The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Alert & Oriented

Related Issues:

Cognition, mentation, confusion, delirium, dementia, depression

Why Mentation is Important:

• Illness may present as subtle or overt changes in cognition
• Age related increased risk of: dementia, delirium, depression, metabolic disturbances

Normal Age-Related Changes:

• Change in numbers and levels of neurotransmitters including serotonin, dopamine and acetylcholine can affect mood, memory and cause slowed processing in central nervous system
• Age-related sensory changes may affect cognition: changes in vision, hearing, touch and sensation
• Changes in sleep patterns, decreased quality of sleep, and changes in sleep/wake cycles may have a significant impact on alertness and functional status (AACN, 2007)

Older adults are at increased risk if they have any of the following:

Conditions

• ​Fatigue
• Pain
• Metabolic alterations/dehydration/malnutrition
• Infection
• Thyroid dysfunction
• Alzheimer's Disease
• Parkinson's Disease
• Mild cognitive impairment (MCI)
• Dementia
• Delirium
• CVA
• Brain tumor
• Hospitalization: older adults who experienced acute care hospitalization and critical illness hospitalization had a greater likelihood of cognitive decline compared with those who had no hospitalization; noncritical illness hospitalization was significantly associated with the development of dementia (Ehlenbach et al., 2010)
• “Metabolic syndrome” (abdominal obesity, impaired fasting glucose, hypertension, low high-density lipoprotein (HDL) and/or high triglycerides), increases the risk of stroke, silent brain infarction, and has been linked to risk of developing dementia and MCI

Behavioral Risk Factors

• Dependence on alcohol, recreational drugs
• Social isolation
• Physical inactivity
• Malnutrition
• Poor sleep hygiene
• Substance use/abuse

Medication-Related Risk Factors

• Polypharmacy​
• Opioids​
• Antiseizure medications
• Benzodiazepines
• Antipsychotics
• Tricyclic antidepressants
• Anticholinergics
• Antihistamines

Chemotherapy-Related Risk Factors

• Acute Confusion: hydroxyurea, interleukin-2, cytarabine (Ara-C), high dose ifosphamide, high dose methotrexate
• Chemo brain: many drugs have been attributed to affecting short term memory

Surgery-Related Risk Factors

• Hypoxia
• Post-op delirium
• Effects of anesthesia

Radiation Risk Factors

• Radiation to the brain increases risk for radiation necrosis and diffuse cerebral atrophy
• Whole Brain Radiation Therapy can cause leukoencephalopathy

Cancer Diagnoses

• CNS tumors

Assessment:

1. Screening Questions

• What is the day of the week, date, month, year, or season?
• Do you forget to take medicines or are you confused about what they are for?
• Are you satisfied with your life? Do you feel sad or hopeless?

2. Observations

• Appearance: Are they dressed appropriately for the current season, setting, their age and gender? Are they well-groomed, clean, not disheveled? (a disheveled appearance in someone previously well groomed may indicate problem)
• Facial expression: (flat, mask-like may indicate depression or parkinsons) Does the patient appear confused?
• Behavior/mood/affect: Are they awake, alert and aware? Do they appear flat, depressed, manic, irritable, anxious, or labile?
• Speech/thought processes: Do they make sense? Can they follow conversation? Is speech quality normal (dysphonia--abnormal volume/pitch, dysarthria--distorted speech, aphasia--missed or misuse of words, transposing words)

3. Screening Tools

• Six Item Cognitive Screen (for baseline cognitive assessment)
• Clock drawing test (Agrell & Dehljn, 1998)
• CAM (Confusion Assessment Method)
• MMSE (note this is copyright form)

4. Physical Assessment: Standard examination with focus on

• Mental status with use of MMSE or Six Item Cognitive Screen for baseline assessment
• Use of CAM to identify patients experiencing delirium

Nursing Intervention:

• Assist in determining underlying etiology of altered mental status if apparent & reverse if possible
• Assess social situation and safety of home. Maximize safety by modifying the environment to compensate for cognitive losses; arrange caregiver assist (HHA) if necessary
• Obtain assistive devices, (eyeglasses, hearing devices) as indicated
• Referrals: geriatric, social work, psychiatric, neurological, pain & palliative care, rehab
• Control any factors that increase stress such as fatigue, physical stressors, competing or overwhelming stimuli, changes in routine, caregiver, or environment, and activities or demands that exceed the person's functional status
• Implement regular rest periods to compensate for fatigue and loss of reserve energy
• Encourage physical activity appropriate to the patient’s functional and medical status
• Encourage cognitive stimulating activities, brain exercises, memory games, relaxation and stress reduction activities, organizational and note-taking strategies, and social stimulation
• Provide education to patient and caregivers
• Delirium risk with procedures/ anesthesia
• Falls risk/safety
• Disease process
• Treatment/management plan
• Planned procedures
• Medication education as indicated for cholinesterase inhibitors: donepezil (Aricept^®), galantamine (Reminyl^®), tacrine (Cognex^®), and rivastigmine (Exelon^®)
• Collaborate with all other healthcare providers
• Evaluate effectiveness of interventions and modify as needed

Agrell, B. & Dehljn, O. (1998). The clock-drawing test. Age and Ageing, 27, 399-403.
American Association of Neuroscience Nurses (2007). Neurologic assessment of the older adult: a guide for nurses. Glenview, IL: AANN.
Callahan, C., Unverzagt, F., Hui, S., Perkins, A., & Hendrie, H. (2002). Six-Item Screener to Identify Cognitive Impairment Among Potential Subjects for Clinical Research. Medical Care, 40(9), 771-781.
Del Parigi, A., Panza, F., Capurso, C., & Solfrizzi, V. (2006).  Nutritional factors, cognitive decline, and dementia. Brain Research Bulletin, 69(1), 1-19.
Ehlenbach, W.J., Hough, C.L., Cranen, P.K., Haneuse, S.J.P.A., Carson, S.S., Curtis, J.R., & Larson, E.B. (2010). Association Between Acute Care and Critical Illness Hospitalization and Cognitive Function in Older Adults. JAMA, 303(8), 763-770.
Panza, F., Capurso, C., D’Introno, A., Colacicco, A., Frisardi, V., Santamato, A., Ranieri, M., Fiore, P., Vendemiale, G., Seripa, D., Pilotto, A., Capurso, A., Solfrizzi, V. (2008). Vascular risk factors, alcohol intake and cognitive decline. The Journal of Nutrition, Health & Aging, 12(6), 376-381.