geriatric syndromes elizabeth k keech phd, rn elise pizzi msn, gnp-bc
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Geriatric SyndromesGeriatric SyndromesElizabeth K Keech PhD, RNElizabeth K Keech PhD, RNElise Pizzi MSN, GNP-BCElise Pizzi MSN, GNP-BC
What are they? What are they?
Conditions, not diseasesConditions, not diseases
Common in the elderlyCommon in the elderly
Typically:Typically:MultifactorialMultifactorialShare risk factorsShare risk factorsLinked with functional decline, Linked with functional decline,
increasing frailty and poor health increasing frailty and poor health outcomesoutcomes
Tend to include:Tend to include:
PolypharmacyPolypharmacy
Chronic painChronic pain
FallsFalls
DeliriumDelirium
Urinary incontinenceUrinary incontinence
Depression.Depression.
PrevalencePrevalence
Study of 62,829 Looked at 3:Study of 62,829 Looked at 3:Falls, Urinary incontinence & DepressionFalls, Urinary incontinence & Depression
Community dwelling women between Community dwelling women between 65 – 81 years of age 65 – 81 years of age
- 34.4% had 1 Geriatric Syndrome- 34.4% had 1 Geriatric Syndrome
- 8.2 % had 2 or more- 8.2 % had 2 or more
Effects: IndependentEffects: Independent
Physical & social functioning and Physical & social functioning and disabilitydisability
Quality of life measuresQuality of life measures
The Odds Ratio were as large for The Odds Ratio were as large for physical and social limitations as physical and social limitations as were those for chronic conditionswere those for chronic conditions
Effect: SynergisticEffect: Synergistic
Concurrence of Chronic diseasesConcurrence of Chronic diseases
Shared Risk FactorsShared Risk Factors
Diabetes:Diabetes:Risk for : Risk for : DementiaDementiaDecline in mobilityDecline in mobilityDisabilityDisabilityFallsFallsUrinary Urinary
IncontinenceIncontinence
Malnutrition:Malnutrition: Correlated with:Correlated with:
- Depression- Depression
- Dementia- Dementia
- Functional - Functional dependencedependence
Associated with:Associated with:
- Multiple co-morbidities- Multiple co-morbidities
Shared Risk factorsShared Risk factors
Older age (Define old) Older age (Define old)
Functional ImpairmentFunctional Impairment
Cognitive ImpairmentCognitive Impairment
Impaired mobility (Inouye et al 2007)Impaired mobility (Inouye et al 2007)
Poor Nutritional statusPoor Nutritional status
Female genderFemale gender
Depressive symptoms (Chen et al. 2010)Depressive symptoms (Chen et al. 2010)
Frailty: “The Dwindles”Frailty: “The Dwindles”
Meet 3 of 5 symptoms:Meet 3 of 5 symptoms:Decreased walking speedDecreased walking speedDecreased grip strengthDecreased grip strengthDecreased physical activityDecreased physical activityExhaustionExhaustionWeight loss (Fried et al. 2001)Weight loss (Fried et al. 2001)
What’s neededWhat’s needed
Prevention: Prevention: Mobility issues and malnutritionMobility issues and malnutrition
Minimize complicationsMinimize complicationsEarly recognition and treatmentEarly recognition and treatment
Basic set of geriatrics knowledge and skills to Basic set of geriatrics knowledge and skills to address the key geriatric syndromes and issues address the key geriatric syndromes and issues that can limit functional independence and that can limit functional independence and complicate medical managementcomplicate medical management
Improving health outcomes Improving health outcomes through research and educationthrough research and education
• Solutions:Solutions:• Educating clinicians, educators Educating clinicians, educators
and studentsand students• Identifying Evidence-based data Identifying Evidence-based data
found in Hartford Institute for found in Hartford Institute for Geriatric NursingGeriatric Nursing
HIGNHIGNHartford Institute for Geriatric Hartford Institute for Geriatric
NursingNursing Mission – Shape the quality of health care of Mission – Shape the quality of health care of
older adults through excellence in nursing older adults through excellence in nursing practicepractice Started in 1996Started in 1996 Geriatric arm of the NYU College of NursingGeriatric arm of the NYU College of Nursing
Addresses 4 vital areas for changeAddresses 4 vital areas for change PRACTICEPRACTICE RESEARCHRESEARCH EDUCATIONEDUCATION ADVOCACY POLICYADVOCACY POLICY Hartford Institute Home Page
EDUCATIONEDUCATION
GNECGNEC
Geriatric Nursing Education ConsortiumGeriatric Nursing Education Consortium National initiative to enhance geriatric content in senior-National initiative to enhance geriatric content in senior-
level undergraduate courseslevel undergraduate courses Administered by AACN in collaboration with Hartford Administered by AACN in collaboration with Hartford
InstituteInstitute Power Point presentations on-linePower Point presentations on-line
Cultural Competence and Chronic Disease Management of Cultural Competence and Chronic Disease Management of Older AdultsOlder Adults
Spirituality and AgingSpirituality and Aging Sexuality in Older AdultsSexuality in Older AdultsSpirituality in Aging
Geropsych CompetencyGeropsych Competency
Geropsychiatric Nursing Collaborative that is Geropsychiatric Nursing Collaborative that is identifying and evaluating the quality and identifying and evaluating the quality and suitability of curricular and training materialssuitability of curricular and training materials
Portal of Geriatric Online Education-rate the Portal of Geriatric Online Education-rate the materials you perusematerials you peruseLog in to view articles, videosLog in to view articles, videosLog in to view modules that develop Log in to view modules that develop
knowledge of gero psych topicsknowledge of gero psych topicsPortal of Geriatric Online Education
Consult GeriRN.orgConsult GeriRN.org
Protocols and topicsProtocols and topicsEvidence-based protocols for Evidence-based protocols for
managing common geriatric managing common geriatric syndromes and conditionssyndromes and conditionsFrom Advance Directives to From Advance Directives to
Urinary IncontinenceUrinary IncontinenceConsultGeriRN
Consult Geri-RNConsult Geri-RN
““Try This” Assessment Tool Series with Try This” Assessment Tool Series with over 30 nationally recommended over 30 nationally recommended instruments for use with older adultsinstruments for use with older adults
TabsTabs““want to know more”want to know more”““topic resources”topic resources”Try This Assessment Tool Series
HIGN e-Learning CenterHIGN e-Learning Center
Continuing Education Continuing Education Portal Portal with free and paid courseswith free and paid coursesSign in to courses Sign in to courses Gerontological Certification Gerontological Certification
Review Course offered by ANCC – Review Course offered by ANCC – fundamental knowledge about fundamental knowledge about care of the older adult care of the older adult
eLearning/
HIGN e-Learning CenterHIGN e-Learning Center
Clinical Teaching Modules Clinical Teaching Modules assist nursing faculty to assist nursing faculty to
integrate care of older adults integrate care of older adults when teaching students in when teaching students in hospitalshospitals
Clinical Teaching Module
HIGN e-LearningHIGN e-Learning
Nursing Home Modules Nursing Home Modules Assist nursing faculty teaching in nursing Assist nursing faculty teaching in nursing
homeshomesHelp faculty select and use nursing Help faculty select and use nursing
homes for clinical placementhomes for clinical placementFocus on nursing homes involved in Focus on nursing homes involved in
resident-directed care and culture resident-directed care and culture changechange
Nursing Modules
Elder MistreatmentElder Mistreatment
eLearning course developedeLearning course developedConcepts Concepts ResearchResearchLegalLegalCare continuumCare continuumTheoriesTheoriesClinical DocumentationClinical DocumentationImpactImpactElder MistreatmentElder Mistreatment
HIGN e-Learning HIGN e-Learning
Web Based geriatric case studies Web Based geriatric case studies that assist faculty to introduce that assist faculty to introduce geriatric concepts into the geriatric concepts into the curriculumcurriculum
Advance Practice Case StudiesAdvance Practice Case Studies
PRACTICEPRACTICE
NICHENICHE
Practice supportivePractice supportiveNurses Improving Care for Health Nurses Improving Care for Health
System EldersSystem EldersGITT – Geriatric Interdisciplinary Team GITT – Geriatric Interdisciplinary Team
TrainingTrainingTraining resources in a GITT Kit to Training resources in a GITT Kit to
help health professionals develop help health professionals develop interdisciplinary teamsinterdisciplinary teams
GITTGITT
Practice SupportPractice Support
Consult Geri RN and Try This SeriesConsult Geri RN and Try This SeriesTab – “Need help stat”Tab – “Need help stat”Need help statNeed help stat
HI Hospital Competencies – HI Hospital Competencies – Competency: Care of Adult 65 years +Competency: Care of Adult 65 years +
Hospital CompetenciesHospital Competencies
IV - HIGN ForumIV - HIGN Forum
Web based “board” for Web based “board” for reading and posting messages reading and posting messages about geriatric topics.about geriatric topics.
HIGN ForumHIGN Forum
USING “TRY THS”- USING “TRY THS”- Medications Medications
Drugs and Older AdultsDrugs and Older Adults
Medication (prescription, over-the-counter and Medication (prescription, over-the-counter and herbal preparations) are widely used by older herbal preparations) are widely used by older adultsadults
At least one RX med used b 81% of community At least one RX med used b 81% of community dwelling adultsdwelling adults
Five or more Rx medications used by: Five or more Rx medications used by: 29% of overall survey population 65 and older29% of overall survey population 65 and older36% of people aged 75 – 85 year olds36% of people aged 75 – 85 year olds46% of RX users took at least one OTC 46% of RX users took at least one OTC
medicationmedication (Qato et al, 2008) (Qato et al, 2008)
MedicationMedication
20% of of community dwelling older adults 20% of of community dwelling older adults in the US are using one or more meds on in the US are using one or more meds on the Beer’s list of drugs that should be the Beer’s list of drugs that should be avoided (Zhan et al, 2001)avoided (Zhan et al, 2001)
All adults over 65 y.o. (12% of population)All adults over 65 y.o. (12% of population)79% take some type of medication79% take some type of medicationConsume 30 – 40% of all prescribed drugsConsume 30 – 40% of all prescribed drugsPurchase 40% of all OTC drugsPurchase 40% of all OTC drugs12% of elderly on 10 or more meds12% of elderly on 10 or more meds23%take 5 or more medications 23%take 5 or more medications
Adverse Drug Adverse Drug Reactions(ADR)Reactions(ADR)
# of drugs prescribed and prior history # of drugs prescribed and prior history of an ADR strongest predictors for of an ADR strongest predictors for subsequent ADR subsequent ADR
Risk doubled for those prescribed 5 -7 Risk doubled for those prescribed 5 -7 medicationsmedications
Fourfold for those receiving 8 or more Fourfold for those receiving 8 or more medicationsmedications(Onder et al, 2010)(Onder et al, 2010)
Post hospital Post hospital medication problemsmedication problems
One or more medication discrepancies One or more medication discrepancies were experienced in 14.1% of patients were experienced in 14.1% of patients post hospitalizationpost hospitalization
Medication discrepancies were associated Medication discrepancies were associated with total number of meds taken and with total number of meds taken and presence of CHFpresence of CHF
14.3% of patients with discrepancies 14.3% of patients with discrepancies rehospitalized in 30 days compared with rehospitalized in 30 days compared with 6.1% without discrepancies6.1% without discrepancies (Coleman et al, 2005) (Coleman et al, 2005)
Try This SeriesTry This Series
Try This SeriesTry This Series
Want To Know MoreWant To Know More
Assessment /Screening ToolsAssessment /Screening Tools
Beers Part I criteriaBeers Part I criteria
Beers Part II criteriaBeers Part II criteria
Article in AJNArticle in AJN
Video on Beers CriteriaVideo on Beers Criteria
Using Beers I CriteriaUsing Beers I Criteriasee handoutsee handout
Part I – Have student review patient RX and Part I – Have student review patient RX and OTC meds to identify inappropriate OTC meds to identify inappropriate medicationsmedicationsGreat exercise for beginning clinical studentsGreat exercise for beginning clinical studentsExample for action on a drug by studentsExample for action on a drug by studentsOTC Benadryl (diphenhydramine)OTC Benadryl (diphenhydramine)
May cause confusion and sedationMay cause confusion and sedationShould not be used as a hypnotic e.g. Should not be used as a hypnotic e.g.
Tylenol PM!!Tylenol PM!!Emergency allergic reaction use – smallest Emergency allergic reaction use – smallest
dose (25 mg), 1 – 2x dose (25 mg), 1 – 2x
Using Beers II CriteriaUsing Beers II Criteriasee handoutsee handout
Part II – Have student review patient meds to Part II – Have student review patient meds to identify inappropriate medications by patient identify inappropriate medications by patient diagnos(es)/condition(s)diagnos(es)/condition(s)Good exercise for higher level studentsGood exercise for higher level studentsUse disease or condition to identify Use disease or condition to identify
inappropriate medications by inappropriate medications by name name or by or by drug classdrug class
Have students group patient’s present list of Have students group patient’s present list of medications both RX and OTC by medications both RX and OTC by diagnoses/conditionsdiagnoses/conditions
Delirium: Most frequent Delirium: Most frequent complication of hospitalized complication of hospitalized
elderlyelderlyYet nurses fail to recognize it more than Yet nurses fail to recognize it more than
30 - 50% of the time30 - 50% of the time
In one study, nurses failed to recognize In one study, nurses failed to recognize delirium in 75% of cases delirium in 75% of cases (Rice et al., 2011) (Rice et al., 2011)
The fluctuating mental status is The fluctuating mental status is important to identify because it often important to identify because it often signals a need for additional treatmentsignals a need for additional treatment
Improving Recognition Improving Recognition through Education that:through Education that:
Differentiates between the 3 D’s Differentiates between the 3 D’s
Delirium, Dementia, DepressionDelirium, Dementia, Depression
Improves knowledge about atypical Improves knowledge about atypical presentations of delirium in the elderlypresentations of delirium in the elderly
Provides competency in mental status Provides competency in mental status assessment: the Mini-cogassessment: the Mini-cog
Recognizes acute confusion as a serious Recognizes acute confusion as a serious conditioncondition
Try This Series: Try This Series: DeliriumDelirium
Overview of the problem Overview of the problem ArticlesArticlesStrategies Strategies Assessment/Screening ToolsAssessment/Screening ToolsAssessment toolsAssessment toolsVideosVideos
CAM (Confusion Assessment Method)
CAM standardized assessment tool CAM standardized assessment tool (Long & Short Versions)(Long & Short Versions)
CAM ICU – non-verbal, ventilated CAM ICU – non-verbal, ventilated PatientPatient
Plus:Plus:Assessing and managing delirium Assessing and managing delirium
superimposed on dementiasuperimposed on dementiaAssessment of Executive FunctioningAssessment of Executive Functioning
Try This Series: (CAM)Try This Series: (CAM)
Identifies 4 features of the disorder that Identifies 4 features of the disorder that distinguish it from other forms of cognitive distinguish it from other forms of cognitive impairment. impairment.
1. status altered from 1. status altered from baseline (acute onset or baseline (acute onset or fluctuating)fluctuating)
2. inattention2. inattention
3. disorganized thinking3. disorganized thinking
4. altered level of consciousness4. altered level of consciousness
Takes 5 minutes and is easily incorporatedTakes 5 minutes and is easily incorporated
Back to Rice’s StudyBack to Rice’s Study
Thank You and Healthy Thank You and Healthy AgingAging
ReferencesReferences Coleman, E. A., Smith, J. D., Raha, D., Min, S. J. (2005). Coleman, E. A., Smith, J. D., Raha, D., Min, S. J. (2005).
Posthospital medication discrepancies: prevalence and Posthospital medication discrepancies: prevalence and contributing factors. contributing factors. Arch Intern Med Arch Intern Med 165:1842. 165:1842.
Fried, L. P., Fernucci, L., Darer, J., Williamson, J. D., Anderson, Fried, L. P., Fernucci, L., Darer, J., Williamson, J. D., Anderson, G. (2004). Untangling the concepts of disability, frailty, and G. (2004). Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. comorbidity: implications for improved targeting and care. Journal of Gerontology: Medical Sciences Journal of Gerontology: Medical Sciences 59(3) 255-263.59(3) 255-263.
Inouye, S. K., Studenski, S., Tinetti, M. E., Kuchel, G. A. Inouye, S. K., Studenski, S., Tinetti, M. E., Kuchel, G. A. (2007) Geriatric syndromes: clinical, research, and policy (2007) Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. implications of a core geriatric concept. Journal of the Journal of the American Geriatric Society American Geriatric Society 55:780-791.55:780-791.
Knight, E. L., Avorn, J. (2001). Quality indicators for Knight, E. L., Avorn, J. (2001). Quality indicators for appropriate medication use in vulnerable elders. appropriate medication use in vulnerable elders. Ann Intern Ann Intern MedMed 135:703. 135:703.
ReferencesReferences
Onder, G., Petrovoc, M., Tanglisura, B., et al. (2010). Onder, G., Petrovoc, M., Tanglisura, B., et al. (2010). Development and validation of a score to assess risk of Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 adverse drug reactions among in-hospital patients 65 years or older: the GerontoNet ADR risk score. years or older: the GerontoNet ADR risk score. Arch Arch Intern MedIntern Med 170:1142 170:1142
Qato, D. M., Alexander, G. C., Conti, R. M. et al. (2008). Qato, D. M., Alexander, G. C., Conti, R. M. et al. (2008). Use of prescription and over-the-counter medications and Use of prescription and over-the-counter medications and dietary supplements among older adults in the United dietary supplements among older adults in the United States. States. JAMAJAMA 300:2867. 300:2867.
Rice, K. L., Bennett, M., Gomez, M., Theall, K. P., Knight, Rice, K. L., Bennett, M., Gomez, M., Theall, K. P., Knight, M., Foreman, M. D. (2011). Nurses' recognition of delirium M., Foreman, M. D. (2011). Nurses' recognition of delirium in the hospitalized older adult. in the hospitalized older adult. ClinicalClinical Nurse Specialist Nurse Specialist 225(6), 299-311.5(6), 299-311.
Russo, A. L., Eaton, C. B., Wallace, R., Gold R., Curb, J. D., Russo, A. L., Eaton, C. B., Wallace, R., Gold R., Curb, J. D., Stefanick, F. L., Okene, J. K., Michael, Y. L. (2011). Combined Stefanick, F. L., Okene, J. K., Michael, Y. L. (2011). Combined impact of geriatric syndromes and cardiometabolic diseases impact of geriatric syndromes and cardiometabolic diseases on measures of function. on measures of function. J Gerontol A Biol Med Sci.J Gerontol A Biol Med Sci. 66A(3):349-35466A(3):349-354. .
Saka, B., Kaya, O., Ozturk, G. B., Erten, N., Karan, M. A. Saka, B., Kaya, O., Ozturk, G. B., Erten, N., Karan, M. A. (2010). Malnutrition in the elderly and its relationship with (2010). Malnutrition in the elderly and its relationship with other geriatric syndromes. other geriatric syndromes. Clinical Nutrition Clinical Nutrition 29(6): 745-8. 29(6): 745-8.
Zhan, C., Sangl, J., Bierman, AS, et al. (2001). Potentially Zhan, C., Sangl, J., Bierman, AS, et al. (2001). Potentially inappropriate medication use in the community-dwelling inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel elderly: findings from the 1996 Medical Expenditure Panel Survey. Survey. JAMAJAMA 286:282.3. 286:282.3.