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MMSE, CAM, GDS, Acute Confusion

Terms in this set (28)

MMSE
Assesses for orientation, immediate recall, attention, delayed verbal recall, naming, repetition, 3-stage command, reading, writing, and copying. Following use of
the MMSE, the interviewer uses a decision
process to determine whether
delirium is present.
Depression
Not a natural part of aging.
GDS Short form
The Short Form is more easily used by physically ill and mildly to moderately demented patients who have short attention spans and/or feel
easily fatigued.
Limitations of the GDS
The GDS is not a substitute for a diagnostic interview by mental health professionals. It is a useful screening tool in the clinical setting to facilitate assessment of depression in older adults especially when baseline measurements are compared to subsequent scores. It does not assess for suicidality.
5 or above on the GDS
Should prompt an in-depth psychological assessment and evaluation for suicidality.
CAM
Confusion assessment method. Quickly and accurately detects delirium. Incorporated into usual assessment. Assesses for acute onset, inattention, disorganized thinking, disorientation, memory impairment, perceptual disturbances, psychomotor agitation or retardation, and sleep-wake cycle.
CAM limitations
The tool identifies the presence or absence of delirium but does not assess the severity of the condition, making it less useful to
detect clinical improvement or deterioration.
CAM diagnostic algorithm
1. Acute Onset or Fluctuating Course
2. Inattention
3. Disorganized thinking
4. Altered Level of consciousness
Delirium
Delirium, or acute confusion,
is a common cause of morbidity
and mortality. It is a medical diagnosis
Patients with delirium are at higher risk for
Adverse reactions to
medications, acquire hospital infections,
fall, develop pressure ulcers,
and have longer hospital stays
compared with patients who do not
develop delirium.
Prevalence of superimposed delirium on dementia
22% to 89% of people with dementia.
Intervention to prevent delirum
Improve outcomes.
Use of different terms
The use of different descriptive and
diagnostic terms for acute cognitive
impairments likely contributes to
clinicians' failure 33% to 66% of the
time to identify older patients with
delirium.
Inappropriate diagnosis of dementia or depression
Delays in care and treatment
for delirium occur when changes
in cognition are inappropriately
diagnosed as dementia or depression.
Acute confusion
Nursing diagnosis.
Delirium Characteristic
Develops over a few hours or days and tends to have a fluctuating course. The disturbance is manifested by a reduced clarity of awareness of the environment and there is an accompanying change in cognition.
Hyperactive delirium
Restlessness/agitation, irritability, and aggression.
Hypoactive delirium
Latency in reaction and in response to verbal stimuli and psychomotor slowing.
Mixed delirium
Both hyperactive and hypoactive delirium.
Predisposing factors
Cognitive impairment, severity of illness, older age, depression, vision and/or hearing impairment, and functional impairment.
Precipitating factors: Noxious insults during hospitalization
Use of physical restraints, indwelling bladder catheter, metabolic disturbances such as azotemia, pH alterations, and nutritional deficiencies, polypharmacy, iatrogenic events, infection, particularly urinary tract and respiratory,
dehydration, electrolyte imbalances, especially those related to sodium and potassium, immobilization, acute hospital admission for fractures and hip surgery, medications with anticholinergic effects, environment, anxiety, and lack of sleep
Delirium in a patient with low
vulnerability
Delirium in a patient with low
vulnerability at hospital admission
requires an in-depth assessment and
management of potentially multiple
contributing factors.
Assessment
Should occur at admission and throughout the patient's hospital stay. Behaviors should be described in depth.
Mental status instruments
Mental status instruments
are helpful because they directly test
the patient's cognitive performance.
However, performance on mental
status tests is strongly affected by
age, educational level, ethnicity, and
language, and such tests may be difficult for acutely ill patients to perform.
Observational Instruments
Advantages include include the minimal response burden for patients, and both cognitive and behavioral function can be
observed and evaluated frequently.
A primary disadvantage of observational
instruments is that they do not
directly test cognitive and behavioral
function but are dependent on the
clinician's judgment.
Interventions
Identification of assessment risk, guidance for staff nurses, electrolyte balance, promotion of nutrition, orientation to current reality, consistent caregivers, pain management, med management, dc of catheter, early mobilization, appropriate use of eyeglasses and hearing aids, and sleep promotion.
Pharmacological interventions
Prophylactic use of haldol, antipsychotics, and neurontin.
Primary prevention
Primary prevention has been suggested to be the most effective strategy for reducing the overall incidence of delirium in patients
on medical-surgical units.
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