Presentation on theme: "Delirium elderly At-Risk Instrument"— Presentation transcript:
1 Delirium elderly At-Risk Instrument Nora McPherson, APRN, CNS, GeriatricsJill Tusing MS, RN, BC Service Line: Behavioral Health
2 SBAR: Delirium Identifying high risk patients Situation: Delirium (acute confusion) a common, under recognized, post-operative complication in elective orthopaedic patients (10%-40%); manifests as acute impairment in cognition and attention.Background: Post-operative delirium is associated with poor outcomes, greater costs, longer lengths of stays, poor recovery, institutionalization, and mortality.
3 Assessment: Currently, HE does not have process to screen patient pre-op for risk Screening pts. may allow for early interventions to reduce severityRecommendation: Trial delirium risk assessment tool (DEAR) with elective total joint population age 65 and older to identify high risk for delirium. Phase 2 (future plans): On care units, patient screening every shift with use of Confusion Assessment Method (CAM)
4 Delirium Elderly At-Risk (DEAR) instrument is used to assess risk for developing post-operative delirium. 5 scoring domains are listed below:YesNoPatient ageAge > 80Sensory ImpairmentPatient uses hearing aidand/orhas very low visionFunctional DependencePatient requires assistance with any of the following:Bathing, dressing toileting, grooming, or feedingSubstance UsePatient consumes >3 drinks of alcohol per weekPatient takes benzodiazepine >3 times/weekCognitionPrevious post-op delirium/confusionorFailed Clock-drawing ScoreA DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium.The Target population for the screening is elective total joints age 65 and over. Patient age of = to or > 80 is a specific risk factor for delirium
5 DEAR Instrument Instructions The circle is a clock face. Ask your patient to place numbers and hands (small and large) on the face so the time reads 10 minutes after three o’clock. The instructions:May be repeated as often as requestedNo other directions or assistance should be givenDo not cover up or conceal any time pieces in the roomAfter your patient has completed this task, you may score their efforts as pass or fail. Please review the following examples displaying pass and fail clocks.
6 Scoring Guidelines : Pass or Fail Hands and numbers are all present in correct positions. Patient corrects without prompting are acceptable.There are slight errorsin placement of handsOROne missing numberwithout number spacingerrors.Moderate errors in placement of hands, confusion with small and large hands ORNumber spacing errors alone.
7 Scoring PassedGuidelines: Placement of hands is significantly off course OR Number spacing is inappropriate. Example: Even though there is bunching, distortion not grossly inappropriate. Typically seen in those who are cued to spatial mistakes once they get to the 6 (because they know it is supposed to be at the bottom), and make correction only to commit same error in subsequent numbers.
8 Score FailGuidelines:Clock hands are used inappropriately ORThere is use of a digital displayCircling of numbers ORPerseveration in writing of numbersExample:The clock hands are clearly pointing inward. This is scored 6, even though the 2 and 3 are correctly indicated, because there is clear evidence that problem solving how to correctly draw in the hands is lacking.
9 Score FailExample: Here is perseveration of numbers (3's and 8's). Only one example of perseverated numbers is needed for a score of 6. The hands are not included in this sample to focus on illustrating number perseveration.
10 Score FailExample: A digital representation of 3:10 is drawn. This is often drawn in the middle of the clock face, or even well outside of it.
11 Example: The numbers are circled to indicate 3:10. Score FailExample: The numbers are circled to indicate 3:10.
12 Score FailExample: This is an inappropriate use of clock hands, where a straight line is drawn from the 3 to the 2, without use of the center of the clock.
13 Score FailGuidelines: Numbers are crowded to one end of the clock. Reversed in order or absent. Example: Numbers are reversed.
14 Score FailExample: All of the numbers are crowded into to one end of the clock face.
15 Score FailGuidelines: There is significant distortion in number sequences. Counterclockwise order many missing numbers OR Number placed outside of clock face border. Example: There are many added numbers. This tends to occur when the patient loses track of the task at hand (drawing the numbers for the clock) and continues to add numbers until they run out of space.
16 Example: Some numbers fall outside of the border Score FailExample: Some numbers fall outside of the border
17 Score FailExample: Numbers placed outside of the clock face. Even if all other criteria are met.
18 Score FailExample: Prompting needed. This is a fairly common presentation of "drawing in the numbers". When this is seen, prompt the patient to put in numbers instead of dashes, allowing them to erase. This should not be scored unless the patient is unable to place the numbers at all, or is significantly confused by the directions.
19 Numbers and clock face are no longer connected in the drawing. Score FailOnly vague representation of a clock or irrelevant spatial representation exist.Numbers and clock face are no longer connected in the drawing.
20 Result cannot be interpreted OR No attempt is made to draw a clock Score FailResult cannot be interpretedORNo attempt is made to draw a clock
21 DEAR scores >1 indicate patient is at higher risk for developing delirium. :YesNoPatient ageAge > 80XSensory ImpairmentPatient uses hearing aidand/orhas very low visionFunctional DependencePatient requires assistance with any of the following:Bathing, dressing toileting, grooming, or feedingSubstance UsePatient consumes >3 drinks of alcohol per weekPatient takes benzodiazepine >3 times/weekCognitionPrevious post-op delirium/confusionorFailed Clock-drawing ScoreA DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium.2Be sure and total and score the YES answers on the bottom of the document. A score of over 1 means the patient is at risk for delirium.
22 Scores of over 1 are considered high risk. Scoring DEAR ToolAdd up all of the yes scores on the left side of the tool and place score on bottom.Scores of over 1 are considered high risk.If a patient is scored to be at high risk for delirium, communicate this risk with the medical team.Place High risk for delirium sticker on patient Care Plan (or write it yourself).
23 ReferencesFeter, S., Dunbar, M., MacLeod, H., Morrison, M., MacKnight, C., et al. (2005) Predicting post- operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age and Ageing, 34(2),HealthEast A3 team: Joe Clubb, Director Behavior Health, Dr. David Frenz; Dr. Alvin Holm, Jill Tusing RN Education, Nora McPherson, APRN, CNS.