1. Utilizing SPICES Focused Geriatric Assessments to Improve Care of the Older Adult Suzanne Purvis, DNP, RN, GCNS-BC Clinical Nurse Specialist, Geriatrics University of Wisconsin Hospital and Clinics

2. Objectives Learner will be able to: name 2 geriatric syndromes describe one nursing implementation practice utilizing the geriatric syndromes at the bedside describe the latest research on how geriatric syndromes affect readmission rates. describe the importance of a focused geriatric assessment

3. Turning Point Question #1 In older breast cancer survivors, age 65 & older, symptoms such as fatigue, weakness, pain, confused thinking are MOST OFTEN attributed by the older adult to: Cancer symptoms Effects of the cancer treatment Other chronic diseases they have Aging changes

4. SPICES: What is a Focused Geriatric Assessment? Addressing those conditions that are common in aging individuals Geriatric ‘marker’ conditions Geriatric Syndromes Geriatric ‘Giants’ Definition of a syndrome: A group of signs/symptoms that occur together & characterize an abnormality

5. Geriatric Syndromes in Nursing: SPICES SPICES* Sleep disorders Problems with eating & feeding Incontinence Confusion Evidence of falls Skin breakdown *Fulmer, T. (2007). Fulmer SPICES. American Journal of Nursing, 107, (10) SPPICCESS @ UW Health – Sleep disorders – Problems with eating and feeding – Pain – Incontinence – Confusion – Constipation – Evidence of falls – Skin breakdown – Sensory

6. Geriatric Syndrome Model Geriatric Syndromes: Affect quality of life Increase disability Chief complaint may be in a different organ than the disease condition being treated (EX: UTI causing delirium) Not clearly defined? Geriatrics as a specialty?

7. Geriatric Syndromes in Medicine Include same syndromes as nursing, but sometimes also; Frailty Functional decline Osteoporosis Dizziness Polypharmacy Need to establish formal criteria, & clarify shared risk factors and appropriate intervention strategies

8. Geriatric Syndromes in Research 29,544 Women age 65 and older in the Women’s Health Initiative Observational Study Free of disabilities at baseline Geriatric syndromes reported at baseline, and 3 year follow- up: Falls, hearing & visual impairment, incontinence, sleep disturbance, pain, polypharmacy, osteoporosis, dizziness 76% had at least one Geriatric Syndrome at baseline Greater number of geriatric syndromes at baseline, was significantly assoc. with ADL disability at 3 year follow-up

9. Researchers Conclusions May be as important as clinically recognized diseases in determining disability Failure to account for geriatric syndromes may lead to an incomplete understanding of how pathology leads to disability as we age

10. SPPICCESS: Improving Care at the Bedside

11. SPPICCESS Audits Geriatric Resource nurse completes a SPPICCESS audit on an older adult they have cared for that month Assess how many geriatric syndromes are found Audit patients chart to determine if the syndromes found were all addressed in the plan of care

12. Turning Point Question #2 In audits of 34 older adults performed at UWHC, which of the following geriatric syndromes identified as present in an older adult, was most likely to not have nursing interventions noted in the older adult’s plan of care?: Sleep Pain Confusion Skin breakdown

13. SPPICCESS Data: 2014-2015 (N=34)

14. Quality Improvement: Identifying Geriatric Syndromes Sleep: 47% had a sleep problem 50% of those with a sleep problem had no interventions listed Problems with eating and feeding 62% had difficulties eating or feeding themselves 32% of those with eating/feeding problems had no interventions listed Sensory (vision & hearing) 79% had vision or hearing problems 50% of those with vision/hearing problems had no plan

15. Geriatric Nursing Competencies* Developed nursing competencies for all new nursing staff based on geriatric syndromes Included elements of the syndrome, components, & available resources Sleep, pain, incontinence, confusion, safety (falls), polypharmacy, functional decline, psycho-social Available literature *Purvis, S., Zupanc, T., VanDenBergh, S., & Martin, H. (2015). Population based nursing competency development. Journal for Nurses in Professional Development, 31 (4), 231-236.

16. Competency Example Confusion/Cognitive Decline Elements: Dementia, delirium, depression, Confusion Assessment Method (CAM), Six Item Screener, Checklist of Non-Verbal Pain Indicators (CNPI) Components: Differentiate clinical presentation of delirium, dementia, and depression Identify non-pharmacological interventions for above Nursing Practice Guidelines on Delirium and Dementia How and when to use Things to Know About Me document Appropriate consults

17. Older Adult Summary Report Electronic Health Record Pulls from Nursing Admission Health Assessment Groups by the Geriatric Syndromes Clinical Picture of the patient on admission Additional: Social Work Assessment of living arrangements

18. Older Adult Summary Report Sleep Eating and feeding - questions from Katz and Lawton Confusion (Dementia, Delirium, Depression) - CAM delirium score and Six Item Screener and depression screening question Functional decline - Katz & Lawton total scores

19. Nursing Practice Guidelines #1: Delirium Management # 2: Care of the Patient with Dementia (communication, identification, pain, medications) #3: Falls Boltz et al (2012). Evidence-based Geriatric Nursing Protocols for Best Practice. Springer Publishing Company

20. Dementia: Pain management Assessing pain in the older adult with a cognitive impairment: Checklist of Nonverbal Pain Indicators (CNPI) Outcomes that could be affected by better pain management: Pain scores, Patient satisfaction, falls, ‘sitters’

21. Dementia Capable Wisconsin: Improving Access to Care Lack of diagnosis Lack of identification of those individuals who have a diagnosis Approaches to dealing with BPSD (Behavioral and Psychological Symptoms of Dementia) Dementia Friendly Communities

22. Where to Focus QI Efforts? Geriatric Syndromes Sleep Problems with eating and feeding Incontinence Constipation Confusion (delirium, dementia & depression) Evidence of falls Skin breakdown Sensory Common Strategic Initiatives in Hospitals Falls Cost of ‘sitters’ Hospital acquired infections Readmissions Cost efficiency

23. Turning Point Question #3 The average LOS for any older adult (age 65 or older) @ UW is 5.3 days. Which do think below is the average LOS for an older adult with delirium? 5.3 days 6 days 11 days 20 days

24. LOS in Older Adults @ UWHC: All older adults, w/delirium, w/dementia Dementia = Alzheimer's Dementia, Vascular Dementia, Mild Cognitive Impairment, & Mild Memory Disturbance

25. References Fulmer, T. (2007). Fulmer SPICES. American Journal of Nursing, 107, (10), 40-48. Locher, J.L., Burgio, K.L., Goode, P.S., Roth, D., & Rodriguez, E. (2002). Effects of Age and Causal Attribution to Aging on Health-Related Behaviors Associated With Urinary Incontinence in Older Women. The Gerontologist, 42 (4), 515-521. Yeom, H. & Heidrich, S. (2009). Effects of perceived barriers to symptom management on quality of life of older breast cancer survivors. Cancer Nursing, 32 (4), 309-316. Boltz et al (2012). Evidence-based Geriatric Nursing Protocols for Best Practice. New York, N.Y., Springer Publishing Company Purvis, S., Zupanc, T., VanDenBergh, S., & Martin, H. (2015). Population based nursing competency development. Journal for Nurses in Professional Development, 31 (4), 231-236. Inouye, S., Studenski, S., Tinetti, M., & Kuchel, G. (2007). Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatric Society, 55, 780-791. Rosso, A., Eaton, C., Wallace, R., Gold, R., Stefanick, M., Ockene, J., Curb, J.D., & Michael, Y. (2013). Geriatric syndromes and incident disability in older women: Results from the women’s health initiative observational study. Journal of the American Geriatric Society 61, 371-379.

26. Turning Point Question #1 Which is NOT an indicator of frailty? A.Decreased strength B.Unintentional weight loss C.Chronic pain D.Falls

27. What is Frailty 2 Models – Phenotype Model Grip strength Exhaustion Gait Speed Low activity Unintentional weight loss

28. What is Frailty 2 Models – Cumulative Deficit Model Number of Deficits accumulated over time in multiple domains – Disease/illness – Ability to carry out ADLs

29. What is Frailty “Frailty is a multidimensional syndrome of decreased reserve and resistance to stressors leading to increased vulnerability to adverse outcomes” (Kalon, et al.) 28

30. Frailty & Geriatric Syndromes 29 Frailty Cycle Ahmed, N., Mandel, R. Fain, M., 2007

31. 30 Frailty & Geriatric Syndromes Ferrucci, et al., 2010

32. Turning Point Question #2 True or False: Frailty is an inevitable part of aging? A.True B.False

33. Assessing Frailty Comprehensive Geriatric Assessment Phenotype model Cumulative deficit model 32

34. Frailty & Readmissions Predictive readmission models perform poorly LACE Index – Length of Stay – Acuity of Admission – Comorbidities – Emergency Visits Attempt at incorporating frailty into the model 33

35. Frailty & Readmissions Clinical Frailty Scale Quantifies frailty Scale 1-9 1 being very fit 9 being terminally illl 34

36. 35

37. Frailty & Readmissions Trauma Specific Frailty Index (TSFI) 15 variables Discharge disposition as favorable vs unfavorable Predictive of readmissions 36

38. Frailty & Readmissions Frailty Indicators in Heart Failure Patients – Dementia – Falls – Incontinence – Immobility – Abnormal weight loss – Care provider dependency

39. Frailty & Readmissions Ambulatory Geriatric Assessment- Frailty Intervention Trail (AGe-FIT) Ongoing study RCT to prevent readmissions & functional decline Comprehensive geriatric assessment vs. usual care 38

40. Turning Point Question #3 Which is NOT a Frailty measure used for predicting readmissions? A.TSFI B.LACE Index C.Clinical Frailty Scale

41. References Ahmed, N., Mandel, R., & Fain, M. (n.d.). Frailty: An emerging geriatric syndrome. The American Journal of Medicine, 120(9), 748-753. doi:10.1016/j.am.med.2006.10.018 Clegg, Andrew, and John Young. "The Frailty Syndrome." Clinical Medicine 11.1 (2011): 72-75. Ferrucci, Luigi, Charles Hesdorffer, Stefania Bandinellie, and Eleanor Simonsick. "Frailty as a Nexus between the Biology of Aging, Environmental Conditions and Clinical Geriatrics." Public Health Views 32.2 (2010): 475-88. Fried, L., Tangen, C., Walston, J., Newman, A., Hirsch, C., Gottdiener, J.,... Burke, G. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology: Medical Sciences, 56A(3), M146-M1456. Jokar T, Rhee P, Zangbar B, and others (2015) Redefining the association between old age and poor outcomes after trauma: The impact of the fraily syndrome. Scientific Forum Abstracts 221:S83–S84. Kahlon, S., Pederson, J., Majumdar, S., Belga, S., Lau, D., Fradette, M.,... McAlister, F. (2015). Association between frailty and 30-day outcomes after discharge from hospital. Canadian Medical Association Journal, 187(11), 799-804. Lucas, R., & Kennedy-Malone, L. (2014). Frailty in the older adult: Will you recognize the signs? The Nurse Practitioner, 39(3), 29-34.

42. References Mazya, A., Eckerblad, J., Hellstrom, I., Krevers, B., Milber, A., Unosson, M.,... Ekdahl, A. (2013). The ambulatory geriatric assessment--a frailty intervention trial (AGe-FIT)- a randomized controlled trial aimed to prevent hosptial readmissions and functional deterioration in high risk older adults: A study protocol. European Geriatric Medicine, 4, 242- 247. Partridge, Judith, Danielle Harari, and Jugdeep Dhes. "Frailty in the Older Surgical Patients: A Review." Age and Aging 41 (2012): 142-47. Rampersand, P., S.E. Bronskill, A. Chong, P.C. Austin, J.V. Tu, and D.S. Lee. "Does Frailty Predict Outcomes amongst Elderly Heart Failure Patients after Hospital Separation?" Canadian Journal of Cardiology 30.10 (2014): S335.