Emergency Department and Outpatient Senior Healthcare Consultant Course

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The one day course provided by Piedmont Hospital of ED and outpatient nursing staff on Geriatric Patient care issues. Funded by the HRSA Comprehensive Geriatric Education Grant.

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  • Nurses rely on signs and symptoms from patients to direct their care. Older adults respond differently to illness, treatments and interventions due to : changes in organ systems Progressive loss of reserve Interaction of multiple conditions with the acute illness
  • Older are more emergent cases Over 20% after ED vs have decrease in ability to care for themselves- get meds, food/meals, manage f/u appointments
  • fast, loud, Difficulty hearing / understanding Flow not conducive to older pt telling his story- has more history- intertwined
  • Older adults there are usually mx issues that need to be addressed to prevent re-visit / adm Vague, nonspecific, ambiguous symptoms Often atypical presentations
  • Evidence based, appropriate for ED setting; look at their presentation in context of functionality and physiology; Look for CAUSES and evaluate Talk about geriatric assessment
  • Treatment and interventions will be more accurate Earlier intervention prevents progression to more serious situation Prevent common complications and issues for older patients We will look at changes is S&S with older adults in general and then specifically with cardiac and infections you are most likely to see in the hospital.
  • Must compare to normal prior to the illness Differentiate between normal aging and illness in signs and symptoms Set of symptoms see in older adults that should raise red flags
  • Older adults have the most variability than any other age group. Perception of older adult may not reflect true abilities situation; verify with family, caregivers, facility staff, etc Frail older adults are most likely to have atypical presentation of illness- their reserves are stressed to the max- Add to this normal aging-
  • Symptoms reported become less specific- that is what the older adults is experiencing- usually due to aging changes indifferent organ systems. Discomfort may become a generalized area rather than a limited spot which more clearly defines which organs are involved The different components to respond are muted or dampened with injury or illness thus symptoms reported and signs we look for will be less Ex: immune system, T cells The sensors and alarms systems in body take longer to marshal a response thus pt will have been ill longer before it is recognized- allows greater load of bacteria or virus, or illness process will be further along This leads us to how do problems present -
  • Cognition: less sharp in processing, impaired thinking, all the way to “confusion” Mobility: older adults presenting with New onset falls, weakness impairing daily activities needs to be evaluated for an underlying problem- not just checked for apparent physical injury Decreased appetite, lethargy, self care can be present with any number of medically treatable conditions Let’s look at infections and cardiac issues you will come in contact with in hospital.
  • Not all older pt have abd discomfort- they may attribute to bowl issues Decline in sense of smell- they might not have noted this at home Pt may not have reported because they assume incontinence is just part of getting older Thinking- here need baseline and comparison by someone other than pt Temp of 100 can be fever if base temp 97 Blood WBC can be nl – by time see left shift in differential have serious infection; may have dehydration in lab due to decrease intake with incontinence and kidney unable to conserve water (aging); Less T cells to respond and less aggressive and slower to present- temp remains lower thus does not provide help in killing off bacteria/virus as temp at 101 does Reduced ability to concentrate; less response to volume depletion, decreased elimination of certain drugs
  • Dehydration makes lungs dry- thus no mucus moving- no cough; May not report this is their nl lifestyle does not have any exertion Nl resp rate 14-16 Falls- no clear explanation but depleted reserves Need baseline and a someone to compare- not sure if due to decreased O2 or stressed reserves chest Xray may not be definitive until hydrated
  • Depending on site: May have peripheral neuropathy, some states pain reception declines as age comes from immune systems response with WBC and increased blood flow to area- all decline with aging Lab: same as with other infections
  • Lifestyle may include little exertion so would not c/o this May already sleep on elevated pillows or recliner for other reasons Rales may be masked by co-existing lung disease Rales can be caused by reclining posture- basilar rales is a sign of ventricular failure Need baseline and someone to compare Not too different but sloe to show elevations Decreased max hr, less efficient response to stress, incresaed likelihood of orthostatic hypotension
  • Pain often isolated to throat, or shoulder or abdomen, or “silent MI” Dyspnea is most common symptom; need baseline, someone to compare; confusion with decreased O2 to brain Slow to elevate; may not elevate high enough to confirm in some malnourished patients
  • 50% of pts with proximal DVT will have asymptomatic PE presentation RARELY hempoptysis Leg edema, discomfort, erythema, warmth Positive D dimer also found in recent surgery, malignancy, trauma, active CV disease ABG can be normal or reveal resp alkalosis due to hyperventilation You can see how the symptoms are vague, overlapping, - not clear cut but are not normal signs for older patients. Try this quick case with an older patient
  • Progressive issues with strength, mobility over short period of time: had falls Some baseline
  • The report you receive does not have any major definitive problems. Let’s look at the symptoms, signs and lab
  • Symptoms indicate a major change that has not improved Temp and resp that could be important – need to know baseline if possible; but know that 20 is higher than expected; temp could indicate a fever From what we have looked at today; could this be heart failure, MI, UTI? Or a combination of these and others such as depression.
  • Recognize the significance of atypical symptoms / presentations and pursue possible causes- may be more than one medical issue involved By recognizing that older adults can have atypical presentations, Nurses can ensure quality care and positive outcomes.
  • 30-40% of cognitive deficit pt missed in ED, not part of nl assessment and pts present well in basic conversation
  • Delirium- medical emergency; Benefit of standard reliable tools- communication between professionals, comparison of results,
  • Is this their baseline mental status or has pt had any fluctuations in mental status in past 24 hrs as evidenced by fluctuation on sedation scale, GCS, or previous delirium assessment
  • First establish that pt can follow a simple “yes” “no” – such as nod head, squeeze hand- if can do this then conclude there is the basic ability to understand directions Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? 2.Letters: Say to patient “ I am going to read you a series of 10 letters. Whenever you hear the letter A, indicate by squeezing my hand” Then read letters in normal tone Score this a incorrect if they squeeze on any letter other than A, or do not squeeze when you say A OR can use pictures- most commonly used in ICUs or CCUs . Show 5 pictures 3 sec each. Then tell them going to show them more pictures and to squeeze or indicate when they see a picture from the first set
  • If pt is not positive on BOTH 1 and 2 then stop. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Use these questions Command Say to pt “Hold up this many fingers ( hold up 2 fingers in front of pt. “Now do same thing with the other hand ( not repeating the number of fingers) This helps affirm that pt did not randomly guess correctly the 4 questions
  • Score 1&2 and either 3 or 4 = for delirium. Alert ( normal) Vigilant ( hyperalert) Stupor (difficult to arouse) Coma (unarousable)
  • Look at handout / worksheet in folder- looks very busy because have put all the info on one page. Do not be overwhelmed- just 4 questions CAM was designed to be scored based on observations made during brief but formal cognitive testing. There is a false positive rate of 10%. Record- report The tool identifies the presence or absence of delirium but does not assess the severity of the condition Now that you have a tool, How frequently do you assess for delirium?
  • These instructions can be repeated, but no additional instructions should be given. If the patient cannot complete the clock drawing test in ≤3 min, move on to the next step
  • Affected by pain, sleep deprivation, pain meds, anxiety Snap shot of how they are doing with you RIGHT NOW in ED
  • Measures individual’s reality orientation, registration abilities, attention and calculation skills, recall, language, and visuoconstruction (seeing and copying designs) Highest possible score: 30 points. Score of less than 24 needs further eval for possible AD or other dementia, depression, delirium, other psych disorder Those who score 20 or less generally have 1 of these disorders Is a screen not a diagnosis CAN CONSULT for help
  • Older white males have highest risk of suicide 14% of older adults have depression Tell more by behaviors in older adults than by answers
  • CAM- discuss with MD, pharmacist, family- any new meds, S&S infection etc MiniCog: fail- look at supports in home for activities this would affect even for short time
  • Same as Minicog If fail executive function important to know who manages meds!!!!!!! Depression screen after score- note observations to support or not this score “ scored 5/15 but overall affect is vibrant and she is grateful to be alive;
  • Observe mobility Katz scale- independent dependent, Decline in order listed; decline can be acute or chronic Verify the adls, iadls
  • Tinetti
  • Katz scale- Elements of self care Inability to independently perform even one may indiacte a need for suportive services Acute or chronic decline OT referral;independent dependent, Verify the adls, iadls;Independent with difficulty IADLS- higher level skills for living independent
  • Katz scale- Elements of self care Inability to independently perform even one may indiacte a need for suportive services Acute or chronic decline OT referral;independent dependent, Verify the adls, iadls;Independent with difficulty IADLS- higher level skills for living independent
  • Chart what you observed
  • During skills time will have chance to practice the tools, and talk about how can integrate these into your practice
  • selection process creates a problem for the patient at risk for pressure ulcer development who may not require immediate care. This disconnect could delay recognition, assessment, and communication about the potential for pressure ulcer development.
  • ( dm neuropathy, phantom limb pain, trigeminal neuralgia, post herpetic , CVA, chemical CA
  • blood pressure is often mistaken for undiagnosed hypertension. Increased heart rate is due to changes in the release of serotonin and endorphins as well as anxiety. Combination can cause decreased perfusion and can lead to increased fatigue for the older adult. Depression- suicide ideation Depletion syndrome: characterized by decreased levels of serotonin and endorphins
  • Goal- max function and QOL Preventive approach- use less med: round clock, pre medicate Dementia: situation where you suspect may have pain- do clinical trial of pain med and non pharmacological stategies
  • In addition to more typical- grimacing, splinting holding, rubbing Facial expressions most sensitive indicator
  • Bone pain- tylenol, advil WHO Rarely see these issues occur with opioids used for pain control and even more rarely in older adults Addisiton Rarely occur with opioids used for pain control and even more rarely in older adults Antiemetics may be needed early on with the initiation of opioid therapy. preventive precautions are often recommended, such as the use of an assistive device. Falls, dizziness, and gait disturbances are not uncommon; therefore, Eventually, for most patients, the analgesic effect of opioids is preserved while tolerance develops to most side effects (eg, respiratory depression, sedation, nausea, and vomiting). 1 , 4 , 10 , 20 However, because tolerance does not develop to gastric hypomotility, patients need to take stool softeners for as long as they are on opioid therapy. Chewing or crushing sustained-release opioids must be avoided as doing so can cause rapid absorption of the entire dose resulting in overdosing Transdermal fentanyl should also be used with extreme caution in the elderly. It has a variable absorption rate in older adults and a long half-life even when the patch is removed. Transdermal fentanyl is contraindicated in opioid-naïve patients Tramadol hydrochloride, an analgesic that has some opioid properties and is used for mild to moderate pain, should be used with caution in the elderly because it may cause dizziness and reduce the seizure threshold. 22
  • Avoid Demerol meperidine- ineffective or have high SE risks- CNS confusion
  • Note that even when talking about health literacy the AMA cannot resist using language that would be difficult for someone with low literacy to be able to understand.
  • They did do a little better in narrowing it down for their definition.
  • The need for today’s patients to be more health literate is greater than ever, because medical care has grown increasingly complex. We treat out patients with an ever-increasing array of medications, and we ask them to undertake more and more complicated self-care regimens.
  • A limited ability to read and understand information translates into poor health outcomes. Most Clinicians are surprised to learn that literacy is the single best predictor of health status. In fact, all of the studies that have investigated the issue report that literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education levels, and racial or ethnic group.
  • Recent studies have shown that almost half of the US population lacks sufficient general literacy to effectively undertake and execute medical treatments and preventive healthcare it needs. Inadequate health literacy affects all segments of the population, although it is more common in the elderly, poor, minorities, and recent immigrants to the United States. Low Health Literacy cost the United States between $50 Billion and $73 Billion a year.
  • Elderly – Limited Health literacy rates for those over 65 are estimated at 59% of the population, well over half.
  • Mr. Day – Believes hypertension refers to a behavioral problem Mrs. Cordell – Signed procedure paperwork and only realized after the fact that she had consented to a hysterectomy Mr. Bell – Scared someone is going to realize his low literacy and often becomes angry or storms out of the doctor’s office Mrs. Grigar – Unable to fill out a form Mrs. Tilsey – Medication review “brown bag” where doctor asks what each medicine is for and how patient takes it Mrs. Grigar again – MD explaining arthritis is a way that she could understand
  • When a patient brings in their medication, review the medications with the patient. Note if the patient opens the bottle and looks at the medication or do they identify their medication by reading the label? Be aware that some patients memorize the label and directions so probe further by asking when did they take the medication last and before that. If they looked confused, suspect the patient memorized.
  • Are You Thinking What I’m Thinking? Liability?
  • According to research from the American Tort Reform Association, Attorneys estimate that a clinician’s communication style and attitude are major factors in nearly 75% of malpractice suits. The most frequently identified communication errors are inadequate explanations of diagnosis or treatment and communicating in such a way that the patients feel their concerns are being ignored.
  • Create a Shame Free Environment Slow Down: Communication is improved by speaking slowly, particularly with older adults who may have a harder time hearing the separation between words Use Plain, Non-medical Language - “Layman's Term” Show or Draw Pictures Limit the Amount of Information and Repeat It Use the Teach-Back or Show-Me Technique Ask Me 3 What is my main problem? What do I need to do about it? Why is it important for me to do this?
  • Provide an example such as telling the patient with CHF to weigh themselves daily, and ask them to provide information back to you.
  • Wouldn’t this be a nice thing to hear that a patient said to someone about you?
  • Nurses rely on signs and symptoms from patients to direct their care. Older adults respond differently to illness, treatments and interventions due to : changes in organ systems Progressive loss of reserve Interaction of multiple conditions with the acute illness
  • Falls, confusion / AMS Instability / dizziness Functional Impairment / malaise
  • Not just an injury Some of underlying issues- if not attended to- will cause revisit or admission not to mention increased linness for older adult
  • Atypical- MI, acute abdomen Infection- uti uri, pneumonia, sepsis, sinusitis Drugs- polyphramacy, mismanagement meds, dehydration, CV Cns parkinsons, cva, tia, nph
  • Decline in sight and hearing can have significant impact on older adult’s fall risk Have wider base, less arm swing, center of balance changes to name a few- All together- Not able to catch self when stumble as you did when you were younger
  • Without adequate nutrition begin to lose strength, affecting mobility, safety Any issue with these systems can result in older adult trying to hurry- leading to higher risk of falls Depression- either under-treated or undiagnosed can impact safe mobility People with dementia lose ability to identify risk situations This can be chronic or acute issue that can result in a fall. So moving on to acute illnesses…………………….
  • These are a few categories of drugs that can increase an older pts fall risk. Certainly there are many more- the idea here is we actively contribute to increasing their risk. So what prevention can we offer our pts?
  • Ortho for dizziness, dehydration measure
  • Communicate with ED MD, family, staff on unit if admitted, facilities if returning, PCP PT eval and tx, assess for aids, exercise, safety check of home, use of aids RN for meds management, nutrition Sixty Plus for case management Family- for increased oversight, to include in teaching, verify information
  • Logically include sensory decline PD
  • Older patients are at high risk for complication of delirium which can require increased nsg time and staff as well as increased LOS, NH placement, morbidity, mortality, fall risk, infection, aspiration, malnutrition- dehydration Delirium is a frequent complication of illness and hospitalization for older adults- up to 80 %, and up to 89% of pts with delirium. But it’s effects can be largely or completely reversed when cause is identified and treated Nurses are the primary professionals to detect delirium in patients and prevent these complications.
  • Delirium comes on over hours to days- Due to inability to maintain homeostasis when confronted with acute illness, medication adverse reaction- more at risk than other ages but can happen at any age May come to ED with delirium, or may begin to be obvious there, or may be prevented in ED agitated, aggressive, hallucinations, constant motion, non-purposeful-repetitive movements, verbally and physically aggressive, hallucinations Clouded inattention- requires strong stimulation to arouse; withdrawn, apathy, inattention; Often unrecognized- poorer overall prognosis- most common in older adults fluctuates unpredictably Behaviors you see demonstrated vary somewhat depending on type of delirium; Generally see trying to escape the environment, removing medical equipment, maybe combative, non purposeful repetitive movements, moaning- calling out, resistive to care Delirium develops over hours- days Lasts days to months First symptom is often anxiety ATTENTION night staff- 1-3 days prior to full blown delirium see change in sleep-wake cycle or disturbed sleep, restless, anxious, irritable, loss of mental clarity or some disorientation, change in ability to shift or change focus
  • Prior to illness- caregiver, facility staff, family, friends Do entire geriatric assessment- often find mix of the 3 D’s- don’t stop because found 1 cause Specific behaviors Avoid general terms i.e. confusion, disoriented Alert vs attentive Medical emergency- need to identify cause and correct- can regain all function Baseline Memory- short term, and processing , completing tasks Alertness is basic arousal, attentiveness = thoughtful engagement with environment; select what want out of environment, sustain focus to process information- without this have safety risk Function- independent, or requires assistance Mobility Now need to compare to current status-
  • Watch labs, record I&O and food intake; encourage 1500 ml as minimum; check orthostatic BP Eval where they are and support; be sure they are using sensory aids- if they do not have, adjust environment: no glasses- put everything close at hands, no hearing aid- use pocket talker or stethescope to help them hear Clocks, calendars, white boards; decrease noise in hallway Glasses, hearing aids- working battery, wears glasses, telephone aids from hospital operator Assessment requires a way that different nurses can compare their findings as well as comparing a patient’s behaviors over time.
  • Collaborate with MDs re: possible untreated infection( often UTI or resp), lab work,; MDs and pharmacists for a med review and evaluate for interactions ( lasix, lanoxin, theophyllin) Family Have them bring familiar items ( pictures, play favorite music; determine if they are a source of support-ask them to stay; educate family delirium is a temporary condition that will improve with tx It is reasonable and appropriate to ask family to help- similar to a parent staying with a frightened hospitalized child ! Remove unnecessary equipment Avoid physical and chemical restraints; foley catheters and IV are one point restraints Only 4 reasons for foley cath: oveflow with obstruction, fl balance is critical, short term for stage 3 or 4 ulcer, severely impaired or terminally ill 80% hosp acquired UTI from foley and 40% of ALL UTI due to foleys Staff continuity- approach in calm manner and voice; use simple terms, avoid sudden movements Proactively address- nutrition, hydration, skin breakdown, blood clots ( immobility), mobility and deconditioning / loss of function, use sensory aids,
  • 50% never diagnosed and treated Most treated are treated inappropriately Alzheimers: most common 70%; tangles and plaques turns into severe cognitive dysfunction as well as behavior and personality changes and, eventually, loss of physical function Vascular, lewey bodies, parkinson’s: sl differences but end result same other conditions that may cause similar symptoms, such as stroke, hypothyroidism, depression, nutritional deficiency, brain tumor, Parkinson’s Disease, or inappropriate medication
  • Often family has not picked up on changes; pt presents well on phone conversations-confabulates; At home they have patterns- not have to process- in new environment processing continuously- very stressed
  • If has dx of dementia, mini cog, mmse can help identify abilities during ED visit MMSE can just frustrate pt with dementia
  • May not remember directions given in ED, not reliable historian- need verify-get info from someone else; health instructions need to include someone who can help pt; would not discharge on his own Clock- executive function- managing meds, safety issues, finances- needs over sight Much dementia is not dx- denial etc Families need to have information so they can plan ahead- possible work with pt while they still able to make decisions
  • At end of life, pts partly or completely bedfast. Death comes mostoften in the forms of aspiration PNA. Unable to swallow properly, the pt breathes food or liquids into the lungs
  • Avoid complexity it creates confusion and anxiety Changes in medications, nutrition, therapy, personnel, or location
  • Agitation: can be caused by need to urinate, as well as by depression, overstimulation Vocal outbursts, restlessness: Distract- Prompt pt to reminisce, touching pt, giving pt soft doll, stuffed animal, audiotapes of soothing sounds
  • May not remember directions given in ED, not reliable historian- need verify-get info from someone else; health instructions need to include someone who can help pt; would not discharge on his own Clock- executive function- managing meds, safety issues, finances- needs over sight Much dementia is not dx- denial etc Families need to have information so they can plan ahead- possible work with pt while they still able to make decisions
  • 60 million Americans greater than 65 yrs. Only 10% of these receive treatment Major public health problem – leading to impaired functional status, increased mortality, and excessive use of healthcare resources.
  • Many theories Chemicals depleted by stress- physical ( ACUTE CHRONIC ILLENSSES) or emotional- losses of aging
  • or pleasure in activities previously enjoyed, personal appearance- self care Usually a decrease in appetite/ daytime sleepiness and fatigue, insomnia, awakenings./memory loss, difficulty concentrating, abnormal thoughts, excessive guilt, thoughts of death and suicide. Different people can present with different symptoms. Some are overtly sad. Others…just angry. OR Apathy...they just don’t care anymore.
  • Women higher prevalence, but white males over the age of 80 have higher rates of suicide. It may not be that women are MORE depressed. It may be the way they show it. Men are less likely to present with overt sadness or crying the way women do. Men more likely to present with anger, irritability, emotional withdrawl or substance abuse. I don’t think older men are any less depressed it is just the way they show it. Biggest risk is number of losses as age- value, income, home, friends, family, spouse, social position etc chemical
  • Pt needs further evaluation for diagnosis. Indicates pt may not attend to instructions, plan of care, fill prescriptions after discharge without prompting- requires f/u in community and additional oversight Could be situational- needs to be watched for
  • Pt needs further evaluation for diagnosis. Indicates pt may not attend to instructions, plan of care, fill prescriptions after discharge without prompting- requires f/u in community and additional oversight
  • Nutrition- oral causes, labs- alb, prealb, cholesterol; swallowissues, functional ability, social issues 85-year-old woman with a three-month history of intermittent abdominal pain, nausea, diarrhea, and gradual weight loss, had been living independently in a mobile home park. Her daughter, who lived nearby, brought the woman home for some meals and prepared leftovers and meals for her to warm in the conventional or microwave oven when she was alone. The initial medical examination showed no underlying cause for the weight loss and abdominal symptoms. The patient was given medication for the abdominal discomfort and was encouraged to add over-the-counter nutritional supplements to her daily diet, yet the patient's condition continued to decline. A referral to the Kaiser Permanente (KP) case management program for the frail elderly led to a home visit--and to a revelation about the abdominal symptoms: The case manager discovered that the elderly woman's refrigerator was noisy and had been disturbing her sleep. The woman had attempted to address this problem by unplugging the refrigerator each evening at 8 pm when she prepared for bed. When informed of this situation, the family replaced the refrigerator, and the abdominal symptoms and weight loss subsided.
  • Don’t stop looking after find 1 Geriatric Assessmentwill keep from missing and covers lot of causes
  • In ED – How many of your patients each day are older adults in the ED? Typically, when asked staff says 40% or so, but studies suggest the number is closer to 20%. Why the difference? (comorbidities, may take longer to triage or work up, more fequently admitted, can be frustrating, etc.) Have you faced a situation where the patient or the caregiver didn't follow or forgot the discharge instructions that you gave them? Do people seem careless and oblivious to those important facts and guidelines that you share with them in the form of instructions at the time of discharge The situations where we see patients, is stressful, anxiety ridden and short- pts are more ill. The directions may be foreign in nature or complicated- or not. Results in confusion, dis-satisfaction, concern that the info was not “gotten” - both for pt / families and nursing staff . Have to repeat information, phone calls after they’ve left Striving to provide discharge information in clear, efficient manner that maximizes the older pts ability to comprehend and function with it
  • As Dee mentioned first thing this morning, older adult patients who are seen in the ED are more likely to be admitted or revisit the ED. Statistics show that 27%, or more than 1 in every 4 older adult patients treated in the ED, will revisit the ED, be hospitalized, or die within 3 months. Delirium – Present in 10% of elderly patients but only recognized in 35%. Missing this diagnosis may mean missing an underlying medical condition. That places these patients at a higher risk for bad outcomes. Discharge planning for older patients is highly involved and time consuming.
  • Transitions means when sending a patient into the hospital, back to a facility, or returning them home.
  • Michelle has already addressed some of this with you earlier today. And it is great that we area assessing these areas, but then the important question becomes what do we do with this information: You assess the person has memory loss and lives alone, do you give them the discharge instructions and send them home in a taxi? You know the person is a fall risk and uses a walker, but the doctor has put their arm in a sling, what do you do? It may mean that we need to get durable medical equipment for a patient. Items such as a cane, walker, bedside commode, or shower chair are very common needs for older adults. How are we doing this currently in the ED? It may also require a request for home health services to follow up with the patient in their homes. Let’s look at some of the reasons home health may be ordered for a patient.
  • Andy More has already touched on some of these items earlier today when discussing health literacy, but they’re important to remember. Language - Medical terms (myocardial infarction), as well as foreign language Avoid technical terms Use specifics Employ active verbs Their interpretation depends upon their background, their language, and their experience with the medical system. Instructions are also open to interpretation : Ask them to repeat the instructions and the sequence of steps that you outlined. (in their own words; ex: how would you do this at home?) This will not only create confidence about the usefulness of the instructions but also make them comfortable in using the instructions. This is called the TEACH BACK method. Hearing - You must remember that if you are trying to help someone read your lips, you need to talk slowly and normally. You may use a voice amplifier if required or a stethoscope in your patient’s ears if you choose to. Some of your patients may come with a hearing aid. Make sure that it is properly installed and working before proceeding with the teaching. Visual- Highlight:When you introduce a new topic, always underline or bold the headers. To highlight important information, indent the text or put it in a text box. Pictures or visuals are great tools for emphasizing important points and making it easier for the patient to understand the instructions. They also break up the text and help hold the patient's attention. SIZE of font Arrangement- white space, ragged edge; Try to include as much white space as you can and keep the spacing at 25 to 30% of the font size. For good readability, the paper-to-print contrast should be 70:30 Memory- Remember that it’s going to take you longer to teach older patients. The slower processing of messages and slower responses add to the memory problems in older patients. Thus you may want to start teaching early to give your patients adequate time to learn and process your instructions. You also need to write more detailed instructions for them to review. Some older adults may take medications that could create or induce forgetfulness. If you want older patients to learn their discharge instructions correctly, the best method will be to present them with real-life scenarios that they can relate to and write down everything they need to remember. KISS
  • We’re going to talk in a few minutes about the Care Transitions intervention and how it addresses discharge instructions, but let’s just touch now on what it is and why we do it. adequate and appropriate useful and critical information about resources inform them about the health problem they are facing, what they need to do to take care of it at home, and advise them regarding options they have. Mandatory- essential part of compliance with regulatory and patient health care standards.
  • Have you noticed there are so many things you need to tell your patients or their caregivers at one time? How many things do you think we can remember at a time? 3 In a nutshell, you need to adjust the teaching material based on audience age, barriers to learning, medical literacy, and cultural beliefs. You may ask yourself, "What is the least amount of information I must include that will motivate behavior change and action?" You should only give your patients and their families as much information they need or want to know. Providing all the information you know on the subject will not serve any purpose.
  • For a patient to be appropriate for home health, he or she must be considered homebound, or at least must face hardship in order to get out of the home. Probably the most clear cut example of home health needs is when physical therapy or occupational therapy is indicated. When these therapists are in the home, they will often conduct a home safety inspection for the patient as well in order to minimize the risks of falls. An order can be placed for “skilled observation and assessment” to allow a nurse to do medication reconciliation and teaching with the patient and/or their caregivers.
  • As long as a skilled service is in place in the home, the patient can receive additional services as well, such as a home health aide to assist with personal care and a medical social worker . Home health nurses are no longer able to go to the patient’s home only to draw labs. In order to do this, they have to be seeing the patient for some other reason as well. When in question, you do have resources available to you. You can always ask myself (ext 1954) or Lakia Porche (ext. 3486).
  • KISS
  • Why?? What brought you to ED as area Rapid triage, diagnosis multiple comorbidities, polypharmacy, subtle S&S, “story to tell”
  • Rapid triage, diagnosis Environment is unfriendly, intimidating: stretcher, floors- slippery/fall risk, no windows- difficult for orientation, noise / bustle- problem hearing, relaxing; reflect the tone of environment multiple comorbidities, polypharmacy, subtle S&S, “story to tell”
  • Modify aspects of speech in response to evaluation of person speaking to, level of competence Over accommodation- simpler vocabulary, high pitched tone, slower speech, exaggerated emphasis on certain words; found in hospitals, NH- using child like language, being abrupt, disrespectful, disinterested, ignoring while talking to others Use of first names, terms of endearment ( adult speaking to child learning language Study of 12 physicians: more abrupt and showed greater disinterest, blocked communication with older pts
  • Who tell you she ‘s new resident- had cva and was dc’d from your hospital 3 wks ago Nurse says that she is a new resident of the NH She came from your hospital three weeks ago after recovering from a stroke. The doctor on call hasn't seen her before and wanted her transferred to the ED because of his concern about a possible new stroke. Worsening weakness has been developing during the past week. She has stumbled and fallen three times in the past week Information not specific or include baseline prior to admission: need timeframe, ADLs
  • When outlined systematically, this change is not subtle. Two features suggest that it is not consistent with progression of aging or with chronic dementia. The progression of functionaI decline with aging is generally apparent over the course of several months or years. The "normal" sequence of functional loss is from bathing to feeding, with bathing first to be lost and feeding last. The time course of decline in this case is rapid, I week. Mrs. Henson has trouble with several ADLs at once: the higher end of the spectrum, dressing, and the lower, feeding. The full review of systems should be repeated with the nursing home nurse because the patient may not give an accurate history. Mrs. Henson seems to be a denier with imperfect recall.
  • The nurse relates the following additional information regarding the reasons for transfer: Mrs. Henson has not felt well for about a week. She's complained of being tired. She's gone to bed early and stayed in bed until asked to get up. For the past 4 days she hasn't been able to button her buttons. Three times in the past week, including today, she was found on the floor, trying to get up. She was awake with no injury except bruises at the knees and elbows. She's been eating less, and today she didn't eat anything except her juice and pills.
  • Was in hospital 3 wks ago- may need to consider hospital acquired pathogens Previous CVA may put at risk for aspiration- pneumonia Recent incontinence- could be sign of UTI
  • . Elderly patients may have asymptomatic bacteria and pyuria that does not require treatment However, in the setting of rapid functional decline and new incontinence, the presence of pyuria should be considered significant The presence of pyuria (>10 WBC/ml of spun urine) is a sensitive though not specific predictor of the presence of bacteriuria. Most(94%) persons with >100,000 CFU/ml will have pyuria."* cNeed to observe improvement after tx of MEDICAL illness
  • Emergency Department and Outpatient Senior Healthcare Consultant Course

    1. 1. Atypical Disease Presentation in Older Adults Dee Tucker, MS, RN, GCNS-BC Clinical Nurse Specialist Gerontoloy Piedmont Healthcare NICHE Coordinator
    2. 2. Reality in ED? <ul><li>Increased crowding which leads to </li></ul><ul><li>Increased wait time </li></ul><ul><li>Decreased quality of care </li></ul><ul><li>Increased crisis management </li></ul><ul><li>Decreased patient satisfaction </li></ul><ul><li>Decreased ED staff satisfaction </li></ul><ul><li>ED volume of older patients will double between 2003 and 2013 </li></ul>
    3. 3. Older Patients in ED <ul><li>Have longer ED stays </li></ul><ul><li>More likely to be admitted or re-visit ED </li></ul><ul><li>Use more resources – </li></ul><ul><li>hospital and community </li></ul><ul><li>Experience increased </li></ul><ul><li>rates of adverse outcomes </li></ul><ul><li> after ED visit </li></ul>
    4. 4. ED / Outpt Environment for Older Patients <ul><li>Can lead to iatrogenic complications- decubitus, dehydration, decreased food intake, falls </li></ul><ul><li>Increases anxiety </li></ul><ul><li>High level of ambient noise </li></ul><ul><li>Lighting – poor, glare </li></ul><ul><li>Physically does not meet aging needs </li></ul><ul><li>Flow - fast </li></ul>
    5. 5. Hospital Process <ul><li>Use the disease-oriented model </li></ul><ul><li>Evaluate for consequences and single causative factor </li></ul><ul><li>Staff are frustrated by older patients’ presentations </li></ul>
    6. 6. NICHE and ENA <ul><li>Best Practices for older patients in ED: </li></ul><ul><li>More comprehensive evaluation </li></ul><ul><li>Screening tools for geriatric assessment </li></ul><ul><li>Recognize normal aging changes that affect assessment </li></ul><ul><li>Identify atypical presentations in this age group </li></ul><ul><li>Referral to resources </li></ul>
    7. 7. Atypical Disease Presentation <ul><li>By assessing older patients for atypical presentations, nurses provide appropriate interventions and prevent complications / crises. </li></ul>
    8. 8. Signs and Symptoms Learn baseline prior to illness Remember aging changes Recognize presenting symptoms
    9. 9. Baseline prior to illness <ul><li>Variability </li></ul><ul><li>Verify </li></ul><ul><li>Frailty </li></ul>
    10. 10. Aging Effect <ul><li>Non specific </li></ul><ul><li>Less acute </li></ul><ul><li>Slow to present </li></ul>
    11. 11. Presenting Symptoms Signs and symptoms in older patients are generalized and can represent any number of medical situations.
    12. 12. Atypical Disease Presentation : UTI <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite, perhaps abdominal discomfort, perhaps foul smell to urine </li></ul><ul><li>Signs </li></ul><ul><li>incontinence, trips/fall, less sharp thinking, perhaps temperature </li></ul><ul><li>Lab </li></ul><ul><li>urine- WBC, bacteria; perhaps WBCs elevated in blood work </li></ul>
    13. 13. Atypical Disease Presentation: Pneumonia / URI <ul><li>Symptoms </li></ul><ul><li>poor appetite, functional decline, weakness, perhaps cough, perhaps shortness of breath </li></ul><ul><li>Signs </li></ul><ul><li>respiratory rate, tripping/fall, perhaps temperature; less sharp thinking </li></ul><ul><li>Lab </li></ul><ul><li>WBC ?, cxr ?, </li></ul>
    14. 14. Atypical Disease Presentation: Skin Infection <ul><li>Symptoms </li></ul><ul><li>tired, some tenderness </li></ul><ul><li>Signs </li></ul><ul><li>increased color, maybe swelling, drainage </li></ul><ul><li>Lab </li></ul><ul><li>blood- ? </li></ul>
    15. 15. Atypical Disease Presentation: Heart Failure with Pulmonary Edema <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite, perhaps shortness of breathe or leg swelling </li></ul><ul><li>Signs </li></ul><ul><li>perhaps rales; less sharp </li></ul><ul><li>thinking </li></ul><ul><li>Lab </li></ul>
    16. 16. Atypical Disease Presentation: Myocardial Infarction <ul><li>Symptoms </li></ul><ul><li>fatigue, weak, restless, shortness of breath, perhaps pain </li></ul><ul><li>Signs </li></ul><ul><li>perhaps syncope, less mental sharpness, perhaps confusion </li></ul><ul><li>Lab </li></ul><ul><li>cardiac enzymes </li></ul>
    17. 17. Atypical Disease Presentation: Pulmonary Emboli <ul><li>Symptoms: </li></ul><ul><li>perhaps chest pain with inspiration, perhaps shortness of breath </li></ul><ul><li>Signs: </li></ul><ul><li>elevated HR, tachypnea, rales; perhaps LE symptoms of DVT, dyspnea </li></ul><ul><li>Lab: </li></ul><ul><li>positive D-dimer; perhaps ABGs changes </li></ul>
    18. 18. More Atypical Presentations <ul><li>Acute abdomen </li></ul><ul><li>with constipation and decreased appetite, rather than severe pain </li></ul><ul><li>D epression </li></ul><ul><li>with agitation, rather than dysphoria </li></ul>
    19. 19. Case <ul><li>86 yo man is admitted to ED for c/o progressive weakness and fatigue: unable to carry out his normal daily activities, 2 falls. </li></ul><ul><li>He lives with his wife in their home. He was independent in all ADL’s and IADLs. He enjoyed his garden daily and worked part time at a real estate office. </li></ul>
    20. 20. Case <ul><li>He is cooperative, pleasant and looks quite well. No history of dyspnea or coughing. He has an IV going and waiting for more lab tests. He requires assistance to get to the bathroom. </li></ul><ul><li>Report from previous shift: he has bilateral basilar rales; temp 99.2, Resp 20; BP unchanged; remains weak; up to bathroom numerous times; no complaints of pain but did not sleep well and is restless </li></ul>
    21. 21. Symptom Presentation in Older Adults <ul><li>Baseline: independent ADLs, IADLs, very active self sufficient; no dyspnea or cough </li></ul><ul><li>Symptoms </li></ul><ul><li>fatigue, unable to do ADLs, requires assistance to ambulate to BR </li></ul><ul><li>Signs </li></ul><ul><li>restless, bilateral basilar rales, little sleep; Temp 99.2; resp 20 </li></ul><ul><li>Lab: none available </li></ul>
    22. 22. Clinical Pearls <ul><li>Symptoms: vague, less acute, slow to present </li></ul><ul><li>Compare to normal baseline </li></ul><ul><li>Assess for potential causes </li></ul>
    23. 23. Older Patients in the ED: Best Practices Dee Tucker RN, MN, GCNS-BC Clinical Nurse Specialist Gerontology Piedmont Hospital
    24. 24. Your ED Setting <ul><li>What is routinely assessed with older patients now? </li></ul><ul><li>How do you make the ED experience geriatric specific? </li></ul>
    25. 25. Geriatric Specific Assessment of Older Patients in ED <ul><li>Screen all patients 70 and older because: </li></ul><ul><li>Easy to miss abnormalities in mental status </li></ul><ul><li>Affects reliability of history </li></ul><ul><li>Pick up on symptoms of medical emergency- delirium </li></ul><ul><li>Can indicate need for further outpt evaluation </li></ul><ul><li>Affects discharge plan </li></ul>
    26. 26. Screening Tools <ul><li>1 st Delirium </li></ul><ul><li>CAM Confusion Assessment Method </li></ul><ul><li>2 nd Cognition </li></ul><ul><li>Orientation x 3 </li></ul><ul><li>MiniCog, if abnormal then MMSE </li></ul><ul><li>Depression Screen </li></ul><ul><li>3 rd Function </li></ul><ul><li>Get Up and Go </li></ul><ul><li>ADLs in order of progression </li></ul>
    27. 27. Assessment for Delirium <ul><li>CAM Confusion Assessment Method </li></ul><ul><li>Acute onset; fluctuating </li></ul><ul><li>Inattentive </li></ul><ul><li>Disorganized thinking </li></ul><ul><li>ALOC </li></ul><ul><li>Delirium = 1 & 2 are present with either #3 or #4 </li></ul>
    28. 28. CAM- Inattention <ul><li>Tests of attention </li></ul><ul><ul><li>Count backwards from 20. </li></ul></ul><ul><ul><li>State days of week forward & backward </li></ul></ul><ul><ul><li>Repeat the following sequence 7-5-8-3-6 </li></ul></ul><ul><ul><li>Letters </li></ul></ul><ul><li>S A V E H A A R T </li></ul><ul><li>Pictures for critical care units </li></ul>
    29. 29. CAM- Disorganized Thinking <ul><li>Yes/No Questions Set A or Set B </li></ul><ul><li>Score less than 4= positive </li></ul><ul><li>Then a Command </li></ul><ul><li>Will stone float? </li></ul><ul><li>Are there fish in the sea? </li></ul><ul><li>Does 1 pound weigh more than 2 pounds? </li></ul><ul><li>Can you use a hammer to pound a nail? </li></ul><ul><li>Will a leaf float on water? </li></ul><ul><li>Are there elephants in the sea? </li></ul><ul><li>Do 2 pounds weigh more than 1 pound? </li></ul><ul><li>Can you use a hammer to cut wood? </li></ul>
    30. 30. CAM-Altered Level of Consciousness <ul><li>Alert </li></ul><ul><li>Hyperalert </li></ul><ul><li>Lethargic </li></ul><ul><li>Stuporous, comatose </li></ul><ul><li>Anything other than alert = positive </li></ul>
    31. 31. CAM <ul><li>CAM Confusion Assessment Method </li></ul><ul><li>Acute onset; fluctuating if no-stop </li></ul><ul><li>Inattentive if no-stop </li></ul><ul><li>Disorganized thinking </li></ul><ul><li>ALOC </li></ul><ul><li>Delirium = 1 & 2 are present with either #3 or #4 </li></ul>
    32. 32. MINI –COG <ul><li>Cued recall, Clock Drawing Test </li></ul><ul><ul><li>1. Ask the patient to listen carefully to and remember following 3 words and then to repeat the words back to you: Ocean Desk Tractor </li></ul></ul><ul><ul><li>2. Instruct the patient to draw the face of a clock, including the numbers and hands pointing to 11 : 10. </li></ul></ul><ul><ul><li>3. Ask the patient to repeat the 3 previously presented words. </li></ul></ul>
    33. 33. Mini-Cog Score <ul><li>One point for each word remembered correctly. </li></ul><ul><li>Clock drawing is Nl or Abn </li></ul><ul><li>All numbers present, in correct quadrants, and hands show correct time </li></ul><ul><li>Fail= Abnormal clock OR recall 0 words </li></ul><ul><li> Then need MMSE </li></ul>
    34. 34. MMSE Orientation : year, season, date, day, month 5 points State, county, town, hospital, floor 5 points Registration : Name 3 objects; ask pt to repeat; 1 point for each correct 3 points Attention and calculation : spell “world” forwards, then backwards OR Subtract 7 from 100 5 times 5 points Recall: ask for 3 objects given earlier 3 points Language : Show pencil and watch- ask to name 2 points Ask to repeat “ No ifs, ands or buts” 1 point Follow 3 stage command “Take this paper in your right hand, Fold it in half and place it on the floor” 3 points Read and Obey “Close Your Eyes” 1 point Write a sentence 1 point Copy the design intersecting pentagons 1 point
    35. 35. MMSE Scoring <ul><li>Score MMSE is affected by education level, age, primary language </li></ul><ul><li> 27 and above considered nl </li></ul><ul><li> 26 to 23 suggests borderline issues </li></ul><ul><li> 22 and below are abn </li></ul><ul><li>What does it mean to you? </li></ul><ul><li>Score below 27 suggests cognitive impairment. This will impact reliability of information, ability to retain-follow-process instructions, is a consideration in discharge planning. Further evaluation is needed- perhaps as outpt. </li></ul>
    36. 36. GDS 5/15 Short Form <ul><li>Each answer indicated by * counts as 1 point </li></ul><ul><li>Are you basically satisfied with your life? Yes No* </li></ul><ul><li>Do you often get bored? Yes* No </li></ul><ul><li>Do you often feel helpless? Yes* No </li></ul><ul><li>Do you prefer to stay at home rather than going out and doing things? Yes* No </li></ul><ul><li>Do you feel worthless the way you are now? Yes* No </li></ul><ul><li>Score 1 or less- stop; 2 or more, continue with other 10 questions </li></ul>
    37. 37. Documentation <ul><li>“ CAM does not suggest delirium” OR </li></ul><ul><li>“ CAM suggest delirium: sudden onset, unable to count backwards from 20, hyperalert” </li></ul><ul><li>“ MiniCog does not suggest impaired cognition” OR </li></ul><ul><li>“ MiniCog: recalled 0/3 words; failed clock drawing- suggested impaired short term memory and executive function at this time” </li></ul>
    38. 38. Documentation <ul><li>“ MMSE: scored 25/30; deficits in orientation to date, 0/3 on recall, unable to copy pentagons; suggests impaired cognition” </li></ul><ul><li>“ Geriatric Depression Screen does not suggest depression at this time “OR </li></ul><ul><li>“ Geriatric Depression screen: scored 5 out of 15 …………..” </li></ul>
    39. 39. Functional Assessment <ul><li>Get Up and Go </li></ul><ul><li>rise from sitting in chair, walk toward a wall, turn and walk back, then sit down </li></ul><ul><li>ADLs- activities of daily living </li></ul><ul><li>IADLs- instrumental activities of daily living </li></ul>
    40. 40. Functional Assessment <ul><li>Get Up and Go: </li></ul><ul><li>Balance Gait </li></ul><ul><li>Sitting Step height,length </li></ul><ul><li>Rising Step Symmetry Standing Step Continuity </li></ul><ul><li>Walking Path </li></ul><ul><li>Turning </li></ul><ul><li>Sitting down </li></ul>Red Flag: Unsafe use of ambulation aids
    41. 41. Functional Assessment <ul><li>ADLs </li></ul><ul><ul><li>Bathing </li></ul></ul><ul><ul><li>Dressing </li></ul></ul><ul><ul><li>Toileting </li></ul></ul><ul><ul><li>Transfers </li></ul></ul><ul><ul><li>Continence </li></ul></ul><ul><ul><li>Feeding </li></ul></ul><ul><ul><li>Dependent or independent </li></ul></ul>Order of “Normal” Decline: Difficulties begin with most physically challenging task at top and progress to least - feeding
    42. 42. Functional Assessment <ul><li>IADLs </li></ul><ul><ul><li>phone, travel, shop, </li></ul></ul><ul><ul><li>prepare meals, </li></ul></ul><ul><ul><li>housework, medications, </li></ul></ul><ul><ul><li>money </li></ul></ul>
    43. 43. Documentation <ul><li>“ Get Up and Go: uses arms to rise, steps clear floor, short step length; uses walker safely; no unsteadiness with gait; balance steady at all times” </li></ul><ul><li>“ ADLs/IADLS: independent in ADLs; requires assistance with some IADLs- lives with daughter who assists; verified with daughter- Elizabeth Crocker” </li></ul>
    44. 44. Best Practices for Older Adults <ul><li>Geriatric Assessment if over 70 years for </li></ul><ul><li>Delirium </li></ul><ul><li>Cognition </li></ul><ul><li>Depression </li></ul><ul><li>Function </li></ul><ul><li>Information obtained: </li></ul><ul><li>Determine reliability of informant </li></ul><ul><li>Picks up on symptoms often missed </li></ul><ul><li>Identify need for further evaluation </li></ul><ul><li>Affect discharge plan </li></ul>
    45. 45. Pressure Ulcer Prevention in the ED
    46. 46. Why Preventing Skin Breakdown Is Important <ul><li>The number of hospital patients who develop pressure sores has risen by 63% over the last 10 years and nearly 60,000 deaths occur every year from hospital-acquired pressure sores. </li></ul><ul><li>The average stay for patients admitted to the hospital for treatment of hospital-acquired pressure sores was 13 days, with an average cost of $37,500 dollars per hospital stay . </li></ul>
    47. 47. Why Preventing Skin Breakdown Is Important <ul><li>Nonpayment by Medicare </li></ul><ul><li>Medicare has made a provision that they will not pay for treatment of hospital acquired pressure ulcers. </li></ul><ul><li>This could result in millions of lost revenue for the hospital. </li></ul>
    48. 48. ED Setting <ul><li>Triage for acuity </li></ul><ul><li>Instructions to patients </li></ul><ul><li>Support surfaces in ED </li></ul><ul><li>Average stay, “Boarding” </li></ul>
    49. 49. Initial Assessment is Imperative <ul><li>A full assessment of the patient’s skin must occur on any admitted patient! </li></ul><ul><li>Documentation of any existing skin breakdown must be charted on admission to the ED. If this is not done the hospital will not be paid for pressure ulcer treatment because it will be assumed it was hospital acquired. </li></ul>
    50. 50. Pressure Ulcer Risk Factors <ul><li>Age </li></ul><ul><li>Limited mobility </li></ul><ul><li>Malnutrition/ </li></ul><ul><li>dehydration </li></ul><ul><li>Moisture </li></ul><ul><li>Pressure ulcers in the past </li></ul><ul><li>Mental, neurological and other physical problems </li></ul><ul><li>Friction & sheering </li></ul><ul><li>Wrinkled sheets or hard objects left in the bed. </li></ul>
    51. 51. Age <ul><li>Normal aging process changes the skin and circulation </li></ul><ul><li>Skin can become dry and very fragile </li></ul><ul><li>Skin can be easily irritated, break open in to a sore and can tear easily </li></ul><ul><li>Older patients may have poor circulation- less O2 to the tissue </li></ul>
    52. 52. Lack of Mobility <ul><li>Pressure ulcers can start within </li></ul><ul><li>1-2 hours. ED average length of stay is 4 hours. </li></ul><ul><li>Pressure ulcers can form from unrelieved pressure in a chair, wheel chair, or bed. </li></ul>
    53. 53. Lack of Mobility continued <ul><li>The weight of the body pushes against a bony area to cut off the blood and O2 to the area. </li></ul><ul><li>The sacrum, hips, spine, elbows, ears, shoulders, toes and heels are areas that can break down if a pt is kept in one position for a long period of time. </li></ul>
    54. 54. Nutrition/Hydration <ul><li>Older patients have decreased reflex to drink. </li></ul><ul><li>The skin and other tissues of the body do not get the food and nutrition they need to stay healthy and to repair damaged skin. </li></ul>
    55. 55. Unwanted Moisture <ul><li>Incontinence of urine or stool, and sweat </li></ul><ul><li>Draining wounds over areas of a boney prominence </li></ul>
    56. 56. Mental, Neurological and other physical problems <ul><li>Confused or sleepy patients may not turn themselves like alert patients. </li></ul><ul><li>People who have a lessened sensation to pain or do not have the physical ability to turn are at risk for pressure ulcers. </li></ul><ul><li>Comatose patients are at HIGH risk! </li></ul>
    57. 57. Friction and Sheering <ul><li>Friction and sheering occur when a patient is pulled up in the stretcher, bed or chair. </li></ul><ul><li>These forces can irritate the skin and can cause the skin to break down. </li></ul>
    58. 58. Bed Sheets and Objects left in Bed <ul><li>Uneven pressure is created when sheets are wrinkled. This can lead to pressure ulcers. </li></ul><ul><li>Objects such as spoons, tissue boxes, food crumbs, and other hard objects left in the bed or chair can cause pressure ulcers. </li></ul>
    59. 59. Pressure Ulcers in the Past <ul><li>Patients who have had a pressure ulcer in the past are at greater RISK of getting another one. </li></ul>
    60. 60. How do Pressure Ulcers Form <ul><li>A warning sign of a pressure ulcer is when pink skin on a bony area turns deep red and is slow to blanch after pressure is relieved. </li></ul><ul><li>Blood cells have “rushed” to the area of pressure turning the skin red </li></ul>
    61. 61. How do Pressure Ulcers Form? <ul><li>The skin may become red and irritated if this pt is not turned. The skin may now feel very warm and the patient may tell you they feel a burning area. </li></ul><ul><li>Top layers of the skin break away and then move downward to layers of skin, muscles, bone or joint . </li></ul><ul><li>The muscle and bone become damaged </li></ul>
    62. 62. Prevention <ul><li>Visual inspection and palpation of high risk areas </li></ul><ul><li>Cue patient or change their position frequently; bridge heels </li></ul><ul><li>Ambulate </li></ul><ul><li>Hydrate if possible </li></ul><ul><li>Toilet </li></ul><ul><li>Work for change in your ED </li></ul>
    63. 63. Documentation <ul><li>Repositioning and comfort measures </li></ul><ul><li>All existing pressure ulcers must be documented on describing the </li></ul><ul><li>stage of ulcer </li></ul><ul><li>location </li></ul><ul><li>color </li></ul><ul><li>drainage </li></ul><ul><li>size </li></ul><ul><li>treatment of pressure ulcer </li></ul>
    64. 64. Urinary Incontinence and the ED
    65. 65. Aging Changes <ul><li>Increased nocturia (1-2x/night >60) </li></ul><ul><li>Bladder fills full at lower volumes </li></ul><ul><li>Reduced strength of bladder contractions </li></ul><ul><li>Increased irritability of bladder </li></ul><ul><li>Delayed recognition of bladder filling </li></ul><ul><li>Incontinence is NOT normal aging </li></ul>
    66. 66. Types <ul><li>Stress – jumping jack </li></ul><ul><li>Urge / Overactive bladder- Detrol </li></ul><ul><li>Mixed- 90% </li></ul><ul><li>Retention with overflow </li></ul><ul><li>Total </li></ul><ul><li>Reflex </li></ul><ul><li>Functional </li></ul>
    67. 67. Functional Incontinence <ul><li>Frequently seen in hospital </li></ul><ul><li>Normal voiding patterns & normal bladder function; usually related to cognitive status, motivation, and/or mobility issues </li></ul><ul><li>DON’T assume new or increased incontinence is functional </li></ul><ul><li>DO provide scheduled opportunities to toilet </li></ul>
    68. 68. Reversible Factors <ul><li>D – Delirium </li></ul><ul><li>I – Infection / Irritants </li></ul><ul><li>A – Atrophic urethritis / vaginitis </li></ul><ul><li>P – Pharmaceuticals </li></ul><ul><li>P – Psychological causes </li></ul><ul><li>E – Endocrine causes (Excess urine) </li></ul><ul><li>R – Restricted Mobility </li></ul><ul><li>S – Stool impaction </li></ul>
    69. 69. Criteria for Indwelling Urinary Catheter CDC <ul><li>Critically Ill : Alteration in BP or volume status requiring continuous, accurate urine volume measurement </li></ul><ul><li>Infection Prevention : to prevent urine from soiling a Stage III or IV pressure ulcer or nearby operative site </li></ul><ul><li>Comfort care : for terminally ill patients </li></ul><ul><li>Surgery : patients going directly to the operating room </li></ul><ul><li>Procedures or Tests requiring an indwelling urinary catheter, removed at the conclusion of the procedure/test </li></ul>
    70. 70. Criteria for Indwelling Urinary Catheter cont <ul><li>GU Indications </li></ul><ul><ul><li>Continuous bladder irrigation </li></ul></ul><ul><ul><li>Instillation of medication into the bladder </li></ul></ul><ul><ul><li>Obstruction to the urinary tract distal to bladder </li></ul></ul><ul><ul><li>Drainage in patient with neurogenic bladder dysfunction, hydronephrosis, and urinary retention not manageable by other means (e.g., with clean intermittent catheterization) </li></ul></ul><ul><ul><li>Aid in urologic surgery or other surgery in contiguous structures </li></ul></ul><ul><ul><li>Ordered by a urologist for a special purpose or difficult insertion </li></ul></ul>
    71. 71. Foley Catheters <ul><li>An indwelling urinary catheter is not appropriate for nursing convenience </li></ul><ul><li>Not Appropriate for urinary incontinence- use barrier creams. </li></ul><ul><li>Assess frequently whether catheter is still needed </li></ul>
    72. 72. Foley Catheters <ul><li>CAUTIs- one of CMS Never Events </li></ul><ul><li>Most effective method to prevent CAUTIs is to AVOID indwelling catheters </li></ul>
    73. 73. Foley Catheters- if MUST have <ul><li>Aseptic technique, </li></ul><ul><li>Closed system, </li></ul><ul><li>Inflate balloon completely </li></ul><ul><li>Secured to leg </li></ul>
    74. 74. Emergency Dept <ul><li>Gateway for most of our older patients </li></ul><ul><li>Ability to initiate change in practice that will carry through the admission </li></ul><ul><li>Eliminate a risk that prolongs LOS and had financial impact </li></ul>
    75. 75. Pain in Older Adults Dee Tucker RN, MN, GCNS-BC Clinical Nurse Specialist Gerontology Piedmont Hospital
    76. 76. Prevalence <ul><li>Community dwelling seniors- 50% </li></ul><ul><li>Nursing home residents 70 to 80%, with 45% have persistent pain </li></ul><ul><li>Associated with high rates of chronic disease in advanced age: arthritis, back pain </li></ul><ul><li>Pain is very common experience yet poorly managed </li></ul>
    77. 77. Common Myths <ul><li>Pain is an expected consequence of aging. </li></ul><ul><li>Barriers to pain relief / patient’s fears: </li></ul><ul><ul><li>They will become addicted to opioids </li></ul></ul><ul><ul><li>They will have side effects from the drugs </li></ul></ul><ul><ul><li>Increasing pain means that the disease is getting worse </li></ul></ul><ul><ul><li>They worry about being a good patient </li></ul></ul>
    78. 78. Pain <ul><li>Acute: from disease process or soft tissue injury, localized, responds to tx </li></ul><ul><li>Chronic: neuropathic- pathology in peripheral or CNS, more diffuse, less responsive to tx, not always be linked to a specific cause </li></ul>
    79. 79. Effects of Unrelieved Pain <ul><li>Elevated blood pressure </li></ul><ul><li>Increased heart rate </li></ul><ul><li>Depression </li></ul><ul><li>Sleep disturbance </li></ul><ul><li>Impaired mobility / function </li></ul>
    80. 80. Effects of Unrelieved Pain <ul><li>Decreased social interactions </li></ul><ul><li>Contributes to: falls, deconditioning, malnutrition, lowered QOL </li></ul><ul><li>Chronic pain sufferers can develop a decrease in their pain threshold </li></ul>
    81. 81. Pain Treatment <ul><li>Gold standard: self assessment </li></ul><ul><li>Cognitive status  Pain </li></ul><ul><li>Goal- max function and QOL </li></ul><ul><li>Preventive approach- use less med: round clock, pre-medicate </li></ul>
    82. 82. Pain Treatment- Dementia <ul><li>Assessment: rely on observation </li></ul><ul><li>Behaviors: rocking, increased or decreased activity level from their normal, changes in typical behaviors </li></ul><ul><li>Dementia: situation where you suspect may have pain- do clinical trial of pain med and non pharmacological strategies </li></ul>
    83. 83. Pain Treatment <ul><li>Tolerance- decrease drug effectiveness over time </li></ul><ul><li>Dependence- uncomfortable symptoms with abrupt withdrawal </li></ul><ul><li>Addiction: psych condition characterized by compulsive drug use and craving </li></ul>
    84. 84. Pain Treatment <ul><li>Opioids </li></ul><ul><li>Transdermal fentanyl </li></ul><ul><li>Tramadol hydrochloride </li></ul>
    85. 85. Pain Treatments to Avoid <ul><li>Demerol meperidine </li></ul><ul><li>Proxpoxyphene and combo products – Darvon, Dravocet, Darvon N, Darvocet N </li></ul><ul><li>Toradol ketorolac </li></ul><ul><li>Talwin pentazocine </li></ul>
    86. 86. Pain <ul><li>What are your biggest issues with pain and older adults in the ED? </li></ul>
    87. 87. Health Literacy in Older Adults Patient/Family Issues
    88. 88. A Quote from the AMA <ul><li>“ Communication, essential for the effective delivery of healthcare, is perhaps one of the most powerful tools in a Clinician’s arsenal. Unfortunately, there is often a mismatch between a Clinician’s level of communication and a patient’s level of comprehension. In fact, evidence shows that patients often misinterpret or do not understand medical information given to them by Clinicians. This lack of understanding can lead to medication errors, missed appointments, adverse medical outcomes, and even malpractice lawsuits.” </li></ul>
    89. 89. Health Literacy Defined by the AMA <ul><li>“ Health Literacy is the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment.” </li></ul>
    90. 90. More important then ever <ul><li>Medical care is growing increasingly complex </li></ul><ul><li>Patients are being treated with more and more medications </li></ul><ul><li>We discharge “quicker and sicker” when the patients are “well enough” </li></ul>
    91. 91. Implications for low health literacy <ul><li>Leads to poor health outcomes </li></ul><ul><li>Is the best predictor of health status </li></ul><ul><li>Leads to higher healthcare costs </li></ul>
    92. 92. Points to Ponder <ul><li>Nearly half of U.S. population has low literacy </li></ul><ul><li>It affects all segments of the population </li></ul><ul><li>It costs the United States between $50 billion and $73 billion a year </li></ul>
    93. 93. Key Risk Factors for Low Health Literacy <ul><li>Elderly </li></ul><ul><li>Low income </li></ul><ul><li>Unemployed </li></ul><ul><li>Did not finish high school </li></ul><ul><li>Minority ethnic group </li></ul><ul><li>Recent immigrant to the U.S. and does not speak English </li></ul><ul><li>English is a second language </li></ul>
    94. 94. Examples of Some Patient Issues and Misunderstandings
    95. 95. Red Flags - Behaviors <ul><li>Forms are incomplete </li></ul><ul><li>Missed appointments </li></ul><ul><li>Noncompliance with medications </li></ul><ul><li>Lack of follow-through with diagnostics </li></ul><ul><li>Clinical values don’t support patient’s report of taking medications or following dietary restrictions as prescribed </li></ul>
    96. 96. Red Flags – Verbal Responses <ul><li>“I forgot my glasses. I’ll read this when I get home.” </li></ul><ul><li>“I forgot my glasses. Can you read this to me?” </li></ul><ul><li>“Let me take this home so I can discuss it with my children.” </li></ul>
    97. 97. Red Flags – Reviewing Medications <ul><li>Unable to name medication(s) </li></ul><ul><li>Unable to explain a medication’s purpose </li></ul><ul><li>Unable to explain timing of medication administration </li></ul><ul><li>Unable to explain basic health or diet concerns related to the medication </li></ul>
    98. 98. “Brown Bag Review” <ul><li>Does patient look at medication or read the label on the bottle? </li></ul><ul><li>Ask when they last took that medication </li></ul><ul><li>If the patient looks confused, suspect memorization </li></ul>
    99. 99. What is the patient reading? <ul><li>Your naicisyhp has dednemmocer that you need a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc. </li></ul>
    100. 100. What you really gave them <ul><li>Your physician has determined that you have a colonoscopy. Colonoscopy is a test for colon cancer. It involves inserting a flexible viewing scope into your rectum. You must drink a special liquid the night before the examination to clean out your colon. </li></ul>
    101. 101. Liability Concerns <ul><li>Clinician’s communication and attitude are factors in 75% or malpractice suits </li></ul><ul><ul><li>Inadequate explanations of diagnosis and treatment </li></ul></ul><ul><ul><li>Communication left patients feeling their concerns were ignored </li></ul></ul>
    102. 102. Steps for Improvement <ul><li>Create a shame free environment </li></ul><ul><li>Slow down </li></ul><ul><li>Use non-medical language </li></ul><ul><li>Draw pictures </li></ul><ul><li>Limit information and repeat it </li></ul><ul><li>Use “Teach-Back” technique </li></ul>
    103. 103. Teach Back <ul><li>Use simple language </li></ul><ul><li>Ask patient/family to repeat understanding of concept </li></ul><ul><li>Identify and correct misunderstandings </li></ul><ul><li>Ask to demonstrate understanding again </li></ul><ul><li>Repeat above until convinced of comprehension or inability to do so </li></ul>
    104. 104. Quote from a patient <ul><li>“ A good Nurse is not too busy to help, doesn’t use big words, sits down and listens, asks how you are doing and what is your problem. The Nurse asks how you want to be addressed, and doesn’t read your chart in front of you. Good Nurses tell you things in plain English and breaks things down to what’s really important. If you don’t understand what the nurse says, you are comfortable asking. If you still don’t understand, then they go out of their way to make sure you do.” </li></ul>
    105. 105. Questions?
    106. 106. Geriatric Syndromes Dee Tucker, MS, RN, GCNS-BC Clinical Nurse Specialist Gerontology Piedmont Healthcare NICHE Coordinator
    107. 107. Older Adult Presentations <ul><li>Complex problems due to </li></ul><ul><li>Diminished organ reserve </li></ul><ul><li>Concurrent chronic diseases </li></ul><ul><li>Acute disease </li></ul><ul><li>Normal aging changes </li></ul><ul><li>Accumulated effect= Geriatric Syndromes </li></ul>
    108. 108. Geriatric Syndromes <ul><li>Falls </li></ul><ul><li>Instability / Dizziness </li></ul><ul><li>Altered Mental Status </li></ul><ul><li>Functional Impairment / Malaise / FTT </li></ul>
    109. 109. Fall Syndrome <ul><li>Consequence: fracture, hematoma, joint injury, subdural hematoma </li></ul><ul><li>Falls are a sentinel event in older adult </li></ul><ul><li>Marker for serious often unrecognized, underlying illness or disability </li></ul>
    110. 110. Fall Syndrome <ul><li>Contributing Factors </li></ul><ul><li>Atypical presentations-Infection </li></ul><ul><li>Drug toxicity </li></ul><ul><li>Postural hypotension </li></ul><ul><li>Malnutrition </li></ul><ul><li>CNS disease </li></ul><ul><li>Elder abuse </li></ul><ul><li>Vestibular disease </li></ul><ul><li>Sensory loss </li></ul>
    111. 111. Fall Syndrome <ul><li>Aging Changes that predispose </li></ul><ul><li>Sensory deficits </li></ul><ul><li>Postural changes </li></ul><ul><li>Flexibility loss </li></ul>
    112. 112. Fall Syndrome <ul><li>Chronic Issues </li></ul><ul><li>Declining nutrition </li></ul><ul><li>Bowel and bladder issues </li></ul><ul><li>Cognition </li></ul><ul><li>Postural hypotension </li></ul>
    113. 113. Fall Syndrome <ul><li>Medications </li></ul><ul><li>Sedatives </li></ul><ul><li>Antihypertensives </li></ul><ul><li>Diuretics </li></ul><ul><li>Narcotics </li></ul>
    114. 114. Fall Syndrome <ul><li>Assessment </li></ul><ul><li>Baseline prior to illness </li></ul><ul><li>Orthostatic BP and HR </li></ul><ul><li>Geriatric assessment </li></ul><ul><li>Med review </li></ul><ul><li>Consider atypical disease </li></ul><ul><li>presentations </li></ul>
    115. 115. Fall Syndrome <ul><li>Interventions: </li></ul><ul><li>Address findings from assessment and critical thinking </li></ul><ul><li>Communicate findings </li></ul><ul><li>Referral </li></ul><ul><ul><li>Physical therapy / OT </li></ul></ul><ul><ul><li>HH RN </li></ul></ul><ul><ul><li>Family </li></ul></ul><ul><ul><li>PCP </li></ul></ul>
    116. 116. Instability / Dizzy Syndrome <ul><li>Contributing factors </li></ul><ul><li>Cardiovascular disease hx- MI, CVA, Angina </li></ul><ul><li>Infections </li></ul><ul><li>Depressive and anxiety symptoms </li></ul><ul><li>Gait impairments </li></ul><ul><li>Neurological syndrome </li></ul><ul><li>Postural blood pressure changes </li></ul><ul><li>Medications </li></ul><ul><li>Aging changes </li></ul>
    117. 117. Instability / Dizzy Syndrome <ul><li>Associated with increased risk for </li></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Functional disability </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul><li>Assessment and Interventions </li></ul></ul><ul><ul><li>Refer to Fall Syndrome </li></ul></ul>
    118. 118. Confusion / AMS Syndrome <ul><li>Potential causes: </li></ul><ul><li>acute confusion- Delirium </li></ul><ul><li>chronic confusion- Dementia </li></ul><ul><li>pseudo confusion- Depression </li></ul><ul><li>Combination of 3 D’s </li></ul>
    119. 119. Confusion / AMS Syndrome <ul><li>Delirium </li></ul><ul><li>Contributing Factors: Normal Aging Changes, Environment, Medications, Medical conditions, Procedures </li></ul><ul><li>3 Types: </li></ul><ul><li>Hyperactive, hyperalert </li></ul><ul><li>Hypoactive, hypoalert </li></ul><ul><li>Mixed </li></ul>
    120. 120. Confusion / AMS Syndrome <ul><li>Assessment </li></ul><ul><li>Baseline prior to illness </li></ul><ul><li>Orthostatic BP & HR </li></ul><ul><li>Geriatric Assessment </li></ul><ul><li>Repeat CAM if behavior changes </li></ul><ul><li>What does it mean if positive for delirium? </li></ul><ul><li>Need to find causes and correct </li></ul>
    121. 121. Confusion / AMS Syndrome <ul><li>Preventing / Treating Delirium </li></ul><ul><li>Ensure hydration and nutrition during visit </li></ul><ul><li>Support Cognition </li></ul><ul><li>Comfort, decrease stress </li></ul><ul><li>Use sensory aids </li></ul><ul><li>Encourage family to stay if able </li></ul>
    122. 122. Confusion / AMS Syndrome <ul><li>Interventions with Delirium </li></ul><ul><li>Collaboration </li></ul><ul><li>Safe environment </li></ul><ul><li>Prevent complications </li></ul><ul><li>Preventive actions listed </li></ul>
    123. 123. Confusion / AMS Syndrome <ul><li>Dementia </li></ul><ul><li>Chronic, progressive confusional state </li></ul><ul><ul><li>Compromise in at least three areas of following mental activities: </li></ul></ul><ul><ul><ul><li>Language </li></ul></ul></ul><ul><ul><ul><li>Memory </li></ul></ul></ul><ul><ul><ul><li>Visuospatial skills </li></ul></ul></ul><ul><ul><ul><li>Personality and emotional state </li></ul></ul></ul><ul><ul><ul><li>Executive Function (abstraction, judgment) </li></ul></ul></ul><ul><li>NOT A NORMAL PART OF AGING!!!! </li></ul>
    124. 124. Confusion / AMS Syndrome <ul><li>Clues: </li></ul><ul><li>Poor historian </li></ul><ul><li>Unable to recall medications but manages own </li></ul><ul><li>Refers to family to answer questions </li></ul><ul><li>Repeatedly and apparently unintentionally fails to follow directions </li></ul><ul><li>Difficulty finding right word or uses inappropriate word </li></ul><ul><li>Repeats stories or questions </li></ul><ul><li>Meds: Aricept (donepezil), Cognex (tacrine), Reminyl (galantamine/ galanthamine) and Exelon (rivastigmine), Namenda(memantine) </li></ul>
    125. 125. Confusion / AMS Syndrome <ul><li>Assessment </li></ul><ul><li>Baseline before this illness </li></ul><ul><li>Geriatric Assessment </li></ul><ul><li>If fails Mini Cog, then MMSE </li></ul><ul><li>May not do MMSE if has dx of dementia and has appropriate supervision / oversight and family/caregiver is present with pt </li></ul>
    126. 126. Confusion / AMS Syndrome <ul><li>What does it mean when fail MiniCog? </li></ul><ul><li>At this moment in time : </li></ul><ul><li>Fails recall- poor short term memory </li></ul><ul><li>Fails clock drawing- impaired executive function </li></ul><ul><li>Fails MMSE- indicates cognitive impairment </li></ul>
    127. 127. Confusion / AMS Syndrome <ul><li>Dementia Progression </li></ul><ul><li>Early Stage MMSE 20-29 </li></ul><ul><ul><li>Memory loss </li></ul></ul><ul><ul><li>Confusion about familiar places (begin to get lost) </li></ul></ul><ul><ul><li>Trouble handling money and paying bills </li></ul></ul><ul><ul><li>Making bad decisions due to impaired judgment </li></ul></ul><ul><ul><li>Withdrawal </li></ul></ul><ul><ul><li>Mood and personality changes, irritability </li></ul></ul><ul><li>Communication difficulties- loses track of conversations </li></ul>
    128. 128. Confusion / AMS Syndrome <ul><li>Middle Stage (2 to 10 years) MMSE 10-19 </li></ul><ul><ul><li>Increasing memory loss ,Shortened attention span, </li></ul></ul><ul><ul><li>Problems recognizing friends and family, problems with reading, writing </li></ul></ul><ul><ul><li>Difficulty thinking logically or to tell time </li></ul></ul><ul><ul><li>Inability to learn new things and Loss of impulse control </li></ul></ul><ul><ul><li>Restlessness, agitation, anxiety, tearfulness, wandering, late-day time disorientation and confusion </li></ul></ul><ul><ul><li>Hallucinations, delusions, suspiciousness, paranoia, irritability </li></ul></ul><ul><ul><li>Requires asst with ADLs </li></ul></ul><ul><ul><li>Communication- increased repeating, word finding issues </li></ul></ul>
    129. 129. Confusion / AMS Syndrome <ul><li>Late Stage MMSE: 0-9 </li></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Seizures, skin infections, difficulty swallowing </li></ul></ul><ul><ul><li>Groaning, moaning, grunting </li></ul></ul><ul><ul><li>Increased sleeping </li></ul></ul><ul><ul><li>Lack of bladder and bowel control </li></ul></ul><ul><ul><li>Communication-Person may repeat something over and over, or copy what nurse says </li></ul></ul>
    130. 130. Confusion / AMS Syndrome <ul><li>Nursing Management </li></ul><ul><li>Keep activities and conversations simple. </li></ul><ul><li>Re-orient only if appropriate </li></ul><ul><li>Support bowel and bladder control. Use scheduled toileting. </li></ul><ul><li>Limit number of staff caregiving/ entering room </li></ul><ul><li>The person needs to be carefully prepared for any changes </li></ul>
    131. 131. Confusion / AMS Syndrome <ul><li>Nursing Management </li></ul><ul><ul><li>Use three Rs: repeat, reassure and redirect / distract </li></ul></ul><ul><ul><li>Anxiety and catastrophic behaviors can result from noisy, crowded, chaotic environment </li></ul></ul><ul><ul><li>Use activity box items </li></ul></ul>
    132. 132. Confusion / AMS Syndrome <ul><li>If pt to return to community: </li></ul><ul><li>refer to Sixty plus for f/u with pt and family </li></ul><ul><li>Arrange appropriate oversight as needed </li></ul><ul><li>If pt admitted to hospital, include geriatric evaluation results in report to nurses </li></ul>
    133. 133. Confusion / AMS Syndrome <ul><li>Depression- pseudo dementia </li></ul><ul><li>lower mood tone </li></ul><ul><li>difficulty thinking </li></ul><ul><li>somatic changes precipitated by feelings of loss and / or guilt. </li></ul><ul><li>mimics dementia </li></ul>
    134. 134. Confusion / AMS Syndrome <ul><li>Contributing Factors </li></ul><ul><li>Brain neurotransmitter imbalance – predominately serotonin and dopamine </li></ul><ul><li>Alcohol and drugs </li></ul><ul><li>Heredity </li></ul><ul><li>Medications </li></ul><ul><li>Illnesses </li></ul>
    135. 135. Confusion / AMS Syndrome <ul><li>Behaviors with depression </li></ul><ul><li>Loss of interest </li></ul><ul><li>Fatigue </li></ul><ul><li>Irritability, agitation </li></ul><ul><li>Change in appetite </li></ul><ul><li>Sleep problems </li></ul><ul><li>Cognition difficulties </li></ul><ul><li>Suicidal ideation </li></ul>
    136. 136. Confusion / AMS Syndrome <ul><li>Risk Factors </li></ul><ul><li>Female </li></ul><ul><li>Social isolation </li></ul><ul><li>Unemployment or retirement </li></ul><ul><li>Widowed, divorced, or separated </li></ul><ul><li>Serious medical conditions, especially vascular problems </li></ul><ul><li>Uncontrolled pain </li></ul>
    137. 137. Confusion / AMS Syndrome <ul><li>Assessment: </li></ul><ul><li>Geriatric Assessment </li></ul><ul><li>Nutrition status </li></ul><ul><li>Personal appearance </li></ul><ul><li>Behaviors </li></ul><ul><li>What does GDS score mean: </li></ul><ul><li>if scores 1 or less on first 5 questions? </li></ul><ul><li>if scores 2 or more on first 5 questions? </li></ul><ul><li>if indicates possible depression? </li></ul><ul><li>What does this mean to you in the ED? </li></ul>
    138. 138. Confusion / AMS Syndrome <ul><li>Interventions </li></ul><ul><li>Explain concern to family / caregivers </li></ul><ul><li>Provide handout for family on signs </li></ul><ul><li>Encourage pt and family to discuss with PCP </li></ul>
    139. 139. Functional Impairment/Malaise/ FTT Syndrome <ul><li>Contributing Factors </li></ul><ul><li>Malnutrition </li></ul><ul><li>Depression </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Impaired function </li></ul><ul><li>Acute illness untreated </li></ul><ul><li>Medications </li></ul><ul><li>Pain </li></ul><ul><li>Abuse & neglect </li></ul><ul><li>Environmental issues </li></ul>
    140. 140. Functional Impairment/Malaise/ FTT Syndrome <ul><li>Presenting symptoms include: </li></ul><ul><li>weight loss, progressive </li></ul><ul><li>decline in physical abilities </li></ul><ul><li>decline in cognitive abilities </li></ul><ul><li>feelings of hopelessness, helplessness </li></ul>
    141. 141. Functional Impairment/Malaise/ FTT Syndrome <ul><li>Assessment: </li></ul><ul><li>Geriatric Assessment </li></ul><ul><li>Nutrition status </li></ul><ul><li>Personal appearance </li></ul><ul><li>Behaviors </li></ul><ul><li>Interventions </li></ul><ul><li>See other syndromes </li></ul><ul><li>Referrals </li></ul>
    142. 142. Key Points to Take Away <ul><li>Multiple causes </li></ul><ul><li>Geriatric Specific assessment if over 70 </li></ul><ul><li>Address findings from assessment and critical thinking </li></ul><ul><li>Clinically relevant to the patient </li></ul><ul><li>Communicate findings </li></ul><ul><li>Get consults / Make referrals </li></ul>
    143. 143. Transitioning Older Patients to community, facility or into hospital Tim Young, LCSW Sixty Plus Older Adult Services
    144. 144. Why is This Important? <ul><li>Frequent returns to ED or hospital </li></ul><ul><li>Greater risk for complications </li></ul><ul><li>Time and discharge planning </li></ul>
    145. 145. Transitions <ul><li>When transitioning a patient, consider: </li></ul><ul><li>Cognitive dysfunction </li></ul><ul><li>Functional status </li></ul><ul><li>Evaluation of ability to care for themselves </li></ul><ul><li>Need for caregiver/ oversight </li></ul><ul><li>Need for referral / resource information </li></ul>
    146. 146. Geriatric Assessments <ul><li>Cognitive Issues </li></ul><ul><li>Mobility </li></ul><ul><li>Activities of Daily Living (ADL’s) </li></ul><ul><li>Depression </li></ul><ul><li>Delirium </li></ul>
    147. 147. Barriers <ul><li>Language </li></ul><ul><li>Reading / Medical literacy </li></ul><ul><li>Hearing </li></ul><ul><li>Visual </li></ul><ul><li>Memory </li></ul>
    148. 148. Discharge Instructions <ul><li>Purpose </li></ul><ul><li>Educate on appropriate care </li></ul><ul><li>Inform on health issues and options </li></ul><ul><li>Notify of resources </li></ul><ul><li>Comply with regulations </li></ul>
    149. 149. Discharge Instructions <ul><li>Discharge Objectives </li></ul><ul><li>Limited number </li></ul><ul><li>Age-specific and appropriate </li></ul><ul><li>Format </li></ul>
    150. 150. Pop Quiz: Which is incorrect? <ul><li>Discharge Instructions: </li></ul><ul><li>Provide useful information on resources that they can use </li></ul><ul><li>Are difficult to teach because older adults can not learn as easily </li></ul><ul><li>Provide a sequence of steps for people to follow for health care </li></ul>
    151. 151. “4 Pillars of Care Transitions” <ul><li>Personal Health Record </li></ul><ul><li>Medication Knowledge </li></ul><ul><li>Follow up with PCP and/or Specialist </li></ul><ul><li>Red Flags </li></ul>
    152. 152. Home Health Referral <ul><li>Situations justifying HH evaluation (according to Medicare rules) </li></ul><ul><li>High risk for re-hospitalization </li></ul><ul><li>Complex discharge plan </li></ul><ul><li>Need for rehab services </li></ul><ul><li>Need for multiple medications </li></ul><ul><li>Physical limitations </li></ul>
    153. 153. Home Health Referral <ul><li>Situations justifying HH evaluation: (according to Medicare rules) </li></ul><ul><li>Deficits in mental or social functioning </li></ul><ul><li>New diagnosis or exacerbation of existing condition </li></ul><ul><li>Sudden weight loss or gain </li></ul><ul><li>Recent changes in cognition </li></ul>
    154. 154. Discharge Instructions and Older Patients Assess knowledge, barriers Limit Objectives Address barriers Provide scenarios “ Take home” materials
    155. 155. Medications and Older Adults Critical Thinking NaaDede Badger, Pharm.D, BCPS
    156. 156. Objectives <ul><li>Discuss polypharmacy and its risk in the elderly </li></ul><ul><li>Discuss pharmacokinetic and pharmacodynamic changes in the elderly </li></ul><ul><li>Adverse drug reactions and adherence </li></ul><ul><li>Underuse of drugs </li></ul><ul><li>Review medication related issues to keep in mind when taking care of the elderly </li></ul>
    157. 157. A look at the geriatric patient .. <ul><li>Complicated drug therapy </li></ul><ul><li>Increase in risk of adverse drug reactions (ADRs) </li></ul><ul><ul><li>Signifcant ADRs especially with drugs with narrow therapeutic windows, ex. Phenytoin, warfarin and theophylline. </li></ul></ul><ul><li>Increased risk of drug-drug interactions </li></ul><ul><li>Pharmacokinetic and pharmacodynamic changes </li></ul>
    158. 158. Social Issues <ul><li>Depression and poor medication adherence </li></ul><ul><li>Use of alcohol </li></ul><ul><li>Economic situations may lead to medication non-adherence </li></ul><ul><li>Cultural differences- 10% of older adults were born outside the US, 13% don’t speak English </li></ul><ul><li>>34% do not have high school diplomas </li></ul>GistYJ, Hetzel LI. We the People: Aging in the United States. Census 2000 Special Reports. December 2004 Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among Medicare beneficiaries. Health Aff (Millwood)2003;22:220-29
    159. 159. Case <ul><li>A 71 yof is admitted with c/o abdominal pain, n&v. Her PMH includes: ischemic colitis, HTN, CAD, chronic pruritis, PVD, and depression. Her meds at admission include: amiloride 5mg BID, ASA 81mg daily, Claritin 10mg daily , Coreg 6.25mg BID, DN-100 prn , Diovan 80mg BID, Hydroxyzine 30mg BID , Lantus 14units hs, magnesium oxide 400mg BID , Remeron 45mg qhs , K-Dur 30meq daily, Prevacid 40mg daily, Aldactone 12.5mg daily , Vitamin C 500mg daily, wellbutrin 300mg daily , Actonel 35mg weekly, demadex 40mg BID , Fibercon prn. </li></ul>
    160. 160. What are the issues with her med list?? <ul><li>Use of multiple anticholinergic agents can increase risk of falls, sedation. </li></ul><ul><li>Use of multiple antidepressants – need to assess and make sure she is supposed to be on both </li></ul><ul><li>Use of multiple diuretics including two potassium sparing diuretics </li></ul><ul><li>Use of multiple medications that can increase the risk of falls </li></ul><ul><li>? Need for Darvocet </li></ul><ul><li>Need for magnesium oxide – do we have a Mg level? </li></ul><ul><li>Need for Vitamin C?? </li></ul>
    161. 161. Polypharmacy <ul><li>Polypharmacy means “many drugs” usually more than 5 medications </li></ul><ul><li>Definition: The use of more medications than is clinically warranted or indicated </li></ul>
    162. 162. Why is polypharmacy common? <ul><li>The elderly have more disease states </li></ul><ul><li>More drugs available </li></ul><ul><li>Readily available drugs over the counter </li></ul><ul><li>Inappropriate prescribing </li></ul><ul><li>Lack of medication review </li></ul><ul><li>The “prescribing cascade” </li></ul>
    163. 163. “ Prescribing cascade” <ul><li>NSAIDs->HTN->antihypertensive therapy </li></ul><ul><li>Reglan->Parkinsonism->Sinemet </li></ul><ul><li>Calcium channel blocker->edema-> </li></ul><ul><li>lasix->potassium supplement </li></ul><ul><li>NSAIDs->H2 blocker->delirium->Haldol </li></ul><ul><li>Sudafed->Urinary retention->alpha blocker </li></ul>
    164. 164. Polypharmacy: Show me the #s!! <ul><li>Elderly make up 13% of population but consume ~ 30% of prescriptions 1 </li></ul><ul><li>Average elderly patient consumes </li></ul><ul><ul><li>2-6 prescription drugs and… </li></ul></ul><ul><ul><li>2-4 over-the-counter drugs </li></ul></ul><ul><li>Average nursing home patient is on 7 drugs </li></ul><ul><li>Average American senior spends ~ $2000 / yr on pharmaceuticals alone 2 </li></ul><ul><li>Williams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24 </li></ul><ul><li>Kamboj S, et a. Cost of Medications in elderly in a nursing home. JLA State Med Soc 1999;151(9):470-2 </li></ul>
    165. 165. Pharmacokinetics <ul><li>What the body does to the drugs </li></ul><ul><ul><li>Absorption </li></ul></ul><ul><ul><li>Distribution </li></ul></ul><ul><ul><li>Metabolism </li></ul></ul><ul><ul><li>Excretion </li></ul></ul>
    166. 166. Pharmacokinetics <ul><li>Absorption: not affected much by aging compared to some of the other parameters </li></ul><ul><ul><li>Reduced gastric emptying </li></ul></ul><ul><ul><li>Reduced gastric acid production </li></ul></ul><ul><ul><li>Reduced GI motility </li></ul></ul><ul><ul><li>Reduced GI blood flow </li></ul></ul><ul><li>Distribution </li></ul><ul><ul><li>Increased body fat and decreased total body water (due to decreased muscle mass) </li></ul></ul><ul><ul><li>Increased in volume of distribution of lipophilic drugs like sedatives ex. Diazepam (Valium ® ) </li></ul></ul>
    167. 167. Pharmacokinetics contd … <ul><li>Metabolism </li></ul><ul><ul><li>Reduced liver blood flow </li></ul></ul><ul><ul><li>Reduced liver metabolism </li></ul></ul><ul><ul><li>Reduced enzyme activities </li></ul></ul>
    168. 168. Common medications with decreased hepatic metabolism <ul><li>Meperidine (Demerol ® ) </li></ul><ul><li>Theophylline (Theo-Dur ® , etc) </li></ul><ul><li>Chlordiazepoxide (Librium ® ) </li></ul><ul><li>Diazepam (Valium ® ) </li></ul><ul><li>Desipramine (Norpramin ® ) </li></ul><ul><li>Quinidine </li></ul>
    169. 169. Pharmacokinetics contd <ul><li>Excretion – reduced by as much as 50% by age 75 </li></ul><ul><ul><li>Reduced glomerular filtration rate </li></ul></ul><ul><ul><li>SCr not a reliable indicator – need CrCl </li></ul></ul>
    170. 170. Medications with decreased renal clearance <ul><li>Aminoglycosides e.x. tobramycin, gentamicin, amikacin </li></ul><ul><li>Meperidine (Demerol ® ) </li></ul><ul><li>Digoxin (Lanoxin ® ) </li></ul><ul><li>Diuretics specifically HCTZ, furosemide, triamterene </li></ul><ul><li>Lithium </li></ul><ul><li>H 2 RA ( ex Tagamet, Zantac) </li></ul>
    171. 171. Pharmacodynamic changes <ul><li>What the drug does to the body: </li></ul><ul><ul><li>Increased Effects: </li></ul></ul><ul><ul><ul><li>Alcohol </li></ul></ul></ul><ul><ul><ul><li>Benzodiazepine </li></ul></ul></ul><ul><ul><ul><li>Warfarin </li></ul></ul></ul><ul><ul><ul><li>Phenergan </li></ul></ul></ul><ul><ul><ul><li>NSAIDs </li></ul></ul></ul><ul><ul><ul><li>Anticholinergics – ex. Benadryl ® </li></ul></ul></ul><ul><ul><li>Some effects are decreased: </li></ul></ul><ul><ul><ul><li>Insulin </li></ul></ul></ul><ul><ul><ul><li>HR response to beta blockers </li></ul></ul></ul>
    172. 172. Drug-disease Interactions <ul><li>Patient with PD have increased risk of drug induced confusion </li></ul><ul><li>NSAIDs (and Cox -2 Inhibitors) can exacerbate CHF </li></ul><ul><li>Urinary retention in BPH patients on decongestants and anticholinergics </li></ul><ul><li>Constipation worsened by calcium channel blockers and anticholinergics </li></ul><ul><li>Quinolones, ultram can lower seizure thresh-hold </li></ul><ul><li>Quinolones can affect blood sugar </li></ul>
    173. 173. Drugs and Falls <ul><li>Long acting benzodiazepines and other sedatives </li></ul><ul><li>Tri-cyclic anti-depressants and also SSRIs </li></ul><ul><li>Mild increase in risk but can be seen with diuretics, anti-arrhythmic, and digoxin </li></ul><ul><li>Beta-blockers have been shown NOT to have that significant of a risk </li></ul>
    174. 174. Drug-Food Interactions <ul><li>Remember warfarin and Vitamin K containing foods (don’t forget green tea) </li></ul><ul><li>Digoxin can cause anorexia </li></ul><ul><li>ACE-Inhibitors may alter taste </li></ul>
    175. 175. Hospitalization: A high risk time <ul><li>40% of medications are stopped during admission </li></ul><ul><li>45% of discharge medications were filled / started by patients </li></ul><ul><li>Prescribing problems considered serious seen in 22% of patients </li></ul><ul><li>Other prescribing problems up to 66% </li></ul>
    176. 176. Inappropriate medications in the elderly Sedatives & Hypnotic agents Chlordiazepoxide (Librium ® ) Antidepressants Amitriptyline (Elavil ® ) Antihypertensive agents Methyldopa Propranolol (Inderal ® ) Reserpine Analgesic agents Indomethacin (Indocin ® ) Propoxyphene (Darvon ® ) **also in Darvocet ® Pentazocine (Talwin ® ) Meperidine (Demerol ® )
    177. 177. Potentially inappropriate meds Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24 Potentially Inappropriate Safer alternatives Promethazine (Phenergan ® ) Prochlorperazine (Compazine ® ) Trimethobenzamide (Tigan ® ) Metoclopramide (Reglan ® ) Methyldopa (Aldomet ® ) Diuretics Diphenhydramine (Benadryl ® ) Loratidine (Claritin ® ), Fexofenadine (Allegra ® ) Indomethacin (Indocin ® ) Celecoxib (Celebrex) Chlordiazepoxide (Librium ® ) and Diazepam (Valium ® ) Lorazepam (Ativan) Amitriptyline (Elavil) – for depression SSRIs Fluoxetine (Prozac ® ) Sertraline (Zoloft ® ), Citalopram (Celexa ® ), Mirtazepine (Remeron ® )
    178. 178. Potentially inappropriate meds Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24 Potentially Inappropriate Safer alternatives Meperidine (Demerol ® ) Morphine Propoxyphene (Darvocet ® ) Percocet ® Diphenhydramine –for sleep Zolpidem (Ambien ® ) Diphenhydramine (Benadryl ® ) Loratidine (Claritin ® ), Fexofenadine (Allegra ® ) NSAIDs for arthritis Acetaminophen (Tylenol ® ) NSAIDs for gout Celecoxib (Celebrex ® )
    179. 179. Keep these in mind <ul><li>Acetaminophen: keep dose < 4000mg / day. Be mindful of combination products like Lortab & Percocet ® , Darvocet ® </li></ul><ul><li>Buproprion (Wellbutrin ® ) – few side effects but can cause insomnia so avoid giving it in the evening </li></ul><ul><li>Mirtazepine (Remeron ® ) – Good in patients with anorexia. Stimulates appetite </li></ul><ul><li>Antipsychotics – atypicals are best choice since older once have higher anticholinergic side effects. Atypical antipsychotics include: Quetiapine (Seroquel ® ), Risperidone (Risperdal ® ) </li></ul>
    180. 180. Do you have any room left, add these … <ul><li>Diphenhydramine (Benadryl ® ) – its use should be reserved for allergic reaction and itching only. Avoid for sedation </li></ul><ul><li>High dose thiazide diuretics ( > 25mg) </li></ul><ul><li>Zolpidem (Ambien ® ) – Best choice for sleep. Always start at 5mg dose (or lower) </li></ul><ul><li>For anxiety – low dose Lorazepam (Ativan ® ) – 0.5mg – 2mg </li></ul>
    181. 181. Formulations that shouldn’t be crushed <ul><li>CR (controlled release) </li></ul><ul><li>CRT (controlled-release tablet) </li></ul><ul><li>LA (long acting) </li></ul><ul><li>SR (sustained release) </li></ul><ul><li>TR (time release) </li></ul><ul><li>SA (sustained action) </li></ul><ul><li>XL or XR (extended release) </li></ul><ul><li>ER (extended release) </li></ul><ul><li>EC (Enteric Coated) </li></ul>
    182. 182. Herbs <ul><li>Some “so called” complementary therapies: </li></ul>DHEA / growth hormone Anti-aging Gingko biloba Dementia Saw Palmetto BPH Chondroitin/ glucosamine Osteoarthritis St. John’s wort/ SAMe Depression
    183. 183. Can we trust these products?? <ul><li>In 1998 California Dept of Health Services </li></ul><ul><ul><li>Screened 250 Asian herbal products </li></ul></ul><ul><li>32% contained unlabeled medications, 14% mercury, 14% arsenic, 10% lead </li></ul><ul><li>Ko, NEJM 1998;339:847 </li></ul>
    184. 184. Herbals & Supplements and Potential interactions with Rx <ul><li>SAMe increases homocysteine levels </li></ul><ul><li>Ginkgo may increase anticoagulant effects of Warfarin, ASA and may interact with MAO-Is </li></ul><ul><li>Rule of Thumb: Try and know what your patient is taking. </li></ul>
    185. 185. Conclusion <ul><li>Drug therapy in the elderly can be complicated due to several reasons. </li></ul><ul><li>Being vigilant and paying closer attention to the medication therapy can help reduce possible ADRs and drug-drug interactions. </li></ul><ul><li>Be diligent with medication reconciliation especially at discharge to make sure patient is not sent home on duplicate therapy. </li></ul><ul><li>Utilize your zone pharmacists for drug information. </li></ul>
    186. 186. Pager: 404-356-3729 Office: 404-605-2632 Cell: 404-788-2513
    187. 187. Elder Abuse and Neglect Dealing with this Difficult Topic when Patient is in the Hospital See PH Policy 2036
    188. 188. Identifying Elder Abuse <ul><li>Physical: </li></ul><ul><li>Bruises, Burns, Injuries to face or neck, Multiple injuries in various stages of healing, Evidence of restraint, Delay in treatment </li></ul><ul><li>Emotional: </li></ul><ul><ul><li>Ambivalence, Fear, Depression, Quiet, Low self-esteem, Paranoia, Anger </li></ul></ul><ul><li>Sexual: </li></ul><ul><li> Bruising on thighs, STDs, Bleeding, Pain Itching in genital area </li></ul>
    189. 189. Identifying Neglect Typical Concerns <ul><li>Abandonment </li></ul><ul><li>Dehydration </li></ul><ul><li>Poor Hygiene </li></ul><ul><li>Over/under use of medications </li></ul><ul><li>Unsafe conditions </li></ul><ul><li>Malnutrition </li></ul><ul><li>Financial exploitation </li></ul><ul><li>Missing assistive devices </li></ul>
    190. 190. What is YOUR Responsibility? What do You do next?
    191. 191. Mandatory Reporting <ul><li>The physician, nurse or case manager (medical personnel) must report suspected abuse/ neglect of a child or disabled adult to the appropriate authority. </li></ul>
    192. 192. Do you know whom you should contact? Who is the person on your floor to whom you would report your suspicions?
    193. 193. Process Involved <ul><li>Assess the situation </li></ul><ul><li>Inform the charge nurse, physician and case manager that you suspect abuse, neglect or domestic violence </li></ul><ul><li>Maintain the patient’s safety </li></ul><ul><li>Determine agency that has jurisdiction </li></ul>
    194. 194. Determine Jurisdiction <ul><li>For Elder Abuse or Neglect: Contact Adult Protective Services (APS) at 404-657-5250 </li></ul><ul><li>For Domestic Violence call county or city Police Dept. where patient resides </li></ul><ul><li>For Domestic Violence, Patient determines if police are to be called. </li></ul><ul><li>*Exception – Does situation meet guidelines consistent with Emergency Dept. Policy on Reportable Cases? </li></ul>
    195. 195. Hospital Policy <ul><li>Preserve and/or collect evidence </li></ul><ul><li>See Policy # PH2040 </li></ul><ul><li>Don’t release patient until authorized by APS </li></ul>
    196. 196. Be responsive to Patient’s needs <ul><li>Give patient opportunity for separation and privacy </li></ul><ul><li>Initiate discussion, share perception </li></ul><ul><li>Document findings in patient’s own words </li></ul><ul><li>Obtain photos when appropriate </li></ul><ul><li>Encourage patient to acknowledge risk and seek safe environment </li></ul><ul><li>Refer patient to appropriate resources </li></ul>
    197. 197. Document, Document, Document Patient’s Medical Record should include: <ul><li>Date and time authorities notified </li></ul><ul><li>Family structure and behaviors </li></ul><ul><li>History indicators </li></ul><ul><li>Physical indicators </li></ul><ul><li>Behavioral indicators </li></ul><ul><li>History and Physical exam sheet </li></ul><ul><li>Agency involvement – APS, Police </li></ul>
    198. 198. Case Presentation <ul><li>Frail looking 76 yo male w GI bleed. Malnourished and unkempt. Smells of urine and stale beer. </li></ul><ul><li>History indicates he is retired office worker. </li></ul><ul><li>Neighbor listed as emergency contact but you find out that “neighbor” is a man in his 30’s who has been staying with patient for an indefinite time. </li></ul><ul><li>Patient admits he is paying other man’s bills. Patient’s tone appears guarded, even fearful. Admits “friend” has threatened him but never actually struck him. </li></ul><ul><li>Patient fears that if man leaves no one will be there to help him. </li></ul><ul><li>What is your responsibility here? </li></ul>
    199. 199. Why Emergency Dept Nursing??? Can this work? Older patients in the ED.
    200. 200. Not designed for older people Medical approach: 1 problem fixes symptoms Have a “story to tell” Geriatric approach: look for all contributing causes ED
    201. 201. Some Thoughts <ul><li>Replaced “high touch” </li></ul><ul><li>with “high-tech </li></ul><ul><li>Hearing loss does not </li></ul><ul><li>equate to mental disability </li></ul><ul><li>Physical weakness does not mean that a person must be any less independent or intelligent </li></ul>
    202. 202. More Thoughts <ul><li>Slower response times does not mean staff should remove or limit patient’s choices </li></ul><ul><li>The ability to learn is not </li></ul><ul><li>impaired by age. </li></ul><ul><li>At triage evaluate for </li></ul><ul><li>cognitive impairment </li></ul>
    203. 203. Language <ul><li>Speech patterns </li></ul><ul><li>Forms of address </li></ul><ul><li>Speech register </li></ul><ul><li>Can affect older people- psychologically and their physical health </li></ul>
    204. 204. Perception vs Reality <ul><li>What does the older adult think of the speaker? </li></ul><ul><li>Less nurturing </li></ul><ul><li>Less competent </li></ul><ul><li>Less benevolent </li></ul><ul><li>Less respectful </li></ul>
    205. 205. Putting IT All Together Geriatrics in ED Nursing Drives Excellence
    206. 206. Pat Henson <ul><li>73-year-old female </li></ul><ul><li>1-week history of weakness and falling </li></ul><ul><li>Referred from a nursing home </li></ul><ul><li>Allergies: none </li></ul><ul><li>Medications: warfarin sodium, atenolol </li></ul><ul><li>Past medical history: stroke, dementia, atrial fibrillation, hypertension </li></ul>
    207. 207. Assessment <ul><li>VS: BP 104/58, P 102, R 24 </li></ul><ul><li>Awake, alert, responsive, cooperative </li></ul><ul><li>Does not feel very sick </li></ul><ul><li>Orthostatic vital signs </li></ul><ul><li>Feels &quot;fine&quot; on standing </li></ul><ul><li>BP drops to 92/50 </li></ul><ul><li>HR increases to 110 started </li></ul><ul><li>Tympanic temperature is 96.4ºF </li></ul>
    208. 208. ????? <ul><li>What are you thinking? </li></ul><ul><li>What would you like to do? </li></ul><ul><li>Repeat Temp- rectally </li></ul>
    209. 209. Assessment <ul><li>Rectal temperature 100.2ºF </li></ul><ul><li>Irregularly irregular heart rate, 108 BPM </li></ul><ul><li>BP 124/64 flat in bed </li></ul><ul><li>ECG shows atrial fibrillation and flattened ST </li></ul><ul><li>Pulse oximetry 98% </li></ul><ul><li>patient feels &quot;fine&quot; </li></ul>
    210. 210. Assessment <ul><li>Oriented to person, week & month, but not to date or year </li></ul><ul><li>Feels weak </li></ul><ul><li>Lacks appetite. </li></ul><ul><li>Doesn't remember falling </li></ul><ul><li>Feels fine now member </li></ul><ul><li>Wants to go back to NH </li></ul>
    211. 211. More Information <ul><li>How do you get more history? </li></ul><ul><li>Other Sources: </li></ul><ul><li>Nursing Home staff </li></ul><ul><li>Previous hospital record </li></ul><ul><li>Concern about the possibility of new stroke </li></ul><ul><li>Weakness worsening over the past week. </li></ul><ul><li>Has fallen 3 times including today </li></ul><ul><li>“ Isn't herself” </li></ul>
    212. 212. ADLs <ul><li>4 weeks ago This week </li></ul><ul><li>Bathing Unassisted uncooperative </li></ul><ul><li>Dressing Unassisted can't do buttons </li></ul><ul><li>Toileting Unassisted forgot to flush </li></ul><ul><li>Transfer Unassisted unassisted </li></ul><ul><li>Continence Intact incontinent 2 nights </li></ul><ul><li>Feeding Unassisted lacks appetite </li></ul>
    213. 213. Baseline Prior to This Illness <ul><li>No new medications </li></ul><ul><li>No previous surgery </li></ul><ul><li>Durable power of attorney with sister </li></ul><ul><li>Baseline mental status: Oriented to person & place, not oriented to year and date </li></ul><ul><li>Right-leg weakness </li></ul><ul><li>Aids: Bifocals, walker . </li></ul><ul><li>Baseline VS: BP 144/82; HR 68; T 97.4ºF </li></ul>
    214. 214. Reason for Transfer <ul><li>Feeling &quot;tired&quot; (1 week) </li></ul><ul><li>Staying in bed today </li></ul><ul><li>Not buttoning clothes (4 days) - </li></ul><ul><li>Falling to floor (3 times) </li></ul><ul><li>Bruising knees and elbows </li></ul><ul><li>Eating nothing today </li></ul>
    215. 215. What Information Next? <ul><li>You have the baseline prior to illness and time frame with changes- now what would you want? </li></ul><ul><li>Minicog / MMSE </li></ul><ul><li>CAM </li></ul><ul><li>Observe function/mobility </li></ul>
    216. 216. Mini Cog, MMSE, CAM <ul><li>Neurologic: </li></ul><ul><li>Mental status: Oriented to person </li></ul><ul><li>Fails clock drawing </li></ul><ul><li>Memory: 2 serial 7’s; recalls 0/3 items on recall. </li></ul><ul><li>Speech: Some difficulty repeating 3 items; no word errors; follows 2-step commands </li></ul><ul><li>CAM: Sudden onset? Inattentive? </li></ul>
    217. 217. Function / Mobility <ul><li>Motor: </li></ul><ul><li>No gross focal deficits other than right leg weakness;, </li></ul><ul><li>Gait: Refuses to walk without walker </li></ul><ul><li>Can raise rt leg off stretcher but can't hold it up against resistance; knee and ankle flexion and extension equally diminished </li></ul><ul><li>Sensation: Intact; reflexes right knee and ankle increased, with a positive Babinski's sign on the right </li></ul>
    218. 218. Possibilities <ul><li>What do you think her acute issues could be? What in her hx puts her at risk ? </li></ul><ul><li>Infections- what kind most common in NH? </li></ul><ul><li>Pneumonia </li></ul><ul><li>Intra-abdominal infection </li></ul><ul><li>Urinary Tract Infection </li></ul><ul><li>Meningitis </li></ul><ul><li>Skin infection </li></ul><ul><li>Endocarditis </li></ul>
    219. 219. Lab Results <ul><li>CXR clear </li></ul><ul><li>CT old left parietal infarct & generalized atrophy </li></ul><ul><li>CBC WBC 10.2, Polys 71 %; Bands 6%; Hgb 12.2; </li></ul><ul><li>Plts 154,000 </li></ul><ul><li>Urine leukocyte esterase, positive </li></ul><ul><li>RBC O - 5. </li></ul><ul><li>WBC 21-50 </li></ul><ul><li>Slight bacteria </li></ul><ul><li>Glucose 116. </li></ul><ul><li>Sodium 145 </li></ul><ul><li>K 4. 3 </li></ul><ul><li>Cl 105 </li></ul><ul><li>CO 24 </li></ul><ul><li>BUN 19 </li></ul><ul><li>CR 1.3 </li></ul>
    220. 220. Outcome <ul><li>What would be treatment and outcome for Pat in your ED? </li></ul>
    221. 221. Wrap-Up <ul><li>Atypical presentation of Infection </li></ul><ul><li>Importance of baseline </li></ul><ul><li>Geriatric Assessment value </li></ul><ul><li>Never assume a single causative factor </li></ul>Nursing Drives Excellence
    222. 222. PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE <ul><li>1. The patient's presentation is frequently complex </li></ul><ul><li>2. Common diseases present atypically in this age group </li></ul><ul><li>3. The confounding effects of co-morbid diseases must be considered </li></ul><ul><li>4. Polypharmacy is common and may be a factor in presentation, diagnosis, and management </li></ul><ul><li>5. Recognition of the possibility for cognitive impairment is important </li></ul><ul><li>6. Some diagnostic tests may have different normal values </li></ul>
    223. 223. PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE <ul><li>7. The likelihood of decreased functional reserve must be anticipated </li></ul><ul><li>8. Social support systems may not be adequate, and patients may need to rely on caregivers </li></ul><ul><li>9. A knowledge of baseline functional status is essential for evaluating new complaints </li></ul><ul><li>10. Health problems must be evaluated for associated psychosocial adjustment </li></ul><ul><li>11. The emergency department encounter is an opportunity to assess important conditions in the patient's personal life </li></ul>

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