WEEK 2 GERIATRIC SYNDROMES - FRAILTY & TCM & PALLIATIVE/HOSPICE CARE INTRO CH 24

Markers of Aging - Lab Values

*C-reactive protein (CRP)* +Activates the inflammatory and clotting cascade +Elevated in frailty +Causes increase in circulating IL-6 *Interleukin-6 (IL-6)* +Elevated in frailty +inflammation NOTES: Not diagnostically definitive - must complete comprehensive assessment

Geriatric Failure to Thrive (*GFTT*) 4 Syndromes.

*Four Syndromes often the result of multiple underlying disease states:* +Impaired physical functioning +Malnutrition +Depression +Cognitive impairment *IOM definition:* +Syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, malnutrition, and inactivity, accompanied by dehydration, depressive symptoms, impaired immune function and low cholesterol levels

Risks of Frailty

*Frailty is more likely* +> age 85 +Dependent in one or more ADL's +Comorbidities (3 or more) +Presence of one or more geriatric syndromes +A frail older person is at high risk for dependency, institutionalization, falls, injuries, hospitalization, slow recovery from illness, and mortality. +Often, the frail older person will suffer a rapid decline and decompensation as a result of acute illness or worsening of a chronic condition NOTES: +High risk for dependency and institutionalization

Hospice Care

+*Hospice care is a system of care for individuals close to death (within 6 months of death) *and provides supportive care for the family up to a year. +Hospice care requires the patient to decline curative treatment. +Hospice care includes palliative care without the curative component.

Disability

+*Inability to perform * -Basic Activities of daily living (BADL) -Instrumental ADL (IADL) -Difficulty with mobility -Does not affect body across multiple organ systems -Not Frailty

Path to and Risks of Frailty

+A frail older person is at high risk for dependency, institutionalization, falls, injuries, hospitalization, slow recovery from illness, and mortality. +Often, the frail older person will suffer a rapid decline and decompensation as a result of acute illness or worsening of a chronic condition

Long-term Care

+Acute and LTC environments can trigger behavior problems and cognitive decline. +Holistic approach +"Nurses should address problem behaviors using social and environmental modifications and creative activities, thereby preserving independence and self-esteem." +Meds for behavioral control should be used cautiously. +Behavioral approaches include training caregivers in therapeutic responses to resistance to care.

Nursing Implications of GFTT

+Assess for & manage symptoms of GFTT +Early recognition and supportive treatment before advanced deterioration +Risk-benefit ratio, especially at end of life +Holistic: psychosocial and physical problems +Assess for Polypharmacy that mimics GFTT

Components of Effective Care Transitions

+Before any decision to transfer, the potential for harm from imposing an additional transfer to a new setting needs to be weighted against the potential for benefit. +Appropriateness of the match between the proposed care setting and the patient's medical, nursing, and functional needs should determine the decision to transfer

Role of the Nurse: Clinical Judgement

+Clinical condition fails to fit a discrete disease category - ask is condition on the Gero Syndrome List? +Presence of gero syndrome & frailty shared risk factors - *older age, cognitive impairment, functional impairment, and impaired mobility* +Presence of 1 or 2 frailty criteria (pre-frail likely reversible) 3 or more frailty criteria (frail)? OR +Presence of GFFT criteria? NOTES: What is the SN/RN to know or do.....

Acute Illness and Hospitalization

+Common causes of hospitalization include pneumonia, influenza, heart failure, ischemic heart disease, urinary tract infection, hip fracture, digestive disorders, and dehydration. +Heart failure and pneumonia are the most common conditions associated with rapid readmissions. +Hospital care is associated with increased use of medications, invasive procedures, diagnostic testing requiring food and fluid restriction, nosocomial infections, and occurrence of adverse events and poor outcomes for hospitalized older patients. +Hospital care is aggressive and goal is to extend life may not be appropriate given the disease trajectory or align with patient values & goals.

Frailty

+Common geriatric syndrome in elderly > 85 years of age (25% -50%) +Decreased reserves in multiple organ systems +Excess demand imposed upon reduced capacity +Initiated by disease, lack of activity, inadequate nutritional intake, stress and/or physiologic changes of aging NOTES: +More common w women and lower socioeconomic classes. +More at risk for poor tx outcomes and even death

Effective Care Transitions - Components of Patient D/C or Transfer

+Communication between sending and receiving clinicians -Common plan of care -Summary of care provided by the sending institution -Patient's goals and preferences (advance directives) -Updated list of problems, baseline physical and cognitive functional status, medications, allergies -Contact information for patient's caregivers and primary care provider

Precipitants to GFTT: *11 "D's"*

+Disease (physical) +Dementia +Delirium +Drinking of alcohol +Drug use +Dysphagia +Deafness or other sensory deficit +Depression +Desertion +Destitution +Despair

Trajectories of Functional Decline

+Frail older adults and individuals at the end of life exhibit *four distinct trajectories of functional decline*: -Sudden death -Diagnosis with a terminal illness -Organ failure -Frailty

*Identifying Frailty* - The Research Three or more of the following.. 7

+Frailty has also been defined as the presence of *three or more* of the following criteria: -Unplanned weight loss (10 lbs. in the last year) - Muscle Weakness (sarcopenia) -Fatigue or Poor endurance (lack of energy) -Decline in grip strength and gait speed -Slowed performance -Low physical activity -Depression

Common Features of Geriatric Syndromes

+High prevalence in older adults, especially frail older people +Do not fit into a discrete disease category +Impact QOL & may lead to disability +Multiple risk factors and multiple organ systems involved +Not always able to identify underlying cause Therapeutic management of clinical manifestation can be helpful even in the absence of a definite diagnosis

Frailty Continuum

+Its a continuum +Prefrail - what has happened to put them in that category.. (fall & they have Heart Disease, when things start to happen they on their way to frailty)

Frailty, Comorbidities, and Functional Status

+Many older people who have chronic conditions and disabilities lead active, productive lives, but some are more disabled and require assistance with activities of daily living. +44% of Americans with chronic conditions (i.e. HF, cancer, AD) are living longer in a variety of LTC systems and will require holistic and interprofessional care. +NIH Goal (2012) "add life to years" +70% of physical decline is r/t modifiable lifestyle changes

Problem with Transitions

+Older adults with complex acute and chronic care needs experience heightened vulnerability during care transitions +Essential elements of patient's care plan developed in one care setting are not always communicated to the next team of clinicians = *follow up failures* +Practice settings operate in silos +*Medication errors* +Confusion over purpose of transfer +Inappropriate discharge patient education

Treatment for Frailty

+Optimal management of illnesses that can cause frailty +*Prevent sarcopenia*: muscle-strengthening exercises, resistance training +*Nutritional program* combined with exercise regimen +*Appetite stimulants *minimally effective in nursing home residents and associated with significant side effects +*Protein calorie supplements, Vitamin D* +*Reduction of polypharmacy*

Palliative Care

+Palliative care can be provided at any point in the disease process. +Palliative care improves the quality of life of older persons and their families when facing the problems associated with chronic and life-threatening illness. +This is achieved through prevention and relief from suffering; early identification, impeccable assessment, and treatment of pain; and recognition and treatment of other physical, psychosocial, and spiritual problems. +The use of social & financial resources on inappropriate or futile medical care depletes healthcare resources, drives up costs, and results in less money that could be spent on providing appropriate healthcare treatment and quality-of-life enhancement for older persons who may improve as a result of such treatment.

Effective Care Transitions - Components of Patient D/C or Transfer (continued)

+Preparation of the patient and caregiver for what to expect at the next site of care +Reconciliation of the patient's medication prescribed before the initial transfer with the current regimen +A follow-up plan for how outstanding tests and follow-up appointments will be completed +Explicit discussion with patient and caregiver regarding warning symptoms or signs to monitor that may indicate the condition has worsened and the name and phone number of who to contact if this occurs.

Manifestations of Frailty

+Sarcopenia (loss of skeletal muscle mass) +Abnormal function in inflammatory and neuroendocrine systems +Poor energy regulation +Decreased ability in body's physiologic response to maintain homeostasis during acute stress NOTES: +Polypharmacy - some of the meds they are on is causing harmful effects.

In any and all practice settings, nurses should practice according to the following guidelines:

+Seek to access and provide the most intensive services to those considered the most frail and those diagnosed with multiple comorbidities. +Practice ethically according to professional standards. +Promote healthy aging in all clinical settings. +Be aware of drug interactions. +Remember that the presentation of illness is less dramatic and more vague than in other age groups. (Atypical Presentations) +Conduct holistic nursing assessments when caring for frail older adults and those with comorbidities. +Recognize and treat pain in older persons. +Become expert at providing end-of-life care. +Seek continuing education programs and pursue advanced degrees.

Examples of Geriatric Syndromes

+Sleep disorders (pain) +Eating/feeding disorders (weight loss & anorexia) +Incontinence - urinary +Confusion +Falls +Skin breakdown (pressure injury) +Delirium +Dizziness/Syncope +Frailty (depression) +Emerging Syndrome: Sarcopenia +Shared risk factors: older age, cognitive impairment, functional impairment, and impaired mobility

Geriatric Syndromes-Defined

+Term used to capture those clinical conditions in older persons that do not fit into discrete disease categories. +Chief complaint does not represent the specific pathologic condition or a specific disease associated with the change in health status +*Common clinical conditions in older adults that share an underlying causative factor and involve multiple organ systems*.

Trajectories of Functional Decline..

+Those who experience entry and reentry trajectories and frailty are likely to require, but may not have access to supportive services because of steadily diminishing reserve capacity to cope with inevitable but unpredictable acute health challenges.

Transitional Care Models

+Transitional Care Model developed at University of Pennsylvania (Naylor, et al., 2004) +The Care Transitions Intervention Model at the University of Health Sciences in Denver

Transitions

+Transitional care (American Geriatrics Society) -Set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location -Levels/locations of care offer differing goals and interventions for the patient. -Locations include, but not limited to: +Hospital, subacute and post acute nursing facilitates, patients' homes, primary and specialty care offices and long-term care facilities

NOTES

+get the modules LNEX? +Geriatric syndromes not just one illness but multiple +searching for underlying causes

Nurse's Role in Palliative Care.

+promote comfort +alleviate suffering +control pain +assist patient with decision making +be a liaison for families and patients - social worker, ethics committee

Impact of Shared Risk Factors

+when you think about geriatric syndrome think of the risk factors -incontinence -confusion -falls (really bad, won't heal as fast, more likely to decline after a fall)