1. CHOPS Care of the Confused Hospitalised Older Persons Study

2. CHOPS ACI in collaboration with CEC and GP NSW and funded through DVA Aims to improve care and reduce harm for confused older people in hospital Expected outcomes include; Improved patient outcomes Decrease length of stay Increase staff awareness Accuracy of coding for Delirium DRG’s

3. The Confused Older Person Dementia ▲ Third leading cause of death after heart disease and stroke ▲ 26 000 new cases diagnosed annually ▲ By 2033 its estimated total cases in NSW will be 341 000 Delirium in Hospital ▲ 30% of admissions ▲ Up to 60% frail elderly patients

4. Key Focus areas Understanding Cognitive assessment Delirium Risk and Prevention Identification and management Communication  Referral pathway  Carer  Discharge

5. Cognitive Assessment Presentation 1

6. Cognitive assessment Cognition assessment for older people is often overlooked in an initial admission process of assessments, thus assuming that any confusion during admission is related to dementia and missing the diagnosis of delirium. By not identifying delirium, or missing those most at risk of delirium, increases the risk of poor outcomes such as falls, falls, pressure injury, inappropriate use of medications and mortality.

7. Understanding Cognitive Assessment Finding a baseline  Talking with significant others  GP  Old medical notes including previous assessments (AMT, MMSE, RUDAS)  Assess premorbid level of functioning  ACAT, home care, residential Aged care facilities Is the presentation different from this?

8. Understanding Cognitive Assessment Formal Assessment of cognition should be completed before the CAM (confusion assessment method) is attempted There are a number of assessment tools available that can take anywhere from 2 minutes to 3 hours Some examples are given in the next slides.

9. AMT (Abbreviated Mental Test) QUESTION 1. How old are you 2. What is the time (nearest hour) Give the patient an address and ask them to repeat it at the end of the test e.g 42 Market St Queanbeyan 3. What year is it? 4. What is the name of this place 5. Can the patient recognise two relevant persons (eg. Nurse/doctor or relative) 6. What is your date of birth? 7. When did the second world war start? (1939) 8. Who is the current Prime Minister? 9. Count down backwards from 20 to 1 10 Can you remember the address I gave you? TOTAL SCORE If score 7 or less screen for delirium using the CAM …… If score 8 or greater assess for delirium symptoms and risk

10. Six-Item Screener Three items to remember, I will say them, then you repeat them. Apple Table Car What is the year? What is the month? What is the day of the week? After 3 minutes ask to repeat the items Apple Table Car Three items to remember, I will say them, then you repeat them. Apple Table Car What is the year? What is the month? What is the day of the week? After 3 minutes ask to repeat the items Apple Table Car

11. Clock Drawing Test Assesses global cognitive function and reflects subtle changes in brain function People with dementia have difficulty in both placing the digits and indicating correct positioning of the hands People with Delirium have difficulty completing the task (inattention) Assesses ▲ Visuospatial organisation ▲ Integrative functions ▲ Abstract thinking Number of scoring systems Watson – 0 perfect score

12. MMSE and SMMSE(Malloy) Most commonly used tool – although recent questions over validity and copyright issues Limits inc ▲ CALD ▲ Age ▲ Socio-economic status ▲ Education – not for those with less than 8 yrs ed. ▲ Frontal impairment 5-10 min to perform Score /30 24/30 indicates cognitive impairment

13. 3MS The Modified Mini-Mental State (3MS) incorporates four added test items, more graded scoring, and some other minor changes. These modifications are designed to sample a broader variety of cognitive functions, cover a wider range of difficulty levels, and enhance the reliability and the validity of the scores. The range of scores from 0-100. Greater sensitivities of the 3MS over the MMS have been demonstrated. The 3Ms is thought to have greater validity 15min to administer

14. RUDAS Developed for multi-cultural setting Assesses wide range of domains including frontal lobe function Limits ▲ Bed bound or immobile patients ▲ Not as familiar Takes 8-10 min Score /30 22/30 indicates cognitive impairment

15. CAM Confusion Assessment Method  Feature 1. Acute Onset of Mental Status changes or fluctuating course  Feature 2. Inattention  Feature 3. Disorganised Thinking  Feature 4. Altered level of consciousness Delirium is diagnosed when both 1 and 2 are positive along with either 3 or 4

16. CAM CriteriaDELIRIUMDEMENTIADEPRESSION Acute onset & fluctuating course Hours to daysMonths to years Decline with no fluctuation Weeks to months Day to day fluctuation possible InattentionPresentPresent in late stagesPossible present Disorganised thinking PresentMemory ImpairmentPresent in severe cases Altered level of consciousness PresentNot present Comparison of CAM Criteria for Delirium, Dementia and Depression

17. What next?