Enhancing Patient Outcomes in Geriatric Populations

1
Enhancing Patient Outcomes in Geriatric
Populations

• An Evidence Based Perspective
• Jane E. Piper, MSN, RN

2
Regulatory Guidelines

• Joint Commission for Accreditation and Healthcare
  Financing Organization (JCAHO)
• http//www.jcaho.org/
• Centers for Medicare and Medicaid Services (CMS)
• http//www.cms.hhs.gov/
• 1990s (FDA) Food Drug Administration required
  clinical trials of drugs include elderly subjects
• http//www.fda.gov/
• Healthy People 2010, 1 Goal
• Increase quality and years of healthy life
• http//www.healthypeople.gov/

3

• Agency for Healthcare Research and Quality goals
  are to improve health outcomes, strengthen
  quality measurement, and enhance access to
  appropriate use of cost-effective strategies
  (AHRQ, 1999).
• National Institute of Nursing Research (NINR,
  1999) goals embrace objectives of relevance for
  aging, including end-of-life/palliative care,
  chronic illness experiences, quality of life and
  quality of care issues, and cost-effective models
  of care.
• (Strumpf, N., 2000)

4
An Aging Population(Fulmer, T., 2001)
(Strumpt, N., 2000)

• Adults 65 years of age and older represent 13 of
  the U.S. population
• By 2030 the number is expected to increase to 20
• Patients 65 years of age and older make up 48 of
  hospital admissions

5
Pharmacology Physiology(Eisenhauer, 1998)

• Decreased Absorption
• Decreased gastric blood flow
• Gastric Ph
• Decreased gastric emptying

• Decreased Distribution
• Causes higher blood or tissue concentrations
• Decreased total body water
• Decreased body fat

6
Pharmacology Physiology cont..

• Decreased skin absorption of topical/transdermal
  patches
• Decreased serum albumin
• Certain drugs bind to albumin
• Increase in concentrations cause increase in side
  effects

7
Pharmacology Physiology cont..

• Decreased Metabolism-Changes in liver function
  where drugs become inactivated related to
  decreased hepatic blood flow and decreased liver
  enzymes.
• Decreased Excretion-Renal function declines
  throughout life related to decreased plasma flow
  tubular excretion.
• Serum creatinine level is less reliable in
  elderly related to decreased muscle mass

8
Pharmacology Physiology cont..

• Drug receptor changes
• Diminished homeostatic response
• Autonomic nervous system
• Decreased stability of
• Blood pressure
• Temperature
• Vasoconstriction/Vasodilation

9
Geriatrics are More Likely to have Adverse Drug
Reactions Eisenhauer, 1998

• Drug Toxicity Signs
• Behavioral changes
• Restlessness
• Confusion
• Irritability
• Anxiety
• Insomnia
• Hallucinations

• Polypharmacy
• Two-Thirds of Geriatrics take at least one (OTC)
  Over The Counter Medication

10
Adverse Drug Reactions

• The elderly use 30 of all prescription drugs in
  the U.S.
• Polypharmacy can result in adverse health
  effects.
• Meds that can cause reactions narcotics,
  sedative-hypnotics, antidepressants, diuretics,
  non-steroidal anti-inflammatory drugs, and ACE
  inhibitors.
• Adverse reactions acute confusion, increased
  falls, dehydration, electrolyte imbalances,
  hypotension, hypertension, decreased kidney
  function, CHF, or GI bleeding.

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20 of Elderly Clients Treated in the EDhave

• Signs and symptoms of mental deterioration or
  pseudodementia that are dismissed as part of the
  aging process..Without First fully assessing
  their medication regimen

12
Elderly Pain Assessment

• These patients may under report their pain use
  non-verbal assessments.
• Some elderly patients are fearful of becoming
  addicted to pain meds.
• Elderly patients think others wont believe they
  are in pain (even if they do not show it, pain is
  what the patient says it is).
• Elderly patients can have adverse reactions to
  pain meds, start with lower doses when
  appropriate.

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Elderly Pain Assessment

• Prolonged bedrest and inactivity can increase
  pain.
• Comfort measures can reduce the amount of pain
  medication needed.
• Acute conditions should always be focused toward
  causative factor.
• Pain may be referred or hard to describe

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Illness in the Elderly-Critical Care Nursing

• Atypical presentation
• Whereas older persons may present with usual and
  classic symptoms, many present with atypical or
  non-specific symptoms.
• It is one of the challenges of geriatric medicine
  to recognize and diagnose the aged individual who
  presents in an atypical manner.
• (Fulmer, 2001.)

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Atypical Presentation Examples

• Typical
• UTI-Incontinence, dysuria
• Pneumonia-Cough, sputum production, fever
• Myocardial Infarction-chest pain

• Atypical
• UTI-Confusion, falls, anorexia
• Pneumonia-Anorexia, decreased activity level,
  confusion
• Myocardial Infarction-breathlessness, decreased
  activity level

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Assessment of the Elderly in the Emergency
Department

• Requires understanding of normal age-related
  psychologic, sociologic, physiologic changes
  and pathology.
• Chronological age is not a good predictor of
  biologic age, related to combined effects of
  genetics, lifelong exposure to health habits,
  medical problems, lifestyle, and environment.
• (Hayes Iola, 2000).

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Assessment Principles

• Recognize altered and nonspecific presentation of
  disease
• Use a heightened index of suspicion with astute
  assessment skills
• Do not allow ageism to bias your assessment
• Trust will encourage sharing of private
  information

• Ensure the patient is comfortable
• Obtain through history of present illness
• Face patient speak low and in clear tones
• Eliminate outside noises
• Use eye contact
• Closed-ended questions helps focus interview

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Assessment cont..

• Consider potential for alcohol abuse or
  dependence on prescription or recreational drugs
• Presenting complaints for these elderly patients
  are most often gastrointestinal problems, fall,
  or other trauma.
• Consider also potential for abuse or neglect in
  any assessment.

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Play Detective

• A chief complaint may not exist!
• CHF-may be described as I have not been able to
  bath myself
• MI-may be described as weakness
• (Hayes Iola, 2000)

20
Patient Presentation-Rule Out Delirium or Acute
Confusion

• Dementia is a chronic progressive mental change
  vs.
• Delirium or acute confusion-a potentially life
  threatening health problem for elders.

• Delirium has a treatable or reversible cause,
  such as
• Dehydration, electrolyte abnormalities,
  hypothyroidism, infection, arrhythmias, heart
  failure, medication adverse reactions, urinary
  retention, or even fecal impaction.
• (Hayes Iola, 2000

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• A History of Acute Onset of Symptoms, fluctuation
  of alertness, attention span, sleep disturbances,
  and the presence of delusions or hallucinations
  can point to acute delirium.
• Depression may present as agitation, anxiety,
  memory loss, or multiple somatic complaints.
• Appropriate assessment is accurate triage and
  identification of potential physical,
  psychological, and sociological problems.

22
Laboratory Values

• If lab values are abnormal they should not be
  blamed on normal aging, they should be
  considered abnormal and evaluated as such.
• Anemia is not normal. Blood loss, iron
  deficiency, or malnutrition are considered if
  hemoglobin and hematocrit levels are low.
• (Hayes Iola, 2000)

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Patient Education

• Barriers to teaching
• Lack of Time
• Lack of Staff
• Lack of approachability
• Lack of appropriate teaching tools
• Lack of innovative strategies

• Barriers to learning
• Sensory impairments
• Cognitive decline
• Lack of motivation
• Depression
• Low literacy skills

24
Cultural Diversity and the Elderly

• Special considerations with diversity and the
  elderly. Avoid stereotyping.
• Meaning of illness, hospitalization, and
  environment are key considerations beyond the
  urgent aspects of care.
• Patterns of decision making, meaning of critical
  illness, and preferences for end-of-life care are
  considered.

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Cultural Diversity cont.

• Ethnicity strongly influences definition,
  recognition, and evaluation of health situations.
• Expressions of pain or discomfort are rooted in
  culture
• Reporting of pain may be effected by
• Obligation to bear pain stoically-under medicated
• Language barrier in ability to describe pain
• Exaggerated expressions of pain-over medicated
• (Fulmer, 2001)

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Health Literacy-How Does Your Patient Score?

• Managed care requires individuals to take more
  responsibility for self-care and symptom
  management.
• Poor Health Literacy may lead to serious negative
  consequences such as increased morbidity and
  mortality when patients are unable to read and
  comprehend instructions for medications,
  follow-up appointments, diet, procedures, and
  other regimens.
• (BASTABLE, 2003)

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Patient Discharge Instructions

• Research reveals that patients forget within 5
  minutes about ½ of any oral instruction they
  receive.
• Inappropriate reading level of materials used to
  reinforce or supplement verbal teaching
• Decreases compliance
• Increases morbidity
• Encourages misuse of healthcare facilities
• (Bastable, 2003)

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Teachable Moments

• When an elderly person is admitted to the
  hospital this provides a teachable moment that
  can impact their day to day life.
• Lack of knowledge and resources can create the
  climate for what we term non compliant.

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REFERENCES

• Bastable, S., (2003). Nurse as Educator.
  Principles of Teaching and Learning for Nursing
  Practice. Jones Bartlett Publishers, Inc.
• Eisenhauer, L., Nichols, L., Spencer, R.,
  Bergan, F. (1998) Clinical Pharmacology Nursing
  Management, (5th Ed). Philadelphia, PA
  Lippincott Raven Publishers.
• Fulmer, T., et al. (2001). Critical Care Nursing
  of the Elderly (2nd ed). New York Springer
  Publishing Co.
• Hayes, K., Iola, K, (2000). Geriatric
  assessment in the emergency department. Journal
  of Emergency Nursing, 26(5), 430-435.
• Strumpt, N., (2000). Improving care for the frail
  elderly The challenge for nursing. Journal of
  Gerontological Nursing, 26(7), 36-44.