Care of the Chronically Ill and the Older Persons

ELECTIVE 2BSN 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 Elements

Medical assessment Problem listComorbid conditions and disease severityMedication reviewNutritional status

Assessment of functioning Basic activities of daily livingInstrumental activities of daily livingActivity/exercise statusGait and balance

Psychological assessment Mental status (cognitive) testingMood/depression testing

Social assessment Informal support needs and assetsCare resource eligibility/financial assessment

Environmental assessment Home safetyTransportation and telehealth

CHRONIC ILLNESS IN ELDERLY

Wellness is the Goal at All Ages

SpiritualFaithMeaning in life

Emotional• Friendship• Connections to others• Sense of well being• Belonging to a family

and community

PhysicalNutritionExercise

MentalActivities and hobbiesProblem-solvingContinuing education

FinancialSecurityIndependenceFlexibility

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Age and Illness

• 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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Being an older adult,Does not mean being ill!

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

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Not just long-term conditions……

• Co-morbidity• Complexity• Frailty

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 Chronic Illness

Onset Abrupt Generally gradual and insidious

Duration Limited Lengthy and indefinite

Cause Usually single Usually multiple and changes over time

Diagnosis & prognosis

Usually accurate Often uncertain

Intervention Usually effective Often indecisive; adverse effects common

Outcome Cure possible No cure

Uncertainty Minimal Pervasive

Knowledge Prof.’s - knowledgeable Patients - inexperienced

Prof.’s and patients have comple-mentary knowledge and experience

Chronic Diseases

• HTN• DM• CHF• OA• COPD• Cancer• Mental Health Illness- depression/

dementia/ psychosis etc• Chronic Infectious Diseases: HIV/AIDS,

Hepatitis

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Complexities of Chronic Illness

Cognitive impairment

Obesity

Diabetes

Impaired mobility

Cardiovascular diseases

Depression

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

Additional Medical Problems * 45%

Functional Limitations ** 50%

> 2 Symptoms *** 35%

Poor Health Habits 30%

For example: Patients with diabetes have

* 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

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

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,ActivatedPatient

ProductiveInteractions

PreparedPractice

Team

• 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

Informed,Activated

PatientProductiveInteractions

PreparedPractice

Team

What is a productive interaction?

Self-Management Support

• Emphasize the patient's central role

• Use effective self-management support strategies that include assessment, goal-setting, 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 evidence-based 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

National Osteoporosis Foundationwww.nof.org/osteoporosis

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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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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

• Ankylosing Spondylitis • Degeneration of the joints that support, and

are part of, the spinal column

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Risk Factors for Arthritis:

Certain foodsHormonal changes

HeredityGender

Age

Treatment

• 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

injections to fight inflammation 55

Often the symptoms of arthritis can be relieved

by basic self-care practices

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

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Handout:

Tools and Gadgets (Assistive Devices)

For Independent Living

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”)

TIA – Transient Ischemic Attack (“small stroke”)59

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

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

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 61

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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• 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

Women at RiskAmerican Heart Association

Response: Call 9-1-1; Start CPR if individual stops breathing (only if qualified) www.americanheart.org

“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

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Angina

• 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

Response Nitroglycerin tablet is placed under the tongue and

allowed to dissolve Works in one-half to three minutes

Response Nitroglycerin tablet is placed under the tongue and

allowed to dissolve Works in one-half to three minutes

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Signs and Symptoms of Diabetes

American Diabetes Association• Frequent urination

• Excessive thirst• Extreme hunger• Unusual weight loss• Increased fatigue• Irritability• Blurry vision• Itching• Poor wound healing• 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

Diabetes is expected to increase as much as 165% over the next 50 years, especially among those age 75 and older

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Diabetes Lifestyle and Treatment

• Balanced diet• Controlled amounts of sugar and starch• Weight management• Exercise• Insulin injections• Oral medications• Good skin care, especially for the feet• Daily blood sugar monitoring

Diabetes requires

a life long focus

on diet, lifestyle, and

medical monitoring

Wear bracelet

or necklace to alert

responders to condition

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