Geriatric Syndromes

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Geriatric Syndromes

• Elizabeth K Keech PhD, RN
• Elise Pizzi MSN, GNP-BC

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What are they?

• Conditions, not diseases
• Common in the elderly
• Typically
• Multifactorial
• Share risk factors
• Linked with functional decline, increasing
  frailty and poor health outcomes

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Tend to include

• Polypharmacy
• Chronic pain
• Falls
• Delirium
• Urinary incontinence
• Depression.

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Prevalence

• Study of 62,829 Looked at 3Falls, Urinary
  incontinence Depression
• Community dwelling women between 65 81 years of
  age
• - 34.4 had 1 Geriatric Syndrome
• - 8.2 had 2 or more

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Effects Independent

• Physical social functioning and disability
• Quality of life measures
• The Odds Ratio were as large for physical and
  social limitations as were those for chronic
  conditions

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Effect Synergistic

• Concurrence of Chronic diseases

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Shared Risk Factors

• Diabetes

• Malnutrition

• Risk for
• Dementia
• Decline in mobility
• Disability
• Falls
• Urinary Incontinence

• Correlated with
• - Depression
• - Dementia
• - Functional dependence
• Associated with
• - Multiple co-morbidities

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Shared Risk factors

• Older age (Define old)
• Functional Impairment
• Cognitive Impairment
• Impaired mobility (Inouye et al 2007)
• Poor Nutritional status
• Female gender
• Depressive symptoms (Chen et al. 2010)

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Frailty The Dwindles

• Meet 3 of 5 symptoms
• Decreased walking speed
• Decreased grip strength
• Decreased physical activity
• Exhaustion
• Weight loss (Fried et al. 2001)

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Whats needed

• Prevention
• Mobility issues and malnutrition
• Minimize complications
• Early recognition and treatment
• Basic set of geriatrics knowledge and skills to
  address the key geriatric syndromes and issues
  that can limit functional independence and
  complicate medical management

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Improving health outcomes through research and
education

• Solutions
• Educating clinicians, educators and students
• Identifying Evidence-based data found in Hartford
  Institute for Geriatric Nursing

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HIGNHartford Institute for Geriatric Nursing

• Mission Shape the quality of health care of
  older adults through excellence in nursing
  practice
• Started in 1996
• Geriatric arm of the NYU College of Nursing
• Addresses 4 vital areas for change
• PRACTICE
• RESEARCH
• EDUCATION
• ADVOCACY POLICY
• Hartford Institute Home Page

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EDUCATION
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GNEC

• Geriatric Nursing Education Consortium
• National initiative to enhance geriatric content
  in senior-level undergraduate courses
• Administered by AACN in collaboration with
  Hartford Institute
• Power Point presentations on-line
• Cultural Competence and Chronic Disease
  Management of Older Adults
• Spirituality and Aging
• Sexuality in Older Adults
• Spirituality in Aging

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Geropsych Competency

• Geropsychiatric Nursing Collaborative that is
  identifying and evaluating the quality and
  suitability of curricular and training materials
• Portal of Geriatric Online Education-rate the
  materials you peruse
• Log in to view articles, videos
• Log in to view modules that develop knowledge of
  gero psych topics
• Portal of Geriatric Online Education

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Consult GeriRN.org

• Protocols and topics
• Evidence-based protocols for managing common
  geriatric syndromes and conditions
• From Advance Directives to Urinary Incontinence
• ConsultGeriRN

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Consult Geri-RN

• Try This Assessment Tool Series with over 30
  nationally recommended instruments for use with
  older adults
• Tabs
• want to know more
• topic resources
• Try This Assessment Tool Series

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HIGN e-Learning Center

• Continuing Education Portal with free and paid
  courses
• Sign in to courses
• Gerontological Certification Review Course
  offered by ANCC fundamental knowledge about
  care of the older adult
• eLearning/

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HIGN e-Learning Center

• Clinical Teaching Modules
• assist nursing faculty to integrate care of
  older adults when teaching students in hospitals
• Clinical Teaching Module

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HIGN e-Learning

• Nursing Home Modules
• Assist nursing faculty teaching in nursing homes
• Help faculty select and use nursing homes for
  clinical placement
• Focus on nursing homes involved in
  resident-directed care and culture change
• Nursing Modules

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Elder Mistreatment

• eLearning course developed
• Concepts
• Research
• Legal
• Care continuum
• Theories
• Clinical Documentation
• Impact
• Elder Mistreatment

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HIGN e-Learning

• Web Based geriatric case studies that assist
  faculty to introduce geriatric concepts into the
  curriculum
• Advance Practice Case Studies

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PRACTICE
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NICHE

• Practice supportive
• Nurses Improving Care for Health System Elders
• GITT Geriatric Interdisciplinary Team Training
• Training resources in a GITT Kit to help health
  professionals develop interdisciplinary teams
• GITT

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Practice Support

• Consult Geri RN and Try This Series
• Tab Need help stat
• Need help stat
• HI Hospital Competencies Competency Care of
  Adult 65 years
• Hospital Competencies

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IV - HIGN Forum

• Web based board for reading and posting
  messages about geriatric topics.
• HIGN Forum

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USING TRY THS- Medications
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Drugs and Older Adults

• Medication (prescription, over-the-counter and
  herbal preparations) are widely used by older
  adults
• At least one RX med used b 81 of community
  dwelling adults
• Five or more Rx medications used by
• 29 of overall survey population 65 and older
• 36 of people aged 75 85 year olds
• 46 of RX users took at least one OTC medication
• (Qato et al, 2008)

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Medication

• 20 of of community dwelling older adults in the
  US are using one or more meds on the Beers list
  of drugs that should be avoided (Zhan et al,
  2001)
• All adults over 65 y.o. (12 of population)
• 79 take some type of medication
• Consume 30 40 of all prescribed drugs
• Purchase 40 of all OTC drugs
• 12 of elderly on 10 or more meds
• 23take 5 or more medications

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Adverse Drug Reactions(ADR)

• of drugs prescribed and prior history of an ADR
  strongest predictors for subsequent ADR
• Risk doubled for those prescribed 5 -7
  medications
• Fourfold for those receiving 8 or more
  medications
• (Onder et al, 2010)

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Post hospital medication problems

• One or more medication discrepancies were
  experienced in 14.1 of patients post
  hospitalization
• Medication discrepancies were associated with
  total number of meds taken and presence of CHF
• 14.3 of patients with discrepancies
  rehospitalized in 30 days compared with 6.1
  without discrepancies
• (Coleman et al, 2005)

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Try This Series
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Try This Series

• Want To Know More
• Assessment /Screening Tools
• Beers Part I criteria
• Beers Part II criteria
• Article in AJN
• Video on Beers Criteria

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Using Beers I Criteriasee handout

• Part I Have student review patient RX and OTC
  meds to identify inappropriate medications
• Great exercise for beginning clinical students
• Example for action on a drug by students
• OTC Benadryl (diphenhydramine)
• May cause confusion and sedation
• Should not be used as a hypnotic e.g. Tylenol
  PM!!
• Emergency allergic reaction use smallest dose
  (25 mg), 1 2x

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Using Beers II Criteriasee handout

• Part II Have student review patient meds to
  identify inappropriate medications by patient
  diagnos(es)/condition(s)
• Good exercise for higher level students
• Use disease or condition to identify
  inappropriate medications by name or by drug
  class
• Have students group patients present list of
  medications both RX and OTC by diagnoses/condition
  s

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Delirium Most frequent complication of
hospitalized elderly

• Yet nurses fail to recognize it more than 30 -
  50 of the time
• In one study, nurses failed to recognize delirium
  in 75 of cases
• (Rice et al., 2011)
• The fluctuating mental status is important to
  identify because it often signals a need for
  additional treatment

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Improving Recognition through Education that

• Differentiates between the 3 Ds
• Delirium, Dementia, Depression
• Improves knowledge about atypical presentations
  of delirium in the elderly
• Provides competency in mental status assessment
  the Mini-cog
• Recognizes acute confusion as a serious condition

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Try This Series Delirium

• Overview of the problem
• Articles
• Strategies
• Assessment/Screening Tools
• Assessment tools
• Videos

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CAM (Confusion Assessment Method)

• CAM standardized assessment tool
• (Long Short Versions)
• CAM ICU non-verbal, ventilated Patient
• Plus
• Assessing and managing delirium superimposed on
  dementia
• Assessment of Executive Functioning

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Try This Series (CAM)

• Identifies 4 features of the disorder that
  distinguish it from other forms of cognitive
  impairment.
• 1. status altered from baseline (acute onset or
  fluctuating)
• 2. inattention
• 3. disorganized thinking
• 4. altered level of consciousness
• Takes 5 minutes and is easily incorporated

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Back to Rices Study
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Thank You and Healthy Aging
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References

• Coleman, E. A., Smith, J. D., Raha, D., Min, S.
  J. (2005). Posthospital medication discrepancies
  prevalence and contributing factors. Arch Intern
  Med 1651842.
• Fried, L. P., Fernucci, L., Darer, J.,
  Williamson, J. D., Anderson, G. (2004).
  Untangling the concepts of disability, frailty,
  and comorbidity implications for improved
  targeting and care. Journal of Gerontology
  Medical Sciences 59(3) 255-263.
• Inouye, S. K., Studenski, S., Tinetti, M. E.,
  Kuchel, G. A. (2007) Geriatric syndromes
  clinical, research, and policy implications of a
  core geriatric concept. Journal of the American
  Geriatric Society 55780-791.
• Knight, E. L., Avorn, J. (2001). Quality
  indicators for appropriate medication use in
  vulnerable elders. Ann Intern Med 135703.

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References

• Onder, G., Petrovoc, M., Tanglisura, B., et al.
  (2010). Development and validation of a score to
  assess risk of adverse drug reactions among
  in-hospital patients 65 years or older the
  GerontoNet ADR risk score. Arch Intern Med
  1701142
• Qato, D. M., Alexander, G. C., Conti, R. M. et
  al. (2008). Use of prescription and
  over-the-counter medications and dietary
  supplements among older adults in the United
  States. JAMA 3002867.
• Rice, K. L., Bennett, M., Gomez, M., Theall, K.
  P., Knight, M., Foreman, M. D. (2011). Nurses'
  recognition of delirium in the hospitalized older
  adult. Clinical Nurse Specialist 25(6), 299-311.

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• Russo, A. L., Eaton, C. B., Wallace, R., Gold
  R., Curb, J. D., Stefanick, F. L., Okene, J. K.,
  Michael, Y. L. (2011). Combined impact of
  geriatric syndromes and cardiometabolic diseases
  on measures of function. J Gerontol A Biol Med
  Sci. 66A(3)349-354.
• Saka, B., Kaya, O., Ozturk, G. B., Erten, N.,
  Karan, M. A. (2010). Malnutrition in the elderly
  and its relationship with other geriatric
  syndromes. Clinical Nutrition 29(6) 745-8.
• Zhan, C., Sangl, J., Bierman, AS, et al. (2001).
  Potentially inappropriate medication use in the
  community-dwelling elderly findings from the
  1996 Medical Expenditure Panel Survey. JAMA
  286282.3.