Challenges in Caring for the Elderly Adult

1. Challenges in Caring for the Elderly Adult The Frail Older Adult Care at the End of Life

2. The complexity of the frail older adult and comorbidities

3. Failure to thrive • Weight loss of >5% of baseline • Poor appetite and nutrition • Dehydration • Immobility • Depression • Impaired immune function • Low cholesterol levels

4. “Frailty” Presence of 3 or more of the following: • Unplanned weight loss (10 lb in past year) • Weakness • Poor endurance and energy • Slowness • Low activity

5. Consequences of frailty • Progressive physiological decline • Chronic illness • Loss of organ function • Recurrent acute illness

6. Risks of frailty

7. Social risks of frailty • Poverty • Social isolation • Functional decline • Cognitive decline

8. Comorbidities: the cumulative effect of chronic conditions and diseases

9. The “geriatric cascade”

10. Strategies: meeting the needs of hospitalized elderly • Diagnose all vague symptoms and complaints accurately • Treat all relevant diseases • Assess effect of current changes in health status • Consider effect of acute illness on chronic disease • Prevent complications of hospitalization

11. Health Trajectory • Trajectory: the path of a moving object through space • Also applies as a model for understanding the eventual course of one’s health status throughout time until death This is the way the world ends This is the way the world ends This is the way the world ends Not with a bang but a whimper. —T.S.Eliot, The Hollow Men (1925)

12. Influences on the Health Trajectory Direct Influences • Genetics • Environment • Wear and tear • Nutrition • Stress • Disease Indirect Influences • Social relationships • Education • Finances • Response to age-related changes

13. Chronic Conditions • More than 50% of persons over 40 years of age have at least 1 chronic condition • More than 80% of non-institutionalized persons over 65 years of age have at least 1 chronic condition • Therefore, health care for the elderly should be oriented toward care of chronic disease regardless of the person’s age • Health care should emphasize: • Improving function • Postponing deterioration and disability • Preventing complications

14. Goals of Chronic Care Nursing • Maintain or improve self care capacity • Effective disease management • Enhance body’s healing abilities • Prevent complications • Delay deterioration and decline • Promote highest possible quality of life • Ensure death with dignity and comfort

15. Effect of Chronic Disease on the Health Trajectory • After each acute episode, patients are left with greaterfunctional deficit or increased problems. • The episodes become increasingly frequent andrefractory to treatment as the patient nears the end of life. • Recognition of a pattern enables those at risk of imminentdeath to be managed more appropriately. • The patient will then have the chancethat most (but not all) patients prefer… to plan and preparefor death, together with their families.

16. Measuring Success in Chronic Care • Use short term goals that are evaluated throughout the trajectory of the disease

17. Disease Trajectory • Each disease, be it acute or chronic, has its own trajectory • The disease trajectory influences the individual’s health trajectory HEALTH DISEASE

18. Disease Trajectory Patterns • Evaluation occurs at each point of change in the trajectory • Goals and interventions are modified to permit change in patient baseline status

19. Factors of treatment decisions • Preferences of patient, preferences of family • Minimize burden to patient if chance of success is reasonable • Allocation of resources to those most likely to benefit • Should not be delivered to alleviate guilt or distress of family

20. Decisions for elderly hospitalized patients • What are our goals of care? • How will we achieve those goals? • Agreement among patient and family members • Agreement on code status

21. Possible levels of care • Aggressive care • Patient has high functioning, satisfactory quality of life • Goal: extension of life • Modified care • Frailty or comorbidities, but likely to respond to treatment • Goal: extension of life considering burden of treatment • Palliative care • Can be delivered with aggressive or modified care or by itself • Goal: patient comfort and quality of life • Life extension is secondary • Hospice care • A type of palliative care for final months or weeks • Patient has life expectancy of 6 months or less • Goal: comfortable death

22. Characteristics of palliative care • Focuses on relieving and preventing the patient’s suffering • Appropriate for patients in all disease stages: • Patients undergoing treatment for curable illnesses • Patients living with chronic diseases • Patients nearing the end of life • Uses a multidisciplinary approach to patient care • Addresses the physical, emotional, spiritual, and social concerns of advanced illness

23. Dying is natural and inevitable • Dying is an inevitable part of living • Helping the dying patient and family find comfort and meaning in the dying experience is often more important than correcting physiological problems

24. Enhancing dignity of the dying patient • Allow patient and family to maintain control • Encourage participation in end-of-life care • Prevent and relieve distress • Physical • Emotional • Spiritual • Know local laws and institutional policies • Living wills • Durable power of attorney • Resuscitation • Specific treatment

25. Principles of providing end of life care • Maintain communication among patient, family, staff • Display sensitivity to specific beliefs • Alleviate pain, promote comfort • Manage psychological, social, and spiritual concerns • Continuous collaboration • Promote access to palliative and hospice care • Respect right to refuse care

26. Importance of patient preferences • Value of quantity of life over quality • Acceptance of pain or disfigurement • Is there perceived value in curative, rehabilitative or preventive care? • Supportive care may be only realistic choice • Plan of care does not terminate • Account for • Patient’s goals • Limits imposed by illness

27. Importance of symptom control • Physical and mental distress commonly experienced by patients with terminal illness • Fear that discomfort cannot be controlled • Relief of discomfort and reassurance that effective treatment is available • Enables living life as fully as possible • Able to focus on unique issues associated with the approach of death

28. Treatment monitoring • Symptoms can have many causes • Patients respond differently as deterioration progresses • Altered drug metabolism likely to occur

29. Pain • About half of patients dying of cancer have severe pain • About half of these receive adequate relief • Often pain is due to: Misconceptions on parts of physicians and patients regarding: • Pain • Drugs used to control pain

30. Treatment must be individualized • Patients perceive pain differently • Fatigue • Insomnia • Anxiety • Depression • Nausea • Supportive environment can help control pain

31. How to chose the best pain medication • What is most available? • Least invasive route • Depends on pain intensity • Analgesics should be given routinely rather than as needed

32. How to give pain medication • Controlling pain after it occurs is more difficult than preventing it • Pain generates anxiety • In hospice situations, nurses, patients and family members can become competent at making dosing or scheduling adjustments

33. Alternative pain-modification techniques • Hypnosis • Guided mental imaging • Counseling for stress and anxiety • Relaxation methods

34. Dyspnea • One of the most feared and most distressing symptoms • Cause should be treated • Dyspnea symptoms are suppressed when physiologic cause cannot be relieved • Demerol (less frequently) • Morphine • Oxygen may be psychologically comforting to patient and family even when not physiologically beneficial

35. Breathlessness • Opioid can slow respirations • Relieve mild chronic symptoms • Allows more comfortable sleep • Morphine 2.5 mg IV every 2 to 4 hours • Morphine may be given by continuous drip or bolus

36. Anorexia • Usually more distressing to family members • Counseling may be necessary for family members to accept anorexia • The patient has “more important things to do” • Tube feedings, parenteral nutrition likely futile

37. Increasing food intake • Small portions if full tray is overwhelming • Specially prepared foods • Flexible meal schedule • Small amount of alcoholic beverage 30 minutes before meals • Foods with strong flavors or smells • Medications • Corticosteroids (dexamethasone) • Antidepressants • Metochlopramide • Megace (progestin) • Marinol (cannabinoid)

38. Tube feedings and parenteral nutrition • Used rarely • Discontinuation may be difficult to accept • Food and fluid symbolize nurturing and caring • Inform family members that dying patient may be more comfortable without artificial administration of food and water • Easy-to-swallow foods may be more appropriate: • Sherbet • Gelatin

39. After decision to forgo artificial administration of food and water… • Supportive care imperative • Good oral hygiene • Brushing teeth • Swabbing oral cavity • Applying lip salve • Ice chips for dry mouth • Physically and psychologically comforting care for family to provide

40. Nausea and vomiting Potential causes • Constipation • Reduced gastric emptying • Bowel obstruction • Central opioid effects • Increased intracranial pressure (ICP) • Gastritis • Peptic ulcer • Hypercalcemia • Uremia • Toxic drug effects

41. Treatment of nausea and vomiting • Phenothiazines act on chemoreceptor zone in the medulla, e.g., prochlorperazine (also an anxiolytic, trade Compazine, et al.) • Metochlopromide (Trade Reglan) • If near death, conservative treatment without relief of obstruction

42. Constipation • Often underestimated by physicians • Give stool softener first • Should give laxatives prophylactically • Stimulant/laxative should be given if patient is being given opioids

43. Confusion • Common causes • Drug therapy • Hypoxia • Metabolic disturbances • Intrinsic CNS disease • Confusion is treated if cause can be determined • Withholding treatment for confusion may be preferable if • Patient is comfortable • Patient less aware of surroundings

44. Medications—confusion • Sedatives (benzodiazepines, e.g., Librium, Valium, Xanax) • Risperdone (trade Risperdal)—produces changes in chemicals in the brain, generally used for schizophrenia, bipolar disease, autism in children) • Olnazapine (trade Zyprexa)— generally useful in schizophrenia and bipolar disease

45. Insomnia • Symptom, not a diagnosis • Depression and anxiety are the leading causes • Also: • Trazodone 25 to 50 mg at bedtime (antidepressant) • Hypnotic (zolpidem [Ambien]) at bedtime • May also try: meditation, relaxation techniques, deep breathing exercises, relaxation tapes

46. Hastening death • Most medical actions perceived as hastening death are based on the need for relieving pain • Physician must inform patient and family that such actions may shorten life • Should be clear that treatment is for pain and symptom relief and not for causing death • Myth: “Good pain management rarely shortens life and may extend it.” • Assisting with suicide is a criminal act in most states…including California.

47. Death determination • Should be made by a physician • Sometimes made by Nurses in the absence of a physician • Determination should be made as soon as possible • Ensure psychological and spiritual needs of family are met • Comfortable environment • Arranging for someone to be with body when family visit can be helpful • Notify clergy or funeral home • Reassure family patient was comfortable • Contact family a few weeks later for follow up