Care of the Chronically Ill and the Older Persons ELECTIVE 2

BSN 14B July 20, 2011

Risk factors associated in Chronic Illness in elderly

Modifiable/non-modifiable

Risk factors: Modifiable

Lifestyle
Smoking Poor nutrition Physical inactivity Failure to use preventive and screening services

Coping styles, stress

Risk factors: Non-modifiable

Age Pre-existing conditions
Long term medication

Hereditary

Patterns of Illness in Elderly

Multiple chronic conditions Undiagnosed diseases Accommodated to disease and impairment Limits toleration (multiplicity of dis) Functionally limited Dependent on others

Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment

A multidimensional, interdisciplinary diagnostic process to determine the:
Medical Psychological Functional capabilities of a frail elderly person

Comprehensive Geriatric Assessment

Purpose
Develop a coordinated and integrated plan for treatment and long-term follow-up Achieve quality and functional status of life

Comprehensive Geriatric Assessment

Purpose
Determine prognosis and outcome of care Employment of interdisciplinary teams Utilize standardized instruments to evaluate aspects of patient functioning, impairments, and social supports

Goals and Objectives (CGA)

To refer those at risk for other more thorough workup To improve process of care:
Improve diagnostic accuracy Improve medical treatment Arrange for long-term case management

Goals and Objectives (CGA)

To improve outcomes of care:
Improve functional status Better quality of life

To contain costs of care:

Reduce use of unnecessary formal services Prolong tenure in the home/community

COMPONENTS OF COMPREHENSIVE ASSESSMENT

Component Medical assessment Elements Problem list Comorbid conditions and disease severity Medication review Nutritional status Basic activities of daily living Instrumental activities of daily living Activity/exercise status Gait and balance Mental status (cognitive) testing Mood/depression testing Informal support needs and assets Care resource eligibility/financial assessment Home safety Transportation and telehealth

Assessment of functioning

Psychological assessment Social assessment Environmental assessment

CHRONIC ILLNESS IN ELDERLY

Wellness is the Goal at All Ages

Spiritual Faith Meaning in life Emotional Friendship Connections to others Sense of well being Belonging to a family and community

Physical Nutrition Exercise

Financial Security Independence Flexibility

Mental Activities and hobbies Problem-solving Continuing education

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Age and Illness

Being an older adult, Does not mean being ill!

Aging does not cause disease nor does disease cause aging Dizziness, confusion, forgetfulness and incontinence are not normal aging, but usually signs of a disease process Even if someone has a disease, symptoms may be corrected or relieved
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Chronic Illness and Chronic Care

Estimated 99M Americans live with chronic illness Most with >1 chronic illness
88% of >65yo have >1 chronic disease 25% of which have >4

Chronic illness accts for 75% national health care costs

Not just long-term conditions Co-morbidity Complexity Frailty

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And for the next steps..

Unlike Acute Illness.

Short-term Either die or get well
Influenza Pneumonia GI infections

Chronic Illness
Persists for a long time and is either incurable and/or results in pathological changes that limit normal functioning. Virtually everyone will eventually develop some type of chronic condition.

Differences between acute and chronic conditions

Acute disease Onset Duration Cause Diagnosis & prognosis Intervention Outcome Uncertainty Knowledge Abrupt Limited Usually single Usually accurate Usually effective Cure possible Minimal Prof.s - knowledgeable Patients - inexperienced Chronic Illness Generally gradual and insidious Lengthy and indefinite Usually multiple and changes over time Often uncertain Often indecisive; adverse effects common No cure Pervasive Prof.s and patients have complementary knowledge and experience

Chronic Diseases
HTN DM CHF OA COPD Cancer Mental Health Illness- depression/ dementia/ psychosis etc Chronic Infectious Diseases: HIV/AIDS, Hepatitis

Complexities of Chronic Illness

Impaired mobility Depression

Obesity

Diabetes Cardiovascular diseases

Cognitive impairment

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Biggest Worries About Having A Chronic Illness (Age 50 +)

1. Losing independence 2. Being burden to family or

friends
3. Affording medical care

The Increasing Burden of Chronic Illness

For example: Patients with diabetes have Additional Medical Problems * Functional Limitations ** > 2 Symptoms *** Poor Health Habits 45% 50% 35% 30%

* Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung (17%) ** Physical (31%), pain (28%), emotional (16%), daily activities (16%) *** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue (23%), foot (21%), backache (20%)

The Impact of Chronic Illness The Individual

Initial Impact
Shock Denial Loss and grief Anxiety and depression
20-25% experience psychological symptoms

If these reactions last too long, they can have an negative effect on the illness

The Impact of Chronic Illness The Individual

Must adjust to:
Symptoms of the disease Stress of Treatment Feelings of vulnerability Loss of Control Threat to self-esteem Financial Concerns Changes in family structure

The Impact of Chronic Illness - The Family

Must adjust to:
Increased stress Change in the nature of the relationship Change in family structure/roles Lost income

Different issues for different relationships

Adult children of ill parents Spouse of ill person Parents of ill children

Issues and trends in Chronic Care

Poverty Illiteracy Centralization & Fragmentation of Care Physician shortages concurrent with restrictions in use of nurse practitioners The Disease-Model of Care Prevention a minor expenditure in health care budget

..Glimmers of Hope
The Cancer, Kidney, Diabetes, & Heart & Stroke Associations working together Moves to develop true community clinics Concerted efforts to produce model of care that makes the best use of resources & improves access to relevant & effective care Government has identified priorities & improved collaboration

Chronic Care Model

Community
Resources and Policies SelfManagement Support

Health System
Health Care Organization Delivery System Design Clinical Information Systems

Decision Support

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Improved Outcomes

Model Development 1993 - Initial experience at GHC Literature review RWJF Chronic Illness Meeting -- Seattle Review and revision by advisory committee of 40 members (32 active participants) Interviews with 72 nominated best practices, site visits to selected group Model applied with diabetes, depression, asthma, CHF, CVD, arthritis, and geriatrics

Essential Element of Good Chronic Illness Care

Informed, Activated Patient

Productive Interactions

Prepared Practice Team

What is a productive interaction?

Informed, Activated Patient Prepared Practice Team

Productive Interactions

Assessment of self-management skills and confidence as well as clinical status Tailoring of clinical management by stepped protocol Collaborative goal-setting and problem-solving resulting in a shared care plan Active, sustained follow-up

Self-Management Support
Emphasize the patient's central role Use effective self-management support strategies that include assessment, goalsetting, action planning, problem-solving, and follow-up Organize resources to provide support

Delivery System Design

Define roles and distribute tasks amongst team members Use planned interactions to support evidencebased care Provide clinical case management services Ensure regular follow-up Give care that patients understand and that fits their culture

Decision Support
Embed evidence-based guidelines into daily clinical practice Integrate specialist expertise and primary care Use proven provider education methods Share guidelines and information with patients

Clinical Information System

Provide reminders for providers and patients Identify relevant patient subpopulations for proactive care Facilitate individual patient care planning Share information with providers and patients Monitor performance of team and system

Health Care Organization

Visibly support improvement at all levels, starting with senior leaders Promote effective improvement strategies aimed at comprehensive system change Encourage open and systematic handling of problems Provide incentives based on quality of care Develop agreements for care coordination

Community Resources and Policies

Encourage patients to participate in effective programs Form partnerships with community organizations to support or develop programs Advocate for policies to improve care

Chronic illness by SYSTEM

Physical Illness

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Osteoporosis (Porous Bones)

Disease process causing bones to become more fragile and likely to break Often progresses painlessly First symptoms may be broken bone, height loss, or curvature of the spine Any bone can be affected, but hip and spine are frequent sites
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National Osteoporosis Foundation www.nof.org/osteoporosis

Osteoporosis Risk Factors

Age:
Greater risk with aging, which Tends to cause bones to weaken and lose density

Gender:
Four times more common in women than men One in three women and one in 12 men over the age of 50
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Osteoporosis Risk Factors

Family History and Personal History of Fractures as an Adult:
Women whose mothers have a history of vertebral fractures seem to have reduced bone mass Personal history of a fracture as an adult

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Osteoporosis Risk Factors

Race
Caucasian and Asian women are more likely to develop osteoporosis African American and Hispanic women at significant risk

Bone structure and body weight

Small-boned and thin women (under 127 pounds)
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Osteoporosis Risk Factors

Lifestyle:
Cigarette smoking, alcohol abuse, consuming an inadequate amount of calcium or getting little or no weight-bearing exercise Medications Chronic Diseases (discuss with doctors)

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Bone Mineral Density (BMD) Test

Safe and painless test for osteoporosis Recommended for all women age 65 and over, and younger women at risk Often reimbursable by Medicare

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Prevention and Treatment

Diet Exercise Hormone replacement therapy (HRT) talk with the doctor to understand the risks

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Osteoarthritis
Cartilage surrounding joint breaks down Knees and hips most common sites, but may affect the back and fingers Those who overuse joints are at greater risk

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Rheumatoid Arthritis
Disease of the immune system affecting tissue surrounding the joint Can appear at any age, but most commonly diagnosed among women between the ages of 20 and 50 More rigorous drug therapy or surgery may be necessary

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Risk Factors for Arthritis:

Other Types of Arthritis Gout

Caused by a buildup of uric acid crystals in the fluid that bathes the joint; usually affects the big toe Causes severe pain and swelling in that joint

Certain foods Hormonal changes Heredity Gender Age

Ankylosing Spondylitis
Degeneration of the joints that support, and are part of, the spinal column
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Treatment

Often the symptoms of arthritis can be relieved by basic self-care practices

Adequate rest Stretching and daily ROM exercises Maintaining ideal weight Taking aspirin and ibuprofen Hot and cold treatments for minor discomfort Over-the-counter preparations containing capsicum, camphor, or menthol For more severe cases, corticosteroid 55 injections to fight inflammation

Call a doctor when

Pain is accompanied by fever Sudden unexplained swelling, redness or pain in any joint Pain is so great that use of the joint is lost Cannot use the joint or it limits regular activities If the problem does not improve after five to six weeks and home care is not working

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Assistive Devices

Canes Lid and jar rubber or synthetic openers Faucet turners Reachers/grabbers Flipper type door handles Extended handles on tools

Handout: Tools and Gadgets (Assistive Devices) For Independent Living

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Hypertension (Blood Pressure above 140/90)

Cause unknown If untreated, is related to development of arteriosclerosis If untreated, may cause stroke, heart attack, congestive heart failure, and/or kidney failure Treatment:
medication low salt diet exercise stress management weight management

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Signs and Symptoms of Stroke

American Stroke Association

Sudden onset of:

Numbness or weakness of face, arm or leg, especially on one side of the body Confusion, trouble speaking or understanding Trouble seeing in one or both eyes Trouble walking, dizziness, loss of balance or coordination Severe headache with no known cause Nausea, fever and vomiting distinguished from a viral illness by the speed of onset (minutes or hours vs. several days) Brief loss of consciousness or period of decreased consciousness (fainting, confusion, convulsions or coma)
TIA Transient Ischemic Attack ( small stroke )
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Treatment and Rehabilitation

Rehabilitation:
Physical therapy (PT) to restore physical functioning and skills like walking and range of movement Occupational therapy (OT) to relearn the skills needed for everyday living such as eating, toileting, dressing and taking care of oneself Speech/language therapy (ST)

Lifestyle:
Encourage use of affected extremity to increase muscle strength Avoid doing things for him/her that he or she can do Be supportive and sympathetic but firm and direct Expect some emotional ups and downs May need to install hand rails by toilet, bed, etc

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Aphasia
American Stroke Association
Stroke survivors, although able to think as well as before the stroke, may experience an interference in the use or understanding of language The individual is unable to get the right words out or is unable to process words coming in
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Responses and Support Be patient Allow the person time to understand and respond Use visual cues and gestures Use short, clear words Use visual aids Nod when understanding Allow person to write instead of speak

Signs and Symptoms of a Heart Attack

American Heart Association

Discomfort in the center of the chest that lasts more than a few minutes Discomfort in other areas of the upper body in one or both arms, the back, neck, jaw or stomach Shortness of breath accompanied by chest discomfort or can occur before the chest discomfort Breaking out in a cold sweat, nausea or lightheadedness

Response: Call 9-1-1; Start CPR if individual stops breathing (only if qualified) www.americanheart.org
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Women at Risk
American Heart Association

The risk of dying from a heart attack is higher for women than men As with men, women's most common heart attack symptom is chest pain or discomfort Women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain
Response: Call 9-1-1; Start CPR if individual stops breathing (only if qualified) www.americanheart.org
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The Red Dress was designed to build awareness that women are at risk; give a sense of hope that women can reduce their risk and empower them to do so; and provide a clear call to action coupled with a sense of urgency. The Heart Truth

Response Nitroglycerin tablet is placed under the tongue and allowed to dissolve Works in Angina one-half to three minutes Mild to severe chest pain which may radiate to the neck or shoulders, lasting less than three minutes Caused by some obstruction in a major blood vessel of the heart (arteriosclerosis) Brought on by exertion, cold, eating a heavy meal or excitement Management strategies: Losing weight, stopping smoking and managing stress

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Signs and Symptoms of Diabetes

American Diabetes Frequent urination Association

Excessive thirst Extreme hunger Unusual weight loss Increased fatigue Irritability Diabetes is expected to Blurry vision increase as much as 165% Itching over the next 50 years, Poor wound healing especially among those age 75 and older Stress such as infection or surgery may worsen symptoms

Caused when the body is unable to make use of sugars and starches Glucose accumulates in the blood and may appear in the urine

www.diabetes.org
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Diabetes Lifestyle and Treatment

Diabetes requires a life long focus Balanced diet on diet, lifestyle, and Controlled amounts of sugar and starch medical monitoring Weight management Exercise Insulin injections Oral medications Wear bracelet Good skin care, especially for the feet or necklace Daily blood sugar monitoring to alert responders to condition

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