Julie Daltrey Nurse Practionter (older adult )

 1950’s Specialty first Gerontological nursing textbook USA  1966 ANA group  1971 Standards of practice ANA (gerontology not geriatric)  1984 Certification NP and CNS  1990 Hartford Institute for Geriatric Nursing at New York University.  2010 recommendations for undergrad  OA are the core business of healthcare ◦ Population aging ◦ Complex factors, pharmacokinetic differences, chronic conditions ◦ More likely to see OA ◦ Collaboration to support healthy ageing, function, and QOL.

 background paper - areas of change to meet need ageing population. 1.more practitioners 2.more specialist services 3.more expertise in older people’s health because of the prevalence of chronic and multiple conditions 4.more support services for older people

◦ atypical presentation of disease ◦ Frailty ◦ multiple co-morbidities ◦ chronic diseases ◦ inappropriate medication use ◦ awareness of social needs and threats to physical function.  From disease focus to system focusing on issues affecting QOL  Collaboration to promote autonomy, wellness, optimal function, comfort and quality of life from health gain to end of life.  Inter-disciplinary, holistic person-centred, across clinical settings.  It includes research related to ageing and its effect on older adults

 The sharp reality is that elder care is rapidly becoming the most evidence rich area for practice,  It needs skilled clinicians who can apply critical thinking and evidence to aging patients in communities to hospital and long-term care settings  And from preventative services to palliative to end of life care.

 It is a multidimensional, multidisciplinary, diagnostic instrument designed to collect data on the medical, psychosocial and functional capabilities and limitations of older adults in order to develop a coordinated and integrated plan for treatment and long term follow up.  It uses any number of standardized instruments to evaluate aspects of patient functioning, impairments, and social supports.  Different from a standard medical evaluation in 3 ways: (1) focuses on older adults with complex problems (2) emphasizes functional status and quality of life (3) frequently uses an interdisciplinary team of providers.

 develop treatment & long-term follow-up plans  arrange for primary care & rehabilitative services  organize & facilitate case management  determine long-term care requirements & optimal placement  make the best use of health care resources.

 OA in hospital less likely to (a) die or experience functional deterioration (b) to be admitted to an institution, and more likely to be alive in their own homes at 12 month follow up (Ellis)  Frail OA with coordinated care based on CGA have improved outcomes & ↓ unnecessary hospital admissions. (Boult)  75+ preventive home visits based on CGA less decline in functional status & prevent ARRC admission. (huss)  Palliative care patients also benefit from CGA methods. (Boult) Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ;:. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report. J Am Geriatr Soc;:- Huss A, Stuck AE, Rubenstein LZ, Egger M, Clough-Gorr KM. Multidimensional geriatric assessment: back to the future. Multidimensional preventive home visit programs for community dwelling older adults: a systematic review and meta- analysis of randomized controlled trials [published correction in: 2009;64:318]. :63:

 The clinical implications are clear—comprehensive geriatric assessment should become standard practice.  Clinical expertise is needed to implement these approaches.  Doctors need to be trained to use the assessment like a laboratory test, linked with diagnostic and prognostic evaluation and therapeutic action.  Ward KT, Reuben DB. Comprehensive geriatric assessment. Schmader KE, ed.

 Older patients cared for by nurses trained in geriatrics are ◦ less likely to be restrained ◦ have fewer admissions to hospital ◦ are less likely to be transferred inappropriately from nursing facilities to hospitals. ◦ Less delirium ◦ UTI ◦ Pneumonia ◦ pressure ulcers ◦ Shorter length of stay ◦ Better documentation and improved family support

 Medical syndrome: group of signs and symptoms that occur together with a single underlying cause  Geriatric syndrome: multifactorial health condition that occur when the accumulated effect of impairments in multiple systems render and older person vulnerable to situational changes ◦ Multiple risk factors (for getting syndrome) ◦ Multiple organ systems involved ◦ Diagnostic studies to identify cause can be ineffective burdensome, dangerous and costly ◦ Therapeutic management can be helpful even without a firm diagnosis ◦ Don’t fit specific disease categories

American Geriatric Society  Frailty  Visual and Hearing impairment  Dizziness and Syncope  Malnutrition  Urinary incontinence  Gait impairment  Falls  Osteoporosis  Dementia  Delirium  Sleep problems  Pressure ulcers  Constipation Classic 5 in the literature  Pressure ulcers  Falls  Incontinence  Functional decline  Delirium

 Approach to multiple morbidity ◦ Treat every disease/symptom? ◦ Or consider in the context of the older adult? ◦ But what’s risk are we rationing?

 Physiological state of heighten vulnerability  2 theories ◦ It’s a multiple morbidity state unrelated diseases ◦ It’s a distinct physiological process resulting from dysregulation of multiple systems that interact and impair each other. Deregulated systems reduce ability to maintain homeostasis in the face of stressors, so people are vulnerable to adverse outcomes from “routine” conditions

Gobbens, van Assen, Luijkx, Schols, (2011) Testing and integral model of frailty Journal of Advanced Nursing 68(9)

 New or increased ◦ Confusion ◦ Agitation ◦ Weakness ◦ Fatigue ◦ Incontinence ◦ Falls ◦ Drowsiness  Change in function ◦ Deterioration in ADL ◦ Stopped eating / drinking  New ◦ Generalised pain ◦ Febrile  Delirium

S eems different than usual Ta lks or communicates less than usual O verall needs more help than usual P articipated in activities less than usual A te less than usual (Not because of dislike of food) N D rank less than usual W eight change A gitated or nervous more than usual T ired, weak, confused, or drowsy C hange in skin colour or condition H elp with walking, transferring, toileting more

 Accidents  Cancer  Organ failure  Frailty and dementia Source: Palliative Care Australia (2010). Health System Reform and Care at the End of Life: a Guidance Document Canberra: Palliative Care Australia. Diagram from Lynn, J., & Adamson, D. M. (2003). Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age RAND Health.

The median projection from Statistics New Zealand is that deaths will rise from around 30,000 a year to 55,500 a year at a national level by The more detailed national, regional and DHB projections are to Data source: Statistics New Zealand. Historic estimates and National population projections, 2014(base)-2068 DHB and Regional Projections National Projections Slide From: Heather McLeod: Extraordinary Professor, Department of Statistics and Actuarial Science, University of Stellenbosch, Adjunct Professor, School of Management Studies, University of Cape Town, Honorary Senior Research Fellow, School Of Nursing, University of Auckland

Data Source: Ministry of Health MORT data Slide From: Heather McLeod: Extraordinary Professor, Department of Statistics and Actuarial Science, University of Stellenbosch, Adjunct Professor, School of Management Studies, University of Cape Town, Honorary Senior Research Fellow, School Of Nursing, University of Auckland

Data Source: Ministry of Health MORT data There are strong patterns by age and gender. Deaths in public hospital are highest under 1 year old and decline at the oldest ages. There is an expanding “funnel” of deaths in residential care at older ages. Slide From: Heather McLeod: Extraordinary Professor, Department of Statistics and Actuarial Science, University of Stellenbosch, Adjunct Professor, School of Management Studies, University of Cape Town, Honorary Senior Research Fellow, School Of Nursing, University of Auckland

Source: National Model of the Need for Palliative Care Proportionately, age 85+ goes from 37.0% to 55.6% of total deaths. Slide From: Heather McLeod: Extraordinary Professor, Department of Statistics and Actuarial Science, University of Stellenbosch, Adjunct Professor, School of Management Studies, University of Cape Town, Honorary Senior Research Fellow, School Of Nursing, University of Auckland

We are at a low point for crude death rate. Rate is expected to rise by the 2050s to levels last seen in the 1940s and 1950s. This is NOT a failure of medicine! Source: Palliative Care Council, Working Paper No. 1, July 2013 Drawn using data from Statistics New Zealand Slide From: Heather McLeod: Extraordinary Professor, Department of Statistics and Actuarial Science, University of Stellenbosch, Adjunct Professor, School of Management Studies, University of Cape Town, Honorary Senior Research Fellow, School Of Nursing, University of Auckland

 Surprise question  Nutritional: progressive irreversible weight loss (> 10% over 6 months) decreasing serum albumin not related to an acute event  Functional: progressive irreversible decline despite therapeutic interventions and increase assistance with activities of daily living  Extreme Frailty: persistent stage 3-4 pressure ulcers, recurrent infections, delirium, persistent dysphagia, falls  Psychosocial sustained emotional distress  Additional two or more urgent admissions to hospital; need for complex continuing care  Co- morbidities two or more concurrent diseases

the process of engaging with the patient to begin the discussion, focusing their needs, for the right care at the right time in the right location

 Advance care planning: advance discussion about what you want & how you want it, may link into advance directive  Advance directives: advance specific refusal/request for medical intervention, in specific circumstances. Only applies when unable to make or communicate own choices, legal document, signed & witnessed, full consent and competence required.  Not for resuscitation: is an example of an advance directive

Every consumer may use an advance directive in accordance with the common law" Clause 4 advance directive means  A written or oral directive a)by which a consumer makes a choice about a possible future health care procedure; and b)this is intended to be effective only when he or she is not competent c)The consumer (patient) must be competent when making an advance directive. Health and Disability Commissioner Act 1994's Code of Health and Disability Consumers Rights clause 7(5)

 NZNO: refusal of treatment (which is a person’s legal right under the New Zealand Bill of Rights Act 1990) must be respected by nurses even when this may conflict with their own beliefs and values.  NZ Medical Association (NZMA) endorse advanced directives as a process of reflection discussion and communication of health care preferences that respects the patients’ right to take an active role in their health care, in an environment of shared decision making

 NOT and ADVANCE CARE PLAN this is an example of an advance directive  Does not mean “do not treat”.  Cardiac arrest is an inevitable part of the process of death, but not necessarily the cause.  For some dying people the chance of successful CPR is virtually zero and clinically futile.

You need know what the patients wants, people want different things depending on  Age, illness and ability of medicine to sustain life  Family emotions when loved ones are sick & possibly dying.  Difficult to make decisions in crisis  If patients become incapacitated due to illness, family and Dr make decisions based on what they think the patient would want.  In the best of circumstances, the patient, family & Dr will have had discussions about treatment options, Frequently, however, such discussions are not held.

 Antibiotics Blood transfusion Temporary tube feeding Temporary respirator Radiation Amputation Dialysis Chemotherapy Resuscitation Permanent respirator Permanent tube feeding  Source: Cohen-Mansfield J, Droge JA, Billig N. Factors influencing hospital patients' preferences in the utilization of life-sustaining treatments. Gerontologist 1992;32(1):89-95.

 We know about disease – so initiate & guide.  If we don’t pts get our “best guess”.  Cancer generally expected trajectory of dying (maintian ADL’s until about 2 months prior to death)  Chronic disease slow decline and sudden severe episodes of illness, often repeated with steady declining, until death. Estimating a time of death difficult.  Treatment CC fixes immediate emergency and extends life, but this could be “the one”  (Teno et al; Lynn et al; Hanson et al)

 Pts say lack of communication causes confusion about medical treatments, conditions, prognoses & choices  One-third of pts would discuss ACP if the Drs brought up the subject  Only 5% stated that they found discussions about ACP too difficult.  ACP & AD discussion increases pt satisfaction for 65+  Pts who talk with families / Drs about preferences for EOL ◦ have less fear & anxiety ◦ feel more able to influence and direct their care. ◦ Believed that their Drs had a better understanding of their wishes. ◦ Indicated greater understanding & comfort level than before the discussion.  Pts who start discussion with HPs continue to talk with their families & can reconcile their differences about EOL

78 yr man; Dementia, liver cirrhosis, acute pulmonary oedema. July ’07 copy of advance directive held in notes 2nd Jan 09, daughter restated NFR, form completed 29 Jan 09 resuscitated in ED died 30th 95 yr woman - Acute CVA Normally independent and lives alone family adamant she would not want invasive care, TLC died next day 73 yr man – Adenocarcinoma Admitted 19 Dec - NFR completed stabilised dx Admitted 30 Dec - noted daughter concerned about fathers ability to cope and cachexia, which resulted in a NG tube being placed Seen by dietician 15 minutes before dying 6 th Jan 09

Barriers Personal values, belief culture Paradigm shift, patient owns document, one document Its not my job! Fear Judging the right time Patient cognitive impairment Involving families in decision esp if family disagreement. Patients “not ready” Skills deficit Organisational confusion around terminology system and process Enablers Personal values, belief, culture Accepting own mortality Belief in the patient’s right to this conversation Patient centred philosophy Structured approach Sooner rather than later avoid crisis point (but never too late) Scripted questions Knowing what is available Seizing the moment Education process/framework Organisational clarity around terminology system and process

 Clinical Champions key to success  Structured process to initiate ACP discussions  Structured follow up process essential  Time is of the essence  Cognitive impairment and complex family issues present challenges in Age-related residential care  Organisation governance & clinical support required.

The Implementation Framework (Clark & Daltrey, 2010) Tools and training for practice NFRCommunication training ACP Comfort Zone Health professional, team and patient comfort with conversations Understanding Context Promotion of ACPOrganisational approachUnit philosophy Understanding Culture Spiritual religiousDeath as the last tabooFamily affair Knowing Self Own MortalityBelief and Values Experience

Baby Boomers Natural Birth, Natural Death?

Data Source: Ministry of Health MORT data The peak moving forward and will become much higher as we enter the period when the “Baby Boomers” reach their last years. Greatest Generation Baby Boomers Silent Generation

At a Death Cafe people drink tea, eat cake and discuss death. Our aim is to increase awareness of death to help people make the most of their (finite) lives. Source:

 Ministry of Health (2006) Health of Older People Information Strategic Plan Directions to 2010 and beyond  Ministry of Health Ageing New Zealand and Health and Disability Services 2001–2021: Background information. International responses to ageing populations. Wellington: Ministry of Health  Grant Thornton (2010) Aged residential care service review  1American Nurses Association (2010) Gerontological Nursing: Scope and Standards of Practice. Nurses Books. Org, Silver Spring, Maryland, USA.  Capezuit E et al (2012) nurses improving care fo healthsystem elders a model for optomisng the geriarric nusing pracitice environment  Mezey et al (2011) A competency based appraoch to educating and training the eldercare workforce Journal of American Society on aging  Bachmann S, et al (2010) Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ. 2010;340:c1718  Kuo HK, Scandrett KG, Dave J, Mitchell SL (2004) The influence of outpatient comprehensive geriatric assessment on survival: a meta- analysis. Arch Gerontol Geriatr. 2004;39(3):245.