Updating Your Knowledge about Geriatric Nursing Care

Mary H. Palmer, PhD, RN, C FAAN, AGSFHelen W. & Thomas L. Umphlet

University of North Carolina at Chapel HillDistinguished Professor in Aging, SONInterim Co-Director Institute on Aging

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

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

Objectives

• Discuss geriatric competencies needed by nurses to care for older adults

• Identify geriatric resources available to nurse educators

Less than 1% of nurses are certified in

geriatric nursing.

Nurses practicing in this country [US] today

are, by default, geriatric nurses6.

Geriatric NursingIn 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, 20012. Perry, 20023. Ingraham et al, 20114. http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf5. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf

Demographic Profile: North Carolina

• 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

AARP. (2009). “Long-Term Care in North Carolina.” Retrieved from http://www.aarp.org

7

http://www.aging.unc.edu/nccoa/2010video/index.html

United States Aging Statistics

Global Aging

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

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)

Ideals of Fitness

The Risks of Aging

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

Baby Boomers: Physical Health

16

• Only one-third of Baby Boomers are satisfied with their physical health

• 3/10 say their physical health is worse than they expected

• 1 in 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

Baby Boomers: Physical Health

Obesity, arthritis, and diabetes will lead to mobility limitations – dependence on others for ADLs

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)

Physical HealthAdult Obesity Rates 2009

The Perfect Storm

Frailty, Disability, Co-morbidity

Frailty

Co-morbidityDisability > 1 ADL

Source: Fried et al., 2001

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

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

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

Looking glass self – old/young

http://asmp.org/articles/best-2010-hussey.html

Looking glass self – old/young

http://asmp.org/articles/best-2010-hussey.html

Physical and Psychological Transitions

Frailty Phenotype Source: Fried et al., 2001

Shrinking

Weakness

Poor endurance: exhaustion

Slowness

Low activity

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

DementiaNew Diagnostic Guidelines:

http://www.alz.org/research/diagnostic_criteria/

Clinical criteria for all cause dementia1. Interferes with ability to function at work or usual

activities2. Decline from previous levels of function3. Not explained by delirium or major psychiatric

disorder

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 functionse. changes in personality, behavior, comportment

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.

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

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 ReversibleCauses: electrolyte imbalances, medications,

infection (UTI or pneumonia), pain, depression, surgery

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

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

Urinary Incontinence: Definition

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

MaybeSeldomUsuallyWaking to pass urine at night

VariableYesOften noAbility to reach the toilet following an urge

VariableSmallLarge (if present)

Amount of urinary leakage

YesYesNoLeaking during physical activity

YesNoYesDaytime Voiding Frequency (>every 2 hours)

YesNoYesUrgency

Mixed symptom

s

Stressincontinenc

e

Overactive

bladderSymptoms

Differential Diagnosis: OAB vs. SUI vs. Mixed UI

Abrams P, Wein AJ. THE OVERACTIVE BLADDER: A widespread and treatable condition. 1998;1-57.

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)

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

Sample Bladder RecordDate Time Urinated

in toiletUI

episodeReason for UI

Bowel movement

Fluid intake

Behavioral Programs

Required skills:Ability to comprehend and follow education

and instructionsIdentify urinary urge sensationLearn to inhibit or control urge to voidKegel (aka: pelvic floor muscle exercises)

exercises

cms.internetstreaming.com

Risk factors for Incident Urinary Incontinence in Hospitalized Elders

Risk Factor OR(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: Zisberg et al., JAGS, 2011.

• 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

They Don’t Tell, We Don’t Ask

EDUCATE study. Morb Mortal Wkly Rep. 1995;44:747,753-754.Branch LG et al. J Am Geriatr Soc. 1994;42:1257-1261.

FallsTotal 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

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.html2. Baumgarten et al JAGS; 57:863-870, 2009

Source:http://latimesblogs.latimes.com/photos/uncategorized/2008/09/09/

cracks1.jpg

Chiarelli et al 2009

Mobility, balance, urine control before and after 4 weeks of daily exercise

Before AfterWalking distance* feet 50 73Balance seconds 24 26Speed inches/second 5.5 7.7UI (7am-3pm) 2.3 1.0UI (7am -10pm) 2.8 2.5

Source: Jirovec Int J Nurs Stud 1991

Assessment for Absorbent Products

Assess resident’s;Functional ability to ambulate, toilet, disrobe, use of

assistive devicesEase in self-toiletingAssess product for:Contain urinary leakageComfortEase of application/removal

cms.internetstreaming.com

Recent Research

Absorbent products are used to manage urinary incontinence in acute care setting1

Absorbent products are associated with development of new urinary incontinence1

Absorbent products are associated with skin changes and increased risk of incontinence-associated dermatitis (IAD)2

Source: 1. Zisberg et al., JAGS, 2011. 2. Shigeta et al., OWM, 2010.

AnergiaConceptually differs both from fatigue, which is usually measured post-exertion, and from depression.

AnergiaAnergia defined as, “sits around a lot for lack of energy”, and any two of six minor criteria: •recently not enough energy•felt slowed physically in past month•doing less than usual in past month•any slowness is worse in the morning•wakes up feeling tired•naps (> 2 hours) during the daySource: Cheng, H., Gurland, B. & Maurer, M. Self-reported lack of energy (anergia) among elders in a multi-ethnic community Journal of Gerontology: MEDICAL SCIENCES 2008, 63A

Anergia• 39% heart failure patients reported anergia1

• Older adults with urinary incontinence 2x more likely than continent to report anergia2

• Anergia was associated with new cases of urinary incontinence in longitudinal study2

1 Maurer, M., Cuddihy, P., Weisenberg, J. (et. Al. (2009). Journal of Cardiac Failure, 15(2), 145-151.2 Cheng, H., Gurland, B. & Maurer, M. (2008).. Journal of Gerontology: MEDICAL SCIENCES, 63A(7), 707-714

Depression

The CES-D-SF is a 10 item 4-point Likert-type depression assessment scale.•Sleep•Emotions•Hopefulness•Concentration•Effort

Heart Failure Prevalence

Prevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 2005–2008). Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute. [http://circ.ahajournals.org/cgi/content/full/123/4/e18/F91][Roger, V. L. et al. Circulation 2011;123:e18-e209]

Heart Failure – Quick Facts

• One quarter HF patients are > 80 years old

• More than half have 5 or more comorbid condition

• More than half are mobility disabled

• Polypharmacy, > 50% 6+ medications

Source: Wong, Chaudhry, Desai et al., (2011). American Journal of Medicine, 124:136-143.

Correlates of …

• Diabetes• Obesity• MI• Hypertension• Age• Race

• Diabetes• Obesity

• Hypertension• Age

Heart Failure Urinary Incontinence

Unifying Model of Shared Risk Factors Source: Inouye et al., 2007

Multidisciplinary Competencies

• Health Promotion and Safety• Evaluation and assessment• Care planning and coordination of care across

the care spectrum• Interdisciplinary and team care• Caregiver support• Healthcare systems and benefits

Emerging Issues

• Need more who understand and can practice geriatrics

• New concepts (anergia) with clinical implications

• New complex conceptual models about treatment of geriatric conditions

• Geriatric competencies• Geriatric resources

Geriatric ResourcesProfessional Organizations:American Nurses Association:

www.Geronurseonline.orgAmerican Geriatrics Society:http://www.americangeriatrics.org/Gerontological Society of America:http://www.geron.org/

Journals:Journal of the American Geriatrics Society (JAGS)Geriatric NursingJournal of Gerontological Nursing