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Guideline Summary
Guideline Title
(1) Caregiving strategies for older adults with delirium, dementia and depression. (2) Caregiving strategies for older adults with delirium, dementia and depression 2010 supplement.
Bibliographic Source(s)
Registered Nurses' Association of Ontario (RNAO). Caregiving strategies for older adults with delirium, dementia and depression 2010 supplement. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2010 May. 36 p. [174 references]

Registered Nurses' Association of Ontario (RNAO). Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2004 Jun. 181 p. [247 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Dementia, delirium, and depression

Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Geriatrics
Neurology
Nursing
Psychiatry
Intended Users
Advanced Practice Nurses
Nurses
Guideline Objective(s)
  • To update the June 2004 Nursing Best Practice Guidelines on Caregiving Strategies for Older Adults with Delirium, Dementia and Depression, based on new evidence obtained since the originally published guidelines
  • To present nursing best practice guidelines for caregiving strategies for older adults with delirium, dementia, and depression
  • To recommend care strategies to assist Registered Nurses (RNs) and Registered Practical Nurses (RPNs) who are working in diverse settings in acute, long-term, and community care
Target Population

Older adults (65 years or older) with delirium, dementia and/or depression

Interventions and Practices Considered
  1. Screening for changes in cognition, function, behavior and/or mood
  2. Promoting healthy aging and protective strategies
  3. Assessing differences between delirium, dementia, and depression (Diagnostic and Statistical Manual [DSM IV-R], Resident Assessment Instrument [RAI], and Minimum Data Set [MDS])
  4. Identifying, recognizing, and preventing contributing factors to dementia, delirium, and depression (i.e., environment, medication, pain)
  5. Developing/facilitating partnerships with family members and caregivers; providing education as needed
  6. Assessing patient ability to provide personal care and treatment and financial decisions
  7. Developing multi-component care strategies (nonpharmacological and pharmacological interventions)
  8. Providing ongoing assessments to identify status changes
  9. Avoiding physical and chemical restraints as first line care strategies
  10. Nursing education strategies directed at the competencies required for practice
  11. Organization and policy strategies directed at practice settings and the environment in order to facilitate nurses' practice
Major Outcomes Considered
  • Morbidity
  • Mortality
  • Quality of life
  • Length of stay in acute care

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

June 2004 Guideline

A database search for existing guidelines was conducted by a university health sciences library. An initial search of the MEDLINE, EMBASE, and CINAHL databases for guidelines and articles published from January 1, 1995, to December 2002, was conducted using the following search terms: "delirium management", "dementia management", "depression management", "geriatrics", "practice guideline(s)", "clinical practice guideline(s)", "standards", "consensus statement(s)", "consensus", "evidence-based guidelines", and "best practice guidelines".

One individual searched an established list of websites for content related to the topic area. This list of sites, reviewed and updated in October 2002, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched, as well as date searched. The websites at times did not house a guideline but directed to another website or source for guideline retrieval. Guidelines were either downloaded, if full versions were available, or were ordered by phone/e-mail.

A website search for existing guidelines on delirium, dementia, and depression was conducted via the search engine "Google," using the search terms identified above. One individual conducted this search, noting the search term results, the websites reviewed, date, and a summary of findings. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were already in possession of a few of the identified guidelines. In some instances, a guideline was identified by panel members and not found through the previous search strategies. These were guidelines that were developed by local groups or specific professional associations. The results of this strategy revealed 21 guidelines and numerous articles related to delirium, dementia, and depression.

The final step in determining whether clinical practice guidelines would be critically appraised was to have two individuals screen the guidelines based on the specific inclusion criteria. These criteria were determined by panel consensus:

  • Guideline was in English, international in scope.
  • Guideline was dated no earlier than 1996.
  • Guideline was strictly about the topic areas (delirium, dementia, depression).
  • Guideline was evidence-based (e.g., contained references, description of evidence, sources of evidence).
  • Guideline was available and accessible for retrieval.

Twelve guidelines were deemed suitable for critical review using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.

2010 Supplement

Literature Review

One individual searched an established list of websites for guidelines and other relevant content. The list was compiled based on existing knowledge of evidence-based practice websites and recommendations from the literature. Members of the panel critically appraised 17 national and international guidelines, published since 2004, using the AGREE instrument (The AGREE Collaboration, 2001). From this review, nine guidelines were identified to inform the review processes.

Concurrent with the review of existing guidelines, a search for recent literature relevant to the scope of the guideline was conducted with guidance from the Team Leader. A search of electronic databases, (Medline, CINAHL, and EMBASE), was conducted by a health sciences librarian. A Research Assistant completed the inclusion/exclusion review, quality appraisal and data extraction of the retrieved studies, and prepared a summary of the literature findings. The comprehensive data tables and reference list were provided to all panel members.

A summary of the review process is provided in the Review/Revision Process flow chart in the original guideline document.

Number of Source Documents

June 2004 Guideline

Following the appraisal process, the guideline development panel identified eight guidelines to develop the recommendations cited in the guideline.

2010 Supplement

The search yielded 2507 abstracts and 17 guidelines; 162 studies and 9 guidelines were retrieved for review.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

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.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
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.

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.

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.

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 Depression

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:

  • 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.

(Level of Evidence = IV)

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 4.2

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.

(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

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.

(Level of Evidence = 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.

Clinical Algorithm(s)

The following algorithms are available in the original guideline document:

  • Kaleidoscope of Care Strategies for Delirium, Dementia and Depression
  • Flow Diagram on Caregiving Strategies for Delirium
  • Model of Care for Dementia
  • Flow Diagram on Caregiving Strategies for Depression
  • Outline of Key Factors in Continuing Treatment for Depression

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Nurses who have acquired the knowledge and skills to properly assess and initiate treatment of delirium, dementia, and depression will help prevent illness, decrease morbidity and mortality, enhance health, and improve the quality of life of the older adults.
  • Early recognition/treatment is associated with decreased morbidity, mortality, length of stay in acute care, and may assist in preventing irreversible cognitive impairment and institutionalization.
  • Identification of a potential delirium may assist in the early detection of a medical illness.
Potential Harms
  • Antidepressant medications need to be carefully monitored for adverse effects on the older adult. If confusion occurs in a cognitively intact older adult, nurses need to consider possible medication effects and immediately review the medication profile.
  • Nurses need to be aware that if antidepressant medications are discontinued, dosages must be tapered slowly to avoid any untoward side effects.
  • Nurses should be aware that antipsychotic medications used to treat delirium may, in fact, also cause delirium. For the older adults lower doses of haloperidol are suggested as haloperidol has an advantage over atypical antipsychotics because of its multiple routes of administration, but may have side effects such as sedation, extrapyramidal side effects, and prolonged QT interval.
  • Second generation antipsychotics have been shown to be useful in caring for some deliriums with fewer extrapyramidal side effects than typical antipsychotics. It should be noted that atypical antipsychotics have been associated with increased risk of cerebrovascular events and mortality in clients with dementia. Selection of atypical antipsychotics to treat delirium should be considered if the client shows signs of extrapyramidal symptoms such as in Parkinson's disease or Lewy body dementia to avoid worsening of symptoms.

Contraindications

Contraindications
  • Nurses need to be aware that many clients take herbal remedies such as St. John's Wort, which may be contraindicated with their antidepressant medication(s).
  • Atypical antipsychotics should be avoided in clients with Lewy body dementia as they may develop severe adverse effects.

Qualifying Statements

Qualifying Statements
  • This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
  • Nurses, other healthcare professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools. It is recommended that the nursing best practice guidelines be used as a resource tool. Nurses providing direct client care will benefit from reviewing the recommendations, the evidence in support of the recommendations and the process that was used to develop the guidelines. However, it is highly recommended that practice settings/environments adapt these guidelines in formats that would be user-friendly for daily use. This guideline has some suggested formats for such local adaptation and tailoring.
  • These best practice guidelines are related only to nursing practice and are not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
  • It is acknowledged that the individual competencies of nurses varies between nurses and across categories of nursing professionals (registered nurses [RNs] and registered practical nurses [RPNs]) and are based on knowledge, skills, attitudes, critical analysis, and decision making which are enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of care for which they have received appropriate education and experience. Since care strategies for delirium, dementia and depression are based on accurate screening assessment of these conditions, the development panel for this guideline strongly recommends the implementation of this guideline in conjunction with the RNAO (2003) Best Practice Guideline entitled Caregiving Strategies for Older Adults with Delirium, Dementia and Depression.
  • It is expected that nurses, both RNs and RPNs, will seek appropriate consultation in instances where the client's care needs surpass the individual's ability to act independently. It is acknowledged that effective health care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients, ever mindful of the personal preferences and unique needs of each individual client.
  • Similar to the original guideline publication, the supplement needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This supplement should be used in conjunction with the original guideline: Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (RNAO, 2003) as a tool to assist in decision-making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.

Implementation of the Guideline

Description of Implementation Strategy

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. The 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 Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating guideline implementation. Specifically, the Toolkit addresses the following key steps:

  1. Identifying a well-developed, evidence-based clinical practice guideline
  2. Identification, assessment, and engagement of stakeholders
  3. Assessment of environmental readiness for guideline implementation
  4. Identifying and planning evidence-based implementation strategies
  5. Planning and implementing evaluation
  6. Identifying and securing required resources for implementation

Implementing practice guidelines that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on the framework outlined in the RNAO Toolkit: Implementation of clinical practice guidelines (2002), illustrates some suggested indicators for monitoring and evaluation.

Implementation Tips

The Registered Nurses' Association of Ontario, the guideline development panel and evaluation team have compiled a list of implementation tips to assist healthcare organizations or healthcare disciplines who are interested in implementing this guideline.

A summary of these strategies follows:

  • Have a dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
  • Establish a steering committee comprised of key stakeholders and members who are committed to leading the initiative. Keep a work plan to track activities, responsibilities and timelines.
  • Provide educational sessions and ongoing support for implementation. The education sessions may consist of Power Point presentations, facilitator's guides, handouts, and case studies. Binders, posters and pocket cards may be used as ongoing reminders of the training. This guideline contains many resources, especially in the appendices, which nurses may use when developing the educational materials.
  • Provide organizational support, such as having the structures in place to facilitate the implementation. For examples, hiring replacement staff so participants will not be distracted by concerns about work, and having an organizational policy that reflects the value of best practices through policies and procedures and documentation tools.
  • Teamwork, collaborative assessment and treatment planning with the client and family through interdisciplinary work are beneficial. It is essential to be cognizant of and to tap the resources that are available in the community. Appendices I and K in the original guideline document highlight some of the resources that are available in the community. Another example would be linking and developing partnerships with regional geriatric programs for referral process. The RNAO's Advanced Clinical/Practice Fellowship (ACPF) Project is another way that registered nurses in Ontario may apply for a fellowship and have an opportunity to work with a mentor who has clinical expertise in delirium, dementia and depression. With the ACPF, the nurse fellow will also have the opportunity to learn more about new resources.

In addition to the tips mentioned above, the RNAO has developed resources that are available on the website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief description of this Toolkit can be found in Appendix Z in the original guideline document. A full version of the document in pdf format is also available at the RNAO website, www.rnao.org/bestpractices External Web Site Policy.

Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
Foreign Language Translations
Mobile Device Resources
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
Staff Training/Competency Material
Tool Kits
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Registered Nurses' Association of Ontario (RNAO). Caregiving strategies for older adults with delirium, dementia and depression 2010 supplement. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2010 May. 36 p. [174 references]

Registered Nurses' Association of Ontario (RNAO). Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2004 Jun. 181 p. [247 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2004 Jun (addendum released 2010 May)
Guideline Developer(s)
Registered Nurses' Association of Ontario - Professional Association
Source(s) of Funding

Funding was provided by the Ontario Ministry of Health and Long-Term Care.

Guideline Committee

Guideline Development Panel

Composition of Group That Authored the Guideline

Revision Panel Members

Dianne Rossy, RN, BN, MScN, GNC(C)
Revision Panel Leader
Advanced Practice Nurse, Geriatrics
The Ottawa Hospital & The Regional Geriatric Program
Ottawa, Ontario

Deborah Burne, RN, BA (Psych), CPMHN(C)
Educator and Consultant
Sheridan College & Institute of Technology & Advanced Learning
Oakville, Ontario

Katherine McGilton, RN, PhD
Senior Scientist, Toronto Rehabilitation Institute
Associate Professor, Lawrence S Bloomberg Faculty of Nursing, University of Toronto
Toronto, Ontario

Susan Phillips, RN, MScN, GNC(C)
Geriatric Nurse Specialist
The Ottawa Hospital, Civic Campus
Ottawa, Ontario

Athina Perivolaris, RN, BScN, MN
Advanced Practice Nurse
Nursing Practice and Professional Services
Centre for Addiction and Mental Health
Toronto, Ontario

Tiziana Rivera, RN, BScN, MSc, GNC(C)
Chief Practice Officer
York Central Hospital
Richmond Hill, Ontario

Carmen Rodrigue, RN, BScN, MSc, CPMHN(C)
Advanced Practice Nurse
Bruyere Continuing Care
Ottawa, Ontario

Anne Stephens, RN, BScN, MEd, GNC(C)
Clinical Nurse Specialist - Seniors Care
Toronto Central CCAC
Toronto, Ontario

Ann Tassonyi, RN, BScN, GNC(C)
Psychogeriatric Resource Consultant
St. Catharines, Ontario

Brenda Dusek, RN, BN, MN
Program Manager
International Affairs and Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Catherine Wood, BMOS
Administrative Assistant
International Affairs and Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses' Association of Ontario (RNAO).

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in English and Spanish in Portable Document Format (PDF) from the Registered Nurses' Association of Ontario (RNAO) Web site External Web Site Policy.

Print copies: Available from Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Availability of Companion Documents

The following are available:

  • Summary of recommendations. Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2010. 5 p. Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses Association of Ontario (RNAO) Web site External Web Site Policy.
  • Nursing Best Practice Guidelines. Restraint prevalence tools. Evaluation user guide. Registered Nurses' Association of Ontario (RNAO); 2006 Nov. 27 p. Electronic copies: Available in PDF in English External Web Site Policy, French External Web Site Policy, and Spanish External Web Site Policy from the RNAO Web site.
  • Toolkit: implementation of clinical practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2002 Mar. 88 p. Electronic copies: Available in PDF from the RNAO Web site External Web Site Policy.
  • Sustainability of best practice guideline implementation. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2006. 24 p. Electronic copies: Available in PDF and as a Power Point presentation from the RNAO Web site External Web Site Policy.
  • Educator's resource: integration of best practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2005 Jun. 123 p. Electronic copies: Available in PDF from the RNAO Web site External Web Site Policy.

Print copies: Available from the Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Various tools, including the Confusion Rating Scale, an example physician order form, and teaching handouts, are available in the appendices of the original guideline document External Web Site Policy. Indicators for monitoring and evaluation are also available in a table.

Mobile versions of RNAO guidelines are available from the RNAO Web site External Web Site Policy. A French version External Web Site Policy of this mobile guideline is also available.

An e-Learning course is available from the RNAO Web site External Web Site Policy.

Patient Resources

The following is available:

  • Health education fact sheet. Caring for persons with delirium, dementia and depression. Registered Nurses' Association of Ontario (RNAO); 2005 Dec. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses Association of Ontario (RNAO) Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on November 3, 2004. The information was verified by the guideline developer on November 23, 2004. This summary was updated by ECRI Institute on July 8, 2011. The updated information was verified by the guideline developer on August 9, 2011.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses' Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario 2010. Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. Toronto, Canada: Registered Nurses' Association of Ontario.

Disclaimer

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