Evidence-Based Care for Older Adults: What Every Clinical Instructor Should Know!

1. Evidence-Based Care for Older Adults: What Every Clinical Instructor Should Know! Eleanor S. McConnell, RN, PhD, APRN, BC Duke University School of NursingCenter of Excellence in Geriatric Nursing Education Durham VA Geriatric Research, Education and Clinical Center Duke Center for the Study of Aging and Human Development August 26, 2010

2. Goals: • Illuminate challenges & opportunities for improving elder care • Showcase linkages between research, practice improvement & education • Highlight opportunities for Clinical Instructors to support current efforts in practice improvement

3. Three critical issues: • Aging & chronic disease  atypical presentation & increased complexity • Tradition-based care denies access to care that can preserve function & save lives • Current practices put older adults at risk..every day!

4. You know this story won’t end well….. • “But three days later, unable to cope with a complicated wound care regimen, he landed back in the hospital. • “My father had become part of a notorious trend. • “Discharge from the hospital is a critical point in a patient’s recovery…The process is supposed to be carefully planned, but instead it often is rushed and poorly coordinated, resulting in complications that send patients back to the emergency room. “

5. No one is Satisfied with the Status Quo • Resources: • AARP: http://assets.aarp.org/rgcenter/health/beyond_50_hcr_1.pdf • National Transitions in Care Coalition • http://www.ntocc.org/ • Centers for Medicare and Medicaid Services (CMS) Quality Improvement Resources (QIOSC) • http://www.cfmc.org/caretransitions/

6. The Cost of a Long Life U.S. UC Project for Global Inequality Slide Courtesy of Rob Califf, Durham Health Summit, 2009

7. Geriatric Syndromes: An Introduction New vocabulary & science(!) for old problems

8. Who makes you worry? 85 y.o. marriedwoman admitted for a diverticular bleed 81 y.o. married woman admitted for a diverticular bleed OR

9. Adults > 80 Are at Greatest Risk for Untoward Health Outcomes %(+) Live alone 44 % of poor living alone 79 Have dementia 5 Live in a NH 5 All Older Women Women over 80 % (+) Live alone 65 % of poor living alone >80 Have dementia 30 Live in a NH 26 Source: Mezey, M. 2005 – Duke Carolina Visiting Professorship in Geriatric Nursing

10. Age: Often the tip of the iceberg! Until you assess, you have no clue whether the 80-something person you are caring for will have “smooth sailing” or a rocky ride!

11. Mrs. A v. Mrs. B Other problems include: Urinary incontinence S/P Hip fracture 2008 Lives in retirementcommunity 83 y.o. married woman admitted for a diverticular bleed 83 y.o. married woman admitted for a diverticular bleed Other problems include: • Hypertension • Diabetes • Lives with daughter Who makes you worry? What makes you worried?

12. Geriatric Syndromes: Examples: Delirium Falls Failure to thrive (malnutrition) Urinary incontinence Challenges: Multiple risk factors & causal pathways Associated with increased morbidity, dysfunction, increased complexity of care Opportunity: Many of risk factors sensitive to nursing care Increasing evidence that we can prevent or treat Clinical conditions common in older adults that do not fit neatly into a disease category

13. Geriatric Syndromes Tuberculosis Autism Idiopathic Heart Failure Parkinson’s Disease Delirium & Falls..OR Falls &Delirium Source: Inouye, Studenski, Tinetti, (2007) JAGS 55: 780-91

14. Lower GI Bleed

15. Treatment of Diverticular Bleed Transfusion with Benadryl & APAP Volume overload& CHF Bowel Prep Benzodiazepines

16. Follow along with me….

17. Mrs. A v. Mrs. B – Day 2 New problems: Indwelling catheter On rounds, trying to getto bathroom unassisted Had near fall 83 y.o. • Married • LGI Bleed • Hip fx 2008 • UI -- stress 83 y.o. • Married • LGI Bleed • Hypertension • Diabetes New problems: • Dyspneic, crackles • Seems confused Now who makes you worry?

18. Geriatric Syndromes: Emerging Evidence Base….. Source: Inouye, Studenski, Tinetti, (2007) JAGS 55: 780-91

19. Mrs. A v. Mrs. B – Day 3 New problems: Fever On rounds, found lying on floor in Bathroom, catheter disconnected No apparent injury 83 y.o. • Married • LGI Bleed • Hip fx 2008 • UI -- stress 83 y.o. • Married • LGI Bleed • Hypertension • Diabetes New problems: • Poor appetite • Hypoglycemic episodes • Doesn’t want to participate in care Now who makes you worry?

20. Follow along with me

21. Mrs. A v. Mrs. B – Day 4 Status: Home to retirement community’s infirmary/SNF How do you think she will do? What concerns do you have? 83 y.o. • married • LGI Bleed • Hip fx 2008 • UI -- stress 83 y.o. • married • LGI Bleed • Hypertension • Diabetes Status: • GI Bleed stopped • Contact daughter: prepareto go home • How do you think she’ll do? Now who makes you worry?

22. For What Geriatric Syndromes are they at Risk?

23. Linking Geriatric Syndromes with Normal Aging

24. Risk for Poor Outcomes among Older Adults Geriatric syndromes associated with poor outcomes Geriatric syndromes have many preventable components Adverse drug events Prevention of dehydration and volume overload Management of co-morbid chronic disease in acute care Much of geriatric syndrome prevention involves nursing care or nursing practice Evidence-base for prevention growing steadily… We can’t afford to wait 20 years to get it implemented! Where do you see your opportunity for influence? Key Ideas….

25. What about Care Transitions? Is there an evidence-base for care improvement?

26. Readmission Rates Decrease with Comprehensive Discharge Planning + Post-discharge Support Relative Risk 2 0.5 1.0 Intervention Control Phillips CO et al. JAMA 2004;291:1358-67. Source: http://www.ntocc.org/Home/PolicyMakers/WWS_PM_Tools.aspx

27. Naylor– Transitional Care ModelUniversity Pennsylvania– NIH-funded • Core elements: • APN with specific competencies • Use of routine visit schedule in-hospital and in-home with interventions targeted implementing EBPs • Structured plan of communications with MDs & family • Continuity of provider Website: www.transitionalcare.info

28. 1 Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly MV. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006. 2 Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620. 3 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684. Slide Courtesy of Dr. Mary Naylor 2010

29. What is the quality of evidence?

30. Implications for Clinical Instructors • Model an Evidence-Based Practice Approach • Connect:http://coegne.nursing.duke.edu • Engage: Look for Geriatric resource Nurses: NICHE