Week 2- Caring for frail and older adults

Things that are loss in hospital or LTC as patients

• Loss of Time Control - From now on, you can only speak when I call on you.

  • make you feel not great, loneliness, fear

• Loss of Choice - You no longer choose when you eat, where you sit, or when you use the bathroom. Someone else decides what is "'safest."

  • loss of autonomy, risk of falls, disruption dermitis(diaper rash), loss of dignity

• Loss of Privacy - Assume every conversation about you happens in the hallway while you are still in the room. Imagine having to use a commode at the bedside with only a curtain.

  • not everyone has hearing loss

• Loss of Competence - People now assume you cannot do things you have done your entire lite unless you prove otherwise.

What are the needs of older adults

• medication

• social life (limitation: mobility or transportation)

• routine

Difference between LTC and retirement home?

LTC= nursing home (publicly funded)

Retirement home= private (9-11k per month, some dont even include food or nursing care)

Definition of a fall according to WHO

An event which results in a person coming to rest inadvertently on the ground or floor or other lower level

Things that can cause a fall

• walking

• getting up

• orthostatic hypertension

• balance

• weight

• strength

• overestimate ability

How many seniors fall every year in Canada?

20-30%

What is the leading cause of injury-related hospitalizations among Canadian seniors?

Falls

What is the single most important predictor of future falls

history of a prior fall

Biggest result of a fall

broken bone, brain bleed

Broken hip due to fall stats

50% have a 1 year survival rate post fall

indicative of other underlying conditions

1st fall → increased chance of falling again

Falls risk factors

• Intrinsic (Patient factors)

• Extrinsic (Environment factors)

• Activity-Related (Task & behavior)

Intrinsic fall risk factors

• Age

• Prior falls

• Vision impairment

• Cognitive impairment

• Dizziness/lightheadedness

• Balance & gait issues

• Muscle weakness

• Chronic illness

• Incontinence

• Pain

• Polypharmacy

Extrinsic fall risk factors

• Poor lighting

• Slippery/uneven floors

• Throw rugs & clutter

• Stairs without railings

• Inappropriate furniture height

• Bathroom hazards

• Footwear/clothing

• Pets underfoot

• IV lines/oxygen tubing

• Unfamiliar environment

Activity-Related fall risk factors

• Rushing to bathroom

• Unsafe transfers

• Walking while distracted

• Not using mobility aids

• Night-time toileting

• Reaching/climbing

• Overestimating abilities

• Fatigue during activity

• Poor pacing of activities

Falls assessment: morse fall risk

• measures risk of patient falling

• done everyday

• 0-24: no additional support needed

• 25-50: low risk fall

• 50+: high risk fall

Bed ridden definition

cant get out of bed

Timed up and go test

• Mainly used in primary care

  • given a practice chance prior to actual testing

  • used to assess eyes, balance, gait, activity intolerance

• 10 seconds: gold standard

• 14+ seconds: need mobility support

Frailty

“A medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death.”

“A clinically recognizable state in which the ability of older people to cope with every day or acute stressors is compromised by an increased vulnerability brought by age- associated declines in physiological reserve and function across multiple organ systems.”

"Diagnosis where older adults are unable to cope with everyday stressors due to age associated declines in physiological reserve and function across multiple organ systems"

• don’t have physiological reserve

• 40% of adults 80 years or older have this

• 7% of older adults have this

• mainly affect women (increased osteoporosis and longer life expectency)

• affects thos with lower income and education and increased BMI more

Clinical frailty scale

• scaled 1-9

• a validated, judgment-based tool used by healthcare providers to summarize an older adult's overall level of fitness or frailty prior to an acute illness or hospital admission

Sarcopenia

• gradual loss of skeletal muscle which leads to weakness

• affected by aging inactivity, poor nutrition, medical conditions

Common fall prevention components

• Strength and balance training

  • 150 mins per week

  • sit to stand or tai chi are good exercises

• Home hazard assessment and intervention

• Vision assessment and referral

• Medication review with modification / withdrawal

Safe environments

• Home assessment

• Risk free environment

  • Even floors/Walkways, entrances - clear and unobstructed

  • Appropriate lighting

  • Appropriate railings and ramps

  • Furniture- appropriate height, stable transfer structures

  • Floor plan / layout - easy accessibility

• Household pets - controlled

• Footwear & clothing

• Assessment of ADL’s

  • Appropriate support implemented

What is polypharmacy

taking more than 5 meds

Polypharmacy, Medication Reconciliation & Falls

• Polypharmacy increases fall risk through dizziness, sedation, hypotension, and confusion

• High-risk classes: benzodiazepines, opioids, antipsychotics, antidepressants, antihypertensives, anticholinergics

• Drug–drug interactions and cumulative side effects compound risk

• Medication reconciliation = verify what the patient actually takes (not just what’s ordered)

What percentage of people have dual sense loss?

30%

What impact does visual and auditory deficits have?

• feel dependent

• isolation/loneliness

• cost

• risks

• reliance/ loss of independence

How do we know if its visual or auditory deficits are age related or related to a disease process?

• vision: disease process, age can affect it tho

  • greatest risk of age disability

Age Related Eye Disease

• Visual acuity worse than 20/70, but better than 20/400 (legal blindness)

• Negative impact on quality of life – snowball effect

• Risk factor for falls

What are some signs and behaviours that may be indicative that there is a vision problem?

squinting, having a device an arms length away, hand eye coordination

What is Glaucoma?

Elevated intraocular pressure resulting in damage to the optic nerve causing peripheral vision issues

irreversible damage

Risk factors for glaucoma

• Age - single most important predictor

• Older women are 2x as likely as older men

Symptoms of glaucoma

• Vision loss, redness, acute pain (red flag), headache, nausea vomiting, blurred vision, light sensitivity, fixed and dilated pupil

Interventions to glaucoma

• Medications - oral or topical eye drops

  • To reduce the amount of aqueous fluid produced

  • Improve flow of aqueous fluid through the drainage angle

Medications used to treat glaucoma (specific catergories)

Prostaglandin Analogs

Beta-Blockers

What is Cataract

• Damage to the ocular lens – protein build up and by fatty acid deposits

• peripheral vision affected first

• painless so deemed normal part of ageing

Cataract risk factors

• Heredity

• Age

• Exposure to excessive sun light

• Poor dietary habits

• Diabetes, hypertension, kidney disease

Cataract symptoms

Halo around objects, blurring or cloudy vision, decreased perception of light and color, sensitivity to glare, poor night vision

Assessment for cataract

look for clouding of the ordinarily clear ocular lens, red reflex (fundus exam) may be absent

Interventions for cataract

• Surgery – remove clouded lens and replace with plastic intraocular lens

• Eye drops (post surgery)

What is Macular Degeneration

Affects the macula, the central part of the eye responsible for clear central vision

• centre affected first

Macular Degeneration risk factors

• Age

• Women at greater risk

• Genetic factors

• Hypertension, hypercholesterolemia, cardiovascular disease

• Smoking

• Family history

Macular Degeneration symptoms

• Usually starts in one eye - progressive loss of central vision, peripheral vision remains, objects don’t seem ‘as bright’

• Blurred area near center of vision and then grows larger

• Farsightedness

Macular Degeneration assessment

Eye exam (Amsler Grid)

• Wavy, curved, or distorted lines (metamorphopsia): Often a sign of fluid or swelling under the retina (such as in wet AMD).

• Blank, dark, or missing spots (scotomas): Can indicate central macular damage or tissue loss.

• Blurred or discolored areas: Points to mild macular dysfunction

Interventions for Macular Degeneration

• Laser photocoagulation

• Eye injections

Dry eye

• Tear production diminishes with age

• Symptoms: dry scratchy feeling in the eye

• Causes: some medications, some diagnoses

• Treatment: artificial tears or saline gel, vitamin A

Communication Tips for Visual troubles

◦ Get the clients attention before speaking

◦ Clearly identify yourself and others with you

◦ Position at face level when speaking

◦ Have adequate lighting

◦ Can use light touch to begin conversation

◦ Make sure clients have their visual aids in place where needed

◦ Ask what they can see (don’t assume ‘blind’ means they can see nothing, or something)

◦ Ask how you can help them (don’t assume they need total assistance)

Percentage of adults aged 70-90 experience hearing loss

65%

Conductive hearing loss

Site of Problem: Outer or middle ear

Common Causes: Earwax, fluid, infections, eardrum injury

Sound Quality: Muffled or lower volume

Reversibility: Often temporary / treatable

Typical Care: Medical therapy or surgery

Sensorineural hearing loss

Site of Problem: Inner ear or auditory nerve

Common Causes: Aging, loud noise, genetics, illness

Sound Quality: Quieter and often distorted

Reversibility: Usually permanent

Typical Care: Hearing aids or cochlear implants

Hearing Loss: The Invisible Barrier

◦ Often under-assessed and under-treated

◦ Linked to isolation, delirium, safety risks, linked to dementia

◦ Men more at risk

Causes of hearing loss

1. Conductive Hearing Loss

Caused by problems in the outer or middle ear that prevent sound from being properly conducted to the inner ear.

Causes include:

• Fluid in the ear.

• Allergies.

• Foreign objects in the ear.

• Ruptured eardrum.

• Impacted ear wax.

2. Sensorineural Hearing Loss

Caused by damage to the inner ear (cochlea), hair cells, or auditory nerve.

Causes include:

• Aging.

• Ototoxicity (medications or substances that damage the inner ear).

• Loud noise exposure.

• Blast or explosion exposure.

• Tumors.

3. Causes of Both Conductive and Sensorineural Hearing Loss

Some conditions can cause either type of hearing loss, depending on which structures are affected.

Causes include:

• Genetic disease.

• Virus, disease, or infection.

• Head trauma.

Symptoms of Age-Related Hearing Loss

• Slow progression

  • May get ignored due to this

• Affects both ears equally

• Sometimes close family or friends may report noticing it first

• Difficulty hearing and understanding speech in noisy environments

• Trouble separating incoming speech from background noise

• May notice difficulty with higher pitched speakers

• Nonverbal signs:

  • Cupping the ear, turning head to one side when asked questions, misunderstanding questions

Management of Hearing Loss

• Do not shout

• Speak directly to the person

• Determine if one ear is better than the other

• Make sure hearing aids are in place

• Unobstructed view of your mouth

• Reduce background noise

• Low tone

• Careful articulation

• Do not speak fast

• Pause between sentences

• Nonverbal approaches - gestures, visual aids, written material

Positive ageing

• Maintaining Mobility

• Designing a Safer Environment

• Nutrition & Hydration: Quiet Drivers of Outcomes

Hospitalized Older Person At risk for

◦ Decreased mobility

◦ Falls

◦ Inadequate nutrition and hydration

◦ Compromised skin integrity

◦ Functional decline

◦ Cognitive function decline

◦ Change in ADLs

◦ Isolation

◦ Stress

Key take aways

Support ≠ taking over: Protect autonomy & dignity

◦ Falls are multifactorial and preventable

◦ Sensory loss changes everything about safety and communication

◦ Mobility, nutrition, and environment preserve independence

◦ Don’t forget about the person