Age Related Conditions - PowerPoint Presentation

Slide1

Age Related Conditions andGeriatric Assessment

Alaa

Mira, MD, CMD

Chief of Geriatrics

St. Luke’s University Health NetworkSlide2

Disclosure Statement of Financial Interest

I do not have financial

relationships with commercial interests to discloseSlide3

Learning Objectives

Review common Geriatric syndromes

Principles of Geriatric assessment

Hazards of hospitalization of older adults Geriatric care models Slide4
Slide5

Older Adults are Hospitals’ CORE Consumers

Older adults 13% of the population:

- But comprise 37% of hospital discharges and 43% of hospital days

- Have longer lengths of stay (7.8 days vs. 5.4 days)

- Higher rates of 30 day hospital re-admissions

Higher rates of functional decline and medical errorsSlide6

Number of

chronic diseases

Risk Ratios

Risk Ratios for Activities of Daily Living Dependency

Cigolle, C. T. et. al. Ann Intern Med 2007;147:156-164Slide7

Number of conditions/diseases

Risk Ratios

Risk Ratios for Activities of Daily Living Dependency

Cigolle, C. T. et. al. Ann Intern Med 2007;147:156-164Slide8

Geriatric

Syndromes

Dementia

Depression

Delirium

Falls

Sensory

impairment

Polypharmacy

Incontinence

S

leep disorders

Weight loss Slide9

Dementia: A Growing EpidemicSlide10

Understanding Dementia

Dementia is a general term used to describe a decline in cognitive function

Progressive

irreversible brain disease No medication can cure dementia Alzheimer’s disease is the most common form of dementia

Caregiver burnout Slide11

Diagnostic Challenges

Is this

“

normal aging”? Is it a change?Slide12

How Is Memory Affected By Aging

As we age, the brain loses some of its abilities that can lead to forgetfulness

This is normal, and begins after the age of 40

Not progressiveNo decline in activities of daily livingProductive and satisfying life Slide13

Diagnostic Challenges

Is this

“

normal aging”? Is it a change?Clinical presentations can be similarSlide14

Conditions that Mimic DementiaSlide15

Diagnostic Challenges

Is this

“

normal aging”? Is it a change?Clinical presentations can be similarC

hanges

can begin up to 20 years before noticeable by self & othersSlide16

Stages of DementiaSlide17

Stages of DementiaSlide18

Is it worth screening for Alzheimer’

s disease or MCI?

“

If there was treatment for AD, I'd recommend screening,

but there is no disease-modifying therapy."

“

All older adults benefit from memory screening because

it detects cognitive problems before memory loss is noticeable.

”

Healthy Aging, 2008

; repost, 2010

“

Memory Screening: Is it Worth It?

”Slide19
Slide20

Reasons to Screen and Diagnosis Dementia Early

Autonomy (right to know)

P

atient can participate in planning and decision makingLifestyle modificationAdvance directives

Patient/caregiver education

Access to information, programs, support, and other resources

Symptomatic and disease modifying therapies are more efficacious with early disease intervention

MedicationsSlide21

Screening Tools For

Dementia

Name

Items/

Scoring

Domains assessed

Web link (accessed Oct 2012)

Mini-Cog

2 items

Score = 5

Visuospatial, executive function, recall

http

://

geriatrics.uthscsa.edu/tools/MINICog.pdf

SLUMS

11 items

Score = 30

Orientation, recall, calculation, naming, attention, executive function

http

://

medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

MoCA

12 items

Score = 30

Orientation, recall, attention, naming, repetition, verbal fluency, abstraction, executive function, visuospatial

www.mocatest.org

Folstein

MMSE

19 items

Score = 30

Orientation, registration, attention, recall, naming, repetition, 3-step command, language, visuospatial

For

purchase:

www.minimental.com

Slide22

Clock TestSlide23

Treatment

Non

-pharmacologic treatment

Lifestyle modifications

Physical therapy and exercise

Socializing

Pharmacologic treatment

No medication can CURE dementia

Medication may slow down the dementia

Treatment should be individualizedSlide24
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Delirium

Also known as

Acute mental status change

Acute confusional stateAltered mental status

Toxic or metabolic encephalopathy

Organic brain syndrome

Delirium is most frequent

complication

of hospitalized elderly

Yet

it is

underdiagnosed

Slide26

Prevalence

Hospitalized medically ill

10

-30%Hospitalized elderly 10-40

%

Postoperative patients

up

to 50

%

Near-death terminal patients up to 80%Slide27

Risk Factors

Age

Preexisting dementia

Recent surgery

Infections

Visual

/hearing

impairment

Polypharmacy

Substance AbuseSlide28

Types of Delirium

Hyperactive

-Better

recognized

-More

attention to treatment

-Associated

with improved outcome

Hypoactive

-Little

recognized

-Depression is primary differential-Associated with poor outcomesMixedSlide29

Clinical features

Prodrome

Fluctuating course

Attentional deficitsImpaired

cognition

Sleep-wake disturbance

Altered perceptions

Affective disturbancesSlide30

Diagnosis of Delirium

Delirium is a clinical diagnosis

History and physical examination

Mental Status Exam

Confusion Assessment Method (CAM

)

Standardized assessment

tool

CAM

ICU-non-verbal, ventilated patients

Identifies

4 features of the disorder -Acute onset or fluctuating-Inattention-Disorganized thinking-Altered

level of

consciousness

Slide31

Delirium: Management

Behavioral/Environmental Strategies

Reorientation, calendars, clocks

Room near nursing station

Lights on/off during day/night

Windows

Family/familiarity

Hearing aids, glasses

Avoid restraintsSlide32

Pharmacological Therapy

Nothing

FDA-approved

Antipsychotics are treatment of choice for agitation compromising care or safety

Haloperidol

best studied, widely

used

Atypical Antipsychotics:

Risperidone

, Olanzapine,

Quetiapine Black box warning- Increased risk of death/CVA in patients with dementiaSlide33

Complications

Increased

morbidity

Increased risk of cognitive decline

Increased risk of mortality

Nursing home placement Slide34

FallsSlide35

Aging and Falls

30-40% of older adults fall every year

20-30% of people who fall suffer moderate to severe

injuries

50% of fallers will report recurrent falls

50-60% of falls happens in or around the home

Incidence

of falling increases with age

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Balance

Central Processing

Sensory Input

Motor Output

Experience

Learning

Visual

Vestibular

Somatosensation

Neural activation

Muscle strength

Range of motion

ReflexesSlide40
Slide41

Falls are

Multifactorial

Intrinsic Factors

Extrinsic Factors

FALLS

Age related changes

Medical conditions

Medications

EnvironmentSlide42
Slide43

Subjects

in the Intervention and Control Groups

Who

Had

Multifactorial Intervention to Reduce the Risk of

Falling

tagesO

Tinetti

M et al. N

Engl

J Med 1994;331:821-827Slide44

Effect of Vitamin D on Falls

Meta-analysis included 5 RCTs with 1237 elderly individuals treated with different vit D analogues for 2 months to 3 years

Vitamin D supplementation reduced the risk of falls among the elderly by 22%

Improved the body sway by 9% and musculoskeletal function by 11%

400 IU of vit D may not be clinically effective

Trials used 800 IU of vit D did find significant reductions in observed fractures

Heike et al. JAMA 2004; 291;1999-2006Slide45

Comprehensive Geriatric Assessment

Multi-disciplinary team approach

Address the unique needs of older adults

Work collaboratively with PCP and other specialistsPatient and family centered care Improve satisfaction and quality of life Slide46

St. Luke’s Senior Care Services

Center for positive aging

Acute

Care for the Elderly (ACE)Geriatrics surgical programNurses Improving Care of

Healthsystem

Elders (NICHE)Slide47

Center for Positive Aging

Comprehensive Geriatric

assessment

Multi-disciplinary approach Social worker

Driving issues

Pre-operative assessment

Family care conference

R

ecommendations to PCP

Slide48

Acute Care for the Elderly(ACE)Slide49

ACE Model Concepts

Specialized model of care

Address the needs of hospitalized older adults

Evidence based best practice Multi-disciplinary team approachPrevent functional decline and NH placement

Reduce iatrogenic complications

Decrease hospital length of stay and costs

Improve outcomes and satisfactionSlide50

ACE Consult Criteria

65 years or older

Acutely ill

Co-morbid conditionsAt risk of functional decline Identification seniors at risk (ISAR) toolSlide51

St. Luke’s ACE Outcome Data 2014

Ativan orders decreased by 33%

Benadryl orders decreased by 13%

LOS decreased by 10%

Delirium rate decreased by 60%Slide52

Geriatrics Surgical Program

Pre-operative geriatric assessment

Nurse navigator

65 years or olderElective surgery Geriatric assessment Update anesthesiologists

and surgeons Slide53
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Slide55

Nurses Improving Care for Healthsystem

Elders

(NICHE)

NICHE is a program of the Hartford Institute at the NYU College of Nursing

NICHE is the only national geriatric nursing program that addresses the needs of hospitalized older adults

There are approximately 680 hospitals in more than 40 states as well as Canada with NICHE designation Slide56

NICHE Program

Goal

Achieve systematic nursing change that will benefit hospitalized older adults

Vision Provide geriatric sensitive and exemplary care to all hospitalized older adults

Mission

Import principles and tools to stimulate change in the culture of healthcare facilities to achieve patient-centered care for older adults Slide57

Nurses are Positioned to Paly a

Central Role

Nurses are the primary caregivers for older patient in hospitals

Nurses are generally not fully prepared to care for older patientsNursing models can improve older patients’ care and decrease hospital complications

Nursing can be the focal point for stimulating interdisciplinary careSlide58

NICHE Resources

Start-up tools

NICHE planning and implementation guide

Leadership training programMeasurementGeriatric Institutional Assessment Profile (GIAP)

Clinical outcomes

Program self-evaluation

Clinical management tools

Organizational strategies and clinical

improvement models

Training and education programs

Care curricula: for nurses, patient care techs (CNA),

other disciplines and general staffWebinars and in-service materialsEducational resources for patients and families ConferencesGeriatric Resource Nurse (GRN)National communitySlide59

Geriatric Resource Nurse (GRN)

Certified GRN

Assist staff in evaluating, planning and implementing geriatric care

Disseminate information about geriatric care GRN core screening tool (SPICES)Geriatric assessment rounding Slide60

NICHE Outcomes

Enhance nursing knowledge and skills regarding the treatment of common geriatric syndromes

Increase patient satisfaction

Decrease length of stayReduce readmission ratesReduce costs associated with elder care Slide61

St. Luke’s Network and NICHE Program

St. Luke’s became NICHE designated in Jan 2014

RNs and Patient Care Assistants completed the NICHE Geriatric Resource Education and St Luke’s older adult sensitization

Non-nursing staff received NICHE information and sensitization experiences

Network-wide Geriatric Institutional Assessment 70% completion rate

St. Luke’s NICHE Program video viewed by over 1100 employees Slide62

St. Luke’s Network Performance Improvement Activities

Reducing

polypharmacy

in older adultsEffective ambulation and reducing deconditioningReducing pressure ulcersReducing delirium Slide63

Fall Rate OutcomesSlide64

Conclusions

Multidisciplinary team approach is recommended to coordinate the care of older adults

Geriatric syndromes are prevalent

Geriatric assessment improves outcomes Geriatric care models (ACE/NICHE) decrease functional decline, falls, polypharmacy

, LOS and increase satisfaction Slide65

“In the end, it’s not the years in your

life that count. It’s the life in your years

.”

Abraham

LincolnSlide66

“Thank You”