Transcript Geriatric Syndromes

Geriatric Syndromes
Elizabeth K Keech PhD, RN
Elise Pizzi MSN, GNP-BC
What are they?
 Conditions, not diseases
 Common in the elderly
 Typically:
 Multifactorial
 Share risk factors
 Linked with functional decline,
increasing frailty and poor health
outcomes
Tend to include:
 Polypharmacy
 Chronic pain
 Falls
 Delirium
 Urinary incontinence
 Depression.
Prevalence
 Study of 62,829 Looked at 3:
Falls, Urinary incontinence & Depression
 Community dwelling women between 65 – 81
years of age
- 34.4% had 1 Geriatric Syndrome
- 8.2 % had 2 or more
Effects: Independent
Physical & social functioning and
disability
 Quality of life measures
 The Odds Ratio were as large for
physical and social limitations as were
those for chronic conditions
Effect: Synergistic
 Concurrence of Chronic diseases
Shared Risk Factors
Diabetes:
Malnutrition:
Risk for :
Dementia
Decline in mobility
Disability
Falls
Urinary Incontinence
Correlated with:
- Depression
- Dementia
- Functional dependence
Associated with:
- Multiple co-morbidities
Shared Risk factors
 Older age (Define old)
 Functional Impairment
 Cognitive Impairment
 Impaired mobility (Inouye et al 2007)
 Poor Nutritional status
 Female gender
 Depressive symptoms (Chen et al. 2010)
Frailty: “The Dwindles”
 Meet 3 of 5 symptoms:
 Decreased walking speed
 Decreased grip strength
 Decreased physical activity
 Exhaustion
 Weight loss (Fried et al. 2001)
What’s needed
 Prevention:
 Mobility issues and malnutrition
 Minimize complications
 Early recognition and treatment
 Basic set of geriatrics knowledge and skills to address
the key geriatric syndromes and issues that can limit
functional independence and complicate medical
management
Improving health outcomes through
research and education
• Solutions:
• Educating clinicians, educators and
students
• Identifying Evidence-based data
found in Hartford Institute for
Geriatric Nursing
HIGN
Hartford Institute for Geriatric Nursing
 Mission – Shape the quality of health care of older
adults through excellence in nursing practice
 Started in 1996
 Geriatric arm of the NYU College of Nursing
 Addresses 4 vital areas for change





PRACTICE
RESEARCH
EDUCATION
ADVOCACY POLICY
Hartford Institute Home Page
EDUCATION
GNEC
 Geriatric Nursing Education Consortium
 National initiative to enhance geriatric content in senior-level
undergraduate courses
 Administered by AACN in collaboration with Hartford Institute
 Power Point presentations on-line
 Cultural Competence and Chronic Disease Management of Older
Adults
 Spirituality and Aging
 Sexuality in Older Adults
 Spirituality in Aging
Geropsych Competency
 Geropsychiatric Nursing Collaborative that is
identifying and evaluating the quality and suitability
of curricular and training materials
 Portal of Geriatric Online Education-rate the materials
you peruse
 Log in to view articles, videos
 Log in to view modules that develop knowledge of
gero psych topics
 Portal of Geriatric Online Education
Consult GeriRN.org
 Protocols and topics
 Evidence-based protocols for managing
common geriatric syndromes and
conditions
 From Advance Directives to Urinary
Incontinence
 ConsultGeriRN
Consult Geri-RN
 “Try This” Assessment Tool Series with over
30 nationally recommended instruments for
use with older adults
 Tabs
 “want to know more”
 “topic resources”
 Try This Assessment Tool Series
HIGN e-Learning Center
 Continuing Education Portal
with free and paid courses
 Sign in to courses
 Gerontological Certification Review
Course offered by ANCC –
fundamental knowledge about care
of the older adult
 eLearning/
HIGN e-Learning Center
 Clinical Teaching Modules
 assist nursing faculty to
integrate care of older adults
when teaching students in
hospitals
 Clinical Teaching Module
HIGN e-Learning
 Nursing Home Modules
 Assist nursing faculty teaching in nursing
homes
 Help faculty select and use nursing homes for
clinical placement
 Focus on nursing homes involved in residentdirected care and culture change
 Nursing Modules
Elder Mistreatment
 eLearning course developed
 Concepts
 Research
 Legal
 Care continuum
 Theories
 Clinical Documentation
 Impact
 Elder Mistreatment
HIGN e-Learning
 Web Based geriatric case studies that
assist faculty to introduce geriatric
concepts into the curriculum
 Advance Practice Case Studies
PRACTICE
NICHE
 Practice supportive
 Nurses Improving Care for Health System
Elders
 GITT – Geriatric Interdisciplinary Team
Training
 Training resources in a GITT Kit to help
health professionals develop
interdisciplinary teams
 GITT
Practice Support
 Consult Geri RN and Try This Series
 Tab – “Need help stat”
 Need help stat
 HI Hospital Competencies – Competency:
Care of Adult 65 years +
 Hospital Competencies
IV - HIGN Forum
 Web based “board” for reading
and posting messages about
geriatric topics.
 HIGN Forum
USING “TRY THS”Medications
Drugs and Older Adults
 Medication (prescription, over-the-counter and
herbal preparations) are widely used by older adults
 At least one RX med used b 81% of community
dwelling adults
 Five or more Rx medications used by:
 29% of overall survey population 65 and older
 36% of people aged 75 – 85 year olds
 46% of RX users took at least one OTC medication
 (Qato et al, 2008)
Medication
 20% of of community dwelling older adults in the
US are using one or more meds on the Beer’s list
of drugs that should be avoided (Zhan et al, 2001)
 All adults over 65 y.o. (12% of population)
 79% take some type of medication
 Consume 30 – 40% of all prescribed drugs
 Purchase 40% of all OTC drugs
 12% of elderly on 10 or more meds
 23%take 5 or more medications
Adverse Drug
Reactions(ADR)
 # of drugs prescribed and prior history of an
ADR strongest predictors for subsequent
ADR
 Risk doubled for those prescribed 5 -7
medications
 Fourfold for those receiving 8 or more
medications
 (Onder et al, 2010)
Post hospital medication
problems
 One or more medication discrepancies were
experienced in 14.1% of patients post
hospitalization
 Medication discrepancies were associated with
total number of meds taken and presence of
CHF
 14.3% of patients with discrepancies
rehospitalized in 30 days compared with 6.1%
without discrepancies
 (Coleman et al, 2005)
Try This Series
Try This Series
 Want To Know More
 Assessment /Screening Tools
 Beers Part I criteria
 Beers Part II criteria
 Article in AJN
 Video on Beers Criteria
Using Beers I Criteria
see handout
 Part I – Have student review patient RX and OTC
meds to identify inappropriate medications
 Great exercise for beginning clinical students
 Example for action on a drug by students
 OTC Benadryl (diphenhydramine)
 May cause confusion and sedation
 Should not be used as a hypnotic e.g. Tylenol
PM!!
 Emergency allergic reaction use – smallest
dose (25 mg), 1 – 2x
Using Beers II Criteria
see handout
 Part II – Have student review patient meds to
identify inappropriate medications by patient
diagnos(es)/condition(s)
 Good exercise for higher level students
 Use disease or condition to identify inappropriate
medications by name or by drug class
 Have students group patient’s present list of
medications both RX and OTC by
diagnoses/conditions
Delirium: Most frequent
complication of hospitalized elderly
 Yet nurses fail to recognize it more than 30 50% of the time
 In one study, nurses failed to recognize
delirium in 75% of cases
 (Rice et al., 2011)
 The fluctuating mental status is important to
identify because it often signals a need for
additional treatment
Improving Recognition
through Education that:
 Differentiates between the 3 D’s
Delirium, Dementia, Depression
 Improves knowledge about atypical
presentations of delirium in the elderly
 Provides competency in mental status
assessment: the Mini-cog
 Recognizes acute confusion as a serious
condition
Try This Series: Delirium
 Overview of the problem
 Articles
 Strategies
 Assessment/Screening Tools
 Assessment tools
 Videos
CAM (Confusion Assessment Method)
CAM standardized assessment tool
(Long & Short Versions)
CAM ICU – non-verbal, ventilated
Patient
Plus:
Assessing and managing delirium
superimposed on dementia
Assessment of Executive Functioning
Try This Series: (CAM)
Identifies 4 features of the disorder that distinguish it
from other forms of cognitive impairment.
1. status altered from baseline (acute onset or
fluctuating)
2. inattention
3. disorganized thinking
4. altered level of consciousness
 Takes 5 minutes and is easily incorporated
Back to Rice’s Study
Thank You and Healthy
Aging
References
 Coleman, E. A., Smith, J. D., Raha, D., Min, S. J. (2005). Posthospital
medication discrepancies: prevalence and contributing factors. Arch
Intern Med 165:1842.
 Fried, L. P., Fernucci, L., Darer, J., Williamson, J. D., Anderson, G.
(2004). Untangling the concepts of disability, frailty, and comorbidity:
implications for improved targeting and care. Journal of Gerontology:
Medical Sciences 59(3) 255-263.
 Inouye, S. K., Studenski, S., Tinetti, M. E., Kuchel, G. A. (2007)
Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. Journal of the American Geriatric Society 55:780791.
 Knight, E. L., Avorn, J. (2001). Quality indicators for appropriate
medication use in vulnerable elders. Ann Intern Med 135:703.
References
 Onder, G., Petrovoc, M., Tanglisura, B., et al. (2010).
Development and validation of a score to assess risk of adverse
drug reactions among in-hospital patients 65 years or older: the
GerontoNet ADR risk score. Arch Intern Med 170:1142
 Qato, D. M., Alexander, G. C., Conti, R. M. et al. (2008). Use of
prescription and over-the-counter medications and dietary
supplements among older adults in the United States. JAMA
300:2867.
 Rice, K. L., Bennett, M., Gomez, M., Theall, K. P., Knight, M.,
Foreman, M. D. (2011). Nurses' recognition of delirium in the
hospitalized older adult. Clinical Nurse Specialist 25(6), 299-311.
 Russo, A. L., Eaton, C. B., Wallace, R., Gold R., Curb, J. D., Stefanick,
F. L., Okene, J. K., Michael, Y. L. (2011). Combined impact of geriatric
syndromes and cardiometabolic diseases on measures of function. J
Gerontol A Biol Med Sci. 66A(3):349-354.
 Saka, B., Kaya, O., Ozturk, G. B., Erten, N., Karan, M. A. (2010).
Malnutrition in the elderly and its relationship with other geriatric
syndromes. Clinical Nutrition 29(6): 745-8.
 Zhan, C., Sangl, J., Bierman, AS, et al. (2001). Potentially
inappropriate medication use in the community-dwelling elderly:
findings from the 1996 Medical Expenditure Panel Survey. JAMA
286:282.3.