1. Training to care for people with dementia
Dementia Training
Training support • Skills development • Competency • Assessment • Scholarships • Education
Training to care for people with dementia

2. Training to care for people with dementia
Development of a brief delirium screen for older patients in the Emergency Department
Malcolm Hare, Fremantle Hospital PhD Candidate
Training to care for people with dementia

3. Training to care for people with dementia
Background
Delirium is an episode of acute confusion, and signals a serious physiological problem.
It occurs frequently in older hospitalised patients and is often present on arrival in ED
Older patients with delirium are at high risk of a range of serious adverse outcomes
Early recognition leads to early treatment and management with better outcomes (↑ survival, ↓ LOS, ↓ falls, ↓ ‘specialling’, ↓ discharge to nursing home etc), BUT
Recognition of delirium by nurses and other health staff is poor
Training to care for people with dementia

4. Training to care for people with dementia
Background
2006:
Investigated nurses’ knowledge of delirium and its risk factors
Demonstrated that nurses knowledge is generally poor, especially in relation to risk factors
Questionnaire (or parts of it) now in use in Victoria, NSW, Queensland, Ireland and the USA
Delirium prevalence by audit of in-patient notes
Approx 10% prevalence
Poor documentation, suggestive of poor understanding
Many cases of probable delirium undiagnosed
Training to care for people with dementia

5. Training to care for people with dementia
Background
2006:
Delirium screening using CAM and AMT with patients aged 65 years and over in the ED
Found to be time-consuming and problematic even with AMT (which is briefer than the required / recommended MMSE)
Published in International Emergency Nursing Journal 2008 –
In top 10 most downloaded articles second half of 2008 and first half of 2009
Training to care for people with dementia

6. Training to care for people with dementia
Background
Tools to screen for cognitive deficit / delirium exist BUT
They need training to use
They take time to administer
They are often difficult or inappropriate to use in ED
Staff lack knowledge
Training to care for people with dementia

7. Training to care for people with dementia
Project
HREC approval (SMAHS and Curtin)
Funding for new project from Office of the Chief nurse
Permission and buy-in from ED research coordination group and nursing management
Training to care for people with dementia

8. Developing a brief delirium screen
Aim:
To develop a brief delirium screen for use by ED nurses
Test whether incorporating risk factors improves the sensitivity etc of the screen
Compare brief screen with full CAM (Confusion Assessment Method) including MMSE
Training to care for people with dementia

9. Training to care for people with dementia
Stage 1: Collect data
Research nurse conducted CAM assessment including MMSE on convenience sample of patients aged 65+
Gathered data on risk factors (from the literature), demographics etc
Consent from patient/relative
Conducted in-service education for ED nurses
Training to care for people with dementia

10. Training to care for people with dementia
Stage 1: Analysis
325 patients assessed
23 with positive screen, 15 with delirium
Analysed which risk factors are likely to have information available to the nurse (ie on patient arrival)
Logistic regression to develop a 3 item risk model
Developed preliminary assessment form with the aim of having high negative predictive value
Training to care for people with dementia

11. Training to care for people with dementia
Stage 2: Process
In-service sessions on delirium
Nurses used assessment form to screen all patients aged 65+ over all shifts in the context of their initial assessment
Research nurse collated data and conducted a full delirium assessment and data collection for patients who had had an ED nurse screen (only if they could assess the patient within 2 hours of the ED nurse screen)
Preliminary assessment form developed into final form during the stage
Training to care for people with dementia

12. Assessment form design
Front page:
AMT4 (4 questions abbreviated from AMT)
Risk screen:
Any evidence of acute onset of confusion
and/or combination of risk factors:
Dementia plus either or both depression and abnormal cardiac rhythm
If negative screen, no further assessment required, total assessment time < 1 min
Training to care for people with dementia

13. Assessment form design
Second page (only if positive risk screen):
Elements from CAM, ignoring fluctuation:
* Fluctuation is required for a diagnosis of delirium, but is not required for a positive screen according to the developers of the CAM. It is assumed that at the first assessment the ED nurse will not have had enough time with the patient to assess for this.
“Delirium screen” score, linked to actions. Highest score = probable delirium
Training to care for people with dementia

14. Assessment form design
Second page (cont):
“Delirium screen” score:
2 points for Inattention, 1 point each for disorganised thinking and altered conscious state
Score 3 or 4 = probable delirium
Score 2 = high risk of delirium
Score 0 or 1 = moderate risk (the patient was already at risk from the front page screen or we would not be on the back page)
Training to care for people with dementia

15. Final form development
Preliminary form designed (intended) to be simple to follow, quick to use and require no reference to other information
Format of initial form redeveloped through iterative process, with changes driven by:
Inconsistent / contradictory results
Feedback from research nurses
Feedback from staff
Readability (layout, wording to improve reliability, repeatability) not core content
Final version released in August, data more consistent.
Stage 2 finalised in November
Training to care for people with dementia

16. Assess impact of in-service education and use of form
Questionnaire to nurses: impact on workload, patient assessment, confidence and care of older patients
Preliminary data from Stage 2:
Time taken to complete each assessment times number of patients = workload over 8 weeks: 1 minute per nurse per day if all patients aged 65 + assessed
Positive responses regarding improvement in knowledge and assessment skills
Mixed responses regarding workload impact
Training to care for people with dementia

17. Stage 3: Testing assessment form
Funding from Nurses Memorial Trust Fund
Break over Christmas (4 hour rule implementation, staffing issues)
Started last week with 1 week run-in
To run for at least 16 weeks
Further education & information to staff (turnover)
Re-focus protocol: day shift only
Training to care for people with dementia

18. Training to care for people with dementia
Questions?
Training to care for people with dementia

19. Acknowledgements and disclaimer
Fremantle Hospital
Curtin University
OCNO
WA DTSC
WA Nurses’ Memorial Trust
The Western Australian Dementia Training Study Centre (WA DTSC) has been established as part of the Australian Government’s Dementia Initiative.
The WA DTSC is one of four Centres nationally that promote dementia studies in Australian graduate and undergraduate curriculum as well as providing tertiary dementia career pathways.
The views expressed in this work are the views of its author(s) and not necessarily those of the Commonwealth of Australia. Despite any permitted use of Graphic Design Guidelines for Training Partner and Projects copyright material, the reader needs to be aware that the information contained in this work is not necessarily endorsed, and its contents may not have been approved or reviewed, by the Australian Government Department of Health and Ageing.
Training to care for people with dementia