Caregiving strategies for older adults with delirium, dementia and depression.

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.

	Recommendation	Level of Evidence
Practice Recommendations	1.1 Nurses should maintain a high index of suspicion for the prevention, early recognition, and urgent treatment of delirium to support positive outcomes.	IIa
	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.	IV
	1.3 Nurses should initiate standardized screening methods to identify risk factors for delirium on initial and ongoing assessments.	IIa
	1.4 Nurses have a role in prevention of delirium and should target prevention efforts to the client's individual risk factors.	Ib
	1.5 In order to target the individual root causes of delirium, nurses working with other disciplines must select and record multicomponent care strategies and implement them simultaneously to prevent delirium. 1.5.1 Consultation/Referral Nurses should initiate prompt consultation to specialized services. 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. 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. 1.5.4 Environmental Nurses need to identify, reduce, or eliminate environmental factors that may contribute to delirium. 1.5.5 Education Nurses should maintain current knowledge of delirium and provide delirium education to the older adult and family. 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 1.5.7 Behavioural Interventions Nurses are responsible for the prevention, identification and implementation of delirium care approaches to minimize disturbing behaviour and provide a safe environment. Further, it is recommended that restraints not be used.	III
	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.	IIb
Practice Recommendations for Dementia	2.1 Nurses should maintain a high index of suspicion for the early symptoms of dementia to initiate appropriate assessments and facilitate individualized care.	IIa
	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.	IV
	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.	IIa
	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 health care facilities.	III
	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.	III
	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.	IV
	2.7 Nurses caring for clients with dementia should be knowledgeable about nonpharmacological interventions for managing behaviour to promote physical and psychological well-being.	III
	2.8 Nurses caring for clients with dementia should be knowledgeable about pharmacological interventions and should advocate for medications that have fewer side effects.	Ia
Practice Recommendations for Depression	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.	IV
	3.2 Nurses should use the diagnostic criteria from the Diagnostic and Statistical Manual (DSM) IV-R to assess for depression.	IV
	3.3 Nurses should use standardized assessment tools to identify the predisposing and precipitating risk factors associated with depression.	IV
	3.4 Nurses must initiate prompt attention for clients exhibiting suicidal ideation or intent to harm others.	IV
	3.5 Nurses must be aware of multi-component care strategies for depression. 3.5.1 Nonpharmacological interventions 3.5.2 Pharmacological caregiving strategies	Ib
	3.6 Nurses need to facilitate creative client/family/community partnerships to ensure quality care that is individualized for the older client with depression.	IV
	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.	Ib
Practice Recommendations for Delirium, Dementia, and Depression	4.1 In consultation/collaboration with the interdisciplinary team: Nurses should determine if a client is capable of personal care, treatment, and financial decisions. If client is incapable, nurses should approach substitute decision makers regarding care issues. Nurses should determine whom the client has appointed as Power of Attorney (POA) for personal care and finances, and whenever possible include the Power of Attorney along with the client in decision-making, consent, and care planning. If there is no Power of Attorney, nurses should encourage and facilitate the process for older adults to appoint Power of Attorney and to have discussions about end of life treatment and wishes while mentally capable.	IV
	4.2 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.	III
	4.3 Nurses should avoid physical and chemical restraints as first line care strategies for older adults with delirium, dementia, and depression.	III
Education 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.	IV
Organization & Policy Recommendations	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.	IV
	6.2 Health care agencies should implement a model of care that promotes consistency of the nurse/client relationship.	IIb
	6.3 Agencies should ensure that nurses’ workloads are maintained at levels conducive to care of persons with delirium, dementia, and depression.	IV
	6.4 Staffing decisions must consider client acuity, complexity level, and the availability of expert resources.	III
	6.5 Organizations must consider the nurses’ well-being as vital to provide care to persons with delirium, dementia and depression.	III
	6.6 Health care 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).	IV
	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.	IV
	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.	IV
	6.9 (Depression) Caregiving activities for the older adult presenting with depression and/or suicidal ideation should encompass primary, secondary and tertiary prevention practices.	IV
	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 education 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 In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical perspectives and consensus. The RNAO strongly recommends the use of this Toolkit for guiding the implementation of the best practice guideline on Caregiving Strategies for Older Adults with Delirium, Dementia and Depression.	IV

Definitions:

Level of Evidence

Ia - Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib - Evidence obtained from at least one randomized controlled trial

IIa - Evidence obtained from at least one well-designed controlled study without randomization

IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III - Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV - Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

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