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2019 MICNP Conference 3/23/2019
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Geriatric-Competent Care MICNP 2019(Joan) Michelle Moccia DNP, ANP-BC, CCRN, GS-C
Objectives
1. Identify patients likely to benefit from a comprehensive geriatric assessment
2. Implement multiple geriatric screenings to assess physical, psychological, social, and quality of life in the older population.
3. Discuss a treatment plan through case examples
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DemographicsU.S. population aged 65 and older (U.S. Census Bureau): 48 million
Nearly double over next 30 years to almost 88 million
Oldest old “age 80 years and older” will triple
Older people will outnumber younger children in next 2 decades
By 2030 all baby boomers will be 65 or older
One in five residents will be retirement age
https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html
Age-Friendly Health Systems: 4M Model of Care• Address the gap between EBP models of older adult care and
the care health systems put into practice
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WHO?
• General aging concerns
• Questions about memory loss
• Concerns about falling
• Consideration of change in living situations
• Assistance with Advance Care Planning
• Concerns about depression or isolation
• Concerns about driving safety
Priorities of Care and Purpose
• For what purpose is this assessment being done?
Patient
Caregiver
• What makes life worth living?
• What would make tomorrow a really great day for you?
• What concerns you most when you think about your health and healthcare in the future?
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Comprehensive assessment• Identifying priorities
• Assessment of ADLs and IADLs
• Medication review and recommendations
• Evaluation of fall risk
• Assessment of Sleep Quality
• Memory screening
• Depression screening
• Nutritional assessment
• Urinary incontinence assessment
• Establish ACP preferences
• Conversation about driver’s safety
• Identify financial resources/long term care/veteran’s benefits
• Connect with resources
History• Head Trauma
• Cardiac or Cerebrovascular
• Metabolic
• Immunological
• Cancer
• Sleep
• Depression or other psychiatric history
• Family history of dementia
• Social History (ETOH or illicit drugs)
• Medications (anti-cholinergic, antihistamines – BEERS)
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Components of Geriatric Assessment • Alcohol, Smoking
• Exercise practices
• Sleep habits
• Dietary regimen
• Social history (marital status, education)
• Work history (occupation, retire year)
• Living arrangements
• Transportation
• Fall history
• Social activities
• Friends and family
• Safety in relationships
• Spirituality
• Finances
• Legal
Vaccination History
• Haemophilus Influenza B
• Hepatitis A
• Hepatitis B
• Herpes-Zoster
Zostavax
Shingrix (two doses required)
• Meningococcal
• Pneumococcal Conjugate
PCV 13
PPSV 23
• Td/Tdap
• Varicella Vaccine
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https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
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Medications• Use more prescription and OTC
• Account for 30% of OTC medications in U.S.
• Significantly likely to experience an adverse drug reaction(ADR)
• 61.5% ED visits occurring because of ADR
• 76% use two or more prescription drugs
• 37% use five or more
Pearl:
Bring medications and OTC to visit – count in front of patient
Ask how they remember to take their medications, what do they do when they miss a med
Educate on safe drug use, side effects and dosing recommendations
Avoid inappropriate medication
Use interaction drug checker
Older adults okay with deprescribing
Medication resources
• https://reference.medscape.com/drug-interactionchecker
• www.knowyourdose.org Acetaminophen Awareness Coalition
• www.knowyourotcs.org Consumer Healthcare Products Assoc.
• www.getreliefresponsibly.com J & J Consumer, Inc.
• www.bemedwise.org and www.bemedwise.org/acetaminophen/seniors National Council on Patient Information and Education
• www.fda.gov/medsinmyhome and www.fda.gov/otcpaininfoU.S. Food and Drug Administration
• www.Healthinaging.org BEERS alternative medications
• https://www.healthinaging.org/files/documents/tipsheets/meds_to_avoid.pdf Ten Medications to Avoid
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ASSESSMENT TOOLShttps://consultgeri.org/tools/try-this-series
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Dementia Prevalence
Age Range
65-74
75-84
85 and older
How many are affected?
5%
15-25%
36-50%
DSM-5 Definitions
• Major neurocognitive disorder
• Minor neurocognitive disorder
Classification
Alzheimer’s disease (AD) 60-80%
Vascular dementia (VSD) 10-20%
Frontotemporal dementia (FTD) 5%
Lewy Body Dementia (LBD) 15%
Parkinson’s Disease 6%
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Not Dementia
Normal Aging Intact memory for
events
Individual more concerned than family
Able to describe forgetfulness details
Word finding difficulties
Preserved function
Mild Cognitive Impairment (MCI)
12% age 70-79
22% aged 80-89
Maybe amnestic or non-amnestic
Objective impairment on 2+ abnormalities in 1+ domain
General function intact
Slide 19-22 from UCLA Dementia and Memory Disorders Program
Mild Dementia
Cognitive
Decreased insight
Short term memory deficits
Poor judgment
Functional impairments
Managing finances
Managing medications
Driving difficulties
Behavioral symptoms
Social withdrawal
Mood changes (apathy, depression)
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Moderate Dementia
Cognitive
Worse memory
Disoriented to time and place
Lost in familiar places
Repetitive questions
Functional impairments
Difficulty with some ADLs
Gait and balance disturbance
Loss of IADLs
Behavioral symptoms
Apathy/depression
Delusions/Agitation/Aggression
Restlessness/anxiety/wandering
Severe Dementia
Cognition
Loss of remote memory
Inability to recognize family or friends
Little or unintelligible verbal communication
Functional impairment
Loss of ADLs and IADLs including continence
Mobility
Swallowing
Behavioral Symptoms
Apathy/depression
Motor or verbal agitation/aggression
Sundowning
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Causes of Dementia
• Alzheimer’s Disease 60-80%
• Vascular Dementia 10-20%
• Dementia with Lewy bodies 15%
• Frontotemporal degeneration 5%
• Other movement disorders 6%
• Toxic-metabolic disorders 4%
10 early signs/symptoms of Alzheimer’s disease• Memory loss that disrupts daily life
• Challenges in planning or solving problems
• Difficulty completing familiar tasks at home, at work or at leisure
• Confusion with time or place
• Trouble understanding visual images and spatial relationship
• New problems with words in speaking or writing
• Misplacing things and losing ability to retrace steps
• Decreased or poor judgment
• Withdrawal from work or social isolation
• Changes in mood and personality
https://www.alz.org/alzheimers-dementia/10_signs
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MoCA Blind
• Adapted version of original MoCA
• Assesses cognitive domains: attention and concentration, memory, language, conceptual thinking, calculation and orientation
• Contains same items as original MoCA except those requiring visual abilities
• 5-10 minutes
• Total possible score: 22
• Score ≥ 18 considered normal
• Cut off score has not been validated
Mini-Cog
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SAGE
• 1. Test Your Memory for Alzheimer's Dementia in 15 Minutes (SAGE) Known as the Self-Administered GeocognitiveExamination (SAGE) this dementia test is highly recommended for testing memory. The SAGE test is a a 15 question writtenexam (quiz) that is used for the early detection of Alzheimer's disease.Aug 27, 2018
• How to Test Your Memory for Alzheimer's and Dementia (5 Best Tests ...
• https://www.alzheimersreadingroom.com/2016/.../alzheimers-dementia-memory-test.htm...
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Depression
The Patient Health Questionnaire -2 (PHQ-2)
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PHQ- 9
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Katz Index ADL Functional Assessment
The Lawson IADLs Assessment
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Possible causes of Transient UI trythis tools– Hartford University
DIAPPERSDeliriumInfection (eg.UTI)Atrophic urethritis or vaginitisPharma( eg. Diuretics, anticholinergis, CCB, sedatives, alcohol, narcotics)Psychological disorders (especially dependent)Endocrine disorders (DM, HF)Restricted mobilityStool impaction
TOILETEDThin, dry vaginal and urethral epitheliumObstruction (stool/constipation)InfectionLimited mobilityEmotional (pychological, depression)Therapeutic medications (Pharmacological)Endocrine disordersDelirium
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Frailty
Condition marked by
loss of function, strength and physiologic reserve
predictive of risk of falling,
disability due to impaired mobility
restricted ADLs
increase risk of infection or prolonged recovery from injury or surgery
Financial burden
Frailty scale
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922366/
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CAREGIVER ASSESSMENTAlz.org/care (Education)
Alz.org/CRF (Resources: adult care programs, in-home assistance, companions)
Alzconnected.org (networking)
24/7 Helpline (800-272-3900) https://www.aarp.org/caregiving/
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Neuropsychiatric Inventory Questionnaire (NPI-Q) tool
•Evaluates neuropsychiatric symptoms in past month from the caregiver
•Measures Severity of symptoms affects the patient
•Measures distress of family/caregiver
NPI-Q
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Labs and Imaging
Labs
CBC, CMP, TSH, B12, Folate, RPR
Imaging
CT scan
MRI
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RESOURCES
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Friendship Line
Fall Risk Education
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ENA and GAPNA Resources• Emergency Nurses Association offers the GENE
program https://nf.ena.org/eweb/DynamicPage.aspx?Site=ENA2015&webcode=ENACOEELearn&pager=10&listcategory=GENE
• The ENA also has a Geriatric Task Force committed to the care of older adults in the ED. Here are two resources: https://www.ena.org/docs/default-source/resource-library/practice-resources/topic-briefs/screening-tools-for-older-adults-in-the-emergency-care-setting and https://www.ena.org/docs/default-source/resource-library/practice-resources/topic-briefs/collaborative-care-for-the-older-adult
• www.gapna.org
• https://www.gapna.org/resources/toolkits/toolkit-gerontology-resources-aprn-preceptors-and-students
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Resources continued
• Older Adult Falls - https://www.cdc.gov/homeandrecreationalsafety/falls/index.html• Important Facts about Falls - https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html• Costs of Falls Among Older Adults - https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html• STEADI – Older Adult Fall Prevention - https://www.cdc.gov/steadi/• https://academic.oup.com/gerontologist/advance-article/doi/10.1093/geront/gny101/5103473• www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx• www.healthinaging.org• www.alzheimer.org
Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome EvaluationThe Gerontologist, gny101, https://doi.org/10.1093/geront/gny101
CDC Emergency Preparedness Toolshttps://www.cdc.gov/aging/emergency/planning_tools/guide.htmOther preparedness information https://www.cdc.gov/aging/emergency/
Resources continued
https://academic.oup.com/gerontologist/advance-article/doi/10.1093/geront/gny101/5103473
Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome Evaluation
The Gerontologist, gny101, https://doi.org/10.1093/geront/gny101
CDC Emergency Preparedness Tools
https://www.cdc.gov/aging/emergency/planning_tools/guide.htm
Other preparedness information
https://www.cdc.gov/aging/emergency/
Florence, C.S., Bergen, G., Atherly, A., Burns, E., Stevens, J., Drake, C. (2018)Medical costs of fatal and nonfatal falls in older adults. JAGS 693-698. DOI:10.1111/jgs.15304
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