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Updating Your Knowledge about Geriatric Nursing Care

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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 – PowerPoint PPT presentation

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Title: Updating Your Knowledge about Geriatric Nursing Care


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
  • 12 of NCs 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

http//www.aging.unc.edu/nccoa/2010video/index.htm
l
AARP. (2009). Long-Term Care in North Carolina.
Retrieved from http//www.aarp.org
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
(No Transcript)
14
The Risks of Aging
15
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

16
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
  • 1 in 8 Baby Boomers will develop Alzheimers
    Disease, the 5th leading cause of death in people
    65 years and over (source Alzheimers Disease
    Association)
  • By 2050 11 to 16 million Baby Boomers will have
    Alzheimers Disease

17
Baby Boomers Physical Health
  • Obesity, arthritis, and diabetes will lead to
    mobility limitations dependence on others for
    ADLs

18
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)

19
Physical Health
Adult Obesity Rates 2009
20
The Perfect Storm
21
Frailty, Disability, Co-morbidity
Source Fried et al., 2001
22
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

23
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

24
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

25
Looking glass self old/young
http//asmp.org/articles/best-2010-hussey.html
26
Looking glass self old/young
http//asmp.org/articles/best-2010-hussey.html
27
Physical and Psychological Transitions
28
Frailty Phenotype Source Fried et al., 2001
29
Shrinking Weakness Poor endurance
exhaustion Slowness Low activity
30
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

31
Dementia
  • New Diagnostic Guidelines http//www.alz.org/rese
    arch/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

32
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

33
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.

34
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/Diagno
    sitic_Recommendations_MCI_due_to_Alz_proof.pdf

35
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

36
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

37
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

38
Urinary Incontinence Definition
  • Urinary incontinence (UI) is the complaint of
    any involuntary leakage of urine. (International
    Continence Society, 2002)

39
Differential Diagnosis OAB vs. SUI vs. Mixed UI
Abrams P, Wein AJ. THE OVERACTIVE BLADDER A
widespread and treatable condition. 19981-57.
40
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)

41
Continence Two Years Prior to Death Source
Covinsky et al., 2003
42
Sample Bladder Record
43
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
44
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 (1.5311.83) .005
  • Adult diaper 2.62 (1.175.87) .02
  • Activities of daily living at admission
    (reference independent)
  • Partially dependent 2.96 (1.018.71)
    .049
  • Dependent 3.27 (1.497.15) .003
  • Adjusted for age, cognitive status, physical
    activity
  • Source Zisberg et al., JAGS, 2011.

45
They Dont Tell, We Dont 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.
199544747,753-754. Branch LG et al. J Am
Geriatr Soc. 1994421257-1261.
46
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

47
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/HomeandRecreationalSafe
    ty/Falls/adulthipfx.html
  • 2. Baumgarten et al JAGS 57863-870, 2009

48
Sourcehttp//latimesblogs.latimes.com/photos/unca
tegorized/2008/09/09/cracks1.jpg
Chiarelli et al 2009
49
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

50
Assessment for Absorbent Products
  • Assess residents
  • 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
51
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-associa
    ted dermatitis (IAD)2
  • Source 1. Zisberg et al., JAGS, 2011.
  • 2. Shigeta et al., OWM, 2010.

52
Anergia
  • Conceptually differs both from fatigue, which is
    usually measured post-exertion, and from
    depression.

53
Anergia
  • Anergia 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 (gt 2 hours) during the day
  • Source 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

54
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

55
Depression
  • The CES-D-SF is a 10 item 4-point Likert-type
    depression assessment scale.
  • Sleep
  • Emotions
  • Hopefulness
  • Concentration
  • Effort

56
Heart Failure Prevalence
Prevalence of heart failure by sex and age
(National Health and Nutrition Examination
Survey 20052008). 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 2011123e18-e209
57
Heart Failure Quick Facts
  • One quarter HF patients are gt 80 years old
  • More than half have 5 or more comorbid condition
  • More than half are mobility disabled
  • Polypharmacy, gt 50 6 medications
  • Source Wong, Chaudhry, Desai et al., (2011).
    American Journal of Medicine, 124136-143.

58
Correlates of
Heart Failure Urinary Incontinence
  • Diabetes
  • Obesity
  • Hypertension
  • Age
  • Diabetes
  • Obesity
  • MI
  • Hypertension
  • Age
  • Race

59
Unifying Model of Shared Risk Factors Source
Inouye et al., 2007
60
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61
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

62
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

63
Geriatric Resources
  • Professional Organizations
  • American Nurses Association
  • www.Geronurseonline.org
  • American Geriatrics Society
  • http//www.americangeriatrics.org/
  • Gerontological Society of America
  • http//www.geron.org/
  • Journals
  • Journal of the American Geriatrics Society (JAGS)
  • Geriatric Nursing
  • Journal of Gerontological Nursing
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