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Angela Johnson, PharmD, CGP
Review general clinical principles related to aging
Recognize geriatric considerations for disease processes
Identify changes in condition that should prompt eLTC/provider notification
Most older adults have at least 3 chronic diseases & take multiple medications
Per CDC, those > 65yr old have more adverse drug events: • More than 2 times as likely to visit ED
• Almost 7 times more likely to get admitted
Changes in body composition and organ function
http://www.cdc.gov/MedicationSafety/Adult_AdverseDrugEvents.html
Polypharmacy Elimination
Physiological Changes Extrinsic Influences
Focus on management of
medical concerns vs function
Functional status decline
Increased falls
Nosocomial infections
Medications changes/additions
Skin issues
•Kleinpell RM, Fletcher K, Jennings BM. Reducing Functional Decline in Hospitalized Elderly. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 11. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2629/
•Gillick MR, Serrell NA, Gillick LS. Adverse consequences of hospitalization in the elderly. Soc Sci Med. 1982;16:1033–8
•Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012
How do we identify who will
go back to the
hospital?
Age
Polypharmacy
Reduced Functional Status
Length of Stay
Multiple Co-morbidities
Discharge to long-term care
• Silverstein MD, Qin H, Mercer SQ, Fong J, Haydar Z. Risk factors for 30-day hospital readmission in patients ≥65 years of age. Proceedings (Baylor University Medical Center). 2008;21(4):363-372
• Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012
Conditions and Payment Reductions: ◦ Acute Myocardial Infarction
◦ Heart Failure
◦ Pneumonia
PCP approach to care
Facility Staffing
Distance to hospital
Family’s Role
Patient Goals Lavenberg JG, Leas B, Umscheid CA, Williams K, Goldmann DR, Kripalani S. Assessing preventability in the quest to reduce
hospital readmissions. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2014;9(9):598-603. doi:10.1002/jhm.2226
Patient Directed Care
Medical complexity balanced with
Philosophy of care which encourages patient and family choice
Advanced Care Planning
Patient Centered Goals of Therapy
Individualized Care Planning
Seems different than usual
Talks or communicates less
Overall needs more help
Pain (new/worse) or participated
< activities
Ate less
No bowel movement x3 days or
diarrhea
Drank less
Weight change
Agitated or nervous > usual
Tired, weak, confused, drowsy
Change in skin color or condition
Help with walking, transferring,
toileting > usual
Look for
Early Warnings
Failed therapies or allergies
Co-morbidities
Changes in body composition
Medication histories
Regulatory Issues
Cost Concerns
A tool like the SBAR helps gather information
Hosp dx: Pneumonia & CHF
Meds: ◦ clopidogrel
◦ metoprolol
◦ simvastatin
◦ lisinopril
Sat 84% on 2L O2
Wt: 170lb (up from 164lb 3 days ago)
Vitals: Temp 98.4
Pulse 112
Resp 24
BP 100/54
Grandma Johnson
A Hypothetical Case
Age: 86yr old Admit: 2wk ago for strengthening
Situation
A change in weight was noted by the CNA
Noted to be more short of breath walking to lunch today
Similar symptoms leading up to hospitalization 2wk ago
Background
In LTC for post-acute care
Dx for hospitalization: pneumonia + CHF
Increase weight of 6lb in 3 day
Medications include diuretic & antiplatelet therapy
BP 100/54, P 112, RR 24, T 98.4, Sat 84% on 2L
Her family held a BD party for her over the weekend and she refused the diuretic
Assessment
Summarization of observations & appearance:
◦ Mrs. Johnson’s weight
gain prompted us to do additional observations today. Increased SOB was noted with activity and with her history of CHF, we are concerned she may be experiencing an exacerbation
Request
Review and Notify: ◦ We would like to
request an assessment of Mrs. Johnson be done & possibly labs ordered
Immediate Notification ◦ Any symptom, sign or apparent discomfort that is:
A marked change in relation to usual symptoms and signs
OR
Unrelieved by measures already prescribed
Non-Immediate Notification ◦ New or worsening symptoms that do not meet
above criteria
http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Change_in_Condition.pdf
Report Immediately Non-immediate
BP ◦ SBP > 200 or < 90
◦ DBP > 115
Resting Pulse ◦ > 100 or < 50
Respirations ◦ > 28 or < 10 (per min)
Oral Temp ◦ > 100.5
O2 Sat ◦ < 90%
DBP > 90 New Irregular Pulse Weight Loss ◦ New onset anorexia +/-
weight loss
◦ 5% within 30 days
◦ 10% with 6 months
Weight Gain ◦ > 5lb in 1 week with:
CHF
Chronic renal failure
Other volume overload
Report Immediately Non-Immediate
CBC ◦ WBC < 14,000
◦ Hct/Hgb < 24/8
◦ Plt < 50,000
Chemistry ◦ BUN > 60
◦ Ca > 12.5
◦ K < 3 or > 6
◦ Na < 125 or > 155
◦ Glu < 70 or > 300
CBC ◦ WBC > 10,000 without
symptoms or fever
Chemistry ◦ Glu consistently > 200
◦ Hgb A1c
◦ Albumin
◦ Bilirubin
◦ Cholesterol/Triglycerides
◦ Other chemistries
Report Immediately Non-immediate
Consult Reports ◦ Recommendations for
immediate action/change
Drug Levels ◦ Level > therapeutic range
INR > 6
(+)Urinalysis ◦ with signs/symptoms
Urine Culture ◦ w/symptoms+>100,000 cc
X-Ray ◦ New/unsuspected finding
(fracture, pneumonia, CHF)
Consult Reports ◦ Recommendations for
routine action/change
Drug Levels ◦ Therapeutic or low level
INR 3-6 (+)Urinalysis ◦ without signs/symptoms
Urine Culture ◦ w/no growth or symptoms
X-Ray ◦ Old or long-standing
finding; no change
* Abdominal pain,
distention,
tenderness
*Abrasion
*agitation
*AMS
*Appetite
*Asthma
*Back injuries,
complaints
*Behaviors
*Bleeding- rectal
*Blisters
*Bowel Sounds
*Burns
*Chest complaints
*Cold
*Complaint – pt or
fam concern
*Confusion
*Consciousness,
altered
*Constipation
*Contusions
*Cough
*Delirium
*Depressed affect
*DM
*Diarrhea
*Discolored skin
*Dizziness
*Dyspnea
*Dysuria
*Earache
*Edema
*Eye injury
*Fainting
*Fall
*Fever
*Fracture,
dislocation
*Gait
disturbance
*Hallucinations
*Head Injuries
*Headache
*Hearing loss
*Hematuria
*Hypothermia
*Incontinence,
of stool or
urine
*Itching
*Jaundice *Laceration
*Lung
sounds
*Med error or
side effects
*Memory loss
*Musculoskeletal
pain
*Nausea
*Nocturia
*Nosebleed
*Pain
*Personality
change
*Pressure sore
*Puncture wounds
*Rash *Seizure
*SOB
*Skin tear
*Sleep disturbance
*Sore throat
*Speech change
*Splinters
*Suicidal potential
*Swallowing difficulty
*Toothache *Urination,
pain, retention,
hesitancy
*Vaginal
bleeding,
spotting,
discharge
*Vision change
*Vomiting,
persistent,
recurrent or
blood
*Walking
difficulty
*Weakness,
arm, leg or
general
*Weight change
*Wounds
Any clinical questions
Family requests resident to be seen by physician
Question if resident needs a clinic or ER visit
Change in condition concerns
Medication or
order clarification
Discuss ways to
address behavior
issues
Advance care
planning assistance INTERACT
coaching
Admission Clarifications
Interdisciplinary Team consult
Peer to Peer Advice
Medication Reviews
ANYTHING… We Are Here To Help
844-322-4236