Transcript Clinical Review

Clinical Review for the
Generalist Hospice and
Palliative Nurse
Geriatric Palliative Care
1
Objectives
1. Identify characteristics of normal aging of the
body systems
2. Identify the complexities of the geriatric
population at end-of-life related to normal
aging and atypical presentation of illness
3. Discuss the principles of Palliative care for the
geriatric population including interventions and
barriers to effective care
2
Objectives
4. Describe pharmaceutical concerns, effective
management, and care approaches specific to
the elderly
5. Identify common distressing symptoms
experienced by the elderly at end-of-life
3
Demographics
 2010-14% of population > 65 yrs
 By 2030 - over 19% of population will be >65 years

About 1 in 5 U.S. residents
 Between
2010 and 2050, the U.S. projected to
experience rapid growth in its older population.
 By 2050, the number will double
 In
2010, 14 % of the population 85 years and older
 By 2050, expected to increase to more than 21%
4
Characteristics


Older population is living longer
Four leading causes of death for persons > 65



heart disease, cancer, cerebrovascular disease and
chronic respiratory disease
Comorbid medical conditions and disabilities
Half of persons > 60 yrs of age have 2 or more
chronic conditions
5
Characteristics

Most common symptoms in elderly at the endof-life




Pain
Respiratory distress
Delirium
Relief – basic for priority of the dying elderly

Facilitates peaceful death
6
Considerations

Caregivers need to be knowledgeable



Normal aging process
Impact of disease on already frail system
Management of symptoms at end-of-life in
elderly differ than with younger because of their
altered response
7
Normal Aging Changes
 Aging – normal process
 Multiple changes in body systems
 Age alters response to illness
 Aging and illness can interact, resulting in
altered/atypical presentation of illness and
response to treatment
8
Normal Aging Changes
Age Classifications



Younger old: age 65 to 75 years
Older old: age 75 to 85 years
Oldest old: over 85 years


Fastest growing segment of the population
Changes most pronounced
9
Cardiovascular System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
10
Cardiovascular System
Aging Changes
 Left ventricle hypertrophy
 Decreased force of contraction, contractile
efficiency
 Decrease in pacemaker cells
 Arterial stiffening & wall thickening
 Decreased O2 uptake by tissues
 Increase heart rate in response to stress
11
Cardiovascular System
Implications
 Increased systolic BP, pulse pressure
 Heart rate 40-100 bpm
 Fatigue, SOB
 Extra heart sound common: S4
 not S3 which is always abnormal
 Strong arterial pulses; diminished peripheral
pulses
12
Cardiovascular System
Risks





Valve dysfunction, systolic murmurs,
conduction abnormalities
Arrhythmias, postural / diuretic hypotension
Carotid artery buckling, jugular venous
distension
Inflamed varicosities
Stroke
13
Cardiovascular System
Assessment




Assess BP (lying, sitting, standing), pulse
pressures
Altered landmarks, distant heart sounds,
difficulty in isolating Point Maximum
Intensity
Assess carotid arteries
Monitor ECG
14
Cardiovascular System
Interventions



Referrals / consults for irregularities
Safety precautions for orthostatic hypotension
Institute fall prevention strategies
15
Respiratory System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
16
Respiratory System
Aging Changes
 Thorax and vertebrae rigid
 Decreased muscle strength & endurance
 Diminished ciliary and macrophage activity
 Drier mucus membranes
 Decreased alveolar function, elastic recoil
 Decreased response to hypoxia & hypercapnia
17
Respiratory System
Implications
 Kyphosis;barrel-shaped chest
 Respiratory rate 12-24 per min.
 Decreased chest/lung expansion, mucus/foreign
matter clearance
 Dyspnea after exertion
 Decreased capacity to maintain acid-base
balance
18
Respiratory System
Risks

Infection and asthma

With aging airways lose flexibility and elasticity
19
Respiratory System
Assessment





Respirations
Note thorax appearance, chest expansion
Assess cough, deep breathing, exercise
capacity
Assess for infections, asthma
Monitor ABG’s, pulse oximetry
20
Respiratory System
Interventions





Maintain patent airway
Preventative measures to decrease risk of
respiratory infections
Provide oxygen as needed
Incentive spriometry
Education on cough enhancement, etc.
21
Genitourinary System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
22
Genitourinary System
Aging Changes
 Decreased kidney weight, blood flow,
oxygenation, glomerular filtration rate

10% decrement/decade after age 30
 Impaired capacity to dilute, concentrate, acidify
urine; impaired sodium regulation
 Reduced bladder elasticity, muscle tone,
capacity
23
Genitourinary System
Aging Changes





Weakened urinary sphincter
Delayed perception of voiding signal
Increased nocturnal urine production
Males, risk of benign prostatic hyperplasia
Post-menopausal females: decreased pelvic
area elasticity; alkaline vaginal pH
24
Genitourinary System
Implications
 Reduced excretion of acid load
 Normal renal function: constant serum creatinine
level; absent proteinuria
 Nocturnal polyuria
 In bladder, increased post-void residual urine
 Decreased drug clearance
25
Genitourinary System
Risks





Renal complications
Dehydration / Volume overload
Hyponatremia / Hypernatremia
Hyperkalemia
UTI
26
Genitourinary System
Assessment





Monitor BP, lab data (creatinine clearance)
Assess for dehydration, volume overload,
electrolyte imbalances
Assess nephrotoxic agents
Palpate bladder after voiding
Assess for incontinence, UTI, nocturnal /
urgent voiding
27
Genitourinary System
Interventions





Preparation for fluid/electrolyte correction
Safety precautions in nocturnal / urgent
voiding and postural hypotension
Prevent falls
Incontinence management
Monitor for nephrotoxic drugs
28
Integumentary System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
29
Integumentary System
Aging Changes

Skin



Decreased subcutaneous fat, interstitial fluid,
muscle tone, glandular activity, sensory receptors
Collagen stiffening
Reduced blood supply and capacity for repair
Hair – decreased melanin and follicles
 Nails – reduced blood supply

30
Integumentary System
Implications
 Skin
 Cool, pale dry skin
 Increased fragility, wrinkling, tenting, sagging
 Decreased feeling / sensation
 Decreased fat and muscle tone
 Hair – graying, thinning
 Nails – brittle, slow growth
31
Integumentary System
Risks




Skin tears, pressure ulcers, dermatitis
Yeast infections
Fungal infections
Injury
32
Integumentary System
Assessment and Interventions
Assessment


Monitor skin temperature
Inspect for changes
Interventions



Prevention
Education
Adequate fluid intake to prevent dehydration
33
Gastrointestinal System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
34
Gastrointestinal System
Aging Changes
 Decreased thirst, taste perception
 Decreased saliva with dry mucosa
 Atrophy of taste & olfactory receptors
 Decreased esophageal, stomach, intestinal
motility
 Decreased defecation sensation
 Decreased liver and pancreatic function
35
Gastrointestinal System
Implications






Impaired digestive ability
Impaired perception of taste and smell
Gastroesophageal Reflux Disease (GERD)
Decreased absorption of fat, CHO, protein
Constipation, flatulence common
Cholecystolithiasis
36
Gastrointestinal System
Risks







Fecal impaction
Adverse drug reactions
Dehydration, electrolyte imbalances,
Dysphagia, hiatal hernia, aspiration
Risk of gingivitis, chewing impairment
Maldigestion
Anemia, osteoporosis
37
Gastrointestinal System
Assessment





Assess abdomen, bowel sounds
Monitor weight, dietary intake, elimination
Assess dentition, chewing and swallowing
abilities, eating habits/nutrition
Assess for pulmonary infection
Evaluate chemosensory complaints of poor food
taste
38
Gastrointestinal System
Interventions

Education on nutrition/diet, approaches to flavor
enhancement, fluid intake, toileting
habits/bowel training, encourage mobility
39
Musculoskeletal System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
40
Musculoskeletal System
Aging Changes
 Narrowed intervertebral disks
 Decrease regeneration of muscle fibers
 Increased latency/contraction time of muscle
 Tendon & ligament stiffening
 In joints, articular cartilage erosion
 Bone loss in women and men
41
Musculoskeletal System
Implications
 Kyphosis, height loss (1-4")
 Gait and balance instability common
 Decreased total body water &
intercellular/interstitial fluid
 Decreased muscle strength & agility; slowed
reflexes/reaction times
 Decreased endurance
42
Musculoskeletal System
Risks



Injury, joint subluxation, crepitus and pain on
ROM
Osteoporosis and fractures, osteoarthritis
Fluid/electrolyte imbalances
43
Musculoskeletal System
Assessment


Assess functionality, mobility, fine and gross
motor skills, ADLS
Ensure joint stabilization and slow movements
in ROM exam to prevent injury
44
Musculoskeletal System
Interventions




Education on nutrition, regular exercise, muscle
strengthening
Information on strategies (including
environmental design) to maximize function
Referrals to physical/occupational therapy
Pain medication to enhance functionality
45
Ocular System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
46
Ocular
Aging Changes
 Decreased muscle elasticity, tear production
 Decreased aqueous humor secretion – reduced
cleansing of lens and cornea
 Lens less elastic, denser, decreased light passage
47
Ocular Aging Changes
Implications






Eyes dry & receded with limited upward gaze
Blurred vision and decreased visual acuity
Vitreous floaters cause webs in vision field
Decreased peripheral vision
Impaired light/dark adaption, color discrimination
Decreased night vision, altered depth perception
48
Ocular Aging Changes
Risks





Ectropion (sagging lower eyelid)
Entropion (inwardly turned eyelid)
Conjunctivitis
Infection
Risk of injury, cataracts, narrow-angle
glaucoma, corneal abrasion
49
Ocular Aging Changes
Assessment


Assess visual acuity (under various light
conditions), color vision
Evaluate impact of vision limitations (day &
night), i.e., ambulation, safety, social
interactions
50
Ocular Aging Changes
Interventions




Education on regular eye exams
Precautions due to visual impairments
Fall prevention
Adequate lighting to improve vision
51
Auditory System
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
52
Auditory
Aging Changes
 Changes in cartilage of pinna
 Decreased ceruminal glands
 Middle ear – tympanic membrane thinning &
loss of resiliency
 Inner ear – atrophy of vestibular structures,
cochlea, organ of Corti plus loss of hair cells
53
Auditory System
Implications & Risks
Implications
 Changes in external ear appearance
 Drier cerumen
 Decreased sound conduction
Risks
 Hearing Loss
 Equilibrium-balance deficits
 Tinnitus
54
Auditory System
Assessment and Interventions
Assessment



Assess hearing, balance & equilibrium, functionality
Inspect ear for cerumen build-up
Evaluate safety issues
Interventions


Education on regular auditory evaluation
Safety
55
Endocrine System
 Aging Changes
 Implications
 Assessment
 Interventions
56
Endocrine System
Aging Changes
 Carbohydrate metabolism
 Mineral metabolism
 Fluid/electrolyte balance
 Body composition affected by decreased growth
hormone, altered glucocorticoid an testosterone
(males) activity
57
Endocrine System
Implications
 Decreased glucose tolerance after challenge,




risk of diabetes mellitus type 2
Bone mineral density loss
Risk of fluid/electrolyte imbalances
Change in body composition, increased fat,
decreased muscle and bone mass
Decreased ability to respond to physiological
stressors
58
Endocrine System
Assessment and Interventions
Assessment



Assess functionality, fall risk, hydration
BP (orthostatic)
Monitor laboratory values, bone mineral density
Interventions

Education on nutrition, hydration, safety
59
Nervous System and Cognition
 Aging Changes
 Implications
 Risks
 Assessment
 Interventions
60
Nervous System and Cognition
Aging Changes
 In CNS, decrease in neurons, brain size,
neurotransmitters
 Slowed nerve impulse conduction
 Decreased peripheral nerve function
 Compromised thermoregulation
61
Nervous System and Cognition
Implications
 Slowed thought processing
 Decreased ability to respond to stimuli
 Increased threshold for light touch and pain
sensation
 Ischemic paresthesia in extremities common
 Great individual variation in cognitive function
62
Nervous System and Cognition
Risks


Poor balance, postural hypotension, falls, injury
Mild cognitive impairment, dementia
63
Nervous System and Cognition
Assessment and Interventions
Assessment


Assess functionality, cognition, BP (orthostatic)
Evaluate hazards in home environment
Interventions


Education on safety, avoidance of falls
Measures to maintain cognitive function
64
Atypical Presentation of
Illnesses in Elderly
 Essential to recognize atypical presentations
 Classic presentations may not be true with the
elderly, i.e. MI, UTI
 First signs of illness in elderly – most often
subtle changes or change in mental status
65
Atypical Presentation of
Illnesses in Elderly
Risks Factors





Over age 85 in particular
Multiple co-morbidities
Multiple medications
Cognitive or functional impairment
Consequences of not identifying atypical presentation of
illnesses
66
Atypical Presentation of
Illnesses in Elderly
Assessment Considerations




Often vague presentation
Non-specific sypmtoms, subtle changes
Changes in behavior often prodrome of acute illness
Acknowlege reports from patient, family, care provider
67
Atypical Presentation of
Illnesses in Elderly
Depression
 Sadness may be interpreted as normal aging
 Presents as preoccupation with somatic symptoms
 Generally present with agitated depression
68
Atypical Presentation of
Illnesses in Elderly
Infectious Diseases
 Lack of typical s/s, may present with decreased appetite,
decreased functional status
Acute Abdomen
 Mild discomfort and constipation, vague respiratory
symptoms
 Recognize change in food/fluid intake
69
Atypical Presentation of
Illnesses in Elderly
Malignancy
 Hidden masses in elderly

Back pain may present as slowing growing breast
mass
Myocardial Infarction
 Vague s/s, i.e., fatigue, nausea
70
Atypical Presentation of
Illnesses in Elderly
Pulmonary Edema
 Usually exhibit with specific clinical signs associated with
CHF
 Insidious onset as change in function, decrease in food/fluid
intake, confusion
71
Atypical Presentation of
Illnesses in Elderly
Thyroid Disease
 Generally present as classic s/s
 Not uncommon to see altered presentation
72
Atypical Presentation of
Illnesses in Elderly
Non-presentation or under reporting




Subtle nature of onset
Regard s/s as ‘normal aging”
Does not want to be a bother, complainer
Communication deficits
73
Palliative Care in the Elderly
 Need for Intervention
 Trajectory of Illness
 Hastings Center Report Special 2005
74
Barriers
to Effective Palliative Care
 Communication
 Prognostication difficult
 Family not in agreement
 Failure to implement end-of-life plan
 Clinician skills lacking
 Failure to recognize treatment futility
 Regulatory issues
75
Principles of Palliative Care
and Needs
 Caregiving needs arise
 Respect wishes, choices, goals of patient and
family
 Utilize resources – IDT
76
Ethical Issues
 Goal of ethical action and decision-making
involves avoiding or minimizing harm and
maximizing benefits
 Elderly and terminally ill vulnerable group
 Components of an ethically responsible
professional relationship
77
Spiritual Suffering
 Religion very important part of many older
adults lives
 Assess spiritual needs as part of the treatment
plan – provide support – include religious
representative
 May be helpful to family/caregivers
78
End-of-Life Decision-making
 Discussion should occur while cognitively intact
 Patients rights
 Advance care planning demonstrates autonomy
of the individual
79
Specific Issues Related to
Palliative Care in the Elderly

Mental Health Issues




May be associated with progressive social isolation,
physical symptoms, sensory losses and lack of
support
Depression is the strongest risk factor of suicide
Older adults commit suicide more frequently than
younger adults
Comprehensive assessment
80
Specific Issues related to
Palliative Care in the Elderly
 “Every patient has a right to have his or her pain
assessed and treated”
The Joint Commission
Clinical Practice Guidelines for Quality Palliative Care


Domain 2: Physical Aspects of Care
Guideline 2.1 Pain, other symptoms,, and side effects are
managed based upon the best available evidence, with
attention to disease specific-pain and symptoms, which is
skillfully and systemically applied.
National Consensus Project 2nd edition, 2009
81
Specific Issues related to
Palliative Care in the Elderly
Pain Issues





Pain may be under reported in the elderly
Assessment/reassessment is often not consistent
Not a consequence of aging
Descriptions – ache, discomfort
Inadequate training may interfere with overall
management of pain
82
Specific Issues related to
Palliative Care in the Elderly
 “Start low and go slow”
 Pharmacokinetics altered with aging and disease
processes – consider using 25-50% of the dose for
a younger person
 Caution with combining drugs – cumulative
effects, i.e., hidden doses of acetaminophen
83
Specific Issues related to
Palliative Care in the Elderly
Pain Issues – Polypharmacy
 Elderly prescribed more medications
 Increases risk of side effects, adverse effects
 Risk factors
 Multiple healthcare givers, multiple
medications
 Physiologic Changes
84
Specific Issues related to
Palliative Care in the Elderly
Pain Issues – Polypharmacy – Prevention
 Use one pharmacy
 Obtain a list of all prescription medication, OTC, herb,
nutritional supplements
 Identify previous problems with medications
 Identify medications that are high risk of side effects,
adverse effects
 Determine understanding of medications
85
Specific Pharmacological
Considerations in the Elderly
Physiologic changes – Organ function changes
 Absorption
 Decreased motility of GI tract
 Increase risk for bleeding, ulceration
 Distribution
 Decrease lean body mass, increase body fat
 Lipid soluble drugs – delay onset of action
86
Specific Pharmacological
Considerations in the Elderly
Physiologic changes – Organ function changes
 Metabolism
 Hepatic changes
 Risk for accumulation
 Elimination
 decrease hepatic and renal function
87
Symptom Management During
Last Weeks
 Effective plan includes communication
 Elderly experience complex symptomatology
 Most difficult to manage – pain, dyspnea,
confusion
 Most common distressing experienced by the
elderly – dyspnea, pain, delirium
88
Dyspnea
 Frightening
 Profound suffering of patient and family
 Structural Changes
 Increase chest wall stiffness
 Decrease in skeletal muscle
 Decrease elastic recoil of lungs
 Other Factors
89
Dyspnea
 Risk Factors
Venous stasis, immobility, CHF
 Treatment
 Aimed at underlying disease process
 Symptomatic treatment is not reversible
 Pharmacological, non-pharmacological
 Procedural

90
Pain
 Elderly more sensitive to therapeutic and toxic
effects of analgesic
 Common types of pain



Acute
Cancer
Chronic nonmalignant
91
Pain
Analgesia selection
Acetaminophen
 Safe analgesic
 Can be used in combination with opioid
 Monitor long term use
 Ceiling is 2.4 to 3 gm/day in elderly
92
Pain
Analgesia selection
NSAID’s
 Use for mild to moderate pain
 Can be used with opioids
 Useful for nociceptive pain
 Has effect on pain receptors
93
Pain
Analgesia selection
NSAID’s
 GI ulcerations, renal dysfunction, platelet
aggregation
 Always take with food and water
 Monitor H&H, test for occult blood
 Consider benefits vs risks
94
Pain
Analgesia selection
Opioids
 Moderate to severe pain
 Short acting easier to titrate and less side
effects
 Reduce initial dosing by 25-50% in elderly
 Morphine most commonly prescribed
95
Pain
Analgesia selection
Opioids
 Hydromorphone
 Oxycodone
 Codeine
 Fentanyl Transdermal Patch
 Methadone
96
Pain
Analgesia selection
Managing Side Effects
 Preventative – ‘start low and go slow’
 Nausea/Vomiting
 Sedation
 Constipation – prescribe laxative/stool
softener when opioid prescribed
97
Pain
Analgesia selection
Adjuvants
 Responses may vary – may need to try more
than one
 Tricyclic antidepressants
 Anticonvulsants
 Corticosteroids
 Local Anesthetics
98
Pain
Analgesia selection
Non-pharmacological Therapies
 Most commonly used by older adults




Heat / Cool Application
Exercise
Prayer
Others
99
Delirium
 May be a presenting factor of
 acute illness
 Exacerbation of chronic illness
 Toxicity from medications
 Distressing
 Safety Risk
 Assessment important
 Treatment
100
Summary
Geriatric population
 Fastest growing population
 Living longer because of medical advances
 Altered response to medications
 Caregivers need to be knowledgeable
 Effective palliative plan of care provides quality
end-of-life care
101
References
1. The Older Population: 2010.
http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf Accessed December
6, 2011.
2. Chronic Conditions. National Center for Health Statistics, Trends in Health and
Aging. www.cdc.gov/nchs/agingact.htm. Accessed December 6, 2011.
3. Smith C, Cotter V. NORMAL AGING CHANGES. Nursing Standard of Practice
Protocol: Age-Related Changes in Health. Evidence-Based Content. Available at
www.consultGeriRN.org. Accessed December 6, 2011.
4. Capezuti E, Zwicker D, Mezey M, Fulmer T. eds. Age-related changes in
health. In: Evidence-Based Geriatric Nursing Protocols for Best Practice. 3rd ed.
New York, NY: Springer Publishing Company; 2008: 431-458.
5. http://www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed December 6, 2011.
6. Ham R, Sloane D, Warshaw G. Primary Care Geriatrics: A Case Based Approach.
St Louis, MO: Mosby, 2002: 32-33.
102
References
7. Lynn J. Living long in fragile health: The New demographics shape end of life care,
Improving end of life care: Why has it been so difficult? Hastings Center Report Special.
Report 35 (No 6.), 2005: S14-S18.
8. Travis SS, Bernard M, Dixon S, McAuley WJ, Loving G, McClanahan L. Obstacles to
palliation and end of life care in a long-term care facility. Gerontologist. 2002; 42(3): 342349
9. Joint Commission's 2001 pain management standards. http://www.jointcommission.org.
Accessed December 6, 2011.
10. Ferrell B.R, Coyle N, eds. Elderly Patients. In: Textbook of Palliative Nursing 3rd ed. New
York, NY: Oxford University Press; 2010: 713-743.
11. McCaffery M, Passero C. Pain: Clinical Manual. St. Louis; MO: Mosby;1999
12. Stein WM, Pirrello R. Clinical pearls on delirium and its treatment. Program and abstracts of
the American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses
Association Annual Assembly; January 19-23, 2005; New Orleans, Louisiana.
103
Additional References

American Pain Society. Principles of analgesic use in the treatment of acute
pain and cancer pain. 3nd ed. Skokie, OL: American Pain Society; 1999.

Bednash G, Ferrell B. End-of-Life Nursing Education Consortium (ELNEC),
Promoting Palliative Care in Geriatric Settings. Washington, DC:
Association of Colleges of Nursing: 2005.

Berry PH, ed. Core Curriculum for the Generalist Hospice and Palliative
Nurse 2nd ed. Dubuque, IA: Kendal/Hunt; 2005.

ConsultGeriRN.org

Food and Drug Administration (www.fda.gov)
104
Additional References

Coyle N, Layman-Goldstein M. Pain assessment and management in
palliative care. In: Matzo ML. Sherman DW, eds. Palliative Care Nursing;
Quality Care to the End of Life. New York, NY: Springer; 2001

Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York,
NY: Oxford University Press; 2006

Gorman L, Beach P, Ersek M, Montana B, Bartel J. Pain Position Statement.
Pittsburgh, PA: Hospice and Palliative Nurses Association: 2003.

Hospice and Palliative Nurses Association (www.hpna.org)
105