UBC Faculty Research and Publications

Implementing the GET program : a toolkit for educators Baumbusch, Jennifer; Shaw, Maureen; Leblanc, Marie-Eve; Kjorven, Mary Colleen; Geriatric Education and Training Program 2013

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:"!!!!! IMPLEMENTING THE GET PROGRAM: A TOOLKIT FOR EDUCATORS!! "TABLE OF CONTENTS  DAY$1:$FOUNDATIONS$IN$NURSING$CARE$OF$OLDER$ADULTS$IN$ACUTE$CARE$GET$Day$1$Schedule…………………………………………………………………………………….…$5$GET$Day$1$Evaluation$Form……………………………………………………………………………$6$Careplanning$Presentation…………………………………………………………..……………….$8$• Nursing$Careplan$Template……………………………………………………….……….$29$3Ds$Presentation…………………………………………………………………………….……………$31$• Handouts$o 4$Steps$for$Communication…………………………………………………….$107$o CMAI$Handout………………………………………………………………………..$108$o GDS$Short$with$SIDECAPS……………………………………………………….$110$o MMSE$Handout……………………………………………………………………...$111$o MoCA$……………………………………………………………………………….……$113$o 3Ds$References………………………………………………………………………$$114$Quality$Improvement$Project$Presentation……………………………………..…………$117$$DAY$2:$CONSEQUENCES$OF$HOSPITALIZATION$GET$Day$2$Schedule……………………………………………………………………………….…..$127$GET$Day$2$Evaluation$Form………………………………………………………………….…….$128$Case$Studies……………………………………………………………………………………….………$130$Iatrogenesis$Presentation………………………………………………………………….……….$146$• Handouts$o Consequences$of$Bedrest$……………………………………………............$215$o Iatrogenesis$References…………………………………………………..…….$216$Challenges$in$Geriatric$Pharmacology$Presentation……………………….……….….$219$• Handout$o AGS$Beers$Pocket$Card……………………………………………..…………...$269$DAY$3:$MEETING$THE$CHALLENGES$IN$OLDER$ADULTS$CARE$GET$Day$3$Schedule………………………………………………………………………..………….$274$GET$Day$3$Evaluation$Form…………………………………………………………..……………$275$Pain$in$Older$Adults$with$Cognitive$and/or$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Language$Impairments$Presentation.……………………………………………..………….$277$• Handouts$o Common$painful$diseases/conditions………………………….…………$309$o Pain$Case$Study………………………………………………………….………….$313$o Pain$in$CognitiveXLanguage$Impaired$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Case$Study$(Presentation)………………………………………………………$316$o Hierarchy$of$Pain$Assessment$Techniques………….....................$320$o Pain$in$Older$Adults$Case$Study………………………………………..……$322$o Pain$References………………………………………………………..……………$323$o VCH$Food$for$Thought$–$Feeding$Tubes$and$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Ethical$Considerations$(Case$Study)……………………….………………$325$o VCH$Ethical$DecisionXMaking$Framework$for$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Tube/Other$Feeding$Options………………………………………….……..$326$o Advanced$Care$Planning………………………………………….…………….$331$$DAY$4:$CELEBRATING$LEARNING$GET$Day$4$Schedule…………………………………………………..………………………………$333$$OTHER$RESOURCES$Summary$of$Educational$Strategies..............................................................$335$$$ $ $  GET Program DAY 1  Foundations in Nursing Care of Older Adults in Acute Care          Geriatric Education & Training Program Course Schedule    Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013    Time Topic   0830 Survey #1  0900 Welcome & Introductions  0930 Patients & Families as Partners in Care x Personhood x Patient & Family Centered Care  1000 Break  1015 The Nursing Process: Bringing Patient Centered Care to the Point of Care  1115 Quality Improvement: Thinking about Patient & Family Centered Care at the Unit and Systems Level  1200 Lunch x Lunch & Learn: Library Services  1300 3Ds: Delirium, Dementia, Depression  1615 Evaluation/Feedback on the day           Geriatric Education & Training Program Course Schedule    Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013    Time Topic   0830 Survey #1  0900 Welcome & Introductions  0930 Patients & Families as Partners in Care x Personhood x Patient & Family Centered Care  1000 Break  1015 The Nursing Process: Bringing Patient Centered Care to the Point of Care  1115 Quality Improvement: Thinking about Patient & Family Centered Care at the Unit and Systems Level  1200 Lunch x Lunch & Learn: Library Services  1300 3Ds: Delirium, Dementia, Depression  1615 Evaluation/Feedback on the day         Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013  Please indicate your level of agreement with the statements below:    Strongly Agree Agree Neutral Disagree Strongly Disagree Comments  The content was organized and easy to follow   € € € € €  The objectives were clearly identified  € € € € €  Participation and interaction were encouraged   € € € € €  Questions and exchanges were encouraged  € € € € €  The material covered was relevant  € € € € €  The amount of time allowed to cover the material was sufficient  € € € € €  The training session met my expectations  € € € € €  Would you recommend this session to someone else?   € € € € €    See reverse         What did you find was the most helpful?         Any suggestions on what should be changed to improve the program.          Please use the area below for any additional comments:              Thank you for your feedbacks The$Nursing$Process:$$Bringing$Pa2ent4Centered$Care$to$the$Point$of$Care$GET$Program$September$18,$2013$•  Review$the$nurses$role$in$the$iden2fica2on$and$management$of$nursing$problems$•  Discuss$the$process$by$which$nurses$come$to$a$clinical$judgment$about$a$pa2ent$or$a$situa2on$•  Apply$the$nursing$process$to$common$geriatric$syndromes$and$clinical$situa2ons$•  “is$a$problem4solving$approach$to$iden2fying,$diagnosing,$and$trea2ng$the$health$issues$of$clients.$It$is$fundamental$to$how$nurses$prac2ce.$…it$is$con2nuous,$and$in$prac2ce,$you$will$learn$to$move$back$an$forth$between$the$various$steps.”$$• The$nursing$process$allows$the$nurse$to$$– Organize$and$systema2ze$nursing$prac2ce$– Make$inferences$about$the$meaning$of$a$client’s$response$to$a$health$problem$or$generalize$about$func2onal$ability$– Clearly$define$the$client’s$issue$or$problem$as$the$basis$for$planning$and$implemen2ng$nursing$interven2ons$and$evalua2ng$the$outcomes$of$care$PoWer$and$Perry$2010,$p.$159$$!  Recognizing$an$issue/concern/client$problem$exists$!  Collec2ng$all$significant$cues$and$other$relevant$informa2on$!  Analyzing$informa2on$(clinical$data)$about$the$issue/concern/client$problem$$!  Verifying$&$valida2ng$the$data$and$drawing$conclusions$!  Iden2fying$nursing$interven2ons$and$priori2es$!  Evalua2ng$nursing$ac2ons/interven2ons$impact$on$client$!  Communica2ng$with$the$pa2ent,$their$family$and$other$health$care$team$members$Medical$Perspec2ve$is$disease$focused$where$the$focus$of$care$is$to$provide$a$differen2al$diagnosis$and$prescribe$treatment$of$the$disease$$Nursing$Perspec2ve$is$focused$on$the$client’s$response$to$the$changes$and$impact$on$everyday$func2oning$and$coping$abili2es$$ASESSMENT'Collect'data'Organize'data'Validates'Data'Document'data'DIAGNOSIS'PLANNING'IMPLIMENTATION'EVALUATION'!  Assessing$is$a$con2nuous$process$carried$out$during$all$phases$of$nursing$process.$All$phases$of$the$nursing$process$depend$on$the$accurate$and$complete$collec2on$of$data.$!  Assessing$is$the$systema2c$and$con2nuous$collec2on,$organiza2on,$valida2on$and$documenta2on$of$data.$$$$$$$$$$$$$$$$$$$$$$$$$$$$PoWer$and$Perry($2006)$"  Comprehensive$$"  Focused$"  Screening$Holis2c,$incorpora2ng$physical$assessment,$health$percep2ons,$social$aspects$etc.;$generalized$assessment$creates$a$profile$of$the$client$(e.g.$Nursing$History)$Limited$to$a$specific$need;$to$further$evaluate$a$specific$problem$or$to$validate$ini2al$findings$or$inferences$(e.g.$respiratory$assessment$for$client$with$pneumonia)$Monitor$specific$problems;$ongoing$observa2on$and$valida2on$related$to$baseline$data$(e.g.$elevated$temperature)$•  Objec2ve$data$•  Observable$and$measurable$data$that$can$be$seen,$heard,$or$felt$by$someone$other$than$the$person$experiencing$them$•  E.g.,$elevated$temperature,$skin$moisture,$vomi2ng$•  Subjec2ve$data$•  Informa2on$perceived$only$by$the$affected$person$•  E.g.,$pain$experience,$feeling$dizzy,$feeling$anxious$•  Valida2on$is$an$ongoing$process$during$data$collec2on$and$aferwards$when$the$data$are$reviewed$and$compared.$•  It$is$important$to$$•  avoid$making$assump2ons$•  jumping$to$conclusions$or$focusing$in$the$wrong$direc2on$•  Missing$per2nent$informa2on$•  Misunderstanding$situa2ons$•  The$client$•  Further$assessment$•  Other$nurses$•  Secondary$sources$i.e.$the$clients$chart$•  Grossly$abnormal$findings$are$re4checked,$objec2ve$and$subjec2ve$data$are$compared$for$congruence$or$inconsistencies$•  Take$care$of$immediate$life4threatening$issues$• *ABCDs$•  AWend$to$safety$issues$•  Pa2ent$iden2fied$priority$issues$•  Nurse$iden2fied$priori2es$based$on$the$client’s$medical$diagnosis$&/or$nursing$care$plan$•  Begins$the$process$of$nursing$care$planning$•  Iden2fy$the$nursing$problem$•  Iden2fy$the$desired$goals$or$outcomes$•  Select$appropriate$nursing$interven2ons$•  Set$priori2es$•  Sources$to$guide$developing$the$care$plan$$•  Nursing$knowledge$•  Evidence$Informed$Clinical$Pathways$•  Prac2ce$Standards$and$Guidelines$•  May$be$an$actual$problem$or$risk$(poten2al$problem)$•  The$suspected$cause$or$reason$for$the$problem$is$related'to$part$of$the$Nursing$Diagnosis$•  The$signs$and$symptoms,$clinical$manifesta2ons$(cues)$or$risk$factors$are$the$as'evidenced'by$part$of$the$Nursing$Diagnosis$•  Iden2fying$appropriate$pa2ent4centered$Nursing$Care$Plan$•  Abdominal$Pain$related'to'appendectomy$as'evidenced'by'score$of$8/10$on$pain$scale,$facial$grimacing,$and$increased$BP.$•  Deficient$knowledge$related'to'appendectomy$as'evidenced'by$lack$of$knowledge$of$post$op$care.$•  Difficulty$breathing$related'to'acute$asthma$exacerba2on$as'evidenced'by'increased$respiratory$rate$and$effort.$•  At$risk$for$falling$related'to'altera2on$in$coordina2on$and$mobility$as'evidenced'by'lef$sided$weakness.$•  Establish$the$goals,$interven2ons$and$outcomes$•  Carry$out$the$plan$•  Con2nue$to$assess$and$collect$data$•  Document$care$• Determine$if$goals$were$met$• Decide$if$care$should$con2nue$OR$• Modify$plan$if$necessary$•  Ensure$consistent,$effec2ve,$individualized$nursing$care$•  Ar2culate$unique$contribu2on$of$nursing$prac2ce$for$older$adults$•  Ross4Kerr,$J.C.,$&$Wood,$M.J.$(2010).$$PoWer$and$Perry:$Canadian$Fundamentals$of$Nursing,$Revised$4th$Edi2on.$Toronto,$ON:$Elsevier$Canada.$     NURSING CARE PLAN Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation                                            ASSESSMENT DATA NURSING'CARE'OF'HOSPITALIZED'OLDER'ADULTS:!DEMENTIA,'DELIRIUM'&'DEPRESSION'Objec;ves'Demen;a,'Delirium'&'Depression'(3Ds)'1.  To!iden*fy!the!risk!factors!and/or!symptoms!associated!with!delirium,!demen*a!&!depression.''2.  To!dis*nguish!4!key!differences!between!demen*a,!delirium!&!depression.!3.  To!describe!3!evidenceCbased!tools!for!assessments.!4.  Discuss!6!evidenceCbased!interven*ons!for!!nursing!care.!CLINICAL'PRESENTATION'My!pa*ent!is!confused!&!irritable:!1. !Is!this!delirium?!(acute!onset,!fluctua*ng!course,!!!!!!!!!disorganized!thoughts,!variable!LOC)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!or!! Depression-or-demen.a-or-drug-effect?-2.!If!this!is!demen*a,!why!should!it!maQer!in!acute!!!!!!!care?!• Isn’t!this!an!issue!that!the!community!should!deal!with?!6/26/14 3 Adapted from: Dr. A. M. Chung, February 2013 DEMENTIA'IN'ACUTE'CARE'Why'Admit?'•  Safety!•  Failure!to!thrive!!•  Neglect/abuse!•  Falls/fall!risks!•  Medica*on!adherence!•  Behavioral!issues!•  Caregiver!stress!Implica;ons?!•  Difficulty!with!care!•  Competency!•  Long!length!of!stay!•  Delirium!(again)!•  Transi*on!challenges!•  Discharge!planning!•  Readmission!risk!DEMENTIA'IN'ACUTE'CARE''''''''''''Implica;ons'for'Discharge'Planning!!– Need!for!ADL!support!– Safety!issues****!– Medica*on!adherence!– Ability!to!complete!follow!up!–  Lack!of!judgment,!insight!– Caregiver!burnout!– Risk!for!readmission!! !Func*ons!that!may!decline!•  Recall!of!names!•  Speed!of!learning!!•  Speed!of!performing!complex!tasks!! !Func*ons!that!do!not!!!!!!decline!•  Vocabulary!•  Store!of!informa*on!SETTING'THE'STAGE:'THE'AGING'BRAIN'1. !↓!in!weight!&!volume!2. !Increased!size!of!ventricles!3. !↓!size/number!of!neurons!4. !Decreased!number/size/transmission!!!!!!of!neurotransmiQers!•  Serotonin,!dopamine,!acetylcholine!FRAGILE'BLOOD'BRAIN'BARRIER'WHAT'IS'DEMENTIA?' 'Adapted from : Alzheimer’s Society 2011 ! A!brain!syndrome*!that!leads!to!a!progressive!decline!in!intellectual!ability!&!interferes!with!social!and!occupa*onal!roles!*!A!cluster!of!symptoms!that,!taken!together,!form!an!illness!or!disorder!WHAT'IS'DEMENTIA?' 'WHAT'ARE'THE'SYMPTOMS?!Dalziel, 2008 DEMENTIA:'AN'UMBRELLA'Most Common-Alzheimers Types of dementia-   vascular, Lewy body,  Parkinsons, ETOH Source: Alzheimers Society TYPES/PREVALENCE'OF'DEMENTIA'5.!!Other!(10%):!•  Parkinson’s!•  Hun*ngton’s!•  Frontotemporal!(Pick’s)!•  Hydrocephalus!•  PostCinfec*on!•  ToxicCmetabolic!•  ETOH!1.  BC:!70,000!people!with!demen*a!! ! !!!2038:!!>!177,000!!!!!!!!!2.  Canada:!7th!cause!of!death!(2000/2009)!! !#!5!women;!!#!7!men;!!4th!>!85!years!! !!!4.  LTC!Prevalence:!!47C78%!!(64%)!! ! ! ! !FACTS'ON'ALZHEIMER’S'Sources: Alzheimer’s Society; Stats Canada; DeVane & Mintzer, 2003  WHAT'IS'ALZHEIMERS'DISEASE?'https://www.youtube.com/watch?v=9Wv9jrk-gXc COURSE'OF'ALZHEIMER’S'DISEASE'Average'life'aXer'diagnosis:'10'years''•  Range:!2C20!years!Poorer'Prognosis'•  Psychiatric!features!(ie,!BPSD)!•  Chronic!illness(es)!•  Alcohol!use!•  Weight!loss!17 NB: Vascular disease ↑ symptoms Adapted from: Dr. A. M. Chung, February 2013 BIOLOGICAL'RESPONSES'&'AGING'SCREENING'TOOLS'•  Mini!Mental!State!Exam!(MMSE)!•  Montreal!Cogni*ve!Assessment!(MoCA)!(!CLOCK'DRAWING'(ABNORMAL)'20 Alzheimer’s Australia (2012). Reducing Behaviours of Concern : A hands on guide: a resource to assist those caring for people living with dementia. Dementia behaviour management advisory series. dbmas.org.au As'Demen;a'Progresses....!Social' Communica;on' ADLs' Orienta;on'(Spa;al)' Health'Process!visual,!hearing!cues!Word!finding!difficulty!(anomia)!Sequencing!Touch!Sense!of!direc*on!•  Pain!•  Symptoms!•  Nutri*on!Process!social!cues!Verbal!language:!• !Expressive!• !Recep*ve!!!!!(aphasia)!Time! Judging!distances!•  Cons*pa*on!•  Infec*on!•  Dehydra*on!Recognize!!current!self,!family,!others!Agraphia! Body!parts!(R/L)!Following!visual!maps!Circadian!rhythm!• !!!!Day/night!• !!!!Sundown!Following!social!conversa*on!Grasp!reflex!Behavioral'&'Psychological'Symptoms'of'Demen;a'(BPSD)'Behavioral! !Aggression,'agita;on'Screaming,'swearing'Wandering*,'shadowing*'Hoarding*'Disinhibi;on'Psychological'Hallucina;ons,'delusions'Suspicious'Depression,'anxiety'Irritable'Night';me'disturbance'TYPES'OF'AGITATION'Physical' Verbal'Defini;on' Physically!striking!self!or!others'Verbally!striking!out!at!others'Examples' • !Hipng,!pushing!• !Scratching,!bi*ng!• !Kicking!• !Grabbing!objects,!!!!!!!!!!!people!• !Throwing,!tearing!• !Physical!sexual!!!!advances!• !Screaming,!yelling!• !Swearing!• !Temper!outbursts!• !Strange!loud!!noises!• !Repe**on!• !Verbal!sexual!!!!!!advances!University of Iowa Gerontology Research Centre, 2005-R ''''''''''RISK'''FACTORS'''FOR'''AGITATION'•  Impaired!social!interac*on' •  Male!gender'•  Impaired!communica*on' •  Mood!disturbance'•  Complex!instruc*ons' •  Irritability'•  ADL!dependence' •  Stress!responses'•  Cool!air/water!temperature' •  Personal!space'•  Medica*ons' •  Fa*gue'•  Pain,!health!issues! •  Sleep!disturbance'•  Caregiver!behaviors!&!banter'University of Iowa Gerontology  Research  Centre, 2005-R;  Shaw, 2011-R The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.During'personal'care'During'staff'breaks'At'night'TREATMENT'•  Donepezil:!Oldest!(10!mg)!•  Rivas;gmine:!Cholinesterase!inhibitor.!Available!as!a!patch!•  Galantamine:'Inhibits!cholinesterase!&!alters!acetylcholine!release!!•  Meman;ne:!NMDA!receptor!antagonist!!!– Used!in!combina*on!therapy!•  Sidedeffects:!!– Syncope,!bradyCarrhythmia,!nightmares,!GI!upset!(↑!with!rivas*gmine),!anorexia,!headaches,!bronchospasm!!27 Adapted from: Dr. A. M. Chung, February 2013 The!most!important!care!provided!to!pa*ents!with!demen*a!is!to:!a) !Keep!them!showered!&!toileted!regularly!even!when!!!!!!agitated.!b)!Meet!their!family!members!expecta*ons.!c)!Provide!caring!care!and!meaningful!rela*onships.!d)!!Have!them!leave!hospital!as!quickly!as!possible.!WHICH of the FOLLOWING is True? DELIRIUM'IS'THE………..'WHAT'IS'DELIRIUM?'• MULTIFACTORIAL!BRAIN!SYNDROME!• TRANSIENT-&-ABNORMAL!DISTURBANCE!OF!COGNITIVE!FUNCTION!• OFTEN!“CONFUSED”!WITH!DEMENTIA!Risk'Factors'for'Delirium'• Demen*a!• Age!>75!years!• Polypharmacy!• History!of!delirium!• Chronic!illnesses!• Post!surgery/procedure!DELIRIUM:'KEY'SYMPTOMS'KEY' OTHER'1.!RAPID!ONSET!•  !Hours!to!days!•  !Abrupt!change!from!baseline'BEHAVIORAL!CHANGES!• !Agita*on,!aggression,!anxiety,!!!!!!!!restlessness!2.!REDUCED!ATTENTION!SPAN!•  Easily!distrac*ble'EMOTIONAL!CHANGES!• !Irritability,!labile!mood!3.!DISORGANIZED!THINKING!•  Rambling,!incoherent!thought'PSYCHOSIS!• !Hallucina*ons'4.!VARIABLE!Level!Of!Consciousness!!!!!!!!!!!!Vigilant!!!!!!!!!!!!!!!!!Comatose!•  Delusions!•  Suspiciousness!SLEEP!DISTURBANCE!•  DayCnight!reversal'CLINICAL!PRESENTATION!WHAT'ARE'THE'SUBTYPES?'DELIRIUM'SUBTYPE' COMMENTS'1.'Hyperalert,'Hyperac;ve!!''''Over!s*mulated!mental!state!with!aggressive,!agitated!behaviors!2.'Hypoalert,'Hypoac;ve'''''Apathe*c,!lethargic!mental!state!that!can!be!mistaken!for!sleep!or!depression!3.'Mixed,'Variable'''''Combina*on!of!hyperC!and!!!!!!!hypoac*ve!features!that!can!!!!fluctuates!between!!!!!!!agita*on!and!apathy''DELIRIUM'SCREENING'with'CAM:'Confusion'Assessment'Method!In'the'past'24'hours,'has'the'pa;ent'had'any'of'the'following'features:'1.  ACUTE/RAPID'ONSET'&'FLUCTUATING'''''''''''COURSE'2.  'INATTENTION'3.  'DISORGANIZED'THINKING'4.  'ALTERED'LOC'Key:'To!have!delirium,!the!pa*ent!must!have!features!1!!!!!!!!!!!!!!and!2!plus!either!3!or!4!''''ASSESSMENT:'PRISMdE'P' •  Pain'•  Psychosocial'R' •  Reten;on'•  Risk'factors'(Agita;on;'Safetydfalls,'elopement)'I' •  Incon;nence''•  Impac;on'•  Intakedoral'•  Infec;on'•  Impaired'cogni;on'S' •  Sensory'losses'•  Sleep'depriva;on'•  Social'isola;on'M' •  Medica;ons' •  Metabolic'E' •  Environment''''''''''''''''''''''''''''''''Vancouver Coastal Health, 2007; 2013 IATROGENESIS (Adverse Effects of Hospitalization) •  Sensory deprivation •  Social isolation •  Cognitive/functional decline •  Depression •  Facility placement •  Early death IS'IT'DELIRIUM'OR'DEMENTIA'OR'BOTH?''2D'COMPARISON'DELIRIUM' DEMENTIA'Defini;on' Acute!&!usually!reversible!loss!of!cogni*ve!func*on!due!to!health,!func*onal,!social!&/or!environmental!changes'Chronic'&'progressive'loss'of'brain'cells'resul;ng'in'decreased'daydtodday'cogni;on'and'func;on'Onset''' Sudden,!abrupt,!hours!to!days' Slow,'oXen'unrecognized'in'early'stages'Course' Fluctuates!over!24!hours;!may!be!worse!at!twilight!or!at!night'Chronic'&'progressive;'stress'may'produce'more'rapid'change'Dura;on''' Hours,!weeks!or!months' Months'to'years'(8d20)'Ajen;on' Impaired,!fluctuates' Generally'normal'Alertness' Increased,!decreased,!or!variable' Generally'normal'Thinking' Disorganized,!distorted,!fragmented,!incoherent,!slowed!or!accelerated!'Decreased'thought'content;'difficulty'with'abstract'ideas,'worddfinding'difficulty''LOC' Increased,!decreased!and/or!fluctuates' Generally'clear'DELIRIOUS'and'at'RISK'Which!pa*ent!is!most-at-risk!with!delirium?!1.  Sleep!/!wake!cycle!disrupted,!comba*ve,!hearing!someone!call!their!name!2.  Quiet,!smiling,!rarely!asking!for!anything,!seems!“pleasantly!confused?”!Developmental'Tasks'of'Aging:'Loss,'Change'&'Becoming'the'Older'Genera;on'•  Role!changes:!re*rement,!loss/disability!of!partner/spouse!•  Normal!biological!changes,!func*oning,!appearance!•  Loss!related!to!health,!death!of!family!members,!friends,!finances!•  Challenging!*me!and!mortality!•  Intergenera*onal!changes!in!rela*onships!•  Modula*ng!dependence!&!independence!             Buckwalter & Piven, 1999; RNAO, 2003 What'is'Depression?'•  Significant!mental!health!problem!in!older!adults!•  Depression!+/C!demen*a!ozen!unrecognized/!untreated!•  Major!Depressive!Disorder!(DSM!IV)!•  Must!have!depressed!mood!+/C!anhedonia!plus!1!of:!•  Weight!loss!•  Sleep!disturbance!•  Psychomotor!agita*on/retarda*on!•  Fa*gue!•  Feelings!of!worthlessness!•  Inability!to!concentrate/indecisiveness!•  Thoughts!of!death;!suicide!idea*on/aQempt!Brown et al., 2007 WHY'SCREEN'FOR'DEPRESSION?'•  May!progress,!especially!when!untreated!•  Does!not!resolve!with!*me!(unlike!bereavement,!SAD)!•  May!lead!to!severe!symptoms!•  Excessive!soma*c!complaints,!suicidal!gestures/!!!!!!idea*on,!psychosis!(hallucina*ons,!delusions),!aggression,!cogni*ve!decline,!death!•  Major!risk!for!suicide,!especially!men!– 1.3!suicides!daily!in!Canada!•  NBC!Segment!on!Depression!!Brown et al., 2007; Smith et al., 2011 Es;mated'Prevalence'– !Canada:!14%!– !Community:!14!–!30%!– !Hospital:!12!–!45%!– !LTC:!!>!40%!CIHI, 2011; Smith et al., 2011 ESTIMATED'PREVALENCE'Condi;on' Prevalence'(%)'Hemodialysis' 6d34'Coronary'Artery'Disease' 17d23'Cancer' 20d50'Stroke' 19d23'Parkinson’s'Disease' 27d51'Alzheimer’s'Disease'(mild)' 28d53'Alzheimer’s'Disease'(moderate'–'advanced)'36d68'Hypothyroidism' 56d80'Diabetes'Mellitus' 9d27'Adapted from: Piven, 2005; Smith et al. 2011 •  Female!•  Widowed/divorced/!estranged!•  History!of!depression!•  Major!disease/illness!•  Physical!disability!•  Polypharmacy!•  Social!isola*on!•  Previous!aQempts!at!self!harm!•  Chronic!pain!•  Chronic!use!of!alcohol,!drugs!•  Adverse!life!events!•  Caregiver!for!another!•  Loss!of!independence!•  Sleep!disturbance!Risk'Factors'for'Depression'Brown et al, 2007; Smith et al., 2011 Implica;ons'of'Depression:'Acute'Care!Why'Depression?'• Addi*ve!effect!of!health!problems,!hospitaliza*on!• CoCexist!with!illness!• Leads!to!more!pain,!illness!symptoms!&!↓!physical,!social!&!role!func*oning!• Func*onal!decline!Implica;ons?!•  ↓!par*cipa*on!in!!ADLs,!D/C!plans!•  Competency!•  ↑!length!of!stay!•  Delirium!risk!•  Transi*on!challenges!•  Readmission!risk!TRIAD!of!DEPRESSIVE!SYMPTOMS!Mood' Percep;on' Soma;c'•  Anxiety,!panic!•  Crying!•  InaQen*on!•  Social!withdrawal!•  Func*onal!decline!•  Sleep!disturbance!•  Fa*gue!•  Irritability! •  Hopelessness!•  Fearfulness!•  Appe*te!changes!(+/)!•  Cons*pa*on,!tachycardia!•  Paranoia! •  Hallucina*ons! •  Speech!changes:!slowed,!paused!monotone!•  Sadness,!guilt!•  Low!mood!•  Delusions!(poverty)!•  Suicide:!thoughts,!aQempts!Adapted from: Buckwalter & Piven, 1999; RNAO, 2003 •  Combina*on!of!apprehensive!expecta*ons!&!worried!that!are!unrealis*c/excessive!• Restlessness,!feeling!“keyed!up/on!edge”!• Fa*gue!• Inability!to!concentrate!• Irritability!• Muscle!tension!• Sleep!disturbance!Anxiety'Smith et al., 2008 Assessment'Tools'1.  Geriatric'Depression'Scale''–  GDSC4!Short!Form!(Isella!et!al.,!2001)!–  Ques*onnaire!used!to!validate!risk!factors!&!symptoms!with!pa*ent!2.  Sig:'E'Caps'(Rivard,!1999)!–  Observa*onal!screen!based!on!DSMCIV!ASSESSMENT'TOOLS:'SIG:'E'CAPS'Sleep!disturbance!Loss!of!interest!Feelings!of!guilt!Low!energy!&!excessive!fa*gue!Concentra*on!&!cogni*ve!difficul*es!Appe*te!disturbance!Psychomotor!changes!Suicidal!idea*on!   Positive Screen: Daily presence of 5+ symptoms for 2 weeks Rivard, 1999 Depression'&'Memory'Depression'&'Cogni;on'Rather!than!viewing!behaviors!from!the!caregiver’s!perspec*ve!as!disrup*ve!or!agitated,!they!are!assessed!from!the!pa.ent’s-point-of-view!as!expressions!of:!NEEDdDRIVEN'DEMENTIA'COMPROMISED''(NDDC)'BEHAVIOR'!  My!behavior!is!meaningful!communica*on.!I!am!trying!to!reach!out!to!tell!you!what!I!need.!!!  Understanding!my!behavior!is!key!to!helping!me!meet!my!needs!&!goals.!!  Your!caring!response!will!help!reduce!my!feelings!of!!danger!&!anxiety.!NEEDdDRIVEN'DEMENTIA'COMPROMISED'(NDDCB)'BEHAVIOR'Pa;ent’s'Perspec;ve'Myth'or'Reality'1.  Most!pa*ents!with!demen*a!become!agitated!and!aggressive.!3.  Pa*ents!with!demen*a!frequently!behave!in!ways!that!are!challenging!just!to!get!aQen*on.!NEEDdDRIVEN''DEMENTIA'COMPROMISED''(NDDC)'BEHAVIOR'Adapted from: Alzheimer’s Society 2011 ASSESSMENT:'4'LENSES'•  Physical/emo*onal!•  Environment!•  TaskCrelated!•  Communica*on!ASSESSING'BEHAVIOR'1.''ASSESS'THE'BEHAVIOR(S)'! What!is!the!behavior?!Examples:!pushing!away,!calling!out,!throwing!objects,!hipng!staff,!spipng,!striking!out!! Is!the!current!behavior!a!change!from!usual?!!! Check!collateral:!Physician,!community,!team!members!(SW,!discharge!planner)!! Be!specific!!AVOIDING'OPINIONS,'LABELS'&'JARGON'ASSESSING'BEHAVIOR'2.!When!does!the!behavior!occur?!•  Examples:!evening/at!night,!family!arriving/leaving,!!!prior!to!pain!medica*ons!• !What!ac*vates!the!behavior?!Examples:!personal!care,!invasion!of!personal!space,!speed!of!care!giving,!toile*ng!needs!3.'WHAT'HAPPENS'BEFORE/'AFTERWARDS?'4.!WHAT'MAKES'THE'BEHAVIOR'BETTER?'WORSE?''''DOES'THE'PATIENT'HAVE'AN'AGENDA?'5.'WHAT'ARE'THE'PATIENT’S'GOALS'&'UNMET''''''NEEDS?!ASSESSING'BEHAVIOR'ASSESSMENT'TOOLS'" 'BEHAVIOR'LOG''" 'SLEEP'&'AGITATION'LOG'" 'COHENdMANSFIELD'AGITATION'''''''''INVENTORY'(CMAI)'CARE'PLAN'GOALS'1.  Understand!the!pa*ent’s!views,!values,!beliefs!2.  Discuss!assessment!findings!with!pa*ent,!family,!caregivers,!staff!3.  Determine!the!in*mate!zone!&!respect!personal!!boundaries!4.  Provide!structure/distrac*on!at!high!risk!*mes!5.  Provide!pa*ent/family!accurate!informa*on,!educa*on!INTERVENTIONS''Modify'Physical'Environment'1.  Reduce!s*mula*on:!noise,!lights,!people!2.  Reduce!shadows!&!glare!3.  Place!equipment!out!of!sight!4.  Provide!safe!wandering,!hoarding!5.  Assess!+/C!interac*ons!6.  Assess!bed!safety!INTERVENTIONS'With'Each'Interac;on:'1. !Comfort!2. !AQen*on!3. !Orienta*on!!  !CONSTANT'OBSERVATION'•  !Iden*fy!&!prevent!triggers!•  !Watch!for!escala*on!•  !!Intervene!early!!  !ASSESS'OVERALL'HEALTH'•  !Pain/discomfort,!PRISMCE!!  !MEDICATIONS'•  !Regular!&!PRNs!!  !COMMUNICATION'True'or'False?'1.  It’s!ok!to!leave!the!pa*ent!out!of!the!conversa*on!because!she/he!cannot!understand!what!is!going!on!anyway.!3.  Pa*ent!should!be!orientated!to!reality!to!keep!their!brain!healthy.!_______________________________________________________________!3.!!! Which!cue!should!you!give!to!an!aggressive!pa*ent!before!talking!with!them?!a)  Visual! ! c)!!Verbal!b)  !Touch!! d)!!It!depends!on!what!I!do!best!NEED'DRIVEN'DEMENTIA'CARE' 'Communica;on:'The'Essen;als'of'Understanding'Goals'&'Needs'Communica;on:'The'Essen;als'of'Understanding'Goals'&'Needs'# Repeat!important!informa*on!# Show/demonstrate!&!talk!# Simplify!what!you!say!&!take!your!*me!# Always!explain!what!is!going!to!happen!# Check!your!approach!•  Watch!your!body!language!#  Don’t!argue,!scold,!or!treat!like!a!child!#  Don’t!tell!the!pa*ent!what!he/she!can’t!do!#  Don’t!ask!a!lot!of!ques*ons!that!rely!on!memory!#  Don’t!talk!about!the!pa*ent!in!front!of!them!#  Don’t!try!to!convince!the!pa*ent!that!their!experience!(see,!hear,!smell!or!believe)!is!not!real!Communication: What Not To Say: Top 5 NURSING'APPROACHES'1. Provide!structure:!Minimize!changes!in!rou*ne,!caregivers,!rooms!2. Distrac*on!3. Environmental!modifica*on!!4. 1:1!socializa*on!!5. Modified,!individualized!rou*nes!!6. Music,!aromatherapy,!meaningful!ac*vi*es!7. Caregiver!educa*on!73 ! Stress,!pace,!turnover!! Emphasis!on!tasks,!meds,!procedures,!discharges!! Crisis!vs!preventa*ve!approach!! Culture!of!safety!CHALLENGES'“Caring'For'Self'While'Caring'For'Others”'! Never,-ever!enter!high!risk!ac*vi*es!alone!1.  !History!of/new!onset!aggression!!2. !New!pa*ent!with!risk!factors!3. !Pa*ent!with!unpredictable!behavior!! Always!enter!with!an!exit!plan!! Always!delay!ac*vi*es!un*l!help!arrives!! Avoid!catch!up!with!medica*ons!STAFF'SUPPORT:'NEEDdDRIVEN'DEMENTIA'CARE'“Caring'For'Self'While'Caring'For'Others”'“Caring'For'Self'While'Caring'For'Others”'Four Steps towards Better Communication with Patients with Dementia  1. Start the interaction in a conversational manner x Approach from the front, calmly and slowly x Make eye contact x Call the patient by their preferred name x State who you are and why you are there x Allow time for a response x Begin in a conversational manner—not task focused  2. Simplify what you say x Use questions that can be answered “yes” or “no” x Use simple, short sentences x Provide choices when possible x Rephrase your sentences  3. Check your approach x Modify your verbal message, tone of voice, rate of speech, volume  x Suggest or invite, don’t tell, as an approach to begin a task x Check your non-verbal message, body language, facial expression, use of touch x Always ask permission before touching  4. Be supportive x Provide the words that the patient is looking for x Listen for the patient’s emotional message in his/her: x Tone of voice x Body language x Facial expression x Validate the emotional message with empathy and acceptance                Adapted from: GeroPsychiatric Education Program (2008), Vancouver Coastal Health Making physical sexual advancesFaire des avances sexuelles physiquesAnciens CombattantsCanadaVeterans AffairsCanadaCohen-Mansfield Agitation Inventory (CMAI) - BehaviourÉvaluation de l'agitation Cohen-Mansfield (CMAI) - Comportement< 1 time/wk< 1 fois par   semaine1-2 times/wk1 ou 2 fois parsemainefew times/wkQuelques foispar semainePhysical, AggressiveAgitation physique agressiveHitting self/othersFrapper les autres/se frapperKickingDonner des coups de piedGrabbing onto peopleS'agripper aux autresPushingBousculerThrowing thingsLancer des objetsBitingMordreScratchingGrifferSpittingCracherHurt self/othersSe blesser/blesser les autresTearing things/destroying propertyDéchirer des objets/détruire des biens1-2 times/day1 ou 2 foispar jourfew times/dayQuelques foispar jourfew times/hrQuelques foispar heureProtected when completed.Protégés une fois rempli.Veterans family nameNom de famille de l'ancien combattantVeterans given name(s)Prenom(s) de l'ancien combattantFile No. - Nº de dossier Date of assessmentDate de l'évaluationVAC 599 (2006-09) Page 1 of/de 2I would like to ask you about certain specificbehaviours sometimes seen in older persons.Some are verbal. Some are physical. Some arequiet behaviours and others are disruptive.I do not expect that all of these behaviours applyto your relative (client).TotalJe voudrais vous demander des questions sur certains comportements remarqués chez les personnes plusâgées. Certains sont verbaux. Certains sont physiques.Certains comportements sont silencieux alors qued'autres sont perturbateurs. Je ne m'attends pas à ceque tous ces comportements s'appliquent à votreparent (client).NeverJamaisDateDesignation - DésignationSignatureVAC 599 (2006-09) Page 2 of/de 2Cohen-Mansfield Agitation Inventory (CMAI) - Behaviour (continued)Évaluation de l'agitation Cohen-Mansfield (CMAI) - Comportement (suite)Constant unwarranted request forattention/helpRecherche constante d'attention/aideinjustifiéeGeneral restlessnessÊtre dans un état d'agitation généraleVerbal, AggressiveAgitation verbale agressiveScreamingPousser des hurlementsMaking verbal sexual advancesFaire des avances sexuelles verbalesCursing or verbal aggressionProférer des jurons et agresser verbalementNeverJamais< 1 time/wk< 1 fois par   semaine1-2 times/wk1 ou 2 fois parsemainefew times/wkQuelques foispar semaine1-2 times/day1 ou 2 foispar jourfew times/dayQuelques foispar jourfew times/hrQuelques foispar heureVerbal non-aggressiveAgitation verbale non agressiveRepetitive sentences or questionsRépéter des phrases ou des questionsStrange noises (weird laughter/crying)Émettre des bruits bizarres (pleurs/riresétranges)ComplainingRâlerNeverJamais< 1 time/wk< 1 fois par   semaine1-2 times/wk1 ou 2 fois parsemainefew times/wkQuelques foispar semaine1-2 times/day1 ou 2 foispar jourfew times/dayQuelques foispar jourfew times/hrQuelques foispar heureNegativismNégativismeNeverJamais< 1 time/wk< 1 fois par   semaine1-2 times/wk1 ou 2 fois parsemainefew times/wkQuelques foispar semainePhysical, Non-aggressiveAgitation physique non agressivePace, aimless wanderingDéambulerInappropriate dress/disrobingS'habiller de façon inappropriée/se déshabillerTrying to get to a different placeEssayer d'aller ailleursIntentional fallingTomber volontairementEating/drinking inappropriate substancesManger/boire des produits non comestiblesHandling things inappropriatelyManipuler des objets de façon non conformeHiding thingsCacher des objetsHoarding thingsAmasser des objetsPerforming repetitive mannerismsAvoir des tics1-2 times/day1 ou 2 foispar jourfew times/dayQuelques foispar jourfew times/hrQuelques foispar heureTotalTotalTotalComplete totalTotal complétéGERIATRIC DEPRESSION SCALE - GDS-4: Short Form with SIGECAPS  Ask the following 4 questions:    1. Are you basically satisfied with your life? □ Yes □ NO   2. Do you feel that your life is empty? □ YES □ No    3. Are you afraid that something bad is going to happen to you? □ YES □ No    4. Do you feel happy most of the time? □ Yes □ NO   Answers in capitals score 1. Score of 1 or more indicates possible depression.    SIG E CAPS  Depressive Symptoms:   At least 5 of the following symptoms* have been present nearly every day, for most of the day, during the same 2-week period and represent a change from previous functioning.    S - Sleep is disturbed.    I - Interest is decreased.   G - Guilt (feelings of guilt are common, having regrets, etc.).   E - Energy is lower than usual.   C - Concentration is poor and memory problems may be exacerbated.   A - Appetite is disturbed, usually a loss of appetite accompanied (or not) by weight loss.   P - Psychomotor retardation or agitation   S - Suicidal ideation, at least a passive wish to die, is frequently present.   Standardised Mini-Mental State Examination (SMMSE)Molloy DW, Alemayehu E, Roberts R. Reliability of a standardized Mini-Mental State Examination compared with the traditional Mini-Mental state Examination. American Journal of Psychiatry, Vol. 14, 1991a, pp.102-105.The Standardised Mini-Mental State Examination (SMMSE) is the copyright of Dr D.W. Molloy and may not be reproduced without the written consent of the author./ 1/ 1/ 1/ / 30Takes paper in correct hand....................Folds it in half....................Puts it on the floor....................TOTAL TEST SCORE:ADJUSTED SCORE :Name of examiner:Name of patient: DOB:Date of test:Say: I am going to ask you some questions and give you some problems to solve. Please try to answer as best you can. 1.  (Allow 10 seconds for each reply). Say:a) What year is this? (Accept exact answer only) .................................................................................................................................................................................................b) What season is this? (During the last week of the old season or first week of a new season, accept either)............................................................................c) What month is this? (On the first day of a new month or the last day of the previous month, accept either)........................................................................d) What is today’s date? (Accept previous or next date)....................................................................................................................................................................................e) What day of the week is this? (Accept exact answer only) .........................................................................................................................................................................2.  (Allow 10 seconds for each reply). Say:a) What country are we in? (Accept exact answer only) ...................................................................................................................................................................................b) What county are we in? (Accept exact answer only)......................................................................................................................................................................................c) What city/town are we in? (Accept exact answer only)................................................................................................................................................................................d) (At home) What is the street address of this house? (Accept street name and house number or equivalent in rural areas)(In facility) What is the name of this building? (Accept exact name of institution only).................................................................................................................e) (At home) What room are we in? (Accept exact answer only)(In facility) What floor of the building are we on? (Accept exact answer only)....................................................................................................................................3.  Say:  I am going to name three objects. When I am finished, I want you to repeat them. Remember what they are because I am  going to ask you to name them again in a few minutes (Say slowly at approximately one-second intervals).For repeated use: Bell, jar, fan; bill, tar, can; bull, bar, panSay: Please repeat the three items for me. (Score one point for each correct reply on the first attempt) .............................................................................................Allow 20 seconds for reply; if the person did not repeat all three, repeat until they are learned or up to a maximum offive times. (But only score first attempt).4.  Spell the word WORLD. (You may help the person to spell the word correctly) Say: Now spell it backwards please (Allow 30 seconds; if the   subject cannot spell World even with assistance, score 0) Refer to accompanying guide for scoring instructions (Score on reverse of this sheet)................5.  Say: Now what were the three objects I asked you to remember? ...................................................................................................................................................................... (Score one point for each correct answer regardless of order; allow 10 seconds)6.  Show wristwatch. Ask: What is this called? ................................................................................................................................................................................................................... (Score one point for correct response; accept “wristwatch” or “watch”; do not accept “clock” or “time”, etc.; allow 10 seconds)7.  Show pencil. Ask: What is this called? .............................................................................................................................................................................................................................. (Score one point for correct response; accept “pencil” only; score 0 for pen; allow 10 seconds for reply)8.  Say: I would like you to repeat a phrase after me: No ifs, ands, or buts............................................................................................................................................................... (Allow 10 seconds for response. Score one point for a correct repetition. Must be exact, e.g. no ifs or buts, score 0)9.  Say: Read the words on this page and then do what it says......................................................................................................................................................................................... Then, hand the person the sheet with CLOSE YOUR EYES (score on reverse of this sheet) on it. If the subject just reads and does not close eyes,   you may repeat: Read the words on this page and then do what it says, (a maximum of three times. See point No. 3 in Directions for Administration   section of accompanying guide). Allow 10 seconds, score one point only if the subject closes eyes. The subject does not have to read aloud.10. Hand the person a pencil and paper. Say: Write any complete sentence on that piece of paper. (Allow 30 seconds. Score one point.   The sentence must make sense. Ignore spelling errors)...............................................................................................................................................................................................11. Place design (see reverse of this sheet), pencil, eraser and paper in front of the person. Say: Copy this design please. Allow multiple tries.   Wait until the person is finished and hands it back. Score one point for a correctly copied diagram. The person must have drawn   a four-sided figure between two five-sided figures. Maximum time: One minute...........................................................................................................................................12. Ask the person if he is right or left handed. Take a piece of paper, hold it up in front of the person and say the following:   Take this paper in your right/left hand (whichever is non-dominant), fold the paper in half once with both hands and put the paper down on the floor. / 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 3/ 5/ 3/ 1/ 1/ 1/ 1/ 1/ 1Ball Car ManPlease see accompanying guide for directions for administration D L R O W =CLOSE YOUR EYESTime: ..................................................................References: 3Ds Dementia, Delirium, Depression Algase, D. L., Beck, C., Kolanowski, A., Whall, A. et al. (1996). Need-driven dementia- compromised behavior: An alternative view of disruptive behavior. American Journal of  Alzheimer’s Disease, 11, 10-19. Alzheimer’s Society of B. C., & Interior Health Authority of BC. (2009; rev. 2010). Making the  connection: Presenter’s notes. Available at: Alzheimer Society of B.C. - Resources for  Health Care Providers. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental     disorders (4th ed.). Arlington, VA: Author. Buckwalter, K. C. & Piven, M. L. (1999). Depression. In J. K. Stone, J. F. Wyman, & S. A.  Salisbury (Eds.), Clinical gerontological nursing: A guide to advanced practice (pp.  267-288). Philadelphia, PA: Saunders Brown, E., Rave, P. J. & Halpert, K. D. (2007). Detection of depression in older adults with  dementia. In D. P. Shoenfelder (Series Ed.). Series on evidence-based practice  guidelines for older adults. Iowa City, IA: University of Iowa College of Nursing  Gerontological Nursing Interventions Research Center, Research Translation and  Dissemination Core. Available at: Evidence-Based Practice Guidelines. Canadian Institute for Health Information. (2011). Information sheet: Seniors and Mental Health.  Available at: Seniors Mental Health. Dalziel, W. B. (2008). Dementia screening and assessment. Regional Geriatric Program of  Ontario. Available at: Dementia Assessment. DeVane, C., & Mintzer, J. (2008). Risperidone in the management of psychiatric and behavioral  symptoms of dementia. Encephale, 34(4), 409-15. Epub 2008 Jan 14.  Fletcher, K. (2008). Dementia. In E. Capezuti, D. Zwicker, M. Mezy & T. Fulmer (Eds.),  Evidence-based geriatric nursing protocols for best  practice (pp. 309-336). New York,  NY: Springer. Fick, D. (2007). Assessing and managing delirium in older adults with dementia, Try This: Best  practices in nursing care to older adults, D8. Available at: Geriatric Nursing  Resources for Care of Older Adults. Folstein, M. F. Folstein, S. E. & McHugh, P. R. (1975). “Mini-Mental State” A practical       method for grading the cognitive state of patients for the clinician. Journal of Psychiatric  Research, 12, 189-198. Greenberg, S. A.(2007). The geriatric depression scale: Short Form. American Journal of  Nursing, 107(10), 60-66. Isella, V., Villa, M. L., & Appollonio, I. M. (2001). Screening and quantification of depression       in mild-moderate dementia through the GDS short forms. Clinical Gerontologist, 24(3/4),  115-125. McGonigal-Kenney, M. L., & Schutte, D. L. (1995; rev 2005). Non-pharmacologic management  of agitated behaviors in persons with Alzheimer disease and other dementing conditions.  In M. G. Titler (Series Ed.), Series on evidence-based practice guidelines for older  adults. Iowa City, IA: University of Iowa College of Nursing Gerontological Nursing  Interventions Research Center, Research Translation and Dissemination Core. Available  at: Evidence-Based Practice Guidelines. Milisen, K., Braes, T., Fick, D. M., & Foreman. (2006). Cognitive assessment and differentiating  the 3 Ds (dementia, depression, delirium). (2005). Nursing Clinics of North America, 11,  1-22.           Piven, M. L. (1998; rev 2005). Detection of depression in the cognitively intact older adult  evidence-based guideline. In D. P. Shoenfelder (Series Ed.). Series on evidence-based  practice guidelines for older adults. Iowa City, IA: University of Iowa College of Nursing  Gerontological Nursing Interventions Research Center, Research Translation and  Dissemination Core. Available at: Evidence-Based Practice Guidelines. Registered Nurses Association of Ontario. (2003, Rev. 2010). Screening for delirium,     dementia and depression in older adults. Available at: Screening for Delirium Dementia  and Depression. Rivard, M. F. (1999). Late-life depression: Diagnosis (Part 1). Parkhurst Exchange, 64-67 Rudolph, J. L., & Marcantonio, E. R. (2011). Postoperative delirium: Acute change with long- term implications. Anesthesia & Analgesia, 112(5), 1202-1211. Sendelback, S., & Guthrie, P. F. (1998; rev 2009). Acute confusion/delirium. In D. P.  Shoenfelder (Series Ed In D. P. Shoenfelder (Series Ed.), Series on evidence-based  practice guidelines for older adults. Iowa City, IA: University of Iowa College of Nursing  Gerontological Nursing Interventions Research Center, Research Translation and  Dissemination Core. Available at: Evidence-Based Practice Guidelines. .Smith, M., & Buckwalter, K. (2005). Behaviors associated with dementia . American Journal of  Nursing, 105(7), 40-52. Smith, M., Ingram, T., & Brighton, V. (2008). Detection and assessment of late life anxiety. In D.  P. Shoenfelder (Series Ed.), In D. P. Shoenfelder (Series Ed.). Series on evidence- based practice guidelines for older adults. Iowa City, IA: University of Iowa College of  Nursing Gerontological Nursing Interventions Research Center, Research Translation  and Dissemination Core. Available at: Evidence-Based Practice Guidelines. Smith, C. M., & Cotter, V. T. (2008). Age-related changes in health. In E. Capezuti, D. Zwicker,  M. Mezey & T  Fulmer (Eds.), Evidence-based geriatric nursing protocols for best  practice 3rd ed. (pp.431-458). Springer: New York, NY. Wiese, B. (2011). Geriatric depression: the use of antidepressants in the elderly. B. C. Medical  Journal, 53(7), 341-347. Woods, D. L. (2013). Evening cortisol is associated with intra-individual instability in daytime  napping in nursing home residents with dementia: An allostatic load perspective.  Biological Research for Nursing, 14(4), 387-395. Tullman, D. F., Mion, L. C., Fletcher, K., & Foreman, M. D. (2008). Delirium: Prevention, early  recognition and treatment. In E. Capezuti, D. Zwicker, M. Mezey & T. Fulmer (Eds.),  Evidence-based geriatric nursing protocols for best practice 3rd ed. (pp.111-125).  Springer: New York, NY. Vancouver Coastal Health. (2007). Clinical Practice Document (C-590): Delirium/acute  confusion: Care of older adults. Available at: CPD C-590 - Delirium/Acute Confusion October 2013  Quality(Improvement:(Pa3ent(&(Family(Centered(Care(at(the(Unit(and(Systems(Level(Learning(Objec-ves(!  Describe(quality(improvement(and(characteris-cs(of(a(QI(process(!  Iden-fy(a(local(quality(improvement(issue(in(your(workplace(!  Consider(how(to(address(local(quality(improvement(issues(by(a)(iden-fying(the(problem/issue,(b)(ar-cula-ng(the(standard(that(should(be(met,(and(c)(exploring(poten-al(avenues(for(mee-ng(the(standard(What(is(Quality(Improvement?(…the%combined%and%unceasing%efforts%of%everyone—healthcare%professionals,%pa8ents%and%their%families,%researchers,%payers,%planners%and%educators—to%make%the%changes%that%will%lead%to%be<er%pa8ent%outcomes%(health),%be<er%system%performance%(care)%and%be<er%professional%development.%%This%defini8on%arises%from%our%convic8on%that%healthcare%will%not%realize%its%full%poten8al%unless%change%making%becomes%an%intrinsic%part%of%everyone’s)job,%every%day,%in%all%parts%of%the%system.%%Batalden%&%Davidoff:%What%is%“quality%improvement”%and%how%can%it%transform%healthcare?%Qual%Saf%Health%Care%(2007),%16(1),%2W3.%doi:%doi:10.1136/qshc.2006.022046% Linked aims of improvement. Batalden P B , and Davidoff F Qual Saf Health Care 2007;16:2-3 Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved. Where(to(start?(•  Problem(iden-fica-on(– Understanding(current(prac-ce,(iden-fying(poten-al(gaps(•  Iden-fy(the(desired(outcome(of(the(improvement(– Defining(the(standard(of(prac-ce((– Determine(measures(of(success(•  Brainstorming(– What(op-ons(may(solve(the(problem?(•  Planning(the(change(– Implemen-ng(PDCA(cycle(Plan,(Do,(Check,(Act(•  Plan(– Determine(goals(and(targets(– Determine(methods(of(reaching(goals(•  Do(– Determine(methods(of(educa-on(and(training(–  Implement(your(plan(•  Check(– Check(the(effects(of(implementa-on((e.g.(audit(tools)(•  Act(– Take(appropriate(ac-on((e.g.(adapt(plan(if(necessary)(Ingredients(for(Success(•  Local(champions(at(the(point(of(care(•  Mentoring(&(support(from(managers(and(clinical(leaders(•  Sharing(experiences(of(local(quality(improvement(ac-vi-es(References(Shafer,(L.,(&(Aziz,(M.G.(((2013).(Shaping(a(unit’s(culture(through(effec-ve(nurse^led(quality(improvement.(MEDSURG%Nursing,%22(4),(229^236.(Wiechula,(R.,(Kitson,(A.,(Marcoionni,(D.,(Page,(T.,(Zeitz,(K.,(&(Silverston,(H.(((2009).((Improving(the(fundamentals(of(care(for(older(people(in(the(acute(hospital(secng:(facilita-ng(prac-ce(improvement(using(a(knowledge(transla-on(toolkit.%%Int%J%Evid%Based%Healthc,%7,(283^295.(Working(in(teams(and(at(the(unit(or(program(level,(bring(to(the(October(GET(Workshop(the(first(2(steps(in(the(QI(process:(1)  Iden-fy(a(problem(or(area(for(improvement(2)  Iden-fy(the(desired(outcome(  GET Program DAY 2  Consequences of Hospitalization          Geriatric Education & Training Program Course Schedule    Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013    Time Topic   0830 Survey #1  0900 Welcome & Introductions  0930 Patients & Families as Partners in Care x Personhood x Patient & Family Centered Care  1000 Break  1015 The Nursing Process: Bringing Patient Centered Care to the Point of Care  1115 Quality Improvement: Thinking about Patient & Family Centered Care at the Unit and Systems Level  1200 Lunch x Lunch & Learn: Library Services  1300 3Ds: Delirium, Dementia, Depression  1615 Evaluation/Feedback on the day           Geriatric Education & Training Program Course Schedule    Day 2: Consequences of Hospitalization October 16, 2013    Time Topic   0830  0900 Introduction  Iatrogenesis: Going Downhill in Hospital  0930 Break  0945 Iatrogenesis Going Downhill in Hospital (cont’d)  1115 Clinical Case Presentations   1200 Lunch  1300  1345 Clinical Case Presentations (cont’d)  Quality Improvement Project: Team work time   1500 Break  1515 Challenges in Medications & Older Adults in Acute Care  1615 Evaluation/Feedback on the day       Day 2: Consequences of Hospitalization October 16, 2013  Please indicate your level of agreement with the statements below:    Strongly Agree Agree Neutral Disagree Strongly Disagree Comments  The content was organized and easy to follow   € € € € €  The objectives were clearly identified  € € € € €  Participation and interaction were encouraged   € € € € €  Questions and exchanges were encouraged  € € € € €  The material covered was relevant  € € € € €  The amount of time allowed to cover the material was sufficient  € € € € €  The training session met my expectations  € € € € €  Would you recommend this session to someone else?   € € € € €    See reverse         What did you find was the most helpful?        Any suggestions on what should be changed to improve the program.         Please use the area below for any additional comments:              Thank you for your feedbacks     1  GET Program Case Studies  Contents  GET Program Case Studies ................................................................................................................... 1 Case Presentation: ED & Falls .......................................................................................................... 2 Case Presentation: Delirium ............................................................................................................ 4 Case Presentation: Dementia .......................................................................................................... 6 Case Presentation:  Dysphagia ........................................................................................................ 8 Case Presentation: Mental Health .................................................................................................. 9 Case Presentation: Transition & Failure to Thrive (FTT) .............................................................. 11 Nursing Interventions for Older Adults/Families ......................................................................... 13 NURSING CARE PLAN FRAMEWORK.............................................................................................. 14 Teaching strategies for case studies ............................................................................................. 15       2  Case Presentation: ED & Falls  Mr. Brown is an 86 years old, widowed father and grandfather who lives independently. He has no community services in place and manages his own personal care and finances independently. Although he needs a cane outdoors and takes Handidart for appointments, Mr. B is active with a senior’s centre. His only daughter lives in another province. Mr. B has Parkinson’s disease, osteoarthritis and CHF and takes over 10 medications including antiarrthymics, analgesics and antihypertensives. Past medical history includes CABG X3, pacemaker and Type II Diabetes.   After Mr. B slipped and fell in his bathroom at home, his daughter, who was visiting at the time, called for an ambulance. Mr. B was then brought to the emergency department (ED) with a possible fractured right wrist.   Due to high demand upon his arrival, Mr. B was triaged (CTAS 5) and instructed to sit in the waiting room where he sat with his daughter for two hours. During this time, Mr. B was instructed not to eat or drink; however, he became increasingly restless and disoriented. Once in the ED, the admitting doctor completed an examination, requesting an X-ray and blood work. An IV was started as Mr B had developed dehydration with acute kidney injury (AKI). He was told to remain in bed until test results became available.   Soon after, Mr B’s daughter informed one of the nurses that her father had appeared more confused than usual in recent days, and was quite unsteady on his feet. The nurse made sure that the side rails were up and told Mr B not to get up by himself, but the information was not noted in the nursing notes or reported to the physician. Fall risk and mental status assessments were not performed. Since it was late in the evening and there was an unexpected delay in getting Mr B’s wrist casted, it was suggested to the daughter that she go home and call the ED first thing in the morning. Overnight, Mr B became even more confused, pulled out the IV and climbed off the stretcher. He fell and sustained bruising to his head, requiring a CT scan, and lacerations to his face, requiring sutures.   Mr B’s daughter returned the next day. She was distressed to find that her father did not recognize her. She was even more upset that measures had not been taken to manage her father’s risk of falls, particularly as she had specifically informed the nurse of his confusion and unsteadiness. Mr B has now been in ED for 14 hours and remained in bed during the entire period.   Questions: 1. Identify name the conditions (ie, acute/chronic, functional, family, psychosocial, environment)  which affected how Mr B was able to adapt to the ED? 2. How did these factors affect the outcome for Mr B (ie, length of stay, dependency on others, iatrogenic complications, comfort etc.)? 3. How would you assess and manage his falls risk and “confusion”? 4. Select and evaluate at least two interventions that you would apply in your care for Mr B? Why? 5. Consider the situation with Mr B’s daughter.  a. What stressors is the daughter experiencing? b. How would you address her views and needs?     3  Case adapted from: Victoria. Department of Health (2012). Best care for older people everywhere: The toolkit 2012. Dept. of Health, Melbourne, 276pp. Retrieved on June 1st, 2013 from http://docs.health.vic.gov.au/docs/doc/32A6DBBBE7D5512BCA257A9300019EAE/$FILE/1208011_BCOPE%20The%20Toolkit_WEB-3rdOct-v02.pdf      4  Case Presentation: Delirium   Mr Schwartz is an 82-year-old man, who wears glasses and has some hearing loss. Mr Schwartz had a fall at home while changing a light bulb and his neighbour, who heard his calls for help after a few hours, found him on the floor and called an ambulance. He was taken to hospital, where an X-ray revealed that he had a fractured neck of femur.   Prior to his presentation at the emergency department (ED), Mr Schwartz was living alone at home independently. Past medical history includes a recent diagnosis of Atrial Fibrillation for which he receives Metoprolol and Coumadin, and mild memory changes noticed by his daughter.  In the ED, the admitting doctor completed a head to toe medical examination and prescribed morphine 2.5 -5mg PO or 1-2 mg subcut Q4 h PRN for Mr Schwartz’s pain. Labs were drawn including CBC, electrolytes, BUN, Creatinine, Albumin, Glucose, INR and PTT.  His results were as follows – HBG 119, lytes normal, BUN & Creatinine slightly elevated, Glucose 6.8, Albumin slightly low, INR 2.3 and PTT normal.  Mr Schwartz is given 5mg morphine PO for pain, and an indwelling foley catheter is inserted.   Mr Schwartz is admitted to the Orthopeadic unit at 2200 hours that evening and is ordered NPO at 2400 hours at which time an IV of D5NS at 75cc / hr is started. He is also given a couple of units of FFP to reverse his INR in preparation for surgery with a repeated INR drawn in the AM. At 1700 hours the next day his surgery is postponed and he receives a dinner tray of which he eats 50%. His urinary output remains within normal limits. He is made NPO at 2400 hours again for OR in the morning.   At 0800 the next morning after receiving his INR result (1.4) Mr Schwarz if transferred to the OR to undergo a hemiarthroplasty of his R hip.   Following surgery, Mr Scwartz returns to the orthopaedic ward where his vital signs are monitored his temp is 37.5, P 88 and slightly irregular, BP 130 /80. His U/O remains approx 26 cc/hr, his pain is scored at 4-5/10. He is given morphine 1.5 mg s/c Q4h and 650 mg of Tylenol plain Q6H while awake.  The next morning his urinary catheter is removed at 0600. He is orientated to person, place and time.  After breakfast he is seen by Physio and assisted to take a few steps using a walker and is assisted to the chair.  His post op labs show his HBG is 89, Na 135, K+ 4.2, BUN Creatinine normal,   When Mr Schwartz’s daughter visited later that day, she found that he had not eaten any of his evening meal. He seemed confused, agitated and unable to keep track of their conversation. She was very concerned about her father’s deterioration and mentioned it to the nurse who was looking after him. The nurse, who had only met Mr Schwartz that afternoon, told his daughter that it was not uncommon for older people to be a ‘bit confused’ for a couple of days after having an anaesthetic.   The next afternoon when Mr Schwartz’s daughter visited, he was less responsive than the day before. He was in bed and seemed unaware of her presence; staring into space. She spoke to the nurse, who took a set of vital signs (temperature 37.5, pulse 98, respirations 12, blood pressure 120/65 and oxygen saturation 92%) and tested Mr Schwartz’s urine, which showed signs of infection ( positive for nitrites and WBC) with frequency and urgency.      5   Questions: 1. In this scenario, name the conditions (ie, acute/chronic, functional, family, psychosocial, environment) which contributed to Mr Schwartz delirium 2. What could have been done in order to reduce the risk of developing delirium? 3. Select and evaluate at least two interventions that you would apply to your care for Mrs Schwartz? Why? 4. How will delirium influence the course of Mr Schwartz hospitalization?    Case adapted from: Victoria. Department of Health (2012). Best care for older people everywhere: The toolkit 2012. Dept. of Health, Melbourne, 276pp. Retrieved on June 1st, 2013 from http://docs.health.vic.gov.au/docs/doc/32A6DBBBE7D5512BCA257A9300019EAE/$FILE/1208011_BCOPE%20The%20Toolkit_WEB-3rdOct-v02.pdf      6  Case Presentation: Dementia         Mr. Wong is an 80 year old man who lives with his wife. He speaks minimal English and needs help with ADLs and dressing. He uses a 2W walker at home. He had increased fatigue, SOB, orthopnea and cough x 2 weeks pre admission. He was sometimes dizzy when up and then collapsed one day en route to the BR at home. He was admitted with CHF exacerbation. Medical history: CHF - NYHA Stage III, A fib, CAD, HTN, renal insufficiency, gout, GERD, Chronic Kidney disease and from his previous admission in April, he had a ? dx of dementia vs  protracted delirium  (MMSE 23/28) He had recently visited his cardiologist who discontinued his Metoprolol and started him on Diltiazem. His meds at home included Lasix, Spironalactone, Nitropatch, Ranitidine, Warfarin, Diltiazam, Candasartan, Tamsulosin, Allopurinol Diet 2 GM Na+, 1.5 L Fluid restriction.    On admission to the unit:  TPR:  36.7 – 70 IR - 20, BP 109/70  O2 sats 98 % on 2 L O2/NP Labs – Troponins negative, CBC within normal limits, Na+ 116, K+ 6, Cr 140 CXray showed a large left pleural effusion and basal atelectasis  He was given IV Lasix and PO Kayexalate. He was ordered Nitropatch, Ranitidine, sc heparin, Allopurinol and Tamsulosin. Other cardiac meds were held till a Cardiology consult and Echo were done. Orthostatic BPs were ordered. (Standing BP was 40 mm Hg lower than lying.)  He had a Foley catheter inserted, and Oxygen applied via NP. He kept trying to remove his oxygen, Foley and Saline lock. He had a pigtail chest tube inserted for pleural effusion.  Caring for him was challenging as he kept trying to remove his tubes and calling out for his wife. Eventually his electrolytes and SOB improved and he no longer needed Oxygen, his chest drainage decreased and the chest tube was removed. However he still had bilateral +3 pitting edema of his lower legs and feet, - and couldn’t wear socks or shoes. Both his lower legs were weeping. He developed a blister on his R foot.  He was a slow eater and his intake remained poor - he only took about 30 % of his meals. He kept asking for his wife, and wouldn’t let staff wash him.  This am he did not let the nurse take his BP in his Right arm. The PCA noticed he winced when she touched his right elbow and it looked red and swollen.  When she tried to get him up for breakfast, he hit her in the arm. The Aggressive Alert was initiated and loxapine was prescribed and given liberally that day and night. The next day he was drowsy, slept through his breakfast and choked on his lunch.  He became SOB in the evening. His O2 sats dropped to 90%. Oxygen was given, and an Xray done, which confirmed Aspiration pneumonia. IV antibiotics were prescribed.  Until then, no one had addressed advanced directives with Mr. Wong.    Questions: 1. Identify the conditions (ie, acute/chronic, functional, family, psychosocial, environment) influencing the course of hospitalization.  2. How did those factors affect the outcomes for Mr. W (ie, length of stay, dependency on others, iatrogenesis, comfort)? 3. How would you address Mr Wong’s behaviour and function?    7  4. Select and justify at least two interventions that you would apply in your care for Mr. W.  How will your intervention influence his trajectory? 5. How would you address Mr. W advanced directives?      8  Case Presentation:  Dysphagia  Mrs Myer is an 82-year-old widow. She lives independently but has a large family with six children, who check in on her regularly.  She has been relatively healthy. Med hx includes mild osteoporosis and GERD. She takes Pantaloc OD and Tums PRN (and avoids spicy foods).  She has slowed down somewhat since last winter when she had pneumonia. Since the pneumonia she finds she gets out of breath if she walks too far or tries to clean her whole apartment without a break. Her GP told her it is just her body telling her to take it easy. Mrs Myer presented to the ED after falling down the concrete stairs outside church. She had pain and severe bruising on her right arm and shoulder, which restricts the use of her arm.  She is very weak and is admitted with soft tissue injuries of her right arm and shoulder and right-sided # 7 and 8 rib fractures.  As she was in the ER x 24 hours with little to eat or drink, she was noted to be dry and was given 1 L of IV fluid.  She is prescribed Tylenol # 3 Q4H prn.   On the unit, Mrs Myer needs help with her meals and ADLs. She gets breathless easily and her shoulder and ribs hurt if she sits up for too long. She doesn’t eat or drink much as she states she has no appetite and is too tired to eat. Her last BM was 4 days ago and she hasn’t slept well since her fall, so is prescribed a bowel protocol and Zopiclone at hs.   The next day Mrs Myer is drowsy, weak, has trouble swallowing and has a raspy voice after breakfast.  She develops a fever and slight cough, with crackles in her right lung. She is made NPO pending swallowing assessment. Xray confirms aspiration pneumonia and she is treated with IV PipTazo. Mrs. Myer’s family is very concerned and want to bring in her favourite foods to improve her appetite.  Questions: 1. Identify the different factors (ie, acute/chronic, functional, family, psychosocial, environment) that contributed to her aspiration pneumonia? How could this have been prevented? 2. Describe how the aspiration pneumonia will affect the outcomes for Mr W (ie, length of stay, dependency on others, iatrogenesis, comfort)? 3. How would you address Mrs. Myer’s dysphagia, pain and function?  4. Using your nursing process, select and evaluate at least two interventions that you would apply in your care for Mrs. Myers. Why?    Case adapted from: Victoria. Department of Health (2012). Best care for older people everywhere: The toolkit 2012. Dept. of Health, Melbourne, 276pp. Retrieved on June 1st, 2013 from http://docs.health.vic.gov.au/docs/doc/32A6DBBBE7D5512BCA257A9300019EAE/$FILE/1208011_BCOPE%20The%20Toolkit_WEB-3rdOct-v02.pdf       9  Case Presentation: Mental Health Mrs. Han is a 74-year-old woman living independently in a social housing complex. She has a schizo- affective disorder, hypertension, COPD and IDDM. She is also currently on analgesics for a wrist injury she sustained a few days ago. She smokes and although she doesn’t drink regularly, in her chart, there is report of occasional binge drinking. A community agency assists her with her finances and monthly homemaking. When going outside, Mrs. Han uses a cane as she has experienced episodes of dizziness. A community health nurse sees her every month for an ulcer on her left heel. Otherwise, she has very little support. Her daughter, with whom she is estranged, lives 200km away.   Four days ago, Mrs. Han was brought to the Emergency Department (ED) after attempting suicide. This was her third known attempt. This time, she took what was left of her Tylenol 3 prescription, together with a large quantity of alcohol. She was found unconscious for an unknown period of time by her landlord. Her apartment was in such disorder that, once found by her landlord, 911 was called and Mrs. Han was brought to hospital by EMS/VPD.  Two days later, after being certified under the mental health act and medically cleared, she was admitted to a mental health unit for treatment of psychosis and depression with persistent suicidal ideations. Since then, Mrs. Han has had a flat affect and is very quiet, refusing to go to the dining room and to interact with other patients. She eats only small amounts of food, even when served in her room. She has been refusing personal care and most glucometer checks, but, when persuaded, cooperates and takes her antipsychotics and anti-hypertensive. Mrs. Han refused her inhaler although she was wheezing and SOB when walking.  Around 1000, when you walk in the room, Mrs. Han is unsteadily coming out of the bathroom, talking to you about her oven and mistaking you for her landlord. While having a loud conversation with herself, she tries to remove her clothes. In your assessment, you find Mrs. Han irritable, unable to concentrate, and feeling guilty about her daughter. Her thoughts appear disorganized and rambling and she is unpredictably jumping from topic to topic.  It is your first day caring for Mrs. Han. From the nursing notes, you were expecting to find her withdrawn and quiet. At lunch time, she yells at the staff, “go away with your stupid food and leave me alone”. As the staff walks out, she rolls over and goes back to sleep. When you walk into her room, she is disoriented.   Questions: 1. How would you assess Mrs. Han’s mood and cognition? 2. What are your hypotheses to explain her disorientation?  3. And what would be your nursing interventions related to your main hypothesis (nursing process)? 4. What acute health condition is this person experiencing? 5. Identify which different conditions (ie, acute/chronic, functional, family, psychosocial, environment) affected how Mrs. Han was able to adapt to hospitalization? 6. Select and evaluate at least two interventions that you would apply to your care for Mrs. H? Why?    10  7. What geriatric & mental health interventions are most important in prevention of functional decline? Why?      11  Case Presentation: Transition & Failure to Thrive (FTT)  Mrs. Phillips is a 77-year-old retired VGH nurse. She was living at home independently until her admission to hospital with Failure to Thrive which included weakness, fatigue, weight loss and “confusion.” No abnormalities were noted on her brain imaging but her haemoglobin and albumin are low.  Mrs. P has osteoarthritis and CHF and takes at least 3 medications daily including a diuretic, antihypertensive, plus Tylenol 3 and ibuprofen (OTC) PRN. Past medical history includes falls and Type II Diabetes. More recently, Mrs. P has had poor balance, anxiety and weight loss. Her husband died 15 months ago and she has become isolated at home and dependent upon her daughter for shopping and banking. For the past 3 months, Mrs. P has been forgetting the date and lunch meetings with friends.   Information from her GP is limited as Mrs. P’s last visit was two years ago. Her daughter, who calls her twice a week, has noted that their conversations have become one-sided and effortful. She feels that her mother is unmotivated and that she should be able to “take care of herself.”   In the first six days of admission, Mrs. P does not initiate self-care activities such as showering and toileting and is physically/verbally very slow. She remains anxious, in bed and sleeping throughout the day. A normally quiet person, Mrs. P has become tearful, rarely speaking to staff. She refuses to participate in physiotherapy. Her balance has not improved and she has made minimal progress in her mobility. Mrs. P has now developed a stage 2 pressure ulcer on her heel.   Morning rehabilitation with PT is provided. However, during the first week, she accepts physiotherapy twice but participates minimally. For the next two weeks, she does not participate despite encouragement from therapists. It is noted that she is not sleeping well at night and wakes early. After a three-week admission, Mrs. P has not improved and has experienced further functional decline in ADLs and mobility. As a result, a discharge plan to residential care is proposed and discussed with her.   Three days later it is noted that Mrs. P has not eaten since the discussion about discharge. Referrals to the dietician and occupational therapist are made. Their assessments indicate poor nutritional status with a low body mass index (BMI) but no swallowing difficulties. A social worker calls Mrs. P’s daughter and discusses her condition. Her daughter suggests that her mother may be depressed. Mrs. P is screened for depression and a psychiatrist is consulted. Mrs. P has a major mood disorder and medication is commenced. Food intake is encouraged by all staff and, after four days, Mrs P starts eating a small amount. She begins to get up with PT, although reluctantly.   Questions: 1. Identify how many different conditions (ie, acute/chronic, functional, family, psychosocial, environment) affected how Mrs. P was able to adapt to hospitalization? 2. How did these factors affect the outcome for Mrs P (ie, length of stay, dependency on others, iatrogenesis, comfort)? 3. Select and evaluate at least two interventions that you would apply in your care for Mrs. P? Why? 4. How would you address Mrs. Ps mood and functional decline?    12  5. What factors have contributed to Mrs. P need for relocation (red flags)? And which factors may contribute to her need for re-admission? 6. What are the considerations for discharge/transition for Mrs. P.?  Consider:  x Red flag symptoms/ warnings (ie potential for readmission) x Communication (who and what should be included) i. Medication management ii. Primary care/specialist follow up   Case adapted from: Victoria. Department of Health (2012). Best care for older people everywhere: The toolkit 2012. Dept. of Health, Melbourne, 276pp. Retrieved on June 1st, 2013 from http://docs.health.vic.gov.au/docs/doc/32A6DBBBE7D5512BCA257A9300019EAE/$FILE/1208011_BCOPE%20The%20Toolkit_WEB-3rdOct-v02.pdf      13  Nursing Interventions for Older Adults/Families    Type of Needs  Interventions  Psychosocial x Anxiety reduction x Coping enhancement x Decision-making support x Emotional support x Touch  Comfort Needs x Pain management x Positioning  Health Promotion Needs x Fall prevention x Risk identification x Environmental management/safety x Medication management x Nutrition/hydration management x Self-care/knowledge of chronic disease process(es) x Sleep enhancement x Anticipatory guidance x Skin surveillance x Education x Disease monitoring x Mental health promotion  Spiritual x Active listening x Instilling hope  Quality of Life x Enhancing experiences of aging/hospitalization x Plans for care - Advance Care Planning   x Adapted from: Miller, C. A. (2009). Nursing for Wellness in Older Adults (2nd ed.). Philadelphia, PA: Wolters Kluwer.  x Case adapted from: Victoria. Department of Health (2012). Best care for older people everywhere: The toolkit 2012. Dept. of Health, Melbourne, 276pp. Retrieved on June 1st, 2013 from http://docs.health.vic.gov.au/docs/doc/32A6DBBBE7D5512BCA257A9300019EAE/$FILE/1208011_BCOPE%20The%20Toolkit_WEB-3rdOct-v02.pdf     14  NURSING CARE PLAN FRAMEWORK Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation                           ASSESSMENT DATA       15  Teaching strategies for case studies   Below is a short list of ideas on how the above case studies might be used. When considering which strategy will best suit your audience, the choice of strategies will vary according to the needs of the participants and their level of expertise as well as the resources available (eg. time, facilitators). The GET cases presented above were developed to meet the various backgrounds and level of expertise of our participants.  Case studies are a useful teaching method for developing participants’ critical thinking. Some of the goals of using case studies in your teaching could be to gain a better understanding of a complex situation, to recognize abnormal or changing situation, to identify appropriate actions and interventions and improve problem solving skills. Case studies focus on knowledge application and they promote reflection, instructor-participants dialogues as well as group discussions (Rowles & Russo, 2009)    This teaching method requires support and feedback to ensure learning objectives are being met. Case studies are more likely to lead to changes in practice than traditional teaching methods.  You can refer to the table below for ideas on how to structure and facilitate learning using case studies.    Strategy Process Advantages Disadvantages  Instructor led case study Class process/discussion ˜ Allows instructor to demonstrate the nursing process that needs to take place.  ˜ Serves as an exemplar/guiding process for subsequent case studies.  ˜ Allows to draw emphasis on most important points/concepts ˜ May be less challenging for more experienced nurses Small groups  ˜ Depending on the group size, ensures a more active participation from all participants ˜ Allow participants to discuss and debate ideas in smaller group, which might be less intimidating ˜ Requires more resources:   Time: participant-led process could be more time consuming  Facilitator: depending on the number of participants, may require     16  more than one facilitator to guide groups as needed. Groups work on same cases Review via whole class discussion ˜ Everyone is exposed to same new knowledge ˜ Allow rich exchange among participants ˜ Allows learning from other participants Allows to cover more cases in less time  Groups work on different cases  With group presentations ˜ Provides an opportunity for feedback and exchanges ˜ Allows all participants to hear the feedbacks and nursing process for all cases without them working on all cases  ˜ Serves the purpose of having participants organizing and verbalizing their nursing process ˜ More time consuming Without presentations  ˜ Less time consuming ˜ May not allow proper feedback period ˜ All participants are not exposed to same  learning process and knowledge    References   Rowles, C. & Russo, B. (2009). Strategies to Promote Critical Thinking and Active Learning. In Billings DM. & Halstead JA (Eds.), Teaching in Nursing: A Guide for Faculty (pp238-261). 3rd Edition. Saunders, St-Louis, Mo.   GOING%DOWNHILL%IN%HOSPITAL:%PREVENTION%OF%IATROGENESIS%Maureen%Shaw,%CNS%Gerontology%Vancouver%Coastal%Health%Esther’s%Voice!Esther's Story-Vancouver Sun Esther's Voice - Coroner's Judgement of Inquiry ObjecIves%• To!define!iatrogenesis!!• To!examine!6!concepts!that!lead!to!iatrogenesis:!– Func7onal!decline!– Hospital!acquired!infec7on!– Transient/func7onal!incon7nence!– Skin!!integrity!– Malnutri7on!– Adverse!effects!of!diagnos7c!&!therapeu7c!procedures!• To!describe!nursing!interven7ons!that!avoid!and/or!limit!the!effect!of!iatrogenic!complica7ons!IATROGENESIS%True%or%False?%1. !Older!pa7ents!should!receive!the!same!!!!!!!!!!!medica7ons!&!treatments!as!younger!adults.!2.!Older!pa7ents!can!retain!their!func7onal!!!!!!abili7es!while!in!hospital.!3.!Hospital!is!a!safe!environment!for!older!!!!!!pa7ents.!IATROGENESIS%DEFINED%Iatrogenesis%is:%• An!unintended!adverse!outcome!due!to!therapeu7c,!diagnos7c!&!prophylac7c!interven7ons!not!considered!part!of!the!disease!process.!• An!unintended!&!untoward!outcomes!of!well!intended!healthcare!interven7ons.!Beyea, retrieved May 2013; Volpato et al, 2007 •  Cascade%Iatrogenesis%– !A!trigger!event!ini7ates!the!serial!development!of!adverse!outcomes!followed!by!func7onal!decline!•  Complica7ons!unrelated!to!the!presen7ng!diagnoses!that!result!in:!– Longer!hospitaliza7ons!– Unan7cipated!medical!and/or!surgical!interven7ons!– Death!!IATROGENESIS%DEFINED%Francis, 2008; adapted from NICHE Core Curriculum •  Prevalence:!!– 35T!58%!of!older!adults!!!!!!!!!!!!!!!!!!!!!!!!experience!iatrogenic!events!!•  May!be!irreversible!•  Referred!to!as:!– Hazards!of!hospitaliza7on!– Dysfunc7onal/!geriatric/!immobility!syndrome!!CASCADE%IATROGENESIS%Beyea, retrieved May 2013; Fernandez et al., 2008; Palmer et al., 2003 PostTop!Delirium!Medicated!for!agita7on!Aspirates!due!to!seda7on!•  Pneumonia!•  Dehydra7on!•  C.!diff!diarrhea!•  Ongoing!delirium!•  Prolonged!bedrest!•  Func7onal!decline!•  Fall!with!hip!#!Iatrogenesis%&%Surgical%Repair%of%Hernia%Outcomes!• !ADL!dependency!• !↑!LOS!• !Facility!placement!• !Death!Adapted from NICHE Core Curriculum Older%Adults%with%Advancing%Age%&%Declining%ADLs%%(Frailty%Syndrome)%AGE% %%With%Frailty/ADL%Loss%70T74! !  23%!75T79! !  28%!80T84! !  38%!85T90! !  50%!90+! !  63%!WHO%IS%AT%RISK%FOR%IATROGENESIS?%Ettinger, 2011; Permpongkosol, 2011; Stone & Steinbach, 1999; Volpato et al., 2007 1.  Frailty%Syndrome%– Advanced!age!– Func7onal!decline!PTA!(ADL/IADL)!– Cogni7ve!impairment!– History!of!falls!in!past!year!– ↑!comorbidity!– Body!composi7on!(lean!vs!adipose)!– Higher!acuity!on!admission!Ettinger, 2011; Permpongkosol, 2011; Stone & Steinbach, 1999; Volpato et al., 2007 WHAT%ARE%THE%RISK%FACTORS?%(Frailty%&%HospitalizaIon)%WHAT%ARE%THE%RISK%FACTORS?%(Frailty%&%HospitalizaIon)%Permpongkosol, 2011; Stone & Steinbach, 1999; Volpato et al., 2007 HAZARDS%%OF%%HOSPITALIZATION%Impaired%Mobility%•  AgeTrelated:!↓ability!to!maintain!gait,!balance,!walking!speed!•  Hospital!related:!Decondi7oning!due!to!bed!rest,!bed!rails/restraints,!lack!of!gait!aides/opportuni7es!for!mobilizing!InfecIon% •  AgeTrelated:!↓!immune!competence;!atypical!presenta7on!•  Hospital!related:!UTI!due!to!catheters;!aspira7on!!pneumonia;!MRSA/VRE/C!DIFF;!sepsis!InconInence% •  AgeTrelated:!Urinary!stasis,!thinning!of!bladder!wall,!↓!capacity!•  Hospital!related:!EnvironmentTshared!toilet,!no!privacy/call!bell;!staff!beliefs!re!dependence;!medica7ons,!procedures,!restraints,!tubing!MedicaIons% •  AgeTrelated:!Exaggerated!effects!of!medicines!•  Hospital!related:!Polypharmacy;!drug!interac7ons,!medica7on!errors,!insufficient!monitoring!MalnutriIon% •  AgeTrelated:!Blunted!thirst!mechanism;!↓!muscle!mass/metabolism!•  IllnessTrelated:!Dysphagia,!anorexia,!pain,!dietary!restric7ons,!cons7pa7on,!diarrhea,!dehydra7on!•  Hospital!related:!Packaging,!restraints,!IV!fluids,!NPO,!7ming!of!meals!Accidents%&%Injuries%•  AgeTrelated:!↓!safety!awareness,!decondi7oning!•  Hospital!related:!Environment,!equipment,!lines/tubes/tethers,!hazards!(gown,!slippers);!lack!of!signage!IATROGENESIS%True%or%False?%• Bedrest!does!not!cause!physiologic!changes!in!older!pa7ents.!• Cascade!iatrogenesis!contributes!to!poor!health!outcomes.!• Hospitaliza7on!can!cause!func7onal!decline!in!older!pa7ents.!COMMON%IATROGENIC%ISSUES%1.  Impaired!mobility,!!&!decondi7oning!&!falls!2.  Hospital!acquired!infec7ons!(HAIs)!3.  Func7onal!incon7nence!4.  Skin!integrity!5.  Malnutri7on!6.  Adverse!effects!of!diagnos7c!&!therapeu7c!procedures!IMPAIRED%MOBILITY%&%DECONDITIONING:%Bedrest%1.  Nega7ve!effects!on!heart!–  Redistributes!500!mL!to!thoracic!circula7on!!•  ↑!HR!&!cardiac!output!!•  Underlying!cardiac!disease!now!evident!•  In!5!days,!cardiac!output!↓!but!HR!remains!elevated!•  Stasis!gradually!reestablished!by!atrial!baroreceptors!3.  ↓!elas7city!of!lungs/aerobic!capacity!4.  Daily!loss!of!5T10%!of!muscle!mass!for!every!week!of!bedrest!Adapted: Francis, 2005; NICHE Core Curriculum; Holohan-Bell & Brummel-Smith, 1999 INCIDENCE%of%IMPAIRED%MOBILITY%%%%%%&%DECONDITIONING%•  Defined:!– Hospitaliza7onTassociated!disability!involves!a!new!loss,!by!D/C,!to!perform!at!least!1!ADL!– Geriatric!syndrome!•  Prevalence:!!– 30T58%!of!pa7ents!>!70!years!•  Consequences:!!– Home!Care,!LTC!placement!– Repeat!hospitaliza7ons*!– Death!! ! ! !!!!!!!!!!Covinsky et al., 2003; Volpato et al., 2006  Predisposing/PrecipitaIng%Factors%Medical/Health • Arthritis/fractures/deformities • Neurological • Cardiovascular, pulmonary • Anemia            Social • Isolation • Meaningful contact • Family discord Decondi7oning/Func7onal!Decline!Adapted from Francis, 2008; Holohan-Bell & Brummel-Smith, 1999 BACKGROUND:%COST%OF%FALLS%•  Seniors!with!fallTrelated!injuries!stay!in!hospital!2X!longer!than!seniors!hospitalized!for!all!other!reasons.!!•  Cost:!>!$195!million!in!2009/2010!(CIHI!DAD).!•  Costs!2005/06T2009/10:!!– FallTrelated!hip!#!accounted!for!47%!of!annual!hospitalTrelated!costs.!!BC%Senior’s%Fall%PrevenIon%Program,%accessed%online%June%11,%2013%WHY%ARE%FALLS%&%FALL%PREVENTION%IMPORTANT%TO%%ACUTE%CARE?!FALLS%IN%ACUTE%CARE%MulIfactorial%Risk%Factors%ImpacIng%Injury%(1/2)%RNAO, 2007; Stone & Wyman, 1999 FALLS%IN%ACUTE%CARE%MulIfactorial%Risk%Factors%ImpacIng%Injury%(2/2)%Key%Symptoms%Associated%with%Falls%"  Delirium!"  Arrhythmia!"  Orthosta7c!hypotension!"  Syncope!"  Ver7go!"  Generalized!weakness!(infec7on,!sepsis)!"  Ataxia!"  Hypoglycemia!"  TIA/CVA!%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Gray-Miceli, 2008 Is!the!pa7ent!agitated,!confused,!or!disorientated?!eg!Consider!history!of!demen7a!delirium,!lack!of!insight!&!judgment!No=0%Yes=1%EliminAIon?% Does!the!pa7ent!require!frequent!toile7ng?!!e.g.!urgency,!frequency,!incon7nence!No=0!Yes=1!Does!the!pa7ent!ambulate!or!transfer!with!an!assis7ve!device!or!assist?!Or!does!the!pa7ent!ambulate!with!an!unsteady!gait!and!no!assistance?!!No=0!Yes=1!Previous%Fall?%Did!the!pa7ent!fall!in!the!last!90!days?!! No=0!Yes=1!Vision%Impaired?%Is!the!pa7ent!visually!impaired!to!the!extent!that!everyday!func7on!is!affected?!!e.g.!blurred!vision,!impaired!peripheral!vision.!!No=0!Yes=1!Scoring% Low/moderate!Risk!=!1T2!High!Risk!=!2+! Score:!/5!FALL%ASSESSMENT:%CAMPbV%SCREEN%Oliver et al., 1997 FALL%ASSESSMENT:%CAMPbV%SCORING%***%MedicaIons%can%affect%each%of%the%above%factors%and%%%%%%%%%%%%should%be%considered%when%compleIng%the%fall%risk%screen%Risk!Level! Score! Ac7on!Low!/!Moderate!Risk! 0!T!1!!Universal!/!Standard!Fall!Precau7ons!High!Risk!! 2!or!more!Complete!Mul7factorial!Risk!Assessment!&!develop!individualized!fall!preven7on!care!plan!Oliver et al., 1997 What%can%nurses%do%to%prevent%falls%in%older%paIents?%•  Pa7ent!•  Environment!•  Nursing!•  Organiza7on!SFU%Video%Analysis%KEY%MESSAGES%•  Func7onal!decline!is!a!leading!consequence!of!iatrogenesis!in!older!pa7ents.!•  Preven7on!is!the!best!interven7on.!•  Focus!on!mobility!and!safety!for!the!best!outcomes.!↓! HOSPITAL%ACQUIRED%INFECTIONS%(HAIs)!True%or%False?%• UTIs!are!normal!with!aging!especially!with!!!!women.!• NPO!is!the!best!approach!for!pa7ents!with!!dysphagia.!• If!an!older!pa7ent!does!not!have!a!!temperature,!he/she!does!not!have!an!!!!infec7on.!HOSPITAL%ACQUIRED%INFECTIONS%(HAIs)%Risk%Factors% % %•  Advancing!age!•  Higher!acuity!•  Immune!compromised!•  Invasive!procedures!•  Intravascular!devices!Consequences%•  ↑!LOS!•  Adverse!complica7ons!•  ↑!mortality!Beyea, retrieved May 2013 BACKGROUND%ON%HAIs%Annually,!in!Canada,!HAIs!!• !Infec7on:!250,000!• !Mortality:!8,000!–!12,000!• !Overall,!one!of!the!leading!causes!of!death!Picard, Globe & Mail, accessed, June 13, 2013 AgebRelated%Change%ImplicaIons%Immune!Response! •  ↓!resistance,!reac7va7on!of!latent!infec7ons!•  Absence!of!classic!response!to!infec7on!•  NonTspecific!presenta7on!(low!grade!fever)!Skin/Mucosa! •  ↓!barriers!to!bacterial/viral!organisms!•  Thinning!of!epidermis!(delayed!healing,!!vulnerability!to!trauma!Respiratory!System! •  ↓!ciliary!ac7on/cough!reflex!GI!Tract! •  ↓!acid/mo7lity;!↓!immunoglobulin,!an7body!in!mucosal!cells!Nutri7on! •  Vitamin!deficiencies!(folate,!zinc).!↓!forma7on!of!RBC.!•  Malnutri7on—low!albumin!INFECTION:%PREDISPOSING%FACTORS%MOST%COMMON%HAIs%•  UTIs%– Most!common!HAI!– Account!for!30T40%!of!all!HAIs!– Related!to!use/dura7on!of!bladder!catheters!•  Bloodstream%– ~!50%!related!to!invasive!device!– 8th!leading!cause!of!death!(ie,!sepsis)!–  ICU:!3TT7%!with!central!line!develop!sepsis!Beyea, retrieved May 2013; Francis 2008 Factors% Comments%•  AgeTRelated! •  Urinary!stasis,!bacterial!growth!•  ↓!immune!func7on!!•  Thinning!of!bladder!wall!•  Social/Cogni7ve! •  Poor!hygiene/mo7va7on!•  Lack!of!awareness!•  HospitalTAcquired! •  Dehydra7on,!dependence,!•  Catheters,!bedpans!•  Func7onal!incon7nence!•  Access!to!commodes/!toilets/!hand!washing!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(Francis,!2008)!MOST%COMMON%HAIs%UTI%&%UROSEPSIS%MOST%COMMON%HAIs%•  Pneumonia!– 2nd!most!common!HAI;!24T36%!mortality!rate!– May!present!as!delirium!(ie!silent!aspira7on)!– Cause:!Aspira7on!of!GI!or!oropharyngeal!secre7ons!– With!dysphagia,!risk!increases!7!fold!•  Surgical!Site!Infec7ons!– 2.7%!– Admixed!from!ICU?!Risk!rises!to!60%!Beyea, retrieved May 2013; Francis, 2008 MOST%COMMON%HAIs%•  Addi7onal:!– Skin!(MRSA)!– GI!Tract!(C.!diff!coli7s;!VRE)!– Oropharyngeal!cavity!(Candida!Albicans)!•  Note:!– !Risk!with!transfer/transi7on!• Unit#unit;!residen7al!#!acute!#!residen7al!care!APIC, 2013; Beyea, retrieved May 2013; Francis 2008 C.%DIFFICILE%DIARRHEA%PRECIPITATED%BY%High!risk!an7bio7c!treatment!such!as!:!1.  Clindamycin!(Dalacin!C)!!2.  BetaTlactams:!!–  Penicillins!(Ampicillin/Amoxicillin)!–  Cephalosporins:!•  Cefazolin!(Ancef/Kefzol)!•  Cefotaxime!(Claforan)!•  Cezriaxone!(Rocephin)!APIC, 2013; Vancouver Acute Formulary, accessed June 10, 2013; KEY%MESSAGES%•  1/3!of!HAIs!are!!preventable.!•  Con7nuously!assess!the!need!for!indwelling!lines!and!tubes!and!remove!as!soon!as!possible.!•  Collaborate!with!MD/NP/pharmacist!on!use!!of!an7bio7cs!know!to!cause!adverse!drug!events!(ADE).!FUNCTIONAL%INCONTINENCE%Which!of!the!following!statements!is!true?!1. !Incon7nence!is!a!normal!part!of!aging.!2. !Transient!incon7nence!is!a!poten7ally!!!!!!reversible!condi7on.!3.!Absorbent!pads!are!the!best!way!to!manage!!!!!!!incon7nence.!FUNCTIONAL%INCONTINENCE%InconInence%caused%by:%1. !Cogni7ve!impairment!(delirium,!Alzheimer’s,!Parkinson’s)!that!results!in!dependence!in!toile7ng!!and/or!2. !Physical!design,!prac7ces/procedures!of!hospital!!– No!signs;!inaccessible!toilets;!lack!of!privacy!– Restraints;!bedrest!– Medica7ons!%%%%%%%%%%%%%%%%%%%Dowling-Castronova & Bradway, 2008; Stone & Steinbach, 1999 RISK%FACTORS%FOR%TRANSIENT%INCONTINENCE% %Incon7nence!caused!by!poten7ally!reversible!symptoms:!– Delirium,!depression!– Infec7on!– Restricted!mobility!– Dehydra7on!– Cons7pa7on!– Diuresis!! ! Dowling-Castronova & Bradway, 2008 PREVENTING%FUNCTIONAL%INCONTINENCE%1.  Provide!individualized,!scheduled!toile7ng!or!prompted!voiding!2.  Provide!adequate!fluid!intake!3.  Modify!environment!to!maximize!independence!4.  Use!absorbent!products!to!meet!pa7ent/family!needs!if!toile7ng!plan!is!unsuccessful!5.  Educate!pa7ent/family!6.  Refer!to!PT/OT!KEY%MESSAGES%•  Transient!incon7nence!is!due!to!condi7ons!outside!of,!or!affec7ng,!the!urinary!system!such!as!delirium,!infec7on!or!impac7on.!•  Func7onal!incon7nence!is!almost!always!associated!with!environmental!barriers.!•  Incon7nent!pa7ents!usually!respond!to!an!individualized!plan!of!care.!SKIN%INTEGRITY% %•  Aging!Changes:!– Loss!of!elas7c,!subcutaneous,!connec7ve!7ssue!– ↓!sweat/sebaceous!gland!ac7vity!– ↓!capillary!blood!supply/skin!turgor!•  Appearance?!– Thin,!fragile,!loose!– Dry,!flaky,!rough!Adapted from Balas, Casey & Happ, 2008 SKIN%INTEGRITY:%Consequences%of%Aging%Why!are!older!pa7ents!at!risk!for!↓!skin!integrity?!SKIN%TEARS%•  Defini7on:!– Dermis!becomes!separated!from!the!epidermis!– Usual!cause?!– Common!areas!effected?!• Shins!• Face!• Dorsal!aspect!of!hands!• Plantar!aspect!of!feet!• Areas!of!purpura!Balas, Casey & Happ, 2008 •  History!of!unhealed!skin!tear!in!last!90!days!•  Unsteady!gait!•  Bruising!present/easily!bruises!•  Confined!to!bed!or!chair!•  DecisionTmaking!capacity!impaired!or!slightly!impaired!•  Resis7ve!to!personal!care!•  Extensive!assist!or!dependent!in!ADLs!•  Aggressive!•  Loss!of!balance! •  Presence!of!restraints!RISKS%FOR%SKIN%TEARS%Adapted from Balas, Casey & Happ, 2008 KEY%MESSAGES%•  Maintaining!skin!integrity!is!important!because:!– Pressure!areas!are!associated!with:!• Iatrogenesis!• Pain!• Reduced!mobility!• !↑!length!of!stay!• Infec7on!MALNUTRITION%True%or%False?%• Malnutri7on!contributes!to!poor!health!outcomes.!• Hydra7on!status!does!not!precipitate!delirium!in!older!adults.!• Adverse!effects!of!medica7ons!are!linked!to!poor!nutri7on!in!older!adults.!• My!unit!rou7ne!does!not!impact!the!older!pa7ent’s!nutri7on.!MALNUTRITION%•  Defined:!!–  Imbalance!of!nutri7on!or!–  Inadequate!macro!nutri7on!(protein,!energy!malnutri7on)!and!inadequate!micro!nutri7on!(vitamin!deficiency).!•  In!acute!care:!– Combina7on!of!cachexia!(diseaseTrelated)!and!malnutri7on!(inadequate!intake!of!nutrients)!•  Prevalence:!up!to!40%!in!acute!care!Australian Health, 2004; Barker et al., 2011 MALNUTRITION%Predisposing%PaIentbRelated%Factors%• !!!!Compromised!nutri7on!upon!admission!—  !Low!albumin!(reflects!status!3!months!ago)!• !!!!Changes!in!taste,!smell;!GI!peristalsis!•  ↓!sensa7on!of!thirst!• !!!!Mul7ple!chronic!illnesses!—  !COPD,!Parkinson’s,!hypertension,!cancer!• !!!!ADL!decline!• !!!!Social!issues:!loneliness,!poverty!MALNUTRITION!PrecipitaIng%PaIentbRelated%Factors%•  Treatment!of!health!condi7ons!$  !N!&!V,!dry!mouth,!polypharmacy!•  Cons7pa7on,!diarrhea!•  Decreased!appe7te,!anorexia!•  Dehydra7on!$  ↑risk!for!UTI,!postural!hypotension!•  NPO!+/T!saline/glucose!IV!•  Dysphagia!MALNUTRITION!PrecipitaIng%SystembRelated%Factors%• Lack!of!recogni7on!of!↑!metabolic!needs!• Restricted!diets:!↑!risk!ADE,!dehydra7on!• Lack!of!meal!7me!support!— Staff!breaks,!lack!of!adap7ve!equipment/!meal7me!assistance,!7ming!of!tests/!procedures!STRATEGIES%FOR%PREVENTION%•  Screening!for!malnutri7on!– Mini!Nutri7onal!Assessment!(MNA)!– Height,!weight,!food/fluid!intake!– Iden7fying!↑!metabolic!needs!•  Referral!to!die77an,!pharmacist!•  Supplements!•  Planning!for!meal!7mes!– Monitoring!schedule!for!diagnos7c!tests!– Providing!meal!7me!assistance!%%%%%%%%%%%%%%%%%%%%%DiMara-Ghalili, 2008; Stone, & Wyman, 1999 KEY%MESSAGES%1.  Poor!nutri7on!&!hydra7on!contribute!to!!morbidity!&!mortality!in!older!adults.!2.  New!onset!delirium!may!be!related!to!dehydra7on.!3.  Be!aware!of!factors!(ie!NPO,!overTuse!of!IV!fluids)!that!contribute!to!under!nutri7on.!4.  Provide!nutri7onal!screening!&!food/fluid!interven7ons!to!avoid!unnecessary!weight!loss.!Dysphagia:%Why%is%Swallowing%Important?%! Ben,!age!74,!was!admixed!to!hospital!for!hip!surgery!due!to!arthri7s!and!chronic!pain.!He!has!a!14Tyear!history!of!Parkinson’s,!taking!! Sinemet!4!7mes!daily.!Ben!was!NPO!! postTop!&!was!also!nauseated.!This!!! worsened!his!Parkinson’s!&!he!had!a!!! newTonset!difficulty!in!swallowing.!You!find!him!drowsy!but!rousable,!coughing,!drooling!&!speaking!in!a!whisper.!Upon!ausculta7on,!you!hear!crackles!in!the!bases!of!both!lungs.!!!!!!!!!!!!!!!!!!!!!!!What!is!happening!to!Ben?!Dysphagia:%Why%is%Swallowing%Important?%•  Aging!changes:!↓!swallowing!rate/gag!reflex!!•  Aspira7on!Pneumonia!– Atypical!presenta7on!in!older!adults!– Signs!&!symptoms:!• Delirium!• Behavior/func7onal!change!• +/T!change!in!vital!signs!• Pleuri7c!chest!pain!• Other?!Palmer & Metheny, 2008 Dysphagia:%Why%is%Swallowing%Important?%What%are%the%intervenIons?%– Dietary!modifica7ons!– Meal7me!assistance!– Posi7oning,!mobiliza7on!– Medica7on!modifica7ons!– Oral!hygiene!– Refer!to!OT/SLP,!die7cian,!pharmacist!Oral%HydraIon!True%or%False?%• Dysphagia!diets!with!thickened!fluids!are!healthy.!• Older!pa7ents!are!not!as!thirsty!as!younger!pa7ents.!• Older!pa7ents!who!are!not!swea7ng!do!not!feel!the!heat!and!are!not!at!risk!for!dehydra7on.!Oral%HydraIon%•  Dehydra7on!defined:!– Deple7on!in!total!body!water!due!to!disease!processes!&/or!↓!water!intake!– Results!in!hypernatremia!•  Symptoms?!– Dry!mouth,!hypotension!– Concentrated!urine,!↓!urine!output!– Labs:!↑Na+/crea7nine/BUN!!Adapted from: Mentes, 2008 Special%PopulaIons%– Chronic!mental!illness!– Dysphagia!– Fas7ng/NPO!for!tests/procedures!– EndTofTlife!Oral%HydraIon%Adapted from: Mentes, 2008 Key%Messages%•  Carefully!monitor!oral!hydra7on!in!pa7ents!with!fever,!diarrhea,!vomi7ng!or!nonfebrile!infec7on.!•  Carefully!consider!hydra7on!status!in!pa7ents!scheduled!for!tests!and!procedures.!•  Implement!fluid/comfort!rounds.!•  Always!offer!a!trial!of!oral!liquids!before!star7ng!IV!fluids.!Adverse%Effects%of%DiagnosIc%&%TherapeuIc%Procedures%•  Rela7vely!risk!free!medical!and!nursing!procedures!can!cause!safety!issues.!•  Iatrogenic!“hypos”!– IV!fluids!!%!hypokalemia!– An7hypertensives!%!hypotension!– Transient!decreased!oral!intake!%hypoglycemia!Adapted from: Francis, 2008; NICHE Core Curriculum Adverse%Effects%of%DiagnosIc%&%TherapeuIc%Procedures!True%or%False?%• !Medical!and!nursing!procedures!are!safe!and!!!!!effec7ve!for!older!pa7ents!with!demen7a.!• !Use!of!tubes!(ie!catheteriza7on,!chest!tubes)!!!!may!be!highTrisk!procedures!for!older!pa7ents.!• !Nurses!should!not!ques7on!a!doctor’s!!!!judgment.!Risk%Factors:%• !High!number!of!medical!procedures!&!therapies!• !Complex!surgical!procedure!requiring!long!anesthesia!• !High!risk!diagnos7c!tests!and!procedures!– Invasive!– Contrast!mediums!– Radia7on!– Thoracentesis!– Cardiac!catheteriza7on%%%%%%%%%%%%%%%%%%%%%%Adapted from: NICHE Core Curriculum Adverse%Effects%of%DiagnosIc%&%TherapeuIc%Procedures%Role%of%the%Registered%Nurse%•  Early!recogni7on!of!risk!and!preven7on!of!iatrogenesis!•  Pa7ent!advocacy!based!on!gerontological!knowledge!•  Educa7on!for!colleagues!&!interdisciplinary!team,!including!physicians!Adverse%Effects%of%DiagnosIc%&%TherapeuIc%Procedures%ASSESSMENT:%SPICES+%Adapted from: NICHE Core Curriculum; Robinson & Weitzel, 2008 CONCLUSION%•  Frailty!&!poten7al!for!complica7ons!highlights!the!importance!of!nurses!in!preven7ng!iatrogenesis!in!hospital!&!during!transi7on!to!another!se~ng.!•  Nursing!care!makes!a!significant!difference!with!frail!pa7ents!who!have!frequent!and!subtle!disease!presenta7ons,!higher!risk!of!iatrogenesis!&!greater!baseline!risk!factors.!PrevenIon%is%always%the%best%intervenIon%1  References Iatrogenesis  Association for Professionals in Infection Control and Epidemiology. 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Salisbury  (Eds.), Clinical gerontological nursing: A guide to advanced practice (pp. 341- 368). Philadelphia, PA: Saunders.  U. S. Department of Health and Human Services/National Institute of Diabetes and  Digestive and Kidney Diseases. (2011). Cephalosporins. National Library of  Medicine [On-line], Available: Cephalosporins.  Volpato, S. Graziano, O., Cavalieri, M., & Guerra, G. Et al. (2007). Characteristics of  nondisabled older patients developing new disability associated with medical  illnesses and hospitalization. Journal of General and Internal Medicine, 22, 668- 674.  Wakefield, B. J. & Holman, J. E. (2007). Functional trajectories associated with  hospitalization in older adults. Western Journal of Nursing Research, 29(2), 161- 177.  Websites:  Nurses Improving Care for Health System Elders (NICHE): Iatrogenesis Presentation  Module (www.nicheprogram.org)  Nurses Improving Care for Health System Elders (NICHE): Geriatric Resource Nurse  Core curriculum: Iatrogenesis [Online]. Available: Iatrogenesis Core Curriculum  John A. Hartford Foundation Institute for Geriatric Nursing: ConsultGeriRN  John A. Hartford Foundation Institute for Geriatric Nursing: Hartford Institute  Other: Palmer, M. H. (2004). Physiologic and psychologic age-related changes that affect  urologic clients. Urologic Nursing, 24(4), 247-257. .    CHALLENGES)IN)GERIATRIC))) PHARMACOLOGY)) ) )Maureen)Shaw,)RN,)MN)Clinical)Nurse)Specialist,)Gerontology)VCH)OUTLINE)1. Why)are)MedicaHons)an)Issue?)2. Drug)AcHon)&)Aging)3. MedicaHons)of)Risk:))!  Benzodiazepines)!  AnHdepressants)!  AnHpsychoHcs)4. )Unique)ConsideraHons)!  Alzheimer’s)Disease)!  Drug)&)Alcohol)Dependency))5. )MedicaHon)Principles)6. )How)Can)I)Help?)“Avoid)anHpsychoHc)drugs)for)elderly,)experts)urge,)a\er)death)risk)study”)) Doctors)should)avoid)prescribing)anHpsychoHc)drugs)for)elderly)people)with)Alzheimer's.)New)research)shows)that)people)taking)these)medicaHons)have)double)the)risk)of)dying)(CBC,))January)9/09))People)over)age)65)experience)medicaHon)related)side)effects)due)to:)True)or)False)1. )Agehrelated)physiological)changes)2. )Polypharmacy)3. )Drug)InteracHons)4. )AddicHon)5. )CogniHve)impairment)WHAT’S)THE)REAL)ISSUE?)"   )Adverse)events)↑)2h7x)"   )Hospital)admissions)2x)higher)WHY?))"   )Higher)dosing,)less)frequent)monitoring,)))))))))incomplete)consideraHon)of)effects)of)other))))))))))drugs,)cogniHve)impairment)RESULTS?)↑)Risk)for)morbidity)&)mortality)↑)Economic)costs)(drugs,)MD)visits)&)hospitalizaHon))PharmacokineHcs—the)body's)reacHon)to)drugs)including:)))))• )AbsorpHon)• )DistribuHon)• )Metabolism))• )EliminaHon)"  )Body)ComposiHon)"  )Key)Areas)of)Change)!  )DigesHve*)! )HepaHc*)! )Renal*)! )Cardiac)! )Brain)PharmacokineHcs!"  )Decreased)body)mass/water)*)! Hydrophilic)drugs)(ie)digoxin,)hydromorphone)"  )Increased)body)fat)*)! Lipophilic)drugs,)ie)diazepam)(long)½)life))"  )Decreased)plasma)albumin)binding)! Examples:)phenytoin,)benzodiazepines,)oral)))))))))))))))))hypoglycemics,)anHcoagulants)"  )ImplicaHon:)High)risk)for)serum)concentraHon,))))))drug)toxicity))))))))&)delirium)• Free)Drug)• Protein)Bound)Drug)KEY)Olice, G. L. et. al. Inhaled Corticosteroids: Is There an Ideal Therapy. Medscape. "  )Decreased)gastric)pH)=)↑)gastric)acidity)"  )Decreased)GI)blood)flow)&)moHlity)"  )Examples:)Digoxin,)levodopa,)enteric))) )coated/SR)drugs,)anHhinflammatories)"  )ImplicaHon:)Nausea,)GI)upset/bleed)! )Why?)Poor)absorpHon,)↑)Hme)to)peak)))))))))))))))))))serum)levels)Avoid)Mineral)oil,)cascara,)bisacodyl,)antacids)(cimeHdine))HEPATIC)CHANGES)"  Decreased)size)of)liver)"  Decreased)blood)flow)(45%),)protein)metabolism))))))&)bile)formaHon)"  Decreased)liver)enzymes)result)in:)! Decreased)metabolism)&)! Increased)blood)levels)&)! Increased)toxicity))"  Examples:)amitriptyline,)metoprolol,)nitroglycerin,)propranolol,)opiods)(codeine,)morphine))RENAL)CHANGES!"  )Decreased)renal)mass)&))))))))blood)flow)"  )Decreased)number)of)))))))nephrons)! EliminaHon)impaired)(50%))"  )Decreased)glomerular)))))))filtraHon)rate)(GFR))! Normal)creaHnine)(Cr))! Reduced)response)to)dehydraHon)))))Examples:)Atenolol,)cefuroxime,)nadolol,))))))levofloxacin,)chlorpropamide,)digoxin)"  ! heart)rate)! )Reduced)cardiac)))))))output)&)circulaHon)"  Overall)decrease))! )Maximum)heart)rate)! )Efficiency)of)valves)! )Pacemaker)response)! )Receptor)sensiHvity)! )Baroreflex)sensiHvity)"  )Hypotension)&)falls)"  )Impact)renal)funcHon)"  )CNS)Effects))! Cross)bloodhbrain)barrier)! Decrease)neurotransmission)! Confusion,)headache,)nightmares,)depression)"  )ReducHon)in)weight)&)volume)"  )Increased)size)of)ventricles)"  )Decreased)size/number)of)neurons)"  )Decreased)number/size/transmission)of)))))))neurotransmiters)! Serotonin,)dopamine,)norepinephrine)FuncHon)of)Neurotransmiters)1.  )AnHdepressants)2.  )Benzodiazepines)3.  )AnHpsychoHcs))True)of)False?)•  AnHdepressants)are)a)good)soluHon)for)demenHa.)•  PaHents)will)respond)to)anHdepressants)within)1h2)weeks.)•  Long)acHng)anHdepressants)are)safer)and)more)effecHve)in)older)adults.!"  Seretonin:)))!  Influences)mood)&)behavior)&))!  Effects)renal,)immune,)GI)systems)"  Effect)mulHple)neurotransmiters)"  May)enhance)other)drugs)(ie)beta)blockers,)neurolepHcs,)benzos))"  )Long)½)life)(up)to)one)week))"  )IndicaHons:)! Depression,)sleep)disturbance,)anorexia)"  )3h6)months)to)recovery)"  )Recognizing)relapse)SelecHve)Serotonin)Reuptake)Inhibitors)))))))))))))))))))))))))))))))))))))))))))))))))))))(SSRIs))"   Citalopram)(Celexa))"   Fluvoxamine)(Luvox))"   Sertraline)(Zolo\))"   ParoxeHne)(Paxil))"   FluoxeHne)(Prozac)))))))))))))))))))))))))Others)"  Venlafaxine)(Effexor))"  Buproprion)(Wellbutrin))"  Tricyclic)(Amitriptyline))"  Trazadone)(Desyrel))"  Mirtazapine)(Remeron))"   )AnHcholinergic)(!)with)older)drugs))"   )Cardiac)! )OrthostaHc)hypotension,)tachycardia)"   )CogniHve/Neurological)! )Tremors)! )HallucinaHons,)delusions,)suicidal)ideaHon)! )Over)sedaHon,)agitaHon)Avoid Tricyclic Antidepressants: Nortriptyline, desipramine, imipramine True)of)False?)•  Benzos)are)a)first)line)treatment)for)older)adults)with)aggressive)behaviors.)•  LonghacHng)benzos)can)be)helpful)in)treaHng)anxiety)disorders.)•  Physical)dependence)with)benzos)is)not)an)issue)with)older)paHents.)"  )IndicaHons:)anxiety,)procedures,)))))ETOH)withdrawal)"  )Prolonged)½)life)with)liver)disease)"  )Produce)physical)dependence))"  )Abrupt)stop)")withdrawal)! )Anxiety,)restlessness,)seizures)! )!)delirium)risk)LONG)ACTING)! )Diazepam)(Valium))! )Clonazepam)(Rivotril))SHORT/INTERMEDIATE))! )Lorazepam)(AHvan))! )Oxazepam)(Serax))! )Alprazolam)(Xanax))! )Temazepam)(Restoril))"  )Paradoxical*)effects)! )Increased)confusion,)disinhibiHon,))))))))))))calling)out,)disrobing,)striking)out)"  )Impaired)gait/balance)"  )Falls)(safety))"  )SedaHon)"  )Memory)impairment)"  )AnHcholinergic)effects)DEFINITION)) )Adverse)symptoms))due)to)blocking)acetylcholine)both)inside))&)outside)the)brain)))))))ADVERSE)EFFECTS)• ))CogniHve)changes)• ))Psychosis/delirium)• ))SedaHon)• ))Tachycardia)• ))Dry)eyes/mouth)• ))Unsteady)gait/falls)• ))ConsHpaHon)• ))Urinary)inconHnence,))))))retenHon)• ))Dysphagia)True)or)False)"  Malnourished)older)adults)should)receive))the)same)dose)of)anHpsychoHc)drugs)as)younger)adults)"  Older)adults)who)are)dehydrated)should)receive)their)usual)dose)of)anHdepressant)&/or)anHpsychoHc)medicaHons)"  AnHpsychoHc)drugs)contribute)to)falls)in)older)adults.)"  )DegeneraHve)brain)disease)with)loss)of))))))funcHon,)memory)"  ↓)release)of)neurochemicals)! )Acetylcholine,)dopamine,)GABA)"  )And)the)problem?)! )Block)acetylcholine)receptors)in)the)brain)"  )Result?)! )Increased)confusion,)delirium,)falls)ALZHEIMER’S)DISEASE)TreaHng)Alzheimer's)Disease)IndicaHons)"  )DemenHa)&)Delirium)!  Treatment)of)agitaHon,)aggression,)hallucinaHons,)sleep)disturbance,)psychosis)2nd))to)treatment)(ie,)steroids))!  Enhance)effecHveness)of)other)drugs)(ie,)anHdepressants))"  )Mental)Illness)!  Treatment)of)psychosis)(ie,)bipolar)disorder,)psychosis,)delusional)depression)))DEFINITION)• Adverse)symptoms)due)to)blocking)dopamine)&)other)brain)chemicals)• Symptoms)similar)to)Parkinson’s)Disease))SYMPTOMS)• )SHffness)• )Shuffling)• )Tremor)• )Rigidity)• )Restlessness)• )Confusion)• )Delirium!Sedation # BP Anti-Cholinergic  EPS Loxapine Mod Mild-Mod Mild-Moderate Mod Nozinan High Mod-High Mod Mild-Mod Quetiapine Mild-Mod Mild-Mod None-Mild Very Mild Olanzepine Mod Mild-Mod Mild-Mod Mild Haldol Mild Mild None? High Risperidone Mod Mod None-Mild Mod 1. )AnHconvulsants)! )GabapenHn,)clonazepam)! )IndicaHons:)Aggression,)anxiety,)mania)2. )Acuphase)(Dopixol))! )Blocks)dopamine)! )IndicaHons:)Aggression,)usually)with)demenHa)! )Rapid)reducHon)of)symptoms)(lasts)2h3)days))3. )Opiods)! )Methadone,)oxycodone)! )IndicaHons:)AgitaHon)20)pain)and)?)demenHa)"   Combine)demenHa)&)anHpsychoHcs)and))))))))))))))$)risk)for:)! Stroke)! Pneumonia)! Death)"   Risk)linked)to)Risperidone)&)Olanzepine)"   Warnings)issued)in)Canada,)UK,)USA)"   ImplicaHon:)AlternaHve)approaches)"   Involves)2)factors:)! Physiological)(need)more)to)achieve)desired)effect))! Psychological)(perceived)need)for)drug))"   Common)substances:)! Alcohol,)nicoHne,)benzos,)opiods,)OTC,)marijuana,)amphetamine,)coffee)"   High)risk:)delirium,)seizures,)elopement)Remember,'''alcoholism'impacts'all'drugs'metabolized'''''''by'the'liver'1.  )OrthostaHc)Hypotension)2.  )Falls)3.  )Movement)Disorder)4.  )Impaired)CogniHon)5.  )Depression)6.  )MalnutriHon)7.  )InconHnence/RetenHon)QuesHons)to)Consider:)! )IndicaHon:)Why)is)this)drug)being)used?)! )Dose:)Appropriate)for)paHent’s)age/health?)! )Length)of)Hme:)Too)short/long?)! )Monitoring:)Ongoing)assessment?)! )Opinion)of)other)professionals)(MD/pharmacist)))) ))&)family/caregivers?)"   )Simplify)! )Once)daily,)with)meals,)SR)someHmes)! )Avoid)injecHons)when)possible)"   )Support)&)educate)paHent,)family,)))))))))caregivers)"   Adverse)effects:))! )Reduce)or)D/C?)"  )Review)medicaHon)history)! )Consult)Beer’s)List,)PharmaNet,)Med)Rec)"  Provide)memory)aids)for)discharge)! )Bubble)pack,)dosete)! )Charts,)pictures)"  )Ensure)readability)! )Language,)literacy,)font,)))))))))))))))))))))))))))glasses,)hearing)aid)"  )Chronic)&)acute)illnesses)"  )Complex)drug)regimens)! Polypharmacy;)MedicaHons)of)risk)"   )PaHent)preferences)"   %)vision,)hearing,)dexterity,)cogniHon)"  )PaHent)complexiHes)! Trading/sharing)medicaHons)AGS BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER ADULTSFROM THE AMERICAN GERIATRICS SOCIETYThis clinical tool, based on The AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS 2012 Beers Criteria), has been developed to assist healthcare providers in improving medication safety in older adults. Our purpose is to inform clinical decision-making concerning the prescribing of medications for older adults in order to improve safety and quality of care. Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers Criteria catalogues medications that cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging. In 2011, the AGS undertook an update of the criteria, assembling a team of experts and funding the develop-ment of the AGS 2012 Beers Criteria using an enhanced, evidence-based methodology.  Each criterion is rated (qual-ity of evidence and strength of evidence) using the American College of Physicians’ Guideline Grading System, which is based on the GRADE scheme developed by Guyatt et al.  The full document together with accompanying resources can be viewed online at www.americangeriatrics.org. INTENDED USEThe goal of this clinical tool is to improve care of older adults by reducing their exposure to Potentially Inappropri-ate Medications (PIMs).   n  This should be viewed as a guide for identifying medications for which the risks of use in older adults outweigh the benefits.n  These criteria are not meant to be applied in a punitive manner.n  This list is not meant to supersede clinical judgment or an individual patient’s values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision-making.n  These criteria also underscore the importance of using a team approach to prescribing and the use of non-pharmacological approaches and of having economic and organizational incentives for this type of model.n  Implicit criteria such as the STOPP/START criteria and Medication Appropriateness Index should be used in a complementary manner with the 2012 AGS Beers Criteria to guide clinicians in making decisions about safe medication use in older adults.The criteria are not applicable in all circumstances (eg, patient’s receiving palliative and hospice care). If a clinician is not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation of the medication as potentially inappropriate can serve as a reminder for close monitoring so that the potential for an adverse drug effect can be incorporated into the medical record and prevented or detected early. TABLE 1:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsOrgan System/Therapeutic Category/Drug(s)Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Anticholinergics (excludes TCAs)First-generation antihistamines (as single agent or as part of combination products)n  Brompheniramine n  Carbinoxamine n  Chlorpheniramine n  Clemastine n  Cyproheptadine n  Dexbrompheniramine n  Dexchlorpheniramine n  Diphenhydramine (oral) n  Doxylamine n  Hydroxyzine n  Promethazine n  TriprolidineAvoid.Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confu-sion, dry mouth, constipation, and other anticholinergic effects/toxicity.Use of diphenhydramine in special situations such as acute treat-ment of severe allergic reaction may be appropriate.QE = High (Hydroxyzine and Promethazine), Moderate (All others); SR = StrongAntiparkinson agentsn  Benztropine (oral)n  TrihexyphenidylAvoid.Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease.QE = Moderate; SR = StrongTable 1 (continued from page 1)Table 1 (continued on page 2) Table 1 (continued on page 3)PAGE 1 PAGE 2TABLE 1:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsOrgan System/Therapeutic Category/Drug(s)Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Antispasmodicsn  Belladonna alkaloidsn  Clidinium-chlordiazepoxiden  Dicyclominen  Hyoscyaminen  Propanthelinen  ScopolamineAvoid except in short-term palliative care to decrease oral secretions. Highly anticholinergic, uncertain effectiveness.QE = Moderate; SR = StrongAntithromboticsDipyridamole, oral short-acting* (does not apply to the extended-release combination with aspirin)Avoid.May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing.QE = Moderate; SR = StrongTiclopidine* Avoid.Safer, effective alternatives available.QE = Moderate; SR = StrongAnti-infectiveNitrofurantoin Avoid for long-term suppression; avoid in patients with CrCl <60 mL/min.Potential for pulmonary toxicity; safer alternatives available; lack of efficacy in patients with CrCl <60 mL/min due to inadequate drug concentration in the urine.QE = Moderate; SR = StrongCardiovascularAlpha1 blockersn  Doxazosinn  Prazosinn  TerazosinAvoid use as an antihypertensive.High risk of orthostatic hypotension; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile.QE = Moderate; SR = StrongAlpha agonistsn  Clonidinen  Guanabenz*n  Guanfacine*n  Methyldopa*n  Reserpine (>0.1 mg/day)*Avoid clonidine as a first-line antihypertensive. Avoid oth-ers as listed.High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension.QE = Low; SR = StrongAntiarrhythmic drugs (Class Ia, Ic, III)n  Amiodaronen  Dofetiliden  Dronedaronen  Flecainiden  Ibutilide n  Procainamiden  Propafenonen  Quinidinen  SotalolAvoid antiarrhythmic drugs as first-line treatment of atrial fibrillation.Data suggest that rate control yields better balance of benefits and harms than rhythm control for most older adults.Amiodarone is associated with multiple toxicities, including thyroid disease, pulmonary disorders, and QT interval prolongation. QE = High; SR = StrongDisopyramide* Avoid.Disopyramide is a potent negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred.QE = Low; SR = StrongDronedarone Avoid in patients with permanent atrial fibrillation or heart failure. Worse outcomes have been reported in patients taking drone-darone who have permanent atrial fibrillation or heart failure.  In general, rate control is preferred over rhythm control for atrial fibrillation.QE = Moderate; SR = StrongDigoxin >0.125 mg/day Avoid.In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance may increase risk of toxicity.QE = Moderate; SR = StrongTable 1 (continued from page 2) Table 1 (continued from page 3)Table 1 (continued on page 4) Table 1 (continued on page 5)PAGE 3 PAGE 4TABLE 1:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsOrgan System/Therapeutic Category/Drug(s)Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Nifedipine, immediate release* Avoid.Potential for hypotension; risk of precipitating myocardial ischemia.QE = High; SR = StrongSpironolactone >25 mg/day Avoid in patients with heart failure or with a CrCl <30 mL/min.In heart failure, the risk of hyperkalemia is higher in older adults if taking >25 mg/day.QE = Moderate; SR = StrongCentral Nervous SystemTertiary TCAs, alone or in combination:n  Amitriptylinen  Chlordiazepoxide-    amitriptylinen  Clomipraminen  Doxepin >6 mg/dayn  Imipraminen  Perphenazine-amitriptylinen  TrimipramineAvoid.Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo.QE = High; SR = StrongAntipsychotics, first- (conventional) and sec-ond- (atypical) generation (see online for full list)Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat to self or others.Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.QE = Moderate; SR = StrongThioridazineMesoridazineAvoid.Highly anticholinergic and greater risk of QT-interval prolongation.QE = Moderate; SR = StrongBarbituratesn  Amobarbital*n  Butabarbital*n  Butalbitaln  Mephobarbital*n  Pentobarbital*n  Phenobarbitaln  Secobarbital*Avoid.High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages.QE = High; SR = StrongBenzodiazepinesShort- and intermediate-acting:     n  Alprazolam     n  Estazolam     n  Lorazepam     n  Oxazepam     n  Temazepam     n  TriazolamLong-acting:     n  Chlorazepate     n  Chlordiazepoxide     n  Chlordiazepoxide-amitriptyline     n  Clidinium-chlordiazepoxide     n  Clonazepam     n  Diazepam     n  Flurazepam     n  QuazepamAvoid benzodiazepines (any type) for treatment of insom-nia, agitation, or delirium.Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all ben-zodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults.May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, end-of-life care.QE = High; SR = StrongChloral hydrate* Avoid.Tolerance occurs within 10 days and risk outweighs the benefits in light of overdose with doses only 3 times the recommended dose.QE = Low; SR = StrongMeprobamate Avoid.High rate of physical dependence; very sedating.QE = Moderate; SR = StrongTABLE 1:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsOrgan System/Therapeutic Category/Drug(s)Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Nonbenzodiazepine hypnoticsn  Eszopiclonen  Zolpidemn  ZaleplonAvoid chronic use (>90 days)Benzodiazepine-receptor agonists that have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); minimal improvement in sleep latency and duration.QE = Moderate; SR = StrongErgot mesylates*Isoxsuprine*Avoid.Lack of efficacy.QE = High; SR = StrongEndocrineAndrogensn  Methyltestosterone*n  TestosteroneAvoid unless indicated for moderate to severe hypogonadism.Potential for cardiac problems and contraindicated in men with prostate cancer.QE = Moderate; SR = WeakDesiccated thyroid Avoid.Concerns about cardiac effects; safer alternatives available.QE = Low; SR = StrongEstrogens with or without progestins Avoid oral and topical patch. Topical vaginal cream: Ac-ceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infec-tions, and other vaginal symptoms.Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dos-ages of estradiol <25 mcg twice weekly.QE = High (Oral and Patch), Moderate (Topical); SR = Strong (Oral and Patch), Weak (Topical)Growth hormone Avoid, except as hormone replacement following pituitary gland removal.Effect on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose.QE = High; SR = StrongInsulin, sliding scale Avoid.Higher risk of hypoglycemia without improvement in hyperglyce-mia management regardless of care setting.QE = Moderate; SR = StrongMegestrol Avoid.Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults.QE = Moderate; SR = StrongSulfonylureas, long-durationn  Chlorpropamiden  GlyburideAvoid.Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes SIADHGlyburide: higher risk of severe prolonged hypoglycemia in older adults.QE = High; SR = StrongGastrointestinalMetoclopramide Avoid, unless for gastroparesis.Can cause extrapyramidal effects including tardive dyskinesia; risk may be further increased in frail older adults.QE = Moderate; SR = StrongMineral oil, given orally Avoid.Potential for aspiration and adverse effects; safer alternatives avail-able.QE = Moderate; SR = StrongTrimethobenzamide Avoid.One of the least effective antiemetic drugs; can cause extrapyrami-dal adverse effects.QE = Moderate; SR = StrongTABLE 2:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or SyndromeDisease or SyndromeDrug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)CardiovascularHeart failure NSAIDs and COX-2 inhibitorsNondihydropyridine CCBs (avoid only for systolic heart failure)n  Diltiazemn  VerapamilPioglitazone, rosiglitazoneCilostazolDronedaroneAvoid.Potential to promote fluid retention and/or exacer-bate heart failure.QE = Moderate (NSAIDs, CCBs, Dronedarone), High (Thia-zolidinediones (glitazones)), Low (Cilostazol); SR = StrongTable 2 (continued from page 5)Table 2 (continued on page 6)Table 1 (continued from page 4)Table 2 (continued on page 7)PAGE 5 PAGE 6TABLE 1:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsOrgan System/Therapeutic Category/Drug(s)Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Pain MedicationsMeperidine Avoid.Not an effective oral analgesic in dosages commonly used; may cause neurotoxicity; safer alternatives available.QE = High; SR = StrongNon-COX-selective NSAIDs, oral n  Aspirin >325 mg/dayn  Diclofenacn  Diflunisaln  Etodolacn  Fenoprofenn  Ibuprofenn  Ketoprofenn  Meclofenamaten  Mefenamic acidn  Meloxicamn  Nabumetonen  Naproxenn  Oxaprozinn  Piroxicamn  Sulindacn  TolmetinAvoid chronic use unless other alternatives are not effec-tive and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).Increases risk of GI bleeding/peptic ulcer disease in high-risk groups, including those ≥75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents. Use of pro-ton pump inhibitor or misoprostol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months, and in about 2%–4% of patients treated for 1 year. These trends continue with longer duration of use.QE = Moderate; SR = StrongIndomethacinKetorolac, includes parenteralAvoid.Increases risk of GI bleeding/peptic ulcer disease in high-risk groups (See Non-COX selective NSAIDs)Of all the NSAIDs, indomethacin has most adverse effects.QE = Moderate (Indomethacin), High (Ketorolac); SR = StrongPentazocine* Avoid.Opioid analgesic that causes CNS adverse effects, including confu-sion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist; safer alternatives available.QE = Low; SR = StrongSkeletal muscle relaxantsn  Carisoprodoln  Chlorzoxazonen  Cyclobenzaprinen  Metaxalonen  Methocarbamoln  OrphenadrineAvoid.Most muscle relaxants poorly tolerated by older adults, because of anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.QE = Moderate; SR = Strong*Infrequently used drugs. Table 1 Abbreviations: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin receptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastroin-testinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SR, Strength of Recommendation;  TCAs, tricyclic antidepressants; QE, Quality of EvidenceTABLE 2:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or SyndromeDisease or SyndromeDrug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Syncope Acetylcholinesterase inhibitors (AChEIs)Peripheral alpha blockers n  Doxazosinn  Prazosinn  TerazosinTertiary TCAsChlorpromazine, thioridazine, and olan-zapineAvoid.Increases risk of orthostatic hypotension or brady-cardia.QE = High (Alpha blockers), Moderate (AChEIs, TCAs and antipsychotics); SR = Strong (AChEIs and TCAs), Weak (Alpha blockers and antipsychotics)Central Nervous SystemChronic seizures or epilepsyBupropionChlorpromazineClozapineMaprotilineOlanzapineThioridazineThiothixeneTramadolAvoid.Lowers seizure threshold; may be acceptable in patients with well-controlled seizures in whom alter-native agents have not been effective.QE = Moderate; SR = StrongDelirium All TCAsAnticholinergics (see online for full list)BenzodiazepinesChlorpromazineCorticosteroidsH2-receptor antagonistMeperidineSedative hypnoticsThioridazineAvoid.Avoid in older adults with or at high risk of delirium because of inducing or worsening delirium in older adults; if discontinuing drugs used chronically, taper to avoid withdrawal symptoms.QE = Moderate; SR = StrongDementia & cognitive impairmentAnticholinergics (see online for full list)BenzodiazepinesH2-receptor antagonistsZolpidemAntipsychotics, chronic and as-needed useAvoid.Avoid due to adverse CNS effects.Avoid antipsychotics for behavioral problems of dementia unless non-pharmacologic options have failed and patient is a threat to themselves or others. Antipsychotics are associated with an increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.QE = High; SR = StrongHistory of falls or fracturesAnticonvulsantsAntipsychoticsBenzodiazepinesNonbenzodiazepine hypnoticsn  Eszopiclonen  Zaleplonn  ZolpidemTCAs/SSRIsAvoid unless safer alternatives are not avail-able; avoid anticonvulsants except for seizure.Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls; shorter-acting benzodiazepines are not safer than long-acting ones.QE = High; SR = StrongInsomnia Oral decongestantsn  Pseudoephedrinen  Phenylephrine Stimulantsn  Amphetaminen  Methylphenidaten  Pemoline Theobrominesn  Theophyllinen  CaffeineAvoid.CNS stimulant effects.QE = Moderate; SR = StrongParkinson’s diseaseAll antipsychotics (see online publica-tion for full list, except for quetiapine and clozapine)Antiemeticsn  Metoclopramiden  Prochlorperazinen  PromethazineAvoid.Dopamine receptor antagonists with potential to worsen parkinsonian symptoms.Quetiapine and clozapine appear to be less likely to precipitate worsening of Parkinson disease.QE = Moderate; SR = StrongTABLE 3:  2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older AdultsDrug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommenda-tion (SR)Aspirin for primary preven-tion of cardiac eventsUse with caution in adults ≥80 years old.Lack of evidence of benefit versus risk in individuals ≥80 years old.QE = Low; SR = WeakDabigatran Use with caution in adults ≥75 years old or if CrCl <30 mL/min.Increased risk of bleeding compared with warfarin in adults ≥75 years old; lack of evidence for efficacy and safety in patients with CrCl <30 mL/minQE = Moderate; SR = WeakPrasugrel Use with caution in adults ≥75 years old.Greater risk of bleeding in older adults; risk may be offset by benefit in highest-risk older patients (eg, those with prior myocardial infarction or diabetes).QE = Moderate; SR = WeakAntipsychoticsCarbamazepineCarboplatinCisplatinMirtazapineSNRIsSSRIsTCAsVincristineUse with caution.May exacerbate or cause SIADH or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk.QE = Moderate; SR = StrongVasodilators Use with caution.May exacerbate episodes of syncope in individuals with history of syncope.QE = Moderate; SR = WeakTable 3 Abbreviations: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of EvidenceTable 2 (continued from page 6)PAGE 7The American Geriatrics Society gratefully acknowledges the support of the John A. Hartford Foundation, Retirement Research Foundation and Robert Wood Johnson Foundation.THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.  40 Fulton Street, 18th Floor  New York, NY 10038 800-247-4779 ot 212-308-1414 www.americangeriatrics.orgAGSTABLE 2:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or SyndromeDisease or SyndromeDrug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)GastrointestinalChronic constipationOral antimuscarinics for urinary inconti-nencen  Darifenacinn  Fesoterodinen  Oxybutynin (oral)n  Solifenacinn  Tolterodinen  TrospiumNondihydropyridine CCBn  Diltiazemn  VerapamilFirst-generation antihistamines as single agent or part of combination productsn  Brompheniramine (various)n  Carbinoxaminen  Chlorpheniraminen  Clemastine (various)n  Cyproheptadinen  Dexbrompheniraminen  Dexchlorpheniramine (various)n  Diphenhydraminen  Doxylaminen  Hydroxyzinen  Promethazinen  TriprolidineAnticholinergics/antispasmodics (see online for full list of drugs with strong anticholinergic properties)n  Antipsychoticsn  Belladonna alkaloidsn  Clidinium-chlordiazepoxiden  Dicyclominen  Hyoscyaminen  Propanthelinen  Scopolaminen  Tertiary TCAs (amitriptyline, clomip-ramine, doxepin, imipramine, and trimip-ramine)Avoid unless no other alternatives.Can worsen constipation; agents for urinary incon-tinence: antimuscarinics overall differ in incidence of constipation; response variable; consider alternative agent if constipation develops.QE = High (For Urinary Incontinence), Moderate/Low (All Others); SR = StrongHistory of gastric or duodenal ulcersAspirin (>325 mg/day)Non–COX-2 selective NSAIDsAvoid unless other alternatives are not ef-fective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).May exacerbate existing ulcers or cause new/addi-tional ulcers.QE = Moderate; SR = StrongKidney/Urinary TractChronic kid-ney disease stages IV and VNSAIDsTriamterene (alone or in combination)Avoid.May increase risk of kidney injury.May increase risk of acute kidney injury.QE = Moderate (NSAIDs), Low (Triamterene); SR = Strong (NSAIDs), Weak (Triamterene)Urinary incontinence (all types) in womenEstrogen oral and transdermal (excludes intravaginal estrogen)Avoid in women.Aggravation of incontinence.QE = High; SR = StrongTABLE 2:  2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or SyndromeDisease or SyndromeDrug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)Lower urinary tract symptoms, benign prostatic hyperplasiaInhaled anticholinergic agentsStrongly anticholinergic drugs, except antimuscarinics for urinary incontinence (see Table 9 for complete list).Avoid in men.May decrease urinary flow and cause urinary reten-tion.QE = Moderate; SR = Strong (Inhaled agents), Weak (All others)Stress or mixed urinary in-continenceAlpha-blockersn  Doxazosinn  Prazosinn  TerazosinAvoid in women.Aggravation of incontinence.QE = Moderate; SR = StrongTable 2 Abbreviations: CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central ner-vous system; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs; SR, Strength of Recommenda-tion; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; QE, Quality of EvidenceTable 2 (continued on page 8) PAGE 8Table 2 (continued from page 7)  GET Program DAY 3  Meeting the Challenges in Older Adults Care          Geriatric Education & Training Program Course Schedule    Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013    Time Topic   0830 Survey #1  0900 Welcome & Introductions  0930 Patients & Families as Partners in Care x Personhood x Patient & Family Centered Care  1000 Break  1015 The Nursing Process: Bringing Patient Centered Care to the Point of Care  1115 Quality Improvement: Thinking about Patient & Family Centered Care at the Unit and Systems Level  1200 Lunch x Lunch & Learn: Library Services  1300 3Ds: Delirium, Dementia, Depression  1615 Evaluation/Feedback on the day        ` Geriatric Education & Training Program Course Schedule    Day 3: Meeting the Challenges in Older Adults Care  November 15, 2013   Time Topic   0830  0900 Introduction  Ethics Discussion with Bethan Everett, Ethicist VCH x End of life care and tube feeding  1030 Break  1045 Pain in the Cognitively Impaired Older Adult  1145  1200 Group Preparation Work for QI Presentation  Lunch  1245 Quality Improvement Project Presentations  1445 The Palliative Approach with Pat Porterfield  1530 Course Wrap-up Questionnaire and Evaluation       Day 3: Meeting the Challenges in Older Adults Care  November 15, 2013  Please indicate your level of agreement with the statements below:    Strongly Agree Agree Neutral Disagree Strongly Disagree Comments  The content was organized and easy to follow   € € € € €  The objectives were clearly identified  € € € € €  Participation and interaction were encouraged   € € € € €  Questions and exchanges were encouraged  € € € € €  The material covered was relevant  € € € € €  The amount of time allowed to cover the material was sufficient  € € € € €  The training session met my expectations  € € € € €  Would you recommend this session to someone else?   € € € € €    See reverse         What did you find was the most helpful?         Any suggestions on what should be changed to improve the program.          Please use the area below for any additional comments:              Thank you for your feedbacks  PAIN%IN%OLDER%ADULTS%WITH%COGNITIVE%&/OR%LANGUAGE%IMPAIRMENT%Maureen%Shaw,%RN,%MN%Clinical%Nurse%Specialist,%Gerontology%November%2013%OBJECTIVES%1. To%iden*fy%5%myths%related%to%pain.%2. To%discuss%the%challenges%of%pain%assessment%in%older%adults%with%cogni*ve/language%impairment.%3. To%apply%concepts%of%pain%assessment%and%management%to%older%adults.%4. To%u*lize%the%Hierarchy%of%Pain%Assessment%Techniques%for%the%assessment,%management%&%evalua*on%of%pain.%Myths%about%Pain%TRUE%or%FALSE?%•  Pain%is%a%normal%part%of%aging.%•  Pain%percep*on%decreases%with%aging.%•  Distrac*ble/inaHen*ve/sleeping%older%pa*ents%are%not%in%pain.%•  Pain%is%oIen%associated%with%behavior%change%in%the%cogni*vely%impaired.%•  Opiods%cause%addic*on/respiratory%arrest%in%older%adults.%SUBROPTIMAL%PAIN%MANAGEMENT:%IMPLICATIONS%for%PATIENTS%•  Inaccurate%assessment%•  Inadequate%management%•  Func*onal%&%cogni*ve%decline%•  Poor%wound%healing,%delirium,%impaired%immune%func*on,%stress%response,%increased%metabolic%needs/fall%risk%Adapted from: Hadjistavropoulos et al., 2007 SUBROPTIMAL%PAIN%MANAGEMENT:%BARRIERS%to%OPTIMAL%CARE%• Social,%language%&/or%cultural%barriers%• CoPexis*ng%illnesses%with%different%sources/%condi*ons/presenta*ons%of%pain%(2+)%• Variable(pain%presenta*ons/response%to%treatment%• Staff%knowledge%• System%obstacles%Background:%DefiniXons%of%Pain%Whatever%the%pa*ent%says%it%is%&%occurs%whenever%the%pa*ent%says%it%does%%%(McCaffery%&%Beebe,%1989)%%Background:%Does%CogniXon%MaYer?%Losses%of%DemenXa%•  Memory%gaps%•  Visual%spa*al%deficits%•  AHen*on%decline%•  Behavioral%issues%•  Aphasia%•  Vision/hearing%loss%Demands%of%Pain%Assessment%Requires%cogni*ve%ability%to:%•  understand%abstract%concepts%•  process%the%task%•  use%short/long%term%memory%&%•  communicate%pain%experience%What%is%Pain?%An%unpleasant%sensory%and%emo*onal%experience%associated%with%actual%or%poten*al%*ssue%damage%or%described%in%terms%of%such%damage%(IASP,%1986)%What%are%the%Types?%– Acute%– Persistent/chronic%– Nocicep*ve%%– Neuropathic%Background:%The%FACES%of%Pain%Background:%The%FACES%of%Pain%Acute%Pain%• Defined:%Begins%suddenly;%secondary%to%*ssue%damage%&/or%inflamma*on%such%as%surgery,%procedure,%or%injury/trauma%• Described:%Sharp%in%quality,%radia*ng%• Usually%associated%with%change%in%vital%signs%&%emo*onal%distress%• Usually%*me%limited%Persistent/Chronic%Pain%• Defined:%Pain%that%con*nues%for%a%longer%period%of%*me%(3+%months)%•  Influenced%by%environmental,%emo*onal,%cultural,%spiritual%&%psychological%factors.%%• Usually%no%*me%limit%Is%There%a%Difference?%NocicepXve%&%Neuropathic%Pain%NocicepXve%Pain%•  Defined:%Pain%produced%in%response%to%injury%and/or%inflamma*on%&%associated%with%*ssue%damage%•  Produced%2O%to%acute%(ie,%angina)%and%chronic%condi*ons%(ie,%arthri*s,%angina)%•  Described:%Diffuse,%dull,%aching,%throbbing%Neuropathic%Pain%• Defined:%Pain%produced%by%damage%to%or%dysfunc*on%in%the%peripheral%or%CNS.%%• Produced%by%radia*on,%carpal%tunnel,%postPstroke,%diabetes,%shingles.%• Described:%Burning,%*ngling,%feeling%of%coldness,%electric%shocks,%shoo*ng,%stabbing%Common%Painful%CondiXons%Diagnoses/CondiXon% PotenXal%Types%of%Pain%Musculoskeletal%(40%)% •  Tightness,%s*ffness,%spasm,%acute%pain%OsteoarthriXs%(37%)% •  Deep$aching(pain,%joint%swelling/pain/%tenderness%Fractures%(14%)% •  Severe$localized(pain,%muscle%spasm%Neuropathy%(11%)% •  Burning,%*ngling,%shockPlike%stabs;%cold/hot;%pins%&%needles%PVD%(8%)% •  Intermi5ent%sharp%stabs,%burning,%s*ffness%Cancer%(3%)% •  Variable:%aching,%stabbing;%acute/chronic%Headaches%(6%)% •  Dull,%aching,%throbbing,%visual%disturbance%Generalized%Pain%(3%)% •  AllPover%discomfort,%aching,%sharp%stabs%Adapted from: Miaskowski, 1999; Stein & Ferrell, 1996 Diagnoses/CondiXon% PotenXal%Types%of%Pain%PleuriXc%% •  Sharp,%localized;%↑%with%coughing,%moving%GI%Reflux% •  Heartburn,%regurgita*on%(sour/biHer%taste)%Myocardial%Ischemia:%Acute/chronic%(angina)%•  Tightness,%squeezing,%indiges*on,%ill6defined(pain$Temporal%ArteriXs% •  Headache,%visual%disturbances%InfecXon:%UTI,%C.%diff,%osteomyeliXs,%wounds%•  Aching,%nausea*ng,%piercing%sharp%stabs,%cramping%Oral%Hygiene/Disease% •  Refusing%to%eat/drink;%dull/sharp,%gnawing%Common%Painful%CondiXons%Adapted from: Miaskowski, 1999; Stein & Ferrell, 1996 Behavioral%Assessment%of%Pain:%CreaXng%a%Picture%Facial%expression% • Sad%expression,%frightened%look;%closed%eyes%• Rapid%blinking;%grimacing;%any%distorted%expression%VocalizaXons% • Sighing,%moaning,%groaning,%noisy%breathing%• Verbally%abusive;%asking%for%help%Body%movements% • Pacing,%rocking;%pushing%away;%restricted%movements;%guarding,%rigid,%tense%posture%Change%in%social%interacXons%• Aggressive,%comba*ve;%irritable;%resis*ng%care%• BedPseeking;%withdrawn;%↑%pacing;%rocking%Change%in%rouXnes/acXviXes%• Change%in%gait,%transfer,%selfPcare;%↑%rest%periods%• %Refusing%food;%change%in%sleep/rou*nes%Change%in%mental%status% •  Crying,%↑%confusion,%irritable/easily%distressed%Adapted from: American Geriatric Society, 2009 “FACES”%of%Pain%Acute Pain    Chronic Pain Pain%in%Older%Adults%Pain and Cognitive Impairment: Reading the Cues Case%Study%#1%•  Mrs.%S:%89%year%old%female%admiHed%aIer%a%fall%at%home%with%a%#%pelvic%rami,%facial%lacera*ons/%bruising%•  History:%Osteoarthri*s,%spinal%stenosis,%GI%bleed,%CHF,%ADL%decline%over%past%2%weeks%•  Meds:%Hydromorphone,%tylenol,%ramipril,%lasix,%a*van%•  SituaXon:%Forehead%wrinkled,%eyes%*ghtly%closed,%yelling%repeatedly%“help,%please%help,”%resis*ve%to%care,%strikes%out%when%approached%Geriatric%Pain%Assessment:%AssumpXons%•  Accept%the%pa*ent%&/or%family/caregiver’s%word%(verbal%&%nonverbal)%about%their%pain.%•  Older%adults%with%cogni*ve/language%impairment%may%not%exhibit%typical%pain%behaviors.%– Consider%a%behavioral%disturbance%as%painPrelated%un*l%proven%otherwise.%•  Assume%painful%procedures/diseases%cause%pain.%•  Set%goals%to%reduce%pain%(acceptable%level)%&%improve%func*on%&%cogni*on.%Hierarchy%of%Pain%Assessment%Techniques%ASSESS •  Focus on present pain •  Involve the family •  Identify pain history  •  Identify pain sources •  Use screening tools •  Observe behaviors MAKE a NURSING DIAGNOSIS •  Acute pain due to …. •  Nonverbal pain indicators…. •  Incident pain due to …. DEVELOP PLAN •  Identify goals/outcomes •  Identify acceptable level of pain •  Recommend Analgesic Trial •  Use nonpharmacological     approaches IMPLEMENT PLAN EVALUATE GOALS •  Interventions effective? •  Acceptable level? •  Verbal/nonverbal    indicators NRS, VDS & FACES Pain Scales Pain in Advanced Dementia (PAINAD) Checklist%of%Nonverbal%Pain%Indicators%(CNPI)%Instruc<ons:$Observe%the%pa*ent%for%the%following%behaviors%both%at%rest%and%during%movement%Behavior With Movement At Rest 1.%Vocal%complaints:%nonverbal%(Sighs,%gasps,%moans,%groans,%cries) 2.%Facial%Grimaces/Winces%(Furrowed%brow,%narrowed%eyes,%clenched%teeth,%*ghtened%lips,%jaw%drop,%distorted%expressions) 3.%Bracing%(Clutching%or%holding%onto%furniture,%equipment,%or%affected%area%during%movement) 4.%Restlessness%(Constant%or%intermiHent%shiIing%of%posi*on,%rocking,%intermiHent%or%constant%hand%mo*ons,%inability%to%keep%s*ll) 5.%Rubbing%(Massaging%affected%area) 6.%Vocal%complaints:%verbal%(Words%expressing%discomfort%or%pain%[e.g.,%"ouch,"%"that%hurts"];%cursing%during%movement;%exclama*ons%of%protest%[e.g.,%"stop,"%"that's%enough"]%) Subtotal%Scores Total%Score Case%Study%#2%•  Mr.%C:%AdmiHed%4%weeks%ago%for%CHF/renal%insufficiency/fall%with%a%#%leI%wrist;%unable%to%return%home%due%to%demen*a;%awai*ng%LTC%in%hospital%•  Meds:%Tylenol%prn,%nifedipine,%lasix,%metoclopramide%%•  History:%Decline%in%ADLs%over%past%2%days;%unable%to%bathe%independently;%bed%seeking/refusing%to%mobilize,%facial%grimacing,%irritable,%seems%more%confused%than%usual%•  Denies%any%pain/discomfort%Hierarchy%of%Pain%Assessment%Techniques%Adapted from: McCaffery & Passero, 2011; WRHA, 2012 Principles%for%Geriatric%Pain%Management%•  Use%WHO%Principle:%! %By%the%mouth%(safest%route)%! %By%the%clock%(regular%dosing)%! %By%the%ladder%(step%approach)%! %For%the%individual%(renal/liver%func*on,%pa*ent%%%%%%preferences)%•  Provide%PRNs%for%procedurePrelated%(incident)%pain%•  Consider%poten*al%side%effects%! %Cons*pa*on,%drowsiness,%nausea,%CNS%effects%Principles%for%Geriatric%Pain%Management%•  Start%low%&%go%slow%but%give%enough%to%make%a%difference%! %Titrate%upward%to%desired%effect%is%reached%•  Remember:%If%the%analgesic%trial%appears%ineffec*ve,%do%not%assume%pain%is%not%present%! %Dose%may%need%to%be%*trated%%upward%before%seeing%an%%%%%%%%improvement%in%pain/discomfort%% %%%%%%%%%%%%%%%%indicators%Adapted from: Horgas & Yoon, 2008; VCH 2013, in press World%Health%OrganizaXon%(WHO)%Analgesic%Ladder%ANALGESIC%TRIAL:%MedicaXon%Ladder%• Acetaminophen%• Opiods%• Adjuvants:%! %An*convulsants%! %NSAIDs,%Other%World Health Organization Analgesic Ladder MedicaXon%Ladder:%Acetaminophen%•  IndicaXons%– Mild%to%moderate%pain%– Mechanism%of%ac*on%unclear%• Dose:%– 4%gm/24%hours%– Ceiling%effect%• LiHle%effect%on%cogni*on,%gastric/%renal%func*on%Adapted from AGS, 2009; Kave et al., 2010 MedicaXon%Ladder:%Opiods:%Selected%Analgesics%IndicaXons% Examples%Mild%–%% •  Morphine,%Codeine*%Moderate%Pain% •  Tramadol/Tramacet*%•  Hydromorphone%%•  Oxycodone*/Oxycon*n%(SR)%•  Percocet%(ceiling%effect)%•  Fentanyl%•  Methadone%Adapted from AGS, 2009; Herr, 2006; Kave et al., 2010 MedicaXon%Ladder:%AnXconvulsants%•  IndicaXons%– Neuropathic%pain%%– Trigeminal%neuralgia,%PVD,%shingles%•  Example:%– Gabapen*n%(max:%3600%mgm/day)%– Pregabalin%(Lyrica)%Adapted from AGS, 2009; Kave et al., 2010 MedicaXon%Ladder:%Other%NSAIDs%— %Ibuprofen,%Advil,%Aleve,%Ketorolac%(Toradol)%— %%COXP2%InhibitorP%Celebrex%— %%GI%upset/bleed,%cogni*ve%effects%Calcitonin%— %Titrate%dose%upward%%— %Analgesic%effect;%GI%upset%Baclofen%(Lioresal)%%— Relieves%spas*city;%%— CNS%effects;%cau*on%with%an*psycho*cs%Adapted from AGS, 2009; Kave, et al., 2010 Key%Points%•  Always%suspect%pain%as%a%cause%of%a%behavioral%disturbance.%•  Use%pain%scales/behavioral%indicators%to%iden*fy%pain%intensity/change%from%baseline.%•  Collaborate%with%the%pa*ent,%family/caregiver%to%iden*fy%an%acceptable%level%of%pain.%•  Consider%an%Analgesic%Trial%to%assess%the%presence%of%pain.%Common Painful Diseases/Conditions  Diagnoses/Condition                     Potential Types of Pain Musculoskeletal (40%) • Tightness, stiffness, spasm, acute pain Osteoarthritis (37%) • Deep aching pain, joint swelling/pain/           tenderness Fractures (14%) • Severe localized pain, muscle spasm Neuropathy (11%) • Burning, tingling, shock-like stabs; cold/hot;            pins & needles PVD (8%) • Intermittent sharp stabs, burning, stiffness Cancer (3%) • Variable: aching, stabbing; acute/chronic Headaches (6%) • Dull, aching, throbbing, visual disturbance Generalized Pain (3%) • All-over discomfort, aching, sharp stabs Pleuritic  • Sharp, localized; ↑ with coughing, moving GI Reflux • Heartburn, regurgitation (sour/bitter taste) Myocardial Ischemia: Acute/chronic (angina) • Tightness, squeezing, indigestion, ill-defined pain Temporal Arteritis • Headache, visual disturbances Infection: UTI, C. diff, osteomyelitis, wounds • Aching, nauseating, piercing sharp stabs, cramping Oral Hygiene/Disease • Refusing to eat/drink; dull/sharp, gnawing   Adapted from: Miaskowski, 1999; Stein & Ferrell, 1996   Pain Scales                       Instructions: Observe the patient for the following behaviors both at rest and during movement.   Behavior With Movement  At Rest 1. Vocal complaints: nonverbal (Sighs, gasps, moans, groans, cries)    2. Facial Grimaces/Winces (Furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expressions)    3. Bracing (Clutching or holding onto furniture, equipment, or affected area during movement)    4. Restlessness (Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still)    5. Rubbing (Massaging affected area)    6. Vocal complaints: verbal (Words expressing discomfort or pain [e.g., "ouch," "that hurts"]; cursing during movement; exclamations of protest [e.g., "stop," "that's enough"] )    Subtotal Scores    Total Score     Scoring: Score a 0 if the behavior was not observed. Score a 1 if the behavior occurred even briefly during activity or at rest. The total number of indicators is summed for the behaviors observed at rest, with movement, and overall. There are no clear cutoff scores to indicate severity of pain; instead, the presence of any of the behaviors may be indicative of pain, warranting further investigation, treatment, and monitoring. Sources: • Feldt KS. (2000).The Checklist of Nonverbal Pain Indicators (CNPI). Pain Management Nursing. 1(1),13-21. • Horgas AL. (2003). Assessing pain in persons with dementia. In: Boltz M, series ed. Try This: Best  Practices in Nursing Care for Hospitalized Older Adults with Dementia, 1(2). The Hartford  Institute for Geriatric Nursing. www.hartfordign.org. Checklist of Nonverbal Pain Indicators (CNPI)  Pain%in%Older%Adults%%Case%Study:%%Mr.%BW%•  Mr.$BW$is$an$86$year$old$man,$admi4ed$from$home$a7er$being$found$unresponsive$by$his$wife.$•  Wife$cares$for$husband$at$home.$They$have$2$adult$children$who$live$in$Ontario.$•  Wife$states$that$her$husband$has$a$history$of$strokes$and$“problems$geEng$his$words$out”$(aphasia)$but$can$usually$get$around$by$himself$without$help.$•  A7er$falling$at$home$three$weeks$ago,$Mr.$BW$had$a$fracture$(healing)$of$his$right$humerus$and$a$T7$compression$fracture.$His$right$upper$arm$is$sLll$bruised$and$his$right$hand$is$swollen.$He$now$needs$help$with$bathing$and$dressing.$•  Mr.$BW$has$been$inconLnent$for$the$past$two$weeks$and$has$been$increasingly$restless,$with$worsening$of$aphasia.$•  His$wife$tried$to$take$him$to$the$family$doctor,$but$he$refused$to$get$in$the$car.$•  Had$one$previous$episode$of$unresponsiveness$with$admission$to$hospital.$Past%History:$Stroke$with$aphasia;$hypertension;$chronic$renal$insufficiency;$BPH,$UTI$Medica:ons:$Tylenol$PRN,$Advil$PRN,$atenolol,$lasix,$warfarin,$Flomax,$Citalopram$Assessment%Mr.$BW$is$awake$and$you$begin$a$pain$assessment.$Denies$pain$but$winces,$moans$and$guards$his$right$arm$when$he$moves.$$You$try$to$obtain$a$selfZreport$of$pain$with$VAS,$but$Mr.$BW$is$now$ina4enLve$and$dozing.$Ques:on%•  What$do$you$do$now?$Pain%in%Older%Adults%%Case%Study:%%Mr.%BW%Assessment%You$decide$to$do$the$CNPIZscreens$posiLve$for$pain.$$Results:%FacialZwinces;$VocalZmoans;$BracingZguards$right$arm;$RubbingZnone$Ques:ons%•  What$informaLon$do$you$need$now?$•  What$is$your$nursing$diagnosis?$$•  What$is$included$in$the$plan$of$care?$What$are$the$goals?$•  How$would$you$evaluate$Mr.$BW’s$response$to$treatment?$•  Which$issues$(ie,$social,$cultural,$knowledge)$pose$barriers$to$pain$management?$Pain%in%Older%Adults%%Case%Study:%%Mr.%BW%Pain%in%Older%Adults%Case%Study%About%the%Pa5ent:%•  Mr.$BW$is$an$86$year$old$man,$admi4ed$from$home$a7er$being$found$$$$$unresponsive$by$his$wife.$•  Wife$cares$for$husband$at$home.$They$have$2$adult$children$who$live$in$Ontario.$•  $Wife$states$that$her$husband$has$a$history$of$strokes$and$“problems$geEng$his$words$out”$(aphasia)$but$can$usually$get$around$by$himself$without$help.$•  A7er$falling$at$home$three$weeks$ago,$Mr.$BW$had$a$fracture$(healing)$of$his$right$humerus$and$a$T7$compression$fracture.$His$right$upper$arm$is$bruised$and$with$right$hand$is$swollen.$Now$needs$help$with$bathing.$•  Mr.$BW$has$been$inconMnent$for$the$past$two$weeks$and$has$been$increasingly$restless,$with$worsening$of$aphasia.$•  His$wife$tried$to$take$him$to$the$family$doctor,$but$he$refused$to$get$in$the$car.$•  One$previous$episode$of$unresponsiveness$with$admission$to$hospital.$Pain%in%Older%Adults%Case%Study%Problems%Reported%by%Wife:$1.  Increasing$restless,$just$prior$to$unresponsiveness.$Worsening$of$aphasia$2.  Unable$to$walk$around$the$neighborhood.$Refusing$to$wear$a$sling$indoors/outdoors.$3.  Unsure$if$husband$is$taking$medicaMons$correctly$%$Past%History:$• Stroke$with$aphasia;$hypertension;$chronic$renal$insufficiency;$BPH,$UTI$Medica5ons:$•  Tylenol$PRN,$Advil$PRN,$atenolol,$lasix,$warfarin,$flomax,$Citalopram$Ques5ons:$1.  What$further$informaMon,$related$to$points$1\3$above,$do$you$need$(ie,$history$of$demenMa,$delirium,$depression,$previous$pain/treatment)?$2.$$Is$Mr.$BW$experiencing$pain?$Why?$Pain%in%Older%Adults%Case%Study%Assessment:$•  Mr.$BW$is$awake$and$you$begin$a$pain$assessment.$Denies$pain$but$winces$when$his$right$arm$is$moved.$•  You$try$to$obtain$a$self\report$of$pain$with$VAS,$but$Mr.$BW$is$now$ina4enMve$and$dozing.$Ques5on:$•  What$do$you$do$now?$Pain%in%Older%Adults%Case%Study%Assessment:%•  You$decide$to$do$the$CNPI\screens$posiMve$for$pain$Ques5ons:%•  What$informaMon$do$you$need$now?$•  What$is$your$nursing$diagnosis?$•  What$is$included$in$the$plan$of$care?$What$are$the$goals?$•  How$would$you$evaluate$Mr.$BS’s$response$to$treatment?$•  Which$issues$(ie,$social,$cultural,$knowledge)$pose$barriers$to$pain$management?$ 1  Hierarchy of Pain Assessment Techniques  A. Assessment/Identify Problems:  1. Focus on the Present Pain/Elicit the Patient’s Self-Report  Use simple yes/no questions (i.e. "Knee aches?", "Toes burn?") or to a numeric rating (NRS) or visual descriptor scale (VDS) with older patients   Ask the patient about the present pain rather than the history of pain. If the patient cannot understand the word ‘pain’, try other words such as ache, burn, hurt or discomfort.   2. Involve the Family/Caregiver  Ask family or caregivers whether the patient’s current behavior (e.g., calling out, restlessness)    is a change from baseline.   3. Identify Pain History  Past pain history (i.e., trauma/falls, comfort measures, treatment effectiveness; impact of pain on sleep, mood, behavior, ADLs).  Location, quality, aggravating/relieving factors  Physiological indicators   Impact of current illness on pain  Pain experiences (i.e, meaning/distress caused by pain).   4. Identify Sources of Pain/Discomfort  Identify potential sources of acute/persistent/chronic/neuropathic pain..  5. Use Pain Screening Tools in Patients with Mild to Moderate Cognitive/Language Impairment  Combining self-report and physical assessment is the best source of data for verbal patients. Three tools are: FACES-R or NRS or VDS.   6. Observe Discomfort/Behavioral Indicators in Patients with Advanced Cognitive/Language Impairment   Observe verbal/nonverbal discomfort or behavioral indicators and changes in functional ability that suggests pain. The three main pain indicators are: ¾ Facial expressions, verbalizations/vocalizations and body movements.   Use a observational pain assessment tool (ie PAINAD, CNPI) to identify the presence of pain and to evaluate the effectiveness of treatment.  B. Develop a Problem Statement/Nursing Diagnosis      Examples:   Acute pain (NRS 7/10) due to # right hip  Nonverbal indicators of pain in both lower limbs due to diabetes as evidenced by calling out and hitting staff with movement.  Incident pain with dressing change due to sacral wound as evidenced by facial expression and yelling during the procedure.  Delirium due to unresolved pain, recent infection, sensory deprivation and environment change.      2 C. Develop/Implement a Plan of Care                                                                                                              Set comfort/function goals or acceptable level of pain with the patient/family/caregiver.  1. Recommend an Analgesic Trial   Collaborate with the physician/NP to initiate an Analgesic Trial to evaluate the presence of pain.   Based on the estimated intensity of pain, recommend a regularly scheduled non-opioid for mild to moderate pain plus an opioid for more severe pain.   If the analgesics reduce discomfort/behavioral indicators and relieve pain, it may be assumed that pain was the cause and the analgesic should be continued.  Notes:  1. For neuropathic pain, recommend an anticonvulsant. 2. Ensure that the patient receives PRN, or breakthrough, analgesic prior to procedures known to cause pain such as wound care, turning, transferring and mobilizing.  3. If the analgesic trial appears ineffective, do not assume that pain is not present. The dose may need to be titrated upwards before seeing an improvement.  2. Implement Nonpharmacologic Approaches           Examples of Nonpharmacolgic Interventions:  Developing a positioning schedule  Assessing the need for therapeutic mattress and seating  Providing assistive devices to maintain participation in ADLs  Promoting adequate periods of rest during the day and sleep and night  Frequent reassurance and acknowledgement of suffering, as appropriate  Providing the patient/family with information about pain and what to expect   Using strategies that patient used successfully at home to relieve pain  Distraction, relaxation                      For patients with moderate to severe pain,  provide pain medications in addition to non-pharmacologic interventions   D. Implement the Plan               E. Evaluate the Plan of Care The effectiveness of analgesia is evaluated by:   1. NonVerbal Behavior Indicators              The behavioral indicators (i.e. PAINAD, CNPI) and/or the family/caregiver report relief of pain.    2. Verbal Indicators             The patient verbally expresses that:  their goals for comfort/function are attained, and  he/she is satisfied with the pain management plan and/or   FACES-R, NRS or VDS scores consistently demonstrates lower scores of pain intensity :           Adapted from: Herr et al., 2006; Pasero & McCaffery, 2011        Pain in Older Adults Case Study-Final  About the Patient:   Mr. BW is an 86 year old man, admitted from home after being found unresponsive by his wife.  Wife cares for husband at home. They have 2 adult children who live in Ontario.  Wife states that her husband has a history of strokes and “problems getting his words out” (aphasia) but can usually get around by himself without help.   After falling at home three weeks ago, Mr. BW had a fracture (healing) of his right humerus and a T7 compression fracture. His right upper arm is bruised and with right hand is swollen. Now needs help with bathing.  Mr. BW has been incontinent for the past two weeks and has been increasingly restless, with worsening of aphasia.  His wife tried to take him to the family doctor, but he refused to get in the car.  One previous episode of unresponsiveness with admission to hospital  Problems Reported by Wife:  1. Increasing restless, just prior to unresponsiveness. Worsening of aphasia 2. Unable to walk around the neighborhood. Refusing to wear a sling indoors/outdoors. 3. Unsure if husband is taking medications correctly  Past History:  Stroke with aphasia; hypertension; chronic renal insufficiency; BPH, UTI  Medications: Tylenol PRN, Advil PRN, atenolol, lasix, warfarin, flomax, Citalopram  Questions:  1. What further information, related to points 1-3 above, do you need (ie, history of dementia, delirium, depression, previous pain/treatment)? 2. Is Mr. BW experiencing pain? Why?  Assessment:   Mr. BW is awake and you begin a pain assessment. Denies pain but winces when his right arm is moved.  You try to obtain a self-report of pain with VAS, but Mr. BW is now inattentive and dozing.  Question: What do you do now?  Assessment:  You decide to do the CNPI-screens positive for pain  Questions:   What information do you need now?  What is your nursing diagnosis?   What is included in the plan of care? What are the goals?  How would you evaluate Mr. BW’s response to treatment?  Which issues (ie, social, cultural, knowledge) pose barriers to pain management? References & Resources:  Pain in the Older Adult with Cognitive/Language Impairment  American Geriatrics Society Panel on Persistent Pain in Older Persons. (2002; updated 2009). The management of persistent pain in older persons. Journal of the American Geriatrics Society, 50(6), S205-S240. Available at: AGS Persistent Pain Guideline.   American Geriatrics Pain Society (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society. 57, 1331-1346.  Arnstein, P. (2010). Assessment of nociceptive versus neuropathic pain in older adults,  Try This: Best practices in nursing care to older adults, SP1. Available at:  Geriatric Nursing Resources for Care of Older Adults   Ersek, M. Herr, K., Neradilek, M. B., Buck, H. G., & Black, B. (2010). Comparing the  psychometric properties of the Checklist of Nonverbal Pain Behaviors (CNPI) and the Pain Assessment in Advanced Dementia (PAIN-AD) instruments. Pain Medicine, 11, 395-404.  Feldt, K. S. (2000). The Checklist of Nonverbal Pain Indicators (CNPI). Pain   Management Nursing, 1(1), 13-21.  Flaherty, E. (2007). Pain in Older Adults, Try This: Best practices in nursing care to older  adults, 7. Available at: Geriatric Nursing Resources for Care of Older Adults   Hadjistavropoulos, T. Herr, K., Turk, D. C., Fine, P. G. et al. (2007). An interdisciplinary  expert consensus statement on assessment of pain in older persons. Clinical  Journal of Pain, 23(1), S1-S43.  Herr, K. & Decker, S. (2006). Tools for assessment of pain in nonverbal older adults with  dementia: A state-of-the-science review. Journal of Pain and Symptom  Management,  31(2), 170-192.  Herr, K., Bjoro, K., Steffensmeier, J., & Rakel, B. (2008). Acute pain management in  older adults. In D. P. Shoenfelder (Series Ed.). Series on evidence-based  practice guidelines for older adults. Iowa City, IA: University of Iowa  College of Nursing Gerontological Nursing Interventions Research  Center, Research Translation and Dissemination Core. Available at:  Evidence-Based Practice Guidelines  Horgas, A. L., & Yoon, S. Y. (2008). Pain management. In E. Capezuti, D. Zwicker, M.  Mezey & T. Fulmer (Eds.), Evidence-based geriatric nursing protocols for best  practice 3rd ed. (pp.199-222). Springer: New York, NY.  Horgas, A. L. (2007). Assessing pain in older adults with dementia, Try This: Best  practices in nursing care to older adults, D2. Available at: Geriatric Nursing  Resources for Care of Older Adults   Kave, A. D., Baluch, A., & Scott, J. T. (2010). Pain management in the elderly  population: A review. Ochsner Journal, 10(3), 179-187.  McLennon, S. M. (2008). Persistent pain management. In M. G. Titler (Series Ed.).  Series on evidence-based practice guidelines for older adults. Iowa City,  IA: University of Iowa College of Nursing Gerontological Nursing  Interventions Research Center, Research Translation and Dissemination  Core. Available at: Evidence-Based Practice Guidelines  Miaskowski, C. (1999). Pain and Discomfort. In J. K. Stone, J. f. Wyman & S. A.  Salisbury, Clinical Gerontological Nursing: A Guide to Advanced Practice, pp.  647-663. Saunders: Philadelphia.  Pasero, C., & McCaffery, M. (2011). Pain Assessment and Pharmacologic Management.  Mosby: St. Louis, MO.  Robinson, S., & Vollmer, C. (2010). Undermedication for pain and precipitation of  delirium. MEDSURG Nursing, 19(2), 80-83.  Vancouver Coastal Health (2013, in press). Clinical Practice Document: Pain in the  Older adult with Cognitive &/or Language Impairment.  Winnipeg Regional Health Authority (2012). Pain Assessment and Management: Clinical  Practice Guidelines. Available at: Pain Assessment & Management  Website Resources:  Canadian Pain Society  City of Hope: Pain Resource Center  Geriatric Pain Resources  Hartford Institute for Geriatric Nursing  International Association for the Study of Pain  National Nursing Home Survey  Pain Assessment and Management (Winnipeg Regional Health Authority)  Pain BC  Registered Nurses Association of Ontario              M. Shaw GET Program, November 15, 2013 Food for Thought What ethical considerations should be taken into account when offering feeding tubes?  JS was an eighty two year old female who lived in a care home for several years. She had a history of dysphagia and psychotic depressions (e.g. heard voices that said she was a “terrible mother and didn’t deserve to have children”). Despite multiple admissions to acute care over the past 10 years and although it was recorded that the patient had refused a feeding tube because it was “unnatural”, there was no record of a reassessment of her wishes and a competency assessment. Although Js’ daughter had POA, there was no Advance Directive or Representation Agreement.  JS’ daughter has severe anxiety and other mental health issues but nothing that would disqualify her from acting as her mother’s temporary substitute decision maker. Their relationship was described by social work as “strained”. It was difficult for both physicians, nurses, and allied health to form a therapeutic relationship with the daughter and it was not clear if she understood her mother’s wishes.  At one point, the care home called outreach psychiatry to assess JS’s mental health as she was clearly having delusions as well as dysphagia with severe coughing. However, JS  would not go to hospital. JS was then certified under the Mental Health Act and admitted to a geriatric mental health centre as a no code which accorded with the care facility’s level of intervention. JS had a severe choking episode with severe respiratory distress. The Critical Care Outreach Team attended and then called a Code Blue and patient was admitted to ICU where a tube feeding was inserted. It is not know who consented to the tube or if it was part of routine care.  Two weeks later, the patient was transferred to the ward as a no code, no intubation and no readmission to ICU. A large number of antipsychotic medications were ordered to try to control delirium and psychosis. JS’ feeding tube accidentally got pulled out and RNs were unable to reinsert. The following day a GJ tube was inserted after nutritional/dysphagia assessment, trial PO and unsuccessful attempts to insert Entriflex. It is not known who gave consent for this.  Two days later, the patient, who was normally withdrawn, became increasingly agitated, confused and remained up all night restless in her wheelchair. When JS became aggressive, restraints were put in place despite the ward’s least restraint policy. Many medical assessments and interventions occurred, including consideration of ECT. The goal in the chart remained “to get patient to care home by the end of this week”. There was no plan for end of life care.  That night the patient began vomiting and RT was called to do deep suctioning which JS resisted. JS slowly lost consciousness and died within the next 4 hours with the nurses present. Because end-of-life care was not addressed, the physician was called to pronounce death.  Recommendations: 1. Emphasize clinician understanding  of and responding to the patient’s wishes 2. Appreciate the importance of Advance Directives and how they can be used to provide care especially at the end-of-life 3. Establish unit-based guidelines for initiating, implementing and stopping tube feeds 4. Emphasize the team/family meeting and goals of care prior to starting  tube feeds 5. Improve understanding of older adult mental health in acute care  Brown Bag Ethics Discussion Sept 24, 2013    VCH ETHICAL DECISION-MAKING FRAMEWORK FOR TUBE/OTHER FEEDING OPTIONS   INTRODUCTION   Eating and drinking by mouth are sometimes difficult or impossible due to a person’s medical condition.   Tube feeding is a common form of support in such situations. It can be used as a short term measure, where the expectation is that the patient will be able to survive without it in the future. Tube feeding may also be used as a long term, life-sustaining measure, where there is no expectation that the patient will ever be independent of it.  Decisions about providing, withholding or withdrawing tube feeding are ethically significant and sensitive: • Providing food and fluids to another in need is commonly taken for granted as basic human care. In light of this, tube feeding may be regarded by some as not a “medical treatment” in the usual sense of that term. Thus, depending on one’s values and beliefs, tube feeding may be viewed as a life-sustaining medical intervention, basic humane care, or an accommodation to disability. (reference 1) • Tube feeding can be a benefit to the patient. It may also be associated with poor survival and significant health complications. (reference 2) Sometimes it is of no benefit and may cause harm e.g. patients with end-stage organ failure or end-stage metastatic cancer. Medical information and values of patients (including clients and residents), families and health care providers are relevant to decision making. • When health conditions are chronic and/or degenerative, situations are often complex and distressing.  While tube feeding is a regular part of work in health care settings, it is probably being faced for the first time by any given patient or family. Patients (including clients and residents) and families may struggle to understand complicated medical information and have difficulty accepting the possibility that they or their loved one is declining or dying. Health care providers may face conflicts in values with patients/families or between themselves in determining the most appropriate feeding options.   In light of these factors, it is important that:  • Consideration be given to who the most appropriate person(s) is to make the decision and who needs to be informed and consulted about the decision making process. • All involved in a specific decision regarding tube feeding are given time to understand these various perspectives. • Decisions concerning feeding should be made on an individual basis. • There must be very good ethical reasons for withholding or withdrawing food and fluids.  When uncertain, one should always choose to maintain a human life and then seek further clarification. • When conflicts about feeding decisions cannot be resolved, consideration should be given to involving the VCH Ethics Service.   Note:  This is a controlled document. A printed or external copy may not reflect the current, electronic version on the Vancouver Coastal Health Authority (VCHA) Intranet.  The VCHA electronic version is always the current version. This clinical practice document has been prepared as a guide to assist and support practice for staff working at Vancouver Coastal Health Authority (VCHA).  It is not a substitute for proper training, experience and the exercise of professional judgment.  VCHA has granted The University of British Columbia’s School of Nursing permission to use this document.     May 2013 VCH Professional Practice – Promoting & Advancing Best Practice Page 1 of 5     DETERMINING APPROPRIATE FEEDING OPTIONS  (See the VCH Clinical Ethics Decision Making Framework)  1. CAPABLE PATIENTS  The fully informed, voluntary, capable patient’s decision about tube feeding should be respected (principle of autonomy).   It is important to be as certain as possible concerning the patient’s capability, comprehension of information, and voluntariness (i.e. informed consent).  Special attention should be paid to conditions such as depression, which may be treatable.  2. INCAPABLE PATIENTS  If there is an Advance Directive as per the September, 2011 legislation, it should be honored in accord with this legislation.   When the patient being offered the option of tube feeding is not capable and there is no advance directive, the decision should made by their substitute decision-maker (SDM) (principle of autonomy) in consultation with the health care team.   a. When the SDM knows the wishes and/or values (possibly by means of a Representation Agreement) of the now incapable patient he/she should ask the question, “If this patient could speak for her/himself, what would s/he choose?”   b. When a patient is not capable, and their wishes/values are not known, the principle of beneficence or well-being comes more prominently into play and a decision should be based on the “best interests” of the patient.  This usually involves a determination of what a reasonable person in the patient’s position would want.   What is regarded as “best interests” or “reasonable” is shaped by a person’s basic beliefs and values. Therefore, in an effort to honor as much as possible the patient’s autonomy, it is important to find out as much as possible about the patient’s worldview (beliefs and values) by consulting with those who know the patient and/or her/his culture, religion and/or spiritual beliefs. Then ask, “From that perspective what is seen as “reasonable”?  In addition, there are two conditions that are widely recognized as ethically valid considerations for assessing what is in a patient’s best interests: o Whether or not the patient is in an irreversible final stage of dying, and tube feeding would only prolong the dying. o Whether or not the patient’s condition and/or prognosis has reached the point when it will be a struggle to cope with the tube feeding. This involves weighing the benefits and burdens of the tube feeding. (principles of beneficence and nonmaleficence )  It is important that the SDM is fully informed. Health care providers should meet with the SDM to discuss all aspects of the patient’s situation and care. Good communication requires trust and respect (virtues) among those involved.  Note:  This is a controlled document. A printed or external copy may not reflect the current, electronic version on the Vancouver Coastal Health Authority (VCHA) Intranet.  The VCHA electronic version is always the current version. This clinical practice document has been prepared as a guide to assist and support practice for staff working at Vancouver Coastal Health Authority (VCHA).  It is not a substitute for proper training, experience and the exercise of professional judgment.  VCHA has granted The University of British Columbia’s School of Nursing permission to use this document.     May 2013 VCH Professional Practice – Promoting & Advancing Best Practice Page 2 of 5    To help ensure that the decision of the patient or SDM is truly a voluntary one, health care providers should be aware of power dynamics in families and of the discrepancy in power that typically exists between health care providers and patients and families.   Families and health care providers often fear that withholding or withdrawing tube feeding will cause the patient discomfort or pain. They should be informed that there is a growing body of literature to support the view that any discomfort as a result of withholding or withdrawing foods and fluids can be successfully treated. (reference 3) Benefits and burdens (for example decreased alertness/arousal) would be reviewed).  Families may need assurance that a decision to withhold or withdraw tube feeding does not imply withholding care and that appropriate comfort measures will always be available.   3. INTENT OF DECISION   If the aim (e.g. reduce suffering or removing an intervention that is prolonging the dying process) is the same, there is no ethical difference between withholding versus withdrawing food and fluids or any life-sustaining treatment. It is important for health care providers to understand that the intent of a decision or action is not to cause death although death may be a foreseeable outcome.  4. ADDITIONAL CONSIDERATIONS  A sound ethical decision must be based on an understanding of the patient’s diagnosis, prognosis, condition, and expressed or inferred preferences, personal values and beliefs.  A careful work-up assembling this information and any other contextual features relevant to the decision should be made. (The grid below may be helpful in collecting this information.) It is beneficial to start these conversations early as families often need time to think through alternatives and may want to consult others.  5. GOALS AND DOCUMENTATION  When tube feeding is initiated, clear goals should be documented and a review time and evaluation date set. The process of setting and evaluating the achievement of goals should continue as long as tube feeding remains in place.  There should be full documentation of goals and review times in the patient’s chart.    PROCESS FOR ETHICAL DECISION MAKING REGARDING FEEDING OPTIONS  A family/team meeting should be held to:  1. Identify the issue of concern.  What is the ethical issue? Why is there difficulty coming to a decision? Would the input of an ethicist or ethics committee be helpful?  2. Gather pertinent information from all relevant sources (may include patient, family/decision-maker, supports chosen by the patient, attending physician, family physician, nurses, social worker, dietician, gastroenterologist, ethicist, physiotherapist, occupational therapist, speech-language pathologist, spiritual care, interpreter, risk management).   Note:  This is a controlled document. A printed or external copy may not reflect the current, electronic version on the Vancouver Coastal Health Authority (VCHA) Intranet.  The VCHA electronic version is always the current version. This clinical practice document has been prepared as a guide to assist and support practice for staff working at Vancouver Coastal Health Authority (VCHA).  It is not a substitute for proper training, experience and the exercise of professional judgment.  VCHA has granted The University of British Columbia’s School of Nursing permission to use this document.     May 2013 VCH Professional Practice – Promoting & Advancing Best Practice Page 3 of 5    The following grid is a useful tool to gather and clarify important considerations.  Clinical Information Patient’s Goals and Preferences • What is the patient’s medical status, overall and as related to feeding? • What is oral intake status?  • What is the result of the swallowing assessment? • Is the problem acute? chronic? critical? emergent? reversible? • What are the potential benefits and disadvantages of tube feeding? • What is the usual experience of patients in similar conditions? • Will tube feeding likely be temporary or long term? • What are the plans if tube feeding does not provide the desired benefits? •  What is the patient’s prognosis with and without tube feeding? • What is the patient’s/decision-maker’s understanding of the situation? Do they understand potential benefits and risks? • What is the patient’s choice? • What are the patient’s values, hopes, and goals? • If the patient lacks decision-making capacity, who is the decision-maker for the patient and do they know the patient’s previously expressed preferences about tube feeding or other medical interventions? • If the patient’s wishes are not known, what would others from similar backgrounds and in similar situations generally prefer? View of Life Contextual Factors • How does the patient view his/her current life? • What gives/gave the patient enjoyment and meaning in their life? • What are the prospects, given various feeding options, of being able to continue with these? • What physical, mental, and social challenges is the patient likely to experience with tube feeding?  • How does the patient evaluate this potential life? • Does the patient have past experiences that may help guide this decision? • Are there biases or previous experiences that might affect the decision-maker’s/health care providers’ decision? • Are there family issues, past medical experiences, religious beliefs, financial considerations, or cultural factors that may influence the patient’s/decision-maker’s preference? • What are the patient’s/decision-maker’s previous experiences with medical interventions, hospitalization, and death of loved ones? • Are there resource limitations or facility constraints with certain options? • Do any of the options impact discharge possibilities? • Is there moral distress among any health care providers and, if so, how is it managed?  3. Identify and be aware of health care providers’ personal values, biases, self-interest, and stressors that may impact a decision.  4. Exhibit kindness, caring, patience, and courage and seek common ground.  5. Identify all options. Be creative and tailor the options to the patient’s particular circumstances.  Note:  This is a controlled document. A printed or external copy may not reflect the current, electronic version on the Vancouver Coastal Health Authority (VCHA) Intranet.  The VCHA electronic version is always the current version. This clinical practice document has been prepared as a guide to assist and support practice for staff working at Vancouver Coastal Health Authority (VCHA).  It is not a substitute for proper training, experience and the exercise of professional judgment.  VCHA has granted The University of British Columbia’s School of Nursing permission to use this document.     May 2013 VCH Professional Practice – Promoting & Advancing Best Practice Page 4 of 5    6. Evaluate the various alternatives considering: the patient’s choices, values, and beliefs; the best interests of the patient; the patient’s contextual factors.  7. Select an option. Document, implement, evaluate and review.   ACKNOWLEDGEMENTS WITH THANKS:  Much of this framework has been derived, with modifications, from 1) Vancouver Coastal Health Guidelines Concerning the Delivery of Food and Fluids by Artificial Means (July, 2001) and 2) Providence Health Care Ethical Decision Making Framework for Feeding Options (http://www.providencehealthcare.org/ethics_services/resources.html, June 25, 2012)   REFERENCES  (1) Brashler R, Savage TA, Mukherjee D, Kirschner KL (2007).  Feeding tubes: three perspectives. Topics in Stroke Rehabilitation, 14(6):74-77. (2) (2) Kuo I, Rhodes R, Mitchell SL, Mor V, Teno JM. (2009). Natural History of Feeding Tube Use in Nursing Home Residents with Advanced Dementia.  Journal of American Medical Directors Association, 10(4): 264-270. (3) McMahon MM, Hurley DL, Kamath PS, Mueller PS (2005).  Medical and ethical aspects of long-term enteral tube feeding. Mayo Clinic Proceedings, 80 (11):1461-76.    ADDITIONAL RELEVANT RESOURCES VCH Consent Guidelines CA_1000, Clinical Administrative, November 8, 2004 VCH Ethical Decision-making Framework (March 2012) Resolution of Disputes about Demands for Care that is not offered. VCH Risk Management Bulletin Issued: November 12, 2004 Resolution of Objections to Decisions made by Authorized Substitute Decision Makers. VCH Risk Management Bulletin Issued: November 12, 2004 (From VCH Guidelines to Special Consent Situations)        VCH Ethics Service (April 9, 2013): Terry Anderson, Bethan Everett, Jenny Young APPROVED BY VCH ETHICS SERVICE REGIONAL COUNCIL: April 18, 2013 REVISED: May 30, 2013  Note:  This is a controlled document. A printed or external copy may not reflect the current, electronic version on the Vancouver Coastal Health Authority (VCHA) Intranet.  The VCHA electronic version is always the current version. This clinical practice document has been prepared as a guide to assist and support practice for staff working at Vancouver Coastal Health Authority (VCHA).  It is not a substitute for proper training, experience and the exercise of professional judgment.  VCHA has granted The University of British Columbia’s School of Nursing permission to use this document.     May 2013 VCH Professional Practice – Promoting & Advancing Best Practice Page 5 of 5   GET Program DAY 4  Celebrating Learning          Geriatric Education & Training Program Course Schedule    Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013    Time Topic   0830 Survey #1  0900 Welcome & Introductions  0930 Patients & Families as Partners in Care x Personhood x Patient & Family Centered Care  1000 Break  1015 The Nursing Process: Bringing Patient Centered Care to the Point of Care  1115 Quality Improvement: Thinking about Patient & Family Centered Care at the Unit and Systems Level  1200 Lunch x Lunch & Learn: Library Services  1300 3Ds: Delirium, Dementia, Depression  1615 Evaluation/Feedback on the day        Geriatric Education & Training Program Course Schedule    Day 4: Celebrating Learning  December 10, 2013   Time Topic   0830 Focus Groups  0930 Break  1000 Panel discussion:   "Ready or Not: Providing Person-Centered Care for Older Adults in Acute Care" with  Dr. Alison Phinney, Associate Professor, UBC School of Nursing Dr. Sandra Lauck, Clinical Nurse Specialist, The Heart Centre, St. Pauls' Hospital Mrs. Mary Kjorven , Clinical Nurse Specialist, Specialized Geriatric Program,  Interior Health BC   1115 Presentation of GET Program Certificates of Completion     GET Program  OTHER RESOURCES  Summary of Educational Strategies          Geriatric Education & Training Program Course Schedule    Day 1: Foundations in Nursing Care of Older Adults in Acute Care  September 18, 2013    Time Topic   0830 Survey #1  0900 Welcome & Introductions  0930 Patients & Families as Partners in Care x Personhood x Patient & Family Centered Care  1000 Break  1015 The Nursing Process: Bringing Patient Centered Care to the Point of Care  1115 Quality Improvement: Thinking about Patient & Family Centered Care at the Unit and Systems Level  1200 Lunch x Lunch & Learn: Library Services  1300 3Ds: Delirium, Dementia, Depression  1615 Evaluation/Feedback on the day          IMPLEMENTING THE GET PROGRAM: A TOOLKIT FOR EDUCATORS           1   Content Toolkit for educators ...................................................................................................................................................................................................... 2 1. Geriatric content: Relevant online references for guidelines and best practices ............................................................................................. 2 2. Selecting your educational strategies ................................................................................................................................................................ 2 Table 1: Active Learning Strategies ............................................................................................................................................................................ 3 Table 2: Suggestions of implementation strategies for case studies......................................................................................................................... 5 Table 3: Passive Learning Strategies .......................................................................................................................................................................... 7 References ................................................................................................................................................................................................................. 8          2  Toolkit for educators  1. Geriatric content: Relevant online references for guidelines and best practices   Senior Friendly Hospital Promising Practices (Ontario, Canada) : http://seniorfriendlyhospitals.ca/processes/processes-care   Geriatric Emergency Management  Network (Ontario, Canada) The Regional Geriatric Program Of Toronto: http://gem.rgp.toronto.on.ca/   RNAO –Best Practice Guidelines (Ontario, Canada): http://rnao.ca/bpg   BC Acute Care Geriatric Nurse Network (and the Geriatric Emergency Nurses Initiative –GENI) (British Columbia, Canada): http://www.acgnn.ca/   GeriRN The Hartford Institute for Geriatric Nursing (US): http://consultgerirn.org/   The best care for older people everywhere-Toolkit 2012 (Victoria, Australia): http://docs.health.vic.gov.au/docs/doc/32A6DBBBE7D5512BCA257A9300019EAE/$FILE/1208011_BCOPE%20The%20Toolkit_WEB-3rdOct.pdf   2. Selecting your educational strategies   A list of educational strategies is presented below to help educators chose the methods which will best suit their audience, their resources and the content they wish to communicate. The choice of strategies will vary according to the needs of the participants and their level of expertise.         3   Not all educational strategies are presented as we believe some are less suitable for this curriculum (eg: problem-based learning, simulation, mentoring etc.). In determining your approach, many suggest a key consideration is the use of interactive strategies or a combination of strategies6. The table below provides some example of how strategies can match specific learning needs.  Educational strategies and expected learning outcomes The first table presents a list of active learning strategies: These teaching modalities are called active as they illicit learner’s participation. In general, these approaches are more likely to stimulate critical thinking than passive strategies.   Table 1: Active Learning Strategies Strategy  Learning objectives Notes Advantages and disadvantages Case studies 5,7     ƒ Critical thinking  ƒ Clinical judgment  ƒ Decision making  ƒ Understanding of complex situations ƒ Ability to recognize abnormal/changing situation ƒ Identification of appropriate action and interventions ƒ Problem solving skills  ƒ Requires support and feedback ƒ May become frustrating for nurses who are more used to traditional methods ƒ More likely to lead to behavior change ƒ Case studies can be presented in various ways depending on time available (see Table 2 for more details)   ƒ Constructing case studies may be time consuming   Debate or buzz sessions 2,3,5,7    ƒ Analytical skills ƒ Judgment  ƒ Reasoning ƒ Ability to construct and present ƒ Ideal to address topics for which there could be multiple perspectives or that rise ethical dilemmas  ƒ Debate may be “artificially provoked” ƒ Learning is not limited to identifying issues, but forces one  to examine different perspectives       4  Strategy  Learning objectives Notes Advantages and disadvantages    an argument ƒ Communication skills  (assigned position), forcing people to consider a different view point  ƒ A synthesis is done by the facilitator following the debate. ƒ Buzz session: multiple groups discussing an issue/question and all present the result of their discussion (eg. of clear concise question: “agree on one advantage or disadvantage of…”)  ƒ Need to allow sufficient time for preparation for an enriched debate ƒ Knowledge sharing ƒ Requires adequate baseline knowledge of a subject  Role play 4,5,7     ƒ Communication skills ƒ Problem solving skills  ƒ Critical thinking  ƒ Decision making   ƒ Structure “Brief, run and debrief “:  -Develop a brief outline of a scenario and assign roles.  -May include an observer for feedback and analysis  ƒ May give the impression of “not being  the real thing” or frustrating for nurses who are more used to traditional methods ƒ The safe environment allows to experience ethically sensitive situations  ƒ Can meet the diverse needs of nurses with various backgrounds and levels of experience  ƒ Immediate feedback ƒ Less threatening environment           5  Table 2 has been developed in the context of the GET Program case study module. The table presents various ways of presenting case studies in a class room context. Even though this was developed for the case studies component of the program, the information provided below could be applicable to other educational strategies such as role play.  Table 2: Suggestions of implementation strategies for case studies Strategy  Process Advantages Disadvantages Instructor led case study Class process/discussion  Allows instructor to demonstrate the nursing process that needs to take place  Serves as an exemplar/guiding process for subsequent case studies  Allows to draw emphasis on most important points/concepts   May be less challenging for more experienced nurses  Participants may feel less engaged Small groups   Depending on the group size, ensures a more active participation from all participants  Allow participants to discuss and debate ideas in smaller group, which might be less intimidating  Requires more resources:   Time: participant-led process could be more time consuming  Facilitator: depending on the number of participants, may require more than one facilitator to assist the reflection process of all groups  Groups work on same case(s) Review in class discussion  Everyone is exposed to the same new knowledge  Allow rich exchange among participants  Allows learning from other participants   Allows to cover more cases in less time  Less cases (and therefore content) covered        6  Strategy  Process Advantages Disadvantages  Groups work on different cases  With group presentations  Provides an opportunity for feedback and exchanges  Allows all participants to hear the feedbacks and nursing process for all cases without them working on all cases   Serves the purpose of having participants organizing and verbalizing their nursing process   More time consuming Without presentations   Less time consuming  May not allow proper feedback period  All participants are not exposed to same  learning process and knowledge            7  The next table (Table 3) presents a short list of passive learning strategies. These strategies have the advantage of facilitating the acquisition of new ideas and knowledge 1, 5. Despite the negative connotation that could be associated with the strategies referred to as “passive”, they are by no means less valuable than active strategies. Again selecting a strategy will vary according to the content, the instructor and the learners.   Table 3: Passive Learning Strategies Strategy  Learning objective Notes Advantages and disadvantages Traditional lectures 7, 8, 9    ƒ Knowledge development   ƒ To make the knowledge more context specific, it may include a component to familiarize themselves with the organization’s existing internal resources   ƒ To stimulate learner’s participation other strategies may be included such as: discussions period, videos, questions/probes or games (eg: Jeopardy, Who wants to be a millionaire etc.)   ƒ Preparation from instructor may be time consuming ƒ Time efficient for covering content ƒ Allows the educator to control the content ƒ Can be used to clarify complex or conflicting information ƒ Students may feel less involved if the knowledge is easy to understand and readily available somewhere else   Free Web-based resources1   ƒ Knowledge development   ƒ Respects individual needs and rhythm ƒ Requires self-motivation ƒ Examples: try this series, RNAO, GNEC webinars  ƒ Inexpensive  ƒ Easily accessible  ƒ Flexible ƒ Can be used by students independently  Video1  ƒ Maybe presented in classroom or sent via ƒ Inexpensive        8  Strategy  Learning objective Notes Advantages and disadvantages   email ƒ Technology required for in-class projection ƒ May be used to support learning experience when used in classroom context   ƒ Easily accessible   Email and social media  ƒ Maybe used to send references to publication, online material ƒ Keep participants engaged outside of class time  References 1. Billings DM. & Halstead JA. (2009). Teaching in Nursing: A Guide for Faculty. 3rd Edition. Saunders, St-Louis, Mo.  2. Bradshaw, MJ. & Lowenstein, AJ. (2014). Innovative Teaching Strategies in Nursing and Related Health Professions. 6th Edition. Burlington, MA. 3. Candela, L., Michael, S., & Mitchell, S. (2003). Ethical debates: enhancing critical thinking in nursing students. Nurse Educator, 28(1), 37-39 4. Lowenstein, AJ. & Harris, M. (2014). Role Play. In Bradshaw & Lowenstein (Eds.) .  Innovative Teaching Strategies in Nursing and Related Health Professions (183-202). 6th Edition. Burlington, MA. 5. Popil, I. (2011). Promotion of critical thinking by using case studies as teaching method. Nurse Education Today, 31(2), 204-207. 6. Registered Nurses’ Association of Ontario (RNAO) (2012). Toolkit: Implementation of Best Practice Guidelines (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario. 7. Rowles, C. & Russo, B. (2009). Strategies to Promote Critical Thinking and Active Learning. In Billings DM. & Halstead JA (Eds.), Teaching in Nursing: A Guide for Faculty (pp238-261). 3rd Edition. Saunders, St-Louis, Mo.  8. Wendel, V., Durso, S., Cayea, D., Arbaje, A., & Tanner, E. (2010). Implementing staff nurse geriatric education in the acute hospital setting. MEDSURG Nursing, 19(5), 274-280.  9. Woodring, BC. & Woodring, RC. (2014). The Lecture: Long-lasting, Logical, and Legitimate.  In Bradshaw & Lowenstein (Eds.).  Innovative Teaching Strategies in Nursing and Related Health Professions (127-158). 6th Edition. Burlington, MA. 

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