Updating Your Knowledge about Geriatric Nursing Care

Mary H. Palmer, PhD, RN, C FAAN, AGSFHelen W. & Thomas L. Umphlet University of North Carolina at Chapel HillDistinguished Professor in Aging, SONInterim Co-Director Institute on Aging

OverviewIntroduction to aging issues in the United States Geriatrics PrinciplesFrailty (and disability and co-morbidity)DementiaDeliriumFallsUrinary IncontinenceAnergiaGeriatric multidisciplinary competencies

ObjectivesIdentify geriatric principles to guide nursing careDiscuss frailty phenotype and its implications to the aging population and to nursing careDiscuss recent research findings on at least 2 geriatric conditions and prevalent geriatric diseases

ObjectivesDiscuss geriatric competencies needed by nurses to care for older adults

Identify geriatric resources available to nurse educators

Less than 1% of nurses are certified in geriatric nursing.

Nurses practicing in this country [US] today are, by default, geriatric nurses6.

Geriatric NursingIn the United States, people 65 and older:represent 36% of hospital stays1represent 49% of all hospital days2 had higher crude and adjusted morbidity and mortality after emergency general surgery3take 1/3 of all prescribed medications represent 88.1% of residents in the 16,100 nursing homes nationally4who were residents in nursing homes between January through June 2007, 14% had a prescription for an atypical anti-psychotic medication5

Sources: 1. Fulmer, 20012. Perry, 20023. Ingraham et al, 20114. http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf5. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf

Demographic Profile: North Carolina12% of NCs population is age 65+ with nearly 150,000 age 85+Projected to grow by 87% of 203020th in the nation in the projected growth rate of the 85+ populationAARP. (2009). Long-Term Care in North Carolina. Retrieved from http://www.aarp.org*http://www.aging.unc.edu/nccoa/2010video/index.html

United States Aging Statistics

Global Aging

Geriatric PrinciplesContinuity of careBolstering home and familyCommunication skillsKnowing the patient Thorough assessment and evaluationPrevention and health maintenanceEthical decision making

Geriatric PrinciplesInter-professional collaborationRespect for the usefulness and value of elderCultural and diversity competenceCompassionate careHelping disconnected familyEnd of life careCultural and diversity competencies

Source: Reichel, Arenson & Scherger (2010)

Ideals of Fitness

The Risks of Aging

Baby Boomers in the United States: Physical HealthBaby Boomers are those born between 1946 and 1964

By the year 2030 (in less than 20 years):14 million baby Boomers will have diabetesHalf of all Baby Boomers will have arthritisHip replacement surgery rates, currently at 700,000/year, will reach 3,500,000/year

Baby Boomers: Physical Health*Only one-third of Baby Boomers are satisfied with their physical health3/10 say their physical health is worse than they expected1 in 8 Baby Boomers will develop Alzheimers Disease, the 5th leading cause of death in people 65 years and over (source: Alzheimers Disease Association)By 2050 11 to 16 million Baby Boomers will have Alzheimers Disease

Baby Boomers: Physical HealthObesity, arthritis, and diabetes will lead to mobility limitations dependence on others for ADLs

Baby Boomers: Cardiovascular health40% of Baby Boomers already have cardiovascular disease35% have hypertension55-60% have high cholesterolDeaths from heart disease are expected to increase 130% in 40 years (by 2050)

Physical HealthAdult Obesity Rates 2009

The Perfect Storm

Frailty, Disability, Co-morbiditySource: Fried et al., 2001

Frailty versus DisabilityFrailty multi-factorial, potentially downward spiralDisability may involve single deficits that may be reversible Source: Fillitt & Butler, 2009Activities of Daily Living (ADLs) Disablement process Source: Verbrugge & Jette, 1994

Pathology Impairment Functional limitation Disability

Presence of FrailtyPositive frailty phenotype:

greater than 3 criteria present

Intermediate or pre-frail:

1 or 2 criteria present

Source: Fried et al., 2001

FrailtyBy age 80 years, 40% of older adults have functional impairments

6% to 11% are considered frailUnited States estimate: 6.1% Source: DuBeau et al., 2009

Psychological effect of transition from robust (independent) to frailty evolving identity, looking glass self Source: Fillitt & Butler, 2009

Looking glass self old/younghttp://asmp.org/articles/best-2010-hussey.html

Looking glass self old/younghttp://asmp.org/articles/best-2010-hussey.html

Physical and Psychological Transitions

Frailty Phenotype Source: Fried et al., 2001

Shrinking

Weakness

Poor endurance: exhaustion

Slowness

Low activity

Frailty: Vulnerable Elders SurveyAgeSelf reported healthPhysical activities (stooping, reaching, lifting, writing, heavy housework, etc)Shopping, managing moneyWalking across a roomLight houseworkBathing or showering

Source: Saliba et al, JAGS 2001

DementiaNew Diagnostic Guidelines: http://www.alz.org/research/diagnostic_criteria/Clinical criteria for all cause dementiaInterferes with ability to function at work or usual activitiesDecline from previous levels of functionNot explained by delirium or major psychiatric disorder

Clinical criteria for all cause dementia (continued)4. Cognitive impairment detected through history taking from patient and knowledgeable informant and objective cognitive assessment5. Cognitive or behavioral impairment involves the minimum of 2 from following domains:a. impaired ability to acquire or remember new informationb. impaired reasoning and handling of complex tasks c. impaired visuospatial abilities (for example, inability to recognize faces)d. impaired language functionse. changes in personality, behavior, comportment

Mild Cognitive ImpairmentDecline in memory, reasoning or visual perception that's measurable and noticeable to themselves or to others, but not severe enough to be diagnosed as Alzheimer's or another dementia. The new guidelines formalize an emerging consensus that everyone who eventually develops Alzheimer's experiences this stage of minimal but detectable impairment, even though it's not currently diagnosed in most people. Not everyone with MCI eventually develops Alzheimer's, because MCI may also occur for other reasons.

Preclinical DementiaExpansion of the conceptual framework for thinking about Alzheimer's disease to include a "preclinical" stage characterized by signature biological changes (biomarkers) that occur years before any disruptions in memory, thinking or behavior can be detected.

Source: http://www.alz.org/documents_custom/Diagnositic_Recommendations_MCI_due_to_Alz_proof.pdf

DeliriumAlso Known As: acute confusional state and acute brain syndromeConsidered a medical emergency due to underlying physical or mental disorderConsidered temporary and ReversibleCauses: electrolyte imbalances, medications, infection (UTI or pneumonia), pain, depression, surgery

Delirium SymptomsChanges in alertness (more alert in am, less in pm)Changes in level of consciousness or awarenessChanges in movement (slow moving OR hyperactive)Changes in sleep patternsDecrease in short-term memory and recallDisorganized thinkingEmotional changes anger, apathy, agitationDisrupted or wandering attention

Delirium Treatment Control or reverse the cause of symptomsStop medications: analgesics (if possible), anticholinergics, cimetidine, lidocaine. Consult Beers criteriaTreat anemia, hypoxia, heart failure, infections, kidney failure, liver failure, nutritional disorders, depression, thyroid disordersIf using meds to treat, start very low dose and adjust as needed: antidepressants, dopamine blockers, sedatives, thiamine. Replace eyeglasses, hearing aids, teeth, treat pain, toilet, sit up in chairReality orientationSafety precautions

Urinary Incontinence: DefinitionUrinary incontinence (UI) is the complaint of any involuntary leakage of urine. (International Continence Society, 2002)

Differential Diagnosis: OAB vs. SUI vs. Mixed UIAbrams P, Wein AJ. THE OVERACTIVE BLADDER: A widespread and treatable condition. 1998;1-57.

Reversible Causes of IncontinenceDeliriumRestricted mobility (illness, injury, gait disorder, restraint)Infection (acute, symptomatic) Inflammation (atrophic vaginitis) also impaction of stoolPolyuria (DM, caffeine intake, volume overload), pharmaceuticals (diuretics, autonomic agents, psychotropics)

Continence Two Years Prior to Death Source: Covinsky et al., 2003

Sample Bladder Record

DateTimeUrinated in toiletUI episodeReason for UIBowel movementFluid intake

Behavioral ProgramsRequired skills:Ability to comprehend and follow education and instructionsIdentify urinary urge sensationLearn to inhibit or control urge to voidKegel (aka: pelvic floor muscle exercises) exercises

cms.internetstreaming.com

Risk factors for Incident Urinary Incontinence in Hospitalized Elders Risk FactorOR(95% CI) p-Value Continence aids (reference: self-toileting) Urinary catheter 4.26 (1.5311.83) .005 Adult diaper 2.62 (1.175.87) .02

Activities of daily living at admission (reference: independent) Partially dependent 2.96 (1.018.71) .049 Dependent 3.27 (1.497.15) .003

** Adjusted for age, cognitive status, physical activity

Source: Zisberg et al., JAGS, 2011.

Only half of patients with incontinence tell their health care provider about their symptomsPerceived as low priority by some primary care providersResult: underreported, undertreatedThey Dont Tell, We Dont AskEDUCATE study. Morb Mortal Wkly Rep. 1995;44:747,753-754.Branch LG et al. J Am Geriatr Soc. 1994;42:1257-1261.

FallsTotal Lifetime Medical Costs of Unintentional Fatal Fall-Related Injuries* in People 65 Years and Older By Sex and Age, United States, 2005 (CDC)*Lifetime medical costs refer to the medical costs (treatment and rehabilitation) associated with the fatal injury event

Falls and Hip Fractures90% hip fractures are from falls1About one third of hip fracture patients developed an acquired pressure ulcer (APU) after surgery2 1 in 5 hip fracture patients die within a year of the fall1Up to one in four of older adults who had been independent before a hip fracture spend up to a year in a nursing home after the fall11. CDC, http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html2. Baumgarten et al JAGS; 57:863-870, 2009

Source:http://latimesblogs.latimes.com/photos/uncategorized/2008/09/09/cracks1.jpg Chiarelli et al 2009

Mobility, balance, urine control before and after 4 weeks of daily exercise

BeforeAfterWalking distance* feet5073Balance seconds2426Speed inches/second5.57.7UI (7am-3pm)2.31.0UI (7am -10pm)2.82.5

Source: Jirovec Int J Nurs Stud 1991

Assessment for Absorbent ProductsAssess residents;Functional ability to ambulate, toilet, disrobe, use of assistive devicesEase in self-toiletingAssess product for:Contain urinary leakageComfortEase of application/removalcms.internetstreaming.com

Recent ResearchAbsorbent products are used to manage urinary incontinence in acute care setting1Absorbent products are associated with development of new urinary incontinence1Absorbent products are associated with skin changes and increased risk of incontinence-associated dermatitis (IAD)2Source: 1. Zisberg et al., JAGS, 2011. 2. Shigeta et al., OWM, 2010.

AnergiaConceptually differs both from fatigue, which is usually measured post-exertion, and from depression.

AnergiaAnergia defined as, sits around a lot for lack of energy, and any two of six minor criteria: recently not enough energyfelt slowed physically in past monthdoing less than usual in past monthany slowness is worse in the morningwakes up feeling tirednaps (> 2 hours) during the day

Source: Cheng, H., Gurland, B. & Maurer, M. Self-reported lack of energy (anergia) among elders in a multi-ethnic community Journal of Gerontology: MEDICAL SCIENCES 2008, 63A

Anergia39% heart failure patients reported anergia1Older adults with urinary incontinence 2x more likely than continent to report anergia2Anergia was associated with new cases of urinary incontinence in longitudinal study2

1 Maurer, M., Cuddihy, P., Weisenberg, J. (et. Al. (2009). Journal of Cardiac Failure, 15(2), 145-151.2 Cheng, H., Gurland, B. & Maurer, M. (2008).. Journal of Gerontology: MEDICAL SCIENCES, 63A(7), 707-714

DepressionThe CES-D-SF is a 10 item 4-point Likert-type depression assessment scale.SleepEmotionsHopefulnessConcentrationEffort

Heart Failure PrevalencePrevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 20052008). Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute. [http://circ.ahajournals.org/cgi/content/full/123/4/e18/F91][Roger, V. L. et al. Circulation 2011;123:e18-e209]

Heart Failure Quick FactsOne quarter HF patients are > 80 years oldMore than half have 5 or more comorbid conditionMore than half are mobility disabledPolypharmacy, > 50% 6+ medications

Source: Wong, Chaudhry, Desai et al., (2011). American Journal of Medicine, 124:136-143.

Correlates of DiabetesObesityMIHypertensionAgeRaceDiabetesObesity

HypertensionAge

Heart Failure Urinary Incontinence

Unifying Model of Shared Risk Factors Source: Inouye et al., 2007

Multidisciplinary CompetenciesHealth Promotion and SafetyEvaluation and assessmentCare planning and coordination of care across the care spectrumInterdisciplinary and team careCaregiver supportHealthcare systems and benefits

Emerging IssuesNeed more who understand and can practice geriatricsNew concepts (anergia) with clinical implicationsNew complex conceptual models about treatment of geriatric conditions Geriatric competenciesGeriatric resources

Geriatric ResourcesProfessional Organizations:American Nurses Association:www.Geronurseonline.orgAmerican Geriatrics Society:http://www.americangeriatrics.org/Gerontological Society of America:http://www.geron.org/Journals:Journal of the American Geriatrics Society (JAGS)Geriatric NursingJournal of Gerontological Nursing

*In the US today, people 65 and older:represent 36% of hospital stays and 49% of all hospital days (Fulmer, 2001; Perry, 2002).Make up over 70% of home care patients4Make up over 90% of all nursing home residents4Because of these changes in demographics, the caseload of most nurses, regardless of their work setting, is made up primarily of older adults. Nurses practicing in this country today are, by default, geriatric nurses However, few nurses or healthcare professionals have received specialized education in caring for older adults4The American Nurses Credentialing Center (ANCC) offers 3 certification options in gerontological nursingThe first is gerontological nursing certification that is open to all RNsHowever, less than 1% of the 2.7 million RNs in US are certified in gerontological nursing 4

I live and work in North Carolina and it is much like other states in the U.S. in that the sheer number of older people is growing at a faster rate than the rest of the younger cohorts. North Carolina is a destination state for retirees and they are coming to North Carolina expecting good weather, good living and excellent health care. At the UNC Institute on Aging, we were mandated by our state legislature to conduct a state-wide survey on the readiness of state agencies for an aging boomer population. We held the Governors conference on aging and the keynote speeches and highlights of the conference are located on our website;

ioa.unc.edu

Starting in 2011, the first wave of Baby Boomers will turn 65 years old. By 2030, when all of the Baby Boomers have reached age 65 or older. They will represent nearly 20% of the US population. (Vincent GK, Velkoff VA. The Next Four Decades: The Older Population in the United States: 2010 to 2050. Washington, DC: U.S. Department of Commerce, Publication 07-6134.**Most people envision their old age and as time of activity, fun, -- many older adults are fit and healthy*We know that 10,000 americans are turning 65 EACH day and many enjoy life and remain engaged in life. The development of chronic illnesses can have a significant impact especially heart failure

*You can see from this montage of photos that falls is a major risk in older adults; primarily because a fall can result in a fracture and a lower level of functioning after fracture repair. Depression is prevalent as losses accumulate and if autonomic nervous system dysfunction exists. Polypharmacy is a major issue: people see a medication as an easy cure and lead to adverse effects and drug interactions. One of the geriatric principles is: Start low and go slow. In the US we have the Beers criteria for potentially inappropriate medications for older adults. But we need clinicians to consult it before perscribing. We have a geriatric unit at UNC hospitals and the nurse practitioner there says that he sees the unit as a drug rehab unit. Patients are taken off all the drugs and they are monitored and drugs are added back only as necessary. More and more we are seeing older adults on medications to treat the side effects of other medications. *Currently 285 million people or 6.4% of the world population lives with diabetes. It is anticipated that there will be 196 million cases of diabetes in the world. The CDC projects that by 2050, 1 in 3 Americans will be diabetes. This figure has major implications to our health care system: amputations, poor healing, blindness. *AARP (2004). Boomers in Midlife 2004: The AARP Life Stage Study. Retrieved from http://www.aarp.org. I went on to a NY Times website that was discussing the topic: When Boomers Get Dementia. Here are some comments from readers: What is this when boomers get dementia? I thought they were born with it.

At the Governors conference I mentioned earlier, there were 650 people in the audience and they focused on healthy aging and what activities they would engage in when they retired. No one said, I might have Alzheimers Disease. It would have been a sobering exercise to have people count off and every 8th person stand so there would be a visual impact of the prevalence of Alzheimers Disease.

Another reader wrote: whenever an article appears about Alzheimers it is accompanied by images of loved ones But an increasing number of people are single or divorced and do not have a support system of family members to take care of them. What we really have in American Society is a growing number of women entering old age single with no support system. Lets hear more about the care of elderly without the platitudes assuming there are relatives available.

Another: We havent had communities in a couple of generations; we have subdivisions. In most of this country if you cant drive or handle stairs, youre in real trouble. The writer goes on and says, One woman cannot lift a 250 pound nonambulatory person from bed to chair; even a mechanical lift requires 2 people to operate safely. Weve got to find a way to fund nursing home care, because truly, most dementia patients will need this care at some point in their illness.And finally another says, I think we need to allow people who are at risk for Alzheimers to decide in advance how long they wish to live with the disease.

When the membersof the silent generation were aged 3544 years, 14%18%were obese. At comparable ages, 28%32% of the youngestbaby boomers were obese.

Leveille, S. G., Wee, C. C., & Iezzoni, L. I. (2005). Trends in obesity and arthritis among baby boomers and their predecessors, 1971-2002 American Journal of Public Health, 95(9), 1607-1613. doi:10.2105/AJPH.2004.060418

Recentprojections show that the aging of baby boomers will resultin a doubling of the numbers of persons aged 65 years or olderwith arthritis or chronic joint symptoms by 2030, when the lastof the baby boom generation will turn 65 years old.

Centers for Disease Control and Prevention. Public health and aging: projected prevalence of self-reported arthritis or chronic joint symptoms among persons aged > 65 yearsUnited States, 20052030.MMWR Morb Mortal Wkly Rep.2003;52:489491.

With each new birthcohort, proportions of members who were obese rose dramaticallyat younger ages. Specifically, members of the baby boom generationexhibited a substantially higher prevalence of obesity, andbecame obese at younger ages, than their predecessors in thesilent generation; the difference was most evident in the 35-to 45-year age range.

*In NC, people who smoke cannot get the premium health insurance from our major provider unless they prove they are in a smoking cessation program. We are moving to an attributional model of the person is responsible for the solution for a problem. *Hospitals are buying more bariatric beds for general medical units. Waiting rooms have the extra wide seats. Society is accomodating the supersizing of boomers, and others. We know the relationship between obesity and diabetes and the morbidity associated with this disease.**UI considered according to its impact on global outcomes of disability passive step to disability or a outcome of disability *Maintaining continence status and toileting skills need to become a priority in the acute care setting.*The way to toilets can be lined with treachery and falls are related to urinary incontinence **2003-2008 data*