Care of the Complex Older Adult with Multimorbidity

Care of the Complex Older Adult with Multimorbidity

Care of the Older Adult with Complex, Multimorbidity Cynthia Gerstenlauer, ANP-BC, GCNS-BC, CDE, CCD Nurse Practitioner, Troy Internal Medicine Disclosures Ms. Gerstenlauer has no disclosures Learning Outcome: The learner will develop an effective patient-centered approach to care of the older adult with complex, multimorbidity, in order to assess and improve function, enhance quality of life, and facilitate the appropriate deliver of health care services This shortfall will place the chronic care of the older adult in the hands of internists, family physicians, nurse practitioners, and physician assistants. As front-line providers in the care of the elderly, these clinicians will need to develop skills in assessment and management of multiple chronic conditions in a single individual and in the recognition, assessment, and management

of geriatric syndromes such as falls, urinary incontinence and dementia. A shift from a disease-driven approach to one that focuses on function and quality of life may be necessary to provide the best care. Larry Lawhorne, MD (2005)1 Care of the Elderly: Shortfall of Geriatricians Multimorbidity To date, little consensus on how multimorbidity is defined; most commonly refers to the coexistence of 2 or more chronic conditions in the same individual 2 Prevalence is much higher in older age groups, with 3 65% of aged 65-84

82% of people >85 More common with age, associated with socio-demographic correlates such as gender and SE status, as well as reduced functional status, subsequent morbidity, 4 poorer quality of life, higher risk of care dependency, 2 and mortality4 Associated with increased health care (hc) utilization and costs; this burden increases as the number of co-occurring chronic conditions increases 2 Associated with > physician visits, ER visits, hospitalizations and rx. Also associated with > need for specialized care & higher referrals to specialized care 2 Dementia and Multimorbidity (MM)3 The rise in the # of people with dementia worldwidefrom 44M now to a projected 135 M in 2050is a function of population aging People with dementia have among the highest levels of MM of any long-term

disorder Only 5.3% of people with a dx of dementia have no other long-term disorder On average, people with dementia have 4.6 additional chronic illnesses An analysis of US primary care data showed that people with dementia had on average, 4 additional chronic medical disorders & were prescribed about 5 drugs. 82% had HTN, 39% had DM. MM with dementia predicts poor outcomes and poor-quality service response People with chronic illness and dementia report fewer symptoms than do those without dementia, & undiagnosed but treatable disease has been reported in almost half of those with dementia Why do older people with MM in general, and people with dementia in particular, get poor-quality care? 3

Health systems are providing 20th-century medicine to todays patient population HC systems designed around a single-disease framework Services and interventions provided are generally designed for young or middle-aged people, with only one disorder and a discrete episode of illness Unidisciplinary, technical superspecialism has grown to dominate policy, research, practice, and education Disorders other than that of the specialty, e.g., dementia, are often seen as complications that are ignored or managed by many specialist referrals which can be both inefficient and ineffective The impression given to patients & families of people with dementia in

hospitals is often that the pt. has failed by not fitting the service 20th Century Medicine Cont. Working assumption is that the optimum treatment of someone with more than one condition is to add together the treatments for the individual conditions Clinical guidelines for chronic illnesses almost always focus on one disorder, although most people with those disorders will have mm, which leads to questions about whether treatments and services that are developed in otherwise healthy people work in people with many health problems What works for those with 1 disorder does not necessarily work in mm, what is safe for those with 1 disorder is not necessarily safe in mm The education of hc staff from all professional backgrounds does not prepare them well for the challenges of mm or long-term conditions. Clinical experience is delivered thru a series of discrete, time-limited clinical placements in

acute and primary-care settings Give a snapshot of different illnesses in different patients, with an emphasis on the acute phase of illness Use of Information Technologies to Help Manage Health5 Vast amount of health information is available online to the public In 2014, 87% Americans were Internet users 57% of them searched for health information online Internet used both as a primary information source (diagnosing illness, checking symptoms) & as a means for further investigation following physician consultation

Older generations are late adopters, are rapidly becoming active Internet users, competency varies greatly Ages 50-64, 88% are users Ages >65 years, 57% Online health information can be particularly beneficial to older-adult populations as they face significantly more health challenges than younger adults To find and understand the information they need online, must have the appropriate knowledge and skill sets to accomplish those tasks Health Literacy (HL) Defined WHO the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health5

IOM: the degree to which individuals can obtain, process, and understand basic health information and services needed to manage ones health, and they need to make appropriate health decisions 8 It is whatever an individual needs to successfully navigate their health care environment A health literate individual will be able to search, evaluate, comprehend, and use the information has gathered5 Importance of Health Literacy The importance of HL has been highlighted as a public health goal in Healthy People 20205 Low HL is a significant challenge in hc globally5

Assessment of an individuals HL is important to hc delivery to ensure the benefits of interventions delivered5 More strongly predicts health status than age, income, education, or race6 Increasing age has a negative relation to HL6 Even well-educated older adults in good health have been shown to have low levels of HL Older adults have lower levels of HL compared to younger individuals across the same educational strata HL encompasses various skills needed to navigate the hc system, including6 Print literacy: reading, writing, interpreting, and understanding written information

Vocabulary does not decrease with age, may even increase7 Reading skills may be resistant to age-related decline because they are practiced frequently7 Oral literacy: speaking/listening effectively, pronunciation Numeracy: applying quantitative information, mathematics If have low numerical abilities may lack the desire or ability to use cell phones, computers and the Internet8 Cognitions: Confidence (self-efficacy), health motivation, decision making, critical thinking, problem solving8 Environmental factors: access8 Individuals with low health literacy skills were less likely to use Internet technology (e.g., email, search engines, and online health information seeking)

Those with low health numeracy skills were less likely to have access to Internet technology (e.g., computers and cell phones) Individuals with Inadequate HL6 US Dept. of Educations Natl Assessment of Adult Literacy (NAAL) found that inadequate HL is especially prevalent among the elderly: 59% of adults > 65 score in the two lowest ranges of HL, basic and below basic. Of these: 29% have below basic HL 68% have difficulty understanding numbers and calculations 71% have difficultly using printed materials 80% have difficulty using health-related documents

May have trouble with even basic health-related tasks, such as following prescription instructions, calculating dosages, completing medical history or insurance forms, communicating with providers, interpreting test results, and understanding the risks and benefits of procedures Older adults with inadequate HL may struggle to self-manage multiple conditions and coordinate their care across various providers in an increasingly complex, hc system Common characteristics of low HL among older adults established6 More likely to be older, male, minorities, and have lower income, education, and are generally sicker with poorer physical and mental health6 Common reported mental health-related characteristics include

Low general literacy, poor decision-making ability, reduced cognitive functioning, and a lack of social support Would coincide with declines in other mental abilities generally, including perceptual skills such as vision and hearing 7 Physical characteristics Lack of engagement in health promoting behaviors such as exercise, reduced physical functioning, poor self-care, more chronic conditions, increased mortality risk, and poorer overall physical health Inadequate HL & Health Outcomes6 Health behaviors including decision-making, compliance with prescription medications, self-management of chronic conditions, and participation in health screenings Associated with suboptimal outcomes including poorer overall health

and physical fitness, increased disability and pain, increased prevalence and severity of certain conditions, reduced physical functioning, limited mobility, reduced QOL, and poorer disease outcomes Shown to impact pt. satisfaction with providers, services and overall care, as well as compliance with recommended preventive services, increased hc utilization including ER Visits, inpatient admissions, and medical expenditures among older adults Measurement of Health Literacy Self-reports Those who rate their health as only fair or poor are twice as likely to have inadequate HL compared to those who rate their health as either good or excellent 6 Ownby et al study: investigated the potential influence of various factors on the relation between health literacy & individuals reported health status 7 Health literacy continues to be related to self-reported health status after taking a number

of explanatory variables into account A validated, single-item screener was used to identify inadequate HL: How confidant are you filling out medical forms by yourself. 5-point response scale: Extremely, Quite a bit, Somewhat, A little bit, and Not at all Responses of A little bit and Not as all were categorized as inadequate HL This single item is routinely used as a screening question for Hl, often included on surveys. Those identified wit inadequate HL can then be targeted for subsequent longer surveys to detail types of literacy deficits and possible interventions Measurement of Health Literacy cont. REALM REALM: Rapid Estimate of Adult Literacy in Medicine8 Word recognition test, participants given a list of 66 medical terms & asked to read them aloud Words that are mispronounced or skipped are counted as incorrect

Literacy level is based on the number of correct answers: 0-18 correct (9th grade) Individuals who score below a 61 on the REALM will struggle with most health materials Measurement of Health Literacy cont. eHEALS Literacy Scale Developed by Norman and Skinner (2006)5 Prior studies showed that it is a reliable &valid tool to assess e-health literacy among younger adults, including teenagers. Chung and Nahm tested the reliability and validity of the eHEALS for older adults using a secondary data analysis Seems to be particularly applicable for older adults who are less familiar with technologies as it is a short (8 items) scale with easily understandable items

Showed high internal consistency (a = .94) Showed significant correlation between e-health literacy, use of the Internet, and computer knowledge indicating construct validity of eHEALS. eHEALS cont. 8 Questions5 I know what health resources are available on the internet I know where to find helpful health resources on the internet I know how to find helpful health resources on the internet I know how to use the Internet to

answer my health questions I know how to use the health information I find on the internet to help me I have the skills I need to evaluate the health resources I find on the internet I can tell highquality from lowquality health resources on the internet I feel confident in using information from the Internet to make health decisions Measurement of Health Literacy cont. TOFHLA

Test of Functional Health Literacy in Adults (TOFHLA; Parker, Baker, Williams & Nurss, Georgia State University,1995)8 Uses patient materials with written information on things they might commonly encounter in the hc setting to assess numeracy and reading comprehension Uses actual health-related materials such as prescription bottle labels and appointment slips Four items assess numeracy Individuals scoring a four out of four would be considered to have sufficient numerical ability to navigate most heath situations8

Reliability (Cronbachs a = .98), as well as its validity )Wide Range Achievement Test-Revised, r 0.745 Assesses reading, comprehension, and numeracy skills using a nutrition label Shown to be reliable (Cronbachs a = .76) and valid (moderate correlation with the TOFHLA, r = 0.59 Measuremen t of Health Literacy cont. The Newest Vital Sign (NVS)5 Health Literacy Efforts Older people may be less likely to use computer technology for health information because they prefer more traditional information sources; may value sources like medical professionals, family, newspapers, or tv news more than source accessed

thru new technologies Target sicker older adults, especially those who are male, less educated, & in poorer health with more chronic conditions UnitedHealthcare and AARP are currently collaborating in this effort to develop initiatives targeting vulnerable seniors with inadequate HL With effective educational interventions such as those planned, improved HL could potentially drive higher patient satisfaction, better compliance with preventive services, and reduced hc utilization & spending Significant advances in technology access and use could be sparked by developing technology interfaces that are accessible to individuals with limited literacy skills Health Literacy Efforts cont.

Literacy and numeracy finding suggest that health communicators and technology developers should:8 Minimize the numerical component of computer technology Increase the interactive capability of new information systems Touch or icon based systems may be more appealing to low-skilled groups With an aging population, it will be increasingly important to cultivate computer technology that is sensitive to declining visual and physical skills Developers should explore the possibility of redesigning Web pages so can be viewed in sections (rather than as long-horizonal intact pages) NIA has senior-friendly website designone paragraph per page Providing Health Information to Older

Adults9 HC professionals must generally use written information for informed decision-making and good health Legibility & formatting are critically important for older adultsmore likely to suffer with visual impairments Written information should be tested for appropriate reading level & presentation WHO recognizes that knowledge is an important contributor to adherence Numerous studies demonstrate that a lack of knowledge leads to poorer decisions and lower adherence

Increased education leads to improved outcomes in terms of fewer complications Providing Health Information to Older Adults cont. Medical records content is written & designed for hcp However, sending pts a copy of their progress notes increased their knowledge of medical conditions Few pts have adequate knowledge of their health conditions or medications upon hospital discharge In one study, only 28% of pts could correctly state the names of their Rx, and 14% could list the common AE Older adults had the poorest recall of the information In general, older age was associated with poorer knowledge of medications and directions Pts. receive a significant amount of information after a physician visit, recall <50% Verbal counseling results in poorer retention; in 1 study, only 3 of 11 pieces of information were recalled Health professionals may not

accurately self-assess their communication abilities Providing Health Informatio n to Older Adults cont. How Material is Presented9 May understand a pictorial representation of probability and risk Icons (pictograms) may be helpful with low HL Older people will seek out sources of information if not provided directly by health professionals With multiple disease states, individuals consistently reported difficulty

in obtaining information from health professionals; most written information is focused on just 1 disease or 1 rx With rx, pts want to know side effects and risks, what the rx does, how it is used and taken, range of tx options, length of tx period, costs & suitability of the rx Information overload is common with a new diagnosis or rx How Material is Presented cont. Written materials continue to be developed that cannot be accessed by those with low HL In 2005, the readability of notice of privacy forms was found to be similar in reading level to medical journals (guidelines recommend a reading level of grade 6)

Information leaflets often include complex structure, which may lead to poorer comprehension of the material 1 in 9 older adults have vision impairments Significant changes occur with aging: loss of accommodation, increased sensitivity to glare, low of low-contrast acuity Increased difficult with reading may lead to not being able to obtain the required information from written materials How Material is Presented cont. Vision impairment resources: The American Council for the Blind, the American Printing House for the Blind Evaluation of written materials: content, formatting, readability Consider patient focus groups, interviews or questionnaires, consumer or

patient testing A number of tools available Culture and language more information being provided in multiple languages, incorporate cultural content; resources available regarding the translation of material Content of material provided must be tailored to what pts want & need, versus what health professionals think the public needs Providing Written Materials to Older Adults9 Font: Times New Roman Point size: At least 12-point

Contrast: Dark on white or reverse Color of type: dark (black) Heaviness: Avoid thin or excessively thick lettering Letter spacing: Mono-spaced letters Alignment: Distinct columns; aligned left Numbers: Distinctiveness between 0, 3, 5, 8

Formatting paragraph: Block paragraphs (no indents) Text setting: Avoid wrapping text around images or objects Line spacing: 1.5 line spacing Paper finish: Non-glossy, no watermark Paper type: Opaque Paper color: Buff or ivory color (not white)

Communicating with the Older Patient Communication is the largest single factor in what kind of relationships we have with others and what happens to us in the world Virginia Satir Caring and communication are inseparably linked. You cannot hope to communicate effectively if you do not care about the person on the receiving end Morrison & Benard Communication is: More than the exchange of information Fundamental aspect of all human relationships Way we connect with other people & maintain our relationships Instrumental in accomplishing tasks:

Problem-solving, information giving Clarification, direction, guidance A skill and an art Verbal and nonverbal Serves social and emotional needs: reassurance, encouragement, concern and understanding, empathy (not sympathy), interest in the person as a human being who has much life experience! Face Get Turn off/down Speak

Effective Communic ation Use Remove Face the person at their level, 3 -5 feet away Get full attention first, use touch as appropriate Turn off/down background noise Speak clearly and slowly, lower than your normal pitch, gentle & calm tone Use pleasant facial expressions & gestures Remove gum & candy from your mouth Keep Keep your hands away from your face Allow

Allow time between sentences Ask Only ask one question at a time Rephrase Use Increase Sit or stand in Effective Communic ation Call Rephrase misunderstood sentences, making it shorter & simpler; dont repeat Use pad/notebook of paper to write notes Print large! Increase lighting without glare Sit or stand in field of vision; arrange to have light on your face, not behind you

Call them by name Start Start with a casual topic Avoid Avoid quick shifts between topics Keep Keep sentences short Dont give Dont give too many choices Effective Communication Clarify purpose tell the person what it is you will be doing Ask open-ended questions: Real questions to which you expect real answers

Ask questions that can help you understand the older persons present state Nonverbal - transmission of message without the use of words; powerful Personal appearance: first thing notices Intonation: tone of voice Facial expression: eyes send overt cues Posture & gait: visible form of self-expression Gestures: visual italics which emphasize, punctuate, & clarify the spoken word Touch: more spontaneous than verbal communication, authentic Body language: gestures, body movements, touch & physical appearance Effective Communications: Telephone Calls Telephone Calls Schedule mid-morning when energy levels are high Identify yourself & affiliation at the very beginning

Ask if a good time to talk Assess whether the member is able to understand & speak preferred language Ask whether they would like an interpreter Tell the member how long the call will last Remind patients to bring their glasses, hearing aids, assistive devices, glucometers, dentures, any logs or journals Encourage active participation in appointments 21st Century Approach to Care of the Older Adult with Multimorbidity

01 02 03 04 05 06 07 PatientCentered Care Care Coordination Interprofession al Team Education and Counseling Adherence to

plan of Care Care Transitions Advanced Directives Health Health Literacy Literacy Concerns Concerns Use Use of of Technology Technology Comprehensive Primary Care Plus CPC+ Developed by CMS program to reduce its program expenditures and improve quality for MC, MA & CHP beneficiaries

5-year multi-payer model that began January 1, 2017 Advanced primary care medical home model that rewards value and quality by offering an innovative payment structure to support delivery of comprehensive primary care Advances in payment are given to provide more comprehensive care that meets the needs of all their patients, especially those with complex needs Currently 444 CPC+ Clinics in MI; partner with BCBSM, Priority Health Requires efficient, advanced health IT to support its population-heath focus & team-based structure; expected to report electronic clinical quality measures at the practice-level CPC+ cont. Payment redesign will offer the ability for greater cash flow and

flexibility for primary are practices to deliver high quality whole-person, patient-centered care and lower the use of unnecessary services that drive total costs of care Practices are provided with a robust learning system, as well as actionable patient-level cost and utilization data to guide their decision making Includes two separate tracks; prospective monthly care management fees based on beneficiary risk tiers Practices may use this enhanced no-visit compensation to support augmented staffing and training needed to meet the model requirements according to the needs of their MC attributed patient population CPC+ cont. Practices are expected to make changes in the way they deliver care, centered on key Comprehensive Primary Care Functions

1. Access and Continuity 2. Care Management 3. Comprehensiveness and Coordination of Care 4. Patient and Caregiver Engagement 5. Planned Care for Chronic Conditions and Population Health 6. Continuous Improvement Driven by Data CPC+ will reward practices based on their performance on patient experience, clinical quality, and utilization measures thru performance based incentive payments CPC+ cont. Potential Team Members Practice Managers, Administrators Primary Care Practitioners: Physicians (lead or other), NP, PA, CNS RN, LPN, MA

Care Managers and Care Coordinators Behavioral health specialists: Clinical psychologist, psychiatrist, or clinical SW Referral coordinator or referral specialist Quality improvement (QI) specialist IT Specialists Financial officers Health educator, dietician, or nutritionist

Clinical pharmacist or doctor of pharmacy CPC+ cont. CMS Assigns MC Beneficiaries to Risk Tiers Based on the individual hierarchical condition category (HCC) score Updated annually based on the beneficiaries claims history Determines which risk quartile the beneficiary will be assigned based on comparison to the population of MC FFS beneficiaries in that region Track 2, the complex tier will be based on a combination of HCC sore and beneficiaries who have a diagnosis of dementia

The top 10% of the HCC risk pool will represent patients who are the sickest of the sick with multiple conditions and high expected costs 5% of patients are responsible for 50% of the costs n most hc systems11 CPC+ cont. Practices can do own Risk Stratification Being done daily based on the physician schedule by the MA Using a template developed by the Arcturus CPC+ team with guidance from the AAFP model Color coded: Green: Level 1, 2 Blue: Level 3, 4

Red: Level 5, 6 Ultimately physician perception makes the final decision on your patients risk level, can change it in the chart Care Managers are involved in all Level 5 patients Monitoring at-risk Patients to Reduce ER Visits, Hospital Admissions11, 12 More frequent prescheduled outpatient physician visits Home phone calls from the physician office Home healthcare

Home visits by primary health providers, Care Managers Hospice/Palliative Care as appropriate Family members Install home cameras, or live close Cognitive coaching systems to perform routine tasks Wearable technology: smart watches, smart clothing: sensing & computing technologies Monitoring at-risk Patients to Reduce ER Visits, Hospital Admissions cont. Home-based safety monitoring systems (fall-detection systems, sensorembedded environmental systems)

Embedded or integrated activity-monitor sensory systems that track behaviors such as movement patterns, sleep behaviors, or medication adherence Systems that monitor vital signs and other health indicators, or provide reminders about health-related activities Smart-home systems: combine automation and programmability with artificial intelligence interfaces and integrated networks of sensors in living environments (lighting, appliances, security systems, environmental conditions, daily activity patterns, vital signs); integrated with mobile phone technology Monitoring at-risk Patients to Reduce ER Visits, Hospital Admissions cont. Low-cost, high-image, quality miniature cameras enable advances in vision-sensing systems that can extract information, detect obstacles that could pose a danger to people with visual impairments, and provide information about a persons location and what they are doing

Implantable devices: cardiac monitoring and cardiac stimulation Systems that monitor social connectedness, involving sensors to foster interaction between family embers eHealth applications: health websites, online health self-management tools, online support groups and blogs, access to personal heath records mHealth: health applications and links to mobile or smart phones; can collect health data, health information can be delivered Monitoring at-risk Patients to Reduce ER Visits, Hospital Admissions cont. eHealth: telemedicine, enables physical ad psychological diagnoses & treatments at a distance; can track weight, vital signs

HER: ability to review a patients entire medical history at one time, the ability to share information across clinical settings or providers PHR: allow pts to communicate electronically with providers, schedule appts, request rx renewals, access health management information, review & track heath summary information & test results (only 25-28% use)12 Robotic devices and coaching systems that harness artificial intelligence technologies Self-management Strategies Ask about: Key areas of functioning, ADL, IADL Falls or fear of falling

Urinary incontinence Appetite, what are they eating, where do they get their food Losses, coping What are they doing to manage their care? Their activity level, exercise Financial challenges Social supports, formal and informal

What do they want from the hc system? Development of Plan of Care Allow ample opportunity to craft advance care directive & honor it after it is in place Clinicians need to become skilled in end-of-life care Anticipating and addressing pain and other common end-of-life symptoms Health plan should emphasize function, quality of life, patient selfdetermination Shared decision making

Patients values and beliefs Activity & exercise goals; reversing deconditioning, sedentary behavior; fall prevention Community supports, resources Case Study: Sally, 88 y/o Caucasian Initial Memory Evaluation HPI (per dau): short-term memory poor, pt. denies problems. Difficulty driving, has gotten lost several times in familiar areas, now has a monitor on her car. Not eating right, questionable if she is eating, what she is eating. Not taking her rx right. Misplaces things Cant report what she has been doing. Onset 1 year ago, worsening past 6 months PMH: Vitamin D def., DM2, non-insulin dependent; Hyperlipidemia, HTN, Afib, GERD, PUD, OA; , LBP, insomnia, renal insufficiency; not using BG monitor

Social: widowed, lives alone 2-story condominium, only uses main level. Former smoker, no alcohol; retired housewife, HS graduate; no exercise, cant walk far, uses cane RX: Triamterene-HCTZ, lovastatin, losartan, glimepiride, metformin, tradjenta, ambien, zantac, ca + d, MVI, ASA Case Study: Sally, 88 y/o Caucasian Initial Memory Evaluation cont. Functional Status: independent in ADLS except goes to a hairdresser weekly; Cooking: doesnt use stove, may use microwave; kids bring over food, doesnt always eat it, kids find spoiled food in fridge; doesnt do any cleaning; cleaning woman monthly; does do laundry; can answer phone, cannot dial; kids find volume turned down or phone off the hook; pills are found all over the place, doesnt typically take; intermittent urinary incontinence; most bills are on automatic pay, dau not sure how finances are PSH: lumbar laminectomy, TKR right

FH: older sister had dementia Vitals: Ht. 61.25, Wt. 150, BMI 28, BP 156/70, 20#weight loss past year PE: alert, cooperative, pleasant, well-developed, well-nourished, WNL, unsteady on feet Case Study: Sally, 88 y/o Caucasian Initial Memory Evaluation cont. Neuropsych: oriented to place, person; short & long-term memory impairment; lack of insight; poor recall, reduced retention; abstract reasoning impaired, concentration impaired, problem solving impaired, decreased fundamentals of knowledge, unaware of current events; normal vocabulary level, able to read and write; able to perform basic calculations MSE: Montreal Cognitive Assessment 16/30, Clock Drawing 3/10, GDS

0/15, Scored poorly executive function tests. Dau rated Functional Activities Questionnaire 16, Alzheimers Dementia Screening Interview 8/8 Lab tests: chol 155, triglycerides 160, LDL 73; vitamin d 16.9, A1C 13.9, negative microalbuminemia, glucose 126, Cr 1.40, BUN 29, GFR 35, TSH nl, Hgb 11.4, UA trace bacteria, vitamin b12 314 Aging adults should be treated with the same respect & dignity with all hc information & decisions; has a right to information unless unable to receive Communication regarding informed consent for treatment & procedures, maintaining autonomy and dignity, can be difficult to accomplish while determining the appropriate level of competence Considering Competenc e when Consenting to Treatment10 Some of the mm that affects the level of competence: CVA, dementia, depression or other disorders affecting the

neurological system Competence is the ability to make a rational decision If a person is given clear accurate information, but cannot understand what has been stated, they are regarded as incompetent to make a decision, and the consent or refusal is not regarded as valid Considering Competence cont. Ability to reason (Edge and Groves, 2006): being able to answer yes to 2 stated questions confirms ability to reason and autonomy 1. Does the patient understand the nature of the illness and the consequences of the various options that may be chosen 2. Is the decision based on a rational reasoning? Rational reason: knowledge coming from logical consistency & generally comes from observations Instruments to screen for cognitive impairment: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), Clock Drawing

Instrument to screen for depression: The Geriatric Depression Scale (GDS) Case Study: Sally, 88 y/o Caucasian Initial Memory Evaluation cont. Demonstrates complex multimorbidity with dementia What is her level of health literacy? Is she considered competent to make her own decisions? What is her self-determination, values What is the plan of care? Case Study: Sally, 88 y/o Caucasian Initial Memory Evaluation cont. Diagnosis: DAT, Uncontrolled diabetes, Vitamin D deficiency, HTN Plan: Memantine initiated, family needs to fill pill box & monitor, stop driving, take over finances; assistant living recommended (pt. refused); close monitoring & supervision by family (dau lives 5 minutes away); family needs to learn to check her BG, give insulin or hire help in home

Dau/pt returned 1 week later: pills placed in box; dau going over twice daily to make sure is taking, pt. stopped from driving (but wishes to renegotiate); dau bring food or taking her out to eat Plan: Teaching to dau re diabetes, BG monitoring, insulin, hypoglycemia, diet teaching. Started on basal insulin, pioglitazone 30; stopped glimepiride; dau plans to get other siblings involved with care to keep Mom at home; eventually added bolus insulin with dinner; 3 mo: A1C 6.3% Case Study: Anne 82 y/o Caucasian HPI: referred by PCP for uncontrolled DM2; pt. had been on basal-bolus insulin until 6 months ago when quit all insulin. Also stopped checking BG then. She had been living in Assisted Living for 5 months, checked herself out against medical advice. Has been home 1 month. Was found on floor 3 weeks ago by caregiver who sees her prn; pt. had reportedly been on floor for 22 hours, unable to get up on own. She was trying to move a vase which was too heavy for her, lost balance and fell. 911 was called, took 4 EMS to get her off the floor; she refused to go to ER. She has a lifeline unit but it was in the charger at the time. She has 4 landline phones (refuses to use a cell phone) but unable to reach. She is wheelchair bound most of the time, can use walker for short-periods in house. Brought in by caregiver.

PMH: DM2 28 years with peripheral neuropathy, HTN, hyperlipidemia, morbid obesity, urinary incontinence, chronic venous stasis; multiple diabetic ulcerations b/l lower extremities, has been going to wound clinic weekly for leg wrappings, peripheral edema. Case Study: Anne 82 y/o Caucasian Cont. Social: Widowed 1 year ago; 4 out of state step-children, she is estranged from; they put her house on the market, sold all her belongings in an estate sale, moved her to assistant living (AL) with her dog. Pt. disliked it there; has never conformed to a schedule for eating, sleeping, didnt like rigidity of situation. Also, another resident yelled at her dog a lot. She bought herself a new car, drove it to her unsold house, had to completely refurnish house for what needs. Has not driven car since her fall. Caregiver takes her to her appts., does her shopping, helps her as necessary around the house. Sees her once daily on week days, calls on weekends. Pt. has to change her clothes 4-5 times daily due to the UI. This is quite an effort for her, gets exhausted. Pt. recognizes the seriousness of her long lie, is being careful not to fall again. As to why she stopped her insulin, BG testing, she just said the AL didnt seem to care she had stopped, so why should she? R. teacher

Case Study: Anne 82 y/o Caucasian Cont. Functional: sponge bathes only; able to dress self, do grooming, Fixes self, cereal, sandwiches, frozen entrees; caregiver brings her McDonalds, milk shakes. Irregular or skip meals. Pt. able to do laundry, take pills, use the telephone, write checks. Unable to do housework, shopping Rx: metformin recently readded, on furosemide, losartan, atorvastatin Labs: A1C 14.2% Vitals: Ht 64, Wt 324, BMI 55.6, BP 134/70. PE: in wc, lower legs wrapped, NAD; A & O times 3; good historian Case Study: Anne 82 y/o Caucasian Cont.

What is her level of health literacy? Is she considered competent to make her own decisions? What is her self-determination, values What is the plan of care? Case Study: Anne 82 y/o Caucasian Cont. Plan: restarted basal insulin, added tradjenta, ordered glucose monitor, check BG twice daily, must eat regular meals. RTO 1 week One week later: Pt. adherent to checking BGs, taking rx, no hypoglycemia. Titrating insulin as ordered. BGs running high, but since alone, do not let BGs<120. Caregiver needs AAA surgery, wont be able to come over for 2-3 months. Her dau may be able to come some but works, too. Pt. successfully problem solved re her lifeline unit & phones so will never not be charged. Referred to Care Manager. Roles of Care Managers/Coordinators13 Physicians are discouraged by the amount of social & non-medical care activities that they are unable to address

RNS are more cost-effective than unlicensed providers because they do not require the same level of targeted education, supervision and support for delivering high quality care Develop and maintain positive relationships with clients and across al care settings Provide comprehensive assessment and reassessment of what clients cannot provide for their own care Conduct face-to-face and home visits with ongoing telephone support Co-create a plan of care with patients & their families that includes goals and targeted dates for completion Roles of Care Managers/Coordinators

cont. Assist clients with coordination of services across the continuum of care especially related to hospitalization Reinforce management of medication and symptoms of a worsening condition Reinforce medical recommendations Collaborate with members of hc team, patient education, manage pt. transitions among care settings Broker community resources, ect. References 1. Lawhorne, L. (2005, Sept.). Care of the older adult in the office setting. In Larry Lawhorne (Ed). Primary care: clinics in office practice (p. xii),

Philadelphia, PA; Elsevier, Inc. 2. Picco, L., Achilla, E., Abdin, E., Chong, S., Vaingankar, J., McCrone, P. et al. (2016). Economic burden of multimorbidity among older adults: impact on health care and societal costs. BioMed Central Health Services Research. 16:173, 1-12. 3. Banerjee, S. (2014, Nov.). Multimorbidity older adults need health care that can count past one. 385, 587-60. 4. Schuz, B., Wolff, J., Warner, L., Ziegelmann, J., Wurm, S. (2014). Multiple illness perceptions in older adults: effects on physical functioning and medication adherence. Psychology & Health. 29 (4), 442-447. References cont. 5. Chung, S. & Nahm, E. (2015, April). Testing Reliability and Validity of the dHealth Literacy Scale (eHEALS) for older adults recruited online. Computers, Informatics, Nursing. 33(4), 150-156. 6. MacLeod, S., Musich, S., Gulyas, S., Cheng, Y., Tkatch, R., Cempelin, D., Bhattarai, G., Hawkins, K., Yeh, C. (2017, Jul/Aug). The impact of inadequate health literacy on patient satisfaction, healthcare utilization and expenditures among older adults. Geriatric Nursing. 38(4), 334-341. 7. Ownby, R., Waldrop-Valverde, D, & Taha, J. (2012). Why is health literacy related to health? An exploration among US national assessment of adult literacy participants 40 years of age and older. Educational Gerontology. 37, 776-787. 8. Hensen, J., King, A., Davis, L., Guntzviller, L. (2010). Utilization of internet technology by low-income adults: the role of health literacy, health numeracy, and computer assistance. Journal of Aging and Health. 22(16), 804-826. References Cont.

9. Sadowski, C. (2011). Providing health information to older adults. Reviews in Clinical Gerontology. 21 (55-66). 10.Brooks, C.L. (2011, May/June). Considering elderly competence with consenting to treatment. Holistic Nursing Practice, 136-139. 11.Takalhashi, P., Hanson, G., Pecina, J., Stroebel, R., Chaudhry, R., Shah, ., Naessens, J. (2010). A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study. Health Services Research. 10 (255), 1-7. 12.Czaja, S. (2015, Spring). Can technology power older adults to manage their health? Journal of the American Society of Aging. 29(1), 45-51. References Cont. 13. Scolz, J. & Minaudo, J. (2015, Sept 30). Registered nurse care coordination: creating a preferred future for older adults with multimorbidity. The online journal of issues in nursing. 20(3), manuscript 4. Note : PP slides RT communication courtesy of Linda Keilman, DNP, MSU, CON.

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