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
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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