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Care Square

Enhancing care of older adults with cognitive impairments

Williams, Rhonda MSN, RN, CNML; Jacques, Katelyn Keith DNP, A-GNP, RN, BSN, CMSRN; Mirza, Sevda BSN, RN-BC, CNIV; Matters, Loretta MSN, RN, GERO-BC; Guerrier, Lillian Denise DNP, RN, GERO-BC

Author Information
doi: 10.1097/01.NURSE.0000769884.72964.d9
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PICTURE THIS SCENARIO: An older adult patient with a cognitive impairment will not stay in bed. She pulls out her I.V. and wanders. The nurses are frustrated by not knowing what to do, and they wish they had been able to give the time or have the tools needed to keep her safely occupied. This situation inspired one community Magnet® hospital to find a solution. This article details how the hospital designed and implemented a program that ensures these patients receive excellent, personalized care that provides alternatives to the typical physical and pharmacologic methods used to address challenging behaviors in older adults with cognitive impairments. The program provides cognitive stimulation, promotes sleep, and provides sensory enhancement to help prevent acute confusion and provide distractions that help nurses manage or even reduce challenging patient behaviors in the hospital.


Like many acute care facilities across the US, the hospital in which this program was implemented is experiencing an increase in the number of older adult patients. Over 50% of its average monthly census is comprised of patients over age 65. Furthermore, the number of Americans age 65 or over will increase from 55 million to 88 million by 2050.1 The Alzheimer's Association estimates that 5.6 million people who are 65 or over are living with Alzheimer disease and other dementias.1

Patients with cognitive impairment pose unique challenges when admitted to acute care hospitals. Cognitive impairment includes difficulty with thinking, problem-solving, memory, learning, spatial and visual input, recognition of time and place, and other aspects of executive function.1,2 Cognitive impairment has many forms, including Alzheimer disease (AD), dementia, delirium, encephalopathy, and altered mental status.1,2

Dementia is a general term that describes a progressive decline in memory and cognitive functions that reduces an individual's ability to perform daily activities.1 AD or mixed AD accounts for most dementias.2 Up to 27% of hospitalized patients have dementia, and up to 50% of them will experience delirium.3,4 In acute care settings, patients with dementia who receive individualized care (such as nurse-led person-centered care) experience a reduction in the severity of challenging behaviors often associated with dementia.4 Knowing the patient and the patient's baseline cognitive status can benefit both the patient and the staff. Simple interventions such as providing an amplified hearing device can support orientation and communication and enhance patient engagement in care, thereby decreasing both patient and staff distress.

Unlike dementia, delirium is an acute change in cognition that may be reversible. It can be brought on by environmental changes, changes in medical or physiologic conditions, exposure to toxins, or withdrawal from drugs or alcohol.5 Delirium can affect up to 70% of hospitalized older adults and is common in hospitalized patients with dementia.3,5

Hospitalization is stressful for older adults, especially those with AD or other dementias. They are at significant risk for adverse medical and other outcomes, incurring longer and more expensive hospital stays.1,3,4,6 There are twice as many hospitalizations for Medicare beneficiaries with AD or other dementia than for those without.1 Cognitively intact patients can express their needs freely, while patients with dementia have difficulty expressing their needs in a clear, direct manner. Because their needs often go unmet, they exhibit challenging behaviors such as resistance, wandering, agitation, aggression, sleep disturbance, and calling out repetitively.7-9 Nursing initiatives that monitor at-risk patients and provide tools to stabilize and improve cognitive function can prevent the development of delirium and shorten hospital stays.5,10 It is essential for staff to be knowledgeable and confident when caring for this population and to have the necessary tools to provide high-quality care.

Care for older adults with cognitive impairments increases staff workload. This can be overwhelming especially in settings without the proper tools to help prevent the use of undesirable interventions such as chemical or physical restraints.2,3,6,9

The COVID-19 pandemic has greatly impacted and complicated the care of critically ill older adults. Reported rates of delirium in older patients with COVID-19 range from 33% to 67%, and 70% of these patients die during their hospitalization.11,12 Cases of delirium in older adults may be underreported or unrecognized due to healthcare staff limiting contact with patients to reduce risk of COVID-19 spread, staff shortages during disease surges, lack of family presence to identify changes from the patient's baseline, communication difficulties due to the use of personal protective equipment, and other factors.11 Delirium can be directly caused by COVID-19 and compounded by coexisting hypoxemia, hypercoagulability, fever, dehydration, and COVID-19–associated cytokine storm. The risk of COVID-19 delirium can also increase from isolation, immobilization, medications such as sedatives, and prone ventilation used to treat acute respiratory distress syndrome.11,12

Identifying the need

The authors' hospital is a 369-bed facility that is part of a larger academic health system. It strives to improve patient care and nursing practice through innovation and evidence-based practice (EBP). An interdisciplinary team called “Optimizing the Care of Older Adults” was formed to enhance the care of older adults using EBP. The team consists of senior nursing leadership, geriatricians, geriatric resource nurses (GRNs), pharmacists, case managers, clinical nurses, patient advocacy representatives, physical therapists, speech therapists, and occupational therapists. The clinical nurses on the team identified that the facility's ability to effectively care for patients with cognitive impairments was limited. The staff lacked knowledge of appropriate strategies and tools to fully engage patients with cognitive impairment.

Sensory improvement Cognition Sleep promotion
  • Kush ball (K)

  • Pat mat (R)

  • Shape molders (R)

  • Bead ball (R)

  • Magnifying glass (R)

  • Reading glasses (R)

  • Silverware sorter (R)

  • Plastic silverware (D)

  • Laundry basket (R)

  • Linens (R)

  • Playing cards (K)

  • Notepad and pen (K)

  • Coloring book (K)

  • Magazine (K)

  • Hidden pictures search (K)

  • Word search (K)

  • Crossword puzzle (K)

  • Crayon packs (K)

  • Ear plugs (K)

  • Sleep masks (K)

  • Calming music (R)

  • MP3 player (R) and ear buds (K or D)

  • Bead ball (R)

  • Closed blinds

  • Computer screen off

(R) = clean and reuse; (D) = dispose of item; (K) = patient can keep item

The team began with a needs assessment to address the problem and chose a representative 34-bed general medicine unit with 49% of patients over age 65. Approximately 38% of these patients had active diagnoses related to cognitive impairment. A smaller work team consisting of unit-based GRNs, a unit manager, physical therapists, and case managers was formed to focus on the issue.

Person-centered, nonpharmacologic therapeutic activities (TAs) are first-line interventions in the care of patients with dementia and delirium.2,5,8,13 The needs assessment confirmed that these types of interventions/tools were not readily available to the staff. The assessment also identified a significant gap in knowledge regarding patients with cognitive impairments and how to care for them. The work team completed a literature review to identify and translate best EBP into workable solutions. The goals of this initiative were to:

  • put into practice an organized and readily available set of TAs for patients with cognitive impairments
  • improve staff knowledge of dementia and delirium
  • increase the confidence level of nurses caring for this population of patients
  • engage families in managing the challenging and unique needs of their loved ones.

The literature review strongly supported the use of a TA cart as an intervention to address the needs gap at the facility.2-4,7,8,10,13-15 The TA cart is an innovative use of technology and resources to enhance the patient experience and care outcomes of older adults with cognitive impairment. Its use can improve patient safety by reducing fall risks, development of delirium, use of sitters, pharmacologic interventions, and physical restraints. Use of the cart enhances collaboration among all healthcare team members, including medical providers, nurses, nursing assistants, physical therapists, occupational therapists, and speech therapists. The cart also fosters autonomy in nursing practice. Any staff member can select an appropriate patient-centered intervention that provides sensory, cognitive, or sleep enhancement through tools and activities that provide distraction, redirection, and comfort to patients. These tools and activities can reduce the use of pharmacologic or physical methods to manage challenging patient behaviors. This, in turn, reduces staff workload and stress levels, and improves workflow and patient and family satisfaction.

Response I have the resources I need to take care of this patient population. The resources for this population are readily available to me. I am confident in teaching families about preventing and managing delirium.
pre post pre post pre post
Strongly agree 0% 20% 0% 16% 8% 22%
Agree 28% 51% 18% 51% 22% 33%
Somewhat agree 26% 20% 40% 24% 40% 31%
Neither agree nor disagree 20% 7% 20% 7% 16% 4%
Somewhat disagree 18% 2% 12% 0% 4% 2%
Disagree 6% 0% 8% 2% 4% 7%
Strongly disagree 2% 0% 2% 0% 6% 0%
Note: There were 50 presurvey respondents and 45 postsurvey respondents.

Prompt Please give an example of how Care Square positively impacted you, your care, or the patient.
  • My patient loved the apron and was calm when touching different items.

  • Keeps patients occupied and they do not feel enclosed or shut off from the world.

  • Music therapy has drastically improved the mood and emotional well-being of my patients.

  • I had a patient with special needs. I gave him the furry ball to play with and it kept him from pulling out his I.V. lines.

  • Tearful, anxious patient calmed down when using a squeeze toy.

  • Disruptive patient with brain trauma used an MP3 player, calmed down, and listened to music until falling asleep.

  • Have used coloring pages with several patients with cognitive impairments to keep them occupied and calm.

With approval from the organization's Institutional Review Board, the team moved forward with piloting the project to introduce a TA cart to the hospital. The staff on the pilot unit engaged in a friendly competition to name the TA cart and settled on the name “Care Square.” Members of the team also consulted with a local long-term-care facility to gain insight into activities that helped their residents with cognitive impairments. That information, coupled with what was learned from the literature review, helped the team finalize a list of materials that would be included in the TA cart (see Care Square contents). Items listed under sensory improvement are used to correct a sensory impairment, such as low vision, or to distract or comfort patients with deeper levels of dementia in the hope of preventing agitation or aggression. Cognition items are used to stimulate cognitive function to improve orientation or prevent confusion.

Sleep disturbance is a risk factor for disorientation, confusion, and delirium.2,5,10 Sleep promotion items/actions help calm patients and provide an environment conducive to sleep. Most of the items on the TA cart are one-time use only and can easily go home with the patient. Each of the items on the TA cart is clearly labeled as clean and reusable or disposable. Reusable items can be cleaned with hospital-approved cleaning disinfectant wipes. Because of this, COVID-19 has not impacted the program's current practice. The cost of the materials on the TA cart is approximately $150. Most of the items were either readily available in the hospital's central supply (ear plugs, sleep masks) or were purchased in bulk.


The team, led by the unit-based GRNs of the Duke Center of Geriatric Nursing Excellence, developed an online educational module that staff completed before Care Square was implemented on the unit. Studies have shown that in-person and online education of nurses about dementia, delirium, and care of patients with cognitive impairments is effective and reduces the incidence of delirium. It also increases the confidence of staff caring for these patients and improves the overall care of patients with cognitive impairments.4,6,10 The module reviewed the structural changes in the brain associated with dementia, discussed the difference between dementia and delirium, described the use and benefits of TA, introduced Care Square and its contents, and provided strategies to educate and involve patients and family members in the use of Care Square. One-to-one and staff huddles were used to educate staff about the implementation of Care Square and how to document use of the various tools for tracking purposes. An educational board displaying important details about Care Square was also created and displayed in the staff breakroom reinforcing implementation and use.

Once all staff were educated, Care Square was piloted for 4 months. The cart was placed in a central location in the nurse's station. The unit's GRNs were responsible for monitoring cart usage, which helped them identify who needed reinforcement regarding its use, including the choice of the most appropriate tool or activity. The team reported to the Optimizing Care of Older Adults team monthly during the pilot period.


Overall usage was assessed at the end of the pilot period. There were 42 documented uses for 38 different patients, 81% of whom were 65 or older. Thirty-eight percent had active diagnoses of cognitive impairment. Inventories showed 30% of used items were unaccounted for by documentation. Based on inventory, the tools and activities were in all likelihood utilized in greater numbers than the documentation indicated. Staff indicated that lack of time to utilize and document TA due to patient load and acuity was often a barrier to using the cart.

The needs assessment was administered after intervention to the same group of people, with 45 responding (see Pre- and postpilot survey results). All questions demonstrated an increase in “strongly agree” and “agree” responses, indicating that the intervention was successful in increasing knowledge and confidence level in caring for patients with cognitive impairments. Increased availability and accessibility of TA for use with patients was also found.


Based on the positive results and feedback from staff, patients, and families, the Optimizing Care of Older Adults team (with support of the CNO) initiated a process to implement Care Square on all inpatient units. The needs assessment was sent out to six inpatient units, including three medical units, two surgical units, and the CCU. Results of this survey further validated the need for the Care Square on these units as well (see Nurses' comments on Care Square).

After Care Square was implemented on all units, usage ranged from 100 to 130 times each month. It offered patients and their families simple activities, which helped reduce the stress and boredom of the hospital environment. It also provided materials to enhance tactile, visual, and hearing senses as well as materials to support sleep. Use of the tools and activities provided staff with alternatives to chemical and physical restraints. Several of the activities also provided patients with tasks that gave them a sense of purpose.

Barriers to the utilization of Care Square will need to be addressed as this program moves forward. This includes restocking and storage of supplies, low visibility of the cart, and helping staff find time to engage patients with these interventions. Comparisons of therapeutic activity usage to past and present quality indicators, such as falls, restraints, sitter usage, length of stay, and mortality index, will be important when expanding the program to the entire health system.

Implementing practice changes, such as Care Square, is part of the vision of this healthcare system. The team is focused on improving the implementation process as the project moves forward, collecting feedback and incorporating beneficial suggestions to streamline Care Square. Care Square represents a successful intervention that improves the care of patients with cognitive impairments, reduces the stress on healthcare staff providing their care, and can easily be replicated at any acute care facility.


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