Empowering Certified Nursing Assistants to Screen for Delirium: If Not Now, When?

Introduction

Mrs. Frank was an 84-year-old nursing home resident who was diagnosed with dementia 2 years before entering the facility. She was active in the nursing home, participating in recreational therapy activities, and had a good rapport with staff. One morning the certified nursing assistant (CNA) noticed she had developed a cough, was sleeping more, and not eating as much. She also did not want to go to her usual exercise class. The CNA let the RN know that Mrs. Frank was not herself and that she was worried she might be developing delirium from an acute illness. The nursing home did not have a process in place for delirium assessment and 2 days later Mrs. Frank had a fall in the nursing home and was admitted to the hospital for pneumonia.

How age-friendly care can optimize delirium management for older adults, including those living with dementia, has been discussed previously (Fick & Shrestha, 2022; Kwak et al., 2024). We seek to expand on this important dialogue and discuss the empowerment of CNAs as nursing homes integrate age-friendly delirium care.

Age-Friendly Delirium Care

Age-Friendly Health Systems (AFHS; https://www.ihi.org/initiatives/age-friendly-health-systems) is a national initiative that aims to ensure all older adults in all care settings consistently receive equitable, person-centered, and evidence-based care. The four pillars of AFHS are What Matters, Medication, Mentation (dementia, depression, delirium), and Mobility, collectively known as the 4Ms Framework. Although most nursing homes are already addressing one or more of the 4Ms, the key to truly becoming age-friendly is the reliable application and integration of all 4Ms as a set during every encounter with every older adult in every setting.

CNAs are responsible for most direct patient care and spend the most time with residents among nursing home staff. CNAs are uniquely positioned to facilitate the implementation of the 4Ms to promote age-friendly delirium care for residents with and without dementia: “What Matters” or goals and preferences of older adults and care partners should be incorporated into all direct care activities, whereas “Mobility” should be encouraged during transferring. Engagement in meaningful activities to keep the mind active and mobility are protective factors for delirium, whereas malnutrition and medication are risk factors. Typical duties of CNAs include assisting residents with bathing, toileting, dressing, turning, repositioning, transferring (What Matters and Mobility); listening to and reporting health concerns of residents to nurses (What Matters); measuring and reporting vital signs (of which mental status should also be included [Fick, 2018]); and serv- ing meals and assistance with eating (What Matters, e.g., food preferences [U.S. Bureau of Labor Statistics, U.S. Department of Labor, 2023]). Regarding Medication, some states allow CNAs to have an expanded role to dispense medication (McMullen et al., 2015). In states where CNAs are not allowed to dispense medication, they could still have an important role in monitoring and reporting signs of medication-induced delirium in older adults who take multiple medications or start on new medications. In terms of Mentation, CNAs working in nursing homes are required by federal regulation 42 CFR 483.152(b)(5) to receive training on “Care of Cognitively Impaired Residents,” including subtopics on techniques for addressing the unique needs and behaviors of individuals with Alzheimer's disease and other dementias; communicating with, understanding the behavior of, and appropriate responses to residents with cognitive impairments; and methods of reducing the effects of cognitive impairments. CNAs should therefore be expected to incorporate learnings from such training in all direct care activities provided to residents with cognitive impairments.

Despite clear alignment between the 4Ms and existing CNA duties, arguably, these are more supportive roles (care delivery) rather than leading and explicit roles (assessment and care planning). The assessment and goal setting of “What Matters” are typically performed by nurses, social workers, and activities staff; “Mobility” by physical and occupational therapists; and Medication by nurses/nurse practitioners and physicians. Having an explicit and defined role for CNAs for the 4Ms is essential in integrating CNAs more fully into interdisciplinary teams.

Empowering CNAs to Provide Age-Friendly Delirium Care

Assessment

One way to empower CNAs is involving them in early detection of delirium using standardized, validated delirium assessment tools. The two delirium assessment tools for nursing homes recommended by the AFHS are the Confusion Assessment Method (CAM; Inouye et al., 1990) and Ultra-Brief Confusion Assessment Method (UB-CAM; Motyl et al., 2020).

The CAM has been incorporated into the Minimum Data Set (MDS) 3.0 since 2010 (CMS.gov, 2024). The MDS is a comprehensive, standardized assessment that is completed at admission, every 3 months (more frequently in skilled nursing settings), yearly, and at discharge on nearly all U.S. nursing home residents. One delirium core feature assessed in the CAM is symptom fluctuation, which may or may not be captured during the patient interview. In this case, the nurse should consult all sources of information to determine whether fluctuation occurs during the 7-day look back period. Given that dementia can look similar to delirium, capturing symptom fluctuations is critical in detecting delirium, which can be a medical emergency, in residents with dementia and allows early treatment. In family caregiver delirium research (Shrestha & Fick, 2020), experts maintain that caregivers have an expert role in observing and reporting symptom fluctuations because they are more likely to spend a prolonged period with their relative or friend than health care professionals. Similarly, CNAs spend the most time with nursing home residents and, therefore, are more likely than other nursing home staff to observe and report fluctuation. Establishing this expert role in observing and reporting symptom fluctuation could be a way to empower CNAs and reduce a sense of not being a valued member in the interdisciplinary team.

The UB-CAM is a two-step screening protocol. Research has shown that CNAs perform similarly well as nurses and physicians in administering the first-step screening of the UB-CAM called the UB-2 (Fick et al., 2015). In a previous study of the UB-2 and UB-CAM, CNAs stated they liked performing the UB-2 because they often knew older adults best (Fick et al., 2018). The UB-CAM has been tested in the real world setting in >500 older adults and with 399 clinicians at the bedside and had close to 90% accuracy (Marcantonio et al., 2021). This tool is also available as a free application on iOS and Android devices (Kuzmik et al., 2023). Having CNAs lead the first-step screening of the UB-CAM and nurses/physicians perform the follow-up assessment (Step 2) empowers CNAs by giving them a key role in detecting delirium as a vital sign (Fick, 2018). The adoption of this two-step protocol, where the follow-up assessment is performed only when the first-step screening by the CNA is positive, will also facilitate routine delirium assessment at frequency recommended by the AFHS (at least every 24 hours and with change in condition in skilled nursing settings, which is more frequent than the MDS requirement), without over-burdening the entire nursing staff.

Education

Education in delirium is not as common in nursing homes and should be required similar to dementia training. Dementia is the largest risk factor for delirium (Fick & Shrestha, 2022). Specific topics suggested by CNAs (Sabbe et al., 2023) are: caring for residents with delirium, recognizing delirium/screening, symptoms of delirium, tools/action plan, and distinction between delirium and dementia. The CAM, UB-CAM, and other delirium tools can be found online at the Network for Investigation of Delirium: Unifying Scientists at https://deliriumnetwork.org/measurement/delirium-info-cards.

Recruitment and Retention

Finally, an important reason to empower CNAs is for recruitment and retention. In previous work (Fick et al., 2018; Marcantonio et al., 2021), CNAs enjoyed using the UB-2 and having their expertise recognized and valued.

Conclusion

Having a lead role in age-friendly care and delirium screening could be incorporated into a clinical ladder for CNAs. Just as we need to see older adults, we also need to see and empower CNAs and help them find joy and purpose in their work.

Shih-Yin Lin, PhD, MPH, MM

NYU Rory Meyers College of Nursing

New York, New York

Donna M. Fick, PhD, RN, GCNS-BC, AGSF,

FGSA, FAAN

Editor

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