1. What is NICHE??
Nurses
Involved in
Care of
Healthsystem
Elderly

2. Effects of Age Related Changes
Diminished reserve and ability to respond to stress
Older adults have difficulty managing the
stress of hospitalization associated with:
Surgery
Anesthesia and other medications
Medical tests and procedures
Physical environment
Schedules
As a result of normal age related changes, challenges related to life stresses may be more difficult for the older adult to manage. These include anything from the physical stress related to being outdoors in extreme weather temperatures to the loss of a spouse or fears about financial loss. Older adults are especially vulnerable to the stress of hospitalization. Common examples of events that are stressful during hospitalization include surgery, anesthesia and other medications, medical tests and procedures, changes in the physical environment such as noise and lighting, and routine hospital schedules like preparation for surgery that requires a patient not to drink or eat anything for an extended period of time before an operation. 2

3. Iatrogenesis Definition – from the Greek word, iatros means healer
iatrogenesis means brought forth by a healer
unintended adverse patient outcome due to
simply being a hospitalized patient
not a natural course of disease
36-58% of older adults suffer iatrogenic illness
during hospitalization.
Iatrogenesis is a common and serious hazard of hospitalization that is often associated with tragic outcomes for the older patient and family. From the Greek word, iatro means healer and iatrogenesis means “brought forth by a healer.”
Iatrogenic harm refers to an unintended adverse patient outcome due to any hospital intervention that is not considered the natural course of the disease. This includes interventions such as surgery, tests, procedures, medications, treatments, and normal routine care.
It is estimated that 36-58% of all older adults suffer from iatrogenic illness during hospitalization. This means that 1/3 to ½ of all older patients experience harm during their hospital stay. Examples of iatrogenesis in older adults are urinary tract infections following placement of a urinary catheter, functional decline, and the development of pressure ulcers.

4. Normal age related changes
Iatrogenesis
Normal age related changes
Lowered reserve and ability to respond to stress
Exaggerated effects of medications
Increased risk of infection
Less aware of the need to drink
Heart less able to deal with stress
There are many reasons why older adults experience such a high rate of harm during hospitalization.
Normal age related changes are primary reasons because they lead to:
Lowered physical reserve and ability to respond to stress
Exaggerated effects of medications leading to more adverse side effects and harm
Increased risk of infection
Less aware of the need to drink which increases risk of dehydration
Heart less able to deal with stress – The ability of the heart to increase its rate during physical activity, stress, or infection is reduced.

5. Geriatric Delirium

6. 0000_NICHE Program Development
DELIRIUM!!
Risk Factors
Most common
Dementia
Male gender
Advanced age
Medical illness
Multiple medications
Predisposing
Poor functional status
Alcohol abuse
Dementia
Depression
Dehydration
Sensory impairment
The pathophysiology of delirium is not well understood and a number of risk factors have been identified suggesting that the etiology of delirium is multifactorial. The most common risk factors associated with delirium are:
Dementia
Male gender
Advanced age
Medical illness
Predisposing factors are:
Poor functional status
Alcohol abuse
Depression
Dehydration
Sensory impairment
** Pathophysiology of delirium is not well understood
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0000_NICHE Program Development

7. 0000_NICHE Program Development
High Risk Medications
Anticholinergics
Zantac, Procardia, Detrol, Atropine
Narcotics
Demerol, Morphine, Percocet, Lortab
Sedative hypnotics (benzodiazepines)
Ativan, Xanax, Valium, Tranxene, Ambien (CNS depressant)
H2 Blockers
Zantac, Pepcid, Tagamet
Corticosteroids
Prednisone, Decadron, Celestone
Centrally acting antihypertensives
Clonidine
Antiparkinsonian drugs
Cogentin, Artane, Sinemet, Mirapex, Requip
Beers Medications
Anticholinergics- Procardia, Detrol, Zantac
Narcotics- Demerol, Darvocet, any combination drugs (Percocet, Lortab, etc. )
Benzos- Ativan
H2 receptors- Pepcid
Corticosteroids- Prednisone, Decadron
Centrally Active antiHTN-
Antiparkinsonian drugs- Sinemet, Cogentin, Artane
We set them up for failure!!
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0000_NICHE Program Development

8. 0000_NICHE Program Development
So… What’s the “take-away” message?
Delirium is…
Common in hospitalized older adults
A major reason for poor health care outcomes
and nursing home placement
Under recognized by doctors and nurses
Preventable and treatable
Potentially life-threatening and needs
immediate medical evaluation
Delirium in a patient with pre-existing dementia is a common problem that may have life-threatening complications, especially if unrecognized and untreated. It can be difficult to assess in older hospitalized adults with dementia due to overlapping clinical features and the uncertainty of the patient’s baseline mental status.
Delirium in older adults with dementia may be a sign of preventable and treatable medical problems or serious underlying illnesses such as a myocardial infarction, urinary tract infection, pneumonia, pain, or dehydration.
9/19/2018 4:36:21 PM
0000_NICHE Program Development

9. #60 on Palmetto Health TV’s
The C.A.R.E.™ Channel
#60 on Palmetto Health TV’s

10. DIVERSIONAL ACTIVITY CART
*How to use the contents of this cart to
REDUCE THE RISK OF DELIRIUM

11. Purpose of the cart:
Geriatric patients are at risk for delirium while they are in the hospital, due to:
Poly-pharmacy
Beers’ (Potentially Inappropriate) Medications
Sleep deprivation
Changes in personal schedule/routine
Un- or under-treated pain
Surgical/procedural stressors and/or anesthesia
Sensory deprivation/restraints/tethers
Boredom &Isolation
This cart includes numerous items and activities that may help divert a patient’s attention from some or all of those stressors that often lead to delirium.
HELP Volunteers will need access to this cart as well.

12. Other diversional activity items examples below: Any items you feel might be helpful that are not on the cart, please donate them and notify Donna Wolff via
Knitted Shawls
Stuffed Animals
Dolls
Wash Cloths
Slinky
Small Coloring Books
Koosh Balls
Extra Crayons
Poker chips
Decks of cards (any kind)
Anything to sort or manipulate
Paint by number with water
Large print books, magazines,
Or devotionals
Knitted hats
New Baseball caps
New colorful socks to sort
Peg boards
Music CD’s
Exercise bands
Smooth, Small pieces of PVC tubes
Smooth, plastic kitchen utensils
(no knives or forks or anything sharp)
Plastic cups
Silk scarves
Lap blankets
Stacking cones, plastic rings
Puzzles
Extra pencils, pens, paper
Blank greeting cards with
Envelopes
Safety scissors (no sharps)

13. Top of the Cart:

14. Top of the Cart: Small basket with: Patient glasses cleaning wipes
NICHE program brochure and NICHE coordinator business card attached
Describes programs
Delirium Family Education brochure
Allay fears, suggests ways to help
Patient glasses cleaning wipes
Patients need to be able to see as clearly as possible,
Decreased vision leads to social isolation, confusion, and delirium

15. FIRST DRAWER:

16. FIRST DRAWER: Mental Stimulation
“Spring Things”: Reminiscing Picture Pages
Useful to stimulate conversations or promote
distraction from unpleasant behaviors
Pencils/Crayons
Large Print Circle-a-Word Puzzles
Large Print Crossword Puzzles
Adult- appropriate Coloring pages
Useful for distraction, mental stimulation
Large Print devotions
Useful for Spiritual needs, calm, prayer, meditation
Printed words to sing-a-long songs
Promotes auditory stimulation, calming, distraction, etc.

17. SECOND DRAWER

18. SECOND DRAWER SENSORY STIMULATION Sound-sensing Light Bar- Busy Apron
Flashes lights in response to sound OR can be
set to automatically flash a light show
Distraction, involvement, visual stimulation
Busy Apron
Distraction, occupies hands, keeps from pulling at tubes, devices
Pop Tubes
Distraction and interesting noises
occupies hands, keeps from pulling at tubes, devices,

19. THIRD DRAWER Lace and trace shapes with strings Vegetables and fruits
Tangle – mental stim & busy hands game
Kitchen utensils

20. THIRD DRAWER Lace and trace shapes with strings Vegetables and fruits
Tangle – mental stim & busy hands game
Kitchen utensils

21. FOURTH DRAWER SENSORY STIMULATION
Plastic cups for sorting game chips, coins, etc.
Colorful plastic chains for sorting
Shoe laces to tie or lace in cardboard, etc.

22. FOURTH DRAWER SENSORY STIMULATION
Plastic cups for sorting game chips, coins, etc.
Colorful plastic chains for sorting, connecting
Shoe laces to tie or lace in cardboard, etc.

23. Final thoughts: cleaning and replacing items:
Give two or three activity sheets/crayons
two or three laces/ soft goods to a patient-
- unable to clean
Hard plastic (wipe-able) items are the property of each unit
- clean with cavi-wipes and return to the cart between
patient use
*Activity aprons, stuffed animals can be washed, please page to have someone come pick the apron up and bring you a new one.
*When you need replacement items for the cart, please NICHE coordinator