Delirium Risk Assessment Tool for Elderly Patients

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D
ELIRIUM
 
ELDERLY
 A
T
-R
ISK
I
NSTRUMENT
Nora McPherson, APRN, CNS,  Geriatrics
Jill Tusing MS, RN, BC  Service Line: Behavioral
Health
SBAR: D
ELIRIUM
  I
DENTIFYING
 
HIGH
 
RISK
PATIENTS
Situation:
Delirium (acute
confusion) a common,
under recognized,
post-operative
complication in
elective orthopaedic
patients (10%-40%);
manifests as acute
impairment in
cognition and
attention.
Background: 
Post-operative delirium
is associated with poor
outcomes, greater
costs, longer lengths
of stays, poor
recovery,
institutionalization,
and mortality.
Assessment:
 Currently, HE does not
have process to screen
patient pre-op for risk
Screening pts. may
allow for early
interventions to
reduce severity
Recommendation:
Trial delirium risk
assessment tool
(DEAR) with 
elective
total joint population
age 65 and older 
to
identify high risk for
delirium.
Phase 2 (future plans):
On care units, patient
screening every shift
with use of Confusion
Assessment Method
(CAM)
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:
DEAR I
NSTRUMENT
 I
NSTRUCTIONS
The circle is a clock face. Ask your patient to place
numbers and hands (small and large) on the face so
the time reads 
10 minutes after three o’clock.
The instructions:
May be repeated as often as requested
No other directions or assistance should be given
Do not cover up or conceal any time pieces in the
room
After your patient has completed this task, you
may score their efforts as pass or fail. Please
review the following examples displaying pass and
fail clocks.
S
CORING
 G
UIDELINES
 : 
P
ASS
 
OR
 F
AIL
PASS:
Hands and numbers are all present in correct
positions. Patient corrects without prompting are
acceptable. 
There are slight errors
in placement of hands
OR
One missing number
without number spacing
errors.
Moderate errors in placement of hands, confusion
with small and large hands OR
Number spacing errors alone.
Guidelines:
Placement of hands is
significantly off course
OR
Number spacing is
inappropriate.
Example:
Even though there is bunching,
distortion not grossly
inappropriate. Typically seen in
those who are cued to spatial
mistakes once they get to the 6
(because they know it is
supposed to be at the bottom),
and make  correction only to
commit same error in
subsequent numbers.
 
Scoring       
Passed
Guidelines:
Clock hands are used
inappropriately OR
There is use of a digital display
Circling of numbers OR
Perseveration in writing of
numbers
Example:
The clock hands are clearly
pointing inward. This is
scored 6, even though the 2
and 3 are correctly indicated,
because there is clear
evidence that problem
solving how to correctly draw
in the hands is lacking. 
 
Score    Fail
Example:
Here is perseveration of
numbers (3's and 8's).
Only 
one
 example of
perseverated numbers is
needed for a score of 6.
The hands are not
included in this sample
to focus on illustrating
number perseveration.
 
Score  
Fail
Example:
A digital representation
of 3:10 is drawn. This is
often drawn in the
middle of the clock face,
or even well outside of
it.
 
Score   
Fail
Example
:
The numbers are circled
to indicate 3:10.
 
Score     
Fail
Example:
This is an inappropriate
use of clock hands,
where a straight line is
drawn from the 3 to the
2, without use of the
center of the clock.
 
Score   
Fail 
Guidelines:
Numbers are crowded to
one end of the clock.
Reversed in order or
absent.
Example:
Numbers are reversed.
 
Score  
 Fail
Example:
All of the numbers are
crowded into to one end
of the clock face.
 
Score  
Fail
Guidelines:
There is significant
distortion in number
sequences. Counterclockwise
order many missing numbers
OR
Number placed outside of
clock face border.
Example:
There are many added
numbers. This tends to occur
when the patient loses track
of the task at hand (drawing
the numbers for the clock)
and continues to add
numbers until they run out
of space.
 
Score    
Fail
Example:
Some numbers fall
outside of the border
 
Score   
Fail
Example:
Numbers placed outside
of the clock face. Even if
all other criteria are
met.
 
Score  
Fail
Example:
Prompting needed.
This is a fairly common
presentation of "drawing
in the numbers". When
this is seen, prompt the
patient to put in numbers
instead of dashes,
allowing them to erase.
This should not be scored
unless the patient is
unable to place the
numbers at all, or is
significantly confused by
the directions.
 
Score 
Fail
Only vague
representation of a
clock or irrelevant
spatial representation
exist.
Numbers and clock
face are no longer
connected in the
drawing.
      Score    
Fail
 
 
Result cannot be interpreted
OR
No attempt is made to draw a clock
Score       
Fail
DEAR scores >1  
indicate patient is at 
higher risk
for developing delirium.
:
Add up all of the yes scores on the left side of
the tool and place score on bottom.
Scores of over 1 are considered high risk.
If a patient is scored to be at high risk for
delirium, communicate this risk with the
medical team.
Place 
High risk for delirium 
 sticker on
patient Care Plan (or write it yourself).
Scoring DEAR Tool
R
EFERENCES
Feter, S., Dunbar, M., MacLeod, H., Morrison,
M., MacKnight, C., et al. (2005) Predicting post-
operative delirium in elective orthopaedic
patients: the Delirium Elderly At-Risk (DEAR)
instrument. Age and Ageing, 34(2), 169-184.
HealthEast A3 team: Joe Clubb, Director Behavior
Health, Dr. David Frenz; Dr. Alvin Holm, Jill
Tusing RN Education, Nora McPherson, APRN,
CNS.
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Assessing the risk of post-operative delirium in elderly patients is crucial for improving outcomes and reducing complications. The Delirium Elderly At-Risk (DEAR) instrument is a valuable tool that evaluates multiple domains including age, sensory impairment, functional dependence, substance use, and cognition to identify high-risk patients. By utilizing this instrument and following scoring guidelines, healthcare professionals can proactively assess and mitigate the risk of delirium in elderly individuals undergoing elective procedures, ultimately enhancing patient care and outcomes.


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  1. DELIRIUM ELDERLY AT-RISK INSTRUMENT Nora McPherson, APRN, CNS, Geriatrics Jill Tusing MS, RN, BC Service Line: Behavioral Health

  2. SBAR: DELIRIUM IDENTIFYING HIGH RISK PATIENTS Situation: Delirium (acute confusion) a common, under recognized, post-operative complication in elective orthopaedic patients (10%-40%); manifests as acute impairment in cognition and attention. Background: Post-operative delirium is associated with poor outcomes, greater costs, longer lengths of stays, poor recovery, institutionalization, and mortality.

  3. Assessment: Recommendation: Trial delirium risk assessment tool (DEAR) with elective total joint population age 65 and older to identify high risk for delirium. Phase 2 (future plans): On care units, patient screening every shift with use of Confusion Assessment Method (CAM) Currently, HE does not have process to screen patient pre-op for risk Screening pts. may allow for early interventions to reduce severity

  4. Delirium Elderly At-Risk (DEAR) instrument is used to assess risk for developing post-operative delirium. 5 scoring domains are listed below: Yes No Patient age Age > 80 Sensory Impairment Patient uses hearing aid and/or has very low vision Functional Dependence Patient requires assistance with any of the following: Bathing, dressing toileting, grooming, or feeding Substance Use Patient consumes >3 drinks of alcohol per week and/or Patient takes benzodiazepine >3 times/week Cognition Previous post-op delirium/confusion or Failed Clock-drawing Score A DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium.

  5. DEAR INSTRUMENT INSTRUCTIONS The circle is a clock face. Ask your patient to place numbers and hands (small and large) on the face so the time reads 10 minutes after three o clock. The instructions: May be repeated as often as requested No other directions or assistance should be given Do not cover up or conceal any time pieces in the room After your patient has completed this task, you may score their efforts as pass or fail. Please review the following examples displaying pass and fail clocks.

  6. SCORING GUIDELINES : PASSOR FAIL PASS: Hands and numbers are all present in correct positions. Patient corrects without prompting are acceptable. There are slight errors in placement of hands OR One missing number without number spacing errors. Moderate errors in placement of hands, confusion with small and large hands OR Number spacing errors alone.

  7. Scoring Passed Guidelines: Placement of hands is significantly off course OR Number spacing is inappropriate. Example: Even though there is bunching, distortion not grossly inappropriate. Typically seen in those who are cued to spatial mistakes once they get to the 6 (because they know it is supposed to be at the bottom), and make correction only to commit same error in subsequent numbers.

  8. Score Fail Guidelines: Clock hands are used inappropriately OR There is use of a digital display Circling of numbers OR Perseveration in writing of numbers Example: The clock hands are clearly pointing inward. This is scored 6, even though the 2 and 3 are correctly indicated, because there is clear evidence that problem solving how to correctly draw in the hands is lacking.

  9. Score Fail Example: Here is perseveration of numbers (3's and 8's). Only one example of perseverated numbers is needed for a score of 6. The hands are not included in this sample to focus on illustrating number perseveration.

  10. Score Fail Example: A digital representation of 3:10 is drawn. This is often drawn in the middle of the clock face, or even well outside of it.

  11. Score Fail Example: The numbers are circled to indicate 3:10.

  12. Score Fail Example: This is an inappropriate use of clock hands, where a straight line is drawn from the 3 to the 2, without use of the center of the clock.

  13. Score Fail Guidelines: Numbers are crowded to one end of the clock. Reversed in order or absent. Example: Numbers are reversed.

  14. Score Fail Example: All of the numbers are crowded into to one end of the clock face.

  15. Score Fail Guidelines: There is significant distortion in number sequences. Counterclockwise order many missing numbers OR Number placed outside of clock face border. Example: There are many added numbers. This tends to occur when the patient loses track of the task at hand (drawing the numbers for the clock) and continues to add numbers until they run out of space.

  16. Score Fail Example: Some numbers fall outside of the border

  17. Score Fail Example: Numbers placed outside of the clock face. Even if all other criteria are met.

  18. Score Fail Example: Prompting needed. This is a fairly common presentation of "drawing in the numbers". When this is seen, prompt the patient to put in numbers instead of dashes, allowing them to erase. This should not be scored unless the patient is unable to place the numbers at all, or is significantly confused by the directions.

  19. Score Fail Only vague representation of a clock or irrelevant spatial representation exist. Numbers and clock face are no longer connected in the drawing.

  20. Score Fail Result cannot be interpreted OR No attempt is made to draw a clock

  21. DEAR scores >1 indicate patient is at higher risk for developing delirium. : Yes X X No Patient age Age > 80 Sensory Impairment Patient uses hearing aid and/or has very low vision Functional Dependence Patient requires assistance with any of the following: Bathing, dressing toileting, grooming, or feeding X Substance Use Patient consumes >3 drinks of alcohol per week and/or Patient takes benzodiazepine >3 times/week X Cognition Previous post-op delirium/confusion or Failed Clock-drawing Score X A DEAR score of Yes > 1 places the patient at higher risk of developing post operative delirium. 2

  22. Scoring DEAR Tool Add up all of the yes scores on the left side of the tool and place score on bottom. Scores of over 1 are considered high risk. If a patient is scored to be at high risk for delirium, communicate this risk with the medical team. Place High risk for delirium sticker on patient Care Plan (or write it yourself).

  23. REFERENCES Feter, S., Dunbar, M., MacLeod, H., Morrison, M., MacKnight, C., et al. (2005) Predicting post- operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age and Ageing, 34(2), 169-184. HealthEast A3 team: Joe Clubb, Director Behavior Health, Dr. David Frenz; Dr. Alvin Holm, Jill Tusing RN Education, Nora McPherson, APRN, CNS.

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