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Advance for Nursing • January 2017

ADVANCE FOR NURSING • January 2017 • 31 recognized as a metric to measure highquality care of older hospitalized patients. Utilizing screening tools to assess for cognitive impairment early in the admission process can help identify patients at risk for developing delirium and allow for the implementation of appropriate preventive interventions.10 It is critical for nurses to identify delirium because in older adults, it is often a symptom of a serious underlying disease. Screening Tools for Delirium The most well-known delirium assessment tool is the Confusion Assessment Method (CAM).11 The CAM includes four criteria: 1. acute onset and fluctuating course; 2. inattention; 3. disorganized thinking; and 4. altered level of consciousness. Delirium can be diagnosed with the presence of features 1 and 2 and either 3 or 4. The CAM is widely known and validated. It is relatively easy to use, can be completed in less than 5 minutes, and is available in at least 12 languages.5 Associated with the CAM is the Family Confusion Assessment Method (FAMCAM), which utilizes reports from families and caregivers to identify delirium symptoms. 12 The CAM-ICU was designed for delirium diagnosis in critically ill ICU patients13 and patients who are nonverbal mechanically ventilated. A two-item delirium screen in hospitalized older adults has been proposed: naming the months of the year in reverse order (one error allowed for scoring) and orientation to the day of the week. These two questions have been associated with a greater than 90% sensitivity for delirium.14 The Delirium-O-Meter (DOM) was developed by nurses as a 12-item rating scale to measure the severity of hypoactive and hyperactive delirium. Twelve items are assessed using a severity scale of 0 to 3, with features including sustained attention; shifting attention; orientation; consciousness; apathy; hypokinetic/psychomotor retardation; incoherence; fluctuations in functioning; restlessness; delusions; hallucinations; and anxiety/fear. It is not a screening test, but it can still be useful to help differentiate among patients with and without delirium (score greater than 5 correctly classified 92.9% of delirium).15 An advantage of the DOM is that it is completed via direct observation by the nursing staff member providing care to the patient and can easily be done on each shift or at more frequent intervals.15 Screening Tools for Dementia Multiple screening tools for dementia exist, but a clear consensus on the best option in the hospitalized older adults does not. Clinicians often familiarize themselves with one or two options and utilize them depending on the patient's level of cognitive impairment, educational attainment and the availability of an informant. The Mini-Cog includes three steps: threeword registration; clock drawing task with hands of the clock at 11:10; and recall of the three words. Scoring is out of 5 points (0-3 points for word recall, and 0 or 2 points for clock). A score of less than 3/5 has been validated for dementia screening, but a score of less than 4 may also indicate a need for more investigation into cognitive abilities.16 The Montreal Cognitive Assessment (MoCA) is a longer and more detailed test. It is helpful for better characterization of performance across multiple cognitive domains and in detecting mild cognitive impairment (i.e., cognitive impairment not sufficient to interfere with functioning). It takes approximately 10 minutes to complete, and it includes verbal and written sections. Administering the MoCA requires training. The instruction manual is available on mocatest.org.17 Cognitive screening tests can be performance based (e.g., Mini-Cog and MoCA) or informant-based, such as the 8-item Interview to Differentiate Aging and Dementia (AD8). The benefit of an informant-based screening tool is that information can be collected from a reliable source, which can be helpful if a patient is unwilling or unable to participate in cognitive screening. The AD8 was designed to distinguish between normal aging and mild dementia by assessing for intra-individual change. Informants answer eight questions. A score of 2 or greater suggests cognitive impairment is likely. The AD8 takes only 3 minutes to complete and is available in multiple languages. The AD8 can be combined with other tools such as the Mini-Cog and MoCA to increase the likelihood of finding early cognitive changes.18 Other Causes Thorough screening for dementia and delirium requires consideration of all potential causes: Alcohol abuse. Alcohol abuse is often underreported and misdiagnosed in older adults, and screening tools are geared toward a younger population.19 Older adults may present with alcohol use disorders and other


Advance for Nursing • January 2017
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