Hartford Institute for Geriatric Nursing
Full Text Guideline
Evidence Supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated.
Implementation of the Guideline
An implementation strategy was not provided.
Mobile Device Resources
Benefits/Harms of Implementing the Guideline Recommendations
The patient remains as independent and functional in the environment of choice for as long as possible, the co-morbid conditions the patient may experience are well managed, and the distressing symptoms that may occur at end of life will be minimized or controlled adequately.
Lay and professional caregivers demonstrate effective caregiving skills; verbalize satisfaction with caregiving; report minimal caregiver burden; are familiar with, have access to, and utilize available resources.
Institutions reflect a safe and enabling environment for delivering care to individuals with progressive dementia; the quality improvement plans address high-risk, problem-prone areas for individuals with dementia, such as falls and the use of restraints.
Rating Scheme for the Strength of the Recommendations
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.
The Search for Evidence Process
Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.
In addition to rating each literature citation to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.
Developing a Search Strategy
Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.
It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.
Weighting According to a Rating Scheme (Scheme Given)
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/consensus panels
AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.
Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.
Review of Published Meta-Analyses
A formal cost analysis was not performed and published cost analyses were not reviewed.
External Peer Review
Internal Peer Review
Identifying Information and Availability
Fletcher K. Dementia. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 163-85.
Not applicable: The guideline was not adapted from another source.
The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.
Hartford Institute for Geriatric Nursing
Primary Author: Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN Administrator of Senior Services, University of Virginia Health System, Charlottesville, Virginia
This is the current release of the guideline.
This guideline updates a previous version: Fletcher K. Dementia. In: Capezuti E. Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 83-109.
Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.
Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.
The followings are available:
- Try This® - issue D1: Avoiding restraints in hospitalized older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in Portable Document Format (PDF) from the Hartford Institute for Geriatric Nursing Web site.
- Try This ® - issue D2: Assessing pain in older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D3: Brief evaluation of executive dysfunction: an essential refinement in the assessment of cognitive impairment. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D4: Therapeutic activity kits. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2013. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D5: Recognition of dementia in hospitalized older adults. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2007. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This ® - issue D6: Wandering in the hospitalized older adult. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D7: Communication difficulties: assessment and interventions in older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2013. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D8: Assessing and managing delirium in older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2013. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D9: Decision making and dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D10: Working with families of hospitalized older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2007. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D11.1: Eating and feeding issues in older adults with dementia: part I: assessment. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2007. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D11.2. Eating and feeding issues in older adults with dementia: part II: interventions. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2007. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D12: Home safety inventory for older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Try This® - issue D13: Use of the Functional Activities Questionnaire in older adults with dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF from the Hartford Institute for Geriatric Nursing Web site.
- Brief evaluation of executive dysfunction: an essential refinement in the assessment of cognitive impairment. How to Try This video. Available from the Hartford Institute for Geriatric Nursing Web site.
- Administering and interpreting the Mini-Cog. How to Try This video. Available from the Hartford Institute for Geriatric Nursing Web site.
The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site.
This NGC summary was completed by ECRI Institute on June 16, 2008. The information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 24, 2013. The updated information was verified by the guideline developer on August 6, 2013.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
- Progressive dementia
- Alzheimer's disease
- Vascular dementia
- Dementia with Lewy bodies
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
To provide a standard of practice protocol for early recognition and appropriate management of individuals with dementia
Older patients with dementia
- Assessment of cognitive parameters
- Use of mental status screening tools
- Folstein Mini-Mental State Examination (MMSE)
- Clock Drawing Test (CDT)
- Mini-Cognitive (Mini-Cog)
- Functional assessment
- Behavioral assessment
- Assessment and monitoring of behavioral changes
- Evaluation for depression
- Physical assessment
- Physical examination
- Evaluation of medications and nutrition
- Laboratory tests and diagnostic imaging
- Assessment of caregiver/environment
- Eliciting caregiver perspective
- Use of Zarit Burden Interview (ZBI) and Caregiver Strain Index (CSI) tool
- Evaluation of caregiver experience and patient–caregiver relationship
- Monitoring effectiveness and side effects of medications
- Use of cognitive-enhancement techniques
- Adequate rest, sleep, nutrition, and pain control
- Avoiding physical and pharmacologic restraints
- Maximization of functional capacity
- Addressing behavioral issues
- Ensuring a safe and therapeutic environment
- Advance-care planning and end-of-life care
- Education, support and community resources for caregivers
- Functional status/decline
- Cognitive changes/decline
Parameters of Assessment
No formal recommendations for cognitive screening are indicated in asymptomatic individuals. Clinicians are advised to be alert for cognitive and functional decline in older adults to detect dementia and dementia-like presentation in early stages. Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment.
- Orientation: person, place, time
- Memory: ability to register, retain, recall information
- Attention: ability to attend and concentrate on stimuli
- Thinking: ability to organize and communicate ideas
- Language: ability to receive and express a message
- Praxis: ability to direct and coordinate movements
- Executive function: ability to abstract, plan, sequence, and use feedback to guide performance
Mental Status Screening Tools
- Folstein Mini-Mental State Examination (MMSE) is the most commonly used test to assess serial cognitive change. The MMSE is copyrighted and a comparable tool called the St. Louis Medical Status (SLUMS) Examination is in the public domain.
- Clock Drawing Test (CDT) is a useful measure of cognitive function that correlates with executive-control functions.
- Mini-Cognitive (Mini-Cog) combines the Clock Drawing Test with the three-word recall.
When the diagnosis remains unclear, the patient may be referred for more extensive screening and neuropsychological testing, which might provide more direction and support for the patient and the caregivers.
- Tests that assess functional limitations such as the Functional Activities Questionnaire (FAQ) can detect dementia. They are also useful in monitoring the progression of functional decline.
- The severity of disease progression in dementia can be demonstrated by performance decline in activity of daily living (ADL) and instrumental ADL (IADL) tasks and is closely correlated with mental-status scores.
- Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.
- Evaluate for depression because it commonly coexists in individuals with dementia. The Geriatric Depression Scale (GDS) is a good screening tool.
- A comprehensive physical examination with a focus on the neurological and cardiovascular system is indicated in individuals with dementia to identify the potential cause and/or the existence of a reversible form of cognitive impairment.
- A thorough evaluation of all prescribed, over-the-counter, homeopathic, herbal, and nutritional products taken is done to determine the potential impact on cognitive status.
- Laboratory tests are valuable in differentiating irreversible from reversible forms of dementia. Structural neuroimaging with noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) scans are appropriate in the routine initial evaluation of patients with dementia.
The caregiver of the patient with dementia often has as many needs as the patient with dementia; therefore, a detailed assessment of the caregiver and the caregiving environment is essential.
- Elicit the caregiver perspective of patient function and the level of support provided.
- Evaluate the impact that the patient's cognitive impairment and problem behaviors have on the caregiver (mastery, satisfaction, and burden). Two useful tools include the Zarit Burden Interview (ZBI) and the Caregiver Strain Index (CSI) Tool.
- Evaluate the caregiver's experience and patient–caregiver relationship.
Nursing Care Strategies
The Progressively Lowered Stress Threshold (PLST) provides a framework for the nursing care of individuals with dementia.
- Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.
- Provide appropriate cognitive-enhancement techniques and social engagement.
- Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
- Avoid the use of physical and pharmacologic restraints.
- Maximize functional capacity: maintain mobility and encourage independence as long as possible; provide graded assistance as needed with ADLs and IADLs; provide scheduled toileting and prompted voiding to reduce urinary incontinence; encourage an exercise routine that expends energy and promotes fatigue at bedtime; and establish bedtime routine and rituals.
- Address behavioral issues: identify environmental triggers, medical conditions, caregiver–patient conflict that may be causing the behavior; define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches; provide reassurance; and refer to appropriate mental health care professionals as indicated.
- Ensure a therapeutic and safe environment: provide an environment that is modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion and understimulation that can cause sensory deprivation and withdrawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, and wander guard. Eliminate any environmental hazards and modify the environment to enhance safety. Provide environmental cues or sensory aids that facilitate cognition, and maintain consistency in caregivers and approaches.
- Encourage and support advance-care planning: explain trajectory of progressive dementia, treatment options, and advance directives.
- Provide appropriate end-of-life care in terminal phase: provide comfort measures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (e.g., tube feeding, antibiotic therapy).
- Provide caregiver education and support: respect family systems/dynamics and avoid making judgments; encourage open dialogue, emphasize the patient's residual strengths; provide access to experienced professionals; and teach caregivers the skills of caregiving.
- Integrate community resources into the plan of care to meet the needs for patient and caregiver information; identify and facilitate both formal (e.g., Alzheimer's associations, respite care, specialized long-term care) and informal (e.g., churches, neighbors, extended family/friends) support systems.
Follow-up to Monitor Condition
- Follow-up appointments are regularly scheduled; frequency depends on the patient's physical, mental, and emotional status and caregiver needs.
- Determine the continued efficacy of pharmacological/nonpharmacological approaches to the care plan and modify as appropriate.
- Identify and treat any underlying or contributing conditions.
- Community resources for education and support are accessed and utilized by the patient and/or caregivers.
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