Updating Your Knowledge about

Geriatric Nursing Care

Mary H. Palmer, PhD, RN, C FAAN, AGSF
Helen W. & Thomas L. Umphlet
University of North Carolina at Chapel Hill
Distinguished Professor in Aging, SON
Interim Co-Director Institute on Aging
Overview
Introduction to aging issues in the United States
Geriatrics Principles
Frailty (and disability and co-morbidity)
Dementia
Delirium
Falls
Urinary Incontinence
Anergia
Geriatric multidisciplinary competencies
Objectives
Identify geriatric principles to guide nursing
care
Discuss frailty phenotype and its implications
to the aging population and to nursing care
Discuss recent research findings on at least 2
geriatric conditions and prevalent geriatric
diseases


Objectives
Discuss geriatric competencies needed by
nurses to care for older adults

Identify geriatric resources available to nurse
educators
Less than 1% of nurses are certified in
geriatric nursing.

Nurses practicing in this country [US] today
are, by default, geriatric nurses
6
.

Geriatric Nursing
In the United States, people 65 and older:
represent 36% of hospital stays
1
represent 49% of all hospital days
2
had higher crude and adjusted morbidity and
mortality after emergency general surgery
3
take 1/3 of all prescribed medications
represent 88.1% of residents in the 16,100 nursing
homes nationally
4
who were residents in nursing homes between
January through June 2007, 14% had a prescription for
an atypical anti-psychotic medication
5


Sources:
1. Fulmer, 2001
2. Perry, 2002
3. Ingraham et al, 2011
4. http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf
5. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf
Demographic Profile: North Carolina
12% of NCs population is
age 65+ with nearly
150,000 age 85+
Projected to grow by 87%
of 2030
20
th
in the nation in the
projected growth rate of
the 85+ population
AARP. (2009). Long-Term Care in North Carolina. Retrieved from http://www.aarp.org
7
http://www.aging.unc.edu/nccoa/2010v
ideo/index.html
United States Aging Statistics

Global Aging
Geriatric Principles
Continuity of care
Bolstering home and family
Communication skills
Knowing the patient
Thorough assessment and evaluation
Prevention and health maintenance
Ethical decision making
Geriatric Principles
Inter-professional collaboration
Respect for the usefulness and value of elder
Cultural and diversity competence
Compassionate care
Helping disconnected family
End of life care
Cultural and diversity competencies

Source: Reichel, Arenson & Scherger (2010)
Ideals of Fitness
The Risks of Aging
Baby Boomers in the United States:
Physical Health
Baby Boomers are those born between 1946 and
1964

By the year 2030 (in less than 20 years):
14 million baby Boomers will have diabetes
Half of all Baby Boomers will have arthritis
Hip replacement surgery rates, currently at
700,000/year, will reach 3,500,000/year
Baby Boomers: Physical Health
16
Only one-third of Baby Boomers are satisfied
with their physical health
3/10 say their physical health is worse than they
expected
1 in 8 Baby Boomers will develop Alzheimers
Disease, the 5
th
leading cause of death in
people 65 years and over (source: Alzheimers
Disease Association)
By 2050 11 to 16 million Baby Boomers will
have Alzheimers Disease
Baby Boomers:
Physical Health
Obesity, arthritis, and
diabetes will lead to
mobility limitations
dependence on
others for ADLs
Baby Boomers: Cardiovascular health
40% of Baby Boomers already have
cardiovascular disease
35% have hypertension
55-60% have high cholesterol
Deaths from heart disease are expected to
increase 130% in 40 years (by 2050)
Physical Health
Adult Obesity Rates 2009
The Perfect Storm
Frailty, Disability, Co-morbidity
Frailty
Co-morbidity
Disability > 1 ADL
Source: Fried et al., 2001
Frailty versus Disability
Frailty multi-factorial, potentially
downward spiral
Disability may involve single deficits that
may be reversible Source: Fillitt & Butler, 2009
Activities of Daily Living (ADLs)
Disablement process Source: Verbrugge & Jette, 1994

Pathology Impairment Functional limitation Disability

Presence of Frailty
Positive frailty phenotype:

greater than 3 criteria present

Intermediate or pre-frail:

1 or 2 criteria present

Source: Fried et al., 2001
Frailty
By age 80 years, 40% of older adults have
functional impairments

6% to 11% are considered frail
United States estimate: 6.1% Source: DuBeau et al., 2009

Psychological effect of transition from robust
(independent) to frailty evolving identity,
looking glass self Source: Fillitt & Butler, 2009



Looking glass self old/young
http://asmp.org/articles/best-2010-hussey.html
Looking glass self old/young
http://asmp.org/articles/best-2010-hussey.html
Physical and Psychological Transitions
Frailty Phenotype Source: Fried et al., 2001
Shrinking

Weakness

Poor endurance:
exhaustion

Slowness

Low activity
Frailty: Vulnerable Elders Survey
Age
Self reported health
Physical activities (stooping, reaching, lifting,
writing, heavy housework, etc)
Shopping, managing money
Walking across a room
Light housework
Bathing or showering

Source: Saliba et al, JAGS 2001
Dementia
New Diagnostic Guidelines:
http://www.alz.org/research/diagnostic_criteria/
Clinical criteria for all cause dementia
1. Interferes with ability to function at work or usual
activities
2. Decline from previous levels of function
3. Not explained by delirium or major psychiatric
disorder
Clinical criteria for all cause dementia
(continued)
4. Cognitive impairment detected through history taking from
patient and knowledgeable informant and objective
cognitive assessment
5. Cognitive or behavioral impairment involves the minimum of 2
from following domains:
a. impaired ability to acquire or remember new
information
b. impaired reasoning and handling of complex tasks
c. impaired visuospatial abilities (for example, inability to
recognize faces)
d. impaired language functions
e. changes in personality, behavior, comportment
Mild Cognitive Impairment
Decline in memory, reasoning or visual perception
that's measurable and noticeable to themselves or to
others, but not severe enough to be diagnosed as
Alzheimer's or another dementia.
The new guidelines formalize an emerging consensus
that everyone who eventually develops Alzheimer's
experiences this stage of minimal but detectable
impairment, even though it's not currently diagnosed
in most people.
Not everyone with MCI eventually develops
Alzheimer's, because MCI may also occur for other
reasons.

Preclinical Dementia
Expansion of the conceptual framework for
thinking about Alzheimer's disease to include a
"preclinical" stage characterized by signature
biological changes (biomarkers) that occur
years before any disruptions in memory,
thinking or behavior can be detected.


Source: http://www.alz.org/documents_custom/Diagnositic_Recommendations_MCI_due_to_Alz_proof.pdf
Delirium
Also Known As: acute confusional state and
acute brain syndrome
Considered a medical emergency due to
underlying physical or mental disorder
Considered temporary and Reversible
Causes: electrolyte imbalances, medications,
infection (UTI or pneumonia), pain,
depression, surgery



Delirium Symptoms
Changes in alertness (more alert in am, less in pm)
Changes in level of consciousness or awareness
Changes in movement (slow moving OR hyperactive)
Changes in sleep patterns
Decrease in short-term memory and recall
Disorganized thinking
Emotional changes anger, apathy, agitation
Disrupted or wandering attention
Delirium Treatment
Control or reverse the cause of symptoms
Stop medications: analgesics (if possible), anticholinergics,
cimetidine, lidocaine. Consult Beers criteria
Treat anemia, hypoxia, heart failure, infections, kidney
failure, liver failure, nutritional disorders, depression,
thyroid disorders
If using meds to treat, start very low dose and adjust as
needed: antidepressants, dopamine blockers, sedatives,
thiamine.
Replace eyeglasses, hearing aids, teeth, treat pain, toilet,
sit up in chair
Reality orientation
Safety precautions
Urinary Incontinence: Definition
Urinary incontinence (UI) is the complaint
of any involuntary leakage of urine.
(International Continence Society, 2002)
Maybe Seldom Usually
Waking to pass urine at night
Variable Yes Often no
Ability to reach the toilet
following an urge
Variable Small
Large
(if present)
Amount of urinary leakage
Yes Yes No

Leaking during physical activity
Yes No Yes
Daytime Voiding Frequency
(>every 2 hours)
Yes No Yes
Urgency
Mixed
symptoms
Stress
incontinence
Overactive
bladder Symptoms
Differential Diagnosis:
OAB vs. SUI vs. Mixed UI
Abrams P, Wein AJ. THE OVERACTIVE BLADDER: A widespread and treatable condition. 1998;1-57.
Reversible Causes of Incontinence
Delirium
Restricted mobility (illness, injury, gait disorder,
restraint)
Infection (acute, symptomatic) Inflammation
(atrophic vaginitis) also impaction of stool
Polyuria (DM, caffeine intake, volume overload),
pharmaceuticals (diuretics, autonomic agents,
psychotropics)
Continence Two Years Prior to Death
Source: Covinsky et al., 2003
Sample Bladder Record
Date Time Urinated
in toilet
UI
episode
Reason
for UI
Bowel
movement
Fluid
intake
Behavioral Programs
Required skills:
Ability to comprehend and follow education
and instructions
Identify urinary urge sensation
Learn to inhibit or control urge to void
Kegel (aka: pelvic floor muscle exercises)
exercises

cms.internetstreaming.com
Risk factors for Incident Urinary
Incontinence in Hospitalized Elders
Risk Factor OR(95% CI) p-Value
Continence aids (reference: self-toileting)
Urinary catheter 4.26 (1.5311.83) .005
Adult diaper 2.62 (1.175.87) .02

Activities of daily living at admission (reference: independent)
Partially dependent 2.96 (1.018.71) .049
Dependent 3.27 (1.497.15) .003

** Adjusted for age, cognitive status, physical activity

Source: Zisberg et al., JAGS, 2011.

Only half of patients with incontinence tell
their health care provider about their
symptoms
Perceived as low priority by some primary
care providers
Result: underreported, undertreated
They Dont Tell, We Dont Ask
EDUCATE study. Morb Mortal Wkly Rep. 1995;44:747,753-754.
Branch LG et al. J Am Geriatr Soc. 1994;42:1257-1261.
Falls
Total Lifetime Medical Costs of Unintentional Fatal Fall-Related Injuries* in
People 65 Years and Older By Sex and Age, United States, 2005 (CDC)
*Lifetime medical costs refer to the medical costs (treatment and rehabilitation) associated with the fatal injury event

Falls and Hip Fractures
90% hip fractures are from falls
1

About one third of hip fracture patients developed
an acquired pressure ulcer (APU) after surgery
2

1 in 5 hip fracture patients die within a year of the
fall
1

Up to one in four of older adults who had been
independent before a hip fracture spend up to a year
in a nursing home after the fall
1

1. CDC, http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html
2. Baumgarten et al JAGS; 57:863-870, 2009
Source:http://latimesblogs.latimes.com/pho
tos/uncategorized/2008/09/09/cracks1.jpg
0
0.5
1
1.5
2
2.5
Any UI Urge UI Stress
UI
Mixed
UI
Odds of Falling
Chiarelli et al 2009
Mobility, balance, urine control before and
after 4 weeks of daily exercise

Before After
Walking distance* feet 50 73
Balance seconds 24 26
Speed inches/second 5.5 7.7
UI (7am-3pm) 2.3 1.0
UI (7am -10pm) 2.8 2.5

Source: Jirovec Int J Nurs Stud 1991
Assessment for Absorbent
Products
Assess residents;
Functional ability to ambulate, toilet, disrobe, use of
assistive devices
Ease in self-toileting
Assess product for:
Contain urinary leakage
Comfort
Ease of application/removal
cms.internetstreaming.com
Recent Research
Absorbent products are used to manage urinary
incontinence in acute care setting
1

Absorbent products are associated with
development of new urinary incontinence
1
Absorbent products are associated with skin
changes and increased risk of incontinence-
associated dermatitis (IAD)
2

Source: 1. Zisberg et al., JAGS, 2011.
2. Shigeta et al., OWM, 2010.
Anergia
Conceptually differs both from
fatigue, which is usually
measured post-exertion, and
from depression.


Anergia
Anergia defined as, sits around a lot for lack of
energy, and any two of six minor criteria:
recently not enough energy
felt slowed physically in past month
doing less than usual in past month
any slowness is worse in the morning
wakes up feeling tired
naps (> 2 hours) during the day

Source: Cheng, H., Gurland, B. & Maurer, M. Self-reported lack of energy (anergia)
among elders in a multi-ethnic community Journal of Gerontology: MEDICAL SCIENCES
2008, 63A
Anergia
39% heart failure patients reported anergia
1

Older adults with urinary incontinence 2x
more likely than continent to report anergia
2

Anergia was associated with new cases of
urinary incontinence in longitudinal study
2

1 Maurer, M., Cuddihy, P., Weisenberg, J. (et. Al. (2009). Journal of Cardiac Failure, 15(2), 145-151.
2 Cheng, H., Gurland, B. & Maurer, M. (2008).. Journal of Gerontology: MEDICAL SCIENCES, 63A(7), 707-714
Depression
The CES-D-SF is a 10 item 4-point Likert-type
depression assessment scale.
Sleep
Emotions
Hopefulness
Concentration
Effort
Heart Failure Prevalence
Prevalence of heart failure by sex and age (National Health and Nutrition Examination
Survey: 20052008). Source: National Center for Health Statistics and National Heart, Lung,
and Blood Institute. [http://circ.ahajournals.org/cgi/content/full/123/4/e18/F91]
[Roger, V. L. et al. Circulation 2011;123:e18-e209]
Heart Failure Quick Facts
One quarter HF patients are > 80 years
old
More than half have 5 or more comorbid
condition
More than half are mobility disabled
Polypharmacy, > 50% 6+ medications



Source: Wong, Chaudhry, Desai et al., (2011). American Journal of Medicine, 124:136-143.
Correlates of
Diabetes
Obesity
MI
Hypertension
Age
Race
Diabetes
Obesity

Hypertension
Age

Heart Failure Urinary Incontinence
Unifying Model of Shared Risk Factors
Source: Inouye et al., 2007
Multidisciplinary Competencies
Health Promotion and Safety
Evaluation and assessment
Care planning and coordination of care across
the care spectrum
Interdisciplinary and team care
Caregiver support
Healthcare systems and benefits
Emerging Issues
Need more who understand and can practice
geriatrics
New concepts (anergia) with clinical
implications
New complex conceptual models about
treatment of geriatric conditions
Geriatric competencies
Geriatric resources

Geriatric Resources
Professional Organizations:
American Nurses Association:
www.Geronurseonline.org
American Geriatrics Society:
http://www.americangeriatrics.org/
Gerontological Society of America:
http://www.geron.org/
Journals:
Journal of the American Geriatrics Society (JAGS)
Geriatric Nursing
Journal of Gerontological Nursing