Chronic Diseases and Restrictive Diets

1. Chronic Diseases and Restrictive Diets • Common Restrictive Diets: • Low/no sugar (Diabetes) • Low fat (Elevated cholesterol) • Low sodium (Congestive heart failure) • Combination of above (High blood pressure) • Associated with poor intake • May be seen in specific ethnic groups • Decreased meat intake • Other dietary preferences and restrictions

2. Dental Problems: Tooth Loss • Most common causes of tooth loss: • Inability or unwillingness to access and pay for preventive/restorative treatment • Loosening of teeth from periodontal disease • Removal of healthy teeth in preparation for dental prosthesis • Leads to diminished chewing efficiency and reduced range of preferred foods

3. Dental Problems: Removable Dentures • Can aid in speech • Restores facial contours • Less likely to restore ability to chew (restriction in range of foods) • Requires frequent professional adjustment • Not covered by Medicare < 10% of older persons have dental insurance

4. Screening for Under-nutrition or Malnutrition Can use a combination of: • Serial body weight • Weight loss over the past months/yrs • Nutrition history:appetite, # of meals/day, taste & amount of food eaten • Laboratory Values: Low serum cholesterol and/or albumin

5. Cultural Competency & Frailty There is a need to include significant family members in health care discussions. It is important to educate both the patient and significant family members regarding the impact of frailty, nutrition and prevention strategies.

6. Cultural Competency & Frailty • Family members instrumental in assuring preventive measures and treatment plans are implemented. • Family members can also be a part of the problem, particularly regarding nutrition. • By educating family members you: • make them a part of the solution • increase your understanding of potential barriers to treatment.

7. Cultural Competency & Frailty Many older ethnic minorities lack formal education. May have difficulty understanding words, concepts and procedures discussed in a medical setting. Important to use words that are easily understood and provide examples. Reduce carbohydrates Reduce your intake of cereals, rice and breads

8. Nutrition Team Challenge You are a team gathered together by the CEO of your hospital. The CEO tells you that a recent survey by the nutrition department demonstrated a large proportion of your hospital’s patients were having eating difficulties and poor nutrition during the hospital stay and this was negatively impacting on their functional status after discharge.

9. Nutrition Team Challenge • Move importantly (to the CEO) this group was having higher 30-day readmission rates. • Your task is to define potential reasons for the eating difficulties and develop some potential solutions for the problem of eating difficulties and poor nutrition during hospitalization among the older adults admitted to your hospital.

10. Consequences of Frailty: Falls

11. Falls Incidence: Community • One-third of community-dwelling persons age > 65, fall each year; less than half talk to their healthcare provider about it. • In approximately half of the cases, falls are recurrent • Rates increase • With age • During the month after hospital discharge

12. Falls Morbidity: Community • In next 17 seconds, an older adult will be treated in hospital ED for fall related injuries. • 10-15% of falls result in injury requiring medical attention • Functional deterioration including: • Fear of falling / loss of confidence • 40-73% of recent fallers • 20-46% without recent fall • Self-limitation of activities

13. Falls Mortality: Community • Unintentional injury, 5th leading cause of death in those > 65 years • Majority due to falls • Especially in those > 85 years • Deaths often related to consequences after the fall, not the fall itself • Hospitalization • Decreased activity

14. Falls Cost: Community • Leading cause of injury-related visits to emergency departments in US • In 2009, 2.2 million nonfatal fall injuries treated in emergency departments. • Direct medical costs of falls: $28.2 billion in 2010 dollars. • Numbers expected to climb as population ages

15. Fall Risk Factors : Community • Focus of most fall research • Falls in community-dwelling older adults tend to be multifactorial in nature • As number of risk factors increases, so does risk of falls

16. Occurrence of Falls According to Number of Risk Factors(Tinetti, 1988) Number of Risk Factors

17. Most Common Risk Factors for Falls (AGS Guidelines, 2011) Risk factor Significant/total Mean RR-OR Range

18. Ambulatory Devices-Unilateral

19. Ambulatory Devices-Bilateral

20. Resources for Teaching about Assistive Devices • Rodriguez O, Ruiz J, Phancao F. "Assistive Devices" Learning Object. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/379 • van Zuilen M, Rodriguez O, Paniagua M, Mintzer M. Choosing the Appropriate Assistive Device: A Card Sorting Activity. MedEdPORTAL; 2008. Available from: www.mededportal.org/publication/823

21. Medications and Falls • Psychotropics, any: RR 1.73 (1.52-1.97) • Neuroleptics: 1.50 (1.25-1.79) • Sedative/hypnotics: 1.54 (1.40-1.70) • Antidepressants: 1.66 (1.40-1.95) • Benzodiazepines: 1.48 (1.23-1.77) • Diuretics: 1.08 (1.02-1.16) • Anti-arrhythmics (Ia) : 1.59 (1.02-2.48) • Digoxin: 1.22 (1.05-1.42)

22. Level of Evidence Recommended Interventions • Multifactorial assessment of risk factors and management of risk factors identified • Adaptation/Modification of home environment • Exercise, particularly balance, strength, and gait training • Withdrawal/Minimization of psychoactive medications • Withdrawal/Minimization of other medications • Management of postural hypotension • Management of foot problems and footwear [A] [A] [A] [B] [C] [C] [C]

23. Falls in the Hospital Setting

24. CMS “Never” Events • “Never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.  • Patient death or injury associated with a fall while being cared for in a healthcare facility considered a “never” event.

25. Hospital Risk Factors • Several factors consistently reported • Gait instability • Agitated confusion • Urinary incontinence/ frequency • Falls history • Medications especially sedative/hypnotics

26. Multifaceted Interventions: Hospitals • A recent meta-analyses showed rate ratio of 0.82 (95% CI 0.68-0.997) for falls • No significant effect on # of fallers or fractures • Multifaceted interventions included: • risk assessment • removal of physical restraints • medical/diagnostic approaches • changes in physical environment • medication review • exercise • care planning • hip protectors

27. A recent meta-analyses of 13 studies showed a rate ratio of 0.82 (95% CI 0.68-0.997) for falls but no significant effect on number of fallers or fractures Study included historical controls A second study that used only prospective controlled trial designed studies found no conclusive evidence that fall prevention programs reduced falls. Results of Meta-Analysis Coussement J, et al. J Am Geriatr Soc, 2008

28. Frailty and Disability

29. Nagi’s Disablement Model Active Pathology • Normal cellular processes and homeostatic efforts to return to normal state are interrupted Impairment • Loss or abnormality at the organ or tissue level Functional Limitation • Have physical or mental limitation at the individual level Disability • Have physical or mental limitation in a social context (i.e. socially defined roles or tasks) Active Pathology Functional Limitation Impairment Disability

30. Criticism of Early Disablement Models • Presented response to disease or illness as a static process with a linear progression through the disablement process. • It was recognized the interaction between disease and disability is more complex, particularly for older persons.

31. ICF Model • International Classification of Functioning, Disability and Health (ICF) released by World Health Organization (WHO)in 2001 by WHO. • Describes decreases in function as consequence of dynamic interaction between various health conditions and contextual factors. • Disability is defined as any decline at any of these levels.

32. Health Condition Diseases, disorders, injuries or aging Body Functions & Structures Physiologic functions and anatomical partsofbody Activity Execution of a task or action Participation Application to a real life situation Environmental Factors Physical, social and attitudinal environment in which people live Personal Factors Characteristics of person not part of health condition or illness International Classification of Functioning, Disability and Health

33. Model Used to Discuss Frailty • We could describe an older woman who has a history of osteoarthritis of the knees and hypertension who presents to rehabilitation after a hip fracture. She lives alone in a second floor apartment and has a daughter who lives six hours away. The patient has a large circle of friends and regularly attends social gatherings at the local senior center.

34. Health Condition New hip fracture Osteoarthritis Hypertension Body Functions and Structures Impairment of ambulation due to hip fracture and knee pain Activity Unable to walk long distances or climb stairs Participation Missing social events/ friends Worried about remaining in apartment alone Environmental Factors Lives in second floor apartment Lives alone, no available caregiver Personal Factors Great attitude Large circle of friends

35. Case Development • As a team develop a case of a frail person with at least 3 issues contributing to their difficulty in an ICF domain. • Break the case down by domain/problem to fit into the ICF model. • After completing your case we will swap cases and develop potential solutions for the problems raised.