Geriatric-Competent Care MICNP 2019€¦ · Geriatric-Competent Care MICNP 2019 (Joan) Michelle...

2019 MICNP Conference 3/23/2019

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Geriatric-Competent Care MICNP 2019(Joan) Michelle Moccia DNP, ANP-BC, CCRN, GS-C

[email protected]

Objectives

1. Identify patients likely to benefit from a comprehensive geriatric assessment

2. Implement multiple geriatric screenings to assess physical, psychological, social, and quality of life in the older population.

3. Discuss a treatment plan through case examples

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DemographicsU.S. population aged 65 and older (U.S. Census Bureau): 48 million

Nearly double over next 30 years to almost 88 million

Oldest old “age 80 years and older” will triple

Older people will outnumber younger children in next 2 decades

By 2030 all baby boomers will be 65 or older

One in five residents will be retirement age

https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html

Age-Friendly Health Systems: 4M Model of Care• Address the gap between EBP models of older adult care and

the care health systems put into practice

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WHO?

• General aging concerns

• Questions about memory loss

• Concerns about falling

• Consideration of change in living situations

• Assistance with Advance Care Planning

• Concerns about depression or isolation

• Concerns about driving safety

Priorities of Care and Purpose

• For what purpose is this assessment being done?

Patient

Caregiver

• What makes life worth living?

• What would make tomorrow a really great day for you?

• What concerns you most when you think about your health and healthcare in the future?

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Comprehensive assessment• Identifying priorities

• Assessment of ADLs and IADLs

• Medication review and recommendations

• Evaluation of fall risk

• Assessment of Sleep Quality

• Memory screening

• Depression screening

• Nutritional assessment

• Urinary incontinence assessment

• Establish ACP preferences

• Conversation about driver’s safety

• Identify financial resources/long term care/veteran’s benefits

• Connect with resources

History• Head Trauma

• Cardiac or Cerebrovascular

• Metabolic

• Immunological

• Cancer

• Sleep

• Depression or other psychiatric history

• Family history of dementia

• Social History (ETOH or illicit drugs)

• Medications (anti-cholinergic, antihistamines – BEERS)

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Components of Geriatric Assessment • Alcohol, Smoking

• Exercise practices

• Sleep habits

• Dietary regimen

• Social history (marital status, education)

• Work history (occupation, retire year)

• Living arrangements

• Transportation

• Fall history

• Social activities

• Friends and family

• Safety in relationships

• Spirituality

• Finances

• Legal

Vaccination History

• Haemophilus Influenza B

• Hepatitis A

• Hepatitis B

• Herpes-Zoster

Zostavax

Shingrix (two doses required)

• Meningococcal

• Pneumococcal Conjugate

PCV 13

PPSV 23

• Td/Tdap

• Varicella Vaccine

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https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf

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Medications• Use more prescription and OTC

• Account for 30% of OTC medications in U.S.

• Significantly likely to experience an adverse drug reaction(ADR)

• 61.5% ED visits occurring because of ADR

• 76% use two or more prescription drugs

• 37% use five or more

Pearl:

Bring medications and OTC to visit – count in front of patient

Ask how they remember to take their medications, what do they do when they miss a med

Educate on safe drug use, side effects and dosing recommendations

Avoid inappropriate medication

Use interaction drug checker

Older adults okay with deprescribing

Medication resources

• https://reference.medscape.com/drug-interactionchecker

• www.knowyourdose.org Acetaminophen Awareness Coalition

• www.knowyourotcs.org Consumer Healthcare Products Assoc.

• www.getreliefresponsibly.com J & J Consumer, Inc.

• www.bemedwise.org and www.bemedwise.org/acetaminophen/seniors National Council on Patient Information and Education

• www.fda.gov/medsinmyhome and www.fda.gov/otcpaininfoU.S. Food and Drug Administration

• www.Healthinaging.org BEERS alternative medications

• https://www.healthinaging.org/files/documents/tipsheets/meds_to_avoid.pdf Ten Medications to Avoid

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ASSESSMENT TOOLShttps://consultgeri.org/tools/try-this-series

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Dementia Prevalence

Age Range

65-74

75-84

85 and older

How many are affected?

5%

15-25%

36-50%

DSM-5 Definitions

• Major neurocognitive disorder

• Minor neurocognitive disorder

Classification

Alzheimer’s disease (AD) 60-80%

Vascular dementia (VSD) 10-20%

Frontotemporal dementia (FTD) 5%

Lewy Body Dementia (LBD) 15%

Parkinson’s Disease 6%

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Not Dementia

Normal Aging Intact memory for

events

Individual more concerned than family

Able to describe forgetfulness details

Word finding difficulties

Preserved function

Mild Cognitive Impairment (MCI)

12% age 70-79

22% aged 80-89

Maybe amnestic or non-amnestic

Objective impairment on 2+ abnormalities in 1+ domain

General function intact

Slide 19-22 from UCLA Dementia and Memory Disorders Program

Mild Dementia

Cognitive

Decreased insight

Short term memory deficits

Poor judgment

Functional impairments

Managing finances

Managing medications

Driving difficulties

Behavioral symptoms

Social withdrawal

Mood changes (apathy, depression)

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Moderate Dementia

Cognitive

Worse memory

Disoriented to time and place

Lost in familiar places

Repetitive questions

Functional impairments

Difficulty with some ADLs

Gait and balance disturbance

Loss of IADLs

Behavioral symptoms

Apathy/depression

Delusions/Agitation/Aggression

Restlessness/anxiety/wandering

Severe Dementia

Cognition

Loss of remote memory

Inability to recognize family or friends

Little or unintelligible verbal communication

Functional impairment

Loss of ADLs and IADLs including continence

Mobility

Swallowing

Behavioral Symptoms

Apathy/depression

Motor or verbal agitation/aggression

Sundowning

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Causes of Dementia

• Alzheimer’s Disease 60-80%

• Vascular Dementia 10-20%

• Dementia with Lewy bodies 15%

• Frontotemporal degeneration 5%

• Other movement disorders 6%

• Toxic-metabolic disorders 4%

10 early signs/symptoms of Alzheimer’s disease• Memory loss that disrupts daily life

• Challenges in planning or solving problems

• Difficulty completing familiar tasks at home, at work or at leisure

• Confusion with time or place

• Trouble understanding visual images and spatial relationship

• New problems with words in speaking or writing

• Misplacing things and losing ability to retrace steps

• Decreased or poor judgment

• Withdrawal from work or social isolation

• Changes in mood and personality

https://www.alz.org/alzheimers-dementia/10_signs

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MoCA Blind

• Adapted version of original MoCA

• Assesses cognitive domains: attention and concentration, memory, language, conceptual thinking, calculation and orientation

• Contains same items as original MoCA except those requiring visual abilities

• 5-10 minutes

• Total possible score: 22

• Score ≥ 18 considered normal

• Cut off score has not been validated

Mini-Cog

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SAGE

• 1. Test Your Memory for Alzheimer's Dementia in 15 Minutes (SAGE) Known as the Self-Administered GeocognitiveExamination (SAGE) this dementia test is highly recommended for testing memory. The SAGE test is a a 15 question writtenexam (quiz) that is used for the early detection of Alzheimer's disease.Aug 27, 2018

• How to Test Your Memory for Alzheimer's and Dementia (5 Best Tests ...

• https://www.alzheimersreadingroom.com/2016/.../alzheimers-dementia-memory-test.htm...

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Depression

The Patient Health Questionnaire -2 (PHQ-2)

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PHQ- 9

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Katz Index ADL Functional Assessment

The Lawson IADLs Assessment

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Possible causes of Transient UI trythis tools– Hartford University

DIAPPERSDeliriumInfection (eg.UTI)Atrophic urethritis or vaginitisPharma( eg. Diuretics, anticholinergis, CCB, sedatives, alcohol, narcotics)Psychological disorders (especially dependent)Endocrine disorders (DM, HF)Restricted mobilityStool impaction

TOILETEDThin, dry vaginal and urethral epitheliumObstruction (stool/constipation)InfectionLimited mobilityEmotional (pychological, depression)Therapeutic medications (Pharmacological)Endocrine disordersDelirium

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Frailty

Condition marked by

loss of function, strength and physiologic reserve

predictive of risk of falling,

disability due to impaired mobility

restricted ADLs

increase risk of infection or prolonged recovery from injury or surgery

Financial burden

Frailty scale

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922366/

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CAREGIVER ASSESSMENTAlz.org/care (Education)

Alz.org/CRF (Resources: adult care programs, in-home assistance, companions)

Alzconnected.org (networking)

24/7 Helpline (800-272-3900) https://www.aarp.org/caregiving/

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Neuropsychiatric Inventory Questionnaire (NPI-Q) tool

•Evaluates neuropsychiatric symptoms in past month from the caregiver

•Measures Severity of symptoms affects the patient

•Measures distress of family/caregiver

NPI-Q

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Labs and Imaging

Labs

CBC, CMP, TSH, B12, Folate, RPR

Imaging

CT scan

MRI

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RESOURCES

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Friendship Line

Fall Risk Education

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ENA and GAPNA Resources• Emergency Nurses Association offers the GENE

program https://nf.ena.org/eweb/DynamicPage.aspx?Site=ENA2015&webcode=ENACOEELearn&pager=10&listcategory=GENE

• The ENA also has a Geriatric Task Force committed to the care of older adults in the ED. Here are two resources: https://www.ena.org/docs/default-source/resource-library/practice-resources/topic-briefs/screening-tools-for-older-adults-in-the-emergency-care-setting and https://www.ena.org/docs/default-source/resource-library/practice-resources/topic-briefs/collaborative-care-for-the-older-adult

• www.gapna.org

• https://www.gapna.org/resources/toolkits/toolkit-gerontology-resources-aprn-preceptors-and-students

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Resources continued

• Older Adult Falls - https://www.cdc.gov/homeandrecreationalsafety/falls/index.html• Important Facts about Falls - https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html• Costs of Falls Among Older Adults - https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html• STEADI – Older Adult Fall Prevention - https://www.cdc.gov/steadi/• https://academic.oup.com/gerontologist/advance-article/doi/10.1093/geront/gny101/5103473• www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx• www.healthinaging.org• www.alzheimer.org

Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome EvaluationThe Gerontologist, gny101, https://doi.org/10.1093/geront/gny101

CDC Emergency Preparedness Toolshttps://www.cdc.gov/aging/emergency/planning_tools/guide.htmOther preparedness information https://www.cdc.gov/aging/emergency/

Resources continued

https://academic.oup.com/gerontologist/advance-article/doi/10.1093/geront/gny101/5103473

Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome Evaluation

The Gerontologist, gny101, https://doi.org/10.1093/geront/gny101

CDC Emergency Preparedness Tools

https://www.cdc.gov/aging/emergency/planning_tools/guide.htm

Other preparedness information

https://www.cdc.gov/aging/emergency/

Florence, C.S., Bergen, G., Atherly, A., Burns, E., Stevens, J., Drake, C. (2018)Medical costs of fatal and nonfatal falls in older adults. JAGS 693-698. DOI:10.1111/jgs.15304

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Geriatric-Competent Care MICNP 2019€¦ · Geriatric-Competent Care MICNP 2019 (Joan) Michelle...

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