1. Age Related Conditions and Geriatric Assessment Alaa Mira, MD, CMD Chief of Geriatrics St. Luke’s University Health Network

2. Disclosure Statement of Financial Interest I do not have financial relationships with commercial interests to disclose

3. Learning Objectives Review common Geriatric syndromes Principles of Geriatric assessment Hazards of hospitalization of older adults Geriatric care models

5. Older Adults are Hospitals’ CORE Consumers Older adults 13% of the population: - But comprise 37% of hospital discharges and 43% of hospital days - Have longer lengths of stay (7.8 days vs. 5.4 days) - Higher rates of 30 day hospital re-admissions -Higher rates of functional decline and medical errors

6. Number of chronic diseases Risk Ratios Risk Ratios for Activities of Daily Living Dependency Cigolle, C. T. et. al. Ann Intern Med 2007;147:156-164

7. Number of conditions/diseases Risk Ratios Risk Ratios for Activities of Daily Living Dependency Cigolle, C. T. et. al. Ann Intern Med 2007;147:156-164

8. Geriatric Syndromes Dementia Depression Delirium Falls Sensory impairment Polypharmacy Incontinence Sleep disorders Weight loss

9. Dementia: A Growing Epidemic

10. Understanding Dementia Dementia is a general term used to describe a decline in cognitive function Progressive irreversible brain disease No medication can cure dementia Alzheimer’s disease is the most common form of dementia Caregiver burnout

11. Diagnostic Challenges Is this “normal aging”? Is it a change?

12. How Is Memory Affected By Aging As we age, the brain loses some of its abilities that can lead to forgetfulness – This is normal, and begins after the age of 40 – Not progressive – No decline in activities of daily living – Productive and satisfying life

13. Diagnostic Challenges Is this “normal aging”? Is it a change? Clinical presentations can be similar

14. Conditions that Mimic Dementia B12 deficiency Hypothyroidism Medications Toxic/Metabolic Infections Cardiovascular disease Pulmonary Systemic Illnesses Depression Psychosocial stressors Drugs Other

15. Diagnostic Challenges Is this “normal aging”? Is it a change? Clinical presentations can be similar Changes can begin up to 20 years before noticeable by self & others

16. Stages of Dementia Normal Cognition Very Mild Cognitive Impairment Mild Cognitive Impairment Moderate Cognitive Impairment Severe Cognitive Impairment

17. Stages of Dementia Normal Cognition Very Mild Cognitive Impairment Mild Cognitive Impairment Moderate Cognitive Impairment Severe Cognitive Impairment

18. Is it worth screening for Alzheimer ’ s disease or MCI? “ If there was treatment for AD, I'd recommend screening, but there is no disease-modifying therapy." “ All older adults benefit from memory screening because it detects cognitive problems before memory loss is noticeable. ” Healthy Aging, 2008; repost, 2010 “ Memory Screening: Is it Worth It? ”

20. Reasons to Screen and Diagnosis Dementia Early Autonomy (right to know) Patient can participate in planning and decision making Lifestyle modification Advance directives Patient/caregiver education Access to information, programs, support, and other resources Symptomatic and disease modifying therapies are more efficacious with early disease intervention Medications

21. Screening Tools For Dementia Name Items/ ScoringDomains assessedWeb link (accessed Oct 2012) Mini-Cog2 items Score = 5 Visuospatial, executive function, recall http://geriatrics.uthscsa.edu/tools /MINICog.pdf SLUMS11 items Score = 30 Orientation, recall, calculation, naming, attention, executive function http://medschool.slu.edu/agingsuc cessfully/pdfsurveys/slumsexam_0 5.pdf MoCA12 items Score = 30 Orientation, recall, attention, naming, repetition, verbal fluency, abstraction, executive function, visuospatial www.mocatest.org Folstein MMSE 19 items Score = 30 Orientation, registration, attention, recall, naming, repetition, 3-step command, language, visuospatial For purchase: www.minimental.com www.minimental.com

22. Clock Test

23. Treatment Non-pharmacologic treatment Lifestyle modifications Physical therapy and exercise Socializing Pharmacologic treatment No medication can CURE dementia Medication may slow down the dementia Treatment should be individualized

25. Delirium Also known as – Acute mental status change – Acute confusional state – Altered mental status – Toxic or metabolic encephalopathy – Organic brain syndrome Delirium is most frequent complication of hospitalized elderly Yet it is underdiagnosed

26. Prevalence Hospitalized medically ill 10-30% Hospitalized elderly10-40% Postoperative patientsup to 50% Near-death terminal patientsup to 80%

27. Risk Factors Age Preexisting dementia Recent surgery Infections Visual/hearing impairment Polypharmacy Substance Abuse

28. Types of Delirium Hyperactive -Better recognized -More attention to treatment -Associated with improved outcome Hypoactive -Little recognized -Depression is primary differential -Associated with poor outcomes Mixed

29. Clinical features Prodrome Fluctuating course Attentional deficits Impaired cognition Sleep-wake disturbance Altered perceptions Affective disturbances

30. Diagnosis of Delirium Delirium is a clinical diagnosis History and physical examination Mental Status Exam Confusion Assessment Method (CAM) Standardized assessment tool CAM ICU-non-verbal, ventilated patients Identifies 4 features of the disorder -Acute onset or fluctuating -Inattention -Disorganized thinking -Altered level of consciousness

31. Delirium: Management Behavioral/Environmental Strategies – Reorientation, calendars, clocks – Room near nursing station – Lights on/off during day/night – Windows – Family/familiarity – Hearing aids, glasses – Avoid restraints

32. Pharmacological Therapy Nothing FDA-approved Antipsychotics are treatment of choice for agitation compromising care or safety Haloperidol best studied, widely used Atypical Antipsychotics: Risperidone, Olanzapine, Quetiapine Black box warning - Increased risk of death/CVA in patients with dementia

33. Complications Increased morbidity Increased risk of cognitive decline Increased risk of mortality Nursing home placement

34. Falls

35. Aging and Falls 30-40% of older adults fall every year 20-30% of people who fall suffer moderate to severe injuries 50% of fallers will report recurrent falls 50-60% of falls happens in or around the home Incidence of falling increases with age

39. Balance Central Processing Sensory InputMotor Output Experience Learning Visual Vestibular Somatosensation Neural activation Muscle strength Range of motion Reflexes

41. Falls are Multifactorial Intrinsic Factors Extrinsic Factors FALLS Age related changes Medical conditions Medications Environment

43. Subjects in the Intervention and Control Groups Who Had Multifactorial Intervention to Reduce the Risk of Falling tagesO Tinetti M et al. N Engl J Med 1994;331:821-827

44. Effect of Vitamin D on Falls Meta-analysis included 5 RCTs with 1237 elderly individuals treated with different vit D analogues for 2 months to 3 years Vitamin D supplementation reduced the risk of falls among the elderly by 22% Improved the body sway by 9% and musculoskeletal function by 11% 400 IU of vit D may not be clinically effective Trials used 800 IU of vit D did find significant reductions in observed fractures Heike et al. JAMA 2004; 291;1999-2006

45. Comprehensive Geriatric Assessment Multi-disciplinary team approach Address the unique needs of older adults Work collaboratively with PCP and other specialists Patient and family centered care Improve satisfaction and quality of life

46. St. Luke’s Senior Care Services Center for positive aging Acute Care for the Elderly (ACE) Geriatrics surgical program Nurses Improving Care of Healthsystem Elders (NICHE)

47. Center for Positive Aging Comprehensive Geriatric assessment Multi-disciplinary approach Social worker Driving issues Pre-operative assessment Family care conference Recommendations to PCP

48. Acute Care for the Elderly (ACE)

49. ACE Model Concepts Specialized model of care Address the needs of hospitalized older adults Evidence based best practice Multi-disciplinary team approach Prevent functional decline and NH placement Reduce iatrogenic complications Decrease hospital length of stay and costs Improve outcomes and satisfaction

50. ACE Consult Criteria 65 years or older Acutely ill Co-morbid conditions At risk of functional decline Identification seniors at risk (ISAR) tool

51. St. Luke’s ACE Outcome Data 2014 Ativan orders decreased by 33% Benadryl orders decreased by 13% LOS decreased by 10% Delirium rate decreased by 60%

52. Geriatrics Surgical Program Pre-operative geriatric assessment Nurse navigator 65 years or older Elective surgery Geriatric assessment Update anesthesiologists and surgeons

55. Nurses Improving Care for Healthsystem Elders (NICHE) NICHE is a program of the Hartford Institute at the NYU College of Nursing NICHE is the only national geriatric nursing program that addresses the needs of hospitalized older adults There are approximately 680 hospitals in more than 40 states as well as Canada with NICHE designation

56. NICHE Program Goal – Achieve systematic nursing change that will benefit hospitalized older adults Vision – Provide geriatric sensitive and exemplary care to all hospitalized older adults Mission – Import principles and tools to stimulate change in the culture of healthcare facilities to achieve patient- centered care for older adults

57. Nurses are Positioned to Paly a Central Role Nurses are the primary caregivers for older patient in hospitals Nurses are generally not fully prepared to care for older patients Nursing models can improve older patients’ care and decrease hospital complications Nursing can be the focal point for stimulating interdisciplinary care

58. NICHE Resources Start-up tools – NICHE planning and implementation guide – Leadership training program Measurement – Geriatric Institutional Assessment Profile (GIAP) – Clinical outcomes – Program self-evaluation Clinical management tools – Organizational strategies and clinical improvement models Training and education programs – Care curricula: for nurses, patient care techs (CNA), other disciplines and general staff – Webinars and in-service materials – Educational resources for patients and families – Conferences – Geriatric Resource Nurse (GRN) National community

59. Geriatric Resource Nurse (GRN) Certified GRN Assist staff in evaluating, planning and implementing geriatric care Disseminate information about geriatric care GRN core screening tool (SPICES) Geriatric assessment rounding

60. NICHE Outcomes Enhance nursing knowledge and skills regarding the treatment of common geriatric syndromes Increase patient satisfaction Decrease length of stay Reduce readmission rates Reduce costs associated with elder care

61. St. Luke’s Network and NICHE Program St. Luke’s became NICHE designated in Jan 2014 RNs and Patient Care Assistants completed the NICHE Geriatric Resource Education and St Luke’s older adult sensitization Non-nursing staff received NICHE information and sensitization experiences Network-wide Geriatric Institutional Assessment 70% completion rate St. Luke’s NICHE Program video viewed by over 1100 employees

62. St. Luke’s Network Performance Improvement Activities Reducing polypharmacy in older adults Effective ambulation and reducing deconditioning Reducing pressure ulcers Reducing delirium

63. Fall Rate Outcomes

64. Conclusions Multidisciplinary team approach is recommended to coordinate the care of older adults Geriatric syndromes are prevalent Geriatric assessment improves outcomes Geriatric care models (ACE/NICHE) decrease functional decline, falls, polypharmacy, LOS and increase satisfaction

65. “In the end, it’s not the years in your life that count. It’s the life in your years.” Abraham Lincoln

66. “Thank You”