Geriatric Issues in High Acuity Nursing

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Geriatric Issues in High Acuity Nursing

• Vaunette Fay, Ph.D., APRN

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What is Aging?

• Aging is a normal developmental event
• It begins with conception and continues
  throughout life until we die.
• Aging is progressive and inevitable

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Complexity of Presentation
Atypical Presentation
Chronic Disease
Polypharmacy
Functional Status
Nutrition
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Multiplicity of Disease

• Arthritis
• Hearing Loss
• Visual Loss
• Hypertension
• Cardiovascular disease
• Sinusitis
• Diabetes

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Atypical Presentation of Disease
Presenting Problem
Immediate cause
Underlying diagnosis
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Atypical Presentation of Disease

• Altered mental status
• Change in alertness
• Change in functional status
• Depression without sadness
• Infections without fever, leukocytosis,
  tachycardia

When you hear hoofbeats, think of horses, not
zebras
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Polypharmacy

• Drug-drug interactions
• Dosing problems
• Cost
• Side effects
• Home remedies

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Poor Nutrition

• Nutritional deficiencies
• Protein-calorie deficiencies
• Dehydration
• Obesity
• Excesses, i.e., alcohol

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Functional Impairment

• Basic activities of daily living
• Instrumental activities of daily living
• Cognitive status
• Emotional well being
• Social support
• Financial resources

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Geriatric Giants

• The problem is more than one problem
• Many, mistaken for normal aging, can often be
  improved
• These so-called Geriatric Giants include
• Cognitive Impairments
• Falls
• Incontinence
• Failure to Thrive

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Emergent Exam of the Older Adult

• Emergent Care of Older Adults
• Admissions from the nursing facility
• Geriatric emergencies

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• Uncommon presentation of common conditions is
  more common than common presentation of uncommon
  conditions
• Sloan

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ED Visits and Older Adults

• 45 vs 18 admission rate from ED
• 46 receive primary care in community
• Treat life threatening emergency
• Stabilization of exacerbations
• Gate keeper to another level of service
• Care of short-term problems
• Primary care services

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Hospitalization

• Older Adults account for
• 36 of all hospital stays
• 49 of all hospital days
• Average length of stay was
• 6.8 days, 5.5 days for
• people under 65
• Length of stay for 65 has
• decreased since introduction
• of DRGs

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The Changes

• 5-10 per decade of life after age 30
• The systems most affected are
• Respiratory
• Cardiovascular
• Renal
• Nervous
• Musculoskeletal

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Fluid Volume Changes

• Impaired water and conservation of sodium
• Delayed and less thirst response
• Increased ADH concentration and secretion
• Total body water decreases
• Ability to concentrate urine decreases

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Respiratory Changes

• Reduced pulmonary capacity
• By age 75, VC may be ê up to 50
• Pao2 decreases with age
• (30yo-90 vs.70yo-70)
• Loss of cilia, reduced cough reflex

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Cardiovascular Changes

• Reduced
• Ability to raise the heart rate
• Compliance of ventricles
• Response to catecholamines
• Conduction pathways, SA, AV node functional cells
• Vasoconstrictive ability
• Between ages 30-80 CO ê by 30. When this is
  added to increased PVR appreciable drop in end
  organ perfusion

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Renal System Changes

• Renal perfusion falls 50, Kidney mass 20 from
  age 30-80
• GFR is reduced 8ml/min/decade
• Hepatic blood flow reduced
• Heightened risk of trauma, infection, etc.

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Nervous System Changes

• By age 70 brain weight reduced by 10
• Decreased
• Cerebral flow,
• Neurotransmitters
• Impulse velocity
• Other factors
• RX
• Heart, lung, hypoglycemia, etc.

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Musculoskeletal Changes

• Muscle shrinkage, calcification
• Osteoporosis, thinning of the disks
• Kyphosis
• Decrease in height 2-3 inches
• Balance changes, falls are common

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Assessing Dehydration

• Dry oral mucosa
• Longitudinal tongue furrows
• Upper body muscle weakness
• Fatigue, confusion

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Blood Loss

• 15 (750 ml) asymptomatic
• 20 - 25 (1000 - 1250 ml) tachycardia,
  tachypnea, capillary blanching, anxious
• 30 - 40 (1500 - 1800 ml) narrowed pulse
  pressure, altered mental status
• 40 - 50 (2000 - 2500 ml) progressive
  deterioration, end organ damage
• VS changes in pulse pressure
• systolic ? with blood loss
• diastolic ? with blood loss

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Geriatric Emergencies

• Trauma
• Cardiac
• Abdominal pain
• Acute confusional states

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Trauma

• Falls
• Motor vehicle accidents
• Battery
• Suicide
• Six times more likely to die
• lt 30 return to baseline functional status
• Injuries more subtle

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Geriatric Trauma

• Trauma is the fifth leading cause of death for
  persons gt65
• A third of traumatic deaths in people 65-74 are
  secondary to vehicular trauma, and 25 result
  from falls. In those gt 75, falls account for 50
  of injury-related deaths

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Falls Risks for Severe Injury

• Anticoagulant use
• History of falls
• Osteoporosis
• Thin
• Severe mobility problems

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Motor Vehicle Injury...

• More deaths in spite of declining miles driven
• Injury severity score younger adults
• Six times higher mortality
• Median lethal dose of trauma 1/2 that of young
• Older trauma victim dies slowly, of pneumonia or
  liver/renal dysfunction

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Vehicular Trauma

• 13 million drivers are gtage 65, in 1990, 7600
  deaths were due to MVAs
• Difficulties with reaction time, perception,
  judgement
• gt2000 elderly pedestrian fatalities/year
• 20 of all traumatic pedestrian fatalities

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Vehicular Trauma

• Risk of death from multiple trauma is 3 times
  greater at age 70 than at age 20.
• Why?
• Protective mechanisms are slow
• Less cardiac reserve

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Battery

• S - Do you feel Safe at home? What Stress do you
  feel in your relationship?
• A - Do you feel Afraid or have you been Abused by
  any of your caregivers?
• F - Are there any Family or Friends that you
  could ask for help or support?
• E Do you have a safe place to go in case of an
  Emergency? Is it an Emergency now?

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Battery Exam

• Skin
• Circular contusions, unexplained lacerations
• Palm prints, unexplained bruises
• MSK
• fractures, various stages of healing
• Mental status
• Fearful, anxious, withdrawn, statement by patient
  of abuse

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Suicide ROS

• Mental status
• Depressed Are you depressed?
• MSK
• Frequent falls
• Social
• Male
• Widow
• Living alone

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Suicide Differential Diagnosis

• Depression
• Grief
• Dementia
• Substance abuse
• Caregiver abuse, neglect

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Acute Myocardial Infarction

• Chest pain becomes unreliable as a symptom of MI
  by age 70
• 45 of patients gt85 have chest pain as a
  complaint.

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Cardiac Emergencies

• Aging Changes
• Atherosclerosis
• Valvular heart disease
• Conduction disorders
• Declining cardiac output
• Decreased maximal heart rate
• 220 - age maximum heart rate

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A MI ROS..

• Angina lt 50 over age 80
• Dyspnea variable
• Diaphoresis, vomiting often absent
• More common
• Weakness
• Syncope
• Confusion
• Abdominal pain

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AMI Late Presentation...

• Pulmonary edema
• Dysrhythmias
• Diagnostics
• EKG changes
• Cardiac markers

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Congestive Heart Failure..

• Presentation
• Restlessness
• Lethargy
• Acute confusion

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CHF PE..

• Pulmonary increased rate, irregular rhythm,
  rales
• CV S3, edema, extremity cyanosis
• Abdomen tenderness
• GU low urinary output
• Neurological Confusion, lethargy, look for CVA

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Geriatric Abdominal Pain..

• 63 ED presentations are admitted
• Double rate of surgical intervention
• Delay in surgical diagnosis increases mortality
• PFSH
• CV Atrial fibrillation
• GI GERD, appy, cholecystectomy
• Medications NSAIDS, steroids

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Abdominal PainDifferential Diagnosis..

• Biliary tract disease
• Acute mesenteric ischemia
• Acute bowel obstruction
• Inflammatory bowel disease
• Appendicitis
• Perforated peptic ulcer
• Abdominal aortic aneurysm

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Acute Confusional States

• Differential Diagnosis
• Sepsis
• Myocardial infarction
• Toxicity
• CNS pathology
• Dementia vs delirium

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Delirium vs Dementia

• Acute
• Attention deficit
• Rambling speech
• Altered level of consciousness
• Fluctuating symptoms
• Delusional
• Illusions
• Often hyperactive
• Medical emergency

• Chronic
• Memory loss
• Cognitive dysfunction
• Restricted speech content

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Global DeteriorationFailure to Thrive

• 10 - 25 outpatient population
• 25 - 40 nursing facility population
• 50 of older adults have lost weight prior to
  hospitalization
• 75 - 90 one year mortality with persistent
  weight loss after hospitalization
• Jrn of Gerontology Med Sci, 52A, M333- M336

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Potential Outcomes

• Falls
• Injuries
• Acute illness
• Hospitalization
• Disability
• Dependency
• Institutionalization
• Death
• Fried, in Principles of Ger. Med. 1994, 1149-56

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Clinical Features

• Decline in physical, psychological, social
  functioning
• Weight loss, malnutrition
• Lack of readily explained cause, i.e., no
  terminal illness, no malignancy

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Which is it?

• Global Decline
• Terminal Illness
• Neglect The failure to provide goods and
  services necessary to avoid
  physical harm, mental anguish, or mental illness.
  

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Transfer Documentation...

• Study 300 admissions to 10 NF from 25 hospitals
• Findings
• 1-2 page transfer form sent 92 of the time
• Mostly legible 84
• Interdisciplinary information completed by
  physician (52), PA (27)
• Medical diagnosis accuracy 70
• Important medications 84

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Consequences of missing data

• Errors in patient management
• Duplication of tests
• Time consuming, unsuccessful attempts to contact
  inpatient manager

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• You Have to Climb the Mountain to Appreciate the
  Beauty of the View