A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients.

OBJECTIVES: To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients. DESIGN: Longitudinal prospective before/after design (sequential design). SETTING: The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium. PARTICIPANTS: 60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12). INTERVENTION: (1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol. MEASUREMENTS: All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively. RESULTS: Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive. CONCLUSIONS: This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.

Utilization of mental health services among rural elderly.

Rural elders are an undeserved and vulnerable population with compromised access to health and human services leading to premature institutionalization. Even though elders living in rural areas have psychiatric illnesses that would prompt them to use mental health services, their use of these services remains low. This study developed predictive models of psychiatric hospitalization, use of mental health services, and use of crisis intervention by rural elders participating in an outreach case-management program. A combination of demographic, health status, and organizational variables were used in stepwise multiple regression. Being married and having supplemental insurance in addition to Medicare predicted 23% of the variance for utilization of psychiatric hospitalization. Only one variable, Medicaid, predicted 14% of the variance for use of mental health services. Type of caregiver, marital status, household composition, and Medicaid insurance accounted for 23% of the variance in utilization of crisis intervention by rural elders. Overall, the two variables that most likely predicted use of psychiatric mental health services were marital status and type of insurance.

Profiling care and benchmarking best practice in care of hospitalized elderly: the Geriatric Institutional Assessment Profile.

This article reports on a new instrument, the Geriatric Institutional Assessment Profile (GIAP), developed to assess (1) hospital workers' knowledge, attitudes, and perceptions regarding care of geriatric patients, and (2) the perceived adequacy of an institutional environment to serve geriatric patients' needs. Findings are reported from 303 questionnaires completed by health care employees from a 658-bed academic medical center. Internal consistency estimates were consistently high for the various components of the GIAP. Factor analysis was performed to examine underlying dimensions of knowledge and institutional environment. The GIAP has the potential to narrow the gap between actual and best practice in geriatric care by identifying staff information needs and concerns, as well as institutional barriers and facilitators to providing quality geriatric hospital care.

Rethinking geriatric nursing.

Geriatric nursing has radically progressed in the past 2 decades, moving from a custodial approach, to one that is anticipatory, evidenced-based, and proactive. This article provides a brief overview on the new thinking that is shaping geriatric nursing practice. Active interventions are discussed within the interdisciplinary mandate.

Differentiated nursing assessment of depressive symptoms in community-dwelling elders.

Because of the complexity in assessing elders for depressive symptoms, we recommend that nurses use a differentiated approach as an adjunct to clinical judgment and other assessment strategies. Based on our research and clinical experience, we advocate the joint use of the Hamilton Rating Scale for Depression and the Dementia Mood Assessment Scale, and propose a two-tiered assessment process. The first differentiation in this process is made by means of a cut-off score to determine whether or not depressive symptoms exist. If depressive symptoms are present, a second system of differentiation may be employed to identify discrete symptom factors. Application of this differentiated approach will enable the nurse to better understand and design interventions for each elder's specific presentation of depressive symptoms.

Delirium in the hospitalized elderly: nursing assessment and management.

Delirium is a serious health problem with significant negative consequences which is experienced by many hospitalized elderly patients. Because of its clinical impact and potential reversibility, prompt treatment of delirium is essential. Therefore an understanding of delirium, its manifestations, methods of detection, prevention, and treatment in hospitalized elderly patients is needed. This article provides an overview of the diagnostic and therapeutic dilemmas of delirium.

Compliance issues with the geriatric population: complexity with aging.

Nonadherence with the prescribed treatment regimen is a major issue in health care. This article focuses specifically on adherence issues in the geriatric population. The strengths and weaknesses of measurement methods to assess nonadherence with medication regimens are discussed. Determinants of noncompliance with special emphasis on risk factors for geriatric patients are described. Finally, an overview of preventative and restorative compliance interventions is given.

Nursing case management for psychogeriatric patients and their families: description of a clinical model.

A theoretical model of clinical case management for psychogeriatric patients and their families is described. Psychogeriatric patients often have complex health care needs, requiring specific nursing interventions. The increasing frailty of these patients over time, together with the risk for institutionalization, make professional nursing contribution to their care even more desirable. Nursing case management is described by means of a conceptual-operational continuum. On the conceptual site, the continuum includes a geriatric definition and core principles of case management. On the operational site, case management is described as a clinical system, a process, a technology, and a role. The process of case management is a deliberate, intellectual activity whereby the practice of nursing is approached in an orderly, systematic manner. It includes components of assessment, diagnosis, planning, implementation, and evaluation. The case management approach requires nurses to assume an active role in designing care maps and to work collaboratively with members of a multidisciplinary team.

Postoperative variation in neurocognitive and functional status in elderly hip fracture patients.

Regaining independence in the performance of activities of daily living (ADL) is a nursing priority in the postoperative care of hip fracture patients, though often impeded by a temporary yet reversible decrease in cognitive status postoperatively. This study investigated the incidence and evolution of decreased cognitive status in geriatric hip fracture patients from admission through to the fifth postoperative day, and the relationship between cognitive abilities and functional (ADL) status. Twenty-six elderly hip fracture patients (f: 21, m: 5) with a mean age of 79.5 years (SD = 8.2) admitted to the emergency room of an academic medical centre were monitored longitudinally from admission until the fifth postoperative day regarding neurocognitive status and ADL status, as measured by the mini-mental state exam (MMSE; including subscales of memory, linguistic ability, concentration and psychomotor executive skills) and an adapted version of the Katz ADL-scale, respectively. Patients were categorized on the basis of cognitive status as follows: no cognitive impairment (MMSE > or = 24), moderate (MMSE < or = 23 but > or = 18) and severe impairment (MMSE < or = 17). Nineteen of the 26 patients (73.1%) showed cognitive impairment (MMSE < or = 23) at some point in time before and/or after surgery. Some improvement in cognitive status was observed yet only selectively across patient cohorts and neurocognitive dimensions. Cognitive status, especially memorial ability and psychomotor executive skills, seemed to be most vulnerable to becoming impaired after hip fracture surgery. A relationship was found between cognitive and functional status, specifically, strong associations between memory and psychomotor skills relative to ADL and modest associations between linguistic ability and concentration relative to ADL. Further, patients with decreased cognitive status postoperatively remained more ADL-dependent than non-impaired patients. This study underscores the importance of a systematic assessment of the cognitive status of elderly hip fracture patients and linking these observations to functional ability in order to enhance the postoperative rehabilitation of this patient group.

Nursing and health care for an aging society: the case of The Netherlands.

1. Demographic developments in European and western countries are not unique. Nurses should embrace the opportunity to learn from each others' care and research initiatives for the elderly population. 2. Current transitions in health care systems should be seized as an opportunity to further establish and develop the nursing profession, for example, through joining and initiating multidisciplinary initiatives. 3. The aging population is the fastest growing population in a number of countries. The training, recruitment, and retainment of nursing staff are key to continuously provide high quality care for the elderly.

Factor structure of the Hamilton Rating Scale for Depression in a cohort of community-dwelling elderly.

We examined the factor structure of the 17-item Hamilton Rating Scale for Depression (HRS-D) in 206 community-dwelling elderly patients. Using principal components analysis and quartimax rotation, a four-factor structure involving all 17 items and accounting for 57.7% of the variance was desired. The factors represented the following dimensions of depressive symptomatology and illness: depressed affect, vegetative symptoms, anxiety, and agitation/insight. This factor structure reflects the presentation of depressive symptomatology and depressive illness in this population. Findings suggest that the HRS-D can be used for clinical assessment of depressive symptomatology along major dimensions of depressive illness in community-dwelling elderly.

Cluster analysis of psychogeriatric characteristics and service use among rural elders.

In developing models of psychiatric service delivery, nurses must be able to target groups on the basis of their health status and service needs. This investigation attempted to develop profiles of rural elderly, a significant risk population, by subjecting data on the psychogeriatric nursing status and health services utilization of 125 subjects to cluster-analytic methods. The cluster analysis yielded a three-cluster model: Cluster 1 (n = 39) predominantly comprised unmarried women in moderate health, but with a high degree of health service utilization; Cluster 2 (n = 53) had rural elders with moderate physical impairments, self-perceptions of poor health, and moderate health service utilization; and Cluster 3 (n = 33) comprised elders with severe cognitive and physical impairments and high health service utilization. Cluster 2 subjects were judged to be mild users of services because they were younger and married without a regular source of health care. Because subjects in Cluster 1 tended to be unmarried women who lived alone, with mild to moderate physical impairments and a regular source of health care, these subjects were assessed as moderate users of services. Cluster 3, which comprised the oldest and most impaired, both physically and cognitively, were judged to be intensive users of services.

Factor structure of the Dementia Mood Assessment Scale in a cohort of community-dwelling elderly.

We examined the factor structure of the 28-item Dementia Mood Assessment Scale (DMAS), an instrument to assess depressive symptoms in older adults with cognitive impairment, in a cohort of 165 community-dwelling elderly with varying degrees of cognitive impairment. Factor analysis using principal components analysis and varimax rotation was performed to explore the presence of subscales and examine construct validity. A five-factor structure involving all 28 items accounting for 63.2% of the variance in the DMAS scores was derived. Factors were named: Depressed Affect, Environmental Interaction, Diurnal Patterns, Agitation/Suspicion, and Somatic Indicators. This factor structure reflects the often differing presentations of depressive symptoms in older adults with varying degrees of cognitive function and establishes the construct validity of the DMAS in this population. We conclude that the DMAS may be used for differentiated clinical assessment of depressive symptoms along major dimensions of depressive illness in this cohort of elderly.

Risk profiles for institutionalization in a cohort of elderly people with dementia or depression.

Seventy-five elderly persons with dementia or depression, served by a nursing outreach assessment and case management service in Belgium, were entered in a risk profiling study. Cluster analysis yielded three clusters, each presenting a different risk profile for institutionalization: (1) High Risk Profile, with subjects of moderately advanced age, highly dependent for activities of daily living (ADL), with severe cognitive impairment, poor communication skills, and behavioral problems; (2) Moderate Risk Profile, with subjects of advanced age, limited ADL-dependency, yet high care demands for Instrumental ADL (IADL), moderate to severe cognitive impairment, adequate communication competency, and some behavioral problems; and (3) Low Risk Profile, consisting of relatively young elderly, partially ADL and IADL-dependent, mild or no cognitive impairment, good communication abilities, and no particular behavioral problems.

Mental health services for rural elderly: innovative service strategies.

This paper reviews issues in planning and delivering mental health services to rural dwelling elderly. First, comparative data on the prevalence of mental illness among rural elderly, and the availability and accessibility of mental health services in rural areas are presented to provide a basis for subsequent discussion. Next, several strategies for improving the development and delivery of geriatric mental health services to rural areas are discussed. These include: increasing the number and quality of rural mental health providers; adapting or developing diagnostic techniques to improve case identification among rural elderly; providing culturally sensitive mental health services; strengthening informal and formal care linkages in rural communities; developing innovative service delivery models building upon the strengths of rural settings; and emphasizing fluidity as well as continuity in treatment models.

Using elderly volunteers to care for the elderly: opportunities for nursing.

A growing population of educated and skilled younger retirees may help provide volunteer services to the growing population of frail elderly in homes, hospitals, and community agencies. Nursing professionals are in key positions to provide insight and guidance in the development of programs that offer new opportunities for older volunteers. Program structures that encourage collaboration, cooperation, and innovation among professionals and volunteers have the potential to increase health care services while decreasing economic challenges.

Classification systems in nursing: formalizing nursing knowledge and implications for nursing information systems.

The development of nursing information systems (NIS) is often hampered by the fact that nursing lacks a unified nursing terminology and classification system. Currently there exist various initiatives in this area. We address the question as to how current initiatives in the development of nursing terminology and classification systems can contribute towards the development of NIS. First, the rationale behind the formalization of nursing knowledge is discussed. Next, using a framework for nursing information processing, the most important developments in the field of nursing on formalization, terminology and classification are critically reviewed. The initiatives discussed include nursing terminology projects in several countries, and the International Classification of Nursing Practice. Suggestions for further developments in the area are discussed. Finally, implications for NIS are presented, as well as the relationships of these components to other sections of an integrated computerized patient record.