Geriatric SyndromesGeriatric SyndromesElizabeth K Keech PhD, RNElizabeth K Keech PhD, RNElise Pizzi MSN, GNP-BCElise Pizzi MSN, GNP-BC

What are they? What are they?

Conditions, not diseasesConditions, not diseases

Common in the elderlyCommon in the elderly

Typically:Typically:MultifactorialMultifactorialShare risk factorsShare risk factorsLinked with functional decline, Linked with functional decline,

increasing frailty and poor health increasing frailty and poor health outcomesoutcomes

Tend to include:Tend to include:

PolypharmacyPolypharmacy

Chronic painChronic pain

FallsFalls

DeliriumDelirium

Urinary incontinenceUrinary incontinence

Depression.Depression.

PrevalencePrevalence

Study of 62,829 Looked at 3:Study of 62,829 Looked at 3:Falls, Urinary incontinence & DepressionFalls, Urinary incontinence & Depression

Community dwelling women between Community dwelling women between 65 – 81 years of age 65 – 81 years of age

- 34.4% had 1 Geriatric Syndrome- 34.4% had 1 Geriatric Syndrome

- 8.2 % had 2 or more- 8.2 % had 2 or more

Effects: IndependentEffects: Independent

Physical & social functioning and Physical & social functioning and disabilitydisability

Quality of life measuresQuality of life measures

The Odds Ratio were as large for The Odds Ratio were as large for physical and social limitations as physical and social limitations as were those for chronic conditionswere those for chronic conditions

Effect: SynergisticEffect: Synergistic

Concurrence of Chronic diseasesConcurrence of Chronic diseases

Shared Risk FactorsShared Risk Factors

Diabetes:Diabetes:Risk for : Risk for : DementiaDementiaDecline in mobilityDecline in mobilityDisabilityDisabilityFallsFallsUrinary Urinary

IncontinenceIncontinence

Malnutrition:Malnutrition: Correlated with:Correlated with:

- Depression- Depression

- Dementia- Dementia

- Functional - Functional dependencedependence

Associated with:Associated with:

- Multiple co-morbidities- Multiple co-morbidities

Shared Risk factorsShared Risk factors

Older age (Define old) Older age (Define old)

Functional ImpairmentFunctional Impairment

Cognitive ImpairmentCognitive Impairment

Impaired mobility (Inouye et al 2007)Impaired mobility (Inouye et al 2007)

Poor Nutritional statusPoor Nutritional status

Female genderFemale gender

Depressive symptoms (Chen et al. 2010)Depressive symptoms (Chen et al. 2010)

Frailty: “The Dwindles”Frailty: “The Dwindles”

Meet 3 of 5 symptoms:Meet 3 of 5 symptoms:Decreased walking speedDecreased walking speedDecreased grip strengthDecreased grip strengthDecreased physical activityDecreased physical activityExhaustionExhaustionWeight loss (Fried et al. 2001)Weight loss (Fried et al. 2001)

What’s neededWhat’s needed

Prevention: Prevention: Mobility issues and malnutritionMobility issues and malnutrition

Minimize complicationsMinimize complicationsEarly recognition and treatmentEarly recognition and treatment

Basic set of geriatrics knowledge and skills to Basic set of geriatrics knowledge and skills to address the key geriatric syndromes and issues address the key geriatric syndromes and issues that can limit functional independence and that can limit functional independence and complicate medical managementcomplicate medical management

Improving health outcomes Improving health outcomes through research and educationthrough research and education

• Solutions:Solutions:• Educating clinicians, educators Educating clinicians, educators

and studentsand students• Identifying Evidence-based data Identifying Evidence-based data

found in Hartford Institute for found in Hartford Institute for Geriatric NursingGeriatric Nursing

HIGNHIGNHartford Institute for Geriatric Hartford Institute for Geriatric

NursingNursing Mission – Shape the quality of health care of Mission – Shape the quality of health care of

older adults through excellence in nursing older adults through excellence in nursing practicepractice Started in 1996Started in 1996 Geriatric arm of the NYU College of NursingGeriatric arm of the NYU College of Nursing

Addresses 4 vital areas for changeAddresses 4 vital areas for change PRACTICEPRACTICE RESEARCHRESEARCH EDUCATIONEDUCATION ADVOCACY POLICYADVOCACY POLICY Hartford Institute Home Page

EDUCATIONEDUCATION

GNECGNEC

Geriatric Nursing Education ConsortiumGeriatric Nursing Education Consortium National initiative to enhance geriatric content in senior-National initiative to enhance geriatric content in senior-

level undergraduate courseslevel undergraduate courses Administered by AACN in collaboration with Hartford Administered by AACN in collaboration with Hartford

InstituteInstitute Power Point presentations on-linePower Point presentations on-line

Cultural Competence and Chronic Disease Management of Cultural Competence and Chronic Disease Management of Older AdultsOlder Adults

Spirituality and AgingSpirituality and Aging Sexuality in Older AdultsSexuality in Older AdultsSpirituality in Aging

Geropsych CompetencyGeropsych Competency

Geropsychiatric Nursing Collaborative that is Geropsychiatric Nursing Collaborative that is identifying and evaluating the quality and identifying and evaluating the quality and suitability of curricular and training materialssuitability of curricular and training materials

Portal of Geriatric Online Education-rate the Portal of Geriatric Online Education-rate the materials you perusematerials you peruseLog in to view articles, videosLog in to view articles, videosLog in to view modules that develop Log in to view modules that develop

knowledge of gero psych topicsknowledge of gero psych topicsPortal of Geriatric Online Education

Consult GeriRN.orgConsult GeriRN.org

Protocols and topicsProtocols and topicsEvidence-based protocols for Evidence-based protocols for

managing common geriatric managing common geriatric syndromes and conditionssyndromes and conditionsFrom Advance Directives to From Advance Directives to

Urinary IncontinenceUrinary IncontinenceConsultGeriRN

Consult Geri-RNConsult Geri-RN

““Try This” Assessment Tool Series with Try This” Assessment Tool Series with over 30 nationally recommended over 30 nationally recommended instruments for use with older adultsinstruments for use with older adults

TabsTabs““want to know more”want to know more”““topic resources”topic resources”Try This Assessment Tool Series

HIGN e-Learning CenterHIGN e-Learning Center

Continuing Education Continuing Education Portal Portal with free and paid courseswith free and paid coursesSign in to courses Sign in to courses Gerontological Certification Gerontological Certification

Review Course offered by ANCC – Review Course offered by ANCC – fundamental knowledge about fundamental knowledge about care of the older adult care of the older adult

eLearning/

HIGN e-Learning CenterHIGN e-Learning Center

Clinical Teaching Modules Clinical Teaching Modules assist nursing faculty to assist nursing faculty to

integrate care of older adults integrate care of older adults when teaching students in when teaching students in hospitalshospitals

Clinical Teaching Module

HIGN e-LearningHIGN e-Learning

Nursing Home Modules Nursing Home Modules Assist nursing faculty teaching in nursing Assist nursing faculty teaching in nursing

homeshomesHelp faculty select and use nursing Help faculty select and use nursing

homes for clinical placementhomes for clinical placementFocus on nursing homes involved in Focus on nursing homes involved in

resident-directed care and culture resident-directed care and culture changechange

Nursing Modules

Elder MistreatmentElder Mistreatment

eLearning course developedeLearning course developedConcepts Concepts ResearchResearchLegalLegalCare continuumCare continuumTheoriesTheoriesClinical DocumentationClinical DocumentationImpactImpactElder MistreatmentElder Mistreatment

HIGN e-Learning HIGN e-Learning

Web Based geriatric case studies Web Based geriatric case studies that assist faculty to introduce that assist faculty to introduce geriatric concepts into the geriatric concepts into the curriculumcurriculum

Advance Practice Case StudiesAdvance Practice Case Studies

PRACTICEPRACTICE

NICHENICHE

Practice supportivePractice supportiveNurses Improving Care for Health Nurses Improving Care for Health

System EldersSystem EldersGITT – Geriatric Interdisciplinary Team GITT – Geriatric Interdisciplinary Team

TrainingTrainingTraining resources in a GITT Kit to Training resources in a GITT Kit to

help health professionals develop help health professionals develop interdisciplinary teamsinterdisciplinary teams

GITTGITT

Practice SupportPractice Support

Consult Geri RN and Try This SeriesConsult Geri RN and Try This SeriesTab – “Need help stat”Tab – “Need help stat”Need help statNeed help stat

HI Hospital Competencies – HI Hospital Competencies – Competency: Care of Adult 65 years +Competency: Care of Adult 65 years +

Hospital CompetenciesHospital Competencies

IV - HIGN ForumIV - HIGN Forum

Web based “board” for Web based “board” for reading and posting messages reading and posting messages about geriatric topics.about geriatric topics.

HIGN ForumHIGN Forum

USING “TRY THS”- USING “TRY THS”- Medications Medications

Drugs and Older AdultsDrugs and Older Adults

Medication (prescription, over-the-counter and Medication (prescription, over-the-counter and herbal preparations) are widely used by older herbal preparations) are widely used by older adultsadults

At least one RX med used b 81% of community At least one RX med used b 81% of community dwelling adultsdwelling adults

Five or more Rx medications used by: Five or more Rx medications used by: 29% of overall survey population 65 and older29% of overall survey population 65 and older36% of people aged 75 – 85 year olds36% of people aged 75 – 85 year olds46% of RX users took at least one OTC 46% of RX users took at least one OTC

medicationmedication (Qato et al, 2008) (Qato et al, 2008)

MedicationMedication

20% of of community dwelling older adults 20% of of community dwelling older adults in the US are using one or more meds on in the US are using one or more meds on the Beer’s list of drugs that should be the Beer’s list of drugs that should be avoided (Zhan et al, 2001)avoided (Zhan et al, 2001)

All adults over 65 y.o. (12% of population)All adults over 65 y.o. (12% of population)79% take some type of medication79% take some type of medicationConsume 30 – 40% of all prescribed drugsConsume 30 – 40% of all prescribed drugsPurchase 40% of all OTC drugsPurchase 40% of all OTC drugs12% of elderly on 10 or more meds12% of elderly on 10 or more meds23%take 5 or more medications 23%take 5 or more medications

Adverse Drug Adverse Drug Reactions(ADR)Reactions(ADR)

# of drugs prescribed and prior history # of drugs prescribed and prior history of an ADR strongest predictors for of an ADR strongest predictors for subsequent ADR subsequent ADR

Risk doubled for those prescribed 5 -7 Risk doubled for those prescribed 5 -7 medicationsmedications

Fourfold for those receiving 8 or more Fourfold for those receiving 8 or more medicationsmedications(Onder et al, 2010)(Onder et al, 2010)

Post hospital Post hospital medication problemsmedication problems

One or more medication discrepancies One or more medication discrepancies were experienced in 14.1% of patients were experienced in 14.1% of patients post hospitalizationpost hospitalization

Medication discrepancies were associated Medication discrepancies were associated with total number of meds taken and with total number of meds taken and presence of CHFpresence of CHF

14.3% of patients with discrepancies 14.3% of patients with discrepancies rehospitalized in 30 days compared with rehospitalized in 30 days compared with 6.1% without discrepancies6.1% without discrepancies (Coleman et al, 2005) (Coleman et al, 2005)

Try This SeriesTry This Series

Try This SeriesTry This Series

Want To Know MoreWant To Know More

Assessment /Screening ToolsAssessment /Screening Tools

Beers Part I criteriaBeers Part I criteria

Beers Part II criteriaBeers Part II criteria

Article in AJNArticle in AJN

Video on Beers CriteriaVideo on Beers Criteria

Using Beers I CriteriaUsing Beers I Criteriasee handoutsee handout

Part I – Have student review patient RX and Part I – Have student review patient RX and OTC meds to identify inappropriate OTC meds to identify inappropriate medicationsmedicationsGreat exercise for beginning clinical studentsGreat exercise for beginning clinical studentsExample for action on a drug by studentsExample for action on a drug by studentsOTC Benadryl (diphenhydramine)OTC Benadryl (diphenhydramine)

May cause confusion and sedationMay cause confusion and sedationShould not be used as a hypnotic e.g. Should not be used as a hypnotic e.g.

Tylenol PM!!Tylenol PM!!Emergency allergic reaction use – smallest Emergency allergic reaction use – smallest

dose (25 mg), 1 – 2x dose (25 mg), 1 – 2x

Using Beers II CriteriaUsing Beers II Criteriasee handoutsee handout

Part II – Have student review patient meds to Part II – Have student review patient meds to identify inappropriate medications by patient identify inappropriate medications by patient diagnos(es)/condition(s)diagnos(es)/condition(s)Good exercise for higher level studentsGood exercise for higher level studentsUse disease or condition to identify Use disease or condition to identify

inappropriate medications by inappropriate medications by name name or by or by drug classdrug class

Have students group patient’s present list of Have students group patient’s present list of medications both RX and OTC by medications both RX and OTC by diagnoses/conditionsdiagnoses/conditions

Delirium: Most frequent Delirium: Most frequent complication of hospitalized complication of hospitalized

elderlyelderlyYet nurses fail to recognize it more than Yet nurses fail to recognize it more than

30 - 50% of the time30 - 50% of the time

In one study, nurses failed to recognize In one study, nurses failed to recognize delirium in 75% of cases delirium in 75% of cases (Rice et al., 2011) (Rice et al., 2011)

The fluctuating mental status is The fluctuating mental status is important to identify because it often important to identify because it often signals a need for additional treatmentsignals a need for additional treatment

Improving Recognition Improving Recognition through Education that:through Education that:

Differentiates between the 3 D’s Differentiates between the 3 D’s

Delirium, Dementia, DepressionDelirium, Dementia, Depression

Improves knowledge about atypical Improves knowledge about atypical presentations of delirium in the elderlypresentations of delirium in the elderly

Provides competency in mental status Provides competency in mental status assessment: the Mini-cogassessment: the Mini-cog

Recognizes acute confusion as a serious Recognizes acute confusion as a serious conditioncondition

Try This Series: Try This Series: DeliriumDelirium

Overview of the problem Overview of the problem ArticlesArticlesStrategies Strategies Assessment/Screening ToolsAssessment/Screening ToolsAssessment toolsAssessment toolsVideosVideos

CAM (Confusion Assessment Method)

CAM standardized assessment tool CAM standardized assessment tool (Long & Short Versions)(Long & Short Versions)

CAM ICU – non-verbal, ventilated CAM ICU – non-verbal, ventilated PatientPatient

Plus:Plus:Assessing and managing delirium Assessing and managing delirium

superimposed on dementiasuperimposed on dementiaAssessment of Executive FunctioningAssessment of Executive Functioning

Try This Series: (CAM)Try This Series: (CAM)

Identifies 4 features of the disorder that Identifies 4 features of the disorder that distinguish it from other forms of cognitive distinguish it from other forms of cognitive impairment. impairment.

1. status altered from 1. status altered from baseline (acute onset or baseline (acute onset or fluctuating)fluctuating)

2. inattention2. inattention

3. disorganized thinking3. disorganized thinking

4. altered level of consciousness4. altered level of consciousness

Takes 5 minutes and is easily incorporatedTakes 5 minutes and is easily incorporated

Back to Rice’s StudyBack to Rice’s Study

Thank You and Healthy Thank You and Healthy AgingAging

ReferencesReferences Coleman, E. A., Smith, J. D., Raha, D., Min, S. J. (2005). Coleman, E. A., Smith, J. D., Raha, D., Min, S. J. (2005).

Posthospital medication discrepancies: prevalence and Posthospital medication discrepancies: prevalence and contributing factors. contributing factors. Arch Intern Med Arch Intern Med 165:1842. 165:1842.

Fried, L. P., Fernucci, L., Darer, J., Williamson, J. D., Anderson, Fried, L. P., Fernucci, L., Darer, J., Williamson, J. D., Anderson, G. (2004). Untangling the concepts of disability, frailty, and G. (2004). Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. comorbidity: implications for improved targeting and care. Journal of Gerontology: Medical Sciences Journal of Gerontology: Medical Sciences 59(3) 255-263.59(3) 255-263.

Inouye, S. K., Studenski, S., Tinetti, M. E., Kuchel, G. A. Inouye, S. K., Studenski, S., Tinetti, M. E., Kuchel, G. A. (2007) Geriatric syndromes: clinical, research, and policy (2007) Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. implications of a core geriatric concept. Journal of the Journal of the American Geriatric Society American Geriatric Society 55:780-791.55:780-791.

Knight, E. L., Avorn, J. (2001). Quality indicators for Knight, E. L., Avorn, J. (2001). Quality indicators for appropriate medication use in vulnerable elders. appropriate medication use in vulnerable elders. Ann Intern Ann Intern MedMed 135:703. 135:703.

ReferencesReferences

Onder, G., Petrovoc, M., Tanglisura, B., et al. (2010). Onder, G., Petrovoc, M., Tanglisura, B., et al. (2010). Development and validation of a score to assess risk of Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 adverse drug reactions among in-hospital patients 65 years or older: the GerontoNet ADR risk score. years or older: the GerontoNet ADR risk score. Arch Arch Intern MedIntern Med 170:1142 170:1142

Qato, D. M., Alexander, G. C., Conti, R. M. et al. (2008). Qato, D. M., Alexander, G. C., Conti, R. M. et al. (2008). Use of prescription and over-the-counter medications and Use of prescription and over-the-counter medications and dietary supplements among older adults in the United dietary supplements among older adults in the United States. States. JAMAJAMA 300:2867. 300:2867.

Rice, K. L., Bennett, M., Gomez, M., Theall, K. P., Knight, Rice, K. L., Bennett, M., Gomez, M., Theall, K. P., Knight, M., Foreman, M. D. (2011). Nurses' recognition of delirium M., Foreman, M. D. (2011). Nurses' recognition of delirium in the hospitalized older adult. in the hospitalized older adult. ClinicalClinical Nurse Specialist Nurse Specialist 225(6), 299-311.5(6), 299-311.

Russo, A. L., Eaton, C. B., Wallace, R., Gold R., Curb, J. D., Russo, A. L., Eaton, C. B., Wallace, R., Gold R., Curb, J. D., Stefanick, F. L., Okene, J. K., Michael, Y. L. (2011). Combined Stefanick, F. L., Okene, J. K., Michael, Y. L. (2011). Combined impact of geriatric syndromes and cardiometabolic diseases impact of geriatric syndromes and cardiometabolic diseases on measures of function. on measures of function. J Gerontol A Biol Med Sci.J Gerontol A Biol Med Sci. 66A(3):349-35466A(3):349-354. .

Saka, B., Kaya, O., Ozturk, G. B., Erten, N., Karan, M. A. Saka, B., Kaya, O., Ozturk, G. B., Erten, N., Karan, M. A. (2010). Malnutrition in the elderly and its relationship with (2010). Malnutrition in the elderly and its relationship with other geriatric syndromes. other geriatric syndromes. Clinical Nutrition Clinical Nutrition 29(6): 745-8. 29(6): 745-8.

Zhan, C., Sangl, J., Bierman, AS, et al. (2001). Potentially Zhan, C., Sangl, J., Bierman, AS, et al. (2001). Potentially inappropriate medication use in the community-dwelling inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel elderly: findings from the 1996 Medical Expenditure Panel Survey. Survey. JAMAJAMA 286:282.3. 286:282.3.