) • Before interacting with visitors and after they leave • Special instructions for Patients:

o When there is concern about whether hands are clean- Patients should be encouraged to ask healthcare providers, family members, and visitors to wash their hands upon entering the patient’s room.

o If visited or cared for by anyone who is coughing or sneezing, please ask him or her to wear a surgical mask or leave the room, (e.g., send a healthy colleague to provide care)

Interventions:

1. Proper Hand Washing Technique: All staff should use facility approved soap and warm water and engage in vigorous rubbing of lathered hands for a period of 20 seconds. (Singing the ‘Happy Birthday’ song from beginning to end twice can be used as a timer). Dry hands thoroughly with a disposable towel and use another clean, dry towel to stop the flow of water after hand washing. Facility approved waterless hand sanitizer may be used in place of washing with soap and water as long as hands are not visibly soiled or dirty. When caring for a patient with C.difficile or other drug-resistant pathogen, staff is required to use soap and water rather than hand sanitizer. Facility approved hand lotion may be used after hand washing to maintain skin integrity and prevent chafing.

2. Additional Infection Control Measures for Health Care Workers:

• Do not report to work if you are ill or have fever

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• Get the flu shot every year. • Wipe the surface of your stethoscope with an alcohol wipe after each patient

examination. • Wash lab coats and uniforms after each wearing or wear facility-provided scrubs if

available. The wearing of neck ties and loose clothing is discouraged in the clinical setting.

• Always practice aseptic technique and do not use anything that has been dropped on the floor or in a contaminated area.

• Safely dispose all used and contaminated needles and equipment in appropriately marked containers when caring for patients.

• Avoid artificial nails or nail extenders if you are involved in direct patient care. Natural nails should not be longer than ¼ inch. Nail polish may be worn as long as it is intact and not chipped.

• Avoid wearing rings, bracelets and upper body jewelry in the clinical setting. • Utilize personal protective equipment for patients in isolation, per hospital policy.

Nursing Staff Education:

The Elder Life Nurse Specialist or Elder Life Specialist provides regular in-services on the following, and introduces the Hand Hygiene Protocol.

• Education of patients, family members, caregivers, health care workers and HELP staff on proper hand hygiene techniques and the indications for hand washing.

• Education of health care workers and HELP staff on other infection control measures. • Consider competency-based evaluations as applicable for site.

Adherence:

• Elder Life Nurse Specialist or Elder Life Specialist monitors and records adherence to intervention. Infection control departments or other hospital departments may be responsible for monitoring and recording adherence.

• Elder Life Specialist implements the speak up program encouraging patients to ask all hospital staff members if they washed their hands.

• Visual and auditory reminders about hand-washing, such as posters, brightly colored signs, eye catching screen-savers, labels on equipment and supplies on the floor.

References: Centers for Disease Control and Prevention, 2013. Wash your

hands. http://www.cdc.gov/features/handwashing/ (Level 1) Davis CR. Infection-free surgery: how to improve hand-hygiene compliance and eradicate

methicillin-resistant Staphylococcus aureus from surgical wards. Ann R Coll Surg Engl. 2010 May; 92(4):316-9. (Level 4)

Landers T, Abusalem S, Coty MB, Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control. 2012 May; 40(4 Suppl 1):S11-7. Review. (Level 4)

Measuring hand hygiene adherence: Overcoming the Challenges (2009). Retrieved from http://www.jointcommission.org/assets/1/18/hh_monograph.pdf (Level 1)

World Health Organization Guidelines on hand hygiene in health care. (2009). Retrieved from http://www.who.int/entity/gpsc/tools/5momentsHandHygiene_A3.pdf (Level 1)

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ELDER LIFE NURSE SPECIALIST PAIN MANAGEMENT PROTOCOL

Eligible Patients: Screen all HELP patients on a daily basis. High risk patients are those who have undergone surgical procedures, suffered from traumatic injury, or have severe or chronic medical illness such as cancer or other illness associated with acute or chronic pain. Particular attention should be paid to those patients who cannot verbalize their levels of pain due to acute illness or severe cognitive impairment.

Evaluation: 1. Pain evaluation will be performed during screening and enrollment procedure using the

following methods: a. Seek pain history from medical record, patient, and/or caregiver. b. Assess current pain from patient, including intensity, character, frequency,

pattern, location, duration, and precipitating and relieving factors. For verbal patients, use the numeric rating scale: “Please rate your pain from 0 to 10 with 0 indicating no pain and 10 representing the worst possible pain”. The Pain Assessment in Advanced Dementia scale (PAINAD, see Appendix) should be used in non-verbal patients with advanced dementia. Choose the scale that works best for each individual patient based on cognitive and verbal ability. Once a scale has been chosen, it should be continued to be used consistently over time.

c. Assess cognitive status, mental status (anxiety, agitation, depression), and functional ability. Perform a more complete assessment if any of the following circumstances exist:

i. The patient has undergone a procedure or injury commonly associated with pain (surgery, trauma) but does not complain of pain.

ii. The patient has limited ability to communicate due to placement of medical equipment or acute illness.

iii. The patient has significant cognitive impairment with loss of ability to communicate.

iv. The patient possesses cultural beliefs that pain should not be expressed or discussed.

v. The patient has changes in vital signs including increased pulse and blood pressure that may be associated with presence of acute pain.

vi. The patient has nonverbal and behavioral signs of pain such as grimacing, withdrawal, guarding, rubbing, limping, shifts in position, moaning, calling out, or crying.

2. Reassess regularly. Daily, all patients will be screened for presence of pain using the

same pain rating scale used for the initial assessment.

Interventions: 1. Elder Life Nurse Specialist communicates appropriate information related to pain

assessment and/or effectiveness of pain management plan with nurse and/or physician. 2. Minimize reliance on physical signs of pain. Teach patient and caregiver to report pain

status regularly and recognize barriers to pain management. 3. Advocate for vigilant analgesic dose titration as necessary to ensure adequate pain

management while avoiding adverse effects such as somnolence or adverse drug

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(cont.) interactions in those taking multiple medications for co-morbid conditions. Advocate for use of acetaminophen to augment opioids and other pain medications. Non-steroidal anti-inflammatory agents can also be used, but the higher risk of gastrointestinal bleeding and renal effects should be considered. Use team approach to select best analgesic regimen and route of delivery (e.g., by mouth, parenteral, dermal patch, patient-controlled analgesia) for the patient.

4. Complementary therapies to enhance pain management include: a. Patient/family education and support b. Use of ice or heat packs as appropriate c. Relaxation techniques: biofeedback, music, warm baths or showers d. Meditation, prayer, spiritual and pastoral support e. Visualization/interactive guided imagery (e.g., ask the patient to remember a

pleasant time or event in his/her life to evoke pleasant memories) f. Backrub or hand massage g. Environmental modifications (e.g., reduce noise, dim lights, close hall door, etc.) h. Repositioning (e.g., use pillows under arms or legs, turning in bed)

5. Goals of interventions: a. Treat acute pain aggressively to avoid pain becoming chronic b. Encourage early intervention for pain rather than waiting until pain is severe c. Allow catch up on sleep once pain is relieved d. Assess and treat chronic pain as exacerbation may occur e. Monitor rate of analgesic use. Be vigilant for oversedation and respiratory

depression. Be vigilant for other side effects and advocate for control of troublesome symptoms such as nausea, constipation, and somnolence

f. Form a therapeutic relationship with the patient/family to move the plan forward g. Improve functioning, sleep, nutrition, and progress towards discharge

Adherence: Elder Life Nurse Specialist or ELS monitors and records adherence to and effectiveness of interventions.

Referrals: The ELS will refer patients with persistent pain to the primary nurse and/or physician.

References

American Geriatric Society (AGS) (2009). The management of persistent pain in older persons. AGS Panel on Pharmacological Management of Persistent Pain in Older Persons. JAGS 57:1331-1346. (Level 1)

American Society of Anesthesiologists Task Force on Acute Pain Management (2012). Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force, Anesthesiology, V 116, (2), p. 248- 273.(Level 1)

American Society of Pain Management Nursing (ASPMN) (2006). Position statement on pain assessment in a nonverbal patient. (Level 5)

Balas, M, Casey, C, Happ, M. (2008). Comprehensive assessment and management of the critically ill. In: Capezuti, E., Zwicker, D., Mezey, M., Fulmer, T., editors. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan, p. 565-593. (Level 5)

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Flaherty, E. (2012). Pain assessment for older adults. Try this: best practices in nursing care to older adults, Issue #7. Hartford Institute for Geriatric Nursing, New York University, College of Nursing. (Level 5)

Herr, K. (2006). Assessing and managing acute pain: Evidence-based practice guideline – Acute pain management of older adults. University of Iowa College of Nursing. Retrieved from http://www.nursing.uiowa.edu/centers/gnirc/protocols.htm (Level 1)

Horgas, A., Yoon, S., Grall, M. (2012). Pain: Nursing standard of practice protocol. Pain management in older adults, Hartford Institute for Geriatric Nursing, Retrieved from http://consultgerirn.org/topics/pain/want_to_know_more (Level 1)

Hospice and Palliative Nursing Association (HPNA) Position statement on pain management. JAGS Persistent Pain Pharmacotherapy Update (2009). Pharmacological Management of

persistent pain in older persons. (Level 5) Warden, V., Hurley, A.C., & Volicer, L.(2003). Development and psychometric evaluation of the

pain assessment in advanced dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4(1), 9-15. (Level 3)

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Appendix

For patients with dementia who are nonverbal, use the Pain Assessment in Advanced Dementia Scale (PAINAD). Warden, V., Hurley, AC, Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15. Used with permission

Suggested Medications for Reported Pain Ranges Mild Pain (1-3): Scheduled or PRN Non-opioid +/- adjuvant medication Moderate Pain (4-6): Scheduled Opioid with PRN Opioid or Non-opioid +/- adjuvant medication Severe Pain (7-10): Increase scheduled Opioid and PRN Opioid +/- adjuvant medication

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ELDER LIFE SPECIALIST PAIN MANAGEMENT PROTOCOL

Eligible Patients: Any HELP patients who complain of pain or exhibit pain behaviors.

Evaluation: 1. Pain Screening will be performed during HELP screening and enrollment procedures. 2. Daily, all patients will be asked about their level of comfort and presence of pain on

numeric rating scale: “Please rate your pain from 0 to 10 with 0 indicating no pain and 10 representing the worst possible pain”.

Interventions:

1. Review pain patient information packet with patient (See Patient Information Packet following this protocol).

2. Elder Life Specialist implements the relaxation protocol (see Volunteer Training Manual). Required equipment includes: • Portable music player or device • Relaxation music • Herbal tea [To avoid any potential toxicities or drug interactions, we recommend only

the following herbal teas: mint or fruit-spice teas (e.g., orange spice, cinnamon apple) with no added herbs or sugar]

• Hospital lotion • Ice packs/heating pads • Aromatherapy

3. Elder Life Specialist orients patients and families to the protocol. 4. Elder Life Specialist reviews the patient information packet with the patient/family as

needed. 5. Daily, Elder Life Specialist initiates nurse or volunteer to provide the Relaxation Protocol

to those patients who report poorly managed pain, side effects of pain medications or who cannot report pain levels appear uncomfortable. This includes: • Environmental modifications for comfort, e.g., fluffing pillows, magazines for reading. • Offer other comfort measures as appropriate:

1. Hot or cold beverage of choice (check with nurse regarding fluid or dietary restrictions; avoid caffeinated beverages)

2. Relaxation music or recordings 3. Backrub or hand massage 4. Cool or hot packs 5. Repositioning

Adherence: Elder Life Specialist monitors and records adherence to and effectiveness of interventions. Referrals: The ELS will refer patients with persistent pain to the Elder Life Nurse Specialist or medical staff.

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References

AGS Panel on Pharmacological Management of Persistent Pain in Older Persons. JAGS 57:1331-1346. (Level 1)

American Society of Anesthesiologists Task Force on Acute Pain Management (2012). Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force, Anesthesiology, V 116, (2), p. 248- 273.(Level 1)

American Society of Pain Management Nursing (ASPMN) (2006). Position statement on pain assessment in a nonverbal patient. (Level 5)

Balas, M, Casey, C, Happ, M. (2008). Comprehensive assessment and management of the critically ill. In: Capezuti, E., Zwicker, D., Mezey, M., Fulmer, T., editors. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan, p. 565-593. (Level 5)

Flaherty, E. (2012). Pain assessment for older adults. Try this: best practices in nursing care to older adults, Issue #7. Hartford Institute for Geriatric Nursing, New York University, College of Nursing. (Level 5)

Herr, K. (2006). Assessing and managing acute pain: Evidence-based practice guideline – Acute pain management of older adults. University of Iowa College of Nursing. Retrieved from http://www.nursing.uiowa.edu/centers/gnirc/protocols.htm (Level 1)

Horgas, A., Yoon, S., Grall, M. (2012). Pain: Nursing standard of practice protocol. Pain management in older adults, Hartford Institute for Geriatric Nursing, Retrieved from http://consultgerirn.org/topics/pain/want_to_know_more (Level 1)

Hospice and Palliative Nursing Association (HPNA) Position statement on pain management. JAGS Persistent Pain Pharmacotherapy Update (2009). Pharmacological Management of

persistent pain in older persons. (Level 5) Warden, V., Hurley, A.C., & Volicer, L.(2003). Development and psychometric evaluation of the

pain assessment in advanced dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4(1), 9-15. (Level 3)

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THE HOSPITAL ELDER LIFE PROGRAM (HELP) PAIN MANAGEMENT PROTOCOL

Patient Information Packet

Having pain while you are ill is a common problem. Pain can result from surgery, injury, or from flare ups of chronic pain you may have from arthritis or other illnesses. If you are having problems with pain while you are here, we would like to offer you our Pain Management Protocol. Many of the recommendations found in the pain management protocol have been tested and been found to be very effective.

The under-treatment or over-treatment of pain is common with some older adults because it is often hard to get the dose of pain medication just right. With over-treatment, older persons are more likely than younger persons to experience complications from pain medications. Pain medications can cause memory loss, confusion, unsteadiness, falls, daytime drowsiness, and constipation. With under-treatment of pain, older adults may not eat or sleep well, may spend too much time sitting still, or become depressed due to the fact they are living with pain. In our pain management program, we want you to be as free from pain as possible without suffering side effects of pain medication.

The Pain Management Protocol Includes: 1. Individualized consideration of your levels of pain. For example, can you think of something

helpful that you do at home when you have pain? 2. Education about the importance and methods of accurately reporting your pain to your

doctors and nurses so that your pain can be relieved with medication. 3. Education about the common side effects of pain medications so that you can report these to

your doctors and nurses should they occur. 4. We will be offering you non-drug based interventions to help manage your pain including:

• A warm or cool drink (let us know your favorite beverage) • An ice pack or heating pad (with your care provider’s permission) • A back-rub or hand massage • Relaxation recordings with music or nature sounds (your choice) • Relaxation exercises • Repositioning • Physical Therapy evaluation (if ordered by your physician)

Additional Pain Management Recommendations:

• Avoid sitting/lying in one position for extended periods of time. • Increase exercise and mobility during the day as much as possible. • Let your nurse and doctor know about your pain, any patterns you have noticed, what

seems to make it better and worse, and any side effects you may be having from your medications.

• Be as specific as you can when describing your pain. Don’t be shy. Let your nurse know about your pain and the effect it has on your functioning and quality of life. Include the effect of pain on your ability to obtain restful sleep, eat nutritious foods, move about without effort, and enjoy visits from your family and friends.

• Report your pain before it becomes severe; waiting will make it harder to relieve pain and require more medication.


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ASPIRATION PREVENTION PROTOCOL

Patient Eligibility: All patients who are at risk of developing aspiration pneumonia. Risk factors include:

• Note: For safety reasons, do not attempt to feed or provide fluids to any patient when they are drowsy or lethargic.

• Patients with gagging or coughing during oral intake. • Patients with decreased level of consciousness or not alert for any reason, including

post-operative recovery from anesthesia and those receiving opioids or other sedating medications.

• Neurological disorders such as stroke, delirium, dementia and Parkinson disease. • Esophageal conditions such as dysphagia, stricture, or gastroesophageal reflux disease

(GERD). • Frailty, bedrest or deconditioning such that sitting upright and swallowing are difficult. • Patients with feeding tubes or tracheostomy.

Evaluation: Elder Life Nurse Specialist will establish patient’s baseline status of aspiration risk and swallowing difficulty. Consider aspiration precautions protocol if any risk factors above are present. While the ELNS can stimulate and motivate the nurses, the actual assessment and evaluation for safe swallowing must remain the responsibility of the primary nurse before every meal. For high risk patients, a formal swallow evaluation should be completed by a certified speech therapist prior to initiation of any oral intake.

Interventions:

• General Aspiration Precautions (All high-risk patients): • If patient nil per os (NPO) by speech therapist, no water pitcher at bedside. Check

with nursing staff to verify feeding status. • Encourage regular oral care by nursing staff:

1. Brush teeth every 12 hours for 1-2 minutes including tongue and gums. 2. Rinse with mouthwash or half-strength peroxide solution every 4 hours

between 8 am and 8pm. 3. Apply water-soluble lip balm.

• Begin oral intake if indicated after swallow evaluation is completed and the speech therapist makes recommendations. Check with the nursing staff to verify food/fluid recommendations (liquid, soft, full). Graded food consistencies may be ordered as part of the safe swallowing plan.

• Patient should be up in chair for all meals. If the patient needs support to remain upright, pillows or foam pads may be used to maintain upright posture. If confined to bed, head of bed must be at least 60 degrees for all oral intake—(food, liquids, pills—and remain elevated for 20 minutes after eating. If unable to tolerate 60 degree or greater angle, notify nursing staff who may hold ALL PO intake.)

• Communicate with team (primary nurse and physician) about potential medication changes. Minimize the use of sedatives and hypnotics since these agents may impair the cough reflex and swallowing. Avoid medications that dry secretions (e.g., medications with anticholinergic properties like diphenhydramine) since they make it more difficult for patients to swallow. Consider discontinuation of proton pump inhibitors or H2 Blockers if not treatment of ulcer disease, since suppression of gastric acid has been associated with higher rates of aspiration pneumonia.


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• Aspiration Precautions During Hand-Feeding:

• Adjust rate of feeding and size of bites to the person’s tolerance; avoid rushed or forced feeding

• Alternate solid and liquid boluses. • Make sure dentures, eye glasses, hearing aids or other assistive devices are in place

to facilitate the feeding process. • Vary placement of food in the person’s mouth according to the type of deficit (e.g.,

place food on the right side of the mouth if left facial weakness is present). • Check the medical record to determine the food viscosity that is recommended by

the speech therapist and best tolerated by the individual. For example, some persons swallow thickened liquids to the consistency of honey more easily than thin liquids.

• Be aware that some patients may find thickened liquids unpalatable and thus drink insufficient fluids.

• Evaluate the effectiveness of cueing, redirection, and environmental modifications to minimize distractions to enhance self-feeding.

• Feeding Tube Assessment: Encourage assessment of correct placement of feeding tubes at regular intervals to minimize the risk for aspiration. At some hospitals, feeding by bolus may be preferred to continuous to reduce risk of aspiration.

• Monitor for Signs of Aspiration Pneumonia: Report any of the following signs

immediately to the nursing staff for further evaluation by the attending physician: 1. Fever or chills 2. Tachypnea, tachycardia 3. Cough with or without sputum 4. Changes in color/consistency of sputum 5. Hypoxemia (See Hypoxemia Protocol) 6. Complaint of shortness of breath, difficulty breathing 7. Delirium or changes in mental status

Nursing Education: The Elder Life Nurse Specialist provides regular in-services on the following, and introduces the Aspiration Prevention Protocol. • Aspiration risk assessment • Aspiration precaution measures • Correct feeding tube placement


References: Altman, K.W., Yu, G.P., & Schaefer, S.D. (2010). Consequence of dysphagia in the hospitalized

patient: Impact on prognosis and hospital resources. Archives of Otolaryngology-Head & Neck Surgery, 136(8), 784-789. (Level 4)

American Association of Critical Care Nurses (2013). Prevention of Aspiration. Retrieved from http://www.aacn.org/wd/practice/content/practicealerts/aspiration-practice- alert.pcms?menu (Level 5)

Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B., Metheny, N.A., Mueller, C., Robbins, S., Wessel, J., & A.S.P.E.N. Board of Directors.


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(2009). A.S.P.E.N. enteral nutrition practice recommendations. Journal of Parenteral and Enteral Nutrition. 33(2), 122-167. doi: 10.1177/0148607108330314 (Level 5)

Colodny, N. (2005). Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist. American Journal of Speech- Language Pathology, 14(1), 61-70. (Level 4)

Dennis, M.S., Lewis, S.C., & Warlow, C. (2005). Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): A multicentre randomized controlled trial. Lancet, 365, 764-772. (Level 2)

Echevarria IM, Schwoebel A. Development of an intervention model for the prevention of aspiration pneumonia in high-risk patients on a medical-surgical unit. Medsurg Nurs. 2012 Sep-Oct;21(5):303-8. (Level 4)

El-Solh, A.A. (2011). Association between pneumonia and oral care in nursing home residents. Lung. 189(3), 173-180. (Level 5)

Frey, K.L. & Ramsberger, G. (2011). Comparison of outcomes before and after implementation of a water protocol for patients with cereberovascular accident and dysphagia. Journal of Neuroscience Nursing, 43(3), 165-171. (Level 4)

Gomes, C.A., Lustosa, S.A., Matos, D., Andriolo, R.B., Waisberg, D.R., & Waisberg, J. (2010). Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database of Systematic Reviews. (11)DC008096. (Level 1)

Leder, S.B., Suiter, D.M., Warner, H.L., Acton, L.M., & Swainson, B.A. (2012). Success of recommending oral diets in acute stroke patients based on passing a 90-cc water swallow challenge protocol. Topics in Stroke Rehabilitation, 19(1), 40-44. Level 4

Marik, P.E. (2011). Pulmonary aspiration syndrome. Current Opinion in Pulmonary Medicine, 17, 148-154. (Level 5)

Marik, P.E., & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest, 124, 328-336. (Level 5)

Metheney, N. (2012). Preventing aspiration pneumonia. Best Practices in Nursing Care, Hartford Institute of Geriatric Nursing (Level 1)

Okada, S., Saitoh, E., Palmer, J.B., Matsuo, K., Yokoyama, M., Shigeta, R., & Baba, M. (2007). What is the chin-down posture? A questionnaire survey of speech language pathologist in Japan and the United States. Dysphagia, 22(3), 204-209. (Level 4)

Rofes, L., Arreloa, V., Almirall, J., Cabre, M., Campins, L., Garcia-Peris, P., Speyer, R., & Clave P. (2011). Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology Research and Practice. Volume 2011, 1-13. doi:10.1155/2011/818979 (Level 5)

Singh, S., & Hamdy, S. (2006). Dysphagia in stroke patients. Postgraduate Medical Journal, 82(968), 383-391. (Level 5)

Starks B, Harbert C. Aspiration prevention protocol: decreasing postoperative pneumonia in heart surgery patients. Crit Care Nurse. 2011 Oct;31(5):38-45. (Level 4)

Swaminathan, A. & Mosenifar, Z. (2013). Aspiration Pneumonia. Retrieved from Medscape at http://emedicine.medscape.com/article/296198-overview#aw2aab6c27 (Level 5)

Terre, R., & Mearin, F. (2012). Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury. A videofluoroscopy study. Neurogastroenterology & Motility, 24(5), 414-419. (Level 3)

Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, Brainin M. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007 Nov;38(11):2948-52. (Level 3)

Van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013 Mar;30(1):3-9. (Level 1)

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ELDER LIFE NURSE SPECIALIST PREVENTION OF CATHETER ASSOCIATED UTI (CAUTI) PROTOCOL

Patient Eligibility: Patients in the HELP program with indwelling urinary catheter.

Evaluation: 1. Elder Life Nurse Specialist will monitor all patients with indwelling catheters daily for

appropriate indications for urinary catheter using the urinary catheter indication checklist. (See Appendix)

2. Elder Life Nurse Specialist (ELNS) will advocate for the earliest possible removal of

catheters in all HELP patients. On a daily basis, the ELNS will evaluate the need for continued use of the catheter.

Interventions:

1. The ELNS will review the chart and communicate with the primary nurse to determine indications for the indwelling catheter, per criteria in Appendix. If an indwelling catheter is being utilized for an indication other than urinary retention, the ELNS will urge the primary nurse to contact providers to advocate for its removal. It is recommended that all catheters be removed if the patient is restless or pulling at the catheter and after 2 days of insertion unless continued use is indicated.

2. The ELNS will educate primary nurses and assist in implementation of strategies

recommended by the Center for Disease Control (CDC) for prevention of catheter- associated urinary tract infection (CAUTI): a. Insert a urethral catheter using appropriate sterile technique only when indicated, and

remove it at the earliest possible time. b. Immediately remove catheter if the patient has any one of the following signs or

symptoms within the same calendar day: fever (>38°C), urgency; frequency; dysuria; suprapubic tenderness; costovertebral angle pain or tenderness and a positive urine culture of ≥105 CFU/ml with no more than 2 species of microorganisms, positive dipstick for leukocyte esterase or nitrite.

c. Maintain good hand hygiene and use gloves before manipulating the catheter. Dispose of gloves and promptly wash hands after contact with the patient and/or the catheter. (See Hand Hygiene Protocol)

d. Maintain a closed drainage system; any opening creates an entry route for bacteria, which can lead to infection. Don’t violate the closed system to collect sterile urine specimens. Instead, collect specimens by aspirating with a sterile needle from the bag sample port only after cleaning the port with 70% isopropyl alcohol and letting it dry thoroughly.

e. Catheter is only changed if needed for clinical indications such as infection, obstruction or when the closed system is compromised. No routine changing of catheters should be done.

f. Perform meatal care twice daily using soap and water and working from the front to the back of the perineal area.

g. Avoid unnecessary irrigation, which has not been proven to decrease bacteriuria.

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h. Secure the catheter to prevent meatal and urethral irritation, tension on the catheter,

bladder-neck trauma, and urethral tearing. It also improves patient comfort and decreases the risk of inadvertent dislodgement.

i. Check the tubing for kinks to ensure that urine flows unobstructed into the drainage bag.

j. Empty the urine collection bag regularly, using a separate container for each patient. Never let the spigot and non-sterile collecting container come into contact with each other, as this can introduce bacteria.

k. Keep the collection bag below bladder level to prevent backflow of contaminated urine.

l. Increase the patient’s fluid intake. This has been shown to decrease urinary tract infection (UTI) incidence, possibly by diluting the urine and flushing out bacteria. (See dehydration protocol)

Suggested Monitoring Following Catheter Removal

Monitor and manage patient’s voiding after catheter removal or after bladder procedures as follows: 1. Monitor for symptoms of urinary retention

a. Complaints of urinary pain, fullness, distention b. Changes in voiding patterns c. Failure to void in past 5 hours d. Frequent voiding with volumes less than 100 ml

2. Closer monitoring required for high risk groups: a. Surgical intervention or trauma that may compromise the ability to void b. Patient history of aggravating factors such as constipation, anxiety

anesthesia, medications UTI, alcohol or illicit drug use

Patient Education:

• Notify the nursing staff immediately if you notice UTI including chills, fever, bloody urine, no urinary drainage, or pain/burning at the catheter site

• Try to drink about 1-2 quarts of fluid each day to decrease the risk of UTI unless contraindicated

• Avoid caffeinated beverages such as coffee, tea and cola’s as they can irritate the bladder and cause spasms

• Try not to lie on or get into a position where the catheter is kinked and urine flow is blocked. Keep bag below bladder level to prevent backflow of contaminated urine

• Make sure the catheter is firmly taped or secured to the skin on your upper thigh to keep it in place and ensure it does not move around or tug

• Ask for assistance when cleaning up after a bowel movement to decrease the risk of infection

• Wash your hands thoroughly after touching the catheter (see Hand Hygiene Protocol)

Nursing Education: The Elder Life Nurse Specialist provides regular in-services on the following, and introduces the Protocol.

• Sterile catheter insertion technique • Appropriate indications for urinary catheters • CAUTI Prevention Protocol • Hand Hygiene

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• Prompt removal unless medically necessary

Adherence: Elder Life Nurse Specialist monitors and records adherence to interventions as indicated.

References:

Bruminhent J, Keegan M, Lakhani A, Roberts IM, Passalacqua J. Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections in a community teaching hospital. Am J Infect Control. 2010 Nov;38(9):689-93. (Level 4)

Bernard MS, Hunter KF, Moore KN. A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urol Nurs. 2012 Jan-Feb;32(1):29-37. Review. (Level 5)

Centers for Disease Control and Prevention (2009). Guideline for prevention of catheter associated urinary tract infection. Retrieved from http://www.cdc.gov/hicpac/cauti/008_evidencereview.html (Level 1)

Centers for Disease Control/National Healthcare Safety Network Protocols, 2013 http://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf (Level 1)

Clinical Center National Institutes of Health (2007). Patient information publications: Foley catheter care. Retrieved from http://www.cc.nih.gov/ccc/patient_education/pepubs/bladder/foley5_17.pdf. (Level 1)

DeSantis L, Saravolatz LD. Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients. Infect Control Hosp Epidemiol. 2008 Sep;29(9):815-9. (Level 4)

Elpern EH, Killeen K, Ketchem A, Wiley A, Patel G, Lateef O. Reducing use of indwelling urinary catheters and associated urinary tract infections. Am J Crit Care. 2009 Nov;18(6):535-41; quiz 542. (Level 4)

Fakih MG, Dueweke C, Meisner S, Berriel-Cass D, Savoy-Moore R, Brach N, Rey J, Titsworth WL, Hester J, Correia T, Reed R, Williams M, Guin P, Layon AJ, Archibald LK, Mocco

J. Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success. J Neurosurg. 2012 Apr;116(4):911-20. (Level 4)

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Appendix

Appropriate Indications for Indwelling Urethral Catheter Use

Patient has acute urinary retention or bladder outlet obstruction

Need for accurate measurements of urinary output in critically ill patients

Perioperative use for selected surgical procedures:

• Patients undergoing urologic surgery or other surgery on contiguous structures of

the genitourinary tract

• Anticipated prolonged duration of surgery (catheters inserted for this reason should

be removed in PACU)

• Patients anticipated to receive large-volume infusions or diuretics during surgery

Need for intraoperative monitoring of urinary output

To assist in healing of open sacral or perineal wounds in incontinent patients

Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)

To improve comfort for end of life care if needed

Reference: http://www.cdc.gov/hicpac/cauti/02_cauti2009_abbrev.html

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ELDER LIFE NURSE SPECIALIST CONSTIPATION PROTOCOL

Note: The general ELNS assessment instructions and worksheets (ie, ‘Patient Profile Sheet’, pg. 49 in clinical manual) include clinical assessment of continence/elimination issues.

Eligible Patients: Patients with clinical evidence of constipation (straining at stool, difficulty passing stool or infrequent bowel movements – usually less than 3/week) and/or dehydration, or who are at high risk of constipation.

Assessment: Elder Life Nurse Specialist assesses each patient daily for constipation.

Risk factors for constipation may include:

• Dehydration (see ELNS Fluid Repletion Protocol) • Medications (particularly opioids and anticholinergics)(see Table below for

additional high risk medications) • Poor mobility • History of chronic constipation or laxative use • Recent abdominal or bowel surgery

Interventions: Initial Management:

1. If patient is dehydrated, ELNS educates and reinforces with patient the importance of increased fluid intake (see ELNS Fluid Repletion Protocol).

2. Encourages patient mobility and regular toileting; coordinate with nursing staff to allow patient routine toileting, particularly after meals.

3. Collaborates with dietician to see if extra fiber can be added to the diet including prunes, prune juice, fruits and vegetables.

4. Collaborates with pharmacist and primary team to evaluate other medications that may be contributing to constipation.

5. Collaborates with pharmacist and primary team to evaluate whether pharmacologic treatment with laxatives is needed, and to assess effectiveness if treatment is initiated.

Ongoing management:

1. Reassesses patient’s status daily via chart review and bedside reassessment. 2. Instructs and reinforces with nursing staff to monitor toilet use. If unable to use toilet,

ensures nursing staff assists patient onto other toileting equipment (e.g., commode or bedpan).

3. Continues to encourage patient mobility (See ELNS Early Mobilization Protocol). 4. Collaborates with physician if signs and symptoms of constipation persist or worsen.

Nursing Staff Education: Elder Life Nurse Specialist provides regular in-services on constipation in the elderly, and introduces the Constipation Protocol.


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Addendum:

MEDICATIONS THAT CAN CAUSE CONSTIPATION

MEDICATION BY CLASS EXAMPLES OF MEDS IN THIS CLASS

OPIOID MEDICATIONS* Morphine, Dilaudid, Oxycodone, Codeine

ANTACIDS WITH ALUMINUM & CALCIUM Aluminum hydroxide (Gaviscon, Maalox), Calcium carbonate (Rolaids, Tums)

ANTIHYPERTENSIVES Diltiazem, Nifedipine, Verapamil

ANTIPARKINSON DRUGS Levadopa

ANTISPASMODICS Atropine, phenobarbital, scopolamine

ANTIDEPRESSANTS Tricyclics (Amitriptylene, Imipramine, Nortritylene)

IRON SUPPLEMENTS Ferrous sulfate

DIURETICS Potassium sparing (Aldactone), Loop (Lasix, Bumex), Thiazide (Zaroxolyn)

ANTICONVULSANTS Phenytoin, Carbamezapine

*Co-prescription of laxative recommended with opioid Adapted from National Digestive Diseases Information Clearing House (NDDIC), 2012.

References:

Edlund A, Lundström M, Brännström B, et al. Delirium before and after operation for femoral neck fracture. Journal of the American Geriatrics Society, 2001, 49(10): 1335-1340. (Level 4)

Marcantonio E R, Flacker J M, Wright R J, et al. Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society, 2001, 49(5): 516-522. (Level 2)

McKay SL, Fravel M, Scanlon C. Management of constipation. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; 2009 Oct. (Level 1)

National Digestive Diseases Information Clearing House (NDDIC), 2012. Constipation. Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/index.aspx. (Level 5)

Registered Nurses' Association of Ontario Prevention of Constipation in the Older Adult Population. Nursing Best Practice Guideline (2005). Full guideline are available at: http://rnao.ca/bpg/guidelines/prevention-constipation-older-adult-population (Level 1)

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ELDER LIFE SPECIALIST CONSTIPATION PROTOCOL

Patient Eligibility: Patients with inadequate oral intake, physical impairment and/or cognitive impairment or complains of constipation or infrequent bowel movements.

Evaluation:

The Elder Life Specialist, in collaboration with the Elder Life Nurse Specialist and hospital staff, regularly observes each patient for:

• Inadequate oral intake (See ELS Feeding Assistance/Fluid Repletion Protocol). • Physical impairment – Specific physical problems preventing the patient from adequate

toileting. • Adequacy of high fiber foods in the diet including fruits and vegetables. • Cognitive impairment – cognitive dysfunction so severe that the patient cannot recognize

or communicate the need to use the bathroom or carry out the act of toileting themselves.

Interventions:

1. The Elder Life Specialist, in collaboration with the Elder Life Nurse Specialist, oversees volunteers in fluid repletion (re-hydration) strategies (See ELNS – Fluid Repletion Protocol) and early mobility strategies (See ELNS – Early Mobility Protocol).

2. The Elder Life Specialist directs the intervention program

• Orients patients and families to the program. • Identifies fruits/vegetables liked and well-tolerated by the patient. • Oversees volunteers’ recordings of intervention activities. • Monitors and records adherence to interventions.

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ELDER LIFE NURSE SPECIALIST HYPOXIA PROTOCOL

Patient Eligibility:

For patients who complain of shortness of breath (i.e., dyspnea), demonstrate rapid breathing (i.e., tachypnea), or have other signs and symptoms of possible hypoxia (i.e., cyanosis). High risk patients include those with diagnosis of chronic obstructive pulmonary disease (COPD), significant cardiac disease, or surgery or trauma to the ribs or thorax.

Evaluation:

1. Elder Life Nurse Specialist (ELNS) checks the medical record for baseline vital signs and oxygenation status including pulse oximetry readings for patients meeting the eligibility criteria.

2. Assess need for oxygen by monitoring for signs and symptoms of hypoxia:

• Shortness of breath, accessory muscle use. • Chest wall movement abnormalities. • Flaring of the nostrils. • Cyanosis. • O2 saturation below 90%. • Myocardial stress, as evidenced by increased heart rate (>100 beats/min). • Decreased tolerance for activity, chest pain, increased dependent edema. • Change in level of consciousness or sudden increased agitation.

3. For patients with any of the above symptoms, ask the patient to speak. Patients who can speak do not have mechanical airway obstruction. For patients with suspected airway obstruction, activate the emergency call procedure as specified by the institution.

Interventions: 1. If patient has hypoxia, the ELNS should notify nursing staff as soon as possible as the

condition requires further assessment and correction. 2. If the patient is receiving continuous oxygen, check that the mask or nasal cannula is

properly positioned on the patient’s mouth or nose and the tubing is patent, without kinks, and snugly attached to the oxygen outlet source in the wall.

3. Check the mouth for retained food, foreign material, blood, or any form of airway obstruction. 4. Position patient with the head of the bed elevated to 30~45 degrees for better lung

functioning and to facilitate oxygen transfer. 5. Report the situation to the patient’s primary nurse so that he/she may notify the physician to

investigate cause of hypoxia, such as COPD exacerbation, pneumonia, myocardial infarction, heart failure, pulmonary embolism, excess sedating medications, or other medical condition.

6. Oxygen administration strategy: If the patient has been receiving supplemental oxygen for more than 24 hours, report any airway discomfort such as dryness or nasal discomfort, and report to the primary nurse for consideration of the use of humidified oxygen.

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7. Referrals: Further evaluation and treatment may be ordered by the physician in order to correct the underlying reason(s) for the hypoxia. The ELNS should communicate with the patient primary nurse and physician for further evaluation of the following concerns: • SaO2 < 90% persistently. • Systolic blood pressure below 90 mm Hg.

Nursing Staff Education: Elder Life Nurse Specialist provides regular in-services on the following: 1. Patient/Family Teaching: instruct patient/family on energy conservation measures (see

Appendix 1). 2. Patient/Family Teaching: Breathing and Relaxation Techniques. (see Appendix 2). Adherence: Elder Life Nurse Specialist collaborates with primary nurse to monitor and record adherence to interventions.

References: American Medical Directors Association. COPD management in the long-term care setting.

2003. (Level 1) Bailey P H, Boyles C M M, Cloutier J D, et al. Best practice in nursing care of dyspnea: The 6th

vital sign in individuals with COPD. Journal of Nursing Education and Practice, 2012, 3(1): p108. (Level 1)

Brooks D, Anderson C M, Carter M A, et al. Clinical practice guidelines for suctioning the airway of the intubated and nonintubated patient. Canadian respiratory journal: journal of the Canadian Thoracic Society, 2001, 8(3): 163. (Level 1)

Björkelund K B, Hommel A, THORNGREN K G, et al. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study. Acta Anaesthesiologica Scandinavica, 2010, 54(6): 678-688. (Level 4)

Feller-Kopman D J, Schwartzstein R M. Use of oxygen in patients with hypercapnia. UpToDate. Waltham, MA: UpToDate, 2010. (Level 1)

Gustafson Y, Brännström B, Berggren D, et al. A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. Journal of the American Geriatrics Society, 1991, 39(7): 655. (Level 4)

Marcantonio E R, Flacker J M, Wright R J, et al. Reducing delirium after hip fracture: a randomized trial. Journal of the American Geriatrics Society, 2001, 49(5): 516-522. (Level 2)

O'Driscoll B R, Howard L S, Davison A G. BTS guideline for emergency oxygen use in.2008. (Level 1)

Wong Tin Niam D M, Bruce J J, Bruce D G. Quality project to prevent delirium after hip fracture. Australasian Journal on Ageing, 2005, 24(3): 174-177. (Level 4)

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Appendix 1

Patient/Family Teaching: Energy Conservation

1) Maintain activity restrictions as ordered by the physician. 2) Instruct client in energy-saving techniques (e.g. using shower chair when showering, sitting

to brush teeth or comb hair). 3) Suggest measures to promote sleep (e.g. elevate head of bed and support arms on pillows

to facilitate breathing, maintain oxygen therapy during sleep, discourage intake of fluids high in caffeine in the evening, reduce environmental stimuli).

4) Protect patient from exposure to irritants such as smoke, flowers, and powder if allergic conditions are known or suspected.

5) Instruct patient to avoid intake of extremely hot or cold foods/fluids (these can stimulate cough).

6) If oxygen therapy is necessary during activity, keep portable oxygen equipment readily available for patient's use.

7) If oxygen therapy is in use, the patient may not smoke or be around anyone who is smoking due to the danger of fire and combustion in the oxygen rich environment. Patients using supplemental oxygen should avoid being near any open flame (e.g. gas stoves, fireplaces).

8) Recommend attention to a varied and nutritious diet to maintain nutritional status. 9) Suggest increase in activity gradually as allowed and tolerated. 10) Immediately report a decreased tolerance for activity. 11) Stop any activity that causes chest pain, increased shortness of breath, dizziness, extreme

fatigue, or weakness. [Reference: Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St. Louis Taylor, K. Chapter 8. Care of the Patient Following a Traumatic Injury]

Appendix 2

Patient/Family Teaching: Breathing and Relaxation Techniques

Control Your Breathing Remember: Breathlessness with physical effort is uncomfortable but not in itself harmful or dangerous. Knowing how to control your breathing will help you to remain calm when you are short of breath. Pursed lip breathing and diaphragmatic breathing will both help if you have lung disease. These breathing methods prevent or reduce the trapped air in your lungs, and allow you to inhale more fresh air. Pursed-Lip Breathing

• Breathe in slowly through your nose for 1 count. • Purse your lips as if you were going to whistle. • Breathe out gently through pursed lips for 2 slow counts (exhale twice as slowly as you

inhale) - let the air escape naturally and don’t force the air out of your lungs. • Keep doing pursed lip breathing until you are not short of breath.

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Diaphragmatic Breathing

• Put one hand on your upper chest, and the other on your abdomen just above your waist. • Breathe in slowly through your nose – you should be able to feel the hand on your

abdomen moving out (the hand on your chest shouldn’t move). • Breathe out slowly through your pursed lips – you should be able to feel the hand on

your abdomen moving in as you exhale. Positions to Reduce Shortness of Breath

1. Sitting: Sit with your back against the back of a chair. Your head and shoulders should be rolled forward and relaxed downwards. Rest your hands and forearms on your thighs, palms turned upwards. DO NOT LEAN ON YOUR HANDS. Your feet should be on the floor, knees rolled slightly outwards. Do S.O.S. for S.O.B. (See below) until breathing is normal.

2. Sitting: Lean back into the chair in a slouched position, your head rolled forward, shoulders relaxed downward. Rest your hands gently on your stomach. Keep your feet on floor, knees rolled outward. Do S.O.S. for S.O.B. until breathing is normal.

3. Sitting: Place a pillow on a table and sit down, arms folded and resting on the pillow. Keep your feet on the floor or a stool, and rest your head on your arms. Do S.O.S. for S.OB. until breathing is normal. This position may also be used standing, arms resting on kitchen counter or back of chair, NOT LEANING, knees bent slightly, one foot in front of the other.

4. Standing: Lean with your back to the wall, a pole, etc. Place your feet slightly apart and at a comfortable distance from the wall, head and shoulders relaxed. Do S.O.S. for S.O.B. until breathing is normal.

S.O.S. for S.O.B. (Help for Shortness of Breath) When on the brink…..think:

• Stop and rest in a comfortable position. • Get your head down. • Get your shoulders down. • Breathe in through your mouth. • Blow out through your mouth. • Breathe in and blow out as fast as is necessary. • Begin to blow out longer, but not forcibly – use pursed lips if you find it effective. • Begin to slow your breathing. • Begin to breathe through your nose. • Begin diaphragmatic breathing. • Stay in position for 5 minutes longer.

[Reference: Bailey P H, Boyles C M M, Cloutier J D, et al. Best practice in nursing care of dyspnea: The 6th vital sign in individuals with COPD. Journal of Nursing Education and Practice, 2012, 3(1): p108. Full guideline are available at: http://rnao.ca/sites/rnao-ca/files/Nursing_Care_of_Dyspnea_- The_6th_Vital_Sign_in_Individuals_with_Chronic_Obstructive_Pulmonary_Disease.pdf]

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*NOTICE* updated: 11/15/2011 HELP POLICY ON MMSE

HELP was developed utilizing the Mini-Mental State Examination in 1993, prior to enforcement of the copyright protection and the MMSE is referenced in manuals. Currently, the instrument is copyrighted by Psychological Assessment Resources, Inc. (PAR), and as of 2001, a per use fee is required for any use of the MMSE using a printed version of the test. Thus, the HELP program does not advocate for use of any printed version of the MMSE. Many sites have decided to use alternative instruments. Our recommendations are outlined below. 1. For clinical use: The MMSE may be administered clinically as long as an

authorized version of the MMSE is used, or the MMSE is administered from memory without a printed version. Otherwise, a per use fee must be paid to PAR.

2. For use in research or for publication: The user must obtain permission from PAR, and pay a per use fee for the MMSE in this context.

3. Because of these restrictions, the HELP Program recommends use of alternative brief cognitive assessment instruments for research purposes. A wide variety of instruments are available which are not restricted by copyright restrictions. These should be chosen by the user depending on their specific goals. A brief review of some of these measures and recommendations are provided below. These can be used to rate the CAM and to evaluate for dementia. Each instrument has its own cutpoints, see attached references.

COGNITIVE SCREENING INSTRUMENTS

INSTRUMENT ADMINISTRATION TIME

COMMENTS

BRIEF INSTRUMENTS (<10 mins)

Short Portable Mental Status Questionnaire*

3-5 mins Recommended, validated brief screening tool

Mini-Cog 3-5 mins Recommended; validated brief screening tool.

LONGER INSTRUMENTS (>10 mins) FOR MORE COMPREHENSIVE ASSESSMENT

3MS 10-15 mins Recommended; includes the MMSE, plus remote memory, verbal fluency, and abstraction

Montreal Cognitive Assessment

10-15 mins Recommended; assesses similar domains to MMSE, and also verbal fluency and abstraction

These listings are NOT comprehensive. Many other effective instruments exist which should be considered; these may be very useful to individual sites depending on timeframes and domains for screening. *At this time we recommend the use of the SPMSQ combined with an attention task, as outlined below.

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REFERENCES

1. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15: 1021–1027

2. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433- 441.

3. Teng EL, Chui HC. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry. 1987;48:314-8.

4. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-699.

Recommendation

At this time the HELP Program recommends that HELP sites use the Short Portable Mental Status Questionnaire combined with an attention task. A worksheet with the SPMSQ and scoring guidelines has been incorporated into the HELP manuals, along with the digits backwards and days of the week backwards attention tasks. These two assessments can be used to rate the CAM and evaluate for cognitive impairment.

Please note: any brief, validated cognitive assessment may be used with the HELP program as long as it is used consistently and patient scores are tracked.

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Hospital Elder Life Program Brief Cognitive Evaluation

Short Portable Mental Status Questionnaire Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41. Copyright E. Pfeiffer 1994. Reproduced with permission.

Question Response Error?

What are the date, month, and year?* Date Month Year

What is the day of the week?

What is the name of this place?

What is your phone number?

How old are you?

When were you born?

Who is the current president?

Who was the president before him?

What was your mother’s maiden name?

Can you count backward from 20 by 3s?

*A mistake on ANY part of this question should be scored as an error

Total Errors:

Suggested Cutpoints for HELP MMSE SPMSQ

score # of errors Application in HELP

24 8 2+ Risk factor for cognitive decline— Enroll in HELP*

20 5 5+ Enrollment in orientation protocol 10 2 8+ Severe impairment; case by case

enrollment *Patients with fewer than 2 errors should also be enrolled in HELP if they have one or more of the additional risk factors outlined in the HELP manuals.

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Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Results of a US Consensus Panel of Experts Donna M. Fick, PhD, RN; James W. Cooper, PhD, RPh; William E. Wade, PharmD, FASHP, FCCP; Jennifer L. Waller, PhD; J. Ross Maclean, MD; Mark H. Beers, MD Arch Intern Med. 2003;163:2716-2724. Background: Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. Methods: This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical condition. Results: This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. Conclusions: This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems. Full‐text of article found here:

http://www.ncbi.nlm.nih.gov/pubmed/14662625

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Beers List

Inappropriate medication use – Independent of diagnoses or conditions

Brand Name Generic Name Concern in Older Adults Severity

Rating Aldomet methyldopa May cause bradycardia & exacerbate

depression High

Aldoril methyldopa-hydrochlorothiazide

May cause bradycardia & exacerbate depression

High

Amphetamines (excluding methylphenidate & anorexics)

CNS stimulant adverse effects High

Amphetamines & anorexic agents

May cause dependence, hypertension, angina & myocardial infarction

High

Android, Virilon & Testrad methyltestosterone Potential for prostatic hypertrophy & cardiac problems

High

Ativan >3 mg lorazepam Increased sensitivity. Total daily doses should rarely exceed suggested maximums.

High

Barbiturates (except phenobarb & to control seizures)

Highly addictive & more adverse effects than most sedative or hypnotic drugs

High

Benadryl diphenhydramine May cause confusion and sedation. Should be used in smallest possible dose.

High

Bentyl dicyclomine Highly anticholinergic with uncertain effectiveness. Should be avoided.

High

Cardura doxazosin Potential for hypotension, dry mouth, & urinary problems

Low

Catapres clonidine Potential for orthostatic hypotension & CNS adverse effects

Low

Chlor-Trimeton chlorpheniramine All nonprescription & many prescription antihistamines cause potent anticholinergic properties

High

Cordarone amiodarone Associated with QT interval problems & risk of provoking torsades de pointes

High

Cyclospasmol cyclandelate Not shown to be effective in the doses studied

Low

Cyclospasmol cyclandelate Lack of efficacy Low Dalmane flurazepam Extremely long half-life causing sedation

& falls/fracture High

Darvon, Darvon w/ASA, Darvon-N, Darvocet-N

propoxyphene Few analgesic advantages over acetaminophen; adverse effects of other narcotic drugs

Low

Dayproq oxaprozin May cause Gl bleeding, renal failure, high blood pressure & heart failure

High

Demerol meperidine May cause confusion. Not effective oral analgesic.

High

Desiccated thyroid Concerns about cardiac effects High Diabinese chlorpropamide Prolonged half-life. Could cause prolonged

hypoglycemia & SIADH High

Ditropan, Dixtropan XL oxybutynin Poorly tolerated, causes sedation, weakness. Dose effectiveness is questionable.

High

Donnatal belladonna alkaloids

Highly anticholinergic with uncertain effectiveness. Should be avoided.

High

Doral quazepam Long half-life causing prolonged sedation and risk of falls/fractures

High

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Beers List (Continued)



Rating Dulcolax bisacodyl May exacerbate bowel dysfunction High Edecrin ethacrynic Potential for hypertension and fluid imbalances Low Elavil amitriptyline Strong anticholinergic and sedation properties.

Rarely an antidepressant. High

Equanil meprobamate Highly addictive and sedating anxiolytic High Estrogens only (oral) Carcinogenic (breast & endometrial) potential.

Lack of cardioprotective effect in women. Low

Feldene piroxicam May cause GI bleeding, renal failure, high blood pressure, and heart failure

High

Ferrous sulfate >325 mg/d Does not dramatically increase amount absorbed but greatly worsens constipation

Low

Flexeril tyclobenzaprine Poorly tolerated, causes sedation, weakness. Dose effectiveness is questionable.

High

Halcion >0.25 mg Triazolam Increased sensitivity. Total daily doses should rarely exceed suggested maximums.

High

Hydergine ergot mesyloids Not shown to be effective in the doses studied Low Hylorel guanadrel May cause orthostatic hypotension High lndocin, lndocin SR indomethacin Of all NSAIDs, this drug produces the most

CNS adverse effects High

Ismelin guanethidine May cause orthostatic hypotension High Lanoxin digoxin Not to exceed 0.125mg/d except when treating

atrial arrhythmias. Decreased renal clearance. Low

Levsin, Levsinex hyoscyamine Highly anticholinergic with uncertain effectiveness. Should be avoided.

High

Librax clidinium-chlordiazepoxide

Long half-life causing prolonged sedation and risk of falls/fractures. Highly anticholinergic.

High

Librium chlordiazepoxide Long half-life causing prolonged sedation and risk of falls/fractures

High

Limbitrol chlordiazepoxide-amitriptyline

Strong anticholinergic and sedation properties. Rarely an antidepressant.

High

Limbitrol chlordiazepoxide-amitriptyline

Long half-life causing prolonged sedation and risk of falls/fractures

High

Macrodantin nitrofurantoin Potential for renal impairment High Mellaril thioridazine Greater potential for CNS and extra pyramidal

adverse effects High

Miltown meprobamate Highly addictive and sedating anxiolytic High Mineral Oil Potential for aspiration and adverse effects High Naprosyn, Avaprox, Aleve naproxen May cause GI bleeding, renal failure, high

blood pressure, and heart failure High

Norflex Orphenadrine Causes more sedation and anticholinergic adverse effects than safer alternatives

High

Norpace, Norpace CR disopyramide Most potent negative isotope. May cause heart failure. Strongly anticholinergic.

High

Paraflex chlorzoxazone Poorly tolerated, causes sedation, weakness. Dose effectiveness is questionable.

High

Paxipam halazepam Long half-life causing prolonged sedation and risk of falls/fractures

High

Periactin cyproheptadine All nonprescription and many prescription antihistamines may have potent anticholinergic properties

High

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Rating Persantine (Long acting) dipyridamole Do not consider the long-acting except with

patients with artificial heart valves Low

Persantine (Short acting) dipyridamole May cause orthostatic hypotension Low Phenergan promethazine All nonprescription and many prescription

antihistamines may have potent anticholinergic properties

High

Polaramine dexchlorpheniramine All nonprescription and many prescription antihistamines may have potent anticholinergic properties

High

Pro-Banthine propantheline Highly anticholinergic with uncertain effectiveness. Should be avoided.

High

Procardia & Adalat nifedipine Potential for hypotension and constipation High Prozac fluoxetine Long half-life. Risks of excessive CNS

stimulation, sleep disturbances, and agitation

High

Reserpine >0.25 mg May induce depression, impotence, sedation, and orthostatic hypotension

Low

Restoril >15 mg temazepam Increased sensitivity. Total daily doses should rarely exceed suggested maximums.

High

Robaxin methocarbamol Poorly tolerated, causes sedation, weakness. Dose effectiveness is questionable.

High

Serax >60 mg oxazepam Increased sensitivity. Total daily doses should rarely exceed suggested maximums.

High

Serentil mesoridazine CNS and extra pyramidal adverse effects. High Sinequan doxepin Strong anticholinergic and sedation

properties. Rarely an antidepressant High

Skelaxin metaxalone Poorly tolerated, cause sedation, weakness. Dose effectiveness is questionable.

High

Soma carisoprodol Poorly tolerated, cause sedation, weakness. Dose effectiveness is questionable.

High

Tagamet cimetidine CNS adverse effects including confusion. Low Talwin pentazocine Narcotic analgesic that causes CNS

adverse effects, including confusion and hallucinations

High

Ticlid ticlopidine No better than aspirin to prevent clotting. May be more toxic than aspirin.

High

Tigan trimethobenzamide One of the least effective antiemetic drugs, yet can cause extra pyramidal adverse effects

High

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Rating Toradol ketorolac May cause asymptomatic Gl pathologic

conditions. Immediate & long-term use· should be avoided.

High

Tranxene chlorazepate Long half-life causing prolonged sedation and risk of falls/fractures

High

Triavil perphenazine-amitriptyline

Strong anticholinergic and sedation properties

High

Valium diazepam Long half-life causing prolonged sedation and risk of falls/fractures

High

Vasodilan isoxsurpine Lack of efficacy Low Vistaril & Atarax hydroxyzine All nonprescription and many prescription

antihistamines may have potent anticholinergic properties

High

Xanax >2 mg alprazolam Increased sensitivity. Total daily doses should rarely exceed suggested maximums.

High

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Beers List

Inappropriate medication use considering diagnoses or conditions

Disease or Condition

Generic Name Brand Name Concern Severity Rating

Anorexia and malnutrition

dextroamphetamine Adderall Concern due to appetite-suppressing effects

High


fluoxetine Prozac Concern due to appetite-suppressing effects

High


methamphetamine Desoxyn Concern due to appetite-suppressing effects

High


methylphenidate Ritalin Concern due to appetite-suppressing effects

High


pemolin Concern due to appetite-suppressing effects

High

Arrhythmias tricyclic antidepressants

Proarrhythmic effects and production of QT interval changes

High

Bladder outflow obstruction

anticholinergics and antihistamines

May decrease urinary flow, leading to urinary retention

High


antidepressants May decrease urinary flow, leading to urinary retention

High


decongestants May decrease urinary flow, leading to urinary retention

High


flavoxate Urispas May decrease urinary flow, leading to urinary retention

High


GI antispasmodics May decrease urinary flow, leading to urinary retention

High


muscle relaxants May decrease urinary flow, leading to urinary retention

High


oxybutynin Ditropan May decrease urinary flow, leading to urinary retention

High


tolterodine Detrol May decrease urinary flow, leading to urinary retention

High

Blood clotting disorders or anticoagulant therapy

aspirin May prolong clotting time and elevate INR or inhibit platelet aggregation. May increase bleeding.

High


clopidogrel Plavix May prolong clotting time and elevate INR or inhibit platelet aggregation. May increase bleeding.

High


dipyridamole Persantin May prolong clotting time and elevate INR or inhibit platelet aggregation. May increase bleeding.

High

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Beers List





NSAIDs May prolong clotting time and elevate INR or inhibit platelet aggregation. May increase bleeding.

High


ticlopidine Ticlid May prolong clotting time and elevate INR or inhibit platelet aggregation. May increase bleeding.

High

Chronic constipation anticholinergics May exacerbate constipation

Low

Chronic constipation calcium channel blockers

May exacerbate constipation

Low

Chronic constipation tricyclic antidepressants

May exacerbate constipation

Low

Cognitive impairment anticholinergics CNS altering effects High Cognitive impairment antispasmodics CNS altering effects High Cognitive impairment barbiturates CNS altering effects High Cognitive impairment dextroamphetamine Adderall CNS altering effects High Cognitive impairment methamphetamine Desoxyn CNS altering effects High Cognitive impairment methylphenidate Ritalin CNS altering effects High Cognitive impairment muscle relaxants CNS altering effects High Cognitive impairment pemolin CNS altering effects High COPD β-blockers Propranolol CNS adverse effects.

May induce, exacerbate, or cause respiratory depression.

High

COPD chlorazepate Tranxene CNS adverse effects. May induce, exacerbate, or cause respiratory depression.

High

COPD chlordiazepoxide Librium CNS adverse effects. May induce, exacerbate, or cause respiratory depression.

High

COPD chlordiazepoxide-amitriptyline

Limbitrol CNS adverse effects. May induce, exacerbate, or cause respiratory depression.

High

COPD diazepam Librax CNS adverse effects. May induce, exacerbate, or cause respiratory depression.

High

COPD halazepam Valium CNS adverse effects. May induce, exacerbate, or cause respiratory depression.

High

COPD quazepam Paxipam CNS adverse effects. May induce, exacerbate, or cause respiratory depression.

High

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Beers List




Depression long-term benzodiazepine

May produce or exacerbate depression

High

Depression methyldopa Aldomet May produce or exacerbate depression

High

Depression quanethidine Ismelin May produce or exacerbate depression

High

Depression reserpine May produce or exacerbate depression

High

Gastric or duodenal ulcers

NSAIDs and aspirin > 325 mg

May exacerbate existing ulcers or produce new/additional ulcers

High

Heart failure disopyramide Norpace Negative isotropic effect. Potential fluid retention, exacerbation of heart failure.

High

Heart failure high sodium content drugs

Negative isotropic effect. Potential fluid retention, exacerbation of heart failure.

High

Hypertension amphetamines May produce elevated blood pressure secondary to sympathomimetic activity.

High

Hypertension phenylpropanolamine hydrochloride

May produce elevated blood pressure secondary to sympathomimetic activity.

High

Hypertension pseudoephedrine and diet pills

May produce elevated blood pressure secondary to sympathomimetic activity.

High

Insomnia amphetamines CNS stimulant effect High Insomnia decongestants CNS stimulant effect High Insomnia MAOIs CNS stimulant effect High Insomnia methylphenidate Ritalin CNS stimulant effect High Insomnia theophylline Theodur CNS stimulant effect High Obesity olanzapine Zyprexa May stimulate appetite and

increase weight gain. Low

Parkinson’s Disease conventional antipsychotics

Antidopaminergic/cholinergic effects

High

Parkinson’s Disease metoclopramide Reglan Antidopaminergic/cholinergic effects

High

Parkinson’s Disease tacrine Cognex Antidopaminergic/cholinergic effects

High

Seizure Disorder bupropion Wellbutrin May lower seizure thresholds.

High

Seizures or epilepsy chlorpromazine Thorazine May lower seizure thresholds.

High

Seizures or epilepsy clozapine Clozaril May lower seizure thresholds.

High

Seizures or epilepsy thioridazine Mellaril May lower seizure thresholds.

High

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Beers List




Seizures or epilepsy thiothixene Navane May lower seizure thresholds.

High

SIADH/hyponatremia citalopram Celexa May exacerbate or cause SIADH.

Low

SIADH/hyponatremia fluoxetine Prozac May exacerbate or cause SIADH.

Low

SIADH/hyponatremia fluvoxamine Luvox May exacerbate or cause SIADH.

Low

SIADH/hyponatremia paroxetine Paxil May exacerbate or cause SIADH.

Low

SIADH/hyponatremia sertraline Zoloft May exacerbate or cause SIADH.

Low

Stress incontinence anticholinergics May produce polyuria and worsening of incontinence.

High

Stress incontinence α-blockers Doxazosin, Prazosin, Terazosin

May produce polyuria and worsening of incontinence.

High

Stress incontinence long-acting benzodiazepines


High

Stress incontinence tricyclic antidepressants


High

Syncope or falls short to intermediate-acting benzodiazepines

May produce ataxia, impaired psychomotor function, syncope, and falls.

High

Syncope or falls tricyclic antidepressants

May produce ataxia, impaired psychomotor function, syncope, and falls.

High

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Top 10 Drug Interactions (Content developed by: Karen E. Brown, PharmD)

1. Warfarin, Coumadin NSAIDs:

Aleve, Anaprox, Anaprox DS, Ansaid, Arthrotec, Cataflam, Clinoril, Daypro, diclofenac, diclofenac/mistoprostrol, diflunisal, Dolobid, etodolac, Feldene, flurbiprofen, ibuprofen, Indocin, Indocin SR, indomethacin, ketoprofen, ketorolac, Lodine, Lodine XL, mefenamic acid, meloxicam, Mabie, Motrin, nabumetone, Naprelan, Naprosyn, naproxen, Orudis, Oruvail, oxaprozin, piroxicam, Ponsel, Relafen, sulindac, Tolectin, Tolectin DS, tolmetin, Toradol, Voltaren, Voltaren XR

IMPACT: Potential for serious gastrointestinal bleeding. MANAGEMENT: Prothrombin time and INR should be monitored every week with co-administration of warfarin with an NSAID. Signs and symptoms of an active bleed should be monitored with particular attention to the appearance and patterns of bruises. Signs of an active bleed include: coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea- colored urine (hematuria), or black, tarry stools (hemoccult positive).

2. Warfarin, Coumadin Sulfa Drugs:

Bactrim DS, Bactrim SS, Cotrim DS, Cotrim SS, erythromycin/sulfisoxazole, Gantanol, Gantrisin, Pediazole, Septra DS, Sulfatrim, sulfamethizole, sulfamethoxazole, sulfisoxazole, Thiosulfil Forte, trimethoprim/sulfamethoxazole

IMPACT: Increased effects of warfarin, with potential for bleeding. MANAGEMENT: Prothrombin time and INR should be monitored every week with co-administration of warfarin with an NSAID. Signs and symptoms of an active bleed should be monitored with particular attention to the appearance and patterns of bruises. Signs of an active bleed include: coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea- colored urine (hematuria), or black, tarry stools (hemoccult positive).

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3. Warfarin, Coumadin Macrolides:

azithromycin, Biaxin, clarithromycin, Dynabac, dirithromycin, E- Mycin, erythromycin base, EES, erythromycin ethyl succinate, Ery-Tab, Eryc, EryPed, Erythrocin, erythromycin stearate, Ilosone, erythromycin estolate, Pediazole, erythromycin/sulfisoxazole, Tao, troleandomycin, Zithromax

IMPACT: Increased effects of warfarin, with potential for bleeding. MANAGEMENT: If use of a macrolide is imperative, then monitor INR every other day and adjust warfarin dosing as necessary. Signs and symptoms of an active bleed should be monitored daily with particular attention to the appearance and patterns of bruises. Signs of an active bleed include: coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea-colored urine (hematuria), or black, tarry stools (hemoccult positive).

4. Warfarin, Coumadin Quinolones:

Alatrofloxacin, Avelox, Cipro, ciprofloxacin, enoxacin, Floxin, gatifloxacin, Levaquin, lvofloxacin, omefloxacin, Maxaquin, moxifloxacin, Noroxin, norloxacin, ofloxacin, Penetrex, sparfloxacin, Tequin, trovafloxacin, Trovan, Trovan IV, Zagam

IMPACT: Increased effects of warfarin, with potential for bleeding. MANAGEMENT: Prothrombin time and INR should be monitored during co-administration of warfarin with a quinolone. If use of ciprofloxacin is imperative, then monitor INR every other day and adjust warfarin dose as necessary. Signs and symptoms of an active bleed should be monitored daily with particular attention to the appearance and patterns of bruises. Signs of an active bleed include: coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea-colored urine (hematuria), or black, tarry stools (hemoccult positive).

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5. Warfarin, Coumadin Phenytoin:

Dilantin, phenytoin

IMPACT: Increased effects of warfarin and/or phenytoin. MANAGEMENT: Prothrombin time, INR, and phenytoin levels should be monitored during co-administration. Signs and symptoms of an active bleed should be monitored daily with particular attention to the appearance and patterns of bruises. Signs of an active bleed include: coughing up blood in the form of coffee grinds (hemoptysis), gum bleeding, nose bleeds, cola- or tea-colored urine (hematuria), or black, tarry stools (hemoccult positive).

6. ACE Inhibitors:

Accupril, Aceon, Altace, benazepril, Capoten, captopril, enalapril, fosinopril, Iisinopril, Lotensin, Mavik, moexipril, Monopril, perindopril, Prinivil, quinapril, ramipril, trandolapril, Univasc, Vasotec, Zestril

Potassium Supplements: K+ Care ET, Kaon, K-dur, Klor-Con, K-Phos, Micro-K, potassium acetate, potassium acid phosphate, potassium bicarbonate, potassium chloride, potassium citrate, potassium gluconate, Urocit-K

IMPACT: Elevated serum potassium.

MANAGEMENT: Potassium levels greater than 5 should be monitored carefully due to risk of severe hyperkalemia and EKG changes. Watch renal function (BUN, SCr) also. Adjust potassium supplementation if levels increase.

7. ACE Inhibitors:

Accupril, Aceon, Altace, benazepril, Capoten, captopril, enalapril, fosinopril, lisinopril, Lotensin, Mavik, moexipril, Monopril, perindopril, Prinivil, quinapril, ramipril, trandolapril, Univasc, Vasotec, Zestril

Spironolactone: Aldactone, spironolactone

IMPACT: Elevated serum potassium.

MANAGEMENT: Potassium levels greater than 5 should be monitored carefully due to risk of severe hyperkalemia and EKG changes. Watch renal function (BUN, SCr) also. Avoid potassium supplements in patients taking this combination of medications, unless the need is documented and the patient is monitored closely for hyperkalemia.

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8.

Digoxin: digoxin, Lanoxin

Amiodarone: amiodarone, Cordarone

IMPACT: Digoxin toxicity. MANAGEMENT: Maintain digoxin levels between 1-2. Monitor for signs and symptoms of digoxin toxicity (abdominal pain, anorexia, bizarre mental symptoms in the elderly, blurred vision, bradycardia, confusion, delirium, depression, diarrhea, disorientation, drowsiness, fatigue, hallucinations, halos around lights, reduction in visual acuity, mydriasis nausea, neuralgia, nightmares, personality changes, photophobia, restlessness, vertigo, vomiting, and weakness).

9. Digoxin:

digoxin, Lanoxin Verapamil:

Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, verapamil, Verelan

IMPACT: Digoxin toxicity. MANAGEMENT: Monitor heart rate and EKG-PR interval. Monitor for signs and symptoms of digoxin toxicity (abdominal pain, anorexia, bizarre mental symptoms in the elderly, blurred vision, bradycardia, confusion, delirium, depression, diarrhea, disorientation, drowsiness, fatigue, hallucinations, halos around lights, reduction in visual acuity, mydriasis nausea, neuralgia, nightmares, personality changes, photophobia, restlessness, vertigo, vomiting, and weakness).

10. Theophylline:

Aminophyllin, Choledyl SA, oxtriphylline, Phyllocontin, Slo-Bid, Slo-0Phyllin, Slo-Phyllin 125, Theo-24, Theo-Dur, Theolair, theophylline, Uniphyl, Uniphyl CR

Quinolones: Alatrofloxacin, Avelox, Cipro, ciprofloxacin, enoxacin, Floxin, gatifloxacin, Levaquin, levofloxacin, omefloxacin, Maxaquin, moxifloxacin, Noroxin, norloxacin, ofloxacin, Penetrex, sparfloxacin, Tequin, trovafloxacin, Trovan, Trovan IV, Zagam

IMPACT: Theophylline toxicity MANAGEMENT: Monitor theophylline levels. Maintain level within targeted range of 5-15 mcg/mL; however, theophylline toxicity may result even when the level is within the targeted range. Signs and symptoms of theophylline toxicity include seizures, nausea, and vomiting.


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SECTION IV

• INTERDISCIPLINARY INTERVENTIONS

Page

o INTERDISCIPLINARY INTERVENTIONS SUMMARY CHART…….. 114 o INTERDISCIPLINARY ROUNDS AND CONSULTATION………….… 115 o GERIATRICIAN CONSULTATION……………………………………………. 116 o COMMUNITY LINKAGES…………………………………………………………. 116 o HELP INTERDISCIPLINARY ROUNDS FORM……………………….….. 117


114

INTERDISCIPLINARY INTERVENTIONS

INTERDISCIPLINARY INTERVENTIONS SUMMARY CHART

Intervention Description of Intervention

Interdisciplinary Rounds Twice weekly rounds to discuss each HELP

patient and set goals with interdisciplinary input. Interventions are recommended and

tracked.

Geriatrician Consultation Targeted consultation on HELP issues, as referred by program staff. Formal geriatric consultation on a limited basis as requested by

primary attending physicians.

Community Linkages and Telephone Follow-up

Referrals and communication with community agencies to optimize transition to home. Telephone call follow-up within 4 days of

discharge.

Interdisciplinary Consultation Provide as-needed consultation and input about HELP patients upon referral by staff.


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1. Interdisciplinary Rounds and Consultation Goal: To provide a mechanism for interdisciplinary expertise to be focused on the diagnosis and treatment of geriatric vital signs of each HELP patient in a timely manner.

Interdisciplinary Rounds:

Process: These twice weekly rounds are coordinated and overseen by the Elder Life Nurse Specialist. Each clinician reports on patients’ progress, new findings and/or any problems delivering recommended interventions.

The primary nurse presents each patient, providing: name, age, date of and reason for admission, past medical history, and geriatric vital signs, i.e., cognition, psychoactive medication use, sleep, functional status, mobility, sensory function (vision and hearing), nutritional status/hydration, incontinence and elimination issues, skin, emotional health, and social issues including discharge planning.

Then each member of the Hospital Elder Life team (including consultants) gives input on each patient, as follows:

• Elder Life Nurse Specialist • Elder Life Specialist • Geriatrician • Rehabilitation therapists, e.g., physical/occupational therapy • Dietitian • Clinical pharmacist • Chaplain

Record keeping and tracking: Each clinician’s evaluations and recommendations are recorded on the attached “HELP Interdisciplinary Rounds” form by a member of the HELP team, e.g., the Elder Life Specialist, and placed in the Interdisciplinary Rounds Notebook. This form is reviewed regularly to assure adherence with the Interdisciplinary Round’s recommendations.

Interdisciplinary Consultation: In addition to regular participation in interdisciplinary rounds, consulting staff provide clinical expertise and support to the program by:

• Providing patient specific consultation • Providing clinical updates and keeping HELP team members

informed of advances in clinical specialties • Providing staff training on an as-needed basis • Participation in volunteer training


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2. Geriatrician Consultation

In addition to participating in HELP interdisciplinary rounds, the geriatrician provides informal consultation to the Elder Life Nurse Specialist and other HELP staff upon request. Likewise, the geriatrician performs formal geriatric medicine consultations upon the request of the patient’s attending physician.

The geriatrician also serves as the medical liaison with the hospital medical staff.

3. Community Linkages

The Elder Life Nurse Specialist develops knowledge of community resources and facilities and works with the nursing and discharge planning staff to facilitate referrals to community agencies when appropriate (see ELNS- Discharge Planning Protocol).


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HELP INTERDISCIPLINARY ROUNDS

DATE: Patient:

Nursing/ELNS ELS Geriatrician

PT Other D/C Planning

Update Update Update


Plan Plan Plan

Plan Plan Plan

DATE: Patient:

Nursing/ELNS ELS Geriatrician

PT Other D/C Planning



Plan Plan Plan

Plan Plan Plan

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SECTION V

• DISCHARGE AND POST DISCHARGE PROCEDURES

Page

o DISCHARGE EVALUATION AND CLINICAL OUTCOMES………………… 119-120 1. DISCHARGE EVALUATION PROCEDURE 2. POST DISCHARGE ASSISTANCE AND EVALUATION

o ELDER LIFE NURSE SPECIALIST: TELEPHONE FOLLOW-UP FORM 121-122 o HOSPITAL ELDER LIFE PROGRAM: PATIENT-FAMILY

SATISFACTION SURVEY………………………………………………………….. 123

119

DISCHARGE AND POST- DISCHARGE PROCEDURES

DISCHARGE EVALUATION AND CLINICAL OUTCOMES

A major goal of the discharge evaluation is to track clinical outcomes related to program interventions. The overall goal of the Hospital Elder Life Program is to reduce cognitive and functional decline of older patients during hospitalization by intervening on risk factors for these conditions. To measure the effectiveness of the program interventions on these risk factors, the following outcomes are measured: a cognitive assessment (i.e., SPMSQ or Mini Cog) and Activities of Daily Living (ADL) scores obtained upon admission into the program are compared to cognitive assessment and ADL scores obtained upon discharge from the program. Additional patient outcomes that are obtained and tracked include: vital status (e.g., death), length of hospital stay, discharge destination (e.g., home vs. nursing home), and use of home services (e.g., visiting nursing services). Hospital costs can also be tracked. Sample charts of the clinical outcomes are found in the Organizational and Procedural Manual I: Overview and Structure.

1. Discharge Evaluation Procedure

The Elder Life Specialist completes the “Patient Discharge Form” which measures and/or indicates the patients’ clinical outcomes. (See Database Manual).

The ELS then distributes to each patient or to a family member the “Hospital Elder Life Program: Patient-Family Satisfaction Survey” (See attached). Patients and/or family members return this anonymous survey in a sealed envelope prior to discharge. Returning the survey prior to discharge assures an adequate response rate, which could not be achieved with a mail-back survey. Information obtained from this survey is reviewed regularly at HELP Working Group and program modifications based on this feedback are proposed and implemented.

2. Post Discharge Assistance and Evaluation

The Elder Life Nurse Specialist makes at least one telephone follow-up call to each HELP patient to assist with the transition from hospital to home. The initial call is made within 4 days of discharge, and additional calls are made if the ELNS determines the need. Issues addressed during the follow-up telephone call include:

• Medical concerns (new problems are referred to the primary

physician as indicated) • Geriatric vital signs • Medication concerns

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• Food and meals • Transportation • Home nursing assistance

See “ELNS: Telephone Follow-Up” form (attached) for additional information to address during telephone follow-up.

121


TELEPHONE FOLLOW-UP* Patient Name:

Telephone Number:

Discharge Date:

Physician:

Date of Phone Call:

Indicate if patient or family member supplied information for follow-up phone call:

PATIENT FAMILY MEMBER

Name: Note: Suggested questions are indicated below:

MEDICAL STATUS/GENERAL:

• How are you feeling?

• Do you have any new medical problems or symptoms?

• Do you have follow-up medical appointments?

• Do you have transportation to your medical appointments?

• Do you have enough food to eat?

GERIATRIC REVIEW OF SYSTEMS:

Are you having any specific problems…?

• With confusion or thinking?

• With sleeping?

• Getting washed and dressed?

• Walking or getting where you need to go (Ask specifically – “Have you had any falls?”)

• With your vision or hearing?

• With urinating, including urinary control?

• With your bowels, including constipation or diarrhea?

• With your skin, including any rashes or sores?

MEDICATIONS:

Many people have trouble taking medications as they are prescribed.

• Are you having any trouble taking your medication?

• Have you gotten all of your prescriptions filled? (If no, why not?)

COMMENTS

ASSISTANCE/SERVICES AT HOME (If applicable):

• Were you expecting visiting nurses to come see you in your home?

• If Yes, have they come to see you?

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TELEPHONE FOLLOW-UP (Continued)

ADDITIONAL COMMENTS:

SUGGESTIONS/INSTRUCTIONS TO PATIENT/FAMILY:

UNRESOLVED ELNS ISSUES:

*Refer any new or unexpected problems to the patient’s primary physician.

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HOSPITAL ELDER LIFE PROGRAM PATIENT AND FAMILY SATISFACTION SURVEY

To our patients and family members: While you were in the hospital, the Hospital Elder Life Program provided you with some extra care to help you recover, and to keep your body and mind active. It is important to the program to get comments from patients and families. Please take the time to complete the following survey. An envelope has been provided. Please leave the completed survey with a program staff person, volunteer, or your nurse. Thank you in advance for your cooperation.

THIS FORM IS ANONYMOUS AND CONFIDENTIAL

Yes No

1. Were volunteers helpful during your hospitalization?

If yes, what was the most helpful?

If no, what was the least helpful?

2. Were the volunteers helpful with…?

Friendly visiting and activities Answering questions Assisting you with meals and/or meal trays Assisting you with exercising and walking

3. Overall, was your room quiet and comfortable for sleeping?

4. Are there other ways the volunteers and program staff could improve the

care of patients in the hospital?

5. Any additional comments?

6. Who completed this form? (Check one) Patient Family Member

Both

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SECTION VI

• EDUCATIONAL INTERVENTIONS TO IMPROVE GERIATRIC EXPERTISE

Page

o PROVIDER EDUCATION PROGRAM…………………………………..125 1. NURSING EDUCATION PROGRAM 2. PHYSICIAN EDUCATION PROGRAM 3. TRAINING SITE

o ELDER LIFE NURSE SPECIALIST: GERONTOLOGICAL NURSING INSERVICE PROTOCOL……………………………….126-127

125

EDUCATIONAL INTERVENTIONS TO IMPROVE GERIATRIC EXPERTISE

PROVIDER EDUCATION PROGRAM

1. Nursing Education Program

The Elder Life Nurse Specialist, geriatrician and interdisciplinary staff provide ongoing education to hospital care providers involved in HELP. Methods include: formal didactic sessions, teaching rounds, one-on- one interactions, newsletters, and resource materials to educate nursing, physician, and other hospital staff about HELP issues. The nursing education program is detailed under the “ELNS: Gerontological Nursing Inservice Protocol”. (See attached). In this program, the ELNS provides inservices and leads case discussion groups with nursing staff. Supportive educational materials, such as a HELP newsletter and articles, are provided.

2. Physician Education Program

The Elder Life Geriatrician provides formal and informal educational sessions for the house staff and hospital staff physicians on topics relating to HELP and geriatric vital signs areas. Formal sessions include lectures and attending rounds on topics such as delirium, dementia, functional decline, management of medications in the elderly, and overview of the program. Informal sessions include bedside teaching and one-on-one interactions with physicians regarding targeted issues on specific patients, or feedback following a requested consultation. In addition, the Geriatrician provides patient recommendations and articles on related topics to physicians.

3. Training Site

The program also serves as a clinical training site and/or internship for bachelor and graduate-level healthcare students, e.g., nurse- practitioner students, pre-medical, rehabilitation (physical/occupational therapy), pharmacy, physician assistant, gerontology, social worker students, etc. The opportunity to gain hands-on patient contact and specific training in practical interventions, such as mobility and orientation, has been valued by the trainees. Rotations have also been offered for medical students, medical residents, and geriatric fellows.

126

THE ELDER LIFE NURSE SPECIALIST GERONTOLOGICAL NURSING INSERVICE PROTOCOL

Goals of Inservices:

1. To provide a forum for collaborating with hospital staff nurses regarding the integration of principles of geriatrics into routine nursing care. Content of inservices will emphasize the physiology of normal aging and feasible interventions to minimize iatrogenesis, re:

• Cognitive function • Psychoactive medications • Sleep • Function and mobility • Physical and chemical restraints • Falls • Sensory function • Hydration/Nutrition • Continence • Skin integrity • Emotional health

2. To provide a forum for nursing contributions to be included in

interdisciplinary assessment and planning for the care of hospitalized elderly patients.

3. To provide comprehensive, individualized, effective discharge planning

of elderly patients. Content will include information regarding: • Psychosocial assessment • Activities of daily living/Instrumental activities of daily living • Caregiver support • Community resources

Strategies to Maximize Participation and Effectiveness of Inservices:

1. Provide inservices to all three shifts of nurses. Schedule inservices at

various times to allow for maximal attendance by all personnel. Include Nurse’s Aides and other caregivers as appropriate.

2. Use “Case Study” format of actual patients on the unit whenever

possible to increase interest and relevance of particular topics. Additional Educational Methods:

1. Posting educational topics, including charts, diagrams, etc. on Bulletin Boards.

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2. Circulating a HELP newsletter geared towards nursing and other hospital staff, which contains articles and information on geriatric issues, i.e., alternatives to restraints.

3. Provide newsletters, articles, and other supportive materials on geriatric vital sign topics and HELP protocols as a resource notebook for all HELP floors.

128



SECTION VII

Page • REFERENCES AND SUGGESTED RESOURCES……………129-137

129

REFERENCES FOR PATIENT ENROLLMENT FORM AND PATIENT DISCHARGE FORM

Cognitive Status

Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. J Psy Res 1975;12:189-198. (used with permission)

Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41. Copyright E. Pfeiffer 1994. Functional Status

Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: The index of ADL, a standardized measure of biological and psychosocial function. JAMA 1963;185:914-919.

Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-186.

Hearing

MacPhee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age and Aging 1988;17:347-351.

Sleep McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. JAGS 1998;46:700-705.

130

SUGGESTED READING For more updated information about delirium and hospital care of older persons, please refer to the searchable HELP bibliography on the HELP website. General Creditor MC. Hazards of hospitalization of the elderly. Ann Int Med 1993;118(3):219-223.

Emmett KR. Nonspecific and atypical presentation of disease in the older patient. Geriatrics 1998;53(2):50-60. Ham RJ, Sloane PD. Primary care geriatrics: A case-based approach. 2nd ed. St. Louis: Mosby-Year Book, Inc; 1992. Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG, editors. Principles of geriatric medicine and gerontology. 4th ed. New York: McGraw- Hill Comp, Inc; 1999. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340(9);669-676. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106:565-573.

Jacelon CS. Preventing cascade iatrogenesis in hospitalized elders: An important role for nurses. J Geron Nur 1999;25(1): 27-33.

The Hartford Institute for Geriatric Nursing. They have cost-free, web-based resources including demonstration videos, and a corresponding print series featured in the AJN, developed to build geriatric skills: http://hartfordign.org/Resources/Try_This_Series/

Cognition Carlson DC, Fleming KC, Smith GE, Evans JM. Management of dementia- related behavioral disturbances: A nonpharmacological approach. Mayo Clin Proc 1995;70:1108-1115.

Cummings IL. Clinical neuropsychiatry. Orlando, FLS: Grune & Stratton, 1985:9. (Reference for Digit Span)

Eden BM, Foreman MD. Problems associated with underrecognition of delirium in critical care: A case study. Heart & Lung 1996;25(5):388-400.

131

Fleming KC, Adams AC, Peterson RC. Dementia: Diagnosis and evaluation. Mayo Clin Proc 1995;70:1093-1107. Geldmacher DS & Whitehouse PJ. Evaluation of dementia. N Engl J Med 1996;335(5):330-336. Inouye SK, VanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Int Med 1990;113:941-8. Lehninger FW, Ravindran VL, Stewart JT. Management strategies for problem behaviors in the patient with dementia. Geriatrics 1998;53(4):55- 75. Morris JC. Differential diagnosis of Alzheimer’s Disease. Clin Geri Med 1994;10:257-276. Siu AL. Screening for dementia and investigating its causes. Ann Int Med 1991;115:122-132. Watson YI, Arfken CL, Birge SJ. Clock completion: An objective screening test for dementia. JAGS 1993;41:1235-1240. Emotional Health Blazer DG. Depression in the elderly: Myths and misconceptions. The Psy Clin of No Am 1997;20(1): 111-119. Fernandez F, Levy J K, Lachar BL, Small GW. The management of depression and anxiety in the elderly. J Clin Psy 1995;56 Suppl 2:20-29. Hay D, Rodriguez MM, Franson KL. Treatment of depression in late life. Clin Geri Med 1998;14(1):33-46. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. In: Brink TL, editor. Clinical gerontology: A guide to assessment and intervention. New York: Haworth Press; 1986. p. 165-173. Valente S. Recognizing depression in elderly patients. Am J Nurs 1994(Dec):19-24. Wholley MA, Avins AL, Miranda J, Browner W. Case-finding instruments for depression: Two questions are as good as many. J Gen Int Med 1997;12:439-445.

132


Medications Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Int Med 1997;157:1531-1536. Carlson J. Perils of polypharmacy: 10 steps to prudent prescribing. Geriatrics 1996;51(7):26-35. Cohen JS. Avoiding adverse reactions: Effective lower-dose drug therapies for older patients. Geriatrics 2000;55(2): 54-64.

Finkel SI. Antipsychotics: Old and new. Clin Geri Med 1998;14(1):87-100.

Larson EB, Kukull WA, Buchner D, Reifler BV. Adverse drug reactions associated with global cognitive impairment in elderly persons. Ann Int Med 1987;107:169-173. Lee F, Cundiff D. Meperidine vs morphine in pancreatitis and cholecystitis [Letter to the editor]. Arch Int Med 1998;158:2399. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. JAGS 1999;47:30-39. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: II. Cardiac and analgesic drugs. JAGS 1999;47:40-50. Max MB, Kishore-Kumar R, Schafer SC, Meister B, Gracely RH, Smoller B, Dubner R. Efficacy of desipramine in painful diabetic neuropathy: A placebo- controlled trial. Pain 1991;45:3-9. Max MB, Lynch SA, Muir J, Shoaf S, Smoller B, Dubner R. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med 1992;326(19):1250-1256. The Medical Letter. Some drugs that cause psychiatric symptoms. The Medical Letter, Inc. 2008;50 (1301/1302):100-102. Staley CA. Three commonly used herbal medications: St. John’s wort, echinacea, and ginkgo biloba. Women’s Health in Primary Care 1999;2(5): 335-336. Vestal RE. Aging and pharmacology. Cancer 1997;80(7):1302-1310. Acute Pain Management

City of Hope Pain and Palliative Care Resource Center: http://prc.coh.org

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Sensory Function Castor TD, Carter TL. Low vision: Physician screening helps to improve patient function. Geriatrics 1995;50(12):51-57. Cohn E. Hearing loss with aging: Presbycusis. Clin Geri Med 1999;15(1):145-159. Elfervig LS. Age-related macular degeneration. Nurse Practitioner Forum 1998;9(1):4-6.

Smith SC. Diabetic retinopathy. Nurse Practitioner Forum 1998;9(1):13-18.

Smith SC. Aging, physiology, and vision. Nurse Practitioner Forum 1998;9(1):19-22.

Nutrition

Chapman KM, Winter L. COPD: Using nutrition to prevent respiratory function decline. Geriatrics 1996;51(12):37-42. Sullivan DH. Risk factors for early hospital readmission in a select population of geriatric rehabilitation patients: The significance of nutritional status. JAGS 1992;40:792-798. Function And Mobility

Fleming KC, Evans JM, Weber DC, Chutka DS. Practical functional assessment of elderly persons: A primary care approach. Mayo Clin Proc 1995;70:890-910.

Inouye SK, Wagner R, Acampora D, Horwitz RI, Cooney LM, Tinetti ME. A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: The Yale Geriatric Care Program. JAGS 1993;41:1353- 1360.

Tinetti ME, Inouye SK, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence: Unifying the approach to geriatric syndromes. JAMA 1995;273(17):1348-1353.

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Incontinence And Elimination

Brown JS, Vittinghoff E, Wyman JF, Stone KL, Nevitt MC, Ensrud KE, Grady D. Urinary incontinence: Does it increase risk for falls and fractures? JAGS 2000;48:721-725. Dutcher JA, Baker D, Rozett RT. Promoting continence among older adults in the community. Through: Project Independence at Gaylord Wallingford, CT. Gaylord Hospital, Inc. June, 1995. Penn C, Lekan-Rutledge D, Marner A, Stolley J, Amhof NV. Assessment of urinary incontinence. J Geron Nur 1996;22(1):8-19. Scientific Committee of the First International Consultation on Incontinence. Assessment and treatment of urinary incontinence. Lancet. 2000;355:2153- 58. Urinary incontinence guideline panel. Urinary incontinence in adults: Clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Dept. of Health and Human Services, 1992 March: Pub. No. 92-0038. Wald A. Fecal incontinence: Three steps to successful management. Geriatrics 1997;52(7):44-52. Skin Bergstrom NI. Strategies for preventing pressure ulcers. Clin Geri Med 1997;13(3):437-454.

Maklebust J. Pressure ulcer assessment. Clin Geri Med 1997;13(3):455-481.

Panel for the prediction and prevention of pressure ulcers in adults. Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1992 May: Pub. No. 92-0047. Sleep McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. JAGS 1998;6:700-705. Nuebauer DN. Sleep problems in the elderly. Am Fam Physi 1999;59(9):2551-2558.

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Social

Aravanis SC, Adelman RD, Breckman R, Fulmer TT, Holder E, Lachs M, O’Brien JG, Sanders AB. Diagnostic and treatment guidelines on elder abuse and neglect. Arch Fam Med 1993;2:371-388. Boykin A, Winland-Brown J. The dark side of caring: Challenges of caregiving. J Geront Nurs 1995;21(5):13-18. Buchsbaum DG, Buchanan RG, Welsh J, Centor RM, Schnoll SH. Screening for drinking disorders in the elderly using the CAGE Questionnaire. JAGS 1992;40:662-665. Gupta KL. Alcoholism in the elderly: Uncovering a hidden problem. Postgrad Med 1993;93(2):203-206. Patient Education Ahmed M, Seigler E. Patient education: Updated list of resources for your older patients and their families. Geriatrics 1997;52(1):43-50.

136


The Medical Letter On Drugs and Therapeutics

Published by The Medical Letter, Inc. ● 1000 Main Street, New Rochelle, N.Y. 10801 ● A Nonprofit Publication Volume 50 (Issue 1301/1302) December 15/29, 2008

SOME DRUGS THAT CAUSE PSYCHIATRIC SYMPTOMS

Full text version of this article can be viewed on the following website:

http://www.medicalletter.org

137


The Confusion Assessment Method (CAM)

Training Manual and Coding Guide

Can be found at the HELP Website, link provided below: http://hospitalelderlifeprogram.org/pdf/The%20Confusion%20Assessment%20Me thod.pdf

RECOMMENDED CITATION: Inouye SK. The Confusion Assessment Method (CAM):

Training Manual and Coding Guide. 2003; Boston: Hospital Elder Life Program. <www.hospitalelderlifeprogram.org>

REFERENCE: Inouye SK, VanDyck CH, Alessi CA et al. Clarifying confusion:

The Confusion Assessment Method. A new method for detecting delirium. Ann Intern Med. 1990; 113:941-8.

Date developed: 1988(CAM); 1991 (Manual) Last revised: September 8, 2014

Copyright © 1988, 2003. Hospital Elder Life Program. All rights reserved.

138




SECTION VIII

Page • AFTERWORD…………………………………………………………………………………… 139

• CUSTOMIZE CLINICAL COMPONENTS TO MATCH FACILITY NEEDS

1. CONSULTING STAFF 2. ENROLLMENT CRITERIA 3. THERAPUTIC ACTIVITIES

• ELDER LIFE SPECIALIST: CHAPLAINCY PROTOCOL……………………. 140

139


AFTERWORD Customize Clinical Components to Match Facility Needs While all of the clinical procedures included in the manual should be executed as described, it is also important that each suite customize the clinical components to match the needs and resources of their individual facilities. Examples of areas to modify include:

1. Consulting Staff: While realizing that consulting experts may not be readily available at all sites, they can add valuable clinical input throughout the entire program. Each facility is encouraged to utilize their clinical experts as fully as feasible. Examples of their contributions to the HELP, in addition to Interdisciplinary Rounds and as formal consultants to patients:

• Provide education to both HELP volunteers and hospital/HELP staff

• Provide direct patient/family education, e.g., pharmacist at bedside performing direct medication teaching at time of discharge for select patients

• Each specialty provides key resource/contact person available to ELNS for informal consultation

• Provide regular updates of clinical advances in their field as they relate to the care of older adults, e.g., pharmacologic updates, nutritional supplement updates

If a consulting staff member(s) becomes an active participant in the program, specific protocols can be written which describe their responsibilities and contributions to the program. For example, a geriatric chaplain can be a valuable resource to the Hospital Elder Life Program. A sample protocol incorporating the role of the chaplain into the program is attached.

2. Enrollment Criteria: Patient age cutoff (suggested cutoff >70 years); maximal number of patients enrolled at any given time, i.e., enrollment cap

3. Therapeutic Activities: Each site will need to develop their own

master list of activities for their patients to choose from. The Therapeutic Activities Chart (see ELS: Therapeutic Activities Protocol) and Therapeutic Activities Program: Activity Information List (See Organizational and Procedural Manual I: Overview and structure) can be used as resources.

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ELDER LIFE SPECIALIST CHAPLAINCY PROTOCOL

Patient Eligibility: All Evaluation:

1. Spirituality screening will be performed during screening and enrollment procedure.

2. The Elder Life Specialist, HELP Staff, and volunteers will be vigilant

regarding any expressions by patients or upsetting circumstances that may benefit from spiritual evaluation and intervention. Examples may include:

• Significant losses or grieving • Significant stress due to procedure/surgery • Feeling abandoned: by God, church/faith community and/or

significant others • Longing for death, wishing “God to take me” • Searching for meaning – “Why is this happening to me?” • Receiving a bad or terminal diagnosis • Loss of independence (due to severe illness, discharge to a

facility/nursing home, etc.) Interventions:

1. Elder Life Specialist (and/or HELP staff) will: • Encourage patients to express feelings, fears and concerns • Assist patients to formulate their questions and their assistance

they desire or feel might be helpful • Validate patient’s feelings • Maintain patient confidentiality • Suggest that some others in similar situations have found it

helpful to visit with the chaplain or their clergy

2. Referrals: Elder Life Specialist refers to chaplain: • Patients requesting a chaplain visit • Patients experiencing any situations as listed above

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