Action 5.29

Implement a system

A well-designed system for caring for patients with for cognitive impairment will support clinicians to:

• Routinely screen for cognitive impairment¹ in patients aged 65 years or over using a validated tool (Action 5.10)
• Screen patients of any age at risk of delirium and when the patient, carer, family or other key informants raise concerns about cognitive impairment.

An initial screen provides a useful baseline for further monitoring. Note that a positive score on a screening tool is not a diagnosis but a prompt for further assessment, early intervention and early family involvement. Document the results and communicate them to patients and family, and the relevant members of the workforce who interact with patients, including primary care clinicians.

For all patients with cognitive impairment:

• Assess for delirium and reassess with any changes in behaviour or thinking¹ using validated delirium assessment tools applicable to the setting (see Action 8.5)
• If delirium is detected, investigate and treat the causes of delirium; comprehensive history taking and physical examination can enable targeted investigations
• Investigate (or refer for investigation) other causes of cognitive impairment – for example, a person may have developed cognitive impairment as a result of a recent acquired brain injury or an undiagnosed dementia, requiring further assessment, treatment and follow-up
• Partner with patients, carers and family members who have a central role in the prevention, early recognition, assessment and management of cognitive impairment; develop systems for their early consultation and involvement
• Comprehensively assess and develop an individualised plan (see Actions 5.12 and 5.13)
• Provide relevant information to patients, carers and families in an easy-to-understand format, including information on delirium risk, delirium, and the roles of patients, carers and families; delirium may be a frightening experience for patients and families, and can be associated with feelings of remorse and shame²
• Respond to other care needs, including assistance with nutrition³ and hydration (see Action 5.27), reorientation, safe mobilising, maintaining or restoring functioning, and providing meaningful activities^4,5; these strategies also assist in prevention of delirium and other geriatric syndromes⁶, and a well-structured and well-supported volunteer program can assist in implementation^7,8
• Set goals of care based on the needs and preferences of the person with cognitive impairment; use processes for informed consent, shared and substitute decision-making, and advance care planning to set goals of care
• Manage medication issues, including
  • treating pain and reducing sedation⁹
  • undertaking medication reconciliation, and reviewing to identify, reduce or stop medicines that can cause or exacerbate cognitive impairment (see Action 4.10)
  • providing accurate medicines lists (see Action 4.12)
  • consulting, informing and educating patients, carers and substitute decision-makers (as well as the patient’s general practitioner and care facility) about these processes
• Communicate effectively¹⁰ and seek information to provide individualised care
• Respond appropriately to behavioural symptoms (see ‘Manage the use of antipsychotic medicines’, below)
• Provide a supportive environment– for example, implement evidence-based design principles in scheduled major capital works or refurbishments, as well as through simple, small-scale changes at the ward and room level (see Actions 1.29 and 1.30), and support carers and family members when they choose to be actively involved in a person’s care
• Manage transitions effectively, including
  • information exchange and transfer of responsibilities among all relevant health service organisations and care providers, including seeking early primary care input (see Actions 6.7 and 6.8)
  • access to hospital substitution, outreach, fast-track or transition programs
  • referral for appropriate follow-up for undiagnosed cognitive impairment and after a delirium episode – for example, many patients who are identified with cognitive impairment or experience delirium may have undiagnosed dementia¹¹
• If a comprehensive diagnostic process is not appropriate during admission, arrangements must be put in place for post-discharge assessment¹²; ensure that referral pathways are in place for post-discharge assessment, and involve and inform patients and carers about ongoing care decisions.¹

Note that these steps are not linear. For example, keeping a person safe through responding to other care needs should happen at the same time as investigating the possible cause of delirium, if detected.

For patients at risk of delirium, implement multi-component delirium prevention strategies^1,13

Patients aged 65 years and over, and patients with a known cognitive impairment (such as dementia), severe medical illness or hip fracture are considered to be at greatest risk.¹

Note that delirium prevention strategies are also useful delirium management strategies – for example, early treatment of dehydration, sepsis, metabolic imbalance, immobilisation, sensory impairment and sleep disturbance.⁹

Introduce protocols to prevent and treat pain, reduce sedation, enable safe early mobilisation and reduce sleep disturbance.⁹

Set up procedures to avoid or remove catheters in a timely manner.

For all patients, be alert to, and assess for, delirium when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (see Action 8.5)

To implement a system for caring for patients with cognitive impairment, use the screening, assessment and comprehensive care planning processes described in the Comprehensive Care Standard for guidance, including items that cover advance care plans.

Other relevant NSQHS Standards include the:

• Clinical Governance Standard, including developing a risk management framework, assessing and responding to training needs, and providing safe environments
• Partnering with Consumers Standard, including actively involving patients in their own care (as well as carers and families), obtaining informed consent, meeting the patient’s information needs and sharing decision making
• Medication Safety Standard, particularly for medication reconciliation and review, and medicines lists
• Communicating for Safety Standard, particularly actions for clinical handover, communicating critical information and documentation
• Recognising and Responding to Acute Deterioration Standard, including systems to recognise and escalate care with acute deterioration in mental state, including delirium.

A Better Way to Care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital and the Delirium Clinical Care Standard set out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment. A Better Way to Care also provides links to further resources that are useful in implementing this action.

Manage the use of antipsychotic medicines

Incorporate best practice¹² and legislation for the use of antipsychotics and other psychoactive medicines for people with cognitive impairment into policies and procedures. This includes:

• Conducting a comprehensive, formal assessment of any behavioural symptoms or changes, including assessment of potential unmet needs
• Communicating effectively and understanding the person
• Involving carers and family members
• Creating a supportive environment
• Managing training and education of the workforce (see Action 5.30)
• Avoiding physical restraint, if possible, and following guidance in Action 5.35 to minimise restraint
• Trying non-pharmacological approaches in the first instance
• Seeking behavioural management advice when required
• Starting pharmacological treatment only if a patient is severely distressed, or is at immediate risk of harm to themselves or others, and non-pharmacological interventions have been ineffective¹
• If pharmacological interventions are prescribed
  • discussing risks and benefits and obtaining informed consent, unless in an emergency
  • following ‘start low, go slow, time limit and review’
  • selecting the agent based on evidence according to diagnosis, severity and patient factors such as comorbidities
  • avoiding multiple agents
  • considering evidence and pharmacokinetics when selecting dose, frequency and timing
  • documenting indications for use and providing instructions for community prescribers^14,15
• Monitoring and collecting feedback on the use of antipsychotics and other psychoactive medicines.

Ensure that policies for preventing and responding to aggression include specific guidance on responding to acute behavioural disturbance in relation to cognitive impairment. Use non-pharmacological approaches in the first instance, involve carers and families, minimise sedation, and ensure that any medicine use is evidence based, including age-specific evidence. Over-sedation can have serious consequences, such as dehydration, falls, respiratory depression, pneumonia and death.¹⁶

Implement a system

Pre-admission screening should identify patients with cognitive impairment or at risk of delirium, to trigger strategies to keep the patient safe and to minimise potential distress. Strategies include:

• Reviewing communication systems to ensure that risk and identified cognitive impairment are flagged, communicated and documented during pre-admission and admission processes
• Providing consumer information in an easy-to-understand format, including information about the risk of delirium
• Involving family members or carers to support patients in pre-admission screening, or consulting with a substitute decision-maker
• Communicating effectively with patients with cognitive impairment
• Consulting with family members on strategies to minimise distress
• Involving family members or carers in the care episode, including reporting any concerns they raise about the patient
• Providing information to other health services (for example, referring clinician) regarding any delirium and further follow-up.

Pre-admission screening should include screening for risk factors for postoperative delirium, including age greater than 65 years, chronic cognitive decline or dementia, certain medicines or multiple medicines, and poor vision or hearing.^16,17

A Better Way to Care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital and the Delirium Clinical Care Standard set out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment. A Better Way to Care also provides links to further resources that are useful in implementing this action.

Examples of evidence

Select only examples currently in use:

• Policy documents that outline processes for
  • recognising, preventing, treating and managing cognitive impairment, including through pre-admission screening for cognitive impairment
  • obtaining early primary care input about a patient’s cognitive difficulties to aid diagnosis, treatment and ongoing management decisions
• Validated tools and resources used to screen for, and assess, cognitive impairment
• Training documents about communicating with, and providing support to, patients with cognitive impairment, and assessing and responding to distress
• Examples of activities that have been implemented and evaluated to improve the environment for people with cognitive impairment
• Examples of non-pharmacological approaches that have been implemented to respond to behavioural symptoms of dementia
• Patient, carer and family information packages that provide information to enable them to participate in the system for caring for patients with cognitive impairment
• Committee and meeting records that show the health service organisation’s involvement in dementia pathway initiatives to integrate primary, community and acute care.

Implement a system

A well-designed system for caring for patients with cognitive impairment will support clinicians to routinely screen for cognitive impairment¹ in patients aged 65 years or over using a validated tool (Action 5.10). Also, at any age, screen patients at risk of delirium and when the patient, carer, family or other key informants raise cognitive concerns.

For all patients with cognitive impairment:

• Assess for delirium and reassess with any changes in behaviour or thinking¹ using validated delirium assessment tools applicable to the setting (see Action 8.5)
• If delirium is detected, investigate and treat the causes of delirium; comprehensive history taking and physical examination can enable targeted investigations
• Investigate (or refer for investigation) other causes of cognitive impairment–for example, a person may have developed cognitive impairment as a result of a recent acquired brain injury or an undiagnosed dementia, requiring further assessment, treatment and follow-up
• Partner with patients, carers and family members who have a central role in the prevention, early recognition, assessment and management of cognitive impairment; develop systems for their early consultation and involvement
• Provide relevant information to patients, carers and families in an easy-to-understand format, including information on delirium risk, delirium, and the roles of patients, carers and families
• Comprehensively assess and develop an individualised plan (see Actions 5.12 and 5.13)
• Respond to other care needs, including assistance with nutrition³ and hydration (see Action 5.27), reorientation, safe mobilising, maintaining or restoring functioning, and providing meaningful activities^4,5
• Set goals of care based on the needs and preferences of the person with cognitive impairment; use processes for informed consent, shared and substitute decision-making, and advance care planning to establish goals of care
• Manage medication issues, including
  • treating pain and reducing sedation⁹
  • undertaking medication reconciliation, and reviewing to identify, reduce or stop medicines that can cause or exacerbate cognitive impairment (see Action 4.10)
• Communicate effectively¹⁰ and seek information to provide individualised care; tools are included in the Resources section at the end of this standard
• Respond appropriately to behavioural symptoms (see ‘Manage the use of antipsychotic medicines’, below)
• Provide a supportive environment – for example, implement evidence-based design principles in scheduled major capital works or refurbishments, as well as through simple, small-scale changes at the ward and room level (see Actions 1.29 and 1.30), and support carers and family members when they choose to be actively involved in a person’s care
• Manage transitions effectively, including referral for appropriate follow-up for undiagnosed cognitive impairment and after a delirium episode
• Involve and inform patients and carers about ongoing care decisions.¹

Note that these steps are not linear. For example, keeping a person safe by responding to other care needs should happen at the same time as investigating the possible cause of delirium, if detected.

For patients at risk of delirium, implement multi-component delirium prevention strategies^1,13

Patients aged 65 years and over, and patients with a known cognitive impairment (such as dementia), severe medical illness or hip fracture are considered to be at greatest risk.¹

Note that delirium prevention strategies are also useful delirium management strategies – for example, early treatment of dehydration, sepsis, metabolic imbalance, immobilisation, sensory impairment and sleep disturbance.⁹

Introduce protocols to prevent and treat pain, reduce sedation, enable safe early mobilisation and reduce sleep disturbance.⁹

Set up procedures to avoid or remove catheters in a timely manner.

For all patients, be alert to, and assess for, delirium when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (see Action 8.5)

Care of Confused Hospitalised Older Persons (CHOP) and the Dementia Care in Hospitals Program provide direction on implementing systems for caring for patients with cognitive impairment.

A Better Way to Care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital and the Delirium Clinical Care Standard set out suggested strategies for health service organisations in early recognition, prevention, treatment and management of cognitive impairment. A Better Way to Care also provides links to further resources that are useful in implementing this action.

Manage the use of antipsychotic medicines

Incorporate best practice and legislation in the use of antipsychotics and other psychoactive medicines for people with cognitive impairment into policies and procedures. This includes:

• Conducting a comprehensive, formal assessment of any behavioural symptoms or changes, including assessment of potential unmet needs
• Communicating effectively and understanding the person
• Involving carers and family members
• Creating a supportive environment
• Managing training and education of the workforce (see Action 5.30)
• Avoiding physical restraint, if possible, and following guidance in Action 5.35 to minimise restraint
• Trying non-pharmacological approaches in the first instance
• Seeking behavioural management advice when required
• Starting pharmacological treatment only if a patient is severely distressed, or is at immediate risk of harm to themselves or others, and non-pharmacological interventions have been ineffective¹
• If pharmacological interventions are prescribed
  • discussing risks and benefits and obtaining informed consent, unless in an emergency
  • following ‘start low, go slow, time limit and review’
  • selecting the agent based on evidence according to diagnosis, severity and patient factors such as comorbidities
  • avoiding multiple agents
  • considering evidence and pharmacokinetics when selecting dose, frequency and timing
  • documenting indications for use and providing instructions for community prescribers^14,15
• Monitoring and collecting feedback on the use of antipsychotics and other psychoactive medicines.

Ensure that policies for preventing and responding to aggression include specific guidance on responding to acute behavioural disturbance in relation to cognitive impairment. Use non-pharmacological approaches in the first instance, involve carers and families, minimise sedation, and ensure that any medicine use is evidence based, including age-specific evidence. Over-sedation can have serious consequences, such as dehydration, falls, respiratory depression, pneumonia and death.¹⁶