Orthostatic hypotension (OH) is a common clinical finding in frail older adults, particularly in those who are institutionalized (Lanier, Mote, & Clay, 2011; Luukinen, Koski, Laippala, & Kivelä, 1999). Older adults have an increased vulnerability to OH as a result of impaired homeostatic mechanisms that result from the aging process (Fessel & Robertson, 2006; Sclater & Alagiakrishnan, 2004). The prevalence of OH also increases with age, disorders that affect autonomic nerve transmission, and the use of medications, including antihypertensive, diuretic, and psychotropic agents (Mosnaim, Abiola, Wolf, & Perlmuter, 2010). Prevalence estimates indicate that OH occurs in 50% to 60% of nursing home residents, and more specifically, in those with dementia (Sonnesyn et al., 2009).
Older adults with progressive dementia experience problems that further complicate their lives and well-being. In the middle to later stages, behavioral symptoms such as aggression, resistance to care, anxiety, and psychosis often develop, threatening the individual’s safety and the safety of others. In addition to disease-related cognitive decline, acute confusional states (delirium), symptomatic of other illnesses, can worsen behaviors. These behaviors are commonly treated with psychotropic medications, including antipsychotic and antidepressant agents. However, these medications have a high side effect profile, including OH (Fessel & Robertson, 2006; Low, 2008), for which the cycle of symptoms repeats (Figure).
Cycle of symptoms of orthostatic hypotension.
Definition and Significance of Orthostatic Hypotension
OH is generally defined as a drop in blood pressure (BP) with position change from lying or sitting to standing. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology (1996) defined OH as “a reduction of systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg within 3 minutes of standing” (p. 1470). Dizziness, light headedness, and syncope, with increased risk for falls, occur if the reduction in BP is sufficient to overcome perfusion (Ejaz, Haley, Wasiluk, Meschia, & Fitzpatrick, 2004).
In long-term care, the symptoms that occur with OH are costly to older adult residents, the facility, and the health care system (Hartholt et al., 2011). For older adults, dizziness, syncopal episodes, and falls often result in emergency department evaluations and hospitalizations for diagnosis and treatment. Even short-term hospitalization is associated with iatrogenic problems such as delirium, decubitus ulcers, and malnutrition. Consequences of falling include fractures, pain and suffering, and functional dependence with increased mortality. These problems set a negative downward spiral in motion from which many older adults never recover (Ejaz at al., 2004; Hartholt et al., 2011).
Costs of OH for long-term care facilities and the health care system are measured in terms of care quality and economics. Long-term care facilities are held accountable for providing a safe and comfortable environment that optimizes quality of life according to federal and state standards. Overall success, reputation, and reimbursement are based on facilities meeting these standards. OH can potentially jeopardize resident safety and be a root cause of sentinel events. Costs of care are increased related to treatment of the symptoms and consequences of OH. These costs reduce facility revenues, especially in capitated systems, and place added financial burden on the health care system as a whole (Hartholt et al., 2011).
Strategies exist to reduce and/or prevent negative outcomes of OH (Hartholt et al., 2011; Lanier et al., 2011; Sclater & Alagiakrishnan, 2004; Shaw, 2003). Successful treatment requires recognition of symptoms and the accurate measurement of BP change. OH should be suspected in older adults with a diagnosis of dementia as supported by the known prevalence (Sonnesyn et al., 2009). Orthostatic BP measurements should routinely be considered. Once OH has been identified, nursing interventions initiated by staff can contribute to symptom management and control. The timely reporting of assessment information to medical care providers facilitates pharmacological treatment.
OH remains an underrecognized and undertreated condition in older adults (Bragg & Kumar, 2005). Several factors affect both the accurate assessment and treatment of OH. The American Heart Association’s guideline for BP measurements defines a sequence of steps and factors relevant to accuracy (Table 1). However, inaccurate basic BP measurement has been identified to be a long-standing concern (O’Brien et al., 2005). Studies have repeatedly confirmed difficulties in the accuracy of basic BP measurement due to many factors including type of equipment used, cuff size, patient preparation, arm position, cuff placement, skills and knowledge of individuals performing the measurement, and the protocol or procedure used (Pickering et al., 2005; Vloet, Smits, Frederiks, Hoefnagels, & Jansen, 2002).
Procedure for Measuring Orthostatic Blood Pressure
The evidence supports that nurses’ knowledge, skills, and procedural compliance measuring supine and standing BPs are not always adequate for accurate assessment of OH in the older adult population (Vloet et al., 2002). Inconsistencies in the procedural sequence and timing of measurement are common. In a study of 170 nurses working with hospitalized older adults, significant variation in measurement technique was identified. Inconsistencies were found in inaccurate cuff placement and arm positioning and the timing of measurements relative to position change (Vloet et al., 2002). Lack of adherence to recommended procedures and poor technique affect validity of the results, which delays or masks the need for treatment (Naschitz & Rosner, 2007).
The prevalence, significance, and potential for successful intervention for OH are often not well understood by staff providing care in dementia units (Sonnesyn et al., 2009). A compounding factor in the long-term care environment is that assistive or unlicensed assistive personnel are often delegated the task of obtaining orthostatic BP measures. These personnel may possess less skill and understanding of recommended procedures and factors that influence results during measurement than licensed staff. With few RNs at the bedside in long-term care facilities, accurate assessment and interpretation of results are decreased. There is an assumption by many staff that treatment of OH is solely the responsibility of medical providers using medications. They are unaware of nursing care measures that may positively impact orthostasis.
This quality improvement (QI) project was planned and implemented to increase staff knowledge and skill in the assessment and care of older adults with advanced dementia at risk for or with OH. An educational in-service program was provided for RNs, licensed practical nurses (LPNs), therapists, and unlicensed caregivers working in dementia care units of two long-term care facilities. Clinical practice guidelines provided the content basis consistent with the Institute of Medicine’s (2000) recommendation to standardize care based on scientific evidence. It was anticipated that the educational program would result in the expected outcomes of increased accuracy of assessment and measurement and the implementation of nursing care interventions by staff caring for this specific population.
Change is a process that requires detailed planning and organization to be effective. This practice change project was planned and conducted according to the Model for Evidence-Based Practice Change (Rosswurm & Larrabee, 1999). The model integrates principles of QI, use of team work tools, and evidence-based translation strategies to promote adoption of a new practice (Melnyk & Fineout-Overholt, 2011).
The topic of OH was chosen for this project based on the prevalence, symptoms, and consequences identified by the project leader functioning in an advanced practice role at the two facilities. During informal discussions with staff, it was clear that they did not connect OH with its presenting symptoms or understand its relevance. Prior to the in-service program, the project leader asked 12 RNs and LPNs: “What interventions can you as a nurse put in place to help or minimize OH?” Four of the 12 answered, “Nothing.” Five responded, “Give the medications ordered by the doctor,” and three replied, “I don’t know.” Clinical observations of the residents from the nurse practitioner perspective combined with the staff’s admitted lack of understanding about OH became the motivation for this practice change project.
Multi-level collaboration was used to gain permission, support, and cooperation. Meetings with administrators, the medical director of the facilities, and the unit managers were conducted to gain project consent and support. Exempt institutional review board approval was provided following an expedited review.
A detailed plan for conducting the in-service meetings with reference to content, learning activities, and the environmental set-up was designed with input from both unit managers 1 month prior to the intended offerings. A nursing care protocol and a procedure for orthostatic BP measurement were defined according to Viscomi and Jeffrey’s (2010) clinical practice guidelines. Nursing measures to minimize or prevent orthostasis from the guideline that were suitable for the dementia care environment were presented as a protocol (Table 2).
Nursing Care Protocol for Residents with Orthostatic Hypotension (OH)
The content for the in-service program was obtained from the literature and previous observations of the project leader. Materials were organized in an outline format to ensure a consistent approach. Informal, participative teaching and learning strategies included discussion, a hands-on procedure demonstration and return demonstration of BP measurement, and compression stocking application. A poster displaying the orthostatic BP measurement procedure (Table 1) and the nursing care protocol (Table 2) was presented in discussion and then posted on each unit for staff reference. Pocket reference cards were provided for each staff member to serve as an easily accessible reference detailing the procedural steps of measurement and the care protocol.
During the 4-week period following the in-service sessions, the project leader observed staff as they measured orthostatic BP on residents as part of routine care. Following the staff’s completion of the procedure, the project leader offered positive feedback as well as suggestions for technique. It was advantageous that the project leader had established working relationships with the staff in these two units. Awkwardness and discomfort of being observed were decreased by the rapport of the project leader with staff. During the observation, the project leader reaffirmed the purpose of observation was solely to evaluate the results of the educational in-service.
Two activities were conducted to evaluate the outcomes. A questionnaire was designed and administered at the beginning and end of the in-service to measure knowledge gained for the 30 staff participants. The posttest was repeated 4 weeks after the in-service session as an indicator of retention of knowledge. The questionnaire was a 6-item objective test containing three true/false questions and three multiple choice questions. The tool was brief to minimize test anxieties and time requirements. Face validity was established by review of two content experts. The questionnaire’s content areas included the commonality of the problem of OH in older adults with dementia, the problematic consequences of OH, and nursing care interventions. Data were analyzed using descriptive statistics and paired t tests.
Audits of residents’ medical records for the 4-week period prior to and following the in-service were conducted as a second means of monitoring outcomes. QI in long-term care facilities relies on methods for analysis and identification of deficiencies in care processes. Conducting audits by medical record review has been a common, effective method to measure the quality of care. Chart audits have been used among nursing home residents to evaluate the processes of care (Wagner, Clark, Parmlee, Capezuti, & Ouslander, 2005). Sixty-one residents were candidates for the chart audit based on their medical diagnosis of dementia and residence in the dementia care unit. This group was further screened for a medical diagnosis of OH within the 6-month period prior to the scheduled in-services. A total of 26 resident charts were audited before and after the in-services according to the QI project plan. The criteria for the audit were the 12 interventions derived directly from the nursing care protocol (Table 2). Each medical record was assigned a unique resident identifier number from 150 to 200 to maintain confidentiality.
In the comparison of pre- and posttest questionnaire mean scores for the 30 staff participants, the pre-test yielded a mean score of 4.8 (possible 6.0), with higher scores indicating greater knowledge. The mean posttest score was 5.6. In a paired samples t test comparing in-service pre- and posttest scores, the average change in knowledge score from pre- to posttest was significant and positive (t = −4.5, df = 29, p < 0.001). For the average staff member, the change was an increase of 0.767 points on the knowledge scale. The mean 4-week posttest score was 5.7 of 6.0. A paired t test found no significant difference between the post-test scores and the 4-week posttest scores (t = −0.81, df = 29, p = 0.423).
Rating compliance in the chart audits was determined by whether each protocol item was specifically mentioned or indicated. The audit was scored using a dichotomous scale using 1 or 0. A score of 1 was assigned for each care-related intervention cited in the medical record for each of the 28 days. Paired sample t tests found a significant increase in the documentation of interventions, as shown in Table 3. The sign in front of each t test result reflects the order in which the mean scores were analyzed. Table 3 also describes the percentage of time that the documentation of each of the protocol interventions increased for the average resident. Interventions showing less change in documentation (<6%) were physical interventions possibly limited due to an individual resident’s decreased mobility capabilities.
Increase in Documentation of Protocol Interventions
In evaluation of this QI project, statistical analysis supports achievement of the expected outcomes. Posttest measures of knowledge following the educational program demonstrated a significant increase in nurses’ knowledge about OH. Chart audits conducted for the 4-week period following the educational intervention showed a significant increase in documentation of nursing interventions according to the nursing protocol for OH. It can be further postulated that accurate, evidence-based nursing interventions will lead to more effective treatment of the symptoms of OH, reducing negative consequences for older adults with dementia.
Discussion and Implications
This QI project identified the need for and benefits of continued education to increase staff knowledge and procedural skill building of OH. Increased knowledge builds competence, which leads to better outcomes. However, an in-service session by itself is not an effective means for practice change. Schulman (2008) identified strategies to facilitate implementation including systems supports such as checklists, electronic reminders, and focus on benefits to the patient or nurse and streamlined processes. Project pocket card reminders, unit-based posters, direct observation, and feedback were used in the current QI project to enhance skills, support, and sustain the practice change.
Likewise, the existence of clinical practice guidelines is not sufficient to ensure quality patient care. Clinical practice guidelines and clinical protocols are standards of care in that they define care that should be given to a defined population within a specific environment. The environmental context, including organizational and staff cultural characteristics, must be incorporated into a comprehensive plan to effect meaningful practice change (Brown, 2009). In the long-term care environment, the level of staffing and skill mix as well as the organizational model of care delivery are important to consider in planning a practice change. Passive approaches are generally not likely to result in a behavior change.
The protocol for OH used in this QI project was derived directly from research-based clinical practice guidelines. It must be kept in mind that protocols are not recipes to be blindly followed (Freidman et al., 2009). In care planning, nurses must selectively individualize interventions listed in the protocol based on medical conditions, functional abilities, and overall feasibility. Patient responses to the protocol interventions must be monitored. Although a protocol is evidence-based, it may not be fitting for every situation (Freidman et al., 2009). Professional nursing judgment is a necessity.
Lastly, as part of a comprehensive educational approach to change and to sustain change in practice, a follow-up education plan for sustaining adherence to clinical practice guidelines is a necessary step of the process (Freidman et al., 2009). Follow up is critically important to support ongoing change. A plan for ongoing educational support and evaluative mechanisms must be put in place after completion of the initial intervention to sustain a long-term change in practice. The use of bedside documentation checklists as protocol reminders and ongoing feedback with staff as part of the holistic care planning process are suggested to support continued knowledge and compliance with the clinical practice guidelines. Realizing that there is generally significant staff turnover in long-term care, the care of residents with or at risk for OH must be included in new staff orientation. Unit-based quality improvement audits are suggested as a mechanism for ongoing monitoring of staff compliance.
The following limitations of this QI project were identified and deserve consideration in practice and further study. The results are not generalizable to long-term care as a whole. There are many different variables within facilities that can affect process and results. There was not a planned, direct method for documenting care measures outlined by the protocol. The relatively small sample may have skewed statistical significance. Practice change in this project was limited due to time constraints of the project assignment. Further encouragement and reinforcement are needed to sustain a positive impact with subsequent analysis of differences in patient outcomes. In addition, basic staff demographic data were not obtained. Specific education and experience levels would be helpful in designing meaningful educational strategies and methods for evaluation. OH is a known side effect of some medications. Although medications were not a specific focus of this project, a systematic review of medications by the patient care team may potentially influence the outcomes of the protocol’s interventions. Finally, assessment techniques were informally evaluated by observation only once after the teaching session. Follow-up competency and compliance checks on BP measurement techniques are recommended for sustained QI.
The assessment and management of OH has a significant impact on the health status and quality of life in older adults, especially those with advanced dementia. Once identified or diagnosed, OH can be effectively managed in most cases. Additional outcome-based studies are needed that evaluate the effectiveness of treatment of OH in regard to its main problematic symptoms of falls, confusion, and behavioral problems, including psychosis.
There is opportunity for improved quality of care for older adults with OH given by nurses according to the evidence structured in clinical practice guidelines. More education is needed to increase nursing knowledge about this significant clinical condition to support and sustain quality care outcomes.
In this QI project, clinical practice guidelines provided the basis for the OH care protocol and orthostatic BP measurement technique. The staff education program resulted in increased awareness, knowledge, and understanding of the relevance of OH and its consequences. The implication is that increased knowledge directly influences the quality of care provided. In long-term care settings, there is potential to further integrate the OH nursing protocol into routine care, building on the positive outcomes achieved. Although results of QI projects are setting- and population-specific, the implication is that increased knowledge directly influences the quality of care provided. Older adults with advanced dementia can clearly benefit by the reduction and/or prevention of OH symptoms.
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Procedure for Measuring Orthostatic Blood Pressure
||Have the older adult lie down for 5 minutes.
||Measure the blood pressure and pulse in both arms. Use the arm with the higher blood pressure for measurements following position change.
||Have the older adult stand. Take the blood pressure and pulse immediately after standing and ask about dizziness.
*If the individual is unable to stand, the blood pressure may be taken while sitting with feet dangling.
||After standing for 3 minutes, repeat the blood pressure and pulse again and ask about dizziness.
||Record the blood pressure, pulse readings, and the presence or absence of dizziness in each position.
Nursing Care Protocol for Residents with Orthostatic Hypotension (OH)
|Purpose: To increase older adult residents’ safety and enhance their quality of life.
Goal: To minimize blood pressure (BP) drop with position change by implementing evidence-based nursing interventions.
|Nursing care for older adult residents with OH (a drop of 20 mmHg in systolic BP and/or 10 mmHg in diastolic BP with position change from lying to standing in 3 minutes) includes:
||Head of bed elevation of 30° at all times.
||Avoid rapid changes in posture, especially in the morning. When assisting the resident out of bed for the first time, have the resident sit up gradually. Have the resident’s feet dangle at the bedside for a few minutes, if able. Assist to a standing position, and support resident’s standing for a few minutes before walking.
||Apply compression stockings during the daytime as tolerated. Thigh-high are preferred if tolerated; otherwise, knee-highs may be used. Apply stockings before getting out of bed in the morning. Take them off at night.
||Encourage coff ee or tea with breakfast, as tolerated.
||Encourage the resident to remain seated approximately 20 minutes after meals.
||Delay physical activities from early morning to afternoon or evening when BP is naturally higher and when most older adult residents tend to feel better.
||Encourage sitting after any type of exercise.
||Avoid standing up too quickly after toileting.
||Encourage fluid intake.
||Avoid bathing or warm showers in the morning.
||Encourage crossing and uncrossing legs often while sitting.
||Instruct dorsiflexion of feet several times before standing.
Increase in Documentation of Protocol Interventions
|Head of bed elevation
|Compression stocking use
|Out of bed, feet dangle slowly
|Tea and coff ee with breakfast
|Remain seated 20 minutes after meals
|Avoid morning activities (e.g., bathing)
|Sit after exercise
|Absence of constipation
|Encourage leg crossing
|Encourage fluids (i.e., 200 cc every 4 hours)
|Flex feet before standing