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GERIATRIC CAREMANAGEMENT
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Chronic Health Conditions
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Geriatric Care Management
Care Management: A response to: Diagnostic Related Groups DRGs The Expanded Role of the Nurse-Discharge Planner
Social Work failing to respond to the demands of health
Perception as a cost center Inability to calculate or articulate cost savings
Case Managers in Health Care Employed by health care system, working for the health care
system; not for the patient
People, especially older adults can not effectively andefficiently navigate the system Family support is very different today than yesterday
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Care Management &
Systems Theory
Older adults seldom age in a vacuum and are
frequently members of family systems
Health care is the combination of multiple
systems (acute, rehab, home, etc.)
Change in one piece of a system, forces
change in the entire system
Every member in system has an establishedrole and acts accordingly
When the system is out of balance, it
provides the opportunity for change
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Defining Geriatric Care
Management
Care ManagementCase Management
Care Coordination
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Involving thefamily in geriatric
care
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It All Starts and Ends With
Assessment
The assessment of the
client (the entire client
system) is an ongoing
process that only endswhen the case is closed
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Engagement is the
Foundation
Engage the client, not the diagnosis
Go slow
Dont make promises
Respect their right to disagree
Determine who the other members
of the family system Engage them as soon as possible
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Engaging the rest of the Client
System Watch the process Let the pathology act out
Assess for the strengths
Everyone has strengths, some just dont know it Educate
Provide accurate information
Facilitate
Help the process to move on Integrate
Bring the pieces together
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Geriatric Assessment
COGNITIVE STATUS
Mini-Mental Status Exam
Evaluate Ability to Understand Options andImplications of Alternatives; Capacity
FUNCTIONAL STATUS
Activities of Daily Living
Instrumental Activities of Daily Living
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EMOTIONAL STATUS
Obtain a complete psychiatric
history of treated and UN-
TREATED symptoms;- Depression
- Anxiety
- Presence of other PsychiatricSymptoms
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Medical Status
Detailed history of medical care
Who, what where, and when
History of clients response to pastevents
Reactive vs. Proactive
Significant changes contributing tocurrent condition
Who are the members of the clientshealth care team
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SOCIAL STATUS
Social Networks
Size of network
Expectations Proximity of network
Ability of network
Competing role demands
Use a Social Eco-Map to VisuallyPresent Strengths/Barriers
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Cultural/Religious Factors Provides guidelines
Preferences for care alternatives
Identify potential sources of conflictrelated to care
Guidelines for Advance Directives
Anticipate the unexpected Prepares client/family with
information to make important
decisions
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Environmental Assessment
Given a choice, most indicate they want
to Age in Place
Home Safety Assessment Cleanliness Flooring, Kitchen, Bath, Bed and
Living Rooms Electrical/Lighting/Heating/Cooling/Cooking
Ask for complete tour (part of physical assessment)
Will what works today, work in the future?
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THE CAREPLANNING
BALANCING ACT
When Preparing a Care Plan You MustBalance the Needs of:
The Patient
The Family/Other Informal Caregivers
Formal Caregivers
Society/Policy Makers
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Strengths Based Care Plan State in positive terms what client is going
to do, rather than stop doingMary will call her daughter when she is low on
groceries
Be realistic and achievable
Mary will use her walker to retrieve the mail
Measurable and visible reflecting one stepat a time
Tom will take his meds during Wheel of Fortune
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Strengths BasedCare Plan(continued)
Specific and time limited no longer than 3months and broken down into small steps
Tom will attend exercise class at the Senior Center
twice a week.
Relevant and understandable to client
Betty will call her granddaughter Sue each week for a ride to her
sewing circle.
Chapin, R & Fast, B. Strengths-Based Care Management for Older Adults.
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CARE PLAN
CONSID
ERATIONS Utilization of formal services
Accessibility
Acceptability
Adaptable
Appropriate
Perception of need
Patient
Family
Provider/Agency
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Goals
Epidemiology
Memory in typical aging
Mild cognitive environment
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Nursing
management ofgeriatric patientswith dementia
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Dementia is the most common psychiatricdisorder on the later age. It is anirreversible disorder.
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How do wehandle dementia
in geriatricpatients?
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Geriatric patients usually have a hardertime doing the ADLs of everyday
Geriatric patients with dementia have aharder time of doing normal activities.
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In assessing the presence or absence of dementiaspecial care should be taken to avoid false,
positive, identification motivational or emotionalfactors. Dementia produces an appreciabledecline in intellectual functioning, interference
with personnel activities of daily living such aswashing, dressing, eating, personal hygiene,
excretory and toilet activities changes in roleperformance occur such as lowered ability tokeep or find job should not be used as criteria ofdementia because of the large cross cultural
difference exist in appropriate because frequent,externally imposed changes in the availability orwork.
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SOME CAUSESOF DEMENTIA A. Degenerative diseases of the central Nervous System.
Senile dementia
Alzheimers disease
Picks disease
Huntingtons chorea
Parkinsons disease
Creutzfeldt Jakob disease
Normal pressure hydrocephalus
Multiple sclerosis
Lewy body disease
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B.Intra Cranial Causes Space occupying lesions Tumors
chronic subdural haematomas chronic abscesses aneurysm
C. Vascular causes Multi-infarct dementia.
Occlusion of the carotid artery
Stroke
Hypertension
Cranial arthritis
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D. Metabolic and endocrine disorders :- Endocrinopathies Addisons disease, Cushings syndrome, Hyperinsulinism, Hypothyroidism, Hypopituitarism, Hyperparathyroidism, Hyperparathyroidism.
Hepatic failure
Renal failure
Renal dialysis
Respiratory failure
Hypoxia
Chronic uremia.
Chronic electrolyte imbalance.
Hypocalcaemia
Hypercalcaemia
Hypokalaemia
Hyponatraemia
Hyper natraemia
Remote effect of Carcinoma or Lymphoma.
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G.Infections and related conditions: -
Encephalitis of any cause
Neurosyphilic Chronic Meningitis
Cerebral Sarcoidosis
Cysticercosis
AIDS and AIDS related complex.
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H.Toxic Causes :
1. Alcohol2. Poisoning with heavy metals lead,arsenic, thallium, mercury, carbonmonoxide.
3. Drug and alcohol withdrawal ofanxiolytic sedative drugs, amphetamine.
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I.Anoxia:-
1. Anemia
2. Post anesthesia3. Cardiac arrest4. Chronic respiratory failure
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Types of dementia- an overview
A. CORTICALAND SUB CORTICALDEMENTIA
Dementia may be associated with multiple
sub cortical or cortical infarcts and clinicalfeatures vary according to that. Non-Alzheimers dementia basically meanssub-cortical dementia. Somedistinguishing features of sub cortical andcortical dementia are as follows:
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Sub cortical dementia Cortical dementia
1. Language No aphasia Aphasia early
2.. Memory Impaired recall>recognition Recall and recognition impaired
equally
3. Attention and immediate recall &
visuospatial skills
Impaired Impaired
4. Calculation Preserved until late Involved early
5. Frontal system abilities (executive
function)
Disproportionately affected Degree of impairment consistent with
other involvement
6. Speed of cognitive processing Slowed early Normal until late in disease
7. Personality Apathetic inert Unconcerned
8. Mood Depressed Euthymic
9. Speech Dysarthric Articulate until late
10. Posture Bowed or extended Upright
11. Co-ordination Impaired Normal until later
12. Motor speed and control Slowed Normal
13. Adventitiois movements Chorea, tremor, tics, dystonia Absent (Alzheimers dementia: some
myoclonus).
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REVERSIBLE AND NON-REVERSIBLE DEMENTIA
Reversible dementia is a term used in themedical literature to describe a dementia that asa specific treatable cause. In the past, dementia
has implied a progressive or irreversible course. E.g. - those arising from inflammatory processes
e.g. encephalopathy caused by systemic lupuserythematosus (SLE) , infections such as syphilis
; or toxic conditions (e.g. Alcohol abuse) thatproduce memory loss and abnormal frontallobe functions
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PRE-SENILEAND SENILEDEMENTIA
PreSenile dementia It resembles that ofsenile dementia except that disorders occurs in
younger age group . the onset of disease occursin people of 40s and 50s and people with thisdisease live an average 11 years after the onset ofdisease.
Senile dementia: It occurs usually after the
age of65yrs. Due to degenerative bring changesas accompanied by a clinical picture of mentaldeterioration. The types of senile dementia arealready mentioned previously.
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Types ofSenile dementia
a)Simple deterioration :- In this patient gradually developsloses of contact with environment poor memory, tendency toreminiscence, intolerance of change, disorientation, restlessness,insomnia, and failure of judgment. This is the commonest psychoticreaction in about 15% of the entire group of senile dementia.
b) Paranoid reaction:- Gradual formation of delusion. He feelsthat his relatives are turned against him and are trying to rob or kill
him c)The presbyophrenic type:- Characterized by jovial mood,marked impairment of memory, restlessness and excitability.
d) Depressed and agitated type:- Severally depressed andagitated, suffers from hypochondrical and Nihilistic delusion.expresses morbid ideas about cancer, syphilis and other diseases.Has marked poverty of ideas.
e) Delirious and contused type: - Shows severe mentalclouding, which make him restless, contused, resistive andincoherent. Completely disoriented to time, place and person.
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Assessment
andmanagement
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Assessment and management
It is important to look for the treatablecauses.
The assessment should also include searchfor treatable, often minor, medicalconditions that are associated ratherprimary causes. Treatment of these
conditions can reduce distress anddisability.
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TREATMENT
Some cases of dementia are regarded as
treatable because the dysfunctional brain tissuemay retain the capacity for recovery if treatmentis timely.
A complete medical history. Physicalexamination , and laboratory tests, includingappropriate brain imaging, should beundertaken as soon as the diagnosis is suspected.
If a patient is suffering from a treatable cause ofdementia, therapy is directed toward treating theunderlying disorder.
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The general treatment approach to patientswith dementia is to provide:
supportive medical care,
emotional support for the patients andtheir families and
pharmacological treatment for specificsymptoms, including disruptive behaviour.
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Symptomatic treatment also includes:
the maintenance of a nutritious diet,
proper exercise,
recreational and activity therapies,
attention to visual and auditory problems,
treatment of infections such as urinarytract infections, decuibtus ulcers, andcardiopulmonary dysfunctions.
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When the diagnosis of vascular dementia is made,risk factors contributing to cerebrovascular
disease should be identified and therapeuticallyaddressed. The factors include:
hypertension
hyperlipidemia
obesity cardiac disease and
diabetes and alcohol dependence.
Patients who smoke should be encouraged to stopsmoking cessation is associated with improvedcerebral perfusion and cognitive functioning.
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Indications for further treatments
Clear indication for hospitalization are:
a history of rapidly deteriorating
symptoms diagnostic uncertainty
failure of usual support system
unmanageable at home advances towards other people
associated medical illness.
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History taking
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History taking
The patients history
More important memories may be maintained indementia because they have been rehearsed often overthe years that they are very fixed. Patient returns to these
memories when the present and recent past are fading.In the earliest stages she will be able to given quite a fullaccount of her life up to recent times, this informationmust be checked for memories become incomplete andtime sequences muddled. These more or less muddled
memories are important in understanding how thepatient reacts to her/his illness.
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The RelativesHistory
From relatives history we can obtain moreinformation about patients previous personality,attitudes, level of activity, interests, socialfunctioning and self care.
It is important to help the relatives separate
recent events, from events that happened beforedementia.
This information will provide clear evidence ofhow much changes has occurred and also helps
in understanding what new problems that familyis having to cope with and so helps to explaintheir reactions.
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Examinations
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The Physical ExaminationA physical examination should be done where indicatedand this is particularly important in the following
circumstances. Where physical symptoms such as weight loss, pain are
present.
Where the patient has a history of potentially relevantphysical disorder like a history of endocrine disorder
Detailed neurological assessment with particularattention to vision and hearing is essential to rule outother neurological problems.Systemic observationshould be made of his behaviour provide a scheme for
assessing memory for general events, past personalevents and recent personal events
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Psychological Testing
a). Wechsler Adult Intelligence Scale (WAIS) :This is a well standardized test providing a profile of
verbal and non-verbal abilities Analysis of sub scores,can provide useful information for diagnosis.
b).Perceptual functions , especiallyspatialrelationship: This test is exemplified by the BentonRevised visual Retention test, which requires the patientto study and reproduce ten designs.
c).NewLearning as a test of memory: a usefulquantitative estimate of memory impairment.
e). Dementia Rating Scale: In this test 2 types ofrating scale is used, the intellectual and behavioural. Thisscale have been over used in diagnosis and limited valuein identifying problems.
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Mental Status Examination
The purpose of the mental stateexamination is to detect abnormal featuresin a patients behaviour and state of mind
at the time of the assessment. If theabnormal features are found thisinformation contributes to the diagnostic
process.
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Mental status examinations
a).General appearance andBehaviour
b).Speech
c).Attitude
d).Mood e). Cognitive function
f).Thought content
g). Judgment
h). Delusions
i).Hallucinations
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Identification of
cause and treatment
Identification of cause and
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Identification of cause and
treatment
Management of hypertension in multi-infract dementia.
Thyroid replacement in hypothyroiddementia .
Shunting in hydrocephalic dementia.
L-Dopa in Parkinsonism.
Removal of toxic agent in toxic dementia.
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Symptomatic Management
Environmental manipulation to reduce stress in day today activities.
Treatment of medical complications
Care of food and hygiene and supportive care for thepatient and family.
Anxiety can be treated with short acting benzodiazepinesin low doses.
Depression can be treated with Trazodone or Miamserinas these agents have low anticholinergic, activity and lowcardiac toxicity. Agents with anticholinergic activity cancause confusion or frank delirium.
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CurrentlyAvailableTreatments
Noortropics: Piracetam, Oxiracetam, Aniracetamderivatives of GABA are postulated to haveneuroprotective effect on CNS against hypoxia.
Ergoloidmesylate: Hydergine is currently used for thenon-specific cognitive impairment.
Aspirin andNSAID: Data suggests that it protectagainst the development of disease due to its anti-inflammatory properties
Estrogen Therapy: Oestrogen therapy inpostmenopausal women might help in the delaying the
development of dementia. Sabeluzole: This substance shown to protect neuronal
cells against gutamate induced and hypoxia inducedinjury and may potentiate the tropic effect of nervegrowth factor. It may improve long term memory of
elderly patient.
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Rivastigmine: Rivastigmine in the dose of 6 to 12mg/Day was given to two groups. One group of patient
was Alzheimers disease with vascular risk factor ashypertension and other group was without riskfactor. After 26 weeks of trial vascular risk factor group
showed significant improvement. Rivastigmine indiffuse Lewy body dementia had shown improvement incognition particularly attention and in psychiatricsymptoms.
Nitrendipine: Elderly people who were suffering from
systolic hypertension when treated with nitrendipine, acalcium channel blocker occurrence of dementia was lessin this group.
Gingko Biloba,Ginseng: It is also helpful indemented patient.
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Psychotherapy
Psychotherapy the specific psychotherapytreatments divided in to 4 broad of range:
Behaviour oriented, Emotion oriented cognitionoriented and stimulation oriented, behaviourapproached can be effective in lessening orabolishing problem behaviour e.g. aggression,incontinence emotion oriented intervention
include supportive psychotherapy reminiscencetherapy sensory integration and stimulatedpresence therapy.
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Types of psychotherapy
Behavior oriented approaches: it can be effective inlessening or abolishing where it occurs, how often itoccurs have to be determined. The next step is anassessment of specific antecedents and consequences,
which will often suggest specific strategies forintervention. Precipitants should be avoided wheneverpossible. Whatever intervention, it is critical to match thelevel of demand on the patients with his or her currentcapacities, to modify the environment in so far as
possible to compensate for deficits and capitalize on thepatients strengths.
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Types of psychotherapy
Emotion oriented approaches The interventionincludes supportive psychotherapy, reminiscencetherapy, validation therapy, sensory integration andsimulated presence therapy.
Reminiscence therapy, which acme to stimulate memoryand mood in the context of the patients life history isassociated with modest short lived gain in mood.
Validation therapy, aims to restore self-worth and reducestress by validating emotional ties to the post.
Simulated presence therapy may be helpful in
diminishing problem behavior with social isolation. Supportive psychotherapy may be helpful in mildly
impaired patients to adjust to their illness.
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Types of psychotherapy
Cognition oriented approaches: thesetechniques include reality orientation and skillstraining. The aim of these treatments is to
redress cognitive deficits, often in a classroomsetting. There is some evidence of transient
benefit from cognitive redemption and fromskills training but here have been report of
frustration in patients and depression incaregivers associated with the type ofintervention.
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Types of psychotherapy
Stimulation orientedapproaches: these treatments includeactivities or recreational therapies (crafts,
gene, and pets) and are therapies (music,dance, art). They provide stimulation andenrichment and thus mobilize the patientsavailable cognitive resources. There are
evidences that, while they are in use, theseinterventions decrease behavioralproblems and improved mood.
h h h l
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Other treatments that may helppatients with dementia
Physiotherapy
It will help to structure their daily activities suchas muscle and joint exercises, breathing
exercises, speech therapy to improv
e bloodcirculation etc. Physiotherapy is helpful forchronic encephalitis, meningitis and generalparesis of insane. It is also helpful to removecontracture of limbs, deformities of extremities
or embolities.; It improves physical health.Appetite, digestion elimination, circulation,muscle tone and body temperature.
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Social Relationship
Dementia patient become isolated fromcommunity. Talking to them and askingordinary questions also help the patient.
More deterioration will take place whenthere is nothing to talk, to think or towork. The social approach plays a greatrole in psychiatric illness. The patient
must learn or relearn how to assumeresponsibility for the welfare of himselfand others for social relationship.
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Daycenters
The day care centers help elder people to meetother people and engage in activities. It isassumed that they will be able to select their
friends and select their activities, will take anactive part in what goes and in most cases, maketheir own way to and from centre. The need forday centers to cater for dementia suffers. Day
care is needed who are the Physically and thementally impaired attending together andinvolving a mice of services.
Th k Y
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Thank YouBE STRONG 4B