Continuing Education continued geriatric syndromes, such as falls, confusion or depression. Consideration of the signs and symptoms associated with alcohol withdrawal are particularly critical to evaluate in hospitalized older adults, and standardized scales are available. These include the Clinical Institute Withdrawal Assessment of Alcohol Scale.20 During the admission history, the patient and/or family should be asked about other substance use that can contribute to delirium, such as nicotine, cocaine, benzodiazepines, narcotics or other illicit drugs.21 Pain. Pain is a known risk factor for delirium and is often the cause of agitation in cognitively impaired older adults. Pain may be under- or overtreated in the hospital, particularly after hip fracture repair.22 Pain treatment for older adults should start with the lowest effective dose of medication,23 generally non-narcotic options. Consideration should be given to standing doses for cognitively impaired older adults who cannot request PRN medications. Older adults with dementia who may not be verbally able to respond to pain assessment questions should have their pain evaluated using observation tools such as the Pain Assessment in Advanced Dementia Scale.24 Medication Assessment and Review. Medication review and reconciliation should be performed at admission and include recent medication changes and OTC or herbal medications. Nurses can collaborate with pharmacy colleagues to consider the anticholinergic burden of medications and/or drug-drug interactions that may be causing symptoms as well as direct drug side effects. For every anticholinergic medication a patient takes, his or her risk of developing cognitive impairment may increase by 46% over 6 years.25 Nurses can refer to sources such as the Beers criteria26 to identify potentially inappropriate medications for older adults. Nonpharmacologic Interventions Nurses spend the most time with hospitalized patients and as such provide critically important information about changes in cognition and behavior that might be indicative of delirium or worsening of baseline cognitive 32 • ADVANCE FOR NURSING • January 2017 function. Any changes in the patient should be communicated across shifts and in team reporting. The overall management of older adults with cognitive impairment requires input from families and caregivers as well as the multidisciplinary team. Communication with older adults who are cognitively impaired should be clear. Directions and instructions should be provided in simple one-step commands. A patient who is aggressive can have a need for personal space that is four times greater than the average person; thus it is best to avoid touching or crowding.27 In situations when the patient is aggressive and agitated, it is helpful to assure that he or she is safe and then to provide some time alone to allow the aggression to dissipate. Certain nursing interventions may worsen BPSD or hyperactive delirium, such as trying to convince the patient that a delusion (i.e., “a nurse stole my walker”) is untrue. Instead, try to distract and redirect the patient by using techniques such as telling him or her that the physical therapist found another walker and “now you can go for a walk.” When the patient is agitated by medical interventions and tethering (e.g., pulse oximetry), work with the healthcare team to evaluate whether discontinuation is possible. Evaluate the patient for a simple solution to his or her behavior. For example, restless behavior may be due to a treatable symptom such as constipation, hunger, pain or urinary retention. Obtain history from families or caregivers about home routines to follow a similar pattern to the extent possible. Explore the situation from the patient’s perspective. Is the environment too loud and noisy? Has the patient missed meals because he or she has gone from test to test? Anticipate periods in which it is likely that patients with confusion will become agitated, such as shift change and high unit activity periods. Utilize whiteboards, familiar objects from home, or calendars for reorientation. Make sur sensory impairments are minimized by ensuring that the patient has access to dentures, glasses and/or hearing aids. Sleep-wake disturbance is often a highly disturbing symptom in patients with cognitive impairment, and it is magnified by reduced staffing and less senior staff overnight. Pharmacologic interventions for sleep should be avoided, including benzodiazepines, antihistamines or antispasmodics. Benzodiazepines can worsen delirium and increase the risk of cognitive impairment, falls and fractures.26 Nonpharmacologic interventions for sleep should include encouraging physical activity during waking hours; establishing a routine for bedtime (i.e., oral care, toileting and dimming or turning off lights); encouraging time out of bed during the day; managing pain; and eliminating noise to the extent possible. Maintaining Safety Physically restraining a patient is not an effective fall prevention intervention.28 Furthermore, restraints are associated with deconditioning, pressure ulcers, agitation, confusion, and even death.28 Specific alternatives to restraint use in the acute care setting should be individualized to the patient. Bed/chair alarms can be considered with assessment to ensure the noise of the alarm does not worsen agitation and does not limit mobility. However, some evidence suggests bed alarms increase the risk of developing delirium and may not reduce the risk of restraint use or improve clinical outcomes.29 Visualization of the patient with cognitive impairment is critical, and it may be helpful to work with family, caregivers, hospital staff and volunteers to have constant observation of the patient. Another way to facilitate patient safety, particularly when resources are limited, is grouping patients with similar symptoms when possible and placing patients who are impulsive and/or agitated near the main nursing station.30 Pod nursing is another option.30 In pod nursing, the workflow encourages teamwork and allows nurses to be close to their patient assignment.30 Environmental changes may also be helpful, such as lowering the bed closer to the floor; assuring that clear pathways exist in the patient’s room and hallway; appropriate safety bars in the bathroom; and raised toilet seats if needed.
Advance for Nursing • January 2017
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