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Catherine “Casey” S. Jones, PhD, APRN, ANP-C Ø Visiting Assistant Clinical Professor at Texas Woman’s University Dallas

Ø Texas Pulmonary & Critical Care Consultants, PA

Ø 1. Identify the various immunizations needed by aging persons.

Ø 2. Describe the implications of chronic conditions and complications on activities of daily living.

Ø 3. Differentiate between dementia and delirium in the older individual.

Ø People aged 65 or older = 44.7 million in 2013

Ø 14.1 % of the U.S. population

Ø 1 in 7 AmericansØ Will be 21.7 % of

the population by 2040

Ø Annual vaccination every fall

Ø Inactivated IM injection - trivalent

Ø High dose vaccine for all those 65 years of age or older – necessary due to poor immune response

Ø Contraindicated with severe egg allergy with anaphylaxis or angioedema (not just hives)

Ø All individuals age 11 and older need ONE TdaP immunization booster

Ø Td booster every 10 years otherwise

Ø Nationally notifiable condition

Ø > 28,600 reported cases in 2014 to the CDC

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Ø Signs & symptoms in the first stage are relatively mild – mild cough, sneezing, low grade fever and rhinorrhea – mimic a viral URI

Ø Adults without the inspiratory “whoop”Ø Progress to cough-vomit syndrome lasting

up to 10 weeks – 100 day coughØ Infants most unprotected & with adverse

outcome

Ø One dose for age 60 and above

Ø Consider vaccination ages 50 and above but may not be funded

Ø May vaccinate patients who have had shingles

Ø Postherpetic neuralgia & visual impairment

Ø Live virus!

Ø Pneumococcal vaccines protect against Streptococcus pneumoniae

Ø Protect against the most invasive serotypes

Ø There are more than 100 different types of pneumonia that will be unprotected by these vaccines

Ø Prevnar 13 – works better than Pneumovax 23 to induce an immune response in older adults

Ø Pneumovax 23 covers 11 serotypes that aren’t in Prevnar 13

Ø Prevnar 13 has one serotype that isn’t in Pneumovax 23

Ø Medicare will pay for both vaccines

Ø All those 65 and older need BOTH Pneumovax 23 and Prevnar 13

Pneumococcal vaccine status

FIRST give THEN give

None/unknown Prevnar 13 Pneumovax 2312 months later

Pneumovax 23 given after 65

Prevnar 13 - 12 months or later after Pneumovax 23

N/A

Pneumovax 23 before 65

Prevnar 13 65 or older & one year or more after Pneumovax 23

Pneumovax 23 - 12 months after Prevnar 13 & 5 years after Pneumovax 23

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Ø Utilize the 10-minute Geriatric Screener

Ø Evaluates vision, hearing, leg mobility, urinary incontinence, nutrition/weight loss, memory, depression & physical disability.

Source: Moore, AA, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. AM J Med. 1996; 100:438-440.

Ø Katz Index of Independence in Activities of Daily Living

Ø Rate bathing, dressing, toileting, transferring, fecal & urinary continence and feeding

Ø Source: Katz s, Downs TD, Cash HR, Grotz RC. Progress in development of

the index of ADL. Gerontologist. 1970; 10(1) 23.

Ø Measured on what the patient is actually doing, not what they are capable of doing

ABCDETT: Ø AmbulationØ BathingØ Continence Ø Dressing Ø EatingØ Toileting Ø Transferring

Ø Lawton Instrumental Activities of Daily Living Scale

Ø Self-rated version with 9 questions

Ø Source: Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3): 181.

Ø **Elsawy, B, Higgins, K. The geriatric assessment. The American Family Physician. 2011; 83(1): 48-56.

Ø Preferred term – persistent pain rather than chronic pain – attempting to avoid the negative attitudes or stereotypes

Ø Musculoskeletal

Ø Night time leg pain & claudication

Ø Persistent pain in as many as 80 % of patients with cancer

Ø Adverse outcomes– Functional impairment– Falls– Slow rehabilitation– Mood changes – depression & anxiety– Decreased socialization– Sleep & appetite disturbance– Greater health-care use & costs

A merican Geriatrics Society Panel (2009). Pharmacological management of pers istent pain in older persons. JAGS. 57: 1331-1346.

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Ø The most common cause of chronic disability in older adults

Ø Two of the most common risk factors for OA are:– Age & obesity

Ø Exercise! Ø Medications – begin with acetaminophen –monitoring the dosage (up to < 4g/24 hours) –reducing dose with hepatic insufficiency or alcohol abuse

Ø NSAIDs or COX-2 inhibitors versus opioid therapy –select patients with extreme caution

Ø Elderly with increased cardiovascular, gastrointestinal and renal issues with NSAIDs or COX-2 inhibitors

Ø Initiate with low doses and careful upward titrationØ Topicals – capsaicin cream – 30 % unable to tolerate

burning sensation

Ø NSAID therapy – GI toxicity increases in frequency & severity with age – dose related and time dependent

Ø Proton pump inhibitor for those taking NSAIDs or COX-2 inhibitors

Ø Consideration of opioids – older age is associated with lower risk of misuse and abuse – fear of addiction, cost, constipation, or negative social stigma

Ø Typically a disease of aging with disability & mortality associated with fractures

Ø 1 in 4 senior womenØ Common in Caucasian and Asian women

(30 million)Ø Mexican-American with highest rate

(almost 25 %) Ø Close to 6 % of men also affected

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Ø White/Asian/Mexican American Female

Ø Family History

Ø Alcohol / Caffeine Use

Ø Tobacco UseØ History of Fracture

ØMenopausal

ØMedications

ØLow BMI

ØCalcium & Vitamin

D Deficiency

Ø Look at the T-score– Osteoporosis T= < -2.5– Osteopenia T= -1.5 to -2.5T-Score is based on the normal reading of a 30

year old woman

Ø ActivityØ Calcium Ø Vitamin DØ BisphosphonatesØ ForteoØ Estrogen Replacement TherapyØ Balloon kyphoplasty

Ø Most common chronic cardiac dysrhythmia in adults

Ø Approximately 2.7 million people in the United States are diagnosed

Ø Prevalence rises with age, affecting approximately 9% of individuals over 80 years old

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Ø Congestive heart failureØ HypertensionØ MyocardiaI infarctionØ Recent heart surgeryØ HyperthyroidismØ Sleep apneaØ Excess ETOH/caffeine intakeØ StressØ Dehydration

Ø Gold standard is presence of AF on a 12 lead EKG showing erratic, disorganized atrial conduction between QRS complexes.

Ø Increased with age, highest prevalence of AF in geriatric population

Ø A key challenge balancing the need for anticoagulation to prevent stroke with the risk of hemorrhage which increases with age

Ø CHA2 DS2VASc scoring helpful to evaluate the risk of stroke, what treatment to use & how aggressive to be.

Ø Age in years: < 65 (0), 65-74 (1), ≥ 75 (2)

Ø Sex (male = 0 & female = 1)

Ø Congestive heart failure history (1)Ø Hypertension history (1)

Ø Stroke/TIA/thromboembolism history (2)

Ø Vascular disease history (1)Ø Diabetes mellitus (1)

Bi rmi n g h am 2 0 0 9

Ø Scoring:

Ø 0 for male or 1 for female = low risk = no anticoagulant therapy

Ø 1 for male = moderate risk = consider oral anticoagulant

Ø 2 or more = high risk = oral anticoagulant is recommended

Ø Coumadin -Warfarin therapy

Ø Cheaper

Ø With reversal agentØ Multiple interactions with medications &

foodØ Disadvantage is underutilization and difficulty

in maintaining serum PT/INR blood level with frequent blood checks especially in elderly

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Ø Dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) – nonvalvular AF & DVT/pulmonary emboli – Eliquis not FDA approved for pulmonary emboli– have fewer drug-drug interaction– achieve therapeutic level in hours – no reversal agent but able to perform

surgery in 2-4 days after cessation– no lab monitoring is needed

Ø Third leading cause of death in the U.S.

Ø More than 120,000 deaths per year

Ø More than 12 million people are diagnosed with COPD

Ø An additional 12 million are likely to have COPD & are undiagnosed

Ø Responsible for ~ 700,000 hospitalizations annually

Ø ~ 20 % of patients hospitalized with COPD exacerbations are rehospitalized within 30 days of discharge & COPD only accounted for 27.6 % of these rehospitalizations

Ø Half occur within 2 weeks of discharge

GRADE DESCRIPTION OF BREATHLESSNESS

0 I only get breathless with strenuous exercise.

1 I get short of breath when hurrying on level ground or walking up a slight

hill.

2 On level ground, I walk slower than people of the same age because of

breathlessness or have to stop for breath when walking at my own pace.

3 I stop for breath after walking about 100 yards or after a few minutes on

the level ground.

4 I am too breathless to leave the house or I am breathless when dressing

or undressing.

Ø Validated questionnaire (8 questions) that the patient completes

Ø Suitable for routine use ~ 3-6 months

Ø Measure health status

Ø Scoring ranges from 0 – 40Ø Available in multiple languages

Ø Online or print version at:– www.CATestonline.org

Ø GROUP A: Low risk, less symptoms– GOLD 1-Mild or 2-Moderate airflow limitation– 0-1 exacerbations/year– mMRC grade 0-1– CAT score < 10

Ø GROUP B: Low risk, more symptoms– GOLD 1-Mild or 2-Moderate airflow limitation– 0-1 exacerbations/year– mMRC grade ≥ 2– CAT score ≥ 10

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Ø GROUP C: High risk, less symptoms– GOLD 3-Severe or 4-Very Severe airflow limitation– ≥ 2 exacerbations/year

– mMRC grade 0-1– CAT score < 10

Ø GROUP D: High risk, more symptoms– GOLD 3-Severe or 4-Very Severe airflow limitation– ≥ 2 exacerbations/year– mMRC grade ≥ 2– CAT score ≥ 10

Ø Tobacco cessation

Ø Influenza & pneumococcal vaccines

Ø Knowledge of current therapy & inhaler technique

Ø Use of long-acting bronchodilators (anticholinergics &/or beta-2 agonists) –with or without inhaled corticosteroids

Ø Phosphodiesterase-4 inhibitors

Ø Risk factors:– Female > male**– Old age (> 65 years)**– Acute/chronic kidney disease– True or effective volume depletion– Hypokalemia/hypomagnesemia– Combinations of toxins/drugs promoting

enhanced nephrotoxicityPerazella, MA . (2009). Renal vulnerability to drug toxicity. Clin J Am Soc Nephrol. 4: 1275-1283.

Ø Risk factors for nephrotoxicity - Medications:– Aminoglycosides– Ciprofloxacin– NSAIDs– Selective COX-2 inhibitors– Acetaminophen – Analgesic combinations– ACE inhibitors/ARBs– Statins– Ephedra sp.– Glycyrrhiza sp.– Radiocontrast

Ø With aging, muscle mass decreases and serum creatinine has different meaning

Ø Look at eGFR on lab slips to help

Ø Examples:– Age 20, male, 70kg, Cr 1.2, eGFR = 97 ml/min– Age 75, male, 70 kg, Cr 1.2, eGFR = 52 ml/min– Age 75, female, 70 kg, Cr 1.2 eGFR = 44 ml/min– (Both elderly pts have Stage III CKD)

Ø Take-home point:– Even with a normal or near normal serum

creatinine, elderly patients have reduced renal function

– Look at or calculate eGFR– Use lower doses of medications and try to

avoid nephrotoxins

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DEMENTIA• Not a diagnosis, name of a

syndrome• Is NOT part of normal

aging• Many causes of dementia• Most common is Dementia

of Alzheimer’s Type (DAT) then following second is Vascular Dementia(formerly known as Multiple Infarct Dementia or MID)

Ø Gradually increasing forgetfulness, especially recent events

Ø May be gradual over years or relatively acute

Ø Decreased self-care

Ø Patient may or may not be aware of change

Ø The Folstein Mini-Mental State Examination is the most widely used tool to measure cognitive impairment in the elderly– The score is reported as the patient’s

score/the highest possible score (e.g., 24/30)

– Level of education, language barriers, and physical capabilities may affect performance

Ø http://lifemanagement.com/nextsteps/Mini_Mental_Status_Exam.pdf

Ø Measures mild cognitive deficits

Ø Easy to do

Ø Catches cognition problems early

Ø Scoring system for Clock Drawing test (CDT)There are a number of scoring systems for this test. The Alzheimer's disease cooperative scoring system is based on a score of five points.1 point for the clock circle1 point for all the numbers being in the correct order1 point for the numbers being in the proper special order1 point for the two hands of the clock1 point for the correct time

Ø A normal score is four or five pointsØ http://alzheimers.about. com /od/di agnosis issue s/ a/ cloc k _test .htm

Sample Clocks

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Ø Two questions:

– Ask patients to recite the months of the year backwards

– What is the day of the week?

Journal of Hos pital Medicine, Sept. 16, 2015

An acute confusional state defined by:

Fluctuating mental status

InattentionDisorganized thinking

Altered level of consciousness

Ø Pre-existing Risk Factors:DementiaChronic illness (including hypertension)Advanced ageDepressionSmokingAlcoholismSeverity of illness on hospital admission

Ø Fluid-electrolyte disturbances

Ø Infections (UTI, pneumonia, pressure ulcers)

Ø Drug toxicity

Ø Metabolic disordersØ Low perfusion states

Ø Withdrawal from alcohol & sedatives

Ø HyperactiveØ Agitation, restlessness, pulling catheters, emotional

labilityØ Easily recognized, “ICU psychosis”Ø Better overall prognosis

Ø Hypoactiveü Unrecognized in 66-84%ü Withdrawal, flat affect, apathy, lethargy, decreased

responsivenessü Worse long-term prognosis

Ø Mixed

Delirium is Acute Brain Failure!

Acute Brain Failure can lead to Chronic Brain Failure, including dementia and

early death

Dr. Valerie Page, Watford Hospital

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Ø 9 out of 10 seriously ill patients declared that they would rather die than survive with severe cognitive impairment.

Rockwood K, Brown M, Merry H, et al. Understanding the treatment preferences seriously ill patients. N Engl J Med 2002; 346:1061-1066

Ø Delirium can no longer be considered a benign problem that will “clear” when the patient is transferred from the ICU

Use caution with these medications!üTargeted sedation using standard scalesüDo not titrate to a general impression of

comfort or discomfort

Through our well-meaning efforts to insure comfort during a traumatic experience, we are inadvertently causing harm.

Risk Factor Modification:

ü Repeated reorientation

ü Repetitively provide cognitive stimulating activities Example: crossword puzzles on vent and after

frequent questions and interaction

ü Sleep enhancement – non-medication

üEarly mobilization, range of motion exercises

üTimely removal of catheters and restraints

üUse of eye glasses, hearing aids, remove ear wax

üMinimize unnecessary noise

Delirium vs. Dementia

FEATURES DELIRIUM DEMENTIAOnset Acute Insidious

Course Fluctuating Progressive

Duration Days to Weeks Months to Years

Consciousness Altered Clear

Attention Impaired Normal, except for severe dementia

Psychomotor Changes

Increased or Decreased

Often Normal

Reversibility Usually Rarely

Thank you!

cjones29@twu.edu