SENIOR ER: THINK 3 D“Advancing Excellence in Geriatric Care”

November 3, 2012J. Michelle Moccia MSN, ANP-BC, CCRN

Program Director, Senior ER

St. Mary Mercy Hospital, Livonia Michiga

Thank you to D. Cannatti, S. Saltzman, Mekeia Foster, Meghan McGinn, Keyaria and Holly Beversdorf, Denise Scott, Sue Penoza for their contribution

COURSE OBJECTIVES

Outline the “Graying” demographics of the U.S. population and the impact on the ER

Identify key organizational factors and implementation strategies for program success

Discuss key components of geriatric nursing assessment using “THINK 3 D” ( a bundled care packet to help assess the older adult)

Adding life to years, not just more years to life

(Gerontological Society of America)

Gray Tsunami By 2030, nearly one in five Americans will

be over the age of 65. (38.7 million) By 2050, this will double to 88.5 million Next 19 years, every single day 10,000

baby boomers reach the age of 65 Centenarians is the fastest age group Every hour 10 more Michiganders turn 65 By 2035, one in 4 Michiganders will be 65

and older

Population age 65 and over in US

This chart for Indicator 1 - Number of Older Americans shows the large growth of the population 65 and older from 1900 to 2008 and the even greater projected growth from 2008 to 2050. It also shows the growing numbers of persons 85 and older and their large projected growth to 2050.

ENA Position Statement (2003)

ENA recognizes that optimal care of the older adult is best achieved by:

Members of the team collaborate to assess and treat

ED nurses must be knowledgeable in physiologic, psychological, sociologic, and economic changes in older adult and how these changes impact assessment, interventions, teaching, discharge decisions, and community referrals

ENA position statement

Geriatric education needs to be included in basic and continuing education

Recognize the patient, the spouse, or family members may need assistance – the need for collaboration with other HCPs, organizations, and groups may be necessary to promote a safe and healthy environment

Medication problems may go unrecognized & screening for elder abuse and reporting must be carried out

ER Nurses on the front line

Front door of the hospital and to the community Encounter a variety of health issues from non-

urgent, urgent to emergent Ranging from the frailest and functionally

impaired to the healthiest and physically active The patients worldview can only be discovered

during conversation…sometimes awakened with reconnecting to their spirit

Impact of Boarding & Crowding

Presentation more complex Higher acuity of care By 2013, number of visits could double

reaching 11.7 million annually Lack of PCP, business hours, homelessness,

psychiatric disorders, substance abuse – ED open 24/7

ED visits ages 65 and 74 have increased by 34% between 1993 and 2003

CONTROLLED CHAOS?

Increased length of stay due to extensive evaluations

Delayed time consuming care due to older adult physiologic needs

Vital information missed due to poor handoff or unintentionally ignored

Special needs not addressed – baseline function, depression, dementia, delirium

Risk of poor outcome, readmissions

Risk Factors Older individuals are discharged are at greater risk for

complications. Independent functioning may be threatened.

Older adults that were discharged from an E.D. experienced a revisit, hospitalization or death within 3 months in 27% of the cases (Hwang U & Morrison RS, 2007).

In one month, office of Inspector General found 14% of Medicare recipients experience and adverse event; 44% were attributed to inadequate monitoring or patient; 60-70% communication errors

One needs to examine one’s own values, attitude, perception and beliefs about caring for an older adult

Aging is not a disease Aging is a process Interaction between environmental (extrinsic)

and genetic (intrinsic) factors Older Americans living longer and healthier

(Key Indicators of Well Being)

Physicians, Nurses, and Researchers have concentrated on interventions and evidence-based protocols to improve the health and living conditions of older adults

“We see the world not as it is but as we are” (Covey, 1990)

SMML Market Share by Age Cohort: FY2009

Source: MIDB

SMML’s market share in the 65+ age group is nearly twice as high as its market share in all other adult age groups

SMML Market Share by Age Cohort

0%

5%

10%

15%

20%

25%

Market Share 3.86% 11.15% 11.84% 11.37% 21.16%

<18 18-24 25-44 45-64 65+

FYI: Every hour 10 more Michiganders turn 65

Growth of SMML 65+ age in 2009

H osp ita l M arket S h are o f P atien ts 65+

S ource: ID S

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

F Y 05 17.80% 12.32% 11.15% 9.06% 7.54% 9.08% 5.75% 5.39% 7.37% 3.78% 10.75%

F Y 06 18.54% 12.77% 10.41% 8.30% 8.13% 8.81% 5.97% 5.14% 7.07% 4.24% 10.63%

F Y 07 19.84% 12.98% 9.25% 8.75% 8.07% 8.24% 5.88% 5.32% 7.12% 4.06% 10.50%

F Y 08 20.78% 13.04% 9.49% 8.37% 7.69% 7.61% 5.87% 5.31% 7.27% 4.20% 10.36%

F Y 09 21.16% 12.21% 8.98% 8.29% 7.73% 7.53% 5.70% 5.14% 4.84% 4.13% 14.30%

S M M L B ots ford G arden C ity S JM HS -A A O ak wood A nnapolisHenry F ord

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ROP rovidenc e U of M A ll O ther

Focusing on Improving Services to Seniors is Critical

SENIOR ER – The Trinity Health Perspective

•Senior population is growing (Baby boomers – one turns 65 at a rate of 8,000 per day)

•Care needs are higher than those of younger people

•They drive most of the cost

•Their families are looking for safe alternatives for them

•They will be the biggest focus of CMS as it changes payment systems

•Providers that are sensitive to the needs of seniors will grow

There is opportunity to improve the outcomes for seniors

• Social services and support

• Optimizing health, wellness and fitness

• Chronic disease management

• Patient-centered medical homes

• PACE programs

• Palliative care

“Senior ER not invented here but still a good idea” (Dave Spivey, CEO SMML)

Build on success of Holy Cross Hospital, Silver Springs, Maryland

St. Mary Mercy Hospital in Livonia – First Senior ER in the State of Michigan July 14,

2010 Quickly followed by SJMO, SJMAA, Port Huron,

Saline, Livingston, Chelsea, Brighton Focus on Safety, Patient loyalty, Growth, Financial,

and Quality

Current ER Flow “Controlled chaos” is a term frequently used by

the Emergency HCP describe ER flow. Fast paced crowded facility: risk for

mismanagement and/or delayed cared. Vital information missed: HCP may fail to

identify any “special needs” i.e. geriatric syndromes; baseline ADLs and unintentionally ignore signs of depression, dementia and delirium.

Current Patient safety and concerns

Cognitive impairment can complicate scenario if they are unable to describe their symptoms or self report their pain.

Absence of advocate adds to their vulnerability. Poor “hand-off” communication in both directions The Emergency Nurse’s Association (ENA) created a

Safer Handoff for the Older Adult (www.ena.org) SMML has created a STARForum group to work with

nursing homes, assisted livings, independent livings, group homes etc. to create a seamless hand-off

(Safe Transition of All Residents For U & Me)

How aging boomers will transform Michigan | Detroit Free Press, October 3, 2010A New Kind of ER

Glaring lights, crowds, the clacking of medical carts and

wheelchairs and beds -- "a loud and chaotic ER is not a

good place for an older person to be," said Michael

Calice, medical director at St. Mary Mercy Livonia, part

of the St. Joseph Mercy Health System. …

Need for enhanced Emergency Area for Seniors (environment)Environment Changes Improve patient comfort – pressure reducing

mattresses, reclining chairs; removal of noise distracters

Reduce risks of fall (flooring, lighting, assistant devices, colors, hand rails)

Reduce risk of delirium (visual aids, hearing device)

Need for Cultural changes

Need to supplement education The ED physician and nurse must be well versed in

the age-related physiologic changes, associated poor physiologic reserves and the high prevalence of comorbidities.

Education modules (GENE and COMET) introduced to provide ED HCP with knowledge to care for the senior population.

Ageism: ‘the process of systemic stereotyping and discrimination against people because they are old”

– Robert Butler, 1969 Dr. Bill Thomas sessions

Senior ER (more than a space) Screenings to identify patients at risk for safety and

poor outcomes that are not often captured with a medical screening

Identify a decline in functioning may enable health care providers to provide a specific plan of care and thus improve the outcomes in the elderly.

Evaluating multiple domains of behavior and function will assist in assurance of positive outcomes.

S.E.N.I.O.R. FYI

Senior ER Core Team used the word SENIOR to define the vision of the First Senior ER in the State of Michigan

Specialized Emergency Nursing

Improving One’s Resilience.Inpatient Team expanded and used the word

SENIOR to define their vision?Sensitivity to Elders Needs

Improving Opportunities for Resilience

T.H.I.N.K . 3 D Triage risk screening & Treatment Here for fall or at risk for falls? Inquire about medication, pain, alcohol use,

advanced directive Nutrition assessment; normal VS may not be

so normal Katz functional assessment “3 D” Dementia, Depression, Delirium(Thank you to Keyaria and Holly Beversdorf Nursing 4040 WSU)

Treatment more complex in older adult than younger adults

Higher risk of complications from hospitalization

Loss of physiologic reserves: impaired renal flow, impaired hepatic flow, and poor homeostatic mechanisms

Loss of functional ability that may be caused by disease or hospitalization.

Cognitive impairment, hearing and visual impairment may affect stay in the ED

Physiologic changes of Aging: Cardiovascular

Increased valve stiffness Heart valves thicken Less able to respond to

volume changes SA node thickening, fewer

pacer cells Barioreceptors less

sensitive to BP changes Decreased CV reserveEmer Jour of Nursing

Hypertension Murmurs Reduced SV & CO

Slow irregular HR Increased risk for

orthostasis Heart failure

Physiologic changes: Neurologic

Blood-brain barrier more permeable

Fewer neurons and nerve fibers

Slower reaction time; decreased proprioception in lower limbs

Decrease in neurotransmitter systems

Increased sensitivity to meds and toxins

Pain sensation changes and less able to localize pain

Risk of falls

Processing is slower and possible memory changes

Physiologic changes: Renal Decrease in GFR Decrease in renal blood

flow Decrease in creatinine

clearance Decrease in ability to

concentrate/dilute urine Decrease in bladder

capacity and increase in residual bladder volumes

Drug doses will need to be adjusted

Elimination of toxins is affected

Dehydration and impaired ability to respond to volume changes

Urinary frequency, urgency, or UTI

Homeostasis – regulation of body temperature, blood pH, fluid balance and thirst

Loss of physiologic and functional reserves

Thermoregulatory response impaired

Shivering less intense, sweating is reduced

Renal changes (GFR, blood flow, creatinine clearance)

Body responds in more exaggerated manner to homeostatic challenges

risk of hypothermia or hyperthermia

Delayed speed of return to normal pH by 80%

Homeostasis continued Respiratory changes: lung

elasticity & weakening of chest wall muscles

Sensitivity of the brain is heightened by diminished capacity for homeostasis

Alterations in tissue sensitivity to hormones (insulin response and glucose tolerance diminished; sensitivity to ADH

Less able to hyperventilate in response to metabolic acidosis, which leads to pH

LOC changes (confusion, lethargy, agitation) often a sentinel sign of illness

Changes in Blood Sugar and alterations in electrolyte levels

THINK 3 D

Triage Risk Screening Tool (TRST): Cleveland project

developed to test the Systematic Intervention for a Geriatric Network of Evaluation and Treatment (SIGNET)

Improves case finding: cognitive impairment, environment (lives alone, support person, lives in senior apartment, assisted, skilled. Fall history; ED or hospital history; any special needs recognized i.e. caregiver strain; abuse or neglect signs; nutrition; frailty

The presence of two or more risk factors designates the older person as being “at high risk”.

Advantages in screening the older adult emergency patient

Identification of a decline in functioning may enable ER providers to provide a specific plan of care

Greater diagnostic accuracy Decreased mortality Decreased LOS in hospitals Prevention of injuries (slip and falls)

Screening is important

ED point of care for patient: admitted, prehospital entry, or point of disposition to an extended or rehab care facility

Special services may be required to support older adult through continuum of care i.e. housing, transportation, nutrition, durable medical equipment, counseling, caregiver support

THINK 3 D: Here for a Fall Leading cause of injury and injury related mortality Leading cause of head injuries Factor in over 90% fractures of distal forearm,

proximal humerus, and hip Nonfatal injuries associated with loss of

independence Not a normal part of aging More likely to be problematic As many as 50% who are hospitalized following a

fall die within one year Highest risk especially those with physical and or

cognitive impairment

Here for fall? Extrinsic factors Gait and balance disorders Cluttered environment, Unfamiliar environment Stairs Throw rugs Unsuitable footwear Poor lighting, poor color distinction Restraints, side rails

Here for fall? Intrinsic factors

Cognitive impairment Polypharmacy – four or more medications Sedatives, antihypertensive and psychotropic

medications Alcohol Impaired mobility Fall history Sensory defects (hearing and vision) Frailty Postural hypotension

ESI Severity Index 1, 2, or 3? 5 Level Triage System (2003 ACEP & ENA) Witnessed? Loss of consciousness? Sitting or standing? Carpet or hard floor? Symptoms prior to fall? On Anticoagulant? (Coumadin, Pradaxa,

Xarelto, including aspirin)

HEAD INJURY & FRACTURES R/O Subdural hematoma Brain loses volume with age, increased dural vein fragility Humerus Hip Femur Rib – high risk – pain, pneumonia due to inadequate

respiratory effort, and risk for VTE due to lack of movement

Evaluation Orthostatic BP Arrhythmias Gait and balancePrior to Discharge: Timed Get Up and Go Test Tinetti Balance and Gait Evaluation www.ConsultGeriRN.org

Here for abuse, neglect?

2.1 million older Americans are victims of abuse, only 10% is reported

Elderly females are the most frequently abused

90% of the abusers are family members People over the age of 80 are abused 2 to 3

times more then any other age group Victims are often abused in several form

Types of Abuse Physical Emotional/Psychological Abuse Sexual Abuse Financial Abuse Neglect of ADLs, confinement, abandonment Coercion abuse, verbal abuse Exploitation

“Elder abuse is defined as the action or the omission of actions that result in harm or threatened harm to the health or welfare

of the older adult.” American Medical Association

Characteristics of abuse, neglect

Extreme mood changes-withdraw, agitation, fearfulnessand depression

Health Care Shopping Series of missed appointments Unexplained Injuries Bruises in different stages of healing Poor Personal Hygiene Sexually transmitted disease Insomnia or excessive sleeping Weight gain or weight loss Documentation is key –drawings, descriptions,

photographs that include measurement of injury

THINK 3 D – Inquire about Medication History

What medications are you currently taking?

OTC? Vitamins, herbal, home remedies? Topicals, eye drops, patches? Med reminders i.e. mealtime, pill box? How do you know when you miss a med?

Inquire about Med History

Consider new symptoms as a possible drug to drug interaction.

5 medications = 70% chance of drug interactions 7 medications = 100% chance of drug interactionsDosing guidelines adjusted to creatinine clearance?Do they see another PCP?Any new med started recently?

Beers Criteria created by Dr. Mark H. Beers, Geriatrician. (1991)Updated 2012 to assist HCP improving medication safety in older adultwww.americangeriatrics.org

THINK 3 D - Inquire about Advance Directive http://www.nhdd.org/

Imagine you cannot speak

Speak up and increase awarenessFacilitate earlier treatment decisionsIncrease communication and

understanding of patients prognosisHelp reduce the use of resources and

time spent by patients in undesirable states before death

Referral to palliative care or hospice

End-of-Life Decisions

Aim for a “good death” defined by the Institute of Medicine

“one that is free from avoidable distress and suffering for pts, families, caregivers; in accord with pts and families’ wishes; and reasonably consistent with clinical cultural and ethical standards”(Reisberg functional Assessment Staging; scale of 1-7)

http://geriatrics.uthscsa.edu/tools/FAST.pdf

THINK 3 D - Inquire about Alcohol Use

Heavy drinking is reported by 3-9% of people over 65

Alcohol abuse or dependence is reported by 2-4%

1/3 of the elderly who abuse or have alcohol dependency started drinking after age 50

14% present to an ER with new diagnosableAlcoholismSerious cause of mortality and morbidity

Signs and Symptoms of Alcohol Flushing Palmar eythema Sarcopenia Spider angiomas Altered level of consciousness Changes in mental status or mood Poor coordination Nystagmus Elevation of liver enzymes Increased MCV in presence of normal hemoglobin

Screening, Referral and Brief Intervention (SBIRT)

Older adult age 65 and > More than seven drinks in a week 3 drinks on any occasion

The American College of Surgeons Community on Trauma (ASCOT) mandate Level 1 and Level II Trauma centers identify patients who are problem drinkers – screening, brief intervention, and referral (SBIRT)

THINK 3 D - Inquire about pain

The elderly under-report pain because it is thought to be a “normal” part of aging.

The elderly may suffer because the cost of pain medications is too high.

Those individuals with cognitive impairments may not be able to verbalize that they are in pain.

The Visual Analogue Scale (VAS), the Numeric Rating Scale (NRS) and the Faces Scale have been used by nursing home patients

Pain scale

The FACES or the Visual Analog or the Numerical Rating Scale may be used even in the situation of mild dementia.

Pain ScalesVerbal /Visual-Pain Distress IntensityScaleNumeric 0-10Pain-AD

(Combination of numeric,Verbal, and Iowa PainThermometer)

PAIN FOR ADVANCED DEMENTIA

Cognitive impairment signs of pain

Look for non-verbal signs: subtle signs such as wincing, moaning or guarding.

A decrease in appetite and activity may be signs of pain.

An inability to want to move may be related to pain.

(Ebersole, Hess, 1998)

THINK 3 D – Nutrition & Normal VS

Normal VS may not be so normal after all

Determine baseline parameter Normal BP in normal hypertensive

patient maybe a signal of volume loss Baseline lactate and base deficit levels Base deficit measure good predictor of

life threatening injury

Nutrition

Unintentional weight change > 10lbs within past 3 months? A reduction in food intake or hydration: patient reported eating or drinking less than half of the usual intake for the past 7 days? Coughing or difficulty with swallowing when drinking fluids ? www.mypyramid.gov

THINK 3 D – What Kan they do?

KATZ assessmentFUNCTION FOCUSED CARE o Inactivity rapidly contributes to muscle shorteningo Bed rest diminishes aerobic activityo Loss of muscle strength leads to falls 40% of ER patients have functional decline

within 30 days of ER discharge!!!* Red Flag: A decrease in function maybe the

indicator the patient is ill

GOAL: Keep people functioning – prevent the revolving door; keep out of skilled facility

KATZ Score

“Normal aging changes and health problems frequently show themselves as declines in the functional status of older adults” (Wallace & Shelkey, Hartford Institute of Geriatric Nursing, 2007).

Why perform the Katz? The Katz Scale is utilized to determine if the

patient can function independently, may require additional help to varying degrees or if the patient may need total assistance.

Decline in functional status is often the first clue to health problems. The Katz scale measures the degree of function.

A score of 6 indicates full function. A score of 4 indicates moderate impairment and a score of 2 or less is severe functional impairment.

THINK 3 D Geriatric Depression Screen

Depression is common late in life, affecting nearly 5 million of the 31 million Americans aged 65 and older (Blazer, 2002).

Depression may be reversed if identified early enough; left untreated, depression may result in physical, social and cognitive impairment as well as cause delayed recovery from illness and may be severe enough to cause suicide (Kurlowicz & Greenburg, 2007).

DEPRESSIVE SYMPTOMS

Depressive Symptoms – shows a modest increase in clinically relevant depressive symptoms for older age categories. Also shows lower levels for men except at the 85 and over group where the levels are similar.

Geriatric Depression Screen

The Geriatric Depression Screen (GDS) consists of 15 questions. Answers in bold font may indicate depression.

3 D Dementia (Mini-Cog)

Cognitive impairment increases with advancing age and increasing age is the greatest risk for Alzheimer’s disease. One in eight >65 (13%)

Early identification of the disease may enable health care providers to start treatment in the early phase of the disease which usually results in a better response.(Cholinesterase inhibitors)

The Mini-Cog consists of a three item recall in combination with a clock drawing exercise. www.alz.org

The Mini-Cog Screening The Mini-Cog Screening ToolTool

Takes 3 minutes to complete

Performs as well as or better than the Mini-Mental State exam that takes much longer to administer

Results not affected by culture, ethnicity or education

Mini-Cog Screening

Performing the screen: tell the patient to listen carefully and remember 3 unrelated words (I.e. cup, train, blue). Have the patient repeat the words to you prior to performing the CDT

Mini-Cog Screening

Instruct the patient to draw the face of a clock, placing the numbers at correct locations. Then tell the patient to draw the hands of the clock to represent 11:10

Scoring of Mini-CogScoring of Mini-Cog

Unable to recall all 3 items: scores as demented

Successful recall of all 3 items: non dementia

Those who recall 1 or 2 items are classified based on the results clock-drawing test

3D Delirium

Delirium occurs frequently (25-60%) in hospitalized adults (Waszynski, 2007). Delirium is often unrecognized by health care professionals and needs constant evaluation and re-evaluation.

Acute, reversible and fluctuating central nervous system dysfunction with an organic cause.

Lasts from a few hours to a few months if left untreated

Types of Delirium

The distinction between delirium and other disorders is often unclear

Can resemble dementia (major risk factor)or depression

Hyperactive form (Positive symptoms): Psychotic episode, agitated, high anxiety, aggressive or combative

Hypoactive form (Negative symptoms): extreme lethargy, inability to focus attention or follow commands (Higher morbidity and mortality)

Mixed: Patient exhibits characteristics of both Hyper and Hypoactive

Risk Factors

Predisposing Factors Advanced Age Dementia or family history Depression Co-Morbidities Severity of illness Hearing/visual impairment Smoking, ETOH, drug use Surgery Male gender

Precipitating Factors Medications (Sedatives,

antipsychotics, analgesics) Hypoxia Room changes Restraints Availability of clock Pain Electrolyte imbalance and

dehydration Immobility Infection Fractures

Delirium Pneumonic

Drug Use, dehydration Electrolyte Imbalance Lack of Drugs (withdrawal or PRN medications) Infection Reduced Sensory in patient Intra Cranial Events Urinary Incontinence/Fecal Impaction Myocardial Infarction, multiple comorbidities

Delirium Assessment“CAM” The Confusion Assessment Method

(CAM) is a tool designed for non-psychiatric trained individuals to recognize delirium quickly and accurately.

The test only identifies if delirium may be present and not the degree of delirium.

Confusion Assessment Method (CAM)

Four Features of Delirium

Feature 1 and Feature 2 need to be present plus Feature 3 or Feature 4

Parameter Depression Delirium Dementia

Onset Weeks Short, rapid, abrupt, hours, days Months to years

Duration 3-6 months, may be chronic Days to 3 weeks 5-15 years

Initial Presentation

Flat affect, hypochondrial, focus

on symptoms, apathy, little effort

to perform

Disorientation, clouded,

consciousness, fluctuation in

moods, disordered thoughts

Vague symptoms, loss of

intellect, easily distracted, great

effort to perform tasks

Recent MemoryNormal or recent/past both

alteredPartial impaired or remains intact Impaired

IntellectSlower, may be unwilling to

respondImpaired Impaired concrete thinking

JudgmentPoor judgment, many “I don’t

know answers”

Impaired, difficulty separating

facts, hallucinations

Impaired, had inappropriate

decisions, denies problem

PatternWorse in the morning, sleep

impaired

Day drowsiness, nighttime

hallucinations, insomnia,

nightmares

Worse in the evening,

sundowning, reverse sleep cycle

Attention/AffectWithdrawn, apathy, hopeless,

distress

Labile, fear/panic, periods of

lucidity

Easily distracted, labile,

inappropriate, anxiety,

depression, suspicious

Orientation IntactDisoriented but not to person.

Periods of lucidityDisoriented

Level of Consciousness Intact Disturbed Intact

Psychiatric symptoms Delusions Delusions Hallucinations

Geriatric Bundle: Differentiating Depression, Delirium and DementiaGeriatric Bundle: Differentiating Depression, Delirium and Dementia

“CARING FOR YOUR FUTURE SELF” Dr. Daniel Keys (EPMG)

“ We should all be concerned about the future because we have to spend the rest of our lives there” C.F. Kettering

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