Angela Johnson, PharmD, CGP

Review general clinical principles related to aging

Recognize geriatric considerations for disease processes

Identify changes in condition that should prompt eLTC/provider notification

Most older adults have at least 3 chronic diseases & take multiple medications

Per CDC, those > 65yr old have more adverse drug events: • More than 2 times as likely to visit ED

• Almost 7 times more likely to get admitted

Changes in body composition and organ function

http://www.cdc.gov/MedicationSafety/Adult_AdverseDrugEvents.html

Polypharmacy Elimination

Physiological Changes Extrinsic Influences

Focus on management of

medical concerns vs function

Functional status decline

Increased falls

Nosocomial infections

Medications changes/additions

Skin issues

•Kleinpell RM, Fletcher K, Jennings BM. Reducing Functional Decline in Hospitalized Elderly. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 11. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2629/

•Gillick MR, Serrell NA, Gillick LS. Adverse consequences of hospitalization in the elderly. Soc Sci Med. 1982;16:1033–8

•Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012

How do we identify who will

go back to the

hospital?

Age

Polypharmacy

Reduced Functional Status

Length of Stay

Multiple Co-morbidities

Discharge to long-term care

• Silverstein MD, Qin H, Mercer SQ, Fong J, Haydar Z. Risk factors for 30-day hospital readmission in patients ≥65 years of age. Proceedings (Baylor University Medical Center). 2008;21(4):363-372

• Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012

Conditions and Payment Reductions: ◦ Acute Myocardial Infarction

◦ Heart Failure

◦ Pneumonia

PCP approach to care

Facility Staffing

Distance to hospital

Family’s Role

Patient Goals Lavenberg JG, Leas B, Umscheid CA, Williams K, Goldmann DR, Kripalani S. Assessing preventability in the quest to reduce

hospital readmissions. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2014;9(9):598-603. doi:10.1002/jhm.2226

Patient Directed Care

Medical complexity balanced with

Philosophy of care which encourages patient and family choice

Advanced Care Planning

Patient Centered Goals of Therapy

Individualized Care Planning

Seems different than usual

Talks or communicates less

Overall needs more help

Pain (new/worse) or participated

< activities

Ate less

No bowel movement x3 days or

diarrhea

Drank less

Weight change

Agitated or nervous > usual

Tired, weak, confused, drowsy

Change in skin color or condition

Help with walking, transferring,

toileting > usual

Look for

Early Warnings

Failed therapies or allergies

Co-morbidities

Changes in body composition

Medication histories

Regulatory Issues

Cost Concerns

A tool like the SBAR helps gather information

Hosp dx: Pneumonia & CHF

Meds: ◦ clopidogrel

◦ metoprolol

◦ simvastatin

◦ lisinopril

Sat 84% on 2L O2

Wt: 170lb (up from 164lb 3 days ago)

Vitals: Temp 98.4

Pulse 112

Resp 24

BP 100/54

Grandma Johnson

A Hypothetical Case

Age: 86yr old Admit: 2wk ago for strengthening

Situation

A change in weight was noted by the CNA

Noted to be more short of breath walking to lunch today

Similar symptoms leading up to hospitalization 2wk ago

Background

In LTC for post-acute care

Dx for hospitalization: pneumonia + CHF

Increase weight of 6lb in 3 day

Medications include diuretic & antiplatelet therapy

BP 100/54, P 112, RR 24, T 98.4, Sat 84% on 2L

Her family held a BD party for her over the weekend and she refused the diuretic

Assessment

Summarization of observations & appearance:

◦ Mrs. Johnson’s weight

gain prompted us to do additional observations today. Increased SOB was noted with activity and with her history of CHF, we are concerned she may be experiencing an exacerbation

Request

Review and Notify: ◦ We would like to

request an assessment of Mrs. Johnson be done & possibly labs ordered

Immediate Notification ◦ Any symptom, sign or apparent discomfort that is:

A marked change in relation to usual symptoms and signs

OR

Unrelieved by measures already prescribed

Non-Immediate Notification ◦ New or worsening symptoms that do not meet

above criteria

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Change_in_Condition.pdf

Report Immediately Non-immediate

BP ◦ SBP > 200 or < 90

◦ DBP > 115

Resting Pulse ◦ > 100 or < 50

Respirations ◦ > 28 or < 10 (per min)

Oral Temp ◦ > 100.5

O2 Sat ◦ < 90%

DBP > 90 New Irregular Pulse Weight Loss ◦ New onset anorexia +/-

weight loss

◦ 5% within 30 days

◦ 10% with 6 months

Weight Gain ◦ > 5lb in 1 week with:

CHF

Chronic renal failure

Other volume overload

Report Immediately Non-Immediate

CBC ◦ WBC < 14,000

◦ Hct/Hgb < 24/8

◦ Plt < 50,000

Chemistry ◦ BUN > 60

◦ Ca > 12.5

◦ K < 3 or > 6

◦ Na < 125 or > 155

◦ Glu < 70 or > 300

CBC ◦ WBC > 10,000 without

symptoms or fever

Chemistry ◦ Glu consistently > 200

◦ Hgb A1c

◦ Albumin

◦ Bilirubin

◦ Cholesterol/Triglycerides

◦ Other chemistries

Report Immediately Non-immediate

Consult Reports ◦ Recommendations for

immediate action/change

Drug Levels ◦ Level > therapeutic range

INR > 6

(+)Urinalysis ◦ with signs/symptoms

Urine Culture ◦ w/symptoms+>100,000 cc

X-Ray ◦ New/unsuspected finding

(fracture, pneumonia, CHF)

Consult Reports ◦ Recommendations for

routine action/change

Drug Levels ◦ Therapeutic or low level

INR 3-6 (+)Urinalysis ◦ without signs/symptoms

Urine Culture ◦ w/no growth or symptoms

X-Ray ◦ Old or long-standing

finding; no change

* Abdominal pain,

distention,

tenderness

*Abrasion

*agitation

*AMS

*Appetite

*Asthma

*Back injuries,

complaints

*Behaviors

*Bleeding- rectal

*Blisters

*Bowel Sounds

*Burns

*Chest complaints

*Cold

*Complaint – pt or

fam concern

*Confusion

*Consciousness,

altered

*Constipation

*Contusions

*Cough

*Delirium

*Depressed affect

*DM

*Diarrhea

*Discolored skin

*Dizziness

*Dyspnea

*Dysuria

*Earache

*Edema

*Eye injury

*Fainting

*Fall

*Fever

*Fracture,

dislocation

*Gait

disturbance

*Hallucinations

*Head Injuries

*Headache

*Hearing loss

*Hematuria

*Hypothermia

*Incontinence,

of stool or

urine

*Itching

*Jaundice *Laceration

*Lung

sounds

*Med error or

side effects

*Memory loss

*Musculoskeletal

pain

*Nausea

*Nocturia

*Nosebleed

*Pain

*Personality

change

*Pressure sore

*Puncture wounds

*Rash *Seizure

*SOB

*Skin tear

*Sleep disturbance

*Sore throat

*Speech change

*Splinters

*Suicidal potential

*Swallowing difficulty

*Toothache *Urination,

pain, retention,

hesitancy

*Vaginal

bleeding,

spotting,

discharge

*Vision change

*Vomiting,

persistent,

recurrent or

blood

*Walking

difficulty

*Weakness,

arm, leg or

general

*Weight change

*Wounds

Any clinical questions

Family requests resident to be seen by physician

Question if resident needs a clinic or ER visit

Change in condition concerns

Medication or

order clarification

Discuss ways to

address behavior

issues

Advance care

planning assistance INTERACT

coaching

Admission Clarifications

Interdisciplinary Team consult

Peer to Peer Advice

Medication Reviews

ANYTHING… We Are Here To Help

844-322-4236