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

Eleanor S. McConnell, RN, PhD, APRN, BCDuke University School of Nursing

Center of Excellence in Geriatric Nursing EducationDurham VA Geriatric Research, Education and Clinical CenterDuke Center for the Study of Aging and Human Development

August 26, 2010

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

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!

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. “

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/

No one is Satisfied with the Status Quo

UC Project for Global InequalityUC Project for Global Inequality

The Cost of a Long LifeU.S.

Slide Courtesy of Rob Califf, Durham Health Summit, 2009

Geriatric Syndromes: An Introduction

New vocabulary & science(!) for old problems

Who makes you worry?

85 y.o. married woman admitted for a diverticular bleed

OR

81 y.o. married woman admitted for a diverticular bleed

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 WomenAll Older WomenAll Older WomenAll Older Women

Source: Mezey, M. 2005 – Duke Carolina Visiting Professorship in Geriatric Nursing

% (+)

Live alone 65

% of poor living alone >80

Have dementia 30

Live in a NH 26

Women over 80Women over 80Women over 80Women over 80

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!

Mrs. A v. Mrs. B

Other problems include: Urinary incontinence S/P Hip fracture 2008 Lives in retirement

community

83 y.o. married woman admitted for a diverticular bleed

Other problems include: Hypertension Diabetes Lives with daughter

83 y.o. married woman admitted for a diverticular bleed

Who makes you worry? What makes you worried?

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

Geriatric Syndromes

Source: Inouye, Studenski, Tinetti, (2007) JAGS 55: 780-91

Idiopathic Heart Failure

Tuberculosis

Parkinson’s Disease

Autism

Delirium & Falls..OR Falls &Delirium

Lower GI Bleed

Treatment of Diverticular BleedTransfusion

with Benadryl & APAPVolume overload

& CHF

Bowel Prep

Benzodiazepines

Follow along with me….

HD 1 HD 2 HD3 HD4--n

Events Admitted

IVF &

Blood

Colonoscopy Prep

Colonoscopy Recovery

Risk factors

Age

Comorbidity

Transfusion

Dehydration

Medication SE

Mrs. A 83

UIs/p Hip Fx

Mrs. B 83

HBPDM

Mrs. A v. Mrs. B – Day 2

New problems: Indwelling catheter On rounds, trying to get

to bathroom unassisted Had near fall

83 y.o. Married LGI Bleed Hip fx 2008 UI -- stress

New problems: Dyspneic, crackles Seems confused

83 y.o. Married LGI Bleed Hypertension Diabetes

Now who makes you worry?

Geriatric Syndromes: Emerging Evidence Base…..

Source: Inouye, Studenski, Tinetti, (2007) JAGS 55: 780-91

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

New problems: Poor appetite Hypoglycemic episodes Doesn’t want to

participate in care

83 y.o. Married LGI Bleed Hypertension Diabetes

Now who makes you worry?

Follow along with meHD 1 HD 2 HD3 HD4--n

Events Admitted

IVF &

Blood

Colonoscopy Prep

Colonoscopy

Recovery

Beneath the surface

Benadryl

Volume overload?

Dehydrdation Benzo-diazepine

Nutrition

Mobility

Co-morbidity

Delirium sequelae

Mrs. AHip Fx ‘08

Mrs. B

DM

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

Status: GI Bleed stopped Contact daughter: prepare

to go home How do you think she’ll do?

83 y.o. married LGI Bleed Hypertension Diabetes

Now who makes you worry?

For What Geriatric Syndromes are they at Risk?

HD 1 HD2 HD3 HD4--nEvents Admitted

IVF & Blood

Colonoscopy Prep

Colonoscopy Recovery

4. Delirium 1. Blood loss

2. Low Hgb

3. Drug SE

7. Volume loss

12. Drug #2 side effect + 7

13. Transfer

8. Falls & dysmobility

1, 3, 4 1,3,4, 7 4, 7, 12 4, 6, 9, 11, 1213

9.Malnutrition

5. NPO 5 4, 7, 12 4, 6, 9, 10, 11, 12

10. Pressure Sores

6. Bed rest+ 4, 5

4, 7, 9, 12 4, 6, 8, 9, 10, 11, 12

11. Urinary Incontinence

1, 3, 4 3, 4, 8 3, 4, 8, 12 4, 6, 8, 12, 13

Linking Geriatric Syndromes with Normal Aging

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….

What about Care Transitions?

Is there an evidence-base for care improvement?

Readmission Rates Decrease with Comprehensive Discharge Planning + Post-discharge Support

Phillips CO et al. JAMA 2004;291:1358-67.

0.5

1.0

2Intervention Control

Relative RiskStrategyStrategy

InterventionIntervention

Events/Events/

Total Total

ControlControl

Events/Events/

TotalTotal

RRRR

(95% CI)(95% CI)

Single home Single home visitvisit 95/23395/233 129/243129/243 0.76 (0.63-0.93)0.76 (0.63-0.93)

Clinic follow-Clinic follow-up +/- phone up +/- phone 151/370151/370 161/395161/395 0.64 (0.32-1.28)0.64 (0.32-1.28)

Home visit +/- Home visit +/- phonephone 168/437168/437 262/533262/533 0.79 (0.69-0.91)0.79 (0.69-0.91)

Extended Extended home carehome care 132/438132/438 152/421152/421 0.82 (0.68-1.00)0.82 (0.68-1.00)

TotalTotal 555/1590555/1590 741/1714741/1714 0.75 (0.64-0.88)0.75 (0.64-0.88)

Source: http://www.ntocc.org/Home/PolicyMakers/WWS_PM_Tools.aspx

Naylor– Transitional Care ModelUniversity Pennsylvania– NIH-funded

Website: www.transitionalcare.info

Core elements:

1. APN with specific competencies

2. Use of routine visit schedule in-hospital and in-home with interventions targeted implementing EBPs

3. Structured plan of communications with MDs & family

4. Continuity of provider

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

What is the quality of evidence?

Implications for Clinical Instructors

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