#1 PRINCIPLE BASICS · Refer to other resources: Referral options: Clinicians - doctors, nurses,...
Transcript of #1 PRINCIPLE BASICS · Refer to other resources: Referral options: Clinicians - doctors, nurses,...
PREVENTIVE CARE IN GERIATRICSAMANDA ARNOLD MD, ANNA SCHWEIKERT MD, NICOLE SORIA MD
THE CHRIST HOSPITAL/UNIVERSITY OF CINCINNATI GERIATRIC FELLOWS
OBJECTIVESPreventive care
PrinciplesTeam effortPreventing common reasons for medical visits
ED transitions
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#1 PRINCIPLE BASICS
What can you do?Using a mask
Hand cleaning
5% doing it right
Does this count?
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20 seconds
PREVENTIVE PRINCIPLES:THINGS TO
KNOW
Not just cancer screening
Different considerations
Underused
PREVENTION: ANNUAL WELLNESS VISIT
Once a year
NOT mandatoryLess than 25% of eligiblepatients receive this visit
Extensive amount to cover
Topics covered include:Medical history, family history, medication list, treatment teams and other providers
Depression screen
Fall risk assessment
Functional assessment
Immunizations
Screening tests
Optional: Advance directives
PREVENTION
IT TAKES A TEAM!
GLADYS… and herTerrible, Horrible, No Good, Very Bad Day
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COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest painPneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
CHEST PAIN
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CAUSES
• Coronary artery disease, acute heart failureC
Cardiac
• Respiratory infections – pneumonia, bronchitis, asthma exacerbationsR i i f i
Pulmonary/pleural
• Gastroesophageal reflux and esophageal spasmG h l fl
Gastrointestinal
MOST MODIFIABLE RISK FACTOR
Smoking cessation
https://www.iconfinder.com/icons/2699404/no_cigarette_no_smoking_no_smoking_sign_non_smoking_area_quit_smoking_icon
WHY QUIT? Smokers benefit from quitting
smoking even after development of smoking-related
diseases
S k b fi f i i
Reduced risk Heart disease Cancer Lung
diseases Infections Hip fracture
IT’S NEVER TOO LATE
STEP 1 – ASK Ask about tobacco use
“Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?”
“I take time to ask all of my patients about tobacco use—because it’s important.”
“Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?”
“Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?”
STEP 2 – ADVISE Advise smokers to quit (clear, strong, personalized)
“Occasional or light smoking is still harmful.”
“Cutting down while you are ill is not enough.”
“It is important you quit as soon as possible, and I can help you.”
“Quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”
Refer to other resources:
Referral options:Clinicians - doctors, nurses, pharmacists, etc.
Local groups - Nicotine Anonymous
Quit lines - Ohio Tobacco Quit Line (1-800-QUIT-NOW) National Cancer Institute (NCI) Quit Line1–877–44U–QUIT
Websites – Quitnow.net, Smokefree.gov
STEP 3 – REFER SMOKING CESSATION AIDS Over-the-counter Nicotine gumNicotine lozengeNicotine transdermal patch
PrescriptionNicotine nasal spray/inhalerBupropion SR (Zyban)Varenicline (Chantix)
SMOKING CESSATION AIDS Over-the-counter Nicotine gumNicotine lozengeNicotine transdermal patch
PrescriptionNicotine nasal spray/inhalerBupropion SR (Zyban)Varenicline (Chantix)
Electronic cigarettes (e-cigarettes)
• Not approved by FDA as a smoking cessation aid. Can contain harmful substances such as lead and carcinogens in addition to nicotine. Limited evidence they are effective in smoking cessation.
SMOKING CESSATION
AIDS
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest pain
PneumoniaStroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
IMMUNIZATIONS
https://www.medscape.com/viewarticle/823109 https://media.makeameme.org/created/when-my-teacher-5c1523.jpg
IMMUNIZATIONSImmunity wanes as we age, regardless of health status
Age increases susceptibility to illnesses
In 2015, for adults age 65 and older:
64% had a pneumonia vaccine
57% had a tetanus vaccine in the past 10 years
34% had a zoster vaccine (Shingrix or Zostavax)
PNEUMONIA VACCINES: OLD V. NEW
Old recommendation:Pneumovax PPSV23 and Prevnar PCV13 recommended for all adults 65 and older.
New in 2019:Pneumovax (PPSV23) recommended for all adults 65+ and shared-decision making regarding Prevnar PCV13.
Herd immunity: Risk for PCV13 disease lower due to vaccinated pediatric population.
PNEUMONIA VACCINATION
CDC recommends shared decision making regarding Prevnar (PCV13) for adults 65 and older.
Increased benefit for our patients in long-term care or nursing homes.
Higher incidence of PCV13 disease in our patients with chronic heart, lung or liver disease, diabetes, alcoholism or tobacco abuse.
https://blog.uvahealth.com/2016/09/28/pneumonia-101-qa/
HERPES ZOSTER (SHINGLES) VACCINATION
Affects 1 in 3 Americans, typically over age 50.
Shingrix: two-dose series separated by 2-6 months.
Shingrix is recommended regardless of prior Zostavax.
(postherpetic neuralgia)
https://pogoe.org/sites/default/files/AgingandImmunityGuide.pdf
2019-nCoV
SARSCoV2https://apicms.thestar.com.my/uploads/images/2020/01/31/535575.jpg
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LET’S COMPARE
?19 million infected
10,000 deaths
?4,600 infected
107 deaths
October 2019 – January 2020
LET’S COMPARE
Influenza19 million infected
10,000 deaths
Coronavirus4,600 infected
107 deaths
October 2019 – January 2020
2018: 80,000 people in US died of influenza
INFLUENZAHighest risk of complications:
>50 years old, residents of nursing homes /LTC.
High dose flu vaccine available for those 65+. 24% more effective than standard dose vaccine.
MANY misconceptions!
What is “the flu”
The flu shot gave me the flu.
But I have an egg allergy…https://health.ucmerced.edu/sites/health.ucmerced.edu/files/flu_pic_keep_calm.png
OTHER VACCINATIONS
Tetanus booster at least every 10 years.
Hepatitis vaccinations for certain at-risk groups/medical conditions.
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QUESTION 1
Older adults have accumulated more immunity over their lifetime, so they benefit less from vaccinations.
TRUEor
FALSE
QUESTION 1
Older adults have accumulated more immunity over their lifetime, so they benefit less from vaccinations.
FALSE
QUESTION 2
It is impossible to get the flu from receiving the flu shot.
TRUEor
FALSE
QUESTION 2
It is impossible to get the flu from receiving the flu shot.
TRUE
QUESTION 3
If your patient has a history of an egg allergy, they cannot receive the flu shot.
TRUEor
FALSE
QUESTION 3
If your patient has a history of an egg allergy, they cannot receive the flu shot.
FALSE
QUESTION 4
If your patient received the Zostavax vaccine, Shingrix is not recommended.
TRUEor
FALSE
QUESTION 4
If your patient received the Zostavax vaccine, Shingrix is not recommended.
FALSE
QUESTION 5
If your patient has cold symptoms, it is safe to administer a vaccine.
TRUEor
FALSE
QUESTION 5
If your patient has cold symptoms, it is safe to administer a vaccine.
TRUE
QUESTION 6
The flu shot is no longer recommended to be administered after January, because it is too late in the flu season.
TRUEor
FALSE
QUESTION 6
The flu shot is no longer recommended to be administered after January, because it is too late in the flu season.
FALSE
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
StrokeMedication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
STROKE
INCIDENCE INCREASES WITH
AGE, APPROXIMATELY
DOUBLING WITH EACH
DECADE
MAJOR CAUSE OF DEATH AND
DISABILITY AMONG OLDER
ADULTS.
~ 795,000 NEW STROKES
ANNUALLY IN THE UNITED
STATES
~ 6.8 MILLION ADULTS WHO ARE
STROKE SURVIVORS
Major risk factors:
Hypertension
Diabetes
Smoking
High cholesterol
Physical inactivity
STROKE
Two categories:
Ischemic
80-85%
Hemorrhagic
10-15%
BENEFITS OF INCREASED PHYSICAL ACTIVITY
Independently lowers risk of stroke.
Lowers risk of several causes of stroke:• Hypertension• Type 2 Diabetes • Hyperlipidemia
RECOMMENDED COMPONENTS
AEROBIC STRENGTH FLEXIBILITY BALANCE
AEROBIC EXERCISE Guidelines
Minimum 150 minutes/week of moderate-intensity aerobic activity
OR
Minimum of 60 minutes/week of vigorous activity
OR
Combination of the twohttps://www.freepik.com/premium-photo/old-couple-relax-after-jogging-they-hold-their-hands-smile_3354314.htm
STRENGTH TRAINING
Goal – maintain or increase muscle strength
Minimum: two days/weekAny activity involving use of major muscle groups against resistance:
Lifting weights and Body weight training
AND/OR
Carrying groceries and Yardwork https://www.yahoo.com/lifestyle/what-s-the-deal-with-1294376358592566.html
Flexibility
Two days/week Minimum 10 minutes/day
Stretching is best performed after aerobic or strengthening activities when the body is warmed up
BalanceAt least two days/weekReduce risk of falls and related injuriesIncludes: walking backward or sideways, heel walking, toe walking, and standing from a sitting positionGroup exercise classes – Tai Chi, Healthy Steps in Motion, Stay Active and Independent for Life (SAIL), etc.
EXERCISE PRESCRIPTION
Can include:Specific activity
Frequency
Intensity
Short and long-term goals to help maintain motivation153 LB
http://www.johnphung.com/tag/82-year-old-granny-lifting-some-weights/
Additive• Can be accumulated throughout the day
Individuals with chronic disabling conditions should be as physically active as can be achieved without harm.
• Intensity scale 0 to 10
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effectsDehydration
Urinary problems
Injuries from falls or accidents
MEDICATION REVIEW
Complicated by:Polypharmacy
Dosing times
Prohibitively expensive
Cognitive impairment
Over-the-counter medications:Many are not safe for older adults to take and are often not reported to their healthcare providers.
Transitions of care:Medications often added, changed, or discontinued.
Whenn you review w yourr patient’sWhenn you reviewy w ouyo r patientpmedication list, which onesmedication list, which ones
raise a red flag for you?
BEWARE – ANTICHOLINERGICSAnticholinergic = blocks acetylcholine, a neurotransmitter involved in cell signaling for memory, learning and muscles.
Older adults have less neurons and receptors at baseline increased susceptibility to their side effects.
Risks include dehydration, blurred vision, dizziness, dry mouth, urinary retention, constipation, delirium and hallucinations. Commonly worsen cognition.
Common medicines! Antihistamines, sleep aids, anxiety medications etc.
BEERS CRITERIA
Clinical tool intended to improve care of older adults by reducing exposure to potentially inappropriate or harmful medications.
Long, comprehensive list
TIME OUT! LET’S
PRACTICE.WHICH MEDICATIONS ON MS. JONES LIST ARE
OF CONCERN?
DISCUSS IN GROUPS OF 2-3!
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COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
DehydrationUrinary problems
Injuries from falls or accidents
DEHYDRATION
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COMMON PRESENTATIONS
Lightheadedness
Palpitations
Kidney injury
MOST COMMON CAUSES
Decreased perception of thirst
Lack of access to water
Gastrointestinal lossesVomiting, diarrhea
Renal lossesEffects of diuretic medications
Hyperglycemia
HOW TO RECOGNIZE
Urine output:Darker color
Strong odor
Decreased output
Dry mouth and chapped lips
Constipation
Confusion
HOW TO RECOGNIZE
https://www.healthline.com/health/hydration-chart
PREVENTION
Have preferred fluidsAvailable and offered regularly
Have fresh water available Variety! Both hot & cold fluids
Provide assistance and special aids as required
NUTRITION CHALLENGES
Altered sense of taste
Decreased appetite
Less efficient nutrient absorption
PREVENTION AND
NUTRITION
Medications given with at least a full glass of fluid
Water glass next to bed to drink first thing in the morning
Ice cream
Nutrition shakes or drinks
Have snack food out/easily available
Variety!
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problemsInjuries from falls or accidents
INCONTINENCE
Very commonOften unreported
Reduces quality of life
Can lead to depression, social isolation, and increased caregiver burden.
**
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INCONTINENCE
First, ensure it is not a new problem. If it is then primary care
physician should evaluate.
The most effective and safest treatment
recommendation for all types of incontinence is
lifestyle changes!
TRASH THE BLADDER IRRITANTS
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TREATCONSTIPATION
Older adults may avoid drinking enough fluids due to their incontinence, which worsens constipation.
Constipation can result in urinary retention
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https://www.niddk.nih.gov/health-information/weight-management/health-tips-african-americans
https://www.hydrationinfo.com/hydration-tips-for-seniors-how-to-get-the-elderly-to-drink-more-water/0
TIMED TOILETINGHelpful for all types of incontinence.
Choose a reasonable interval2 hours is a good starting point
Toilet at that interval regardless of urge throughout the day.
Extend interval for bladder training in select patients.
https://dailycaring.com/wp-content/uploads/2014/06/elderlytoilet1200x630.jpg
KEGELEXERCISES
Locate pelvic muscles: “Pretend you are trying to
avoid passing gas.”
Contract and relax:• Contract pelvic floor
muscles for 3-5 sec then relax 3-5 sec.
• Repeat cycle 10 times.• Goal: 10 sec contractions.
Most important: Repeat throughout the day
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HYGIENE
Over-exposure to moisture causes skin to become macerated and fragile
Dermatitis (“diaper rash”) may result
Moist warm environment is a bacteria breeding ground
P you are the pros!Change incontinence products as soon as possible after soiling occurs.
Barrier cream - use to minimize skin contact with urine.
Cleanse gently to avoid friction.
Clear the path
Add grab bars for extra support when sitting and standing
Add a raised toilet seat with arms
Make cleaning up easier
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https://www.amazon.com/Long-Reach-Self-Wipe-Bathroom-Toileting/dp/B07JQ77HK4
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
COMMON REASONS FOR MEDICAL VISITS
Chest pain
Pneumonia
Stroke
Medication side effects
Dehydration
Urinary problems
Injuries from falls or accidents
FALLS
Nearly 1/3 of older adults report falling annually.
Over 3 million ED visits/year25% hospitalized
Half of older adults do not discuss falls with their health care provider.
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SCREENING FOR FALLS
Single most predictive question for detecting high fall risk:
Have you fallen in the past year?
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FALL RISK ASSESSMENT
Modifiable risk factorsPolypharmacy
Environmental hazards
Gait impairmentMuscle weakness, Hearing or vision problems, Inappropriate footwear, Fear of falling
Acute illness
Non-modifiable risk factorsAge
Comorbidities including Cognitive disorders
History of falls/fractures
Recent hospital discharge INTERVENTIONS
INTERVENTIONS
Problem:Poor strength
Unsteady gait
Poor balance
Solution:
https://www.bethesdahealth.org/physical-therapy-rehabilitation-vital-senior-healing/
INTERVENTIONS
KEEP PRACTICING
YOUR MEDICATION
REVIEWhttp://babyboomhealth.com/elderly-polypharmacy-issue/
INTERVENTIONS
HOME SAFETY
ASSESSMENT
https://www.sherrardlaw.com/single-post/2017/06/29/Home-Modifications-and-Occupational-Therapy
http://www.onlinearchitecture.net/decorating-top-of-kitchen-cabinets-dos-and-donts.html
EMERGENCYDEPARTMENTTRANSITIONS
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BACK TO GLADYS
Recap: 82
Smoker
Polypharmacy complicated by…
Environmental hazards
Fallhttps://specials-images.forbesimg.com/imageserve/962984430/960x0.jpg?fit=scale
UP TO DATE MEDICATION
INFORMATION
Should be carried with them…
ALL THE TIME
Pharmacy
Date last updated
ALL THE AIDS
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MENTAL BASELINE
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CODE STATUS
DNR-CC ARREST
DNR-CC
Medication list
Aids
Mental baseline
Code status
SUMMARY
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