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Enhancing Patient Outcomes in Geriatric Populations

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Geriatrics are More Likely to have Adverse Drug Reactions. Eisenhauer, 1998 ... Two-Thirds of Geriatrics take at least one (OTC) Over The Counter Medication ... – PowerPoint PPT presentation

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Title: Enhancing Patient Outcomes in Geriatric Populations


1
Enhancing Patient Outcomes in Geriatric
Populations
  • An Evidence Based Perspective
  • Jane E. Piper, MSN, RN

2
Regulatory Guidelines
  • Joint Commission for Accreditation and Healthcare
    Financing Organization (JCAHO)
  • http//www.jcaho.org/
  • Centers for Medicare and Medicaid Services (CMS)
  • http//www.cms.hhs.gov/
  • 1990s (FDA) Food Drug Administration required
    clinical trials of drugs include elderly subjects
  • http//www.fda.gov/
  • Healthy People 2010, 1 Goal
  • Increase quality and years of healthy life
  • http//www.healthypeople.gov/

3
  • Agency for Healthcare Research and Quality goals
    are to improve health outcomes, strengthen
    quality measurement, and enhance access to
    appropriate use of cost-effective strategies
    (AHRQ, 1999).
  • National Institute of Nursing Research (NINR,
    1999) goals embrace objectives of relevance for
    aging, including end-of-life/palliative care,
    chronic illness experiences, quality of life and
    quality of care issues, and cost-effective models
    of care.
  • (Strumpf, N., 2000)

4
An Aging Population(Fulmer, T., 2001)
(Strumpt, N., 2000)
  • Adults 65 years of age and older represent 13 of
    the U.S. population
  • By 2030 the number is expected to increase to 20
  • Patients 65 years of age and older make up 48 of
    hospital admissions

5
Pharmacology Physiology(Eisenhauer, 1998)
  • Decreased Absorption
  • Decreased gastric blood flow
  • Gastric Ph
  • Decreased gastric emptying
  • Decreased Distribution
  • Causes higher blood or tissue concentrations
  • Decreased total body water
  • Decreased body fat

6
Pharmacology Physiology cont..
  • Decreased skin absorption of topical/transdermal
    patches
  • Decreased serum albumin
  • Certain drugs bind to albumin
  • Increase in concentrations cause increase in side
    effects

7
Pharmacology Physiology cont..
  • Decreased Metabolism-Changes in liver function
    where drugs become inactivated related to
    decreased hepatic blood flow and decreased liver
    enzymes.
  • Decreased Excretion-Renal function declines
    throughout life related to decreased plasma flow
    tubular excretion.
  • Serum creatinine level is less reliable in
    elderly related to decreased muscle mass

8
Pharmacology Physiology cont..
  • Drug receptor changes
  • Diminished homeostatic response
  • Autonomic nervous system
  • Decreased stability of
  • Blood pressure
  • Temperature
  • Vasoconstriction/Vasodilation

9
Geriatrics are More Likely to have Adverse Drug
Reactions Eisenhauer, 1998
  • Drug Toxicity Signs
  • Behavioral changes
  • Restlessness
  • Confusion
  • Irritability
  • Anxiety
  • Insomnia
  • Hallucinations
  • Polypharmacy
  • Two-Thirds of Geriatrics take at least one (OTC)
    Over The Counter Medication

10
Adverse Drug Reactions
  • The elderly use 30 of all prescription drugs in
    the U.S.
  • Polypharmacy can result in adverse health
    effects.
  • Meds that can cause reactions narcotics,
    sedative-hypnotics, antidepressants, diuretics,
    non-steroidal anti-inflammatory drugs, and ACE
    inhibitors.
  • Adverse reactions acute confusion, increased
    falls, dehydration, electrolyte imbalances,
    hypotension, hypertension, decreased kidney
    function, CHF, or GI bleeding.

11
20 of Elderly Clients Treated in the EDhave
  • Signs and symptoms of mental deterioration or
    pseudodementia that are dismissed as part of the
    aging process..Without First fully assessing
    their medication regimen

12
Elderly Pain Assessment
  • These patients may under report their pain use
    non-verbal assessments.
  • Some elderly patients are fearful of becoming
    addicted to pain meds.
  • Elderly patients think others wont believe they
    are in pain (even if they do not show it, pain is
    what the patient says it is).
  • Elderly patients can have adverse reactions to
    pain meds, start with lower doses when
    appropriate.

13
Elderly Pain Assessment
  • Prolonged bedrest and inactivity can increase
    pain.
  • Comfort measures can reduce the amount of pain
    medication needed.
  • Acute conditions should always be focused toward
    causative factor.
  • Pain may be referred or hard to describe

14
Illness in the Elderly-Critical Care Nursing
  • Atypical presentation
  • Whereas older persons may present with usual and
    classic symptoms, many present with atypical or
    non-specific symptoms.
  • It is one of the challenges of geriatric medicine
    to recognize and diagnose the aged individual who
    presents in an atypical manner.
  • (Fulmer, 2001.)

15
Atypical Presentation Examples
  • Typical
  • UTI-Incontinence, dysuria
  • Pneumonia-Cough, sputum production, fever
  • Myocardial Infarction-chest pain
  • Atypical
  • UTI-Confusion, falls, anorexia
  • Pneumonia-Anorexia, decreased activity level,
    confusion
  • Myocardial Infarction-breathlessness, decreased
    activity level

16
Assessment of the Elderly in the Emergency
Department
  • Requires understanding of normal age-related
    psychologic, sociologic, physiologic changes
    and pathology.
  • Chronological age is not a good predictor of
    biologic age, related to combined effects of
    genetics, lifelong exposure to health habits,
    medical problems, lifestyle, and environment.
  • (Hayes Iola, 2000).

17
Assessment Principles
  • Recognize altered and nonspecific presentation of
    disease
  • Use a heightened index of suspicion with astute
    assessment skills
  • Do not allow ageism to bias your assessment
  • Trust will encourage sharing of private
    information
  • Ensure the patient is comfortable
  • Obtain through history of present illness
  • Face patient speak low and in clear tones
  • Eliminate outside noises
  • Use eye contact
  • Closed-ended questions helps focus interview

18
Assessment cont..
  • Consider potential for alcohol abuse or
    dependence on prescription or recreational drugs
  • Presenting complaints for these elderly patients
    are most often gastrointestinal problems, fall,
    or other trauma.
  • Consider also potential for abuse or neglect in
    any assessment.

19
Play Detective
  • A chief complaint may not exist!
  • CHF-may be described as I have not been able to
    bath myself
  • MI-may be described as weakness
  • (Hayes Iola, 2000)

20
Patient Presentation-Rule Out Delirium or Acute
Confusion
  • Dementia is a chronic progressive mental change
    vs.
  • Delirium or acute confusion-a potentially life
    threatening health problem for elders.
  • Delirium has a treatable or reversible cause,
    such as
  • Dehydration, electrolyte abnormalities,
    hypothyroidism, infection, arrhythmias, heart
    failure, medication adverse reactions, urinary
    retention, or even fecal impaction.
  • (Hayes Iola, 2000

21
  • A History of Acute Onset of Symptoms, fluctuation
    of alertness, attention span, sleep disturbances,
    and the presence of delusions or hallucinations
    can point to acute delirium.
  • Depression may present as agitation, anxiety,
    memory loss, or multiple somatic complaints.
  • Appropriate assessment is accurate triage and
    identification of potential physical,
    psychological, and sociological problems.

22
Laboratory Values
  • If lab values are abnormal they should not be
    blamed on normal aging, they should be
    considered abnormal and evaluated as such.
  • Anemia is not normal. Blood loss, iron
    deficiency, or malnutrition are considered if
    hemoglobin and hematocrit levels are low.
  • (Hayes Iola, 2000)

23
Patient Education
  • Barriers to teaching
  • Lack of Time
  • Lack of Staff
  • Lack of approachability
  • Lack of appropriate teaching tools
  • Lack of innovative strategies
  • Barriers to learning
  • Sensory impairments
  • Cognitive decline
  • Lack of motivation
  • Depression
  • Low literacy skills

24
Cultural Diversity and the Elderly
  • Special considerations with diversity and the
    elderly. Avoid stereotyping.
  • Meaning of illness, hospitalization, and
    environment are key considerations beyond the
    urgent aspects of care.
  • Patterns of decision making, meaning of critical
    illness, and preferences for end-of-life care are
    considered.

25
Cultural Diversity cont.
  • Ethnicity strongly influences definition,
    recognition, and evaluation of health situations.
  • Expressions of pain or discomfort are rooted in
    culture
  • Reporting of pain may be effected by
  • Obligation to bear pain stoically-under medicated
  • Language barrier in ability to describe pain
  • Exaggerated expressions of pain-over medicated
  • (Fulmer, 2001)

26
Health Literacy-How Does Your Patient Score?
  • Managed care requires individuals to take more
    responsibility for self-care and symptom
    management.
  • Poor Health Literacy may lead to serious negative
    consequences such as increased morbidity and
    mortality when patients are unable to read and
    comprehend instructions for medications,
    follow-up appointments, diet, procedures, and
    other regimens.
  • (BASTABLE, 2003)

27
Patient Discharge Instructions
  • Research reveals that patients forget within 5
    minutes about ½ of any oral instruction they
    receive.
  • Inappropriate reading level of materials used to
    reinforce or supplement verbal teaching
  • Decreases compliance
  • Increases morbidity
  • Encourages misuse of healthcare facilities
  • (Bastable, 2003)

28
Teachable Moments
  • When an elderly person is admitted to the
    hospital this provides a teachable moment that
    can impact their day to day life.
  • Lack of knowledge and resources can create the
    climate for what we term non compliant.

29
REFERENCES
  • Bastable, S., (2003). Nurse as Educator.
    Principles of Teaching and Learning for Nursing
    Practice. Jones Bartlett Publishers, Inc.
  • Eisenhauer, L., Nichols, L., Spencer, R.,
    Bergan, F. (1998) Clinical Pharmacology Nursing
    Management, (5th Ed). Philadelphia, PA
    Lippincott Raven Publishers.
  • Fulmer, T., et al. (2001). Critical Care Nursing
    of the Elderly (2nd ed). New York Springer
    Publishing Co.
  • Hayes, K., Iola, K, (2000). Geriatric
    assessment in the emergency department. Journal
    of Emergency Nursing, 26(5), 430-435.
  • Strumpt, N., (2000). Improving care for the frail
    elderly The challenge for nursing. Journal of
    Gerontological Nursing, 26(7), 36-44.
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