Care of Older Adults during illness

When Older Adults become sick

Hospital staff failed them by:

-Not feeding them properly

-Not getting them out of bed early and long enough

Health care providers failed them by:

-Restricting movements by tethering them to beds with O2 tanks and IV poles

-Not controlling their pain adequately

-Subjecting them to unnecessary procedures 

-Depriving them of sleep by placing them in noisy wards or checking vital signs at all hours of the night

These challenges can be annoying for younger patients but they often cause lasting damage to older adults

Characteristics of Illness in Older Adults

-One or more chronic conditions accumulate and affect daily function and quality of life

-Self-management essential

-Presence of many interacting conditions and factors: Acute illness, Chronic conditions, Psychosocial factors, Environmental conditions, Age-related changes, Medication effects

-Multimorbidity: 50% have 3 or more chronic conditions, Interplay between chronic and acute exacerbations, Increased risk of negative health outcomes

-Atypical presentation: S/S of disease differ from what is expected, Especially common in cognitively impaired, Adverse effects of medications

-Nursing responsibility: Maintain awareness of atypical presentation, Explore all potential underlying causes

Frailty

Common geriatric syndrome characterized by age-associated multisystem dysregulation and decreased physiological reserve, leading to increased vulnerability to adverse health outcomes

Pathophysiology of Frailty

-Cumulative decline with mutlisystem dysregulations lead to decreased physiologic reserve and increased vulnerability for subsequent morbidity and mortality

• Sarcopenia

• Renal insufficiency

• Anemia

• Deficiencies in anabolic hormones

• Excess exposure to cortisol

• Insulin resistance

• Compromised altered immune function

• Micronutrient deficiencies

• Oxidative stress 

-Frailty worsens with advancing age (older than 85 years), more common in older women, among those of lower SES, dependent in 1+ ADLs, and decrease hand grasp strength

Complications Associated with Frailty

-Disability

-Falls

-Peri-operative complications

-Increased length of hospital stay and 30-day readmission rate

-Less likely to discharge home— more likely to needed skilled nursing

-Increased risk of mortality

Role of Nursing:

-Nurses play a central role in early detection of frailty and providing timely interventions to prevent complications

-Aggressive measures are needed to prevent complications in frail older adults during hospitalization

Perioperative care of the older adult

-Older adults constitute of 1/3 of all surgical cases

-Increased risk for post operative delirium

-Dehydration

-Use of medications such as benzodiazepines, anticholingerics, and diphenhydramine

-Use of sedation or prophylactic antipsychotics

-Infection, lack of sleep, poor vision or hearing

-Need comprehensive pain management for a pain score greater than 5

Promoting wellness for older adults with cancer

-Disproportionately affected by cancer, less likely to be screened for cancer, diagnosed at later stage

-Nursing assessment: Identify knowledge and attitudes about screenings, interventions for prevention, and promote wellness by identifying psychosocial apsects

-Wellness nursing diagnoses and wellness outcomes: Early detection, Outcomes: comfort, coping, and quality of life

-Nursing Interventions: Address all aspects of pain and comfort

Applying Wellness concepts in adults with diabetes: Promoting wellness for older adults with DM

-Most common chronic condition 1:4 age 65+ DM/ 1:2 pre-diabetes

-Highest prevalence among Native Americans, Alaskan Natives, African American and Hispanics

-Complicated by the common occurrence of concomitant conditions

Applying Wellness concepts in adults with diabetes: Nursing assessment

-HBA1C 6.5% or more

-Fasting blood glucose 126mg/dL or more

-Symptoms of hyperglycemia (polyuria, polydipsia, weight loss) and a random blood glucose of 200 mg/dL or more

Applying Wellness concepts in adults with diabetes: Nursing interventions

-Monitoring DM
-Nutritional therapy

-Medications

-PA

-Foot care

-Vision assessment

-Resource for education and support

-Management of associated medication conditions

Applying Wellness Concepts in Older Adults with Heart Failure

-Heart failure: inability of the heart to pump blood sufficient to meet the body’s needs

-Leading cause of hospitalization and readmissions

-50% of readmissions are potentially preventable with adequate self-care

-Teach them when to contact PCP:

-Weight gain 2-5 lbs over last 1-2 days

-Increased SOB

-Increased swelling of ankles or abdomen

Acute care for elders (ACE) ward

-Designed to address the unique needs of older patients

-Less on the original diagnosis and more on how to get the patients back home, living as independently as possible

Goal of care of hospitalized older adult

-Provide evidence-based intervention to prevent complications

-Prevent complications in older adults

-Provide exquisite care to older adults to help them return to baseline functional status

-Promote interdisciplinary communication

-Start comprehensive discharge planning early

Preventing Complications and Promoting Functions

-Promote physical activity and mobility; mitigate fall risk without restricting movement; encourage independence in ADLs

-Promote cognitive activity; prevent, recognize, and treat delirium promptly

-Prevent complications: pressure ulcers, DVT, and adverse medication/procedure reactions

-Optimize nutrition and maintain ongoing oral hygiene

Care in Transition to Home

-Exercise (resistance, strength, mobility, lingual); nutritional maintenance/supplementation; oral health maintenance

-Alert the post-acute provider of the older adult’s frailty status

-Educate family/caregivers; modify home environment to support independence and self-reliance

Patient-centered care

-Incorporate older adult’s preferences

-Consider treatment burden

Evidence and risk-based decisions

-Apply medical literature specific to older adults

-Frame management within risks, burdens, benefits, and prognosis

-Therapies that optimize benefit -

Ongoing and Collaborative Care

-Ongoing education and assessments

-Interdisciplinary teams