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Updating Your Knowledge about Geriatric Nursing Care

Updating Your Knowledge about Geriatric Nursing Care. Mary H. Palmer, PhD, RN, C FAAN, AGSF Helen W. & Thomas L. Umphlet University of North Carolina at Chapel Hill Distinguished Professor in Aging, SON Interim Co-Director Institute on Aging. Overview.

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Updating Your Knowledge about Geriatric Nursing Care

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  1. Updating Your Knowledge about Geriatric Nursing Care Mary H. Palmer, PhD, RN, C FAAN, AGSF Helen W. & Thomas L. Umphlet University of North Carolina at Chapel Hill Distinguished Professor in Aging, SON Interim Co-Director Institute on Aging

  2. Overview • Introduction to aging issues in the United States • Geriatrics Principles • Frailty (and disability and co-morbidity) • Dementia • Delirium • Falls • Urinary Incontinence • Anergia • Geriatric multidisciplinary competencies

  3. Objectives • Identify geriatric principles to guide nursing care • Discuss frailty phenotype and its implications to the aging population and to nursing care • Discuss recent research findings on at least 2 geriatric conditions and prevalent geriatric diseases

  4. Objectives • Discuss geriatric competencies needed by nurses to care for older adults • Identify geriatric resources available to nurse educators

  5. Less than 1% of nurses are certified in geriatric nursing.Nurses practicing in this country [US] today are, by default, geriatric nurses6.

  6. Geriatric Nursing In the United States, people 65 and older: • represent 36% of hospital stays1 • represent 49% of all hospital days2 • had higher crude and adjusted morbidity and mortality after emergency general surgery3 • take 1/3 of all prescribed medications • represent 88.1% of residents in the 16,100 nursing homes nationally4 • who were residents in nursing homes between January through June 2007, 14% had a prescription for an atypical anti-psychotic medication5 Sources: 1. Fulmer, 2001 2. Perry, 2002 3. Ingraham et al, 2011 4. http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf 5. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf

  7. Demographic Profile: North Carolina http://www.aging.unc.edu/nccoa/2010video/index.html AARP. (2009). “Long-Term Care in North Carolina.” Retrieved from http://www.aarp.org 12% of NC’s population is age 65+ with nearly 150,000 age 85+ Projected to grow by 87% of 2030 20th in the nation in the projected growth rate of the 85+ population

  8. United States Aging Statistics

  9. Global Aging

  10. Geriatric Principles • Continuity of care • Bolstering home and family • Communication skills • Knowing the patient • Thorough assessment and evaluation • Prevention and health maintenance • Ethical decision making

  11. Geriatric Principles • Inter-professional collaboration • Respect for the usefulness and value of elder • Cultural and diversity competence • Compassionate care • Helping disconnected family • End of life care • Cultural and diversity competencies Source: Reichel, Arenson & Scherger (2010)

  12. Ideals of Fitness

  13. The Risks of Aging

  14. Baby Boomers in the United States: Physical Health Baby Boomers are those born between 1946 and 1964 By the year 2030 (in less than 20 years): • 14 million baby Boomers will have diabetes • Half of all Baby Boomers will have arthritis • Hip replacement surgery rates, currently at 700,000/year, will reach 3,500,000/year

  15. Baby Boomers: Physical Health • Only one-third of Baby Boomers are satisfied with their physical health • 3/10 say their physical health is worse than they expected • 1in 8 Baby Boomers will develop Alzheimer’s Disease, the 5th leading cause of death in people 65 years and over (source: Alzheimer’s Disease Association) • By 2050 11 to 16 million Baby Boomers will have Alzheimer’s Disease

  16. Baby Boomers: Physical Health Obesity, arthritis, and diabetes will lead to mobility limitations – dependence on others for ADLs

  17. Baby Boomers: Cardiovascular health • 40% of Baby Boomers already have cardiovascular disease • 35% have hypertension • 55-60% have high cholesterol • Deaths from heart disease are expected to increase 130% in 40 years (by 2050)

  18. Physical Health Adult Obesity Rates 2009

  19. The Perfect Storm

  20. Frailty, Disability, Co-morbidity Disability > 1 ADL Co-morbidity Frailty Source: Fried et al., 2001

  21. Frailty versus Disability • Frailty – multi-factorial, potentially downward spiral • Disability may involve single deficits that may be reversible Source: Fillitt & Butler, 2009 • Activities of Daily Living (ADLs) • Disablement process Source: Verbrugge & Jette, 1994 Pathology  Impairment  Functional limitation  Disability

  22. Presence of Frailty Positive frailty phenotype: greater than 3 criteria present Intermediate or pre-frail: 1 or 2 criteria present Source: Fried et al., 2001

  23. Frailty • By age 80 years, 40% of older adults have functional impairments • 6% to 11% are considered frail • United States estimate: 6.1% Source: DuBeau et al., 2009 • Psychological effect of transition from robust (independent) to frailty – evolving identity, “looking glass self” Source: Fillitt & Butler, 2009

  24. Looking glass self – old/young http://asmp.org/articles/best-2010-hussey.html

  25. Looking glass self – old/young http://asmp.org/articles/best-2010-hussey.html

  26. Physical and Psychological Transitions

  27. Frailty Phenotype Source: Fried et al., 2001

  28. Shrinking Weakness Poor endurance: exhaustion Slowness Low activity

  29. Frailty: Vulnerable Elders Survey • Age • Self reported health • Physical activities (stooping, reaching, lifting, writing, heavy housework, etc) • Shopping, managing money • Walking across a room • Light housework • Bathing or showering Source: Saliba et al, JAGS 2001

  30. Dementia New Diagnostic Guidelines: http://www.alz.org/research/diagnostic_criteria/ Clinical criteria for all cause dementia Interferes with ability to function at work or usual activities Decline from previous levels of function Not explained by delirium or major psychiatric disorder

  31. Clinical criteria for all cause dementia (continued) 4. Cognitive impairment detected through history taking from patient and knowledgeable informant and objective cognitive assessment 5. Cognitive or behavioral impairment involves the minimum of 2 from following domains: a. impaired ability to acquire or remember new information b. impaired reasoning and handling of complex tasks c. impaired visuospatial abilities (for example, inability to recognize faces) d. impaired language functions e. changes in personality, behavior, comportment

  32. Mild Cognitive Impairment Decline in memory, reasoning or visual perception that's measurable and noticeable to themselves or to others, but not severe enough to be diagnosed as Alzheimer's or another dementia. The new guidelines formalize an emerging consensus that everyone who eventually develops Alzheimer's experiences this stage of minimal but detectable impairment, even though it's not currently diagnosed in most people. Not everyone with MCI eventually develops Alzheimer's, because MCI may also occur for other reasons.

  33. Preclinical Dementia Expansion of the conceptual framework for thinking about Alzheimer's disease to include a "preclinical" stage characterized by signature biological changes (biomarkers) that occur years before any disruptions in memory, thinking or behavior can be detected. Source: http://www.alz.org/documents_custom/Diagnositic_Recommendations_MCI_due_to_Alz_proof.pdf

  34. Delirium Also Known As: acute confusional state and acute brain syndrome Considered a medical emergency due to underlying physical or mental disorder Considered temporary and Reversible Causes: electrolyte imbalances, medications, infection (UTI or pneumonia), pain, depression, surgery

  35. Delirium Symptoms • Changes in alertness (more alert in am, less in pm) • Changes in level of consciousness or awareness • Changes in movement (slow moving OR hyperactive) • Changes in sleep patterns • Decrease in short-term memory and recall • Disorganized thinking • Emotional changes – anger, apathy, agitation • Disrupted or wandering attention

  36. Delirium Treatment • Control or reverse the cause of symptoms • Stop medications: analgesics (if possible), anticholinergics, cimetidine, lidocaine. Consult Beers criteria • Treat anemia, hypoxia, heart failure, infections, kidney failure, liver failure, nutritional disorders, depression, thyroid disorders • If using meds to treat, start very low dose and adjust as needed: antidepressants, dopamine blockers, sedatives, thiamine. • Replace eyeglasses, hearing aids, teeth, treat pain, toilet, sit up in chair • Reality orientation • Safety precautions

  37. Urinary Incontinence: Definition • Urinary incontinence (UI) “is the complaint of any involuntary leakage of urine”. (International Continence Society, 2002)

  38. Symptoms Overactivebladder Stressincontinence Mixed symptoms Urgency Yes No Yes Daytime Voiding Frequency (>every 2 hours) Yes No Yes Leaking during physical activity No Yes Yes Amount of urinary leakage Large (if present) Small Variable Ability to reach the toilet following an urge Often no Yes Variable Waking to pass urine at night Usually Seldom Maybe Differential Diagnosis: OAB vs. SUI vs. Mixed UI Abrams P, Wein AJ. THE OVERACTIVE BLADDER: A widespread and treatable condition. 1998;1-57.

  39. Reversible Causes of Incontinence • Delirium • Restricted mobility (illness, injury, gait disorder, restraint) • Infection (acute, symptomatic) Inflammation (atrophic vaginitis) also impaction of stool • Polyuria (DM, caffeine intake, volume overload), pharmaceuticals (diuretics, autonomic agents, psychotropics)

  40. Continence – Two Years Prior to Death Source: Covinsky et al., 2003

  41. Sample Bladder Record

  42. Behavioral Programs Required skills: • Ability to comprehend and follow education and instructions • Identify urinary urge sensation • Learn to inhibit or control urge to void • Kegel (aka: pelvic floor muscle exercises) exercises cms.internetstreaming.com

  43. Risk factors for Incident Urinary Incontinence in Hospitalized Elders Risk FactorOR(95% CI) p-Value Continence aids (reference: self-toileting) • Urinary catheter 4.26 (1.53–11.83) .005 • Adult diaper 2.62 (1.17–5.87) .02 Activities of daily living at admission (reference: independent) • Partially dependent 2.96 (1.01–8.71) .049 • Dependent 3.27 (1.49–7.15) .003 ** Adjusted for age, cognitive status, physical activity Source: Zisberget al., JAGS, 2011.

  44. They Don’t Tell, We Don’t Ask • Only half of patients with incontinence tell their health care provider about their symptoms • Perceived as low priority by some primary care providers • Result: underreported, undertreated EDUCATE study. Morb Mortal Wkly Rep. 1995;44:747,753-754. Branch LG et al. J Am Geriatr Soc.1994;42:1257-1261.

  45. Falls Total Lifetime Medical Costs of Unintentional Fatal Fall-Related Injuries* in People 65 Years and Older By Sex and Age, United States, 2005 (CDC) *Lifetime medical costs refer to the medical costs (treatment and rehabilitation) associated with the fatal injury event

  46. Falls and Hip Fractures • 90% hip fractures are from falls1 • About one third of hip fracture patients developed an acquired pressure ulcer (APU) after surgery2 • 1 in 5 hip fracture patients die within a year of the fall1 • Up to one in four of older adults who had been independent before a hip fracture spend up to a year in a nursing home after the fall1 1. CDC, http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html 2. Baumgarten et al JAGS; 57:863-870, 2009

  47. Source:http://latimesblogs.latimes.com/photos/uncategorized/2008/09/09/cracks1.jpg Chiarelli et al 2009

  48. Mobility, balance, urine control before and after 4 weeks of daily exercise Before After Walking distance* feet 50 73 Balance seconds 24 26 Speed inches/second 5.5 7.7 UI (7am-3pm) 2.3 1.0 UI (7am -10pm) 2.8 2.5 Source: Jirovec Int J Nurs Stud 1991

  49. Assessment for Absorbent Products Assess resident’s; • Functional ability to ambulate, toilet, disrobe, use of assistive devices • Ease in self-toileting Assess product for: • Contain urinary leakage • Comfort • Ease of application/removal cms.internetstreaming.com

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