Emergency Department and Outpatient Senior Healthcare Consultant Course

Atypical Disease Atypical Disease Presentation in Presentation in Older AdultsOlder Adults

Dee Tucker, MS, RN, GCNS-BCDee Tucker, MS, RN, GCNS-BCClinical Nurse Specialist GerontoloyClinical Nurse Specialist GerontoloyPiedmont Healthcare NICHE CoordinatorPiedmont Healthcare NICHE Coordinator

Reality in ED?Reality in ED?

Increased crowding which leads toIncreased crowding which leads to• Increased wait timeIncreased wait time• Decreased quality of careDecreased quality of care• Increased crisis managementIncreased crisis management• Decreased patient satisfactionDecreased patient satisfaction• Decreased ED staff satisfactionDecreased ED staff satisfactionED volume of older patients will double ED volume of older patients will double

between 2003 and 2013 between 2003 and 2013

Older Patients in EDOlder Patients in ED Have longer ED staysHave longer ED stays More likely to be admitted or re-visit EDMore likely to be admitted or re-visit ED Use more resources – Use more resources –

hospital and communityhospital and community Experience increased Experience increased

rates of adverse outcomesrates of adverse outcomes after ED visitafter ED visit

ED / Outpt Environment ED / Outpt Environment for Older Patientsfor Older Patients

Can lead to iatrogenic complications- Can lead to iatrogenic complications- decubitus, dehydration, decreased food decubitus, dehydration, decreased food intake, fallsintake, falls

Increases anxiety Increases anxiety High level of ambient noise High level of ambient noise Lighting – poor, glare Lighting – poor, glare Physically does not meet aging needsPhysically does not meet aging needs Flow - fastFlow - fast

Hospital ProcessHospital Process

Use the disease-oriented modelUse the disease-oriented model Evaluate for consequences and single Evaluate for consequences and single

causative factorcausative factor Staff are frustrated by older patients’ Staff are frustrated by older patients’

presentationspresentations

NICHE and ENANICHE and ENA

Best Practices for older patients in ED: Best Practices for older patients in ED: More comprehensive evaluation More comprehensive evaluation Screening tools for geriatric assessment Screening tools for geriatric assessment Recognize normal aging changes that Recognize normal aging changes that

affect assessmentaffect assessment Identify atypical presentations in this age Identify atypical presentations in this age

groupgroup Referral to resourcesReferral to resources

Atypical Disease Atypical Disease PresentationPresentation

By assessing older patients for By assessing older patients for atypical presentations, nurses atypical presentations, nurses provide appropriate interventions provide appropriate interventions and prevent complications / and prevent complications / crises. crises.

Signs and SymptomsSigns and Symptoms

Learn baseline prior to illness Remember

aging changes

Recognize presenting symptoms

Baseline prior to illnessBaseline prior to illness

VariabilityVariability

VerifyVerify

FrailtyFrailty

Aging EffectAging Effect

Non specificNon specific

Less acuteLess acute

Slow to presentSlow to present

Presenting SymptomsPresenting Symptoms

Signs and symptoms in older patients are generalized and can represent any number of medical situations.

Atypical Disease Atypical Disease Presentation : Presentation : UTIUTI

SymptomsSymptomstired, poor appetite, tired, poor appetite, perhapsperhaps abdominal discomfort, abdominal discomfort, perhapsperhaps foul smell to urine foul smell to urine

SignsSignsincontinence, trips/fall, less incontinence, trips/fall, less sharp thinking, sharp thinking, perhapsperhaps temperaturetemperature

LabLaburine- WBC, bacteria; urine- WBC, bacteria; perhapsperhaps WBCs elevated in blood workWBCs elevated in blood work

Atypical Disease Atypical Disease Presentation: Presentation: Pneumonia / Pneumonia / URIURISymptomsSymptoms

poor appetite, functional poor appetite, functional decline, weakness, decline, weakness, perhaps perhaps cough, cough, perhapsperhaps shortness of shortness of breathbreath

SignsSignsrespiratory rate, tripping/fall, respiratory rate, tripping/fall, perhapsperhaps temperature; less temperature; less sharp thinkingsharp thinking

LabLabWBC ?, cxr ?, WBC ?, cxr ?,

Atypical Disease Atypical Disease Presentation: Presentation: Skin InfectionSkin Infection

SymptomsSymptoms

tired, some tendernesstired, some tenderness

SignsSigns

increased color, increased color, maybe maybe swelling, swelling, drainagedrainage

LabLab

blood- ?blood- ?

Atypical Disease Atypical Disease Presentation:Presentation: Heart Failure Heart Failure with Pulmonary Edemawith Pulmonary Edema

SymptomsSymptomstired, poor appetite, tired, poor appetite, perhaps perhaps shortness shortness of breathe or leg swellingof breathe or leg swelling

SignsSignsperhapsperhaps rales; less sharp rales; less sharp thinkingthinking

LabLab

Atypical Disease Atypical Disease Presentation: Presentation: Myocardial Myocardial InfarctionInfarction

SymptomsSymptoms

fatigue, weak, restless, shortness of fatigue, weak, restless, shortness of breath, breath, perhapsperhaps pain pain

SignsSigns

perhapsperhaps syncope, less mental sharpness, syncope, less mental sharpness, perhapsperhaps confusion confusion

LabLab

cardiac enzymescardiac enzymes

Atypical Disease Presentation: Atypical Disease Presentation: Pulmonary EmboliPulmonary Emboli

Symptoms: Symptoms: perhaps perhaps chest pain with inspiration, chest pain with inspiration,

perhapsperhaps shortness of breath shortness of breath

Signs: Signs: elevated HR, tachypnea, rales; elevated HR, tachypnea, rales; perhapsperhaps LE LE

symptoms of DVT, dyspneasymptoms of DVT, dyspnea

Lab: Lab: positive D-dimer; positive D-dimer; perhapsperhaps ABGs changes ABGs changes

More Atypical More Atypical PresentationsPresentations

Acute abdomenAcute abdomen with constipation and decreased with constipation and decreased

appetite, rather than severe painappetite, rather than severe pain

DDepressionepression with agitation, rather than dysphoriawith agitation, rather than dysphoria

CaseCase

86 yo man is admitted to ED for c/o 86 yo man is admitted to ED for c/o progressive weakness and fatigue: unable to progressive weakness and fatigue: unable to carry out his normal daily activities, 2 falls. carry out his normal daily activities, 2 falls.

He lives with his wife in their home. He was He lives with his wife in their home. He was independent in all ADL’s and IADLs. He independent in all ADL’s and IADLs. He enjoyed his garden daily and worked part enjoyed his garden daily and worked part time at a real estate office.time at a real estate office.

CaseCase

He is cooperative, pleasant and looks quite well. He is cooperative, pleasant and looks quite well. No history of dyspnea or coughing. He has an No history of dyspnea or coughing. He has an IV going and waiting for more lab tests. He IV going and waiting for more lab tests. He requires assistance to get to the bathroom.requires assistance to get to the bathroom.

Report from previous shift: he has bilateral Report from previous shift: he has bilateral basilar rales; temp 99.2, Resp 20; BP basilar rales; temp 99.2, Resp 20; BP unchanged; remains weak; up to bathroom unchanged; remains weak; up to bathroom numerous times; no complaints of pain but did numerous times; no complaints of pain but did not sleep well and is restlessnot sleep well and is restless

Symptom Presentation in Symptom Presentation in Older AdultsOlder Adults

Baseline: independent ADLs, IADLs, very active Baseline: independent ADLs, IADLs, very active self sufficient; no dyspnea or coughself sufficient; no dyspnea or cough

SymptomsSymptoms

fatigue, unable to do ADLs, requires assistance fatigue, unable to do ADLs, requires assistance to ambulate to BR to ambulate to BR

SignsSigns

restless, bilateral basilar rales, little sleep; Temp restless, bilateral basilar rales, little sleep; Temp 99.2; resp 2099.2; resp 20

Lab: none availableLab: none available

Clinical PearlsClinical Pearls

Symptoms: vague, less acute, slow to Symptoms: vague, less acute, slow to presentpresent

Compare to normal baselineCompare to normal baseline

Assess for potential Assess for potential causescauses

Older Patients in the ED:Older Patients in the ED:Best PracticesBest Practices

Dee Tucker RN, MN, GCNS-BCClinical Nurse Specialist GerontologyPiedmont Hospital

Your ED SettingYour ED Setting

What is routinely assessed with older What is routinely assessed with older patients now?patients now?

How do you make the ED experience How do you make the ED experience geriatric specific?geriatric specific?

Geriatric Specific Assessment of Geriatric Specific Assessment of Older Patients in EDOlder Patients in ED

Screen all patients 70 and older because:Screen all patients 70 and older because:• Easy to miss abnormalities in mental Easy to miss abnormalities in mental

status status • Affects reliability of historyAffects reliability of history• Pick up on symptoms of medical Pick up on symptoms of medical

emergency- deliriumemergency- delirium• Can indicate need for further outpt Can indicate need for further outpt

evaluationevaluation• Affects discharge planAffects discharge plan

Screening ToolsScreening Tools

11stst DeliriumDeliriumCAM Confusion Assessment CAM Confusion Assessment

MethodMethod22ndnd CognitionCognition

Orientation x 3Orientation x 3MiniCog, if abnormal then MMSEMiniCog, if abnormal then MMSEDepression ScreenDepression Screen

33rdrd FunctionFunctionGet Up and GoGet Up and GoADLs in order of progressionADLs in order of progression

Assessment for DeliriumAssessment for Delirium

CAM Confusion Assessment MethodCAM Confusion Assessment Method

1.1. Acute onset; fluctuatingAcute onset; fluctuating

2.2. InattentiveInattentive

3.3. Disorganized thinkingDisorganized thinking

4.4. ALOCALOC

Delirium = 1 & 2 are present with either #3 Delirium = 1 & 2 are present with either #3 or #4or #4

CAM- InattentionCAM- Inattention

Tests of attention Tests of attention • Count backwards from 20.Count backwards from 20.• State days of week forward & backwardState days of week forward & backward• Repeat the following sequence 7-5-8-3-6Repeat the following sequence 7-5-8-3-6• LettersLetters

S A V E H A A R TS A V E H A A R T

Pictures for critical care unitsPictures for critical care units

CAM- Disorganized ThinkingCAM- Disorganized ThinkingYes/No Questions Set A or Set BYes/No Questions Set A or Set BScore less than 4= positive Score less than 4= positive Then a CommandThen a Command

1. Will stone float?

2. Are there fish in the sea?

3. Does 1 pound weigh more than 2 pounds?

4. Can you use a hammer to pound a nail?

1. Will a leaf float on water?

2. Are there elephants in the sea?

3. Do 2 pounds weigh more than 1 pound?

4. Can you use a hammer to cut wood?

CAM-Altered Level of ConsciousnessCAM-Altered Level of Consciousness

AlertAlert HyperalertHyperalert LethargicLethargic Stuporous, comatoseStuporous, comatose

Anything other than alert = positiveAnything other than alert = positive

CAMCAM

CAM Confusion Assessment MethodCAM Confusion Assessment Method1.1. Acute onset; fluctuating Acute onset; fluctuating if no-stopif no-stop2.2. Inattentive Inattentive if no-stopif no-stop3.3. Disorganized thinkingDisorganized thinking4.4. ALOCALOC

Delirium = 1 & 2 are present with either #3 Delirium = 1 & 2 are present with either #3 or #4or #4

MINI –COGMINI –COG

Cued recall, Clock Drawing TestCued recall, Clock Drawing Test1. Ask the patient to listen carefully to and

remember following 3 words and then to repeat the words back to you: Ocean Desk Tractor

2. Instruct the patient to draw the face of a clock, including the numbers and hands pointing to 11:10.

3. Ask the patient to repeat the 3 previously presented words.

Mini-Cog ScoreMini-Cog ScoreOne point for each word remembered One point for each word remembered

correctly.correctly.

Clock drawing is Nl or AbnClock drawing is Nl or Abn

All numbers present, in correct All numbers present, in correct quadrants, and hands show correct quadrants, and hands show correct timetime

Fail= Abnormal clock OR recall 0 wordsFail= Abnormal clock OR recall 0 words

Then need MMSEThen need MMSE

MMSEMMSEOrientation: 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

MMSE ScoringMMSE Scoring

Score MMSE is affected by education level, age, Score MMSE is affected by education level, age, primary languageprimary language

27 and above considered nl27 and above considered nl 26 to 23 suggests borderline issues26 to 23 suggests borderline issues 22 and below are abn22 and below are abn

What does it mean to you?What does it mean to you?Score below 27 suggests cognitive impairment. This Score below 27 suggests cognitive impairment. This

will impact reliability of information, ability to will impact reliability of information, ability to retain-follow-process instructions, is a retain-follow-process instructions, is a consideration in discharge planning. Further consideration in discharge planning. Further evaluation is needed- perhaps as outpt. evaluation is needed- perhaps as outpt.

GDS 5/15 Short FormGDS 5/15 Short Form

Each answer indicated by * counts as 1 pointEach answer indicated by * counts as 1 point1.1. Are you basically satisfied with your life? Are you basically satisfied with your life?

Yes No*Yes No*2.2. Do you often get bored? Yes* NoDo you often get bored? Yes* No3.3. Do you often feel helpless? Yes* NoDo you often feel helpless? Yes* No4.4. Do you prefer to stay at home rather than Do you prefer to stay at home rather than

going out and doing things? Yes* Nogoing out and doing things? Yes* No5.5. Do you feel worthless the way you are Do you feel worthless the way you are

now? Yes* Nonow? Yes* NoScore 1 or less- stop; 2 or more, continue with Score 1 or less- stop; 2 or more, continue with

other 10 questionsother 10 questions

DocumentationDocumentation

““CAM does not suggest delirium” CAM does not suggest delirium” OROR““CAM suggest delirium: sudden onset, unable CAM suggest delirium: sudden onset, unable

to count backwards from 20, hyperalert”to count backwards from 20, hyperalert”

““MiniCog does not suggest impaired MiniCog does not suggest impaired cognition” cognition” OROR

““MiniCog: recalled 0/3 words; failed clock MiniCog: recalled 0/3 words; failed clock drawing- suggested impaired short term drawing- suggested impaired short term memory and executive function at this memory and executive function at this time”time”

““MMSE: scored 25/30; deficits in MMSE: scored 25/30; deficits in orientation to date, 0/3 on recall, orientation to date, 0/3 on recall, unable to copy pentagons; suggests unable to copy pentagons; suggests impaired cognition”impaired cognition”

““Geriatric Depression Screen does not Geriatric Depression Screen does not suggest depression at this time “ORsuggest depression at this time “OR

““Geriatric Depression screen: scored 5 Geriatric Depression screen: scored 5 out of 15 …………..”out of 15 …………..”

Functional AssessmentFunctional Assessment

Get Up and GoGet Up and Gorise from sitting in chair, walk toward a wall, turn rise from sitting in chair, walk toward a wall, turn and walk back, then sit downand walk back, then sit down

ADLs- activities of daily livingADLs- activities of daily living

IADLs- instrumental activities of daily livingIADLs- instrumental activities of daily living

Functional AssessmentFunctional AssessmentGet Up and Go:Get Up and Go:

BalanceBalance GaitGait

SittingSitting Step height,lengthStep height,length

RisingRising Step Symmetry Step Symmetry StandingStanding Step ContinuityStep Continuity

WalkingWalking PathPath

TurningTurning

Sitting downSitting down

Red Flag: Unsafe use of ambulation aids

ADLsADLsBathingBathingDressingDressingToiletingToiletingTransfersTransfersContinenceContinenceFeedingFeeding

Dependent or Dependent or independentindependent

Order of “Normal” Decline:

Difficulties begin with most physically challenging task at top and progress to least - feeding

IADLsIADLs

phone, travel, shop, phone, travel, shop,

prepare meals, prepare meals,

housework, medications, housework, medications,

moneymoney

““Get Up and Go: uses arms to rise, steps Get Up and Go: uses arms to rise, steps clear floor, short step length; uses clear floor, short step length; uses walker safely; no unsteadiness with walker safely; no unsteadiness with gait; balance steady at all times”gait; balance steady at all times”

““ADLs/IADLS: independent in ADLs; ADLs/IADLS: independent in ADLs; requires assistance with some IADLs- requires assistance with some IADLs- lives with daughter who assists; verified lives with daughter who assists; verified with daughter- Elizabeth Crocker”with daughter- Elizabeth Crocker”

Best Practices for Older Best Practices for Older AdultsAdults

Geriatric Assessment if over 70 years Geriatric Assessment if over 70 years for for

Delirium Delirium CognitionCognitionDepressionDepressionFunctionFunction

Information obtained: Information obtained: • Determine reliability of informantDetermine reliability of informant• Picks up on symptoms often missedPicks up on symptoms often missed• Identify need for further evaluationIdentify need for further evaluation• Affect discharge planAffect discharge plan

Pressure Ulcer PreventionPressure Ulcer Preventionin the EDin the ED

Why Preventing Skin Breakdown Is Why Preventing Skin Breakdown Is ImportantImportant

The number of hospital patients who The number of hospital patients who develop pressure sores has risen by 63% develop pressure sores has risen by 63% over the last 10 years and nearly 60,000 over the last 10 years and nearly 60,000 deaths occur every year from hospital-deaths occur every year from hospital-acquired pressure sores.acquired pressure sores.

The average stay for patients admitted to The average stay for patients admitted to the hospital for treatment of hospital-the hospital for treatment of hospital-acquired pressure sores was 13 days, with acquired pressure sores was 13 days, with an average cost of $37,500 dollars per an average cost of $37,500 dollars per hospital stayhospital stay..

Why Preventing Skin Breakdown Is Why Preventing Skin Breakdown Is ImportantImportant

Nonpayment by Nonpayment by MedicareMedicare

Medicare has made a provision that Medicare has made a provision that they will not pay for treatment of they will not pay for treatment of hospital acquiredhospital acquired pressure ulcers. pressure ulcers.

This could result in millions of lost This could result in millions of lost revenue for the hospital.revenue for the hospital.

ED SettingED Setting

Triage for acuityTriage for acuity

Instructions to patientsInstructions to patients

Support surfaces in EDSupport surfaces in ED

Average stay, “Boarding”Average stay, “Boarding”

Initial Assessment is ImperativeInitial Assessment is Imperative

A full assessment of the patient’s skin A full assessment of the patient’s skin must occur on any admitted patient!must occur on any admitted patient!

Documentation of any existing skin Documentation of any existing skin breakdown must be charted on breakdown must be charted on admission to the ED. If this is not done admission to the ED. If this is not done the hospital will not be paid for the hospital will not be paid for pressure ulcer treatment because it will pressure ulcer treatment because it will be assumed it was hospital acquired.be assumed it was hospital acquired.

Pressure Ulcer Risk FactorsPressure Ulcer Risk FactorsAgeAge

Limited mobilityLimited mobility

Malnutrition/Malnutrition/

dehydrationdehydration

MoistureMoisture

Pressure ulcers in Pressure ulcers in thethe past past

Mental, Mental, neurological and neurological and other physical other physical problemsproblems

Friction & Friction & sheeringsheering

Wrinkled sheets Wrinkled sheets or hard objects or hard objects left in the bed.left in the bed.

AgeAge

Normal aging process changes the Normal aging process changes the skin and circulationskin and circulation

Skin can become dry and very fragileSkin can become dry and very fragile

Skin can be easily irritated, break Skin can be easily irritated, break open in to a sore and can tear easilyopen in to a sore and can tear easily

Older patients may have poor Older patients may have poor circulation- less O2 to the tissuecirculation- less O2 to the tissue

Lack of MobilityLack of MobilityPressure ulcers can start withinPressure ulcers can start within

1-2 hours. ED average length of stay is 4 1-2 hours. ED average length of stay is 4 hours.hours.

Pressure ulcers can form from unrelieved Pressure ulcers can form from unrelieved pressure in a chair, wheel chair, or bed.pressure in a chair, wheel chair, or bed.

Lack of Mobility continuedLack of Mobility continued

The weight of the body pushes The weight of the body pushes against a bony area to cut off the against a bony area to cut off the blood and O2 to the area.blood and O2 to the area.

The sacrum, hips, spine, elbows, The sacrum, hips, spine, elbows, ears, shoulders, toes and heels are ears, shoulders, toes and heels are areas that can break down if a pt is areas that can break down if a pt is kept in one position for a long period kept in one position for a long period of time.of time.

Nutrition/HydrationNutrition/Hydration

Older patients have decreased reflex Older patients have decreased reflex to drink.to drink.

The skin and other tissues of the The skin and other tissues of the body do not get the food and body do not get the food and nutrition they need to stay healthy nutrition they need to stay healthy and to repair damaged skin.and to repair damaged skin.

Unwanted MoistureUnwanted Moisture

Incontinence of urine or stool, and Incontinence of urine or stool, and sweat sweat

Draining wounds over areas of a Draining wounds over areas of a boney prominenceboney prominence

Mental, Neurological and other Mental, Neurological and other physical problemsphysical problems

Confused or sleepy patients may not Confused or sleepy patients may not turn themselves like alert patients.turn themselves like alert patients.

People who have a lessened People who have a lessened sensation to pain or do not have the sensation to pain or do not have the physical ability to turn are at risk for physical ability to turn are at risk for pressure ulcers.pressure ulcers.

Comatose patients are at HIGH risk!Comatose patients are at HIGH risk!

Friction and SheeringFriction and Sheering

Friction and sheering occur when a Friction and sheering occur when a patient is pulled up in the stretcher, patient is pulled up in the stretcher, bed or chair.bed or chair.

These forces can irritate the skin and These forces can irritate the skin and can cause the skin to break down.can cause the skin to break down.

Bed Sheets and Objects left in BedBed Sheets and Objects left in Bed

Uneven pressure is created when Uneven pressure is created when sheets are wrinkled. This can lead to sheets are wrinkled. This can lead to pressure ulcers.pressure ulcers.Objects such as spoons, tissue boxes, Objects such as spoons, tissue boxes, food crumbs, and other hard objects food crumbs, and other hard objects left in the bed or chair can cause left in the bed or chair can cause pressure ulcers.pressure ulcers.

Pressure Ulcers in the PastPressure Ulcers in the Past

Patients who have had a Patients who have had a pressure ulcer in the pressure ulcer in the past are at greater RISK past are at greater RISK of getting another one.of getting another one.

How do Pressure Ulcers FormHow do Pressure Ulcers Form

A warning sign of a pressure ulcer is A warning sign of a pressure ulcer is when pink skin on a bony area turns when pink skin on a bony area turns deep red and is slow to blanch after deep red and is slow to blanch after pressure is relieved.pressure is relieved.

Blood cells have “rushed” to the area Blood cells have “rushed” to the area of pressure turning the skin redof pressure turning the skin red

How do Pressure Ulcers Form?How do Pressure Ulcers Form?

The skin may become red and irritated if The skin may become red and irritated if this pt is not turned. The skin may now this pt is not turned. The skin may now feel very warm and the patient may tell feel very warm and the patient may tell you they feel a burning area.you they feel a burning area.

Top layers of the skin break away and then Top layers of the skin break away and then move downward to layers of skin, muscles, move downward to layers of skin, muscles, bone or joint .bone or joint .

The muscle and bone become damagedThe muscle and bone become damaged

PreventionPrevention

Visual inspection and palpation of Visual inspection and palpation of high risk areashigh risk areas

Cue patient or change their position Cue patient or change their position frequently; bridge heelsfrequently; bridge heels

AmbulateAmbulate

Hydrate if possibleHydrate if possible

ToiletToilet

Work for change in your EDWork for change in your ED

DocumentationDocumentationRepositioning and comfort measuresRepositioning and comfort measuresAll existing pressure ulcers must be All existing pressure ulcers must be documented on describing thedocumented on describing the

stage of ulcerstage of ulcer locationlocation color color drainagedrainage sizesize treatment of pressure ulcertreatment of pressure ulcer

Urinary Incontinence Urinary Incontinence and the EDand the ED

Aging ChangesAging Changes

Increased nocturia (1-2x/night >60)Increased nocturia (1-2x/night >60) Bladder fills full at lower volumesBladder fills full at lower volumes Reduced strength of bladder contractionsReduced strength of bladder contractions Increased irritability of bladderIncreased irritability of bladder Delayed recognition of bladder fillingDelayed recognition of bladder filling

Incontinence is NOT normal agingIncontinence is NOT normal aging

TypesTypes

Stress – jumping jackStress – jumping jack Urge / Overactive bladder- DetrolUrge / Overactive bladder- Detrol Mixed- 90%Mixed- 90% Retention with overflowRetention with overflow TotalTotal ReflexReflex FunctionalFunctional

Functional IncontinenceFunctional Incontinence

Frequently seen in hospitalFrequently seen in hospital Normal voiding patterns & normal bladder Normal voiding patterns & normal bladder

function; usually related to cognitive function; usually related to cognitive status, motivation, and/or mobility issuesstatus, motivation, and/or mobility issues

DON’T assume new or increased DON’T assume new or increased incontinence is functionalincontinence is functional

DO provide scheduled opportunities to DO provide scheduled opportunities to toilettoilet

Reversible Factors Reversible Factors

D – DeliriumD – Delirium I – Infection / IrritantsI – Infection / Irritants A – Atrophic urethritis / vaginitisA – Atrophic urethritis / vaginitis P – PharmaceuticalsP – Pharmaceuticals P – Psychological causesP – Psychological causes E – Endocrine causes (Excess urine)E – Endocrine causes (Excess urine) R – Restricted MobilityR – Restricted Mobility S – Stool impactionS – Stool impaction

Criteria for Indwelling Urinary Criteria for Indwelling Urinary Catheter Catheter CDC CDC

Critically IllCritically Ill: Alteration in BP or volume status : Alteration in BP or volume status requiring continuous, accurate urine volume requiring continuous, accurate urine volume measurementmeasurement

Infection PreventionInfection Prevention: to prevent urine from soiling a : to prevent urine from soiling a Stage III or IV pressure ulcer or nearby operative Stage III or IV pressure ulcer or nearby operative sitesite

Comfort careComfort care: for terminally ill patients: for terminally ill patients SurgerySurgery: patients going directly to the operating : patients going directly to the operating

roomroom Procedures or TestsProcedures or Tests requiring an indwelling urinary requiring an indwelling urinary

catheter, removed at the conclusion of the catheter, removed at the conclusion of the procedure/testprocedure/test

Criteria for Indwelling Urinary Criteria for Indwelling Urinary Catheter Catheter contcont

GU IndicationsGU Indications Continuous bladder irrigation Continuous bladder irrigation Instillation of medication into the bladderInstillation of medication into the bladder Obstruction to the urinary tract distal to bladderObstruction to the urinary tract distal to bladder Drainage in patient with neurogenic bladder Drainage in patient with neurogenic bladder

dysfunction, hydronephrosis, and urinary retention not dysfunction, hydronephrosis, and urinary retention not manageable by other means (e.g., with clean manageable by other means (e.g., with clean intermittent catheterization)intermittent catheterization)

Aid in urologic surgery or other surgery in contiguous Aid in urologic surgery or other surgery in contiguous structuresstructures

Ordered by a urologist for a special purpose or Ordered by a urologist for a special purpose or difficult insertiondifficult insertion

Foley Catheters Foley Catheters

An indwelling urinary catheter is An indwelling urinary catheter is notnot appropriate for nursing convenience appropriate for nursing convenience

Not Not Appropriate for urinary incontinence- Appropriate for urinary incontinence- use barrier creams.use barrier creams.

Assess frequently whether catheter is still Assess frequently whether catheter is still neededneeded

Foley Catheters Foley Catheters

CAUTIs- one of CMS Never EventsCAUTIs- one of CMS Never Events

Most effective method to prevent CAUTIs Most effective method to prevent CAUTIs is to AVOID indwelling cathetersis to AVOID indwelling catheters

Foley Catheters- if MUST haveFoley Catheters- if MUST haveAseptic technique, Aseptic technique, Closed system, Closed system, Inflate balloon completelyInflate balloon completelySecured to legSecured to leg

Emergency DeptEmergency Dept

• Gateway for most of our older patientsGateway for most of our older patients• Ability to initiate change in practice that will Ability to initiate change in practice that will

carry through the admissioncarry through the admission• Eliminate a risk that prolongs LOS and Eliminate a risk that prolongs LOS and

had financial impacthad financial impact

Pain in Older Adults

Dee Tucker RN, MN, GCNS-BCClinical Nurse Specialist Gerontology

Piedmont Hospital

Prevalence

• Community dwelling seniors- 50%

• Nursing home residents 70 to 80%, with 45% have persistent pain

• Associated with high rates of chronic disease in advanced age: arthritis, back pain

Pain is very common experience yet poorly managed

Common Myths

Pain is an expected consequence of aging.

Barriers to pain relief / patient’s fears:– They will become addicted to opioids– They will have side effects from the drugs– Increasing pain means that the disease is getting

worse– They worry about being a good patient

Acute: from disease process or soft tissue injury, localized, responds to tx

Chronic: neuropathic- pathology in peripheral or CNS, more diffuse, less responsive to tx, not always be linked to a specific cause

Effects of Unrelieved Pain

• Elevated blood pressure

• Increased heart rate

• Depression

• Sleep disturbance

• Impaired mobility / function

Effects of Unrelieved Pain

• Decreased social interactions

• Contributes to: falls, deconditioning, malnutrition, lowered QOL

• Chronic pain sufferers can develop a decrease in their pain threshold

Pain Treatment

• Gold standard: self assessment

• Cognitive status Pain

• Goal- max function and QOL

• Preventive approach- use less med: round clock, pre-medicate

Pain Treatment- Dementia

• Assessment: rely on observation

• Behaviors: rocking, increased or decreased activity level from their normal, changes in typical behaviors

• Dementia: situation where you suspect may have pain- do clinical trial of pain med and non pharmacological strategies

Pain Treatment

• Tolerance- decrease drug effectiveness over time

• Dependence- uncomfortable symptoms with abrupt withdrawal

• Addiction: psych condition characterized by compulsive drug use and craving

Pain Treatment

• Opioids

• Transdermal fentanyl

• Tramadol hydrochloride

Pain Treatments to Avoid

• Demerol meperidine

• Proxpoxyphene and combo products – Darvon, Dravocet, Darvon N, Darvocet N

• Toradol ketorolac

• Talwin pentazocine

What are your biggest issues with pain and older adults in the ED?

Health Literacy in Older Adults

Patient/Family Issues

A Quote from the AMA“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.”

Health Literacy Defined by the AMA

“Health Literacy is the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment.”

More important then ever

• Medical care is growing increasingly complex

• Patients are being treated with more and more medications

• We discharge “quicker and sicker” when the patients are “well enough”

Implications for low health literacy

• Leads to poor health outcomes

• Is the best predictor of health status

• Leads to higher healthcare costs

Points to Ponder

• Nearly half of U.S. population has low literacy

• It affects all segments of the population

• It costs the United States between $50 billion and $73 billion a year

Key Risk Factors for Low Health Literacy

• Elderly• Low income• Unemployed• Did not finish high school• Minority ethnic group• Recent immigrant to the U.S. and does not

speak English• English is a second language

Examples of Some Patient Issues and Misunderstandings

Red Flags - Behaviors

• Forms are incomplete• Missed appointments• Noncompliance with

medications• Lack of follow-through

with diagnostics

• Clinical values don’t support patient’s report of taking medications or following dietary restrictions as prescribed

Red Flags – Verbal Responses

- “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.”

Red Flags – Reviewing Medications

- Unable to name medication(s)

- Unable to explain a medication’s purpose

- Unable to explain timing of medication administration

- Unable to explain basic health or diet concerns related to the medication

“Brown Bag Review”

• Does patient look at medication or read the label on the bottle?

• Ask when they last took that medication

• If the patient looks confused, suspect memorization

What is the patient reading?

• 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.

What you really gave them

• 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.

Liability Concerns

• Clinician’s communication and attitude are factors in 75% or malpractice suits– Inadequate explanations of diagnosis and

treatment– Communication left patients feeling their

concerns were ignored

Steps for Improvement

• Create a shame free environment

• Slow down

• Use non-medical language

• Draw pictures

• Limit information and repeat it

• Use “Teach-Back” technique

Teach Back• Use simple language

• Ask patient/family to repeat understanding of concept

• Identify and correct misunderstandings

• Ask to demonstrate understanding again

• Repeat above until convinced of comprehension or inability to do so

Quote from a patient

“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.”

Questions?

Geriatric Syndromes Geriatric Syndromes

Dee Tucker, MS, RN, GCNS-BCClinical Nurse Specialist GerontologyPiedmont Healthcare NICHE Coordinator

Older Adult PresentationsOlder Adult Presentations

Complex problems due to• Diminished organ reserve• Concurrent chronic diseases• Acute disease• Normal aging changes

Accumulated effect= Geriatric Syndromes

Complex problems due to• Diminished organ reserve• Concurrent chronic diseases• Acute disease• Normal aging changes

Accumulated effect= Geriatric Syndromes

Geriatric SyndromesGeriatric Syndromes

Falls Instability / DizzinessAltered Mental StatusFunctional Impairment / Malaise /

Fall SyndromeFall Syndrome

Consequence: fracture, hematoma, joint injury, subdural hematoma

Falls are a sentinel event in older adult

Marker for serious often unrecognized, underlying illness or disability

Consequence: fracture, hematoma, joint injury, subdural hematoma

Falls are a sentinel event in older adult

Marker for serious often unrecognized, underlying illness or disability

Contributing Factors Atypical presentations-Infection Drug toxicity Postural hypotension Malnutrition CNS disease Elder abuse Vestibular disease Sensory loss

Aging Changes that predisposeSensory deficitsPostural changesFlexibility loss

Chronic Issues Declining nutritionBowel and bladder issuesCognitionPostural hypotension

Medications

•Sedatives

•Antihypertensives

•Diuretics

•Narcotics

AssessmentBaseline prior to illnessOrthostatic BP and HRGeriatric assessment Med reviewConsider atypical disease

presentations

AssessmentBaseline prior to illnessOrthostatic BP and HRGeriatric assessment Med reviewConsider atypical disease

presentations

Interventions:Address findings from assessment and critical thinkingCommunicate findingsReferral• Physical therapy / OT• HH RN• Family • PCP

Instability / Dizzy Syndrome

Contributing factors• Cardiovascular disease hx- MI, CVA, Angina• Infections • Depressive and anxiety symptoms • Gait impairments• Neurological syndrome• Postural blood pressure changes• Medications• Aging changes

Instability / Dizzy Syndrome

Associated with increased risk for• Falls• Functional disability• CVA

Assessment and InterventionsRefer to Fall Syndrome

Associated with increased risk for• Falls• Functional disability• CVA

Assessment and InterventionsRefer to Fall Syndrome

Confusion / AMS Syndrome

Potential causes: acute confusion- Delirium chronic confusion- Dementia pseudo confusion- Depression Combination of 3 D’s

DeliriumContributing Factors: Normal Aging

Changes, Environment, Medications, Medical conditions, Procedures

3 Types: Hyperactive, hyperalertHypoactive, hypoalertMixed

DeliriumContributing Factors: Normal Aging

Changes, Environment, Medications, Medical conditions, Procedures

3 Types: Hyperactive, hyperalertHypoactive, hypoalertMixed

Confusion / AMSSyndrome

Assessment Baseline prior to illness Orthostatic BP & HRGeriatric Assessment Repeat CAM if behavior changes

What does it mean if positive for delirium?Need to find causes and correct

Assessment Baseline prior to illness Orthostatic BP & HRGeriatric Assessment Repeat CAM if behavior changes

What does it mean if positive for delirium?Need to find causes and correct

Preventing / Treating DeliriumEnsure hydration and nutrition during

visitSupport CognitionComfort, decrease stressUse sensory aidsEncourage family to stay if able

Preventing / Treating DeliriumEnsure hydration and nutrition during

visitSupport CognitionComfort, decrease stressUse sensory aidsEncourage family to stay if able

Interventions with Delirium

Collaboration

Safe environment

Prevent complications

Preventive actions listed

Interventions with Delirium

Collaboration

Safe environment

Prevent complications

Preventive actions listed

DementiaChronic, progressive confusional state

Compromise in at least three areas of following mental activities:

LanguageMemoryVisuospatial skillsPersonality and emotional stateExecutive Function (abstraction, judgment)

NOT A NORMAL PART OF AGING!!!!

DementiaChronic, progressive confusional state

Compromise in at least three areas of following mental activities:

LanguageMemoryVisuospatial skillsPersonality and emotional stateExecutive Function (abstraction, judgment)

NOT A NORMAL PART OF AGING!!!!

Clues:• Poor historian• Unable to recall medications but manages

own• Refers to family to answer questions• Repeatedly and apparently unintentionally

fails to follow directions• Difficulty finding right word or uses

inappropriate word• Repeats stories or questions• Meds: Aricept (donepezil), Cognex (tacrine),

Reminyl (galantamine/ galanthamine) and Exelon (rivastigmine), Namenda(memantine)

Clues:• Poor historian• Unable to recall medications but manages

own• Refers to family to answer questions• Repeatedly and apparently unintentionally

fails to follow directions• Difficulty finding right word or uses

inappropriate word• Repeats stories or questions• Meds: Aricept (donepezil), Cognex (tacrine),

Reminyl (galantamine/ galanthamine) and Exelon (rivastigmine), Namenda(memantine)

AssessmentBaseline before this illnessGeriatric Assessment

If fails Mini Cog, then MMSE

May not do MMSE if has dx of dementia and has appropriate supervision / oversight and family/caregiver is present with pt

AssessmentBaseline before this illnessGeriatric Assessment

If fails Mini Cog, then MMSE

May not do MMSE if has dx of dementia and has appropriate supervision / oversight and family/caregiver is present with pt

What does it mean when fail MiniCog?

At this moment in time:Fails recall- poor short term memoryFails clock drawing- impaired executive

functionFails MMSE- indicates cognitive

impairment

What does it mean when fail MiniCog?

At this moment in time:Fails recall- poor short term memoryFails clock drawing- impaired executive

functionFails MMSE- indicates cognitive

impairment

Dementia ProgressionEarly Stage MMSE 20-29

Memory loss Confusion about familiar places (begin to get

lost) Trouble handling money and paying bills Making bad decisions due to impaired judgment Withdrawal Mood and personality changes, irritability

Communication difficulties- loses track of conversations

Dementia ProgressionEarly Stage MMSE 20-29

Memory loss Confusion about familiar places (begin to get

lost) Trouble handling money and paying bills Making bad decisions due to impaired judgment Withdrawal Mood and personality changes, irritability

Communication difficulties- loses track of conversations

Middle Stage (2 to 10 years) MMSE 10-19 Increasing memory loss ,Shortened attention span, Problems recognizing friends and family, problems

with reading, writing Difficulty thinking logically or to tell time Inability to learn new things and Loss of impulse

control Restlessness, agitation, anxiety, tearfulness,

wandering, late-day time disorientation and confusion

Hallucinations, delusions, suspiciousness, paranoia, irritability

Requires asst with ADLsCommunication- increased repeating, word

finding issues

Middle Stage (2 to 10 years) MMSE 10-19 Increasing memory loss ,Shortened attention span, Problems recognizing friends and family, problems

with reading, writing Difficulty thinking logically or to tell time Inability to learn new things and Loss of impulse

control Restlessness, agitation, anxiety, tearfulness,

wandering, late-day time disorientation and confusion

Hallucinations, delusions, suspiciousness, paranoia, irritability

Requires asst with ADLsCommunication- increased repeating, word

finding issues

Late Stage MMSE: 0-9Weight lossSeizures, skin infections, difficulty

swallowingGroaning, moaning, gruntingIncreased sleepingLack of bladder and bowel controlCommunication-Person may repeat

something over and over, or copy what nurse says

Late Stage MMSE: 0-9Weight lossSeizures, skin infections, difficulty

swallowingGroaning, moaning, gruntingIncreased sleepingLack of bladder and bowel controlCommunication-Person may repeat

something over and over, or copy what nurse says

Nursing Management Keep activities and conversations

simple. Re-orient only if appropriate Support bowel and bladder control. Use

scheduled toileting. Limit number of staff caregiving/

entering room The person needs to be carefully

prepared for any changes

Nursing Management Keep activities and conversations

simple. Re-orient only if appropriate Support bowel and bladder control. Use

scheduled toileting. Limit number of staff caregiving/

entering room The person needs to be carefully

prepared for any changes

Nursing ManagementUse three Rs: repeat, reassure and

redirect / distractAnxiety and catastrophic behaviors can

result from noisy, crowded, chaotic environment

Use activity box items

Nursing ManagementUse three Rs: repeat, reassure and

redirect / distractAnxiety and catastrophic behaviors can

result from noisy, crowded, chaotic environment

Use activity box items

If pt to return to community:• refer to Sixty plus for f/u with pt

and family• Arrange appropriate oversight as

needed

If pt admitted to hospital, include geriatric evaluation results in report to nurses

If pt to return to community:• refer to Sixty plus for f/u with pt

and family• Arrange appropriate oversight as

needed

If pt admitted to hospital, include geriatric evaluation results in report to nurses

Depression- pseudo dementia

• lower mood tone• difficulty thinking• somatic changes precipitated by

feelings of loss and / or guilt.• mimics dementia

Depression- pseudo dementia

• lower mood tone• difficulty thinking• somatic changes precipitated by

feelings of loss and / or guilt.• mimics dementia

Contributing FactorsBrain neurotransmitter imbalance

– predominately serotonin and dopamine

Alcohol and drugsHeredityMedications Illnesses

Contributing FactorsBrain neurotransmitter imbalance

– predominately serotonin and dopamine

Alcohol and drugsHeredityMedications Illnesses

Behaviors with depressionLoss of interest Fatigue Irritability, agitationChange in appetiteSleep problemsCognition difficultiesSuicidal ideation

Risk FactorsFemale Social isolationUnemployment or retirementWidowed, divorced, or separatedSerious medical conditions,

especially vascular problemsUncontrolled pain

Risk FactorsFemale Social isolationUnemployment or retirementWidowed, divorced, or separatedSerious medical conditions,

especially vascular problemsUncontrolled pain

Assessment:Geriatric AssessmentNutrition statusPersonal appearanceBehaviors

What does GDS score mean:if scores 1 or less on first 5 questions?if scores 2 or more on first 5 questions?if indicates possible depression?

What does this mean to you in the ED?

What does GDS score mean:if scores 1 or less on first 5 questions?if scores 2 or more on first 5 questions?if indicates possible depression?

What does this mean to you in the ED?

Interventions• Explain concern to family /

caregivers• Provide handout for family on

signs• Encourage pt and family to discuss

with PCP

Interventions• Explain concern to family /

caregivers• Provide handout for family on

signs• Encourage pt and family to discuss

with PCP

Functional Impairment/Malaise/ FTT

Syndrome

SyndromeContributing Factors• Malnutrition• Depression• Cognitive impairment• Impaired function• Acute illness untreated• Medications• Pain• Abuse & neglect• Environmental issues

Contributing Factors• Malnutrition• Depression• Cognitive impairment• Impaired function• Acute illness untreated• Medications• Pain• Abuse & neglect• Environmental issues

Syndrome

Presenting symptoms include:weight loss, progressivedecline in physical abilitiesdecline in cognitive abilitiesfeelings of hopelessness, helplessness

Syndrome

SyndromeAssessment:

Geriatric AssessmentNutrition statusPersonal appearanceBehaviors

InterventionsSee other syndromesReferrals

Key Points to Take AwayKey Points to Take Away

Multiple causes Geriatric Specific assessment if

over 70Address findings from assessment

and critical thinking Clinically relevant to the patientCommunicate findingsGet consults / Make referrals

Multiple causes Geriatric Specific assessment if

over 70Address findings from assessment

and critical thinking Clinically relevant to the patientCommunicate findingsGet consults / Make referrals

Transitioning Older Patientsto community, facility or into hospital

Tim Young, LCSW

Sixty Plus Older Adult Services

Why is This Important?

• Frequent returns to ED or hospital

• Greater risk for complications

• Time and discharge planning

Transitions

When transitioning a patient, consider:

• Cognitive dysfunction

• Functional status

• Evaluation of ability to care for themselves

• Need for caregiver/ oversight

• Need for referral / resource information

Geriatric Assessments

• Cognitive Issues

• Mobility

• Activities of Daily Living (ADL’s)

• Depression

• Delirium

Barriers

LanguageReading /

Medical literacyHearing VisualMemory

Discharge Instructions

Purpose

• Educate on appropriate care

• Inform on health issues and options

• Notify of resources

• Comply with regulations

Discharge Instructions

Discharge Objectives

• Limited number

• Age-specific and appropriate

• Format

Pop Quiz: Which is incorrect?

Discharge Instructions:

1. Provide useful information on resources that they can use

2. Are difficult to teach because older adults can not learn as easily

3. Provide a sequence of steps for people to follow for health care

“4 Pillars of Care Transitions”

• Personal Health Record

• Medication Knowledge

• Follow up with PCP and/or Specialist

• Red Flags

Home Health Referral

Situations justifying HH evaluation (according to Medicare rules)

• High risk for re-hospitalization

• Complex discharge plan

• Need for rehab services

• Need for multiple medications

• Physical limitations

Home Health Referral

Situations justifying HH evaluation: (according to Medicare rules)

• Deficits in mental or social functioning

• New diagnosis or exacerbation of existing condition

• Sudden weight loss or gain

• Recent changes in cognition

Discharge Instructions and Older Patients

Assess knowledge, barriers

Limit Objectives

Address barriers

Provide scenarios

“Take home” materials

Medications and Older Medications and Older Adults Critical ThinkingAdults Critical Thinking

NaaDede Badger, Pharm.D, NaaDede Badger, Pharm.D, BCPSBCPS

ObjectivesObjectives

Discuss polypharmacy and its risk in the Discuss polypharmacy and its risk in the elderlyelderly

Discuss pharmacokinetic and Discuss pharmacokinetic and pharmacodynamic changes in the elderlypharmacodynamic changes in the elderly

Adverse drug reactions and adherenceAdverse drug reactions and adherence Underuse of drugsUnderuse of drugs Review medication related issues to keep Review medication related issues to keep

in mind when taking care of the elderlyin mind when taking care of the elderly

A look at the geriatric A look at the geriatric patient ..patient ..

Complicated drug therapyComplicated drug therapy Increase in risk of adverse drug Increase in risk of adverse drug

reactions (ADRs)reactions (ADRs)– Signifcant ADRs especially with drugs with Signifcant ADRs especially with drugs with

narrow therapeutic windows, ex. narrow therapeutic windows, ex. Phenytoin, warfarin and theophylline.Phenytoin, warfarin and theophylline.

Increased risk of drug-drug interactionsIncreased risk of drug-drug interactions Pharmacokinetic and Pharmacokinetic and

pharmacodynamic changespharmacodynamic changes

Social IssuesSocial Issues Depression and poor medication Depression and poor medication

adherenceadherence Use of alcohol Use of alcohol Economic situations may lead to Economic situations may lead to

medication non-adherencemedication non-adherence Cultural differences- 10% of older adults Cultural differences- 10% of older adults

were born outside the US, 13% don’t were born outside the US, 13% don’t speak Englishspeak English

>34% do not have high school diplomas>34% do not have high school diplomas

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

CaseCase

A 71 yof is admitted with c/o abdominal pain, A 71 yof is admitted with c/o abdominal pain, n&v. Her PMH includes: ischemic colitis, HTN, n&v. Her PMH includes: ischemic colitis, HTN, CAD, chronic pruritis, PVD, and depression. Her CAD, chronic pruritis, PVD, and depression. Her meds at admission include: amiloride 5mg BID, meds at admission include: amiloride 5mg BID, ASA 81mg daily, ASA 81mg daily, Claritin 10mg dailyClaritin 10mg daily, Coreg , Coreg 6.25mg BID, 6.25mg BID, DN-100 prnDN-100 prn, Diovan 80mg BID, , Diovan 80mg BID, Hydroxyzine 30mg BIDHydroxyzine 30mg BID, Lantus 14units hs, , Lantus 14units hs, magnesium oxide 400mg BIDmagnesium oxide 400mg BID, , Remeron Remeron 45mg qhs45mg qhs, K-Dur 30meq daily, Prevacid 40mg , K-Dur 30meq daily, Prevacid 40mg daily, daily, Aldactone 12.5mg dailyAldactone 12.5mg daily, Vitamin C , Vitamin C 500mg daily, 500mg daily, wellbutrin 300mg dailywellbutrin 300mg daily, , Actonel 35mg weekly, Actonel 35mg weekly, demadex 40mg BIDdemadex 40mg BID, , Fibercon prn.Fibercon prn.

What are the issues with What are the issues with her med list??her med list??

Use of multiple anticholinergic agents can Use of multiple anticholinergic agents can increase risk of falls, sedation.increase risk of falls, sedation.

Use of multiple antidepressants – need to Use of multiple antidepressants – need to assess and make sure she is supposed to be assess and make sure she is supposed to be on bothon both

Use of multiple diuretics including two Use of multiple diuretics including two potassium sparing diureticspotassium sparing diuretics

Use of multiple medications that can increase Use of multiple medications that can increase the risk of fallsthe risk of falls

? Need for Darvocet? Need for Darvocet Need for magnesium oxide – do we have a Mg Need for magnesium oxide – do we have a Mg

level?level? Need for Vitamin C??Need for Vitamin C??

PolypharmacyPolypharmacy

Polypharmacy means “many drugs” Polypharmacy means “many drugs” usually more than 5 medicationsusually more than 5 medications

Definition: The use of more Definition: The use of more medications than is clinically medications than is clinically warranted or indicatedwarranted or indicated

Why is polypharmacy Why is polypharmacy common?common?

The elderly have more disease statesThe elderly have more disease states More drugs availableMore drugs available Readily available drugs over the Readily available drugs over the

countercounter Inappropriate prescribingInappropriate prescribing Lack of medication reviewLack of medication review The “prescribing cascade”The “prescribing cascade”

““Prescribing cascade”Prescribing cascade”

NSAIDs->HTN->antihypertensive NSAIDs->HTN->antihypertensive therapytherapy

Reglan->Parkinsonism->SinemetReglan->Parkinsonism->Sinemet Calcium channel blocker->edema->Calcium channel blocker->edema->

lasix->potassium supplementlasix->potassium supplement NSAIDs->H2 blocker->delirium->HaldolNSAIDs->H2 blocker->delirium->Haldol Sudafed->Urinary retention->alpha Sudafed->Urinary retention->alpha

blockerblocker

Polypharmacy: Show me Polypharmacy: Show me the #s!!the #s!!

Elderly make up 13% of population Elderly make up 13% of population but consume ~ 30% of prescriptionsbut consume ~ 30% of prescriptions11

Average elderly patient consumesAverage elderly patient consumes– 2-6 prescription drugs and…2-6 prescription drugs and…– 2-4 over-the-counter drugs2-4 over-the-counter drugs

Average nursing home patient is on 7 Average nursing home patient is on 7 drugsdrugs

Average American senior spends ~ Average American senior spends ~ $2000 / yr on pharmaceuticals alone$2000 / yr on pharmaceuticals alone22

1. Williams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24

2. Kamboj S, et a. Cost of Medications in elderly in a nursing home. JLA State Med Soc 1999;151(9):470-2

PharmacokineticsPharmacokinetics

What the body does to the drugsWhat the body does to the drugs– AbsorptionAbsorption

– DistributionDistribution

– MetabolismMetabolism

– ExcretionExcretion

PharmacokineticsPharmacokinetics

Absorption: not affected much by aging Absorption: not affected much by aging compared to some of the other parameterscompared to some of the other parameters– Reduced gastric emptyingReduced gastric emptying– Reduced gastric acid productionReduced gastric acid production– Reduced GI motilityReduced GI motility– Reduced GI blood flowReduced GI blood flow

DistributionDistribution– Increased body fat and decreased total body Increased body fat and decreased total body

water (due to decreased muscle mass)water (due to decreased muscle mass)– Increased in volume of distribution of lipophilic Increased in volume of distribution of lipophilic

drugs like sedatives ex. Diazepam (Valiumdrugs like sedatives ex. Diazepam (Valium®®))

Pharmacokinetics contdPharmacokinetics contd……

MetabolismMetabolism– Reduced liver blood flowReduced liver blood flow– Reduced liver metabolismReduced liver metabolism– Reduced enzyme activitiesReduced enzyme activities

Common medications with Common medications with decreased hepatic decreased hepatic

metabolismmetabolism Meperidine (DemerolMeperidine (Demerol®®)) Theophylline (Theo-DurTheophylline (Theo-Dur®®, etc), etc) Chlordiazepoxide (LibriumChlordiazepoxide (Librium®®)) Diazepam (ValiumDiazepam (Valium®®)) Desipramine (NorpraminDesipramine (Norpramin®®)) QuinidineQuinidine

Pharmacokinetics contdPharmacokinetics contd

Excretion – reduced by as much as Excretion – reduced by as much as 50% by age 7550% by age 75– Reduced glomerular filtration rateReduced glomerular filtration rate– SCr not a reliable indicator – need CrClSCr not a reliable indicator – need CrCl

Medications with decreased Medications with decreased renal clearancerenal clearance

Aminoglycosides e.x. tobramycin, Aminoglycosides e.x. tobramycin, gentamicin, amikacingentamicin, amikacin

Meperidine (DemerolMeperidine (Demerol®®)) Digoxin (LanoxinDigoxin (Lanoxin®®)) Diuretics specifically HCTZ, Diuretics specifically HCTZ,

furosemide, triamterenefurosemide, triamterene LithiumLithium HH22RA ( ex Tagamet, Zantac)RA ( ex Tagamet, Zantac)

Pharmacodynamic Pharmacodynamic changeschanges

What the drug does to the body:What the drug does to the body:– Increased Effects:Increased Effects:

AlcoholAlcohol BenzodiazepineBenzodiazepine WarfarinWarfarin PhenerganPhenergan NSAIDs NSAIDs Anticholinergics – ex. BenadrylAnticholinergics – ex. Benadryl®®

– Some effects are decreased:Some effects are decreased: InsulinInsulin HR response to beta blockersHR response to beta blockers

Drug-disease InteractionsDrug-disease Interactions Patient with PD have increased risk of drug Patient with PD have increased risk of drug

induced confusioninduced confusion NSAIDs (and Cox -2 Inhibitors) can NSAIDs (and Cox -2 Inhibitors) can

exacerbate CHFexacerbate CHF Urinary retention in BPH patients on Urinary retention in BPH patients on

decongestants and anticholinergicsdecongestants and anticholinergics Constipation worsened by calcium channel Constipation worsened by calcium channel

blockers and anticholinergicsblockers and anticholinergics Quinolones, ultram can lower seizure Quinolones, ultram can lower seizure

thresh-holdthresh-hold Quinolones can affect blood sugarQuinolones can affect blood sugar

Drugs and FallsDrugs and Falls

Long acting benzodiazepines and Long acting benzodiazepines and other sedativesother sedatives

Tri-cyclic anti-depressants and also Tri-cyclic anti-depressants and also SSRIsSSRIs

Mild increase in risk but can be seen Mild increase in risk but can be seen with diuretics, anti-arrhythmic, and with diuretics, anti-arrhythmic, and digoxindigoxin

Beta-blockers have been shown Beta-blockers have been shown NOTNOT to have that significant of a riskto have that significant of a risk

Drug-Food InteractionsDrug-Food Interactions

Remember warfarin and Vitamin K Remember warfarin and Vitamin K containing foods (don’t forget green containing foods (don’t forget green tea)tea)

Digoxin can cause anorexiaDigoxin can cause anorexia ACE-Inhibitors may alter tasteACE-Inhibitors may alter taste

Hospitalization: A high risk Hospitalization: A high risk timetime

40% of medications are stopped 40% of medications are stopped during admissionduring admission

45% of discharge medications were 45% of discharge medications were filled / started by patientsfilled / started by patients

Prescribing problems considered Prescribing problems considered serious seen in 22% of patientsserious seen in 22% of patients

Other prescribing problems up to Other prescribing problems up to 66%66%

Inappropriate medications Inappropriate medications in the elderlyin the elderly

Sedatives & Sedatives & Hypnotic agentsHypnotic agents

Chlordiazepoxide Chlordiazepoxide (Librium(Librium®®))

AntidepressantsAntidepressants

Amitriptyline (ElavilAmitriptyline (Elavil®®))

Antihypertensive Antihypertensive agentsagents

MethyldopaMethyldopa

Propranolol (InderalPropranolol (Inderal®®))

ReserpineReserpine

Analgesic agentsAnalgesic agents

Indomethacin (IndocinIndomethacin (Indocin®®))

Propoxyphene (DarvonPropoxyphene (Darvon®®) ) **also in Darvocet**also in Darvocet®®

Pentazocine (TalwinPentazocine (Talwin®®))

Meperidine (DemerolMeperidine (Demerol®®))

Potentially inappropriate Potentially inappropriate medsmeds

Potentially Potentially InappropriateInappropriate

Safer alternativesSafer alternatives

Promethazine (PhenerganPromethazine (Phenergan®®)) Prochlorperazine (CompazineProchlorperazine (Compazine®®))

Trimethobenzamide Trimethobenzamide (Tigan(Tigan®®))

Metoclopramide (ReglanMetoclopramide (Reglan®®))

Methyldopa (AldometMethyldopa (Aldomet®®)) DiureticsDiuretics

Diphenhydramine Diphenhydramine (Benadryl(Benadryl®®))

Loratidine (ClaritinLoratidine (Claritin®®), ), Fexofenadine (AllegraFexofenadine (Allegra®®))

Indomethacin (IndocinIndomethacin (Indocin®®)) Celecoxib (Celebrex)Celecoxib (Celebrex)

Chlordiazepoxide (LibriumChlordiazepoxide (Librium®®) ) and Diazepam (Valiumand Diazepam (Valium®®))

Lorazepam (Ativan)Lorazepam (Ativan)

Amitriptyline (Elavil) – Amitriptyline (Elavil) – for for depressiondepression

SSRIsSSRIs

Fluoxetine (ProzacFluoxetine (Prozac®®)) Sertraline (ZoloftSertraline (Zoloft®®), Citalopram ), Citalopram (Celexa(Celexa®®), Mirtazepine ), Mirtazepine (Remeron(Remeron®®))

Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24

Potentially inappropriate Potentially inappropriate medsmeds

Potentially Potentially InappropriateInappropriate

Safer Safer alternativesalternatives

Meperidine (DemerolMeperidine (Demerol®®)) MorphineMorphine

Propoxyphene Propoxyphene (Darvocet(Darvocet®®))

PercocetPercocet®®

Diphenhydramine –for Diphenhydramine –for sleepsleep

Zolpidem (AmbienZolpidem (Ambien®®))

Diphenhydramine Diphenhydramine (Benadryl(Benadryl®®))

Loratidine (ClaritinLoratidine (Claritin®®), ), Fexofenadine (AllegraFexofenadine (Allegra®®))

NSAIDs for arthritisNSAIDs for arthritis Acetaminophen Acetaminophen (Tylenol(Tylenol®®))

NSAIDs for goutNSAIDs for gout Celecoxib (CelebrexCelecoxib (Celebrex®®))Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24

Keep these in mindKeep these in mind Acetaminophen: keep dose < 4000mg / day. Acetaminophen: keep dose < 4000mg / day.

Be mindful of combination products like Lortab Be mindful of combination products like Lortab & Percocet& Percocet®®, Darvocet, Darvocet®®

Buproprion (WellbutrinBuproprion (Wellbutrin®®) – few side effects but ) – few side effects but can cause insomnia so avoid giving it in the can cause insomnia so avoid giving it in the eveningevening

Mirtazepine (RemeronMirtazepine (Remeron®®) – Good in patients with ) – Good in patients with anorexia. Stimulates appetiteanorexia. Stimulates appetite

Antipsychotics – atypicals are best choice since Antipsychotics – atypicals are best choice since older once have higher anticholinergic side older once have higher anticholinergic side effects. Atypical antipsychotics include: effects. Atypical antipsychotics include: Quetiapine (SeroquelQuetiapine (Seroquel®®), Risperidone (Risperdal), Risperidone (Risperdal®®))

Do you have any room Do you have any room left,left,

add these … add these … Diphenhydramine (BenadrylDiphenhydramine (Benadryl®®) – its use ) – its use should be reserved for allergic reaction should be reserved for allergic reaction and itching only. Avoid for sedationand itching only. Avoid for sedation

High dose thiazide diuretics ( > 25mg)High dose thiazide diuretics ( > 25mg) Zolpidem (AmbienZolpidem (Ambien®®) – Best choice for ) – Best choice for

sleep. Always start at 5mg dose (or sleep. Always start at 5mg dose (or lower)lower)

For anxiety – low dose Lorazepam For anxiety – low dose Lorazepam (Ativan(Ativan®®) – 0.5mg – 2mg) – 0.5mg – 2mg

Formulations that shouldn’t Formulations that shouldn’t be crushedbe crushed

CR (controlled release)CR (controlled release)CRT (controlled-release tablet)CRT (controlled-release tablet)LA (long acting)LA (long acting)SR (sustained release)SR (sustained release)TR (time release)TR (time release)SA (sustained action)SA (sustained action)XL or XR (extended release)XL or XR (extended release)ER (extended release)ER (extended release)EC (Enteric Coated)EC (Enteric Coated)

HerbsHerbs

Some “so called” Some “so called” complementary complementary therapies:therapies:

DHEA / DHEA / growth growth hormonehormone

Anti-agingAnti-aging

Gingko Gingko bilobabiloba

DementiaDementia

Saw Saw PalmettoPalmetto

BPHBPH

Chondroitin/Chondroitin/

glucosamineglucosamineOsteoarthritisOsteoarthritis

St. John’s St. John’s wort/ SAMewort/ SAMe

DepressionDepression

Can we trust these Can we trust these products??products??

In 1998 California Dept of Health In 1998 California Dept of Health ServicesServices– Screened 250 Asian herbal productsScreened 250 Asian herbal products

32% contained unlabeled medications, 32% contained unlabeled medications, 14% mercury, 14% arsenic, 10% lead14% mercury, 14% arsenic, 10% lead

Ko, NEJM 1998;339:847Ko, NEJM 1998;339:847

Herbals & Supplements and Herbals & Supplements and Potential interactions with RxPotential interactions with Rx

SAMe increases homocysteine levelsSAMe increases homocysteine levels Ginkgo may increase anticoagulant Ginkgo may increase anticoagulant

effects of Warfarin, ASA and may effects of Warfarin, ASA and may interact with MAO-Isinteract with MAO-Is

Rule of Thumb: Try and know what Rule of Thumb: Try and know what your patient is taking.your patient is taking.

ConclusionConclusion

Drug therapy in the elderly can be Drug therapy in the elderly can be complicated due to several reasons.complicated due to several reasons.

Being vigilant and paying closer attention to Being vigilant and paying closer attention to the medication therapy can help reduce the medication therapy can help reduce possible ADRs and drug-drug interactions. possible ADRs and drug-drug interactions.

Be diligent with medication reconciliation Be diligent with medication reconciliation especially at discharge to make sure patient especially at discharge to make sure patient is not sent home on duplicate therapy.is not sent home on duplicate therapy.

Utilize your zone pharmacists for drug Utilize your zone pharmacists for drug information.information.

Pager: 404-356-3729

Office: 404-605-2632

Cell: 404-788-2513

Elder Abuse and Neglect

Dealing with this Difficult Topic when Patient is in the Hospital

See PH Policy 2036

Identifying Elder Abuse

• Physical: Bruises, Burns, Injuries to face or neck, Multiple injuries in various stages of healing, Evidence of restraint, Delay in treatment

• Emotional: Ambivalence, Fear, Depression, Quiet, Low self-esteem, Paranoia,

• Sexual: Bruising on thighs, STDs, Bleeding, Pain Itching in genital area

Identifying NeglectTypical Concerns

• Abandonment

• Dehydration

• Poor Hygiene

• Over/under use of medications

• Unsafe conditions• Malnutrition• Financial

exploitation• Missing assistive

devices

What is YOUR Responsibility?

What do You do next?

Mandatory Reporting

• The physician, nurse or case manager (medical personnel) must report suspected abuse/ neglect of a child or disabled adult to the appropriate authority.

Do you know whom you should contact?

Who is the person on your floor to whom you would report your

suspicions?

Process Involved

• Assess the situation

• Inform the charge nurse, physician and case manager that you suspect abuse, neglect or domestic violence

• Maintain the patient’s safety

• Determine agency that has jurisdiction

Determine Jurisdiction

• For Elder Abuse or Neglect: Contact Adult Protective Services (APS) at 404-657-5250

• For Domestic Violence call county or city Police Dept. where patient resides

• For Domestic Violence, Patient determines if police are to be called.

• *Exception – Does situation meet guidelines consistent with Emergency Dept. Policy on Reportable Cases?

Hospital Policy

• Preserve and/or collect evidence

See Policy # PH2040

• Don’t release patient until authorized by APS

Be responsive to Patient’s needs

• Give patient opportunity for separation and privacy

• Initiate discussion, share perception• Document findings in patient’s own words• Obtain photos when appropriate• Encourage patient to acknowledge risk

and seek safe environment• Refer patient to appropriate resources

Document, Document, DocumentPatient’s Medical Record should include:

• Date and time authorities notified

• Family structure and behaviors

• History indicators• Physical indicators

• Behavioral indicators• History and Physical

exam sheet• Agency involvement –

APS, Police

Case Presentation

• Frail looking 76 yo male w GI bleed. Malnourished and unkempt. Smells of urine and stale beer.

• History indicates he is retired office worker. • 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.

• 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.

• Patient fears that if man leaves no one will be there to help him.

• What is your responsibility here?

Why Emergency Dept Nursing???

Can this work? Older patients in the ED.

Not designed for older people

Medical approach: 1 problem fixes symptoms

Have a “story to tell”

Geriatric approach: look for all contributing causes

Some Thoughts

• Replaced “high touch”

with “high-tech

• Hearing loss does not

equate to mental disability

• Physical weakness does not mean that a person must be any less independent or intelligent

More Thoughts

• Slower response times does not mean staff should remove or limit patient’s choices

• The ability to learn is not

impaired by age.

• At triage evaluate for

cognitive impairment

Language

• Speech patterns

• Forms of address

• Speech register

Can affect older people- psychologically and their physical health

Perception vs Reality

What does the older adult think of the speaker?

• Less nurturing

• Less competent

• Less benevolent

• Less respectful

Putting IT All TogetherGeriatrics in ED

Nursing Drives Excellence

Pat Henson

• 73-year-old female

• 1-week history of weakness and falling

• Referred from a nursing home

• Allergies: none

• Medications: warfarin sodium, atenolol

• Past medical history: stroke, dementia, atrial fibrillation, hypertension

Assessment

VS: BP 104/58, P 102, R 24Awake, alert, responsive, cooperativeDoes not feel very sick• Orthostatic vital signs• Feels "fine" on standing • BP drops to 92/50• HR increases to 110 started • Tympanic temperature is 96.4ºF

What are you thinking?

What would you like to do?

Repeat Temp- rectally

Assessment

• Rectal temperature 100.2ºF

• Irregularly irregular heart rate, 108 BPM

• BP 124/64 flat in bed

• ECG shows atrial fibrillation and flattened ST

• Pulse oximetry 98%

• patient feels "fine"

Assessment

• Oriented to person, week & month, but not to date or year

• Feels weak

• Lacks appetite.

• Doesn't remember falling

• Feels fine now member

• Wants to go back to NH

More Information

How do you get more history?Other Sources:• Nursing Home staff• Previous hospital record

• Concern about the possibility of new stroke • Weakness worsening over the past week.• Has fallen 3 times including today • “Isn't herself”

4 weeks ago This week

Bathing Unassisted uncooperative

Dressing Unassisted can't do buttons

Toileting Unassisted forgot to flush

Transfer Unassisted unassisted

Continence Intact incontinent 2 nights

Feeding Unassisted lacks appetite

Baseline Prior to This Illness

• No new medications• No previous surgery • Durable power of attorney with sister • Baseline mental status: Oriented to person

& place, not oriented to year and date• Right-leg weakness• Aids: Bifocals, walker .• Baseline VS: BP 144/82; HR 68; T 97.4ºF

Reason for Transfer

• Feeling "tired" (1 week)

• Staying in bed today

• Not buttoning clothes (4 days) -

• Falling to floor (3 times)

• Bruising knees and elbows

• Eating nothing today

What Information Next?

You have the baseline prior to illness and time frame with changes- now what would you want?

Minicog / MMSE

Observe function/mobility

Mini Cog, MMSE, CAM

Neurologic:

• Mental status: Oriented to person

• Fails clock drawing

• Memory: 2 serial 7’s; recalls 0/3 items on recall.

• Speech: Some difficulty repeating 3 items; no word errors; follows 2-step commands

CAM: Sudden onset? Inattentive?

Function / Mobility

Motor: • No gross focal deficits other than right leg

weakness;, • Gait: Refuses to walk without walker • Can raise rt leg off stretcher but can't hold it up

against resistance; knee and ankle flexion and extension equally diminished

• Sensation: Intact; reflexes right knee and ankle increased, with a positive Babinski's sign on the right

Possibilities

What do you think her acute issues could be? What in her hx puts her at risk ?

Infections- what kind most common in NH?• Pneumonia • Intra-abdominal infection• Urinary Tract Infection • Meningitis • Skin infection • Endocarditis

Lab Results• CXR clear• CT old left parietal infarct & generalized atrophy • CBC WBC 10.2, Polys 71 %; Bands 6%; Hgb 12.2;• Plts 154,000 • Urine leukocyte esterase, positive • RBC O - 5.• WBC 21-50 • Slight bacteria • Glucose 116.• Sodium 145 • K 4. 3• Cl 105 • CO 24 • BUN 19 • CR 1.3

Outcome

What would be treatment and outcome for Pat in your ED?

Wrap-Up

• Atypical presentation of Infection

• Importance of baseline

• Geriatric Assessment value

• Never assume a single causative factor

Nursing Drives Excellence

PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE

1. The patient's presentation is frequently complex2. Common diseases present atypically in this age

group3. The confounding effects of co-morbid diseases must

be considered4. Polypharmacy is common and may be a factor in

presentation, diagnosis, and management5. Recognition of the possibility for cognitive

impairment is important6. Some diagnostic tests may have different normal

values

PRINCIPLES OF GERIATRIC EMERGENCY MEDICINE

7. The likelihood of decreased functional reserve must be anticipated

8. Social support systems may not be adequate, and patients may need to rely on caregivers

9. A knowledge of baseline functional status is essential for evaluating new complaints

10. Health problems must be evaluated for associated psychosocial adjustment

11. The emergency department encounter is an opportunity to assess important conditions in the patient's personal life

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