The goal for this activity is to increase the participant’s knowledge and ability to apply the Age-Friendly 4Ms Framework when caring for older adults (65 and up) with a Possible UTI in a convenience care setting.
1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Grand Rounds
Susan Plante, Pharm D.
NP
Dr. Castro-Zarrag
Topic: AFHS: Possible Urinary Tract Infection (UTI) in the Older Adult
NP
2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Grand Rounds
Topic: AFHS: Possible Urinary Tract Infection (UTI) in
the Older Adult
3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Providing Age-Friendly Care
The goal is for all care with older adults to be Age-Friendly care, which:
• Follows an essential set of evidence-based practices;
• Causes no harm; and
• Aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each
case scenario. The 4Ms include:
• What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
• Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation,
and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the
older adult, Mobility, or Mentation
• Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
• Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that
older adults move safely in order to maintain function and do What Matters
6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Possible UTI in an Older Adult
(S) Situation: Shirley is an 84 y/o female who comes in to the clinic with her daughter who is visiting from out of
town. Shirley lives alone and takes great pride in her independence. Shirley has refused any housekeeping help.
This trip, her daughter notices her mother’s home is not in its usual pristine condition. She also notes several
unpaid bills and a traffic ticket on the kitchen table. The daughter is concerned that her mother is declining
cognitively and has heard urinary tract infections (UTI) can cause confusion. Upon questioning, Shirley does
admit to foul smelling urine over the past few weeks.
(B) Background: PMH: hyperlipidemia, hypertension, osteoarthritis, macular degeneration
Medications: hydrochlorothiazide 25mg PO daily, lisinopril 5mg PO daily, atorvastatin 20mg PO daily, fish oil daily,
acetaminophen 650mg PO every 6 hours PRN pain
7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Possible UTI in an Older Adult (Cont.)
(A) Assessment: VS: BP 125/70 mmHg HR 78/min, RR 14/min, Temp 98.7F, SpO2 95% on room air
Mentation: PHQ-2 = 0 (negative); Mini-Cog = 3 (negative: missed 2 words on recall)
Mobility: Patient walks in unassisted wearing appropriate footwear. Get Up and Go test: No difficulty getting up
from a chair, walking 10 feet, turning around, walking back, and sitting back in chair.
General: Alert, pleasant, cooperative with exam, in no apparent distress
Mouth: Dry mucus membranes
Respiratory: Resonant and clear bilateral all lobes
Cardiac: Regular rate and rhythm, S1, S2, no murmurs or gallops
Abdomen: Soft, non-tender, negative CVA tenderness
Musculoskeletal: Normal gait, no signs of imbalance, instability, or stumbling
Urinalysis dip: +3 leucocytes, + nitrites, specific gravity is high, color is dark yellow, negative for protein and blood
(R) Recommendation: Let’s discuss…
8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Recommendation
• Older adults may be colonized with and present with asymptomatic bacteriuria. Dehydration
may be an issue and cause delirium, both potentially treated with hydration. Increase fluid
intake. Differentiate asymptomatic bacteriuria from UTI and mild delirium caused from infection.
• Collect/send urine out for culture and sensitivity
• Consider antibiotic for possible UTI, keeping in mind antibiotic stewardship; Treat with
antibiotics if clear indication of infection per guidelines
• Follow up for re-check in 2 days with PCP, or in clinic if PCP unavailable, to see if cognition has
improved or if further cognitive work up is needed
• If culture and sensitivity is negative, consider discontinuing antibiotic if one was started
• Recommend someone check-in with the patient more frequently: the daughter, other family
member, friend, or neighbor
9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Summary: ASSESS and ACT ON the 4Ms as a set
What Matters: Know and act on each patient’s specific health outcome goals and care preferences
• Follow up on ability to keep the home clean; Ask what the patient may be looking forward to during the upcoming week
and what activities she likes to do; Tailor plan according to what matters to her
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and
what matters
• Increase fluid intake as specific gravity is high. Consider polypharmacy and possibility for deprescribing (e.g. fish oil,
atorvastatin, decrease dose of hydrochlorothiazide) https://deprescribing.org
• Keep in mind antibiotic stewardship; Treat with antibiotics if evidence of infection is clear
Mentation: Focus on dementia and depression and delirium
• Follow up mental status assessment after urinalysis clear
• May have early stage dementia (unpaid bills); Address executive decision making (e.g. paying bills; addressing
driving); May need social work referral
• Educate regarding cognitive stimulation such as puzzles, games, reading the newspaper, socialization
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Encourage daily mobility; Consider yoga, exercise program
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider
10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Interprofessional Team Discussion…
11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Acknowledgements
Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare
Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health
Association of the United States (CHA).
MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A.
Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Thank You
Editor's Notes
Today’s topic is: Possible Urinary Tract Infection (UTI) in the Older Adult
Today’s topic is: Possible Urinary Tract Infection (UTI) in the Older Adult
The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older.
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include:
What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation
Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
S: Situation: Shirley is an 84 y/o female who comes in to the clinic with her daughter who is visiting from out of town. Shirley lives alone and takes great pride in her independence. Shirley has refused any housekeeping help. This trip, her daughter notices her mother’s home is not in its usual pristine condition. She also notes several unpaid bills and a traffic ticket on the kitchen table. The daughter is concerned that her mother is declining cognitively and has heard urinary tract infections (UTI) can cause confusion. Upon questioning, Shirley does admit to foul smelling urine over the past few weeks.
B: Background: PMH: hyperlipidemia, hypertension, osteoarthritis, macular degeneration
Medications: hydrochlorothiazide 25mg PO daily, lisinopril 5mg PO daily, atorvastatin 20mg PO daily, fish oil daily, acetaminophen 650mg PO every 6 hours PRN pain
A: Assessment: VS: BP 125/70 mmHg HR 78/min, RR 14/min, Temp 98.7F, SpO2 95% on room air
Mentation: PHQ-2 = 0 (negative); Mini-Cog = 3 (negative: missed 2 words on recall)
Mobility: Patient walks in unassisted wearing appropriate footwear. Get Up and Go test: No difficulty getting up from a chair, walking 10 feet, turning around, walking back, and sitting back in chair.
General: Alert, pleasant, cooperative with exam, in no apparent distress
Mouth: Dry mucus membranes
Respiratory: Resonant and clear bilateral all lobes
Cardiac: Regular rate and rhythm, S1, S2, no murmurs or gallops
Abdomen: Soft, non-tender, negative CVA tenderness
Musculoskeletal: Normal gait, no signs of imbalance, instability, or stumbling
Urinalysis dip: +3 leucocytes, + nitrites, specific gravity is high, color is dark yellow, negative for protein and blood
R: Recommendation: Let’s discuss
There are a few things to consider in this case.
Older adults may be colonized with and present with asymptomatic bacteriuria. Dehydration may be an issue and cause delirium, both potentially treated with hydration. Increase fluid intake. Differentiate asymptomatic bacteriuria from UTI and mild delirium caused from infection.
Collect/send urine out for culture and sensitivity
Consider antibiotic for possible UTI, keeping in mind antibiotic stewardship; Treat with antibiotics if clear indication of infection per guidelines
Follow up for re-check in 2 days with PCP, or in clinic if PCP unavailable, to see if cognition has improved or if further cognitive work up is needed
If culture and sensitivity is negative, consider discontinuing antibiotic if one was started
Recommend someone check-in with the patient more frequently: the daughter, other family member, friend, or neighbor
Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set.
What Matters: Know and act on each patient’s specific health outcome goals and care preferences.
Follow up on ability to keep the home clean; Ask what the patient may be looking forward to during the upcoming week and what activities she likes to do; Tailor plan according to what matters to her.
If what matters does not come up naturally during the course of the visit, when you are creating treatment plan, you can ask, “I’d like to individualize your treatment to what matters most to you.” Then, tailor the plan.
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters.
Increase fluid intake as specific gravity is high. Consider polypharmacy and possibility for deprescribing (e.g. fish oil, atorvastatin, decrease dose of hydrochlorothiazide). The website for deprescribing.org is provided: https://deprescribing.org
Keep in mind antibiotic stewardship; Treat with antibiotics if evidence of infection is clear
Mentation: Focus on dementia, depression, and delirium
Follow up mental status assessment after urinalysis clear
May have early stage dementia (unpaid bills); Address executive decision making (e.g. paying bills; addressing driving); May need social work referral
Educate regarding cognitive stimulation such as puzzles, games, reading the newspaper, socialization
Mobility: Maintain mobility and function and prevent/treat complications of immobility.
Encourage daily mobility; Consider yoga, exercise program
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider
