Transcript Chronic Diseases and Restrictive Diets

Chronic Diseases and Restrictive Diets
• Common Restrictive Diets:
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Low/no sugar (Diabetes)
Low fat (Elevated cholesterol)
Low sodium (Congestive heart failure)
Combination of above (High blood pressure)
• Associated with poor intake
• May be seen in specific ethnic groups
– Decreased meat intake
– Other dietary preferences and restrictions
Dental Problems: Tooth Loss
• Most common causes of tooth loss:
 Inability or unwillingness to access and
pay for preventive/restorative treatment
 Loosening of teeth from periodontal
disease
 Removal of healthy teeth in preparation
for dental prosthesis
• Leads to diminished chewing efficiency
and reduced range of preferred foods
Dental Problems: Removable Dentures
• Can aid in speech
• Restores facial contours
• Less likely to restore
ability to chew (restriction
in range of foods)
• Requires frequent
professional adjustment
• Not covered by Medicare
< 10% of older persons have
dental insurance
Screening for Under-nutrition
or Malnutrition
Can use a combination of:
 Serial body weight
 Weight loss over the past months/yrs
 Nutrition history: appetite, # of meals/day,
taste & amount of food eaten
 Laboratory Values: Low serum cholesterol
and/or albumin
Cultural Competency & Frailty
• There is a need to include significant family
members in health care discussions.
• It is important to educate both the patient
and significant family members regarding the
impact of frailty, nutrition and prevention
strategies.
Cultural Competency & Frailty
• Family members instrumental in assuring
preventive measures and treatment plans
are implemented.
• Family members can also be a part of the
problem, particularly regarding nutrition.
• By educating family members you:
– make them a part of the solution
– increase your understanding of potential barriers
to treatment.
Cultural Competency & Frailty
• Many older ethnic minorities lack formal
education.
• May have difficulty understanding words,
concepts and procedures discussed in a
medical setting.
• Important to use words that are easily
understood and provide examples.
– Reduce carbohydrates
– Reduce your intake of cereals, rice and breads
Nutrition Team Challenge
• You are a team gathered together by the
CEO of your hospital.
• The CEO tells you that a recent survey by
the nutrition department demonstrated a
large proportion of your hospital’s patients
were having eating difficulties and poor
nutrition during the hospital stay and this was
negatively impacting on their functional
status after discharge.
Nutrition Team Challenge
• Move importantly (to the CEO) this group
was having higher 30-day readmission
rates.
• Your task is to define potential reasons for
the eating difficulties and develop some
potential solutions for the problem of eating
difficulties and poor nutrition during
hospitalization among the older adults
admitted to your hospital.
Consequences of Frailty:
Falls
Falls Incidence: Community
• One-third of community-dwelling persons
age > 65, fall each year; less than half talk to
their healthcare provider about it.
• In approximately half of the cases, falls are
recurrent
• Rates increase
– With age
– During the month after hospital discharge
Falls Morbidity: Community
• In next 17 seconds, an older adult will be
treated in hospital ED for fall related injuries.
• 10-15% of falls result in injury requiring
medical attention
• Functional deterioration including:
– Fear of falling / loss of confidence
• 40-73% of recent fallers
• 20-46% without recent fall
– Self-limitation of activities
Falls Mortality: Community
• Unintentional injury, 5th leading cause of
death in those > 65 years
– Majority due to falls
– Especially in those > 85 years
• Deaths often related to consequences after
the fall, not the fall itself
– Hospitalization
– Decreased activity
Falls Cost: Community
• Leading cause of injury-related visits to
emergency departments in US
• In 2009, 2.2 million nonfatal fall injuries
treated in emergency departments.
• Direct medical costs of falls: $28.2 billion
in 2010 dollars.
• Numbers expected to climb as population
ages
Fall Risk Factors : Community
• Focus of most fall research
• Falls in community-dwelling older adults tend
to be multifactorial in nature
• As number of risk factors increases, so does
risk of falls
Occurrence of Falls According to
Number of Risk Factors (Tinetti, 1988)
Number of Risk Factors
Most Common Risk Factors for
Falls (AGS Guidelines, 2011)
Risk factor
Significant/total Mean RR-OR Range
Muscle weakness
10/11
4.4
1.5-10.3
History of falls
12/13
3.0
1.7-7.0
Gait deficit
10/12
2.9
1.3-5.6
Balance deficit
8/11
2.9
1.6-5.4
Use asst device
6/12
2.6
1.2-4.6
Visual deficit
6/12
2.5
1.6-3.5
Arthritis
3/7
2.4
1.9-2.9
Cognitive impairment
4/11
1.8
1.0-2.3
Ambulatory Devices-Unilateral
Device
Benefits
Drawbacks
Clinical situations
Straight
cane
• Assists with
balance and
proprioception
• Reduced weight
bearing on
opposite side
• May not provide
enough support
• Doesn’t stand up on
its own making it
difficult to carry
objects and open
doors
• Osteoarthritis of
knee or hip
Quad or 4- • More stable than
point cane
straight cane
• Allows greater
weight bearing on
device
• Peripheral
neuropathy
• Heavier than single
• Stroke with
point cane
hemiparesis
• Increased base of
support may increase
risk of tripping over
device
Ambulatory Devices-Bilateral
Device
Benefits
Twowheeled
Rolling
Walker
• Easier to advance
than standard
walker
• Allows smoother,
faster gait pattern
• Very stable
• Allows non-weight
bearing movement
Standard
“Pick-up”
Walker
Rollator or
4-wheeled
walker
Drawbacks
• Less stable than
standard walker
• Turns less smooth
than rollator due to
fixed wheels
• Must be lifted requiring
strength/ coordination
• Gait pattern and turns
not smooth due to lack
of wheels
• Allows for
• Less stable than
smoother, faster
standard or rolling
gait
walker
• Large wheels: turns • Requires increased
easy; good outside
coordination due to
• Seat for resting
brakes
• More expensive than
other walkers
Clinical situations
• Deconditioning
• Parkinson’s dz
• Hip fracture; nonweight bearing
• After amputation
• Cardiopulmonary
dz
• Peripheral
neuropathy with
balance difficulty
Resources for Teaching about
Assistive Devices
• Rodriguez O, Ruiz J, Phancao F. "Assistive
Devices" Learning Object. MedEdPORTAL;
2007. Available from:
www.mededportal.org/publication/379
• van Zuilen M, Rodriguez O, Paniagua M,
Mintzer M. Choosing the Appropriate
Assistive Device: A Card Sorting Activity.
MedEdPORTAL; 2008. Available from:
www.mededportal.org/publication/823
Medications and Falls
• Psychotropics, any: RR 1.73 (1.52-1.97)
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Neuroleptics:
Sedative/hypnotics:
Antidepressants:
Benzodiazepines:
• Diuretics:
• Anti-arrhythmics (Ia) :
• Digoxin:
1.50 (1.25-1.79)
1.54 (1.40-1.70)
1.66 (1.40-1.95)
1.48 (1.23-1.77)
1.08 (1.02-1.16)
1.59 (1.02-2.48)
1.22 (1.05-1.42)
Recommended Interventions
Level of Evidence
• Multifactorial assessment of risk factors and
management of risk factors identified
• Adaptation/Modification of home environment
• Exercise, particularly balance, strength, and
gait training
• Withdrawal/Minimization of psychoactive
medications
• Withdrawal/Minimization of other medications
• Management of postural hypotension
• Management of foot problems and footwear
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Falls in the
Hospital Setting
CMS “Never” Events
• “Never events” are errors in medical care that
are clearly identifiable, preventable, and
serious in their consequences for patients.
• Patient death or injury associated with a fall
while being cared for in a healthcare facility
considered a “never” event.
Hospital Risk Factors
• Several factors consistently reported
– Gait instability
– Agitated confusion
– Urinary incontinence/ frequency
– Falls history
– Medications especially sedative/hypnotics
Multifaceted Interventions: Hospitals
• A recent meta-analyses showed rate ratio of
0.82 (95% CI 0.68-0.997) for falls
• No significant effect on # of fallers or fractures
• Multifaceted interventions included:
– risk assessment
– removal of physical restraints
– medical/diagnostic approaches
– changes in physical environment
– medication review
– exercise
– care planning
– hip protectors
Results of Meta-Analysis
• A recent meta-analyses of 13 studies
showed a rate ratio of 0.82 (95% CI 0.680.997) for falls but no significant effect on
number of fallers or fractures
– Study included historical controls
• A second study that used only prospective
controlled trial designed studies found no
conclusive evidence that fall prevention
programs reduced falls.
Coussement J, et al. J Am Geriatr Soc, 2008
Frailty and Disability
Nagi’s Disablement Model
Active Pathology
• Normal cellular processes and homeostatic efforts to return
to normal state are interrupted
Impairment
• Loss or abnormality at the organ or tissue level
Functional Limitation
• Have physical or mental limitation at the individual level
Disability
• Have physical or mental limitation in a social context (i.e.
socially defined roles or tasks)
Active
Pathology
Impairment
Functional
Limitation
Disability
Criticism of Early Disablement
Models
• Presented response to disease or illness
as a static process with a linear
progression through the disablement
process.
• It was recognized the interaction between
disease and disability is more complex,
particularly for older persons.
ICF Model
• International Classification of Functioning,
Disability and Health (ICF) released by World
Health Organization (WHO)in 2001 by WHO.
• Describes decreases in function as
consequence of dynamic interaction between
various health conditions and contextual
factors.
• Disability is defined as any decline at any of
these levels.
Health Condition
Diseases, disorders, injuries
or aging
Body Functions &
Structures
Physiologic functions and
anatomical parts of body
Environmental Factors
Physical, social and attitudinal
environment in which people live
Activity
Execution of a task or
action
Participation
Application to a real
life situation
Personal Factors Characteristics of
person not part of health condition
or illness
International Classification of Functioning, Disability and Health
Model Used to Discuss Frailty
• We could describe an older woman who
has a history of osteoarthritis of the knees
and hypertension who presents to
rehabilitation after a hip fracture. She lives
alone in a second floor apartment and has
a daughter who lives six hours away. The
patient has a large circle of friends and
regularly attends social gatherings at the
local senior center.
Health Condition
New hip fracture
Osteoarthritis
Hypertension
Body Functions
and Structures
Impairment of
ambulation due to
hip fracture and
knee pain
Activity
Unable to walk
long distances or
climb stairs
Environmental Factors
Lives in second floor
apartment
Lives alone, no available
caregiver
Participation
Missing social
events/ friends
Worried about
remaining in
apartment alone
Personal Factors
Great attitude
Large circle of friends
Case Development
• As a team develop a case of a frail person
with at least 3 issues contributing to their
difficulty in an ICF domain.
• Break the case down by domain/problem to
fit into the ICF model.
• After completing your case we will swap
cases and develop potential solutions for
the problems raised.