Geriatric Syndromes Elizabeth K Keech Ph D RN

Geriatric Syndromes Elizabeth K Keech Ph. D, RN Elise Pizzi MSN, GNP-BC

What are they? Conditions, not diseases Common in the elderly Typically: Multifactorial Share risk factors Linked with functional decline, increasing frailty and poor health outcomes

Tend to include: Polypharmacy Chronic pain Falls Delirium Urinary incontinence Depression.

Prevalence Study of 62, 829 Looked at 3: Falls, Urinary incontinence & Depression Community dwelling women between 65 – 81 years of age - 34. 4% had 1 Geriatric Syndrome - 8. 2 % had 2 or more

Effects: Independent Physical & social functioning and disability Quality of life measures The Odds Ratio were as large for physical and social limitations as were those for chronic conditions

Effect: Synergistic Concurrence of Chronic diseases

Shared Risk Factors Diabetes: Malnutrition: Risk for : Dementia Decline in mobility Disability Falls Urinary Incontinence Correlated with: - Depression - Dementia - Functional dependence Associated with: - Multiple co-morbidities

Shared Risk factors Older age (Define old) Functional Impairment Cognitive Impairment Impaired mobility (Inouye et al 2007) Poor Nutritional status Female gender Depressive symptoms (Chen et al. 2010)

Frailty: “The Dwindles” Meet 3 of 5 symptoms: Decreased walking speed Decreased grip strength Decreased physical activity Exhaustion Weight loss (Fried et al. 2001)

What’s needed Prevention: Mobility issues and malnutrition Minimize complications Early recognition and treatment Basic set of geriatrics knowledge and skills to address the key geriatric syndromes and issues that can limit functional independence and complicate medical management

Improving health outcomes through research and education • Solutions: • Educating clinicians, educators and students • Identifying Evidence-based data found in Hartford Institute for Geriatric Nursing

HIGN Hartford Institute for Geriatric Nursing Mission – Shape the quality of health care of older adults through excellence in nursing practice Started in 1996 Geriatric arm of the NYU College of Nursing Addresses 4 vital areas for change PRACTICE RESEARCH EDUCATION ADVOCACY POLICY Hartford Institute Home Page

EDUCATION

GNEC Geriatric Nursing Education Consortium National initiative to enhance geriatric content in senior-level undergraduate courses Administered by AACN in collaboration with Hartford Institute Power Point presentations on-line Cultural Competence and Chronic Disease Management of Older Adults Spirituality and Aging Sexuality in Older Adults Spirituality in Aging

Geropsych Competency Geropsychiatric Nursing Collaborative that is identifying and evaluating the quality and suitability of curricular and training materials Portal of Geriatric Online Education-rate the materials you peruse Log in to view articles, videos Log in to view modules that develop knowledge of gero psych topics Portal of Geriatric Online Education

Consult Geri. RN. org Protocols and topics Evidence-based protocols for managing common geriatric syndromes and conditions From Advance Directives to Urinary Incontinence Consult. Geri. RN

Consult Geri-RN “Try This” Assessment Tool Series with over 30 nationally recommended instruments for use with older adults Tabs “want to know more” “topic resources” Try This Assessment Tool Series

HIGN e-Learning Center Continuing Education Portal with free and paid courses Sign in to courses Gerontological Certification Review Course offered by ANCC – fundamental knowledge about care of the older adult e. Learning/

HIGN e-Learning Center Clinical Teaching Modules assist nursing faculty to integrate care of older adults when teaching students in hospitals Clinical Teaching Module

HIGN e-Learning Nursing Home Modules Assist nursing faculty teaching in nursing homes Help faculty select and use nursing homes for clinical placement Focus on nursing homes involved in residentdirected care and culture change Nursing Modules

Elder Mistreatment e. Learning course developed Concepts Research Legal Care continuum Theories Clinical Documentation Impact Elder Mistreatment

HIGN e-Learning Web Based geriatric case studies that assist faculty to introduce geriatric concepts into the curriculum Advance Practice Case Studies

PRACTICE

NICHE Practice supportive Nurses Improving Care for Health System Elders GITT – Geriatric Interdisciplinary Team Training resources in a GITT Kit to help health professionals develop interdisciplinary teams GITT

Practice Support Consult Geri RN and Try This Series Tab – “Need help stat” Need help stat HI Hospital Competencies – Competency: Care of Adult 65 years + Hospital Competencies

IV - HIGN Forum Web based “board” for reading and posting messages about geriatric topics. HIGN Forum

USING “TRY THS”- Medications

Drugs and Older Adults Medication (prescription, over-the-counter and herbal preparations) are widely used by older adults At least one RX med used b 81% of community dwelling adults Five or more Rx medications used by: 29% of overall survey population 65 and older 36% of people aged 75 – 85 year olds 46% of RX users took at least one OTC medication (Qato et al, 2008)

Medication 20% of of community dwelling older adults in the US are using one or more meds on the Beer’s list of drugs that should be avoided (Zhan et al, 2001) All adults over 65 y. o. (12% of population) 79% take some type of medication Consume 30 – 40% of all prescribed drugs Purchase 40% of all OTC drugs 12% of elderly on 10 or more meds 23%take 5 or more medications

Adverse Drug Reactions(ADR) # of drugs prescribed and prior history of an ADR strongest predictors for subsequent ADR Risk doubled for those prescribed 5 -7 medications Fourfold for those receiving 8 or more medications (Onder et al, 2010)

Post hospital medication problems One or more medication discrepancies were experienced in 14. 1% of patients post hospitalization Medication discrepancies were associated with total number of meds taken and presence of CHF 14. 3% of patients with discrepancies rehospitalized in 30 days compared with 6. 1% without discrepancies (Coleman et al, 2005)

Try This Series

Try This Series Want To Know More Assessment /Screening Tools Beers Part I criteria Beers Part II criteria Article in AJN Video on Beers Criteria

Using Beers I Criteria see handout Part I – Have student review patient RX and OTC meds to identify inappropriate medications Great exercise for beginning clinical students Example for action on a drug by students OTC Benadryl (diphenhydramine) May cause confusion and sedation Should not be used as a hypnotic e. g. Tylenol PM!! Emergency allergic reaction use – smallest dose (25 mg), 1 – 2 x

Using Beers II Criteria see handout Part II – Have student review patient meds to identify inappropriate medications by patient diagnos(es)/condition(s) Good exercise for higher level students Use disease or condition to identify inappropriate medications by name or by drug class Have students group patient’s present list of medications both RX and OTC by diagnoses/conditions

Delirium: Most frequent complication of hospitalized elderly Yet nurses fail to recognize it more than 30 - 50% of the time In one study, nurses failed to recognize delirium in 75% of cases (Rice et al. , 2011) The fluctuating mental status is important to identify because it often signals a need for additional treatment

Improving Recognition through Education that: Differentiates between the 3 D’s Delirium, Dementia, Depression Improves knowledge about atypical presentations of delirium in the elderly Provides competency in mental status assessment: the Mini-cog Recognizes acute confusion as a serious condition

Try This Series: Delirium Overview of the problem Articles Strategies Assessment/Screening Tools Assessment tools Videos

CAM (Confusion Assessment Method) CAM standardized assessment tool (Long & Short Versions) CAM ICU – non-verbal, ventilated Patient Plus: Assessing and managing delirium superimposed on dementia Assessment of Executive Functioning

Try This Series: (CAM) Identifies 4 features of the disorder that distinguish it from other forms of cognitive impairment. 1. status altered from baseline (acute onset or fluctuating) 2. inattention 3. disorganized thinking 4. altered level of consciousness Takes 5 minutes and is easily incorporated

Back to Rice’s Study

Thank You and Healthy Aging

References Coleman, E. A. , Smith, J. D. , Raha, D. , Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 165: 1842. Fried, L. P. , Fernucci, L. , Darer, J. , Williamson, J. D. , Anderson, G. (2004). Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. Journal of Gerontology: Medical Sciences 59(3) 255 -263. Inouye, S. K. , Studenski, S. , Tinetti, M. E. , Kuchel, G. A. (2007) Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatric Society 55: 780 -791. Knight, E. L. , Avorn, J. (2001). Quality indicators for appropriate medication use in vulnerable elders. Ann Intern Med 135: 703.

References Onder, G. , Petrovoc, M. , Tanglisura, B. , et al. (2010). Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older: the Geronto. Net ADR risk score. Arch Intern Med 170: 1142 Qato, D. M. , Alexander, G. C. , Conti, R. M. et al. (2008). Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 300: 2867. Rice, K. L. , Bennett, M. , Gomez, M. , Theall, K. P. , Knight, M. , Foreman, M. D. (2011). Nurses' recognition of delirium in the hospitalized older adult. Clinical Nurse Specialist 25(6), 299 -311.

Russo, A. L. , Eaton, C. B. , Wallace, R. , Gold R. , Curb, J. D. , Stefanick, F. L. , Okene, J. K. , Michael, Y. L. (2011). Combined impact of geriatric syndromes and cardiometabolic diseases on measures of function. J Gerontol A Biol Med Sci. 66 A(3): 349 -354. Saka, B. , Kaya, O. , Ozturk, G. B. , Erten, N. , Karan, M. A. (2010). Malnutrition in the elderly and its relationship with other geriatric syndromes. Clinical Nutrition 29(6): 745 -8. Zhan, C. , Sangl, J. , Bierman, AS, et al. (2001). Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 286: 282. 3.