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SERIES

The Gerontological Clinical Nurse Specialist’s Role in Prevention, Early Recognition, and Management Of Delirium in Hospitalized Older Adults
Deborah Marks Conley

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rofessional nurses continue to focus on providing best practices for safe and effective patient and family care, even with increasing pressure to decrease costs and improve patient outcomes. Support for nursing practice at the bedside is an essential cost-effective step toward this endeavor. Employing the expertise of the advanced practice registered nurse (APRN), a gerontological clinical nurse specialist (GCNS) can increase awareness and facilitate rapid identification of critical problems, such as delirium in the aging inpatient population. Implementation of gerontological nursing best practices in hospitalized patients with delirium has demonstrated a positive impact on the overall outcome for these patients.

The purpose of this article is to describe the role of the acute care gerontological clinical nurse specialist (GCNS) and provide an exemplar of using GCNS expertise in the implementation of gerontological nursing best practices in hospitalized patients with delirium. © 2011 Society of Urologic Nurses and Associates Urologic Nursing, pp. 337-343.
Key Words: Advanced practice registered nurse (APRN), gerontological clinical nurse specialist (GCNS), delirium, Hartford Center for Geriatric Nursing, geriatrics, older adult, gerontological nursing.

Objectives 1. Explain the development of the advanced practice nurse role. 2. Describe the role of the gerontological clinical nurse specialist. 3. Discuss delirium in the older adult population and evidencebased practice tools used for screening.

Demographics of Aging The United States population is aging exponentially. Each day, 10,000 individuals turn 65 years of age, and 100 individuals turn 100 years old (National Institute on Aging [NIA], 2011). An esti-

Deborah Marks Conley, MSN, APRNCNS, GCNS-BC, FNGNA, is a Gerontological Clinical Nurse Specialist-Advanced Practice Registered Nurse, Nebraska Methodist Hospital, Omaha, NE, and Nebraska Methodist College, Omaha, NE. Note: Objectives and CNE Evaluation Form appear on page 343. Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

mated 50% of all hospital admissions are age 65 or older (NIA, 2011). Demands are being placed on health care systems to meet the specialized needs of this population and enhance gerontological nurse competence.

Urologic Nursing Editorial Board Statements of Disclosure
In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below. Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’ Bureau for Coloplast. All other Urologic Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article.

UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6

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especially in post-op patients Primary discharge diagnosis of cardiovascular disorders * Severe risk for delirium. implemented her vision of preparing the psychiatric CNS at the master’s degree level at Rutgers University. Risk Factors for Delirium Dementia* – Increases risk 2. and systems leadership. nurse practitioner. 2009). The DNP curriculum builds on traditional master’s programs by providing education in focused areas of evidence-based practice. or suspected encephalitis Source: Spivack. the three spheres of influence model (patient. which focuses on population. quality improvement. Today. In 1953. nurses/ 338 Table1. particularly that of advanced practice registered nurses (APRNs). American Association of Colleges of Nursing (AACN). These include the CNS. focused neurological findings. 2010. NACNS supports the wide range of specialties in which the CNS practices. four distinct master’s-prepared APRN roles are recognized by the American Nurses Association (ANA). occult infections. certified nurse-midwife. Innovations in health care and nursing practice have dramatically changed the role of the nursing profession. Each APRN practice is unique. and most State Boards of Nursing. UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 .SERIES The Development of the Advanced Practice Role The clinical nurse specialist (CNS) was the first advanced practice role to require a master’s degree in nursing. For the purpose of this article. but the focus includes implementing evidencebased practice.to 3-fold Advancing age* (85 or older) Alcohol abuse* Impaired physical function/mobility* Sensory impairment* On 4 or more drugs* Decreased albumin or protein-energy malnutrition* Sleep deprivation* Dehydration* Undiagnosed medical conditions – Infections* Fracture on admission Male gender Pain Depression Admitted emergently Incontinence Fecal impaction Psychiatric co-morbidity. fever of unknown origin. Table 2. 2011). 2010. quality improvement/patient outcomes. head trauma. Hildegard Peplau. Nurses pursuing APRN roles today are encouraged to obtain a doctorate in nursing practice (DNP). or Montreal Cognitive Assessment) Pain evaluation using appropriate pain scales Nutritional assessment Targeted laboratory tests (drug levels. Mini-Cog.or disease-specific nursing practices (Joel. Source: Spivack. use Beer’s list of potentially inappropriate drugs for older adults) Cognitive assessment (Modified Mini-Mental State Examination. The National Association of Clinical Nurse Specialists (NACNS) identified three distinct models of CNS practice in its CNS Core Competencies Executive Summary. and certified registered nurse anesthetist. and information and technology. She led the way to current CNS practice. Complete Evaluation for Patient with Delirium History and physical with focused neurological examination Collateral source history for validation (family or friend) Thorough medication review (benzodiazepine/alcohol history. The DNP is a terminal degree in nursing practice and offers an alternative to research-focused PhD programs (AACN. and metabolic abnormalities) Radiology (chest X-ray) ECG (identify underlying arrhythmias) MRI – Brain imaging for history of recent fall. a pioneer in CNS practice.

family and friends at bedside Private room. mentoring. drug toxicity. dehydration. and consultation with nursing staff (nurses/nursing practice). Foreman. Protocols for Nursing Intervention Personal Care Needs Pain assessment/management with scheduled dose analgesia when appropriate Nutritional support Thirst – Oral and/or IV fluid intake Promote continence and evaluate urine output/bowel movements Maximize mobility to decrease deconditioning and improve cognitive status Pressure ulcer prevention and skin care Eliminate potential risk factors. Clinical practice is continuously evaluated. Interprofessional collaboration. medications Review goals of care pneumonia. and practice innovations are refined based on expertise. The Gerontological Clinical Nurse Specialist The GCNS promotes an environment of excellence. consult MD for use of low-dose haloperidol (Haldol®) to promote REM sleep.SERIES nursing practice. alcohol withdrawal. which supports a culture of inquiry to improve clinical and health system outcomes. 2467). 2010). evidence. Katz. Table 3. if possible Noise reduction Fall risk reduction Sensory aids as appropriate Avoid physical restraints Symptom Control Aggressive daily assessment with standardized tools Sleep hygiene Delirium prevention bag (see Figures 1 and 2) Review and limit number of medications ordered Obtain pharmacy consult Vital signs monitoring and management For psychotic-type behaviors (hallucinations. A significant proportion of delirium is preventable by identifying modifiable risk factors and using a standardized assessment 339 UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 . Delirium is underrecognized by clinicians and is often mistaken as a “normal part of aging” (Inouye. or electrolyte/metabolic imbalance). Patient-Family Involvement and Education (see Figure 3) Ask family to stay with patient when possible Explain in simple terms – Delirium. 2004). such as identifying/treating infections and avoiding high-risk medications. The underlying cause of delirium is usually a disease process outside of the central nervous system (such as urinary tract infection. The GCNS mentors other health care providers in evaluating and using research findings to implement best practices in the care of older adults and their families. 2001. & Cooney. with alterations in the sleep-wake cycle and psychomotor behavior. Mion. maximize oxygen therapy as appropriate Environment Promote reality orientation and validation of feelings Supervised with minimal stimulation Temperature control and use of warm blankets Low light/night lights Remove hazards from environment Foster familiarity with consistent staff. The Phenomena of Delirium Delirium is among the oldest phenomena known to medicine. or for patients who pose a safety hazard to themselves or others. transient symptoms that manifests as acute impairment in cognition and attention. • Education. is fundamental GCNS practice (McCabe & Raudonis. It is a cluster of multifactorial. recognition. delusions. disease processes. This example highlights GCNS practices in all three spheres of influence as defined by NACNS: • Advanced assessment and care coordination (patient). • Computerization of standardized evidence-based tools/ protocols (organizational/systems). such as intubation. p. and outcome and benchmarking data. severe pain. which facilitates the achievement of best practices. belongings from home. and organizational/systems) will be used to provide the foundation of the GCNS practice (NACNS. which interrupt essential medical therapies. An excellent example of GCNS acute care practice is the prevention. and severe agitation). and management of delirium.

rehabilitation. agitation. With early intervention. 2011). employs the Attention Screening Exam. if delirium is suspected. which includes five thought questions (Ely et al. turn off TV.. An estimated 2. It contributes to falls. Inouye et al. inattention. 2011). alcoholic dementia. including acute onset and fluctuating course.. nurses can identify patients at severe risk for delirium upon admission to the hospital. Source: Reprinted with permission from Nebraska Methodist Hospital. close drapes. which can be included in the electronic medical record. Both tools focus on key characteristics of delirium. long-term institutionalization. The overall total costs attributable to delirium average from $3. and delirium increases the average length of hospital stay by 6 days (Rubin et al. glasses) • Quiet environment. fractures. Nursing interven- Source: Reprinted with permission from Nebraska Methodist Hospital.000 per patient per hospitalization (Rubin et al. What is Delirium? Delirium is not a disease. and altered levels of consciousness. 1990). Parkinson’s dementia. and caregiver burden. Alzheimer’s disease. When the patient is pulling at tubes and or IV lines. avoid arguments and saying “no” or “can’t” • “Re-orienting” the patient often increases frustration • Use sensory aids (pocket talker. Delirium Prevention Bag and nursing management protocol (Rubin. vascular dementia.. as well as long-term cognitive and functional impairment. keeping them occupied with these Diversional Activities can help. the Spiritual Well-Being TV Network on Channel 11 can be turned on to provide calming music and photos. Delirium is usually reversible. The CAM-ICU has been validated in non-verbal ICU patients and adds the key elements of the Richmond Agitation and Sedation scale. a GCNS. Two of the most important risk factors for the development of delirium are advancing age and patients with existing dementia (for example. which validates a measure of consciousness. & reduce visitors • Optimize rest & uninterrupted sleep • Mobilize patient when possible with staff help • Provide and encourage intake of good nutrition • Monitor & treat pain with staff help • Bring familiar items from home (pictures…) Additional education on this subject is found in this bag. it is associated with increased mortality and hospital costs. 2001). All items provided can be shared with the patient to determine which ones are of interest and helps keep the patient occupied. Patients should be evaluated during each shift using a standardized assessment tool. or a geriatric nurse practitioner (see Table 2). 340 UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 . home care services. This intervention is intended to help patients who are experiencing behavioral and or cognitive issues (memory. Patients with a positive screen or those with a known diagnosis of delirium should be evaluated further by a physician. hearing aides.SERIES Figure 1. or confusion) while hospitalized. Malnutrition. The Confusion Assessment Method (CAM) and CAMICU (in intensive care units) are evidence-based tools for adoption into clinical practice.3 million older adults are hospitalized each year. and the introduction of more than three new medications in a 24-hour period significantly contribute to the development of delirium in older adults (see Table 1). 2001. or trying to get out of bed. therefore the entire bag should be taken to the patient’s room and the bag becomes the property of the patient and can be sent home with him or her. Screening positive for delirium requires the presence of the first two characteristics and either the third or the fourth characteristic. Delirium Prevention Bag Tag (Front & Back) Delirium Prevention and Diversional Activities Bag This Delirium Prevention and Diversional Activities bag is for a single-patient use. Nurses can administer these quick and easy-to-use tools in less than five minutes per patient. the use of physical restraints or indwelling urethral catheters. It is characterized by: • Disordered thinking • Hallucinations • Fluctuating confusion • Reduced ability to focus Delirium often causes changes in behavior including: • Anxiety • Agitation • Aggression • Apathy How can you help? • Familiar faces of family provide comfort & decrease fears • Validate feelings. Annual hospital costs are over $8 billion dollars for patients experiencing delirium. Post-hospitalization costs are even higher – roughly $100 billion for institutionalization.. After the nurse administers the CAM or CAM-ICU. & Inouye. and frontaltemporal lobe dementia). and death. a search for underlying contributing factors is essential. Hassan. These tools provide a standardized assessment for delirium recognition (Ely et al.000 to $6.. disorganized thinking. Fenlon. The CAM has a sensitivity rate of 94% and a specificity rate of 89%. however. Neal. 2011). In addition. Contact Recreational Therapy if you need more supplies or bags. Figure 2.

– Infection causes chills. What causes delirium? • Advanced age. hearing aides. pulling at tubes. explain all procedures. 1999. – Increased sodium causes high blood pressure. UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 . and muscle stiffness. nutrition. Delirium is a common. call patient by name. and fluctuates (gets worse. increases length of hospital stay by 5 to 6 days.. depression. agitation. serious. What complications are associated with delirium? • Potential for pressure ulcers. then better). Communication: • Calmly. infections. • Reduce the risk of falls by using a sit-stand alarm. “Reorienting” the patient often increases frustration. Delirium is a prognostic marker for functional and cognitive decline. infection. can increase mortality.” but instead. • Educate family about a quiet environment. Understanding the severity of poor outcomes for these patients can help nurses ensure early assessment and appropriate 341 Delirium in Hospitalized Older Adults What is delirium? • A disturbance in consciousness with reduced ability to focus or shift attention. Recognition of risk factors and preventing the initial development of delirium upon admission improves patient outcomes. weakness. Patient Care Sitter Responsibilities: • Accurately monitor intake and output. and some side effects may continue even after hospitalization. lethargy. turn off TV. – Hypoxia (caused by infection. 2008. illness. paranoia. sensory deprivation. The GCNS is prepared as an expert practitioner in care of older adults and plays a vital role in framing health care systems for the future. • Avoid arguments and saying “no” or “can’t. therefore. What are the symptoms of delirium? • Restlessness. fever. slowly introduce yourself. fluids. The NACNS spheres of influence model is an excellent framework for a gerontological nursing best-practices approach to delirium prevention and care. pulmonary emboli. and irregular breathing. and potentially preventable source of morbidity and mortality among hospitalized older adults. maybe unable to return home. attempt using consistent caregivers. anorexia. immobility. Sudden onset of impaired attention. incoherent speech. – Dehydration causes low blood pressure. chronic obstructive lung disease. the GCNS could facilitate implementation of the Hospital Elder Life Program (HELP) for delirium prevention. clearly. with protocols focusing on four main areas: personal care needs environment.SERIES Figure 3. restlessness. brain impairment. poor appetite. develops quickly. symptom control. 2011).. provide oral hygiene. and lightheadedness. and reduce visitors. Source: Fick & Mion. psycho-motor agitation-restlessness. validate the patient’s feelings. alcohol use. or anemia). lightheadedness. use sensory aids (pocket talker. picking at the air. and manage delirium in hospitalized older adults. fever. dry mouth. many medications. glasses). This innovative care model has been used successfully in various hospital settings to prevent delirium and decrease functional decline by utilizing trained volunteers along with professional staff to provide best practices (Inouye et al. • Ambulate and assist patient up for all meals unless physician has ordered bed rest. protect from hazards and minimize changes. change in vital signs. and disorientation. lethargy. Additionally. hallucinations. and ask simple closed-ended questions (yes /no answers) and wait for response. agitation. let patients know you hear what they are saying. keep things close and bed in low-locked position. recognize. lethargy. close drapes. – Pain contributes to restlessness. frequent (every 2 hours) toileting. Patient/Family Education Handout tions should be multi-component. moaning. and/or nausea. pain. dehydration. and patient-family involvement and education (see Table 3). What can be done for the patient who experiences delirium? Behavioral: • Reassure patient and family. and low heart rate. and comfort. weakness. and abnormal blood sodium or potassium levels. falls. Summary The GCNS plays a vital role in implementing and sustaining health system initiatives to empower nurses to prevent. lack of sleep. Mentoring staff nurses in evidencebased practice and participating in the interdisciplinary care of older adults is a key role of the GCNS. uninterrupted rest. disturbance in sleep-awake cycle. validating feelings is more successful. chills. Processes and protocols can be implemented to recognize risk factors for delirium and intervene aggressively for prevention (see Figures 1-3). reduce stimulation. pulling at curtains. Rubin et al. nausea.

... A new method for detection of delirium. and improved compliance with Joint Commission standards (HIGN. About the National Gerontological Nursing Association. Sustainability and scalability of the hospital elder life program at a community hospital. Jr. Joel. NICHE organizations have demonstrated improved patient outcomes. A multi-component intervention to prevent delirium in hospitalized older patients.. Spivack.gov/NewsAndEvents/ Nurses Improving Care for Healthsystem Elders (NICHE).org/public/public-main. Mion. Prompt assessment for causative factors and engaging the interdisciplinary team early promotes positive outcomes on all levels.pdf Need CNE? Visit www. J. Retrieved from http://nursingcertification. Additional Reading National CNS Competency Task Force. Rubin. Acampora. Harrisburg. Journal of the American Geriatrics Society. HIGN supports the new Resourcefully Enhancing Aging in Specialty Nursing (REASN) project.edu/Media/FactSheets/dnp. McCabe.nia. 2011. (2010). 669-676. Fick. Fenlon. Retrieved from http:// www. L.. S.. Its Web site provides clinicians and families with resources about HELP and materials about delirium (www. K... S. S. L. 2011). K..html National Institute on Aging (NIA). (2011. (1990). Retrieved from http:// www. 2006-2008 CNS core competencies executive summary. Alessi.A.. 108(1). L. Neal. Silver Spring.org 342 UROLOGIC NURSING / November-December 2011 / Volume 31 Number 6 .. The NICHE Program. 2011).A.K. L.hartfordign. The doctor of nursing practice (fact sheet). Jr..K.H. How to try this: Delirium superimposed on dementia. Katz. S. Statement on clinical nurse specialist practice and education (2nd ed. R. 941-948. Siegal. NICHE.. (2011). Journal of the American Medical Association. D. T. National Association of Clinical Nurse Specialists (NACNS)..nih. S. 2011). Hassan. S. Home page... Retrieved from http:// www. & Cooney. S.A. Hartford Institute for Geriatric Nursing (HIGN). 2703-2710. PA: Author. The Hospital Elder Life Program (HELP) is a patient care program designed to prevent delirium in hospitalized older adults. Dr.K. Clarifying confusion: the confusion assessment method. Delirium in mechanically ventilated patients: Validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).H. Bernardm G..). D.) What’s new. van Dyck. Gerontological nursing: Scope and standards of practice.org/about/core-purposea-values.K. National Gerontological Nursing Association (NGNA). 340(9). Philadelphia: F.clinicalgeriatrics.R. a five-year initiative to increase the knowledge and skills of nurses in specialty areas and nursing organizations in the delivery of appropriate and evidence-based care to older adults. B. Additionally.. Nurses Recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine. Davis Company. P.nicheprogram. The CAM Tool and the CAM-ICU “Try This” Series can be accessed at www. (2001). Annals of Internal Medicine.com/articles/ Dr-Sharon-Inouye-Presents-LectureDelirium-Elderly diagnostic testing. B. Balkin. L. http://www. hospitalelderlifeprogram. NICHE is the leading organization designed to support health care professionals in improvement of clinical skills and nursing competence in the care of older adults. Leo-Summers. (2008). (2009).aacn.ngna. C.. nche.S. This professional nursing organization focuses on improving the quality of nursing care provided to older adults across diverse care settings (NGNA. Foreman. 113. org/program_overview. A. In 2002.T..M.org Inouye. Francis. Charpentier.suna. 59(2). & Raudonis.org/Practice/ConsultGeriRN/ Vanderbilt University Medical Center CAM-ICU tool and resources can be found at www. htm Ely. altering current treatment or managing the environment.M. Another key gerontological nursing resource is the National Gerontological Nursing Association (NGNA). & Inouye. The Society of Urologic Nurses and Associates (SUNA) participated in this initiative in 2005. R.D. HIGN and the American Nurses Association (ANA) launched the Nurse Competence in Aging (NCA) program..I. (2011).). 52-60. (2004). Retrieved from http://hartfordign. The New England Journal of Medicine.H.. K. M. & Horwitz.. S. F. … Dittus. L.SERIES Appendix Gerontological Nursing Resources The Hartford Institute for Geriatric Nursing (HIGN) at New York University designates health care organizations that implement and sustain system-wide gerontological nursing best practices at Nurses Improving Care for Healthsystem Elders (NICHE) facilities. May. 359-365.R.ICUDELIRIUM. MD: American Nurses Association. L. E. American Journal of Nursing. S. (2010). 286(21). (2011).. (2010).. & Mion. Gordon.org/ pdf/Exec%20Summary%20-%20Core %20CNS%20Competencies. (2001). Inouye. Bogardus. Advanced practice nursing essentials for role development (2nd ed. higher satisfaction scores..P.org/ Inouye. References American Association of Colleges of Nursing (AACN). 2467-2473.. C.K. Holford. 161.. Inouye.php). (2011).W. (1999). Sharon Inouye presents lecture on delirium in the elderly. Retrieved from http://www. which focuses on enhancing gerontological nursing care and increasing involvement of specialty nursing associations in improving nursing competencies in providing care to older adults (HIGN. & Cooney..C. B. (2011).

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