Professional nurses continue

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1 The Gerontological Clinical Nurse Specialist s Role in Prevention, Early Recognition, and Management Of Delirium in Hospitalized Older Adults Deborah Marks Conley Professional nurses continue to focus on providing best practices for safe and effective patient and family care, even with increasing pressure to decrease costs and im - prove patient outcomes. Support for nursing practice at the bedside is an essential cost-effective step toward this endeavor. Employing the expertise of the advanced practice registered nurse (APRN), a gerontological clinical nurse specialist (GCNS) can increase awareness and facilitate rapid identification of critical problems, such as delirium in the aging inpatient population. Im - plementation of gerontological nursing best practices in hospitalized patients with delirium has demonstrated a positive impact on the overall outcome for these patients. Deborah Marks Conley, MSN, APRN- CNS, GCNS-BC, FNGNA, is a Geronto - logical Clinical Nurse Specialist-Advanced Practice Registered Nurse, Nebraska Methodist Hospital, Omaha, NE, and Nebraska Methodist College, Omaha, NE. Note: Objectives and CNE Evaluation Form appear on page 343. Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity. The purpose of this article is to describe the role of the acute care gerontological clinical nurse specialist (GCNS) and provide an exemplar of using GCNS expertise in the implementation of gerontological nursing best practices in hospitalized patients with delirium. Key Words: Objectives 2011 Society of Urologic Nurses and Associates Urologic Nursing, pp Advanced practice registered nurse (APRN), gerontological clinical nurse specialist (GCNS), delirium, Hartford Center for Geriatric Nursing, geriatrics, older adult, gerontological nursing. 1. Explain the development of the advanced practice nurse role. 2. Describe the role of the gerontological clinical nurse specialist. 3. Discuss delirium in the older adult population and evidencebased practice tools used for screening. Demographics of Aging The United States population is aging exponentially. Each day, 10,000 individuals turn 65 years of age, and 100 individuals turn 100 years old (National Institute on Aging [NIA], 2011). An estimated 50% of all hospital admissions are age 65 or older (NIA, 2011). Demands are being placed on health care systems to meet the specialized needs of this population and enhance gerontological nurse competence. Urologic Nursing Editorial Board Statements of Disclosure In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below. Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants Bureau for Coloplast. All other Urologic Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article. UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 337

2 The Development of the Advanced Practice Role The clinical nurse specialist (CNS) was the first advanced practice role to require a master s degree in nursing. In 1953, Hildegard Peplau, a pioneer in CNS practice, implemented her vision of preparing the psychiatric CNS at the master s degree level at Rutgers University. She led the way to current CNS practice, which focuses on population- or disease-specific nursing practices (Joel, 2009). Innovations in health care and nursing practice have dramatically changed the role of the nursing profession, particularly that of advanced practice registered nurses (APRNs). Today, four distinct master s-prepared APRN roles are recognized by the American Nurses Association (ANA), American Association of Colleges of Nursing (AACN), and most State Boards of Nursing. These include the CNS, nurse practitioner, certified nurse-midwife, and certified registered nurse anesthetist. Each APRN practice is unique, but the focus includes implementing evidencebased practice, quality improvement/patient outcomes, and information and technology. Nurses pursuing APRN roles today are encouraged to obtain a doctorate in nursing practice (DNP). The DNP curriculum builds on traditional master s programs by providing education in focused areas of evidence-based practice, quality improvement, and systems leadership. The DNP is a terminal degree in nursing practice and offers an alternative to research-focused PhD programs (AACN, 2011). The National Association of Clinical Nurse Specialists (NACNS) identified three distinct models of CNS practice in its CNS Core Competencies Executive Summary. NACNS supports the wide range of specialties in which the CNS practices. For the purpose of this article, the three spheres of influence model (patient, nurses/ * Severe risk for delirium. Source: Spivack, Table1. Risk Factors for Delirium Dementia* Increases risk 2- to 3-fold Advancing age* (85 or older) Alcohol abuse* Impaired physical function/mobility* Sensory impairment* On 4 or more drugs* Decreased albumin or protein-energy malnutrition* Sleep deprivation* Dehydration* Undiagnosed medical conditions Infections* Fracture on admission Male gender Pain Depression Admitted emergently Incontinence Fecal impaction Psychiatric co-morbidity, especially in post-op patients Primary discharge diagnosis of cardiovascular disorders Source: Spivack, Table 2. Complete Evaluation for Patient with Delirium History and physical with focused neurological examination Collateral source history for validation (family or friend) Thorough medication review (benzodiazepine/alcohol history; use Beer s list of potentially inappropriate drugs for older adults) Cognitive assessment (Modified Mini-Mental State Examination, Mini-Cog, or Montreal Cognitive Assessment) Pain evaluation using appropriate pain scales Nutritional assessment Targeted laboratory tests (drug levels, occult infections, and metabolic abnormalities) Radiology (chest X-ray) ECG (identify underlying arrhythmias) MRI Brain imaging for history of recent fall, head trauma, fever of unknown origin, focused neurological findings, or suspected encephalitis 338 UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6

3 nursing practice, and organizational/ systems) will be used to provide the foundation of the GCNS practice (NACNS, 2004). The Gerontological Clinical Nurse Specialist The GCNS promotes an environment of excellence, which supports a culture of inquiry to improve clinical and health system outcomes. Clinical practice is continuously evaluated, and practice innovations are refined based on expertise, evidence, and outcome and benchmarking data. The GCNS mentors other health care providers in evaluating and using research findings to implement best practices in the care of older adults and their families. Interprofes sional collaboration, which facilitates the achievement of best practices, is fundamental GCNS practice (McCabe & Raudonis, 2010). An excellent example of GCNS acute care practice is the pre - vention, recognition, and manage - ment of delirium. This example highlights GCNS practices in all three spheres of influence as defined by NACNS: Advanced assessment and care coordination (patient). Education, mentoring, and consultation with nursing staff (nurses/nursing practice). Computerization of standardized evidence-based tools/ protocols (organizational/systems). The Phenomena of Delirium Delirium is among the oldest phenomena known to medicine. It is a cluster of multifactorial, transient symptoms that manifests as acute impairment in cognition and attention, with alterations in the sleep-wake cycle and psychomotor behavior. The underlying cause of delirium is usually a disease process outside of the central nervous system (such as urinary tract infection, Table 3. Protocols for Nursing Intervention Personal Care Needs Pain assessment/management with scheduled dose analgesia when appropriate Nutritional support Thirst Oral and/or IV fluid intake Promote continence and evaluate urine output/bowel movements Maximize mobility to decrease deconditioning and improve cognitive status Pressure ulcer prevention and skin care Eliminate potential risk factors, such as identifying/treating infections and avoiding high-risk medications; maximize oxygen therapy as appropriate Environment Promote reality orientation and validation of feelings Supervised with minimal stimulation Temperature control and use of warm blankets Low light/night lights Remove hazards from environment Foster familiarity with consistent staff, belongings from home, family and friends at bedside Private room, if possible Noise reduction Fall risk reduction Sensory aids as appropriate Avoid physical restraints Symptom Control Aggressive daily assessment with standardized tools Sleep hygiene Delirium prevention bag (see Figures 1 and 2) Review and limit number of medications ordered Obtain pharmacy consult Vital signs monitoring and management For psychotic-type behaviors (hallucinations, delusions, and severe agitation), which interrupt essential medical therapies, such as intubation, or for patients who pose a safety hazard to themselves or others, consult MD for use of low-dose haloperidol (Haldol ) to promote REM sleep. Patient-Family Involvement and Education (see Figure 3) Ask family to stay with patient when possible Explain in simple terms Delirium, disease processes, medications Review goals of care pneumonia, drug toxicity, alcohol withdrawal, severe pain, dehydration, or electrolyte/metabolic imbalance). Delirium is underrecognized by clinicians and is often mistaken as a normal part of aging (Inouye, Foreman, Mion, Katz, & Cooney, 2001, p. 2467). A significant proportion of delirium is preventable by identifying modifiable risk factors and using a standardized assessment UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 339

4 Figure 1. Delirium Prevention Bag Source: Reprinted with permission from Nebraska Methodist Hospital. Figure 2. Delirium Prevention Bag Tag (Front & Back) Delirium Prevention and Diversional Activities Bag This Delirium Prevention and Diversional Activities bag is for a single-patient use; therefore the entire bag should be taken to the patient s room and the bag becomes the property of the patient and can be sent home with him or her. This intervention is intended to help patients who are experiencing behavioral and or cognitive issues (memory, agitation, or confusion) while hospitalized. All items provided can be shared with the patient to determine which ones are of interest and helps keep the patient occupied. When the patient is pulling at tubes and or IV lines, or trying to get out of bed, keeping them occupied with these Diversional Activities can help. In addition, the Spiritual Well-Being TV Network on Channel 11 can be turned on to provide calming music and photos. Contact Recreational Therapy if you need more supplies or bags. What is Delirium? Delirium is not a disease. It is characterized by: Disordered thinking Hallucinations Fluctuating confusion Reduced ability to focus Delirium often causes changes in behavior including: Anxiety Agitation Aggression Apathy How can you help? Familiar faces of family provide comfort & decrease fears Validate feelings; avoid arguments and saying no or can t Re-orienting the patient often increases frustration Use sensory aids (pocket talker, hearing aides, glasses) Quiet environment, turn off TV, close drapes, & reduce visitors Optimize rest & uninterrupted sleep Mobilize patient when possible with staff help Provide and encourage intake of good nutrition Monitor & treat pain with staff help Bring familiar items from home (pictures ) Additional education on this subject is found in this bag. Source: Reprinted with permission from Nebraska Methodist Hospital. and nursing management protocol (Rubin, Neal, Fenlon, Hassan, & Inouye, 2011). Delirium is usually reversible; however, it is associated with increased mortality and hospital costs, as well as long-term cognitive and functional impairment. It contributes to falls, fractures, long-term institutionalization, and death. An estimated 2.3 million older adults are hospitalized each year, and delirium increases the average length of hospital stay by 6 days (Rubin et al., 2011). Annual hospital costs are over $8 billion dollars for patients experiencing delirium. Post-hospitalization costs are even higher roughly $100 billion for institutionalization, rehabilitation, home care services, and caregiver burden. The overall total costs attributable to delirium average from $3,000 to $6,000 per patient per hospitalization (Rubin et al., 2011). With early intervention, nurses can identify patients at severe risk for delirium upon admission to the hospital. Two of the most important risk factors for the development of delirium are advancing age and patients with existing dementia (for example, Alzheimer s disease, vascular dementia, alcoholic dementia, Parkinson s dementia, and frontaltemporal lobe dementia). Malnutrition, the use of physical restraints or indwelling urethral catheters, and the introduction of more than three new medications in a 24-hour period significantly contribute to the development of delirium in older adults (see Table 1). Patients should be evaluated during each shift using a standardized assessment tool, which can be included in the electronic medical record. The Confusion Assessment Method (CAM) and CAM- ICU (in intensive care units) are evidence-based tools for adoption into clinical practice. Nurses can administer these quick and easy-to-use tools in less than five minutes per patient. These tools provide a standardized assessment for delirium recognition (Ely et al., 2001; Inouye et al., 1990). The CAM has a sensitivity rate of 94% and a specificity rate of 89%. The CAM-ICU has been validated in non-verbal ICU patients and adds the key elements of the Richmond Agitation and Sedation scale, which validates a measure of consciousness, employs the Attention Screening Exam, which includes five thought questions (Ely et al., 2001). Both tools focus on key characteristics of delirium, including acute onset and fluctuating course, inattention, disorganized thinking, and altered levels of consciousness. Screening positive for delirium requires the presence of the first two characteristics and either the third or the fourth characteristic. After the nurse administers the CAM or CAM-ICU, if delirium is suspected, a search for underlying contributing factors is essential. Patients with a positive screen or those with a known diagnosis of delirium should be evaluated further by a physician, a GCNS, or a geriatric nurse practitioner (see Table 2). Nursing interven- 340 UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6

5 Figure 3. Patient/Family Education Handout Delirium in Hospitalized Older Adults What is delirium? A disturbance in consciousness with reduced ability to focus or shift attention; develops quickly, and fluctuates (gets worse, then better), psycho-motor agitation-restlessness. Sudden onset of impaired attention, incoherent speech, disturbance in sleep-awake cycle, agitation, lethargy, and disorientation. What causes delirium? Advanced age, illness, many medications, brain impairment, depression, alcohol use, lack of sleep, immobility, sensory deprivation, infection, dehydration, pain, and abnormal blood sodium or potassium levels. What are the symptoms of delirium? Restlessness, agitation, pulling at tubes, picking at the air, pulling at curtains, paranoia, hallucinations, chills, fever, poor appetite, nausea, change in vital signs, weakness, lethargy, dry mouth, and lightheadedness. Increased sodium causes high blood pressure, lethargy, and/or nausea. Dehydration causes low blood pressure, weakness, lightheadedness. Infection causes chills, fever, anorexia, and low heart rate. Hypoxia (caused by infection, chronic obstructive lung disease, pulmonary emboli, or anemia), restlessness, and irregular breathing. Pain contributes to restlessness, moaning, and muscle stiffness. What complications are associated with delirium? Potential for pressure ulcers, falls, infections, maybe unable to return home, increases length of hospital stay by 5 to 6 days, can increase mortality, and some side effects may continue even after hospitalization. What can be done for the patient who experiences delirium? Behavioral: Reassure patient and family, protect from hazards and minimize changes, use sensory aids (pocket talker, hearing aides, glasses), attempt using consistent caregivers. Educate family about a quiet environment, reduce stimulation, turn off TV, close drapes, and reduce visitors. Communication: Calmly, clearly, slowly introduce yourself, call patient by name, explain all procedures, and ask simple closed-ended questions (yes /no answers) and wait for response. Avoid arguments and saying no or can t, but instead, validate the patient s feelings; let patients know you hear what they are saying. Reorienting the patient often increases frustration; therefore, validating feelings is more successful. Patient Care Sitter Responsibilities: Accurately monitor intake and output; provide oral hygiene, uninterrupted rest, nutrition, fluids, frequent (every 2 hours) toileting, and comfort. Reduce the risk of falls by using a sit-stand alarm, keep things close and bed in low-locked position. Ambulate and assist patient up for all meals unless physician has ordered bed rest. Source: Fick & Mion, tions should be multi-component, with protocols focusing on four main areas: personal care needs environment, symptom control, and patient-family involvement and education (see Table 3). Additionally, the GCNS could facilitate implementation of the Hospital Elder Life Program (HELP) for delirium prevention. This innovative care model has been used successfully in various hospital settings to prevent delirium and decrease functional decline by utilizing trained volunteers along with professional staff to provide best practices (Inouye et al., 1999; Rubin et al., 2011). Summary The GCNS plays a vital role in implementing and sustaining health system initiatives to empower nurses to prevent, recognize, and manage delirium in hospitalized older adults. Men - toring staff nurses in evidencebased practice and participating in the interdisciplinary care of older adults is a key role of the GCNS. The GCNS is prepared as an expert practitioner in care of older adults and plays a vital role in framing health care systems for the future. The NACNS spheres of influence model is an excellent framework for a gerontological nursing best-practices approach to delirium prevention and care. Delirium is a common, serious, and potentially preventable source of morbidity and mortality among hospitalized older adults. Processes and protocols can be implemented to recognize risk factors for delirium and intervene aggressively for prevention (see Figures 1-3). Recognition of risk factors and preventing the initial development of delirium upon admission improves patient outcomes. Delirium is a prognostic marker for functional and cognitive decline. Understanding the severity of poor outcomes for these patients can help nurses ensure early assessment and appropriate UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 341

6 diagnostic testing, altering current treatment or managing the environment. Prompt assessment for causative factors and engaging the interdisciplinary team early promotes positive outcomes on all levels. References American Association of Colleges of Nursing (AACN). (2011). The doctor of nursing practice (fact sheet). Retrieved from nche.edu/media/factsheets/dnp. htm Ely, E.W., Inouye, S.K., Bernardm G.R., Gordon, S., Francis, J., May, L., Dittus, R. (2001). Delirium in mechanically ventilated patients: Validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Journal of the American Medical Association, 286(21), Fick, D., & Mion, L. (2008). How to try this: Delirium superimposed on dementia. American Journal of Nursing, 108(1), Appendix Gerontological Nursing Resources The Hartford Institute for Geriatric Nursing (HIGN) at New York University designates health care organizations that implement and sustain system-wide gerontological nursing best practices at Nurses Improving Care for Healthsystem Elders (NICHE) facilities. NICHE is the leading organization designed to support health care professionals in improvement of clinical skills and nursing competence in the care of older adults. NICHE organizations have demonstrated improved patient outcomes, higher satisfaction scores, and improved compliance with Joint Commission standards (HIGN, 2011; NICHE, 2011). In 2002, HIGN and the American Nurses Association (ANA) launched the Nurse Competence in Aging (NCA) program, a five-year initiative to increase the knowledge and skills of nurses in specialty areas and nursing organizations in the delivery of appropriate and evidence-based care to older adults. The Society of Urologic Nurses and Associates (SUNA) participated in this initiative in Additionally, HIGN supports the new Resourcefully Enhancing Aging in Specialty Nursing (REASN) project, which focuses on enhancing gerontological nursing care and increasing involvement of specialty nursing associations in improving nursing competencies in providing care to older adults (HIGN, 2011). Another key gerontological nursing resource is the National Gerontological Nursing Association (NGNA). This professional nursing organization focuses on improving the quality of nursing care provided to older adults across diverse care settings (NGNA, 2011). The Hospital Elder Life Program (HELP) is a patient care program designed to prevent delirium in hospitalized older adults. Its Web site provides clinicians and families with resources about HELP and materials about delirium (www. hospitalelderlifeprogram.org/public/public-main.php). The CAM Tool and the CAM-ICU Try This Series can be accessed at Vanderbilt University Medical Center CAM-ICU tool and resources can be found at Hartford Institute for Geriatric Nursing (HIGN). (2011). Home page. Retrieved from Inouye, S.K., Bogardus, S.T., Charpentier, P.A., Leo-Summers, L., Acampora, D., Holford, T.R., & Cooney, L.M., Jr. (1999). A multi-component intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340(9), Inouye, S.K., Foreman, M.D., Mion, L.C., Katz, K.H., & Cooney, Jr., L.M. (2001). Nurses Recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, Inouye, S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P., & Horwitz, R.I. (1990). Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. 113, Joel, L. (2009). Advanced practice nursing essentials for role development (2nd ed.). Philadelphia: F.A. Davis Company. McCabe, B., & Raudonis, B. (2010). Gerontological nursing: Scope and standards of practice. Silver Spring, MD: American Nurses Association. National Association of Clinical Nurse Specialists (NACNS). (2004). State - ment on clinical nurse specialist practice and education (2nd ed.). Harrisburg, PA: Author. National Gerontological Nursing Asso - ciation (NGNA). (2011). About the National Gerontological Nursing Association. Retrieved from National Institute on Aging (NIA). (2011.) What s new. Retrieved from www. nia. nih.gov/newsandevents/ Nurses Improving Care for Healthsystem Elders (NICHE), (2011). The NICHE Program. org/program_overview. Rubin, F.H., Neal, K., Fenlon, K., Hassan, S., & Inouye, S.K. (2011). Sustain - ability and scalability of the hospital elder life program at a community hospital. Journal of the American Geriatrics Society, 59(2), Spivack, B.S. (2010). Dr. Sharon Inouye presents lecture on delirium in the elderly. Retrieved from Dr-Sharon-Inouye-Presents-Lecture- Delirium-Elderly Additional Reading National CNS Competency Task Force. (2010) CNS core competencies executive summary. Retrieved from pdf/ Exec%20Summary%20-% 20 Core % 20 CNS%20Competencies.pdf Need CNE? Visit UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6