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Care of the Chronically Ill and
the Older PersonsELECTIVE 2BSN 14B
July 20, 2011
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Risk factors associated in
Chronic Illness in elderly
Modifiable/non-modifiable
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Risk factors: Modifiable
Lifestyle
Smoking
Poor nutritionPhysical inactivity
Failure to use preventive and screening
services
Coping styles, stress
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Risk factors: Non-modifiable
Age
Pre-existing conditions
Long term medication
Hereditary
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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
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Comprehensive Geriatric
Assessment
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Comprehensive Geriatric
Assessment A multidimensional, interdisciplinary
diagnostic process to determine the:
MedicalPsychological
Functional capabilities of a frail elderly
person
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Comprehensive Geriatric
AssessmentPurpose
Develop a coordinated and integrated plan
for treatment and long-term follow-up Achieve quality and functional status of life
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Comprehensive Geriatric
AssessmentPurpose
Determine prognosis and outcome of care
Employment of interdisciplinary teams Utilize standardized instruments to
evaluate aspects of patient functioning,
impairments, and social supports
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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
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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
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COMPONENTS OF
COMPREHENSIVE ASSESSMENT
Component Elements
Medical assessment Problem list
Comorbid conditions and disease severity
Medication review
Nutritional status
Assessment of functioning Basic activities of daily living
Instrumental activities of daily living
Activity/exercise status
Gait and balance
Psychological assessment Mental status (cognitive) testing
Mood/depression testing
Social assessment Informal support needs and assets
Care resource eligibility/financial assessment
Environmental assessment Home safety
Transportation and telehealth
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CHRONIC ILLNESS IN
ELDERLY
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Wellness is the Goal at All Ages
Spiritual
Faith
Meaning in life
EmotionalFriendship
Connections to others
Sense of well being
Belonging to a family
and community
Physical
Nutrition
Exercise
Mental
Activities and hobbiesProblem-solving
Continuing education
Financial
Security
IndependenceFlexibility
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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 maybe corrected or relieved
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Being an older adult,Does not mean being ill!
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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% nationalhealth care costs
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Not just long-term conditions
Co-morbidity
Complexity
Frailty
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And for the next steps..
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Unlike Acute Illness.
Short-term
Either die or get
well Influenza
Pneumonia
GI infections
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Chronic Illness
Persists for a long
time and is either
incurable and/orresults in
pathological
changes that limit
normal functioning.
Virtually everyone
will eventually
develop some typeof chronic
condition.
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Differences between acute and
chronic conditionsAcute disease Chronic Illness
Onset Abrupt Generally gradual and insidious
Duration Limited Lengthy and indefiniteCause Usually single Usually multiple and changes over
time
Diagnosis &
prognosis
Usually accurate Often uncertain
Intervention Usually effective Often indecisive; adverse effectscommon
Outcome Cure possible No cure
Uncertainty Minimal Pervasive
Knowledge Prof.s - knowledgeable
Patients - inexperienced
Prof.s and patients have comple-
mentary knowledge and experience
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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
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BiggestWorries About Having A
Chronic Illness (Age 50 +)
1. Losing independence
2. Being burden to family or
friends
3. Affording medical care
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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%)
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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 toolong, they can have an
negative effect on the
illness
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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
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The Impact of Chronic Illness - The
Family
Must adjust to:
Increased stress
Change in thenature 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
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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
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..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
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Informed,
ActivatedPatient
Productive
Interactions
Prepared,
ProactivePractice Team
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources and
Policies
Community
Health Care Organization
Chronic Care Model
Improved Outcomes
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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, sitevisits to selected group
Model applied with diabetes, depression, asthma,
CHF, CVD, arthritis, and geriatrics
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Essential Element of Good
Chronic Illness Care
Informed,Activated
Patient
ProductiveInteractions
PreparedPractice
Team
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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
PatientProductive
Interactions
Prepared
Practice
Team
What is a productive interaction?
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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
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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 fitstheir culture
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Decision Support
Embed evidence-based guidelines into
daily clinical practice
Integrate specialist expertise and primarycare
Use proven provider education methods
Share guidelines and information withpatients
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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
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Community Resources and
Policies Encourage patients to participate ineffective programs
Form partnerships with communityorganizations to support or develop
programs
Advocate for policies to improve care
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Chronic illness by SYSTEM
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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 Foundation
www.nof.org/osteoporosis44
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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 thanmen
One in three women and one in 12 menover the age of 50
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Osteoporosis Risk Factors
Family History and Personal History ofFractures as an Adult:
Women whose mothers have a history of
vertebral fractures seem to have reducedbone mass
Personal history of a fracture as an adult
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Osteoporosis Risk Factors
Race
Caucasian and Asian women are morelikely to develop osteoporosis
African American and Hispanic women atsignificant risk
Bone structure and body weight
Small-boned and thin women (under 127pounds)
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Osteoporosis Risk Factors
Lifestyle:
Cigarette smoking, alcohol abuse,
consuming an inadequate amount ofcalcium or getting little or no weight-bearingexercise
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 mostcommonly 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; usuallyaffects the big toe
Causes severe pain and swelling in thatjoint
Ankylosing Spondylitis Degeneration of the joints that support, and
are part of, the spinal column
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Risk Factors for Arthritis:
Certain foods
Hormonal changes
Heredity
Gender
Age
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Treatment
Adequate rest
Stretching and daily ROM exercises
Maintaining ideal weight
Taking aspirin and ibuprofen
Hot and cold treatments for minordiscomfort
Over-the-counter preparations containingcapsicum, camphor, or menthol
For more severe cases, corticosteroid
injections to fight inflammation55
Often the symptoms of
arthritis can be relieved
by basic self-care practices
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Call a doctor when
Pain is accompanied by fever
Sudden unexplained swelling, redness or pain inany 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 sixweeks 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
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Hypertension
(Blood Pressure above 140/90)
Cause unknown
If untreated, is related to development of arteriosclerosis
If untreated, may cause stroke, heart attack, congestiveheart failure, and/or kidney failure
Treatment: medication
low salt diet
exercise
stress management weight management
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Signs and Symptoms of StrokeAmerican Stroke Association
Sudden onset of: Numbness or weakness of face, arm or leg, especially on one sideof 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 thespeed of onset (minutes or hours vs. several days)
Brief loss of consciousness or period of decreased consciousness
(fainting, confusion, convulsions or coma)
TIA Transient IschemicAttack (small stroke)
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T t t d R h bilit ti
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Treatment and Rehabilitation
Rehabilitation:
Physical therapy (PT) to restore physical functioning and skills likewalking and range of movement
Occupational therapy (OT) to relearn the skills needed foreveryday living such as eating, toileting, dressing and taking careof 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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AphasiaAmerican 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 abletothink as well asbeforethestroke,
may experience aninterferenceintheuseorunderstanding oflanguage Theindividualis unable
to gettherightwordsoutorisunableto processwordscoming in
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Si d S t f H t Att k
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Signs and Symptoms of a Heart AttackAmerican Heart Association
Discomfort in the center of the chest that lastsmore than a few minutes
Discomfort in other areas of the upper body inone or both arms, the back, neck, jaw or stomach
Shortness of breath accompanied by chest
discomfort or can occur before the chestdiscomfort
Breaking out in a cold sweat, nausea orlightheadedness
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 ishigher for women than men
As with men, women's most commonheart attack symptom is chest pain ordiscomfort
Women are somewhat more likely thanmen to experience some of the othercommon symptoms, particularlyshortness 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 aclear 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 theheart (arteriosclerosis)
Brought on by exertion, cold, eating a heavy meal or
excitement
Management strategies: Losing weight, stopping smokingand managing stress
Response Nitroglycerin tabletis placed under the tongue and
allowed to dissolve Works in
one-half to three minutes
Response Nitroglycerin tabletis placed under the tongue and
allowed to dissolve Works in
one-half to three minutes
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A i Di b t
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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 surgerymay 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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