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Delirium, Dementia, and Depression in Older Adults: Assessment and Care

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Delirium, Dementia, and Depression in Older Adults: Assessment and Care Delirium, Dementia, and Depression in Older Adults: Assessment and Care Long-Term Care Case Study and Discussion Guide January 2017 Delirium, Dementia, and Depression in Older Adults: Assessment and Care Long-Term Care Case Study and Discussion Guide Delirium, dementia, and depression in older adults: Assessment and care Page 1 of 55 Long-term care case study and discussion guide Delirium, Dementia, and Depression in Older Adults: Assessment and Care Long-Term Care Case Study and Discussion Guide Authors This resource was developed by Valerie Nguyen, RN, BMSc, BScN, MN Student, Ryerson University, together with support from her preceptor, Susan McNeill, RN, MPH, Program Manager, International Affairs and Best Practices Guidelines (IABPG) Centre, at the Registered Nurses’ Association of Ontario (RNAO). Further acknowledgements for the development of this resource are: Sue Bailey, RN, BA, MScN, GNC(C), Long-Term Care Best Practice Coordinator, Central LHIN, RNAO Beverly Faubert, RN, BScN, Long-Term Care Best Practice Coordinator, Erie St. Clair LHIN, RNAO Sue Sweeney, RN, Long-Term Care Best Practice Coordinator, Southwest LHIN, RNAO Verity White, BSc, Project Coordinator, IABPG Program, RNAO Connie Wood, RN, BScN, MN, Long-Term Care Best Practice Coordinator, Central East LHIN, RNAO Acknowledgement and thanks goes to Parkview Home Long-Term Care for inviting the author to pilot this resource. The well-received learning sessions provided valuable feedback in moving forward with developing this resource. Delirium, dementia, and depression in older adults: Assessment and care Page 2 of 55 Long-term care case study and discussion guide TABLE OF CONTENTS Page Introduction 4 How to Use this Discussion Guide 5 Background on Delirium, Dementia, and Depression 6 Section A: Questions about Differentiating Delirium, Dementia, and Depression 9 Section B: Questions about Delirium and Care Strategies 13 Section C: Questions about Dementia and Care Strategies 17 Section D: Questions about Depression and Care Strategies 21 Appendix A: Case Study – Mr. Y’s Story 24 Appendix B: Case Study – Mr. Y’s Story (Facilitator’s Version) 27 Appendix C: Venn Diagram of Delirium, Dementia, and Depression 30 Pages from RNAO Best Practice Guideline 31 - 55 Delirium, dementia, and depression in older adults: Assessment and care Page 3 of 55 Long-term care case study and discussion guide Introduction The Registered Nurses’ Association of Ontario’s (RNAO) Delirium, Dementia, and Depression in Older Adults: Assessment and Care Best Practice Guideline (BPG) outlines recommendations that guide best practices for nurses and health-care providers. The BPG can be used across different health-care settings, including long-term care. The BPG was developed using a rigorous process, including a systematic literature review and the development of recommendations with experts in the field, including health-care providers from the long-term care sector. The Case Study (see Appendix A in this guide, pg. 24) and its accompanying Discussion Guide were developed for educational purposes in long-term care homes to promote use of the RNAO Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG. Long-term care staff are asked to read the Case Study – Mr. Y’s Story, and participate in a learning session through a facilitated discussion with other participants who work in the long-term care setting. The facilitator of the discussion should be a member in the long-term care setting who is responsible for the education of the long-term care staff. Possible facilitators could be the nurse educator, nurse manager, or charge nurse at the long-term care setting. The Discussion Guide is used by the facilitator to elicit topics for discussion and to cover key points from the RNAO Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG. Education should focus not only on increasing content knowledge, but also foster attitudes and practices conducive to the care of people with delirium, dementia, and depression. Overall goals of the Case Study and Discussion Guide are to: • Actively engage participants in discussions about delirium, dementia, and depression • Help long-term care staff identify the differences between delirium, dementia, and depression • Help long-term care staff become familiar with key resources they can use at the point-of-care to support identification of delirium, dementia, and depression • Reinforce best practices for the care of delirium, dementia, depression in older adults Detailed information and references in this Discussion Guide can be found in the RNAO Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG unless otherwise stated. The RNAO Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG can be found online at RNAO.ca/bpg Delirium, dementia, and depression in older adults: Assessment and care Page 4 of 55 Long-term care case study and discussion guide How to Use this Discussion Guide In preparation, the facilitator should be familiar with the following: • Registered Nurses’ Association of Ontario Delirium, Dementia, and Depression in Older Adults: Assessment and Care Best Practice Guideline (2016) • Case Study – Mr. Y’s Story (Facilitator’s Version) (see Appendix B in this guide, pg. 27) • Discussion Guide content o Background on Delirium, Dementia, and Depression o Section A: Questions about Differentiating Delirium, Dementia, and Depression o Section B: Questions about Delirium and Care Strategies o Section C: Questions about Dementia and Care Strategies o Section D: Questions about Depression and Care Strategies Depending on the time available for the learning session, the facilitator may choose to focus on one or more of the sections in the Discussion Guide. For example, Section A could be focused on in a 30-45- minute learning session. There is no recommended order of sequence in which sections should be delivered. The section selection for the learning session is up to the facilitator and the learning needs of the long-term care participants. Each section includes: • Aims of the section • Relevant BPG recommendations to consider • BPG resources to be provided as handouts • Suggested discussion questions • Possible answers • Facilitator tips • Key points to cover Facilitator Tip: Create a safe learning environment. Participants will be work colleagues with various work, education, and life experiences. Participants will hold different employment positions at the long- term care setting. The facilitator should inform participants that the learning session will be a safe, confidential, non-judgmental learning environment in order to encourage discussion, participation and to learn with each other. The ideal seating arrangement is a circle or half-circle to promote sense of community/team and encourages participation by involving everyone in the group. Participants are unobstructed from speaking directly to each other. There is no designated leader position; this creates a sense of equality among the group. Delirium, dementia, and depression in older adults: Assessment and care Page 5 of 55 Long-term care case study and discussion guide Background on Delirium, Dementia, and Depression This section gives a brief description of delirium, dementia, depression, and the importance of being able to differentiate the three conditions. This section can be used by the facilitator to review the conditions with the long-term care staff at the start of a learning session. Delirium Delirium is a complex condition and can be thought of as acute brain failure.1 It is a medical emergency and needs to be addressed quickly because delirium can permanently affect the brain. Unfortunately, delirium is common in long-term care settings,2 and often leads to hospital transfers.3 Delirium develops because of a combination of conditions that make an older adult vulnerable to different risk factors.4 Risk factors can be found in the BPG’s Appendix G: Delirium Risk Factors and Interventions (pg. 31 of this guide). Delirium comes on quickly and typically lasts less than a month.5 It causes changes in someone’s level of attention, orientation, alertness, memory, thinking, perception, physical function, and social behaviour. Important changes to know can be found in the BPG’s Table 1: Changes That May Indicate Delirium (pg. 33 of this guide). There are three main types of delirium.6 Older adults with hyperactive delirium present with restlessness, agitation, delusions, and/or aggressive behaviour. Older adults with hypoactive delirium are lethargic, sleepier, have less spontaneous movements, slowed movements, disinterested behaviour. Older adults with mixed delirium have phases of hyperactive and hypoactive delirium. Hypoactive delirium accounts for 65 percent of delirium cases;7 it is the most common type of delirium. Prevention of delirium is important. Actions to prevent delirium can reduce the incidence of delirium by approximately 30 percent.8 Dementia Dementia is an umbrella term for a number of diseases that create irreversible changes in the brain that affect learning, memory, mood and behaviour.9 A summary of the main types of dementia, including Alzheimer’s disease and vascular dementia, can be found in the BPG’s Appendix E: Types of Dementia (pg. 34 of this guide). 1 Inouye et al., 2014 2 American Medical Directors Association, 2008 3 Clegg et al., 2014 4 Holroyd-Leduc, Khandwala & Sink, 2010; Martinez et al., 2015 5 Flaherty et al., 2011; American Medical Directors Association, 2008 6 National Institute for Health and Care Excellence, 2010 7Khurana, Gambhir, & Kishore 2011 8 Martinez et al., 2015 9 Alzheimer Society of Ontario, 2012 Delirium, dementia, and depression in older adults: Assessment and care Page 6 of 55 Long-term care case study and discussion guide Dementia develops gradually with early warning signs of a decline in memory, thinking, and orientation. Other signs that can be used to signal when someone should be assessed for dementia can be found in the BPG’s Table 8: Early Warning Signs Suggesting Cognitive Challenges (pg. 37 of this guide). Eighty percent of older adults with dementia present behavioural and psychological symptoms of dementia (BPSD).
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