Updating Your Knowledge about
Geriatric Nursing Care
Mary H. Palmer, PhD, RN, C FAAN, AGSF
Helen W. & Thomas L. Umphlet
University of North Carolina at Chapel Hill
Distinguished Professor in Aging, SON
Interim Co-Director Institute on Aging
Overview
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Introduction to aging issues in the United States
Geriatrics Principles
Frailty (and disability and co-morbidity)
Dementia
Delirium
Falls
Urinary Incontinence
Anergia
Geriatric multidisciplinary competencies
Objectives
• Identify geriatric principles to guide nursing
care
• Discuss frailty phenotype and its implications
to the aging population and to nursing care
• Discuss recent research findings on at least 2
geriatric conditions and prevalent geriatric
diseases
Objectives
• Discuss geriatric competencies needed by
nurses to care for older adults
• Identify geriatric resources available to nurse
educators
Less than 1% of nurses are certified in
geriatric nursing.
Nurses practicing in this country [US] today
are, by default, geriatric nurses6.
Geriatric Nursing
In the United States, people 65 and older:
• represent 36% of hospital stays1
• represent 49% of all hospital days2
• had higher crude and adjusted morbidity and
mortality after emergency general surgery3
• take 1/3 of all prescribed medications
• represent 88.1% of residents in the 16,100 nursing
homes nationally4
• who were residents in nursing homes between
January through June 2007, 14% had a prescription for
an atypical anti-psychotic medication5
Sources:
1. Fulmer, 2001
2. Perry, 2002
3. Ingraham et al, 2011
4. http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf
5. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf
Demographic Profile: North Carolina
• 12% of NC’s population is
age 65+ with nearly
150,000 age 85+
• Projected to grow by 87%
of 2030
• 20th in the nation in the
projected growth rate of
the 85+ population
http://www.aging.unc.edu/nccoa/2010v
ideo/index.html
AARP. (2009). “Long-Term Care in North Carolina.” Retrieved from http://www.aarp.org
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United States Aging Statistics
Global Aging
Geriatric Principles
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Continuity of care
Bolstering home and family
Communication skills
Knowing the patient
Thorough assessment and evaluation
Prevention and health maintenance
Ethical decision making
Geriatric Principles
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Inter-professional collaboration
Respect for the usefulness and value of elder
Cultural and diversity competence
Compassionate care
Helping disconnected family
End of life care
Cultural and diversity competencies
Source: Reichel, Arenson & Scherger (2010)
Ideals of Fitness
The Risks of Aging
Baby Boomers in the United States:
Physical Health
Baby Boomers are those born between 1946 and
1964
By the year 2030 (in less than 20 years):
• 14 million baby Boomers will have diabetes
• Half of all Baby Boomers will have arthritis
• Hip replacement surgery rates, currently at
700,000/year, will reach 3,500,000/year
Baby Boomers: Physical Health
• Only one-third of Baby Boomers are satisfied
with their physical health
• 3/10 say their physical health is worse than they
expected
• 1 in 8 Baby Boomers will develop Alzheimer’s
Disease, the 5th leading cause of death in
people 65 years and over (source: Alzheimer’s
Disease Association)
• By 2050 11 to 16 million Baby Boomers will
have Alzheimer’s Disease
16
Baby Boomers:
Physical Health
Obesity, arthritis, and
diabetes will lead to
mobility limitations –
dependence on
others for ADLs
Baby Boomers: Cardiovascular health
• 40% of Baby Boomers already have
cardiovascular disease
• 35% have hypertension
• 55-60% have high cholesterol
• Deaths from heart disease are expected to
increase 130% in 40 years (by 2050)
Physical Health
Adult Obesity Rates 2009
The Perfect Storm
Frailty, Disability, Co-morbidity
Disability > 1 ADL
Co-morbidity
Frailty
Source: Fried et al., 2001
Frailty versus Disability
• Frailty – multi-factorial, potentially
downward spiral
• Disability may involve single deficits that
may be reversible Source: Fillitt & Butler, 2009
• Activities of Daily Living (ADLs)
• Disablement process Source: Verbrugge & Jette, 1994
Pathology  Impairment  Functional limitation  Disability
Presence of Frailty
Positive frailty phenotype:
greater than 3 criteria present
Intermediate or pre-frail:
1 or 2 criteria present
Source: Fried et al., 2001
Frailty
• By age 80 years, 40% of older adults have
functional impairments
• 6% to 11% are considered frail
– United States estimate: 6.1% Source: DuBeau et al., 2009
• Psychological effect of transition from robust
(independent) to frailty – evolving identity,
“looking glass self” Source: Fillitt & Butler, 2009
Looking glass self – old/young
http://asmp.org/articles/best-2010-hussey.html
Looking glass self – old/young
http://asmp.org/articles/best-2010-hussey.html
Physical and Psychological Transitions
Frailty Phenotype Source: Fried et al., 2001
Shrinking
Weakness
Poor endurance:
exhaustion
Slowness
Low activity
Frailty: Vulnerable Elders Survey
• Age
• Self reported health
• Physical activities (stooping, reaching, lifting,
writing, heavy housework, etc)
• Shopping, managing money
• Walking across a room
• Light housework
• Bathing or showering
Source: Saliba et al, JAGS 2001
Dementia
New Diagnostic Guidelines:
http://www.alz.org/research/diagnostic_criteria/
Clinical criteria for all cause dementia
1.
2.
3.
Interferes with ability to function at work or usual
activities
Decline from previous levels of function
Not explained by delirium or major psychiatric
disorder
Clinical criteria for all cause dementia
(continued)
4. Cognitive impairment detected through history taking from
patient and knowledgeable informant and objective
cognitive assessment
5. Cognitive or behavioral impairment involves the minimum of 2
from following domains:
a. impaired ability to acquire or remember new
information
b. impaired reasoning and handling of complex tasks
c. impaired visuospatial abilities (for example, inability to
recognize faces)
d. impaired language functions
e. changes in personality, behavior, comportment
Mild Cognitive Impairment
Decline in memory, reasoning or visual perception
that's measurable and noticeable to themselves or to
others, but not severe enough to be diagnosed as
Alzheimer's or another dementia.
The new guidelines formalize an emerging consensus
that everyone who eventually develops Alzheimer's
experiences this stage of minimal but detectable
impairment, even though it's not currently diagnosed
in most people.
Not everyone with MCI eventually develops
Alzheimer's, because MCI may also occur for other
reasons.
Preclinical Dementia
Expansion of the conceptual framework for
thinking about Alzheimer's disease to include a
"preclinical" stage characterized by signature
biological changes (biomarkers) that occur
years before any disruptions in memory,
thinking or behavior can be detected.
Source: http://www.alz.org/documents_custom/Diagnositic_Recommendations_MCI_due_to_Alz_proof.pdf
Delirium
Also Known As: acute confusional state and
acute brain syndrome
Considered a medical emergency due to
underlying physical or mental disorder
Considered temporary and Reversible
Causes: electrolyte imbalances, medications,
infection (UTI or pneumonia), pain,
depression, surgery
Delirium Symptoms
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Changes in alertness (more alert in am, less in pm)
Changes in level of consciousness or awareness
Changes in movement (slow moving OR hyperactive)
Changes in sleep patterns
Decrease in short-term memory and recall
Disorganized thinking
Emotional changes – anger, apathy, agitation
Disrupted or wandering attention
Delirium Treatment
• Control or reverse the cause of symptoms
• Stop medications: analgesics (if possible), anticholinergics,
cimetidine, lidocaine. Consult Beers criteria
• Treat anemia, hypoxia, heart failure, infections, kidney
failure, liver failure, nutritional disorders, depression,
thyroid disorders
• If using meds to treat, start very low dose and adjust as
needed: antidepressants, dopamine blockers, sedatives,
thiamine.
• Replace eyeglasses, hearing aids, teeth, treat pain, toilet,
sit up in chair
• Reality orientation
• Safety precautions
Urinary Incontinence: Definition
• Urinary incontinence (UI) “is the complaint
of any involuntary leakage of urine”.
(International Continence Society, 2002)
Differential Diagnosis:
OAB vs. SUI vs. Mixed UI
Overactive
bladder
Stress
incontinence
Mixed
symptoms
Urgency
Yes
No
Yes
Daytime Voiding Frequency
(>every 2 hours)
Yes
No
Yes
Leaking during physical activity
No
Yes
Yes
Large
(if present)
Small
Variable
Ability to reach the toilet
following an urge
Often no
Yes
Variable
Waking to pass urine at night
Usually
Seldom
Maybe
Symptoms
Amount of urinary leakage
Abrams P, Wein AJ. THE OVERACTIVE BLADDER: A widespread and treatable condition. 1998;1-57.
Reversible Causes of Incontinence
• Delirium
• Restricted mobility (illness, injury, gait disorder,
restraint)
• Infection (acute, symptomatic) Inflammation
(atrophic vaginitis) also impaction of stool
• Polyuria (DM, caffeine intake, volume overload),
pharmaceuticals (diuretics, autonomic agents,
psychotropics)
Continence – Two Years Prior to Death
Source: Covinsky et al., 2003
Sample Bladder Record
Date
Time
Urinated
in toilet
UI
episode
Reason
for UI
Bowel
movement
Fluid
intake
Behavioral Programs
Required skills:
Ability to comprehend and follow education
and instructions
Identify urinary urge sensation
Learn to inhibit or control urge to void
Kegel (aka: pelvic floor muscle exercises)
exercises
cms.internetstreaming.com
Risk factors for Incident Urinary
Incontinence in Hospitalized Elders
Risk Factor
OR(95% CI)
p-Value
Continence aids (reference: self-toileting)
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Urinary catheter
4.26 (1.53–11.83) .005
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Adult diaper
2.62 (1.17–5.87) .02
Activities of daily living at admission (reference: independent)
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Partially dependent
2.96 (1.01–8.71) .049
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Dependent
3.27 (1.49–7.15) .003
** Adjusted for age, cognitive status, physical activity
Source: Zisberg et al., JAGS, 2011.
They Don’t Tell, We Don’t Ask
• Only half of patients with incontinence tell
their health care provider about their
symptoms
• Perceived as low priority by some primary
care providers
• Result: underreported, undertreated
EDUCATE study. Morb Mortal Wkly Rep. 1995;44:747,753-754.
Branch LG et al. J Am Geriatr Soc. 1994;42:1257-1261.
Falls
Total Lifetime Medical Costs of Unintentional Fatal Fall-Related Injuries* in
People 65 Years and Older By Sex and Age, United States, 2005 (CDC)
*Lifetime medical costs refer to the medical costs (treatment and rehabilitation) associated with the fatal injury event
Falls and Hip Fractures
• 90% hip fractures are from falls1
• About one third of hip fracture patients developed
an acquired pressure ulcer (APU) after surgery2
• 1 in 5 hip fracture patients die within a year of the
fall1
• Up to one in four of older adults who had been
independent before a hip fracture spend up to a year
in a nursing home after the fall1
1. CDC, http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html
2. Baumgarten et al JAGS; 57:863-870, 2009
Odds of Falling
2.5
2
1.5
1
0.5
0
Any UI Urge UI Stress
UI
Mixed
UI
Chiarelli et al 2009
Source:http://latimesblogs.latimes.com/pho
tos/uncategorized/2008/09/09/cracks1.jpg
Mobility, balance, urine control before and
after 4 weeks of daily exercise
Walking distance* feet
Balance seconds
Speed inches/second
UI (7am-3pm)
UI (7am -10pm)
5.5
Source: Jirovec Int J Nurs Stud 1991
Before
50
24
7.7
2.3
2.8
After
73
26
1.0
2.5
Assessment for Absorbent
Products
Assess resident’s;
 Functional ability to ambulate, toilet, disrobe, use of
assistive devices
 Ease in self-toileting
Assess product for:
 Contain urinary leakage
 Comfort
 Ease of application/removal
cms.internetstreaming.com
Recent Research
Absorbent products are used to manage urinary
incontinence in acute care setting1
Absorbent products are associated with
development of new urinary incontinence1
Absorbent products are associated with skin
changes and increased risk of incontinenceassociated dermatitis (IAD)2
Source: 1. Zisberg et al., JAGS, 2011.
2. Shigeta et al., OWM, 2010.
Anergia
Conceptually differs both from
fatigue, which is usually
measured post-exertion, and
from depression.
Anergia
Anergia defined as, “sits around a lot for lack of
energy”, and any two of six minor criteria:
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recently not enough energy
felt slowed physically in past month
doing less than usual in past month
any slowness is worse in the morning
wakes up feeling tired
naps (> 2 hours) during the day
Source: Cheng, H., Gurland, B. & Maurer, M. Self-reported lack of energy (anergia)
among elders in a multi-ethnic community Journal of Gerontology: MEDICAL SCIENCES
2008, 63A
Anergia
• 39% heart failure patients reported anergia1
• Older adults with urinary incontinence 2x
more likely than continent to report anergia2
• Anergia was associated with new cases of
urinary incontinence in longitudinal study2
1 Maurer, M., Cuddihy, P., Weisenberg, J. (et. Al. (2009). Journal of Cardiac Failure, 15(2), 145-151.
2 Cheng, H., Gurland, B. & Maurer, M. (2008).. Journal of Gerontology: MEDICAL SCIENCES, 63A(7), 707-714
Depression
The CES-D-SF is a 10 item 4-point Likert-type
depression assessment scale.
• Sleep
• Emotions
• Hopefulness
• Concentration
• Effort
Heart Failure Prevalence
Prevalence of heart failure by sex and age (National Health and Nutrition Examination
Survey: 2005–2008). Source: National Center for Health Statistics and National Heart, Lung,
and Blood Institute. [http://circ.ahajournals.org/cgi/content/full/123/4/e18/F91]
[Roger, V. L. et al. Circulation 2011;123:e18-e209]
Heart Failure – Quick Facts
• One quarter HF patients are > 80 years
old
• More than half have 5 or more comorbid
condition
• More than half are mobility disabled
• Polypharmacy, > 50% 6+ medications
Source: Wong, Chaudhry, Desai et al., (2011). American Journal of Medicine, 124:136-143.
Correlates of …
Heart Failure
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Diabetes
Obesity
MI
Hypertension
Age
Race
Urinary Incontinence
• Diabetes
• Obesity
• Hypertension
• Age
Unifying Model of Shared Risk Factors
Source: Inouye et al., 2007
Multidisciplinary Competencies
• Health Promotion and Safety
• Evaluation and assessment
• Care planning and coordination of care across
the care spectrum
• Interdisciplinary and team care
• Caregiver support
• Healthcare systems and benefits
Emerging Issues
• Need more who understand and can practice
geriatrics
• New concepts (anergia) with clinical
implications
• New complex conceptual models about
treatment of geriatric conditions
• Geriatric competencies
• Geriatric resources
Geriatric Resources
Professional Organizations:
American Nurses Association:
www.Geronurseonline.org
American Geriatrics Society:
http://www.americangeriatrics.org/
Gerontological Society of America:
http://www.geron.org/
Journals:
Journal of the American Geriatrics Society (JAGS)
Geriatric Nursing
Journal of Gerontological Nursing