What is it?
Cognitive impairment refers to an individual having memory and thinking problems. The person may have difficulty with learning new things, concentrating, or making decisions that affect their daily life. The most common causes of cognitive impairment among older people are dementia and delirium.1
Dementia is a general term used to describe a form of cognitive impairment that is chronic, generally progressive and occurs over a period of months to years. It can affect memory, language, perception, personality and cognitive skills.2
Delirium is an acute disturbance of attention and cognition where the patient experiences confusion. It is temporary and is a symptom of an underlying issue.3 Delirium is often overlooked or misdiagnosed in the hospital setting.4
Depression is not just low mood or feeling sad, but a serious condition that needs treatment. Its symptoms can mimic those associated with cognitive impairment and it is often overlooked or misdiagnosed.
Why is it important?
- In the hospital environment almost 30 per cent of older people have cognitive impairment.5
- Older people with a cognitive impairment are at greater risk of:
- hospital-acquired pressure injuries
- developing incontinence
- medication issues.
- These risks often lead to an increased hospital stay6,7 and poorer outcomes for older people.
- Screening and early recognition is vital as the first presentation of cognitive impairment can occur during hospital admission.5
- Ten to 15 per cent of older people have delirium at admission, and a further five to 40 percent are estimated to develop it during their hospital stay. Patients with dementia have double the risk of developing delirium.5
- The hospital environment can increase levels of distress and disorientation experienced by people with cognitive impairment. This can put older people at risk and be distressing for staff, carers and family.
- If unrecognised, cognitive impairment can increase the likelihood that an older person will end up in a premature placement rather than return home.
How can you care for people with cognitive impairment?
All hospital staff have a shared role in caring for patients with cognitive impairment. Best practice informs us that all patients over the age of 65 should be screened for cognitive impairment at the first point of contact with the health service, and when they transition to another area in the hospital. It is vital that this screening is documented in the patient’s medical record, and that the patient’s premorbid state is taken into account.
Screen and assess patients with cognitive impairment
- Recognise the different characteristics of delirium and dementia and rule out the possibility of depression.
- It is vital that the all patients with a delirium are thoroughly investigated for the underlying cause so it can be treated.
- Use a validated screening tool for cognitive impairment. These tools enable you to determine a baseline, develop a person-centred care plan and implement risk management strategies. The most commonly used tools in hospitals include:
- Abbreviated Mental Test (AMT)
- Standardised Mini-Mental State Examination (SMMSE)
- Clock Drawing Test (CDT).
- Identify the presence of behavioural and psychological symptoms of dementia (BPSD) that respond to changes in the environment:
- resistance to care
- screaming/calling out/agitation
- Always check your observations with the person’s family or carer to ascertain if these BPSD symptoms are long standing or new. This will assist in developing an intervention plan and in forming a diagnosis.
- If the patient is displaying signs of agitation, consider whether they may need to go to the toilet, if they are hungry or are in pain.
Actively engage patients and families in all aspects of their care plan
Families and carers offer a wealth of expertise and can often suggest care strategies to minimise risk of functional decline and the person’s level of distress.
- Involve the family and carer in the care planning process and provide them with written information about cognitive and memory difficulties.
- Establish the patient’s pre-morbid cognitive status. This will help you to determine intervention strategies.
- Be mindful that a diagnosis can be quite confronting for the individual and their family and carer.
- Screen the patient’s carer and family for carer stress and refer to appropriate inpatient and outpatient support services such as the Social Work team, Alzheimer’s Victoria and Carers Victoria.
- Communicate clearly by using the strategies outlined in the Improving communication factsheet.
- Use these key points:
- introduce yourself
- always use the patient’s name when addressing them
- make sure you have eye contact at all times
- remain calm and talk in a matter-of-fact way
- keep sentences short and simple
- give time for a response
- take the time to explain what you are going to do and why you are doing it
- focus on one instruction at a time
- repeat yourself – don't assume you have been understood
- don’t offer too many choices.
- Encourage the patient and family and carer to discuss advance care planning with each other and the care team. See Advance care planning factsheet for more information.
Respond to the needs of a patient with cognitive impairment
- Adjust the immediate environment to minimise patient distress:
- make every effort to reduce the number of times a patient transfers between wards
- reduce stimulation
- use diversional strategies such as engaging in a one-on-one conversation
- situate the patient within sight of the nursing station
- make sure the call bell is within the patient’s reach
- involve the family and carers in providing direct care.
- Engage in intentional rounding (carrying out regular checks with the patient at set intervals). Assist the patient with eating, drinking, pain relief, ambulation, regular toileting and repositioning (as required).
- Some hospitals place the cognitive impairment identifier (cii), the information about me form, and a universal falls symbol above a patient’s bed, which acts as a communication tool to all staff.
- Consider whether your health service could complete an environmental audit.
Improving the environment for older people in health services: an audit tool
Dementia Enabling Environment Principles.
Monitor and evaluate a patient’s ongoing care
- Document all interventions, and in conjunction with family and staff monitor whether they have been successful.
- Formally handover that the older person has a cognitive concern and any strategies that you have found helpful to respond to these concerns:
- between nursing shifts
- within interdisciplinary care planning meetings
- when the patient transfers to another area of the health service.
All healthcare organisations and clinicians must practice in alignment with the National Safety and Quality Health Service Standards.
1. Milisen K, Braes T, Fick DM & Foreman MD 2006, ‘Cognitive Assessment and Differentiating the 3 Ds (Dementia, Depression, Delirium)’, Nursing Clinics of North America, 41(3):1-22.
2. Australian Institute of Health and Welfare 2012, Dementia in Australia, Australian Institute of Health and Welfare, Canberra, Australia.
3. Clinical Epidemiology and Health Service Evaluation Unit, Melbourne Health 2006, Clinical Practice Guidelines for the Management of Delirium in Older People. Report to Australian Health Ministers’ Advisory Council.
4. Inouye S, Foreman M, Mion L, Katz K & Cooney L. 2001, ‘Nurses' recognition of delirium and its symptoms – Comparison of nurse and researcher ratings’, Archives of Internal Medicine, 160(20):2467-2473.
5. Travers C, Byrne G, Pachana N, Klein K & Gray L. 2013, ‘Prospective observational study of dementia and delirium in the acute hospital setting’, Internal Medicine Journal, 43(3):262-269.
6. Australian Institute of Health and Welfare 2013, Dementia care in hospitals: costs and strategies, Australian Institute of Health and Welfare, Canberra, Australia.
7. Bail K, Berry H, Grealish L, Draper B, Karmel R, Gibson D & Peut A 2013, ‘Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study’, BMJ Open, 3(6):2770.