Geriatric Syndromes & Assessment

The 3 Methods of Collecting Assessment Data

(1) Self-report (2) Report by proxy (3) Observation

Functional Assessments

Tasks needed to perform self-care (ADLs) - Katz - Barthel Index - FIM Tasks needed for independent living (IADLs) - Lawton & Brody Functional performance tests: balance, walking speed, chair-stand Blessed Dementia Score - Incorporates ADLs, IADLs, memory, recall, outdoor orienting

Geriatric Assessment (purpose)

Useful in planning and guiding care Leads to improved outcomes: - Decreased length of stay - Decreased iatrogenesis, complications - Decreased nursing home admissions and cost of care - Increased overall survival - Improved quality of life (QOL)

Blessed Dementia Scale

- Used to assess both functional status and cognitive abilities - Incorporates aspects of ADLs, IADLs, memory, recalling events, and finding one's way (orienting) outdoors. - A 22-item test, scored 0-27, a higher score indicating greater degree of dementia.

Clock Drawing Test

- Used to identify cognitive impairment & measure severity but does not establish criteria for dementia. - Should not be used with pts who have limitations in use of their dominant hand. - Patient is asked to draw, on a blank sheet of paper, the face of a clock and a specific time (e.g., 2:40). - Scoring based on both the position of the numbers and the position of the hands on the clock.

Aspects of Geriatric Assessment

- Very Complex - Requires specialized skills - Culturally appropriate approaches - Types of assessments: problem-oriented vs. comprehensive (best completed by inter-disciplinary team) - May be setting-specific: RAI, OASIS

Barthel Index

- Measures the physical assistance required when a person cannot carry out ADLs. - Ranks functional status as either independent or dependent - Provides further classification of independent into "intact" or "limited" and dependent into "needing a helper" or "unable to do the activity at all." - Especially useful in documenting improvement in a patient's ability, especially those who have suffered strokes. - Commonly used in rehabilitation settings.

Cascade Iatrogenesis (definition)

Spiraling, unintended decline of health, caused by medical treatments and interventions

Geriatric Depression Scale (GDS)

- Most commonly used mood measure in middle-aged and older adults. - Determines depression because it de-emphasizes physical complaints, sex drive, and appetite, which are most affected by medications.

Geriatric Syndrome (causes)

- Multiple medications, reactions - Multiple diseases - Environmental conditions - Age-related changes

Geriatric Syndromes (the "giants")

- Pressure ulcers - Cognitive changes/confusion - Gait instability - Falls - Urinary incontinence - Sleep disturbances - Pain - Malnutrition

Confusion - Nursing Interventions

- Prevention - Early detection

Incontinence - Nursing Interventions

- Provide a regular toileting schedule - Prevent moisture

Functional Independence Measure (FIM)

- Provides a more detailed picture of a pt's functional dependence. - Measures ADLs, mobility, cognition, and social functioning. - Requires more time to administer than the Barthel Index. - Completed through the joint efforts of an interdisciplinary team and used for planning and evaluation of progress, most often in the acute rehabilitation setting.

Benefits of Geriatric Assessment Tools

- Standardized collection of data - Increased reliability of data - Availability of tools from literature - Modifiable for setting - Addresses topics frequently overlooked by HCPS: sexual dysfunction, depression, incontinence, alcoholism, muscular stiffness, hearing loss, memory loss, confusion

Older Americans Resources & Services (OARS)

- The original integrated assessment that evaluates ability, disability, and the capacity level at which the person functions. - Comprised of 5 sub-scales that may be used independently: (1) social resources, (2) economic resources, (3) physical health, (4) mental health, and (5) the ability to perform ADLs. - Capacity in each sub-scale is ranked from 1 (excellent) to 6 (completely impaired). A cumulative impairment score (CIS) established: 6 (most capable) to 30 (total disability) - Establishes the degree of need and resources required for ADLs and QOL - Comprehensive and thus requires a collaborative and interdisciplinary approach & training.

Concept of Frailty

*An age-associated medical syndrome* comprised of chronic fatigue, generalized weakness, weight loss, loss of muscle mass, low exercise tolerance, and/or exhaustion. *Nursing implications* include that patients are at a higher risk for falls, disability, acute hospitalization, worse outcomes, and mortality.

Mini-Cog

- *The evidence-based tool now recommended to establish cognitive status.* - Combines the ST memory recall of the MMSE with the test of executive function of the Clock Drawing Test. - Highly sensitive to diagnosing dementia and as a predictor of delirium in older hospitalized adults.

Mini Mental State Examination (MMSE)

- A 30-point tool used to screen for cognitive difficulties. - Often used in the determination of a diagnosis of dementia or delirium. - Tests orientation, ST memory and attention, calculation ability, language, and construction. - Cannot be given to pts who cannot see or write or who are not proficient in English. - A score below 24 suggests *potential* dementia

Global Deterioration Scale

- A classic measure of levels of cognitive changes as one passes through the process of dementia. - Used to develop interventions to help the patient optimize his/her health and anticipate future needs.

Katz Index

- A framework for measuring ADLs, useful because it creates a common language about patient function for all caregivers involved in planning overall care. - There are several versions each assigning points to score abilities as independent, assistive, dependent, or unable to perform. - A higher score indicates independence, and a lower score indicates dependence. - Equal weight is placed on all activities.

Sleep efficiency (definition)

- A ratio of the amount of time spent sleeping compared to the amount of time spent in bed (time sleeping / time in bed) - Sleep efficiency decreases with age - In older adults, sleep efficiency drops below 0.8 to as low as 0.4 and people spend less time in later stages of sleep

Epworth Sleepiness Scale (ESS)

- A scale intended to measure *daytime sleepiness*, by administration of short questionnaire - Subjects rate their probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations

Pittsburg Sleep Quality Index (PSQI)

- A self-rated questionnaire that assesses sleep quality and disturbances over 1-month - Seven "component" scores generated: (1) subjective sleep quality (2) sleep latency (3) sleep duration (4) habitual sleep efficiency (5) sleep disturbances (6) use of sleeping medication, and (7) daytime dysfunction - Sum the seven components yields one global score

Components Affecting Geriatric Syndrome(s)

- Age-related changes - Diseases - Co-morbidity/polypharmacy - Frailty - Cognitive impairment - Sensory impairment - Psycho-social factors

Evidence of Falls - Nursing Interventions

- Assess for risk & monitor patient - Avoid clutter in room - Ensure call lights are accessible and visible - Avoid restraints - Teach safe transfer techniques & fall prevention to pts + family - Use/provide assistive devices - Review medications that may contribute to falls - Post-fall assessment to determine whether pt is injured as well as contributing factors *One study found falls were reduced 20% by reviewing toileting protocols, use of non-skid bedside mats, and identifying pts at risk*

Pain - Nursing Interventions

- Assessing, documenting, & advocating for pain relief - Administering analgesics, NSAIDs, opioids - Preventing "breakthrough" pain - Assessing for constipation - Providing comfort & reassurance - Establishing rapport, being present with pt - Providing education on the meaning of pain, approach for treatment - Offer psychological/spiritual support - Alternative therapy: relaxation, massage, reflexology, etc. - Monitor for effects on sleeping, eating, ADLs

Sleep Disturbance - Nursing Interventions

- Avoid chemicals, especially ETOH & caffeine before bed - Avoid heavy meals & fluids before bed (nocturia is common) - Avoid activity/excitement after 17:00 - Encourage a regular schedule - going to bed and waking at the same time everyday - Alternative therapies - guided imagery aromatherapy, relaxation

Outcomes & Assessment Information Set (OASIS & OASIS-C)

- Created and mandated for use by certified home care agencies. - Provides the format for documentation of a comprehensive assessment, which forms the basis for planning care and measuring patient outcomes-based quality improvement. - The "-C" version is used to improve the quality of care and communication about the individual and serve as a guide for reimbursement.

Problems with Eating & Feeding - Nursing Interventions

- Identify food preferences - Position OOB in chair, upright - Make meal time as normal as possible, avoid interruptions - Encourage significant others to be there when eating (socialization) - Assess ability to use utensils & offer assistance when needed - Determine whether OT is needed - Maintain exercise to increase mobility - Make dentures, glasses are available when eating

Mental Status / Cognitive Ability Assessments

- MMSE - Clock drawing - Mini-Cog - GDS - CAM - CAM-ICU

Skin Breakdown - Nursing Interventions

- Maintain skin integrity - Position and turn regularly

Lawton & Brody

- Measures IADLs, which are more complex than ADLs and require greater physical and cognitive functioning. - Uses self-report, proxy, and observation methods of data collection with three levels of functioning - "independent," "assisted," and "unable to perform." - Same pros and cons of functional tests of ADLs

FANCAPES

A comprehensive assessment model for the frail elderly, emphasizing basic needs that form the basic levels of Maslow's Hierarchy: F - Fluids A - Aeration N - Nutrition C - Communication A - Activity P - Pain E - Elimination S - Socialization & social skills

Geriatric Syndrome (definition)

A symptom, or a complex of symptoms, resulting from multiple diseases and risk factors

Phenotype of Frailty

Clinically defined by the presence of 3 or more of the following criteria: - weight loss - weakness - fatigue - slowed walking - low activity tolerance

Integrated Assessments

Comprehensive assessment tools used rather than a collection of separate tools and assessments Serve as a resource for a detailed plan of care and include the following: - Resident Assessment Index (RAI) - Older Americans Resources & Services (OARS) - Fulmer "SPICES" - Outcomes & Assessment Information Set (OASIS & OASIS-C)

Pain (leading symptom in hospitals)

Contributing factors: - co-morbidities, DM, post CVA, PHN - medical procedures & nursing tasks Implications: - depression, poor sleep, *delerium* - decreased mobility and function - decreased immunity Assessment tools: - faces pain scale (revised) - for cognitively impaired - numeric rating scale - verbal descriptor scale - non-verbal signs - for sleeping or severely cognitively impaired

SPICE*S* - Skin Breakdown

Contributing factors: - neuropathy, inability to sense pain - immobility, bed rest - shearing, friction, moisture - poor nutrition Assessment tools: - Head-to-Toe assessment on admission, frequently - Predicting Pressure Ulcer Risk - Braden Scale: (1) sensory preception, (2) moisture, (3) activity, (4) mobility, (5) nutrition, (6) fiction/shearing

SPIC*E*S - Evidence of Falls

Contributing factors: - extrinsic/hospital - inability to walk from bed to bath, clutter - intrinsic - confusion, sensory deficits Implications: - injury & immobility - fear of falling & loss of independence Assessment tools: - Morse Fall Scale - Hendrich II Model - Hopkins Fall Risk Assessment

Resident Assessment Instrument (RAI)

Created and mandated for use in all LTC facilities receiving compensation from Mcr/Mcd. It is comprised of 3 parts: (1) a 450-item *Minimum Data Set* (MDS), which provides a health/function profile of the patient during their stay; (2) the *Resident Assessment Protocols* (RAPs), which provide a framework for organizing and directing care for the patient; and (3) associated *Resource Utilization Groups* (RUGs), which is used to determine the reimbursement rate - Dynamic and solution-oriented; used to gather definitive information on the resident's functioning.

"DIAPER" incontinence assessment

D - Delerium I - Infection A - Atrophic vaginitis (urethritis) P - Pharmacology & psychosocial factors E - Endocrine R - Restricted mobility

Iatrogenic Complications (definition)

Illness caused by medical examination or treatment, common in hospitalized older adults with complex illnesses and longer lengths of stay

SP*I*CES - Incontinence (bladder)

Problem: cannot control urination Contributing factors: - illness - medication Implications: - longer hospitalization and increased cost ($$$) - poor outcomes - decreased sense of well-being Assessment tools: - "DIAPER" - medical hx, medications, past surgeries, GU/GYN hx

*S*PICES - Sleep Disturbance

Problem: decreased sleep efficiency Contributing factors: - co-morbidities & sleep disorders - medications - environment & lifestyle Implications: prolonged illness Assessment tools: - sleep diary - Epworth Sleepiness Scale - Pittsburgh Sleep Quality Index

S*P*ICES - Problems with Eating and Feeding

Problem: inadequate feeding Contributing factors: - inability to feed self - bedside table out of reach, poor positioning - food gets cold - IV lines/equipment in the way - poor appetite, nausea r/t medications, worry/anxiety, pain Implications: malnutrition, prolonged illness Assessment tools: *The Mini Nutritional Assessment*

SPI*C*ES - Confusion (delirium)

Problem: patient is confused, not oriented, has loss of memory Assessment tools: - MiniCog - CAM (Confusion Assessment Method): requires (1) acute change in mental status, (2) inattention, and (3) either disorganized thinking or (4) altered LOC (hypo/hyperactive)

"SPICES" Framework (Fulmer) for assessing for Geriatric Syndromes

S - Sleep disorders/disturbance P - Problems eating or feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdown