1. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

2. HELP Project Planning Tool In this section think about…. Will you start with some or all of the HELP interventions? What HELP interventions will your system find most challenging? What strategies will you use to support their introduction? The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

4. ELS & CNS Protocols RISK FACTORSELS PROTOCOLNURSING PROTOCOL Cognitive Impairment Daily Visitor /Orientation/ Therapeutic Activities Delirium/Dementia/ Psychoactive Medications Sleep DeprivationSleep Enhancement ImmobilityEarly Mobilization Vision ImpairmentVisionSame Hearing ImpairmentHearingSame DehydrationMeal Assistance/ Fluid Repletion Fluid Repletion Protocol The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

5. Orientation/Daily Visitor/Therapeutic Activities Criteria- all patients are enrolled Intervention-Orient 1 time per day if SMMSE >20, orient 3 times per day if SMMSE <20 -Explore patient’s interests and possible therapeutic activities -Discuss current events, structured reminiscence, word games (Inouye et al. N. Engl. J. Med. 1999, March 4 340 (9): 669-676) The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

6. Delirium Protocol Assessment methods: pt. interview, chart review, interview with nursing staff and families, reports from volunteers, CAM assessment Interventions: medication review, occult infection, drug/alcohol withdrawal; occult illness; non- pharmacological management; optimal environment, behavioral management techniques, family involvement, delirium order sets, referrals The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

7. More Delirium Interventions Non-Pharmacological Management Education for staff, involve family Optimal environment Strategies to decrease agitation and improve sleep Communication techniques The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

8. Dementia Protocol Baseline cognitive status Baseline screening information (social situation/caregiving needs/ADLs/IADLs/ nutrition, sleep) Interventions (medical workup, effective behavioral management strategies, nursing education, avoiding psychoactive medications) The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

9. Psychoactive Medication Protocol Past and current medication use Screening for medications associated with delirium Anticholinergic Cognitive Burden scale Nursing staff education The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

10. Healthy Vision/Healthy Hearing Vision Criteria- if near vision in both eyes <20/70 Intervention - Eyeglasses clean and on - Magnifying glass Hearing Criteria-<3 whispers from each ear on whisper test Intervention -Hearing aids in and turned on -Consider use of hearing amplifier The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

11. Healthy Eating/Fluid Repletion Criteria-appetite rated as poor Criteria-clinical evidence of Intervention- dehydration and Assist with set-up of meals Urea X10/Creatinine> 0.7 Encourage food intake Intervention- Encourage fluids Ensure regular mouth care if not contraindicated Assist with menu completion The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

12. Fluid Repletion Protocol Assessment: criter; risk factors, postural hypotension Interventions: patient/family education re: fluid intake and postural hypotension; collaboration with nursing and medical staff; direction for volunteers, patient preference ; collaboration with physician if symptoms persist The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

13. Poor Appetite Further assessment by CNS: Physical appearance Weight loss Weight loss etiology Weight loss markers CNS’ Interventions: Referrals to RD, OT, MD Communication with nursing staff Communication with families The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

14. Early Mobilization Criteria- all patients assessed for early mobilization Intervention- ELS/CNS consults with Physiotherapist to determine appropriate mobilization protocol: Active range of motion exercises 3 times per day Supervised walking 3 times per day according to PT guidelines The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

15. Early Mobilization –CNS role Assessment: patient’s self-report of functional abilities, direct mobility assessment, physician order, hospital staff assessment, pain and pain management assessment Intervention: referral to Physiotherapist/OT, patient/family education, staff education (deconditioning, falls prevention) The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

16. Sleep Enhancement Criteria- difficulty falling asleep or sleeps poorly at home or in hospital Intervention Avoid sleeping pills Instead: Back rub/ hand rub (if not contraindicated) Warm blanket Warm drink such as herbal tea or warm milk Soft music The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

17. Sleep protocol –CNS role Risk factors Medication Patient/family education on sleep hygiene practices:  Increase physical activity during the day  Avoid naps  Limit caffeine, nicotine intake  Have light snack before going to bed  No TV before going to bed The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

18. At HHS, the HELP nurse ……. Follows HELP delirium protocols Structured cognitive assessment is not carried out daily but on admission and as indicated SMMSE is not done prior to discharge The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

19. Adherence-What dose of HELP is enough ? The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions Higher levels of adherence resulted in reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group. Inouye SK. Arch Intern Med. 2003;163:958-964 The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

20. At HHS…… Start Up Adherence 68%-best for orientation, vision and hearing, therapeutic activities and feeding protocol 34% -lowest for mobility and sleep protocol Followed up with more training The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

21. What factors affect adherence? Are they modifiable? The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

22. HELP Project Planning Tool Will you start with some or all of the HELP interventions? What HELP interventions will your system find most challenging? What strategies will you use to support their introduction? The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH