CoCare-CI: A Clinical Innovation to Address Behavioral Symptoms in Hospitalized Older Adults With Cognitive Impairment.

Abstract

Introduction: Behavioral symptoms in hospitalized older adults with cognitive impairment often lead to physical and chemical restraint use, despite associated harms. Patient-centered care models show promise in reducing restraint use but are rarely implemented in routine practice. This project implemented CoCare-CI, a clinical innovation to address behavioral symptoms in hospitalized older adults with cognitive impairment.

Methods: CoCare-CI was implemented on a 24-bed ACE unit in a 128-bed community hospital from January 2023 to August 2024 by a multidisciplinary team led by a geriatric nurse practitioner (GNP). CoCare-CI emphasized (1) systematic screening and assessment of mentation, and (2) individualized management plans for delirium or dementia. Implementation followed a phased, cyclical approach with champions supporting process improvement. Baseline restraint data (January-August 2023) were compared to intervention data (September 2023-August 2024). Primary outcomes included physical and chemical restraint use; process measures included documentation rates of the Confusion Assessment Method (CAM), CAM-Severity (CAM-S), Six-Item Cognitive Impairment Test (6CIT), and 4Ms checklist.

Results: Among 949 patients (mean age 81.5 years, 59% female, 80.6% White), 34.1% had cognitive impairment at baseline, including 22.6% with dementia and 11.5% with a significant 6CIT score (≥ 8). Documentation rates improved for CAM (68%-86%), CAM-S (0%-79%), 6CIT (0%-89%), and 4Ms checklist (0%-96%). Physical restraint use decreased from 4.3% to 0.7%, and chemical restraint use dropped from 7.6% to 2.3%. Most restraint use (84.2%, 16/19) was deemed potentially avoidable, with root cause analysis revealing that 78.6% (11/14) of patients with restraint orders had moderate to severe dementia with behavioral symptoms.

Conclusions: CoCare-CI is associated with reductions in reduced physical and chemical restraint use, demonstrating potential for dissemination within routine clinical practice. Future research should assess sustainability, broader applicability, and integration of additional 4Ms components.