Clinicians Need the Right Tools to Care for Older Patients With Cognitive Deficits
As the U.S. population ages, hospital providers are confronting the complicated challenge of meeting the needs of more patients with dementia, delirium, and other cognitive deficits.
To get ahead of this demographic trend, some health systems have developed initiatives aimed at equipping their workforce with the knowledge and tools to recognize and manage this population better while also offering a more compassionate and welcoming face to patients and families.
Meanwhile, the American College of Emergency Physicians (ACEP), the Institute for Healthcare Improvement, and other professional organizations are taking steps to identify best practices and improve the care that is provided to older patients. While most of these initiatives maintain a strong focus on boosting clinical results, the creators of some programs also have made a strong business case for their efforts.
As of 2018, there are an estimated 170,000 people 65 years of age and older in North Carolina living with Alzheimer’s dementia. That number is expected to grow to 210,000 by 2025.1 Hospitals in the state are well aware of this reality. Dementia poses significant challenges to clinicians as they strive to provide appropriate care to patients who often struggle to communicate their needs and may be fearful of the care providers who are trying to help. Considering such encounters can be difficult for even the most experienced clinicians, UNC Health Care in Chapel Hill has launched a large-scale effort aimed at providing the thousands of employees who work in four of the health system’s hospitals with training so they can assess, treat, and communicate better with patients who have dementia.
Dubbed the dementia-friendly hospital initiative, the goal is not only to provide hospital employees with the skills to confidently and compassionately care for dementia patients in a cost-effective manner, but also to affect hospital use. Developers believe that by reaching patients with dementia in the hospital setting, they could shorten the average length of stay (LOS) and curb 30-day readmissions. Data show that patients with dementia stay in the hospital longer, comprise more 30-day readmissions, experience worse outcomes, and die at a faster rate than the general population.
Funded by a grant from The Duke Endowment, the initiative is in pilot testing at UNC Hospitals Hillsborough Campus where every employee who may encounter with a patient with dementia is receiving the new training. However, staff members in the ED at Hillsborough may have a head start in the process. The ED there recently became the first in the state to receive Geriatric Emergency Department Accreditation (GEDA), a program sponsored by ACEP.
Kevin Biese, MD, MAT, FACEP, co-director of the Geriatric Emergency Medicine Service at the UNC School of Medicine, is on the board of advisors for the dementia-friendly initiative and also chairs ACEP’s accreditation effort. He sees both initiatives driving toward the same goal of improving care for older adults. “We have to make sure that all of these initiatives talk to each other and offer a cohesive range of options for healthcare systems,” he says. “They are getting at many of the same issues, but from different angles. We want healthcare system leaders to have a simple, comprehensive way of creating strategies that are better for taking care of older adults.”
Use Cognitive Screening
As the dementia-friendly hospital initiative rolls out, Biese envisions more use of cognitive screening, a practice he has found to be particularly valuable in the ED. “It is important to understand the capacity of your patients for giving you an accurate history,” he says. “So much of what we are worried about depends on the history of what is bothering the patient ... but if he or she doesn’t have good short-term memory, then the patient is not a reliable historian.” Consequently, Biese adds that it is important to conduct cognitive screening to ensure the clinician’s evaluation is appropriate to why the patient is there.
A second reason to conduct cognitive screening is because it addresses the inescapable fact that the U.S. population is aging. “More of our patients are older and demented. The sooner we can recognize that and provide them with appropriate interventions, the better,” Biese shares.
Further, some of the simple, fast screeners that are available for cognitive screening can identify opportunities to intervene even if the issues identified are not what brought a patient to the ED. “We should take advantage of the opportunity that a patient presents by coming to the ED, to plug him or her back in with their primary care provider or other community resources so that this opportunity is not missed,” Biese advises. He adds that one instrument with which he is familiar, the Mini-Cog, can be administered quickly.2 “If we can identify and intervene with patients who have dementia sooner than they might otherwise be identified, that is a good thing.”
Make it Interdisciplinary
One feature that is common to both the GEDA program and UNC’s dementia-friendly initiative is the focus on interdisciplinary training, Biese explains. “For example, with GEDA you must have a nursing champion as well as a physician champion. Both the physician and nurse have to receive additional education in geriatric syndromes and conditions,” he says. “Then, we also incorporate [this education] into pharmacy, case management, social work, occupational therapy, and physical therapy ... it is absolutely an interdisciplinary effort. The same practice is being utilized in the dementia-friendly initiative.”
For frail patients or any patient with cognitive impairment, the entire team has to approach the situation therapeutically. For instance, a clinician may walk into a room calmly, putting a patient with dementia at ease. Suddenly, a tech arrives and turns on bright lights, which could agitate or frighten the patient. “All of us have to work together to accomplish [a positive result for the patient], and that is true of both initiatives,” Biese notes.
The GEDA program, based on Geriatric Emergency Department Guidelines developed on an interdisciplinary basis in 2013, outlines 27 best practices that EDs can adopt to better meet the needs of their older patients. As more best practices are adopted, EDs can achieve a higher level of accreditation. Level 3 is the lowest level; level 1 is for EDs that have adopted at least 20 best practices.3 “We accredited our first EDs in May of 2018 ... there are now 55 accredited EDs, and there are more than 200 EDs that have started the process of accreditation in one way or another,” Biese observes.
The dementia-friendly initiative will cover some of the same ground, although on a hospitalwide basis. Further, program developers note that the program is moving beyond a provider-centric focus by involving both clinical and nonclinical staff in the effort to connect with dementia patients more effectively and in a way that makes them feel safe and well cared for.
Once training has been completed on the Hillsborough Campus, program administrators plan to expand the program to North Carolina Memorial Hospital in Chapel Hill, Pardee UNC Health Care in Hendersonville, and Wayne UNC Health Care in Goldsboro.
Embed the Program
Hartford (CT) Hospital also is focused on improving the care it provides to the growing population of older patients. In particular, since 2012, clinicians have been engaged in a hospitalwide program to prevent and address delirium, a sudden change in mental status that is common in older adults during an illness or injury. The program is a geriatric consult service referred to as ADAPT (Actions for Delirium Assessment, Prevention, and Treatment). The program has been in place for seven years, and in that time administrative leaders have documented significant gains from the effort, both in terms of patient outcomes and reduced resource use.
“[Delirium] is associated with increased mortality, morbidity, falls, persistent and future cognitive impairment, and post-traumatic stress disorder, all harms that can occur to the patient,” explained Christine Waszynski, DNP, APRN, GNP-BC, the coordinator of ADAPT, who outlined the program on June 13 during a presentation entitled “Assessing the value of age-friendly health care,” sponsored by the Institute for Health Care Improvement.5 “[Delirium] is also associated with less-than-optimal system-related outcomes such as prolonged length of hospitalization, discharge to a higher level of care, readmission, and increased cost.”
Waszynski noted that experts believe delirium is as much as 30% to 40% preventable, and that the condition can be caused by the action or inaction of the healthcare team. “The condition is often under-recognized and poorly managed, which then leads to delayed diagnosis and [delayed] implementation of treatment and management,” she said. “Therefore, early recognition and implementation of best-practice interventions can improve outcomes.”
Consequently, the first step of the ADAPT program focused on implementation of a hospitalwide screening program for delirium that could identify all instances of the condition at an early stage. To do this, the hospital used a screening tool called the confusion assessment method (CAM) and a companion tool called the CAM ICU.4 “Since 2012, we have had nurses performing these delirium screens on every patient in our hospital every eight hours. This has required many different approaches to educate the nursing staff initially as well as on an ongoing basis,” Waszynski noted.
To make this possible, program administrators embedded the structure of the program into the hospital’s systems, Robert Dicks, MD, FACEP, a geriatric internist and the director of geriatric programs at Hartford Hospital, explained during the same June 13 session. “We were able to integrate the CAM into our electronic health record [EHR]. With strong nursing engagement, we made the CAM a required field,” he noted. “That allowed us to get nearly 100% compliance for screening. Because of EHR integration and the reporting of results, we have been able to pull the CAM [findings] into a real-time registry.”
From the registry, program administrators can monitor both the compliance with screening and protocols as well as outcomes, according to Dicks. “We have been able to capture our own outcomes rather than deal with reference outcomes,” he said. “Over time, we have been able to track the incidence [of delirium], LOS, disposition and readmission, and the response to protocol enhancements over time.”
Employ Data-Driven Approach
Once program administrators showed delirium’s effect on patient outcomes in the hospital, they developed a delirium care pathway that includes interprofessional approaches to care and advice to clinicians, other professionals, volunteers, patients, and families, Waszynski said. “It spells out the best practices for prevention, screening, treatment, and management, with a big focus on patient safety, patient comfort, and preserving patient function.”
The protocol is updated as new data come to light, Waszynski observed. “From this [pathway], order sets and structured notes have been created to produce a tangible method of standardizing care for patients at risk for delirium and for those who are experiencing delirium at our hospital,” she said.
Further, by collaborating with finance to acquire actual cost data to go along with clinical data captured through the program, administrators have demonstrated the value that the ADAPT approach has delivered, both in terms of outcomes and costs, Dicks shared. “In our most recent analysis, we experienced a 40% decrease in delirium-attributable days over the last six years ... with an estimated cost savings of $6.5 million annually,” he said. “We are now engaged with finance and research to do a more structured, deeper dive [into the data] to look at matched outcomes.”
REFERENCES
- Alzheimer’s Association. 2018 Alzheimer’s Disease Facts and Figures. Available at: http://bit.ly/32LD8d8. Accessed Sept. 9, 2019.
- Mini-Cog. Screening for Cognitive Impairment in Older Adults. Available at: http://bit.ly/2OhCdOl. Accessed Sept. 9, 2019.
- American College of Emergency Physicians. Geriatric Emergency Department Accreditation Program. Available at: http://bit.ly/2JWhqvG. Accessed Sept. 9, 2019.
- Waszynski CM. The Confusion Assessment Method (CAM). The Hartford Institute for Geriatric Nursing. Available at: http://bit.ly/2MiMOWD. Accessed Sept. 9, 2019.
- Institute for Healthcare Improvement (IHI). WIHI: Assessing the Value of Age-Friendly Health Care. Available at: http://bit.ly/2z4hFOQ. Accessed Sept. 9, 2019.
As the U.S. population ages, hospital providers are confronting the complicated challenge of meeting the needs of more patients with dementia, delirium, and other cognitive deficits. To get ahead of this demographic trend, some health systems have developed initiatives aimed at equipping their workforce with the knowledge and tools to recognize and manage this population better while also offering a more compassionate and welcoming face to patients and families.
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