Acute pain results from injury, surgery, or disease-related tissue damage. It is usually associated with autonomic activity, such as tachycardia and diaphoresis and relatively brief and subsides when healing occurs. In contrast, chronic pain endures past the normal duration of tissue damage usually more than 3 to 6 months, and autonomic activity is usually absent. Chronic pain can lead to functional loss, reduced quality of life, and mood and behavior changes, especially when the pain is not treated adequately.
The prevalence of acute pain decreases with increased age while the prevalence of chronic pain increases as a person ages. The prevalence of pain in adults over age 60 yearThe frequency of undertreated pain in the older adult is unknown. However, there is a correlation between under-medication for pain and advanced age even though there is frequently overmedication of the older adult for other purposes. Who are at risk for undertreatment or overtreatment: Those who are frail and debilitated, cognitively impaired or confused, those with dementia and memory difficulties, and those who misuse alcohol. One of the important assessments to be made is history about recent alcoholism.s is double that of those below the age of 60.
Pain management is most successful when the underlying cause of pain is identified and treated definitively. There is a need to evaluate acute pain that may indicate any new concurrent illness and to distinguish the pain from exacerbated chronic pain.
The most accurate and reliable evidence of pain and its intensity is based on the client’s description and self-report. Older adults may be reluctant to report pain, either because they expect pain with aging and become used to it, or because they often describe their pain as discomfort, burning, or aching rather than use the term PAIN. Culture and gender influence how older adults react to pain. Various terms synonymous with pain should be used, for example, “burning”, “discomfort”, “aching”, “soreness”, “heaviness”, and “tightness” may be used to elicit description of a pain experience. The first principle of assessing pain is to ask about the presence of pain on regular and frequent intervals. Don’t trust that a patient isn’t having pain because he "looks comfortable." Always ask, and believe the patient’s assessment of his own pain.
Wong-Baker FACES Pain Rating Scale is scored from 0 – 10, uses pictures to represent pain intensity by self-report, and is useful for older adults who have cognitive and language barriers. Older adults unable to complete pain instruments may evidence pain by vocalizations and disruptive behaviors. Assessing Pain in Persons with Dementia provides a non-verbal checklist of pain indicators such as:•Vocal complaints•Facial grimaces•Bracing•Restlessness•and Rubbing
The DN4 has a higher sensitivity (83%) and specificity (90%) than the other tools describedNociceptive pain is caused by an active illness, injury and/or inflammatoryprocess associated with actual or potential tissue damage. Recognition of nociceptive pain can help identify an acute condition (e.g. angina,temporal arteritis, thrombosis, torn ligament) demanding prompt treatment, or a chronic condition (e.g. arthritis, osteoporosis) guidingtreatment to halt tissue damage. Neuropathic pain results from a lesion or a malfunction within the nervous system. High intensityneuropathic pain interferes with daily living and has been linked to a loss of muscle, bone and brain mass. Older adults are at greater riskfor developing neuropathic pain because of fewer inhibitory nerves, lower endorphin levels and a slowed capacity to reverse processes thatsensitize nerves. For example, postherpetic neuralgia develops in half of those over age 70, compared to 3% under 60 years old.
Failure to apply standardized assessment instruments consistently will cause inconsistencies in assessment and consequently in the type of treatment used.4.Some healthcare workers believe that a cognitively impaired older adult cannot be assessed for pain.5.Other healthcare workers tend to misinterpret the cognitively impaired person’s behavior as being unrelated to pain, therefore will fail to treat pain.
Adverse consequences of chronic pain include greatly decreased quality of life, depression, decreased socialization, sleep disturbance, impaired ambulation, suicidal ideation, decreased appetite and food intake, and increased health care utilization and costs.
Older adults with pain should be assessed for depression. Depressed older adults may be more reluctant to report pain because they lack the hope that anything can be done. Nonverbal cues such as changes in function and behavior often indicate pain in depressed older adults or those with dementia. Pain may have adverse effects on mobility, sleep, nutrition, bowel and bladder, and cognition. Chronic pain is associated with worsened gait disturbances, slower rehabilitation, and adverse effects of multiple drug prescriptions. Uncontrolled pain may bring about feelings of hopelessness and suffering. The presence of coexisting physical, psychological, spiritual, and cultural factors may impact adversely on pain management. These conditions include past experiences with pain and treatment successes and failures.
The least invasive route of administering medications should be attempted first. Dosing requires careful titration, frequent assessment, and adjustments to optimize pain relief while monitoring and managing side effects. As people age, physiologic changes influence the pharmacodynamics, that is, the effect of drug on the body, and pharmacokinetics, the concentration of active drug in the body. Further, gastric pH, decreased intestinal blood flow, decreased lean body mass, increased fat, decreased water content, and increased plasma protein, all reduce the absorption and distribution of medications.
Expert consensus opinion supports a three-step approach to treating pain by oral medication (the WHO Ladder): non-opioid agents, followed by low-potency opioids and, if necessary, high potency opioids. Pharmacologic treatment is most effective when combined with nonpharmacologic strategies for managing pain.For short-term, self-limiting pain, a fast-onset, short-acting analgesic medication is the drug of choice. For mild-to-moderate musculoskeletal pain, Acetaminophen is the medication of choice. For episodic or chronic pain, opioid analgesic medications are the drugs of choice. Chronic use of nonsteroidal anti-inflammatory drugs (NSAIDS) should be monitored cautiously in older adults. NSAIDS should not be used on patients with abnormal renal function, peptic ulcer disease, or bleeding diathesis.
ROUTE po & rectal-30min-1hr ONSET po & rectal – 1-3hrPEAK po 3-8hr rectal 3-4hr
If opioids are prescribed for an older adult, the patient should be encouraged to drink extra fluid, exercise, and take a combination of a stool softener and a non–bulk-forming laxative because constipation is a common and often serious complication of opioid use in this population. Other side effects that can be minimized with appropriate medications are gastric distress, sedation, and nausea.Managing pain has never been more complicated. There's a wide variety of different analgesics available on the market; dosage forms that range from lollipops to patches; an assortment of delivery vehicles from implantable devices to patient controlled analgesia (PCA); and varying routes of administration.Now more than ever, it's imperative for healthcare organizations to revisit this issue to ensure a safe, effective, and realistic approach to managing pain.
Education programs - Patients who receive pain education are more likely to take their pain medications and show significant decreases in pain intensity, anxiety, and fear of addiction.•Cognitive programs aimed at modifying the global experience of pain and distress through imagery, relaxation, biofeedback, and hypnosis. The major goal is to enhance the older person’s personal control, or self-efficacy.•Behavioral programs discourage abnormal, unpredictable, or self-defeating behavior, and provide positive reinforcement for successes in achieving goals.•Exercise programs•Acupuncture•Transcutaneous nerve stimulations (TCNA)•Distractions or change focus away from pain•Physical methods (heat, cold, massage) most useful in older adults with some cognitive impairment.•Chiropractic•Heat, Cold, Massage, Relaxation•Alternative / Complementary therapies•Homeopathic•Naturopathic•Spiritual healing
The World Health Organization defines palliative care as the active total care of patients whose disease is not responsive to curative treatment. The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care is both a philosophy of care and an organized, highly structured system for delivering care. It expands traditional disease-model medical treatment and its goal includes the enhancing of the patient and family’s quality of life, optimizing their function and helping them with decision-making and opportunities for personal growth.Control of pain, other symptoms, and psychological, social, and spiritual problems is paramount. Many aspects of palliative care are also applicable earlier in the course of an illness in conjunction with curative treatmentThe goal of care is to enhance maximum comfort and function for the total patient. The goal of care is to provide physical, spiritual, and emotional support to promote wellbeing at the end of life.Palliative care focuses on active communication between caregivers, families, and patients to promote comfort and the reassurance that they will not be abandoned.Care for the patient and family requires the holistic intervention of a multidisciplinary team.
Assess all dimensions of a person and family and how changes in those dimensions influence the quality of life. Base your subjective and objective data collected from a palliative / comfort care perspective on what patients and families perceive as important to them at this time. When they share their goals, these become the focus and driving force for the care plan. Your role will be to assess and identify specific issues and their causes, including:1.Are there physical, psychosocial and spiritual problems?2.Accomplishment of developmental tasks of life. Do they perceive that there is completion and closure to the extent that the patient/ family will choose to participate in the palliative care goals3.What challenges will you be facing related to family dynamics / relationship issues / opportunities?4.Are there grief / loss / and bereavement issues5.What is the patient’s functional status / environmental status?1.The nurse identifies patient and family needs.2.The nurse identifies and recruits members of the health care team that can make a contribution to palliative care of patient and family including: Physician, Symptom Management Specialist, Social Worker, Psychologist or counselor, Pastoral Care, Physical Therapist, Occupational Therapist, Pharmacist, Volunteers, Family and Significant Others.3.Many older adults have chronic coexisting problems and multiple pain needs. An interdisciplinary pain program can coordinate care by providing extensive and comprehensive management.4.Problems such as cognitive impairment, limited mobility, psychiatric disturbances, and social isolation can be appropriately managed by using a team approach.5.Team conferences provide the opportunity for the care providers to create an individualized treatment plan with and for the patient.6.The nurse identifies patient appropriateness for Hospice services and their availability.7.The patient and family should be encouraged to participate in goals of care, processes of care, and evaluation of the care program.
Instrumental Activities of Daily Living (IADLs) are the basic daily activities needed to live independently in the community – shopping, food preparation, cooking, using the telephone, doing laundry, housekeeping, managing medications, managing finances, maintaining a home and property, performing duties of employment or volunteer work, and traveling (driving or using public or private transportation systems).Psychological Function is assessed by measuring cognitive mental and affective functions independently (See Module 5).Social functioning includes social interactions and resources, subjective well-being and coping, and person-environment fitCo morbid conditions that might negatively impact functional status:Acute illnessAlteration in nutrition and / or hydrationChronic illnessDeliriumDementiaEconomicsEnvironmentMedicationsPsychiatric comorbidities, especially depressionPsychological / social stressors.
The Katz ADL Index has established reliability and is easy to use. It was first developed in 1963 by Dr. Sidney Katz, who wanted to find a way to measure function and how it changed over time in older people who had progressive chronic illnesses. It has been modified and simplified and different approaches to scoring were used from categorical scoring (yes/no), to point scaling (independent, some assistance, or dependent). There were no formal reliability and validity reports in the literature; however, it is used extensively to assess functional capabilities of older adults at home and in the clinical setting. The Katz inventory is useful in creating a common language about a patient’s function for all care givers involved, evaluating older adults according to levels of independence. A number of adapted versions are in use today.
Competency 4. . Plan strategies to promote / maintain optimal function in older adults. Exercise and physical activity help to prevent heart disease, hypertension, depression, and a tendency toward diabetes.Design environments with handrails, wide doorways, raised toilet seats, shower seats, enhanced lighting, low beds, and chairs of various types and heightSchedule regular examinations for prevention and early detection of cancer; prevention of heart disease and stroke; and prevention and treatment of osteoarthritis.Judicious assessment and monitoring of medications and their dosages, especially psychoactive medications.Maintain vaccination status.Optimize nutritional patterns. Provide sufficient protein and caloric intake to ensure adequate intake and prevent further decline. Liberalize diet to include personal preferences.Maintain and enhance mental functioning.Minimize bed rest.Explore alternatives to physical restraints useObtain assessment by physical and occupational therapists as needed to help regain function.Maintain and enhance social relationships and support.Provide information to caregivers on causes of functional decline related to acute and chronic conditions.Help them access counseling and resources remaking physical modifications to the environment or gaining access to equipment. (Rowe & Kahn, 1998)Kresevic, D. M., & Mezey, M. (2003). Assessment of function. In M. Mezey, T. Fulmer, I. Abraham, & D. S. Zwicker (Eds.), Geriatric nursing protocols for best practice. (2nd ed., pp. 31-46). New York: Springer.
Senior Healthcare Consultant (Geriatric) class at Piedmont Hospitals
Health Literacy in Older Adults<br />Patient/Family Issues<br />
A Quote from the AMA<br />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.<br />
The need for today’s patients to be more health literate is greater than ever, because medical care has grown increasingly complex. <br />We treat out patients with an ever-increasing array of medications, and we ask them to undertake more and more complicated self-care regimens. <br />
Points to Ponder<br />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.<br />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.<br />Low Health Literacy cost the United States between $50 Billion and $73 Billion a year.<br />
Health Literacy Defined by the AMA<br />Health Literacy is the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment.<br />
Implications of Limited Literacy<br />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.<br />
Examples of Some Patient Issues and Misunderstandings<br />Video<br />
You Can’t Tell by Looking<br />Key Risk Factors for Limited Literacy:<br /> -Elderly<br /> -Low Income<br /> -Unemployed<br /> -Did not Finish High School<br /> -Minority Ethnic Group<br /> -Recent Immigrant to the United States and does not speak English<br /> -Born in the United States, but English is a second language<br />
Red Flags<br />Behaviors:<br />-Forms are Incomplete, Missed Appointments, Noncompliance with Medications, Lack of Follow-Through with Diagnostics, and Patients state they are taking their medications, but the clinical values don’t support their claims.<br />
Red Flags<br />Responses to Receiving Written Information:<br /><ul><li>“I forgot my glasses. I’ll read this when I get home.”
“I forgot my glasses. Can you read this to me?”
“Let me take this home so I can discuss it with my children.”</li></li></ul><li>Red Flags<br />Responses to Questions about Medication Regimens:<br /><ul><li>Unable to Name Medication
Unable to Explain timing of Medication Administration
Unable to Explain basic Health or Diet Concerns Related to the Medication</li></li></ul><li>“Brown Bag Review”<br />When a patient brings in their medication, review the medications with the patient.<br />Note if the patient opens the bottle and looks at the medication or do they identify their medication by reading the label?<br />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.<br />
What is Your Patient Really Reading?<br />Your naicisyp 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 you noloc.<br />
What You Actually Gave Them<br />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.<br /><ul><li>Are You Thinking What I’m Thinking?
Liability?</li></li></ul><li>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.<br />
Steps to Improve Communication<br />Slow Down: Communication is improved by speaking slowly<br />Use Plain, Non-medical Language “Layman's Term”<br />Show or Draw Pictures<br />Limit the Amount of Information and Repeat It<br />Use the Teach-Back or Show-Me Technique<br />Create a Shame Free Environment<br />
Quote From a Patient<br />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.<br />
DEMENTIA<br />An irreversible confusional state, impairment and progressive decline of mental function<br />Compromise in at least three areas of following mental activities:<br />Language<br />Memory<br />Visuospatial skills<br />Personality and emotional state<br />Executive Function (abstraction, judgment)<br />50% never diagnosed and treated<br />Most treated are treated inappropriately<br />NOT A NORMAL PART OF AGING!!!!<br />
Types of Dementia<br />Alzheimer’s<br /><ul><li>Frequency: 55-75%
Treatment of Dementias<br />Medications <br /><ul><li>ACIs acetylcholinesterase </li></ul> Aricept<br /> Excelon<br /> Reminyl<br /><ul><li>Memantine</li></li></ul><li>Presentation<br />Poor historian<br />Unable to recall phone number, address, names of children, <br />Word finding problems<br />Repeats same information or stories<br />Poor personal hygiene<br />Irritability or refusal to participate in screening<br />
Behaviors and Psychological Symptoms<br />Depression<br />Agitation and aggression<br />Delusions<br />Hallucinations<br />Poor sleep<br />Wandering<br />
CONFIDENTIAL<br />Learning Objectives<br />Identify the incidence of pain in older adults<br />Assess pain using client self report or validated pain instruments.<br />Discuss barriers to pain relief in older adults.<br />Identify problems and strategies in assessing pain in cognitively impaired older adults. <br />Describe adverse consequences associated with pain in older adults.<br />Identify considerations and specific strategies in treating pain in older adults.<br />Explain the dimensions of palliative care.<br />Describe the nurse’s role in end of life care.<br />
CONFIDENTIAL<br />Objective 1 Incidence<br />Pain is an unpleasant sensory and/or emotional experience<br />whatever the experiencing person says it is, existing whenever he/she says it does (McCaffrey)<br />Acute pain <br />results from injury, surgery, or disease related tissue damage <br />is usually associated with autonomic activity such as tachycardia and diaphoresis<br />Chronic pain <br />endures past the normal duration of tissue damage,<br />usually more than 3 to 6 months<br />autonomic activity is usually absent<br />
CONFIDENTIAL<br />Objective 1<br />Prevalence in adults > age 60 is double those below the age of 60<br />Pain is the most common symptom at the end of life, occurring in 90% of patients<br />It has been estimated that as much as 95% of pain at the end of life can be relieved.<br />CME Resource August 2006, Vol. 131 No.10<br />
CONFIDENTIAL<br />Objective 1<br />Common disorders associated with pain<br />cancer, AIDS, ESRD, and COPD<br />Older adults are likely to suffer from<br />arthritis (Osteoarthritis is the most common)<br />bone and joint disorders<br />back problems<br />post stroke central or neuropathic pain<br />post herpetic neuralgia<br />post amputation (phantom limb) pain<br />
CONFIDENTIAL<br />Objective 1<br />Under-treated pain in older adults can be correlated with advanced age, even though there is frequent overmedication of the older adult for other purposes<br />Why would RNs overmedicate an older adult who is not in pain?<br />healthcare professionals said that under-treated pain was their primary ethical concern<br />American Pain Society<br />CME Resource August 2006, Vol.131 No.10<br />
CONFIDENTIAL<br />Objective 2 Assessment<br />Pain is a subjective experience <br />most reliable indicator is patient’s self report <br />Ask the patient about the pain experience <br />believe the patient’s assessment of his own pain<br />Questions should be asked to elicit descriptions of the pain characteristics<br />Remember COLDSPA?<br />Character<br />Onset<br />Location<br />Duration<br />Severity<br />Pattern<br />Alleviating factors<br />
CONFIDENTIAL<br />Objective 2 Assessment<br />Wong-Baker FACES scale developed for pediatric setting<br />Facial expressions and physical indicators don’t always change when a client has chronic or persistent pain<br />Pain instruments may assist in qualifying pain<br />
CONFIDENTIAL<br />Objective 3: Barriers to pain relief <br />Patient’s fears:<br />addicted to opioids<br />side effects<br />Increasing pain = disease is getting worse<br />being a good patient<br />keys to overcoming barriers<br />Open communication and education<br />CME Resource August 2006, Vol. 10<br />
CONFIDENTIAL<br />Objective 3: System barriers<br />Other barriers include:<br />Failure to apply standardized assessment instruments<br />Belief that the cognitively impaired older adult cannot be assessed for pain.<br />Misinterpretation of cognitively impaired person’s behavior as being unrelated to pain.<br />
CONFIDENTIAL<br />Objective 4Cognitively Impaired Older Adults<br />May or may not be able to communicate pain<br />Evaluate nonverbal pain behavior<br />Recent changes in function and vocalizations<br />Utilize objective pain instruments:<br />Assess for changes in behavior after analgesics are used<br />Caregiver Reports<br />
CONFIDENTIAL<br />Objective 4Physical Exam Nursing Assessment<br />Determine underlying causes of pain<br />History- subjective data<br />If non-verbal?<br />Moaning <br />Grimacing<br />Protective movements<br />Vocalizations<br />Disruptive behaviors<br />Detect evidence of trauma or skin breakdown<br />Examination of painful area – objective data<br />Inspection, auscultation, percussion, palpation<br />There is no substitute for good assessment skills!<br />
CONFIDENTIAL<br />Assessment- Other Causes of Pain<br />Fear<br />Anxiety<br />Depression<br />Family concerns<br />Lying in bed<br />Loneliness <br />
CONFIDENTIAL<br />Objective 5 Consequences<br />Adverse effects of chronic pain<br />decreased quality of life<br />depression<br />decreased socialization<br />sleep disturbance<br />impaired ambulation<br />suicidal ideation<br />decreased appetite and food intake<br />increased health care utilization and cost<br />
CONFIDENTIAL<br />Objective 5<br />Assess patient for depression <br />Geriatric Depression Scale (GDS)<br />Pain may effect mobility, sleep, bowel, bladder, and cognition<br />Ask if sleep and toileting patterns changed<br />Uncontrolled pain may be evidenced in hopelessness and suffering<br />Observe the patient <br />note how pain limits movement <br />ask the patient or family how the pain interferes with normal activities<br />
CONFIDENTIAL<br />Objective 6 Treatment<br />Objectives of pharmacologic management of pain include :<br />Selection of appropriate drug, dose, route, and interval<br />Aggressive titration of the drug dose<br />Prevention of pain and relief of breakthrough pain<br />Use of appropriate co-analgesic medications<br />Prevention and management of side effects<br />
CONFIDENTIAL<br />World Health Organization 3 step analgesic ladder <br />designates the type of analgesic agent based on the severity of pain<br />Mild pain (score 1-3) <br />non-opioid with or without co-analgesic<br />Moderate pain (score 4-6) <br />calls for low dose opioid<br />Severe pain (score 7-10) <br />Opioids are optimum choice at doses higher than step 2.<br />Objective 6 Treatment<br />
CONFIDENTIAL<br />Objective 6 Treatment<br />Non-opioid analgesics used for mild pain, *also helpful as co-analgesics*:<br />Acetaminophen (Tylenol = safest) <br />doses higher than 4000mg/day can cause liver dysfunction<br />NSAIDS (Motrin, Naproxen, and Indocin)<br />most effective for pain associated with inflammation as well as bone pain. <br />inhibit platelet aggregation, increasing the risk of bleeding & can damage stomach mucosal lining, leading to GI bleeding<br />ASA<br />
CONFIDENTIAL<br />Objective 6 Treatment<br />Morphine<br />most commonly used opioid <br />drug of choice for severe pain by the WHO<br />Most potent opioids <br />Dilaudid <br />Fentanyl (the most potent) 80-100x’s more potent than morphine<br />Methadone <br />commonly used for treating pain<br />toxic accumulation can cause respiratory depression & death<br />average half life of Methadone is 24 to 36 hours<br />Demerol is not recommended <br />neuro-toxic effects may cause tremor, irritability, cognitive changes, and seizures<br />
CONFIDENTIAL<br />Objective 6 Treatment<br />Darvon is an opioid similar to Methadone<br />Not recommended due to long half life and toxicity of by-products<br />Toradol requires increased assessment<br />due to decreased clearance and increased half life in the elderly<br />Precautionary Measures for Opioids:<br />Encourage extra fluid<br />Exercise<br />Combination stool softener + non-bulk-forming laxative<br />Minimize side effects<br />Gastric distress, sedation, nausea<br />
CONFIDENTIAL<br />Objective 7 Palliative Care<br />Cost of medication <br />In hospice care there is no cost to the patient<br />Relief of pain symptoms and the stress of serious illness<br />Pain<br />Shortness of breath<br />Fatigue<br />Constipation<br />Nausea<br />Difficulty Sleeping<br />
CONFIDENTIAL<br />Objective #8The Nurses Role in End of Life Care<br />Physical, psychosocial, and spiritual problems<br />Accomplishment of developmental tasks of life<br />Family dynamics / relationship issues / opportunities<br />Grief / loss / bereavement issues<br />Functional status / environmental status<br />• Identifies patient and family needs<br />• Recruits health care team members<br />• Coordinate interdisciplinary pain program and manage chroniccoexisting problems<br />• Identify patient appropriateness for Hospice services<br />• Encourage family to participate in goals, processes and evaluation ofcare<br />
CONFIDENTIAL<br />Assurance<br />Availability of pain relievers cannot be exhausted<br />there will always be medication if pain becomes more severe<br />Patients’ biggest Fear- Unrelieved pain<br />Side effects can occur but they can be managed promptly<br />Pain and severity of disease are not necessarily related<br />
CONFIDENTIAL<br />Addiction<br />Addiction is not a concern at the end of life!<br />Give the dosage that is ordered<br />It may relieve the shortness of breath<br />
CONFIDENTIAL<br />REMEMBER<br />PAIN IS WHAT THE PATIENT SAYS IT IS AND IT EXISTS WHENEVER THE PATIENT SAYS IT EXIST.<br />
CONFIDENTIAL<br />References<br />Best practice information on care of older adults: www.ConsultGeriRN.org.<br />Bennett, M.I., Attal, N., Backonja, M.M., et al. (2007). Using screening tools to identify neuropathic pain. Pain, 127, 199-203.<br />Bouhassira, D., Attal, N., Alchaar, H., et al. (2005). Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain, 114(1-2), 29-36.<br />Gilron, I., Watson, C.P.N., Cahill, C.M., & Moulin, D.E. (2006). Neuropathic pain: A practical guide for the clinician. Canadian Medical Association Journal, 175(3), 265-275.<br />Hadjistavropoulos, T., Herr, K., Turk, D.C., et al. (2007, Jan). An interdisciplinary expert consensus statement on assessment of pain in older persons. The Clinical Journal of Pain, 23(1 Suppl), S1-S43.<br />Krause, S.J., & Backonja, M.M. (2003). Development of a Neuropathic Pain Questionnaire. The Clinical Journal of Pain, 19(5), 306–314.<br />McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd.ed.). St. Louis, MO: Mosby.<br />http://consultgerirn.org/resources/media/?vid_id=4669429#player_container (retrieved 12/29/ 2009)<br />
Incontinence<br />Clinical Definition (UI):<br />Urine loss of sufficient problem to be perceived as bothersome or it creates a prompt desire to seek care<br />An Estimated 16 million people in the U.S.Over 50% Prevalence in the Institutionalized Elderly <br />
Bladder Differences by Gender<br /> Female<br /> Longitudinal Section<br /> Male Male<br /> Longitudinal Section Lateral View<br />
Most Prevalent Types – Urinary Incontinence<br />Stress UI: urine loss due to sphincter dysfunction-Prolonged use of a Urinary catheter<br />Urge / Over-active Bladder (OAB)<br />Total UI: complete loss of sphincter function or fistula formation<br />
Another type of Urinary Incontinence<br />Functional UI: normal voiding patterns & normal bladder function; usually related to cognitive status, motivation, and/or mobility issues, environment<br />Management<br />Prompted / Scheduled voiding<br />
Effects of Aging R/T Continence<br />Increased nocturia (1-2x/night >60)<br />Bladder fills full at lower volumes<br />Reduced strength of bladder contractions<br />Increased irritability of bladder<br />Delayed recognition of bladder filling<br />Adequate fluid intake?<br />
Indwelling Foley Catheters <br />30-40% of HAI<br />Risk for UTI 1-2% for a single insertion<br />Increases to 5-8% per day with indwelling catheter<br />CAUTIs- one of CMS Never Events<br />
Foley Catheters <br />CAUTIs- one of CMS Never Events<br />Most effective method to prevent CAUTIs is to avoid indwelling catheters<br />If MUST have- then aseptic technique, closed system, secured to leg<br />
Indications for a Urinary CatheterCDC Recommendations<br />Critically Ill: Alteration in BP or volume status requiring continuous, accurate urine volume measurement<br />Infection Prevention: to prevent urine from soiling a Stage III or IV pressure ulcer or nearby operative site<br />Comfort care: for terminally ill patients<br />
Indications for a Urinary CatheterCDC Recommendations<br />Comfort care: for terminally ill patients<br />Surgery: patients going directly to the operating room<br />Procedures or Tests requiring an indwelling urinary catheter, removed at the conclusion of the procedure/test<br />
Indications for a Urinary CatheterCDC Recommendations<br />GU Indications<br />Continuous bladder irrigation <br />Instillation of medication into the bladder<br />Obstruction to the urinary tract distal to bladder<br />Drainage in patient with neurogenic bladder dysfunction, hydronephrosis, and urinary retention not manageable by other means (e.g., with clean intermittent catheterization)<br />Aid in urologic surgery or other surgery in contiguous structures<br />Ordered by a urologist for a special purpose or difficult insertion<br />
Indications for a Urinary CatheterCDC Recommendations<br />Prolonged immobilization due to unstable or multiple traumatic injuries<br />An indwelling urinary catheter is not appropriate for nursing convenience or for urinary incontinence in the absence of skin breakdown.<br />When NOT to use a Catheter?<br />
Use CAUTION = <br />Prevent C.A.U.T.I.<br />C – Closed system<br />A – Aseptic mgmt of indwelling catheter<br />U – Use standard precautions<br />T – Tubing secured to leg & clipped to sheet<br />I – Indications (do I still need it?)<br />O – Obstruction free<br />N – No dependent loops<br />
ED<br /><ul><li>Gateway for most of our older patients
Ability to initiate change in practice that will carry through the admission
Eliminate a risk that prolongs LOS and had financial impact</li></li></ul><li>Functional Assessment <br />Falls in Older Adults<br />Monica Tennant RN, MSN, CCNS<br />Geriatric Clinical Nurse Specialist<br />
<object width="400" height="300"><param name="allowfullscreen" value="true" /><param name="allowscriptaccess" value="always" /><param name="movie" value="http://vimeo.com/moogaloop.swf?clip_id=4610636&server=vimeo.com&show_title=1&show_byline=1&show_portrait=0&color=&fullscreen=1" /><embed src="http://vimeo.com/moogaloop.swf?clip_id=4610636&server=vimeo.com&show_title=1&show_byline=1&show_portrait=0&color=&fullscreen=1" type="application/x-shockwave-flash" allowfullscreen="true" allowscriptaccess="always" width="400" height="300"></embed></object><p><a href="http://vimeo.com/4610636">Katz Index of Independence in Activities of Daily Living</a> from <a href="http://vimeo.com/hartford">Hartford Institute</a> on <a href="http://vimeo.com">Vimeo</a>.</p><br />
Objectives<br />Define functional assessment.<br />Describe characteristics of functional decline in older persons.<br />Identify comorbid conditions that might impact negatively on the functional status of an older adult<br />Assess function using validated tools<br />Plan strategies to promote and maintain optimal function in older adults.<br />
Assessment<br /><ul><li>Baseline vs current status
Needs to return to living situation</li></li></ul><li>Observation<br />Transfers: bed-chair, sit-stand<br />Balance: standing, walking, turning<br />Gait: even, steady, speed<br />Unsafe behaviors<br />What can be done during admission? <br />Avg LOS 4-5 days: can they progress to be safely discharged home?<br />
Your Nursing Area<br />Goals<br />Clinically relevant<br />Annual Program<br />
Key Points to Take Away<br /><ul><li>Falls have multiple causes
Assess function-mobility by observing specific components
Prevent falls in older patients by: identifying patient, communicate risk, intervene with specifics
Use critical thinking to change your unit</li></li></ul><li>References<br />Assessment of the Older Adult. (1996). [Video, Two-part series]. Philadelphia: Lippincott, Williams, & Wilkins.<br />Gallo, J. J., Fulmer, T., Paveza, G. J., & Reichel, W. (2000). Handbook of geriatric assessment. (3rd ed.). Gaithersburg, MD: Aspen.<br />Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility, and instrumental activities of daily living. Journal of the American Geriatrics Society, 3(12).<br />Katz, S. (1989). Functional assessment in geriatrics: A review of progress and directions. Journal of the American Geriatrics Society, 37.<br />Kresevic, D. M., & Mezey, M. (2003). Assessment of function. In M. Mezey, T. Fulmer, I. Abraham, & D. S. Zwicker (Eds.), Geriatric nursing protocols for best practice. (2nd ed., pp. 31-46). New York: Springer.<br />Podsiadlo, D., Richardson, S. (1991). The timed “Up and Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 29(2), 142-148.<br />Wallace, M., Fulmer, T. (2000). Fulmer SPICES: An overall assessment tool of older adults. Geriatric Nursing, 21(3), 147.<br />
Objectives<br />Discuss polypharmacy and its risk in the elderly<br />Discuss pharmacokinetic and pharmacodynamic changes in the elderly<br />Review medication related issues to keep in mind when taking care of the elderly<br />
A look at the geriatric patient ..<br />Complicated drug therapy<br />Increase in risk of adverse drug reactions (ADRs)<br />Signifcant ADRs especially with drugs with narrow therapeutic windows, ex. Phenytoin, warfarin and theophylline.<br />Increased risk of drug-drug interactions<br />Pharmacokinetic and pharmacodynamic changes<br />
Social Issues<br />Depression and poor medication adherence<br />Economic situations may lead to medication non-adherence<br />Cultural differences- 10% of older adults were born outside the US, 13% don’t speak English<br />>34% do not have high school diplomas<br />Use of alcohol<br />GistYJ, Hetzel LI. We the People: Aging in the United States. Census 2000 Special Reports. December 2004<br />Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among Medicare beneficiaries. Health Aff (Millwood)2003;22:220-29<br />
What are the issues with her med list??<br />Use of multiple anticholinergic agents can increase risk of falls, sedation.<br />Use of multiple antidepressants – need to assess and make sure she is supposed to be on both<br />Use of multiple diuretics including two potassium sparing diuretics<br />Use of multiple medications that can increase the risk of falls<br />? Need for Darvocet<br />Need for magnesium oxide – do we have a Mg level?<br />Need for Vitamin C??<br />
Polypharmacy<br />Polypharmacy means “many drugs”<br />Definition: The use of more medications than is clinically warranted or indicated<br />
Why is polypharmacy common?<br />The elderly have more disease states<br />More drugs available<br />Readily available drugs over the counter<br />Inappropriate prescribing<br />Lack of medication review<br />The “prescribing cascade”<br />
Polypharmacy: Show me the #s!!<br />Elderly make up 13% of population but consume ~ 30% of prescriptions1<br />Average elderly patient consumes<br />2-6 prescription drugs and…<br />1-3.4 over-the-counter drugs<br />Average American senior spends~ $700 / yr on pharmaceuticals alone<br />Williams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24<br />Williams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24<br />
Polypharmacy: What’s the big deal???<br />More adverse drug events<br />Corresponds to the # of medications being taken<br />More drug-drug interactions<br />50% risk in pts taking 5 meds vs. 6% in pts taking 2 meds<br />Decreased compliance – increased hospital visits<br />Poor quality of life<br />Unnecessary drug expense<br />Gurwitz JH, Field TS. Et al. Incidence and preventability of adverse drug events among older persons in the ambulatory care setting. JAMA 2003;289:1107-1116<br />
Pharmacokinetics<br />What the body does to the drugs<br />Absorption<br />Distribution<br />Metabolism<br />Excretion<br />
Pharmacokinetics<br />Absorption<br />Reduced gastric emptying<br />Reduced gastric acid production<br />Reduced GI motility<br />Reduced GI blood flow<br />Distribution<br />Decreased plasma protein<br />Increased body fat and decreased total body water<br />Increased in volume of distribution of lipophilic drugs like sedatives ex. Diazepam (Valium®)<br />
Pharmacokinetics contd…<br />Metabolism<br />Reduced liver blood flow<br />Reduced liver metabolism<br />Reduced enzyme activities<br />Excretion – reduced by as much as 50% by age 75<br />Reduced renal blood flow<br />Reduced glomerular filtration rate<br />Reduced renal tubular secretory function<br />
Common medications with decreased hepatic metabolism<br />Meperidine (Demerol®)<br />Theophylline (Theo-Dur®, etc)<br />Chlordiazepoxide (Librium®)<br />Diazepam (Valium®)<br />Desipramine (Norpramin®)<br />Quinidine<br />
Pharmacodynamic changes<br />What the drug does to the body:<br />Insulin sensitivity (↓)<br />Benzodiazepine (↑)<br />Warfarin (↑)<br />Anti-hypertensive agents (↑)<br />Phenothiazine (ex. Phenergan®) (↑)<br />GI side effects of NSAIDs like Naproxen, Ibuprofen (↑)<br />Central effects of anticholinergics like Benadryl® (↑)<br />
Practice Question 1<br />Mrs. Brown was asked to start taking calcium replacement by her physician. Which of the following factors can affect absorption of her calcium?<br />Reduced gastric acid production<br />Increased gastric acid production<br />The formulation of calcium she buys<br />Two of the above<br />None of the above<br />
Practice Question 2<br />All of the following drugs are considered inappropriate in the elderly except:<br />Meperidine (Demerol®)<br />Indomethacin (Indocin®)<br />Chlordiazepoxide (Librium®)<br />Metoclopramide (Reglan®)<br />
Inappropriate medications in the elderly<br />
Potentially inappropriate meds<br />Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24<br />
Potentially inappropriate meds<br />Beers et al. Updating the Beers Criteria forPotentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24<br />
Question<br />Which of the following is / are considered drug-disease states interaction(s)?<br />NSAIDs and CHF<br />Benadryl and Urinary Retention<br />Narcotics and Constipation<br />A and B<br />All of the above<br />
Drug-Disease State Interaction<br />Patient with PD have increased risk of drug induced confusion<br />NSAIDs (and Cox -2 Inhibitors) can exacerbate CHF<br />Urinary retention in BPH patients on decongestants and anticholinergics<br />Constipation worsened by calcium channel blockers, anticholinergics and narcotics<br />Quinolones, ultram can lower seizure thresh-hold<br />Quinolones can affect blood sugar<br />
Some “take home” points<br />Acetaminophen: keep dose < 4000mg / day. Be mindful of combination products like Lortab & Percocet®, Darvocet®<br />Buproprion (Wellbutrin®) – few side effects but can cause insomnia so avoid giving it in the evening<br />Mirtazepine (Remeron®) – Good in patients with anorexia. Stimulates appetite<br />Antipsychotics – atypicals are best choice since older once have higher anticholinergic side effects. Atypical antipsychotics include: Quetiapine (Seroquel®), Risperidone (Risperdal®)<br />
More “take home”<br />Diphenhydramine (Benadryl®) – its use should be reserved for allergic reaction and itching only. Avoid for sedation<br />Zolpidem (Ambien®) – Best choice for sleep. Always start at 5mg dose (or lower)<br />For anxiety – low dose Lorazepam (Ativan®) – 0.5mg – 2mg<br />
Minimizing interactions between liquid phenytoin and enteral feeds<br />Give phenytoin as a single daily dose<br />Stop feeds 2 hrs before and 2 hours after dose OR suspend feeds between 10 p.m. and 6 a.m. and give phenytoin as a single dose at midnight. <br />Dilute phenytoin suspension with at least equal parts (up to 1:3) of water<br />Flush enteral tube with plenty of water before and after administration<br />** different dosage forms have different bioavailability so appropriate dosage adjustment must be made when switching from liquid to capsules<br />
Pneumovax®<br />Why is it important?<br />Who needs to be vaccinated?<br />When do you re-administer<br />Where can I find prior pneumovax administration in the hospital?<br />Documentation in SCM<br />
Conclusion<br />Drug therapy in the elderly can be complicated due to several reasons.<br />Being vigilant and paying closer attention to the medication therapy can help reduce possible ADRs and drug-drug interactions. <br />Be diligent with medication reconciliation especially at discharge to make sure patient is not sent home on duplicate therapy.<br />Utilize your zone pharmacists for drug information.<br />