Description of Methods Used to Formulate the Recommendations
June 2004 Guideline
In January of 2003, a panel of nurses and researchers with expertise in practice, education, and research related to gerontology and geriatric mental health care was convened under the auspices of the Registered Nurses' Association of Ontario (RNAO). At the onset, the panel discussed and came to a consensus on the scope of the best practice guideline.
Following the extraction of identified recommendations and content from eight guidelines, the panel underwent a process of review, discussion, and consensus on the key evidence-based assessment criteria.
The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to consensus on a draft guideline.
2010 Supplement
The Registered Nurses' Association of Ontario has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline.
A panel of nurses was assembled for this review, comprised of members from the original development panel as well as other recommended individuals with particular expertise in this practice area. A structured evidence review based on the scope of the original guideline and supported by three clinical questions was conducted to capture the relevant literature and guidelines published since the publication of the original guideline in 2004.
Initial findings regarding the impact of the current evidence, based on the original recommendations, were summarized and circulated to the review panel. The revision panel members were given a mandate to review the original guideline in light of the new evidence, specifically to ensure the validity, appropriateness and safety of the guideline recommendations as published in 2004.
In October 2009, the panel was convened to achieve consensus on the need to revise the existing set of recommendations. A review of the most recent studies and relevant guidelines published since June 2004 does not support dramatic changes to the recommendations, but rather suggests some refinements and stronger evidence for the approach.
In January of 2003, a panel of nurses and researchers with expertise in practice, education, and research related to gerontology and geriatric mental health care was convened under the auspices of the Registered Nurses' Association of Ontario (RNAO). At the onset, the panel discussed and came to a consensus on the scope of the best practice guideline.
Following the extraction of identified recommendations and content from eight guidelines, the panel underwent a process of review, discussion, and consensus on the key evidence-based assessment criteria.
The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to consensus on a draft guideline.
2010 Supplement
The Registered Nurses' Association of Ontario has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline.
A panel of nurses was assembled for this review, comprised of members from the original development panel as well as other recommended individuals with particular expertise in this practice area. A structured evidence review based on the scope of the original guideline and supported by three clinical questions was conducted to capture the relevant literature and guidelines published since the publication of the original guideline in 2004.
Initial findings regarding the impact of the current evidence, based on the original recommendations, were summarized and circulated to the review panel. The revision panel members were given a mandate to review the original guideline in light of the new evidence, specifically to ensure the validity, appropriateness and safety of the guideline recommendations as published in 2004.
In October 2009, the panel was convened to achieve consensus on the need to revise the existing set of recommendations. A review of the most recent studies and relevant guidelines published since June 2004 does not support dramatic changes to the recommendations, but rather suggests some refinements and stronger evidence for the approach.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
The
development process yielded an initial set of recommendations. The panel
members as a whole reviewed the recommendations, discussed gaps and
available evidence, and came to consensus on a draft guideline.
The draft (2004 guideline) was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various health care disciplines as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel. Discussion and consensus resulted in revisions to the draft document prior to publication and evaluation.
The draft (2004 guideline) was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various health care disciplines as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel. Discussion and consensus resulted in revisions to the draft document prior to publication and evaluation.
Recommendations
Major Recommendations
Note from the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO):
In October 2009, the panel was convened to achieve consensus on the
need to revise the existing set of recommendations. A review of the most
recent studies and relevant guidelines published since June 2004 does
not support dramatic changes to the recommendations, but rather suggests
some refinements and stronger evidence for the approach.
The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. See the original guideline document for additional information provided in the "Discussion of Evidence."
Practice Recommendations for Delirium
Recommendation 1.1
Nurses should maintain a high index of suspicion for the prevention, early recognition, and urgent treatment of delirium to support positive outcomes.
(Level of Evidence = IIa)
Recommendation 1.2
Nurses should use the diagnostic criteria from the Diagnostic and Statistical Manual (DSM) IV-R to assess for delirium, and document mental status observations of hypoactive and hyperactive delirium.
(Level of Evidence = IV)
Recommendation 1.3
Nurses should initiate standardized screening methods to identify risk factors for delirium on initial and ongoing assessments.
(Level of Evidence = IIa)
Recommendation 1.4
Nurses have a role in prevention of delirium and should target prevention efforts to the client's individual risk factors.
(Level of Evidence = Ib)
Recommendation 1.5
In order to target the individual root causes of delirium, nurses working with other disciplines must select and record multi-component care strategies and implement them simultaneously to prevent delirium.
Recommendation 1.5.1
Consultation/Referral
Nurses should initiate prompt consultation to specialized services.
Recommendation 1.5.2
Physiological Stability/Reversible Causes
Nurses are responsible for assessing, interpreting, managing, documenting, and communicating the physiological status of their client on an ongoing basis.
Recommendation 1.5.3
Pharmacological
Nurses need to maintain awareness of the effect of pharmacological interventions, carefully review the older adults' medication profiles, and report medications that may contribute to potential delirium.
Recommendation 1.5.4
Environmental
Nurses need to identify, reduce, or eliminate environmental factors that may contribute to delirium.
Recommendation 1.5.5
Education
Nurses should maintain current knowledge of delirium and provide delirium education to the older adult and family.
Recommendation 1.5.6
Communication/Emotional Support
Nurses need to establish and maintain a therapeutic supportive relationship with older adults based on the individual's social and psychological aspects.
Recommendation 1.5.7 (Updated 2010)
Behavioural Strategies
Behavioural strategies: Nurses have a role in the prevention, identification and implementation of delirium care approaches to minimize responsive behaviours of the person and provide a safe environment. Further, it is recommended that restraints should only be used as a last resort to prevent harm to self and others.
Recommendation 1.6
Nurses must monitor, evaluate, and modify the multi-component intervention strategies on an ongoing basis to address the fluctuating course associated with delirium.
(Level of Evidence = IIb)
Practice Recommendations for Dementia
Recommendation 2.1
Nurses should maintain a high index of suspicion for the early symptoms of dementia to initiate appropriate assessments and facilitate individualized care.
(Level of Evidence = IIa)
Recommendation 2.2
Nurses should have knowledge of the most common presenting symptoms of Alzheimer disease, vascular dementia, frontotemporal lobe dementia, and Lewy body dementia, and be aware that there are mixed dementias.
(Level of Evidence = IV)
Recommendation 2.3
Nurses should contribute to comprehensive standardized assessments to rule out or support the identification and monitoring of dementia based on their ongoing observations and expressed concerns from the client, family, and interdisciplinary team.
(Level of Evidence = III)
Recommendation 2.4
Nurses should create partnerships with family members or significant others in the care of clients. This is true for clients who live in either the community or in healthcare facilities.
(Level of Evidence = III)
Recommendation 2.5
Nurses should know their clients, recognize their retained abilities, understand the impact of the environment, and relate effectively when tailoring and implementing their caregiving strategies.
(Level of Evidence = III)
Recommendation 2.6
Nurses caring for clients with dementia should be knowledgeable about pain assessment and management in this population to promote physical and emotional well-being.
(Level of Evidence = IV)
Recommendation 2.7
Nurses caring for clients with dementia should be knowledgeable about nonpharmacological interventions for managing behaviour to promote physical and psychological well-being.
(Level of Evidence = III)
Recommendation 2.8 (Updated 2010)
Nurses caring for clients with dementia should be knowledgeable about pharmacological interventions, and contribute to the decisions and education regarding the risks and benefits of medication for targeted symptoms, monitor for efficacy and side effects, document response, and advocate for re-evaluation and withdrawal of psychotropics after a time period of behavioural stability.
(Level of Evidence = Ia)
Recommendation 2.9 (Updated 2010)
Nurses caring for older adults should promote healthy aging and protective strategies to minimize the risk of future cognitive changes.
(Level of Evidence = IIa)
Recommendation 3.1
Nurses should maintain a high index of suspicion for early recognition/early treatment of depression in order to facilitate support and individualized care.
(Level of Evidence = IV)
Recommendation 3.2
Nurses should use the diagnostic criteria from the DSM IV-R to assess for depression.
(Level of Evidence = IV)
Recommendation 3.3
Nurses should use standardized assessment tools to identify the predisposing and precipitating risk factors associated with depression.
(Level of Evidence = IV)
Recommendation 3.4
Nurses must initiate prompt attention for clients exhibiting suicidal ideation or intent to harm others.
(Level of Evidence = IV)
Recommendation 3.5
Nurses must be aware of multi-component care strategies for depression:
Recommendation 3.5.1
Nonpharmacological interventions
Recommendation 3.5.2
Pharmacological caregiving strategies
(Level of Evidence = Ib)
Recommendation 3.6
Nurses need to facilitate creative client/family/community partnerships to ensure quality care that is individualized for the older client with depression.
(Level of Evidence = IV)
Recommendation 3.7
Nurses should monitor the older adult for re-occurrence of depression for 6 months to 2 years in the early stages of recovery and ongoing for those with chronic depression.
(Level of Evidence = Ib)
Practice Recommendations for Delirium, Dementia, and Depression
Recommendation 4.1 (Updated 2010)
In consultation/collaboration with the interdisciplinary team:
In care settings where Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) instruments are mandated assessment tools, nurses should utilize the MDS data to assist with assessment for delirium, dementia and depression.
(Level of Evidence = III)
Recommendations 4.3
Nurses should avoid physical and chemical restraints as first line care strategies for older adults with delirium, dementia, and depression.
(Level of Evidence = III)
Education Recommendation
Recommendation 5.1
All entry-level nursing programs should include specialized content about the older adult such as normal aging; involvement of client and family throughout the process of nursing care; diseases of old age; assessment and management of delirium, dementia and depression; communication techniques; and appropriate nursing interventions.
(Level of Evidence = IV)
Organization and Policy Recommendations
Recommendation 6.1
Organizations should consider integration of a variety of professional development opportunities to support nurses in effectively developing knowledge and skills to provide care for older adults with delirium, dementia and depression.
(Level of Evidence = IV)
Recommendation 6.2
Healthcare agencies should implement a model of care that promotes consistency of the nurse/client relationship.
(Level of Evidence = IIb)
Recommendation 6.3
Agencies should ensure that nurses' workloads are maintained at levels conducive to care of persons with delirium, dementia and depression.
(Level of Evidence = IV)
Recommendation 6.4
Staffing decisions must consider client acuity, complexity level, and the availability of expert resources.
(Level of Evidence = III)
Recommendation 6.5
Organizations must consider the nurses' well-being as vital to provide care to persons with delirium, dementia and depression.
(Level of Evidence = III)
Recommendation 6.6
Healthcare agencies should ensure the coordination of care through the appropriate processes to transfer information (e.g., appropriate referrals, communication, documentation, policies that support formal methods of information transfer, and networking between health care providers).
(Level of Evidence = IV)
Recommendation 6.7 (Delirium)
Brief screening questions for delirium should be incorporated into nursing histories and/or client contact documents with opportunity to implement care strategies.
(Level of Evidence = IV)
Recommendation 6.8 (Delirium)
Organizations should consider delirium programs that contain screening for early recognition and multi-component interventions for treatment of clients with, but not limited to, hip fractures, post-operation surgery, and those with complex medical conditions.
(Level of Evidence = IV)
Recommendation 6.9 (Depression)
Caregiving activities for the older adult presenting with depression and/or suicidal ideation should encompass primary, secondary and tertiary prevention practices.
(Level of Evidence = IV)
Recommendation 6.10
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
(Level of Evidence = IV)
The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. See the original guideline document for additional information provided in the "Discussion of Evidence."
Practice Recommendations for Delirium
Recommendation 1.1
Nurses should maintain a high index of suspicion for the prevention, early recognition, and urgent treatment of delirium to support positive outcomes.
(Level of Evidence = IIa)
Recommendation 1.2
Nurses should use the diagnostic criteria from the Diagnostic and Statistical Manual (DSM) IV-R to assess for delirium, and document mental status observations of hypoactive and hyperactive delirium.
(Level of Evidence = IV)
Recommendation 1.3
Nurses should initiate standardized screening methods to identify risk factors for delirium on initial and ongoing assessments.
(Level of Evidence = IIa)
Recommendation 1.4
Nurses have a role in prevention of delirium and should target prevention efforts to the client's individual risk factors.
(Level of Evidence = Ib)
Recommendation 1.5
In order to target the individual root causes of delirium, nurses working with other disciplines must select and record multi-component care strategies and implement them simultaneously to prevent delirium.
Recommendation 1.5.1
Consultation/Referral
Nurses should initiate prompt consultation to specialized services.
Recommendation 1.5.2
Physiological Stability/Reversible Causes
Nurses are responsible for assessing, interpreting, managing, documenting, and communicating the physiological status of their client on an ongoing basis.
Recommendation 1.5.3
Pharmacological
Nurses need to maintain awareness of the effect of pharmacological interventions, carefully review the older adults' medication profiles, and report medications that may contribute to potential delirium.
Recommendation 1.5.4
Environmental
Nurses need to identify, reduce, or eliminate environmental factors that may contribute to delirium.
Recommendation 1.5.5
Education
Nurses should maintain current knowledge of delirium and provide delirium education to the older adult and family.
Recommendation 1.5.6
Communication/Emotional Support
Nurses need to establish and maintain a therapeutic supportive relationship with older adults based on the individual's social and psychological aspects.
Recommendation 1.5.7 (Updated 2010)
Behavioural Strategies
Behavioural strategies: Nurses have a role in the prevention, identification and implementation of delirium care approaches to minimize responsive behaviours of the person and provide a safe environment. Further, it is recommended that restraints should only be used as a last resort to prevent harm to self and others.
Note: This recommendation has been
changed from behavioural interventions to behavioural strategies. This
subsection has had a change in terminology from disturbing behaviour to
responsive behaviours of the person to reflect new language in regards
to demonstrated client behaviours. The last sentence of the
recommendation has been changed to reflect restraints should only be
used as a last resort to prevent harm to self and others.
(Level of Evidence = III)Recommendation 1.6
Nurses must monitor, evaluate, and modify the multi-component intervention strategies on an ongoing basis to address the fluctuating course associated with delirium.
(Level of Evidence = IIb)
Practice Recommendations for Dementia
Recommendation 2.1
Nurses should maintain a high index of suspicion for the early symptoms of dementia to initiate appropriate assessments and facilitate individualized care.
(Level of Evidence = IIa)
Recommendation 2.2
Nurses should have knowledge of the most common presenting symptoms of Alzheimer disease, vascular dementia, frontotemporal lobe dementia, and Lewy body dementia, and be aware that there are mixed dementias.
(Level of Evidence = IV)
Recommendation 2.3
Nurses should contribute to comprehensive standardized assessments to rule out or support the identification and monitoring of dementia based on their ongoing observations and expressed concerns from the client, family, and interdisciplinary team.
(Level of Evidence = III)
Recommendation 2.4
Nurses should create partnerships with family members or significant others in the care of clients. This is true for clients who live in either the community or in healthcare facilities.
(Level of Evidence = III)
Recommendation 2.5
Nurses should know their clients, recognize their retained abilities, understand the impact of the environment, and relate effectively when tailoring and implementing their caregiving strategies.
(Level of Evidence = III)
Recommendation 2.6
Nurses caring for clients with dementia should be knowledgeable about pain assessment and management in this population to promote physical and emotional well-being.
(Level of Evidence = IV)
Recommendation 2.7
Nurses caring for clients with dementia should be knowledgeable about nonpharmacological interventions for managing behaviour to promote physical and psychological well-being.
(Level of Evidence = III)
Recommendation 2.8 (Updated 2010)
Nurses caring for clients with dementia should be knowledgeable about pharmacological interventions, and contribute to the decisions and education regarding the risks and benefits of medication for targeted symptoms, monitor for efficacy and side effects, document response, and advocate for re-evaluation and withdrawal of psychotropics after a time period of behavioural stability.
(Level of Evidence = Ia)
Recommendation 2.9 (Updated 2010)
Nurses caring for older adults should promote healthy aging and protective strategies to minimize the risk of future cognitive changes.
(Level of Evidence = IIa)
Note: This recommendation was added to reflect the importance of prevention strategies for dementia.
Practice Recommendations for DepressionRecommendation 3.1
Nurses should maintain a high index of suspicion for early recognition/early treatment of depression in order to facilitate support and individualized care.
(Level of Evidence = IV)
Recommendation 3.2
Nurses should use the diagnostic criteria from the DSM IV-R to assess for depression.
(Level of Evidence = IV)
Recommendation 3.3
Nurses should use standardized assessment tools to identify the predisposing and precipitating risk factors associated with depression.
(Level of Evidence = IV)
Recommendation 3.4
Nurses must initiate prompt attention for clients exhibiting suicidal ideation or intent to harm others.
(Level of Evidence = IV)
Recommendation 3.5
Nurses must be aware of multi-component care strategies for depression:
Recommendation 3.5.1
Nonpharmacological interventions
Recommendation 3.5.2
Pharmacological caregiving strategies
(Level of Evidence = Ib)
Recommendation 3.6
Nurses need to facilitate creative client/family/community partnerships to ensure quality care that is individualized for the older client with depression.
(Level of Evidence = IV)
Recommendation 3.7
Nurses should monitor the older adult for re-occurrence of depression for 6 months to 2 years in the early stages of recovery and ongoing for those with chronic depression.
(Level of Evidence = Ib)
Practice Recommendations for Delirium, Dementia, and Depression
Recommendation 4.1 (Updated 2010)
In consultation/collaboration with the interdisciplinary team:
- Nurses should determine if a client is capable of personal care, treatment, and property decisions.
- If client is incapable, nurses should approach substitute decision makers regarding care issues.
- Nurses should determine whom the client has appointed as Powers of Attorney (POA) for personal care, and property and whenever possible include the POA along with the client in decision-making, consent, and care planning.
- If there is no POA for Personal Care, nurses should encourage and facilitate the process for older adults to appoint POA for Personal Care and to have discussions about end of life treatment and wishes while mentally capable.
Note: The terminology in Recommendation
4.1 has been changed from Power of Attorney for Personal Care and
Finances throughout the recommendation to reflect correct terminology as
Power of Attorney (POA) for personal care and property.
Recommendation 4.2In care settings where Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) instruments are mandated assessment tools, nurses should utilize the MDS data to assist with assessment for delirium, dementia and depression.
(Level of Evidence = III)
Recommendations 4.3
Nurses should avoid physical and chemical restraints as first line care strategies for older adults with delirium, dementia, and depression.
(Level of Evidence = III)
Education Recommendation
Recommendation 5.1
All entry-level nursing programs should include specialized content about the older adult such as normal aging; involvement of client and family throughout the process of nursing care; diseases of old age; assessment and management of delirium, dementia and depression; communication techniques; and appropriate nursing interventions.
(Level of Evidence = IV)
Organization and Policy Recommendations
Recommendation 6.1
Organizations should consider integration of a variety of professional development opportunities to support nurses in effectively developing knowledge and skills to provide care for older adults with delirium, dementia and depression.
(Level of Evidence = IV)
Recommendation 6.2
Healthcare agencies should implement a model of care that promotes consistency of the nurse/client relationship.
(Level of Evidence = IIb)
Recommendation 6.3
Agencies should ensure that nurses' workloads are maintained at levels conducive to care of persons with delirium, dementia and depression.
(Level of Evidence = IV)
Recommendation 6.4
Staffing decisions must consider client acuity, complexity level, and the availability of expert resources.
(Level of Evidence = III)
Recommendation 6.5
Organizations must consider the nurses' well-being as vital to provide care to persons with delirium, dementia and depression.
(Level of Evidence = III)
Recommendation 6.6
Healthcare agencies should ensure the coordination of care through the appropriate processes to transfer information (e.g., appropriate referrals, communication, documentation, policies that support formal methods of information transfer, and networking between health care providers).
(Level of Evidence = IV)
Recommendation 6.7 (Delirium)
Brief screening questions for delirium should be incorporated into nursing histories and/or client contact documents with opportunity to implement care strategies.
(Level of Evidence = IV)
Recommendation 6.8 (Delirium)
Organizations should consider delirium programs that contain screening for early recognition and multi-component interventions for treatment of clients with, but not limited to, hip fractures, post-operation surgery, and those with complex medical conditions.
(Level of Evidence = IV)
Recommendation 6.9 (Depression)
Caregiving activities for the older adult presenting with depression and/or suicidal ideation should encompass primary, secondary and tertiary prevention practices.
(Level of Evidence = IV)
Recommendation 6.10
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to implementation
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing guidelines
(Level of Evidence = IV)
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