Aging Part 2

Geriatric Syndromes

• Geriatric Syndromes: Complex health conditions in older adults affected by multiple impairments from various systems.

• Examples:

  • Delirium: Acute condition caused by a physiological problem that CAN be corrected

  • Falls

  • Failure to thrive (malnutrition)

  • Urinary incontinence

• Challenges:

  • Multiple risk factors

  • Increased physical and mental dysfunction

  • Increased complexity of care

• Opportunities:

  • Nurses can prevent or treat

  • Many risk factors are sensitive to nursing care

SPICES Tool for Geriatric Assessment

• SPICES Tool identifies common issues in elderly patients requiring nursing intervention:

  • S: Sleep disorders

  • P: Problems with eating/feeding

  • I: Incontinence

  • C: Confusion

  • E: Evidence of falls

  • S: Skin breakdown

Characteristics of Geriatric Syndromes

• Definition: Syndromes with multifactorial origins impacting older adult’s vulnerability to additional challenges.

• Multifactorial etiologies: most commonly found from research include pressure ulcers, incontinence, falls, functional decline, and delirium

• Risks:

  • Older age, cognitive decline (Alzheimer’s), functional impairment (ADLs/Instrumental ADLs), and impaired mobility

  • This is associated with increased morbidity and mortality.

Identified Geriatric Syndromes

Classics have a *

• Dementia: Chronic (often slow starting) irreversible decline in cognition (family usually does not recognize it)

• *Delirium: Acute onset of confusion is usually reversible and can be treated

• *Urinary Incontinence: Increased risk of falls, skin issues, VERY SERIOUS.

• Falls

• Gait disturbances:

• Dizziness

• Syncope: Fainting

• Hearing Impairment

• Visual Impairment

• Osteopenia: Loss of bone cells before osteoporosis

• *Malnutrition

• *Pressure Ulcers

• *Sleep Problems

• Polypharmacy: Complications from medication

• Elder Abuse

• Self Neglect: Do not get help for certain needs and may not get proper care

• Frailty

Iatrogenesis

Malnutrition

• Poor oral health: Periodontal disease

• Medications: Digoxin

• Poor Vision: can’t read labels or recipes

• Economics: Low income, No glasses, and No dentures

• Social Isolation: Eating alone, Poor mealtime, and Abience

• Arthritis: Impaired Dexterity, Immobility

• Congestive Heart Failure: Na restriction, Anoxeria, and Fatigability

• Sarcopenia: Muscle protein and muscle strength decrease

• Depression

Case Study: Mrs. D

• Profile: An 83-year-old female with multiple health challenges comes into the ER for a fall.

• diabetes, visual impairment/cataracts (sensory deficit cause falls), multiple medications (polypharmacy), previous falls, osteoarthritis (Falls),

• just put on new BP medication

• Lives with husband alone (also 83)

• Children visit weekly (Not enough times)

• Swaps meds with her husband sometimes (Financial issues)

• Key Questions:

  • Why did she fall? ALL OF IT!

  • What defines a fall as a geriatric syndrome?

  • How to treat the geriatric syndrome of falls? Assess to identify.

“Fall” as Geriatric Syndrome

• Defined as an unintentional change in position leading to being on the ground.

• Encourage alert system

• Potential Causes for Mrs. D's fall include:

  • Medical Issues: Hyper/hypoglycemia, orthostatic hypotension, neuropathy (loss of sensation in lower extremities), acute illness, and medications (Overdose on accident).

  • Functional Issues: Arthritis, impaired mobility.

CATASTROPHE Mnemonic

• A checklist for evaluating the elderly after a fall:

  • C: Caregiver and housing adequacy

  • A: Alcohol and/or withdrawal? Any illicit drugs?

  • T: Treatment compliance

  • A: Affect (depression)

  • S: Syncope

  • T: Teeting (dizziness)

  • R: Reduction in cognition

  • O: Ocular problems

  • P: Pain/mobility issues

  • H: Hearing impairment

  • E: Environmental hazards (stairs)

Assessment of Activities of Daily Living (ADL)

• Essential skills are categorized as:

  • ADLs

  • Dressing, Eating, Ambulating, Toileting, Hygiene

  • IADLs

  • Shopping, Housekeeping, Accounting, Food preparation, Transportation

Common Problems

Safe Medication Administration

Nonadherence

• Look for the reason why a patient is not taking their medication the way they are supposed to

• Misunderstanding

• Cost

• Visual impairments

• Polypharmacy

• Physical disability

Nursing Process to Teach

• Assessment

  • accurate medication history

  • barriers to adherence

• Planning

  • education about medications

  • home medication record

• Implementation

  • Pillbox

  • Schedule for administration

  • Safety

• Evaluation

  • Reassessment

  • try again if not effective

Dysphagia Case Study

• Dysphagia leads to severe complications like aspiration pneumonia due to swallowing difficulties.

Patients at Risk

• Stroke and neurological dysfunction (30-60% dysphagia)

• Up to 50% of patients with Parkinson’s Disease (or MS, ALS, decreased LOC) are susceptible

• GERD can cause bacterial issues and can cause things to get into the lungs

• Swallowing tract dysfunction (weakened or damaged to muscles and nerves used in swallowing)

• It cannot protect the airway!

Consequences & Complications

• Aspiration

• Can be silent- aspiration w/o coughing. Goes undetected until the person is seriously ill w/an infection

• Malnutrition & Dehydration

• Increased Anxiety

• Airway & Lung Scarring

• Restricted Airway

• Increased incidence of sinus infection

• Diminished Independence, self-image, self-esteem

• Need for invasive feeding devices

Aspiration Pneumonia

• Significantly fewer symptoms (underdiagnosed)

  • Atypical presentation includes confusion/delirium as the only clue that the older adult may have an infection

• Elevated respiratory rate (depth of respiration) is an early clue

  • Fever, chills, pleuritic chest pain and crackles

Assessment is key for high-risk patients

Patient Considerations

• Concentration during meals- quiet, minimal to no conversation during meals, minimum stimuli, limited interruptions, and supervision

• Positioning- always elevated (90 degrees) for 30- 1 hour after eating

• Food texture and size- liquids thick and gelatinous, semisolid foods, small bite sizes, never offer food and liquid together (causes them to choke), food with strong tastes are easier to swallow, water is hard to swallow (chilled goes down easier), and foods should be cold or warm.

• Provide a 30-minute rest period prior to feeding

• No straws

• Minimize sedatives prior because it can impair cough reflexes and swallowing

• Good oral care can prevent aspiration

Frailty in Older Adults

• Geriatric Syndromes: Incontinence, Falls, Pressure Ulcers, Delirium, Functional Decline

• Complications of frailty include Increased risk of falls, pressure ulcers, and functional decline.

• Poor Outcomes: Disability, Nursing Homes, and Death

• Higher incidence in nursing homes vs community

• Increases advancing age

• More common in the lower socio-economic groups and in women

• Characterized by weakness, slowness, reduced activity, low energy, and unintended weight loss

• Sarcopenia, osteoporosis, kyphosis, and fatigue

Iatrogenesis

• Refers to unintended consequences of medical interventions. Highlights the critical impact on older patients.

• Cascade Iatrogenesis: a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline

• Occurring most often among the oldest (90-100+), most functionally impaired, high severity of illness

• Most common events result from:

  • Adverse reaction to medications

  • Adverse reaction to procedures

  • Infections, delirium, deconditioning, etc.

  • Falls

  • Bias providers

Atypical Presentation

Confusion, falls, and/or lack of fever

3 D’s

Delirium, Dementia, and Depression

Transitions in Care

• Defined as the movement across care settings. Important for effective health outcomes.

• Make sure you give report

• Why transition care programs matter:

  • Reduce hospital readmissions and cost-effective interventions for improved patient care.

Why do we NEED Transition Care Programs

• Cost: 1/5 patients who leave the hospital will be readmitted within 30 days

• 76% of these readmissions may be preventable. The average cost to Medicare per preventable readmission is $15,200 per admission

• Allow hospitals to focus on reducing those numbers by improving the care coordination for patients between settings, which in turn lessens the likelihood that they will return for a related readmission

Seven Essential Interventions

• Medication Management

• Transition Planning

• Client/family education and counseling

• Information Transfer- sharing of important care information in a timely and effective manner.

• Follow-up Care

• Shared accountability across providers and organizations

TCM

• Identification of patients’ health goals

• Coordination and continuity of care

• Development of a streamlined plan of care to prevent future hospitalizations

• Preparation of the patient and family caregivers to implement said plan

• Accomplish everything with the active engagement of patients and families in collaboration with the patients physician and other health care team members.

Ten Essentials of TCM

• Nurse-led process who acts as a coordinator

• In hospital assessment, health team collaboration to:

  • Reduce adverse events, prevent functional decline, develop EBP plan of care

• Regular home visits, telephone support for at least 2 months after discharge

• Continuity of care

• Comprehensive Plan: needs, goals, problems, risks

• Early ID and Response

• Multidisciplinary approach

• Collaboration

• Communication