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Challenges in Caring for the Elderly AdultThe Frail Older AdultCare at the End of Life

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The complexity of the frail older adult and comorbidities

Delays in treatment

Atypical presentation

Diminished organ reserve

Need for many pharmaceuticals

Lack of knowledg

eLikelihood of poor outcomes

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Failure to thrive• Weight loss of >5% of baseline• Poor appetite and nutrition• Dehydration• Immobility• Depression• Impaired immune function• Low cholesterol levels

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“Frailty”Presence of 3 or more of the following:

• Unplanned weight loss (10 lb in past year)• Weakness• Poor endurance and energy• Slowness• Low activity

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Consequences of frailty• Progressive physiological decline• Chronic illness• Loss of organ function• Recurrent acute illness

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Risks of frailty

Frailty

Dependency

Institutional-ization

Falls

InjuriesHospitalization

Slow recovery

Mortality

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Social risks of frailty• Poverty• Social isolation• Functional decline• Cognitive decline

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Comorbidities: the cumulative effect of chronic conditions and diseases

Frailty and

Disability

HTN

CVDCAD

Diabetes

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The “geriatric cascade”

Frailty

Acute illnessWorsened

chronic condition Stress of

care provided

Poor treatment outcome or death

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Strategies: meeting the needs of hospitalized elderly• Diagnose all vague symptoms and complaints

accurately• Treat all relevant diseases• Assess effect of current changes in health status• Consider effect of acute illness on chronic disease• Prevent complications of hospitalization

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Health Trajectory• Trajectory: the path of a moving object through

space• Also applies as a model for understanding the

eventual course of one’s health status throughout time until death

This is the way the world ends This is the way the world ends This is the way the world ends Not with a bang but a whimper.—T.S.Eliot, The Hollow Men (1925)

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Influences on the Health TrajectoryDirect Influences• Genetics• Environment• Wear and tear• Nutrition• Stress • Disease

Indirect Influences• Social relationships• Education• Finances• Response to age-related changes

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Chronic Conditions• More than 50% of persons over 40 years of age

have at least 1 chronic condition• More than 80% of non-institutionalized persons over

65 years of age have at least 1 chronic condition• Therefore, health care for the elderly should be

oriented toward care of chronic disease regardless of the person’s age

• Health care should emphasize:• Improving function• Postponing deterioration and disability• Preventing complications

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Goals of Chronic Care Nursing• Maintain or improve self care

capacity• Effective disease management• Enhance body’s healing abilities• Prevent complications• Delay deterioration and decline• Promote highest possible quality of

life• Ensure death with dignity

and comfort

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Effect of Chronic Disease on the Health Trajectory• After each acute episode, patients are left with

greater functional deficit or increased problems.• The episodes become increasingly frequent and

refractory to treatment as the patient nears the end of life.

• Recognition of a pattern enables those at risk of imminent death to be managed more appropriately.

• The patient will then have the chance that most (but not all) patients prefer…

to plan and prepare for death, together with their families.

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Measuring Success in Chronic Care• Use short term goals that are evaluated

throughout the trajectory of the disease

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Disease Trajectory• Each disease, be it acute or chronic, has its own

trajectory• The disease trajectory influences the individual’s

health trajectory

HEALTH DISEASE

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Disease Trajectory Patterns• Evaluation occurs at

each point of change in the trajectory

• Goals and interventions are modified to permit change in patient baseline status

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Factors of treatment decisions• Preferences of patient, preferences of family• Minimize burden to patient if chance of success is

reasonable• Allocation of resources to those most likely to

benefit• Should not be delivered to alleviate guilt or

distress of family

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Decisions for elderly hospitalized patients• What are our goals of care?• How will we achieve those goals?• Agreement among patient and family members• Agreement on code status

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Possible levels of care• Aggressive care• Patient has high functioning, satisfactory quality of life• Goal: extension of life

• Modified care• Frailty or comorbidities, but likely to respond to treatment• Goal: extension of life considering burden of treatment

• Palliative care• Can be delivered with aggressive or modified care or by itself• Goal: patient comfort and quality of life• Life extension is secondary

• Hospice care• A type of palliative care for final months or weeks• Patient has life expectancy of 6 months or less• Goal: comfortable death

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Characteristics of palliative care• Focuses on relieving and preventing the patient’s

suffering • Appropriate for patients in all disease stages:• Patients undergoing treatment for curable illnesses• Patients living with chronic diseases• Patients nearing the end of life

• Uses a multidisciplinary approach to patient care• Addresses the physical, emotional, spiritual, and social concerns of advanced illness

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Dying is natural and inevitable• Dying is an inevitable part of living• Helping the dying patient and family find comfort

and meaning in the dying experience is often more important than correcting physiological problems

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Enhancing dignity of the dying patient• Allow patient and family to maintain control• Encourage participation in end-of-life care• Prevent and relieve distress• Physical• Emotional• Spiritual

• Know local laws and institutional policies• Living wills• Durable power of attorney• Resuscitation• Specific treatment

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Principles of providing end of life care• Maintain communication among patient, family,

staff• Display sensitivity to specific beliefs• Alleviate pain, promote comfort• Manage psychological, social, and spiritual concerns• Continuous collaboration• Promote access to palliative and hospice care• Respect right to refuse care

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Importance of patient preferences• Value of quantity of life over quality• Acceptance of pain or disfigurement• Is there perceived value in curative, rehabilitative

or preventive care?• Supportive care may be only realistic choice• Plan of care does not terminate• Account for• Patient’s goals• Limits imposed by illness

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Importance of symptom control• Physical and mental distress commonly

experienced by patients with terminal illness• Fear that discomfort cannot be controlled• Relief of discomfort and reassurance that effective

treatment is available• Enables living life as fully as possible• Able to focus on unique issues associated with the

approach of death

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Treatment monitoring• Symptoms can have many causes• Patients respond differently as deterioration

progresses• Altered drug metabolism likely to occur

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Pain• About half of patients dying of cancer have severe

pain• About half of these receive adequate relief• Often pain is due to:

Misconceptions on parts of physicians and patientsregarding:• Pain• Drugs used to control pain

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Treatment must be individualized• Patients perceive pain differently• Fatigue• Insomnia• Anxiety• Depression• Nausea• Supportive environment can help control pain

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How to chose the best pain medication• What is most available?• Least invasive route• Depends on pain intensity• Analgesics should be given routinely rather than as needed

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How to give pain medication• Controlling pain after it occurs is more difficult

than preventing it• Pain generates anxiety• In hospice situations, nurses, patients and family

members can become competent at making dosing or scheduling adjustments

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Alternative pain-modification techniques• Hypnosis• Guided mental imaging• Counseling for stress and anxiety• Relaxation methods

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Dyspnea• One of the most feared and most distressing

symptoms• Cause should be treated• Dyspnea symptoms are suppressed when

physiologic cause cannot be relieved• Demerol (less frequently)• Morphine

• Oxygen may be psychologically comforting to patient and family even when not physiologically beneficial

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Breathlessness• Opioid can slow respirations• Relieve mild chronic symptoms• Allows more comfortable sleep• Morphine 2.5 mg IV every 2 to 4 hours• Morphine may be given by continuous drip or bolus

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Anorexia• Usually more distressing to family members• Counseling may be necessary for family members

to accept anorexia• The patient has “more important things to do”• Tube feedings, parenteral nutrition likely futile

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Increasing food intake• Small portions if full tray is overwhelming• Specially prepared foods• Flexible meal schedule• Small amount of alcoholic beverage 30 minutes

before meals• Foods with strong flavors or smells• Medications• Corticosteroids (dexamethasone)• Antidepressants• Metochlopramide• Megace (progestin)• Marinol (cannabinoid)

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Tube feedings and parenteral nutrition• Used rarely• Discontinuation may be difficult to accept• Food and fluid symbolize nurturing and caring• Inform family members that dying patient may be

more comfortable without artificial administration of food and water

• Easy-to-swallow foods may be more appropriate:• Sherbet• Gelatin

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After decision to forgo artificial administration of food and water…• Supportive care imperative• Good oral hygiene• Brushing teeth• Swabbing oral cavity• Applying lip salve• Ice chips for dry mouth

• Physically and psychologically comforting care for family to provide

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Nausea and vomitingPotential causes

• Constipation• Reduced gastric emptying• Bowel obstruction• Central opioid effects• Increased intracranial pressure (ICP)• Gastritis• Peptic ulcer• Hypercalcemia• Uremia• Toxic drug effects

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Treatment of nausea and vomiting• Phenothiazines act on chemoreceptor zone in the

medulla, e.g., prochlorperazine (also an anxiolytic, trade Compazine, et al.)

• Metochlopromide (Trade Reglan)• If near death, conservative treatment without relief of obstruction

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Constipation• Often underestimated by physicians• Give stool softener first• Should give laxatives prophylactically• Stimulant/laxative should be given if patient is

being given opioids

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Confusion• Common causes• Drug therapy• Hypoxia• Metabolic disturbances• Intrinsic CNS disease

• Confusion is treated if cause can be determined• Withholding treatment for confusion may be

preferable if• Patient is comfortable• Patient less aware of surroundings

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Medications—confusion • Sedatives (benzodiazepines, e.g., Librium, Valium,

Xanax)• Risperdone (trade Risperdal)—produces changes

in chemicals in the brain, generally used for schizophrenia, bipolar disease, autism in children)

• Olnazapine (trade Zyprexa)— generally useful in schizophrenia and bipolar disease

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Insomnia• Symptom, not a diagnosis• Depression and anxiety are the leading causes• Also:• Trazodone 25 to 50 mg at bedtime

(antidepressant)• Hypnotic (zolpidem [Ambien]) at bedtime• May also try: meditation, relaxation techniques,

deep breathing exercises, relaxation tapes

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Hastening death• Most medical actions perceived as hastening

death are based on the need for relieving pain• Physician must inform patient and family that

such actions may shorten life• Should be clear that treatment is for pain and

symptom relief and not for causing death• Myth: “Good pain management rarely shortens

life and may extend it.”• Assisting with suicide is a criminal act in most states…including California.

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Death determination• Should be made by a physician• Sometimes made by Nurses in the absence of a

physician• Determination should be made as soon as possible• Ensure psychological and spiritual needs of family are

met• Comfortable environment• Arranging for someone to be with body when family

visit can be helpful• Notify clergy or funeral home• Reassure family patient was comfortable• Contact family a few weeks later for follow up