EVIDENCE-BASED
GERIATRIC NURSING
PROTOCOLS
FOR BEST PRACTICE
F O U R T H E D I T I O N
MARIE BOLTZ
ELIZABETH CAPEZUTI
TERRY FULMER
D
EANNE ZWICKER
E D I T O R S
A R DI S O’M E A R A
Ma n agi n g Ed i tor
11 W. 42nd Street
New York, NY 10036-8002
www.springerpub.com
9 780826 171283
ISBN 978-0-8261-7128-3
Evidence-Based Geriatric Nursing
Protocols for Best Practice
F O U R T H E D I T I O N
Marie Boltz, PhD, RN, APRN-BC • Elizabeth Capezuti, PhD, RN, FAAN •
Terry Fulmer, PhD, RN, FAAN • DeAnne Zwicker, DrNP, APRN-BC • EDI TOR S
Ardis O’Meara, MA • M A NAGI NG EDI TOR
“Now more than ever, nurses are called upon to lead efforts to embed evidence-based practice in daily operations. As
the IOM report states, ‘nurses have key roles to play as team members and leaders for a reformed and better-integrated,
patient-centered health care system.’ The process of implementing sweeping change in health care will likely take years;
however, nurses must start pragmatically and focus on these critically important protocols that have demonstrated improved
outcomes for older adults. Simply stated, ‘Pick this book up and use it.’”
—Susan L. Carlson,
MSN, APRN, ACNS-BC, GNP-BC, FNGNA
President, National Gerontological Nursing Association
From the Foreword
“As a gerontological clinical educator/research nurse, I will often use this as a reference. The format and the content are
good, and the explanations of how to best use the evidence simplify the process of sifting through mountains of information
to figure the best practice.”
—Doody’s, Score: 97; 5 Stars
O
ne of the premier reference books for geriatric nurses in hospital, long-term, and community settings, this
fourth edition has been thoroughly updated to provide the most current, evidence-based protocols for care
of common clinical conditions and issues in elderly patients. Designed to improve the quality, outcomes, and
cost-effectiveness of health care, these guidelines are the result of collaboration between leading practitioners and
educators in geriatric nursing and New York University College of Nursing.
Protocols for each clinical condition have been developed by experts in that particular area, and most have been
systematically tested by over 300 participating hospitals in “Nurses Improving Care for Health System Elders”
(NICHE). Evidence is derived from all levels of care, including community, primary, and long-term care. A
systematic method in compliance with the AGREE appraisal process was used to rate the levels of evidence for each
protocol. Protocols are organized in a consistent format for ease of use, and each includes an overview, evidence-
based assessment and intervention strategies, and an illustrative case study with discussion. Additionally, each
protocol is embedded within chapter text, which provides the context and detailed evidence for the protocol. Each
chapter contains resources for further study.
K EY FE AT UR ES :
• U
pdated to provide a wide range of evidence-based geriatric protocols for best practices
• Contains new chapters on function-focused care, catheter-associated urinary tract infections, mistreatment
detection, acute care models, and transitional care
• Illustrates application of clinical protocols to real-life practice through case studies and discussion
• Edited by nationally known leaders in geriatric nursing education and practice, who are endorsed by the
Hartford Institute for Geriatric Nursing and NICHE
• Encompasses the contributions of 58 leading practitioners of geriatric care
• Written for nursing students, nurse leaders, and practitioners at all levels, including those in specialty roles
EVIDENCE-BASED
GERIATRIC NURSING
PROTOCOLS
FOR BEST PRACTICE
BOLTZ • C APEZU TI •
FULMER • ZW ICKER •
O’ME A R A
F O U R T H E D I T I O N
Evidence-Based Geriatric Nursing
Protocols for Best Practice
Marie Boltz, PhD, RN, APRN-BC, is an assistant professor at New York University (NYU) where
she has directed the undergraduate course in Nursing Care of Adults and Elders. Dr. Boltz is also
practice director of the NICHE (Nurses Improving Care for Healthsystem Elders) program, which is
the only national nursing program designed to improve care of the older adult patient. Her areas of
research are the geriatric care environment including measures of quality, the geriatric nurse practice
environment, and the prevention of functional decline in hospitalized older adults. She has presented
nationally and internationally and authored and coauthored numerous journal publications, organi-
zational tools, and book chapters in these areas. Dr. Boltz is a John A. Hartford Foundation Claire
M. Fagin fellow and the 2009–2010 American Nurses Credentialing Center (ANCC) Margretta
Madden Styles Credentialing scholar.
Elizabeth Capezuti, PhD, RN, FAAN, is the Dr. John W. Rowe Professor in Successful Aging at
the College of Nursing at NYU. She also serves as codirector for the Hartford Institute for Geriatric
Nursing where she directs the research center. She is an internationally recognized geriatric nurse
researcher, known for her work in improving the care of older adults by interventions and models
that positively inuence a health care provider’s knowledge and work environment. Her current stud-
ies focus primarily on translating eective interventions into actual practice, specically, testing of
new technologies for promoting independence and system change approaches to transform provider
behavior. A recipient of more than $8 million in research and training grants, she has disseminated the
ndings of 35 funded projects in four coedited books and more than a hundred peer reviewed articles
and book chapters. Dr. Capezuti received her doctoral degree in nursing from the University of Penn-
sylvania in 1995. She joined the NYU faculty in 2003 and was promoted to professor in 2008. She
has also been on the faculty of the University of Pennsylvania School of Nursing from 1984 to 2000
where she received the 1995 Provost’s Award for Distinguished Teaching. From 2000 to 2003, she
held the Independence Foundation—Wesley Woods Chair in Gerontologic Nursing at Emory Uni-
versity. She is a fellow of the American Academy of Nursing, the Gerontological Society of America,
the American Association of Nurse Practitioners, and the New York Academy of Medicine.
Terry Fulmer, PhD, RN, FAAN, is the dean of the Bouvé College of Health Sciences at North-
eastern University. She received her bachelor’s degree from Skidmore College, her master’s and doc-
toral degrees from Boston College, and her Geriatric Nurse Practitioner Post-Master’s Certicate
from NYU. Dr. Fulmer’s program of research focuses on acute care of the elderly and, specically,
elder abuse and neglect. She has received the status of fellow in the American Academy of Nursing,
the Gerontological Society of America, and the New York Academy of Medicine. She completed
a Brookdale National Fellowship and is a distinguished practitioner of the National Academies of
Practice. Dr. Fulmer was the rst nurse to be elected to the board of the American Geriatrics Society
and the rst nurse to serve as the president of the Gerontological Society of America.
DeAnne Zwicker, DrNP, APRN, BC is an ANCC certied adult nurse practitioner and is currently
working as independent geriatric consultant. She completed her doctor of nursing practice (DrNP)
in 2010 with a primary focus as a clinical scientist and secondary in education at Drexel University
in Philadelphia. Her dissertation was entitled Preparedness, Appraisal of Behaviors, and Role Strain in
Dementia Family Caregivers and the Caregiver Perspective of Preparedness and was a mixed-method
study. She was a coeditor and chapter author for the fourth edition of Evidence-based Geriatric Nurs-
ing Protocols (in press) as well as the third edition (2008), and managing editor for the second edi-
tion (2003). She has served as the content editor of www.ConsultGeriRN.org since its inception.
She recently instituted the NICHE program at Washington Hospital Center, which was awarded
national NICHE designation. Ms. Zwicker has been a registered nurse for 32 years, with clinical
practice experience as a geriatric nurse practitioner since 1992 in primary care, subacute care, long-
term care, and clinical expert consultant in geriatrics. She has also taught nursing at the graduate level
at NYU and Drexel University. Her areas of interest in geriatrics include proactive interventions in
older adults, including prevention of adverse drug events and iatrogenesis in persons with dementia
and prevention and/or early recognition of delirium.
Ardis O’Meara, MA manages Geriatric Nursing, Heart and Lung: e Journal of Acute and Critical
Care, and other geriatric nursing books. Her experience includes cardiology and research.
Evidence-Based Geriatric Nursing
Protocols for Best Practice
4th Edition
Marie Boltz, PhD, RN, APRN-BC
Elizabeth Capezuti, PhD, RN, FAAN
Terry Fulmer, PhD, RN, FAAN
DeAnne Zwicker, DrNP, APRN, BC
EDITORS
Ardis O’Meara, MA
MANAGING EDITOR
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Evidence-based geriatric nursing protocols for best practice / [edited by] Marie Boltz ... [et al.]. — 4th ed.
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Includes bibliographical references and index.
ISBN 978-0-8261-7128-3 — ISBN 978-0-8261-7129-0 (e-book)
I. Boltz, Marie.
[DNLM: 1. Geriatric Nursing—methods. 2. Nursing Care. 3. Aged. 4. Evidence-Based Nursing. 5.
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v
Contents
Contributors vii
Foreword xi
Susan L. Carlson
Acknowledgments xiii
Introduction xv
1. Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 1
Rona F. Levin and Susan Kaplan Jacobs
2. Measuring Performance, Improving Quality 11
Lenard L. Parisi
3. Age-Related Changes in Health 23
Constance M. Smith and Valerie T. Cotter
4. Sensory Changes 48
Pamela Z. Cacchione
5. Excessive Sleepiness 74
Eileen R. Chasens and Mary Grace Umlauf
6. Assessment of Physical Function 89
Denise M. Kresevic
7. Interventions to Prevent Functional Decline in the Acute Care Setting 104
Marie Boltz, Barbara Resnick, and Elizabeth Galik
8. Assessing Cognitive Function 122
Koen Milisen, Tom Braes, and Marquis D. Foreman
9. Depression in Older Adults 135
eresa A. Harvath and Glenise L. McKenzie
10. Dementia 163
Kathleen Fletcher
11. Delirium 186
Dorothy F. Tullmann, Kathleen Fletcher, and Marquis D. Foreman
12. Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 200
Deborah C. Francis and Jeanne M. Lahaie
13. Physical Restraints and Side Rails in Acute and Critical Care Settings 229
Cheryl M. Bradas, Satinderpal K. Sandhu, and Lorraine C. Mion
14. Pain Management 246
Ann L. Horgas, Saunjoo L. Yoon, and Mindy Grall
15. Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 268
Deanna Gray-Miceli and Patricia A. Quigley
vi Contents
16. Preventing Pressure Ulcers and Skin Tears 298
Elizabeth Ann Ayello and R. Gary Sibbald
17. Reducing Adverse Drug Events 324
DeAnne Zwicker and Terry Fulmer
18. Urinary Incontinence 363
Annemarie Dowling-Castronovo and Christine Bradway
19. Catheter-Associated Urinary Tract Infection Prevention 388
Heidi L. Wald, Regina M. Fink, Mary Beth Flynn Makic, and Kathleen S. Oman
20. Oral Health Care 409
Linda J. O’Connor
21. Managing Oral Hydration 419
Janet C. Mentes
22. Nutrition 439
Rose Ann DiMaria-Ghalili
23. Mealtime Diculties 453
Elaine J. Amella and Melissa B. Aselage
24. Family Caregiving 469
Deborah C. Messecar
25. Issues Regarding Sexuality 500
Meredith Wallace Kazer
26. Substance Misuse and Alcohol Use Disorders 516
Madeline Naegle
27. Mistreatment Detection 544
Billy A. Caceres and Terry Fulmer
28. Health Care Decision Making 562
Ethel L. Mitty and Linda Farber Post
29. Advance Directives 579
Ethel L. Mitty
30. Comprehensive Assessment and Management of the Critically Ill 600
Michele C. Balas, Colleen M. Casey, and Mary Beth Happ
31. Fluid Overload: Identifying and Managing Heart Failure Patients at Risk
for Hospital Readmission 628
Judith E. Schipper, Jessica Coviello, and Deborah A. Chyun
32. Cancer Assessment and Intervention Strategies 658
Janine Overcash
33. Acute Care Models 670
Elizabeth Capezuti, Marie Boltz, and Cynthia J. Nigolian
34. Transitional Care 682
Fidelindo Lim, Janice Foust, and Janet Van Cleave
Index 703
vii
Contributors
Elaine J. Amella, PhD, RN, FAAN Professor, Medical University of South Carolina,
Mt. Pleasant, SC
Melissa B. Aselage, MSN, RN-BC, FNP-BC Lecturer, University of North Carolina,
Wilmington, NC
Elizabeth Ann Ayello, PhD, RN, APRN, BC, CWOCN, FAPWCA, FAAN President,
Ayello, Harris & Associates, Inc., Clinical Associate Editor, Advances in Skin & Wound Care,
Faculty, Excelsior College, School of Nursing, Executive Editor, Journal of World Council of
Enterostomal erapists
Michele C. Balas, PhD, RN, APRN-NP, CCRN Assistant Professor, University of Nebraska
Medical Center (UNMC), Omaha, NE
Marie Boltz, PhD, RN, APRN-BC Assistant Professor, New York University, New York, NY
Cheryl M. Bradas, RN, MSN, GCNS-BC, CHPN Geriatric Clinical Nurse Specialist,
MetroHealth Medical Center, Cleveland, OH
Christine Bradway, PhD, RN, CRNP Assistant Professor, University of Pennsylvania,
Philadelphia, PA
Tom Braes, RN, MSN Managing Director, Nursing Home Zoniën, OCMW Tervuren,
Belgium
Pamela Z. Cacchione, PhD, RN, GNP-BC Associate Professor, University of Pennsylvania,
Philadelphia, PA
Elizabeth Capezuti, PhD, RN, FAAN Dr. John W. Rowe Professor in Successful Aging at
the College of Nursing, New York University, New York, NY
Billy A. Caceres, RN, BSN, BA Research Assistant, New York University, New York, NY
Colleen M. Casey, PhD, MS, RN, CCRN, CNS Nurse Practitioner, Internal Medicine and
Geriatrics Oregon Health Sciences University Healthcare
Eileen R. Chasens, DSN Assistant Professor, University of Pittsburgh, Pittsburgh, PA
Deborah A. Chyun, MSN, PhD, RN Associate Professor, Yale University, New Haven, CT
Valerie T. Cotter, DrNP, CRNP, FAANP Advanced Senior Lecturer, University of
Pennsylvania School of Nursing, Philadelphia, PA
Jessica Coviello, MSN, APRN Associate Professor, Yale University, New Haven, CT
Rose Ann DiMaria-Ghalili, PhD, RN, CNSN Associate Professor, Drexel University,
Philadelphia, PA
viii Contributors
Annemarie Dowling-Castronovo, MA, RN, GNP Assistant Professor, Wagner College,
Staten Island, NY
Regina M. Fink, RN, PhD, FAAN, AOCN Research Nurse Scientist, University of
Colorado Hospital, Aurora, CO
Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN Administrator of Senior Services,
University of Virginia Health System, Charlottesville, Virginia.
Marquis D. Foreman, PhD, RN, FAAN Professor and Chairperson, Rush University,
Chicago, IL
Janice Foust, PhD, RN Assistant Professor, University of Massachusetts, Boston, MA
Deborah C. Francis, RN, MSN, GCNS-BC Geriatric Clinical Nurse Specialist, Kaiser
Permanente Medical Center, South Sacramento, CA
Terry Fulmer, PhD, RN, FAAN Dean of the Bouvé College of Health Sciences,
Northeastern University, Boston, MA
Elizabeth Galik, PhD, CRNP Assistant Professor, University of Maryland, Baltimore, MD
Mindy Grall, PhD, APRN, BC Advanced Registered Nurse Practitioner, Baptist Medical
Center, Jacksonville, FL
Deanna Gray-Miceli, PhD, GNP-BC, FAANP Assistant Professor, Rutgers University,
New Brunswick, NJ
Mary Beth Happ, PhD, RN, FAAN Professor, University of Pittsburgh, Pittsburgh, PA
eresa A. Harvath, PhD, RN, CNS, FAAN Professor, Oregon Health & Science
University, Portland, OR
Ann L. Horgas, PhD, RN, FGSA, FAAN Associate Professor, University of Florida,
Gainesville, FL
Susan Kaplan Jacobs, MLS, MA, RN, AHIP Health Sciences Librarian/Associate Curator,
Elmer Holmes Bobst Library, New York University, New York, NY
Meredith Wallace Kazer, PhD, APRN, A/GNP-BC Associate Professor, Faireld
University, Faireld, CT
Denise M. Kresevic, RN, PhD, GNP-BC, GCNS-BC Nurse Researcher, Louis Stokes
Cleveland VAMC, University Hospitals Case Medical Center, Case Western Reserve
University, Cleveland, OH
Jeanne M. Lahaie, RN, MS, GCNS-BC Elder Life Nurse Specialist, Hospital Elder Life
Program (HELP), California Pacic Medical Center, San Francisco, CA
Rona F. Levin, PhD, RN Professor, Pace University and Visiting Faculty, Visiting Nurse
Service of New York, New York, NY
Fidelindo Lim, RN, MA Clinical Instructor, New York University, New York, NY
Glenise L. McKenzie, RN, MN, PhD Assistant Professor, Oregon Health & Science
University, Ashland, OR
Contributors ix
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, CCRN Research Nurse Scientist,
University of Colorado Hospital and Assistant Professor, Adjoint, University of Colorado,
Aurora, CO
Janet C. Mentes, PhD, APRN, BC, FGSA Associate Professor, University of California,
Los Angeles, Los Angeles, CA
Deborah C. Messecar, PhD, MPH, GCNS-BC, RN Associate Professor, Oregon Health &
Science University, School of Nursing, Portland, OR
Koen Milisen, PhD, RN Professor, Katholieke Universiteit, Leuven, Belgium
Lorraine C. Mion, PhD, RN, FAAN Independence Foundation Professor of Nursing,
Vanderbilt University, Nashville, TN
Ethel L. Mitty, EdD, RN Adjunct Clinical Professor, New York University, New York, NY
Madeline Naegle, APRN, BC, PhD, FAAN Professor, New York University, New York, NY
Cynthia J. Nigolian, RN, GCNS, BC NICHE Clinical Administrator, New York, NY
Linda J. O’Connor, MSN, RNC, GCNS-BC, CLNC Assistant Administrator for Nursing
and Hospital Aairs, Mount Sinai Hospital, New York, NY
Kathleen S. Oman, RN, MS, PhD Research Nurse Scientist, Assistant Professor (Adjoint),
University of Colorado Hospital, Aurora, CO
Janine Overcash, PhD, GNP Assistant Professor, University of South Florida, Tampa, FL
Lenard L. Parisi, RN, MA, CPHQ, FNAHQ Vice President, Quality Management/
Performance Improvement, Metropolitan Jewish Health System, Brooklyn, NY
Linda Farber Post, JD, MA, BSN Director, Bioethics, Hackensack University Medical
Center, Hackensack, NJ
Patricia A. Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP Associate Chief, Nursing
Service for Research, Health Service and Rehabilitation Research Center of Excellence:
Maximizing Rehabilitation Outcomes and Associate Director, VISN 8 Patient Safety Center,
James A. Haley VA Hospital, Tampa, FL
Barbara Resnick, PhD, CRNP, FAAN, FAANP Professor and Sonya Ziporkin Gershowitz
Chair in Gerontology, University of Maryland, Baltimore, MD
Satinderpal K. Sandhu, MD Assistant Professor, MetroHealth Medical Center and Case
Western Reserve University School of Medicine, Cleveland, OH
Judith E. Schipper, MS, NP-C, CLS, FNLA, FPCNA Clinical Coordinator, Heart Failure
Program, New York University Langone Medical Center, New York, NY
R. Gary Sibbald, MD, FRCPC, ABIM, DABD, Med Director, Wound Healing Clinic,
e New Women’s College Hospital and Professor, Public Health Sciences and Medicine,
University of Toronto, Toronto, CA
Constance M. Smith, PhD, RN Wilmington, DE
Dorothy F. Tullmann, PhD, RN Assistant Professor, University of Virginia, School of
Nursing, Charlottesville, VA
x Contributors
Mary Grace Umlauf, RN, PhD, FAAN Professor, e University of Alabama, Tuscaloosa, AL
Janet Van Cleave, MBA, MSN, PhD Post-Doctoral Research Fellow, University of
Pennsylvania, Philadelphia, PA
Heidi L. Wald, MD, MSPH Assistant Professor, University of Colorado, Denver, CO
Saunjoo L. Yoon, PhD, RN Assistant Professor, University of Florida, College of Nursing,
Gainesville, FL
DeAnne Zwicker, DrNP, APRN, BC ANCC certied adult nurse practitioner and is cur-
rently working as independent geriatric consultant.
xi
Foreword
e rst book I reached for in 2001 when I began my serious inquiry of best nursing
practices for older adults was the initial edition of this very text. In fact, I had both a
home version and an oce version. It was never far from my reach, and I used it daily
when developing a series of teaching plans to educate nurses on the care of hospitalized
elders. Because each protocol was and remains research or evidence based, it represented
the state of the science on care problems faced by sta nurses caring for older adults.
So, you might imagine how thrilled I was to be asked to write the foreword for the
fourth edition of Evidence-Based Geriatric Nursing Protocols for Best Practice. Initially
only 15 chapters, the fourth edition now has 34 chapters—testimony to the grow-
ing body of geriatric nursing knowledge. New chapters include function-focused care,
catheter-associated urinary tract infection prevention, mistreatment detection, acute
care models, and transitional care. ere is a heightened sense of urgency to deploy these
protocols in practice and education because of recent reports and policy changes that are
spotlighted by the debate and discussion surrounding the passage of the 2010 Aord-
able Care Act. Whereas the nal outcome of the law remains to be seen, Americans agree
that there is an urgent resolve for action. e public is waking up to the fact that “It’s
tomorrow already,” as discussed in a recent AARP Bulletin—speaking to the multitude
of complex national issues, not the least of which is health care reform (Toedtman,
2011). e message to nurses is that we must embrace this reality and work to fully use
and promote these geriatric nursing protocols and motivate others to do the same.
Proposed changes to the Centers for Medicare and Medicaid Services (CMS) mea-
surements of quality and cost in health care delivery include the introduction of account-
able care organizations (ACO) and value-based purchasing (VBP; CMS, 2011; Welton,
2010). Delivery model innovation mandates that health care must break away from tra-
ditional models and practices and move toward more ecient and safer care—a clinical
transformation calling for the use of clinical protocols and improved coordination and
collaboration (Health Care Advisory Board, 2010). Although the new language may seem
daunting, geriatric nurses have used this paradigm for years. A recent Wall Street Journal
report on health care summarized it best by saying, “Sometimes innovation means get-
ting back to basics” (Landro, 2011). In truth, it is exactly why geriatric nursing protocols
may be better received and, most importantly, implemented in the years ahead. ese
protocols address basic gerontological tenets: access and quality of care, especially for vul-
nerable populations; prevention of iatrogenic conditions; the institutionalization of best
practices; and the application of innovative and interdisciplinary models of care.
ese are uncertain times in health care, with new payment systems and models of
care being developed; however, the overriding theme is urgency and delivering results.
erefore, take these protocols and adopt them as your unit based standards. Talk to
your patients and families about how nurses have developed methods to improve their
care and reduce the risk of complications. Create teaching plans that supplement the
protocols with actual patient situations, develop documentation templates to integrate
xii Foreword
the protocols into your charting system, and develop quality improvement initiatives
to measure the degree to which you are currently using these protocols and set goals to
improve their use.
e 2011 Institute of Medicine (IOM) report, e Future of Nursing: Leading
Change, Advancing Health, makes our directive clear and powerful. e IOM was
founded on the following premise: “Knowing is not enough; we must apply. Willing is not
enough, we must do” (von Goethe).
Now, more than ever, nurses are called upon to lead eorts to embed evidence-based
practice in daily operations. As the IOM report states, “nurses have key roles to play as
team members and leaders for a reformed and better-integrated, patient-centered health
care system” (p. xii). e process of implementing sweeping change in health care will
likely take years; however, nurses must start pragmatically and focus on these critically
important protocols that have demonstrated improved outcomes for older adults. Sim-
ply stated, “Pick this book up and use it.”
Susan L. Carlson, MSN, APRN, ACNS-BC, GNP-BC, FNGNA
President
National Gerontological Nursing Association
REFERENCES
Centers for Medicare & Medicaid Services. (2011). Special open door forum: Hospital inpatient value-
based purchasing program. Fiscal year 2013. Proposed rule overview. Baltimore, MD.
Health Care Advisory Board. (2010). Health care’s accountability moment: 15 imperatives for success
under risk-based reimbursement. Washington, DC: e Advisory Board Company.
Institute of Medicine. (2011). e future of nursing: Leading change, advancing health. Washington,
DC: National Academies Press.
Landro, L. (2011, March 28). e time to innovate is now. e Wall Street Journal, R1.
Toedtman, J. (2011, March 3). It’s tomorrow already. AARP Bulletin.2.Centers for Medicare &
Medicaid Services (CMS). Special Open Door Forum: Hospital Value-Based Purchasing Proposed
Rule Overview for Facilities, Providers, and Suppliers. Baltimore, MD; 2011.
Welton, J. M. (2010). Value-based nursing care. Journal of Nursing Administration, 40(10), 399–401.
xiii
Acknowledgments
We would like to thank the following for their involvement, support, and leadership
during the production of this book:
n All of the expert contributors for this fourth edition
n ose nursing experts who participated in the Nurse Competence in Aging proj-
ect and contributed protocols to www.HartfordIGN.org, many of which were
the impetus for new topics added to this edition
n e institutions that supported faculty and geriatric clinicians participating as
contributors of the evidence-based protocols
n ose who provided a valuable contribution in the rst and second editions and
their ongoing geriatric research
n Faculty and clinicians involved in the project of the American Association of
Colleges of Nursing to develop geriatric content for upper-division baccalaure-
ate nursing programs
n Springer Publishing Company for its ongoing support of quality geriatric nurs-
ing publications
n Nurses Improving Care for HealthSystem Elders (NICHE) hospitals that bring
many of these protocols to the bedside and are leaders in ensuring geriatric nurs-
ing best practices
xv
Introduction
Older adults are overwhelmingly the majority of hospitalized patients and are, by far, the
most complicated patients to care for in the acute care setting. ey suer from mul-
tiple complex medical problems, take multiple medications, are the most vulnerable to
iatrogenic events, experience prolonged hospital stays, and are the more likely to die in
the hospital (versus community or other setting). Acute care nurses have an enormous
responsibility when providing care to older adults in this rapidly changing healthcare envi-
ronment with increasing regulatory requirements and short stang. Even though older
persons are our fastest growing segment in the United States, most nursing programs,
like medical programs, are just now incorporating geriatrics into the curriculum. Many
unfamiliar with geriatrics might ask: What’s so dierent about older people? Don’t they
have the same diagnoses as younger adults, like diabetes, hypertension, and heart disease?
e answer to that is yes, they do have the same diseases; however, physiological changes
that occur with aging, multiple coexisting medical problems, and multiple medications
place older adults at signicantly higher risk for complications, including death, while
hospitalized. e nurse armed with information on the unique ways in which older adults
present with subtle signs and symptoms may actually avert complications. Additionally,
the nurse equipped with knowledge about and implementation of proactive assessment
and interventions may actually prevent these complications in the rst place.
As in the previous, second edition (honored as American Journal of Nursing, Geriatric
Book of the Year, 2003), we will present assessment and interventions for common geri-
atric syndromes. Geriatric syndromes are increasingly recognized as being related to
preventable iatrogenic complications, or those that occur as a direct result of medical
and nursing care, causing serious adverse outcomes in older patients (See Iatrogenesis
chapter). We are also very happy to present ve new topics and several new expert con-
tributors in this edition. Many of these topics have been updated from the protocols
that appear on the website of the Hartford Institute for Geriatric Nursing at NYU
(www.HartfordIGN.org). e new topics in this edition are:
n Interventions to Prevent Functional Decline in the Acute Care Setting
n Catheter-Associated Urinary Tract Infection Prevention
n Mistreatment Detection
n Acute Care Models
n Transitional Care
In this fourth edition of Evidence-Based Geriatric Nursing Protocols for Best Prac-
tice, we provide guidelines that are developed by experts on the topics of each chapter
and are based on best available evidence. A systematic method, the AGREE appraisal
process (AGREE Next Steps Consortium, 2009; Levin & Vetter, 2007; Singleton &
Levin, 2008), was used to evaluate the protocols in the second edition and identify a
process to help us improve validity of the book’s content. us, a systematic process,
xvi Introduction
described in Chapter 1, was developed to retrieve and evaluate the level of evidence of
key references related to specic assessment and management strategies in each chap-
ter. e purpose in determining the best available evidence was to answer the clinical
questions posed. e chapter authors rated the levels of evidence based on the work of
Stetler and colleagues (1998) and Melnyk and Fineout-Overholt (2011). e rst chap-
ter in this book, “Developing and Evaluating Clinical Practice Guidelines: A Systematic
Approach,” details the process of how the clinical practice guidelines were developed
and how they complied with the AGREE items for rigour of development (AGREE
Next Steps Consortium, 2009). Chapter 1, written by leaders in the eld of evidence-
based practice in the United States, will most likely be the most important chapter refer-
ence for understanding the rating of the levels of evidence. Most of the protocols reect
assessment and intervention strategies for acute care recommended by expert authors
who have reviewed the evidence using this process; the evidence provided may come
from all levels of care and may not have been specically tested in the hospital setting.
How to Best Use This Book
e standard nursing approach was used as a guideline for the outline of each topic
as deemed appropriate by the chapter author(s) providing: overview and background
information on the topic, evidence-based assessment and intervention strategies, and a
topic-specic case study with discussion. e text of the chapter provides the context
and detailed evidence for the protocol; the tabular protocol is not intended to be used in
isolation of the text. We recommend the reader to take the following into consideration
when reviewing the chapters:
n Review the objectives to ascertain what is to be achieved by reviewing the chapter.
n Review the text, noting the level of evidence presented in the reference section—
Level I, being the highest (e.g., systematic review/meta-analysis) and Level VI,
the lowest (e.g., expert opinion). Refer back to Chapter 1, Figure 1.2 for deni-
tions of level of evidence to understand the quantitative evidence that supports
each of the recommendations. Keep in mind that it is virtually impossible to
have evidence for all assessments and interventions, which does not mean it is not
going to be used as an intervention. Many interventions that have been success-
fully used for years have not been quantitatively researched but are well known
to be eective to experts in the eld of geriatrics.
n Review the protocols, and keep in mind they reect assessment and interven-
tion strategies for acute care, recommended by experts who have reviewed the
evidence. is evidence is from all levels of care (e.g., community, primary care,
long-term care) and not necessarily the hospital setting and should be applied to
the unique needs of the individual patient.
n e focus should always be patient centered, which takes into consideration
many other factors specic to the individual.
n Review the case study and discussion in each topic, which provides a more real
life, practical manner in which the protocol may be applied in clinical practice.
n Resources in each chapter to provide easy access to tools discussed in the chapter
and to link readers with organizations that provide on-going, up-to-date infor-
mation and resources on the topic.
n An Appendix provides additional geriatric-specic resources for the reader that
can be applied to all topics.
Introduction xvii
Although this book is entitled Evidence-Based Geriatric Nursing: Protocols for Best
Practice, the text may be utilized by educators for geriatric nursing courses and advance
practice nurses and by many other disciplines including interdisciplinary team mem-
bers, nursing home and other sta educators, social workers, dieticians, advance prac-
tice nurses, physician assistants, and physicians. Many interventions that are proactively
identied and implemented by nurses can make a signicant dierence in improving
outcomes, but nurses cannot provide for the complex needs of older adults in isolation.
Research has shown that interdisciplinary teams have dramatically improved geriatric
patient care and outcomes. We know that communication and collaboration are essen-
tial to improve care coordination and prevent iatrogenic complications (IOM, 2001).
Caring for the older adult, as the baby boom population continues to “age in,” will be
an ultimate challenge in healthcare. Each of us must work together and be committed
to provide a culture of safety that vulnerable older adults need in order to receive the
safest, evidence-based clinical care with optimum outcomes.
Marie Boltz
Elizabeth Capezuti
Terry Fulmer
DeAnne Zwicker
REFERENCES
AGREE Next Steps Consortium. (2009). Appraisal of guidelines for research & evaluation II. Retrieved
from http://www.agreetrust.org/?o=1397
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century.
Washington, DC: National Academy Press.
Levin, R. F., & Vetter, M. (2007). Evidence-based practice: A guide to negotiate the clinical practice
guideline maze. Research and eory for Nursing Practice, 21(1), 5–9.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A
guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Singleton, J. K., & Levin, R. F. (2008). Strategies for learning evidence-based practice: Critically
appraising clinical practice guidelines. Journal of Nursing Education, 47(8), 380–383.
Stetler, C. B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., . . . Sheridan, E. A.
(1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research,
11(4), 195–206.
Evidence-Based Geriatric Nursing
Protocols for Best Practice
1
Clinical decision making that is grounded in the best available evidence is essential to pro-
mote patient safety and quality health care outcomes. With the knowledge base for geri-
atric nursing rapidly expanding, assessing geriatric clinical practice guidelines (CPGs) for
their validity and incorporation of the best available evidence is critical to the safety and
outcomes of care. In the second edition of this book, Lucas and Fulmer (2003) challenged
geriatric nurses to take the lead in the assessment of geriatric clinical practice guidelines
(CPGs), recognizing that in the absence of best evidence, guidelines and protocols have
little value for clinical decision making. In the third edition of this book, Levin, Singleton,
and Jacobs (2008) proposed a method for ensuring that the protocols included in the
book were based on a systematic review of the literature and synthesis of best evidence.
e purpose of this chapter is to describe the process that was used to create the
fourth edition of Evidence-Based Geriatric Nursing Protocols for Best Practice. Prior to
the third edition of this book, each chapter author individually gathered and synthe-
sized evidence on a particular topic and then developed a “nursing standard of practice
protocol” based on that evidence. ere was no standard process or specic criteria for
protocol development nor was there any indication of the “level of evidence” of each
source cited in the chapter (i.e., the evidence base for the protocol). In the third edition
and this fourth edition, the process previously used to develop the geriatric nursing
protocols has been enhanced. is chapter is a guide to understanding how the geriatric
nursing protocols in these third and fourth editions were developed and describes how
to use the process to guide the assessment and/or development and updating of practice
protocols in any area of nursing practice.
DEFINITION OF TERMS
Evidence-based practice (EBP) is a framework for clinical practice that integrates the best
available scientic evidence with the expertise of the clinician and with patients’ prefer-
ences and values to make decisions about health care (Levin & Feldman, 2006; Straus,
Richardson, Glasziou, & Haynes, 2005). Health care professionals often use the terms
recommendations, guidelines, and protocols interchangeably, but they are not synonymous.
A recommendation is a suggestion for practice, not necessarily sanctioned by a formal,
expert group. A clinical practice guideline is an “ocial recommendation” or suggested
approach to diagnose and manage a broad health condition (e.g., heart failure, smoking
Rona F. Levin and Susan Kaplan Jacobs
1
Developing and Evaluating
Clinical Practice Guidelines:
A Systematic Approach
2 Evidence-Based Geriatric Nursing Protocols for Best Practice
cessation, or pain management). A protocol is a more detailed guide for approaching a
clinical problem or health condition and is tailored to a specic practice situation. For
example, guidelines for falls prevention recommend developing a protocol for toileting
elderly, sedated, or confused patients (Rich & Newland, 2006). e specic practices
or protocol each agency implements, however, is agency specic. e validity of any of
these practice guides can vary depending on the type and the level of evidence on which
they are based. Using standard criteria to develop or rene CPGs or protocols assures
reliability of their content. Standardization gives both nurses, who use the guideline/
protocol, and patients, who receive care based on the guideline/protocol, assurance that
the geriatric content and practice recommendations are based on the best evidence.
In contrast to these practice guides, “standards of practice” are not specic or necessar-
ily evidence based; rather, they are a generally accepted, formal, published framework for
practice. As an example, the American Nurses Association document, Nursing: Scope and
Standards of Practice (American Nurses Association, 2010), contains a standard regarding
nurses’ accountability for making an assessment of a patient’s health status. e standard
is a general statement. A protocol, on the other hand, may specify the assessment tool(s)
to use in that assessment—for example, an instrument to predict pressure-ulcer risk.
THE AGREE INSTRUMENT
e AGREE (Appraisal of Guidelines for Research & Evaluation) instrument (http://www
.agreecollaboration.org/), created and evaluated by international guideline developers
and researchers for use by the National Health Services (AGREE Collaboration, 2001),
was initially supported by the UK National Health Services Management Executive and
later by the European Union (Cluzeau, Littlejohns, Grimshaw, Feder, & Moran, 1999).
Released in 2001 in its initial form, the purpose of the AGREE instrument is to pro-
vide standard criteria with which to appraise CPGs. is appraisal includes evaluation of
the methods used to develop the CPG, assessment of the validity of the recommendations
made in the guideline, and consideration of factors related to the use of the CPG in prac-
tice. Although the AGREE instrument was created to critically appraise CPGs, the process
and criteria can also be applied to the development and evaluation of clinical practice pro-
tocols. us, the AGREE instrument has been expanded for that purpose: to standardize
the creation and revision of the geriatric nursing practice protocols in this book.
e initial AGREE instrument and the one used for clinical guideline/protocol
development in the third edition of this book has six quality domains: (a) scope and
purpose, (b) stakeholder involvement, (c) rigour of development, (d) clarity and presenta-
tion, (e) application, and (f) editorial independence. A total of 23 items divided among
the domains were rated on a 4-point Likert-type scale from strongly disagree to strongly
agree. Appraisers evaluate how well the guideline they are assessing meets the criteria
(i.e., items) of the six quality domains. For example, when evaluating the rigour of
development, appraisers rated seven items. e reliability of the AGREE instrument is
increased when each guideline is appraised by more than one appraiser. Each of the six
domains receives an individual domain score and, based on these scores, the appraiser
subjectively assesses the overall quality of a guideline.
Important to note, however, is that the original AGREE instrument was revised in
2009 (http://www.agreetrust.org/), is now called AGREE II, and is the version that we
used for this fourth edition (AGREE Next Steps Consortium, 2009). e revision added
one new item to the rigour of development domain. is is the current Item 9, which
underscores the importance of evaluating the evidence that is applied to practice. Item 9
Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 3
reads: “e strengths and limitations of the body of evidence are clearly described.” e
remainder of the changes included a revision of the Likert-type scale used to evaluate each
item in the AGREE II, a reordering of the number assigned to each item based on the
addition of the new Item 9 and minor editing of items for clarity. No other substantive
changes were made. Table 1.1 includes the items that are in the rigour of development
domain and were used for evaluation of evidence in the current edition of this book.
e rigour of development section of the AGREE instrument provides standards
for literature-searching and documenting the databases and terms searched. Adhering
to these criteria to nd and use the best available evidence on a clinical question is criti-
cal to the validity of geriatric nursing protocols and, ultimately, to patient safety and
outcomes of care.
Published guidelines can be appraised using the AGREE instrument as discussed
previously. In the process of guideline development, however, the clinician is faced with
the added responsibility of appraising all available evidence for its quality and relevance.
In other words, how well does the available evidence support recommended clinical
practices? e clinician needs to be able to support or defend the inclusion of each
recommendation in the protocol based on its level of evidence. To do so, the guideline
must reect a systematic, structured approach to nd and assess the available evidence.
The Search for Evidence Process
Models of EBP describe the evidence-based process in ve steps:
1. Develop an answerable question.
2. Locate the best evidence.
3. Critically appraise the evidence.
4. Integrate the evidence into practice using clinical expertise with attention to patient’s
values and perspectives.
5. Evaluate outcome(s).
(Flemming, 1998; McKibbon, Wilczynski, Eady, & Marks, 2009; Melnyk & Fineout-
Overholt, 2011)
Sample domain and items from the AGREE II instrument for critical appraisal
of clinical practice guidelines with rating scale.
Domain 3: Rigour of Development
7. Systematic methods were used to search for evidence.
8. The criteria for selecting the evidence are clearly described.
9. The strengths and limitations of the body of evidence are clearly described
10. The methods for formulating the recommendations are clearly described.
11. The health benefits, side effects, and risks have been considered in formulating the
recommendations.
12. There is an explicit link between the recommendations and the supporting evidence.
13. The guideline has been externally reviewed by experts prior to its publication.
14. A procedure for updating the guideline is provided.
Source: e AGREE Research Trust. (2009). Appraisal of Guidelines for Research and Evaluation, AGREE II
Instrument. Retrieved from http://www.agreetrust.org/index.aspx?o=1397
TABLE 1.1
4 Evidence-Based Geriatric Nursing Protocols for Best Practice
Locating evidence to support development of protocols, guidelines, and reviews
requires a comprehensive and systematic review of the published literature, following
Steps 1 and 2. A search begins with Step 1, developing an answerable question, which
may be in the form of a specic “foreground” question (one that is focused on a par-
ticular clinical issue), or it may be a broad question (one that asks for overview infor-
mation about a disease, condition, or aspect of healthcare) (Flemming, 1998; Melnyk
& Fineout-Overholt, 2011; Straus et al., 2005) to gain an overview of the practice
problem and interventions and gain insight into its signicance. is step is critical to
identifying appropriate search terms, possible synonyms, construction of a search strat-
egy, and retrieving relevant results. One example of an answerable foreground question
asked in this book is “What is the eectiveness of restraints in reducing the occurrence
of falls in patients 65 years of age and older?” Foreground questions are best answered by
individual primary studies or syntheses of studies, such as systematic reviews or meta-
analyses. PICO templates work best to gather the evidence for focused clinical questions
(Glasziou, Del Mar, & Salisbury, 2003). PICO is an acronym for population, interven-
tion (or occurrence or risk factor), comparison (or control), and outcome. In the preced-
ing question, the population is patients at risk of falling, 65 years of age and older; the
intervention is use of restraints; the implied comparison or control is no restraints; and
the desired outcome is decreased incidence of falls. An initial database search would
consider the problem (falls) and the intervention (restraints) to begin to cast a wide net
to gather evidence. A broader research query, related to a larger category of disease or
problem and encompassing multiple interventions, might be “What is the best available
evidence regarding the use of restraints in residential facilities?” (Griggs, 2009)
General or overview/background questions may be answered in textbooks, review
articles, and “point-of-care” tools that aggregate overviews of best evidence, for example,
online encyclopedias, systematic reviews, and synthesis tools (BMJ Publishing Group
Limited; e Cochrane Collaboration; Joanna Briggs Institute; UpToDate; Wolters
Kluwer Health). is may be helpful in the initial steps of gathering external evidence
to support the signicance of the problem you believe exists prior to developing your
PICO question and investing a great deal of time in a narrow question for which there
might be limited evidence.
Step 2, locating the evidence, requires a literature search based on the elements
identied in the clinical question. Gathering the evidence for the protocols in this book
presented the challenge to conduct literature reviews, encompassing both the breadth of
overview information as well as the depth of specicity represented in high-level system-
atic reviews and clinical trials to answer specic clinical questions.
Not every nurse, whether he or she is a clinical practitioner, educator, or adminis-
trator, has developed procient database search skills to conduct a literature review to
locate evidence. Beyond a basic knowledge of Boolean logic, truncation, and applying
categorical limits to lter results, competency in “information literacy” (Association
of College & Research Libraries, 2000) requires experience with the idiosyncrasies of
databases, selection of terms, and ease with controlled vocabularies and database func-
tionality. Many nurses report that limited access to resources, gaps in information lit-
eracy skills, and, most of all, a lack of time are barriers to “readiness” for EBP (Praviko,
Tanner, & Pierce, 2005).
For both the third and current edition of this book, the authors enlisted the assis-
tance of a team of New York University health sciences librarians to assure a standard and
ecient approach to collecting evidence on clinical topics. Librarians as intermediaries
Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 5
have been called “an essential part of the health care team by allowing knowledge con-
sumers to focus on the wise interpretation and use of knowledge for critical decision
making, rather than spending unproductive time on its access and retrieval” (Homan,
2010, p. 51). e Cochrane Handbook for Systematic Reviews of Interventions points out
the complexity of conducting a systematic literature review and highly recommends
enlisting the help of a healthcare librarian when searching for studies to support locat-
ing studies for systematic reviews (Section 6.3.1; Higgins & Green, 2008). e team of
librarian/searchers were given the topics, keywords, and suggested synonyms, as well as
the evidence pyramid we agreed upon, and they were asked to locate the best available
evidence for each broad area addressed in the following chapters.
Search Strategies for Broad Topics
e literature search begins with database selection and translation of search terms into
the controlled vocabulary of the database if possible. e major databases for nding the
best primary evidence for most clinical nursing questions are CINAHL (Cumulative
Index to Nursing and Allied Health Literature) and MEDLINE. e PubMed inter-
face to MEDLINE was used, as it includes added “unprocessed” records to provide
access to the most recently published citations. For most topics, the PsycINFO data-
base was searched to ensure capturing relevant evidence in the literature of psychol-
ogy and behavioral sciences. e Cochrane Database of Systematic Reviews and the
Joanna Briggs Institute’s evidence summaries (e Cochrane Collaboration; Joanna
Briggs Institute) were also searched to provide authors with another synthesized source
of evidence for broad topic areas.
e AGREE II instrument was used as a standard against which we could evalu-
ate the process for evidence searching and use in chapter and protocol development
(AGREE Next Steps Consortium, 2009). Domain 3, rigour of development, Item 7,
states: “e search strategy should be as comprehensive as possible and executed in a
manner free from potential biases and suciently detailed to be replicated.” Taking a tip
from the Cochrane Handbook, a literature search should capture both the subject terms
and the methodological aspects of studies when gathering relevant records (Higgins &
Green, 2008). Both of these directions were used to develop search strategies and deliver
results to chapter authors using the following guidelines:
n To facilitate replication and update of searches in all databases, search results
sent to authors were accompanied by a search strategy: listing the keywords/
descriptors and search string used in each database searched (e.g., MEDLINE,
PsycINFO, CINAHL).
n e time period searched was specied (e.g, 2006–2010).
n Categorical limits or methodological lters were specied. (Some examples are
the article type: “meta-analysis” or the “systematic review subset” in Pubmed;
the “methodology” limit in PsycINFO for meta-analysis OR clinical trial; the
“research” limit in CINAHL.)
n To facilitate replication and update of MEDLINE/PubMed searches, searches
were saved and chapter authors were supplied with a login and password
for a My NCBI account (National Center for Biotechnology Information,
U.S. National Library of Medicine), linking to Saved Searches to be rerun at
later dates.
6 Evidence-Based Geriatric Nursing Protocols for Best Practice
e librarian then aggregated evidence in a RefWorks database and sent this output
to all chapter authors to enhance their knowledge base and provide a foundation for
further exploration of the literature.
Limits, Hedges, and Publication Types
Most bibliographic databases have the functionality to exploit the architecture of the
individual citations to limit to articles tagged with publication types (such as “meta-
analysis” or “randomized controlled trial” in MEDLINE). In CINAHL, methodologi-
cal lters or “hedges” (Haynes, Wilczynski, McKibbon, Walker, & Sinclair, 1994) for
publication types “systematic review,” “clinical trials,” or “research” articles are avail-
able. e commonly used PubMed “Clinical Queries” feature (http://www.nlm.nih.
gov/pubs/techbull/mj10/mj10_clin_query.html) is designed for specic clinical ques-
tions such as the example mentioned previously. Gathering evidence to support broader
topics, such as the protocols in this book, presents the searcher with a larger challenge.
Limiting searches by methodology can unwittingly eliminate the best evidence for study
designs that do not lend themselves to these methods. For example, a cross-sectional
retrospective design may provide the highest level of evidence for a study that examines
“nurses’ perception” of the practice environment (Boltz et al., 2008). Methodological
lters have other limitations, such as retrieving citations tagged “randomized controlled
trials as topic” or abstracts that state a “systematic review of the literature” was con-
ducted (which is not the same as retrieving a study that is actually a systematic review).
Chapter authors were cautioned that the CINAHL database assigns publication type
“systematic review” to numerous citations that upon review, we judged to be “Level V”
review articles (narrative reviews or literature reviews), not necessarily the high level of
evidence we would call “Level I,” (which according to our scheme are studies that do
a rigorous synthesis and pooling or analysis of research results). It may not be easily
discernible from an article title and abstract whether the study is a systematic review
with evidence synthesis or a narrative literature review (Lindbloom, Brandt, Hough, &
Meadows, 2007). ese pitfalls of computerized retrieval are justication for the review
by the searcher to weed false hits from the retrieved list of articles.
Precision and Recall
An additional challenge to an intermediary searcher is the need to balance the compre-
hensiveness of recall (or “sensitivity”) with precision (“specicity”) to retrieve a “useful”
number of references. e Cochrane Handbook states: “Searches should seek high sensitiv-
ity, which may result in relatively low precision” (Section 6.3; Higgins & Green, 2008).
us, retrieving a large set of articles may include many irrelevant hits. Conversely, put-
ting too many restrictions on a search may exclude relevant studies. e goal of retrieving
the relevant studies for broad topic areas required “sacricing precision” and deferring to
the chapter authors to lter false or irrelevant hits (Jenkins, 2004; Matthews et al., 1999).
e iterative nature of a literature search requires that an initial set of relevant references
for both broad or specic research questions serves to point authors toward best evidence
as an adjunct to their own knowledge, their own pursuit of “chains of citation” (McLellan,
2001) and related records, and their clinical expertise. us, a list of core references on
physical restraints, supplied to a chapter author, might lead to exploring citations related
to wandering, psychogeriatric care, or elder abuse (Fulmer, 2002).
Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 7
LEVELS OF EVIDENCE
Step 3, critical appraisal of the evidence, begins with identifying the methodology
used in a study (often evident from reviewing the article abstract) followed by a critical
reading and evaluation of the research methodology and results. e coding scheme
described in the subsequent text provides the rst step in ltering retrieved studies based
on research methods.
Levels of evidence oer a schema that, once known, helps the reader to understand the
value of the information presented to the clinical topic or question under review. ere are
many schemas that are used to identify the level of evidence sources. Although multiple
schemas exist, they have commonalities in their hierarchical structure, often represented
by a pyramid or “publishing wedge” (DiCenso, Bayley, & Haynes, 2009; McKibbon et
al., 2009). e highest level of evidence is seen at the top of a pyramid, characterized by
increased relevance to the clinical setting in a smaller number of studies. e schema used
by the authors in this book for rating the level of evidence comes from the work of Stetler
et al. (1998) and Melnyk and Fineout-Overholt (2005; See Figure 1.1).
A Level I evidence rating is given to evidence from synthesized sources (systematic
reviews), which can either be meta-analyses or structured integrative reviews of evidence,
and CPG’s based on Level I evidence. Evidence rated as Level II comes from a randomized
controlled trial. A quasi-experimental study such as a nonrandomized controlled single
Levels of quantitative evidence.
FIGURE 1.1
Level I
Systematic Reviews
Level II
Single experimental study (RCT’s)
Level III
Quasi-experimental studies
Level IV
Non-experimental studies
Level V
Case report/program evaluation/narrative literature reviews
Level VI
Opinions of respected authorities
Systematic Reviews (Integrative/Meta-analyses/CPG’s based on systematic reviews) Adapted from Stetler,
C. B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., . . . Sheridan, E. A. (1998).
Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4), 195–206;
Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to
best practice (p. 608). Philadelphia, PA: Lippincott Williams & Wilkins.
8 Evidence-Based Geriatric Nursing Protocols for Best Practice
group pretest and posttest time series or matched case-controlled study is considered Level
III evidence. Level IV evidence comes from a nonexperimental study, such as correlational
descriptive research and qualitative or case- control studies. A narrative literature review,
a case report systematically obtained and of veriable quality, or program evaluation data
are rated as Level V. Level VI evidence is identied as the opinion of respected authorities
(e.g., nationally known) based on their clinical experience or the opinions of an expert
committee, including their interpretation of non-research-based information. is level
also includes regulatory or legal opinions. Level I evidence is considered the strongest.
For all topics, the results of literature searches were organized in a searchable, web-
based RefWorks “shared” folder and coded for level of evidence. e authors were then
charged with reviewing the evidence and deciding on its quality and relevance for inclu-
sion in their chapter or protocol. e critical appraisal of research uses specialized tools
designed to evaluate the methodology of the study. Examples are the AGREE instru-
ment (which this volume of protocols conforms to) (AGREE Next Steps Consortium,
2009), the Critical Appraisal Skills Programme (CASP) (Solutions for Public Health),
and the PRISMA Statement (PRISMA: Transparent reporting) among others.
An additional feature implemented in the previous edition of this book is the inclu-
sion of the level and type of evidence for each reference, which leads to a recommenda-
tion for practice (See Exhibit 1.1). Using this type of standard approach ensures that
this book contains protocols and recommendations for use with geriatric patients and
their families that are based on the best available evidence.
SUMMARY
e protocols contained in this edition, therefore, have been rened, revised, and/or
developed by the authors using the best available research evidence as a foundation,
An example of a coded literature citation supplied to protocol author.
REF ID: 22449 Level IV
Boltz, M., Capezuti, E., Bowar-Ferres, S., Norman, R., Secic, M., Kim, H. et al. (2008). Hospital
nurses’ perception of the geriatric nurse practice environment. Journal of Nursing Scholarship,
40(3), 282-289.
Purpose: To test the relationship between nurses’ perceptions of the geriatric nurse practice
environment (GNPE) and perceptions of geriatric-care delivery, and geriatric nursing knowledge.
Design: A secondary analysis of data collected by the New York University Hartford Institute
Benchmarking Service staff using a retrospective, cross-sectional, design. Methods: Responses
of 9,802 direct-care registered nurses from 75 acute-care hospitals in the US that administered
the GIAP (Geriatric Institutional Assessment Profile) from January 1997 to December 2005 were
analyzed using linear mixed effects modeling to explore associations between variables while
controlling for potential covariates. Findings: Controlling for hospital and nurse characteristics, a
positive geriatric nurse practice environment was associated with positive geriatric care delivery
(F=4,686, p<.0001) but not geriatric nursing knowledge. The independent contribution of all three
dimensions of the geriatric nurse practice environment (resource availability, institutional values, and
capacity for collaboration) influences care delivery for hospitalized older-adult patients. Conclusions:
Organizational support for geriatric nursing is an important influence upon quality of geriatric care.
Clinical Relevance: Hospitals that utilize an organizational approach addressing the multifaceted
nature of the GNPE are more likely to improve the hospital experience of older adults.
EXHIBIT 1.1
Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 9
with the ultimate goal of improving patient safety and outcomes. e systematic pro-
cess we used for nding, retrieving, and disseminating the best evidence for the fourth
edition of Geriatric Nursing Protocols for Best Practice provides a model for the use of
research evidence in nursing education and in clinical practice. Translating nursing
research into practice requires competency in information literacy, knowledge of the
evidence-based process, and the ability to discern the context of a research study as
ranked hierarchically. e following chapters and protocols present both overview and
foreground information in readiness for taking the next steps in the EBP process: Step
4, integrate the evidence with clinical expertise and patient’s values and perspective, and
Step 5, evaluate outcome.
REFERENCES
American Nurses Association. (2010). Nursing: Scope and standards of practice. Silver Spring, MD:
Authors.
AGREE Collaboration. (2001). Appraisal of Guidelines Research and Evaluation. Retrieved from
http://www.agreecollaboration.org/
AGREE Next Steps Consortium. (2009). Appraisal of guidelines for research & evaluation II.
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11
EDUCATIONAL OBJECTIVES
After completion of this chapter, the reader will be able to:
1. discuss key components of the denition of quality as outlined by the Institute of
Medicine (IOM)
2. describe three challenges of measuring quality of care
3. delineate three strategies for addressing the challenges of measuring quality
4. list three characteristics of a good performance measure
Nadzam and Abraham (2003) state that, “e main objective of implementing best
practice protocols for geriatric nursing is to stimulate nurses to practice with greater
knowledge and skill, and thus improve the quality of care to older adults” (p. 11).
Although improved patient care and safety certainly is a goal, providers also need to be
focused on the implementation of evidence-based practice and on improving outcomes
of care. e implementation of evidenced-based nursing practice as a means to provid-
ing safe, quality patient care, and positive outcomes is well supported in the literature.
However, in order to ensure that protocols are implemented correctly, as is true with
the delivery of all nursing care, it is essential to evaluate the care provided. Outcomes
of care are gaining increased attention and will be of particular interest to providers as
the health care industry continues to move toward a “pay-for-performance (P4P)/value-
based purchasing (VBP)” reimbursement model.
BACKGROUND AND STATEMENT OF PROBLEM
e improvement of care and clinical outcomes––or, as it is commonly known as Per-
formance Improvement––requires a dened, organized approach. Improvement eorts
are typically guided by the organization’s Quality Assessment (measurement) and Per-
formance Improvement (process improvement) model. Some well-known models or
approaches for improving care and processes include Plan-Do-Study-Act (PDSA; Insti-
tute for Health Care Improvement, see http://www.ihi.org/IHI/Topics/Improvement/
ImprovementMethods/Tools/Plan-Do-Study-Act%20(PDSA)%20Worksheet) and Six
Lenard L. Parisi
2
Measuring Performance,
Improving Quality
12 Evidence-Based Geriatric Nursing Protocols for Best Practice
Sigma (see http://asq.org/learn-about-quality/six-sigma/overview/overview.html). ese
methodologies are simply an organized approach to dening improvement priorities,
collecting data, analyzing the data, making sound recommendations for process improve-
ment, implementing identied changes, and then reevaluating the measures. rough
Performance Improvement, standards of care (e.g., Nurses Improving Care for Health-
system Elders [NICHE] protocols, in this case) are identied, evaluated, analyzed for
variances, and improved. e goal is to standardize and improve patient care and out-
comes. Restructuring, redesigning, and innovative processes aid in improving the qual-
ity of patient care. However, nursing professionals must be supported by a structure of
continuous improvement that empowers nurses to make changes and delivers reliable
outcomes (Johnson, Hallsey, Meredith, & Warden, 2006).
From the very beginning of the NICHE project in the early 1990s (Fulmer et
al., 2002), the NICHE team has struggled with the following questions: How can we
measure whether the combination of models of care, sta education and development,
and organizational change leads to improvements in patient care? How can we provide
hospitals and health systems that are committed to improving their nursing care to
older adults with guidance and frameworks, let alone tools for measuring the quality
of geriatric care? In turn, these questions generated many other questions: Is it possible
to measure quality? Can we identify direct indicators of quality? Or do we have to rely
on indirect indicators (e.g., if 30-day readmissions of patients older than the age of 65
drop, can we reasonably state that this reects an improvement in the quality of care)?
What factors may inuence our desired quality outcomes, whether these are unrelated
factors (e.g., the pressure to reduce length of stay) or related factors (e.g., the severity
of illness)? How can we design evaluation programs that enable us to measure quality
without adding more burden (of data collection, of taking time away from direct nurs-
ing care)? No doubt, the results from evaluation programs should be useful at the “local”
level. Would it be helpful, though, to have results that are comparable across clinical
settings (within the same hospital or health system) and across institutions (e.g., as qual-
ity benchmarking tools)? Many of these questions remain unanswered today, although
the focus on dening practice through an evidence-based approach is becoming the
standard, for it is against a standard of care that we monitor and evaluate expected care.
Dening outcomes for internal and external reporting is expected, as is the improve-
ment of processes required to deliver safe, aordable, and quality patient care.
is chapter provides guidance in the selection, development, and use of perfor-
mance measures to monitor quality of care as a springboard to Performance Improve-
ment initiatives. Following a denition of quality of care, the chapter identies several
challenges in the measurement of quality. e concept of performance measures as the
evaluation link between care delivery and quality improvement is introduced. Next, the
chapter oers practical advice on what and how to measure (Fulmer et al., 2002). It also
describes external comparative databases sponsored by Centers for Medicare & Medic-
aid Services (CMS) and other quality improvement organizations. It concludes with a
description of the challenge to selecting performance measures.
It is important to rearm two key principles for the purposes of evaluating nurs-
ing care in this context. First, at the management level, it is indispensable to measure
the quality of geriatric nursing care; however, doing so must help those who actually
provide care (nurses) and must impact on those who receive care (older adult patients).
Second, measuring quality of care is not the end goal; rather, it is done to enable the
continuous use of quality-of-care information to improve patient care.
Measuring Performance, Improving Quality 13
ASSESSMENT OF THE PROBLEM
Quality Health Care Defined
It is not uncommon to begin a discussion of quality-related topics without reecting on
one’s own values and beliefs surrounding quality health care. Many have tried to dene
the concept; but like the old cliché “beauty is in the eye of the beholder,” so is our own
perception of quality. Health care consumers and providers alike are often asked, “What
does quality mean to you?” e response typically varies and includes statements such as
“a safe health care experience,” “receiving correct medications,” “receiving medications
in a timely manner,” “a pain-free procedure or postoperative experience,” “compliance
with regulation,” “accessibility to services,” “eectiveness of treatments and medica-
tions,” “eciency of services,” “good communication among providers,” “information
sharing,” and “a caring environment.” ese are important attributes to remember when
discussing the provision of care with clients and patients.
e IOM denes quality of care as “the degree to which health services for indi-
viduals and populations increase[s] the likelihood of desired health outcomes and
are consistent with current professional knowledge” (Kohn, Corrigan, & Donaldson,
2000, p. 211). Note that this denition does not tell us what quality is, but what
quality should achieve. is denition also does not say that quality exists if certain
conditions are met (e.g., a ratio of x falls to y older orthopedic surgery patients, a
30-day readmission rate of z). Instead, it emphasizes that the likelihood of achiev-
ing desired levels of care is what matters. In other words, quality is not a matter of
reaching something but, rather, the challenge, over and over, of improving the odds
of reaching the desired level of outcomes. us, the denition implies the cyclical and
longitudinal nature of quality: What we achieve today must guide us as to what to do
tomorrow—better and better, over and over. e focus being on improving processes
while demonstrating sustained improvement.
e IOM denition stresses the framework within which to conceptualize quality:
knowledge. e best knowledge to have is research evidence—preferably from random-
ized clinical trials (experimental studies)—yet without ignoring the relevance of less
rigorous studies (nonrandomized studies, epidemiological investigations, descriptive
studies, even case studies). Realistically, in nursing, we have limited evidence to guide
the care of older adults. erefore, professional consensus among clinical and research
experts is a critical factor in determining quality. Furthermore, knowledge is needed
at three levels: To achieve quality, we need to know what to do (knowledge about best
practice), we need to know how to do it (knowledge about behavioral skills), and we
need to know what outcomes to achieve (knowledge about best outcomes).
e IOM denition of quality of care contains several other important elements.
“Health services” focuses the denition on the care itself. Granted, the quality of care
provided is determined by such factors as knowledgeable professionals, good technol-
ogy, and ecient organizations; however, these are not the focus of quality measure-
ment. Rather, the denition implies a challenge to health care organizations: e system
should be organized in such a way that knowledge-based care is provided and that its
eects can be measured. is brings us to the “desired health outcomes” element of the
denition. Quality is not an attribute (as in “My hospital is in the top 100 hospitals in
the United States as ranked by U.S. News & World Report”), but an ability (as in “Only
x% of our older adult surgical patients go into acute confusion; of those who do, y%
return to normal cognitive function within z hours after onset”).
14 Evidence-Based Geriatric Nursing Protocols for Best Practice
In the IOM denition, degree implies that quality occurs on a continuum from
unacceptable to excellent. e clinical consequences are on a continuum as well. If
the care is of unacceptable quality, the likelihood that we will achieve the desired out-
comes is nil. In fact, we probably will achieve outcomes that are the opposite of what
are desired. As the care moves up the scale toward excellent, the more likely the desired
outcomes will be achieved. Degree also implies quantication. Although it helps to be
able to talk to colleagues about, say, unacceptable, poor, average, good, or excellent care,
these terms should be anchored by a measurement system. Such systems enable us to
interpret what, for instance, poor care is by providing us with a range of numbers that
correspond to poor. In turn, these numbers can provide us with a reference point for
improving care to the level of average: We measure care again, looking at whether the
numbers have improved, then checking whether these numbers fall in the range dened
as average. Likewise, if we see a worsening of scores, we will be able to conclude whether
we have gone from, say, good to average. Individuals and populations underscores that
quality of care is reected in the outcomes of one patient and in the outcomes of a set of
patients. It focuses our attention on providing quality care to individuals while aiming
to raise the level of care provided to populations of patients.
In summary, the IOM denition of quality of care forces us to think about qual-
ity in relative and dynamic rather than in absolute and static terms. Quality of care is
not a state of being but a process of becoming. Quality is and should be measurable,
using performance measures—“a quantitative tool that provides an indication of an
organization’s performance in relation to a specied process or outcome” (Schyve &
Nadzam, 1998, p. 222).
Quality improvement is a process of attaining ever better levels of care in parallel
with advances in knowledge and technology. It strives toward increasing the likelihood
that certain outcomes will be achieved. is is the professional responsibility of those
who are charged with providing care (clinicians, managers, and their organizations). On
the other hand, consumers of health care (not only patients but also purchasers, payors,
regulators, and accreditors) are much less concerned with the processes in place, as with
the results of those processes.
Clinical Outcomes and Publicly Reported Quality Measures
Although it is important to evaluate clinical practices and processes, it is equally
important to evaluate and improve outcomes of care. Clinical outcome indicators
are receiving unprecedented attention within the health care industry from provid-
ers, payors, and consumers alike. Regulatory and accrediting bodies review outcome
indicators to evaluate the care provided by the organization prior to and during
regulatory and accrediting surveys, and to evaluate clinical and related processes.
Organizations are expected to use outcome data to identify and prioritize the pro-
cesses that support clinical care and demonstrate an attempt to improve performance.
Providers may use outcomes data to support best practices by benchmarking their
results with similar organizations. e benchmarking process is supported through
publicly reported outcomes data at the national and state levels. National reporting
occurs on the CMS website, where consumers and providers alike may access informa-
tion and compare hospitals, home-care agencies, nursing homes, and managed care
plans. For example, the websites http://www.hospitalcompare.hhs.gov, http://www
.medicare.gov/nhcompare/, and http://www.medicare.gov/HomeHealthCompare
Measuring Performance, Improving Quality 15
list outcome indicators relative to the specic service or delivery model. Consumers
may use those websites to select organizations and compare outcomes, one against
another, to aid in their selection of a facility or service. ese websites also serve
as a resource for providers to benchmark their outcomes against those of another
organization. Outcomes data also become increasingly important to providers as the
industry shifts toward a P4P/ VBP model.
In a P4P/VBP model, practitioners are reimbursed for achieved quality-of-care
outcomes. Currently, the CMS has several P4P initiatives and demonstration proj-
ects (see http://www.cms.gov/DemoProjectsEvalRpts/ for details). e Hospital
Quality Initiative (see http://www.cms.gov/HospitalQualityInits/ and http://www
.cms.gov/HospitalQualityInits/Downloads/Hospital_VBP_102610.pdf for a detailed
overview) is part of the U.S. Department of Health and Human Services’ broader
national quality initiative that focuses on an initial set of 10 quality measures by link-
ing reporting of those measures to the payments the hospitals receive for each dis-
charge. e purpose of the Premier Hospital Quality Incentive Demonstration (see
http://www.cms.gov/HospitalQualityInits/35_HospitalPremier.asp for more details
and outcomes) was to have improved the quality of inpatient care for Medicare ben-
eciaries by giving nancial incentives to almost 300 hospitals for high quality. e
Physician Group Practice Demonstration, mandated by the Medicare, Medicaid,
and State Children’s Health Insurance Program (SCHIP) Benets Improvement and
Protection Act of 2000 (BIPA), is the rst P4P initiative for physicians under the
Medicare program. e Medicare Care Management Performance Demonstration
(Medicare Modernization Act [MMA] section 649), modeled on the “bridges to
excellence” program, is a 3-year P4P demonstration with physicians to promote
the adoption and use of health information technology to improve the quality of
patient care for chronically ill Medicare patients. e Medicare Health Care Quality
Demonstration, mandated by section 646 of the MMA, is a 5-year demonstration
program under which projects enhance quality by improving patient safety, reducing
variations in utilization by appropriate use of evidence-based care and best practice
guidelines, encouraging shared decision making, and using culturally and ethnically
appropriate care.
INTERVENTIONS AND CARE STRATEGIES
Measuring Quality of Care
Schyve and Nadzam (1998) identied several challenges to measuring quality. First,
the suggestion that quality of care is in the eye of the beholder points to the dierent
interests of multiple users. is issue encompasses both measurement and communica-
tion challenges. Measurement and analysis methods must generate information about
the quality of care that meets the needs of dierent stakeholders. In addition, the results
must be communicated in ways that meet these dierent needs. Second, we must have
good and generally accepted tools for measuring quality. us, user groups must come
together in their conceptualization of quality care so that relevant health care measures
can be identied and standardized. A common language of measurement must be devel-
oped, grounded in a shared perspective on quality that is cohesive across, yet meets the
needs of various user groups. ird, once the measurement systems are in place, data
must be collected. is translates into resource demands and logistic issues as to who is
16 Evidence-Based Geriatric Nursing Protocols for Best Practice
to report, record, collect, and manage data. Fourth, data must be analyzed in statistically
appropriate ways. is is not just a matter of using the right statistical methods. More
important, user groups must agree on a framework for analyzing quality data to inter-
pret the results. Fifth, health care environments are complex and dynamic in nature.
ere are dierences across health care environments, between types of provider organi-
zations, and within organizations. Furthermore, changes in health care occur frequently,
such as the movement of care from one setting to another and the introduction of new
technology. Finding common denominators is a major challenge.
Addressing the Challenges
ese challenges are not insurmountable. However, making a commitment to quality
care entails a commitment to putting the processes and systems in place to measure
quality through performance measures and to report quality-of-care results. is com-
mitment applies as much to a quality-improvement initiative on a nursing unit as it
does to a corporate commitment by a large health care system. In other words, once
an organization decides to pursue excellence (i.e., quality), it must accept the need to
overcome the various challenges to measurement and reporting. Let us examine how
this could be done in a clinical setting.
McGlynn and Asch (1998) oer several strategies for addressing the challenges to
measuring quality. First, the various user groups must identify and balance competing
perspectives. is is a process of giving and taking: not only proposing highly clinical
measures (e.g., prevalence pressure ulcers) but also providing more general data (e.g.,
use of restraints). It is a process of asking and responding: not only asking management
for monthly statistics on medication errors but also agreeing to provide management
with the necessary documentation of the reasons stated for restraint use. Second, there
must be an accountability framework. Committing to quality care implies that nurses
assume several responsibilities and are willing to be held accountable for each of them:
(a) providing the best possible care to older patients, (b) examining their own geriatric
nursing knowledge and practice, (c) seeking ways to improve it, (d) agreeing to evalua-
tion of their practice, and (e) responding to needs for improvement. ird, there must
be objectivity in the evaluation of quality. is requires setting and adopting explicit
criteria for judging performance, then building the evaluation process on these criteria.
Nurses, their colleagues, and their managers need to reach consensus on how perfor-
mance will be measured and what will be considered excellent (and good, average, etc.)
performance. Fourth, once these indicators have been identied, nurses need to select a
subset of indicators for routine reporting. Indicators should give a reliable snapshot of
the team’s care to older patients. Fifth, it is critical to separate as much as possible the
use of indicators for evaluating patient care and the use of these indicators for nancial
or nonnancial incentives. Should the team be cost conscious? Yes, but cost should not
inuence any clinical judgment as to what is best for patients. Finally, nurses in the
clinical setting must plan how to collect the data. At the institutional level, this may be
facilitated by information systems that allow performance measurement and reporting.
Ideally, point-of-care documentation will also provide the data necessary for a system-
atic and goal-directed quality-improvement program, thus, eliminating separate data
abstraction and collection activities.
e success of a quality-improvement program in geriatric nursing care (and the
ability to overcome many of the challenges) hinges on the decision as to what to measure.
Measuring Performance, Improving Quality 17
We know that good performance measures must be objective, that data collection must
be easy and as burdenless as possible, that statistical analysis must be guided by princi-
ples and placed within a framework, and that communication of results must be targeted
toward dierent user groups. Conceivably, we could try to measure every possible aspect
of care; realistically, however, the planning for this will never reach the implementation
stage. Instead, nurses need to establish priorities by asking these questions: Based on
our clinical expertise, what is critical for us to know? What aspects of our care to older
patients are high risk or high volume? What parts of our elder care are problem-prone,
either because we have experienced diculties in the past or because we can anticipate
problems caused by the lack of knowledge or resources? What clinical indicators would
be of interest to other user groups: patients, the general public, management, payors,
accreditors, and practitioners? roughout this prioritization process, nurses should
keep asking themselves: What questions are we trying to answer, and for whom?
Measuring Performance—Selecting Quality Indicators
e correct selection of performance measures or quality indicators is a crucial step in
evaluating nursing care and is based on two important factors: frequency and volume.
Clearly, high-volume practices or frequent processes require focused attention––to ensure
that the care is being delivered according to protocol or processes are functioning as
designed. Problem-prone or high-risk processes would also warrant a review because these
are processes with inherent risk to patients or variances in implementing the process. e
selection of indicators must also be conistent with organizational goals for improvement.
is provides buy-in from practitioners as well as administration when reporting and
identifying opportunities for improvement. Performance measures (indicators) must be
based on either a standard of care, policy, procedure, or protocol. ese documents, or
standards of care, dene practice and expectations in the clinical setting and, therefore,
determine the criteria for the monitoring tool. e measurement of these standards sim-
ply reects adherence to or implementation of these standards. Once it is decided what
to measure, nurses in the clinical geriatric practice setting face the task of deciding how to
measure performance. ere are two possibilities: either the appropriate measure (indica-
tor) already exists or a new performance measure must be developed. Either way, there are
a number of requirements of a good performance measure that will need to be applied.
Although indicators used to monitor patient care and performance do not need to
be subject to the rigors of research, it is imperative that they reect some of the attributes
necessary to make relevant statements about the care. e measure and its output need to
focus on improvement, not merely the description of something. It is not helpful to have
a very accurate measure that just tells the status of a given dimension of practice. Instead,
the measure needs to inform us about current quality levels and relate them to previ-
ous and future quality levels. It needs to be able to compute improvements or declines
in quality over time so that we can plan for the future. For example, to have a measure
that only tells the number of medication errors in the past month would not be helpful.
Instead, a measure that tells what types of medication errors were made, perhaps even
with a severity rating indicated, compares this to medication errors made during the pre-
vious months, and shows in numbers and graphs the changes over time that will enable us
to do the necessary root-cause analysis to prevent more medication errors in the future.
Performance measures need to be clearly dened, including the terms used, the
data elements collected, and the calculation steps employed. Establishing the denition
18 Evidence-Based Geriatric Nursing Protocols for Best Practice
prior to implementing the monitoring activity allows for precise data collection. It also
facilitates benchmarking with other organizations when the data elements are similarly
dened and the data collection methodologies are consistent. Imagine that we want to
monitor falls on the unit. e initial questions would be as follows: What is consid-
ered a fall? Does the patient have to be on the oor? Does a patient slumping against
the wall or onto a table while trying to prevent himself or herself from falling to the
oor constitute a fall? Is a fall due to physical weakness or orthostatic hypotension
treated the same as a fall caused by tripping over an obstacle? e next question would
be the following: Over what time are falls measured: a week, a fortnight, a month,
a quarter, a year? e time frame is not a matter of convenience but of accuracy. To
be able to monitor falls accurately, we need to identify a time frame that will capture
enough events to be meaningful and interpretable from a quality improvement point
of view. External indicator denitions, such as those dened for use in the National
Database of Nursing Quality Indicators, provide guidance for both the indicator de-
nition as well as the data collection methodology for nursing-sensitive indicators. e
nursing-sensitive indicators reect the structure, process, and outcomes of nursing care.
e structure of nursing care is indicated by the supply of nursing sta, the skill level
of the nursing sta, and the education/certication of nursing sta. Process indicators
measure aspects of nursing care such as assessment, intervention, and registered nurse
(RN) job satisfaction. Patient outcomes that are determined to be nursing sensitive are
those that improve if there is a greater quantity or quality of nursing care (e.g., pressure
ulcers, falls, intravenous [IV] inltrations) and are not considered “nursing-sensitive”
(e.g., frequency of primary C-sections, cardiac failure; see http://www.nursingquality
.org/FAQPage.aspx#1 for details). Several nursing organizations across the country par-
ticipate in data collection and submission, which allows for a robust database and excel-
lent benchmarking opportunities.
Additional indicator attributes include validity, sensitivity, and specicity. Validity
refers to whether the measure “actually measures what it purports to measure” (Wilson,
1989). Sensitivity and specicity refer to the ability of the measure to capture all true
cases of the event being measured, and only true cases. We want to make sure that a per-
formance measure identies true cases as true, and false cases as false, and does not iden-
tify a true case as false or a false case as true. Sensitivity of a performance measure is the
likelihood of a positive test when a condition is present. Lack of sensitivity is expressed
as false positives: e indicator calculates a condition as present when in fact it is not.
Specicity refers to the likelihood of a negative test when a condition is not present.
False-negatives reect lack of specicity: e indicators calculate that a condition is not
present when in fact it is. Consider the case of depression and the recommendation in
Chapter 9, Depression in Older Adults, to use the Geriatric Depression Scale, in which
a score of 11 or greater is indicative of depression. How robust is this cuto score of 11?
What is the likelihood that someone with a score of 9 or 10 (i.e., negative for depres-
sion) might actually be depressed (false-negative)? Similarly, what is the likelihood that
a patient with a score of 13 would not be depressed (false positive)?
Reliability means that results are reproducible; the indicator measures the same
attribute consistently across the same patients and across time. Reliability begins with a
precise denition and specication, as described earlier. A measure is reliable if dierent
people calculate the same rate for the same patient sample. e core issue of reliability is
measurement error, or the dierence between the actual phenomenon and its measure-
ment: e greater the dierence, the less reliable the performance measure. For example,
Measuring Performance, Improving Quality 19
suppose that we want to focus on pain management in older adults with end-stage can-
cer. One way of measuring pain would be to ask patients to rate their pain as none, a
little, some, quite a bit, or a lot. An alternative approach would be to administer a visual
analog scale, a 10-point line on which patients indicate their pain levels. Yet another
approach would be to ask the pharmacy to produce monthly reports of analgesic use by
type and dose. Generally speaking, the more subjective the scoring or measurement, the
less reliable it will be. If all these measures were of equal reliability, they would yield the
same result. Concept of reliability, particularly inter-rate reliability, becomes increasingly
important to consider in those situations where data collection is assigned to several sta
members. It is important to review the data collection methodology and the instrument
in detail to avoid dierent approaches by the various people collecting the data.
Several of the examples given earlier imply the criterion of interpretability. A per-
formance measure must be interpretable; that is, it must convey a result that can be
linked to the quality of clinical care. First, the quantitative output of a performance
measure must be scaled in such a way that users can interpret it. For example, a scale
that starts with 0 as the lowest possible level and ends with 100 is a lot easier to interpret
than a scale that starts with 13.325 and has no upper boundary except innity. Second,
we should be able to place the number within a context. Suppose we are working in a
hemodialysis center that serves quite a large proportion of patients with end-stage renal
disease (ESRD) and are older than the age of 60—the group least likely to be t for
a kidney transplant yet with several years of life expectancy remaining. We know that
virtually all patients with ESRD develop anemia (hemoglobin [Hb] level less than 11
g/dL), which in turn impacts on their activities of daily living (ADL) and independent
activities of daily living (IADL) performance. In collaboration with the nephrologists,
we initiate a systematic program of anemia monitoring and management, relying in part
on published best practice guidelines. We want to achieve the best practice guideline of
85% of all patients having Hb levels equal to or greater than 11 g/dL. We should be able
to succeed because the central laboratory provides us with Hb levels, which allows us to
calculate the percentage of patients at Hb of 11 g/dL or greater.
e concept of risk-adjusted performance measures or outcome indicators is an
important one. Some patients are more sick than others, some have more comorbidi-
ties, and some are older and frailer. No doubt, we could come up with many more
risk variables that inuence how patients respond to nursing care. Good performance
measures take this dierential risk into consideration. ey create a “level playing eld”
by adjusting quality indicators on the basis of the (risk for) severity of illness of the
patients. It would not be fair to the health care team if the patients on the unit are a lot
sicker than those on the unit a oor above. e team is at greater risk for having lower
quality outcomes, not because they provide inferior care, but because the patients are a
lot more sick and are at greater risk for a compromised response to the care provided.
e more sick patients are more demanding in terms of care and ultimately are less
likely to achieve the same outcomes as less ill patients. Performance measures must be
easy to collect. e many examples cited earlier also refer to the importance of using
performance measures for which data are readily available, can be retrieved from exist-
ing sources or can be collected with little burden. e goal is to gather good data quickly
without running the risk of having “quick and dirty” data.
We begin the process of deciding how to measure by reviewing existing measures.
ere is no need to reinvent the wheel, especially if good measures are out there. Nurses
should review the literature, check with national organizations, and consult with
20 Evidence-Based Geriatric Nursing Protocols for Best Practice
colleagues. Yet, we should not adopt existing measures blindly. Instead, we need to
subject them to a thorough review using the characteristics identied previously. Also,
health care organizations that have adopted these measures can oer their experience.
It may be that after an exhaustive search, we cannot nd measures that meet the
various requirements outlined previously. We decide instead to develop our own in-
house measure. e following are some important guidelines:
1. Zero in on the population to be measured. If we are measuring an undesirable event, we
must determine the group at risk for experiencing that event, then limit the denomi-
nator population to that group. If we are measuring a desirable event or process,
we must identify the group that should experience the event or receive the process.
Where do problems tend to occur? What variables of this problem are within our
control? If some are not within our control, how can we zero in even more on the
target population? In other words, we exclude patients from the population when
good reason exists to do so (e.g., those allergic to the medication being measured).
2. Dene terms. is is a painstaking but essential eort. It is better to measure 80% of
an issue with 100% accuracy than 100% of an issue with 80% accuracy.
3. Identify and dene the data elements and allowable values required to calculate the measure.
is is another painstaking but essential eort. e 80/100 rule applies here, as well.
4. Test the data collection process. Once we have a prototype of a measure ready, we must
examine how easy or dicult it is to get all the required data.
IMPLEMENTING THE QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
Successful Performance Improvement programs require an organizational commit-
ment to implementation of the Performance Improvement processes and principles
outlined in this chapter. Consequently, this commitment requires a dened, organized
approach that most organizations embrace and dene in the form of a written plan.
e plan outlines the approach the organization uses to improve care and safety for
its patients. ere are several important elements that must be addressed in order to
implement the Performance Improvement program eectively. e scope of service,
which addresses the types of patients and care that is rendered, provides direction on
the selection of performance measures. An authority and responsibility statement in
the document denes who is able to implement the quality program and make deci-
sions that will aect its implementation. Finally, it is important to dene the commit-
tee structure used to eectively analyze and communicate improvement eorts to the
organization.
e success of the Performance Improvement program is highly dependent on a well-
dened structure and appropriate selection of performance measures. e following is a list
of issues that, if not addressed, may negatively impact the success of the quality program:
1. Lack of focus: a measure that tries to track too many criteria at the same time or is too
complicated to administer, interpret, or use for quality monitoring and improvement
2. Wrong type of measure: a measure that calculates indicators the wrong way (e.g., uses
rates when ratios are more appropriate; uses a continuous scale rather than a discrete
scale; measures a process when the outcome is measurable and of greater interest)
3. Unclear denitions: a measure that is too broad or too vague in its scope and deni-
tions (e.g., population is too heterogeneous, no risk adjustment, unclear data ele-
ments, poorly dened values)
Measuring Performance, Improving Quality 21
4. Too much work: a measure that requires too much clinician time to generate the data
or too much manual chart abstraction
5. Reinventing the wheel: a measure that is a reinvention rather than an improvement of
a performance measure
6. Events not under control: measure focuses on a process or outcome that is out of the
organization (or the unit’s) control to improve
7. Trying to do research rather than quality improvement: data collection and analysis are
done for the sake of research rather than for improvement of nursing care and the
health and well-being of the patients
8 Poor communication of results: the format of communication does not target and
enable change
9. Uninterpretable and underused: uninterpretable results are of little relevance to
improving geriatric nursing care
In summary, the success of the Quality Assessment Performance Improvement
Program’s ability to measure, evaluate, and improve the quality of nursing care to health
system elders is in the planning. First, it is important to dene the scope of services
provided and those to be monitored and improved. Second, identify performance mea-
sures that are reective of the care provided. Indicators may be developed internally or
may be obtained from external sources of outcomes and data collection methodologies.
ird, it is important to analyze the data, pulling together the right people to evaluate
processes, make recommendations, and improve care. Finally, it is important to com-
municate ndings across the organization and celebrate success.
RESOURCES
Hospital Compare
http://www.hospitalcompare.hhs.gov/
Nursing Home Compare
http://www.medicare.gov/nhcompare/
Home Health Compare
http://www.medicare.gov/HomeHealthCompare
Centers for Medicare and Medicaid Services Hospital Quality Initiatives
http://www.cms.gov/HospitalQualityInits/
Centers for Medicare and Medicaid Services Hospital Quality Initiatives Press Release, dated 9/17/09
http://www.cms.gov/HospitalQualityInits/downloads/HospitalPremierPressReleases20090817.pdf
Centers for Medicare and Medicaid Services Demonstration Projects and Evaluation Reports
http://www.cms.gov/DemoProjectsEvalRpts/MD/list.asp?intNumPerPage=all
REFERENCES
Fulmer, T., Mezey, M., Bottrell, M., Abraham, I., Sazant, J., Grossman, S., & Grisham, E. (2002).
Nurses Improving Care for Health System Elders (NICHE): Using outcomes and benchmarks
for evidence-based practice. Geriatric Nursing, 23(3), 121–127.
Johnson, K., Hallsey, D., Meredith, R. L., & Warden, E. (2006). A nurse-driven system for improv-
ing patient quality outcomes. Journal of Nursing Care Quality, 21(2), 168–175.
22 Evidence-Based Geriatric Nursing Protocols for Best Practice
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer
health system (p. 222). Washington, DC: National Academy Press.
McGlynn, E. A., & Asch, S. M. (1998). Developing a clinical performance measure. American Jour-
nal of Preventive Medicine, 14(3 Suppl.), 14–21.
Nadzam, D. M., & Abraham, I. L. (2003). Measuring performance, improving quality. In M. D.
Mezey, T. Fulmer, & I. Abraham (Eds.), Geriatric nursing protocols for best practice (2nd ed., pp.
15–30). New York, NY: Springer Publishing Company.
Schyve, P. M., & Nadzam, D. M. (1998). Performance measurement in healthcare. Journal of Strate-
gic Performance Measurement, 2(4), 34–42.
State Children’s Health Insurance Program (SCHIP). (2010). e National Center for Public Policy
Research. Accessed August 23, 2011, from http://www.schip-info.org
Wilson, H. S. (1989). Research in nursing (2nd ed., p. 355). Reading, MA: Addison-Wesley.
ADDITIONAL READINGS
Albanese, M. P., Evans, D. A., Schantz, C. A., Bowen, M., Disbot, M., Moa, J. S., . . . Polomano,
R. C. (2010). Engaging clinical nurses in quality and performance improvement activities.
Nursing Administration Quarterly, 34(3), 226–245.
Bowling, A. (2001). Measuring disease: A review of disease-specic quality of life measurement scales
(2nd ed.). Philadelphia, PA: Open University Press.
Bryant, L. L., Floersch, N., Richard, A. A., & Schlenker, R. E. (2004). Measuring healthcare out-
comes to improve quality of care across post-acute care provider settings. Journal of Nursing Care
Quality, 19(4), 368–376.
Coopey, M., Nix, M. P., & Clancy, C. M. (2006). Translating research into evdience-based nursing
practice and evaluating eectiveness. Journal of Nursing Care Quality, 21(3), 195–202.
Hart, S., Bergquist, S., Gajewski, B., & Dunton, N. (2006). Reliability testing of the National
Database of Nursing Quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality,
21(3), 256–265.
Hoo, W. E., & Parisi, L. L. (2005). Nursing informatics approach to analyzing stang eectiveness
indicators. Journal of Nursing Care Quality, 20(3), 215–219.
Kliger, J., Lacey, S. R., Olney, A., Cox, K. S., & O’Neil, E. (2010). Nurse-driven programs to
improve patient outcomes: Transforming care at the bedside, integrated nurse leadership pro-
gram, and the clinical scene investigator academy. e Journal of Nursing Administration, 40(3),
109–114.
Kovner, C. T., Brewer, C. S., Yingrengreung, S., & Fairchild, S. (2010). New nurses’ views of quality
improvement education. Joint Commission Journal on Quality and Patient Safety/Joint Commission
Resources, 36(1), 29–35.
Lageson, C. (2004). Quality focus of the rst line nurse manager and relationship to unit outcomes.
Journal of Nursing Care Quality, 19(4), 336–342.
23
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe the structural and functional changes in multiple body systems that occur
during the normal aging process
2. understand the clinical signicance of these age-related changes regarding the health
and disease risks of the older adult
3. discuss the components of a nursing assessment for the older adult in light of the
manifestations of normal aging
4. identify care strategies to promote successful aging in older adults, with consderation
of age-related changes
e process of normal aging, independent of disease, is accompanied by a myriad of
changes in body systems. As evidenced by longitudinal studies such as the Baltimore
Longitudinal Study of Aging (2010), modications occur in both structure and func-
tion of organs and are most pronounced in advanced age of 85 years or older (Hall,
2002). Many of these alterations are characterized by a decline in physiological reserve,
so that, although baseline function is preserved, organ systems become progressively less
capable of maintaining homeostasis in the face of stresses imposed by the environment,
disease, or medical therapies (Miller, 2009). Age-related changes are strongly impacted
by genetics, as well as by long-term lifestyle factors, including physical activity, diet,
alcohol consumption, and tobacco use (Kitzman & Taet, 2009). Furthermore, great
heterogeneity occurs among older adults; clinical manifestations of aging can range
from stability to signicant decline in function of specic organ systems (Beck, 1998).
e clinical implications of these age-related alterations are important in nursing
assessment and care of the older adult for several reasons. First, changes associated with
normal aging must be dierentiated from pathological processes in order to develop
appropriate interventions (Gallagher, O’Mahony, & Quigley, 2008). Manifestations of
aging can also adversely impact the health and functional capability of older adults and
Constance M. Smith and Valerie T. Cotter
3
Age-Related Changes in Health
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
24 Evidence-Based Geriatric Nursing Protocols for Best Practice
require therapeutic strategies to correct (Matsumura & Ambrose, 2006). Age-associated
changes predispose older persons to selected diseases (Kitzman & Taet, 2009). us,
nurses’ understanding of these risks can serve to develop more eective approaches to
assessment and care. Finally, aging and illness may interact reciprocally, resulting in
altered presentation of illness, response to treatment, and outcomes (Hall, 2002).
is chapter describes age-dependent changes for several body systems. Clinical
implications of these alterations, including associated disease risks, are then discussed
followed by nursing assessment and care strategies related to these changes.
CARDIOVASCULAR SYSTEM
Cardiac reserve declines in normal aging. is alteration does not aect cardiac func-
tion at rest and resting heart rate, ejection fraction, and cardiac output remain virtually
unchanged with age. However, under physiological stress, the ability of the older adult’s
heart to increase both rate and cardiac output, in response to increased cardiac demand,
such as physical activity or infection, is compromised (Lakatta, 2000). Such diminished
functional reserve results in reduced exercise tolerance, fatigue, shortness of breath, slow
recovery from tachycardia (Watters, 2002), and intolerance of volume depletion (Mick
& Ackerman, 2004). Furthermore, because of the decreased maximal attainable heart
rate with aging, a heart rate of greater than 90 beats per minute (bpm) in an older adult
indicates signicant physiological stress (Kitzman & Taet, 2009).
Age-dependent changes in both the vasculature and the heart contribute to the
impairment in cardiac reserve. An increase in the wall thickness and stiness of the
aorta and carotid arteries results in diminished vessel compliance and greater systemic
vascular resistance (omas & Rich, 2007). Elevated systolic blood pressure (BP) with
constant diastolic pressure follows, increasing the risk of isolated systolic hypertension
and widened pulse pressure (Joint National Committee [JNC], 2004). Strong arterial
pulses, diminished peripheral pulses, and increased potential for inamed varicosities
occur commonly with age. Reductions in capillary density restrict blood ow in the
extremities, producing cool skin (Mick & Ackerman, 2004).
As an adaptive measure to increased workload against noncompliant arteries, the left
ventricle and atrium hypertrophy become rigid. e ensuing impairment in relaxation
of the left ventricle during diastole places greater dependence on atrial contractions to
achieve left ventricular lling (Lakatta, 2000). In addition, sympathetic response in the
heart is blunted because of diminished
b
-adrenergic sensitivity, resulting in decreased
myocardial contractility (omas & Rich, 2007).
Additional age-related changes include sclerosis of atrial and mitral valves, which
impairs their tight closure and increases the risk of dysfunction. e ensuing leaky
heart valves may result in aortic regurgitation or mitral stenosis, presenting on exam
as heart murmurs (Kitzman & Taet, 2009). Loss of pacemaker and conduction cells
contributes to changes in the resting electrocardiogram (ECG) of older adults. Isolated
premature atrial and ventricular complexes are common arrhythmias, and the risk of
atrial brillation is increased (omas & Rich, 2007). Because of atrial contractions in
diastole, S
4
frequently develops as an extra heart sound (Lakatta, 2000).
Baroreceptor function, which regulates BP, is impaired with age, particularly with
change in position. Postural hypotension with orthostatic symptoms may follow, espe-
cially after prolonged bed rest, dehydration, or cardiovascular drug use, and can cause
dizziness and potential for falls (Mukai & Lipsitz, 2002).
Age-Related Changes in Health 25
Cardiac assessment of an older adult includes performing an ECG and monitoring
heart rate (40–100 bpm within normal limits), rhythm (noting whether it is regular or
irregular), heart sounds (S
1
, S
2
, or extra heart sounds S
3
in heart disease or S
4
as a com-
mon nding), and murmurs (noting location where loudest). e apical impulse is dis-
placed laterally. In palpation of the carotid arteries, asymmetric volumes and decreased
pulsations may indicate aortic stenosis and impaired left cardiac output, respectively.
Auscultation of a bruit potentially suggests occlusive arterial disease. Peripheral pulses
should be assessed bilaterally at a minimum of one pulse point in each extremity. Assess-
ment may reveal asymmetry in pulse volume suggesting insuciency in arterial circula-
tion (Docherty, 2002). e nurse should examine lower extremities for varicose veins
and note dilation or swelling. In addition, dyspnea with exertion and exercise intoler-
ance are critical to note (Mahler, Fierro-Carrion, & Baird, 2003).
BP should be measured at least twice (Kestel, 2005) on the older adult and per-
formed in a comfortably seated position with back supported and feet at on the oor.
e BP should then be repeated after 5 minutes of rest. Measurements in both supine
and standing positions evaluate postural hypotension (Mukai & Lipsitz, 2002).
Nursing care strategies include referrals for older adults who have irregularities of heart
rhythm and decreased or asymmetric peripheral pulses. e risk of postural hypotension
emphasizes the need for safety precautions (Mukai & Lipsitz, 2002) to prevent falls. ese
include avoiding prolonged recumbency or motionless standing and encouraging the older
adult to rise slowly from lying or sitting positions and wait for 1 to 2 minutes after a posi-
tion change to stand or transfer. Overt signs of hypotension such as a change in sensorium
or mental status, dizziness, or orthostasis should be monitored, and fall-prevention strate-
gies should be instituted. Sucient uid intake is advised to ensure adequate hydration and
prevent hypovolemia for optimal cardiac functioning (Docherty, 2002; Watters, 2002).
Older adults should be encouraged to adopt lifestyle practices for cardiovascular t-
ness with the aim of a healthy body weight (body mass index [BMI] 18.5–24.9 kg/m
2
;
American Heart Association Nutrition Committee et al., 2006) and normal BP (JNC,
2004). ese practices involve a healthful diet (Knoops et al., 2004), physical activity
appropriate for age and health status (Netz, Wu, Becker, & Tenenbaum, 2005), and
elimination of the use of and exposure to tobacco products (U.S. Department of Health
and Human Services [USDHHS], 2004a).
PULMONARY SYSTEM
Respiratory function slowly and progressively deteriorates with age. is decline in
ventilatory capacity seldom aects breathing during rest or customary limited physical
activity in healthy older adults (Zeleznik, 2003); however, with greater than usual exer-
tional demands, pulmonary reserve against hypoxia is readily exhausted and dyspnea
occurs (Imperato & Sanchez, 2006).
Several age-dependent anatomic and physiologic changes combine to impair the
functional reserve of the pulmonary system. Respiratory muscle strength and endurance
deteriorate to restrict maximal ventilatory capacity (Buchman et al., 2008). Secondary
to calcication of rib cage cartilage, the chest wall becomes rigid (Imperato & Sanchez,
2006), limiting thoracic compliance. Loss of elastic bers reduces recoil of small air-
ways, which can collapse and cause air trapping, particularly in dependent portions of
the lung. Decreases in alveolar surface area, vascularization, and surfactant production
adversely aect gaseous exchange (Zeleznik, 2003).
26 Evidence-Based Geriatric Nursing Protocols for Best Practice
Additional clinical consequences of aging include an increased anteroposterior chest
diameter caused by skeletal changes. An elevated respiratory rate of 12–24 breaths per
minute accompanies reduced tidal volume for rapid, shallow breathing. Limited dia-
phragmatic excursion and chest/lung expansion can result in less eective inspiration
and expiration (Buchman et al., 2008; Mick & Ackerman, 2004). Because of decreased
cough reex eectiveness and deep breathing capacity, mucus and foreign matter clear-
ance is restricted, predisposing to aspiration, infection, and bronchospasm (Watters,
2002). Further, elevating the risk of infection is a decline in ciliary and macrophage
activities and drying of the mucosal membranes with more dicult mucous excretion
(Htwe, Mushtaq, Robinson, Rosher, & Khardori, 2007). With the loss of elastic recoil
comes the potential for atelectasis. Because of reduced respiratory center sensitivity,
ventilatory responses to hypoxia and hypercapnia are blunted (Imperato & Sanchez,
2006), putting the older adult at risk for development of respiratory distress with illness
or administration of narcotics (Zeleznik, 2003).
e modications in ventilatory capacity with age are reected in changes in pul-
monary function tests measuring lung volumes, ow rates, diusing capacity, and gas
exchange. Whereas total lung capacity remains constant, vital capacity is reduced and
residual volume is increased. Reductions in all measures of expiratory ow (forced expi-
ratory volume in 1 second [FEV
1
], forced vital capacity [FVC], FEV
1
/FVC, peak expira-
tory ow rate [PEFR]) quantify a decline in useful air movement (Imperato & Sanchez,
2006). Because of impaired alveolar function, diusing capacity of the lung for carbon
monoxide (DLCO) declines as does pulmonary arterial oxygen tension (PaO
2
), indicat-
ing impaired oxygen exchange; however, arterial pH and partial pressure of arterial car-
bon dioxide (PaCO
2
) remain constant (Enright, 2009). Reductions in arterial oxygen
saturation and cardiac output restrict the amount of oxygen available for use by tissues,
particularly in the supine position, although arterial blood gas seldom limits exercise in
healthy subjects (Zeleznik, 2003).
Respiratory assessment includes determination of breathing rate, rhythm, regular-
ity, volume (hyperventilation/hypoventilation), depth (shallow, deep; Docherty, 2002),
and eort (dyspnea; Mahler et al., 2003). Auscultation of breath sounds throughout
the lung elds may reveal decreased air exchange at the lung bases (Mick & Ackerman,
2004). orax and symmetry of chest expansion should be inspected. A history of
respiratory disease (tuberculosis, asthma), tobacco use (expressed as pack years), and
extended exposure to environmental irritants through work or avocation is contributory
(Imperato & Sanchez, 2006).
Subjective assessment of cough includes questions on quality (productive/nonpro-
ductive), sputum characteristics (note hemoptysis; purulence indicating possible infec-
tion), and frequency (during eating or drinking, suggesting dysphagia and aspiration;
Smith & Connolly, 2003).
Secretions and decreased breathing rate during sedation can reduce ventilation and
oxygenation (Watters, 2002). Oxygen saturation can be followed through arterial blood
gases and pulse oximetry (Zeleznik, 2003) while breathing rate (greater than 24 respira-
tions per minute), accessory muscle use, and skin color (cyanosis, pallor) should also be
monitored (Docherty, 2002). e inability to expectorate secretions, the appearance of
dyspnea, and decreased saturation of oxygen (SaO
2
) levels suggest the need for suction-
ing to clear airways (Smith & Connolly, 2003). Optimal positioning to facilitate respira-
tion should be regularly monitored with use of upright positions (Fowler’s or orthopneic
position) recommended (Docherty, 2002). Pain assessment may be necessary to allow
Age-Related Changes in Health 27
ambulation and deep breathing (Mick & Ackerman, 2004). See Atypical Presentation
of Disease section for assessment of pneumonia, tuberculosis, and inuenza.
Nursing care strategies useful in facilitating respiration and maintaining patent air-
ways in the older adult include positioning to allow maximum chest expansion through
the use of semi- or high-Fowler’s or orthopneic position (Docherty, 2002). Additionally,
frequent repositioning in bed or encouraging ambulation, if mobility permits, is advised
(Watters, 2002). Analgesics may be necessary for ambulation and deep breathing (Mick
& Ackerman, 2004).
Hydration is maintained through uid intake (6–8 oz per day) and air humidica-
tion, which prevent desiccation of mucous membranes and loosen secretions to facili-
tate expectoration (Suhayda & Walton, 2002). Suctioning may be necessary to clear
airways of secretions (Smith & Connolly, 2003) while oxygen should be provided as
needed (Docherty, 2002). Incentive spirometry, with use of sustained maximal inspira-
tion devices (SMIs), can improve pulmonary ventilation, mainly inhalation, as well as
loosen respiratory secretions, particularly in older adults who are unable to ambulate or
are declining in function (Dunn, 2004).
Deep breathing exercises, such as abdominal (diaphragmatic) and pursed-lip
breathing, in addition to controlled and hu coughing, can further facilitate respira-
tory function. Techniques for healthy breathing, including sitting and standing erect,
nose breathing (Dunn, 2004), and regular exercise (Netz et al., 2005) should be pro-
moted. Education on eliminating the use of and exposure to tobacco problems should
be emphasized (USDHHS, 2004a).
RENAL AND GENITOURINARY SYSTEMS
In normal aging, the mass of the kidney declines with a loss of functional glomeruli
and tubules in addition to a reduction in blood ow. Concomitantly, changes occur
in the activity of the regulatory hormones, vasopressin (antidiuretic hormone), atrial
natriuretic hormone, and renin-angiotensin-aldosterone system (Miller, 2009). ese
alterations combine to result in diminished glomerular ltration rate (GFR), with a
10% decrement per decade starting at age 30, as well as impaired electrolyte and water
management (Beck, 1998).
Despite these changes, the older adult maintains the ability to regulate uid bal-
ance under baseline conditions; however, with age, the renal system is more limited in
its capacity to respond to externally imposed stresses. is reduced functional reserve
increases vulnerability to disturbances in uid homeostasis as well as to renal complica-
tions and failure (Lerma, 2009), particularly from uid/electrolyte overload and decit,
medications, or illness (Miller, 2009).
e decline in functional nephrons emphasizes the risk from nephrotoxic agents
including nonsteroidal anti-inammatory drugs (NSAIDs),
b
-lactam antibiotics, and
radiocontrast dyes. Reduced GFR impairs the older adult’s ability to excrete renally
cleared medications such as aminoglycoside antibiotics (e.g., gentamicin) and digoxin,
increasing the risk of adverse drug reactions (Beyth & Shorr, 2002). Dosages should
be based on GFR estimated by the Cockcroft-Gault equation for creatinine clearance
(Péquignot et al., 2009) or the modication of diet in renal disease (MDRD) rather than
by serum creatinine concentration (Miller, 2009; National Kidney Disease Education
Program, 2009). Values of serum creatinine remain unchanged despite an age- associated
decline in GFR because of the parallel decrease in both older adults’ skeletal muscle
28 Evidence-Based Geriatric Nursing Protocols for Best Practice
mass, which produces creatinine and GFR for creatinine elimination. us, serum crea-
tinine levels overestimate GFR to result in potential drug overdose (Beck, 1998).
Increased risk of electrolyte imbalances can result from an age-dependent impair-
ment in the excretion of excessive sodium loads, particularly in heart failure and with
NSAID use, leading to intravascular volume overload. Clinical indicators include
weight gain (greater than 2%); intake is greater than output; edema; change in men-
tal status; tachycardia; bounding pulse; pulmonary congestion with dyspnea, rales;
increased BP and central venous pressure (CVP); and distended neck/peripheral veins
(Beck, 1998).
Conversely, sodium wasting or excess sodium excretion when maximal sodium
conservation is needed, can occur with diarrhea. Hypovolemia and dehydration may
ensue (Stern, 2006), manifesting as acute change in mental status (may be the initial
symptom), weight loss (greater than 2%), decreased tissue turgor, dry oral mucosa,
tachycardia, decreased BP, postural hypotension, at neck veins, poor capillary rell,
oliguria (less than 30 mL/hr), increased hematocrit and specic gravity of urine, blood
urea nitrogen (BUN): plasma creatinine ratio greater than 20:1, and serum osmolality
greater than 300 mOsm/kg (Mentes, 2006).
Impaired potassium excretion puts the older adult at risk for hyperkalemia, particu-
larly in heart failure and with use of potassium supplements, potassium-sparing diuret-
ics, NSAIDs, and angiotensin-converting enzyme (ACE) inhibitors (Mick & Ackerman,
2004). Clinical indicators include diarrhea, change in mental status, cardiac dysrhyth-
mias or arrest, muscle weakness and areexia, paresthesias and numbness in extremities,
ECG abnormalities, and serum potassium greater than 5.0 mEq/L (Beck, 1998).
Limited acid excretion capability can cause metabolic acidosis during acute ill-
ness in the older adult. is condition presents as Kussmaul’s respirations, change in
mental status, nausea, vomiting, arterial blood pH less than 7.35, serum bicarbonate
less than 22 mEq/L, and PaCO
2
less than 38 mm Hg with respiratory compensation
(Beck, 1998).
Causes of abnormal water metabolism with age include diminution in maximal
urinary concentrating ability, which, in concert with blunted thirst sensation and total
body water, can result in hypertonic dehydration and hypernatremia (Mentes, 2006).
Often associated with insensible uid loss from fever (Miller, 2009), hypernatremia
presents with thirst; dry oral mucosa; dry, furrowed tongue; postural hypotension; weak-
ness; lethargy; serum sodium less than 150 mEq/L; and serum osmolality less than 290
mOsm/kg. Disorientation, seizures, and coma occur in severe hypernatremia (Suhayda
& Walton, 2002).
Impaired excretion of a water load, exacerbated by ACE inhibitors, thiazide diuretics
(Miller, 2009), and selective serotonin reuptake inhibitors (SSRIs; Mentes, 2006), pre-
disposes the older adult to water intoxication and hyponatremia (Beck, 1998). Clinical
indicators involve lethargy, nausea, muscle weakness and cramps, serum sodium less
than 135 mEq/L, and serum osmolality less than 290 mOsm/kg. Confusion, coma, and
seizures are seen in severe hyponatremia (Suhayda & Walton, 2002).
Changes in the lower urinary tract with age include reduced bladder elasticity and
innervation, which contribute to decreases in urine ow rate, voided volume, and blad-
der capacity, as well as increases in postvoid residual and involuntary bladder contrac-
tions. A delayed or decreased perception of the signal from the bladder to void translates
into urinary urgency (Kevorkian, 2004). Increased nocturnal urine ow, which results
from altered regulatory hormone production, impaired ability to concentrate urine,
Age-Related Changes in Health 29
and bladder–muscle instability, can lead to nocturnal polyuria (Miller, 2009). In older
men, benign prostatic hyperplasia (BPH) can result in urinary urgency, hesitancy, and
frequency. All these changes combine to increase the risk of urinary incontinence in the
older adult. Further, urgency and nocturia increase the risk of falls. Changes with age in
the physiology of the urinary tract such as increased vaginal pH and decreased antibac-
terial activity of urine in addition to the functional changes of the bladder contribute to
the development of bacteriuria, with potential for urinary tract infection (UTI; Htwe
et al., 2007; Stern, 2006).
Renal assessment includes monitoring for renal function (GFR) based on creati-
nine clearance, particularly in acute and chronic illness (Lerma, 2009; Miller, 2009;
Péquignot et al., 2009). e choice, dose, need, and alternatives for nephrotoxic and
renally excreted agents should be considered (Beyth & Shorr, 2002).
Dehydration, volume overload, and electrolyte status are assessed rst by screening
for risk of uid/electrolyte imbalances based on the older adult’s age, medical and nutri-
tional history, medications, cognitive and functional abilities, psychosocial status, and
bowel and bladder patterns. Data on uid intake and output; daily weights; and vital
signs, including orthostatic BP measurements, are needed. Heart rate is a less reliable
indicator for dehydration in older adults because of the eects of medications and heart
disease (Suhayda & Walton, 2002).
Physical assessment for uid/electrolyte status focuses on skin for edema and turgor.
Note that turgor in older adults is a less reliable indicator for dehydration because of
poor skin elasticity, and assessment over the sternum or inner thigh is recommended.
Additional assessment involves the oral mucosa for dryness as well as cardiovascular,
respiratory, and neurologic systems. Acute changes in mental status, reasoning, mem-
ory, or attention may be initial symptoms of dehydration (Suhayda & Walton, 2002).
Pertinent laboratory tests include serum electrolytes, serum osmolality, complete blood
count (CBC), urine pH and specic gravity, BUN, hematocrit (Mentes, 2006), and
arterial blood gases (Beck, 1998).
Evaluations of urinary incontinence, UTI, and nocturnal polyuria using a 72-hour
voiding diary are recommended. See Atypical Presentation of Diseases section for UTI.
Voiding history and rectal exam are required to diagnose BPH (see Chapter 18, Urinary
Incontinence). Fall risk should be addressed when nocturnal or urgent voiding is present
(see Chapter 15, Fall Prevention: Assessment, Diagnoses, and Intervention Strategies).
Ongoing care involves monitoring for renal function (Lerma, 2009; Miller, 2009;
Péquignot et al., 2009) and for levels of nephrotoxic and renally cleared drugs (Beyth &
Shorr, 2002). Maintenance of uid/electrolyte balance is paramount (Beck, 1998). To
prevent dehydration, older adults weighing between 50 and 80 kg are advised to have a
minimum uid intake of 1,500–2,500 mL/day (unless contraindicated by medical con-
dition; Suhayda & Walton, 2002) from both uids and food sources including fruits,
vegetables, soups, and gelatin with avoidance of high salt and caeine (Mentes, 2006;
Ney, Weiss, Kind, & Robbins, 2009).
Incontinence care and exercise can contribute to management of voiding prob-
lems, including reduced incontinence, of nursing home residents (Schnelle et al., 2002).
Behavioral interventions recommended for nocturnal polyuria include limited uid
intake in the evening, avoidance of caeine and alcohol, and prompted voiding sched-
ule (Miller, 2009). Institution of safety precautions and fall prevention strategies are
needed in nocturnal or urgent voiding (see Chapter 15, Fall Prevention: Assessment,
Diagnoses, and Intervention Strategies).
30 Evidence-Based Geriatric Nursing Protocols for Best Practice
OROPHARYNGEAL AND GASTROINTESTINAL SYSTEMS
Age-specic alterations in the oral cavity can adversely aect the older adult’s nutri-
tional status. Deterioration in the strength of muscles of mastication as well as poten-
tial for tooth loss and xerostomia because of dehydration or medications may reduce
food intake (Hall, 2009). Contributing to poor appetite are an altered taste perception
and a diminished sense of smell (see Chapter 20, Oral Health Care; Ney et al., 2009;
Visvanathan & Chapman, 2009).
Changes in the esophagus with age include delayed emptying in addition to decreases
in upper and lower esophageal sphincter pressures, sphincter relaxation, and peristaltic
contractions. Although these alterations rarely impair esophageal function and swallowing
suciently to cause dysphagia or aspiration in normal aging, such conditions can develop
in conjunction with disease or medication side eects in older adults (Gregersen, Pedersen,
& Drewes, 2008; Ney et al., 2009). Diminished gastric motility with delayed emptying
contributes to altered oral drug passage time and absorption in the stomach; elevated risk of
gastroesophageal reux disease (GERD; Hall, 2009); and decreased postprandial hunger,
leading to diminished food intake and possible malnutrition (Visvanathan & Chapman,
2009). Reduced mucin secretion impairs the protective function of the gastric mucosal
barrier and increases the incidence of NSAID-induced gastric ulcerations (Newton, 2005).
Although the motility and most absorptive functions of the small intestine are preserved
with age, absorption of vitamin B
12
, folic acid, and carbohydrates declines (Hall, 2009). In
addition, malabsorption of calcium and vitamin D contributes to the risk of osteoporosis.
Supplementation with calcium and vitamins D and B
12
is now recommended for older
adults (USDHHS, 2005; Visvanathan & Chapman, 2009).
Age-dependent weakening of the large intestine wall predisposes older adults to
diverticulosis and may lead to diverticulitis (Hall, 2009). Because motility of the colon
appears to be preserved with age, increased self-reports of constipation in older adults
may be attributed instead to altered dietary intake, medications, inactivity, or illness.
Diminished rectal elasticity, internal anal sphincter thickening, and impaired sensation
to defecate contribute to the risk of fecal incontinence in older adults (Gallagher et al.,
2008), although this condition is primarily found in combination with previous bowel
surgery or disease and not in normal aging (Hall, 2009).
Pancreatic exocrine output of digestive enzymes is preserved to allow normal diges-
tive capacity with aging (Hall, 2009). Regarding endocrine function, aging changes in
carbohydrate metabolism allow a genetic predisposition for diabetes to become manifest
(Meneilly, 2010). An age-related decrease in gallbladder function increases the risk of
gallstone formation. Although liver size and blood ow decline with age, reserve capac-
ity maintains adequate hepatic function, and values of liver function tests remain stable;
however, the liver is more susceptible to damage by stressors including alcohol and
tobacco. Associated with changes in the hepatic and intestinal cytochrome P450 system
(Hall, 2009), clearance of a range of medications, including many benzodiazepines,
declines to result in increased potential for dose-dependent adverse reactions to these
drugs (Beyth & Shorr, 2002).
Reductions in antimicrobial activity of saliva and immune response of the gastroin-
testinal tract with age contribute to a high risk for infectious and inammatory diseases
of this system (Htwe et al., 2007). Further, impaired enteric neuronal function may
blunt the older adult’s reaction to infection and inammation and result in atypical
presentation of disease (see Atypical Presentation of Disease section; Hall, 2002).
Age-Related Changes in Health 31
In the gastrointestinal evaluation, the abdomen and bowel sounds are assessed. Liver
size, as well as reports of pain, anorexia, nausea, vomiting, and altered bowel habits should
be noted (Visvanathan & Chapman, 2009). Assessment of the oral cavity includes denti-
tion and chewing capacity (Chapman, 2007; see Chapter 20, Oral Health Care).
Weight is monitored with calculation of BMI and compared to recommended val-
ues (American Hearth Association Nutrition Committee et al., 2006; Visvanathan &
Chapman, 2009). Deciencies in diet can be identied through comparisons of dietary
intake, using a 24- to 72-hour food intake record, with nutritional guidelines (Chapman,
2007; Roberts & Dallal, 2005; USDHHS, 2005). In addition, laboratory values of serum
albumin, prealbumin, and transferrin are useful nutritional indicators. Low albumin
concentration can also aect ecacy and potential for toxicity of selected drugs, includ-
ing digoxin and warfarin (Beyth & Shorr, 2002). Several instruments for screening the
nutritional status, eating habits, and appetite of older adults are available (see Resources
section and Chapter 22, Nutrition; Ney et al., 2009).
Signs of dysphagia such as coughing or choking with solid or liquid food intake should
be reported for further evaluation. If aspiration from dysphagia is suspected, the lungs
must be assessed for the presence of infection, typically indicated by unilateral or bilateral
basilar crackles in the lungs, dyspnea, tachypnea, and cough (Imperato & Sanchez, 2006).
A decline in function or change in mental status may signal atypical presentation of respi-
ratory infection from aspiration (Ney et al., 2009). Evaluation of GERD is based on typi-
cal and atypical symptoms (see Atypical Presentation of Disease section; Hall, 2009).
To assess constipation or fecal incontinence, a careful history with a 2-week bowel
log noting laxative use is needed. Fecal impaction is assessed by digital examination of
the rectum as a hardened mass of feces, which can be palpated. e impaction may also
be palpated through the abdomen (Gallagher et al., 2008).
For continuing care, referrals should be provided to a registered dietician for poor food
intake, unhealthy BMI (healthy BMI: 18.5–24.9 kg/m
2
; overweight: 25–29.9 kg/m
2
; obe-
sity: 30 kg/m
2
or greater; American Hearth Association Nutrition Committee et al., 2006),
and unintentional weight loss of 10% or greater in 6 months (Chapman, 2007; Ney et al.,
2009). Drug levels and liver function tests are monitored if drugs are metabolized hepatically
(Beyth & Shorr, 2002). Explanation of normal bowel frequency, the importance of diet and
exercise, and recommended types of laxatives addresses constipation problems (Gallagher
et al., 2008). Mobility should be encouraged to prevent constipation, and prophylactic laxa-
tives should be provided if constipating medications such as opiates are prescribed (Stern,
2006). Community-based food and nutrition programs (Visvanathan & Chapman, 2009)
and education on healthful diets using the food pyramid for older adults may be useful in
improving dietary intake (see Chapter 22, Nutrition; JNC, 2004; USDHHS, 2005).
MUSCULOSKELETAL SYSTEM
Musculoskeletal tissues undergo age-associated changes that can negatively impact func-
tion in the older adult. In sarcopenia or the loss of muscle mass and strength, a decline in
the size, number, and quality of skeletal muscle bers occurs with aging. Lean body mass is
replaced by fat and brous tissue (Loeser & Delbono, 2009) so that by age 75, only 15%
of the total body mass is muscle compared to 30% in a young, healthy adult (Matsumura
& Ambrose, 2006). ese alterations result in diminished contractile muscle force with
increased weakness and fatigue plus poor exercise tolerance. Age-specic physiological
alterations contributing to sarcopenia include reductions in muscle innervation, insulin
32 Evidence-Based Geriatric Nursing Protocols for Best Practice
activity, and sex steroid (estrogen, testosterone) and growth hormone levels. Additionally,
individual factors such as weight loss, protein deciency, and physical inactivity can
accelerate development of this condition to progress to a clinically signicant problem
( Jones et al., 2009). Sarcopenia has been documented to aect function adversely in older
adults by increasing the risk of disability, falls, unstable gait, and need for assistive devices.
Physical activity, particularly strength training, and adequate intake of energy and protein
can prevent or reverse sarcopenia (Narici, Maulli, & Maganaris, 2008).
Age-dependent bone loss occurs in both sexes and at all sites in the skeleton. Whereas
bone mass peaks between ages 30 and 35, density decreases thereafter at a rate of 0.5% per
year. is decrement, caused by reduced osteoblast activity in the deposition of new bone,
is accompanied by deterioration in bone architecture and strength. Further, from 5–7 years
following menopause during estrogen decline, bone loss in women accelerates to a 3%–5%
annual rate (USDHHS, 2004b). is loss, resulting from osteoclast activation with ele-
vated bone breakdown or resorption, occurs mainly in cancellous or trabecular bone such
as the vertebral body and may develop into Type I osteoporosis in women aged 51–75 years
who risk vertebral fractures. Following this postmenopausal period, bone loss slows again
in women and involves cortical bone in the long bones of the extremities. With aging, both
women and men may develop Type II osteoporosis and are susceptible to hip fractures and
kyphosis from vertebral compression fractures in later life (Simon, 2005).
An age-associated decline in the strength of ligaments and tendons, which are inte-
gral to normal joint function, predisposes to increased ligament and tendon injury,
more limited joint range of motion (ROM), and reduced joint stability, leading to
osteoarthritis (Narici et al., 2008). Degeneration of intervertebral discs caused by dehy-
dration and poor nutrient inux elevates the risk of spinal osteoarthritis, spondylosis,
and stenosis with aging (Loeser & Delbono, 2009).
Age-related changes in articular cartilage, which covers the bone endings in joints to
allow smooth movement, involve increased dehydration, stiening, crystal formation,
calcication, and roughening of the cartilage surface. Although these alterations have a
minor eect on joint function under baseline conditions, the aging joint is less capable
of withstanding mechanical stress, such as the stress caused by obesity or excess physical
activity, and is also more susceptible to disease including osteoarthritis (Loeser, 2010).
Age-dependent changes in stature include dorsal kyphosis, reduction in height, ex-
ion of the hips and knees, and a backward tilt of the head to compensate for the thoracic
curvature. A shorter stride, reduced velocity, and broader base of support with feet more
widely spaced characterize modications in gait with age (Harris et al., 2008).
e musculoskeletal assessment includes inspection of posture, gait, balance, sym-
metry of body parts, and alignment of extremities. Kyphosis, bony enlargements, or
other abnormalities should be noted. e clinician should palpate bones, joints, and
surrounding muscles, evaluating muscle strength on a scale of 0/5, and noting sym-
metry and signs of atrophy of major upper and lower extremity muscle groups. Active
and passive ROM for major joints is evaluated, noting pain, limitation of ROM, and
joint laxity. Joint stabilization and slow movements in ROM examinations are advised to
prevent injury. Functionality, mobility, ne and gross motor skills, balance, and fall risk
should be assessed (see Chapter 6, Assessment of Physical Function and Chapter 15, Fall
Prevention: Assessment, Diagnoses, and Intervention Strategies; Harris et al., 2008).
For continuing care, referrals to physical or occupational therapy may be appropriate.
Increased physical activity, including exercises for ROM (Netz et al., 2005) and muscle
strengthening and power (Narici et al., 2008) are recommended to maintain maximal
Age-Related Changes in Health 33
function. Interventions to promote such behavior in older adults involve health education,
goal setting, and self-monitoring (Conn, Minor, Burks, Rantz, & Pomeroy, 2003). Pain
medication may be needed to enhance functionality (see Chapter 14, Pain Management;
McCleane, 2008). Strategies to prevent falls (see Chapter 15, Falls Prevention: Assessment,
Diagnoses, and Intervention Strategies) and avoid physical restraints (see Chapter 13, Phys-
ical Restraints and Side Rails in Acute and Critical Care Settings) are appropriate.
To prevent and treat osteoporosis, adequate daily intake of calcium (1,200 mg for
women aged 50 years and older) and vitamin D (400 IU for women aged 50–70 years
and 600 IU for women aged 71 years and older), physical exercise, and smoking cessa-
tion are recommended (USDHHS, 2004b). In addition, routine bone mineral density
screening for osteoporosis is advised for women aged 65 years and older, as well as
for women aged 60–64 years at increased risk for osteoporotic fractures (Agency for
Healthcare Research and Quality, 2010).
NERVOUS SYSTEM AND COGNITION
Age-related alterations in the nervous system can aect function and cognition in older
adults. Changes include a reduced number of cerebral and peripheral neurons (Hall,
2002), modications in dendrites and glial support cells in the brain, and loss and
remodeling of synapses. Decreased levels of neurotransmitters, particularly dopamine,
as well as decits in systems that relay signals between neurons and regulate neuronal
plasticity also occur with aging (Mattson, 2009).
Combined, these neurological changes contribute to decrements in general mus-
cle strength; deep tendon reexes; sensation of touch, pain, and vibration; and nerve
conduction velocity (Hall, 2002), which result in slowed coordinated movements and
increased response time to stimuli (Matsumura & Ambrose, 2006). ese clinical con-
sequences, although relatively mild in normal aging, cause an overall slowing of motor
skills with potential decits in balance, gait, coordination, reaction time, and agility
(Harris et al., 2008; Narici et al., 2008). Such decline in function can adversely aect
an older adult’s daily activities, notably ambulation and driving, and predispose to falls
and injury (Craft, Cholerton, & Reger, 2009).
Neurological changes, along with thinning of the skin, compromise thermoregula-
tion in the older adult. ese result in decreased sensitivity to ambient temperature as
well as impaired heat conservation, production, and dissipation with predisposition to
hypothermia and hyperthermia (Kuchel, 2009). Febrile responses to infection may be
blunted or absent (see Atypical Presentation of Disease section; High, 2009; Htwe et
al., 2007; Watters, 2002).
With age, the speed of cognitive processing slows (Bashore & Ridderinkhof, 2002)
and some degree of cognitive decline is common (Park, O’Connell, & omson,
2003) but not universal in the older adult population (Stewart, 2004). Older adults
demonstrate signicant heterogeneity in cognitive performance, which may be posi-
tively impacted by education, good health, and physical activity (Christensen, 2001;
Colcombe & Kramer, 2003).
Specic cognitive abilities exhibit diering levels of stability or decline with age. For
example, crystallized intelligence, or the information and skills acquired from experi-
ence, remains largely intact, whereas uid intelligence, or creative reasoning and prob-
lem solving, declines (Christensen, 2001). Sustained attention is unaected by aging,
although divided attention, or the ability to concentrate on multiple tasks concurrently,
34 Evidence-Based Geriatric Nursing Protocols for Best Practice
deteriorates. e mild decline in executive function, which includes the capability of
directing behavior and completing multistep tasks, usually has minimal impact on an
older adult’s ability to manage daily activities. Although language abilities and compre-
hension appear stable, spontaneous word nding may deteriorate and is often a com-
plaint of older adults. Remote memory, or recalling events in the distant past, and
procedural memory, or remembering ways to perform tasks, remain intact but declara-
tive memory, or learning new information, is slowed (Craft et al., 2009). However,
despite some decits, memory functions are adequate for normal life in successful aging
(Henry, MacLeod, Phillips, & Crawford, 2004).
Changes in the nervous system increase the risk of sleep disorders (Espiritu, 2008)
and delirium in the older adult, especially in acute care (see Chapter 11, Delirium).
Neural changes aect the perception, tolerance, and response to treatment of pain
(McCleane, 2008). In addition, age-specic alterations predispose neurons to degenera-
tion, contributing to Alzheimer’s disease (Charter & Alekoumbides, 2004), Parkinson’s
disease, and Huntington’s disease (Mattson, 2009).
Assessment, with periodic reassessment, of baseline functional status (see Chapter
6, Assessment of Physical Function) should include evaluation of fall risk, gait, and
balance (see Chapter 15, Falls Prevention: Assessment, Diagnoses, and Intervention
Strategies) as well as basic, instrumental, and advanced activities of daily living (ADLs).
During acute illness, functional status, pain (see Chapter 14, Pain Management), and
symptoms of delirium (see Chapter 11, Delirium) should be monitored. Evaluation
of baseline cognition with periodic reassessment (see Chapter 8, Assessing Cognitive
Function) and sleep disorders (Espiritu, 2008) is warranted. e impact of physical and
cognitive changes of aging on an older adult’s level of safety and attentiveness in daily
tasks should be determined (Bashore & Ridderinkhof, 2002; Craft et al., 2009; Henry
et al., 2004; Park et al., 2003). Temperature indicating hypothermia (less than 95 °F or
less than 35 °C) or hyperthermia (greater than 105 °F or greater than 40.6 °C) must be
closely watched (Kuchel, 2009; Lu, Leasure, & Dai, 2010).
For care of the older adult, fall prevention strategies should be implemented
(see Chapter 15, Fall Prevention: Assessment, Diagnoses, and Intervention Strate-
gies). If delirium is identied, nursing interventions for its treatment are needed (see
Chapter 11, Delirium). Particularly during surgery, procedures such as the use of warmed
intravenous uids and humidied gases should be instituted to maintain normal tem-
peratures and prevent hypothermia in the older patient (Watters, 2002). Lifestyle modi-
cations recommended to improve cognitive function include regular physical exercise
(Colcombe & Kramer, 2003), intellectual stimulation (Mattson, 2009), and a healthful
diet (JNC, 2004; USDHHS, 2005). Behavioral interventions for sleep disorders may
be warranted (Irwin, Cole, & Nicassio, 2006).
IMMUNE SYSTEM AND VACCINATION
Immunosenescence, or the age-related dysfunction in immune response, is characterized
by reduced cell-mediated immune function and humoral immune responses (Weiskopf,
Weinberger, & Grubeck-Loebenstein, 2009), as well as increased inammatory response
(High, 2009; Hunt, Walsh, Voegeli, & Roberts, 2010). In older adults, it is responsible,
in part, for the increased susceptibility to and severity of infectious diseases (Htwe et al.,
2007), the lower ecacy of vaccination (Weiskopf et al., 2009), and the chronic inam-
matory state, which may contribute to chronic disease with age (Hunt et al., 2010).
Age-Related Changes in Health 35
Infectious diseases are a critical threat to older adults, especially since vaccination
ecacy declines with age. Mortality rates for infectious diseases are highest for adults
older than 85 years (Htwe et al., 2007), whereas reactivation of viruses, particularly vari-
cella zoster leading to herpes zoster, occurs signicantly more frequently in older adults
(High, 2009). Immunosenescence, by dampening the induction of adaptive immune
responses, results in reduced response rates to vaccination. For example, inuenza vac-
cination has a protection rate of only 56% in older persons. Further, antibody titers
following booster vaccinations, such as against tetanus, are lower and decline faster
with diminished antibody function in older adults compared to younger individuals
(Weiskopf et al., 2009).
Current immunization recommendations for older adults are available from the
Centers for Disease Control and Prevention (CDC, 2010). Vaccination with pneumococ-
cal polysaccharide for pneumococcal infections is recommended for individuals 65 years
of age and older, with one-time revaccination indicated if the patient was vaccinated
5 or more years previously and was aged younger than 65 years at the time of primary
vaccination. For seasonal inuenza, all individuals 50 years of age and older should be
vaccinated with the inactivated vaccine just prior to inuenza season each year. A single
dose of zoster vaccine is recommended for all adults 60 years of age and older regardless
of prior zoster history. A complete tetanus vaccine series is indicated for individuals hav-
ing an uncertain history of tetanus immunization or having received fewer than three
doses. Boosters should be given at 10-year intervals or more frequently with high-risk
injuries. Hepatitis vaccines should also be considered for older adults depending on cir-
cumstances such as potential exposure and travel (CDC, 2010; High, 2009).
ATYPICAL PRESENTATION OF DISEASE
Diseases, particularly infections, often manifest with atypical features in older adults.
Signs and symptoms are frequently subtle in the very old. ese may initially involve
nonspecic declines in functional or mental status, anorexia with reduced oral intake,
incontinence, falls (Htwe et al., 2007), fatigue (Hall, 2002), or exacerbation of chronic
illness such as heart failure or diabetes (High, 2009).
As a presenting sign of infection, fever is often blunted or absent, particularly in
the very old (High, 2009), frail, or malnourished (Watters, 2002) adults. Compared
to young adults with a normal mean baseline body temperature of 98.6 °F (37 °C),
frail older adults have a lower mean oral baseline temperature of 97.4 °F (36.3 °C; Lu
et al., 2010). A blunted response to inammatory stimuli in combination with lower
basal temperature can result in a lack of measurable febrile response. Increasing age is a
predisposing factor for the absence of fever (Htwe et al., 2007).
Assessment of the older patient should note any changes from baseline (includ-
ing those that are subtle and nonspecic) in functioning, mental status and behavior
(e.g., increased/new onset confusion), appetite, or exacerbation of chronic illness (High,
2009; Watters, 2002). is is especially important in individuals with cognitive impair-
ment who are unable to describe symptoms.
To detect fever, normal temperature should be established for the older adult and
monitored for changes of 2–2.4 °F (1.1–1.3 °C) above baseline (Htwe et al., 2007). Oral
temperatures of 99 °F (37.2 °C) or greater on repeated measurements also can be used to
signify fever. e diculty of diagnosing infection based on signs and symptoms may
result in greater reliance on laboratory and radiologic evaluations (High, 2009).
36 Evidence-Based Geriatric Nursing Protocols for Best Practice
In the assessment of disease, both typical and atypical symptoms must be consid-
ered. Evaluation for pneumococcal pneumonia includes monitoring for typical symp-
toms such as productive cough, fever, chills, and dyspnea as well as insidious, atypical
symptoms including tachypnea, lethargy (Bartlett et al., 2000), weakness, falls, decline
in functional status, delirium, or increased/new-onset confusion with absent high fever.
Decreased appetite and dehydration may be the only initial symptoms in the older adult
(Imperato & Sanchez, 2006). Although chest radiograph is basic to diagnosis, the older
adult who is dehydrated may not show inltrate or consolidation, and these ndings
may appear only after hydration (Htwe et al., 2007).
Clinical features of tuberculosis in the older person are often atypical and nonspe-
cic. Presenting symptoms may include dizziness, nonspecic pain, or impaired cogni-
tion rather than the typical manifestations of fever, night sweats, cough, or hemoptysis
(High, 2009). Typical inuenza symptoms of cough, fever, and chills may be combined
with altered mental status in older adults (Htwe et al., 2007).
UTI in older adults may present with classical symptoms of dysuria, ank or supra-
pubic discomfort, hematuria, and urinary frequency and urgency, or atypical symptoms
of new-onset/worsening incontinence, anorexia, confusion, nocturia, or enuresis (Htwe
et al., 2007).
For peritonitis, atypical symptoms such as confusion and fatigue may be manifest
rather than the typical symptoms of rigidity (Hall, 2002). Evaluation of GERD is based
on typical presenting symptoms of heartburn (pyrosis) and acid regurgitation, as well
as atypical symptoms in the older adult of dysphagia, chest pain, hoarseness, vomiting,
chronic cough, or recurrent aspiration pneumonia (Hall, 2009).
Ms. M is an 89-year-old woman presenting with productive cough, dyspnea, fatigue,
and increased confusion over the past week. Her vital signs are pulse, 96 bpm; tem-
perature, 98.6 °F; respiration, 31 bpm; and BP, 110/55. A chest radiograph shows
multilobe inltrates with a diagnosis of pneumonia. How severe is her pneumonia?
Ms. M’s symptoms of a respiratory rate greater than 30 respirations per minute,
multilobe inltrates on a chest radiograph, and diastolic BP of less than 60 mm Hg
characterize her pneumonia as severe (Bartlett et al., 2000), and she is likely to require
admission to an intensive care unit. However, several age-related changes aect her
symptoms of pneumonia. Pneumonia may present in the older adult with typical symp-
toms of productive cough, fever, and dyspnea or with more insidious, atypical symp-
toms of tachypnea, lethargy (Bartlett et al., 2000), weakness, falls, decline in functional
status, or increased/new-onset confusion. Decreased appetite and dehydration may be
the only initial symptoms (Imperato & Sanchez, 2006).
Because of reduced sympathetic innervation of the heart with age, the heart rate of an
older adult does not increase in response to stress comparable to that of a younger indi-
vidual (Kitzman & Taet, 2009). us, 96 bpm in an 89-year-old person is tachycardic
and indicates a severe stress reaction. Furthermore, because of a blunted febrile response to
infection particularly in a very old, frail, or malnourished adult, a fever may not be mani-
fest even with severe infection (High, 2009; Htwe, 2007; Lu et al., 2010; Watters, 2002).
CASE STUDY
Age-Related Changes in Health 37
SUMMARY
Changes that occur with age strongly impact the health and functional status of older
adults. us, recognition of and attention to these alterations are critically important in
nursing assessment and care. Armed with knowledge of age-related changes and using
the clinical protocol described in this chapter, nurses can play a vital role in improving
geriatric standards of practice. Designing interventions that take age-related changes
into consideration, educating patients and family caregivers on these alterations, and
sharing information with professional colleagues will all serve to ensure optimal care of
older adults.
(continued)
Protocol 3.1: Age-Related Changes in Health
I. GOAL: To identify anatomical and physiological changes, which are attributed to
the normal aging process.
II. OVERVIEW: Age-associated changes are most pronounced in advanced age of 85
years or older, may alter the older person’s response to illness, show great variability among
individuals, are often impacted by genetic and long-term lifestyle factors, and commonly
involve a decline in functional reserve with reduced response to stressors.
III. STATEMENT OF PROBLEM: Gerontological changes are important in nurs-
ing assessment and care because they can adversely aect health and functionality and
require therapeutic strategies; must be dierentiated from pathological processes to
allow development of appropriate interventions; predispose to disease, thus empha-
sizing the need for risk evaluation of the older adult; and can interact reciprocally
with illness, resulting in altered disease presentation, response to treatment, and
outcomes.
IV. AGE-ASSOCIATED CARDIOVASCULAR CHANGES
A. Denition(s)
Isolated systolic hypertension: systolic BP .140 mm Hg and diastolic BP ,90
mm Hg.
B. Etiology
1. Arterial wall thickening and stiening, decreased compliance.
2. Left ventricular and atrial hypertrophy. Sclerosis of atrial and mitral valves.
3. Strong arterial pulses, diminished peripheral pulses, cool extremities.
C. Implications
1. Decreased cardiac reserve.
a. At rest: No change in heart rate, cardiac output.
b. Under physiological stress and exercise: Decreased maximal heart rate
and cardiac output, resulting in fatigue, shortness of breath, slow recov-
ery from tachycardia.
NURSING STANDARD OF PRACTICE
38 Evidence-Based Geriatric Nursing Protocols for Best Practice
c. Risk of isolated systolic hypertension; inamed varicosities.
d. Risk of arrhythmias, postural, and diuretic-induced hypotension. May
cause syncope.
D. Parameters of Cardiovascular Assessment
1. Cardiac assessment: ECG; heart rate, rhythm, murmurs, heart sounds (S
4
common, S3 in disease). Palpate carotid artery and peripheral pulses for
symmetry (Docherty, 2002).
2. Assess BP (lying, sitting, standing) and pulse pressure (Mukai & Lipsitz,
2002).
V. AGE-ASSOCIATED CHANGES IN THE PULMONARY SYSTEM
A. Etiology
1. Decreased respiratory muscle strength; stier chest wall with reduced
compliance.
2. Diminished ciliary and macrophage activity, drier mucus membranes.
Decreased cough reex.
3. Decreased response to hypoxia and hypercapnia.
B. Implications
1. Reduced pulmonary functional reserve.
a. At rest: No change.
b. With exertion: Dyspnea, decreased exercise tolerance.
2. Decreased respiratory excursion and chest/lung expansion with less eec-
tive exhalation. Respiratory rate of 12–24 breaths per minute.
3. Decreased cough and mucus/foreign matter clearance.
4. Increased risk of infection and bronchospasm with airway obstruction.
C. Parameters of Pulmonary Assessment
1. Assess respiration rate, rhythm, regularity, volume, depth (Docherty,
2002), and exercise capacity (Mahler et al., 2003). Ascultate breath sounds
throughout lung elds (Mick & Ackerman, 2004).
2. Inspect thorax appearance, symmetry of chest expansion. Obtain smoking
history.
3. Monitor secretions, breathing rate during sedation, positioning (Watters, 2002;
Docherty, 2002), arterial blood gases, pulse oximetry (Zeleznik, 2003).
4. Assess cough, need for suctioning (Smith & Connolly, 2003).
D. Nursing Care Strategies
1. Maintain patent airways through upright positioning/repositioning
(Docherty, 2002), suctioning (Smith & Connolly, 2003).
2. Provide oxygen as needed (Docherty, 2002); maintain hydration and mobil-
ity (Watters, 2002).
3. Incentive spirometry as indicated, particularly if immobile or declining in
function (Dunn, 2004).
4. Education on cough enhancement (Dunn, 2004), smoking cessation
(USDHHS, 2004a).
Protocol 3.1: Age-Related Changes in Health (cont.)
(continued)
Age-Related Changes in Health 39
VI. AGE-ASSOCIATED CHANGES IN THE RENAL AND
GENITOURINARY SYSTEMS
A. Denition(s)
To determine renal function (GFR):
Cockcroft-Gault equation: Calculation of creatinine clearance in older adults
(Péquignot et al., 2009).
For Men
Creatinine clearance (mL/min) 5
(140 2 age in years) 3 (body weight in kg)
_____________________________
72 3 (serum creatinine, mg/dL)
For women, the calculated value is multiplied by 85% (0.85).
MDRD: see National Kidney Disease Education Program calculator (National
Kidney Disease Education Program, 2009).
B. Etiology
1. Decreases in kidney mass, blood ow, GFR (10% decrement/decade after
age 30). Decreased drug clearance.
2. Reduced bladder elasticity, muscle tone, capacity.
3. Increased postvoid residual, nocturnal urine production.
4. In males, prostate enlargement with risk of BPH.
C. Implications
1. Reduced renal functional reserve; risk of renal complications in illness.
2. Risk of nephrotoxic injury and adverse reactions from drugs.
3. Risk of volume overload (in heart failure), dehydration, hyponatremia (with
thiazide diuretics), hypernatremia (associated with fever), hyperkalemia
(with potassium-sparing diuretics). Reduced excretion of acid load.
4. Increased risk of urinary urgency, incontinence (not a normal nding), uri-
nary tract infection, nocturnal polyuria. Potential for falls.
D. Parameters of Renal and Genitourinary Assessment
1. Assess renal function (GFR through creatinine clearance; Lerma, 2009;
Miller, 2009; National Kidney Disease Education Program, 2009; Péqui-
gnot et al., 2009).
2. Assess choice/need/dose of nephrotoxic agents and renally cleared drugs
(Beyth & Shorr, 2002; see Chapter 17, Reducing Adverse Drug Events.
3. Assess for uid/electrolyte and acid/base imbalances (Suhayda & Walton,
2002).
4. Evaluate nocturnal polyuria, urinary incontinence, BPH (Miller, 2009).
Assess UTI symptoms (see Atypical Presentation of Disease section; Htwe
et al., 2007).
5. Assess fall risk if nocturnal or urgent voiding (see Chapter 15, Fall Preven-
tion: Assessment, Diagnoses, and Intervention Strategies)
E. Nursing Care Strategies
1. Monitor nephrotoxic and renally cleared drug levels (Beyth & Shorr, 2002).
2. Maintain uid/electrolyte balance. Minimum 1,500–2,500 mL/day from
uids and foods for 50- to 80-kg adults to prevent dehydration (Suhayda &
Walton, 2002).
3. For nocturnal polyuria: limit uids in evening, avoid caeine, use prompted
voiding schedule (Miller, 2009).
Protocol 3.1: Age-Related Changes in Health (cont.)
(continued)
40 Evidence-Based Geriatric Nursing Protocols for Best Practice
4. Fall prevention for nocturnal or urgent voiding (see Chapter 15, Fall Pre-
vention: Assessment, Diagnoses, and Intervention Strategies).
VII. AGE-ASSOCIATED CHANGES IN THE OROPHARYNGEAL AND
GASTROINTESTINAL SYSTEMS
A. Denition(s)
BMI: Healthy, 18.5–24.9 kg/m
2
; overweight, 25–29.9 kg/m
2
; obesity, 30 kg/
m
2
or greater.
B. Etiology
1. Decreases in strength of muscles of mastication, taste, and thirst perception.
2. Decreased gastric motility with delayed emptying.
3. Atrophy of protective mucosa.
4. Malabsorption of carbohydrates, vitamins B
12
and D, folic acid, calcium.
5. Impaired sensation to defecate.
6. Reduced hepatic reserve. Decreased metabolism of drugs.
C. Implications
1. Risk of chewing impairment, uid/electrolyte imbalances, poor nutrition.
2. Gastric changes: altered drug absorption, increased risk of GERD, mal-
digestion, NSAID-induced ulcers.
3. Constipation not a normal nding. Risk of fecal incontinence with disease
(not in healthy aging).
4. Stable liver function tests. Risk of adverse drug reactions.
D. Parameters of Oropharyngeal and Gastrointestinal Assessment
1. Assess abdomen, bowel sounds.
2. Assess oral cavity (see Chapter 20, Oral Health Care); chewing and swal-
lowing capacity, dysphagia (coughing, choking with food/uid intake; Ney
et al., 2009). If aspiration, assess lungs (rales) for infection and typical/
atypical symptoms (Bartlett et al., 2000; High, 2009; see Atypical Presenta-
tion of Disease section).
3. Monitor weight, calculate BMI, compare to standards (American Hearth
Association Nutrition Committee et al., 2006). Determine dietary intake,
compare to nutritional guidelines (Chapman, 2007; USDHHS, 2005; Vis-
vanathan & Chapman, 2009; see Chapter 22, Nutrition).
4. Assess for GERD; constipation and fecal incontinence; fecal impaction by
digital examination of rectum or palpation of abdomen.
E. Nursing Care Strategies
1. Monitor drug levels and liver function tests if on medications metabolized
by liver. Assess nutritional indicators (Chapman, 2007; USDHHS, 2005;
Visvanathan & Chapman, 2009).
2. Educate on lifestyle modications and over-the-counter (OTC) medica-
tions for GERD.
3. Educate on normal bowel frequency, diet, exercise, recommended laxatives.
Encourage mobility, provide laxatives if on constipating medications (Stern,
2006).
4. Encourage participation in community-based nutrition programs (Visvanathan
& Chapman, 2009); educate on healthful diets (USDHHS, 2005).
Protocol 3.1: Age-Related Changes in Health (cont.)
(continued)
Age-Related Changes in Health 41
VIII. AGE-ASSOCIATED CHANGES IN THE MUSCULOSKELETAL SYSTEM
A. Denition(s)
Sarcopenia: Decline in muscle mass and strength associated with aging.
B. Etiology
1. Sarcopenia evokes increased weakness and poor exercise tolerance.
2. Lean body mass replaced by fat with redistribution of fat.
3. Bone loss in women and men after peak mass at age 30 to 35 years.
4. Decreased ligament and tendon strength. Intervertebral disc degeneration.
Articular cartilage erosion. Changes in stature with kyphosis, height reduction.
C. Implications
1. Sarcopenia: increased risk of disability, falls, unstable gait.
2. Risk of osteopenia and osteoporosis.
3. Limited ROM, joint instability, risk of osteoarthritis.
D. Nursing Care Strategies
1. Encourage physical activity through health education and goal setting
(Conn, 2003) to maintain function (Netz et al., 2005).
2. Pain medication to enhance functionality (see Chapter 14, Pain
Management). Implement strategies to prevent falls (see Chapter 15, Fall
Prevention: Assessment, Diagnoses, and Intervention Strategies and Chapter
13, Physical Restraints and Side Rails in Acute and Critical Care Settings).
3. Prevent osteoporosis by adequate daily intake of calcium and vitamin D,
physical exercise, smoking cessation (USDHHS, 2004b). Advise routine
bone mineral density screening (Agency for Healthcare Research and
Quality, 2010).
IX. AGE-ASSOCIATED CHANGES IN THE NERVOUS SYSTEM AND
COGNITION
A. Etiology
1. Decrease in neurons and neurotransmitters.
2. Modications in cerebral dendrites, glial support cells, synapses.
3. Compromised thermoregulation.
B. Implications
1. Impairments in general muscle strength; deep tendon reexes; nerve con-
duction velocity. Slowed motor skills and potential decits in balance and
coordination.
2. Decreased temperature sensitivity. Blunted or absent fever response.
3. Slowed speed of cognitive processing. Some cognitive decline is common
but not universal. Most memory functions are adequate for normal life.
4. Increased risk of sleep disorders, delirium, neurodegenerative diseases.
C. Parameters of Nervous System and Cognition Assessments
1. Assess, with periodic reassessment, baseline functional status (Craft et al.,
2009; see Chapter 6, Assessment of Physical Function and Chapter 15, Fall
Prevention: Assessment, Diagnoses, and Intervention Strategies). During acute
illness, monitor functional status and delirium (see Chapter 11, Delirium).
2. Evaluate, with periodic reassessment, baseline cognition (see Chapter 8,
Assessing Cognitive Function) and sleep disorders (Espiritu, 2008).
Protocol 3.1: Age-Related Changes in Health (cont.)
(continued)
42 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Assess impact of age-related changes on level of safely and attentiveness in
daily tasks (Park et al., 2003; Henry et al., 2004).
4. Assess temperature during illness or surgery (Kuchel, 2009).
D. Nursing Care Strategies
1. Institute fall preventions strategies (see Chapter 15, Fall Prevention: Assess-
ment, Diagnoses, and Intervention Strategies).
2. To maintain cognitive function, encourage lifestyle practices of regular
physical exercise (Colcombe & Kramer, 2003), intellectual stimulation
(Mattson, 2009), healthful diet (JNC, 2004).
3. Recommend behavioral interventions for sleep disorders.
X. AGE-ASSOCIATED CHANGES IN THE IMMUNE SYSTEM
A. Etiology
1. Immune response dysfunction (Kuchel, 2009) with increased susceptibility
to infection, reduced ecacy of vaccination (Htwe et al., 2007), chronic
inammatory state (Hunt et al., 2010).
B. Nursing Care Strategies
1. Follow CDC immunization recommendations for pneumococcal infec-
tions, seasonal inuenza, zoster, tetanus, and hepatitis for the older adult
(CDC, 2010; High, 2009).
XI. ATYPICAL PRESENTATION OF DISEASE
A. Etiology
1. Diseases, especially infections, may manifest with atypical symptoms in
older adults.
2. Symptoms/signs often subtle include nonspecic declines in function or
mental status, decreased appetite, incontinence, falls (Htwe et al., 2007),
fatigue (Hall, 2002), exacerbation of chronic illness (High, 2009).
3. Fever blunted or absent in very old (High, 2009), frail, or malnourished
(Watters, 2002) adults. Baseline oral temperature in older adults is 97.4 °F
(36.3 °C) versus 98.6 °F (37 °C) in younger adults (Lu et al., 2010).
B. Parameters of Disease Assessment
1. Note any change from baseline in function, mental status, behavior, appe-
tite, chronic illness (High, 2009).
2. Assess fever. Determine baseline and monitor for changes 2–2.4 °F
(1.1–1.3 °C) above baseline (Htwe et al., 2007). Oral temperatures above
99 °F (37.2 °C) or greater also indicate fever (High, 2009).
3. Note typical and atypical symptoms of pneumococcal pneumonia (Bartlett
et al., 2000; Htwe et al., 2007; Imperato & Sanchez, 2006), tuberculosis
(Kuchel, 2009), inuenza (Htwe et al., 2007), UTI (Htwe et al., 2007),
peritonitis (Hall, 2002), and GERD (Hall, 2009).
XII. EVALUATION/EXPECTED OUTCOMES (FOR ALL SYSTEMS)
A. Older adult will experience successful aging through appropriate lifestyle prac-
tices and health care.
Protocol 3.1: Age-Related Changes in Health (cont.)
(continued)
Age-Related Changes in Health 43
B. Health care provider will
1. Identify normative changes in aging and dierentiate these from pathologi-
cal processes.
2. Develop interventions to correct for adverse eects associated with aging.
C. Institution will
1. Develop programs to promote successful aging.
D. Will provide sta education on age-related changes in health.
XIII. FOLLOW-UP MONITORING OF CONDITION
A. Continue to reassess eectiveness of interventions.
B. Incorporate continuous quality improvement criteria into existing programs.
RESOURCES
Government Informational Agencies
Agency for Healthcare Research and Quality
http://www.ahrq.gov
Administration on Aging
http://www.aoa.gov
National Institute on Aging
http://www.nia.nih.gov
Non-Profit Organizations
Health and Age Foundation
http://www.healthandage.org
American Federation of Aging Research
http://www.afar.org
Alliance for Aging Research
http://www.agingresearch.org
National Council on Aging
http://www.ncoa.org
Smith-Kettlewell Eye Research Institute
http://www.ski.org
CRONOS
http://www.unu.edu/unupress/food/V183e/begin.htm
Professional Societies
e National Gerontological Nursing Association
http://www.ngna.org
Protocol 3.1: Age-Related Changes in Health (cont.)
44 Evidence-Based Geriatric Nursing Protocols for Best Practice
e National Conference of Gerontological Nurse Practitioners
http://www.ncgnp.org/
e American Geriatrics Society
http://www.americangeriatrics.org/
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Miller, M. (2009). Disorders of uid balance. In J. B. Halter, J. G. Ouslander, M. E. Tinetti, S.
Studenski, K. P. High, & S. Asthana (Eds.), Hazzard’s geriatric medicine and gerontology (6th ed.,
pp. 1047–1058). New York, NY: McGraw-Hill. Evidence Level V.
Mukai, S., & Lipsitz, L. A. (2002). Orthostatic hypotension. Clinics in Geriatric Medicine, 18(2),
253–268.
Narici, M. V., Maulli, N., & Maganaris, C. N. (2008). Ageing of human muscles and tendons.
Disability and Rehabilitation, 30(20–22), 1548–1554. Evidence Level V.
National Kidney Disease Education Program. (2009). Health professionals: GFR MDRD calculators
for adults (conventional units). Retrieved from http://www.nkdep.nih.gov/professionals/gfr_cal-
culators/orig_con.htm/. Evidence Level I.
Netz, Y., Wu, M. J., Becker, B. J., & Tenenbaum, G. (2005). Physical activity and psychological
well-being in advanced age: A meta-analysis of intervention studies. Psychology & Aging, 20(2),
272–284. Evidence Level I.
Newton, J. L. (2005). Eect of age-related changes in gastric physiology on tolerability of medica-
tions for older people. Drugs & Aging, 22(8), 655–661. Evidence Level V.
Ney, D. M., Weiss, J. M., Kind, A. J., & Robbins, J. (2009). Senescent swallowing: Impact, strate-
gies, and interventions. Nutrition in Clinical Practice, 24(3), 395–413. Evidence Level V.
Park, H. L., O’Connell, J. E., & omson, R. G. (2003). A systematic review of cognitive decline in
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Evidence Level I.
Péquignot, R., Belmin, J., Chauvelier, S., Gaubert, J. Y., Konrat, C., Duron, E., & Hanon, O. (2009).
Renal function in older hospital patients is more accurately estimated using the Cockcroft-Gault
formula than the modication diet in renal disease formula. Journal of the American Geriatrics
Society, 57(9), 1638–1643. Evidence Level II.
Age-Related Changes in Health 47
Roberts, S. B., & Dallal, G. E. (2005). Energy requirements and aging. Public Health Nutrition,
8(7A), 1028–1036. Evidence Level I.
Schnelle, J. F., Alessi, C. A., Simmons, S. F., Al-Samarrai, N. R., Beck, J. C., & Ouslander, J. G.
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Smith, H. A., & Connolly, M. J. (2003). Evaluation and treatment of dysphagia following stroke.
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Stern, M. (2006). Neurogenic bowel and bladder in the older adult. Clinics in Geriatric Medicine,
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U.S. Department of Health and Human Services. (2004b). Bone health and osteoporosis: A report
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1–18. Evidence Level V.
48
4
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe the normal changes of aging that aect the senses in the older adult
2. identify common disorders that impact the senses in the older adult
3. determine how best to assess sensory status in the older adult
4. identify nursing strategies to manage sensory impairment in the older adult
5. collaborate with interprofessional team members who can assist the older adults with
sensory impairment
BACKGROUND AND STATEMENT OF PROBLEM
Individuals experience and interact with their environments through their senses. Vision,
hearing, smell, taste, and peripheral sensation allow us to safely experience and enjoy the
world around us. As people age, they often experience changes in their sensory func-
tion (vision, hearing, smell, taste, and peripheral sensation). ese sensory changes can
negatively impact the older adults’ ability to interact with their environment, decreasing
their quality of life. For example, changes in hearing can impact an older person’s com-
munication skills; changes in vision can impact their health literacy limiting their ability
to take medications safely. Healthy People 2020 emphasizes the importance of healthy
senses, including vision, hearing, balance, smell, and taste. Vision and hearing abilities
are essential to language, whether spoken, signed, or read (U.S. Department of Health
and Human Services [USDHHS], 2010). Decreases in sense of smell can interfere with
an older adult’s ability to smell smoke in a re or recognize spoiled food. Many adults
report a decrease in taste that impacts their desire to eat. Decreased peripheral sensation
sets up an individual for falls.
Understanding how to assess the senses as well as manage sensory decits is essen-
tial to holistic nursing. A goal of Healthy People 2020 is to decrease the prevalence and
Pamela Z. Cacchione
Sensory Changes
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Sensory Changes 49
severity of disorders of vision, hearing, balance, smell, and taste, as well as voice, speech,
and language (USDHHS, 2010). is chapter on sensory changes addresses common
age- related changes associated with the senses as well as disease states and injuries to
the senses that occur more commonly with aging. Nursing care related to the Healthy
People 2020 goals regarding sensory changes will also be addressed.
Normal Changes of Aging Senses
e senses—vision, hearing, taste, smell, balance, and peripheral sensation—change with
aging, usually presenting primarily with a slowing of function. A summary table is presented
describing the changes that occur and the functional outcomes for each sense (Table 4.1).
Vision
ere are several changes that occur with vision as people age. e eyelids start to lag,
potentially obscuring vision; the pupil takes longer to dilate and contract, slowing
accommodation; and presbyopia is widespread.
Presbyopia
A loss of elasticity in the lens and stiening of the muscle bers of the lens of the eye
leads to a decrease in the eyes’ ability to change the shape of the lens to focus on near
objects, such as ne print, and decreases ability to adapt to light (National Eye Institute
[NEI], 2004a; Whiteside, Wallhagen, & Pettengill, 2006).
Hearing
Normal changes of aging impacting hearing include the decrease in function of the
hair bers in the ear canal that normally aid in the natural removal of cerumen and the
protection of the ear canal from external elements.
Presbycusis
Presbycusis is the most common form of hearing loss in the United States (Bagai,
avendiranathan, & Detsky, 2006). is high-frequency sensorineural hearing loss is a
multifactorial process that varies in severity and is associated with aging (Gates & Mills,
2005). Presbycusis usually has a bilateral progressive onset and is caused by gradual loss
of hair cells and brous changes in the small blood vessels that supply the cochlea. Risk
factors include heredity, environmental exposure, free radical, and mitochondrial deoxy-
ribonucleic acid (DNA) damage (Huang & Tang, 2010). Presenting clinical symptoms
of this irreversible condition includes high-frequency hearing loss and diculty hearing
high-pitched sounds such as /t/, /p/, /k/, /s/, /z/, /sh/, and /ch/ (Huang & Tang, 2010;
Wallhagen, Strawbridge, Shema, & Kaplan, 2004). Background noise further aggravates
this hearing decit.
Smell
Changes in smell are common as we age, but are not considered a normal part of aging.
Frequently, older adults complain of distortions of smell. Factors associated with loss of sense
of smell include age and sex with older males being more prone to smell loss (Homan,
Cruickshanks, & Davis, 2009). e environment, trauma, diseases, or illness can diminish
50 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 4.1
Normal Changes of Aging
Sense Change of Aging Functional Outcome
Vision
n Decreased dark adaptation
n Decreased upward gaze
n Eyes become drier and produce
less tears
n Cornea becomes less sensitive
n Pupils decrease in size
n Visual fields become smaller
n Increased safety risk in changing environmental
light
n Decreased field of vision
n Dry irritated eyes
n Slow to recognize injury to the cornea
n Inability to adjust to glare and change in lighting
conditions
n Safety risk for driving and maneuvering in the
environment
Hearing
n Ear drum thickens
n Loss of high-frequency hearing
acuity
n Decreased ability to process
sounds after age 50
n Increased cerumen impactions
n Thickened ear drum decreases sound moving
across the ear canal
n Decreased ability to hear sounds, such as /p/,
/w/, /f/, /sh/, and women’s and children’s voices
n Requires more time to process and respond to
auditory stimuli
n Decreased hearing because of blockage of sound
Smell
n Decreased ability to identify odors
n Impacts ability to taste
n Inability to identify spoiled food or smoke
n Limits enjoyment in eating
Taste
n Decreased number of taste buds
n Limited decrease in taste
supported by studies
n Less saliva production
n Decreased sensitivity to flavors
n Dry mouth affecting ability to swallow
Sensation
n Decreased vibratory sense
n Decreased two-point
discrimination
n Decreased temperature sensitivity
n Decreased balance
n Decreased proprioception
n Changed pain sensation
n Increases risk for injury
n Decreased ability to sense pressure
n Decreased protective response to withdraw
from hot objects
n Risk of falls
n Risk of falls
n Decreased protective mechanism
Note. Adapted from: Bromley, S. M. (2000). Smell and taste disorders: A primary care approach. American Family
Physician, 61(2), 427–436, 438. Evidence Level VI. Linton, A. D. (2007). Age-related changes in the special senses.
In A. D. Linton & H. W. Lach (Eds.), Matteson & McConnell’s gerontological nursing, concepts and practice (3rd ed.,
pp. 600–630). St. Louis, MO: Saunders Elsevier. Evidence Level V. Murphy, C., Schubert, C. R., Cruickshanks,
K. J., Klein, B. E., Klein, R., & Nondahl, D. M. (2002). Prevalence of olfactory impairment in older adults. Journal
of the American Medical Association, 288(18), 2307–2312. Evidence Level III. Schiman, S. S. (1997). Taste and
smell losses in normal aging and disease. Journal of the American Medical Association, 278(16), 1357–1362. Evidence
Level V. Seiberling, K. A., & Conley, D. B. (2004). Aging and olfactory and taste function. Otolaryngologic Clinics of
North America, 37(6), 1209–1228. Evidence Level V. Wallhagen, M. I., Pettengill, E., & Whiteside, M. (2006). Sen-
sory impairment in older adults: Part 1: Hearing loss. e American Journal of Nursing, 106(10), 40–48. Evidence Level
VI. Whiteside, M. M., Wallhagen, M. I., & Pettengill E. (2006). Sensory impairment in older adults: Part 2: Vision
loss. e American Journal of Nursing, 106(11), 52–61. Evidence Level V.
the sense of smell (Homan et al., 2009). Changes in the sense of smell have also been found
to correlate with neurological conditions such as Parkinson’s disease and Alzheimer’s disease
(Albers, Tabert, & Devanand, 2006; Wilson, Arnold, Schneider, Tang, & Bennett, 2007).
Taste
Common changes in taste include a decreased ability to detect the intensity of taste but
not somatic sensations such as touch and burning pain in the tongue when compared
Sensory Changes 51
to younger adults (Fukunaga, Uematsu, & Sugimoto, 2005). However, complete loss
of taste is rare and changes in taste are more often related to dental concerns; diseases or
illness such as rhinitis, allergies, or infections; and medications or cancer treatments to
the head and neck (Fukunaga et al., 2005; Homan et al., 2009).
Peripheral Sensation
Peripheral nerve function that controls the sense of touch declines slightly with age.
Two-point discrimination and vibratory sense both decrease with age. e ability to
perceive painful stimuli is preserved in aging. However, there may be a slowed reaction
time for pulling away from painful stimuli with aging (Linton, 2007).
ASSESSMENT OF THE PROBLEM
Vision
e prevalence of visual impairment increases with age and the settings in which
older adults live. Data from the National Health and Nutrition Examination Survey
(NHANES; Dillon, Gu, Homan, & Ko, 2010) in older adults aged 70 years and
older identied, 15.4% were found to be visually impaired but this varied by race
and ethnicity with non-Hispanic Whites (13.8%), non-Hispanic Blacks (21.1%), and
Mexican Americans (24%). In adults aged 80 years and older, 24.6% were found to
be visually impaired (Dillon et al., 2010). In another study, adults aged 80 years and
older are 7.7% of one study but accounted 69% of the cases of blindness (Congdon
et al., 2004). is is worrisome because this is the fastest growing segment of our
population.
Studies evaluating older adults in long-term care settings demonstrate prevalence
rates from 27% to 54% of older adults with visual impairment (Bron & Caird, 1997;
Cacchione, Culp, Dyck, & Laing, 2003). Uncorrected refractive error was also found
to be common in visually impaired older adults. In one study, of the 8.8% of the older
adults found to be visually impaired, 59% of those were impaired because of an uncor-
rected refractive error (Vitale, Cotch, & Sperduto, 2006). Leading causes of blindness
by race and ethnicity was found to be macular degeneration in Whites, cataracts and
open-angle glaucoma in Blacks, and open-angle glaucoma in Hispanic persons (Con-
gdon et al., 2004). Cataracts, one of the leading causes of blindness, are unilateral or
bilateral clouding of the crystalline lens that presents as painless, progressive loss of
vision (NEI, 2004a).
e denition of visual impairment varies by dierent groups and by country
(Agency for Healthcare Research and Quality [AHRQ], 2004). e United States
denes low vision as best corrected visual acuity:
n Normal vision: visual acuity of 20/20 or better
n Mild vision impairment: 20/25 to 20/50
n Moderate visual impairment: 20/60 to 20/160
n Severe visual impairment (legally blind): 20/200 to 20/400
n Profound vision impairment: 20/400 to 20/1,000
n Near-total vision loss: less than or equal to 20/1,250
n Total blindness: no light perception
52 Evidence-Based Geriatric Nursing Protocols for Best Practice
Low vision can also be dened based on visual eld limitations. Severe visual impair-
ment is dened as best corrected eld less than or equal to 20 degrees (legal blindness).
Profound visual impairment is dened as visual eld less than or equal to 10 degrees
(AHRQ, 2004).
Nursing Assessment of Vision
e health history is an essential part of vision assessment. Several health conditions pre-
dispose older adults to visual impairment. Diabetes is a common cause of disease-related
blindness related to diabetic retinopathy, with 6% of diabetics older than the age of
65 years developing diabetic retinopathy (Baker, 2003; NEI, 2004b). Hypertension car-
ries with it the risk of hypertensive retinopathy. Ascertaining a thorough baseline health
history with yearly reviews and updates is essential in maintaining visual health. Health
questions related to visual health include the questions shown in Table 4.2 ( Cacchione,
2007; Wallhagen, Pettengill, & Whiteside, 2006).
Examination of the Eye
e external structures can cause decreased vision if the lids lag because of laxity of the
skin of the upper eyelid. Lid lag can interfere with visual acuity and elds, which may
require surgery. A decreased level of tear function can negatively impact visual acuity.
Cataracts in severe cases can be visible with the naked eye and appear as a whitish gray
pupil instead of black. Cloudiness of the whole cornea of the eye is indicative of a cor-
neal problem, not a cataract. If the person has had cataract surgery, the lens implant may
be visible on close inspection.
Fundus Exam. Using an ophthalmoscope, a nurse can visualize the red reex and, with expe-
rience and practice, the fundus of the eye. is is often dicult with small pupils. Dark-
ening the room may help with dilating the pupils. Optometrists and ophthalmologists
TABLE 4.2
Vision History Questions
n When was your last eye exam?
n How would you describe your eyesight?
n Any change in your eyesight?
n When did you notice this change?
n Are you experiencing any blurred vision?
n Are you having any double vision?
n Are you bothered by glare?
n Are you experiencing any eye pain?
n Are you using any eye drops for any reason?
n Any history of trauma or injury to your eyes?
n Have you had any eye surgeries?
n Do you have cataracts?
n Any family history of eye problems?
Note. Adapted from: Cacchione, P. Z. (2007). Nursing care of older adults with age-related vision loss. In S. Crocker-
Houde (Ed.), Vision loss in older adults: Nursing assessment and care management (pp. 131–148). New York, NY:
Springer Publishing. Evidence Level VI. Whiteside, M. M., Wallhagen, M. I., & Pettengill E. (2006). Sensory
impairment in older adults: Part 2. Vision loss. e American Journal of Nursing, 106(11), 52–61. Evidence Level V.
Sensory Changes 53
dilate the pupils to allow for a better view of the fundus. Cataracts will appear as a dark
shadow in the anterior portion of the lens in front of the retina.
Vision Testing. Vision testing should be completed before the eyes are dilated and com-
pleted with both uncorrected and corrected (with glasses) vision.
Distance Vision. e “gold standard” in eye charts, the Snellen chart, is one of the most
commonly used to assess distance vision. Visual acuity is tested at 20 ft. e individual
is asked to read the letters on the chart until he or she miss more than two on a line of
acuity. Acuity equals the line above the line with more than two errors. Acuity measures
range from 20/10 to 20/800 on the Snellen chart.
Early Treatment Diabetic Retinopathy Study. e Early Treatment Diabetic Retinopathy Study
(ETDRS; Ferris, Kasso, Bresnick, & Bailey, 1982) eye chart is also used frequently
and can be used at a distance of 4 m. At this distance, the greatest visual acuity measured
is 20/200—the equivalent of legal blindness.
Pin-Hole Test. With best vision, with or without glasses, a card with a small pin hole or
a multiple pin-hole occluder can be placed in front of the eye, and the vision is tested
again at the last line the individual was able to read. is test identies refractive error of
the peripheral cornea of the lens of the eye by allowing only perpendicular light to the
lens (Kalinowski, 2008). If the individual can read farther down the chart with the pin
hole, his or her vision may be improved with better refraction of his or her eyeglasses or,
if he or she do not have glasses, with eyeglasses.
Near Vision. Near vision is important for health literacy, especially regarding reading
food or medication labels. ere are several ways to assess near vision. Two commonly
used tools are the Rosenbaum Pocket Eye Screener and the Lighthouse for the Blind
Near Vision Screener. e Rosenbaum Pocket Eye Screener is a non-copyrighted tool
based on the Snellen chart that can be useful in assessing near vision in the acute care
and primary care settings. e Rosenbaum is true to scale when compared with the
Snellen chart at the 20/200, 20/400, and 20/800 acuity levels. However, the other
levels are slightly too large, causing an overestimation of visual acuity (Horton &
Jones, 1997).
Lighthouse for the Blind Near Vision Screener (Lighthouse for the Blind). is handheld vision screener
has a cord that can be used at 40 and 20 cm to measure the proper distance for testing
near vision. is near vision screener mimics the ETDRS eye chart in a smaller version
but is not pocket size. It does not, however, have the concern over the scale matching of
the ETDRS distance acuity level. For research purposes, it has the added feature of the
cord for measuring a consistent distance.
Contrast Sensitivity. Contrast sensitivity is often compromised by aging and diseases or con-
ditions of the eye. Decreases in contrast sensitivity occur with cataracts, glaucoma, and
retinopathies (Mäntyjärvi & Laitinen, 2001; Wilensky & Hawkins, 2001). Contrast
sensitivity provides information on how well an individual may perform in real-life con-
ditions. Decline in contrast sensitivity impacts one’s ability to distinguish when one step
ends and another begins, identify light switches on the wall, read materials not made in
high-contrast font, or identify the buttons on the remote. Intact contrast sensitivity is
important for day-to-day safety and function within the environment.
54 Evidence-Based Geriatric Nursing Protocols for Best Practice
e Pelli–Robson Contrast Sensitivity Chart (Pelli, Robson, & Wilkins, 1988) is
read at the 1- or 3-m distance. All letters are presented at the 20/200 acuity level but
in decreasing shades of black to gray. e Pelli–Robson Contrast Sensitivity Chart is
widely used in practice and works well for older adults who are experienced in recog-
nizing letters (Hirvelä & Laatikainen, 1995; Morse & Rosenthal, 1997). e Vistech
Contrast Sensitivity Test, another contrast sensitivity measure, has four patches of gray
circles with lines in dierent directions (Kennedy & Dunlap, 1990). e person being
examined points to the direction the lines within the circle are pointed (Morse & Rosen-
thal, 1997).
Visual Fields. Fields of vision refers to the area of peripheral vision visible when the indi-
vidual is focusing straight ahead (Cassin & Rubin, 2001). e vision in visual elds can
be aected by many eye conditions, as well as neurological disorders that inhibit eye
movement or aect the blood supply to the optic nerve. Intact visual elds are impor-
tant to function safely in one’s environment. In assessing visual elds by confrontation,
a gross clinical measure of visual elds, the examiner faces the patient and determines if
the patient can identify the examiner’s moving ngers as they are moving into their eld
of view (Seidel, Dains, Ball, & Benedict, 2003). Although subjective and dependent on
the examiner having normal elds of vision, the confrontation test is useful in quickly
identifying large losses in visual elds.
e Humphrey Visual Field Test is completed by an ophthalmologist and assesses
visual elds using a static type of perimetry (Gianutsos & Sucho, 1997). is measure
provides a more reliable measure of functional visual elds. e Goldman VI4e kinetic
perimetry visual eld testing, on the other hand, assesses kinetic type of functional
visual elds (Gillmore, 2002). Kinetic perimetry entails the introduction of a moving
stimulus moving from a nonvisible area toward the xed point of view. e Goldman
VI4e kinetic perimetry visual eld testing is hard to standardize because it is operator
dependent (Gillmore, 2002). Because these automated methods are more widely used,
the location of the visual eld decit may clue the examiner about the type of eye con-
dition. For example, unilateral visual eld decits may be related to a cerebral vascular
accident, glaucoma will aect the peripheral elds, and macular degeneration has asso-
ciated central eld of vision loss.
Stereopsis. Stereopsis is the process where humans have the ability to use the dierent
viewpoints provided by their eyes to produce a vivid perception of depth and three-
dimensional shapes (Norman et al., 2008; Read, Phillipson, Serrano-Pedraza, Milner, &
Parker, 2010). ere are multiple methods of measuring stereopsis and it is not thought
to be aected by aging but may be negatively impacted by distance acuity and eye dis-
eases (Norman et al., 2008).
Visual Function Questionnaire-25
e NEI Visual Function Questionnaire (VFQ) is a 25-item survey that assesses the
functional impact visual impairment. It provides a subjective report on 12 functional
subscales: General Vision, Near Vision, Distance Vision, Driving, Peripheral Vision,
Color Vision, Ocular Pain, General Health, Vision Specic Role Diculties, Depen-
dency, Social Function, and Mental Health (Revicki, Rentz, Harnam, omas, &
Lanzetta, 2010). e NEI VFQ-25 has sound psychometric properties in cognitively
intact older adults (Mangione et al., 2001).
Sensory Changes 55
Conditions of the Eye
Diseases That Alter Vision Seen More Frequently as People Age
Cataracts. Clouding of the crystalline lens that presents either unilaterally or bilaterally
as painless, progressive loss of vision (NEI, 2009). Cataracts are usually age related but
they can be secondary to glaucoma, diabetes, Alzheimer’s disease; congenital; injury
related; or related to medications or radiation (NEI, 2009). e management of cata-
racts includes early identication and monitoring followed by surgical extraction and
lens implantation once vision is aected.
Macular Degeneration. Involves the development of drusen deposits in the retinal pigmented
epithelium and is the leading cause of central vision loss and legal blindness in older adults
(Revicki et al., 2010). Macular degeneration is more common in fair-haired, blue-eyed
individuals. Other risk factors include smoking and excessive sunlight exposure. ere
are wet and dry forms of macular degeneration. e wet form of macular degeneration is
more easily treated than the dry form. Newer treatments of expensive injectable medica-
tions are available to slow the progression of dry macular degeneration.
Glaucoma. Glaucoma is a progressive, serious form of eye disease that can damage the optic
nerve and result in vision loss and blindness (NEI, 2009). Primary open-angle glaucoma is
the most common form of glaucoma in older adults (Linton, 2007). Increased intraocular
pressure causes atrophy and cupping of the optic nerve head that leads to visual eld decits
that can progress to blindness. Vision changes include loss of peripheral vision, intolerance
to glare, decreased perception of contrast, and decreased ability to adapt to the dark.
Diabetic Retinopathy. is results from end-organ damage from diabetes causing retinopa-
thy and spotty vision. Risk can be reduced by tight blood sugar control. Almost 6% of
diabetics aged 65–74 years old develop diabetic retinopathy (NEI, 2004a). Diabetic
retinopathy starts as mild nonproliferative retinopathy with microaneurysms on the
retina and progresses as moderate-to-severe nonproliferative retinopathy where blood
vessels in the retina are blocked, depriving the retina with adequate blood supply, then
progressing to proliferative retinopathy where the growth of new abnormal blood vessels
that leak can cause blindness (NEI, 2009).
Hypertensive Retinopathy. is is caused by end-organ damage from poorly controlled hyper-
tension causing background and eventual proliferative retinopathy. Hypertensive retin-
opathy is usually treated with laser photocoagulation and tight blood pressure control.
Temporal Arteritis. is is an autoimmune disorder that causes inammation of the tem-
poral artery, also known as giant cell arteritis. It presents as malaise, scalp tenderness,
unilateral temporal headache, jaw claudication, and sudden vision loss (usually unilat-
eral). is vision loss is a medical emergency but is potentially reversible if identied
immediately. e client should see an ophthalmologist or go to the emergency room
immediately if symptoms develop.
Detached Retina. is is a condition that can occur in patients with cataracts or recent
cataract surgery, trauma, or occur spontaneously. A detached retina presents as a cur-
tain coming down across a patient’s line of vision. An individual experiencing this
should see an ophthalmologist or proceed to the closest emergency room immediately.
See Table 4.3 for the implications of vision changes on an older adult’s function.
56 Evidence-Based Geriatric Nursing Protocols for Best Practice
INTERVENTIONS AND CARE STRATEGIES
Vision
e nurse should obtain a past medical history to avoid disruption in the management
of chronic eye conditions, assuring continuation of ongoing regimens such as eye drops
for glaucoma. Without the continuation of the individual’s eye drops, eye pressures
could precipitously increase causing an acute exacerbation of their glaucoma, potentially
dramatically limiting their vision. If an acute change in an individual’s vision occurs,
the primary care provider should be notied immediately. Depending on the signs and
symptoms present, the individual may need to see an ophthalmologist or go to the emer-
gency room to receive treatment to restore the vision or limit the deterioration.
Lighting is important in an individual’s environment. Too little light can limit an
individual’s vision. Too much light depending on the individual’s eye condition, such
as cataracts or macular degeneration, may cause eye pain and glare. It is important to
ascertain whether an individual is sensitive to light. If he or she is sensitive to light, indi-
rect light and night lights may be helpful to provide a safe environment. e majority
of older adults benet from improved lighting. To avoid glare, directing incandescent
lamps directly on a task such as sewing or reading often improves visual acuity and is
well tolerated. Glare occurs when a light shines directly into the eye or reects o a
shiny surface. Low vision specialists recommend trying dierent positions and wattage
of lighting to nd what works best for each individual (Community Services for the
Blind and Partially Sighted, 2004).
Encourage the use of the person’s eyeglasses. Older adults’ eyeglasses should be
labeled with the person’s name so they can be reconnected to their owner if they are
set down and left behind. Even with eyeglasses, magnication may be helpful. Have
family provide lighted magnication if needed (large lighted magniers are available at
low vision centers). A low vision optometrist or specialist can assist in recommending
appropriate levels of magniers.
Contrast sensitivity is a problem with several eye conditions including cataracts,
glaucoma, and macular degeneration. Adding contrast to the edge of each step, xtures
in the home, light switches that blend into the wall, or faucets that blend into the sink
can create a safer and more functional environment.
Annual mass screening is not recommended in the older adult (Chou, Dana, &
Bougatsos, 2009). However, nurses should encourage an annual dilated eye exam either
with an optometrist or ophthalmologist. is is crucial in people who have a diagnosis
TABLE 4.3
Implications of Vision Changes in Older Adults
Impact on safety
Inability to read medication labels
Difficulty navigating stairs of curbs
Difficulty driving
Difficulty crossing streets
Impact on quality of life
Reduces ability to remain independent
Difficulty or unable to read
Falls
Sensory Changes 57
of diabetes or hypertension (NEI, 2009). Nurses are members of the interprofessional
team responsible for preventing unnecessary disability. erefore, nurses should make
sure that there is a mechanism in place to trigger these visits on an annual basis.
Hearing Impairment
Surveys to identify older adults with hearing impairment often suer from underreporting
on self-report instruments. e latest version of the NHANES included audiometric test-
ing in older adults and found a prevalence rate of 26.3% in those older than age 70 years
and 45.4% in those older than age 80 years (Dillon et al., 2010). Hearing loss has been
found to be greater in men and progresses more quickly than in women (Chao & Chen,
2009; National Institute on Deafness and Other Communication Disorders [NIDCD],
2007). is dramatic increase in prevalence rates is magnied in the nursing home popu-
lation. Prevalence rates of hearing impairment in the nursing home are similar to rates
of visual impairment, approximately 24% (Warnat & Tabloski, 2006). When hearing is
tested through audiometry, the prevalence rates increase to 42%–90% (Bagai et al., 2006;
Cacchione et al., 2003; Tolson, Swan, & Knussen, 2002). e American Academy of
Audiology denes hearing loss based on decibels or loudness and the hertz or the pitch of
sound. Normal speech is in the 0- to 25-dB level, mild hearing loss is dened as hearing in
the 25- to 40-dB level. Hearing between 40 and 70 dB is considered moderate hearing loss.
Severe hearing loss is between 70 and 90 dB. Greater than 90 dB is considered profound
hearing loss (Mehr, 2007). Aging impairs the processing of sound through the ear canal as
well as the central nervous system processing of sounds, making it more dicult to hear the
higher frequencies including women’s and children’s voices (Huang & Tang, 2010).
Assessment of Hearing
Often, it is easy to determine when an older adult is hard of hearing just by having a con-
versation with them. e older adult may lean closer in an attempt to hear better, turn
their head to their “good ear,” or cup their hand behind their ear. Older adults may have
to ask for things to be repeated; they may report having trouble hearing their grandchil-
dren’s or other’s high-pitched voices. Older adults often complain that people are mum-
bling. Any or all of these signs may be present. Regardless of whether any of these signs
are present, all older adults should have their hearing screened annually at their primary
care visit (Bagai et al., 2006). Primary care providers play an important role in screening
for hearing loss and making appropriate referrals for older adults (Johnson, Danhauer,
Bennett, & Harrison, 2009). Methods of screening are described herein.
Hearing Handicap Inventory for the Elderly-Screen
e Hearing Handicap Inventory for the Elderly-Screen (HHIE-S; Ventry & Weinstein,
1983) is a 10-item scale to determine how hearing is impacting an older adult’s daily
life and to assist in identifying who might benet from a hearing aid and an audiol-
ogy referral. e scale takes approximately 5 minutes to complete and is targeted for
community-dwelling older adults. is scale is available online through the Hartford
Foundation Institute for Geriatric Nursing “Try is Best Practices in Care for Older
Adults” (Demers, 2001). e HHIE-S has reported excellent sensitivity and specicity
for severe hearing loss, but the sensitivity and specicity decreases as the level of hearing
impairment lessens (Adams-Wendling, Pimple, Adams, & Titler, 2008).
58 Evidence-Based Geriatric Nursing Protocols for Best Practice
Whisper Test
e whisper test involves covering or rubbing one ear canal, and from a distance of 2 ft,
whispering a three-syllable word on an exhale that the patient either correctly or incor-
rectly repeats back. An incorrect response triggers a repeat attempt to see if the older
adult can identify a dierent three-syllable word. e consistency of the level of the
whispered word makes this test dicult to compare from examiner to examiner. How-
ever, despite this diculty, it has been found to be a valid and reliable test to screen for
hearing loss (Bagai et al., 2006).
Handheld Audioscope
e handheld audioscope is a device developed to specically screen for hearing impair-
ment. It has a test tone that is presented at the 60-dB level. e decibel levels that
may be tested include the 20-, 25-, and 40-dB levels at the 500-, 1,000-, 2,000-, and
4,000-Hz levels (Yueh et al., 2007). e audioscope has an otoscope that allows for the
direct inspection of the tympanic membrane or cerumen impactions that can result in
conductive hearing loss present in up to 30% of older adults (Lewis-Cullinan & Janken,
1990; Yueh, Shapiro, MacLean, & Shekelle, 2003). Testing using the audioscope should
be performed in a quiet setting and may not be as useful in the long-term care environ-
ment with high noise levels.
Pure Tone Audiometry
is is the gold standard of hearing tests, particularly if completed in a sound-proof booth
with 92% sensitivity and 94% specicity in detecting sensorineural hearing loss (Frank &
Petersen, 1987). Pure tone audiometry allows for testing of a wide range of decibels and
hertz levels, or loudness and pitch or frequencies, allowing for testing at the 5- to 120-dB
level and 250–4,000 Hz. Portable pure tone audiometers with noise-reduction earphones
are available and can be used in the community, outpatient, and long-term care settings
when access to an audiologist is limited. is wide range of tones allows for a better under-
standing of the individual’s functional hearing. Pure tone audiometry by an audiologist is
the next step after screening has identied a hearing decit (Yueh et al., 2003).
Tuning Fork Tests
Two tuning fork tests have been used in hearing screenings, although a recent sys-
tematic review discouraged their use because they were found to be unreliable with
limited accuracy (Bagai et al., 2006). e tuning fork should be either 256 or 512 Hz
(M. I. Wallhagen, personal communication, 2006). e Rinne test is meant to dif-
ferentiate whether an older adult hears better by bone or air conduction and can help
determine if an individual had sensorineural or conductive hearing loss. e Weber test
is used to help identify unilateral hearing loss.
Hearing Changes Common in Older Adults
Conductive hearing loss usually involves abnormalities of the middle or external ear,
including the ear canal, tympanic membrane, and ossicular chain of bones in the mid-
dle ear (Marcincuk & Roland, 2002; Yueh et al., 2003). Causes of conductive hearing
impairment include cerumen impactions or foreign bodies, ruptured eardrum, otitis
media, and otosclerosis (Wallhagen et al., 2006; Yueh et al., 2003).
Sensory Changes 59
Sensorineural hearing loss is the most common form of hearing loss in older adults
(Linton, 2007) that involves damage to the inner ear, the cochlea, or the bers of the
eighth cranial nerve. Sensorineural hearing loss is usually a bilateral progressive onset
and is caused by gradual loss of hair cells, and brous changes in the small blood ves-
sels that supply the cochlea. Risk factors include heredity, environmental exposure, free
radical, and mitochondrial DNA damage (Huang & Tang, 2010). Additional causes of
sensorineural hearing loss include viral or bacterial infections, trauma, tumors, noise
exposure, cardiovascular conditions, ototoxic drugs, and Ménière’s disease (Wallhagen
et al., 2006).
Central auditory processing disorder is an uncommon disorder that includes an
inability to process incoming signals and is often found in patients with stroke and
older adults with neurological conditions such as Alzheimer’s disease and Parkinson’s
disease (Pekkonen et al., 1999). e person’s hearing is intact but his or her ability to
process the sound is impaired.
Tinnitus, otherwise known as ringing in the ear, is of two types: subjective
and objective. Subjective tinnitus is a condition where there is perceived sound in
the absence of acoustic stimulus (Ahmad & Seidman, 2004; Lockwood, Salvi, &
Burkard, 2002). Objective tinnitus is considered rare and presents as ringing in
the ear that is audible by the individual and others. It is thought to have a vascular
or neurological condition or Eustachian tube dysfunction (Crummer & Hassan,
2004). Subjective ringing in the ears may uctuate and can be caused by damage
to the hair receptors of the cochlear nerve and age-related changes in the organs of
hearing and balance. Patients with tinnitus should be referred to an ear, nose, and
throat (ENT) specialist.
Ménière’s disease is characterized by uctuating hearing loss, dizziness, vertigo, tinni-
tus, and a sensation of pressure in the aected ear (NIDCD, 2001). Unfortunately, the
uctuating hearing loss can become permanent hearing loss over time. Possible causes
of Ménière’s disease include hypothyroidism, diabetes, and neurosyphilis.
Implications of Hearing Changes
Older adults who have hearing impairment experience a decreased quality of commu-
nication, social isolation, low self-esteem, and generally lower quality of life. Decreased
hearing impacts an individual’s word recognition, decreasing the ability to communi-
cate. is in turn can lead to signicant safety issues. For example, if patient education
about medication administration is provided only verbally, key information can be mis-
heard and misinterpreted. Diculty understanding the spoken word can lead to fatigue
and speech paucity of friends and loved ones.
Speech paucity is described as decreased attempts to have meaningful conversations
because of the diculty in getting the message through to a hearing-impaired loved one.
Speech paucity (Wallhagen et al., 2006) leads to social isolation of the hearing impaired
because only the necessary information is transferred and no everyday social informa-
tion is shared (Wallhagen et al., 2004). is can lead to depression and low self-esteem
in the hearing-impaired individual and the partner. Other factors that lead to social
isolation in hearing-impaired older adults include the inability to hear the phone or the
doorbell ringing or knocking at the door.
Ideally, an older adult who develops hearing loss will see an audiologist and obtain
unilateral or bilateral hearing aids to improve their ability to communicate with the
people around them. Unfortunately, the stigma, cost, and delay in pursuing hearing
60 Evidence-Based Geriatric Nursing Protocols for Best Practice
aids are barriers to their success. Hearing aids should be pursued early in the course
of hearing impairment. For example, hearing aids can be very helpful when hearing is
impaired to the point that background noise interferes with understanding the spoken
word. Success in using hearing aids at this level of hearing improves the chance that
older adults will continue with hearing aids. Once an individual is oered a hearing aid,
hearing rehabilitation should accompany the hearing aid dispensing; this will increase
the use of the hearing aid and positively impact their independent living and quality of
life (Yueh & Shekelle, 2007). Once older adults become used to the silence, it is hard
to adapt to the increased ambient noise heard with hearing aids. Often, older adults
require extensive coaching from an audiologist to get through the transition phase of
wearing hearing aids. Technology has improved to the point of analog hearing aids that
can be nely tuned to the individual’s needs (Wallhagen et al., 2006). In one interven-
tion group of older adults tted with hearing aids, 98% experienced benet and their
caregivers perceived signicant benet as well (Tolson et al., 2002). University settings
are often the most cost-eective locations to pursue hearing aids. e cost of hearing
aids is an important factor because most insurance plans including Medicare do not
cover hearing aids.
Cochlear implants are another technological advancement that has demon-
strated positive outcomes in older adults in the areas of speech recognition. A
cochlear implant works by bypassing the damaged parts of the ear and stimulat-
ing the auditory nerve. ese impulses are sent to the brain through the auditory
nerve and the brain recognizes them as sound (NIDCD, 2001). Severe hearing
impairment must be present unilaterally or bilaterally prior to this surgical inter-
vention will be considered. Cochlear implants were found in one study to improve
word recognition and health-related quality of life (Francis, Chee, Yeagle, Cheng, &
Niparko, 2002). At this time, there is only evidence for unilateral cochlear implants
in profoundly deaf adults rather than bilateral cochlear implants because of cost and
limited functional gain (Bond et al., 2009). Despite these improvements, relatively
few adults have received this new technology. According to the U.S. Food and Drug
Administration, nearly 22,000 adults have received cochlear implants (NIDCD,
2001). Technological advances will continue to improve our options for hearing-
impaired older adults.
Smell and Taste
Smell and taste are two senses that are dicult to separate because they overlap,
particularly, when food is involved. Both these senses are dependent on chemosen-
sation, the ability of the nose, mouth, and throat to identify tastes and smells based
on chemical reactions that occur when odors or tastes are present in the environ-
ment (American Academy of Otolaryngology-Head and Neck Surgery, 2001). e
sense of smell and ability to identify odors decreases because of normal changes in
aging. Up to 50% of octogenarians have smell disorders (Murphy et al., 2002). is
can be problematic for safety reasons. An inability to smell smoke for instance could
put an older adult at risk. Studies have also linked the loss of smell to Alzheimer’s
disease and Parkinson’s disease (Mesholam, Moberg, Mahr, & Doty, 1998; Müller,
Reichmann, Livermore, & Hummel, 2002). Taste problems are rare, ranging in
those aged 65 years and older (0.72%) to those aged 85 years and older (1.7%;
Homan et al., 2009).
Sensory Changes 61
CHANGES IN SMELL AND TASTE COMMON TO OLDER ADULTS
ere are four medical terms used when describing olfactory disorders: (a) hyposmia is
the reduction of the sense of smell; (b) parosmia is the distortion in the sense of smell-
ing the presence of an odor; (c) anosmia is no sense of smell; and (d) phantosmia is the
perception of an odor when no odor source is present (Albers et al., 2006). Olfactory
disorders impact quality of life in older adults. Common complaints from people with
olfactory disorders include diculty with cooking, decreased appetite, eating spoiled
food, too little perception of body odor, and inability to detect gas leaks or smoke
(Albers et al., 2006; Murphy et al., 2002).
Because of the impact on quality of life, it is important to take a complete his-
tory and physical with older adults. A thorough cranial nerve exam and head and neck
examination should be included. If an olfactory disorder is identied, the individual
should be referred to an otorhinolaryngologist (ENT; Miwa et al., 2001).
Most changes in taste are thought to occur because of an oral condition, xerostomia
(dry mouth), decreased sense of smell, medications, diseases, and tobacco use (Seiberling
& Conley, 2004). Dysgeusias or taste disorders may resolve spontaneously. e taste
sensory system has the capacity to recover function after being damaged (Homan et
al., 2009). However, because of the poor outcomes for older adults with taste disorders,
referral for treatment is indicated either to an otolaryngologist, neurologist, or a subspe-
cialist at a smell and taste center (Bromley, 2000; Homan et al., 2009).
As with olfactory disorders, disorders of taste are often identied on history not by
physical exam. ere are very few tests to assess for taste disorders. erefore, the history
is essential. Substance abuse including tobacco, alcohol, and cocaine should be reviewed.
e individual’s dietary habits should be reviewed. Questions regarding recent dental work
or procedures should also be asked. Ascertaining whether the individual has a history of
gastric reux could surface manageable conditions impacting taste. A thorough review of
their medications is fundamental in the evaluation of a taste disorder (Bromley, 2000).
Diseases That Alter Taste Seen More Frequently as People Age
Burning Mouth Syndrome
is is a sensation that one’s tongue is tingling or burning. ere may be several con-
tributing factors: vitamin B deciencies, local trauma, gastrointestinal disorders causing
reux, allergies, salivary dysfunction, and diabetes.
Xerostomia
Dry mouth is common with many medications used to treat disorders common to
older adults, including anticholinergic medications, antidepressants, antihistamines,
angiotensin-converting enzyme (ACE)-inhibitors, lipid-lowering agents, antiparkinso-
nian medications, and anticonvulsants to name a few (Bromley, 2000; Seiberling &
Conley, 2004).
Implications of Taste and Smell Changes
Inability to smell limits some of the pleasures of everyday life. e smell of a spring
rain, smell of a Christmas tree, owers, or coee brewing may not be detectable. Taste
is diminished because of inability to smell. Of signicant concern in older adults who
62 Evidence-Based Geriatric Nursing Protocols for Best Practice
have smell and taste disorders is malnutrition. Appetite is detrimentally aected because
of inability to smell and taste the food. Inability to smell is a safety hazard because of the
inability to smell smoke in a re or a gas leak. Decreased sense of taste may also result in
inability to recognize spoiled food resulting in nausea, vomiting, or infectious diarrhea.
Peripheral Sensation
Two percent to 7% of all patients presenting with symptoms of neuropathy in a general
medical practice will have peripheral neuropathy (Smith & Singleton, 2004). In older
adults in the NHANES study older than the age of 70 years, 27% reported the loss of
feeling in their feet, this grew to 34% in adults older than 80 years (Dillon et al., 2010).
A prospective study evaluating older adults for peripheral sensory neuropathy found
prevalence rates of 26% for those 65–74 years old and 54% for those 85 years and older
(Mold, Vesely, Keyl, Schenk, & Roberts, 2004). Common disorders that increase the
risk of peripheral neuropathy include diabetes, alcoholism, osteoporosis with compres-
sion fractures, peripheral vascular disease, infections, nutritional deciencies particu-
larly vitamins (e.g., thiamine and B
12
), and malignancies (Mold et al., 2004). Because
of the multitude of risk factors for peripheral neuropathy and neurology, consultation is
recommended for complicated presentations of peripheral neuropathy to help tease out
the best evaluation and management of the condition.
Changes in Peripheral Sensation Common to Older Adults
Conditions that alter peripheral sensation are seen more frequently as people age and include
peripheral neuropathy, diabetic neuropathy, phantom limb pain, and acute sensory loss.
Peripheral Neuropathy. is is nerve pain in the distal extremities related to nerve damage
from circulatory problems or vitamin deciencies. Common vitamin deciencies that
impact peripheral nerves include thiamine and B
12
.
Diabetic Neuropathy. is is end-organ damage to the peripheral nerves from microvascular
changes that occur with diabetes. It often leads to loss of sensation in the feet of diabetics,
contributing to undetected trauma to the extremities and subsequent refractory infec-
tions because of poor vascular supply to the extremity. It is extremely important to teach
diabetics and patients with peripheral neuropathy to provide special care to their feet.
Phantom Limb Pain. is is the experience of pain that can range from dull ache to crushing
pain where an amputated limb once was. e sensory cortex of the brain has inuence
in this mechanism. is pain is often chronic and requires special interventions to con-
trol and manage the pain, including electronic prosthetics, analgesics, and psychosocial
support.
Acute Sensory Loss. Acute sensory loss may be caused by a stroke, acute nerve entrapment in
the spine, or compartment syndrome because of trauma to a limb and presents with acute
onset of numbness, tingling, or lack of sensation and function in the aected extremity.
Implications of Peripheral Sensation Changes
Inability to recognize position sense, pressure, or to ascertain where feet are on the oor
can lead to falls, burns, lacerations, calluses, and pressure ulcers. Intact peripheral sensa-
tion is essential for keeping ourselves safe in our environment.
Sensory Changes 63
Nursing Assessment and Care Strategies of Peripheral Sensation
Nurses should take appropriate health histories to ascertain the presence of decreased
sensation or pain in limbs. Physical exams should always include a thorough inspection
and physical examination of the individual’s legs and feet (Hellman, 2002). Diabetics
and people known to have peripheral neuropathy should have thorough neurological
exams including vibratory sense with a tuning fork over bony prominences and Semmes–
Weinstein monolament testing of the feet and proprioception (Boike & Hall, 2002).
Semmes–Weinstein Monofilament Test
is inexpensive simple procedure is used to screen for decreased sensation in several
plantar sites on the foot. e monolament is placed against the sole of the foot in eight
dierent areas on the foot. e individual is asked to report any sensations (Boike &
Hall, 2002). e Semmes–Weinstein nylon monolament 5.04 gauge buckles at a pres-
sure of 10 g. Loss of sensation at this level of pressure indicates a risk for ulcer develop-
ment. Identication of this risk is important for improving the vigilance of foot care
(Armstrong & Lavery, 1998).
Vibratory Sense
is is assessed by using a 128-Hz vibrating tuning fork on a lower extremity bony
prominence and asking the individual if they feel any vibration (Boike & Hall, 2002).
Older adults should be able to feel the vibration.
Proprioception
is is the ability for an individual to determine where they are in space. To assess for
decits in proprioception in the feet that may set the older adult up for falls and local
trauma, have the individual close his or her eyes then hold the large toe on the sides
and move the foot up or down and ask the individual to identify which direction the
toe was moved. Inability to correctly identify the direction is an indication of decreased
proprioception.
Individualized Sensory Enhancement of the Elderly
e Individualized Sensory Enhancement of the Elderly (I-SEE) program was developed
to tailor nursing interventions to the type and level of sensory impairment experienced
by the older adult (Wilensky & Hawkins, 2001). Originally developed to address hear-
ing and visually impaired older adults, the I-SEE can logically be extended to address
sensory impairment in smell, taste, and peripheral sensation. ere are three levels to
the I-SEE program: nursing assessments, nursing actions, and nursing referrals.
NURSING SENSORY ASSESSMENTS
History
n Ask questions about changes in hearing, vision, sense of smell, and taste as well
as any numbness and tingling in extremities.
n Review medications that may be exacerbating the sensory problem, such as anti-
cholinergic medications, antibiotics, aminoglycosides, and high-dose aspirin.
64 Evidence-Based Geriatric Nursing Protocols for Best Practice
n Determine if symptoms occurred suddenly or gradually.
n Clarify if symptoms are unilateral or bilateral.
n Inquire whether the individual has had any prior treatment for sensory conditions.
n Ascertain if sensory conditions interfere with daily function.
n Ask about ability to drive, both daytime and nighttime driving can be impacted
by visual impairment as well as hearing and the peripheral nervous system.
n Determine interest in receiving treatment for these conditions.
For each positive symptom reported, gather more information by asking about the
Character, Associated symptoms, Radiation, Location, Intensity, and Duration, as well
as what makes it Better, what Medications the individual has tried for these symp-
toms, and what makes it Worse. ese questions can be easily remembered by using
the acronym CAR LID BMW. ese questions provide a better understanding of the
individual’s concerns.
Physical Exam for All Systems
n Inspect the external structures of the eyes and ears; examine ear canal for ceru-
men using otoscope.
n Check visual acuity with a near vision screener and distance acuity measure and
contrast sensitivity.
n Perform whisper test to assess rough hearing. If available in your setting, use a
handheld audioscope to assess up to 40-dB hearing. If a greater range of hearing
testing is needed, use a portable audiometer with noise reduction earphones—a
referral to audiology may be indicated.
n Assess the nares, determine if they are patent using the otoscope.
n Inspect the mouth and tongue for any obvious lesions or deviations from normal.
n Perform a neurosensory exam of the extremities including a monolament test.
n Complete a monolament test on all diabetics. is test quanties the level of
sensory impairment in the feet of patients with diabetes.
n Assess vibratory sense of the extremities with a 128-Hz tuning fork and
proprioception.
Nursing Actions and Referrals
Vision
n Avoid disruption in the management of chronic eye conditions by obtaining
past history and assuring continuation of ongoing regimens such as eye drops for
glaucoma.
n Notify the primary care provider of any acute change in vision.
n Encourage the use of good lighting in patient rooms. Avoid glare whenever possible.
n Encourage the use of the patient’s eyeglasses. Have family provide lighted magni-
cation if needed. (ese are the large magniers with a light attached. Available
for purchase on a sliding scale at low vision centers.)
n Add contrast to the xtures and electronics in the room if light switches blend
into the wall or faucets blend into the sink. Other low contrast items in the envi-
ronment include remote controls, television sets, and radios.
n Encourage annual eye exams either with an optometrist or ophthalmologist.
Sensory Changes 65
n Schedule an annual dilated exam for patients with diabetes and hypertension by
ophthalmologist.
n Written materials should be provided in 14–16 high contrasting fonts with gen-
erous white space to improve visual tracking.
n Encourage use of adaptive equipment.
Hearing
n Assess for cerumen impactions. Request cerumen softening drops followed by
cerumen removal or ENT consultation.
n Get the person’s attention and face them before speaking to assist the individual
with lip reading, if female consider wearing red lipstick to increase the contrast
of your lips, a common compensatory mechanism for older adults.
n Have at least one pocket amplier on the nursing unit to use with hard of hear-
ing individuals.
n Do not shout at people with hearing impairments, but rather use lower tones of
your voice.
n Provide written instructions (use large black marker if person is also visually
impaired).
n Assure appropriate care for hearing aids: remove batteries out at night; use brush
provided to gently clean the tubes to reduce wax accumulation. Before sending
bed linens or clothing to the laundry, determine if the patient has hearing aid in
his or her ear or in their designated location (bedside table or medication cart).
n Notify the primary care provider of any sudden change in hearing.
n Referral to audiologist and/or ENT as indicated (i.e., complicated cerumen
impactions, new onset tinnitus, or vertigo).
n Encourage use of adaptive equipment.
Taste and Smell
n Take all complaints of inability or decreased ability to smell or taste seriously. Do
not pass them o to medications or poor dentition.
n Notify primary care provider of an abrupt change in taste or smell.
n ENT referral for evaluation for change in smell or taste.
n Patient teaching should focus on safety issues with odors of gas and spoiled food.
n Educate seniors to have smoke and carbon monoxide detectors in their home
and to date all food at time refrigerator, evaluate food with other methods other
than sense of smell and taste.
Peripheral Sensation
n e individual should be taught to examine his or her feet daily, as well as look
inside his or her shoes daily prior to putting them on each day.
n e individual should be taught to always wear shoes or protective slippers when
he or she is ambulating to avoid unintentional injury to his or her feet.
n e individual should be instructed to inform his or her primary provider of any
lesions, calluses, or red areas.
n Extremities should be kept clean and thoroughly dry prior to applying lotion.
n Encourage the individual to bring in footwear for evaluation by the advanced
practice nurse if he or she has concerns about the safety. Most medical supply
66 Evidence-Based Geriatric Nursing Protocols for Best Practice
companies carry diabetic healing shoes that have wide toe boxes and Velcro straps
that can be purchased for less than $50.
n Refer diabetics to facilities with certied diabetes educator and foot care specialist.
n Implement fall precautions and initiate referral to physical therapy for all diabet-
ics with peripheral neuropathy.
n Refer all older adults with decreased sensation or circulation to a podiatrist of
foot care specialist for ongoing foot care.
n Encourage a diet rich in thiamine and B
12
.
Expected Outcomes
n Baseline visual acuity and hearing acuity for all older patients will be performed
prior to discharge from the hospital, and on admission to home care or nursing
home.
n Fall precautions should be in place for all older patients with sensory impair-
ments. Older adults should avoid falls and injuries to extremities if they have
decreased sensation of lower extremities.
n Accidental exposure to toxins either in the air or in food because of decreased
sense of smell or taste should be avoided.
Follow-up Monitoring
n Annual vision assessment—Medicaid in most states will pay for a new pair of
eyeglasses every 2 years.
n When vision is worse than 20/125, individuals should be referred to a low vision
specialist to provide training in the use of visual assistive devices.
n Given that hearing can change signicantly over time, an audiological evaluation
for hearing impaired older adults every 2 years is important. Some states will pay
through Medicaid for one hearing aid under limited conditions. Hearing aids
have been shown to be better accepted if older adults receive them when they
start having diculty with word nding with background noise. Encourage-
ment and hearing rehabilitation is needed to improve the consistent use of hear-
ing aid. Audiologists can help train older adults and their families in the use of
hearing aids that may be necessary.
n When abrupt changes in smell or taste are reported, a referral to a dentist or
ENT is indicated.
n Long-term adjustments must be made in the home when smell and taste are
aected. First, food should be dated and discarded after 48 hours to avoid
accidentally eating spoiled food. Smoke and carbon monoxide detectors must
be present.
n When xerostomia (severe dry mouth) is found, a referral to a dentist is indicated.
n Older adults with decreased peripheral sensation should be followed regularly by
a podiatrist or foot care specialist.
Interprofessional Care of Sensory Changes
Care of the aging senses is an interdisciplinary endeavor. Nurses who frequently have
the most contact with clients can take the lead in assessing and screening older adults for
decreased sensory function. Once these decits are identied, it is important to take the
Sensory Changes 67
appropriate steps and identify the resources available to the older adult. Occupational
therapists, low vision specialists, audiologists, nutritionists, otolaryngologists, and neu-
rologists are just some of the interprofessionals who may be part of the team caring for
the sensory-impaired older adult. Good communication among disciplines is essential
to assist the older adult benet from each specialist.
MR. SWEETS
Mr. Sweets is a 75-year-old African American male living by himself in the commu-
nity. He lives in a senior apartment building where he receives housekeeping services
and can participate in a meal plan if he would like. He arrives on the Acute Care of
the Elderly (ACE) Unit in your hospital with a diagnosis of hyperglycemia and a
urinary tract infection. He also has a history of hypertension, hyperlipidemia, and
osteoarthritis of the left hip. He is widowed and has three children: two live in the
area, the other lives out of state. He is a retired aeronautical engineer. His medications
include Amaryl 6 mg that was recently increased from 4 mg; Zocor, 40 mg p.o. daily;
lisinopril, 20 mg daily; hydrochlorothiazide (HCTZ), 25 mg daily; and Tylenol ES,
1,000 mg three times a day for his hip discomfort.
Upon your admission assessment, you discover that he remembers receiving ver-
bal instructions to cut his diabetic pills in half. us, since that appointment, he has
only been taking 2 mg of Amaryl instead of 6 mg. His primary care provider had
instructed him to take one and one half tablets of his Amaryl not just one half tablet.
You were not sure if it was just a misunderstanding or if Mr. Sweets was having di-
culty hearing. You are also concerned that his vision may be a problem as well because
of his 5-year history of known diabetes.
After you complete taking your history, you gather your supplies to complete
your physical exam. Your supplies include an audioscope, Lighthouse for the Blind
Near Vision Screener, three plastic bags—one full of coee, baby powder, and pep-
permint candies—128-Hz tuning fork, and a Semmes–Weinstein monolament test.
e audioscope reveals that Mr. Sweets’ ear canals are completely occluded with ceru-
men and he can only hear the test tone that is delivered at the 60-dB level. On the
near vision screener, he scored 20/125 in both eyes with his dirty glasses. Unfortu-
nately, because his blood sugar is and has been elevated, it is unclear how much of
the decreased vision is caused by his elevated blood sugar and how much is related to
possible refractive error or diabetic retinopathy. Mr. Sweets was able to correctly iden-
tify each scent in the plastic bags. When you examine his feet, you identify that he has
signicant sensation loss on the bottom of his feet. He has intact vibratory sense in the
ankle but his vibratory sense is decreased in both toes. His feet are currently free of any
calluses, deformities, or open wounds. He does have some thickened toe nails.
ese assessments impact the care plan for Mr. Sweets. His sensory decits most
likely precipitated his hospital admission. Written instructions may have helped pre-
vent this, but his near vision may have interfered with the understanding of the written
directions as well. He should have written instructions in large font, ideally because
CASE STUDY
(continued)
68 Evidence-Based Geriatric Nursing Protocols for Best Practice
of his vision in 24-point font. Because of bilateral cerumen impactions, he will need
cerumen softening drops started and the cerumen removed with a cerumen spoon
after a few days. If this is not successful, he may need to be seen by an otolaryngologist
(ENT) to have the cerumen removed. If his hearing is still impaired after the cerumen
is removed, Mr. Sweets should see an audiologist.
If his vision does not improve with blood sugar control, he should be seen by an oph-
thalmologist to determine if any treatments for his diabetic retinopathy are necessary. He
should also see an ophthalmologist if he has not been to one in a year. He would qualify
for low vision services if his acuity remained at 20/125. He would also benet from
increased contrast. Older adults with diabetic retinopathy often need enhanced contrast.
is can be achieved by adding red or white to light xtures, remote controls, and other
electrical devices that are usually solid colors with limited contrast. A low vision specialist
could be very helpful here to make his home environment more safe and user friendly.
Mr. Sweets should be evaluated by a diabetic foot nurse and a podiatrist to have
his nails trimmed and to learn more about foot care. He will need to learn how to
complete daily foot inspections as well as assistance learning of what type of foot wear
is appropriate for his feet. His hip may cause him some diculty reaching his feet.
It will be important for him to use mirrors and palpation to assist him in his self-care.
A diabetic nurse educator can assist him with further information on the management
of the disease and empower him to ask more questions and clarify when information
does not appear compatible with what his symptoms are.
Mr. Sweets was discharged from the hospital after 4 days. His Amaryl was increased
to 6 mg; he is afebrile and discharged on oral antibiotics for his urinary tract infection.
He had his ears cleaned out over those 4 days so his hearing has improved to where
he can hear at the 40-dB level. He has an appointment to see the audiologist. An
appointment was also made for ophthalmology. Follow-up appointments have also
been made with endocrine, with the diabetic nurse educator and diabetic foot nurse
on the same visit. ese appointments were written out on a 4- 3 6-in, index card with
a black marker that he could read with his glasses.
Sensory impairment is an interprofessional health care problem. Good communi-
cation between disciplines is essential in maintaining Mr. Sweets’ functional status and
ability to stay in the community. Nurses are best prepared to help Mr. Sweets navigate
and coordinate visits to the other disciplines. Screening completed by nurses either in
the community, acute care, or long-term care settings can identify problems that have
often been passed o by the older adult as they are just getting older.
RESOURCES
Related Professional Organizations and Informational Sites
Administration on Aging
http://www.aoa.gov
American Speech-Language-Hearing Association
http://www.asha.org
CASE STUDY (continued)
Sensory Changes 69
Assisted Listening Devices: Summary of available assisted listening devices
http://www.asha.org/public/hearing/treatment/assist_tech.htm
Cochlear Implants
General information including video on cochlear implants.
http://www.fda.gov/cdrh/cochlear
Hear Now
Will accept donated hearing aids to ret for the underserved.
http://www.starkeyhearingfoundation.org/hear-now.php
e Lighthouse for the Blind
Consumer and health professional information on visual impairment and dual impairment. Will
accept donated hearing aids to ret for the underserved.
http://www.lighthouse.org
Lighting Research Center
Consumer, Builders, and Health Professional information on lighting.
http://www.lrc.rpi.edu/programs/lightHealth/AARP/index.asp
e National Eye Institute
Contains health information for consumers and health professionals. Also have images of eye diseases
and eye charts.
http://www.nei.nih.gov
National Institute on Aging Information Center
http://www.nia.nih.gov
National Institute on Deafness and Other Communication Disorders
Contains information for health care providers and consumers.
http://www.nidcd.nih.gov
Talking Tapes
Access to talking books for visually impaired older adult.
http://www.talkingtapes.org
For Patients and Families
Aging in the Know
Your gateway to health and aging resources on the web. Created by the American Geriatrics Society
Foundation for Health in Aging (FHA).
http://www.healthinaging.org/agingintheknow/
League for Hard of Hearing
http://www.lhh.org/
Prentiss Care Networks Project
Care networks for formal and informal caregivers of older adults.
http://caregiving.case.edu
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74
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. identify the signs and symptoms of excessive sleepiness and quantify them using a
standardized scale
2. describe the signs, symptoms, and usual treatments for the most primary sleep disor-
ders causing excessive sleepiness in older adults: obstructive sleep apnea, restless leg
syndrome, insomnia, and short sleep duration
3. discuss the implications of chronic illness, medications, and acute hospitalization on sleep
4. provide nursing care that incorporates sleep hygiene measures and provide consistent
ongoing treatment for existing sleep disorders
5. educate patients and families about sleep disorders and sleep hygiene measures
OVERVIEW
Excessive sleepiness, sometimes called excessive daytime sleepiness, is common in older
adults. Fatigue manifests as diculty in sustaining a high level of physical performance;
excessive sleepiness refers to the inability to maintain alertness or vigilance because of hyper-
somnolence. Many factors can aect nighttime sleep and result in daytime sleepiness in
older adults. ese include psychological disorders, symptoms of chronic illnesses (e.g.,
pain), medication side eects, environmental factors, and lifestyle preferences. Increases
in sleepiness can result from age-related changes in chronobiology and sleep disorders.
In older adults, the most common primary sleep disorders are obstructive sleep apnea
(OSA), restless leg syndrome, and insomnia. e extent to which changes in sleep patterns
experienced by older adults are caused by normal physiological alterations, pathological
events, sleep disorders, or poor sleep hygiene remains unclear. Hospitalization and insti-
tutionalization can also interfere with sleep quality or quantity. ere are many eective
treatments for sleep disorders, but the rst step is to identify the cause of excessive daytime
Eileen R. Chasens and Mary Grace Umlauf
Excessive Sleepiness
5
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Excessive Sleepiness 75
sleepiness and then to quantify and aggressively treat this condition in the older adult.
is chapter outlines an overview of sleep disorders common in older adults, describes
how to assess sleep, and provides interventions to improve sleep in older adults.
BACKGROUND AND STATEMENT OF PROBLEM
e Institute of Medicine (Colten & Altevogt, 2006) reports that 50–70 million Americans
are aected by chronic disorders of sleep and wakefulness. Recent data from the Behavioral
Risk Factor Surveillance System (BRFSS) conducted by the Centers for Disease Control and
Prevention (CDC) found that among community dwelling persons older than age 65 years
(n 5 23,167), nearly a quarter (24.5%) reported sleeping, on average, less than 7 hours in a
24-hour period and more than half (50.5%) of these older adults reported snoring (CDC,
2011b). Data from the 2005–2008 National Health and Nutrition Examination Survey
(NHANES) show that 32% of persons older than age 60 years (n 5 3,716) slept less than
7 hours per night on weekdays or workdays (CDC, 2011a). Likewise, the Cardiovascular
Health Study documented excessive sleepiness in 20% among subjects older than age 65
years (n 5 4,578; Whitney et al., 1998). Further, some sleep disorders are more common in
patients in acute and chronic care settings. Ancoli-Israel and colleagues (1991) and Ancoli-
Israel, Kripke, and Mason (1987) studied only persons older than age 65 years and found
undiagnosed sleep apnea in 24% of those living independently in the community, in 33%
of those in acute care settings, and in 42% of older adults in nursing home settings.
CONSEQUENCES OF EXCESSIVE SLEEPINESS
e primary consequences of sleepiness are decreased alertness, delayed reaction time,
and reduced cognitive performance (Ohayon & Vecchierini, 2002). e BRFSS found
that nearly half (44%) of subjects in this telephone survey reported that they uninten-
tionally fell asleep during the day at least once in the preceding month and that one
out of 50 older adults had fallen asleep while driving in the preceding month (CDC,
2011a). e 2005–2008 NHANES data also show that older adults reported di-
culty concentrating (18%) and remembering (14.7%) because of sleep-related problems
(CDC, 2011a). Recent studies show that daytime sleepiness is signicantly associated
with declining cognitive function (Cohen-Zion et al., 2001), falls (Brassington, King, &
Bliwise, 2000), and cardiovascular events (Whitney et al., 1998). In the Cardiovascular
Health Study, daytime sleepiness was the only sleep symptom associated with mortal-
ity, incident cardiovascular disease morbidity and mortality, myocardial infarction, and
congestive heart failure, particularly among women (Newman et al., 2000). is link-
age between sleep and medical conditions is consistent with the 2005–2008 NHANES
results that demonstrated a greater rate of sleep-related problems with concentration,
memory, and activities of daily living among women (CDC, 2011a).
PHYSIOLOGICAL CHANGES IN SLEEP THAT ACCOMPANY AGING
Normal changes in sleep that occur as part of human development and lifestyle choices
must be dierentiated from pathological sleep conditions that are common among older
adults. Although older adults require as much sleep as younger adults, older adults may
divide their sleep between nighttime slumber and daytime naps, rather than a single
consolidated period. e endogenous circadian pacemaker, located in the suprachias-
matic nucleus, along with exogenous environmental cues and a homeostatic need for
76 Evidence-Based Geriatric Nursing Protocols for Best Practice
sleep, mediate the normal wake and sleep pattern. With aging, the circadian pattern for
sleep-wake decreases in amplitude, possibly in association with less robust changes in
core body temperature (Richardson, Carskadon, Orav, & Dement, 1982). Compared
with younger adults, healthy older adults have a more pronounced biphasic pattern of
sleepiness during the afternoon hours (about 2–6 p.m.) and a phase advancement of
nighttime sleepiness earlier in the evening (Roehrs, Turner, & Roth, 2000).
Changes in sleep architecture associated with normal aging include increased dif-
culty in falling asleep, poorer sleep quality with decreased sleep eciency, more time
awake after sleep onset, increased “light” sleep (Stages 1 and 2 sleep), and decreased
quantity and amplitude of restorative “deep” slow-wave sleep (Stages 3 and 4). Although
older women report more sleep disturbances than older men, studies indicate that their
sleep is less disturbed than that of men (Rediehs, Reis, & Creason, 1990).
PRIMARY CAUSES OF EXCESSIVE DAYTIME SLEEPINESS
Obstructive Sleep Apnea
OSA is a condition in which intermittent pharyngeal obstruction causes cessation of
respiratory airow (apneas) or reductions of airow (hypopneas) that lasts for at least
10 seconds. is results in a microarousal that restores upper airway patency, permit-
ting breathing and airow to resume. According to the American Academy of Sleep
Medicine (AASM, 2005) Task Force, OSA is diagnosed when these events occur at a
rate of greater than ve per hour of sleep and is accompanied by daytime sleepiness
and impaired daytime functioning. It is common for patients with severe symptoms to
experience multiple arousals during the night. ese multiple arousals severely fragment
sleep, preventing the deep sleep (Stages 3 and 4) and rapid eye movement (REM) sleep
necessary for healthy mental and physical functioning.
OSA is both an age-related and an age-dependent condition, with an overlap in
both distributions in the 60- to 70-year-old age range (Bliwise, King, & Harris, 1994).
Age-related risk factors for OSA in older adults include an increased prevalence of over-
weight and obesity. Conversely, age-dependent risk factors include increased collapsibil-
ity of the upper airway, decreased lung capacity, altered ventilatory control, decreased
muscular endurance, and altered sleep architecture (Brassington et al., 2000).
Treatments for OSA depend on the contributing pathology and patient preference and
include nocturnal positive airway pressure, surgical procedures designed to increase the pos-
terior pharyngeal area, oral appliances, and weight reduction when obesity is a contributing
factor. Nasal continuous positive airway pressure (CPAP) therapy, which is highly eective
when individually titrated to eliminate apneas and hypopneas, is currently the gold stan-
dard for treating OSA (Morgenthaler et al., 2006). Older adults tolerate CPAP therapy,
with patterns of compliance similar to that of middle-aged adults (Weaver & Chasens,
2007). Although oral appliances oer a low-tech treatment option, they require a stable
dentition that may be problematic for persons with extensive tooth loss or dentures.
Insomnia
Insomnia can be dened as delayed sleep onset, diculty in maintaining sleep, pre-
mature waking, and/or very early arousals that result in insucient sleep (Ancoli-Israel
& Martin, 2006). Insomnia can be transient or chronic, and the perception of sleep
loss may not correspond to objective assessment. e frequent awakenings suggestive of
Excessive Sleepiness 77
insomnia may be a conditioned arousal response because of environmental (e.g., noise or
extremes of temperature) or behavioral cues. Anxiety associated with emotional conict,
stress, recent loss, feeling insecure at night, or signicant changes in living arrangements
can also produce insomnia (Ancoli-Israel & Martin, 2006). Chronic insomnia can result
in a conditioned response of anxiety and arousal at bedtime in anticipation of diculty
falling asleep; this may prompt use of hypnotic medications, over-the-counter (OTC)
drugs, or alcohol. Although the use of hypnotics may produce short-term relief, they also
aect sleep architecture and consequently lead to deterioration of sleep quality. e cycle
of dependency and substance abuse is a potential problem in this age group (see Chapter
17, Reducing Adverse Drug Events). At this time, the general recommendation is, when
hypnotics are indicated, the most short-acting drug should be selected and, optimally,
used in conjunction with an appropriate behavioral intervention (Ancoli-Israel, 2000).
Both the cause and duration of insomnia should inform the choice of treatment. For
example, insomnia associated with a psychological origin, such as depression or anxiety,
is best treated from that perspective. If pain is aecting sleep, pain management should
be addressed rst and strategies to promote sleep onset should be added secondarily.
Short-term pharmacotherapy may be appropriate if insomnia is situational and of recent
onset. When insomnia has been “learned” and the behavior becomes chronic, behav-
ioral interventions are most appropriate. Behavioral treatments for insomnia include
stimulus control, progressive muscle relaxation, paradoxical intention, sleep restriction,
biofeedback, and multifaceted cognitive behavior therapy (Morin et al., 1999). Data
show that 70%–80% of patients benet from behavioral therapies and that improve-
ment in sleep are often sustained for a minimum of 6 months after treatment.
Restless Legs Syndrome
Restless legs syndrome (RLS) is a neurological condition that is characterized by the irre-
sistible urge to move the legs. It is usually associated with disagreeable leg sensations that
become worse during inactivity and often interferes with initiating and maintaining sleep.
As a secondary condition, this movement disorder can be caused by iron deciency anemia,
uremia, neurological lesions, diabetes, Parkinson’s disease, rheumatoid arthritis, or it can
be a side eect of certain drugs (e.g., tricyclic antidepressants, serotonin reuptake inhibi-
tors, lithium, dopamine blockers, xanthines). Periodic leg movement disorder (PLMD) is
a similar condition also known as nocturnal myoclonus. However, PLMD is characterized
by involuntary exion of the leg and foot that produces microarousals or full arousals from
sleep that interfere with achieving and maintaining restorative slow-wave sleep (Stages
3 and 4). Although the etiology and associated mechanism of this specic movement
disorder are not well dened, this condition has been linked to metabolic, vascular, and
neurologic causes. Dopaminergic drugs are the most eective agents for treating RLS and
PLMD as well as opioids, benzodiazepines, anticonvulsants, adrenergics, and iron supple-
ments. However, their ecacy for long-term treatment in older adults has not been suf-
ciently evaluated (Ancoli-Israel & Martin, 2006; Gamaldo & Earley, 2006).
SECONDARY CAUSES OF EXCESSIVE DAYTIME SLEEPINESS
Medical and psychiatric illness can interfere with sleep quality and disturb sleep. For
example, depression or anxiety appears to have a bidirectional relationship with insom-
nia (Buysse, 2004). Painful chronic conditions, such as arthritis, reduce sleep eciency,
78 Evidence-Based Geriatric Nursing Protocols for Best Practice
or simply changing body position, may be painful enough to cause awakenings. Because
older adults frequently have multiple medical conditions, they are also more likely to
take OTC and prescription medications for symptom relief. However, many medica-
tions and nonprescription drugs (e.g., pseudoephedrine, alcohol, caeine, and nicotine)
interfere with sleep. us, health care providers must be acutely aware of which OTC
medications and beverages can cause sleep problems. Symptom management must be
balanced against preventing polypharmacy in older adults to maintain sleep quality
(Ancoli-Israel, 2005).
Sleep Disturbance During Hospitalization
Studies have shown that as many as 22%–61% of hospitalized patients experience
impaired sleep (Redeker, 2000). Many older adults have primary sleep disorders (OSA,
insomnia, restless leg syndrome) and these conditions can become more pronounced or
acute during acute illness and hospitalization. Sleep disorders may go unrecognized in
acute care settings, thus patients may experience acute sleep deprivation concurrently
with a medical crisis or surgical intervention.
Protecting sleep and monitoring sleep quality should be routine elements of care
in hospital settings (Young, Bourgeois, Hilty, & Hardin, 2008). ere are three com-
mon causes for sleep disruption in hospitals that are often overlooked by nursing
sta: noise, light, and patient-care activities (Redeker, 2000). Further, anesthesia, car-
diopulmonary disorders, and pain medications can reduce the respiratory drive and
lead to hypopnea and apnea. Medications typically administered postoperatively can
aect alertness by causing excessive sedation, changes in sleep architecture, decreased
REM sleep, nightmares, or insomnia. Pain and anxiety may also cause older patients
to have insomnia. Inadequate sleep impedes healing and recovery and may be associ-
ated with acute mental confusion in older adults (Young, Bourgeois, Hilty, & Hardin,
2009). In summary, older adults in acute care settings are exposed to many conditions
that can negatively aect sleep and result in excessive daytime sleepiness.
e sleep environment and the quality of patients’ sleep can be improved in hospital
settings if caregivers recognize the essential importance of sleep in illness and health.
As a standard practice, nurses should include a thorough sleep history (Table 5.1) dur-
ing admission to determine usual sleep patterns and/or symptoms of sleep disorders.
Patients with OSA who use CPAP at home should be instructed to bring their machines
with them to the hospital. Sleep hygiene measures should be incorporated into nurs-
ing care routines during evening and night hours and also incorporated into care plans
on every nursing unit. is includes simple practices such as reducing light intensity,
maintaining a quiet environment, and ecient delivery of patient care to minimize
sleep disruption among patients. Anticipatory and preventive pain management is also
an important element of care to promote adequate sleep in the hospital setting (Young
et al., 2009).
ASSESSMENT OF THE PROBLEM
ere are several valid and reliable measures to screen for sleepiness. One of the most com-
monly used instruments is the Epworth Sleepiness Scale (ESS; Johns, 1991). Although
OSA can only be diagnosed with a sleep study, the risk of OSA can be determined using
Excessive Sleepiness 79
the Multivariable Apnea Prediction Index (Maislin et al., 1995), the Berlin Question-
naire (Netzer, Stoohs, Netzer, Clark, & Strohl, 1999), or the STOP-Bang Question-
naire (Chung et al., 2008). e STOP-Bang questionnaire (Table 5.2), rst developed
to screen for OSA in persons scheduled for anesthesia, consists of eight questions and
has sensitivity from 76% to 96%. e Functional Outcomes of Sleep Questionnaire
(Weaver et al., 1997b) is used to evaluate the impact of sleepiness on functional status;
the Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kup-
fer, 1989) quanties sleep quality over the past month (see Sleep topic at http://www.
hartfordign.org). Many sleep clinicians use the ESS to screen for sleepiness and track
symptoms over the previous week during common activities such as sitting and reading,
watching TV, or riding in a car. It is easy to administer and includes a scoring parameter
to indicate the need for a medical evaluation. A brief sleep history can be obtained by
using the questionnaire in Table 5.1. In a sleep laboratory setting, a completed evalu-
ation of sleep is conducted using polysomnography that includes electroencephalog-
raphy (EEG), electromyogram (EMG), electro-oculogram (EOG), respiratory eort,
TABLE 5.1
Sleep History
Basic Sleep History Questions Follow-Up Questions Sleep Disorders to Consider
n Do you have any difficulty
falling asleep?
n Are you having any difficulty
sleeping until morning?
n Are you having difficulty
sleeping throughout the
night?
n Have you or anyone else ever
noticed that you snore loudly
or stop breathing in your
sleep?
n Do you find yourself falling
asleep during the day when
you do not want to?
n What time do you usually go
to bed?
n Fall asleep?
n What prevents you from
falling asleep?
n Review intake of alcohol,
nicotine, caffeine, all
medications.
n Review of depressive
symptoms: weight loss,
sadness, or recent losses.
n How often do you waken?
n How long are you awake?
n Do you have any pain,
discomfort, or shortness of
breath during the night?
n What prevents you from
falling back to sleep?
n Are you sleepy or tired during
the day?
n Review risk factors (e.g.,
obesity, arthritis, poorly
controlled illnesses).
n Do your legs kick or jump
around while you sleep?
n Do you stay outdoors in
natural daylight on most days?
n Shift work/sleep schedule
disorders
n Psychophysiologic insomnia
n Restless leg syndrome
n Psychiatric disorders
n Substance/medications
related disorders
n Depression
n Insomnia
n Medical causes of sleep
disturbance
n Obstructive sleep apnea
n Obstructive sleep apnea
n Functional impairment
resulting from sleep disorder
n Periodic leg movement
disorders
Note. Adapted from Avidan, A. Y. (2005). Sleep in the geriatric patient population. Seminars in Neurology, 25(1),
52–63. Evidence Level I. Bloom, H. G., Ahmed, I., Alessi, C. A., Ancoli-Israel, S., Buysse, D. J., Kryger, M. H., . . .
Zee, P. C. (2009). Evidence-based recommendations for the assessment and management of sleep disorders in older
persons. Journal of the American Geriatrics Society, 57(5), 761–789. Evidence Level I.
80 Evidence-Based Geriatric Nursing Protocols for Best Practice
oxygen saturation, and electrophysiological cardiac aspects of sleep. Additional electro-
physiological tests, such as the Multiple Sleep Latency Test, are also used to quantify
daytime sleepiness. Most important in the assessment of sleepiness is an evaluation of
the patient’s knowledge and application of sleep hygiene measures (Table 5.3) that are
also eective behavioral strategies to maximize, promote, and protect sleep.
TABLE 5.2
STOP-Bang (OSA Risk Questionnaire)
1. Snoring
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes or No
2. Tired
Do you often feel tired, fatigued, or sleepy during daytime? Yes or No
3. Observed
Has anyone observed you stop breathing during your sleep? Yes or No
4. Blood pressure
Do you have or are you being treated for high blood pressure? Yes or No
5. BMI
BMI more than 35 kg/m
2
? Yes or No
6. Age
Age over 50 years old? Yes or No
7. Neck circumference
Neck circumference greater than 40 cm? Yes or No
8. Gender
Gender male? Yes or No
Scoring
High risk of OSA: answering yes to three or more items
Low risk of OSA: answering yes to less than three items
Note. OSA 5 obstructive sleep apnea. Adapted from Chung, F., Yegneswaran, B., Liao, P., Chung, S. A.,
Vairavanathan, S., Islam, S., . . . Shapiro, C. M. (2008). STOP questionnaire: A tool to screen patients for
obstructive sleep apnea. Anesthesiology, 108(5), 812–821.
TABLE 5.3
Sleep Hygiene Measures
n Use the bed only for sleeping or sex.
n Develop consistent and rest-promoting bedtime routines.
n Maintain the same bedtime and waking time every day.
n Exposure to bright sunlight is desirable upon awakening.
n Upon awakening, get out of bed slowly, no matter what time it is to prevent postural hypotension.
n If awakened during the night, avoid looking at the clock; frequent time checks may heighten anxiety
and hinder sleep onset.
n Avoid naps if they negatively affect nighttime sleep. Limit naps to 15–30 minutes’ duration.
n Sleep in a cool, quiet environment.
n If you cannot fall asleep after 15 or 20 minutes in bed, get up and go into another room, read, or do a
quiet activity, using dim lighting, until you are sleepy again.
n Before bedtime, avoid the following:
● caffeine and nicotine after noon
● alcohol intake (more than three drinks)
● large meals or exercise 3–4 hours before bedtime
● emotional upset or emotionally charged activities including television programs that are troubling
Excessive Sleepiness 81
INTERVENTIONS AND CARE STRATEGIES
e rst line of defense against excessive sleepiness is a lifestyle that promotes and ensures
adequate sleep and rest. Although humans have a natural drive to sleep, environment and
habituation play an important behavioral role in sleep. Sleep hygiene, those practices that
permit and promote sleep onset and sleep maintenance, has many aspects and requires
regular reinforcement. Regardless of health status, sleep hygiene practices and routines
are as important for older adults as they are for children, adolescents, and other adults.
Scenario
Mrs. M. complained to her friends that she sleeps poorly because her husband snores
“loud enough to wake the dead” and “he even stops breathing on and o all night.”
She relates that they “don’t have sex very often,” he had diculty with “doing it.” In
addition, they are both too tired to be “in the mood” so she has started sleeping in the
guest room. Her friends have urged her to talk to their primary care physician about
his symptoms and her concerns.
History
Mr. M. is a 62-year-old man who is obese (height, 692; weight, 260 lbs; body mass
index [BMI], 33.4). He is hypertensive (sitting blood pressure, 154/98 mm Hg) and
takes several medications to control his blood pressure (i.e., amlodipine, digoxin,
hydrochlorothiazide, lisinopril, pravastatin, enteric-coated aspirin). He was diagnosed
with Type II diabetes almost 10 years ago (HbA1c, 8.2%) and is on metformin 1,000
mg BID and glimepiride 2 mg daily. He has a history of snoring (more than 20 years)
and was a smoker until 12 years ago.
Symptoms
Mr. M. says, “I have no energy. I can sleep anytime and anywhere, but I am tired all the
time. I went to the Diabetic Educator and learned what I need to do with exercise and
diet. Usually, I am so tired I just grab some fast food on the way home and then do noth-
ing when I get home.” He reports that he wakes unrefreshed, has morning headaches,
and that his sleep is disturbed by nocturia four times per night. He reports that he has
heartburn at night and his legs jerk during sleep. He has diculty driving any distance on
the highway because of extreme sleepiness, and cannot attend church or movies without
falling asleep. Although he takes frequent naps, he consumes more than six cups of coee
per day. Mr. M. has one or two alcoholic beverage in the evenings before bedtime.
Assessment
e patient has severe daytime sleepiness and symptoms of OSA. His sleep hygiene
habits are poor and he self-medicates with caeine as a daytime stimulant and uses
CASE STUDY
(continued)
82 Evidence-Based Geriatric Nursing Protocols for Best Practice
alcohol as a hypnotic. With a BMI greater than 30, he has a high risk for both OSA
and poorly controlled Type II diabetes. Clearly, Mr. M. is a high-risk driver, even
during daylight hours. Although depression can cause sleep disruption, this patient’s
medical history and symptoms are compelling indicators of excessive sleepiness and
warrant a referral to a sleep specialist for evaluation and treatment.
Interventions
e immediate intervention was referral to sleep specialist who ordered an overnight
polysomnography to evaluate for OSA and begin treatment. e results of the over-
night polysomnography are as follows:
TABLE 5.4
Results of Overnight Polysomnography
Total recording time 368 min REM sleep 0
Total sleep time 256 min Stage 1 sleep 92%
Sleep efficiency 70% Stage 2 sleep 8%
Lowest O
2
saturation 65% Stages 3 & 4 sleep 0
Apnea/Hypopnea index 56/hr of sleep Longest apnea 39 s
Note. REM 5 rapid eye movement.
Intermediate interventions include a referral to the dietician for assistance in man-
aging his diabetic diet and achieving weight loss. He requires instruction on sleep
hygiene measures, avoidance of sedating OTC drugs (i.e., alcohol), which can exac-
erbate OSA symptoms, and avoidance of driving long distances alone or at night
until treatment of OSA has begun. With CPAP treatment adherence, Mr. M. is
more likely to be successful with weight loss involving increased activity, which can
improve hypertension and glucose control. In addition, eective treatment of OSA
often improves nocturia as well as reduced libido.
Diagnosis
Severe obstructive sleep apnea.
Treatment
Because of the obstructive character of the patient’s sleep-related breathing disorder,
CPAP at 14 cm water pressure.
Six-Month Follow-Up
Since starting CPAP, Mr. M. has lost 30 lbs, and his CPAP pressures and antihyper-
tensive medications have already been titrated downward. His blood pressure has
dropped to 132/88 mm Hg, his HbA1c has improved (7.6%), and he seldom has
CASE STUDY (continued)
(continued)
Excessive Sleepiness 83
SUMMARY
Nurses must be able to identify, screen, and refer patients with excessive daytime sleepi-
ness and symptoms of sleep disorders. No other group of health care providers watch
more people sleep than nurses, and sleep disorders can aect all aspects of health and
illness. Sleep medicine is a relatively new specialty, and many health care providers have
had no preparation in the science of sleep. Nurses also must incorporate sleep hygiene
measures and actively address existing sleep disorders in care plans of older adults to
ensure adequate sleep in all settings: acute care, primary care, and at home. Failing to
identify, diagnose, or treat excessive sleepiness and its underlying cause(s) can adversely
aect the health and longevity of older adults.
Protocol 5.1: Excessive Sleepiness
I. GOAL: Older adults will maintain an optimal state of alertness while awake and
optimal quality and quantity of sleep during their preferred sleep interval.
II. OVERVIEW: Although normal aging is accompanied by decreased “deep sleep,”
sleep eciency, and increased time awake after sleep onset, these changes should not
result in excessive daytime sleepiness. Daytime sleepiness is not only a symptom of
sleep disorders but also results in decreased health and functional outcomes in the
older adult.
III. BACKGROUND
A. Denition
Excessive sleepiness: somnolence, hypersomnia, excessive daytime sleepiness,
subjective sleepiness. Sleepiness is an ubiquitous phenomenon, experienced
not only as a symptom in a number of medical, psychiatric, and primary sleep
disorders, but also as a normal physiological state by most individuals over any
(continued)
NURSING STANDARD OF PRACTICE
nocturia or takes naps. e patient reduced his caeine intake to one or two cups
of coee per day and stopped using OTC products or alcohol as a sleeping aid. He
no longer feels tired and has driven his car on several car trips without feeling sleepy.
Mr. M. also states that he has started taking 30-minute walks with his wife at least
four times a week. He reports, “I did not know how tired I was until I started on this
breathing machine at night. I will admit, a few nights I haven’t used it. But, the next
day, I always know that I made a mistake by skipping the night before.”
CASE STUDY (continued)
84 Evidence-Based Geriatric Nursing Protocols for Best Practice
given 24-hour period. Sleepiness can be considered abnormal when it occurs
at inappropriate times, or does not occur when desired (Shen, Barbera, &
Shapiro, 2006).
B. Etiology and Epidemiology
1. Excessive sleepiness may be caused by diculty initiating sleep, impaired sleep
maintenance, waking prematurely, sleep disorders, or sleep fragmentation.
2. ere are many types of sleep diagnoses and the most common disorders
reported by older adults are obstructive sleep apnea (OSA), insomnia, and
restless leg syndrome.
3. Many sleep disorders share excessive sleepiness as a common symptom, but
this symptom is often not evaluated or treated because health care providers are
uninformed about the nature of sleep disorders, the symptoms of these disor-
ders, and the many eective treatments available for these conditions.
IV. PARAMETERS OF ASSESSMENT
A. A sleep history (see Table 5.1) should include information from both the patient
and family members. People who share living and sleeping spaces can provide
important information about sleep behavior that the patient may not be able
to convey.
B. e Epworth Sleepiness Scale (Johns, 1991) is a brief instrument to screen for
severity of daytime sleepiness in the community setting. It can also be found
under “Resources” at http://consultgerirn.org/resources
C. e Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989) is useful to
screen for sleep problems in the home environment and to monitor changes
in sleep quality. is instrument can be found under “Resources” at http://
consultgerirn.org/resources
V. NURSING CARE STRATEGIES
A. Vigilance by nursing sta in observing patients for snoring, apneas during
sleep, excessive leg movements during sleep, and diculty staying awake dur-
ing normal daytime activities (Ancoli-Israel & Martin, 2006; Avidan, 2005).
B. Management of medical conditions, psychological disorders, and symptoms
that interfere with sleep, such as depression, pain, hot ashes, anemia, or ure-
mia (Ancoli-Israel & Martin, 2006; Avidan, 2005).
C. For patients with a current diagnosis of a sleep disorder, ongoing treatments
such as continuous positive airway pressure (CPAP) should be documented,
maintained, and reinforced through patient and family education (Avidan,
2005). Nursing sta should reinforce patient instruction in cleaning and main-
taining positive airway pressure equipment and masks.
D. Instruction for patients and families regarding sleep hygiene techniques to
protect and promote sleep among all family members (see Table 5.3; Avidan,
2005).
E. Review and, if necessary, adjustment of medications that interact with one
another or whose side eects include drowsiness or sleep impairment (Ancoli-
Israel & Martin, 2006).
(continued)
Protocol 5.1: Excessive Sleepiness (cont.)
Excessive Sleepiness 85
F. Referral to a sleep specialist for moderate or severe sleepiness or a clinical pro-
le consistent with major sleep disorders such as OSA or restless leg syndrome
(Avidan, 2005).
G. Aggressive planning, monitoring, and management of patients with OSA when
sedative medications or anesthesia are given (Avidan, 2005).
H. Ongoing assessment of adherence to prescriptions for sleep hygiene, medica-
tions, and devices to support respiration during sleep (Avidan, 2005).
VI. EVALUATION AND EXPECTED OUTCOMES
A. Quality Assurance Actions
1. Provide sta education on the major causes of excessive sleepiness (i.e., OSA,
insomnia, restless leg syndrome).
2. Provide sta with in-services on how to use and monitor CPAP equipment.
3. Have individual nursing units conduct environmental surveys regarding
noise level during the night hours and then develop strategies to reduce
sleep disruption caused by noise and care patterns.
4. Add sleep as a parameter of the admission assessment for patients and pro-
vide written instructions for patients using CPAP at home to always bring
the equipment with them to the hospital.
Include sleep quality (e.g., see PSQI tool; http://www.hartfordign.org).
5. Utilize posthospital surveys of patient satisfaction with their sleep while in
the hospital and provide feedback for nursing sta (see http://www.hartfor-
dign.org, Sleep topic).
B. Quality Outcomes
Improved quality and/or quantity of sleep during normal sleep intervals as
reported by patients and stas.
VII. FOLLOW-UP MONITORING
A. Depending on the diagnosis, follow-up may include long-term reinforcement
of the original interventions along with support for adhering to treatments
prescribed by a sleep specialist. For example, patient compliance with CPAP
therapy for OSA is critical to its ecacy and should be assessed during the rst
week of treatment (Weaver et al., 1997a). All patients benet from positive
reinforcement while trying to acclimate to nightly use of a positive airway pres-
sure device.
B. CPAP masks may require minor adjustments or retting to nd the most com-
fortable t. Most such changes are needed during the acclimation period, but
patients should be encouraged to seek assistance if mask problems develop
(Weaver et al., 1997a). In the acute care setting, respiratory care technicians
are valuable in-house resources when sta from a sleep center are not readily
available.
C. During the initial treatment phase of insomnia, sleep deprivation may cause
rebound sleepiness, which should subside over time. Follow-up should include
ongoing assessment of napping habits and sleepiness to track treatment eec-
tiveness (Avidan, 2005).
(continued)
Protocol 5.1: Excessive Sleepiness (cont.)
86 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
American Academy of Sleep Medicine (AASM)
is organization for sleep professionals is also a great source of information for the public and for
practice guidelines for professionals.
http://www.aasmnet.org/
Basics of Sleep Guide
is Sleep Research Society publication is designed for students, sleep researchers, and nonsleep
professionals interested in studying sleep across the life cycle, sleep deprivation or restriction,
and sleep physiology. Information about this publication and how to order it can be found on
the Sleep Research Society website.
http://www.sleepresearchsociety.org/Products.aspx
National Institutes of Health, National Center on Sleep Disorders Research
is site includes brochures that may be downloaded or printed for distribution to patients or for the
education of other health care providers.
For patients and the general public: http://www.nhlbi.nih.gov/health/public/sleep/index.htm
For health care professionals: http://www.nhlbi.nih.gov/health/prof/sleep/index.htm
New Abstracts and Papers in Sleep
is free online subscription service is an excellent resource for professionals to nd the most recent
research on sleep disorders and their treatments on a regular basis. Services include weekly
personalized e-mail alerts of new citations, author abstracts, a compilation of the current week’s
literature in sleep, and an archive of the current year’s literature in sleep.
http://www.websciences.org/bibliosleep/naps/
Restless Leg Syndrome Foundation
is organization is dedicated to improving the lives of the men, women, and children who live
with this often devastating disease. e organization’s goals are to increase awareness of RLS, to
improve treatments, and, through research, to nd a cure.
http://www.rls.org
Sleep Research Society
is professional organization fosters scientic investigation, professional education, and career
development in sleep research and academic sleep medicine. It is an excellent resource for nurses
who are interested in studying issues of sleep and circadian processes.
http://www.sleepresearchsociety.org/
D. If obesity has been a complicating health factor, weight loss is a desirable long-
term goal. With reduction in daytime sleepiness, the timing is ripe for increas-
ing the activity level. Treatment of sleep disorders should include planning for
strategic changes in lifestyle that include regular exercise, which is also consis-
tent with cardiovascular health and long-term diabetes control (Ancoli-Israel &
Ayalon, 2006).
Protocol 5.1: Excessive Sleepiness (cont.)
Excessive Sleepiness 87
REFERENCES
American Academy of Sleep Medicine. (2005). International classication of sleep disorders: Diagnostic
and Coding Manual (2nd ed.). Westchester, MN: Author.
Ancoli-Israel, S. (2000). Insomnia in the elderly: A review for the primary care practitioner. Sleep,
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Ancoli-Israel, S. (2005). Sleep and aging: Prevalence of disturbed sleep and treatment considerations in
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Ancoli-Israel, S., & Ayalon, L. (2006). Diagnosis and treatment of sleep disorders in older adults. e
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Ancoli-Israel, S., Kripke, D. F., Klauber, M. R., Mason, W. J., Fell, R., & Kaplan, O. (1991). Sleep-
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Avidan, A. Y. (2005). Sleep in the geriatric patient population. Seminars in Neurology, 25(1), 52–63.
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Brassington, G. S., King, A. C., & Bliwise, D. L. (2000). Sleep problems as a risk factor for falls in
a sample of community-dwelling adults aged 64–99 years. Journal of the American Geriatrics
Society, 48(10), 1234–1240. Evidence Level III.
Buysse, D. J. (2004). Insomnia, depression and aging. Assessing sleep and mood interactions in older
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Buysse, D. J., Reynolds, C. F., III, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). e Pitts-
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(2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiol-
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nal of the American Geriatrics Society, 49(12), 1622–1627. Evidence Level III.
Colten, H. R., & Altevogt, B. M. (Eds.). (2006). Sleep disorders and sleep deprivation: An unmet public
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Gamaldo, C. E., & Earley, C. J. (2006). Restless legs syndrome: A clinical update. Chest, 130(5),
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88 Evidence-Based Geriatric Nursing Protocols for Best Practice
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89
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe common components of standardized functional assessment instruments
for acute care
2. identify unique challenges to gathering information from older adults regarding
functional assessments
3. describe common nursing care strategies to restore, maintain, and promote func-
tional health in older adults in acute care settings
OVERVIEW
Physical functioning is a dynamic process of interaction between individuals and
their environments. e process is inuenced by motivation, physical capacity,
illness, cognitive ability, and the external environment including social supports.
Management of these day-to-day activities (e.g., eating, bathing, ambulating, man-
aging money) serves as the foundation for safe, independent functioning of all
adults. Functional assessment instruments provide a common language of health
for patients, family members, and health care providers across settings, especially for
care of older adults.
e consequences of not assessing for change in status are signicant. Acute changes
in functional ability often signal an acute illness and an increased need for assistance
to maintain safety. ese changes have important implications for nursing care across
settings, but especially during hospitalization. e ability to assess functional status is
critical in accurately identifying normal aging changes, illness, and disability, and in
developing an individualized plan for continuity of care across settings. e failure to
assess function can lead to increased decline (e.g., malnutrition, falls), decreased quality
of life, and the need for institutional care.
Denise M. Kresevic
6
Assessment of Physical Function
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
90 Evidence-Based Geriatric Nursing Protocols for Best Practice
BACKGROUND AND STATEMENT OF PROBLEM
e ability to manage day-to-day functioning (e.g., bathing, dressing, managing medica-
tions), rather than the absence of disease, is the cornerstone of health for older adults. As
individuals age or become ill, they may require assistance to accomplish these activities
independently. Hospitalization can also contribute to functional decline, with decline
experienced by an estimated 20%–40% of hospitalized older adults (Landefeld, Palmer,
Kresevic, Fortinsky, & Kowal, 1995). Although the exact cause of the decline is often a
combination of factors including acute illness, it can in part be caused by environmental
factors of hospitalization that could be prevented or ameliorated by skilled nursing care
(McCusker, Kakuma, & Abrahamowicz, 2002). In fact, hospitalization provides a unique
opportunity to assess function, plan for services, and promote “successful aging.”
Common risk factors for functional decline include falls, injuries, acute illness,
medication side eects, depression, malnutrition, baseline functional impairment, and
decreased mobility associated with iatrogenic complications such as incontinence, falls,
and pressure sores (Creditor, 1993). In one randomized clinical trial of hospitalized older
adults, the daily nursing assessment of ability to perform bathing, dressing, grooming,
toileting, transferring, and ambulation during routine nursing care yielded information
necessary for maintenance of function in self-care activities (Landefeld et al., 1995).
is chapter addresses the need for and goals of functional assessment of older
adults in acute care, and it provides a clinical practice protocol to guide nurses in this
assessment (Protocol 6.1).
ASSESSMENT OF THE PROBLEM
Assessment of function includes an ongoing systematic process of identifying the older
person’s physical abilities and need for help. Functional assessment also provides the
opportunity to identify individual strengths and measures of “successful aging.” is
information is especially important for nurses in planning for discharge and evaluating
continuity of care. Nurses are in a pivotal position in all care settings, but particularly
during hospitalization, to assess the functional status of older adults by direct observa-
tion during routine care and through information gathered from the individual patient,
the patient’s family, and any other long-term caregivers.
Including critical components of functional assessments into routine assessments
in the acute care setting can provide (a) baseline functional capacity and recent changes
in level of independence indicative of possible illness, especially infections; (b) baseline
information to benchmark patients’ response to treatment as they move along the con-
tinuum from acute care to rehabilitation or from acute to subacute care (e.g., following
a new stroke or hip replacement surgery); (c) information regarding care needs and
eligibility for services, including safety, physical therapy, and posthospitalization needs;
and (d) information on quality of care. e ongoing use of a standardized functional
assessment instrument promotes systematic communication of the patient’s health sta-
tus between care settings. It also allows units to compare their level of care with other
units in the facility, measure outcomes, and plan for continuity of care (see Table 6.1;
Campbell, Seymour, Primrose, & ACMEPLUS Project, 2004).
Although gathering information about functional status is a critical indicator of quality
care in geriatrics, it requires signicant time, skill, and knowledge. Older persons often
present to the care setting with multiple medical conditions resulting in fatigue and pain.
Acute illnesses may be superimposed upon multiple interrelated medical comorbidities.
Assessment of Physical Function 91
TABLE 6.1
Functional Assessment of Older Adults
Dimension Assessment Parameter
Standardized
Instrument Nursing Strategy
ADLs
Bathing
Dressing
Eating
Toileting
Hygiene
Transferring
Self-report of patient
Surrogate report
Observation during
hospitalization
Katz ADL index
(Katz et al.,
1963)
Orient to environment
Encourage active participation
in ADLs
Range of motion exercises
Encourage to be out of bed
Promote continence
Consult PT/OT for strengthening
exercises
Mobility
Balance sitting
and standing
Gait steadiness
Turns
Self-report
Surrogate report
Observation
“Get Up and
Go” test
(Mathias et al.,
1986)
Ambulate
PT/OT consult
Mobility aids
Community referrals
IADLs
Housework
Finances
Driving
Shopping
Meal preparation
Reading
Medication
adherence
Aware of current
events
Hobbies
Employment
Volunteer work
Self-report (include normal
daily routine)
Surrogate report (able
to balance check book,
traffic violations)
Lawton IADL
scale Lawton
& Brody, 1969;
Gurland et al.,
1994)
DAFA–for
patients with
dementia
(Karagiozis et
al., 1998)
Assess ability to:
n Find hospital room
n Read newspaper
n Read pill bottles
n Order hospital meals from menu
Facilitate as needed:
n Community referrals for
transportation and/or Meals on
Wheels
n OT consult to assess home
management skills (cooking,
laundry, etc.)
n Home care referral including
medication management,
follow-up medical care,
rehabilitation, home safety
management, and ADL support
Note. ADLs 5 activities of daily living; IADLs 5 instrumental activities of daily living;
PT/OT 5 physical therapist/occupational therapist
In addition, sensory aging changes, particularly vision and hearing, can threaten the accu-
racy of responses. Ideally, information regarding functional status should be elicited as
part of the routine history of older adults and incorporated into daily care routines of all
caregivers. In addition, comprehensive assessment of function provides an opportunity to
teach patients and families about normal aging as well as indicators of pathology.
Assessment Instruments
Collecting systematic information regarding tasks of daily living (e.g., bathing, dressing,
ambulating, using a phone, taking medications, managing nances) can be accomplished
by the use of standardized instruments. e use of standardized instruments serves to
ensure inclusive assessments, the ability to communicate in a common language, and the
ability to benchmark information over time. Several instruments have been developed
92 Evidence-Based Geriatric Nursing Protocols for Best Practice
over the years to measure function. Although all measure components of function, the
decision of which instrument to use depends on the primary purpose of the assessment
and the institutional preferences and resources (Kane & Kane, 2000). No single instru-
ment will meet the needs of all care settings.
Many performance-based measures and observational instruments can be incorpo-
rated into routine care practices without signicantly burdening caregivers. Incorporating
electronic medical record templates into routine documentation can function as a prompt
for providers, decreasing the time and increasing the communication of the results of these
assessments.
e Katz Index of Independence in Activities of Daily Living (commonly referred
to as Katz ADL index) assesses activities of daily living (ADL) including bathing, dress-
ing, transferring, toileting, continence, and feeding (Katz, Ford, Moskowitz, Jackson,
& Jae, 1963). is scale is used widely to assess function of older adults in all settings
including during hospitalization (Mezey, Rauckhorst, & Stokes, 1993). Originally, the
Katz ADL index was proposed as an observation tool with scores ranging from 1 to 3,
indicating independent ability, limited assistance, and extensive assistance for each activ-
ity. Over time, the instrument has evolved into a dichotomized tool with independent
versus dependent ability of each task (Kane & Kane, 2000). With established reliability
(0.94–0.97), it is easy to use either as an observational or self-reported measure of level
of independence (Kane & Kane, 2000). e Katz ADL index is easily incorporated
into history and physical assessment owsheets and takes little time to complete. Many
other tools exist to assess ADLs, including the Barthel index for physical functioning
and the Older Americans Resources and Services ADL scale (Burton, Damon, Dillinger,
Erickson, & Peterson, 1978; Mahoney & Barthel, 1965; Mezey et al., 1993).
In addition to ADL tools, instruments to measure more complex physical function
called instrumental activities of daily living (IADLs) have been proposed to be included
in a comprehensive assessment of function in older adults. e majority of these instru-
ments assess the individual’s function in relation to the environment. Common IADL
skills identied include using a phone, shopping, meal preparation, housekeeping, laun-
dry, medication administration, transportation, and money management (Kane & Kane,
2000). Although assessment of ADLs provides useful information for nursing care needs
both during and after hospitalization, IADL information helps target critical posthospi-
tal care needs. Although direct observation of the patient’s IADLs may not occur during
an acute hospitalization, it is important for the nurse to assess this information to plan
for the patient’s discharge. Common instruments used to measure IADLs include the
Lawton IADL scale, the Older Americans Resource and Services IADL (OARS-IADL)
scale, and the Direct Assessment of Functional Abilities (DAFA) scale.
Perhaps the most widely used IADL instrument for hospitalized older adults is the
Lawton IADL scale. is scale assesses eight items with each scored from 0 (dependence)
to 8 (independent self-care). Reliability coecients have been reported to be 0.96 for
men and 0.93 for women (Kane & Kane, 2000).
Assessment of function in individuals with dementia presents a unique challenge.
A recently developed instrument, the DAFA, is a 10-item observational measure of
IADLs useful in assessing function in the presence of dementia (Karagiozis, Gray, Sacco,
Shapiro, & Kawas, 1998; see http://www.consultgerirn.org/resources and the Resources
section of this chapter for assessment instruments).
Regardless of the instrument used, basic ADL and IADL function should be assessed
for each patient, including capacity for dressing, eating, transferring, toileting, hygiene,
Assessment of Physical Function 93
ambulation, and medication adherence (see Chapter 17, Reducing Adverse Drug
Events). Appropriate assessment instruments should be readily available on the acute
care unit for reference and/or incorporated into routine documentation instruments for
history, daily assessment, and discharge planning. To adequately assess function, sensory
and cognitive capacity should be established and environmental adaptations, such as
magnifying glasses or hearing ampliers, may be necessary and should be accessible to
nursing sta.
Direct Assessment of Patient
Although nurses often rely on reports of physical functioning and capacity for ADL and
IADL from patients and family members, direct observation provides strong evidence
for current capacity versus past ability.
Functional assessments are constantly conducted by nurses every time they notice
that a patient can no longer pick up a fork or has diculty walking. A comprehensive
functional assessment leads to more than simply noticing a change in activity or ability,
however. In a systematic manner, nurses need to assess the ability of a patient to perform
ADLs in the context of the patient’s baseline functional and hospitalization status.
While assessing functional status, the patient should be made as comfortable as
possible, with frequent rest periods allowed. Adaptive aids, such as glasses and hear-
ing aids, should be applied. Often, family members accompany the older person and
can assist in answering questions regarding function. It is important for patients and
family members to understand that baseline functional levels as well as any recent
changes in function need to be reported. Many older adults may be reluctant to
report decline in function, fearing that such reports will threaten their autonomy and
independent living.
Occasionally, the history and physical exam may reveal clues to further identify
functional status. Muscle weakness and atrophy of legs may indicate lack of ability to
safely ambulate independently. Temporal muscle wasting may indicate moderate-to-
severe malnutrition resulting from inability to shop, prepare meals, or adequately con-
sume sucient calories. Hand contractures present with arthritis or cerebral vascular
accidents alert the nurse to pay particular attention to performance versus self-report of
ability to open pill bottles, dial a phone, or write checks. General appearance (e.g., hair,
teeth, ngernails) and condition of clothing (e.g., clean and dry versus urine-soaked
undergarments) may give rise to information on bathing, dressing, continence, and
ability to do laundry.
Specific Functional Assessments
Ambulation
Inherent in both ADLs and IADLs is ambulation, a critical parameter for functional
assessment. Early nursing assessment of the hospitalized patient’s ability to walk is very
important in order to ensure safety and prevent falls and injuries (see Chapter 15, Fall Pre-
vention: Assessment, Diagnoses, and Intervention Strategies). e ability to safely ambulate
is contingent on the ability to transfer, propel forward, and pivot with sucient strength
and balance. Ambulation is necessary for self-care both in the hospital and posthospital
discharge. It is also a very sensitive indicator of acute health changes. erefore, the ability
to ambulate should be assessed by both self- or proxy report and by direct observation.
94 Evidence-Based Geriatric Nursing Protocols for Best Practice
Some instruments used to assess ambulation, balance, and gait are sensitive mea-
sures of mobility (Applegate, Blass, & Franklin, 1990); however, they are also complex
and time consuming to use. erefore, direct observation of an individual’s ability to
get out of bed, sit in a chair, assume a standing position, and steadily walk a short
distance—with or without assistive devices—is much simpler to do yet important to
ensure safety (Applegate et al., 1990; Cress et al., 1995).
An ecient performance-based measure of ambulation, balance, and gait that can
be observed during routine care of the hospitalized patient is the “Get Up and Go” test
(Cress et al., 1995). To do a Get Up and Go test, patients are observed sitting in a chair,
standing, walking, and pivoting. Direct observation of the patient should include an
assessment of speed of performance, hesitancy, stumbling, swaying, grabbing for sup-
port, or unsafe maneuvers such as sitting too close to the edge of a chair or dizziness
while pivoting (Tinetti & Ginter, 1998). Performance is scored from 1 (normal balance
and steady gait) to 5 (severely abnormal balance and gait) which is clear evidence of falls
risk (Kane & Kane, 2000). Assessment of unsafe transfers or ambulation indicates the
need to begin immediate restorative therapies to prevent falls and injuries. ese can
include attention to environmental designs such walking paths free of clutter, hand
rails, and rest areas to encourage daily ambulation as opposed to bed rest and immo-
bility (Creditor, 1993). Although the Get Up and Go test is easy to do, it is relatively
subjective. Objectivity may be enhanced by timing the tasks (Kane & Kane, 2000).
Sensory Capacity
Evaluation of the potential impact of sensory changes on the performance of ADLs is
often underestimated. Impaired vision is especially important in medication adherence
and safety. A simple test for functional vision is to have older adults read from a news-
paper. A moderate impairment can be noted if only the headline can be read (Tinetti
& Ginter, 1998). Another way to assess vision is to have older persons read prescription
bottles. Functional assessment of safe medication administration includes the ability to
read pill bottles and repeat directions for use, potential side eects, and instructions of
when to contact a health care provider. Glasses should be available with clean lenses.
Inability to read raises questions of literacy, undiagnosed vision diculties, and safety
for medication administration. Often overlooked is the number of older people who
may not be able to read but are too embarrassed to reveal that information. As part
of routine care, older adults should be encouraged to actively participate each day in
learning about medications. In addition, at the time of discharge, nurses need to verify
patient and family knowledge and skills regarding medications. is may include dis-
cussing medications as well as directly observing older adults opening pill bottles and
identifying the correct pills.
Hearing ability is also essential for functioning and cognition. Individuals with
decreased hearing may be inaccurately labeled as cognitively impaired. Hearing aids may not
have been sent to the hospital with the older patient and should be obtained by the family.
Hearing acuity may be validated by asking patients to identify the sound of a ticking watch.
e “whisper test” may also be used. is is performed by whispering 10 words while
standing 6 in. away from the individual. Inability to repeat 5 of the 10 words indicates a
need for further assessment of hearing acuity. Occlusion of the external ear canal by ceru-
men, an easily treatable cause of decreased hearing acuity, may be evident with visualiza-
tion (Mathias, Nayak, & Isaacs, 1986). Individuals with hearing decits detected as part of
Assessment of Physical Function 95
bedside assessment should be referred for additional assessment and treatment. Amplier
devices may be useful and are an inexpensive item to stock on hospital nursing units.
Cognitive Capacity
Cognitive function is a major factor in a person’s functional capacity, and baseline data
regarding cognitive function should be gathered. However, such assessments most often
initially rely on information provided by family members because acute illness may man-
ifest as acute confusional states and not reect baseline cognitive function (Kruianski &
Gurland, 1976; see Chapter 8, Assessing Cognitive Function). Fluctuating attention may
indicate an acute, reversible impairment (delirium) or temporary reactions to hospitaliza-
tion. An acute change in cognition should be evaluated immediately for the presence of a
potentially life-threatening, reversible medical condition (see Chapter 11, Delirium).
Cause of Functional Decline
All instances of functional decline should be assessed for an underlying reversible cause
such as acute illness. With the resolution of acute illness (e.g., urinary tract infection
[UTI], pneumonia, postoperative recovery), impaired ADLs are expected to return to
baseline with appropriate care and rehabilitation. Comprehensive musculoskeletal or
neurologic examination, laboratory tests, or referral for a therapeutic trial of physical or
occupational therapy may be needed to boost recovery.
INTERVENTIONS AND CARE STRATEGIES
Functional ability is a sensitive indicator of health in older adults. e need for assis-
tance with ADLs is an important nursing assessment that aids in care planning during
and after a hospital stay. Sudden loss of function, including the ability to ambulate,
is the hallmark of acute illness in older adults. Although recovery from illness may be
associated with improvements in function, early nursing interventions to address care
needs, refer to therapy, and modify environments of care help to ensure safety and
decrease further loss of function. erefore, all nurses must be skilled at incorporat-
ing a comprehensive functional assessment into all patient care assessments. Nurses
need to be knowledgeable and skilled in assessment of function, implementing support-
ive environments, and providing geriatric-sensitive care to prevent functional decline.
Geriatric-sensitive care incorporates strategies to prevent bed rest, encourage exercise
and ambulation, ensure adequate nutrition, and encourage ongoing communication
among all team members. Such care is essential in maximizing safe, independent func-
tioning of hospitalized older adults (see Chapter 7, Interventions to Prevent Funtional
Decline in the Acute Care Setting).
Use of Assessment Information
Knowledge of ADL and IADL abilities, including shopping, housework, nances, food
preparation, medication administration, and transportation, is an important part of pro-
viding individual nursing care for comprehensive discharge planning (Woolf, 1990). In
summary, for older people, the evaluation of function represents the cornerstone of good
nursing care and aords a sound baseline by which to provide information essential to
plan for continued care across settings.
96 Evidence-Based Geriatric Nursing Protocols for Best Practice
Mrs. Hope, a 74-year-old retired night nurse and recent widow, is admitted to the
hospital from her physician’s oce. Her admitting diagnosis is pneumonia, dehydra-
tion, and weakness. She is accompanied by her daughter. Her past medical history is
signicant for hypertension, congestive heart failure (CHF), and chronic obstructive
pulmonary disease (COPD). She is extremely hard of hearing, but has refused to wear
her hearing aid. She smokes approximately 10 cigarettes a day, which she has done for
more than 50 years. Her daughter admits that lately, Mrs. Hope has not been taking
most of her pills, although she has been taking aspirin for pain. She has also been los-
ing weight and has poor appetite and intake. Laboratory values indicate anemia with
a very low hematocrit and a UTI.
While on the unit, Mrs. Hope prefers to sleep in the recliner, saying she is most
comfortable there and prefers to nap during the day. Despite intravenous uids,
blood transfusions, diuresis for uid overload, oxygen therapy, occupational therapy
for energy conservation, and round-the-clock acetaminophen for “aches and pains,”
Mrs. Hope continues to be weak and need assistance with daily bathing and ambula-
tion. She is able to communicate well using an amplier, after her ears are cleaned
from wax. She is assessed by the multidisciplinary care team over the next several
days. After the team meeting consultations are obtained for physical therapy, nutri-
tion services, pharmacy, geriatric clinical nurse specialist, and social work. Her fatigue
improves. Referrals for home care are made for nursing and therapy as well as for
telehealth to monitor her CHF. Mrs. Hope’s medication regimen is adjusted, sub-
stituting acetaminophen rather than aspirin for her pain. She and her daughter are
instructed on a high-calorie diet and are provided with information on senior care
and smoking cessation programs. She is given vaccines for inuenza and pneumonia.
A future outpatient appointment for a comprehensive geriatric evaluation is made to
do an anemia workup and more accurately assess her cognitive status once her acute
conditions resolve.
Mrs. Hope is discharged home with her daughter after medications, diet, and
exercises are reviewed. e numbers for the home care agency and directions to the
outpatient appointment are printed out for her at the time of discharge.
Case Study Review
is case study indicates the need to assess baseline function, changes in function, and
trajectory of function following acute care. Assessment in this case used components
from several standardized functional assessment instruments and incorporated them
into existing care routines. Care was enhanced by collaboration between multiple
disciplines and across settings. Opportunities for assessment and resolution of impair-
ment rely on institutional preferences and resources, as well as the functional level
of the patient. Despite impaired function of Mrs. Hope, hospital sta worked to
enhance her physical functioning as much as possible within the current care setting
and a context of safety.
CASE STUDY
Assessment of Physical Function 97
Protocol 6.1: Assessment of Physical Function
I. GOAL: e following nursing care protocol has been designed to help bedside
nurses to monitor function in older adults, prevent decline, and maintain the function
of older adults during acute hospitalization.
II. OBJECTIVE: To maximize physical functioning, prevent or minimize decline in
activity of daily living (ADL) function, and plan for transitions of care.
III. BACKGROUND
A. Functional status of individuals describes the capacity and performance of
safe ADLs and instrumental activities of daily living (IADLs; Applegate et al.,
1990; Kane & Kane, 2000; Katz et al., 1963; Lawton & Brody, 1969); and is
a sensitive indicator of health or illness in older adults. It is therefore a critical
nursing assessment (Byles, 2000; Campbell et al., 2004; Kresevic et al., 1998;
Mezey et al., 1993).
B. Some functional decline may be prevented or ameliorated with prompt and
aggressive nursing intervention (e.g., ambulation, toileting schedules, enhanced
communication, adaptive equipment, and attention to medications and dos-
ages [Bates-Jensen et al., 2004; Counsell et al., 2000; Landefeld et al., 1995;
Palmer, Counsell, & Landefeld, 1998]).
C. Some functional decline may occur progressively and is not reversible. is
decline often accompanies chronic and terminal disease states such as degen-
erative joint disease, Parkinson’s disease, dementia, heart failure, and cancer
(Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990).
D. Functional status is inuenced by physiological aging changes, acute and chronic
illness, and adaptation to the physical environment. Functional decline is often
the initial symptom of acute illness such as infections (e.g., pneumonia and uri-
nary tract infection). ese declines are usually reversible and require medical
evaluation (Applegate et al., 1990; Sager & Rudberg, 1998). Functional status
is contingent on motivation, cognition, and sensory capacity, including vision
and hearing (Pearson, 2000).
E. Risk factors for functional decline include injuries, acute illness, medication
side eects, pain, depression, malnutrition, decreased mobility, prolonged bed
rest (including the use of physical restraints), prolonged use of Foley catheters,
and changes in environment or routines (Counsell et al., 2000; Landefeld et al.,
1995; McCusker et al., 2002).
F. Additional complications of functional decline include loss of independence,
falls, incontinence, malnutrition, decreased socialization, and increased risk for
long-term institutionalization and depression (Covinsky et al., 1998; Creditor,
1993; Landefeld et al., 1995). (See related chapters.)
G. Recovery of function can also be a measure of return to health, such as for those
individuals recovering from exacerbations of cardiovascular or respiratory dis-
eases and acute infections, recovering from joint replacement surgery, or new
strokes (Katz et al., 1963).
NURSING STANDARD OF PRACTICE
(continued)
98 Evidence-Based Geriatric Nursing Protocols for Best Practice
H. Functional status evaluation assists in planning future care needs posthospital-
ization, such as short-term skilled care, home care, and need for community
services (Graf, 2006; Landefeld et al., 1995).
I. Physical environments of care with attention to the special needs of older adults
serve to maintain and enhance function (i.e., chairs with arms, elevated toilet
seat, levers versus door knobs, enhanced lighting; Kresevic et al., 1998; Lande-
feld et al., 1995).
IV. ASSESSMENT PARAMETERS
A. Comprehensive functional assessment of older adults includes independent
performance of basic ADLs, social activities, or IADLs, the assistance needed
to accomplish these tasks, and sensory ability, cognition, and capacity to ambu-
late (Campbell et al., 2004; Doran et al., 2006; Freedman, Martin, & Schoeni,
2002; Kane & Kane, 2000; Katz et al., 1963; Lawton & Brody, 1969; Light-
body & Baldwin, 2002; McCusker et al., 2002; Tinetti & Ginter, 1998).
1. Basic ADLs (bathing, dressing, grooming, eating, continence, transferring)
2. IADLs (meal preparation, shopping, medication administration, house-
work, transportation, accounting)
3. Mobility (ambulation, pivoting)
B. Older adults may view their health in terms of how well they can function
rather than in terms of disease alone. Strengths should be emphasized as well as
needs for assistance (Depp & Jeste, 2006; Pearson, 2000).
C. e clinician should document baseline functional status and recent or pro-
gressive decline in function (Graf, 2006).
D. Function should be assessed over time to validate capacity, decline, or progress
(Applegate et al., 1990; Callahan, omas, Goldhirsh, & Leipzig, 2002; Kane
& Kane, 2000).
E. Standard instruments selected to assess function should be ecient to adminis-
ter and easy to interpret. ey should provide useful practical information for
clinicians and be incorporated into routine history taking and daily assessments
(Kane & Kane, 2000; Kresevic et al., 1998). (see “Function” topic at http://
www.consultgerirn.org for tools.)
F. Interdisciplinary communication regarding functional status, changes, and
expected trajectory should be part of all care settings and should include the
patient and family whenever possible (Counsell et al., 2000; Covinsky et al.,
1998; Kresevic et al., 1998; Landefeld et al., 1995).
V. CARE STRATEGIES
A. Strategies to maximize functional status and to prevent decline
1. Maintain individual’s daily routine. Help to maintain physical, cognitive,
and social function through physical activity and socialization. Encourage
ambulation, allow exible visitation, including pets, and encourage reading
the newspaper (Kresevic & Holder, 1998; Landefeld et al., 1995).
2. Educate older adults, family, and formal caregivers on the value of indepen-
dent functioning and the consequences of functional decline (Graf, 2006;
Kresevic & Holder, 1998; Vass, Avlund, Lauridsen, & Hendriksen, 2005).
a. Physiological and psychological value of independent functioning
(continued)
Protocol 6.1: Assessment of Physical Function (cont.)
Assessment of Physical Function 99
b. Reversible functional decline associated with acute illness (Hirsch et al.,
1990; Sager & Rudberg, 1998)
c. Strategies to prevent functional decline: exercise, nutrition, pain man-
agement, and socialization (Kresevic & Holder, 1998; Landefeld et al.,
1995; Siegler, Glick, & Lee, 2002; Tucker, Molsberger, & Clark, 2004)
d. Sources of assistance to manage decline
3. Encourage activity, including routine exercise, range of motion, and ambu-
lation to maintain activity, exibility, and function (Counsell et al., 2000;
Landefeld et al., 1995; Pedersen & Saltin, 2006).
4. Minimize bed rest (Bates-Jensen et al., 2004; Covinsky et al., 1998; Kresevic
& Holder, 1998; Landefeld et al., 1995).
5. Explore alternatives to physical restraint use (Covinsky et al., 1998; Kresevic
& Holder, 1998; see Chapter 13, Physical Retraints and Side Rails and
Critical Care Settings).
6. Judiciously use medications, especially psychoactive medications, in geri-
atric dosages (Inouye, Rushing, Foreman, Palmer, & Pompei, 1998; see
Chapter 17, Reducing Adverse Drug Events).
7. Assess and treat for pain (Covinsky et al., 1998).
8. Design environments with handrails, wide doorways, raised toilet seats,
shower seats, enhanced lighting, low beds, and chairs of various types and
height (Cunningham & Michael, 2004; Kresevic et al., 1998).
9. Help individuals regain baseline function after acute illnesses by using exer-
cise, physical or occupational therapy consultation, nutrition, and coaching
(Conn, Minor, Burks, Rantz, & Pomeroy, 2003; Covinsky et al., 1998;
Engberg, Sereika, McDowell, Weber, & Brodak, 2002; Forbes, 2005;
Hodgkinson, Evans, & Wood, 2003; Kresevic et al., 1998).
B. Strategies to help older individuals cope with functional decline
1. Help older adults and family members determine realistic functional capac-
ity with interdisciplinary consultation (Kresevic & Holder, 1998).
2. Provide caregiver education and support for families of individuals when
decline cannot be ameliorated in spite of nursing and rehabilitative eorts
(Graf, 2006).
3. Carefully document all intervention strategies and patient response (Graf,
2006).
4. Provide information to caregivers on causes of functional decline related to
acute and chronic conditions (Covinsky et al., 1998).
5. Provide education to address safety care needs for falls, injuries, and com-
mon complications. Short-term skilled care for physical therapy may be
needed; long-term care settings may be required to ensure safety (Covinsky
et al., 1998).
6. Provide sucient protein and caloric intake to ensure adequate intake
and prevent further decline. Liberalize diet to include personal preferences
(Edington et al., 2004; Landefeld et al., 1995).
7. Provide caregiver support and community services, such as home care, nurs-
ing, and physical and occupational therapy services to manage functional
decline (Covinsky et al., 1998; Graf, 2006).
(continued)
Protocol 6.1: Assessment of Physical Function (cont.)
100 Evidence-Based Geriatric Nursing Protocols for Best Practice
VI. EXPECTED OUTCOMES
A. Patients can
1. Maintain safe level of ADL and ambulation.
2. Make necessary adaptations to maintain safety and independence, includ-
ing assistive devices and environmental adaptations.
3. Strive to attain highest quality of life despite functional level.
B. Providers can demonstrate
1. Increased assessment, identication, and management of patients suscepti-
ble to or experiencing functional decline. Routine assessment of functional
capacity despite level of care.
2. Ongoing documentation and communication of capacity, interventions,
goals, and outcomes.
3. Competence in preventive and restorative strategies for function.
4. Competence in assessing safe environments of care that foster safe indepen-
dent function.
C. Institution will experience
1. System-wide incorporation of functional assessment into routine assessments.
2. A reduction in incidence and prevalence of functional decline.
3. A decrease in morbidity and mortality rates associated with functional decline.
4. Reduction in the use of physical restraints, prolonged bed rest, and Foley
catheters.
5. Decreased incidence of delirium.
6. An increase in prevalence of patients who leave hospital with baseline or
improved functional status.
7. Decreased readmission rate.
8. Increased early utilization of rehabilitative services (occupational and physi-
cal therapy).
9. Evidence of geriatric sensitive physical care environments that facilitate
safe, independent function, such as caregiver educational eorts and walk-
ing programs.
10. Evidence of continued interdisciplinary assessments, care planning, and
evaluation of care related to function.
VII. RELEVENT PRACTICE GUIDELINES
Several resources are now available to guide adoption of evidenced based nursing
interventions to enhance function in older adults.
A. Agency for Healthcare Research and Quality & National Guideline Clearing-
house; http://www.guideline.gov/
B. McGill University Health Centre Research & Clinical Resources for Evidence
Based Nursing; http://www.muhc-ebn.mcgill.ca/
C. National Quality Forum; http://www.qualityforum.org/Home.aspx
D. Registered Nurses Association of Ontario. (2005). Clinical practice guidelines.
Retrieved from http://www.rnao.org/Page.asp?PageID=861&SiteNodeID=27
0&BL_ExpandID
E. University of Iowa Hartford Center of Geriatric Nursing Excellence. Evidence-
based practice guidelines. Retrieved from http://www.nursing.uiowa.edu/hartford/
nurse/ebp.htm
Protocol 6.1: Assessment of Physical Function (cont.)
Assessment of Physical Function 101
RESOURCES
Agency for Healthcare Research and Quality & National Guideline Clearinghouse
http://www.guideline.gov/
McGill University Health Centre Research & Research and Clinical Resources for Evidence Based Nursing
http://www.muhc-ebn.mcgill.ca/
National Quality Forum
http://www.qualityforum.org/Home.aspx
Registered Nurses Association of Ontario. Clinical practice guidelines.
http://www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL_ExpandID
University of Iowa Hartford Center of Geriatric Nursing Excellence. Evidence-based practice guidelines.
http://www.nursing.uiowa.edu/hartford/nurse/ebp.htm
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104
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. discuss the functional trajectory of the hospitalized older adult
2. identify risk factors for functional decline
3. describe the inuence of the care environment upon physical function
4. discuss interventions to optimize physical function of hospitalized older adults
OVERVIEW
As described in Chapter 6, Assessment of Function, functional decline is a common
complication in hospitalized older adults, even in those with good baseline function
(Gill, Allore, Gahbauer, & Murphy, 2010). Loss of physical function is associated
with poor long-term outcomes, including increased likelihood of being discharged to
a nursing home setting (Fortinsky, Covinsky, Palmer, & Landefeld, 1999), increased
morbidity and mortality (Boyd, Xue, Guralnik, & Fried, 2005; Rozzini et al., 2005),
increased rehabilitation costs, and decreased functional recovery (Boyd et al., 2008;
Boyd et al., 2005; Gill, Allore, Holford, & Guo, 2004; Volpato et al., 2007). e
immobility associated with functional decline results in infections, pressure ulcers,
falls, a persistent decline in function and physical activity and nonelective rehospital-
izations (Gill et al., 2004).
e promotion of function is a basic gerontological tenet, and functional status is
a key determinant of quality of life for older adults (Boltz, Capezuti, Shabbat, & Hall,
2010). Although the acute care setting, with its focus on correcting the admitting medical
problem, typically prioritizes nursing tasks such as medication administration, coordina-
tion of care, and documentation over the promotion of function as a clinical outcome,
there is growing awareness of the need to attend to the functional status of the hospitalized
older adult (Nolan & omas, 2008). Older adults themselves expect that an acute care
Marie Boltz, Barbara Resnick, and Elizabeth Galik
Interventions to Prevent
Functional Decline in the
Acute Care Setting
7
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Interventions to Prevent Functional Decline in the Acute Care Setting 105
stay will not result in functional decline but instead lead to the resumption of normal roles
and activities posthospitalization (Boltz, Capezuti, Shabbat, & Hall, 2010). is chapter
addresses the trajectory of change in physical function during the acute care stay, the fac-
tors associated with functional decline, and function-promoting interventions that can
potentially modify these factors. Finally, a clinical practice protocol to guide a unit-level
approach to function-focused care (Protocol 7.1: Protocol for FFC) is provided.
BACKGROUND AND STATEMENT OF PROBLEM
Physical Function as a Clinical Measure
Functional decline may result from the acute illness and can begin preadmission
(Fortinsky et al., 1999) and continue after discharge (Sager et al., 1996). In a large
prospective observational study, Covinsky and colleagues (2003) evaluated the changes
in performance of activities of daily living (ADL) function prior to and posthospital-
izations of older adults with medical illness. Over one third declined in ADL function
between baseline (2 weeks before admission) and discharge. is included the 23% of
patients who declined between baseline and admission and failed to recover to base-
line function between admission and discharge, and the 12% of patients who did not
decline between baseline and admission but declined between hospital admission and
discharge. Older adults age 85 and older comprised the age cohort demonstrating the
most functional loss, with rates exceeding 50%.
In their examination of the functional trajectory of hospitalized older adults, Wakeeld
and Holman (2007) also assessed function at baseline, as well as upon admission and
Day 4. e largest change in functional status was a decline in ADL from baseline to the
time of admission; ADL did not return to baseline during the rst 4 days in the hospital.
e older adults whose ADL scores declined during hospitalization (regardless of baseline
status) were more likely than others to die within 3 months of discharge.
e results of these studies demonstrate that ADL status is unstable in large percentage
of older adults. Consequently, Covinsky et al. (2003) suggest that an older adult’s func-
tional trajectory is a critical “vital sign,” an important prognostic marker, and an indicator
to guide care delivery and transitional care. Baseline function may serve as a useful bench-
mark when developing discharge goals. Older adults who have sustained loss of ADL func-
tion prior to admission would ideally have rehabilitation as a goal of their hospital care. For
those patients who have acquired ADL disability from admission to discharge, aggressive
post-acute rehabilitation plans could be mobilized with the goal of preventing disability.
Patient Risk Factors for Functional Decline
Intrinsic vulnerabilities to functional decline include prehospitalization functional status,
the presence of two or more comorbidities, taking ve or more prescription medications,
and having had a hospitalization or emergency room visit in the previous 12 months
(McCusker, Kakuma, & Abrahamowicz, 2002). Depression scores are associated with
ADL decline before admission (Covinsky, Fortinsky, Palmer, Kresevic, & Landefeld, 1997).
Symptoms of depression during hospitalization have also been associated with dependence
in basic ADL at discharge and 30 and 90 days after discharge (Covinsky et al., 1997).
e association between functional status and cognitive status must also be consid-
ered (Inouye, Schlesinger, & Lydon, 1999). Cognitive impairment, including delirium,
increases the risk of functional decline in the older adults during and after hospitalization
106 Evidence-Based Geriatric Nursing Protocols for Best Practice
(McCusker et al., 2002). A study of 2,557 patients from two teaching hospitals exam-
ined the association between performance on a cognitive status screen and maintenance
and recovery of functioning from admission to discharge (Narain et al., 1988). Among
patients who needed help performing one or more ADLs at the time of admission, 23%
had moderate-to-severe cognitive impairment, 49% had mild impairment, and 67%
had little or no impairment in cognitive performance recovered the ability to indepen-
dently execute an additional ADL by discharge (p , 0.001; Narain et al., 1988).
Pain (Reid, Williams, & Gill, 2005), nutritional problems, and adverse medica-
tion eects also contribute to functional decline (Graf, 2006). Fear of falling (Boltz,
Capezuti, & Shabbat, 2010; Boltz, Capezuti, Shabbat, & Hall, 2010), self-ecacy, and
outcome expectations (McAuley et al., 2006; Resnick, 2002), attitudes towards func-
tional independence, and views on hospitalization (Boltz, Capezuti, & Shabbat, 2010;
Boltz, Capezuti, Shabbat, & Hall, 2010; Brown, Williams, Woodby, Davis, & Allman,
2007) inuence the level of engagement in physical activity and mobility in older adults
in general and thus may inuence acute care functional outcomes.
ASSESSMENT OF THE PROBLEM
A social ecological perspective assumes that the physical, social, and organizational
environment contribute to patient outcomes (Moos, 1979; Stokols, 1992), including
functional measures (Galik, 2010). e hospital environment, with its emphasis on
biomedical interventions for acute medical and surgical problems is challenged to “t”
the complex physical, social, and psychological circumstances, which predisposes the
hospitalized older adult to functional decline. Parke and Chappell (2010) recommend
that the older adult hospital environment t be viewed through four dimensions: care
systems and processes, social climate, policy and procedure, and physical design.
Hospital Care Systems and Processes
Hospitalization is associated with signicantly greater loss of total, lean, and fat mass and
strength in older persons. ese eects appear particularly important in persons hospital-
ized for 8 or more days per year (Alley et al., 2010). Hospitalization itself may also pose
risks for functional decline due to the deleterious eects of bed rest and restricted activity
(Gill, Allore, & Guo, 2004). Bed rest results in loss of muscle strength and lean muscle
mass (Kortebein, Ferrando, Lombeida, Wolfe, & Evans, 2007; Kortebein et al., 2008),
decreased aerobic capacity (Kortebein et al., 2008), diminished pulmonary ventilation,
altered sensory awareness, reduced appetite and thirst, and decreased plasma volume
(Creditor, 1993; Harper & Lyles, 1988; Hoenig & Rubenstein, 1991). Brown, Redden,
Flood, and Allman (2009) describe bed rest and low mobility as an “underrecognized
epidemic.” In their study of hospitalized older veterans, they used accelerometers to mea-
sure activity level. Despite the fact that most were able to walk independently (78%),
83% of the measured hospital stay was spent lying in bed (Brown et al., 2009).
Another study (Brown, Friedkin, & Inouye, 2004) that evaluated the outcomes
associated with mobility level found that 66 (83%) were on complete bed rest for at
least 24 hours during hospitalization. Almost 60% of the observations had no docu-
mented medical reason for the bed rest. Physician’s orders for bed rest were present on
the date of bed rest for only 92 (52%) of the 176 observations. Low mobility (dened as
having an average mobility level of bed rest or bed to chair for the entire hospitalization)
Interventions to Prevent Functional Decline in the Acute Care Setting 107
was compared with high mobility (ambulation two or more times with partial or no
assistance, on average). e low mobility group had a statistically signicant higher rate
of ADL decline, new institutionalization, and death. Similarly, Zisberg and colleagues
(2011) found that low versus high in-hospital mobility was associated with worse func-
tional status at discharge and at 1-month follow-up, even in older adults who were
functionally stable prior to admission.
Also indicative of the low priority placed upon mobility promotion is the common
process of restricting the patients’ ability to walk to tests and procedures within the hospi-
tal. Other care processes associated with immobility include physical restraints and “teth-
ering devices” such as catheters, intravenous (IV) lines, and medications that contribute
to delirium and/or cause sedation (Boltz, Capezuti, & Shabbat, 2010; Graf, 2006; King,
2006). Additionally, there is a tendency for sta to perform ADLs for patients that could
participate or do it for themselves, placing older adults at risk for loss of self-care ability
(Boltz, Capezuti, & Shabbat, 2010). is “doing for,” as opposed to promoting functional
independence, is often associated with a lack of understanding of the patient’s underlying
capability. Interdisciplinary rounds support a functional approach, with the goal of pre-
venting functional decline and discharging the older adult to the least restrictive setting
(McVey, Becker, Saltz, Feussner, & Cohen, 1989). Key elements to be addressed include
functional assessment (baseline, admission, and current ADL status, as well as physical
capability), alternatives to the use of potentially restrictive devices and agents, and a plan
for progressive mobility and engagement in ADL (McVey et al., 1989).
Social Climate
Leadership commitment to rehabilitative values is essential to support a social climate con-
ducive to the promotion of function (Boltz, Capezuti, & Shabbat, 2010; Resnick, 2004).
Older adults have identied that respectful, encouraging communication and engagement
in decision making as important to facilitating independence (Boltz, Capezuti, Shabbat, &
Hall, 2010; Jacelon, 2004). Sta education that addresses the physiology, manifestations,
and prevention of hospital-acquired deconditioning; assessment of physical capability;
rehabilitative techniques and use of adaptive equipment; interdisciplinary collaboration;
and communication that motivates are associated with a function-promoting philosophy
(Boltz, Capezuti, & Shabbat, 2010; Jacelon, 2004; Gillis, MacDonald, & MacIsaac, 2008;
Weitzel & Robinson, 2004). Nursing sta have also described the need for well-dened
roles, including areas of accountability for follow-through for function-promoting activi-
ties (Jacelon, 2004; Resnick, et al., 2011). Clear communication of patient needs among
sta and dissemination of data (e.g., compliance with treatment plans and functional
outcomes) also support these activities (Boltz, Capezuti, & Shabbat, 2010).
Policy and Procedure
Policies that clearly dene sta roles in assessing physical function and cognition and
implementing interventions are foundational to implement function-promoting care
(Boltz, Capezuti, & Shabbat, 2010). Additionally, protocols that minimize adverse eects
of selected procedures (e.g., urinary catheterization) and medications (e.g., sedative-
hypnotic agents) contribute to positive functional outcomes (Kleinpell, 2007). Other
supporting policies address identication and storage of sensory devices (e.g., glasses,
hearing aids/ampliers) and mobility and other assistive devices (St. Pierre, 1998).
108 Evidence-Based Geriatric Nursing Protocols for Best Practice
Physical Design
Acute care environments directly impact patient function and physical activity. e bed
is often the only accessible furniture in the room and the height of toilets, beds, and
available chairs does not always fall within the range in which transfers and function
are optimized (Capezuti et al., 2008). Accessible functional seating and safe walking
areas with relevant destination areas promote functional mobility. Adequate lighting,
nonglare ooring, door levers, and hand rails (including in the patient room) are basic
requirements to promote safe mobility (Gulwadi & Calkins, 2008; Ulrich et al., 2008).
Environmental enhancements to promote orientation include large-print calendars and
clocks (Kleinpell, 2007) and control of ambient noise levels, especially in critical care
units (Gabor et al., 2003).
In addition to the environment in general, it is important to consider person–
environment (P–E) t. P–E Fit can be measured using the Housing Enabler instrument
(Iwarsson, 1999), which includes an assessment of the patient’s functional limitations,
dependence on mobility devices, and a detailed assessment of environmental barriers to
engaging in functional activities. Assessments include a focus on the outdoor environ-
ment, entrances, indoor environment, and communication features (e.g., signage) of a
community. For each environmental barrier item, the instrument comprises predened
severity ratings and is scored from 1 (potential accessibility problem) to 4 (very severe
accessibility problem). e assessment of the individuals’ limitations is matched with the
environment and a score calculated using Housing Enabler software. Higher scores are
indicative of a less desirable P–E t. Areas of concern can then be altered to improve the
t between the individual and the environment to optimize function (Iwarsson, 1999).
INTERVENTIONS AND CARE STRATEGIES
Support for Cognition
Cognition and physical function are closely linked in older adults. e ability to engage
in ADL and physical activity requires varying types and degrees of cognitive capability,
including memory, executive function, and visuospatial ability. erefore, an appraisal
of the older adult’s cognition (baseline, admission, and ongoing) is an essential activity
associated with promoting physical function (see Chapter 8, Assessing Cognitive
Function) in order to develop, implement, and evaluate a plan to promote maximum
physical functioning (Coelho, Santos-Galduroz, Gobbi, & Stella, 2009; Yu, Kolanowski,
Strumpf, & Eslinger, 2006).
Interventions to prevent, detect, and manage delirium are associated with improved
cognition and, thus, are integral components of a plan to prevent functional decline (Fore-
man, Wakeeld, Culp, & Milisen, 2001). Liberal visiting hours and familiar items brought
in from home (e.g., photos, blanket) provide meaningful sensory input and along with
control of excessive noise and attention to sleep hygiene enhance function-promoting
interventions (Galik et al., 2008; Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995).
Diversional activities such as TV, movies, and word games are associated with “keeping the
mind active” and engagement in self-care and physical activity (Boltz, Capezuti, Shabbat,
& Hall, 2010). For patients with cognitive challenges, including dementia, activity kits
that include tactile, auditory, and visual items enhance cognitive integration, perceptual
processing, and neuromuscular strength as well as provide solace and an opportunity for
emotional expression and relief of boredom (Kresevic & Holder, 1998). Activity kits can
Interventions to Prevent Functional Decline in the Acute Care Setting 109
include a wide range of items such as audiotapes and nontoxic art supplies. In addition,
items such as pieces of textured fabric, cloth to fold, tools, and key and lock boards,
are included for the person with more advanced dementia (Conedera & Mitchell, 2010;
Glantz & Richman, 2007). For more information, see Chapter 11, Delirium.
Older adults with cognitive impairment can benet from function-promoting
interventions with demonstrated improvements in mood and behavior (Galik et al.,
2008). Galik, Resnick, and Pretzer-Abo (2009), in their work with nursing assistants,
identied critical factors associated with successfully engaging persons with cognitive
impairment in restorative care activities. An understanding of the person’s values, past
experiences, and relationships supports meaningful communication to motivate them,
along with the use of humor and verbal cues. In addition, teamwork with other nursing
sta, rehabilitative sta, medical providers, and families was considered a key compo-
nent in facilitating self-care and physical activity (Galik et al., 2009).
In addition, adapted communication techniques are necessary to accommodate
receptive diculties associated with cognitive impairment, including dementia. e
ability to participate in ADLs is often more preserved than clinicians believe because
activities like washing face, brushing teeth, and walking rely on psychomotor memory
that is preserved even in those with moderate to severe cognitive impairment. Com-
municating with short simple verbal requests and visual cues and modeling the activity
can be helpful in promoting independence in ADLs. (For example, assist the person to
the sink, set them up to brush teeth, hand them tooth brush, and model the behavior;
Galik et al., 2008; Galik et al., 2009.)
Physical Therapy and Exercise
Interventions such as implementation of physical therapy and individualized, targeted
exercise programs as soon as possible postadmission have all been tested as ways in
which to increase physical activity and prevent deconditioning and functional decline in
hospitalized older adults. A single-blinded randomized controlled trial was conducted
in a tertiary metropolitan hospital involving 180 acute general medical patients aged
65 years and older(Jones, Lowe, MacGregor, & Brand, 2006). In addition to usual
physiotherapy care, the intervention group performed an exercise program for 30 min-
utes twice daily, with supervision and assistance provided by an allied health assistant
(AHA). In older adults with low admission ADL scores (modied Barthel Index score
lower than 48), there was improvement in function among individuals exposed to the
exercise interventions versus those who were not (Jones et al., 2006). Similarly, an indi-
vidually tailored exercise program to maintain functional mobility, prescribed and pro-
gressed by a physical therapist and supervised by an AHA, provided in addition to usual
physiotherapy care was associated with reduced likelihood of referral for nursing home
admissions (Nolan & omas, 2008). Despite the known benet of staying engaged in
function and physical activity when hospitalized a 2007 Cochrane review (de Morton,
Keating, & Jes, 2007) concluded that, in general, patient participation in these pro-
grams has been poor. Challenges to feasibility and implementation of these interventions
included competing care demands (e.g., test schedules), illness severity, short hospital
stays, a general unwillingness of patients to consent to or actively participate in exercise
interventions, and a persistent belief among patients that bed rest will assure recovery
(Brown, Peel, Bamman, & Allman, 2006; de Morton, Keating, Berlowitz, Jackson, &
Lim, 2007; de Morton et al., 2007).
110 Evidence-Based Geriatric Nursing Protocols for Best Practice
Functional Mobility Programs
One of the most common forms of physical activity encouraged in acute care settings
are functional mobility programs. Mobility is conceptualized as a continuum pro-
gressing from bedbound to independent walking (Callen, Mahoney, Wells, Enloe, &
Hughes, 2004). e benets of interventions aimed at promoting functional mobility
have recently received growing attention. Tucker, Molsberger, and Clark (2004) dem-
onstrated the feasibility of a “Walking for Wellness” program comprised of a patient
education program, a screening process to identify patients who would benet from
physical therapy daily walking assistance from cross-trained transportation sta. Walk-
ing opportunities included “walking trails” marked inside the hospital, with markers
placed every 10 ft at the baseboard of the hallways provided a measure of walking dis-
tance as well as a visual incentive for patients walking in the halls. Unless otherwise indi-
cated by the medical provider, the goal for participants was to walk in the hallways two
to three times a day with trained escorts, nursing sta, family, or friends. Weitzel and
Robinson (2004) developed an educational program for nursing assistants on a medi-
cal unit that emphasized promoting the functional status of hospitalized older adults.
Content included therapeutic communication, promotion of functional mobility, skin
care, and eating/feeding problems. Discharge destination (home or nursing home) and
length of stay were compared for patients preimplementation and postimplementation.
ere was a signicant reduction on length of stay (2.4 days) and increase in the per-
centage of patients discharged to the home setting (Weitzel & Robinson, 2004).
e positive association between mobility and shorter length of stay was also sup-
ported on the Acute Care for Elderly (ACE) unit, where ambulation was measured by
a step monitor (Fisher et al., 2011). Patients on the ACE unit who had shorter stays
tended to ambulate more on the rst complete day of hospitalization and had a mark-
edly greater increase in mobility on the second day than patients with longer length of
stay. ere were no signicant dierences in mean daily steps according to illness sever-
ity or reason for admission.
To address motivational issues, Mudge and colleagues (2008) evaluated a functional
mobility program enhanced with cognitive interventions. is research team used an
individualized, graduated exercise, and mobility program with an activity diary, progres-
sive encouragement of functional independence by nursing sta and other members of
the multidisciplinary team, and cognitive stimulation sessions in older adults age 70 and
older on a medical unit. e intervention group had greater improvement in functional
status than the control group, with a median modied Barthel Index improvement of
8.5 versus 3.5 points (p 5 .03). In the intervention group, there was a reduction in
delirium (19.4% vs. 35.5%, p 5 .04) and a trend to reduced falls (4.8% vs. 11.3%,
p 5 .19).
In patients recovering from hip surgery, functional mobility programs are enhanced
with measures to prevent postoperative complications. Siu, Penrod, et al. (2006) and Siu,
Boockvar, et al. (2006) found that positive processes related to mobilization (including
time from admission to surgery, mobilization to and beyond the chair, use of anticoagu-
lants and prophylactic antibiotics, pain control, physical therapy, catheter and restraint
use, and active clinical issues) were associated with improved locomotion and self-care
at 2 months postdischarge. Patients who experienced no hospital complications and
no readmissions retained benets in locomotion at 6 months. Olsson, Karlsson, and
Ekman (2007) demonstrated that interventions focused on skin care, pain control, and
progressive ambulation yielded improved functional discharge outcomes.
Interventions to Prevent Functional Decline in the Acute Care Setting 111
Critical Care Initiatives to Prevent Functional Decline
e geriatric imperative to support physical function has also been recognized in criti-
cal care, and studies are emerging that examine mobility promotion in the critically ill
patient, including older adults. A study conducted in a respiratory intensive care unit
(RICU) examined the feasibility of early mobility as well as its safety in six activity-
related adverse events: fall to knees, tube removal, systolic blood pressure higher than
200 mm Hg, systolic blood pressure lower than 90 mm Hg, oxygen desaturation less
than 80%, and extubation. ere were less than 1% activity-related adverse events;
most survivors (69%) were able to ambulate farther than 100 ft at RICU discharges
(Bailey et al., 2007).
Similarly, a mobility team (critical care nurse, nursing assistant, and physical therapist)
in a medical intensive care unit (ICU) initiated a mobility protocol for patients with acute
respiratory failure. e protocol consisted of progressive mobility interventions ranging
from passive range of motion for unconscious patients, to active assistive and active range
of motion exercise, to functional activities such as transfer to edge of bed; safe transfers
to and from bed, chair, or commode; seated balance activities; pregait standing activities
(forward and lateral weight shifting, marching in place); and ambulation. As compared to
usual care (passive range of motion only), protocol patients were out of bed earlier (5 vs.
11 days, p # .001), had therapy initiated more frequently in the ICU (91% vs. 13%, p #
.001), and had similar low complication rates. For protocol patients, ICU length of stay
was 5.5 vs. 6.9 days for usual care (p 5 .025); hospital length of stay for protocol patients
was 11.2 versus 14.5 days for usual care (p 5 .006). (e ICU/hospital length of stay
adjusted for body mass index, Acute Physiology, and Chronic Health Evaluation II, and
use of a vasopressor.) ere were no adverse events during an ICU mobility session and no
cost dierence between the protocol and usual care costs (Morris et al., 2008).
Function-Focused Care: A Multimodal Intervention
Function-focused care (FFC) is a comprehensive, system–level approach that priori-
tizes the preservation and restoration of functional capability. It is predicated on the
philosophy that physical function is as important a treatment goal as correcting the
acute admitting problem and recognizing the multifactorial nature of functional decline
(Jacelon, 2004). FFC, previously referred to as restorative care from its use in long-term
care (Resnick, Gruber-Baldini, et al., 2009; Resnick & Simpson, 2003; Resnick, Rogers,
Galik, & Gruber-Baldini, 2007), uses a philosophy of care in which nurses acknowledge
older adults’ physical and cognitive capabilities with regard to function and integrate
functional and physical activities into all care interactions. e components of FFC are
n assessment of Environment and Policy/Procedures for Function and Physical
Activity;
n education of nursing sta and other members of the interdisciplinary team
(e.g., social work, physical therapy) on rehabilitative techniques (Resnick, Cayo,
Galik, & Pretzer-Abo, 2009);
n education of patients and families regarding FFC;
n establishing FFC goals, including discharge goals based on capability assess-
ments, communication with other members of the team (e.g., medicine, physi-
cal therapy), and input from patients;
n addressing risk factors that impact goal achievement (e. g., cognitive status, ane-
mia, nutritional status, pain, fear of falling, fatigue, medications and drug side
112 Evidence-Based Geriatric Nursing Protocols for Best Practice
eects such as somnolence) by the interdisciplinary team to optimize patient
participation in functional and physical activity; and
n mentoring and motivating provided by a nurse change agent (e.g., geriatric
resource nurse) using theoretically based interventions for monitoring and moti-
vating the nursing sta to provide FFC and thereby help the nurses to motivate
patients to engage in functional and physical activity.
When implemented in long-term care settings, FFC interventions increased nursing
knowledge of beliefs in and observed performance of FFC and resulted in improvements in
function (ambulation, gait, and balance) and physical activity in nursing home and assisted-
living residents and decreased transfers from nursing homes to acute care settings (Resnick,
Gruber-Baldini, et al., 2009; Resnick & Simpson, 2003; Resnick et al., 2007). Addition-
ally, Resnick and colleagues (2011) demonstrated that nurses were willing to be engaged
in a FFC educational intervention on medical–surgical units and showed improvements
in knowledge and outcome expectations associated with FFC. FFC interactions between
patient and nurses have also demonstrated an association with a decrease in the overall loss
of ADL function from baseline to discharge (Boyd, Capezuti, & Shabbat, in press).
TS is an 80-year-old man who was admitted from an assisted living to the Emergency
Department after he was found on the oor. His workup is negative for fractures and
head trauma. His admitting diagnoses include pneumonia, anemia, and dehydration.
His past medical history, per his daughter’s report, is remarkable for mild hyperten-
sion, treated with hydrochlorothiazide (HCTZ) and captopril, and dementia. Upon
admission to the oor, TS was somnolent but able to respond to his name. He is
receiving IV antibiotics and hydration. e IV site is “camouaged” with kling and
covered with his sweater so as to not cue him to remove it.
e admitting nurse learns from TS’s daughter and the sta at the assisted-living
facility that TS’s normal or baseline function is that he is independent in ambulation, con-
tinent, (although at times has trouble waynding), and needs verbal cues (“prompting”)
to get dressed and bathe. After hydration, TS becomes more alert. He is able to respond
to one-step commands and is moving all extremities, with good range of motion. e
interdisciplinary team makes rounds that afternoon and develops the following plan:
n Monitor confusion assessment method (CAM) and mental status when able to
respond
nDaughter to bring in familiar robe, shoes, and family photo; she also plans to
complete social prole “all about me” to be shared with hospital sta.
n Glasses were labeled with his name and placed on TS.
nNo restraints; adjustable height low bed, in low position, then adjusted to
lower leg length to promote safe transfers.
nSwitch to oral antibiotics; cap IV when able to take sucient uids by mouth.
n Assist out of bed for meals, starting that evening.
nIn AM, attempt to ambulate to bathroom; not to be left unattended. Ambulate
as tolerated in room, progress to hallway ambulation three times a day.
CASE STUDY
(continued)
Interventions to Prevent Functional Decline in the Acute Care Setting 113
SUMMARY
Hospitalization poses many challenges to the functional health of older adults. How-
ever, functional decline is not inevitable. Interventions formerly perceived to be relevant
only for the rehabilitation setting are slowly being recognized as integral to the care and
treatment of the older adult in the acute setting. Function-focused care employs nurs-
ing care practices that acknowledge the older person’s capabilities and potential while
positively modifying the care environment to prevent avoidable functional decline.
n Pressure reducing mattress.
n Assist, cue, and redirect as needed during meal; monitor for aspiration.
n Encourage self-care during bathing; cue as needed.
n Anemia workup.
nPlan to discharge back to assisted living at baseline level of function; estimated
discharge in 48–72 hours.
Discussion
e case study demonstrates decision making that recognizes the potential of TS
to return to his baseline physical function. e interdisciplinary team implements
measures to correct his delirium and prevent avoidable complications (falls and pres-
sure ulcers) that could negatively impact his function. e plan to promote physical
activity and independence in ADL is adapted to his cognitive impairment. His daugh-
ter is engaged in his care and the nurse leverages this support to benet TS.
Protocol 7.1: Function-Focused Care (FFC) Interventions
I. GOAL: e following protocol has been designed to help nurses collaborate with
the interdisciplinary team to implement interventions that maximize the older adult’s
functional abilities and performance. is protocol can be used in combination with
Chapter 6, Assessment of Physical Function.
II. OBJECTIVE: As stated in Chapter 3, to restore or maximize physical functioning,
prevent or minimize decline in ADL function, and plan for transitions of care.
III. BACKGROUND
A. Functional decline is a common complication in hospitalized older adults, even
in those with good baseline function (Gill et al., 2010).
NURSING STANDARD OF PRACTICE
(continued)
CASE STUDY (continued)
114 Evidence-Based Geriatric Nursing Protocols for Best Practice
B. Loss of physical function is associated with poor long-term outcomes, includ-
ing increased likelihood of being discharged to a nursing home setting (Fortin-
sky et al., 1999), increased mortality (Boyd et al., 2005; Rozzini et al, 2005),
increased rehabilitation costs, and decreased functional recovery (Boyd et al.,
2008; Boyd et al., 2005; Gill et al., 2004; Volpato et al., 2007). e immobility
associated with functional decline results in infections, pressure ulcers, falls, a
persistent decline in function and physical activity, and nonelective rehospital-
izations (Gill et al., 2004).
C. Functional decline may result from the acute illness and can begin preadmis-
sion (Fortinsky et al., 1999) and continue after discharge (Sager et al., 1996).
Baseline function serves as a useful benchmark when developing discharge goals
(Covinsky et al., 2003; Fortinsky et al., 1999; Sager et al., 1996; Wakeeld &
Holman, 2007).
D. Patient risk factors for functional decline include prehospitalization functional
loss; the presence of two or more comorbidities; taking ve or more prescrip-
tion medications; having had a hospitalization or emergency room visit in the
previous 12 months (McCusker et al., 2002); depression (Covinsky et al., 1997);
impaired cognition, including delirium (Inouye et al., 1999; Narain et al., 1988);
pain (Reid et al., 2005); nutritional problems; adverse medication eects (Graf,
2006); fear of falling (Boltz, Capezuti, & Shabbat, 2010); low self-ecacy and
outcome expectations (McAuley et al., 2006; Resnick, 2002); and attitudes
toward functional independence and views on hospitalization (Boyd, Capezuti,
& Shabbat, 2010; Boltz, Capezuti, Shabbat, & Hall, 2010; Brown et al., 2007).
E. Bed rest results in loss of muscle strength and lean muscle mass (Kortebein et
al., 2007; Kortebein et al., 2008), decreased aerobic capacity (Kortebein et al.,
2008), diminished pulmonary ventilation, altered sensory awareness, reduced
appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper et
al., 1988; Hoenig & Rubenstein, 1991). Care processes that curtail mobility
such as the use of restraints and tethering devices (Boltz, Capezuti, & Shabbat,
2010; Graf, 2006; King, 2006) are associated with low mobility, higher rate of
ADL decline (Brown et al, 2004; Zisberg et al., 2011), new institutionaliza-
tion, and death (Brown et al., 2004).
F. Interdisciplinary rounds support promotion of function by addressing func-
tional assessment (baseline and current), evaluate potentially restrictive devices
and agents, and yield a plan for progressive mobility (McVey et al., 1989).
G. Leadership commitment to rehabilitative values is essential to support a social
climate conducive to the promotion of function (Boltz, Capezuti, & Shabbat,
2010; Resnick, 2004).
H. FFC educational intervention on medical–surgical units have shown improve-
ments in knowledge and outcome expectations associated with function-
promoting care (Resnick et al., 2011).
IV. FUNCTION-FOCUSED CARE INTERVENTIONS
A. Hospital care systems and processes
1. Evaluation of leadership commitment to rehabilitative values (Boltz, Cap-
ezuti, & Shabbat, 2010; Resnick, 2004).
(continued)
Protocol 7.1: Function-Focused Care (FFC) Interventions (cont.)
Interventions to Prevent Functional Decline in the Acute Care Setting 115
2. Interdisciplinary rounds that address functional assessment (baseline and
current), evaluate potentially restrictive devices and agents, and yield a plan
for progressive mobility (McVey et al., 1989).
3. Well-dened roles, including areas of accountability for assessment and
follow-through for function-promoting activities (Jacelon, 2004; Resnick
et al., 2011).
4. Method of evaluating communication of patient needs among sta (Boyd,
Capezuti, & Shabbat, 2010).
5. Process of disseminating data (e.g., compliance with treatment plans and
functional outcomes; Boyd, Capezuti, & Shabbat, 2010).
B. Policy and procedures to support function promotion
1. Protocols that minimize adverse eects of selected procedures (e.g., urinary
catheterization) and medications (e.g., sedative-hypnotic agents) contribute
to positive functional outcomes (Kleinpell, 2007).
2. Supporting policies: identication and storage of sensory (e.g., glasses, hear-
ing aids/ampliers) and mobility devices and other assistive devices (Boyd,
Capezuti, & Shabbat, 2010; St. Pierre, 1998).
3. Discharge policies that address the continuous plan for function promo-
tion (Boyd, Capezuti, & Shabbat, 2010; Boyd, Capezuti, Shabbat, & Hall,
2010)
C. Physical design
1. Toilets, beds, and chairs at appropriate height to promote safe transfers and
function (Capezuti et al., 2008).
2. Functional and accessible furniture and safe walking areas with relevant/
interesting destination areas (Gulwadi & Calkins, 2008; Ulrich et al., 2008)
and with distance markers (Callen et al., 2004).
3. Adequate lighting, nonglare ooring, door levers, and hand rails (including
in the patient room; Gulwadi & Calkins, 2008; Ulrich et al., 2008).
4. Large-print calendars and clocks to promote orientation (Kleinpell, 2007).
5. Control of ambient noise levels (Gabor et al., 2003).
D. Education of nursing sta, and other members of the interdisciplinary team
(e.g., social work, physical therapy), regarding
1. the physiology, manifestations, and prevention of hospital-acquired decon-
ditioning (Boyd, Capezuti, & Shabbat, 2010; Gillis et al., 2008; Resnick
et al., 2011; Weitzel & Robinson, 2004);
2. assessment of physical capability (Resnick, Cayo et al., 2009; Resnick et al.,
2011);
3. rehabilitative techniques and use of adaptive equipment (Weitzel & Robin-
son, 2004; Resnick et al., 2011; Resnick, Cayo et al., 2009);
4. interdisciplinary collaboration (Resnick et al., 2011; Resnick, Cayo et al.,
2009);
5. engagement in decision making (Boltz, Capezuti, & Shabbat, 2010; Boltz,
Capezuti, Shabbat, & Hall, 2010; Jacelon, 2004); and
6. communication that motivates are associated with a function- promoting
philosophy (Boltz, Capezuti, & Shabbat, 2010; Gillis et al., 2008; Jacelon,
2004; Weitzel & Robinson, 2004).
(continued)
Protocol 7.1: Function-Focused Care (FFC) Interventions (cont.)
116 Evidence-Based Geriatric Nursing Protocols for Best Practice
E. Education of patients and families regarding FFC (Resnick, Cayo, et al., 2009),
including the benets of FFC, the safe use of equipment, and self-advocacy
(Boltz, Capezuti, Shabbat & Hall, 2010)
F. Clinical Assessment and interventions
1. Assessment of physical function and capability (baseline, at admission and
daily) and cognition (at a minimum daily; Boltz, Capezuti, & Shabbat,
2010; Covinsky et al., 2003; Fortinsky et al., 1999; Sager et al., 1996;
Wakeeld & Holman, 2007).
2. Establishing functional goals based on assessments and communication
with other members of the team and input from patients (Resnick, Cayo,
et al., 2009; Resnick et al., 2011; Resnick, Gruber-Baldini, et al., 2009;
Resnick et al., 2007; Resnick & Simpson, 2003).
3. Social assessment: history, roles, values, living situation, and methods of
coping (Boltz, Capezuti, & Shabbat, 2010; Boltz, Capezuti, Shabbat, &
Hall, 2010).
4. Addressing risk factors that impact goal achievement (e. g., cognitive status,
anemia, nutritional status, pain, fear of falling, fatigue, medications and
drug side eects such as somnolence) by the interdisciplinary team to opti-
mize patient participation in functional and physical activity (Boltz et al.,
in press; Resnick, Cayo, et al., 2009; Resnick et al., 2011; Resnick, Gruber-
Baldini, et al., 2009; Resnick et al., 2007; Resnick & Simpson, 2003).
5. Development of discharge plans that include carryover of functional inter-
ventions, and addressing the unique preferences and needs of the patient
(Nolan & omas, 2008).
V. EXPECTED OUTCOMES
A. Patients will
1. Be discharged, functioning at their maximum level.
B. Providers can demonstrate
1. Competence in assessing physical function and devloping an individualized
plan to promote function, in collaboration with the patient and interdisci-
plinary team.
2. Physical and social environments that enable optimal physical function for
older adults.
3. Individualized discharge plans.
C. Institution will experience
1. A reduction in incidence and prevalence of functional decline.
2. Reduction in the use of physical restraints, prolonged bed rest, Foley cath-
eters.
3. Decreased incidence of delirium and other advserse events (pressure ulcers
and falls).
4. An increase in prevalence of patients who leave hospital at their baseline or
with improved functional status.
5. Physical environments that are safe and enabling.
6. Increased patient satisfaction.
7. Enhanced sta satisfaction and teamwork.
(continued)
Protocol 7.1: Function-Focused Care (FFC) Interventions (cont.)
Interventions to Prevent Functional Decline in the Acute Care Setting 117
VI. RELEVANT PRACTICE GUIDELINES
Several resources are now available to guide adoption of evidence-based nursing
interventions to enhance function in older adults.
1. Agency for Healthcare Research and Quality, National Guideline Clearing-
house; http://www.guideline.gov/
2. McGill University Health Centre. Research & Clinical Resources for Evi-
dence Based Nursing (EBN); http://www.muhc-ebn.mcgill.ca/
3. National Quality Forum; http://www.qualityforum.org/Home.aspx
4. Registered Nurses Association of Ontario. Clinical Practice Guidelines Pro-
gram; http://www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL
_ExpandID
5. University of Iowa Hartford Center of Geriatric Nursing Excellence (HCGNE).
Evidence-Based Practice Guidelines; http://www.nursing.uiowa.edu/hartford/
nurse/ebp.htm
Protocol 7.1: Function-Focused Care (FFC) Interventions (cont.)
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122
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. discuss the importance of assessing cognitive function
2. describe the goals of assessing cognitive function
3. compare and contrast the clinical features of delirium, dementia, and depression
4. incorporate the assessment of cognitive function into daily practice
OVERVIEW
Cognitive functioning comprises perception, memory, and thinking—the pro-
cesses by which a person perceives, recognizes, registers, stores, and uses infor-
mation ( Foreman & Vermeersch, 2004). Cognitive functioning can be affected,
positively and negatively, by illness and its treatment. Consequently, assessing an
individual’s cognitive functioning is paramount for identifying the presence of spe-
cific pathological conditions, such as dementia and delirium, for monitoring the
effectiveness of various health interventions, and for determining an individual’s
readiness to learn and ability to make decisions (Foreman & Vermeersch, 2004).
Despite the importance of assessing cognitive functioning, physicians and nurses
routinely fail to assess an individual’s cognitive functioning (Foreman & Milisen,
2004). This failure to assess cognitive functioning has profoundly serious conse-
quences that include the failure to detect a potentially correctable condition of
cognitive impairment and death (Inouye, Foreman, Mion, Katz, & Cooney, 2001)
and outcomes that could be prevented or minimized by early recognition of their
existence afforded by the routine assessment of cognitive functioning (Foreman &
Milisen, 2004).
Koen Milisen, Tom Braes, and Marquis D. Foreman
8
Assessing Cognitive Function
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Assessing Cognitive Function 123
BACKGROUND AND STATEMENT OF PROBLEM
Declines in cognitive functioning are a hallmark of aging (McEvoy, 2001); however,
most declines in cognition with aging are not pathological. Examples of nonpatho-
logical changes include a diminished ability to learn complex information, a delayed
response time, and minor loss of recent memory; declines are especially evident with
complex tasks or with those requiring multiple steps for completion (McEvoy, 2001).
Pathological conditions of cognitive impairment that are prevalent with aging include
delirium, dementia, and depression (please see Table 8.1 for a comparison of the clinical fea-
tures and also refer to the respective chapters, Chapter 9, Depression, Chapter 10, Dementia,
and Chapter 11, Delirium). ere are protocols to prevent and treat delirium, and protocols
to slow the progression of decline with dementia (Protocol 8.1; however, these opportuni-
ties exist only when and if these conditions are detected early, and the possibility of early
detection exists only when cognitive function is assessed systematically (Chow & MacLean,
2001; Registered Nurse Association of Ontario, 2003). Without systematic assessment, these
pathological conditions go unchecked, and the individuals with these conditions face much
greater accelerated and long-term cognitive and functional decline and death (Fick, Agostini,
& Inouye, 2002; Fick & Foreman, 2000; Hopkins & Jackson, 2006; Lang et al., 2006).
Despite these profoundly negative consequences, nurses and physicians fail to access
cognitive function (Ely et al., 2004; Foreman & Milisen, 2004; Inouye et al., 2001). Yet,
it is clear that the assessment of cognitive function is the rst and most crucial step in a
cascade of strategies to prevent, reverse, halt, or minimize cognitive decline (Chow &
MacLean, 2001; Registered Nurse Association of Ontario, 2003).
ASSESSMENT OF THE PROBLEM
Reasons for Assessing Cognitive Functioning
ere are several reasons for assessing an individual’s cognitive functioning:
Screening is conducted to determine the presence or absence of impairment. Bedside
screening methods, however, are not useful in and of themselves for diagnosing specic
pathological conditions of impairment such as delirium or dementia. Screening is also
an important element in determining an individual’s readiness to learn, and capacity to
consent (Shekelle, MacLean, Morton, & Wenger, 2001). As a result, screening activities
enable the early detection of impairment that aords the opportunity to determine the
nature of the impairment. at is, is the impairment delirium, dementia, or depression,
or possibly one superimposed upon another? Only through early detection can treatment
be initiated promptly and accurately to either reverse, halt, or slow the progression of
impairment (Chow & MacLean, 2001; Registered Nurse Association of Ontario, 2003).
Monitoring is conducted to track cognitive function over time as a means for fol-
lowing the progression or regression of impairment especially in response to treatment
(Registered Nurse Association of Ontario, 2003; Shekelle et al., 2001).
How to Assess Cognitive Functioning
For assessing cognitive functioning, Folstein’s Mini-Mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975) is the most frequently recommended instrument
(British Geriatrics Society Clinical Guidelines, 2005; Fletcher, 2007; Registered Nurse
Association of Ontario, 2003). e MMSE is a brief instrument, consisting of 11 items
124 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 8.1
A Comparison of the Clinical Features of Delirium, Dementia, and Depression
Clinical Feature Delirium Dementia Depression
Onset Sudden/abrupt; depends on
cause; often at twilight
Insidious/slow and often
unrecognized; depends on
cause
Coincides with major life
changes; often abrupt, but
can be gradual
Course Short; diurnal fluctuations in
symptoms; worse at night, in
darkness, and on awakening
Long, no diurnal effects,
symptoms progressive
yet relatively stable over
time, may see deficits
with increased stress
Diurnal effects, typically
worse in the morning;
situational fluctuations in
symptoms, but less than with
delirium
Progression Abrupt Slow but uneven Variable; rapid or slow but
generally even
Duration Hours to less than 1 month;
longer if unrecognized and
untreated
Months to years At least 6 weeks, can be
several months to years
Consciousness Disturbed Clear Clear
Alertness Fluctuates from stuporous to
hypervigilant
Generally normal Normal
Attention Inattentive, easily distractible
and may have difficulty
shifting attention from one
focus to another
Generally normal Minimal impairment, but is
distractible
Orientation Generally impaired; disoriented
to time and place, should not be
disoriented to person
Generally normal Selective disorientation
Memory Recent and immediate
impaired; unable to recall
events of hospitalization
and current illness, forgetful,
unable to recall instructions
Recent and remote
impaired
Selective or “patchy”
impairment, “islands” of intact
memory, evaluation often
difficult due to low motivation
Thinking Disorganized; rambling,
irrelevant and incoherent
conversation; unclear or illogi-
cal flow of ideas
Difficulty with abstraction,
thoughts impoverished;
judgment impaired; words
difficult to find
Intact but with themes of
hopelessness, helplessness,
or self-deprecation
Perception Perceptual disturbances
such as illusions and visual
and auditory hallucinations;
misperceptions of common
people and objects common
Misperceptions usually
absent
Intact; delusions and
hallucinations absent except
in severe cases
Psychomotor
behavior
Variable; hypoactive,
hyperactive, and mixed
Normal, may have apraxia Variable; psychomotor
retardation or agitation
Associated
features
Variable affective changes;
symptoms of autonomic hypo-
hyperarousal
Affect tends to be
superficial, inappropriate,
and labile; attempts to
conceal deficits in intellect;
personality changes,
aphasia, agnosia may be
present; lacks insight
Affect depressed; dysphoric
mood, exaggerated and
detailed complaints;
preoccupied with personal
thoughts; insight present;
verbal elaboration; somatic
complaints, poor hygiene,
and neglect of self
Assessment Distracted from task;
fails to remember
instructions, frequent
errors without notice
Failings highlighted by
family, frequent “near
miss” answers, struggles
with test, great effort to
find an appropriate reply,
frequent requests for
feedback on performance
Failings highlighted by
individual; frequent “don’t
know” answers, little
effort; frequently gives up;
indifferent toward test: does
not care or attempt to find
answer
Assessing Cognitive Function 125
and taking about 7–10 minutes to complete. It is composed of items assessing orien-
tation, attention, memory, concentration, language, and constructional ability (Tom-
baugh & McIntyre, 1992). Each question is scored as either correct or incorrect; the
total score ranges from 0 to 30 and reects the number of correct responses. A score less
than 24 is considered evidence of impaired cognition (Tombaugh & McIntyre, 1992).
Although considered the best available method for screening for impairment, the
performance on the MMSE is signicantly inuenced by education (individuals with
less than an 8th grade education commit more errors), language (individuals for whom
English is not their primary language commit more errors) and verbal ability (the
MMSE can only be used with individuals who can respond verbally to questioning),
and age (older people do less well; Tombaugh & McIntyre, 1992). Others contend that
the MMSE takes too long to administer in hectic, fast-paced health care environments
(e.g., more than 10 minutes; Borson, Scanlan, Watanabe, Tu, & Lessiq, 2005).
To minimize the limitations of the MMSE while maximizing practical aspects of assess-
ing cognitive function, the Mini-Cog was developed (Borson, Scanlan, Brush, Vitaliano,
& Dokmak, 2000). e aim was to have a brief screening test that required no equip-
ment and little training to use while not being negatively inuenced by age, education, or
language (Borson, Scanlan, Brush, et al., 2000; Borson, Scanlan, Watanabe, et al., 2005).
e Mini-Cog is a four-item screening test consisting of three-item recall similar to the
MMSE, and a clock-drawing item (e.g., draw the face of a clock, number the clock face,
and place the hands on the clock face to indicate a specic time such as 11:10).
Since its initial development in 2000, the Mini-Cog has been used with various samples
of people from dierent cultural, educational, age, and language backgrounds. In a recent
systematic review, it was reported that the Mini-Cog was suitable for the routine screening
for cognitive impairment (Brodaty, Low, Gibson, & Burns, 2006) and, even more recently,
was found to predict the development of in-hospital delirium (Alagiakrishnan et al., 2007).
Another brief cognitive assessment tool (e Sweet 16) has recently been developed
to address the aforementioned limitations of the MMSE. It is reported to be an easy-
to-use instrument that can be completed in 2–3 minutes. In contrast to MMSE and
Mini-Cog, it requires no pen, paper, or props to administer. It may be, therefore, more
appropriate in frail older patients admitted to an acute hospital setting in which ability
to write and manipulate props may be limited for reasons other than cognitive impair-
ment (IV tubing, positioning in bed, etc.). Initial validation of the Sweet 16 indicates
its performance to be equivalent or superior to that of the MMSE; however, much more
research is needed to further validate the Sweet 16 (Fong et al., 2010).
With respect to MMSE, Mini-Cog, and Sweet 16, they are classied as simple
bedside cognitive screens. is means that they are all qualied for determining the
presence or absence of cognitive impairment; however, none are capable of determining
if the impairment is delirium, dementia, or depression. If the results of this cognitive
assessment or screening indicate the individuals to be impaired, further in-depth evalua-
tion is necessary to conrm a diagnosis of dementia, depression, delirium, or some other
health problem (see Chapter 10, Dementia, and Chapter 11, Delirium).
INTERVENTIONS AND CARE STRATEGIES
When to Assess Cognitive Functioning
When and how frequently to assess cognitive functioning, either using the MMSE, Mini-
Cog, or Sweet 16, is in part a function of the purpose for the assessment, the condition of
126 Evidence-Based Geriatric Nursing Protocols for Best Practice
the patient, and the results of prior or current testing. Recommendations for the systematic
assessment of cognition using standardized and validated tools include on admission to and
discharge from an institutional care setting (British Geriatrics Society Clinical Guidelines,
2005; Shekelle et al., 2001); upon transfer from one care setting to another (Shekelle et al.,
2001); during hospitalization, every 8–12 hours throughout hospitalization (http://www.
mc.vanderbilt.edu/icudelirium/); as follow-up to hospital care, within 6 weeks of discharge
(Shekelle et al., 2001); before making important health care decisions as an adjunct to deter-
mining an individual’s capacity to consent; on the rst visit to a new care provider; following
major changes in pharmacotherapy (Shekelle et al., 2001); and with behavior that is unusual
for the individual and/or inappropriate to the situation (Foreman & Vermeersch, 2004).
It is also recommended that formal cognitive testing be supplemented with infor-
mation from close intimate others (Cole et al., 2002; Registered Nurse Association of
Ontario, 2003) and from naturally occurring observations and conversations (Foreman,
Fletcher, Mion, & Trygslad, 2003). One method for obtaining information from intimate
others (Cole et al., 2002) is through the use of the Informant Questionnaire on Cogni-
tive Decline in the Elderly (IQCDE; Jorm, 1994). Obtaining information from intimate
others about an individual’s cognitive functioning assists in determining the duration of
impairment necessary for determining whether the impairment is delirium or dementia
(see Chapter 10, Dementia, and Chapter 11, Delirium). Whereas naturally occurring
observations and conversations during everyday nursing care activities in which it becomes
apparent that the individual is inattentive, and responding unusually or inappropriately to
conversation or questioning may be the rst indication of the need to formally assess the
individual’s cognitive functioning by using one of the aforementioned instruments. How-
ever, formal assessment is not always possible (e.g., patient is too sick for formal testing).
In contrast with formal testing, naturally occurring observations are based on daily and
routine contacts with the patient (e.g., during bathing, feeding, transferring the patient)
in a natural setting (e.g., not in a formal test setting). One criticism of naturally occur-
ring observations (Persoon, 2010) is that they lack standardization. Since well-validated
observation scales are scarce and cognitive functioning is often assessed in a limited way
by these instruments, Persoon and colleagues recently developed and validated the new
Nurses’ Observation Scale for Cognitive Abilities (NOSCA; Persoon, 2010). By using
this instrument, nurses can easily—and in a nonthreatening way—evaluate the patients’
cognitive functioning in a comprehensive way (e.g., consciousness, attention, perception,
orientation, memory, thoughts, higher cognitive functioning, language, and praxis).
Cautions for Assessing Cognitive Functioning
Various characteristics of the physical environment should be considered to ensure that
the results of the cognitive assessment accurately reect the individual’s abilities and not
extraneous factors. Overall, the ideal assessment environment should maximize the com-
fort and privacy of both the assessor and the individual. e environment should enhance
performance by maximizing the individual’s ability to participate in the assessment pro-
cess (Dellasega, 1998). To accomplish this, the room should be well lit and of comfort-
able ambient temperature. Lighting must be balanced to be sucient for the individual
to see adequately the examination materials, while not being so bright that it creates glare.
Additionally, the environment should be free from distractions that can result from extra-
neous noise, scattered assessment materials, or brightly colored and/or patterned clothing
and ashy jewelry on the assessor (Lezak, Howieson, & Loring, 2004).
Assessing Cognitive Function 127
It will be vital to prepare the individual for the assessment, explaining what will
take place and how long it will take, this way reducing anxiety and creating an emotion-
ally nonthreatening environment and a safe individual–assessor relationship (Engberg
& McDowell, 2000). Performing the assessment in the presence of others should be
avoided when possible because the other individual may be distracting. If the other is
a signicant intimate relative, additional problems may arise. For example, when the
individual fails to respond or responds in error, signicant others have been known to
provide the answer, or to say such things as “Now, you know the answer to that,” or
“Now, you know that’s wrong.” In most instances, the presence of another only height-
ens anxiety. Rarely does the presence of another facilitate the performance of an individ-
ual on cognitive assessment. Older adults are especially sensitive to any insinuation that
they may have some “memory problem”; therefore, the dilemma for the assessor is to
stress the importance of the assessment while taking care not to increase the individual’s
anxiety. Further, it can be counterproductive to describe the assessment as consisting of
“simple,” “silly,” or “stupid” questions. Such explanations tend to diminish motivation
to perform and only heighten anxiety when errors are committed.
e assessment can be perceived by the individual as intrusive, intimidating, fatigu-
ing, and oensive—characteristics that can seriously and negatively aect performance.
Consequently, Lezak et al., 2004 recommends an initial period to establish rapport with
the individual. is period also allows a determination of the individual’s capacity for
assessment. For example, do conditions exist that could alter the performance of the
individual or interpretation of results such as sensory decrements? As a consequence,
the assessor can alter the testing environment through simple methods (e.g., by taking a
position across from the individual or a little to the side). In this position, the individual
can readily use the assessor’s nonverbal communication as well as read the assessor’s lips.
Positioning also is important relative to lighting and glare.
Finally, avoid assessment periods immediately upon awakening from sleep (wait
at least 30 minutes); immediately before and after meals, medical diagnostic, or thera-
peutic procedures; and when the individual is in pain or is uncomfortable (Foreman
et al., 2003).
Mrs. O is a 79-year-old retired nurse who lives at home with her husband who is phys-
ically frail. Mrs. O was diagnosed with probable Alzheimer’s disease approximately
3 years ago. In addition, she has Type II diabetes that is generally well controlled
on Actoplus (pioglitazone hydrochloride and metformin hydrochloride). She and her
husband are able to remain living in their own home with help from their children,
neighbors, friends, and a monthly visit from a home health nurse. Mrs. O. is quite
mobile but recently has begun to wander at times. Her husband reports that she seems
more confused in the past few days and has fallen twice since yesterday. ere is evi-
dence of minor physical injury, which Mrs. O insists is “nothing.” Her husband is also
concerned that she has not been taking her Actoplus as prescribed; although she has
been eating okay, but she has not been drinking enough. Because of these concerns,
CASE STUDY
(continued)
128 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
e determination of an individual’s cognitive status is critical in the process and out-
comes of illness and its treatment. Being competent in the assessment of cognitive
functioning requires (a) knowledge and skill as they relate to the performance of the
assessment of cognitive functioning, (b) sensitivity to the issues that can negatively bias
the results and interpretation of this assessment, (c) accurate and comprehensive docu-
mentation of the assessment, and (d) the incorporation of the results of the assessment
in the development of the individual’s plan of care.
he calls the home health nurse to come and evaluate the situation. Mr. O’s concerns
are real and the call to the home health nurse is appropriate.
When the nurse arrives, she assesses Mrs. O, including her cognitive functioning.
e results of her assessment indicate that Mrs. O’s cognitive functioning has deterio-
rated signicantly in the past. Mrs. O is more disoriented to time and place, more eas-
ily distracted, her conversation is disorganized, and she has greater diculty following
commands and remembering simple objects. In talking with the husband, the nurse
learns that these changes occurred in the past 2 days. e nurse suspects delirium as
evidenced by the sudden and dramatic decline in Mrs. O’s cognitive abilities. e
nurse thinks that Mrs. O may be severely dehydrated because her diabetes is no lon-
ger controlled, and is concerned about impending hyperosmolar, nonketotic coma.
e nurse seeks an emergency admission to the local hospital for further diagnostic
workup to determine the cause for her suspected delirium; is she hyperglycemic and
dehydrated? (e nurse’s suspected diagnosis is certainly a health emergency warrant-
ing further diagnostic workup to conrm a diagnosis of delirium and the identica-
tion of the underlying causes.)
Mrs. O is admitted with a diagnosis of mental status changes, and is described by
the hospital nurse as “cooperative, lying quietly in bed, but being slow to respond”—
changes the nurse attributes to merely a worsening of her dementia and nothing new.
e hospital nurse moves on to more “important” patient care concerns. A couple
of hours later, the nurse goes back to check on Mrs. O only to nd her obtunded,
unresponsive to physical stimuli, hypotensive, and tachycardic. e nurse calls a code,
but Mrs. O fails to respond and dies. (What went wrong here? It is likely that the
assessment performed by the home health nurse was not transmitted to the nurse in
the hospital. us, vital information was missing, and the nurse in the hospital was
working at a disadvantage.) In addition, it is not uncommon for health care providers
to assume because an older person is “confused,” that this confusion is either a result
of their age or an exacerbation of their underlying dementia or both (Fick & Foreman,
2000). However, this is an erroneous assumption, and in this case dangerous as the
undetected worsening of Mrs. O’s cognitive impairment resulted in lack of treatment
of the underlying hyperglycemia and severe dehydration leading to her eventual death.
e cascade of mortal events could have been prevented with detection of the impair-
ment, diagnosis of delirium, and prompt treatment of the underlying cause.
CASE STUDY (continued)
Assessing Cognitive Function 129
Protocol 8.1: Assessing Cognitive Functioning
I. GOAL: e goals of cognitive assessment include:
A. To determine an individual’s cognitive abilities.
B. To recognize early the presence of an impairment in cognitive functioning.
C. To monitor an individual’s cognitive response to various treatments.
II. OVERVIEW
A. Undetected impairment in cognition is associated with greater morbidity and
mortality (Inouye et al., 2001).
B. Assessing cognitive function is the foundation for early detection and prompt
treatment of impairment (Shekelle et al., 2001).
III. BACKGROUND AND STATEMENT OF PROBLEM
A. Denition of cognitive functioning includes the processes by which an indi-
vidual perceives, registers, sores, retrieves, and uses information.
B. Conditions in which cognitive functioning is impaired:
1. Dementia (e.g., Alzheimer’s or vascular) is a syndrome of cognitive dete-
rioration that involves memory impairment and a disturbance in at least
one other cognitive function (e.g., aphasia, apraxia, or agnosia that result
in changes in function and behavior; American Psychiatric Association,
2000).
2. Delirium is a disturbance of consciousness with impaired attention and
disorganized thinking that develops rapidly. Evidence of an underlying
physiologic or medical condition is generally present (American Psychiatric
Association, 2000).
3. Depression is a syndrome of either depressed mood or loss of interest or
pleasure in most activities of the day; these symptoms represent a change
from usual functioning for the individual and have been present for at least
2 weeks (American Psychiatric Association, 2000).
IV. ASSESSMENT OF COGNITIVE FUNCTION
A. Reasons/Purposes of Assessment
1. Screening: to determine the absence or presence of impairment ( Foreman
et al., 2003).
2. Monitoring: to track cognitive status over time, especially response to treat-
ment (Foreman et al., 2003).
B. How to Assess Cognitive Function
1. Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh,
1975) can be used to screen for or monitor cognitive function instrument;
however, performance on the MMSE is adversely inuenced by education,
age, language, and verbal ability. e MMSE is also criticized for taking too
long to administer and score.
2. Mini-Cog (Borson, Scanlan, Watanabe, et al., 2005) or Sweet-16 (Fong et
al., 2010) can also be used to screen and monitor cognitive function; is not
NURSING STANDARD OF PRACTICE
(continued)
130 Evidence-Based Geriatric Nursing Protocols for Best Practice
adversely inuenced by age, language, and education; and takes about half
as much time to administer and score as the MMSE.
3. Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE)
is useful to supplement testing with the MMSE or Mini-Cog as it is use-
ful to determining onset, duration and functional impact of the cognitive
impairment. Information from intimate others can be obtained by using
the IQCDE (Jorm, 1994).
4. Naturally occurring interactions: Observations and conversations during
naturally occurring care interactions can be the impetus for additional
screening/monitoring of cognitive function with the MMSE or Mini-Cog
(Foreman et al., 2003). Furthermore, observations should be standardized
by using a formal observation instrument such as the Nurses’ Observation
Scale for Cognitive Abilities (NOSCA; Persoon, 2010).
C. When to Assess Cognitive Function
1. On admission to and discharge from an institutional care setting ( British
Geriatrics Society Clinical Guidelines, 2005; Shekelle et al., 2001)
2. Upon transfer from one care setting to another (Shekelle et al., 2001)
3. During hospitalization, every 8–12 hours throughout hospitalization
(http://www.mc.vanderbilt.edu/icudelirium/)
4. As follow-up to hospital care, within 6 weeks of discharge (Shekelle et al.,
2001)
5. Before making important health care decisions as an adjunct to determin-
ing an individual’s capacity to consent (Shekelle et al., 2001)
6. On the rst visit to a new care provider (Shekelle et al., 2001).
7. Following major changes in pharmacotherapy (Shekelle et al., 2001)
8. With behavior that is unusual for the individual and/or inappropriate to
the situation (Foreman & Vermeersch, 2004)
D. Cautions for Assessing Cognitive Function
1. Physical environment (Dellasega, 1998)
a. Comfortable ambient temperature
b. Adequate lighting (not glaring)
c. Free of distractions (e.g., should be conducted in the absence of others
and other activities)
d. Position self to maximize individual’s sensory abilities
2. Interpersonal environment (Engberg & McDowell, 2000)
a. Prepare individual for assessment
b. Initiate assessment within nonthreatening conversation
c. Let individual set pace of assessment
d. Be emotionally nonthreatening
3. Timing of assessment (Foreman et al., 2003)
a. Select time of assessment to reect actual cognitive abilities of the indi-
vidual.
b. Avoid the following times.
i. Immediately upon awakening from sleep, wait at least 30 minutes
ii. Immediately before and after meals
Protocol 8.1: Assessing Cognitive Functioning (cont.)
(continued)
Assessing Cognitive Function 131
iii. Immediately before and after medical diagnostic or therapeutic pro-
cedures
iv. In the presence of pain or discomfort
V. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Is assessed at recommended time points
2. Any impairment detected early
3. Care tailored to appropriately address cognitive status/impairment
4. Satisfaction with care improved
B. Health Care Provider
1. Competent to assess cognitive function
2. Able to dierentiate among delirium, dementia, and depression
3. Uses standardized cognitive assessment protocol
4. Satisfaction with care improved
C. Institution
1. Improved documentation of cognitive assessments
2. Impairments in cognitive function identied promptly and accurately
3. Improved referral to appropriate advanced providers (e.g., geriatricians,
geriatric nurse practitioners) for additional assessment and treatment rec-
ommendations
4. Decreased overall costs of care
VI. FOLLOW-UP MONITORING
A. Provider competence in the assessment of cognitive function
B. Consistent and appropriate documentation of cognitive assessment
C. Consistent and appropriate care and follow-up in instances of impairment
D. Timely and appropriate referral for diagnostic and treatment recommendations
VII. RELEVANT PRACTICE GUIDELINES
A. e Registered Nurse Association of Ontario Best Practice Guideline for
Screening for Delirium, Dementia and Depression in Older Adults. Retrieved
from http://rnao.org/Page.asp?PageID=924&ContentID=818
B. Guidelines and Protocols Advisory Committee (GPAC) guideline. Cognitive
impairment in the elderly—recognition, diagnosis, management. Retrieved
from http://www.bcguidelines.ca/gpac/guideline_cognitive.html
C. National Institute for Health and Clinical Excellence (NICE) guideline. Delir-
ium: diagnosis, prevention and management. Retrieved from http://guidance.
nice.org.uk/CG103
D. e National Guideline Clearinghouse. Delirium, dementia, amnestic, cog-
nitive disorders. Retrieved from http://www.guideline.gov/browse/by-topic-
detail.aspx?id=13949
Protocol 8.1: Assessing Cognitive Functioning (cont.)
132 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
Recommended Instruments for Assessing Cognitive Functioning
Mini-Cog
http://www.nursingcenter.com/prodev/ce_article.asp?tid=756614
Mini-Mental State
http://www.minimental.com
Sweet 16
http://www.hospitalelderlifeprogram.org
Additional Online Information About Assessing Cognitive Functioning
e Iowa Index of Geriatric Assessment Tools (IIGAT)
http://www.healthcare.uiowa.edu/igec/tools/
“Try is”
A series of tips on various aspects of assessing and caring for older adults sponsored by the Hartford
Institute for Geriatric Nursing at New York University College of Nursing.
http://www.consultgerirn.org
e Registered Nurse Association of Ontario Best Practice Guideline for Screening for Delirium,
Dementia and Depression in Older Adults.
http://rnao.org/Page.asp?PageID=924&ContentID=818
Geriatric Toolkits
http://www.gericareonline.net/tools/index.html
ICU Delirium and Cognitive Impairment Study Group
http://www.icudelirium.org
Assessing care of vulnerable elders (ACOVE)
http://www.rand.org/health/projects/acove.html
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Lang, P. O., Heitz, D., Hédelin, G., Dramé, M., Jovenin, N., Ankri, J., . . . Blanchard, F. (2006).
Early markers of prolonged hospital stays in older people: A prospective, multicenter study
of 908 inpatients in French acute hospitals. Journal of the American Geriatrics Society, 54(7),
1031–1039. Evidence Level IV.
Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychological assessment (4th ed.).
New York, NY: Oxford University Press. Evidence Level VI.
134 Evidence-Based Geriatric Nursing Protocols for Best Practice
McEvoy, C. L. (2001). Cognitive changes in aging. In M .D. Mezey (Ed.), e encyclopedia of elder
care (pp. 139–141), New York, NY: Springer Publishing. Evidence Level VI.
Persoon, A. (2010). Development and validation of the Nurse Observation Scale for Cognitive
Abilities – NOSCA (Doctoral thesis, Radboud University, Nijmegen, e Netherlands).
Evidence Level IV.
Registered Nurse Association of Ontario. (2003). Screening for delirium, dementia and depression in
older adults..Retrieved from http://rnao.org/Page.asp?PageID=924&ContentID=818.
Shekelle, P. G., MacLean, C. H., Morton, S. C., & Wenger, N. S. (2001). ACOVE quality indica-
tors. Annals of Internal Medicine, 135(8 Pt 2) 653–667. Evidence Level I.
Tombaugh, T. N., & McIntyre, N. J. (1992). e Mini-Mental State Examination: A comprehensive
review. Journal of the American Geriatrics Society, 40(9), 922–935. Evidence Level I.
135
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. discuss the major risk factors for late-life depression
2. discuss the consequences of late-life depression
3. identify the core competencies of a systematic nursing assessment for depression
with older adults
4. identify nursing strategies for older adults with depression
OVERVIEW
Contrary to popular belief, depression is not a normal part of aging. Rather, depression
is a medical disorder that causes suering for patients and their families, interferes with a
person’s ability to function, exacerbates coexisting medical illnesses, and increases use of
health services (Lebowitz, 1996). Despite the ecacious treatments available for late-life
depression, many older adults lack access to adequate resources; barriers in the health care
reimbursement system are particular challenges for low income and ethnic minority older
adults (Charney et al., 2003). In a comprehensive review of research on the prevalence of
depression in later life, Hybels and Blazer (2003) found that although major depressive
disorders are not prevalent in late life (1%–5%), the prevalence of clinically signicant
depressive symptoms is high (3%–30%). What is more, these depressive symptoms are
associated with higher morbidity and mortality rates in older adults than in younger
adults (Bagulho, 2002; Lyness et al., 2007).
e rates of depressive symptoms vary, depending on the population of older adults:
community-dwelling older adults (3%–26%), primary care (10%), hospitalized older
adults (23%), and nursing home residents (16%–30%; Hybels & Blazer, 2003).
Certain subgroups have higher levels of depressive symptoms, particularly those
with more severe or chronic disabling conditions, such as those older people in acute
eresa A. Harvath and Glenise McKenzie
9
Depression in Older Adults
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
136 Evidence-Based Geriatric Nursing Protocols for Best Practice
and long-term care settings. Depression also frequently coexists with dementia, speci-
cally Alzheimer’s disease, with prevalence rates ranging from 22% to 54% (Zubenko
et al., 2003). Cognitive impairment may be a secondary symptom of depression, or
depression may be the result of dementia (Blazer, 2002, 2003). It also should be noted
that the prevalence of major depression has been increasing in those born more recently,
so that it can be expected that the prevalence of depression in older adults will go up in
the years to come.
Late-life depression often occurs within a context of medical illnesses, disability,
cognitive dysfunction, and psychosocial adversity, frequently impeding timely rec-
ognition and treatment of depression, with subsequent unnecessary morbidity and
death (Bagulho, 2002; Lyness et al., 2007). A substantial number of older patients
encountered by nurses will have clinically relevant depressive symptoms. Nurses
remain at the frontline in the early recognition of depression and the facilitation
of older patients’ access to mental health care. is chapter presents an overview of
depression in older patients, with emphasis on age-related assessment considerations,
clinical decision making, and nursing intervention strategies for older adults with
depression. A standard of practice protocol for use by nurses in practice settings also
is presented.
BACKGROUND AND STATEMENT OF PROBLEM
What is Depression?
In the broadest sense, depression is dened as a syndrome comprised of a constellation
of aective, cognitive, and somatic or physiological manifestation (National Institutes of
Health [NIH] Consensus Development Panel, 1992). Depression may range in severity
from mild symptoms to more severe forms, both of which can persist over longer time
with negative consequences for the older patient. Suicidal ideation, psychotic features
(especially delusional thinking), and excessive somatic concerns frequently accompany
more severe depression (NIH Consensus Development Panel, 1992). Symptoms of
anxiety may also coexist with depression in many older adults (Cassidy, Lauderdale,
& Sheikh, 2005; DeLuca et al., 2005). In fact, comorbid anxiety and depression have
been associated with more severe symptoms, decreases in memory, poorer treatment
outcomes (DeLuca et al., 2005; Lenze, et al., 2001), and increased rates of suicidal ide-
ation (Sareen et al., 2005).
Major Depression
e Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR)
lists criteria for the diagnosis of major depressive disorder, the most severe form of
depression. ese criteria are frequently used as the standard by which older patients’
depressive symptoms are assessed in clinical settings (American Psychiatric Association
[APA], 2000). Five criteria from a list of nine must be present nearly every day dur-
ing the same 2-week period and must represent a change from previous functioning:
(a) depressed, sad, or irritable mood; (b) anhedonia or diminished pleasure in usually
pleasurable people or activities; (c) feelings of worthlessness, self-reproach, or excessive
guilt; (d) diculty with thinking or diminished concentration; (e) suicidal thinking or
attempts; (f ) fatigue and loss of energy; (g) changes in appetite and weight; (h) disturbed
sleep; and (i) psychomotor agitation or retardation. For this diagnosis, at least one of the
Depression in Older Adults 137
ve symptoms must include either depressed mood, by the patient’s subjective account
or observation of others, or markedly diminished pleasure in almost all people or activi-
ties. Concurrent medical conditions are frequently present in older patients and should
not preclude a diagnosis of depression; indeed, there is a high incidence of medical
comorbidity.
Major depression, as dened by the DSM-IV-TR, seems to be as common among
older as younger cohorts. A recent review found diagnostic thresholds (number and
type of symptoms) to be consistent between older adults (age 60 and older) and middle
aged adults (age 40 and older; Anderson, Slade, Andrews, & Sachdev, 2009). However,
older adults may more readily report somatic or physical symptoms than depressed
mood (Pfa & Almeida, 2005). e somatic or physical symptoms of depression, how-
ever, are often dicult to distinguish from somatic or physical symptoms associated
with acute or chronic physical illness, especially in the hospitalized older patient, or
the somatic symptoms that are part of common aging processes (Kurlowicz, 1994). For
instance, disturbed sleep may be associated with chronic lung disease or congestive heart
failure. Diminished energy or increased lethargy may be caused by an acute metabolic
disturbance or drug response. erefore, a challenge for nurses in acute care hospitals
and other clinical settings is to not overlook or disregard somatic or physical complaints
while also “looking beyond” such complaints to assess the full spectrum of depres-
sive symptoms in older patients. In older adults with acute medical illnesses, somatic
symptoms that persist may indicate a more serious depression, despite treatment of the
underlying medical illness or discontinuance of a depressogenic medication (Kurlowicz,
1994). Older patients may link their somatic or physical complaints to a depressed
mood or anhedonia.
In older adults with signicant cognitive impairment, symptoms may dier from
those who are cognitively intact. Depression may be expressed through repetitive ver-
balizations (e.g., calling out for help) or agitated vocalizations (e.g., screaming, yelling,
or shouting), repetitive questions, expressions of unrealistic fears (e.g., fear of abandon-
ment, being left alone), repetitive statements that something bad will happen, repeti-
tive health-related concerns, and verbal and/or physical aggression (Cohen-Manseld,
Werner, & Marx, 1990). Based on the dierences in presentation, Olin, Katz, Meyers,
Schneider, and Lebowitz (2002) developed a set of provisional criteria (based on DSM-
IV-TR) for the diagnosis of depression in Alzheimer’s disease.
Minor Depression
Depressive symptoms that do not meet standard criteria for a specic depressive dis-
order are highly prevalent (15%–25%) in older adults. ese symptoms are clinically
signicant and warrant treatment (Bagulho, 2002; Lyness et al., 2007). Such depres-
sive symptoms have been variously referred to in the literature as “minor depression,”
“subsyndromal depression,” “dysthymic depression,” “subclinical depression,” “elevated
depressive symptoms,” and “mild depression.” e DSM-IV-TR also lists criteria for the
diagnosis of “minor depressive disorder” and includes episodes of at least 2 weeks of
depressive symptoms but with less than the ve criteria required for major depressive
disorder. Minor depression is two to four times as common as major depression in older
adults and is associated with increased risk of subsequent major depression, greater use of
health services, and has a negative impact on physical and social functioning and quality
of life (Bagulho, 2002; Gaynes, Burns, Tweed, & Erickson, 2002; Lyness et al., 2007).
138 Evidence-Based Geriatric Nursing Protocols for Best Practice
Course of Depression
Depression can occur for the rst time in late life, or it can be part of a long-standing
aective or mood disorder with onset in earlier years. Hospitalized older medical patients
with depression are also more likely to have had a previous depression and experience
higher rates of mortality than older patients without depression (von Ammon Cavanaugh,
Furlanetto, Creech, & Powell, 2001). As in younger people, the course of depression in
older adults is characterized by exacerbations, remissions, and chronicity (NIH Con-
sensus Development Panel, 1992); however, older adults appear to be at increased risk
for relapse (Mitchell & Subramaniam, 2005). erefore, a wait-and-see approach with
regard to treatment is not recommended.
Depression in Late Life is Serious
Depression is associated with serious negative consequences for older adults, especially for
frail older patients, such as those recovering from a severe medical illness or those in nurs-
ing homes. Consequences of depression include heightened pain and disability, delayed
recovery from medical illness or surgery, worsening of medical symptoms, risk of physi-
cal illness, increased health care use, alcoholism, cognitive impairment, worsening social
impairment, protein–calorie subnutrition, loss of bone mineral density, functional decline,
and increased rates of suicide- and non-suicide-related death (Bagulho, 2002; Hoogerduijn
et al., 2007; Smalbrugge et al., 2006; von Ammon Cavanaugh et al., 2001; Wu Q, Magnus,
Liu, Bencaz, & Hentz, 2009). e “amplication” hypothesis proposed by Katz, Streim,
and Parmelee (1994) stated that depression can “turn up the volume” on several aspects of
physical, psychosocial, and behavioral functioning in older patients ultimately accelerating
the course of medical illness. For example, Gaynes et al. (2002) found that major depression
and comorbid medical conditions interacted to adversely aect health-related quality of life
in older adults, and Courtney, O’Reilly, Edwards, and Hassall (2009) identied depression
as one of the factors most often associated with poorer quality of life for older adults in
nursing homes. For older nursing home residents, depression is also associated with poor
adjustment to the nursing home, resistance to daily care, treatment refusal, inability to par-
ticipate in activities, and further social isolation (Achterberg et al., 2003).
Mortality by suicide is higher among older persons with depression than among
their counterparts without depression (Juurlink, Herrmann, Szalai, Kopp, & Redelmeier,
2004). Rates of suicide among older adults (15–20 per 100,000) are the highest of any
age group and even exceed rates among adolescents (McKeowen, Cue, & Schulz, 2006).
is is, in large part, caused by the fact that White men older than the age of 85 are at
greatest risk for suicide, where rates of suicide are estimated to be 80–113 per 100,000
(Erlangsen, Vach, & Jeune, 2005). In the oldest old (80 years and older), men and women
had higher suicide rates than nonhospitalized older adults in the same age range, this age
group had signicantly higher rates of hospitalization than younger cohorts; three or more
medical diagnoses were associated with increased suicide risk (Erlangsen et al., 2005).
Among older psychiatric inpatients, increased risk for suicide was associated with aective
disorders and rst versus later admission (Erlangsen, Zarit, Tu, & Conwell, 2006).
Depressive symptoms, perception of lower health status, poor sleep quality, and
absence of a condant predicted late-life suicide (Turvey et al., 2002). Whereas physi-
cal illness and functional impairment increase risk for suicide in older adults, it appears
that this relationship is strengthened by comorbid depression (Conwell, Duberstein, &
Caine, 2002). Disruption of social support (Conwell et al., 2002), family conict, and
Depression in Older Adults 139
loneliness (Waern, Rubenowitz, & Wilhelmson, 2003) are also signicantly associated
with suicide in late life. Treatment of depression rapidly decreased suicidal ideation in
older adults (Bruce et al., 2004; Szanto, Mulsant, Houck, Dew, & Reynolds, 2003).
However, older adults in higher risk groups (male, older) needed a signicantly longer
response time to demonstrate a decrease in suicidal ideation (Szanto et al., 2003).
Studies have also shown that contact between suicidal older adults and their pri-
mary care provider is common (Luoma, Martin, & Pearson, 2002). Almost half of older
suicide victims had seen their primary care provider within 1 month of committing
suicide (Luoma et al., 2002), whereas 20% had seen a mental health provider. Most of
the suicidal patients experienced their rst episode of major depression, which was only
moderately severe, yet the depressive symptoms went unrecognized and untreated. Older
adults with clinically signicant depressive symptomatology presented with physical
rather than psychological symptoms, including patients who, when asked, admitted
having suicidal ideation (Pfa & Almeida, 2005).
Although the risk for suicide increases with advancing age (Hybels & Blazer, 2003),
a growing body of evidence suggests that depression is also associated with higher rates
of nonsuicide mortality in older adults (Kronish, Rieckmann, Schwartz, Schwartz, &
Davidson, 2009; Schulz, Drayer, & Rollman, 2002); however, evidence is inclusive
regarding depression as predictive of mortality in hospitalized older adults (Cole, 2007).
Depression can also inuence decision-making capacity and may be the cause of indi-
rect life-threatening behavior such as refusal of food, medications, or other treatments in
older patients (McDade-Montez, Christensen, Cvengros, & Lawton, 2006; Stapleton,
Nielsen, Engelberg, Patrick, & Curtis, 2005). Furthermore, depressive symptoms in older
adults have been associated with cognitive impairment and, in some cases, progression to
dementia (Walker & Steens, 2010). ese observations suggest that accurate diagnosis
and treatment of depression in older patients may reduce the mortality rate in this popu-
lation. It is in the clinical setting, therefore, that screening procedures and assessment
protocols have the most direct impact.
Depression in Late Life Is Misunderstood
Despite its prevalence, associated negative outcomes, and good treatment response,
depression in older adults is highly underrecognized, misdiagnosed, and subsequently
undertreated. According to a report by the Administration on Aging (2001), less than
3% of older adults receive treatment from mental health professionals. Use of mental
health services is lower for older adults than any other age group (Administration on
Aging, 2001). Barriers to care for older adults with depression exist at many levels. In
particular, some older adults refuse to seek help because of perceived stigma of mental
illness. Others may simply accept their feelings of profound sadness without realiz-
ing they are clinically depressed. Lack of care provider training in the identication
and diagnosis of depression in older adults is also a barrier to timely recognition and
treatment (Ayalon, Fialová, Areán, & Onder, 2010). Recognition of depression also is
frequently obscured by anxiety and/or the various somatic or dementia-like symptoms
manifest in older patients with depression, or because patient or providers believe that it
is a “normal” response to medical illness, hospitalization, relocation to a nursing home,
or other stressful life events. However, depression—major or minor—is not a necessary
or normative consequence of life adversity (Snowdon, 2001). When depression occurs
after an adverse life event, it represents pathology that should be treated.
140 Evidence-Based Geriatric Nursing Protocols for Best Practice
Treatment for Late-Life Depression Works
e goals of treating depression in older patients are to decrease depressive symptoms,
reduce relapse and recurrence, improve functioning and quality of life, improve medi-
cal health, and reduce mortality and health care costs. Depression in older patients can
be eectively treated using either pharmacotherapy or psychosocial therapies, or both
(Blazer, 2002, 2003; Mackin & Areán, 2005). If recognized, the treatment response
for depression is good: 60%–80% of older adults remain relapse-free with medication
maintenance for 6–18 months (NIH Consensus Development Panel, 1992). In addi-
tion, treatment of depression improves pain and functional outcomes in older adults
(Lin et al., 2003). Recurrence of depression is a serious problem and has been associated
with reduced responsiveness to treatment and higher rates of cognitive and functional
decline (Driscoll et al., 2005). When compared to younger patients, older adults dem-
onstrate comparable treatment response rates; however, they tend to have higher rates of
relapse following treatment (Mitchell & Subramaniam, 2005). erefore, continuation
of treatment to prevent early relapse and longer term maintenance treatment to pre-
vent later occurrences is important. Even in those patients with depression who have a
comorbid medical illness or dementia, treatment response can be good (Iosifescu, 2007).
Depressed older patients who have mild cognitive impairment are at greater risk for
developing dementia if their depression goes untreated (Modrego & Ferrandez, 2004).
CAUSE AND RISK FACTORS
Several biologic and psychosocial factors have been associated with increased risk for late-
life depression. Genetic factors or heredity seem to play more of a role when older adults
have had depression throughout their life (Blazer & Hybels, 2005). Additional biologic
causes associated with late-life depression include neurotransmitter or “chemical messen-
ger” imbalance or dysregulation of endocrine function (Blazer, 2002, 2003). Elevated levels
of homocysteine have also been associated with increased risk for depression in older adults
(Almeida et al., 2008). Neuroanatomic correlates, cerebrovascular disease, brain metabolism
alterations, gross brain disease, and the presence of apolipoprotein E have also been etiologi-
cally linked to late-life depression (Butters et al., 2003). Risk for depression in late life has
been associated with physical disability, severe stroke, and cognitive impairment (Hackett
& Anderson, 2005). Huang, Dong, Lu, Yue, and Liu (2010) found that depression was
associated with arthritis, hypertension, diabetes, urologic problems, and severe stroke.
Psychosocial risk factors for depression in older adults include cognitive distortions,
stressful life events (especially loss), chronic stress, low self-ecacy expectations (Blazer,
2002, 2003; Blazer & Hybels, 2005), poor self-perceived health, inadequate coping
strategies, previous psychopathology (Vink, Aartsen, & Schoevers, 2008), narcissistic
personality traits (Heisel, Links, Conn, van Reekum, & Flett, 2007), and a history of
alcohol abuse (Hasin & Grant, 2002). (For more information, see Chapter 26, Sub-
stance Misuse and Alcohol Use Disorders.)
e social and demographic risk factors for depression in older adults include female
sex, unmarried status, stressful life events, smaller network size, female gender, and the
absence of a supportive social network (NIH Consensus Development Panel, 1992;
Vink et al., 2008). Bereavement is also a risk factor for depression, especially in older
women (Cole, 2007; Onrust & Cuijpers, 2006).
Interestingly, in a meta-analysis of the impact of negative life events on depression
in older adults, Kraaij, Arensman, and Spinhoven (2002) found that while specic
Depression in Older Adults 141
negative life events (e.g., death of signicant others, illness in self or spouse, or nega-
tive relationship events) were moderately associated with increases in depression, the
total number of negative life events and daily hassles had the strongest relationships
with depression in older adults. e stress associated with family care giving has been
repeatedly associated with higher rates of depression in older caregivers (Pinquart &
Sorensen, 2004). In particular, caring for an older adult with dementia has been associ-
ated with higher rates of depression than other caregiving situations and with higher
mortality rates (Pinquart & Sorensen, 2004). is suggests that clinicians should pay
close attention to the accumulation of negative life events and daily hassles when devel-
oping programs and targeting interventions to mitigate depression in older adults who
are at risk for developing depression.
In older adults, there is additional emphasis on the co-occurrence of specic physi-
cal conditions such as stroke, cancer, dementia, arthritis, hip fracture surgery, myocar-
dial infarction, chronic obstructive pulmonary disease, and Parkinson’s disease. Medical
comorbidity is the hallmark of depression in older patients and this factor represents a
major dierence from depression in younger populations (Alexopoulos, Schultz, & Leb-
owitz, 2005). Several conditions have been associated with higher levels of depression
in older adults, including heart failure (Johansson, Dahlström, & Broström, 2006) and
other cardiovascular diseases (Van der Kooy et al., 2007), Alzheimer’s disease, stroke,
and Parkinson’s disease (Hackett, Anderson, House, & Xia, 2008; Strober & Arnett,
2009). In an evidence-based review, Cole (2005) found that disability, older age, new
medical diagnosis, and poor health status were among the most robust and consistent
of all correlates of depression among older medical patients. ose with functional dis-
abilities, especially those with new functional loss, are also at risk. For example, comor-
bid depression is common in older patients with hip fractures (Holmes & House, 2000;
see Table 9.1).
Major depressive disorder has been found to be twice as common in community-
dwelling older adults compared to primary care settings (Bruce et al., 2002). In a sys-
tematic review and meta-analysis, Cole and Dendukuuri (2003) found that depression
in community-dwelling older adults was associated with bereavement, sleep disturbance,
disability, prior depression, and female gender. Other signicant factors included poor
health status, poor self-perceived health, and new medical illness with disability (Cole,
2005; Cole & Dendukuuri, 2003).
Depression Among Minority Older Adults
Rates of depression among minority older adults are not well understood. Beals and
colleagues (2005) found that the rates of major depressive episodes among older Ameri-
can Indians were 30% of the national average. In a review, Kales and Mellow (2006)
found lower rates of depression and higher rates of psychotic diagnoses among African
American older adults. In a systematic review of studies of older Asian immigrants,
Kuo, Chong, and Joseph (2008) found that the prevalence of depression among Asian
Americans ranged from 18% to 20% with signicant variability between dierent Asian
minority groups. For example, studies of Vietnamese older adults estimated depression
at 50%, whereas studies of older Japanese Americans was at 3%. Depression was linked
to gender, recency of immigration, English prociency, acculturation, service barriers,
and social support.
Baker and Whiteld (2006) reported that depressive symptoms were signicantly
associated with increased physical impairment among older Blacks. Williams and
142 Evidence-Based Geriatric Nursing Protocols for Best Practice
Metabolic disturbances
n Dehydration
n Azotemia, uremia
n Acid-base disturbances
n Hypoxia
n Hyponatremia and hypernatremia.
n Hypoglycemia and hyperglycemia
n Hypocalcemia and hypercalcemia
Endocrine disorders
n Hypothyroidism and hyperthyroidism
n Hyperparathyroidism
n Diabetes mellitus
n Cushing’s disease
n Addison’s disease
Infections
n Viral
n Pneumonia
n Encephalitis
n Bacterial
n Pneumonia
n Urinary tract
n Meningitis
n Endocarditis
n Other
n Tuberculosis
n Brucellosis
n Fungal meningitis
n Neurosyphilis
Cardiovascular disorders
n Congestive heart failure
n Myocardial infarction, angina
Pulmonary disorders
n Chronic obstructive lung disease
n Malignancy
Gastrointestinal disorders
n Malignancy (especially pancreatic)
n Irritable bowel
n Other organic causes of chronic abdominal
pain, ulcer, diverticulosis
n Hepatitis
Genitourinary disorders
n Urinary incontinence
Musculoskeletal disorders
n Degenerative arthritis
Osteoporosis with vertebral compression or hip
fractures
n Polymyalgia rheumatica
n Paget’s disease
Neurologic disorders
n Cerebrovascular disease
n Transient ischemic attacks
n Stroke
n Dementia (all types)
n Intracranial mass
n Primary or metastatic tumors
n Parkinson’s disease
Other Illness
n Anemia (of any cause)
n Vitamin deficiencies
n Hematologic or other systemic malignancy
n Immune Disorders
*Sources: Alexopoulos, G. S., Schultz, S. K., Lebowitz, B. D. (2005). Late-life depression: A model for medical clas-
sication. Biological Psychiatry, 58, 283–289; Cole, M. G. (2005). Evidence-based review of risk factors for geriatric
depression and brief preventive interventions. Psychiatric Clinics of North America, 28(4), 785–803; Holmes, J. D.,
& House, A. O. (2000). Psychiatric illness in hip fracture. Age and Ageing, 29(6), 537–546. Evidence Level I.
colleagues (2007) found that when African American and Caribbean Blacks experience
a major depressive disorder, it is usually untreated, more severe, and more disabling
than for non-Hispanic Whites. Furthermore, signicant disparities exist in the quality
of mental health services received by minority older adults (Virnig et al., 2004). A study
of Medicare 1 Choice plans enrollees revealed that minority older adults received sub-
stantially less follow-up for mental health problems following hospitalization (Virnig
et al., 2004).
Although misdiagnosis and subsequent inappropriate treatment can lead to poor
health outcomes for minority older adults (Kales & Mellow, 2006), it is not clear that
“simple” bias alone can explain the disparities in depression management that exist. For
example, Beals and colleagues (2005) point out that dierences in the social construction
of depressive experiences may confound the measurement of depression in ethnic older
TABLE 9.1
Physical Illnesses Associated with Depression in Older Patients*
Depression in Older Adults 143
adults. Older American Indians may be reluctant to endorse symptoms of depression
because cultural norms associate these complaints with weakness (Beals et al., 2005).
In a thoughtful analysis of health disparities, Cooper, Beach, Johnson, and Inui (2006)
explore the complex interactions and relationships between patients and providers that
frame the context in which disparities can occur. ey point out that many historical,
cultural, and class-related factors can inuence the development of therapeutic relation-
ships between providers and patients. Until more research claries the symptom pattern
of late-life depression in minority populations, it is important that clinicians be open to
atypical presentations of depression that warrant closer scrutiny.
ASSESSMENT OF THE PROBLEM
Protocol 9.1 presents a standard of practice protocol for depression in older adults that
emphasizes a systematic assessment guide for early recognition of depression by nurses
in hospitals and other clinical settings. Early recognition of depression is enhanced by
targeting high-risk groups of older adults for assessment methods that are routine, stan-
dardized, and systematic by use of both a depression screening tool and individualized
depression assessment or interview (Piven, 2001).
It can be challenging to dierentiate depression symptoms from dementia symp-
toms because cognitive impairment is frequently a symptom of depression and sig-
nicant cognitive impairment in older depressed adults has been implicated in later
development of dementia. erefore, assessment for presenting symptoms indicative of
both depression and dementia requires focused attention on the historical progression
of symptoms, getting collateral information from a reliable informant (family or care-
giver) and using a screening tool sensitive to change in mood symptoms in cognitively
impaired individuals (Steens, 2008).
Depression Screening Tools
Because many older adults do not present with obvious depressive symptoms (Pfa &
Almeida, 2005), it is important that screening for depression among older adults is incor-
porated into routine health assessments. Nursing assessment of depression in older patients
can be facilitated by the use of a screening tool designed to detect symptoms of depres-
sion. Several depression screening tools have been developed for use with older adults.
In a systematic review, Watson and Pignone (2003) evaluated the accuracy of dierent
depression screening tools. ey found that the Geriatric Depression Scale—Short Form
(GDS-SF; Sheikh & Yesavage, 1986), the Center for Epidemiologic Studies Depression
Scale (CES-D; Radlo, 1977), and the SelfCARE(D) (Banerjee, Shamash, MacDonald,
& Mann, 1998) were the most accurate screening tools to detect major depression as well
as subsyndromal depressive symptoms (Watson & Pignone, 2003).
In a more recent targeted review of evidence-based depression screening tools for
older adults, the two most commonly cited were the GDS-SF and the CES-D. In addi-
tion, the Brief Patient Health Questionnaire-9 (BPHQ-9) and the Cornell Scale for
Depression in Dementia (CSDD) were reviewed in depth because they are also evidence
based and are being used with increasing regularity with older adults (Roman & Callen,
2008). e GDS-SF has been a reliable screening tool for depressive symptoms in mild
cognitive impairment but not in older adults with Alzheimer’s disease (Debruyne et al.,
2009). e CSDD was developed specically to detect symptoms of depression in older
adults with dementia.
144 Evidence-Based Geriatric Nursing Protocols for Best Practice
Individualized Assessment and Interview
Central to the individualized depression assessment and interview is a focused assess-
ment of the full spectrum of symptoms (nine) for major depression as delineated by the
DSM-IV-TR (APA, 2000). Furthermore, patients should be asked directly and speci-
cally if they have been having suicidal ideation—that is, thoughts that life is not worth
living—or if they have been contemplating or have attempted suicide. e number of
symptoms, type, duration, frequency, and patterns of depressive symptoms, as well as
a change from the patient’s normal mood of functioning, should be noted. Additional
components of the individualized depression assessment include evidence of psychotic
thinking (especially delusional thoughts), anniversary dates of previous losses or nodal/
stressful events, previous coping style (specically alcohol or other substance abuse),
relationship changes, physical health changes, a history of depression or other psychi-
atric illness that required some form of treatment, a general loss and crises inventory,
and any concurrent life stressors. Subsequent questioning of the family or caregiver is
recommended to obtain further information about the older adult’s verbal and nonver-
bal expressions of depression.
DIFFERENTIATION OF MEDICAL OR IATROGENIC CAUSES OF DEPRESSION
Once depressive symptoms are recognized, medical and drug-related causes should
be explored. As part of the initial assessment of depression in the older patient, it
is important to obtain and review the medical history and physical and/or neuro-
logical examinations. Key laboratory tests should also be obtained and/or reviewed
and include thyroid- stimulating hormone levels, chemistry screen, complete blood
count, and medication levels if needed. An electrocardiogram, serum B
12
, a uri-
nalysis, and serum folate should also be considered to assess for coexisting medical
conditions. ese conditions may contribute to depression or might complicate
treatment of the depression ( Alexopoulos, Katz, Reynolds, Carpenter, & Docherty,
2001; see Table 9.2). In medically older patients, who frequently have multiple
medical diagnoses and are prescribed with multiple medications, these “organic”
factors in the cause of depression are a major issue in nursing assessment. In col-
laboration with the patient’s physician, eorts should be directed toward treatment,
correction, or stabilization of associated metabolic or systemic conditions. When
medically feasible, depressogenic medications should be eliminated, minimized,
or substituted with those that are less depressogenic (Dhondt et al., 1999). Even
when an underlying medical condition or medication is contributing to the depres-
sion, treatment of that condition or discontinuation or substitution of the oend-
ing agent alone is often not sucient to resolve the depression, and antidepressant
medication is often needed.
INTERVENTIONS AND CARE STRATEGIES
Clinical Decision Making and Treatment
Regardless of the setting, older patients who exhibit the number of symptoms indicative
of a major depression, specically suicidal thoughts or psychosis, and who score above
the established cuto score for depression on a depression screening tool (e.g., 5 on the
Depression in Older Adults 145
*Source: Dhondt, T., Derksen, P., Hooijer, C., Van Heycop Ten Ham, B., Van Gent, P. P., & Heeren, T. (1999).
Depressogenic medication as an aetiological factor in major depression: An analysis in a clinical population of
depressed elderly people. International Journal of Geriatric Psychiatry, 14, 875–881.
**By causing dehydration or electrolyte imbalance.
1Toxicity.
11By causing hypoglycemia.
Antihypertensives
n Reserpine
n Methyldope
n Propranolol
n Clonidine
n Hydralazine
n Guanethidine
n Diuretics**
Analgesics
n Narcotic
n Morphine
n Codeine
n Meperidine
n Pentazocine
n Propoxphene
Nonnarcotic
n Indomethacin
Antiparkinsonian agents
n L-Dopa
Antimicrobials
n Sulfonamides
n Isoniazid
Cardiovascular agents
n Digitals
n Lidocaine1
Hypoglycemic agents1
Steroids
n Corticosteroids
n Estrogens
Others
n Cimetidine
n Cancer chemotherapeutic agents
GDS-SF) should be referred for a comprehensive psychiatric evaluation. Older patients
with less severe depressive symptoms without suicidal thoughts or psychosis but who also
score above the cuto score on the depression screening tool (e.g., 5 on the GDS-SF)
should be referred to available psychosocial services (i.e., psychiatric liaison nurses, gerop-
sychiatric advanced practice nurses, social workers, psychologists, a clergy member) for
psychotherapy or other psychosocial therapies, as well as to determine whether medica-
tion for depression is warranted. It is also important to note that older adults at risk
for depression may benet from brief interventions that focus on preventing the devel-
opment of depression (Cole, 2008; Cole & Dendukuuri, 2003; Forsman, Jane-Llopis,
Schierenbeck, & Wahlbeck, 2009).
e type and severity of depressive symptoms inuence the type of treatment
approach. In general, more severe depression, especially with suicidal thoughts or psy-
chosis, requires intensive psychiatric treatment, including hospitalization, medication
with an antidepressant or antipsychotic drug, electroconvulsive therapy (ECT), and
intensive psychosocial support (Blazer, 2002, 2003). Less severe depression without
suicidal thoughts or psychosis may require treatment with psychotherapy or medica-
tion, often on an outpatient basis. Collectively, these data also suggest that patients who
have depression complicated by multiple medical and psychiatric comorbidities may
benet from a referral to an interdisciplinary treatment team with specic expertise in
geropsychiatry.
TABLE 9.2
Drugs Used to Treat Physical Illness
at Can Cause Symptoms of Depression in Patients*
146 Evidence-Based Geriatric Nursing Protocols for Best Practice
e three major categories of treatment for depression in older adults are biologic
therapies (e.g., pharmacotherapy, ECT, and exercise), psychosocial therapies (e.g., cognitive-
behavioral, psychodynamic, and reminiscence therapy), and interdisciplinary team inter-
ventions. A compelling body of evidence supports the ecacy of these diverse treatment
modalities for older adults with depression (Areán & Cook, 2002; Cuijpers, van Straten, &
Smit, 2006; Hollon et al., 2005).
Biologic Therapies in Treatment of Late-Life Depression
In the past, tricyclic antidepressants (TCAs) were often contraindicated in older
adults because of the anticholinergic side-eect prole (Mottram, Wilson, & Strobl,
2006). More recently, however, there has been a dramatic increase in the devel-
opment and testing of dierent pharmacological agents used to treat depression
in older adults. e most common classes of these newer medications include the
selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake
inhibitors (SNRIs), and TCA-related medications. ese agents work selectively on
neurotransmitters in the brain to alleviate depression. SSRIs have been eective in
treating poststroke depression (Hackett et al., 2008; Chen, Guo, Zhan, & Patel,
2006) and depression in persons with Alzheimer’s disease (ompson, Herrmann,
Rapoport, & Lanctôt, 2007).
When the SSRIs are compared to other classes of antidepressants to treat late-life
depression (e.g., SNRIs, TCAs, TCA-related medications), they have similar treat-
ment ecacy (Mottram et al., 2006; Mukai & Tampi, 2009; Salzman, Wong, &
Wright, 2002; Shanmugham, Karp, Drayer, Reynolds, & Alexopoulos, 2005). However,
SSRIs and SNRIs generally pose a lower treatment risk for older adults with depres-
sion ( Chemali, Chahine, & Fricchione, 2009; Mottram et al., 2006; Mukai & Tampi,
2009; Shanmugham et al., 2005). Still, in a systematic review of the literature, Wilson,
Mottram, and Vassilas (2008) found that although SSRIs are generally well tolerated
in older adults, a signicant minority experience serious side eects, including nausea,
vomiting, dizziness, and drowsiness. In addition, serious hyponatremia has been asso-
ciated with the use of SSRIs in older adults (Jacob & Spinler, 2006). Judicious use of
TCA-related drugs may be an eective alternative for older adults who cannot tolerate
SSRIs (Wilson et al., 2008).
Older patients should be closely monitored for therapeutic response to and
potential side eects of antidepressant medication to assess whether dose adjustment
of antidepressant medication may be warranted. Although, in general, it is necessary
to start antidepressant medication at low doses in older patients, it is also necessary
to ensure that older adults with persistent depressive symptoms receive adequate
treatment (American Association of Geriatric Psychiatry, 1992; M. Buum & J.
Buum, 2005).
Recent research that has suggested that the use of SSRIs in adolescents can increase
suicidality has raised concerns about a similar dynamic with older adults. Several
studies, however, have found that the use of SSRI antidepressants to treat late-life
depression is not associated with increases in suicidal ideation (Barbui, Esposito, &
Cipriani, 2009; Nelson, Delucchi, & Schneider, 2008; Stone et al., 2009). In fact,
treatment of late-life depression with SSRIs has been shown to signicantly reduce
suicidal ideation and behavior in older adults (Barbui et al., 2009; Nelson et al., 2008;
Stone et al., 2009).
Depression in Older Adults 147
Electroconvulsive Therapy
When older adults are not able to take antidepressants for treatment of late-life
depression, clinicians are increasingly looking to the use of ECT to reduce symp-
toms of depression and improve function. For many individuals, the use of ECT
conjures up images of barbaric treatments that leave patients severely cognitively
impaired. Although the debate on the ecacy and appropriate use of ECT to treat
late-life depression continues (Dombrovski & Mulsant, 2007), some research sug-
gests that ECT can be an eective option for older adults with depression that is not
responsive to other treatments (Navarro et al., 2008). Several studies have found
that ECT does not cause increased cognitive impairment in older adults (Gardner
& O’Connor, 2008).
Exercise Interventions
Physical exercise has been established as an eective treatment for depression in the
general population, and evidence to support the use in older adults is building. In two
recent systematic reviews of physical exercise, interventions concluded that exercise pro-
grams decrease depressive symptoms in older adults with major and minor depression
(Sjosten & Kivela, 2006). Tai Chi and Qigong are specic meditative exercise methods
that also may decrease depressive symptoms (Rogers, Larkey, & Keller, 2009).
PSYCHOSOCIAL APPROACHES
e term psychosocial encompasses a wide array of approaches. is section provides an
overview of the three major psychosocial approaches used in the studies reviewed here:
(a) cognitive behavioral, (b) psychodynamic, and (c) reminiscence or life review.
Cognitive behavioral therapies (CBT) seek to change the cognitive and/or behavioral
context in which depression occurs through the use of various specic techniques such as
providing new information, teaching problem-solving strategies, correcting skills decits,
modifying ineective communication patterns, or changing the physical environment.
Although specic treatment protocols vary, CBT approaches tend to be active and
focused on solving specic, current day-to-day problems, rather than seeking global
personality change in the client. Based on a large and growing evidence base, CBT has
been shown eective in decreasing depression in clinically depressed older adults (Hill &
Brettle, 2005; Laidlaw et al., 2008; Pinquart, Duberstein, & Lyness, 2007; Steinman et
al., 2007; Wilson et al., 2008). Training caregivers (family or paid caregivers) to use CBT
approaches (improved communication, increasing pleasant events, problem-solving
behaviors) has also been shown to decrease depression and related behaviors in older
adults with dementia (Teri, Mckenzie, & LaFazia, 2005). Gallagher-ompson and
Coon (2007) also identied CBT interventions as eective in decreasing depression in
the older adults who are caregivers for family members with dementia.
Psychodynamic approaches focus on establishing a therapeutic relationship as a
mechanism of change, as well as the historical causes of current client mood and
behavior. e clients’ psychological insight and ongoing emotional experience are
considered critical for psychological progress. e evidence for eectiveness of psycho-
dynamic approaches with older adults is limited. However, Pinquart and colleagues
(2007) reported signicant changes in depression with psychodynamic therapies
based on three studies and nonsignicant changes in three studies of interpersonal
148 Evidence-Based Geriatric Nursing Protocols for Best Practice
therapy. Additionally, Bharucha, Dew, Miller, Borson, and Reynolds (2006) reviewed
18 studies of psychodynamic approaches (“talk therapy”) with residents of long-term
care settings and reported signicant positive outcomes on measures of depression,
hopelessness, and self-esteem. Marital and family therapy may also be benecial in
treating older adults with depression, especially older spouses engaged in caregiving
(Buckwalter et al., 1999).
In reminiscence therapy, older adults are encouraged to remember the past and
to share their memories, either with a therapist or with peers, as a way of increasing
self-esteem and social intimacy. It is often highly directive and structured, with the
therapist picking each session’s reminiscence topic. In systematic reviews of the litera-
ture, reminiscence therapy was found to signicantly reduce depression in older adults
(Bohlmeijer, Smit, & Cuijpers, 2003; Hsieh & Wang, 2003; Mackin & Areán, 2005;
Pinquart et al., 2007). Nursing interventions to encourage reminiscence include asking
patients directly about their past or by linking events in history with the patient’s life
experience. e use of photographs, old magazines, scrapbooks, and other objects can
also stimulate discussion.
In summary, psychosocial treatment has been found eective in decreasing depres-
sion in cognitively intact older adults. ere is also empirical evidence for the ecacy of
cognitive behavioral based therapies in decreasing depression in individuals with demen-
tia and for the older adults who are caregivers for individuals with dementia. Current
studies also demonstrate the utility of working closely with caregivers—whether family
or sta—to reduce depression in persons with dementia. ere is also a small but grow-
ing body of evidence related to the use of psychodynamic approaches aimed at decreas-
ing depression in older adults associated with comorbid illnesses such as heart disease
(Kang-Yi & Gellis, 2010; Lane, Chong Aun Yeong, & Gregory, 2005).
Interdisciplinary Team Models of Care
Several studies support the use of an interdisciplinary geriatric assessment team for late-
life depression (Bao, Post, Ten, Schackman, & Bruce, 2009; Katon et al., 2005; Skultety
& Zeiss, 2006). Interdisciplinary treatment teams improved physical functioning in
older adults with major depressive disorder (Bao et al., 2009; Callahan et al., 2005;
Katon et al., 2005; Skultety & Zeiss, 2006) and eectively reduced the depressive symp-
toms in community-dwelling older adults (age 70 years and older) who were at risk for
hospitalization (Boult et al., 2001). Ethnic minority older adults experienced improved
treatment of depression when treated by an interdisciplinary treatment team (Areán et
al., 2005) as did low-income older adults (Areán, Gum, Tang, & Unützer, 2007). Simi-
larly, patients with multiple comorbid medical conditions responded positively to an
interdisciplinary approach to depression management (Harpole et al., 2005; Unützer et
al., 2002). Although older adults with comorbid anxiety disorders took longer to respond
to treatment, they experienced greater reductions in depression when treated by an inter-
disciplinary team than similar patients receiving usual primary care (Hegel et al., 2005).
Individualized Nursing Interventions for Depression
Psychosocial and behavioral nursing interventions can be incorporated into the plan
of care, based on the patient’s individualized need. Provision of safety precautions for
patients with suicidal thinking is a priority. In acute medical settings, patients may
Depression in Older Adults 149
require transfer to the psychiatric service when suicidal risk is high and stang is not
adequate to provide continuous observation of the patient. In outpatient settings, con-
tinuous surveillance of the patient should be provided while an emergency psychiatric
evaluation and disposition is obtained.
Promotion of nutrition, elimination, sleep/rest patterns, physical comfort, and pain
control has been recommended specically for depressed medically ill older adult (Voyer
& Martin, 2003). Relaxation strategies should be oered to relieve anxiety as an adjunct
to pain management. Nursing interventions should also focus on enhancement of the
older adult’s physical function through structured and regular activity and exercise;
referral to physical, occupational, and recreational therapies; and the development of a
daily activity schedule (Barbour & Blumenthal, 2005). Enhancement of social support
is also an important function of the nurse. is may be done by identifying, mobiliz-
ing, or designating a support person such as family, a condant, friends, volunteers or
other hospital resources, church member, support groups, patient or peer visitors, and
particularly by accessing appropriate clergy for spiritual support.
Nurses should maximize the older adult’s autonomy, personal control, self-ecacy,
and decision making about clinical care, daily schedules, and personal routines ( Lawton,
Moss, Winter, & Homan, 2002). e use of a graded task assignment where a larger
goal or task is subdivided into several small steps can be helpful in enhancing function,
assuring successful experiences, and building older patients’ condence in their perfor-
mance of various activities (Areán &, Cook, 2002). Participation in regular, predictable,
and pleasant activities can result in more positive mood changes for older adults with
depression (Koenig, 1991). A pleasant events inventory, elicited from the patient, can be
used to incorporate pleasurable activities into the older patient’s daily schedule (Koenig,
1991). Music therapy customized to the patient’s preference is also recommended to
reduce depressive symptoms (Siedliecki & Good, 2006).
Nurses should provide emotional support for depressed older patients by provid-
ing empathetic, supportive listening; encouraging patients to express their feelings in
a focused manner on issues such as grief or role transition, supportive adaptive coping
strategies; identifying and reinforcing strengths and capabilities; maintaining privacy
and respect; and instilling hope. In particular, it is important to increase the patient’s
and family’s awareness of the symptoms as part of a depression that is treatable and not
the person’s fault as a result of personal inadequacies.
Ray Stimson is an 87-year-old man with multiple medical problems. He has a history
of coronary artery disease (CAD) and had triple bypass surgery 4 years ago. He also
has hypertension, Type II diabetes, and is hard of hearing. He was admitted to the
hospital for surgical repair of a hip fracture following a fall in his home. Mr. Stimson
is widowed (11 months) and has two adult children who do not live locally. Prior to
his fall, he was living independently in the community; however, his children were
growing increasingly concerned about his safety. Following surgery, Mr. Stimson was
irritable and resisted eorts by the nursing sta to participate in self-care activities
CASE STUDY AND DISCUSSION
(continued)
150 Evidence-Based Geriatric Nursing Protocols for Best Practice
(e.g., walking, bathing). ey often found him laying stoically in bed, staring into
space. e nurses also observed that he was occasionally confused and would ask
about his deceased wife.
A subsequent referral to the geropsychiatric consultation liaison nurse revealed that
Mr. Stimson was experiencing a great deal of postoperative pain that was not well treated
on his current medicine regimen. Nursing sta had charted concerns that his opioid
analgesic was contributing to his mental confusion. e geropsychiatric evaluation also
revealed that Mr. Stimson had been growing increasingly depressed over the past few
months and was still actively grieving the loss of his wife of 62 years. As his health had
failed and his independent living was threatened, he admitted he had contemplated sui-
cide, stating, “Life is just not worth living anymore.” Further assessment revealed that he
did not have a specic plan in mind and admitted that he did not really think that was
a solution to his problems, but that he could not see that he had many options.
e liaison nurse worked with the medical team to develop a more aggressive plan
for pain management. She also arranged for a family conference to discuss discharge
planning issues. During the family conference, the liaison nurse spoke to Mr. Stimson’s
children about long-term planning. She explained how important it was for Mr. Stim-
son to participate in any placement decisions they may be contemplating and to have a
sense of control. Although his children were able to express their reservations and con-
cerns about safety, they agreed to explore the kinds of community support services that
could be activated to help support their father in his own home for as long as possible.
Mr. Stimson was able to participate in rehabilitation and gained enough strength
to return to his home. Arrangements were made for follow-up with mental health
services. He was started on an antidepressant and agreed to participate in the senior
lunch program twice a week to increase the opportunity for socialization. Several
months after his discharge, Mr. Stimson reported that he still missed his wife terribly
and that he still was lonely at times. However, he had developed some friendships at
the senior center and was getting out one to two times each week. His children called
more often and had, for the time being, stopped sending him brochures for assisted
living facilities. He acknowledged that he may need to move to a more supervised set-
ting in the future, but for now, he was content to stay in the home where he had many
pleasant memories to keep him company.
CASE STUDY (continued)
SUMMARY
Depression signicantly threatens the personal integrity, health, and “experience of
life” of many older adults. Depression is often reversible with prompt and appropriate
treatment. Early recognition can be enhanced by training health care personnel in the
use of a standardized protocol that outlines a systematic method for depression assess-
ment adapted for older adults in various settings and with diverse comorbid conditions.
Early identication of depression and successful treatment demonstrates to society that
depression is the most treatable mental problem in late life. As Blazer (1989) stated,
“When there is depression, hope remains” (pp. 164–166).
Depression in Older Adults 151
Protocol 9.1: Depression in Older Adults
I. BACKGROUND*
A. Depression—both major depressive disorders and minor depression—is highly
prevalent in community-dwelling, medically ill, and institutionalized older
adults.
B. Depression is not a natural part of aging or a normal reaction to acute illness
hospitalization.
C. Consequences of depression include amplication of pain and disability,
delayed recovery from illness and surgery, worsening of drug side eects, excess
use of health services, cognitive impairment, subnutrition, and increased sui-
cide- and non-suicide-related death.
D. Depression tends to be long lasting and recurrent. erefore, a wait-and-see
approach is undesirable, and immediate clinical attention is necessary. If recog-
nized, treatment response is good.
E. Somatic symptoms may be more prominent than depressed mood in late-life
depression.
F. Mixed depression and anxiety features may be evident among many older
adults.
G. Recognition of depression is hindered by the coexistence of physical illness and
social and economic problems common in late life. Early recognition, interven-
tion, and referral by nurses can reduce the negative eects of depression.
II. ASSESSMENT PARAMETERS
A. Identify risk factors/high risk groups.
1. Current alcohol/substance use disorder (Hasin & Grant, 2002).
2. Specic comorbid conditions: dementia, stroke, cancer, arthritis, hip frac-
ture, myocardial infarction, chronic obstructive pulmonary disease, and
Parkinson’s disease (Alexopoulos et al., 2005; Butters et al., 2003).
3. Functional disability (especially new functional loss; Cole, 2003, 2005).
4. Widow/widowers (NIH Consensus Development Panel, 1992).
5. Caregivers (Pinquart & Sorensen, 2004).
6. Social isolation/absence of social support (Kraaij et al., 2002).
7. Diminished perception of light in one’s environment (Friberg, Bremer, &
Dickinsen, 2008).
B. Assess all at-risk groups using a standardized depression screening tool and doc-
umentation score. e GDS-SF is recommended because it takes approximately
5 minutes to administer, has been validated and extensively used with medically
ill older adults, and includes few somatic items that may be confounded with
physical illness (Pfa & Almeida, 2005; Watson & Pignone, 2003).
C. Perform a focused depression assessment on all at-risk groups and document results.
Note the number of symptoms; onset; frequency/patterns; duration (especially
2 weeks); change from normal mood, behavior, and functioning (APA, 2000).
1. Depressive symptoms
2. Depressed or irritable mood, frequent crying
(continued)
NURSING STANDARD OF PRACTICE
152 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Loss of interest, pleasure (in family, friends, hobbies, sex)
4. Weight loss or gain (especially loss)
5. Sleep disturbance (especially insomnia)
6. Fatigue/loss of energy
7. Psychomotor slowing/agitation
8. Diminished concentration
9. Feelings of worthlessness/guilt
10. Suicidal thoughts or attempts, hopelessness
11. Psychosis (i.e., delusional/paranoid thoughts, hallucinations)
12. History of depression, current substance abuse (especially alcohol), previ-
ous coping style
13. Recent losses or crises (e.g., death of spouse, friend, pet; retirement; anni-
versary dates; move to another residence, nursing home); change in physi-
cal health status, relationships, roles
D. Obtain/review medical history and physical/neurological examination (Alexo-
poulos et al., 2001).
E. Assess for depressogenic medications (e.g., steroids, narcotics, sedative/hypnot-
ics, benzodiazepines, antihypertensives, H
2
antagonists, beta-blockers, antipsy-
chotics, immunosuppressive, cytotoxic agents).
F. Assess for related systematic and metabolic processes (e.g., infection, anemia,
hypothyroidism or hyperthyroidism, hyponatremia, hypercalcemia, hypogly-
cemia, congestive heart failure, kidney failure).
G. Assess for cognitive dysfunction.
H. Assess level of functional disability.
III. CARE PARAMETERS
A. For severe depression (GDS score 11 or greater, ve to nine depressive symp-
toms [must include depressed mood or loss of pleasure] plus other posi-
tive responses on individualized assessment [especially suicidal thoughts or
psychosis and comorbid substance abuse], refer for psychiatric evaluation.
Treatment options may include medication or cognitive behavioral, interper-
sonal, or brief psychodynamic psychotherapy/counseling (individual, group,
family); hospitalization; or electroconvulsive therapy (Areán & Cook, 2002;
Hollon et al., 2005).
B. For less severe depression (GDS score 6 or greater, less than ve depressive
symptoms plus other positive responses on individualized assessment), refer to
mental health services for psychotherapy/counseling (see previous types), espe-
cially for specic issues identied in individualized assessment and to deter-
mine whether medication therapy may be warranted. Consider resources such
as psychiatric liaison nurses, geropsychiatric advanced practice nurses, social
workers, psychologists, and other community and institution-specic mental
health services. If suicidal thoughts, psychosis, or comorbid substance abuse are
present, a referral for a comprehensive psychiatric evaluation should always be
made (Areán & Cook, 2002; Hollon et al., 2005).
(continued)
Protocol 9.1: Depression in Older Adults (cont.)
Depression in Older Adults 153
C. For all levels of depression, develop an individualized plan integrating the fol-
lowing nursing interventions:
1. Institute safety precautions for suicide risk as per institutional policy (in
outpatient settings, ensure continuous surveillance of the patient while
obtaining an emergency psychiatric evaluation and disposition).
2. Remove or control etiologic agents.
a. Avoid/remove/change depressogenic medications.
b. Correct/treat metabolic/systemic disturbances.
3. Monitor and promote nutrition, elimination, sleep/rest patterns, physical
comfort (especially pain control).
4. Enhance physical function (i.e., structure regular exercise/activity; refer to phys-
ical, occupational, recreational therapies); develop a daily activity schedule.
5. Enhance social support (i.e., identify/mobilize a support person(s) [e.g.,
family, condant, friends, hospital resources, support groups, patient visi-
tors]); ascertain need for spiritual support and contact appropriate clergy.
6. Maximize autonomy/personal control/self-ecacy (e.g., include patient in
active participation in making daily schedules, short-term goals).
7. Identify and reinforce strengths and capabilities.
8. Structure and encourage daily participation in relaxation therapies, pleas-
ant activities (conduct a pleasant activity inventory), music therapy.
9. Monitor and document response to medication and other therapies; read-
minister depression screening tool.
10. Provide practical assistance; assist with problem solving.
11. Provide emotional support (i.e., empathic, supportive listening, encourage
expression of feelings, hope instillation), support adaptive coping, encour-
age pleasant reminiscences.
12. Provide information about the physical illness and treatment(s) and about depres-
sion (i.e., that depression is common, treatable, and not the person’s fault).
13. Educate about the importance of adherence to prescribed treatment regi-
men for depression (especially medication) to prevent recurrence; educate
about specic antidepressant side eects due to personal inadequacies.
14. Ensure mental health community link up; consider psychiatric, nursing
home care intervention.
IV. EVALUATION OF EXPECTED OUTCOMES
A. Patient
1. Patient safety will be maintained.
2. Patients with severe depression will be evaluated by psychiatric services.
3. Patients will report a reduction of symptoms that are indicative of depres-
sion. A reduction in the GDS score will be evident and suicidal thoughts or
psychosis will resolve.
4. Patient’s daily functioning will improve.
B. Health care provider
1. Early recognition of patient at risk, referral, and interventions for depres-
sion, and documentation of outcomes will be improved.
(continued)
Protocol 9.1: Depression in Older Adults (cont.)
154 Evidence-Based Geriatric Nursing Protocols for Best Practice
C. Institution
1. e number of patients identied with depression will increase.
2. e number of in-hospital suicide attempts will not increase.
3. e number of referrals to mental health services will increase.
4. e number of referrals to psychiatric nursing home care services will increase.
5. Sta will receive ongoing education on depression recognition, assessment,
and interventions.
V. FOLLOW-UP TO MONITOR CONDITION
A. Continue to track prevalence and documentation of depression in at-risk groups.
B. Show evidence of transfer of information to postdischarge mental health ser-
vice delivery system.
C. Educate caregivers to continue assessment processes.
*Somatic symptoms, also seen in many physical illnesses, are frequently associated with A and B;
therefore, the full range of depressive symptoms should be assessed.
Protocol 9.1: Depression in Older Adults (cont.)
ACKNOWLEDGMENTS
is chapter is based partly on Chapter 5 of the third edition coauthored by Dr. Lenore H.
Kurlowicz who died on September 21, 2007. e authors and coeditors acknowledge her
tremendous contributions to the eld of geropsychiatric nursing.
RESOURCES
Recommended Instruments for Screening for Depression
Geriatric Depression Scale-Short Form (GDS-SF)
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric depression scale (GDS) recent evidence and develop-
ment of a shorter version. Clinical Gerontologist, 5, 165–173.
Center for Epidemiological Studies Depression Scale (CES-D)
Radlo, L. S. (1977). e CES-D scale: A self-report depression scale for research in the general
population. Applied Psychological Measurement, 1, 385–401.
SelfCARE(D)
Banerjee, S., Shamash, K., Macdonald, A. J. D., & Mann, A. H. (1998). e use of SELFCARE(D)
as a screening tool for depression in the clients of local authority home care services – a prelimi-
nary study. International Journal of Geriatric Psychiatry, 13, 695–699.
Additional Online Information About Assessing Depression
“Try is”
A series of tips on various aspects of assessing and caring for older adults sponsored by the Hartford
Institute for Geriatric Nursing at New York University College of Nursing.
http://consultgerirn.org/resources
Depression in Older Adults 155
Portal of Geriatric Online Education
Provides resources for assessment and management of geriatric health issues.
http://www.pogoe.org/kmsearch
e Registered Nurse Association of Ontario Best Practice Guideline for Screening for Delirium,
Dementia and Depression in Older Adults.
http://rnao.org/Page.asp?PageID = 924&ContentID = 818
Assessing Care of Vulnerable Elders (ACOVE)
http://www.rand.org/health/projects/acove.html
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aged: A systematic review. International Journal of Geriatric Psychiatry, 21(5), 410–418. Evidence
Level I.
Skultety, K. M., & Zeiss, A. (2006). e treatment of depression in older adults in the primary care
setting: An evidence-based review. Health Psychology, 25(6), 665–674. Evidence Level I.
Smalbrugge, M., Pot, A. M., Jongenelis, L., Gundy, C. M., Beekman, A. T., & Eefsting, J. A. (2006).
e impact of depression and anxiety on well being, disability and use of health care services in
nursing home patients. International Journal of Geriatric Psychiatry, 21(4), 325–332. Evidence
Level IV.
Snowdon, J. (2001). Is depression more prevalent in old age? Australian and New Zealand Journal of
Psychiatry, 35, 782–787. Evidence Level VI.
Stapleton, R. D., Nielsen, E. L., Engelberg, R. A., Patrick, D. L., Curtis JR. (2005). Association of
depression and life-sustaining treatment. Chest, 127(1), 328–334. Evidence Level III.
Steens, D. C. (2008). Separating mood disturbance from mild cognitive impairment in geriatric
depression. International Review of Psychiatry, 20(4), 374–381. Evidence Level V.
Steinman, L. E., Frederick, J. T., Prohaska, T., Satariano, W. A., Dornberg-Lee, S., Fisher, R., . . . Snowden,
M. (2007). Recommendations for treating depression in community-based older adults. American
Journal of Preventive Medicine, 33(3), 175–181. Evidence Level I.
Stone, M., Laughren, T., Jones, M. L., Levenson, M., Holland, P. C., Hughes, A., . . . Rochester G.
(2009). Risk of suicidality in clinical trials of antidepressants in adults: Analysis of proprietary
data submitted to US food and drug administration. British Medical Journal, 339, b2880.
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Strober, L. B., & Arnett, P. A. (2009). Assessment of depression in three medically ill, elderly popula-
tions: Alzheimer’s disease, parkinson’s disease, and stroke. e Clinical Neuropsychologist, 23(2),
205–230. Evidence Level I.
Szanto, K., Mulsant, B. H., Houck, P., Dew, M. A., & Reynolds, C. F., III. (2003). Occurrence and
course of suicidality during short-term treatment of late-life depression. Archives of General
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Teri, L., Mckenzie, G., & LaFazia, D. (2005). Psychosocial treatment of depression in older adults
with dementia. Clinical Psychology: Science and Practice, 12(3), 303–316. Evidence Level I.
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162 Evidence-Based Geriatric Nursing Protocols for Best Practice
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(2002). Risk factors for late-life suicide: A prospective, community-based study. American
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Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., . . . Langston,
C. (2002). Collaborative care management of late-life depression in the primary care setting: A
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Depression and the risk for cardiovascular diseases: Systematic review and meta analysis. Inter-
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Jackson, J. S. (2007). Prevalence and distribution of major depressive disorder in African
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Zubenko, G. S., Zubenko, W. N., McPherson, S., Spoor, E., Marin, D. B., Farlow, M. R., . . . Sunder-
land, T. (2003). A collaborative study of the emergence and clinical features of the major depres-
sive syndrome of Alzheimer’s disease. American Journal of Psychiatry, 160, 857–866. Evidence
Level I.
163
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe the spectrum of dementia syndromes
2. recognize the clinical features of dementia
3. discuss pharmacological and nonpharmacological approaches in the management of
dementia
4. develop a nursing plan of care for an older adult with dementia
OVERVIEW
Dementia is most commonly dened as a clinical syndrome of cognitive decits that
involves both memory impairments and a disturbance in at least one other area of cog-
nition (American Psychiatric Association, 2000). In addition to disruptions in cogni-
tion, dementia is associated with a gradual decline in function and changes in mood
and behavior.
ere are many causes of dementia and dementia-like presentations. Dierentiat-
ing these changes early in the course of illness is important because condition-specic
assessment, monitoring, and management strategies can be employed. Dierential diag-
noses among conditions that cause cognitive impairment are confounded by the fact
that these conditions may coexist and disparate dementing disorders may be similarly
clinically expressed.
Major goals in the clinical approach to a person presenting with cognitive impair-
ments are identication and resolution of potentially reversible conditions (e.g.,
delirium, depression), recognition and control of comorbid conditions, early diagnosis
and management of a dementing illness, and the provision of caregiver support. e
focus of this chapter is on assessment and management of the progressive dementia
syndromes.
Kathleen Fletcher
10
Dementia
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
164 Evidence-Based Geriatric Nursing Protocols for Best Practice
BACKGROUND AND STATEMENT OF PROBLEM
Global estimates reect that 24.3 million people have dementia today, with 4–6 million
new cases every year (Ferri et al., 2005). e rapid growth of the older adult popu-
lation in the United States is associated with a signicant increase in the prevalence
of dementia. Dementia aects about 5% of individuals aged 65 and older (Richie &
Lovestone, 2002), and the prevalence increases exponentially with age rising to nearly
50% in individuals aged 85 and older (Evans et al., 1989). More than 4.5 million
Americans have the most common form of dementia, Alzheimer’s disease (AD), a num-
ber that is expected to triple by the middle of the 21st century (Hebert, Scherr, Bienias,
Bennett, & Evans, 2003).
is chapter will discuss the most common forms of progressive dementia, AD,
vascular dementia (VaD), and dementia with Lewy bodies (DLB). Less common,
although not less signicant, is progressive dementia associated with Parkinson’s disease
(PDD), frontotemporal dementia, dementias associated with HIV, and Creutzfeld-
Jakob disease.
AD, the most common form of dementia, accounts for more than 60% of all cases.
A chronic neurodegenerative disease, rst described by Alois Alzheimer in 1907, AD is
characterized by neurobrillary plaques and “tangles” in the brain. e extracellular
accumulation of amyloid beta-proteins in the neuritic plaques is one of the hallmarks of
AD (Ariga, Miyatake, & Yu, 2010). e variation in the clinical presentation of the dis-
ease depends on the area of the brain that is aected. Classic features of AD include pro-
gressive loss of memory, deterioration of language and other cognitive functions, decline
in the ability to perform activities of daily living (ADLs), and changes in personality and
behavior and judgment dysfunction (Castellani, Rolston, & Smith, 2010). Mild cogni-
tive impairment (MCI), a syndrome dened as cognitive decline greater than expected
for an individual’s age that minimally interferes with ADLs (Gauthier et al., 2006), may
be a precursor of dementia. Incidence rates of MCI are 51–76.8 per 1,000 person-years,
with a higher incidence in advanced age, lower education, and hypertension (Luck,
Luppa, Briel, & Riedel-Heller, 2010). Individuals with MCI are nearly twice as likely to
die and more than three times as likely to develop AD in a 5-year period as a cohort of
individuals without MCI (Bennett et al., 2002).
VaD, sometimes referred to as vascular cognitive impairment and previously known
as multi-infarct dementia (MID), refers to dementia resulting from cerebrovascular dis-
ease. It is the second most common cause of dementia among older adults and represents
approximately 20% of all cases of dementia in the United States (Román, 2003). ere
are many types of VaD, and lumping them under a single rubric causes some diagnostic
confusion (Kirshner, 2009). e diagnosis of VaD is based on the association between a
cerebrovascular event and the onset of clinical features of dementia, including evidence
of focal decits, gait disturbances, and impairments in executive function. As compared
with AD, memory may not be impaired or is more mildly aected. It is not uncommon
that AD and VaD pathology coexist and this, often referred to as a mixed dementia, is
likely to increase as the population ages (Langa, Foster, & Larson, 2004).
DLB is a neurodegenerative dementia that results when Lewy bodies form in
the brain. Lewy bodies are pathological aggregations of alpha-synuclein found in the
cytoplasma of neurons (McKeith et al., 2003). Clinical features include cognitive and
behavioral changes in combination with features of parkinsonism. Disorders of execu-
tive function occur early. Hallucinations and visuospatial disturbances are prominent.
Although rigidity and unsteady gait are common, tremors are not (Geldmacher, 2004).
Dementia 165
Many, but not all, patients with Parkinson’s disease develop a dementia years after the
motor symptoms appear. Distinctions have been made clinically between the DLB and
the PDD based on the sequence of the appearance of symptoms (McKeith et al., 2005).
DLB and PDD may represent the same pathological process along a disease spectrum
(Hanson & Lippa, 2009).
ASSESSMENT OF THE PROBLEM
Goals of Assessment
Early identication of cognitive impairment is the most important goal in assessment.
Cognitive impairment resulting from conditions such as dementia, delirium, or depres-
sion represents critically serious pathology and requires urgent assessment and tailored
interventions. Yet, diminished or altered cognitive functioning is often perceived by
health care professionals as a normal consequence of aging, and opportunities for timely
intervention are too often missed (Milisen, Braes, Fick, & Foreman, 2006). Although
distinctions have been made comparing the clinical features of the common cognitive
impairments associated with delirium, dementia, and depression, this is dicult to do
clinically because these conditions often coexist and older adults can demonstrate atypi-
cal features in any of these conditions.
e second most important assessment goal is to identify a potentially reversible
primary or contributing cause of a cognitive impairment. e common causes of revers-
ible cognitive impairment (i.e., delirium) in the older adult are covered in the delirium
chapter in this text.
History Taking
Complaints from the patient or observations made by others of memory loss, problems
with decision making and/or judgment, or a decline in an ADL function should alert
the health care professional that a progressive form of dementia might exist. Collect-
ing an accurate history is the cornerstone to the assessment process, yet this obviously
is a challenge in the individual presenting with cognitive impairment. e assessment
domains covered in history taking include functional, cognitive, and behavioral queries
and observations. e history-taking process involves rst interviewing the patient fol-
lowed, perhaps, by clarifying, elaborating, and validating information with the family
or others familiar with the capabilities and expressions of the patient.
Even when a diagnosis of dementia has been made, it is often not communicated
well across care settings. e easiest way to increase recognition of dementia in older
hospital patients is to add the items “severe memory problems,” “AD,” and “dementia”
to the list of diseases and conditions patients and families are routinely asked about on
intake forms and in intake interviews.
Functional Assessment
AD is characterized by deterioration in the ability to perform ADLs. Because cognitive
assessment can be embarrassing and/or threatening, it may be more respectful to initiate
the conversation around the patient’s functional domain. Asking the patient to elabo-
rate on his or her functional abilities in ADLs as well as instrumental activities of daily
living (IADLs) and eliciting any identied decline with specied chronology can pro-
vide some insight. e reader is referred to Chapter 6, Assessment of Physical Function,
166 Evidence-Based Geriatric Nursing Protocols for Best Practice
on function in this test for general approach and tools for functional assessment. Several
functional tools have been tested specically in individuals with dementia.
e Functional Activities Questionnaire (FAQ) is an informant-based measure of
functional ability and has been recognized for its ability to discriminate early dementia
(Pfeer, Kurosaki, Harrah, Chance, & Filos, 1982). An informant, typically the pri-
mary caregiver, is asked to rate the performance of the patient in 10 dierent activities.
e Modied Alzheimer’s Disease Cooperative Study–Activities of Daily Living Inven-
tory (ADCS-ADL) is a specic functional tool used primarily in clinical drug trials to
assess and monitor patients with moderate-to-severe AD (Galasko et al., 1997). Clinical
studies using this scale have indicated that cholinesterase inhibitors oer an eective
approach to treating functional decline (Potkin, 2002). e patient’s daily caregiver is
asked to rate the older adult’s usual performance on the more basic measures of function
over the previous month to identify progression of functional decline.
Cognitive Assessment
e cognitive domain is assessed as part of a broader mental status evaluation, the
components of which are listed in Table 10.1. Whereas some of the parameters of a
mental status evaluation (such as memory or cognition) might be measured with a
standardized tool such as the Mini-Mental State Examination (MMSE), others require
specic inquiry or direct or indirect observation by the health care professional and/or
caregiver. e measure of mood is totally subjective and is based on self-report status.
e evaluation always provides the opportunity to identify sensory impairments (i.e.,
vision and hearing loss), which can further impact cognition, function, and behavior.
ere are a variety of tools for assessing cognitive impairment, some more sensitive to
mild dementia and others to moderate-to-severe dementia.
e gold standard of tools that measure cognition is the MMSE developed more
than 30 years ago (Folstein, Folstein, & McHugh, 1975). Used extensively in clinical
trials as well as in a variety of clinical settings, it is relatively easy to administer and score
and can be used to assess cognitive changes over time. e annual rate of decline on the
MMSE in AD is 3.3 points annually (Han, Cole, Bellavance, McCusker, & Primeau,
2000). e MMSE has established validity and reliability, although concerns continue
to be expressed by clinicians that it is time consuming and, in some circumstances, the
Components of mental status evaluation.
Orientation: person, place, time
Attention and concentration: ability to attend and concentrate
Memory: ability to register, recall, retain
Judgment: ability to make appropriate decisions
Executive control functions: ability to abstract, plan, sequence, and use feedback to guide
performance
Speech and language: ability to communicate ideas and receive and express a message
Presence of delusions, hallucinations
Mood and affect
TABLE 10.1
Dementia 167
relevancy of selected questions has been raised. e MMSE score is strongly related
to education, with high false-positive rates for those with little education, and predic-
tive power is also signicantly inuenced by language (Parker & Philp, 2004). It is
insensitive to executive dysfunction and has been criticized for a lack of sensitivity
in detecting early or mild dementia (Leifer, 2003). As has been suggested with other
measures of cognitive testing, the MMSE may have a cultural bias (Manly & Espino,
2004). Clinicians must remain aware that a high score on the MMSE does not rule
out cognitive decline or the possibility of dementia, particularly in high-functioning
individuals with cognitive complaints (Manning, 2004). e tool is no longer in the
public domain and copyright permission must be secured. A tool with comparable
sensitivity and specicity for detecting dementia is the St. Louis University Medical
Status (SLUMS) examination, and it is available free (Tariq, Tumosa, Chibnall, Perry,
& Morley, 2006).
Unlike the more language-based tools described earlier, the Clock Drawing Test
(CDT) assesses cognition focused on executive function. A systematic review of the
literature identied the CDT’s usefulness in predicting future cognitive impairment
(Peters & Pinto, 2008). Scoring is based on the ability to free-hand draw the face of a
clock, insert the hour numbers in the appropriate location, and then set the hands of
the clock to the time designated by the examiner. e CDT is strongly correlated with
executive function (i.e., the ability to execute complex behaviors and to solve prob-
lems) and is useful in the detection of mild dementia (Royall, Mulroy, Chiodo, & Polk,
1999). It also correlates moderately with driving performance—as the CDT score drops,
the number of driving errors increases (Freund, Gravenstein, & Ferris, 2002; Freund,
Gravenstein, Ferris, Burke, & Shaheen, 2005).
A clinically useful tool that combines the CDT with measures of cognition (i.e., three-
word recall) is the Mini-Cognitive (Mini-Cog; Borson, Scanlan, Brush, Vitaliano, &
Dokmak, 2000). e Mini-Cog detected cognitive impairment in a community sample
of predominately ethnic minority better than primary care physician assessment (84%
vs. 41%), particularly in milder stages of the disease (Borson, Scanlan, Watanabe, Tu, &
Lessig, 2005).
A systematic review of the Mini-Cog for screening for dementia in primary care
demonstrated that it was brief, easy to administer, clinically acceptable and eec-
tive, and minimally aected by education, gender, and ethnicity (Milne, Culverwell,
Guss, Tuppen, & Whelton, 2008) with psychometric properties similar to the MMSE
(Brodaty, Low, Gibson, & Burns, 2006).
Behavioral Assessment
Behavioral changes occur both early and throughout dementia (Kilik, Hopkins, Day,
Prince, Prince, & Rows, 2008) and are also seen in MCI; commonly, these include
depression, anxiety, and irritability (Monastero, Mangialasche, Camarda, Ercolani, &
Camarda, 2009). Regular assessment and monitoring can help identify the triggers of
disruptive behavior and early manifestations of the behavior. Timely interventions that
result in de-escalation of the behavior can help decrease the level of distress experi-
enced by both the patient and the caregiver. Behavioral management can help maintain
functionality and safety. Commonly demonstrated behaviors are those associated with
agitation and psychosis. Asking the patient about levels of restlessness, anxiety, and irri-
tability is important because, at times, these emotional or behavioral states occur even
168 Evidence-Based Geriatric Nursing Protocols for Best Practice
earlier than cognitive changes. Aggression, wandering, delusions and hallucinations,
and resistance to care are manageable with pharmacological and nonpharmacological
treatment options.
e literature on the link between psychosis and aggression in people with dementia
is mixed (Shub, Ball, Abbas, Gottumukkala, & Kunik, 2010). e Neuropsychiatric
Inventory (NPI) measures frequency and severity of psychiatric symptoms and behav-
ioral manifestations in individuals with dementias. e NPI takes about 10 minutes to
administer, during which the caregiver is asked screening and probing questions related
to the presence and degree of behaviors such as agitation, anxiety, irritability, apathy,
and disinhibition. e NPI also includes a measure of caregiver stress. A briefer ques-
tionnaire version, the NPI-Q, also has established validity (Kaufer et al., 2000).
Because as many as 50% of individuals with dementia have coexisting depressive
symptoms (Lee & Lyketsos, 2003), it is important to conduct an adjunctive assessment
of depression. Recognizing depressive symptoms in older adults is challenging, and using
an interviewer-rated instrument is recommended in addition to using clinical judgment
(Onega, 2006). e Geriatric Depression Scale (GDS) is a screening instrument that
takes only a few minutes to administer and is discussed along with appropriate depres-
sion management strategies in detail in Chapter 9, Depression in Older Adults.
Referral of the patient to a neuropsychologist for more extensive neuropsychologi-
cal testing might be indicated to provide more specic diagnostic information associ-
ated with neurodegenerative disease states and areas of brain dysfunction. is kind of
assessment can identify subtle cognitive impairments in higher functioning individuals,
can distinguish MCI from dementia, and can provide direction and support for care
providers and the family (Adelman & Daly, 2005).
Physical Examination and Diagnostics
Once the functional, cognitive, and behavioral domains in progressive dementia have
been established through history taking of the patient and caregiver, a thorough review
of systems is undertaken, followed by the physical examination. e history-taking pro-
cess narrows the dierential diagnosis of reversible and irreversible causes for demen-
tia. A thorough neurological and cardiovascular examination will help to specify the
etiology of a single type or combined dementia that will direct the need for laboratory
and imaging tests. Cardiovascular ndings such as hypertension, arrhythmias, and extra
heart sounds or murmurs along with focal neurological ndings such as weakness and
sensory decit may favor a diagnosis of VaD; pathological reexes, gait disorders, and
abnormal cerebellar ndings may be indicative of AD; and parkinsonian signs might
indicate dementia associated with either Lewy bodies or Parkinson’s disease (Kane,
Ouslander, Abrass, & Resnick, 2009).
ere are no specic laboratory tests for the diagnosis of progressive dementia
other than those that can primarily indicate a potentially reversible or contributing
cause. e American Academy of Neurology (AAN) recommends two specic labora-
tory tests (i.e., thyroid function and B
12
) in the initial evaluation of suspected demen-
tia (Knopman et al., 2001). e AAN similarly recommends that all patients with
suspected dementia have a magnetic resonance imaging (MRI) study or noncontrast
computed tomography (CT) as part of the initial workup. Once dementia has become
clinically relevant and a cause becomes apparent, there is no further diagnostic yield
aorded by imaging.
Dementia 169
Caregiver Assessment
It is important to remember that the caregiver is a patient, too, in that they suer, as does the
patient with dementia. Caregiver need and burden refers to the psychological, physical, and
nancial burden associated with caregiving. Caregivers are at risk for depression, physical
illness, and anxiety (Cooper, Balamurali, & Livingston, 2007; Schoenmakers, Buntinx, &
Delepeleire, 2010). e Zarit Burden Interview (ZBI) can be used to identify the degree
of burden experienced by the caregiver. e ZBI is a four-item screening followed by an
additional 12 items with good reliability and validity (Higginson, Gao, Jackson, Murray, &
Harding, 2010). Administration of this tool to a community-dwelling caregiver can indi-
cate the extent of impact caregiving has on the caregiver’s health, social, and emotional
well-being and nances. e Modied Caregiver Strain Index (CSI) is another tool that has
been used to identify families with caregiving concerns (Onega, 2008). ere is a growing
body of literature that describes the relationship between people with dementia and the
family members who care for them (Ablitt, Jones, & Muers, 2009).
INTERVENTIONS AND CARE STRATEGIES
ere is no cure for progressive dementia. e management of individuals with demen-
tia requires pharmacological and nonpharmacological interventions.
Pharmacological Interventions
e goals of pharmacological therapy in dementia include preserving what the disease
destroys in cognitive and functional ability, minimizing what the disease imposes in the
way of behavior disturbances, and slowing the progression of the disease eects brought
on by the destruction of neurons (Geldmacher, 2003). Nurses, regardless of whether they
are the prescribers of drug therapy, need to be informed about the variety of drugs used
in managing dementia and the evidence supporting the pharmacological approaches.
Although there is substantial evidence that adults with mild-to-moderate AD (and perhaps
VaD and DLB) would benet from drug therapy, there are no solid data in support for
drug therapy into the advanced stage of the disease (Olsen, Poulsen, & Lublin, 2005).
Acetylcholinesterase inhibitors are the mainstay of treatment. Four are currently
available in the United States: donepezil hydrochloride (Aricept), rivastigmine tartrate
(Exelon), galantamine hydrobromide (Reminyl), and tacrine hydrochloride (Tacrine)—
the oldest and less favored drug because of its adverse eect on the liver and multiple
daily dosing. Cognitive improvements in patients with mild-to-moderate AD have
been shown for each of the other three drugs (Birks, Grimley Evans, Iakovidou, &
Tsolaki, 2000; Birks & Harvey, 2006; Loy & Schneider 2006). ese drugs also provide
cognitive and behavioral improvement in other forms of progressive dementia including
VaD (Kavirajan & Schneider 2007) and DLB (Erkinjuntti et al., 2002; Wild, Pettit, &
Burns, 2003). With the exception of Tacrine, the acetylcholinesterase inhibitors are safe
and well tolerated; however, they may have gastrointestinal side eects (i.e., nausea,
anorexia, and diarrhea). Dementia pharmacological therapy can improve the quality of
life for the patient and the caregiver and delays nursing home placement (Geldmacher,
Provenzano, McRae, Mastey, & Ieni, 2003; Lopez et al., 2002). Rivastigmine is also
available as a transdermal patch.
Memantine (Namenda), approved for moderate-to-severe dementia, has a dierent
mechanism of action than the acetylcholinesterase inhibitors. is N-methyl-D-aspartate
170 Evidence-Based Geriatric Nursing Protocols for Best Practice
receptor antagonist has neuroprotective eects that prevent excitatory neurotoxicity.
Individuals with AD and VaD have improved cognition and behavior on this drug
(McShane, Areosa Sastre, & Minakaran, 2006). Side eects of memantine, although
uncommon, include diarrhea, insomnia, and agitation. Combined administration of
cholinesterase inhibitors with memantine demonstrated increased ecacy in advanced
AD as compared to cholinesterase inhibitors alone (Riepe et al., 2007).
Pharmacological Therapy for Problematic Behaviors
Behavior changes are common in the mid to later stages of progressive dementia and,
although nonpharmacological interventions are preferred, supplementation with a
tailored drug regimen is sometimes necessary. Psychotropic medications, primarily
antipsychotics, can be administered to help the individual regain control and be less
disruptive—positive outcomes for the caregiver as well as the patient. Drugs must be
prescribed in the lowest eective dose for the shortest amount of time (Gray, 2004).
e patient needs to be closely monitored for eectiveness and adverse side eects. Psy-
chotropic medications have a high risk of adverse drug events and this is covered in the
Chapter 17, Reducing Adverse Drug Events.
Psychotropic therapy for dierent behaviors is always short term (i.e., 3–6 months).
Once the target symptoms are relieved or abbreviated, then consideration must be given
to terminate therapy. Long-term psychotropic drug therapy should be considered only
if the symptoms reoccur. Psychotic symptoms (such as delusions and hallucinations)
frequently occur in the later stages of progressive dementia (Ropacki & Jeste, 2005) and
are often associated with agitation and aggression (Holroyd, 2004). e conventional
antipsychotic haloperidol (Haldol) has been used for decades and remains the most
commonly used drug for control of psychotic symptoms in individuals with dementia.
A Cochrane Review (Lonergan, Luxenberg, & Colford, 2002) validated the useful role
of Haldol in managing aggression but did not nd evidence for its role in managing
agitation for patients with dementia. e side eects of conventional antipsychotics
are considerable and include extrapyramidal symptoms, tardive dyskinesia, sedation,
orthostatic hypotension, and falls.
Although not approved by the U.S. Food and Drug Administration (FDA), the
atypical antipsychotics are often prescribed for use in patients with dementia. Evidence
reects that they may benet people with dementia, but the risks of adverse events
(e.g., cardiovascular, extrapyrimidal symptoms) may outweigh the benet, especially
with long-term treatment (Ballard & Waite, 2006). Agents available on the market
include risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and paliperidone.
ere is little to no published data on the ecacy and safety of the last three drugs listed
earlier. Additional research is needed to determine when and how to use psychotropic
medications to address behaviors in individuals with dementia. Other drug categories
are sometimes used to control behavioral symptoms.
Benzodiazepines (e.g., lorazepam, oxazepam, alprazolam) are sometimes used to
manage agitation and aggression; however, the risk–benet ratio is often unsatisfactory.
Although benzodiazepines may be useful in rapidly sedating the agitated patient with
dementia, the potential for falls and worsening of cognition limit long-term use.
Although antidepressants and anticonvulsants are sometimes used to treat agitation
in dementia, there is insucient evidence to support their use. Behavioral disturbances
should not necessarily be interpreted as depression.
Dementia 171
Supplemental Drugs
Anti-inammatory drugs and estrogen; herbals such as gingko; and vitamins such as
B
12
, folate, and vitamin E—although sometimes touted and commonly used—have
no proven ecacy for dementia, although some isolated studies have demonstrated a
benet. Dementia associated with VaD requires appropriate control of hypertension,
hyperlipidemia, and aspirin therapy. Parkinsonism (rigidity), seen with DLB, may ben-
et from dopaminergic therapy.
Nonpharmacological Strategies
Nonpharmacological strategies including those from the cognitive, behavioral, and
environmental domains in combination with sta support and education are eective
(Burgener & Twigg, 2002). Physical/functional, environmental, psychosocial, behav-
ioral, and end-of-life (EOL) care interventions are discussed in the succeeding section.
Physical/Functional Interventions
Maintaining physical and functional well-being of the individual with progressive
dementia facilitates independence, maintains health status, and can ease the caregiving
burden. Interventions include adequate nutrition and hydration, regular exercise, main-
tenance of ADLs, proper rest and sleep, appropriate bowel and bladder routines, proper
dental hygiene and care, and current vaccinations. Because comorbidities are common
(Lyketsos et al., 2005), regular assessment, vigilant monitoring, and aggressive manage-
ment of acute and chronic conditions are necessary. Vehicular driving safety might need
to be examined because recent evidence indicates that individuals with dementia pose
a risk in driving safety (Man-Son-Hing, Marshall, Molnar, & Wilson, 2007). ere
is insucient evidence to support or refute the benet of neuropsychiatric testing or
intervention strategies for drivers with dementia (Iverson et al., 2010).
Environmental Interventions
A specialized ecological model of care, which facilitates interaction between the person
and environment in a more home-like environment, has proven to be benecial for indi-
viduals with dementia. is model aords greater privacy, encourages meaningful activi-
ties, and permits more choice than the traditional model of care. It also demonstrates that
individuals with dementia experience less decline in ADLs and are more engaged with the
environment with no measurable dierences found in cognitive measures, depression, or
social withdrawal (Reimer, Slaughter, Donaldson, Currie, & Eliasziw, 2004).
A systematic review reported inclusive results and suggested that more research is
needed with regard to the use of bright light in fostering better sleep and reducing
behavior problems in dementia (Forbes et al., 2009). e use of aromatherapy to reduce
disturbed behavior, promote sleep, and stimulate motivation also shows promise but
needs more study (orgrimsen, Spector, Wiles, & Orrell, 2003). Manipulation of the
environment (e.g., alarms, circular hallways, visual or structural barriers) to minimize
wandering has not conclusively demonstrated to be eective (Peateld, Futrell, & Cox,
2002). ere is a lack of robust evidence supporting nonpharmacological interventions
for wandering (Robinson et al., 2007).
172 Evidence-Based Geriatric Nursing Protocols for Best Practice
Psychosocial Interventions
Mental and social engagement is important to the well-being of all older adults. Meaning-
ful activity and involvement is no less important in individuals with dementia. Although
the eectiveness of counseling or procedural memory stimulation is not supported in mild-
stage dementia, reality orientation does appear to be eective (Bates, Boote, & Beverley,
2004). e evidence suggests that cognitive therapy is more benecial than no therapy at
all, but it may be patient-specic (Forbes, 2004). Validation therapy, based on caregiver
acceptance of the reality of the person with dementia’s experience, may be of value but the
evidence is lacking (Neal & Briggs, 2003).
Recreational therapies including music have shown to reduce psychological symptoms
in dementia with limited ecacy and questionable duration of action (O’Connor, Ames,
Gardner, & King, 2009), and more research is needed to explore the eects of music ther-
apy on the behavior and well-being of individuals with dementia (Wall & Duy, 2010).
Support groups, counseling, and education for individuals with early AD and their
caregivers are essential. Caregivers often experience physical, nancial, social, and emo-
tional losses, and providing information through a structured education program and
engaging them in the care planning process are essential (Jayasekara, 2009). Areas for
caregiver education are detailed in Table 10.2.
Behavioral Interventions
Behavioral and psychosocial symptoms of dementia are common with every form of pro-
gressive dementia, particularly in the moderate stage. e three most troublesome symp-
toms are agitation, aggression, and wandering. Problematic behaviors that occur during
meals or bathing can be particularly challenging. It is important to recognize and realize
that any new behavior could be a sign of an acute illness or an environmental inuence.
Unrecognized pain can cause disruptive behavior. Short-term use of physical restraints may
be necessary, but those selected should always be the least restrictive type and used for the
shortest duration of time. e Progressively Lowered Stress reshold (PLST) is a framework
to optimize function, minimize disruption, and help the caregiver (Smith, Hall, Gerdner,
& Buckwalter, 2006). e PLST model increases the positive appraisal and decreases the
negative appraisal of the caregiving situation (Stolley, Reed, & Buckwalter, 2002) and helps
Points to cover when educating caregivers.
Information about the disease and its progression
Strategies to maintain function and independence
Preservation of cognitive and physical vitality in dementia
Maintaining a safe and comfortable environment
Giving physical and emotional care
Communicating with the individual with dementia
Managing behavioral problems
Advance planning: health care and finances
Caregiver survival tips
Building a caregiver support network
TABLE 10.2
Dementia 173
the caregiver manage the aggressive behaviors demonstrated in AD (Lindsey & Buckwalter,
2009). By adapting the environment and routines, interventions are designed to help the
patient with dementia use his or her functional skills and minimize potentially triggering
reactions. ere are six essential principles of care in the PLST:
1. Maximize safe function: Use familiar routines, limit choices, provide rest periods,
reduce stimuli when stress occurs, and routinely identify and anticipate physical
stressors (i.e., pain, urinary symptoms, hunger, or thirst).
2. Provide unconditional positive regard: Use respectful conversation, simple and under-
standable language, and nonverbal expressions of touch.
3. Use behaviors to gauge activity and stimulation: Monitor for early signs of anxiety
(e.g., pacing, facial grimacing) and intervene before behavior escalates.
4. Teach caregivers to “listen” to the behaviors: Monitor the language pattern (e.g., repeti-
tion, jargon) and behaviors (e.g., rummaging) that might be showing how the person
reduces stress when needs are not being met.
5. Modify the environment: Assess the environment to ensure safe mobility and promote
way nding and orientation through cues.
6. Provide ongoing assistance to the caregiver: Assess and address the need for education
and support.
Advance Planning and End-of-Life Care Interventions
Advanced planning and providing directives for care are important in guiding the types
of interventions used at the end of life and can decrease the caregiver stress in proxy
decision making. Nursing homes are common sites for EOL care for people with pro-
gressive dementia; however, only 51% of all nursing home residents nationally have an
advance directive (Mezey, Mitty, Bottrell, Ramsey, & Fisher, 2000). As many as 90% of
the 4 million Americans with dementia will be institutionalized before death (Smith,
Kokmen, & O’Brien, 2000), making this environment in particular an important focus
for EOL care. ere is a lack of research published on EOL care in nursing homes and
most of it is descriptive (Oliver, Porock, & Zweig, 2004). e end stage of AD may last
as long as 2–3 years (Brookmeyer, Corrada, Curriero, & Kawas, 2002) and frequently
distressing signs and symptoms occur at this time.
Dementia itself or often-associated conditions can cause physical symptoms such
as poor nutrition, urinary incontinence, skin breakdown, pain, infection, shortness of
breath, fatigue, diculty in swallowing, choking, and gurgling in addition to the behav-
ioral symptoms mentioned earlier. ere is no acceptable standard treatment for the
consequences of advanced dementia and, where guidelines do exist, there is minimal
to no palliative care content. Aggressive treatments such as antibiotics, tube feedings,
psychotropic drugs, and physical restrains to address problematic behaviors appear to be
prevalent, although there is no substantial evidence that these approaches are eective in
end-stage dementia and that prognosis and life expectancy are improved by these strate-
gies (Evers, Purohit, Perl, Khan, & Marin, 2002). Measuring quality of care at the end
of life for those with dementia poses signicant challenges because of the limitations in
subjective reporting and therefore relies on the caregiver’s analysis of cues to monitor
the patient’s condition and experience (Volicer, Hurley, & Blasi, 2001). Despite the
clear recognition that signicant improvements in EOL care for those with dementia is
needed (Scherder et al., 2005), there is a lack of systematic evidence on how to approach
palliative care for this population (Sampson, Ritchie, Lai, Raven, & Blanchard, 2005).
174 Evidence-Based Geriatric Nursing Protocols for Best Practice
Mrs. P. is an 85-year-old Caucasian woman brought into the primary care clinic by her
daughter for a geriatric consultation. She has a 4-year history of cognitive impairment
that began with memory loss and impaired judgment that appears to be worsening;
she is now experiencing some behavioral problems. Mrs. P. is high school educated,
has been widowed for 10 years, and is a retired short-order cook. She currently lives
with her daughter, son-in-law (both work full time), and grandson.
Her primary care physician completed a dementia workup at the time the symp-
toms appeared 4 years ago and started her on Donepezil, which was discontinued
within a few days because of gastrointestinal side eects. She recently had paranoid
ideation in which she accused her 15-year-old grandson of listening in on her phone
conversations and taking some money from her purse. Her daughter reports that
Mrs. P. has “a short fuse” and gets agitated easily. “She called me a moron and even
took a swing at me the other day when I told her she smelled bad and needed to take
a shower.”
Mrs. P. performs her own personal hygiene, although she needs reminders and
cueing at times; she is continent. She does not perform any IADLs (e.g., cook-
ing, shopping), and it was unclear if she truly was no longer capable of perform-
ing these functions or no longer had the opportunity or desire to do them. Mrs.
P. reports no desire to eat and had a weight loss resulting in a change in at least
three clothing sizes that has occurred slowly over the past few years. When asked
about her mood, she becomes tearful and says, “I get disgusted; no one cares about
me anymore.” Mrs. P. says she hates to be alone and that the family “just come
and goes—they never talk with me.” Her MMSE score is 18/30, with decits in
memory, calculation, and ability to copy the intersecting pentagons. She scores
10/15 on the GDS.
Past medical history includes thyroidectomy, left cataract extraction, cholecys-
tectomy, and hysterectomy for benign disease. Her daughter thinks that Mrs. P.
may have been on antihypertensives in the past. e only medication Mrs. P. takes
at present is for her thyroid, but neither she nor her daughter knew the name of
the drug.
On physical exam, she is afebrile; her blood pressure is 132/70, and she is about
10 lbs below her ideal body weight. Mrs. P. is alert, cooperative, and smiles at inter-
vals during the examination and has slight hearing loss with clear canals—no thy-
romegaly. Cardiovascular exam reveals no murmur, edema, or discolorations of the
extremities. Pulses are strong throughout. ere are no focal neurological symptoms.
Gait is slow but steady. Breasts are free of masses and abdomen is soft, nontender, and
with no organ enlargement.
A diagnosis of depression and progressive dementia of the Alzheimer’s type is
made, and she is started on the combination of Donepezil and Memantine, both to
be titrated slowly. Additional information from Mrs. P’s primary care physician will
be consulted about her thyroid function. Antidepressant therapy may be considered
at a later date. Health teaching and additional resource information is provided to the
family.
CASE STUDY
(continued)
Dementia 175
Case Study Discussion
Depression is not uncommon in those with a progressive dementia. Severe anxi-
ety, agitation, and aggression can occur; tearfulness and decreased appetite with
weight loss may also be present. Using the PLST model, the nurse focuses on
teaching the daughter to recognize triggers and prodromal signs of increasing
anxiety and intervene appropriately when anxiety and agitation occur. Strategies
are emphasized in each of the six PLST principles of care: maximize safe function,
provide unconditional regard, use behaviors to gauge activity and stimulation,
“listen” to the behaviors, modify the environment, and provide ongoing assis-
tance to the caregiver. Less confrontational language and behaviors are empha-
sized in approaches and interactions with Mrs. P. e daughter is also provided
with specic contact information of the geriatrician’s oce as well as the local
and national resources available through the Alzheimer’s Association (1-800-272-
3900; www.alz.org) and the Alzheimer’s Disease Education and Referral Center
(ADEAR; 1-800-438-4380; http://www.nia.nih.gov/ Alzheimers/). Additional
instructions include dietary strategies to increase nutritional density, noting that
additional resource information is available at the ADEAR site listed herein. Spe-
cic medication instructions with particular emphasis on how to use the titra-
tion packet are provided—with the recommendation to coadminister with food to
reduce the likelihood of gastrointestinal side eects. e nurse plans a follow-up
phone call for the next day and schedules a follow-up medical and health teach-
ing appointment in 1 month to evaluate the eectiveness of the plan of care. e
patient and family are instructed to call or return if new or changed behaviors or
physical symptoms develop.
SUMMARY
It is important that health care professionals identify cognitive impairments in
older adults early and dierentiate a progressive from a reversible etiology, such as
delirium. Comprehensive assessment, monitoring and pharmacological, and non-
pharmacological management of physical, functional, cognitive, and behavioral
problems are important, both in initial identication and in the ongoing care of
the individual with progressive dementia. Education and support of the family and
professional caregiver are essential. It is dicult to identify clearly what consti-
tutes quality of life for the individual with progressive dementia, what interventions
enhance this quality, and how this is accomplished. ere is limited evidence in
gerontological nursing to guide our care (Abraham, MacDonald, & Nadzam, 2006).
It is imperative that geriatric nurses evaluate practice and generate new knowledge
to ensure best practice in the care of individuals with progressive dementia as well
as their caregivers.
CASE STUDY (continued)
176 Evidence-Based Geriatric Nursing Protocols for Best Practice
Protocol 10.1: Recognition and Management of Dementia
I. GOALS
A. Early recognition of dementing illness
B. Appropriate management strategies in care of individuals with dementia
II. OVERVIEW
e rapid growth of the aging population is associated with an increase in the preva-
lence of progressive dementias. It is imperative that a dierential diagnosis be ascer-
tained early in the course of cognitive impairment and that the patient is closely
monitored for coexisting morbidities. Nurses have a central role in assessment and
management of individuals with progressive dementia.
III. BACKGROUND
A. Denitions/Distinctions
1. Dementia is a clinical syndrome of cognitive decits that involves both
memory impairments and a disturbance in at least one other area of
cognition, such as aphasia, apraxia, agnosia, and disturbance in executive
functioning.
2. In addition to disruptions in cognition, dementias are commonly associated
with changes in function and behavior.
3. e most common forms of progressive dementia are Alzheimer’s disease
(AD), vascular dementia, and dementia with Lewy bodies; the pathophysi-
ology for each is poorly understood.
4. Dierential diagnosis of dementing conditions is complicated by the fact
that concurrent disease states (i.e., comorbidities) often coexist.
B. Prevalence
1. Dementia aects about 5% of individuals 65 years and older.
2. Four to ve million Americans have AD.
3. Fourteen million are projected to have AD by the year 2040.
4. Global prevalence of dementia is about 24.3 million, with 6 million new
cases every year.
C. Risk Factors
1. Advanced age
2. Mild cognitive impairment
3. Cardiovascular disease
4. Genetics: family history of dementia, Parkinson’s disease, cardiovascular
disease, stroke, presence of ApoE4 allele on chromosome 19
5. Environment: head injury, alcohol abuse
IV. PARAMETERS OF ASSESSMENT
No formal recommendations for cognitive screening are indicated in asymptom-
atic individuals. Clinicians are advised to be alert for cognitive and functional
decline in older adults to detect dementia and dementia-like presentation in early
(continued)
NURSING STANDARD OF PRACTICE
Dementia 177
stages. Assessment domains include cognitive, functional, behavioral, physical,
caregiver, and environment.
A. Cognitive Parameters
1. Orientation: person, place, time
2. Memory: ability to register, retain, recall information
3. Attention: ability to attend and concentrate on stimuli
4. inking: ability to organize and communicate ideas
5. Language: ability to receive and express a message
6. Praxis: ability to direct and coordinate movements
7. Executive function: ability to abstract, plan, sequence, and use feedback to
guide performance
B. Mental Status Screening Tools
1. Folstein Mini-Mental State Examination is the most commonly used test to
assess serial cognitive change. e MMSE is copyrighted and a comparable
tool called the St. Louis University Medical Status (SLUMS) Examination
is in the public domain.
2. Clock Drawing Test (CDT) is a useful measure of cognitive function that
correlates with executive control functions.
3. Mini-Cognitive (Mini-Cog) combines the Clock Drawing Test with the
three-word recall.
When the diagnosis remains unclear, the patient may be referred for more extensive
screening and neuropsychological testing, which might provide more direction and
support for the patient and the caregivers.
C. Functional Assessment
1. Tests that assess functional limitations such as the Functional Activities
Questionnaire (FAQ) can detect dementia. ey are also useful in monitor-
ing the progression of functional decline.
2. e severity of disease progression in dementia can be demonstrated by per-
formance decline in activity of daily living (ADL) and instrumental activity
of daily living (IADL) tasks and is closely correlated with mental status
scores.
D. Behavioral Assessment
1. Assess and monitor for behavioral changes, in particular, the presence of
agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.
2. Evaluate for depression because it commonly coexists in individuals with
dementia. e Geriatric Depression Scale (GDS) is a good screening tool.
E. Physical Assessment
1. A comprehensive physical examination with a focus on the neurological
and cardiovascular system is indicated in individuals with dementia to iden-
tify the potential cause and/or the existence of a reversible form of cognitive
impairment.
2. A thorough evaluation of all prescribed, over-the-counter, homeopathic,
herbal, and nutritional products taken is done to determine the potential
impact on cognitive status.
(continued)
Protocol 10.1: Recognition and Management of Dementia (cont.)
178 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Laboratory tests are valuable in dierentiating irreversible from reversible
forms of dementia. Structural neuroimaging with noncontrast computed
tomography (CT) or magnetic resonance imaging (MRI) scans are appro-
priate in the routine initial evaluation of patients with dementia.
F. Caregiver/Environment
e caregiver of the patient with dementia often has as many needs as the
patient with dementia; therefore, a detailed assessment of the caregiver and the
caregiving environment is essential.
1. Elicit the caregiver perspective of patient function and the level of support
provided.
2. Evaluate the impact that the patient’s cognitive impairment and problem
behaviors have on the caregiver (mastery, satisfaction, and burden). Two
useful tools include the Zarit Burden Interview (ZBI) and the Caregiver
Strain Index (CSI) tool.
3. Evaluate the caregiver’s experience and patient–caregiver relationship.
V. NURSING CARE STRATEGIES
e Progressively Lowered Stress reshold (PLST) provides a framework for the
nursing care of individuals with dementia.
A. Monitor the eectiveness and potential side eects of medications given to
improve cognitive function or delay cognitive decline.
B. Provide appropriate cognitive enhancement techniques and social engagement.
C. Ensure adequate rest, sleep, uid, nutrition, elimination, pain control, and
comfort measures.
D. Avoid the use of physical and pharmacological restraints.
E. Maximize functional capacity: maintain mobility and encourage independence
as long as possible; provide graded assistance as needed with ADL and IADL;
provide scheduled toileting and prompted voiding to reduce urinary inconti-
nence; encourage an exercise routine that expends energy and promotes fatigue
at bedtime; and establish bedtime routine and rituals.
F. Address behavioral issues: identify environmental triggers, medical conditions,
caregiver–patient conict that may be causing the behavior; dene the target
symptom (i.e., agitation, aggression, wandering) and pharmacological (psycho-
tropics) and nonpharmacological (manage aect, limit stimuli, respect space,
distract, redirect) approaches; provide reassurance; and refer to appropriate
mental health care professionals as indicated.
G. Ensure a therapeutic and safe environment: provide an environment that is mod-
estly stimulating, avoiding overstimulation that can cause agitation and increase
confusion and understimulation that can cause sensory deprivation and with-
drawal. Utilize patient identiers (name tags), medic alert systems and bracelets,
locks, and wander guard. Eliminate any environmental hazards and modify the
environment to enhance safety. Provide environmental cues or sensory aids that
facilitate cognition, and maintain consistency in caregivers and approaches.
H. Encourage and support advance care planning: explain trajectory of progressive
dementia, treatment options, and advance directives.
(continued)
Protocol 10.1: Recognition and Management of Dementia (cont.)
Dementia 179
I. Provide appropriate end-of-life care in terminal phase: provide comfort mea-
sures including adequate pain management; weigh the benets/risks of the use
of aggressive treatment (e.g., tube feeding, antibiotic therapy).
J. Provide caregiver education and support: respect family systems/dynamics and
avoid making judgments; encourage open dialogue, emphasize the patient’s
residual strengths; provide access to experienced professionals; and teach care-
givers the skills of caregiving.
K. Integrate community resources into the plan of care to meet the needs for
patient and caregiver information; identify and facilitate both formal (e.g.,
Alzheimer’s association, respite care, specialized long-term care) and informal
(e.g., churches, neighbors, extended family/friends) support systems.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient Outcomes: e patient remains as independent and functional in the
environment of choice for as long as possible, the comorbid conditions the
patient may experience are well managed, and the distressing symptoms that
may occur at end of life are minimized or controlled adequately.
B. Caregiver Outcomes (lay and professional): Caregivers demonstrate eec-
tive caregiving skills; verbalize satisfaction with caregiving; report minimal
caregiver burden; are familiar with, have access to, and utilize available
resources.
C. Institutional Outcomes: e institution reects a safe and enabling environment
for delivering care to individuals with progressive dementia; the quality
improvement plan addresses high-risk problem-prone areas for individuals
with dementia, such as falls and the use of restraints.
VII. FOLLOW UP TO MONITOR CONDITION
A. Follow-up appointments are regularly scheduled; frequency depends on the
patient’s physical, mental, and emotional status and caregiver needs.
B. Determine the continued ecacy of pharmacological/nonpharmacological
approaches to the care plan and modify as appropriate.
C. Identify and treat any underlying or contributing conditions.
D. Community resources for education and support are accessed and utilized by
the patient and/or caregivers.
VIII. RELEVANT PRACTICE GUIDELINES
A. American Academy of Neurology: Detection of Dementia, Diagnosis of
Dementia, Management of Dementia, and Encounter Kit for Dementia;
http://www.aan.com/go/practice/guidelines
B. American Association of Geriatric Psychiatry: Position Statement: Principles of
Care for Patients With Dementia Resulting From Alzheimer Disease; http://
www.aagponline.org/prof/position_caredmnalz.asp
C. Alzheimer’s Foundation of America (AFA): Excellence in Care; http://www.
alzfdn.org
Protocol 10.1: Recognition and Management of Dementia (cont.)
180 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
Alzheimer’s Association
http://www.alz.org
Alzheimer’s Disease Education and Referral Center
http://www.alzheimers.nia.nih.gov
e National Family Caregiver’s Association (NFCA)
http://www.nfcacares.org
American Association of Retired Persons (AARP)
http://www.aarp.org/caregiving
ElderWeb
http://www.elderweb.com
ConsultGeriRN
http://www.consultgerirn.org/resources
Hartford Institute for Geriatric Nursing
http://www.hartfordign.org/
National Conference of Gerontological Nurse Practitioners: Mental Health Toolkit
http://www.ncgnp.org/
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186
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe hospitalized older adults at risk for delirium
2. list four outcomes associated with delirium
3. discuss the importance of early recognition of delirium
4. develop a plan to prevent or treat delirium
OVERVIEW
Delirium is a common syndrome in hospitalized older adults and is one of the major
contributors to poor outcomes of health care and institutionalization for older patients
(Siddiqi, House, & Holmes, 2006). Delirium has been shown to be preventable by
identifying modiable risk factors and using a standardized nursing practice proto-
col (Milisen, Lemiengre, Braes, & Foreman, 2005) and involving a geriatric special-
ist (Siddiqi, Stockdale, Britton, & Holmes, 2007). If delirium does develop, early
recognition is of paramount importance in order to treat the underlying pathology
and minimize delirium’s sequelae. Nurses play a key role in both the prevention and
early recognition of this potentially devastating condition in older hospitalized adults
(Milisen et al., 2005).
BACKGROUND AND STATEMENT OF PROBLEM
Definition
Delirium is a disturbance of consciousness with impaired attention and disorganized
thinking that develops rapidly and with evidence of an underlying physiologic or medi-
cal condition (American Psychiatric Association [APA], 2000). Delirium is character-
ized by a reduced ability to focus, sustain, or shift attention; memory impairment;
Dorothy F. Tullmann, Kathleen Fletcher, and
Marquis D. Foreman
Delirium
11
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Delirium 187
disorientation and/or illusions; visual or other hallucinations; or misperceptions of stim-
uli. Delusional thinking may also occur. Unlike other chronic cognitive impairments,
delirium develops over a short time and tends to uctuate during the course of the day.
A patient may present with either hyperactive, hypoactive, or mixed motoric subtypes
of delirium (Meagher, 2009). Nurses typically associate delirium with hyperactivity and
distressing, time-consuming, and harmful patient behaviors. However, the hypoactive
subtype, with its lack of overt psychomotor activity, is also common (Meagher, 2009;
Pandharipande, Cotton, et al., 2007) and has a higher risk of mortality, especially when
superimposed on dementia (Yang et al., 2009).
Etiology and Epidemiology
Prevalence and Incidence
Among medical inpatients, delirium is present on admission to the hospital in 10%–31%
of older patients, and during hospitalization, 11% to 42% of older adults develop
delirium (Siddiqi et al., 2006). Among hip surgery patients, the incidence of delirium
is 4%–53%. ose with hip fractures and cognitive impairment have the highest risk
of delirium. (Bruce, Ritchie, Blizard, Lai, & Raven, 2007). Older adults admitted to
medical intensive care units (ICUs) have both prevalent and incident delirium of 31%
(McNicoll et al., 2003). In surgical (S) ICUs, the prevalence of delirium on admis-
sion is only 2.6%, but 28.3% develop delirium during their SICU stay (Balas et al.,
2007). Up to 83% of mechanically ventilated patients in ICUs experience delirium (Ely,
Inouye, et al., 2001), and more than half of older patients in medical ICUs still have
delirium when transferred (Pisani, Murphy, Araujo, & Van Ness, 2010). e incidence
of delirium superimposed on dementia ranges from 22% to 89% (Fick, Agostini, &
Inouye, 2002). Delirium may persist for months after discharge (Cole, Ciampi, Belzile,
& Zhong, 2009).
Pathophysiology
e pathogenesis of delirium is not well understood, but increasing evidence supports
cholinergic deciency and/or dopamine excess as well as cytokine activity as causes of
delirium (Inouye, 2006). A genetic association between delirium and the apolipopro-
tein E epsilon 4 allele has also been identied (van Munster, Korevaar, Zwinderman,
Leeang, & de Rooji, 2009).
Risk Factors
e strongest predisposing risk factors for delirium are age (70 years and older), sever-
ity of illness, and cognitive impairment (Michaud et al., 2007). Other factors include
depression, sensory impairment, uid and electrolyte disturbances, and polyphar-
macy (especially psychotropics). Precipitating factors for delirium occurring during
hospitalization include central nervous system pathology (such as stroke), metabolic,
electrolyte and/or endocrine disturbances, and infection and drug toxicity or with-
drawal. Pain, hypoperfusion/hypoxia, number of drugs (especially psychotropic and
anticholinergic), and restraints have also been implicated. Finally, environmental fac-
tors such as ICU admission, multiple room changes, and an absence of a clock or
glasses may also contribute to the development of delirium (Michaud et al., 2007). In
older patients admitted for hip surgery, early cognitive impairment, such as memory
188 Evidence-Based Geriatric Nursing Protocols for Best Practice
impairments, incoherence, disorientation, as well as an underlying physical illness
and age, are especially strong predictors of delirium (de Jonghe et al., 2007; Kalisvaart
et al., 2006).
Outcomes
e outcomes of delirium are grave, especially in hospitalized older patients whose delir-
ium persists postdischarge. ose with persistent delirium at 1, 3, and 6 months post-
discharge consistently have increased mortality, nursing home placement, and decreased
functional status and cognition than older adults who do not experience delirium (Cole,
McCusker, Ciampi, & Belzile, 2008; Witlox et al., 2010).
Delirium also results in signicant distress for the patient, their family members,
and nurses (Bruera et al., 2009; Cohen, Pace, Kaur, & Bruera, 2009). Clearly, delirium
is a high-priority nursing challenge for all who care for hospitalized older adults.
ASSESSMENT OF THE PROBLEM
e rst critically important step in the assessment of delirium is identifying the risk
factors for delirium (see discussed “Risk Factors”) because eliminating or reducing these
risk factors may prevent delirium in many cases (Milisen et al., 2005). Recognizing the
features of delirium is important in order to further identify, eliminate, or reduce the
precipitating factor(s) such as pain, infection, or other acute illnesses. is can best be
done by routinely assessing patients at risk for delirium with a standardized screening
tool for delirium (see “Resources” section), although this is currently occurring only in
17% of hospitals (Neuman, Speck, Karlawish, Schwartz, & Shea, 2010).
e Confusion Assessment Method (CAM) has high sensitivity and specicity in
ICU, Emergency Department, acute and long-term care settings for detecting delir-
ium (Wei, Fearing, Sternberg, & Inouye, 2008), and is the most widely used delirium
screening instrument in hospitalized older adults. A version of the CAM for patients in
intensive care units (CAM-ICU; Ely, Margolin, et al., 2001) is recommended for use
with critically ill older adults (Jacobi et al., 2002; Schuurmans, Deschamps, Markham,
Shortridge-Baggett, & Duursma, 2003). e CAM instrument identies the key fea-
tures of delirium—acute onset, inattention, disorganized thinking, altered level of con-
sciousness, disorientation, memory impairment, perceptual disturbances, psychomotor
agitation or retardation, and altered sleep–wake cycles (Inouye et al., 1990). For a diag-
nosis of delirium, there must be the presence of Feature 1 (acute onset or uctuat-
ing course), Feature 2 (inattention), and either Feature 3 (disorganized thinking) or
Feature 4 (altered level of consciousness).
It is important to remember that delirium may occur concurrently with dementia
or depression. From 22% to 89% of older adults with dementia also have delirium
superimposed on the dementia (Fick et al., 2002). As noted, patients with dementia are
at increased risk for developing delirium and have worse outcomes when they do (Yang
et al., 2009). Family and caregivers can be invaluable in helping to distinguish cogni-
tive changes in those circumstances when the patient is not well known (see Chapter 8,
Assessing Cognitive Function).
Bedside nurses are in the best position to recognize delirium because they possess
the skill and responsibility of ongoing patient assessment and are in key positions to
recognize risk factors for delirium and the earliest cognitive changes heralding the onset
of delirium. Early identication of risk factors for and the earliest onset of delirium are
Delirium 189
critical to implement strategies to minimize the occurrence of this devastating pathology
in hospitalized older adults.
INTERVENTIONS AND CARE STRATEGIES
According to the most recent Cochrane Review (Siddiqi et al., 2007), there is no strong
evidence from delirium prevention studies to guide clinical practice. Only one of six
randomized controlled trials (RCT) eectively prevented delirium with proactive geri-
atric consultation for older adults undergoing surgery for hip fracture (Marcantonio
et al., 2001). Prophylactically administered low-dose haloperidol reduced the severity
and duration of delirium but not its incidence (Kalisvaart et al., 2005). However, given
the prevalence and seriousness of delirium, its complex and varied etiology, and the
challenges associated with conduction RCTs, we strongly recommend the use of clinical
practice guidelines based on other strong intervention studies for both prevention and
treatment of delirium.
Once it has been determined that the patient is at risk for delirium, a standardized
delirium protocol should be initiated immediately. Protocols tested in two multicom-
ponent interventions eectively prevented delirium (Inouye et al., 1999; Marcantonio
et al., 2001). e protocols varied somewhat, but two principles emerged from the
research: Minimize the risk for delirium by preventing or eliminating the etiologic agent
or agents and provide a therapeutic environment and general supportive nursing care
(see Section V, Nursing Care Strategies, in Protocol 11.1). Older adults on a specialized
geriatric unit receiving interprofessionally and protocol-guided care by a sta that had
received specialized geriatric care education also developed signicantly less delirium
(Lundstrom et al., 2007).
Patients who developed delirium after hip surgery, when treated with a mul-
ticomponent intervention program had fewer days of delirium, complications,
total days of hospitalization (Lundstrom et al., 2007), and improved health-related
quality of life without incurring increased costs (Pitkala et al., 2008). Although
multicomponent delirium-reduction interventions have yet to be tested in critical
care settings, sedation interruption and early occupational and physical therapy in
patients who are mechanically ventilated resulted in shorter duration of delirium
(Schweickert et al., 2009).
Although nonpharmacologic interventions are preferred and should be used rst
(Michaud et al., 2007), antipsychotics (such as haloperidol) are used and are found to be
ecacious in certain populations with agitated delirium (Breitbart et al., 1996; Devlin
et al., 2010). Light propofol sedation my reduce severity and duration of delirium in hip
surgery patients (Sieber et al., 2010).
Dexmedetomidine (dex; a g-aminobutyric acid receptor agonist), a promising alter-
native for sedation, resulted in decreased delirium when compared with other commonly
used sedation in ICU settings. When used for postoperative sedation after cardiac sur-
gery, dex has been associated with lower rates of delirium and costs when compared with
propofol and midazolam (Maldonado et al., 2009) and shorter duration of delirium
when compared to morphine (Shehabi et al., 2009). In patients who are mechanically
ventilated, dex is more ecacious than lorazepam in number of days at the targeted
level of sedation and more days alive without coma or delirium (Pandharipande, Pun,
et al., 2007). When compared to midazolam in patients who are mechanically venti-
lated, patients treated with dex have less delirium (Riker et al., 2009).
190 Evidence-Based Geriatric Nursing Protocols for Best Practice
Alternative forms of pain management may also help reduce delirium. Hip fracture
patients at low risk for delirium who received a prophylactic fascia iliac block developed
signicantly less delirium than those receiving traditional pain management regimens
(Mouzopoulos et al., 2009).
Mr. Z is an 82-year-old patient admitted to your unit for prostate surgery. He is a retired
accountant, lives with his wife, and is very active. He drives a car, plays golf, and regu-
larly participates in activities at the senior center. His Type II diabetes is well controlled
on Actoplus Met (pioglitazone hydrochloride and metformin hydrochloride). Mr. Z
reports that he has decreased his uid intake so he can avoid waking several times dur-
ing the night to urinate. He also has a history of hypertension, moderate hearing loss
(hearing aids bilaterally), and previous surgery for inguinal hernia repair. He wears bifo-
cal glasses for distance and reading. He is alert, oriented, and expresses a good under-
standing of his upcoming surgery. His preoperative laboratory values are within normal
limits except for a low hematocrit and a blood urea nitrogen/creatinine (BUN/Cr) ratio
slightly elevated. His medications include Actoplus Met (pioglitazone hydrochloride and
metformin hydrochloride) for his diabetes and Calan (verapamil) for hypertension.
What Factors Present on Admission to the Hospital Put Mr. Z at Risk for Developing Delirium?
n Age. Older adults are at greater risk for delirium, particularly if they have
underlying dementia or depression. Physiologic changes that occur with aging
can aect the ability of older adults to respond to physical and physiologic
stress and to maintain homeostasis.
n Dehydration. An elevated BUN/Cr ratio indicates dehydration (from decreased
uid intake), a frequent contributing factor (along with electrolyte imbalance)
to delirium of hospitalized older adults.
n Anemia. Because of a low hematocrit, the body has diminished ability to
deliver adequate oxygen to the brain, making delirium more likely.
n Sensory decits. ose with vision and hearing loss are more likely to misinter-
pret sensory input, which places them at increased risk for delirium.
It is important to understand that it might not be one particular factor but the
interplay of patient vulnerability (predisposing factors) and precipitating factors—
common during hospitalization—which place the older adult at risk for delirium.
What Can You Do to Help Prevent Delirium in Mr. Z?
n If possible, consult with a geriatric specialist (geriatrician or geriatric nurse
practitioner) for a thorough geriatric assessment of Mr. Z.
n Make sure his glasses and hearing aids are on and functioning.
n Explore reasons for the low hematocrit.
CASE STUDY
(continued)
Delirium 191
You provide care for Mr. Z again 2 days after surgery. He is confused and picking at the
air and oriented to self only. An indwelling urinary catheter and peripheral intravenous line
are in place. In his report, the day-shift nurse mentioned considering a physical restraint
because Mr. Z was increasingly restless and was CAM positive, indicating he has delirium.
What Are the Clinical Features of Delirium?
n Disturbance of consciousness characterized by reduced clarity and awareness of
the environment: reduced ability to focus, sustain, and shift attention. Patients
have trouble following instructions or making sense of their environment, even
with cues. ey may also get “stuck” on a particular concern or thought.
n Cognitive changes: memory decit, disorientation, language disturbance, and/
or perceptual disturbance.
n Perceptual disturbances: Hallucinations and delusions are common. Patients
can be hyperactive and agitated or lethargic (hypoactive) and less active. e
latter presentation is of particular concern because it is often not recognized
by health care providers as delirium. e presentation may also be mixed, with
the patient uctuating from one to the other behavioral state.
n Delirium can be characterized by disturbances in the sleep–wake cycle and rap-
idly shifting emotional disturbances, with escalation of the disturbed behavior
at night (sundowning).
n e cardinal sign of delirium is that the cited changes occur rapidly over several
hours or days.
It is also important to consider that delirium may occur concurrently with demen-
tia or depression. In fact, these patients are at increased risk for developing delirium.
Family and caregivers can be invaluable in helping to identify or distinguish cognitive
changes in circumstances when the patient is not well known to you.
What Additional Factors May Now Be Contributing to Mr. Z’s Delirium?
n Anesthesia and other medications. It takes several hours for the body to clear the
eects of anesthesia. Inasmuch as older adults have a larger percentage of body fat
than younger persons do, and many drugs are fat-soluble, drug eects will last lon-
ger. Also, older adults tend to have less cellular water; hence, water- soluble drugs
will be more concentrated and have a more pronounced eect. Nurses need to ask
the patient or family if any new drugs other than pain medication have been added.
What is the dose and frequency of the pain medications? Is the dose appropriate?
n Pain. What is Mr. Z’s pain control regimen and status? Poor pain control con-
tributes to restlessness and is associated with delirium. Is the current drug the
best for good pain relief in this patient?
n Hypoxemia. Mr. Z is at risk because of limited mobility and possible atelectasis
after surgery. What is his oxygen saturation (SpO
2
)? Does he have crackles or
diminished breath sounds?
(continued)
CASE STUDY (continued)
192 Evidence-Based Geriatric Nursing Protocols for Best Practice
n Infection, inammation, or other medical illness. Postoperative infections, intra-
operative myocardial infarctions (MIs), or strokes are possible causes of delir-
ium in this case. Could Mr. Z have a urinary tract infection (UTI) since his
postprostate surgery and particularly since he has a Foley catheter? An inam-
matory response to a new medical problem may be the cause of the delirium.
n Unfamiliar surroundings. Particularly for those with sensory decits, unfamil-
iar environments can lead to misinterpretations of information, which may
contribute to delirium.
What Steps Should Be Taken Now?
n Avoid the use of restraints, which could worsen Mr. Z’s agitation.
n Call the physician or nurse practitioner immediately and report your ndings;
request that the patient be evaluated to determine the underlying cause of the
delirium. If Mr. Z’s delirium worsens, he may also need medication (e.g., low
dose haloperidol) to control his symptoms.
n Frequent reality orientation. Frequent orientation, reassurance, and helping
Mr. Z interpret his environment and what is happening to him should be
helpful. (Monitor the patient’s reaction. If the patient becomes upset or angry,
you will need to modify your approach to that of more reassurance and vali-
dating the patient’s experience rather than reorienting).
n Are Mr. Z’s hearing aids and glasses in place, and clean and functioning? Impaired
sensory input contributes signicantly to delirium. Also, he may seem more
confused than he really is if he is not able to hear what you are saying.
n Invite family/signicant others to stay as much as they are able to assist with his
orientation, reassurance, and sense of well-being. Monitor the eect of family
visitation. If the patient has increased agitation or anxiety, then limit the visita-
tion of the individual who seems to be triggering Mr. Z’s upset.
n Mobilize the patient. Mobility assists with orientation and helps prevent problems
associated with immobility, such as atelectasis and deep venous thrombosis.
n Judicious use of medications for pain, sleep, or anxiety. Drugs used to address
these issues can exacerbate the delirium. Try nonpharmacologic approaches for
sleep and anxiety rst. If Mr. Z is having pain, are the drug and dose appropri-
ate for him? A regular schedule of a smaller dose or non-narcotic pain medica-
tion almost always is better than prn dosing.
n Try to provide for adequate sleep: noise reduction at night; soft, relaxing
music; warm milk; herbal tea; massage; and rescheduling care in order not
to interrupt sleep.
n Make sure the patient is well hydrated.
n Talk to the doctor or NP about removing the indwelling urinary catheter. Because
of his surgery, Mr. Z may need it immediately post-op, but it should be removed
as soon as possible. Additionally, recommend a urinalysis to rule out UTI.
n Address safety concerns (e.g., increase surveillance). Mr. Z is now also at risk for
falls and/or pressure ulcers.
CASE STUDY (continued)
Delirium 193
Protocol 11.1: Delirium
I. GOAL: To reduce the incidence of delirium in hospitalized older adults.
II. OVERVIEW:
A. Delirium is a common syndrome in hospitalized older adults and is associated
with increased mortality, hospital costs, and long-term cognitive and functional
impairment (Siddiqi et al., 2006).
B. Delirium can sometimes be prevented with the recognition of high-risk patients,
implementation of a standardized delirium-reduction protocol, and proactive
geriatric consultation (Bruera et al., 2009).
C. Recognition of risk factors and routine screening for delirium should be part of
comprehensive nursing care of older adults (Milisen et al., 2005).
III. BACKGROUND AND STATEMENT OF PROBLEM:
A. Denition: Delirium is a disturbance of consciousness with impaired attention
and disorganized thinking or perceptual disturbance that develops acutely, has
a uctuating course, and with evidence that there is an underlying physiologic
or medical condition causing the disorder (APA, 2000).
B. Etiology and Epidemiology
1. Prevalence and incidence: Medical inpatients, prevalence is 10% to 31%; inci-
dence is 3% to 29% (Siddiqi et al., 2006). Hip surgery patients, incidence of
delirium is 4% to 53% with hip fractures and cognitive causing higher risk of
delirium (Bruce et al., 2007). Medical ICUs, prevalence and incidence both
31% (McNicoll et al., 2003). Surgical ICUs, prevalence 2.6%, incidence 28.3%
(Balas et al., 2007). Mechanically ventilated patients in ICU, up to 83% during
ICU stay (Ely et al., 2001), more than 50% of medical ICU patients still have
delirium when transferred (Pisani et al., 2010). Incidence of delirium superim-
posed on dementia, 22% to 89% (Fick et al., 2002).
2. Pathophysiology: Unclear, may be cholinergic deciency, dopamine excess, or
cytokine activity (Inouye, 2006). A genetic association with apolipoprotein E
epsilon 4 allele identied (van Munster et al., 2009).
NURSING STANDARD OF PRACTICE
(continued)
SUMMARY
Delirium is a common occurrence in hospitalized older adults and contributes to poor
outcomes. us, it is important to promptly identify those patients at risk for delir-
ium and implement preventive measures as well as promptly recognize delirium when
it appears. Nursing assessments using validated delirium screening instruments must
become routine. A standard of practice protocol provides concise information to guide
nursing care of individuals at risk for or experiencing delirium.
194 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Risk factors: Predisposing, age (70 years and older), severity of illness and cog-
nitive impairment; also depression, sensory impairment, uid and electrolyte
disturbances and polypharmacy (especially psychotropics). Precipitating, cen-
tral nervous system pathology (such as stroke), metabolic, electrolyte and/or
endocrine disturbances, infection and drug toxicity or withdrawal; also pain,
hypoperfusion/hypoxia, number of drugs, (especially psychotropic and anti-
cholinergic) and restraints. Environmental factors, ICU admission, multiple
room changes, and an absence of a clock or glasses (Michaud et al., 2007).
4. Outcomes: Increased mortality, nursing home placement, and decreased
functional status and cognition (Cole et al., 2008; Witlox et al., 2010).
Distress for the patient, their family members, and nurses (Cohen et al.,
2009; Bruera et al., 2009).
IV. PARAMETERS OF ASSESSMENT
A. Assess for risk factors (Michaud et al., 2007)
1. Baseline or pre-morbid cognitive impairment (see Chapter 8, Assessing
Cognitive Function)
2. Medications review (see Chapter 17, Reducing Adverse Drug Events)
3. Pain (see Chapter 14, Pain Management)
4. Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia,
hypokalemia)
5. Hypoperfusion/hypoxemia (BP, capillary rell, SpO2)
6. Dehydration (physical signs/symptoms, intake/output, Na1, BUN/Cr)
7. Infection (fever, WBCs with dierential, cultures)
8. Environment (sensory overload or deprivation, restraints)
9. Impaired mobility
10. Sensory impairment (vision, hearing)
B. Features of delirium (APA, 2000; Inouye et al., 1990)—assess every shift (see
“Resources” for validated instruments)
1. Acute onset; evidence of underlying medical condition
2. Alertness: Fluctuates from stuporous to hypervigilant
3. Attention: Inattentive, easily distractible, and may have diculty shifting
attention from one focus to another; has diculty keeping track of what
is being said
4. Orientation: Disoriented to time and place; should not be disoriented to
person
5. Memory: Inability to recall events of hospitalization and current illness;
unable to remember instructions; forgetful of names, events, activities,
current news, and so forth
6. inking: Disorganized thinking; rambling, irrelevant, incoherent con-
versation; unclear or illogical ow of ideas; or unpredictable switching
from topic to topic; diculty in expressing needs and concerns; speech
may be garbled
7. Perception: Perceptual disturbances such as illusions and visual or audi-
tory hallucinations; and misperceptions such as calling a stranger by a
relative’s name.
Protocol 11.1: Delirium (cont.)
(continued)
Delirium 195
8. Psychomotor activity: May uctuate between hypoactive, hyperactive,
and mixed subtypes
V. NURSING CARE STRATEGIES (based on protocols in multicomponent delirium
prevention studies [Inouye et al., 1999; Lundstrom et al., 2007; Marcantonio, Flacker,
Wright, & Resnick, 2001])
A. Obtain geriatric consultation.
B. Eliminate or minimize risk factors.
1. Administer medications judiciously; avoid high-risk medications (see Chap-
ter 17, Reducing Adverse Drug Events).
2. Prevent/promptly and appropriately treat infections.
3. Prevent/promptly treat dehydration and electrolyte disturbances.
4. Provide adequate pain control (see Chapter 14, Pain Management).
5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as
needed).
6. Use sensory aids as appropriate.
7. Regulate bowel/bladder function.
8. Provide adequate nutrition (see Chapter 22, Nutrition).
C. Provide a therapeutic environment.
1. Foster orientation: frequently reassure and reorient patient (unless patient
becomes agitated); use easily visible calendars, clocks, caregiver identication;
carefully explain all activities; communicate clearly.
2. Provide appropriate sensory stimulation: quiet room; adequate light; one
task at a time; noise reduction strategies.
3. Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relax-
ation music/tapes; noise reduction measures; avoid awaking patient.
4. Foster familiarity: encourage family/friends to stay at bedside; bring familiar
objects from home; maintain consistency of caregivers; minimize relocations.
5. Maximize mobility: avoid restraints (see Chapter 13, Physical Restraints
and Side Rails in Acute and Critical Care Settings) and urinary catheters;
ambulate or active ROM three times daily.
6. Communicate clearly, provide explanations.
7. Reassure and educate family (see Chapter 24, Family Caregiving).
8. Minimize invasive interventions.
9. Consider psychotropic medication as a last resort for agitation.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Absence of delirium or
2. Cognitive status returned to baseline (prior to delirium)
3. Functional status returned to baseline (prior to delirium)
4. Discharged to same destination as prehospitalization
B. Health care provider
1. Regular use of delirium screening tool
2. Increased detection of delirium
3. Implementation of appropriate interventions to prevent/treat delirium
from standardized protocol
Protocol 11.1: Delirium (cont.)
(continued)
196 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
Recommended Delirium Screening Instruments
Confusion Assessment Method (CAM; Inouye et al., 1990; Wei et al., 2008)
Confusion Assessment Method for the Intensive Care Unit (CAM-ICU; Ely et al., 2001).
Other Delirium Screening Instruments
Delirium-O-Meter (de Jonghe, Kalisvaart, Timmers, Kat, & Jackson, 2005)
May be used for monitoring the dierent characteristics and the severity of delirium in geriatric
patients.
Delirium Rating Scale (DRS)-98 (Trzepacz et al., 2001)
May be used to assess delirium severity.
Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975; O’Keee, Mulkerrin,
Nayeem, Varughese, & Pillay, 2005)
May be used to monitor course of delirium in hospitalized patients.
Additional Information About Delirium
Consult GeriRN
An online resources containing information regarding assessing and caring for older adults sponsored
by the Hartford Institute for Geriatric Nursing at New York University College of Nursing.
http://consultgerirn.org/resources
4. Decreased use of physical restraints
5. Decreased use of antipsychotic medications
6. Increased satisfaction in care of hospitalized older adults
C. Institution
1. Sta education and interprofessional care planning
2. Implementation of standardized delirium screening protocol
3. Decreased overall cost
4. Decreased length of stays
5. Decreased morbidity and mortality
6. Increased referrals and consultation to above-specied specialists
7. Improved satisfaction of patients, families, and nursing sta
VII. FOLLOW-UP MONITORING OF CONDITION
A. Decreased delirium to become a measure of quality care
B. Incidence of delirium to decrease
C. Patient days with delirium to decrease
D. Sta competence in recognition and treatment of acute confusion/delirium
E. Documentation of a variety of interventions for acute confusion/delirium
Na
1
5 sodium; BUN/Cr 5 blood urea nitrogen/creatinine ratio; BP 5 blood pressure; Hgb/Hct 5
hemoglobin and hematocrit; SpO
2
5 pulse oxygen saturation; WBCs 5 white blood cells;
URI 5 upper respiratory infection; UTI 5 urinary tract infection; ROM 5 range of motion
Protocol 11.1: Delirium (cont.)
Delirium 197
ICU Delirium and Cognitive Impairment Study Group
http://www.icudelirium.org/delirium/
Hospital Elderlife Program
http://elderlife.med.yale.edu/public/pubs.php?pageid=01.03.07
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(2003). e measurement of delirium: Review of scales. Research and eory for Nursing Practice,
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200
12
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader will be able to:
1. dene iatrogenesis
2. describe the common iatrogenic problems aecting older adults
3. describe the nurse’s role in preventing iatrogenic harm in hospitalized older adults
OVERVIEW
Iatrogenesis is a common and serious hazard of hospitalization that is associated with
increased patient morbidity and mortality, prolonged hospital stays, and nursing home
placement, at signicant cost to patients and health care organizations alike. From the
Greek word iatros, iatrogenesis means harm brought forth by a healer or any unintended
adverse patient outcome because of a health care intervention, not considered the natural
course of the illness or injury. Common well-known iatrogenic problems aecting older
adults include adverse drug events (ADE), complications of diagnostic and therapeutic
interventions, nosocomial or hospital-acquired infections (HAI), pain, and a variety of
geriatric syndromes (e.g., falls, delirium, functional decline, pressure ulcers). Less well
recognized are the potentially harmful inuences of the knowledge, values, beliefs, and
attitudes of well-intentioned health care providers and patients themselves, upon patient
outcomes. e purpose of this chapter is to describe common iatrogenic problems aect-
ing older adults and to describe the role of the nurse in preventing iatrogenic harm.
Iatrogenesis is not new to modern medicine. In the 1840s, Semmelweis noted that
deaths from puerperal sepsis were lower in those patients treated by midwives who were
working only with laboring mothers (Hani, 2010). ese low death rates contrasted
sharply with high death rates in those mothers treated by medical students who were also
dissecting cadavers and performing surgery. Semmelweis introduced a hand-washing
Deborah C. Francis and Jeanne M. Lahaie
Iatrogenesis: e Nurse’s Role in
Preventing Patient Harm
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 201
program that lowered the cases of fatal puerperal fever from 12.84% to 2.38%, leading
to his development of germ theory and the critical role of hand hygiene in the pre-
vention of infection. In 1981, Steel, Gertman, Crescenzi, and Anderson (2004) raised
the alarm after reporting that, even with very conservative inclusion criteria, 36% of
patients suered at least one iatrogenic event during a hospital stay.
BACKGROUND AND STATEMENT OF PROBLEM
Iatrogenesis became a commonly used term when medical errors causing patient harm
made headlines with the release of the landmark Institute of Medicine (IOM; Kohn,
Corrigan, & Donaldson, 1999) report, To Err is Human: Building a Safer Health Sys-
tem. It reported that errors made by medical practitioners caused between 44,000 and
98,000 deaths per year at a cost of up to $29 billion in unnecessary health care expenses,
disability, and lost income. e report strongly urged immediate, vast, and comprehen-
sive systemwide changes, including both voluntary and mandatory reporting programs
by health care organizations, jump-starting the patient safety movement of today. In
2004, a national study of 37 million Medicare patients in 5,000 hospitals found that
an average of 195,000 people die every year because of potentially preventable patient
safety incidents (Health Grades, Inc., 2004). Although To Err is Human called for cut-
ting medical errors by half, iatrogenesis persists. e Agency for Healthcare Research
and Quality (AHRQ) reported to Congress in 2008 that preventable medical inju-
ries were increasing by 1% annually (Agency for HealthCare Research and Quality,
2008). Further, in November 2010, the U.S. Department and Health and Human
Services’ Oce of the Inspector General reported an alarming increase in the number of
deaths from adverse events—180,000 patients each year—associated with $4.4 billion
to government costs. In addition, it is estimated that one in seven Medicare benecia-
ries (13.5%)—some 134,000 patients a month—experience at least one adverse event,
many preventable (Wilson, 2010).
e patients at greatest risk for experiencing an adverse event while in the hospital are
older (Rothschild, Bates, & Leape, 2000), critically ill (Garrouste et al., 2008), or repre-
sent an ethnic or racial minority group (Johnstone & Kanitsaki, 2006), and up to 70% of
the events are considered preventable (Soop, Fryksmark, Köster, & Haglund, 2009; Zegers
et al., 2009). e true extent of the problem remains poorly understood because of a host
of factors. Lack of standardization in the literature as to what constitutes iatrogenesis and
dierent methods of data collection and analysis hinders knowledge of the issue. In addi-
tion, there is both a lack of recognition of the problem and standardized procedures for
investigating and reporting adverse events by hospitals and providers, who are known to
disagree about what constitutes a complication and quality of care (Weingart et al., 2006).
Patients themselves, especially older adults, are hesitant to formally identify and report
iatrogenic harm, if they even recognize it. Many are too ill or do not understand sophis-
ticated medical care enough to recognize an adverse event (Bismark, Brennan, Paterson,
Davis, & Studdert, 2006). As such, it is dicult to estimate the true human and nancial
cost of this problem, and what we know of iatrogenesis may be the tip of the iceberg.
Iatrogenesis in the Older Adult
e risk of an iatrogenic event is highest among patients 65 years and older (Rothschild
et al., 2000; Rowell, Nghiem, Jorm, & Jackson, (2010), with evidence suggesting it
202 Evidence-Based Geriatric Nursing Protocols for Best Practice
aects between 10.6% and 58.3 % of hospitalized older adults (Rowell et al., 2010;
Steel et al., 2004; Marengoni et al., 2010; ornlow, Anderson, & Oddone, 2009).
A landmark Harvard Medical Practice Study in 2000 found that older adults suered
twice as many diagnostic complications, two-and-one-half times as many medication
reactions, four times as many therapeutic mishaps, and nine times as many falls as
compared to younger patients (Rothschild & Leape, 2000). A more recent review of
the national Healthcare Cost and Utilization Project (HCUP) scores found that for 11
of 13 safety indicators, older patients, especially those older than 85 years, were more
likely than younger patients to experience higher rates of adverse events (ornlow,
2009). e diagnosis of heart failure in combination with either chronic renal failure or
chronic obstructive pulmonary disease signicantly increases the risk of adverse event-
related, in-hospital death (Marengoni et al., 2010). Patients admitted from a skilled
nursing facility (SNF) are at a signicantly greater risk for developing complications in
the hospital (Malone & DantoNocton, 2004).
Endogenous Risk Factors for Iatrogenesis
Normal age-related changes and diminished physiological reserve capacity, especially
in hepatic, renal, and cognitive function, and impaired homeostatic and compensatory
mechanisms impede the ability of the older patient to respond to the physiological and
psychological stressors related to acute illness, and make the older adult more vulner-
able to iatrogenesis. Age-associated physiological changes tend to exaggerate the eects
of medications, leading to more adverse side eects, which are often treated with the
addition of more medications, compounding the risk of iatrogenic harm. is risk is
potentiated by the presence of multiple comorbid conditions and drug–drug and drug–
disease interactions from resulting polypharmacy (Robinson & Weitzel, 2008).
Aging is associated with an increased risk of infection caused by immune senescence.
is age-related blunting of the febrile response and the decreased physiological abil-
ity of many older adults to mount an immune response or a fever can delay diagnosis
and treatment, and may result in inappropriate care (McElhaney, 2005). A diminished
thirst sensation dramatically increases the risk of dehydration in the older patient who,
for functional or cognitive reasons, may also be unable to independently drink adequate
amounts of uids. e older adult with age-associated decline in cardiac reserve who is
receiving continuous intravenous uids is also at increased risk for iatrogenic congestive
heart failure (CHF).
Another important consideration is the atypical presentation of disease in the older
adult. Early symptoms of acute medical conditions tend to be vague, more insidious, and
atypical, and so are often missed or misinterpreted by clinicians, family, caregivers, and
patients alike. is impairs accurate diagnosis and timely treatment, and subsequently
results in a greater frequency of emergent, higher risk interventions. For example, an
acute appendicitis in the older adult may present as nonlocalized abdominal discomfort
or may not manifest symptoms until perforation occurs. An older person with a myo-
cardial infarction may have no pain at all. Older adults with a urinary tract infection
(UTI) or pneumonia commonly present with confusion, falls, or functional impair-
ment, rather than the typical symptoms of infection seen in younger persons. Lack of
awareness of atypical presentation can lead to delay in treatment and to patients being
inappropriately treated with high-risk medications or labeled as “demented,” rather than
assessing for and treating unmet needs, such as delirium-related infection or pain.
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 203
Exogenous Risk Factors for Iatrogenesis
e hospital environment and the complex interrelationships of hospital and provider
practice patterns inuence patient safety outcomes. For example, inadequate nurse sta-
ing has consistently been associated with adverse patient outcomes (Frith et al., 2010),
and interruptions during clinical care are known to cause more nursing errors (West-
brook, Woods, Rob, Dunsmuir, & Day, 2010). e hospital environment itself can also
be hazardous to vulnerable elders with sensory, functional, and cognitive decits, lead-
ing to more falls and fall-related injury. To further complicate matters, physicians and
nurses are typically not adequately trained in geriatric care, and so are not prepared to
manage the complex, chronic care needed by frail older patients (IOM, 2008). Without
a solid understanding of the special needs of the geriatric patient and the factors within
an organization that can increase risk, nurses may inadvertently cause more harm to
patients during the course of treatment.
e hospitalized older adult is at particularly high risk for cascade iatrogenesis,
which occurs when an initial medical or nursing intervention triggers a series of
complications, initiating a cascade of decline that is often irreversible (Robinson &
Weitzel, 2008). For example, the cognitively impaired surgical patient who is inap-
propriately treated for pain may develop delirium, be medicated for agitated behaviors,
become lethargic from oversedation, and subsequently develop aspiration pneumonia.
Deconditioning caused by prolonged bed rest increases fall risk and could lead to a
fractured hip when the patient falls while trying to get to the bathroom. is prolongs
the hospital stay, increasing the risk of further complications and adverse outcomes.
Iatrogenic cascades have been found to occur most frequently among the oldest, most
functionally impaired patients, and those with a higher severity of illness upon admis-
sion (Robinson & Weitzel, 2008).
ASSESSMENT OF THE PROBLEM
Adverse Drug Events
Adverse eects of medications are the most common type of iatrogenesis in hospitalized
older adults. ese include not only any adverse outcome that occurs during the course
of routine, appropriate medication use, but also adverse outcomes caused by inappro-
priate prescribing, administration errors, and suboptimal adherence by the patient. It is
estimated that 35% of older persons experience ADE every year, almost half of which are
preventable (Safran et al., 2005). On average, patients with ADE experience longer hos-
pital stays and have greater in-hospital and 30-day mortality. Some 10%–20% of older
adults are prescribed nonsteroidal anti-inammatory drugs (NSAIDs) in spite of known
gastrointestinal side eects, including ulcerations and bleeding, and the increased risk
of impaired renal function, resulting in an estimated 3,300 excess deaths and 41,000
excess hospitalizations annually (Arnstein, 2010). Still, many nurses and other health
care practitioners are not aware of the risks, with some hospital protocols continuing
to use NSAIDs as a rst-line agent to treat pain in older adults, in spite of the 2009
guidelines from the American Geriatric Society (2009) to the contrary.
Polypharmacy, which is prevalent among older patients, increases the risk of drug–
drug interactions, whose eect on this population is more dramatic. It has been shown
to be a signicant predictor of hospitalization, nursing home placement, death, hypo-
glycemia, fractures, impaired mobility, pneumonia, and malnutrition (Frazier, 2005).
204 Evidence-Based Geriatric Nursing Protocols for Best Practice
A 2004 national study estimated that 888,000 ADE occurred in hospitalized Medicare
patients from high-risk medications alone, including warfarin, hypoglycemic agents,
digoxin, and antibiotics (Classen, Jaser, & Budnitz, 2010). e nurse needs to closely
monitor the patient for adverse side eects of medication and be aware of the need for
age-adjusted doses especially with high-risk medications. Anticoagulation dosing based
on creatinine clearance and weight, for example, is critical in order to avoid further
harm to the patient (Jaer & Brotman, 2006). Medication reconciliation upon admis-
sion, transfer, and discharge is another key strategy needed to maintain geriatric patient
safety. e reader is referred to Chapter 17, Reducing Adverse Drug Events for assess-
ment and interventions to prevent ADE.
Adverse Effects of Diagnostic, Medical, Surgical, and Nursing Procedures
Acutely ill older patients are at greatest risk for iatrogenic harm, due in part to the need
for more diagnostic, prophylactic, and therapeutic medical, surgical, or nursing proce-
dures and interventions
Diagnostic procedures involve some degree of risk based on whether they are inva-
sive or administer a pharmacological or radiological agent, such as contrast material.
Contrast dye, commonly used in CT scans and myelography, can produce both aller-
gic and nonallergic reactions ranging from urticaria, angioedema, and anaphylaxis.
Radiocontrast infusion in patients with renal impairment can cause acute renal failure
(ARF) or an exacerbation of CHF. Gadolinium, used as a contrast agent for magnetic
resonance imaging (MRI), has been associated with nephrogenic systemic sclerosis
in patients with impaired renal function. In addition, patients with preexisting renal
impairment exposed to nephrotoxins such as aminoglycosides or a radiocontrast agent
and patients with CHF given NSAIDs are at signicantly greater risk for ARF (Cheung,
Ponnusamy, & Anderton, 2008). Exposure to iodinated radiocontrast material should
be avoided or minimized in patients with renal insuciency, and nursing sta must
closely monitor the patient’s hydration status before and after the use of contrast dye in
diagnostic studies. Particular attention needs to be paid to the patient’s orthostatic blood
pressure, urine output, and jugular venous pressure (Cheung et al., 2008). Administer-
ing age-adjusted, appropriate medications to premedicate prior to procedures is critical,
as is the ability of the nurse to question what may be a high-risk drug or dose for the
older adult. For example, the anticholinergic antihistamine, diphenhydramine, which is
routinely prescribed before a blood transfusion to prevent minor transfusion reactions,
can precipitate delirium in older patients.
Medical procedures such as thoracentesis and cardiac catheterization have also been
linked to signicantly more preventable adverse eects in the older adult, such as car-
diac arrhythmias, bleeding, infection, and pneumothorax (Dumont, Keeling, Bourgui-
gnon, Sarembock, & Turner, 2006). e literature is full of case reports of iatrogenic
injuries and deaths due to medical or nursing procedures such as venous embolism
caused by the injection of CT contrast (Imai, Tamada, Gyoten, Yamashita, & Kajihara,
2004); aspiration deaths caused by barium, emollient laxatives, and contrast medium
(Hunsaker & Hunsaker, 2002); colonic perforations caused by endoscopy or enema
(Bobba & Arsura, 2004); and complications associated with percutaneous endoscopic
gastrostomy tubes (Ghevariya, Paleti, Momeni, Krishnaiah, & Anand, 2009).
Risk for injurious falls is higher in older adults with devices or lines that tether
the patient to the bed. As such, proactive assessment of when to discontinue tethering
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 205
devices, and ongoing evaluation of the potential safety hazard is important. Restraints,
including full hospital bed rails, once a cornerstone of fall prevention programs, have
increasingly been recognized as harmful and potentially fatal to patients. It is the older
adult who is at greatest risk for being restrained in an eort to prevent a fall or to man-
age agitated behaviors associated with delirium, so every eort must be made to imple-
ment nonpharmacological, restraint-free behavior management and fall prevention
interventions as noted in the protocol chapters. Restraining the patient with physical
devices or medication often exacerbates agitated behavior and may contribute to falls,
aspiration, skin breakdown, deconditioning, and other complications, especially when
applied without addressing pain, elimination, or other care needs.
Medical and nursing interventions, even those that are considered relatively risk free,
such as the administration of intravenous therapy, can be dangerous in the older patient.
Excessive venipuncture (e.g., from laboratory tests ordered daily in stable patients)
places the vulnerable older patient at increased risk not only for infection, but also for
phlebitis, venous thrombotic embolism (VTE), and unnecessary suering. Given the
age-related reduced cardiac reserve, intravenous uids can lead to preventable CHF or
electrolyte abnormalities. Sherman (2005) identies three forms of geriatric iatrogene-
sis, referred to as the hypo’s of hospitalization, that can delay discharge, increase costs, and
lead to adverse patient outcomes. Iatrogenic-induced hypokalemia occurs when intrave-
nous uids are given without potassium, whereas orthostatic hypotension can be induced
when an antihypertensive medication is given based exclusively on supine blood pres-
sures. Transient decreases in oral intake in patients receiving oral hypoglycemic agents,
or standing insulin orders can cause preventable hypoglycemia.
Bed rest, in and of itself, can have serious negative eects on older patients, includ-
ing functional decline, VTE, pressure ulcers, delirium, orthostatic hypotension, falls,
anorexia, constipation, and fecal impaction, among other adverse outcomes. Older
adults are at greatest risk for VTE, which is both preventable and common in hospi-
talized older adults, due in part to underuse of prophylactic anticoagulation (Jacobs,
2003). Aggressive pharmacological thromboprophylaxis is necessary unless there is a
contraindication such as active bleeding, when mechanical prophylaxis with sequential
compression devices is warranted (Jaer & Brotman, 2006).
Perioperative complications in older patients can be as high as twice that of younger
patients, and mortality can be three to seven times higher (Saver, 2010). Bentrem,
Cohen, Hynes, Ko, and Bilimoria (2009) found that older adults were more likely to
experience the following surgical complications: cardiac (acute myocardial infarction
and cardiac arrest), pulmonary (pneumonia, pulmonary embolism, and respiratory fail-
ure), and urological (UTI and renal failure). On a positive note, the authors found that
surgical site infections (SSIs), postoperative bleeding events, VTE, and rates of return to
the OR were not signicantly dierent than those of younger adults.
Nurses are called upon to take a more active role in identifying older patients at
higher risk of surgical complications, given the evidence that only a small percentage
of surgeons and anesthetists recognize these age-associated risks and routinely order
commensurate postoperative monitoring in older patients (Pirret, 2003). A simple
preoperative nursing assessment tool used in more than 7,000 patients over a 2-year
period identied the higher risk patients in need of improved postoperative monitor-
ing and reduced acute admissions to the ICU from 40% to 19% (Pirret, 2003). Saver
(2010) recommends a multipronged approach to reduce surgical complications in the
older adult that includes tracking clinical indicators, performing a thorough assessment,
206 Evidence-Based Geriatric Nursing Protocols for Best Practice
protecting patients intraoperatively, and providing patient education. e assessment
should review six preoperative markers that have been linked to 6-month mortality in
older adults: impaired cognition, recent falls, low serum albumin, anemia, functional
dependence, and multiple comorbidities. Functional dependence in activities of daily
living (ADLs) is the biggest predictor of mortality, and having four or more of the pre-
operative markers predicted mortality with high sensitivity and specicity. Assessment
ndings can be used to target post-op interventions including prevention of delirium,
falls, and functional decline. Also, nurses can collaborate with nutrition services to
increase postoperative monitoring and management (Barbosa-Silva & Barros, 2005).
Postoperative nursing care that focused on preventing infection, reducing tension
at the surgical site, and optimizing nutritional status eectively prevents surgical wound
dehiscence, a serious complication with up to 50% mortality (Hahler, 2006). e older
adult’s oral intake needs to be carefully monitored and reported, and insulin adjusted
to prevent hypoglycemia and optimize glycemic control (Sherman, 2005). It is also
important to monitor the geriatric patient for atrial brillation, a potentially prevent-
able condition that occurs in about one-third of patients after coronary artery bypass
surgery and has been associated with other complications, including cognitive changes,
renal impairment, infection (Mathew et al., 2004), and stroke (Lip & Edwards, 2006).
Safe nursing processes of care must be adopted and well integrated into the hospital
and nursing culture. Westbrook et al. (2010) demonstrated that interruption of a nurse
during a medication pass resulted in a 12.1% increase in failure to follow a standard pro-
cedure and a 12.7% increase in clinical errors. Hospital initiatives now include eorts to
ensure nurses who are passing medications are not disturbed and to expect more involve-
ment by the patient in care decisions and treatment planning so as to mitigate this risk.
Given the plethora of evidence that communication and other systems problems
cause iatrogenic patient harm, e Joint Commission (TJC) mandates more involve-
ment of patients in their care and formal time outs and other verication procedures at
high-risk times to prevent wrong-site surgeries and other errors. Prior to any invasive
procedure, nurses must also ensure the patient clearly understands the inherent risks
and benets before giving informed consent. Although health care professionals (HCPs)
are trained to weigh the risks and benets, it is critical to heighten one’s assessment of
the situation and to err on the side of caution in the geriatric patient. Potentially harm-
ful diagnostic and therapeutic procedures may well be contraindicated if the potential
benet does not clearly increase the potential for improving patient outcomes. is is
particularly important, given the strong evidence that the older population tends to
have lower rates of understanding the risks and benets of the procedure for which they
are providing written or verbal consent (Mahon, 2010).
Given the age-associated increase in sensory decits, it is critical to identify and
address any visual or hearing decits that may impede patient understanding. Several
discussions over time to evaluate and ensure that the patient understands the situation
may be warranted. If a dierence of professional opinion occurs, nurses are encouraged
to bring signicant issues of potential harm up the chain of command.
Hospital-Acquired Infection
HAI, rst dened in 1970 by the Centers for Disease Control and Prevention (CDC) as
one that develops in a patient after hospital admission, is a serious risk for any patient.
Like other iatrogenic harm, the risk and potential for poor outcomes related to HAIs
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 207
rises dramatically with age (Duy, 2002). HAIs are one of the leading causes of morbid-
ity and mortality in hospitalized patients (World Health Organization [WHO], 2002).
It is estimated that HAIs aect more than 2 million patients in the United States every
year and cause at least 90,000 deaths (Leape & Berwick, 2005), at a cost exceeding $4.5
billion (Hollenbeak et al., 2006). Although the true incidence is dicult to determine,
evidence suggests that 5%–10% of patients develop HAI, which increases morbidity,
mortality, length of stay, and cost of care (Gordts, Vrijens, Hulstaert, Devriese, & Van
de Sande, 2010; Lanini et al., 2009). In addition, a disturbing increase in risk has been
noted in recent decades (Burke, 2003). e rate of HAI is highest among older (Roth-
schild et al., 2000) and critically ill patients, who tend to be the most sick and most
immunocompromised, undergo more invasive procedures, and receive more intravascu-
lar devices, which signicantly increases the risk of secondary infection.
UTIs are the most common HAIs, accounting for 30% to 40% of all nosocomial
infections (Brosnahan, Jull, & Tracy, 2004). e risk is directly related to the use and
duration of indwelling urethral catheters, accounting for approximately 80% of hospital-
acquired UTIs. In one series, 9% of older patients who received an indwelling catheter
developed a UTI during the acute hospital stay; 50% of catheters used were determined
not to be clinically justied (Hazelett, Tsai, Gareri, & Allen, 2006). A systematic review
of the eects of duration of indwelling catheters on patient outcomes revealed both a
signicant increase in UTIs when the catheter was left in for more than 48 hours and a
reduction in hospital length of stay when it was removed within 48 hours (Fernandez &
Griths, 2006). Even without a catheter, the older patient is at increased risk for a UTI
because of age-related physiological changes, functional abnormalities (prostate enlarge-
ment), the use of medications that promote urinary retention, and chronic diseases
that increase infection risk or impair bladder function (e.g., diabetes; see Chapter 19,
Catheter-Associated Urinary Tract Infection Prevention).
Hospital-acquired pneumonia (HAP) is the second most common type of nosoco-
mial infection after UTI, with an estimated mortality rate of 20%–46% (Arozullah,
Khuri, Henderson, Paley, & Daley, 2001), and is the third most common postoperative
complication after urinary tract and wound infections. Patients receiving continuous
mechanical ventilation have a six- to twenty-one-fold increased risk of developing bacte-
rial HAP (CDC, 2003). Pulmonary aspiration of secretions from the oropharyngeal or
gastrointestinal tract is the most common cause of HAP and is considered preventable
in the majority of cases (Weitzel, Robinson, & Holmes, 2006).
Hospital-acquired bloodstream infections are common, serious, and costly infec-
tions that are a leading cause of death in this country (Wenzel & Edmond, 2001). ese
infections are most often related to the use of an invasive device, and more than 50%
occur in the critically ill patient. Catheter-associated bloodstream infections (CABSI)
are serious infections in ICU patients, occurring in 3%–7% of all patients with cen-
tral venous catheters (Warren, Zack, Cox, Cohen, & Fraser, 2003), associated with
increased mortality and cost (Shannon et al., 2006).
SSI are the most common type of nosocomial infection in patients undergoing
surgery, and are associated with prolonged and more costly hospitalizations (Malone,
Genuit, Tracy, Gannon, & Napolitano, 2002). Patients with SSIs are also twice as likely
to die, 60% more likely to be admitted to the ICU, and ve times more likely to
be rehospitalized than patients who do not develop SSI (Kirkland, Briggs, Trivette,
Wilkinson, & Sexton, 1999). Gram-positive organisms account for the majority of bac-
terial infections (Malone et al., 2002). Although the risk of SSI varies according to type
208 Evidence-Based Geriatric Nursing Protocols for Best Practice
of surgery and patient-specic factors, evidence demonstrates that factors related to
the hospital itself, such as practice patterns and the environment of care, signicantly
increase the risk of patient harm (Hollenbeak et al., 2006).
Other infections that commonly aect hospitalized older patients include those
aecting the gastrointestinal tract, such as Clostridium dicile (C. dicile) colitis and the
skin, such as methicillin-resistant Staphylococcus aureus (MRSA). C. dicile infections
are aecting signicant numbers of hospitalized older patients. It is estimated that 20%
–40% of hospitalized patients are colonized with the C. dicile toxin as compared to
2%–3% of healthy adults (Bartlett, 2006). Fifteen percent to 25% of patients with anti-
biotic-associated diarrhea, and more than 95% with pseudomembranous colitis carry
the C. dicile toxin, which is becoming more refractory to treatment and more apt to
relapse (Freeman et al., 2010; Dubberke et al., 2010).
e alarming increase in antimicrobial-resistant organisms, such as MRSA and van-
comycin-resistant enterococcus (VRE) is of great concern. Patients older than 80 years
of age are at signicantly greater risk for being carriers of MRSA (Eveillard, Mortier,
et al., 2006). MRSA increased in prevalence from 2% of S. aureus infections in 1974 to
63% in 2004, whereas VRE has steadily increased from less than 1% in 1990 to 28.5%
of enterococcol isolates in 2003 (CDC, 2006). On a positive note, a more recent review
from nine U.S. hospitals suggests that MRSA decreased 9.4% per year from 2005 to
2008 (Kallen et al., 2010). Vancomycin resistance has been shown to be an independent
risk factor for death and is associated with poor patient outcomes, including longer
length of stay, increased mortality, and higher costs of care (Salgado & Farr, 2003).
More recently, the increase in multiple drug-resistant organisms has been associated
with signicantly longer hospital stays, increased cost, and higher mortality.
INTERVENTIONS AND CARE STRATEGIES
Nursing Strategies for Hospital-Acquired Infections
Reducing the rate of HAI comprises one of TJC’s National Patient Safety Goals and
three of the six goals of the Institute of Healthcare Improvement (IHI) 5 Million Lives
Campaign. e WHO and the CDC have published numerous guidelines for the pre-
vention of health care infections with recommendations based on levels of evidence from
the literature. Adherence to these evidence-based best practices, such as hand hygiene
and infection control, is key to preventing iatrogenic infections. e reader is referred
to the list of evidence-based CDC guidelines at the end of this chapter.
Infection control sta must be actively involved in implementing guidelines, train-
ing sta and performing ongoing surveillance, and reporting processes with support
from hospital leadership. Infection control eorts need to address strict adherence to
appropriate cleansing of equipment and the environment, isolation of colonized patients,
and appropriate surveillance programs as outlined in CDC guidelines. Hospitals par-
ticipating in the CDC’s National Nosocomial Infections Surveillance (NNIS) system
signicantly reduced bloodstream infections, UTIs, and pneumonia in ICU patients,
as well as SSIs. Success was attributed to the use of standardized denitions and surveil-
lance protocols and risk stratication for calculation of infection rates, combined with
an active prevention program (Jarvis, 2003).
Nurses play an important role in monitoring immunizations as well as antibiotic
stewardship, critical to slowing the emergence of bacterial resistance. Nurses also have a
voice in the formulation of policy as well as clinical decision making. ey can educate
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 209
other clinicians about a hospital’s antibiotic prescribing policies, including reserving
newer or broader-spectrum antibiotics and vancomycin for cases of proven drug resis-
tance or life-threatening emergencies.
Given the increased risk in patients who are mechanically ventilated, implemen-
tation of bundled evidence-based interventions for ventilator-associated pneumonia
(VAP) prevention, such as those proposed by IHI, is imperative (Wip & Napolitano,
2009). Avoidance of the supine position is critical in preventing aspiration pneumonia,
especially in patients receiving enteral feeding (Li Bassi & Torres, 2011). Placing the
patient in the prone position to promote drainage of oropharyngeal and airway secre-
tions has also been noted to be benecial, and more research is warranted in the use of
the lateral Trendelenburg position (Li Bassi & Torres, 2011). Although the evidence
suggests that elevating the head of the bed between 30 and 45 degrees decreases the
incidence of VAP, adherence to the optimal 45-degree level is problematic and increases
the risk of a sacral pressure ulcer. Unfortunately, there is limited evidence to recommend
the safest, lowest head-of-bed (HOB) elevation (Li Bassi & Torres, 2011).
Besides adherence to hand hygiene and HOB elevation, there is good evidence
that routine oral care eectively reduces the rate of HAP in critical care patients
(Simmons-Trau, Cenek, Counterman, Hockenbury, & Litwiller, 2004). Unfortunately,
oral hygiene continues to be a nursing function of “low priority” in most health care
settings (Wenzel & Edmond, 2001). A review of the evidence on subglottal secretion
aspiration revealed it consistently and signicantly reduced the incidence of VAP, yet the
practice is limited in clinical settings (Scherzer, 2010). Systematic review of the factors
associated with enteral feeding in preventing VAP found appropriate enteral feeding to
be the most important factor (Chen, 2009). In addition, intermittent enteral feeding
and ensuring small residual volume is recommended to reduce gastroesophageal reux,
and early feeding and increased total volume intake can prevent ICU mortality. Use
of an antiseptic oral rinse for cardiac-surgery patients, noninvasive positive pressure
ventilation, condensate collection, subglottal secretion drainage, early extubation, and
avoiding gastric overdistension and unplanned extubation have also been found to be
eective preventive measures for VAP (Hsieh & Tuite, 2006). Tolentino-DelosReyes,
Ruppert, and Shiao (2007) demonstrated a signicant improvement in critical care
nurses’ knowledge and adherence to evidence-based practice after an educational pro-
gram on the ventilator “bundle,” or set of interventions, to decrease VAP. e implemen-
tation of an evidence-based guideline in ve U.S. hospitals that included ve nursing
interventions (HOB elevation, oral care, ventilator tubing condensate removal, hand
hygiene, and glove use) reduced the rates of VAP and length of ICU stay, although not
signicantly (Abbott, Dremsa, Stewart, Mark, & Swift, 2006).
Central venous catheter infections can be signicantly reduced using nontechno-
logical strategies such as strict hand washing, maximal sterile barrier precautions, use of
antiseptic solutions, insertion and management by trained personnel, and continuing
quality improvement programs (Gnass et al., 2004). It has been suggested that cleans-
ing the access port with either 70% alcohol or 3.15% chlorhexidine/70% alcohol for
15 seconds is eective in disinfecting the port (Kaler & Chinn, 2007), and that nursing
sta must be diligent in this practice to protect the patient.
Patients with malnutrition, diabetes, postoperative anemia, and ascites are known
to be at increased risk for SSI, so nurses need to closely monitor those patients and col-
laborate with nutrition services to intervene as indicated (Malone et al., 2002). Multiple
evidence-based guidelines for SSI prevention have been developed and include antibiotic
210 Evidence-Based Geriatric Nursing Protocols for Best Practice
prophylaxis within 1 hour of incision with discontinuation within 24 hours. As such,
the timing of antibiotic administration must be a nursing priority, and attention paid
to processes of care to ensure adherence (Gagliardi, Fenech, Eskicioglu, Nathens, &
McLeod, 2009).
Encouraging early mobilization and lung expansion interventions, such as cough-
ing and deep breathing exercises, incentive spirometry, and chest physiotherapy, are
critical nursing interventions to prevent atelectesis, secretion retention, and pneumonia.
Unfortunately, there is a clear lack of evidence in specically which surgical patients
most benet from perioperative lung expansion interventions (Freitas, Soares, Cardoso,
& Atallah, 2007; Lawrence, Cornell, & Smetana, 2006).
Close monitoring and eective glycemic control in critically ill patients can eec-
tively reduce nosocomial infection rates (Grey & Perdrizet, 2004), as well as in-hospital
mortality and length of stay in the ICU (Krinsley, 2004). Tight glycemic control of
older adults, however, does not lower the risk of mortality in the inpatient setting and,
in fact, can put seniors at risk for hypoglycemia and its complications (Alagiakrishnan &
Mereu, 2010).
Besides active prevention measures, maintaining a high degree of vigilance for infec-
tion throughout the hospital stay is critical. Although assessment of vital signs and white
blood cell counts provide important information, the more atypical presentation of
infection requires that nursing sta closely monitor the geriatric patient for any cogni-
tive and functional changes that could reect the presence of infection. Nursing sta
must be aware of the increased vulnerability of the frail, older patient due to immune
senescence, which reduces the T cell response to an infectious agent. Fever can be absent
in 30%–50% of older adults with infection, and any two-point increase from baseline
needs to be considered a fever equivalent. Infection may present as confusion, falls,
decline in self-care ability, reduced food and/or uid intake, re-emergence of previously
resolved stroke symptoms, new incontinence, generalized asthenia, new-onset atrial
brillation, worsened glycemic control, or a host of other subtle ndings. e develop-
ment of any of these conditions should prompt suspicion for occult infection. us, the
role of the nurse as patient advocate is crucial—one that demands ongoing vigilance.
Quality Improvement Initiatives to Minimize Infection
Processes of care need to be reviewed and interdisciplinary quality improvement eorts
initiated to minimize infection, as well as any patient harm. Gagliardi et al. (2009) found
that individual knowledge, attitudes, and beliefs, along with systems issues, such as team
communication, allocation of resources, and organizational support for promoting and
monitoring care processes, highly inuence practice regarding antibiotic prophylaxis for
the prevention of SSI infection. ey recommend written order sets, multidisciplinary
pathways, and quality improvement strategies to ensure adherence to SSI prophylaxis.
A 5-year nurse-led interdisciplinary patient safety initiative used a systems approach
to improve nurse-identied issues by addressing human factors, sta education, and
no-blame reporting systems and successfully reduced the rate of serious ADEs by 45%
(Luther et al., 2002). In addition, it eectively reduced (a) VAP (from 47.8 to 10.9/1000
ventilator days), (b) CABSI (from 90th to 50th percentile), (c) length of hospital stay
(from 8.1 to 4.5 days), (d) RN vacancy rate, and (e) the use of contracted nurses by
more than half (50% ICU, 65% medical–surgical units). Strong organizational com-
mitment was noted as key to success (Luther et al., 2002).
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 211
Another study found monthly feedback of infection rates to sta and training
resulted in a 66% reduction in CABSIs in the ICU (Coopersmith et al., 2002). Pro-
viding nursing sta with quarterly unit-specic data on catherter-associated UTI rates
reduced the overall rate of catheter patient days from 32 to 17.4/1000 at a cost savings
of $403,000 for more than an 18-month period (Goetz, Kedzuf, Wagener, & Muder,
1999). Gastmeier et al. (2002) demonstrated that nosocomial infection rates can be
reduced by quality improvement eorts such as quality circles and continuous sur-
veillance. ese ndings demonstrate the importance of sta education and quality
improvement eorts using a multidisciplinary approach and close interdepartmental
collaboration and communication with organizational support at all levels.
GERIATRIC SYNDROMES
Overview
Geriatric syndromes are health conditions associated with aging and frailty, with a vari-
ety of causes that fail to fall into discrete disease categories (Inouye, Studenski, Tinetti,
& Kuchel, 2007). ese syndromes are increasingly being recognized as serious and
preventable iatrogenic complications that increase risk for adverse outcomes, including
prolonged length of stay and discharge to a more dependent level of care, loss of func-
tion and independence, and even death (Anpalahan & Gibson, 2008). ey are highly
prevalent, especially among the frail elder, multifactorial in nature, and associated with
signicant disability and diminished quality of life. Geriatric syndromes include, but are
not limited to delirium, functional decline, falls, malnutrition, pressure ulcers, depres-
sion, incontinence, and pain that occur in the course of receiving medical and nursing
care. e reader is referred to the appropriate book chapters in this book that address
the assessment and management of these common iatrogenic geriatric syndromes.
It has been suggested that geriatric syndromes need to be recognized as a valu-
able theoretical framework,and used to train nurses (Stierle et al.,2006) and medical
students (Olde Rikkert, Rigaud, van Hoeyweghen, & de Graaf, 2003). Tsilimingras,
Rosen, and Berlowitz (2003) contend that the patient safety initiatives sparked by To
Err Is Human do not go far enough to address the unique needs of the older patient who
is at greatest risk for iatrogenic harm. ey recommend that geriatric syndromes need
to be recognized as distinct iatrogenic events, going so far as to call them medical errors,
and urge major system reform to address these preventable and costly problems. ey
propose the need to routinely identify and report all geriatric syndromes and, when
they occur, proactively identify and address system failures, reduce ADEs, improve the
continuity of care, improve geriatric training programs, and establish dedicated geriatric
units (Tsilimingras et al., 2003).
Nursing Management of Geriatric Syndromes
Evidence-based standards of practice for HAI, falls, functional decline, pressure ulcers,
delirium, and other geriatric syndromes, as outlined in this book, need to be adopted
in targeted high-risk patients to prevent iatrogenesis. Nurses are also encouraged to
use risk assessment tools and best practice interventions, such as the ones described
at the How to Try is series on the Hartford Center for Geriatric Nursing website
(http://consultgerirn.org/resources). Clinical pathways of evidence-based interventions
designed to reduce complications in older adults have achieved measurable success in
212 Evidence-Based Geriatric Nursing Protocols for Best Practice
acute care hospitals. For example, a clinical pathway signicantly reduced the postop-
erative morbidity in patients with hip fractures by reducing postoperative CHF and
cardiac arrhythmias from 5% to 1%, and reducing postoperative delirium from 51% to
22% (Beaupre et al., 2006). In addition, nurses identifying the at-risk older adult and
implementing delirium prevention best practice interventions is key to preventing this
serious and costly complication (Fick, Agostini, & Inouye, 2002). Vigilant nurses com-
petent in geriatrics will use the knowledge of the concept of diminishing physiological
reserve capacity to identify the need to balance diagnostic and therapeutic interventions
with the need for rest and sleep. Closely monitoring sleep patterns in order to prevent
sleep deprivation and scheduling tests and therapy only after the patient has adequate
rest is critical to prevent delirium and promote healing.
A nurse-driven mobility protocol has been shown to decrease functional decline
and length of stay in hospitalized older adults (Padula, Hughes, & Baumhover, 2009).
Nurses also have a responsibility to optimize nutritional status in order to prevent iatro-
genic complications. e older adult’s oral intake needs to be carefully monitored and
reported and insulin adjusted to prevent hypoglycemia and optimize glycemic control
(Sherman, 2005).
Nursing sta should routinely take orthostatic vital signs or at least measure the
blood pressure of the older patient in the sitting position to ensure that signicant
orthostatic hypotension is not induced by treating supine hypertension (Sherman,
2005). Older adults tend to be at greatest risk for falling caused by a variety of intrinsic
and extrinsic factors that are well documented in the literature. Proactive identication
and management of risk factors is critical, and the reader is referred to Chapter 15, Fall
Prevention: Assessment, Diagnoses, and Intervention Strategies.
Pain, in and of itself, can be a form of iatrogenic harm. Pain management is a key
nursing responsibility from an ethical, legal, and regulatory standpoint, and every eort
must be implemented to ensure the patient is not suering needlessly because of acute
or chronic pain (Pasero & McCaery, 2001). A 2010 study of older adults with pain on
an acute medical unit found that (a) 70% of the patients had pain, although their nurses
did not ask them if they had pain in 75% of these cases; (b) nurses documented pain
assessment or management in only 33% of cases; (c) nearly 50% of patients did not
receive a prescribed analgesic for their pain; (d) 14% of patients with pain did not have
any analgesia ordered; and (e) more than 50% of the patients did not receive appropri-
ate pain management (Coker et al., 2010).
Undertreatment of pain in older adults may lead to the iatrogenic condition known
as pseudoaddiction, where the HCP may confuse relief-seeking requests for more pain
medication as the “drug-seeking behavior” of an addict (Pergolizzi et al., 2008). Under-
treated pain limits function in older adults and has been shown to lead to disability and
it can lead to decreased quality of life, depression, and diminished socialization (D’Arcy,
2009; Reid, Williams, & Gill, 2005). Iatrogenic disturbance pain (IDP), the presence
of day-to-day pain that accompanies routine nursing caregiving activities, has also been
described as a signicant source of suering impacting quality of life (Mentes, Teer, &
Cadogan, 2004). e reader is referred to Chapter 14, Pain Management for a more
comprehensive discussion of this topic.
In summary, nurses are in a unique role to prevent geriatric syndromes and cascade
iatrogenesis (Robinson & Weitzel, 2008) and must use their knowledge of aging to
proactively advocate for safe, quality geriatric patient care to members of the health
care team. Moore and Duy (2007) argue that the main reason why older adults are in
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 213
the hospital is the need for nursing vigilance, whereby the nurse has the knowledge to
understand what is happening, the ability to anticipate what can happen, to weigh the
risks and benets, and to intervene to minimize the risk and to monitor outcomes.
INTERVENTIONS RELATED TO CHANGING PROVIDER AND PATIENT KNOWLEDGE,
BELIEFS, AND ATTITUDES
Nurses’ Knowledge, Attitudes, and Beliefs
Although the majority of the literature focuses on iatrogenic illness and injuries that
result from either the commission or omission of a physical act, arguments can be made
that equally detrimental eects to patients can occur as a direct result of the knowledge,
values, attitudes, beliefs, fears, and biases of nurses and other HCPs. A nurse’s percep-
tion of older adults as chronically ill and frail may foster increasing dependence and
functional decline if the patient is not provided the opportunity or assistance to rou-
tinely ambulate or engage in self-care skills.
A nurse who fails to place the patient’s values ahead of his or her own may cause
undue suering and harm when these values are in conict. Failure to treat pain in dying
patients for fear of hastening death increases suering, lowers quality of life remaining,
and conicts with evidence that treatment of pain in dying patients can prolong life and
provide a higher quality of the life that remains. Conversely, nurses who participated
in programs such as the End-of-Life Nursing Education Consortium (ELNEC) have
reported an improvement in their knowledge, condence, and attitudes regarding pal-
liative care for dying patients as well as a decrease in their anxiety regarding death of
patients (Barrere, Durkin, & LaCoursiere, 2008). Likewise, outdated myths and atti-
tudes of aging can interfere with a nurse’s role in protecting the vulnerable older adult,
including eective pain management (D’Arcy, 2009). It is well known that a signicant
number of nursing home patients suer needlessly in pain due in part to fear of addic-
tion that takes precedence over comfort. Older adults, more than any other age group,
tend to be undertreated for pain (Robinson, 2007) and other conditions, including
osteoporosis (Davis, Ashe, Guy, & Khan, 2006) and depression (Harman et al., 2002).
e assumption that the quality of life of the demented person is “poor” may lead the
nurse to assume that institutionalization or palliation is the most appropriate goal of
care, regardless of the values of the elder (Kenny, 1990).
Kenny (1990) asserts that the current and traditional system of hospital care not only
perpetuates dependency and iatrogenesis among geriatric patients, but also “erodes” their
identity, self-esteem, and individuality. In addition, prolonged hospital stays are known
to increase social isolation, decrease function, and foster dependence (Graf, 2008). One
is left to wonder how much this may contribute to the high rates of depression seen in
the hospitalized older patient. Nurses must be careful to distinguish between “care as
discipline” and the gift of care, dened by Fox as the relationship between the patient and
the provider that is mediated by love, generosity, trust, and delight (Greenwood, 2007),
e danger lies in labeling a recipient of care who has impaired cognition as a “dementia
patient,” or a patient with multiple admissions as a “frequent ier,” thus diminishing sen-
sitivity to the humanity of the individual who is hospitalized (Greenwood, 2007). A diag-
nosis of dementia may lead an uneducated or age-biased nurse to expect less of a patient,
and inadvertently promote functional decline, or to inaccurately assess for pain and
undermedicate, promoting patient suering and more complications (D’Arcy, 2009).
214 Evidence-Based Geriatric Nursing Protocols for Best Practice
Nurses have a responsibility to educate themselves in order to act responsibly
and safely. In addition, it is important to carefully examine one’s values and beliefs
systems, so as not to unwittingly contribute to the patient’s suering because of igno-
rance or biases against older patients that can compromise clinical objectivity and
patient care.
Patient Knowledge, Attitudes, and Beliefs
To make matters worse, older patients are known to underreport or deny symptoms
(Coker et al., 2010), in part because they have grown accustomed to living with chronic
aches and pains and may interpret new symptoms as the presentation of a long-standing
health problem. ey may believe the symptom is a normal part of aging or fear a loss
of independence or, worse, institutionalization, if they admit to a physical or cogni-
tive decit. Underreporting of pain is particularly common and problematic among
older adults. Some 40% of fatalities following hip replacement surgeries in seniors are
caused by pulmonary embolism (Morrison et al., 2003). Researchers posit that this is
related to immobility and could be because of seniors’ reluctance to take needed pain
medication that allows them to ambulate and participate in therapy, as well as providers’
lack of knowledge that severe pain is associated with a ninefold increased risk of delir-
ium in cognitively intact patients (Morrison et al., 2003) means to prevent error and
patient harm (Sherwood, omas, Bennett, & Lewis, 2002; Wallace, Spurgeon, Benn,
Koutantji, & Vincent, 2009).
INTERVENTIONS RELATED TO NATIONAL AND ORGANIZATIONAL PRIORITIES
In 2010, the National Council of the State Boards of Nursing in the United States
recognized the need to improve the educational preparation of nurses in geriatrics and,
at the time of this publication, is in the planning stages to require all nurses to have
training in the care of geriatric patients. In addition, the U.S. Department of Health
and Human Services (USDHHS, 2010) has included training in geriatric care by phy-
sicians, nurses, and other health care providers in its Healthy People 2020 goals. ese
goals aim to increase the number of physicians and nurses certied in geriatric care from
2.7% to 3% for physicians and 1.4% to 1.5% for nurses—a 10% improvement for both
disciplines.
National geriatric nursing leaders have been promoting the geriatric nursing skills
and competence of all nurses, including those in subspecialty nursing. Wakeeld et al.
(2005) argue that nursing and medical school must integrate patient safety principles
into their curricula in order to teach HCPs to more eectively prevent and manage
errors, and to ease the burden on an already overstretched health care system. More
emphasis placed on teaching the “aviation” model derived from high-risk industries,
which emphasizes feedback, teamwork, and communication is recommended.
e IOM’s To Err Is Human report increased provider awareness to the dangers
of diagnostic and therapeutic interventions and led to a signicant increase in patient
safety research, literature, and initiatives (Stelfox, Palmisani, Scurlock, Orav, & Bates,
2006). Continued funding for patient safety research and major patient safety initia-
tives such as those provided by the AHRQ, the IHI, Leapfrog Group, and the IOM will
continue to support hospitals in their eorts to create safe care environments (Leape &
Berwick, 2005).
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 215
Organizational Imperatives to Prevent Iatrogenesis
It is now well recognized that a signicant proportion of iatrogenic complications are
directly related to the complex interplay of organizational and human factors that cre-
ate opportunities for patient harm (Leape, 2009). Hospitals and nursing leadership are
urged to comply with not only regulatory mandates, but also to embrace patient safety
as an explicit organizational goal, actively promoting a just culture of safety in which
everyone is aware of the signicance of iatrogenesis. is goal is supported by practices
that enforce, recognize, and reward safety behaviors at the individual, unit, and organi-
zational levels (Dennison, 2005).
Nurses at all levels play a pivotal role in promoting patient safety. ey are not only
the largest workforce of health care providers, providing the nal safety checkpoint at
the bedside (Hughes & Clancy, 2005). Ensuring nurse competence in geriatric nurs-
ing is critical to preventing iatrogenesis in vulnerable older patients, and hospitals that
are committed to implementing geriatric best practices have been shown to positively
inuence patient care (Boltz et al., 2008). Organizations that ensure coordinated and
eective training in both patient safety and geriatric patient care, well integrated into
sta orientation and ongoing training programs, are poised to be eective. Collabora-
tion between nursing education and risk management, quality improvement, infection
control, and medicine will help to identify an institution’s educational priorities and the
most appropriate training strategies.
Although it is the lack of systems such as those for decision support and medication
reconciliation that is often the cause of patient harm (Morris, 2004), hospitals have
been known to assign culpability, punishment, and blame to individuals involved in
the errors, rather than encouraging the reporting of these errors to conduct a root cause
analysis (Dennison, 2005; Morris, 2004). Accordingly, a national survey of nurses in
25 U.S. hospitals found that a large percentage of iatrogenic harm is not reported by
nurses; a mere 36% felt near misses should be reported (Blegen et al., 2004). Hospitals
need to recognize both what constitutes high-risk situations and those patients most
at risk of adverse outcomes, and implement eective patient safety and performance
improvement strategies designed to minimize harm. Nursing peer review and other
audit functions are important processes that promote the understanding of the factors
involved in patient safety incidents (Diaz, 2008).
Nurses need to be at the forefront and engaged in interdisciplinary eorts to
improve the safety culture of an organization (Blegen et al., 2010). Signicant strides
in improving patient care have been made with nurses actively involved in identifying
care-related problems. For example, the IHI and the Robert Wood Johnson Founda-
tion sponsored national initiative, Transforming Care at the Bedside (TCAB) creates,
tests, and implements nurse-generated practice changes to improve patient care and
safety (Viney, Batcheller, Houston, & Belcik, 2006). A nationwide study of the eect of
nursing rounds at least every 2 hours, with specic attention to patient comfort, posi-
tioning, and toileting, demonstrated a signicant decrease in call light use, and a subse-
quent reduction in patient falls and increase in patient satisfaction (Meade, Bursell, &
Ketelsen, 2006). A nurse-led project to improve medication administration reliability
using strategies that addressed process improvement and nursing leadership skills led to
a sustained accuracy rate of 96% at 18 months, from 85% at baseline (Kliger, Blegen,
Gootee, & O’Neil, 2009). e critical need for optimal implementation of, and adher-
ence to, evidence-based practice, including adoption of nursing protocols, to minimize
the risk of error and patient harm cannot be overemphasized.
216 Evidence-Based Geriatric Nursing Protocols for Best Practice
Safety-Promoting Structures and Processes
Nursing leadership has the responsibility to ensure that hospital structure and processes of
care maximize sta eectiveness and minimize the risk of harm for vulnerable patients. Safe
patient care cannot be ensured without the appropriate organizational systems that pro-
mote a positive work environment and ecient communication of pertinent information.
Appropriate nurse stang and nursing competence is imperative given strong evidence that
both stang levels and educational preparation inversely aect patient care and outcomes
(Frith et al., 2010; Kendall-Gallagher & Blegen, 2010). e groundbreaking AHRQ report
entitled Keeping Patients Safe: Transforming the Work Environment of Nurses demonstrated
that stang and workow design clearly impact errors and patient safety outcomes (Page,
2004). A study of HAIs in the ICU conrmed previous data that nurse stang is directly
related to infection rate. e authors noted an increase in infection several days after heavy
workload and advocate maintaining stang at higher levels to minimize the risk of infec-
tion (Hugonnet, Chevrolet, & Pittet, 2007). Lower nurse stang correlates with increased
mortality (Aiken, Clarke, Sloane, Lake, & Cheney, 2008), and Loan, Jennings, Brosch,
Depaul, and Hildreth (2003) call for the need to develop databases to further examine the
eect on stang data and patient outcomes. Scott, Rogers, Hwang, & Zhang (2006) sur-
veyed critical care nurses in the United States and found evidence that longer work hours
not only decreased nurse’s vigilance but also increased the risk of errors and near misses,
supporting the IOM recommendations to limit nurse’s work hours to a maximum of 12
hours in a 24-hour period. Yet, in spite of increased attention and major research done in
this area, lack of standardized data and other problems continue to hinder attempts to nd
a clear solution to the optimal stang needed to minimize error (Blegen, 2006). Research
must continue in this area so that improvements in nurse stang, work areas, and transfer
of knowledge both between providers and within the organization is optimized in order to
maintain patient safety (Blegen, 2006).
Communication and collaboration is vital to ensure appropriate exchange of
information and coordination of care (IOM, 2001) because lack of communication is
considered a major contributor to iatrogenic complications. TJC recognized that com-
munication breakdown is the cause of nearly 70% of all sentinel events, whereas a study
to elicit stories of preventable physical or psychological harm caused by medical error
found breakdown in communication was a far greater problem than technical error
(Kuzel et al., 2004). It is critical to evaluate and optimize what patient information
is communicated during any hand-o report, especially at high-risk times, and create
evidence-based guidelines as to what needs to be included during this process (Alvarado
et al., 2006). Inaccurate or absent information can dramatically increase the risk of
harmful eects on older patients. e plan of care for the older patient that lacks critical
baseline functional and cognitive data can hamper recognition of subtle changes in con-
dition and may contribute to functional decline and other adverse outcomes, including
cascade iatrogenesis. Nurses need to include daily functional priorities and goals that
have been developed with the patient and/or family into every shift or hand o report.
Patient transfer or any hand o presents opportunities for increased harm to
patients. Patient transfer from either another unit or hospital has been found to be
independently associated with the development of nosocomial infections (Eveillard,
Quenon, Rufat, Mangeol, & Fauvelle, 2001), whereas patient transfer from hospital to
a SNF is a signicant risk factor for ADEs (Boockvar et al., 2004). Every eort must
be made to also address the communication of appropriate data during any transfer
of patient care. Posthospital medication management strategies using interdisciplinary
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 217
teams, information technology, and transitional care models need to be considered to
minimize the risk of ADEs postdischarge (Foust, Naylor, Boling, & Cappuzzo, 2005).
Phone calls to recently discharged patients can be an eective intervention to minimize
adverse events and prevent unnecessary readmissions (Forster et al., 2004).
Information technology has the potential to signicantly improve our ability to
provide safe patient care by enhancing communication and providing decision support.
e electronic medical record (EMR) needs to be considered a priority by the organiza-
tion as a means to ensure evidence-based patient care is implemented and monitored
(IOM, 2001), yet a mere 1.5% of U.S. hospitals have even basic EMR keeping in
place, and only 9.1% have computerized physician order entry (CPOE; Landrigan et
al., 2010). A well-designed EMR with CPOE has been shown to reduce the number of
medication errors by 81% (Koppel et al., 2005). Not only are prescription errors caused
by illegible handwriting prevented, but also the EMR can ensure best-practice pre-
scribing using standardized order sets and preprogrammed medication alerts to prevent
adverse drug–drug interactions. e EMR also has the capability to provide decision
support, promote continuity of care and decrease adverse events with more ecient
communication among care providers, especially at high-risk times such as during cross-
coverage (Petersen, Orav, Teich, O’Neil, & Brennan, 1998) and any hando. Comput-
erized prompts to use a nonpharmacological sleep protocol, which is as eective and
far less harmful than sedative-hypnotic medications and promotes higher quality sleep,
has decreased the use of higher risk sleeping medications among hospitalized patients
(Agostini, Zhang, & Inouye, 2007).
Koppel et al. (2005) warns, however, that attention needs to be paid to the role of
the EMR in facilitating medication errors and every measure taken to reduce this risk
after identifying 22 types of error risks with the CPOE system. Nurses need to be aware
of the limitations of CPOE and remain vigilant partners in care to ensure patient safety.
It is also important that health care providers with geriatric expertise be involved from
the onset with the building of the EMR to ensure that best-practice geriatric assessment
and management protocols are included.
Environmental safety needs to be an organizational priority and should involve all
sta and physicians. Routine safety rounds that include leadership and encourage open
discussions of safety at the unit level can be successful in promoting a culture of safety
(Reinertsen & Johnson, 2010). Regularly scheduled safety inspections of the environ-
ment and equipment need to occur and include clinicians with geriatric expertise to
assist in identifying potential safety hazards related to aging changes such as lighting
and seating heights. Standardization of equipment is important to minimize the risk
of error, although mechanisms need to be in place to ensure prompt reporting and
removal from service of any malfunctioning equipment. In addition, considering nor-
mal changes of aging is important when planning hospital construction and renovation,
so that architectural design promotes geriatric patient safety and function.
Partnering With Patients
Nurses can eectively encourage patients to be vigilant and proactive partners in care in
order to prevent unnecessary harm (Hibbard, Peters, Slovic, & Tusler, 2005). Provid-
ing patient education about medical errors has been shown to increase self-advocacy
behaviors and satisfaction in patients (Hibbard et al., 2005). Berntsen (2006) calls for
the implementation of a patient-centered philosophy as a way of minimizing patient
harm. Patient- centeredness espouses that the needs, wants, and preferences of the patient
218 Evidence-Based Geriatric Nursing Protocols for Best Practice
should drive health care interventions (Berntsen, 2006). Nurses providing patient-cen-
tered care compassionately and empathetically respond to the needs of the patient and
oer ample opportunities for patients and families to direct their care through involved
and informed decision making (Berntsen, 2006). A collaborative relationship between
the nurse and the patient to attain mutually agreed upon goals can foster more patient
control, self-care, autonomy, and prevent iatrogenesis (Messmer, 2006). In older patients
with cognitive impairment or language barriers, family members should become integral
partners in this process.
SUMMARY
Signicant progress has been made in better understanding and addressing the problem
of iatrogenesis with the work of agencies such as the AHRQ, IHI, TJC, IOM, National
Patient Safety Foundation, Leapfrog Group, and others. Major strides have been made
in the Veterans Administration heath system, which has emerged as a leader in this area
by implementing systemwide patient safety training initiatives and creating multiple
patient safety research centers. Yet, there remains much work to be done, especially in
the area of preventing harm to the vulnerable older adult patient.
Nurses must recognize their critical role in preventing iatrogenic complications,
which far too often can and do trigger a cascade of physical and cognitive decline that
could have been prevented. Nurses have a responsibility to maintain vigilance and
advocate for their patients, especially for patients who cannot do so for themselves,
such as cognitively impaired elders and those without family support. Hospitalized
older adults depend on the nurse’s knowledge of their baseline functional and cognitive
status and risk factors in order to implement individualized and function-promoting
treatment plans. ey rely on the nursing sta’s ability to recognize subtle changes
and to proactively intervene to keep older patients safe while hospitalized. ey also
depend on nurses to be actively engaged in monitoring safety, conducting problem
solving, and leading quality initiatives to promote the best possible hospital experience
and outcomes.
Involving patients, family, and caregivers as much as possible, and providing predis-
charge training and referral to community resources can help discharge at-risk patients
in a timelier manner and prevent unnecessary hospital readmissions. No longer should
iatrogenic harm be the unfortunate price patients pay for medical progress, nor should
we accept the fact that random, unfortunate events happen in a chaotic environment.
Rather, nurses need to take a stand to understand their role as patient advocates and
educate themselves and others to the problem of iatrogenesis, and to take every precau-
tion necessary to ensure a culture of patient safety.
RESOURCES
Patient Safety
Agency for Health Care Research and Quality (AHRQ)
Patient Safety Network: http://www.psnet.ahrq.gov/
http://healthit.ahrq.gov/portal/server.pt?open=512&objID=653&PageID=5583&cached=false&mode=2
Medical error: http://www.ahrq.gov/qual/errorsix.htm
Iatrogenesis: e Nurse’s Role in Preventing Patient Harm 219
Institute for Healthcare Improvement
http://www.ihi.org/IHI/
Institute of Medicine
http://www.iom.edu/
IOM Crossing the Quality Chasm
http://www.iom.edu/CMS/8089.aspx
e Joint Commission
http://www.jointcommission.org/PatientSafety
National Patient Safety Foundation
http://www.npsf.org/
United States Department of Veterans Aairs National Center for Patient Safety
http://www.patientsafety.gov/
World Health Organization World Alliance on Patient Safety
http://www.who.int/patientsafety/en/
Healthy People 2020, Objectives for Older Adults
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid531
Infection Control
Centers for Disease Control and Prevention (CDC)
http://www.cdc.gov
Association for Professionals in Infection Control and Epidemiology (APIC), Society of Healthcare
Epidemiology of America (SHEA),
http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/MandatoryReporting/Position
Papers/mr_position_papers.htm
National Nosocomial Infection Surveillance System:
http://www.cdc.gov/ncidod/dhqp/nnis.html
Handwashing Guidelines
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005186/frame.html
World Health Organization’s World Alliance for Patient Safety
Guidelines on Hand Hygiene in Health Care (Advanced Draft, 2005)
http://www.who.int/patientsafety/events/05/HH_en.pdf
Clinical Practice
AHRQ (Agency for Healthcare Research and Quality) Clinical Practice Guidelines
http://www.ahrq.gov/clinic/cpgsix.htm
EPIQ (Eective Practice, Informatics and Quality Improvement)
Supports eective, evidence-based practice, health informatics, and quality improvement initiatives
http://www.health.auckland.ac.nz/population-health/epidemiology-biostats/epiq/
National Guideline Clearinghouse: a public resource for evidence-based clinical practice guidelines
http://www.guideline.gov/
Joanna Briggs Institute (Promote and Support Best Practice): International, interdisciplinary
evidence-based resources.
http://www.joannabriggs.edu.au/about/home.php
American Geriatrics Society
http://www.adgapstudy.uc.edu/
220 Evidence-Based Geriatric Nursing Protocols for Best Practice
Hartford Institute for Geriatric Nursing
http://hartfordign.org/uploads/File/hcr_geriatric_nursing_tips.pdf
American Geriatrics Society Clinical Practice Guidelines
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_
recommendations/
Geriatric and Palliative Care Weblogs
http://www.geripal.org/
Clinical Geriatrics
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_
recommendations/
Workforce Development
Institute of Medicine
http://www.iom.edu/Reports/2008/Retooling-for-an-Aging-America-Building-the-Health-Care-
Workforce.aspx
http://www.iom.edu/~/media/Files/Report%20Files/2008/Retooling-for-an-Aging-America-
Building-the-Health-Care-Workforce/ReportBriefRetoolingforanAgingAmericaBuilding
theHealthCareWorkforce.pdf
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229
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe the consequences of physical restraint use, including side rails in older
adults
2. describe the characteristics of an eective restraint reduction program
3. develop individualized care plan strategies that promote alternatives to restraint use
through evidence-based care for falls, delirium, nutrition, medications, sleep, pain,
and function
4. evaluate educational needs of patients and families related to restraint reduction
5. facilitate interdisciplinary team collaboration to ensure all aspects of restraint reduc-
tion program are addressed
OVERVIEW
e Centers for Medicare and Medicaid Services (CMS) denes physical restraint as
“any manual method, physical or mechanical device, material, or equipment that immo-
bilizes or reduces the ability of the patient to move his or her arms, legs, body or head
freely” (U. S. Department of Health and Human Services [HHS], 2007). Examples
include wrist or leg restraints, hand mitts, Geri-chairs, and, in certain situations, full
side rails and reclining chairs. Despite the federal regulations placed on hospitals since
1999, eliminating the use of physical restraints for the management of patients in acute
nonpsychiatric settings has remained challenging. Typically, health care professionals
utilize physical restraints and/or side rails to protect the patient or others (Evans &
FitzGerald, 2002). However, the use of physical restraints or side rails for the involuntary
immobilization of the patient may not only be an infringement of the patient’s rights,
but can also result in patient harm, including soft tissue injury, fractures, delirium, and
Cheryl M. Bradas, Satinderpal K. Sandhu, and
Lorraine C. Mion
13
Physical Restraints and Side Rails
in Acute and Critical
Care Settings
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
230 Evidence-Based Geriatric Nursing Protocols for Best Practice
even death (Bower, McCullough, & Timmons, 2003; Evans, Wood, & Lambert, 2003;
Miles, 1993).
e standards from e Joint Commission (TJC) and regulations from CMS have
raised concerns among hospital professionals about the feasibility and safety of elimi-
nating use of physical restraints and side rails in hospitals. e almost nonexistent use
of physical restraint in the United Kingdom in comparable settings provides evidence
that this can be achieved (O’Keee, Jack, & Lye, 1996; Williams & Finch, 1997). is
chapter focuses on the issues of physical restraint in acute, nonpsychiatric hospital set-
tings with particular attention to older adult patients.
BACKGROUND AND LEGAL ISSUES
Regulations and Accrediting Standards
In 1992, the U.S. Food and Drug Administration (FDA) issued a medical alert on the
potential hazards of restraint devices (FDA, 2006a). Any harm that arises from the use
of a restraining device, which now includes bedside rails, must be reported to the FDA.
TJC hospital standards began to address the use of physical restraints in the early 1990s.
Over the ensuing years, the standards have become increasingly prescriptive.
In 1999, CMS established an interim rule for hospitals and, in December 2006,
nalized the Patients’ Rights Condition of Participation (HHS, 2007). ese conditions
establish the minimum protections of patients’ rights and safety and may be superseded
by state regulations or accrediting agencies. In brief, use of physical restraint should be
used as a last resort; only used when less restrictive mechanisms have been determined
to be ineective; the use of restraint must be in accordance with a written modication
to the patient’s plan of care; used in accordance with the order of a physician or licensed
independent practitioner; must never be written as a PRN order; each order must be
renewed every 24 hours for reasons of violent or self-destructive behavior; each order for
restraint use for nonviolent reasons must be renewed according to hospital policy; and
restraint must be discontinued at the earliest possible time.
Risks of Liability
A major obstacle in reducing clinicians’ use of physical restraint or side rails is the fear
of liability if restraints are not used. Case law has been mixed; hospitals have been found
liable both for the use of physical restraints and for not using physical restraints (Kapp,
1994; Kapp, 1996). Although hospitals have a clear duty to protect patients from harm,
they do not have a duty to restrain patients. As the practice in hospitals becomes one of
reduced restraints because of changing legal and accrediting standards, it will become
easier for hospitals to justify nonuse of restraints in instances of patient injury where use
of nonrestraint interventions were clearly demonstrated (Kapp, 1999).
Professional Standards of Care
A number of organizations have established guidelines for the use of physical restraints,
including the American Nurses Association and the Society for Critical Care Medi-
cine (American Nurses Association, 2001; Maccioli et al., 2003). e National Quality
Forum has designated physical restraint as a nursing-sensitive measure to be monitored
in hospitals and nursing facilities. Lastly, as part of the condition for participation as a
magnet facility, hospitals must examine the use of physical restraint in relation to nursing
Physical Restraints and Side Rails in Acute and Critical Care Settings 231
skill mix and hours. ese guidelines have become the standard for customary practice
and are used as an appropriate legal standard that denes the parameters of liability. Fur-
thermore, these guidelines in combination with TJC and CMS requirements are used to
establish hospital-based policies and procedures and quality of performance activities.
PREVALENCE AND RATIONALE OF STAFF
Extent of Use
ese standards and guidelines have led to an overall decrease in physical restraint use
in acute care and a change in practice patterns. In the 1980s, the overall prevalence rate
of physical restraint use on general oors ranged from 6% to 13%, with higher rates
(18%–22%) among older adult patients (Frengley & Mion, 1998). In the late 1990s,
the overall hospital restraint prevalence decreased but varied as much as three-fold, with
rates ranging from 39 restraint days/1,000 patient days to 82 restraint days/1,000 patient
days (Minnick, Mion, Leipzig, Lamb, & Palmer, 1998; Mion et al., 2001). For the rst
time, restraint use was examined in critical care units and was noted to be as high as
500 restraint days/1,000 patient days. Intensive care unit (ICU) rates varied markedly,
between units in the same hospital setting as well as matched units between hospitals.
A national prevalence study involving 434 units in 40 acute care hospitals selected
at random from ve geographic areas was completed in 2005 (Minnick, Mion, Johnson,
Catrambone, & Leipzig, 2007). Findings from this study revealed overall hospital prev-
alence of 50 restraint days/1,000 patient days but with a 10-fold variation among hos-
pitals from a rate of 9–94 restraint days/1,000 patient days. e majority of use was
accounted for in ICUs. e pattern of dierences by type of unit was again present (e.g.,
medical versus surgical and adult versus pediatric). However, even when controlling by
type of unit, more than 10-fold variation existed among similar settings. For example,
overall prevalence among the 41 general ICUs was 202.6 restraint days/1,000 patient
days with a range of 9–351/1,000 patient days. Further, analyses revealed that variation
in practice persisted even when controlling for size of hospital, academic or nonaca-
demic status, geographic region, type of hospital (e.g., nonprot, prot, and govern-
ment), stang ratios, and nursing skill mix. Clearly, there are major practice dierences
even when controlling for patient population.
Decision to Use Physical Restraint
Today’s hospital nurses cite prevention of patient therapy disruption as the primary
reason for restraint use (reported for 75% of restraint days), presence of “confusion”
(25.4% of the restraint days), and fall prevention (17.6% of the restraint days; Minnick
et al., 2007). Other less commonly voiced reasons included management of agitation
or violent behavior, wandering, and positioning. Although most nurses cite patient
care issues as the rationale to use physical restraint, a small proportion of nurses have
cited insucient stang for restrained patients (Evans & FitzGerald, 2002; Minnick
et al.,1998).
e CMS regulations mandate that physicians or licensed independent practitio-
ners must order physical restraint. Similar to nurses, physicians vary in their decisions
to order physical restraint (Mion et al., 2010; Sandhu et al., 2010). Factors associated
with physicians’ decisions to order restraint include (a) lack of knowledge of physical
restraint and hospital policy, (b) higher appraisal of patient harm, (c) specialty (family
practice or general surgery), (d) trusting the nurse, (e) patient behavior, and (f) presence
232 Evidence-Based Geriatric Nursing Protocols for Best Practice
of dementia. Given the variation in actual use of restraint, it appears that the decision
to use physical restraint continues to be one based on individual judgment and beliefs
rather than on scientically validated guidelines or protocols.
ETHICAL ISSUES IN THE USE OF PHYSICAL RESTRAINT
e primary ethical dilemma resulting from physical restraint is the clinician’s value or
emphasis of benecence versus the patient’s autonomy (Schafer, 1985; Slomka, Agich,
Stagno, & Smith, 1998). Clinicians believe that physical restraint prevents patient falls and
patient disruption of therapy (Frengley & Mion, 1998; Lamb, Minnick, Mion, Palmer, &
Leipzig, 1999). e presence of a physical restraint, by its very nature, is applied against
a patient’s wishes and inevitably compromises the individual’s dignity and diminishes
respect for the person. Benecence requires that at least no harm should arise from the use
of physical restraint and that, optimally, a good outcome would result from use. e lack
of benecial results from the use of physical restraints has been well documented in many
health care settings. Little is known, however, of the risk-to- benet ratio of use or nonuse
of physical restraint in patients who are critically ill (Maccioli et al., 2003).
e discussion of physical restraints from an ethical viewpoint must also incorporate
the sociocultural and political contexts. For example, clinicians have reported on low to
nonexistent use of physical restraint in the United Kingdom, stemming perhaps from a
legal mandate existing since the 1800s prohibiting their use. It has been suggested that
in the United States, the domination of risk in geriatric assessment (e.g., prevent harm,
prevent falls) shapes much of clinicians’ understanding of old age (Kaufman, 1994).
If one’s primary focus is on the likelihood of patient risk resulting in harm, one is less
likely to see self-esteem or dignity as the more important value or model to guide clini-
cal decisions (Slomka et al., 1998). Interestingly, Slomka and associates point out the
contradictory nature of the frequent use of physical restraint in the United States—that
is, a society that places a high value on autonomy yet so willing to violate that autonomy
in the interest of perceived patient benet (Slomka et al., 1998).
e discussion of ethics in clinical practice must also acknowledge the realities
of reduced resources and escalating costs (Minnick et al., 2007; Slomka et al., 1998).
Decisions and protocols about the use of physical restraints and methods to reduce and/
or eliminate restraints will be impacted by cost-containment eorts, and clinicians and
administrators alike may be reluctant to minimize or eliminate restraints. If alterna-
tives to physical restraints in acute care settings can be shown to contribute to quality
outcomes (e.g., patient safety, patient dignity, or satisfaction) and within existing cost-
containment eorts, then there is an increased likelihood of successfully implementing
and maintaining practice guidelines. ere is a chance, however, that if restraint reduc-
tion eorts are seen as too expensive (e.g., use of “sitters”), then the emphasis on cost
constraint may trump other considerations (Slomka et al., 1998).
ADMINISTRATIVE RESPONSIBILITIES
Changing established practices and philosophies of care can be a daunting task. Although
education and training is important, the single most important factor in aecting a major
shift in the present paradigm of care to one that is restraint-free care is the commit-
ment by administrators and key clinical leaders (Mion et al., 2001; Williams & Finch,
1997). Indeed, the huge variation seen in the rates among 40 hospitals that cannot be
explained by size of hospital, type of hospital, or geographic location lends support to
Physical Restraints and Side Rails in Acute and Critical Care Settings 233
this observation. Administrators, including nurse managers, set the tone for the practice
on the unit. Reducing health care providers’ reliance on physical restraint in managing
confused or agitated patients, especially in the critical care units, is a major shift that
leaves many sta uneasy. Clinical sta, especially the frontline care providers, must feel
supported during the transition period. e goal set and supported by administration
of a restraint-free environment would establish the presence of a physical restraint as an
outlier that requires a full analysis as for a sentinel event. e outcome of such analyses
may well lead to the recognition of system problems and organizational arrangements
that can be improved, which, in turn, lead to even fewer restraints in use.
INTERVENTIONS AND CARE STRATEGIES
e studies of the prevalence of the use of physical restraints for nonpsychiatric pur-
poses in hospitals have shown that there is great discrepancy between general medical
and surgical units and ICUs in terms of the extent and rationale. erefore, the use of
physical restraints and approaches to possible alternatives can be considered separately
for general hospital units and critical care units.
General Medical and Surgical Units
Although rates of physical restraint use on general medical and surgical units have declined
in the past 20 years, wide variation exists: from 3 to 123 restraint days/1,000 patient
days on medical units and from 0 to 65 restraint days/1,000 patient days on surgical
units (Minnick et al., 2007). It is apparent there are units that demonstrate best prac-
tices, but also that further eorts are needed to eliminate this practice as a national
standard. Otherwise, signicant numbers of patients will continue to be restrained.
Many hospitals provide care for acutely ill, frail older adults in settings that are not
designed environmentally for the care of such older people (Catrambone, Johnson, Mion,
& Minnick, 2009; Mion et al., 2006; Palmer, Landefeld, Kresevic, & Kowal, 1994).
Environmental structure can either facilitate or inhibit monitoring and surveillance,
noise control, appropriate lighting, socialization, cognition, and function (Catrambone
et al., 2009; Palmer et al., 1994). Studies in long-term care settings have demonstrated
that the use of environmental strategies can enhance function among those suering
from dementia; similar strategies need to be considered in acute care settings.
Besides environmental strategies, organizational factors such as systems to determine
stang numbers and mix, models of care delivery, and transmission or communication
of the plan of care among multiple disciplines and departments are gaining increased
recognition in the patient safety movement (Leape & Berwick, 2005). Many health
care providers lack the knowledge, skills, and sensitivity in providing appropriate care
to older adults. TJC standard to ensure age-specic education and training is a step in
the right direction, but further eorts are required.
No single approach to eliminating physical restraints on general medical and sur-
gical units can be successful. Studies in a variety of settings have shown that the use
of advanced practice nurses, comprehensive interdisciplinary approaches to enhance
cognitive and physical function, sta education, organizational strategies, and environ-
mental interventions can eliminate or reduce physical restraints in a cost-eective man-
ner while promoting other patient outcomes, such as reduced fall rates (Amato, Salter,
& Mion, 2006; Inouye et al., 1999; Landefeld, Palmer, Kresevic, Fortinsky, & Kowal,
1995; Mion et al., 2001).
234 Evidence-Based Geriatric Nursing Protocols for Best Practice
Critical Care Units
e practice of physical restraints is now predominantly within ICUs to maintain
needed life-sustaining therapies or life-maintaining therapies (Minnick et al., 2007).
Strategies that have been used with success in long-term care settings, rehabilitation
settings, and general hospital units are not as successful in critical care environments
(Mion et al., 2001). e severity of illness of patients, the intensity and delivery of care,
the pace of activity, and the consequences of interruptions, delays, or disruptions of
therapeutic devices dier signicantly between non-ICUs and ICUs. e thought of
delirious patients dislodging external ventricular drains with subsequent brain damage,
pulling out central lines with threat of hemorrhage, or self-extubation from mechanical
ventilation with subsequent respiratory arrest is one that heavily inuences critical care
nurses’ decisions to use physical restraints (Frengley & Mion, 1998; Happ, 2000).
Eorts to limit physical restraint use in the ICU are hampered by lack of informa-
tion regarding the extent of therapy disruption in these units or the resulting immediate
and subsequent harm to patients (Maccioli et al., 2003). A number of studies, mostly
single site, have examined self-extubation from mechanical ventilation ( Frengley &
Mion, 1998). Rates have ranged from 0.3% to 14.3%, with higher rates in medi-
cal ICUs. Reintubation after self-extubation ranged from 11% to 76%. Importantly,
33%–91% of those who self-extubated did so while physically restrained. As part of the
national prevalence study described earlier, the authors also examined the prevalence
of patient-initiated device removal, patient contexts, patient risk-adjusted factors, and
consequences (Mion, Minnick, Leipzig, Catrambone, & Johnson, 2007). In 49 ICUs
in 39 hospitals, the authors collected data on 49,482 patient days. Patients removed
1,623 devices on 1,097 occasions for an overall rate of 22.1 episodes/1,000 patient days.
Similar to results on physical restraint prevalence, wide variation in rates were noted:
from none to 102.4 episodes/1,000 patient days. Approximately, half the episodes
occurred on day shift, and 44% were in physical restraint at the time of the episode.
Patient harm occurred in 250 (23%) events, mostly minor in nature. In 10 (0.9%) epi-
sodes, patients incurred major harm. No deaths occurred. e authors examined rates
of reinsertion and found these varied by type of device. Devices that are easily applied,
such as monitor lead or oxygen masks, had much higher reinsertion rates than devices
that are more complex and dicult to insert (such as endotracheal tubes or surgical
drains). It may be that devices are utilized too long, which could contribute to pro-
longed use of physical restraint. In turn, physical restraint may contribute to agitation
and delirium (Inouye & Charpentier, 1996). Additional hospital resources (e.g., x-rays,
laboratory tests) were utilized in slightly more than half the episodes; thus, a potentially
costly problem (Fraser, Riker, Prato, & Wilkins, 2001).
Information gathered on stang levels and mix showed little variation among these
ICUs; hence, there was no association between stang ratios and therapy disruptions.
Of the three studies on self-extubation that examined relationship to stang levels, two
also showed no association (Boulain, 1998; Chevron et al., 1998; Marcin et al., 2005).
e authors found no association between a unit’s restraint rate and rate of therapy disrup-
tion, a nding similar to some studies (Kapadia, Bajan, & Raje, 2000; Mion et al., 2001)
but not others (Carrión et al., 2000; Tominaga, Rudzwick, Scannell, & Waxman, 1995).
Finally, the pattern of sedation and analgesia in these units was unclear, and 30% of the
patients had received no analgesia or sedation in the 24 hours prior to the episode. Others
have reported on inconsistent sedation and analgesia practices in ICUs (Bair et al., 2000;
Egerod, Christensen, & Johansen, 2006; Mehta et al., 2006). In an earlier cohort study, the
Physical Restraints and Side Rails in Acute and Critical Care Settings 235
authors examined medical intensive care unit (MICU) patient outcomes after implement-
ing sedation and analgesia guidelines and found that those cared for with the guidelines
had less self-extubation events and use of physical restraints (Bair et al., 2000). Examining
appropriate strategies for sedation and analgesia in critically ill patients may well result in
improved clinical outcomes while providing care in a more humane fashion.
Attention to the environment of the ICU is as important as any other setting.
Indeed, the environment can aect more strongly persons whose personal competence is
low and who are unable to exert control over the environment. Inouye and Charpentier
(1996) exquisitely demonstrated the inverse relationship of the individual’s level of vul-
nerability with that of environmental or process insults on subsequent development of
delirium among hospitalized older adults. Environmental features such as noise, light,
and unit design have been shown to be associated with agitation, anxiety, and disorien-
tation of ICU patients (Frengley & Mion, 1998).
Lack of communication with ICU patients by care providers has been documented
and results in distress, anxiety, and confusion (Fontaine, 1994). Attention to the physi-
cal environment, use of communication techniques with seemingly noncommunicative
patients, encouragement of collaborative practice among ICU disciplines, and non-
pharmacologic approaches to relieve patient distress, anxiety, and agitation have been
suggested but largely untested (Maccioli et al., 2003). Nevertheless, a multipronged
approach to optimize physical and cognitive function, address onset, as well as manage-
ment of delirium, and appropriate and adequate pain control are likely to aect nurses’
and physicians’ reliance on physical restraint.
ALTERNATIVES TO PHYSICAL RESTRAINTS
Overview
is book has provided the reader with a number of protocols addressing care issues
such as falls, delirium, sleep, nutrition, medications, and function. e reader is encour-
aged to review these protocols closely. Implementing best practices aimed at these areas
will in itself reduce the use of physical restraints. A brief overview of an approach that
the authors have found successful is presented herein.
e two major reasons for using physical restraints to prevent therapy disruption and
falls require comprehensive yet targeted approaches. e act of self-terminating therapy
among hospitalized, acutely ill older adults is most likely a manifestation of delirium
and less likely a desire to enact a clinical decision, as with advanced directives. Both
falls and delirium are well-known syndromes with signicant morbidity and mortality
among older adults. Both are complex syndromes with multiple underlying etiologies
that require a combination of individual-, environmental-, and organizational-specic
strategies (Tinetti, Inouye, Gill, & Doucette, 1995). Inouye and colleagues (1999)
have demonstrated a multicomponent approach to preventing delirium in a random-
ized controlled trial and subsequently implemented in a number of hospitals (Bradley,
Webster, Schlesinger, Baker, & Inouye, 2006). Fall prevention also requires a multi-
component approach (Oliver, Healey, & Haines, 2010). Given the complexity of falls
and delirium, it is unlikely that any single intervention would suce as an alternative
to physical restraint. Rather, attention to the environment and organization of the unit,
as described in the two previous sections, combined with patient-specic approaches
provides the most successful approach to eliminating restraint use (Amato et al., 2006;
Mion et al., 2001).
236 Evidence-Based Geriatric Nursing Protocols for Best Practice
Fall Prevention
Falls are well-known, serious events in hospitalized older patients. Although nurses perceive
that physical restraint prevents falls from occurring, the reality is that physical restraints
have not been shown to prevent falls and can actually contribute to fall injury (Frengley
& Mion, 1998). e goal is to minimize the risk or probability of falling without compro-
mising the older individual’s mobility and functional independence. Using a systematic or
standardized approach, the nurse and physician assess the patient for intrinsic (personal),
extrinsic (environment), and situational (activity) factors. Common intrinsic risk factors
include impaired gait or balance, sedating medications, vision and hearing impairments,
and cognitive impairment including impaired memory, impulsiveness, or poor judgment;
a number of fall risk assessment guidelines are available (Oliver et al., 2010). e reader is
referred to Chapter 15, Fall Prevention: Assessment, Diagnoses, and Intervention Strate-
gies, for a more in depth discussion. What is important to note is that the evaluation for
intrinsic factors need not be complex or time consuming. For instance, the nurse can do
a simple evaluation of gait and balance by simply observing the person’s ability to transfer
in and out of bed or chair and ability to walk to and from the bathroom. e nurse can
quickly note any diculty with steadiness, ability to stand up independently without
using a rocking motion or use of upper extremities, ability to sit down without “plopping”
onto the surface of the chair, and the ability to walk steadily to the bathroom without
holding onto objects or the wall. At this time, notation can be made of lightheadedness or
dizziness, presence of orthostatic hypotension, and use of sedating medications.
Extrinsic factors include clothing and footwear. Shoes or slippers should be nonskid,
but rubber-soled footwear is not recommended because this material can “grip” the oor
causing the person to pitch forward. Furniture design, such as beds at a proper height
and chairs with extended armrests for easier leverage, can facilitate mobility. Reclining
chairs are helpful for those with poor trunk control and who slide out of chairs with a
90-degree seating angle. On the other hand, reclining chairs could be a type of restraint
if used for patients with general deconditioning or weakened states who subsequently
struggle to rise out of the chair. Although beds low to oor assist with preventing fall
injury, they may actually contribute to a fall in a person with weak quadriceps muscle
strength who struggles to stand upright from a very low position (Capezuti et al., 2008;
Tominaga et al., 1995; Tzeng & Yin, 2008); hence, the nurse must use clinical judg-
ment of whether the intervention is to prevent a fall or prevent a fall injury. ese goals
do not necessarily result in similar interventions. Hospital equipment can also contrib-
ute to falls such as legs collapsing on bedside commodes, wheelchairs tipping when a
patient leans forward, or tubing from lower extremity intermittent compression devices
that are left on when a patient stands up from bed.
e ndings of either intrinsic or extrinsic factors should lead to targeted inter-
ventions. ere are some fall-prevention strategies that one could consider as
“universal,”—that is, be implemented for all patients regardless of the risk level. For
instance, all patients should have beds at appropriate heights for ease of exiting and
entering, have call bells within reach, and have clear pathways. Depending on the type
of unit, some units may elect to incorporate universal interventions that other oors
would consider a targeted intervention. For example, an acute stroke unit may elect to
automatically place all patients on a toileting schedule at time of admission and reevalu-
ate continually whether this intervention is required, whereas the other units in the
hospital would elect to use this as a targeted intervention only for those patients with
cognitive impairment and incontinence. An important fall prevention strategy in any
Physical Restraints and Side Rails in Acute and Critical Care Settings 237
setting is mobilization and exercise. Even in critical care settings, there is a growing body
of literature that demonstrates the physiologic and physical benets of early mobiliza-
tion and rehabilitation (Truong, Fan, Brower, & Needham, 2009).
Protection of Medical Devices
Disruption of therapy or self-termination of devices can be dealt with by rst identifying
the underlying reason for the patient’s attempts to terminate therapies. In many cases,
the nurse will identify “confusion” as the underlying cause. As discussed in earlier chap-
ters, the nurse needs to dierentiate dementia, delirium, or delirium superimposed on
dementia. Additionally, the interdisciplinary team must discern the underlying causes of
delirium, including pain. A systematic approach to determine the cause of the behavior
is necessary for treatment. For example, if an older adult is suering from alcohol with-
drawal, it is unlikely that interventions such as increased surveillance or pain relief will
have much impact on the person’s agitation and delirium. Refer to Chapter 10, Dementia;
Chapter 11, Delirium; and Chapter 8, Assessment of Cognitive Function, for further
protocols to identify cognitive impairments and to prevent and manage delirium.
Historically, the options for managing agitation in the critical care unit have been
sedation and/or physical restraint. e type and amount of sedation, however, may
actually contribute to delirium and agitation (Wunsch & Kress, 2009). Multiple studies
suggest that limiting the use of benzodiazepines and use of an alternative medication
dexmedetomidine can decrease ventilator time, length of stay, and long-term brain dys-
function (Wunsch & Kress, 2009). e use of physical restraint in critical care settings
has been associated with delirium as well as posttraumatic stress disorder (Jones et al.,
2007; Micek, Anand, Laible, Shannon, & Kollef, 2005; Nirmalan, Dark, Nightingale,
& Harris, 2004; Wallen, Chaboyer, alib, & Creedy, 2008).
As the health care team works to address the patient’s behavior, nonpharmacologic
approaches to protecting the device from self-termination can be made. First, evaluate daily
whether the device is absolutely necessary. Since the occurrence of the CMS designation of
nonpayment of nosocomial catheter infections (e.g., urinary tract infections from indwell-
ing catheters, ventilator-related pneumonia), many ICUs have implemented multidisci-
plinary daily mandatory checklists that incorporates assessment for compliance to infection
control and timely discontinuation of devices (Byrnes et al., 2009; DuBose et al., 2010).
Even in the critical care environment, major therapy devices may not be reinserted once
a patient pulls it out. us, always question whether the device is absolutely necessary or
whether a less noxious device or approach may be used instead. For example, if a nasogas-
tric tube is used for nutrition, request the assessment of other disciplines, such as speech or
occupational therapists, to determine whether oral feeding could be introduced. If long-
term enteral feeding is required, an interdisciplinary team plan with the patient and family
is warranted given the known deleterious eects of tube feedings with certain conditions.
Some therapeutic devices cannot be altered or discontinued, for example, use of
endotracheal tubes, nasal cannula, or oxygen masks. A second approach is to use anchor-
ing techniques to secure the device against the patient’s attempts to dislodge the device
or to use camouage to “hide” the device from the patient. Proper anchoring addresses
comfort as well as stabilization of the device(s). For example, it is not unusual for pres-
sure ulcers to develop on nares or behind ears and neck because of undue pressure from
the device; clearly a source of discomfort for the patient. Proper stabilization of the tube
or device with secure anchoring can minimize accidental dislodgment as well as deter
more purposeful removal. For instance, a nasogastric tube can be placed so as to not
238 Evidence-Based Geriatric Nursing Protocols for Best Practice
interfere with or interrupt the person’s visual eld. Seeing the tube dangling in front
of one’s eyes or pulling on one’s nares is an obvious irritant. If a gastrostomy tube is
determined to be appropriate in the person’s plan of care, abdominal binders can aid in
reducing the person’s ability to pull it out. ere are a number of commercial products
available to secure various tubes, including nasogastric tubes, endotracheal tubes, intra-
venous lines, and indwelling bladder catheters. Although none of these devices is likely
to prevent a determined person from pulling out a device, they do provide anchoring
and stability of the device that are probably more secure than taping methods.
Side Rails
A discussion on physical restraints in hospitals would not be complete without mention-
ing side rails. Side rails, in and of themselves, are not considered a restraining device by
either TJC or CMS. It is the nurse’s intent of their use that determines whether side rails
are a restraining device or a protective device. is has led to some confusion by nurses.
Full side rails to transfer patients in carts, during procedures (e.g., conscious sedation),
or protect a sedated or lethargic patient from rolling out of the bed can be considered as
protective devices. A number of specialty beds, such as ICU pulmonary beds or bariatric
beds, require full side rails in use. Many bed manufacturers have bed controls and call
systems embedded in the side rail frames, resulting in patients requesting the side rails
be kept raised for ease of control. Hospital patients have also been observed to request
partial to full side rails to be raised because of the narrowness of the beds or to facilitate
movement (e.g., transfers, repositioning).
In ICU settings, full side rails are used predominantly because of bed equipment speci-
cation (e.g., pulmonary beds) or because of procedural considerations (e.g., sedation pro-
tocols; Minnick, Mion, Johnson, Catrambone, & Leipzig, 2008). In non-ICUs, nurses
use full side rails primarily for fall prevention (46%), especially for older patients (Minnick
et al., 2008). Full side rails to keep patients in bed who desire to leave bed are restraints.
It does not matter what the cognitive level of the person is. If a severely demented patient
wishes to leave the bed, full side rails are considered a restraint, even if the nurse believes
the side rails are for “patient safety.” Side rails have been shown to increase fall injuries
because patients either try to squeeze through rails or climb over the foot of the bed or are
not a recommended strategy for fall prevention for the conscious but cognitively impaired
patient (Braun & Capezuti, 2000). Indeed, the FDA has received reports of more than
400 deaths as a direct result of side rail entrapment from a variety of health care settings,
including hospitals (FDA, 2006b). e reader is referred to Braun and Capezuti (2000)
for an excellent review of the legal and medical aspects of side rail use.
SUMMARY
e pattern and rationale for physical restraint use has changed over the past two decades.
Focusing on assessment and prevention of delirium and falls will likely minimize their
use. Further work is needed in the ICU settings for best strategies to identify, prevent,
and manage delirium that would include nonpharmacologic as well as pharmacologic
approaches. To avoid the use of physical restraints, practical and cost-eective strategies
need to be devised and tested. is would best be done in an interdisciplinary patient-
centered fashion.
Physical Restraints and Side Rails in Acute and Critical Care Settings 239
Protocol 13.1: Physical Restraints and Side Rails in
Acute and Critical Care Settings
I. GOAL: To eliminate the use of physical restraints and side rails in acute and critical
care settings.
II. OVERVIEW
A. e use of physical restraints or side rails for the involuntary immobilization
of the patient may not only be an infringement of the patient’s rights, but can
also result in patient harm, including soft tissue injury, fractures, delirium, and
even death (Bower et al., 2003; Evans et al., 2003; Miles, 1993).
B. e primary ethical dilemma resulting from physical restraint is the clinician’s
value or emphasis of benecence versus the patient’s autonomy.
C. Use of physical restraint should be used as a last resort; only used when less
restrictive mechanisms have been determined to be ineective; the use of restraint
must be in accordance with a written modication to the patient’s plan of care;
used in accordance with the order of a physician or licensed independent practi-
tioner (LIP); must never be written as a PRN order; each order must be renewed
every 4 hours, for adults up to 24 hours at which time a reevaluation by a LIP is
required for reasons of violent or self- destructive behavior; each order of restraint
use for nonviolent reasons must be renewed according to hospital policy; and
restraint must be discontinued at the earliest possible time (HHS, 2007).
III. BACKGROUND AND STATEMENT OF PROBLEM
A. Denition: e Centers for Medicare and Medicaid Services (CMS) denes
physical restraint as “any manual method, physical or mechanical device, mate-
rial, or equipment that immobilizes or reduces the ability of the patient to move
his or her arms, legs, body or head freely” (HHS, 2007). Examples include
wrist or leg restraints, hand mitts, Geri-chairs, and, in certain situations, full
side rails and reclining chairs.
B. Etiology: Hospital nurses’ reasons for use of physical restraint are prevention
of patient disruption of medical devices and therapy (75%), confusion (25%),
and fall prevention (18%; Minnick et al., 2007).
C. Epidemiology
1. Prevalence of physical restraint use on individual non-ICU rates range
from 0 to 123 restraint days/1,000 patient days, with overall rates ranging
among types of units from 3.6 (pediatric units) to 49.2 (neuroscience units;
Minnick et al., 2007).
2. Individual ICU rates range from 0 to 267.9 restraint days/1,000 patient
days with overall rates ranging by types from 50.6 (pediatric ICUs) to 267
(neurology and neurosurgery ICUs; Minnick et al., 2007).
IV. PARAMETERS OF ASSESSMENT
A. Assess for underlying cause(s) of agitation and cognitive impairment leading
to patient-initiated device removal (refer to Chapter 8, Assessing Cognitive
NURSING STANDARD OF PRACTICE
(continued)
240 Evidence-Based Geriatric Nursing Protocols for Best Practice
Function; Chapter 9, Depression in Older Adults; Chapter 10, Dementia; and
Chapter 11, Delirium).
1. If abrupt change in perception, attention, or level of consciousness:
a. Assess for life-threatening physiologic impairments
b. Respiratory, neurologic, fever and sepsis, hypoglycemia and hyperglycemia,
alcohol or substance withdrawal, and uid and electrolyte imbalance
c. Notify physician of change in mental status and compromised physi-
ologic status
2. Dierential assessment (interdisciplinary)
a. Obtain baseline or premorbid cognitive function from family and caregivers
b. Establish whether the patient has history of dementia or depression
c. Review medications to identify drug–drug interactions, adverse eects
d. Review current laboratory values
B. Assess fall risk: intrinsic, extrinsic, and situational factors (refer to Chapter 15,
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies)
C. Assess for medications that may cause drug–drug interactions and adverse drug
eects (refer to Chapter 17, Reducing Adverse Drug Events).
V. NURSING CARE STRATEGIES
A. Interventions to Minimize or Reduce Patient-Initiated Device Removal
1. Disruption of any device
a. Reassess daily to determine whether it is medically possible to discon-
tinue device; try alternative mode of therapy (DuBose et al., 2010; Mion
et al., 2001; Nirmalan et al., 2004).
b. For mild-to-moderate cognitive impairment, explain device and allow
patient to feel under nurse’s guidance.
2. Attempted or actual disruption: ventilator
a. Determine underlying cause of behavior for appropriate medical and/or
pharmacologic approach
b. More secure anchoring
c. Appropriate sedation and analgesia protocol
d. Start with less restrictive means: mitts, elbow extenders
3. Attempted or actual disruption: nasogastric tube
a. If for feeding purposes, consult with nutritionist and speech or occupa-
tional therapist for swallow evaluation.
b. Consider gastrostomy tube for feeding as appropriate if other measures
are ineective.
c. Anchoring of tube, either by taping techniques or commercial tube holder
d. If restraints are needed, start with least restrictive: mitts, elbow extenders
4. Attempted or actual disruption: intravenous (IV) lines
a. Commercial tube holder for anchoring
b. Long-sleeved robes, commercial sleeves for arms
c. Consider Hep-Lock and cover with gauze
d. Taping, securement of IV line under gown, sleeves
e. Keep IV bag out of visual eld
f. Consider alternative therapy: oral uids, drugs
(continued)
Protocol 13.1: Physical Restraints and Side Rails in
Acute and Critical Care Settings (cont.)
Physical Restraints and Side Rails in Acute and Critical Care Settings 241
5. Treatment (Interdisciplinary)
a. Treat underlying disorder(s)
b. Judicious, low dose use of medication if warranted for agitation
c. Communication techniques: low voice, simple commands, reorientation
d. Frequent reassurance and orientation
e. Surveillance and observation: Determine whether family member(s)
willing to stay with patient; move patient closer to nurses’ station; per-
form safety checks more frequently; redeploy sta to provide one-on-one
observation if other measure is ineective
6. Attempted or actual disruption: bladder catheter
a. Consider intermittent catheterization if appropriate
b. Proper securement, anchoring to leg. Commercial tube holders available
B. Interventions to Reduce Fall Risk
1. Patient-centered interventions
a. Supervised, progressive ambulation even in ICUs (Inouye et al., 1999;
Truong et al., 2009)
b. Physical therapist/occupational therapist (PT/OT) consultation: weakened
or unsteady gait, trunk weakness, upper arm weakness
c. Provide physical aids in hearing, vision, walking
d. Modify clothing: skidproof slippers, slipper socks, robes no longer than
ankle length
e. Bedside commode if impaired or weakened gait
f. Postural hypotension: behavioral recommendations such as ankle pumps,
hand clenching, reviewing medications, elevating head of bed
2. Organizational interventions (Mion, 2001)
a. Examine pattern of falls on unit (e.g., time of day, day of week)
b. Examine unit factors that can contribute to falls that can be ameliorated
(e.g., report in back room versus walking rounds to improve surveillance)
c. Restructure sta routines to increase number of available sta through-
out the day
d. Set and maintain toilet schedules
e. Install electronic alarms for wanderers
f. Consider bed and chair alarms (note: no to little evidence on eectiveness)
g. Moving patient closer to nurse station
h. Increased checks on high-risk patients
3. Environmental interventions (Amato et al., 2006; Landefeld et al., 1995)
a. Keep bed in low, locked position
b. Safety features, such as grab bars, call bells, bed alarms, are in good
working order
c. Ensure bedside tables and dressers are in easy reach
d. Clear pathways of hazards
c. Bolster cushions to assist with posture, maintain seat in chair
d. Adequate lighting, especially bathroom at night
e. Furniture to facilitate seating: reclining chairs (note: may be considered
restraint in some instances), extended arm rests, high back
C. Review medications using Beers Criteria for potentially inappropriate medications
Protocol 13.1: Physical Restraints and Side Rails in
Acute and Critical Care Settings (cont.)
(continued)
242 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
Additional Information About Restraints
Consult GeriRN
An online resources containing information regarding assessing and caring for older adults sponsored by
the Hartford Institute for Geriatric Nursing at New York University College of Nursing.
http://consultgerirn.org/resources
e Joint Commission: Sentinel Event Alert
http://www.jointcommission.org/sentinel_event_alert_issue_8_preventing_restraint_deaths/
VI. EVALUATION AND EXPECTED OUTCOMES
A. Patient
1. Patient will remain free of restraints
2. Physical restraints will be used only as a last resort
B. Nursing Sta
1. Will be able to accurately assess patients who are at risk for use of physical
restraint
2. Will only use physical restraints when less restrictive mechanisms have been
determined to be ineective
3. Will have an increased use of nonrestraint, safety alternatives
C. Organization
1. Will have a decrease in incidence and/or prevalence of restraints
2. Will not have an increase of falls, agitated behavior, and patient-initiated
removal of medical devices
VII. FOLLOW-UP MONITORING OF CONDITION
A. Monitor restraint incidence comparing benchmark rates over time by unit
B. Document prevalence rate of restraint use on an ongoing basis
C. Focus education on assessment and prevention of delirium and falls
D. Consult with interdisciplinary members to identify additional safety
alternatives
VIII. RELEVANT PRACTICE GUIDELINES
A. American Nurses Association. (2001). Position statement: Reduction of patient
restraint and seclusion in health care settings. Retrieved from NursingWorld
website: http://www.nursingworld.org/MainMenuCategories/Ethics Standards/
Ethics-Position-Statements/prtetrestrnt14452.aspx
B. Maccioli, G. A., Dorman, T., Brown, B. R., Mazuski, J. E., McLean, B. A.,
Rosenbaum, S. H., . . . Society of Critical Care Medicine. (2003). Clini-
cal practice guidelines for the maintenance of patient physical safety in the
intensive care unit: Use of restraining therapies—American College of Criti-
cal Care Medicine Task Force 2001–2002. Critical Care Medicine, 31(11),
2665–2676.
Protocol 13.1: Physical Restraints and Side Rails in
Acute and Critical Care Settings (cont.)
Physical Restraints and Side Rails in Acute and Critical Care Settings 243
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246
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader will be able to:
1. discuss the importance of eective pain management for older adults
2. describe best methods of assessing pain
3. discuss pharmacological and nonpharmacological strategies for managing pain
4. state at least two key points to include in education for patients and families
OVERVIEW
Pain is a very common experience among older adults. e prevalence of pain in older
adults ranges from 50% to 86% (Horgas, Elliott, & Marsiske, 2009). Across all care set-
tings and most specialty areas, nurses will interact with older adults (Herr, 2010). By the
year 2030, it is projected that one in ve US residents will be older than 65 years of age
(Rosenthal & Kavic, 2004), and those older than age 85 represent the fastest growing
segment of the population. In 2000, adults older than the age of 65 accounted for half
of all hospital inpatient days (Rosenthal & Kavic, 2004). Furthermore, approximately
50% of admissions to the intensive care unit (ICU) are adults older than the age of 65
(McNicoll et al., 2003; Pisani, McNicoll, & Inouye, 2003). us, care of older adults
is no longer restricted to nurses working in long-term care. Nurses in the acute care set-
ting also need to be knowledgeable about the most eective strategies for assessing and
managing pain in this population (Herr, 2010).
BACKGROUND AND STATEMENT OF PROBLEM
ere are many causes of pain in older adults. Acute pain is typically associated with
surgery, fractures, or trauma (Herr, Bjoro, Steensmeier, & Rakel, 2006). Persistent pain
(i.e.., pain that continues for more than 3–6 months) is most frequently associated
Ann L. Horgas, Saunjoo L. Yoon, and Mindy Grall
Pain Management
14
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Pain Management 247
with musculoskeletal conditions such as osteoarthritis (e American Geriatrics Society
[AGS] Panel on the Pharmacological Management of Persistent Pain in Older Persons,
2009). In 2000, it was estimated that almost 9 million surgeries were performed on
older adults, including 1.25 million musculoskeletal surgeries (Herr, Titler, & Schilling,
2004). In addition, cancer is associated with signicant pain for one third of patients
with active disease and for two thirds of those with advanced disease (Reiner & Lacasse,
2006). In the acute care setting, older adults are therefore likely to have acute pain
superimposed on persistent pain.
Pain has major implications for older adults’ health, functioning, and quality of life
(Wells, Pasero, & McCaery, 2008). Pain is associated with depression, social withdrawal,
sleep disturbances, impaired mobility, decreased activity engagement, and increased
health care use (AGS Panel on the Pharmacological Management of Persistent Pain in
Older Persons, 2009). Other geriatric conditions that can be exacerbated by pain include
falls, cognitive decline, deconditioning, malnutrition, gate disturbances, and slowed reha-
bilitation (AGS Panel on the Pharmacological Management of Persistent Pain in Older
Persons, 2009). In the hospital setting, older adults suering from acute pain have been
reported to be at increased risk for thromboembolism, hospital-acquired pneumonia, and
functional decline (Wells et al., 2008). Unrelieved acute pain has also been implicated
in the development of subsequent persistent pain (Desbiens, Mueller-Rizner, Connors,
Hamel, & Wenger, 1997; Desbiens, Wu, et al., 1997). Unrelieved pain, thus, has impor-
tant implications for physical, functional, and mental health among older adults.
Over the past decade, a substantial number of clinical and empirical eorts have
been undertaken to improve the assessment and management of pain in older adults.
For instance, in 2001, the Joint Commission on Accreditation of Healthcare Organiza-
tions (JCAHO) addressed pain assessment and management as part of the survey and
accreditation process. e Joint Commission (2001) asserted that patients have the
right to appropriate assessment and management of pain and declared pain as the fth
vital sign. is mandate exposed some of the challenges associated with assessing and
managing pain in older adults in general, and in persons with dementia in particular.
is, in part, spurred clinical and research activity to develop measures for assessing pain
in older adults, particularly those with cognitive impairment. ese behavioral measures
have been reviewed in several published reports (Herr, Bjoro, & Decker, 2006; Herr,
Bursch, Ersek, Miller, & Swaord, 2010), including a comprehensive chapter focusing
specically on pain assessment tools in the classic reference by Pasero and McCaery
(2011). In addition, there have been multiple clinical guidelines by leading scientic
and clinical organizations including the AGS (AGS Panel on the Pharmacological Man-
agement of Persistent Pain in Older Persons, 2009; Hadjistavropoulos et al., 2007),
the American Pain Society (Hadjistavropoulos et al., 2007), and the American Society
for Pain Management Nursing (Herr, Coyne, et al., 2006). Links to these resources
are included at the end of this chapter. Despite the Joint Commission mandate and
the dissemination of clinical guidelines aimed at improving pain management, there is
persistent evidence that pain remains ineectively assessed and poorly managed in older
adults across care settings (Herr, 2010; Herr et al., 2004; Horgas et al., 2009; Morrison,
Magaziner, McLaughlin, et al., 2003; Titler et al., 2009).
e purpose of this chapter is to provide the best evidence on the assessment and
treatment of pain in older adults, especially those with cognitive impairment. It is hoped
that the information here can be used to establish, implement, and evaluate protocols in
the acute care setting that will improve pain management for older adults.
248 Evidence-Based Geriatric Nursing Protocols for Best Practice
ASSESSMENT OF PAIN
Pain is dened as a complex, multidimensional subjective experience with sensory, cog-
nitive, and emotional dimensions (AGS Panel on the Pharmacological Management of
Persistent Pain in Older Persons, 2009; Melzack & Casey, 1968). For clinical practice,
Margo McCaery’s classic denition of pain is perhaps the most relevant. She states
Pain is whatever the experiencing person says it is, existing whenever he says it does
(McCaery, 1968). is denition serves as a reminder that pain is highly subjective
and that patients’ self-report and description of pain is paramount in the pain assess-
ment process. is denition, however, also highlights the diculty inherent in pain
assessment. ere is no objective measure of pain; the sensation and experience of pain
are completely subjective. As such, there is a tendency for clinicians to doubt patients’
reports of pain. Pasero and McCaery (2011) provided a comprehensive chapter on
biases, misconceptions, and misunderstandings that hampered clinicians’ assessment
and treatment of patients who reported pain. ese issues apply to patients across the
life span, and led the authors to conclude the following:
A veritable mountain of literature published during the past three decades
attests to the undertreatment of pain. Much of this literature is consistent with
the hypothesis that human beings, including health care providers in all societ-
ies, have strong tendencies or motivations to deny or discount pain, especially
severe pain, and to avoid relieving the pain. Certainly we should struggle to
identify and correct personal tendencies that lean to inadequate pain manage-
ment, but this may not be a battle that can be won. Perhaps it is best to assume
that there are far too many biases to overcome and that the best strategy is to
establish policies and procedures that protect patients and ourselves from being
victims of these inuences. (p. 48)
Among older adults, there is persistent evidence that pain is underdetected and poorly
managed among older adults (Herr, 2010; Horgas et al., 2009; Horgas & Tsai, 1998;
Smith, 2005). ere are a number of factors that contribute to this situation, including
individual-based, caregiver-based, and organizational-based factors. Individual-based
factors that may impair pain assessment include the following: (a) belief that pain is
a normal part of aging, (b) concern of being labeled a hypochondriac or complainer,
(c) fear of the meaning of pain in relation to disease progression or prognosis, (d) fear
of narcotic addiction and analgesics, (e) worry about health care costs, and (f) a belief
that pain is not important to health care providers (AGS Panel on Persistent Pain in
Older Persons, 2002; Gordon et al., 2002). In addition, cognitive impairment is an
important factor in reducing older adults’ ability to report pain (Horgas et al., 2009;
Smith, 2005).
Pain detection and management are also inuenced by provider-based factors.
Health care providers have been found to share the mistaken belief that pain is a part of
the normal aging process and to avoid using opioids due to fear about potential addic-
tion and adverse side eects (Pasero & McCaery, 2011). Similarly, cognitive status
inuences providers’ assessment and treatment of pain. Several studies have documented
that cognitively impaired older adults were prescribed and administered signicantly
less analgesic medication than were cognitively intact older adults (Horgas & Tsai,
1998; Morrison, Magaziner, Gilbert, et al., 2003). is nding may reect cognitively
impaired adults’ inability to recall and report the presence of pain to their health care
Pain Management 249
providers. It may also reect caregivers’ inability to detect pain, especially among frail
older adults. Health care providers should face the challenge of pain assessment by rst
systematically examining their own biases, beliefs, and behaviors about pain, and elicit-
ing and understanding the challenges and beliefs their patients bring to the situation as
well (Pasero & McCaery, 2011).
Self-Reported Pain
ere is no objective biological marker or laboratory test for the presence of pain.
us, the patients’ self-report is considered the gold standard for pain assessment (AGS
Panel on Persistent Pain in Older Persons, 2002, AGS Panel on the Pharmacological
Management of Persistent Pain in Older Persons, 2009). e rst principle of pain
assessment is to ask about the presence of pain in regular and frequent intervals (Pasero
& McCaery, 2011). It is important to allow older adults sucient time to process the
questions and formulate answers, especially when working with cognitively impaired
older adults. It is also important to explore dierent words that patients may use syn-
onymously with pain, such as discomfort or aching.
Pain intensity can be measured in various ways. Some commonly used tools include
the numerical rating scale, the verbal descriptor scale, and the faces scale (Herr, 2002a).
e numerical rating scale (NRS) is widely used in hospital settings. Patients are asked to
rate the intensity of their pain on a 0–10 scale. e NRS requires the ability to discrimi-
nate dierences in pain intensity and may be dicult for some older adults to complete.
e verbal descriptor scale, however, has been specically recommended for use with
older adults (Herr, 2002a). is tool measures pain intensity by asking participants to
select a word that best describes their present pain (e.g., no pain to worst pain imagin-
able). is measure has been found to be a reliable and valid measure of pain intensity
and is reported to be the easiest to complete and the most preferred by older adults
(Herr, Bjoro, & Decker, 2006). Pictures of faces are also used to measure pain intensity,
especially among cognitively impaired older adults. e Faces Pain Scale (FPS), initially
developed to assess pain intensity in children, consists of seven facial depictions, ranging
from the least pain to the most pain possible (Herr, Bjoro, & Decker, 2006). Among
adults, the FPS is considered more appropriate than other pictorial scales because the
cartoon faces are not age-, gender-, or race-specic. However, the FPS has relatively low
reliability and validity when used among older adults with cognitive impairment and
is not recommended for use in this population (Herr, Bjoro, & Decker, 2006). See the
Resources section for information on accessing these measurement tools.
Observed Pain Indicators
Dementia compromises older adults’ ability to self-report pain. In patients with demen-
tia, and other patients who cannot provide self-report, other assessment approaches
must be used to identify the presence of pain. A hierarchical pain assessment approach
is recommended that includes four steps:
1. attempt to obtain a self-report of pain;
2. search for an underlying cause of pain, such as surgery or a procedure;
3. observe for pain behaviors; and
4. seek input from family and caregivers (Herr, Coyne, et al., 2006; Wells et al., 2008).
250 Evidence-Based Geriatric Nursing Protocols for Best Practice
If any of these steps are positive, the nurse should assume that pain is present and
a trial of analgesics can be initiated. Pain behaviors should be observed before and after
the analgesic trial in order to evaluate if the analgesic was eective or if a stronger dose
is needed.
Observational techniques for pain assessment focus on behavioral or nonverbal
indicators of pain (Hadjistavropoulos et al., 2007; Herr, Coyne, et al., 2006; Horgas
et al., 2009). Behaviors such as guarded movement, bracing, rubbing the aected area,
grimacing, painful noises or words, and restlessness are often considered pain behav-
iors (Horgas & Elliott, 2004; Horgas et al., 2009). In the acute care setting, vital signs
are often considered physiological indicators of pain. It is important to note, however,
that elevated vital signs are not considered a reliable indicator of pain, although they
can be indicative of the need for pain assessment (Herr, Coyne, et al., 2006; Pasero &
McCaery, 2011).
A number of observational measures have been developed over the past decade.
ese behavioral tools are typically either pain behavior scales (scored by identifying
the number and intensity of behaviors) or pain checklists (identifying the number
and types of behaviors that individuals display, without intensity ratings; Wells et al.,
2008). Although there is no perfect behavioral measure of pain, three specic tools
have been recommended for use in patients who cannot self-report (Pasero & McCaf-
fery, 2011). ese are the Checklist of Nonverbal Pain Indicators (CNPI; Feldt, 2000),
the Pain Assessment in Advanced Dementia (PAINAD) scale (Warden, Hurley, &
Volicer, 2003), and the Pain Assessment Checklist for Seniors With Severe Dementia
(PACSLAC; Fuchs-Lacelle & Hadjistavropoulos, 2004). A comprehensive review of
these measures, as well as other similar tools, is available on the City of Hope website
(see Resources section). In addition, the Hartford Institute for Geriatric Nursing pro-
vides online resources for pain assessment in older adults with dementia that include
information on the PAINAD tool, and an instructional video on how to use it (see
Resources section for link). Several caveats about observational tools must be noted:
(a) the presence of these behaviors is suggestive of pain but is not always a reliable
indicator of pain, and (b) the presence of pain behaviors does not provide information
about the intensity of pain (Pasero & McCaery, 2011; Wells et al., 2008). As such,
pain behavior tools are one part of a comprehensive pain assessment.
In summary, pain assessment is a clinical procedure that can be hampered by many
factors. Systematic and thorough assessment, however, is a critical rst step in appro-
priately managing pain in older adults. Assessment issues are summarized in the recom-
mended pain management protocol. e use of a standardized pain assessment tool
is important in measuring pain. It enables health care providers to document their
assessment, measure change in pain, evaluate treatment eectiveness, and communicate
to other health care providers, the patient, and the family. Comprehensive pain assess-
ment includes measures of self-reported pain and pain behaviors. Information from
family and caregivers should also be obtained, although these data should be considered
supplemental rather than denitive (Horgas & Dunn, 2001).
INTERVENTIONS AND CARE STRATEGIES
Managing pain in older adults can be a challenging process. e main goal is to maxi-
mize function and quality of life by minimizing pain whenever possible (Herr, 2010;
Wells et al., 2008). Optimal pain treatment uses a multimodal approach, tailored
Pain Management 251
to the patient, that combines pharmacological and nonpharmacological strategies
(Wells et al., 2008). Pharmacological interventions are an integral component of pain
management in older adults (Pasero & McCaery, 2011). Important considerations
regarding the use of pharmacological pain management must be taken into account,
given the physiological changes that occur with aging. It should be emphasized that
pharmaceutical pain management is often more imperative in older adults with
dementia because their ability to participate in nonpharmacological pain manage-
ment strategies may be limited by their cognitive capacity (Buum, Hutt, Chang,
Craine, & Snow, 2007).
When choosing pain strategies, consideration should be given to severity of pain
because moderate and severe pain often require dierent modalities in order to pro-
vide adequate pain relief. Additionally, cognitive impairments are often confounded by
visual and hearing impairments in older adults. erefore, to optimize pain relief while
minimizing the potential for poor outcomes, careful consideration should be given to
an individual’s ability to adhere to treatment (Pergolizzi et al., 2008).
Several excellent pain management guidelines and protocols have been developed
for use in the management of pain in older adults. For instance, the AGS has recently
updated their clinical practice guidelines for managing persistent pain in older adults
(AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons,
2009). e consensus statement by the World Health Organization (WHO) on the use
of Step III opioids for chronic, severe pain in older adults provides detailed guidelines
pertaining to the assessment of pain and use of opioids for cancer and non-cancer-
related pain (Pergolizzi et al., 2008). In addition, there are other published guidelines
for the assessment and management of pain in specic diseases, such as osteoarthri-
tis (American Pain Society, 2002; American Pain Society Quality of Care Committee,
1995). Pasero and McCaery (2011) also provide one of the most comprehensive guides
for pain management, including a recently updated edition that addresses pain manage-
ment in older adults. See Resources section of Protocol 14.1 for more information on
accessing these resources.
Pharmacological Pain Treatment
Pain treatment with medications involves decision making based on multiple consider-
ations. Ideally, it is a mutual process among health care providers, patients, and caregiv-
ers, with the goal of optimizing quality of life and functioning (Wells et al., 2008). An
eective pain management strategy includes a careful discussion of risks versus benets,
frequent reviews of drug regimens used by older adults, and the establishment of clear
goals of therapy with the patient. It is often a process of trial and error that aims to bal-
ance medication eectiveness with management of side eects.
Guiding principles for optimal pain management in older adults include the fol-
lowing components (Buum et al., 2007; Gordon et al., 2005). First, the treatment of
pain should be initiated immediately upon the detection of pain. Secondly, regularly
scheduled (rather than “as-needed”) dosing of pain medications should be employed.
Additionally, multiple modalities for the evaluation of pain control should be used,
including verbal, behavioral, and functional responses to pain medication. Pain medi-
cation should be titrated according to these responses, and a pain medication regimen
should be chosen based on what is known about each individual patient. is includes
the severity of cognitive impairment and how this aects the patient’s ability to express
252 Evidence-Based Geriatric Nursing Protocols for Best Practice
pain, interaction of pain medications with other medications, and knowledge of pain
medication side eects, such as constipation.
For individuals with cancer-related pain, the WHO provides a three-step analge-
sic ladder that has been widely used as a guide for treating pain in this population.
Choices are made from three drug categories based on pain severity: the nonopioids,
opioids, and adjuvant agents. Combinations of drugs are used because two or more
drugs can treat dierent underlying pain mechanisms, dierent types of pain, and allow
for smaller doses of each analgesic to be used, thus minimizing side eects. In 2008, the
WHO established guidelines for the use of Step III opioids (buprenorphine, fentanyl,
hydromorphone, methadone, morphine, and oxycodone) in older adults with cancer
and noncancer pain (Pergolizzi et al., 2008). eir criteria for the selection of analge-
sics in older adults with cancer are based on the type of pain, ecacy of the medica-
tion, side-eect prole, potential for abuse, and interactions with other medications
(Pergolizzi et al., 2008). ese guidelines make clear that Step III opioids are the gold
standard of treatment for cancer pain and are also ecacious in noncancer diseases. e
authors point out, however, a dearth of specic studies investigating the use of these
drugs in older adults.
Special Considerations for Administering Analgesics
When considering the addition of pain medication to an older, and potentially frail
person’s medication regimen, several issues must be evaluated. Confounding factors
for medication side eects include comorbidities, the use of multiple medications, and
drug-to-drug interactions (Klotz, 2009). Normal physiological changes that occur with
aging, superimposed on comorbidities, place older adults at higher risk for side eects.
Specic age-related changes inuence the pharmacodynamics (mechanisms of drug
action in the body) and pharmacokinetics (processes of drug absorption, distribution,
metabolism, and elimination in the body; Klotz, 2009). Specic side eects to consider
when prescribing and/or administering pain medications to the older adult include risks
for sedation, mental status changes and cognition, balance, and gastrointestinal side
eects—including bleeding and constipation (Buum et al., 2007).
Recommendations for beginning pain medication treatment include starting at low
doses and gradually titrating upward, while monitoring and managing side eects. e
adage “start low and go slow” is often used. Titrate doses upward to desired eect using
short-acting medications rst, and consider using longer duration medications for long-
lasting pain, once drug tolerability has been established. For most older adults, choose
a drug with a short half-life and the fewest side eects if possible (Pasero & McCaery,
2011; Wells et al., 2008).
Multiple drug routes are available for administration of pain medications. As long
as patients are able to swallow safely, the oral route is the rst choice because it is the
least invasive and very eective. e onset of action is within 30 minutes to 2 hours. For
more immediate pain relief, intravenous administration is recommended, particularly
in the immediate postoperative period. Intramuscular injections should be avoided in
older adults because of the potential for tissue injury and unpredictable absorption, and
because they produce pain. Overall, adopting a preventive approach to pain manage-
ment, whenever possible, is recommended. By treating pain before it occurs, less medi-
cation is required than to relieve it (Wells et al., 2008). Examples of pain prevention are
around-the-clock dosing and dosing prior to a painful treatment or event.
Pain Management 253
Types of Analgesic Medications
e AGS has recently published updated guidelines for pain management in older
adults (AGS Panel on the Pharmacological Management of Persistent Pain in Older
Persons, 2009). Information on accessing these guidelines is included in the Resources
section at the end of this chapter. e guidelines provide comprehensive information
about managing persistent pain, but the recommendations apply to acute pain manage-
ment as well. us, the reader is referred to these guidelines for more comprehensive
information.
Nonopioid Medications. Acetaminophen is considered the drug of choice for mild-to-moderate
pain in older adults (Herr, Bjoro, Steensmeier, et al., 2006). It is recommended that
the total daily dose should not exceed 4 g per day (maximum 3 g/day in frail elders).
Because of the potential for hepatic toxicity, the maximum dosage should be reduced
by 50%–75% in adults with impaired hepatic metabolism, renal disease, or a history of
alcohol abuse (Herr, Bjoro, Steensmeier, et al., 2006).
Nonsteroidal anti-inammatory drugs (NSAIDs), commonly used to treat pain in
the general population, are not recommended for use in persons older than the age of 75
(Kuehn, 2009). ere are two types of NSAIDs: nonselective (e.g., ibuprofen, naproxen)
and cyclooxygenase (COX)-2 selective inhibitors. Several of the COX-2 drugs have
been removed from the market because of serious, life-threatening cardiovascular side
eects, and those that remain available should be used with caution and only within the
recommended dosages (AGS Panel on the Pharmacological Management of Persistent
Pain in Older Persons, 2009).
NSAIDs are associated with serious cardiovascular and gastrointestinal side eects,
and gastric damage is the most common side eect. All adults older than the age of 65
are considered to be at moderate risk for gastrointestinal side eects and should receive
gastric protective therapy with proton pump inhibitor (Kuehn, 2009).
Opioid Medications. Opioid drugs (e.g., codeine and morphine) are eective at treating
moderate-to-severe pain from multiple causes. According to the AGS (AGS Panel on
the Pharmacological Management of Persistent Pain in Older Persons, 2009), opioid
analgesics can be used safely and eectively in older adults if they are properly selected
and monitored. All providers caring for older patients should prescribe opioids based on
clearly dened therapeutic goals. Prescribing should occur based on serial attempts to
reach these goals, with the lowest doses chosen based on ecacy and side eects.
Many older adults and health care providers are reluctant to use opioids because
of fears of addiction, side eects, and intolerance. Potential side eects include nausea,
pruritus, constipation, drowsiness, cognitive eects, and respiratory depression. e
most serious side eect, respiratory depression, is rare and can be mitigated by slow
dose escalation and careful monitoring for signs of sedation (AGS Panel on the Pharma-
cological Management of Persistent Pain in Older Persons, 2009; Wells et al., 2008). To
prevent constipation, preventive measures should be initiated when the opioid is started
(e.g., stool softeners, adequate uid intake, moderate activity; AGS Panel on Persistent
Pain in Older Persons, 2002).
Adjuvant Drugs. Adjuvant drugs are those drugs administered in conjunction with anal-
gesics to relieve pain. ey are often administered with nonopioids and opioids to
achieve optimal pain control through additive analgesic eects or to enhance response
254 Evidence-Based Geriatric Nursing Protocols for Best Practice
to analgesics, especially for neuropathic pain (AGS Panel on Persistent Pain in Older
Persons, 2002; Wells et al., 2008). Although tricyclic antidepressants (e.g., nortriptyline,
desipramine) have shown dual eects on both pain and depression, they are inappropri-
ate for pain management in older adults because of high rates of serious anticholinergic
side eects (AGS Panel on the Pharmacological Management of Persistent Pain in Older
Persons, 2009; Fick et al., 2003). With the advent of antidepressants that exert sero-
tonin reuptake inhibition, and mixed serotonin and norepinephrine uptake inhibition,
pain management with these types of medications has become more common in older
adults because they are eective in the treatment of neuropathic pain and have a better
side-eect prole (AGS Panel on the Pharmacological Management of Persistent Pain in
Older Persons, 2009). Anticonvulsants (e.g., gabapentin) may be used as adjuvant drugs
for neuropathic pain, such as trigeminal neuralgia and postherpetic neuralgia, and they
have fewer side eects than tricyclic antidepressants (AGS Panel on the Pharmacologi-
cal Management of Persistent Pain in Older Persons, 2009). Local anesthetics, such as
lidocaine as a patch, gel, or cream, can be used as an additional treatment for the pain
of postherpetic neuralgia.
Equianalgesia refers to equivalent analgesia eects. Understanding equianalgesic
dosing (e.g., dose conversion chart, conversion ratio) improves prescribing practices for
managing pain in older adults. Equianalgesic dosing charts provide lists of drugs and
doses of commonly prescribed pain medications that are approximately equal in provid-
ing pain relief and can provide practical information for selecting appropriate starting
doses when changing from one drug to another or nding optimal drug combinations
(AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons,
2009; Pasero & McCaery, 2011; Pasero, Portenoy, McCaery, 1999).
Drugs to Avoid in Older Adults
Some medications should be generally avoided in older adults because they are
either ineective for them or cause higher risk of having side eects. Meperidine
(Demerol), ketorolac (Toradol), and pentazocine (Talwin) are considered inappropri-
ate analgesic medications for older adults. ese medications cause central nervous
system side eects, including confusion or hallucinations, and may not be eective
enough when administered at the commonly prescribed dose or may produce more
side eects than positive analgesic eect (Fick et al., 2003). Additionally, sedatives,
antihistamines, and antiemetics should be used with caution because of long dura-
tion of action, risk of falls, hypotension, anticholinergic eects, and sedating eects
( Gordon et al., 2005).
Nonpharmacological Pain Treatment
Nondrug strategies are an important component of pain management. Many older
adults report using several nonpharmacological modalities to manage pain (AGS Panel
on Persistent Pain in Older Persons, 2002; Barry, Gill, Kerns, & Reid, 2005; Herr,
2002b). e most commonly reported nonpharmacological strategies used in the acute
care setting were relaxation (e.g., breathing, meditation, imagery, music), activity modi-
cation, massage, and heat or cold application (Wells et al., 2008). Older adult patients
should be encouraged to use nonpharmacological treatment in combination with phar-
macological treatment.
Pain Management 255
Types of Nonpharmacological Treatment Strategies
Nonpharmacological pain treatment strategies generally fall into two major catego-
ries: physical pain relief modalities and psychological pain relief modalities. Physical
pain relief modalities include, but are not limited to, transcutaneous electrical nerve
stimulation (TENS), physical therapies, use of heat and cold, massage, and move-
ment. Psychological pain relief modalities focus on changes in the person’s percep-
tion of the pain and improvement of coping strategies (Rudy, Hanlon, & Markham,
2002). ese include relaxation, distraction, guided imagery, and hypnosis. Cognitive
behavioral treatment, meditation, and biofeedback are strategies used for persistent
pain. Various types of dietary supplements are also commonly used nonpharmacolog-
ical pain treatments among older adults. To date, a few of these nonpharmacological
strategies have been empirically evaluated for their eectiveness in pain management
(Wells et al., 2008).
For persistent pain, several physical strategies such as exercise, electrical stimula-
tion (e.g., TENS), and low-level laser therapy have been evaluated, but the results
are equivocal (Furlan, Imamura, Dryden, & Irvin, 2009). e AGS Panel on Exer-
cise and Osteoarthritis (2001) provided guidelines of exercise prescriptions for older
adults with osteoarthritis pain. Recommendations should be individualized based
on the person’s comorbidities, adherence, personal preference, and feasibility of
exercise. Massage therapy may be eective to manage chronic low back pain and
can be more benecial when it is combined with education and exercise (Furlan et
al., 2009). Despite many trials of tai chi, the eectiveness of this intervention for
chronic pain in older adults is still inconclusive because of methodological issues in
the studies (Hall, Maher, Latimer, & Ferreira, 2009). Electrical stimulation, includ-
ing TENS, has shown signicant benets for shoulder pain after stroke (Price &
Pandyan, 2001).
Psychological pain relief modalities, such as cognitive behavioral therapy, biofeed-
back, and meditation, are commonly used for persistent pain (Middaugh & Pawlick,
2002). Cognitive behavioral treatments, including relaxation, guided imagery, and
meditation, have also shown signicant improvement in pain and mobility due to
osteoarthritis among older adults (Baird, Murawski, & Wu, 2010). In the acute care
setting, relaxation, massage, and music are often used to help manage acute pain
(Wells et al., 2008). Each of these nondrug approaches has demonstrated mixed
results, largely because of individual patient preferences and methodological dier-
ences in how the studies were conducted. us, there is no conclusive evidence that
these modalities relieve pain. Instead, they should be considered on an individualized
basis, depending on patient preference and response, and as an adjunct to pharmaco-
logical treatment.
In summary, nonpharmacological treatments are widely used comfort measures to
help manage pain. ese approaches are challenging to study because it is dicult to
nd a convincing placebo and to control the dose of the treatment. In addition, studies
have contributed inconsistent ndings because of dierences in study designs, inconsis-
tent measures, and mixed intervention durations. Despite the lack of rigorous support
for these nondrug approaches, older adults express interest in using these strategies to
manage their pain (Dunn & Horgas, 2000; Herr, 2002b; Horgas & Elliott, 2004).
us, nurses should consider all possible options for managing pain and discuss these
approaches with their older adult patients.
256 Evidence-Based Geriatric Nursing Protocols for Best Practice
Special Considerations of Using Nonpharmacological Treatment for Older Adults
Individuals vary widely in their preferences for and ability to use nonpharmacological
interventions to manage pain. Spiritual and/or religious coping strategies, for instance,
must be consistent with individual values and beliefs. Other strategies, such as guided
imagery, biofeedback, or relaxation, may not be feasible for cognitively impaired older
adults. erefore, it is important for health care providers to consider a broad array of
nonpharmacological pain management strategies and to tailor selections to the individ-
ual. It is also important to gain individual and family input about the use of home and
folk remedies because use of herbals or home remedies is often not disclosed to health
care providers and may result in negative drug–herb interactions (Yoon & Horne, 2001;
Yoon, Horne, & Adams, 2004; Yoon & Schaer, 2006).
IMPROVING PAIN MANAGEMENT IN CARE SETTINGS
Nurses have a critical role in assessing and managing pain. e promotion of comfort
and relief of pain is fundamental to nursing practice and, as integral members of inter-
disciplinary health care teams, nurses must work collaboratively to eectively assess
and treat pain. Given the prevalence of pain in older adults and the burgeoning aging
population seeking care in our health care systems, this nursing role is vitally important.
In addition, nurses have the primary responsibility to teach the patient and family about
pain and how to manage it both pharmacologically and nonpharmacologically. As such,
nurses must be knowledgeable about pain management in general, and about manag-
ing pain in older adults in particular. Moreover, nurses are responsible for basing their
practice on the best evidence available, and helping to bridge the gap between evidence,
recommendations, and clinical practice.
Nurses, however, must work within an organizational climate that supports
and encourages eorts to improve pain management. ese eorts must go beyond
simply distributing guidelines and recommendations because this approach has
not been eective (Dirks, 2010). Some quality improvement processes that should
be considered in promoting improved pain management include the following
(Dirks, 2010):
1. Facilities/institutions must demonstrate and maintain strong institutional commit-
ment and leadership to improve pain management.
2. Facilities/institutions will establish an internal pain team of committed and knowl-
edgeable sta who can lead quality improvement eorts to improve pain manage-
ment practices.
3. Facilities/institutions must establish evidence of documentation of pain assessment,
intervention, and evaluation of treatment eectiveness. is includes adding pain
assessment and reassessment questions to ow sheets and electronic forms.
4. Facilities/institutions will provide evidence of using a multispecialty approach to
pain management. is includes referral to specialists for specic therapies (e.g.,
psychiatry, psychology, physical therapy, interdisciplinary pain treatment specialists).
Clinical pathways and decision support tools will be developed to improve referrals
and multispecialty consultation.
5. Facilities/institutions will provide evidence of pain management resources for sta
(e.g., educational opportunities; print materials, access to web-based guidelines and
information).
Pain Management 257
SUMMARY
Pain is a signicant problem for older adults, which has the potential to negatively impact
independence, functioning, and quality of life. In the acute care setting, pain can nega-
tively aect healing. In order for pain to be eectively managed, it must rst be carefully
and systematically assessed. Pain assessment in older adults should start with self-reported
pain. It should also incorporate assessment of nonverbal pain behaviors and family input
about usual pain responses and patterns, particularly in patients unable to communicate
their pain. e use of established pain assessment/measurement tools is recommended.
Pain treatment in older adults should be tailored to the type and severity of pain, with
medications that can be safely used in older adults, or combined with nonpharmaco-
logical treatment for heightened eectiveness. Older adults, their families, and their care
providers should be knowledgeable about pain and how to manage it. us, education
is an important part of the process and should not be overlooked. Health care settings
must emphasize the importance of eective pain management and empower their sta
through resources, education, committed leadership, and organizational policies to pro-
vide high quality pain management to older adults. Pain management is a critical nursing
role that can improve the health care experience and quality of life for older adults.
Mrs.B. is a 93-year-old woman, living with her daughter in the community. She has
been diagnosed with anxiety disorder, hypertension, and diabetes, and has a severe
hearing problem. Recently, Mrs. B. fell in her bathroom and broke her right leg,
which resulted in admission to the hospital. Prior to the fall, she typically walked
around the neighborhood daily with her daughter. She now stays in her hospital bed
with bruising, swelling, and pain in her right lower extremity. Her daughter has stayed
with Mrs. B. at the bedside and is worried about her anxiety and pain. Mrs. B. is
ordered oxycodone hydrochloride 5–10 mg every 6 hours orally or morphine sulfate
1 mg intravenously every 4 hours for pain as needed.
e nurse conducted an assessment of vital signs and completed a thorough pain
assessment and mental status assessment, starting with self-report questions and asking
the daughter for observations about her mother’s response. e nurse explained the anal-
gesic choices, including the types, routes, dosages, and potential side eects, to the patient
and her daughter. When the nurse asked Mrs. B. and her daughter about their perspec-
tive of pain medications and their acceptable level of pain (pain goal), both expressed
fear of taking opioid medications. After further discussions with the nurse, Mrs. B. and
her daughter agreed to oxycodone 5 mg (instead of 10 mg) to manage Mrs. B.’s pain.
ey expressed that this was an informed decision—that Mrs. B.’s anxiety about pain
medication was relieved, and that they felt relieved to be part of the pain treatment deci-
sion. Follow-up pain evaluation revealed that 5 mg of oxycodone did not relieve Mrs.
B.’s pain. Another 5 mg of oxycodone was given to Mrs. B. for pain. Afterward, Mrs. B.
rested comfortably. Her daughter was relieved to see her mother resting comfortably and
felt more knowledgeable about her mother’s pain experience and how to manage it.
CASE STUDY
258 Evidence-Based Geriatric Nursing Protocols for Best Practice
Protocol 14.1: Pain Management in Older Adults
I. STANDARD: All older adults will either be pain free or their pain will be con-
trolled to a level that is acceptable to the patient and allows the person to maintain the
highest level of functioning possible.
II. OVERVIEW: Pain, a common, subjective experience for many older adults, is
associated with a number of acute (e.g., surgery, trauma) and chronic (e.g., osteo-
arthritis) conditions. Despite its prevalence, evidence suggests that pain is often poorly
assessed and poorly managed, especially in older adults. Cognitive impairment due to
dementia represents a particular challenge to pain management because older adults
with these conditions may be unable to verbalize their pain. Nurses, an integral part
of the interdisciplinary care team, need to understand the myths associated with pain
management, including addiction and belief that pain is a normal result of aging,
to provide optimal care and to educate patients and families about managing pain.
Nurses must also examine their personal biases about pain and its management.
III. BACKGROUND
A. Denitions
1. Pain: Pain is dened as “an unpleasant sensory and emotional experience”
(AGS, 2002, 2009) and also as “whatever the experiencing person says it
is, existing whenever he says it does” (McCaery, 1968). ese denitions
highlight the multidimensional and highly subjective nature of pain. Pain
is usually characterized according to the duration of pain (e.g., acute vs.
persistent) and the cause of pain (e.g., nociceptive vs. neuropathic). ese
denitions have implications for pain management strategies.
2. Acute pain: Denes pain that results from injury, surgery, or trauma. It may
be associated with autonomic activity such as tachycardia and diaphoresis.
Acute pain is usually time limited and subsides with healing.
3. Persistent pain: Denes pain that lasts for a prolonged period (usually more
than 3–6 months) and is associated with chronic disease or injury (e.g.,
osteoarthritis; AGS, 2009). Persistent pain is not always time dependent,
however, and can be characterized as pain that lasts longer than the antic-
ipated healing time. Autonomic activity is usually absent, but persistent
pain is often associated with functional loss, mood disruptions, behavior
changes, and reduced quality of life.
4. Nociceptive pain: e term refers to pain caused by stimulation of specic
peripheral or visceral pain receptors. is type of pain results from disease
processes (e.g., osteoarthritis), soft-tissue injuries (e.g., falls), and medical
treatment (e.g., surgery, venipuncture, and other procedures). It is usually
localized and responsive to treatment.
5. Neuropathic pain: Refers to pain caused by damage to the peripheral or
central nervous system. is type of pain is associated with diabetic
neuropathies, postherpetic and trigeminal neuralgias, stroke, and chemo-
therapy treatment for cancer. It is usually more diuse and less responsive
to analgesic medications.
NURSING STANDARD OF PRACTICE
(continued)
Pain Management 259
B. Epidemiology
1. Approximately 50% of community-dwelling older adults and 85% of nurs-
ing home residents experience persistent pain.
2. More than one half of all inpatient hospital days are occupied by older
adults, and more than 9 million surgeries are performed on older adults
annually (Rosenthal & Kavic, 2004). us, pain is a common experience
among older adults in the acute care setting (Herr, 2010).
C. Etiology
1. More than 80% of older adults have chronic medical conditions that are
typically associated with pain, such as osteoarthritis and peripheral vascular
disease.
2. Older adults often have multiple medical conditions, both chronic and/or
acute, and may suer from multiple types and sources of pain.
D. Signicance
1. Pain has major implications for older adults’ health, functioning, and qual-
ity of life. If unrelieved, pain is associated with the following (Pasero &
McCaery, 2011; Wells et al., 2008):
a. Impaired immune function and healing
b. Impaired mobility
c. Postoperative complications related to immobility (e.g., thrombosis,
embolus, pneumonia)
d. Sleep disturbances
e. Mental health symptoms (e.g., depression, anxiety)
f. Withdrawal and decreased socialization
g. Functional loss and increased dependency
h. Exacerbation of cognitive impairment
i. Increased health care utilization and costs
2. Nurses have a key role in pain management. e promotion of comfort and
relief of pain is fundamental to nursing practice. Nurses need to be knowledge-
able about pain in late life in order to provide optimal care, to educate patients
and families, and to work eectively in interdisciplinary health care teams.
3. e Joint Commission requires regular and systematic assessment of pain in
all hospitalized patients. Since older adults constitute a signicant portion
of the patient population in many acute care settings, nurses need to have
the knowledge and skill to address specic pain needs of older adults.
IV. ASSESSMENT PARAMETERS
A. Assumptions (AGS, 2002, 2009; Herr, Coyne, et al., 2006; Pasero & McCaery,
2011)
1. Most hospitalized older patients suer from both acute and persistent pain.
2. Older adults with cognitive impairment experience pain but are often
unable to verbalize it.
3. Both patients and health care providers have personal beliefs, prior experi-
ences, insucient knowledge, and mistaken beliefs about pain and pain
management that (a) inuence the pain management process, and (b) must
be acknowledged before optimal pain relief can be achieved.
(continued)
Protocol 14.1: Pain Management in Older Adults (cont.)
260 Evidence-Based Geriatric Nursing Protocols for Best Practice
4. Pain assessment must be regular, systematic, and documented in order to
accurately evaluate treatment eectiveness.
5. Self-report is the gold standard for pain assessment.
6. Eective pain management requires an individualized approach.
B. Strategies for Pain Assessment
1. Initial, quick pain assessment (Herr, Bjoro, Steensmeier, et al., 2006)
a. Assess older adults who present with acute pain of moderate-to-severe
intensity or who appear to be in distress.
b. Assess pain location, intensity, duration, quality, and onset.
c. Assess vital signs. If changes in vital signs are absent, do not assume that
pain is absent (Herr, Coyne, et al. 2006).
2. Comprehensive pain assessment (AGS, 2009; Herr, Coyne, et al., 2006;
Pasero & McCaery, 2011)
a. Review medical history, physical exam, and laboratory and diagnostic
tests in order to understand sequence of events contributing to pain.
b. Assess cognitive status (e.g., dementia, delirium), mental state (e.g.,
anxiety, agitation, depression), and functional status. If there is evidence
of cognitive impairment, do not assume that the patient cannot provide
a self-report of pain. Be prepared to augment self-report with observa-
tional measures and proxy report using the hierarchical approach.
c. Assess present pain, including intensity, character, frequency, pattern,
location, duration, and precipitating and relieving factors.
d. Assess pain history, including prior injuries, illnesses, and surgeries; pain
experiences; and pain interference with daily activities.
e. Review medications, including current and previously used prescription
drugs, over-the-counter drugs, and complementary therapies (including
home remedies). Determine what pain control methods have previously
been eective for the patient. Assess patient’s attitudes and beliefs about
pain and the use of analgesics, adjuvant drugs, and nonpharmacological
treatments. Assess history of medication or alcohol abuse.
f. Assess self-reported pain using a standardized measurement tool. Choose
from published measurement tools and recall that older adults may have
diculty using 10-point numerical rating scales. Vertical verbal descrip-
tor scales or faces scales may be more useful with older adults.
g. Assess pain regularly and frequently, but at least every 4 hours. Monitor
pain intensity after giving medications to evaluate eectiveness.
h. Observe for nonverbal and behavioral signs of pain, such as facial gri-
macing, withdrawal, guarding, rubbing, limping, shifting of position,
aggression, agitation, depression, vocalizations, and crying. Also watch
for changes in behavior from the patient’s usual patterns.
i. Gather information from family members about the patient’s pain expe-
riences. Ask about the patient’s verbal and nonverbal/behavioral expres-
sions of pain, particularly in older adults with dementia.
j. When pain is suspected but assessment instruments or observation is ambig-
uous, institute a clinical trial of pain treatment (i.e., in persons with demen-
tia). If symptoms persist, assume pain is unrelieved and treat accordingly.
Protocol 14.1: Pain Management in Older Adults (cont.)
(continued)
Pain Management 261
V. NURSING CARE STRATEGIES (AGS, 2009; Hadjistavropoulos et al., 2007; Herr,
Bjoro, Steensmeier, et al., 2006; Herr, Coyne, et al., 2006, Wells et al., 2008)
A. General Approach
1. Pain management requires an individualized approach.
2. Older adults with pain require comprehensive, individualized plans that
incorporate personal goals, specify treatments, and address strategies to
minimize the pain and its consequences on functioning, sleep, mood, and
behavior.
B. Pain Prevention
1. Develop a written pain treatment plan upon admission to the hospital, or
prior to surgery or treatments. Help the patient to set realistic pain treat-
ment goals, and document the goals and plan.
2. Assess pain regularly and frequently to facilitate appropriate treatment.
3. Anticipate and aggressively treat for pain before, during, and after painful
diagnostic and/or therapeutic treatments. Administer analgesics 30 minutes
prior to activities.
4. Educate patients, families, and other clinicians to use analgesic medications
prophylactically prior to and after painful procedures.
5. Educate patients and families about pain medications, their side eects,
adverse eects, and issues of addiction, dependence, and tolerance.
6. Educate patients to take medications for pain on a regular basis and to
avoid allowing pain to escalate.
7. Educate patients, families, and other clinicians to use nonpharmacological
strategies to manage pain, such as relaxation, massage, and the use of heat
and cold.
C. Treatment Guidelines
1. Pharmacological (AGS, 2009; Pasero & McCaery, 2011)
a. Administer pain drugs on a regular basis to maintain therapeutic levels.
Use PRN (as needed) medications for breakthrough pain.
b. Document treatment plan to maintain consistency across shifts and
with other care providers.
c. Use equianalgesic dosing to obtain optimal pain relief and to minimize
side eects.
d. For postoperative pain, choose the least invasive route. Intravenous
analgesics are the rst choice after major surgery. Avoid intramuscu-
lar injections. Transition from parenteral medications to oral analgesics
when the patient has oral intake.
e. Choose the correct type of analgesic. Use opioids for treating moderate-
to-severe pain and nonopioids for mild-to-moderate pain. Select the
analgesic based on thorough medical history, comorbidities, other med-
ications, and history of drug reactions.
f. Among nonopioid medications, acetaminophen is the preferred drug
for treating mild-to-moderate pain. Guidelines recommend not exceed-
ing 4 g per day (maximum 3 g/day in frail elders). e maximum dose
should be reduced to 50%–75% in adults with reduced hepatic function
or history of alcohol abuse.
(continued)
Protocol 14.1: Pain Management in Older Adults (cont.)
262 Evidence-Based Geriatric Nursing Protocols for Best Practice
g. e other major class of nonopioid medications, nonsteroidal anti-
inammatory drugs (NSAIDs), should be used with caution in older
adults. Monitor for gastrointestinal (GI) bleeding and consider giving
with a proton pump inhibitor to reduce gastric irritation. Also monitor
for bleeding, nephrotoxicity, and delirium.
h. Older adults are at increased risk for adverse drug reactions due to
age- and disease-related changes in pharmacokinetics and pharmaco-
dynamics. Monitor medication eects closely to avoid overmedication
or undermedication and to detect adverse eects. Assess hepatic and
renal functioning.
2. Nonpharmacological (Pasero & McCaery, 2011; Wells et al., 2008)
a. Investigate older patients’ attitudes and beliefs about, preference for,
and experience with nonpharmacological pain treatment strategies.
b. Tailor nonpharmacological techniques to the individual.
c. Cognitive behavioral strategies focus on changing the person’s percep-
tion of pain (e.g., relaxation therapy, education, distraction) and may
not be appropriate for cognitively impaired persons.
d. Physical pain relief strategies focus on promoting comfort and altering
physiologic responses to pain (e.g., heat, cold, TENS units) and are
generally safe and eective.
D. Follow-up Assessment
1. Monitor treatment eects within 1 hour of administration, and at least
every 4 hours.
2. Evaluate patient for pain relief and side eects of treatment.
3. Document patient’s response to treatment eects.
4. Document treatment regimen in patient care plan to facilitate consistent
implementation.
VI. EXPECTED OUTCOMES
A. Patient
1. Patient will be either pain free or pain will be at a level that the patient
judges as acceptable.
2. Patient maintains highest level of self-care, functional ability, and activity
level possible.
3. Patient experiences no iatrogenic complications, such as falls, GI upset/
bleeding, or altered cognitive status.
B. Nurse
1. e nurse will demonstrate evidence of ongoing and comprehensive pain
assessment.
2. e nurse will document evidence of prompt and eective pain manage-
ment interventions.
3. e nurse will document systematic evaluation of treatment eectiveness.
4. e nurse will demonstrate knowledge of pain management in older
patients, including assessment strategies, pain medications, nonpharmaco-
logical interventions, and patient/family education.
Protocol 14.1: Pain Management in Older Adults (cont.)
(continued)
Pain Management 263
RESOURCES
Pain Assessment and Management
Hartford Institute for Geriatric Nursing: Try is Series: Assessing Pain in Older Adults.
http://www.consultgerirn.org/resources
American Geriatrics Society Guideline on the Management of Persistent Pain in Older Adults.
http://www.americangeriatrics.org/les/documents/2009_Guideline.pdf
Agency for Healthcare Research and Quality National Clinical Guideline Clearinghouse.
http://www.guideline.gov/content.aspx?id=10198
American Association of Pain Management Nurses (ASPMN): Geriatric Pain Assessment: Self-
Directed Learning.
https://www.commercecorner.com/aspmn/productlist1.aspx
American Pain Society: Pain Guidelines and Online Resource Centers.
http://www.ampainsoc.org/library/principles.htm
http://www.ampainsoc.org/resources/clinician1.htm
C. Institution (Dirks, 2010)
1. Facilities/institutions will maintain strong institutional commitment and
leadership to improve pain management. Evidence of institutional commit-
ment include:
a. Providing adequate resources (including compensation for sta educa-
tion and time; necessary materials)
b. Clear communication of how better pain management is congruent
with organizational goals
c. Establishment of policies and standard operating procedures for the
organization
d. Requiring clear accountability for outcomes
2. Facilities/institutions will establish an internal pain team of committed and
knowledgeable sta who can lead quality improvement eorts to improve
pain management practices.
3. Facilities/institutions will require evidence of documentation of pain assess-
ment, intervention, and evaluation of treatment eectiveness. is includes
adding pain assessment and reassessment questions to ow sheets and elec-
tronic forms.
4. Facilities/institutions will provide evidence of using a multispecialty approach
to pain management. is includes referral to specialists for specic therapies
(e.g., psychiatry, psychology, physical therapy, interdisciplinary pain treat-
ment specialists). Clinical pathways and decision support tools will be devel-
oped to improve referrals and multispecialty consultation.
5. Facilities/institutions will provide evidence of pain management resources
for sta (e.g., educational opportunities; print materials, access to web-
based guidelines and information).
Protocol 14.1: Pain Management in Older Adults (cont.)
264 Evidence-Based Geriatric Nursing Protocols for Best Practice
American Medical Directors Association (AMDA: Clinical Practice Guideline: Pain Management in
the Long-Term Care Setting.
http://www.amda.com/tools/cpg/chronicpain.cfm
City of Hope: State of the Art Review of Tools for Assessing Pain in Nonverbal Older Adults.
http://prc.coh.org//elderly.asp
American Association of Pain Management Nurses (ASPMN: Pain Assessment in the Non-verbal
Patient: Position Statement with Clinical Practice Recommendations.
http://aspmn.org/Organization/position_papers.htm
Medical College of Wisconsin: Improving Pain Management in Long-Term Care Facilities
http://www2.edc.org/lastacts/archives/archivesJan01/featureinn.asp
Measurement Tools
See City of Hope website listed previously for comprehensive review of tools for persons with dementia.
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268
EDUCATIONAL OBJECTIVES
On the completion of this chapter, the reader should be able to:
1. evaluate the older adult patient who is unsafe and at risk for fall and injury, as well as
corresponding nursing interventions to minimize risks for injury among fall-prone
hospitalized older adults
2. design nursing plans of care aimed at reducing serious injuries among older adults
prone to falls based on the suspected fall type
3. use ndings from a comprehensive postfall assessment to develop an individualized
plan of nursing care for the secondary prevention of recurrent falls
4. mobilize institutional resources to provide a collaborative interprofessional falls or
safety team
5. use the latest evidence innovations in practice to champion a nurse-led fall prevention
intervention to prevent recurrent falls
OVERVIEW
Two specic aims of any eort in acute care institutions to reduce falls among older adults
are (a) to reduce risk of injury from falls including fatal falls and (b) to champion an
interprofessional fall prevention program to prevent patient falls. Both aims seek to pro-
mote improvements in patient safety by reducing preventable falls through system-wide
solutions whenever possible (Joint Commission National Patient Safety Goals, 2006).
Overall, across all patient settings, evidence exists that fall prevention programs
are eective. e RAND report cites, from a meta-analysis of 20 randomized clinical
trials (among all patient settings, but mostly long-term care), that fall prevention pro-
grams reduced either the number of older adults who fell or the monthly rate of falling
(U.S. Department of Health and Human Services, 2004). Hospital-based studies are
emerging to provide solid scientic evidence of the eect of fall prevention programs on
fall rates and, more importantly, fall-related injuries.
Oliver and colleagues (2007) have produced a compilation of the best evidence of
practice innovations used by hospitals across the United States and the United Kingdom,
Deanna Gray-Miceli and Patricia A. Quigley
Fall Prevention:
Assessment, Diagnoses, and
Intervention Strategies
15
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 269
and their outcome eect on falls and injury reduction. After careful scrutiny (Oliver
et al., 2007), they have identied the key components guiding multifactorial interven-
tions used to prevent falls in hospitals (i.e., education, use of toileting schedules, and
alarm devices). Oliver et al.’s (2007) approach has analyzed and weighed the individual
intervention—within the multifactorial intervention—into its constitute parts, thereby
minimizing any methodological design issues (Oliver, Healy, & Haines, 2010). Many
of these multifactorial interventions are targeted to education initiatives, environmental
issues, or seek to improve equipment implicated in falls.
Before beginning any discussion on specic individual fall prevention interven-
tion, the acute care nurse must realize one’s role in championing a team eort in fall
and injury prevention. Professional nurses are uniquely poised because they know the
biopsychosocial and functional needs of their patients and situational contexts of how
patients respond to the acute care environment. Such individual knowledge of each
patient they care for positions the professional nurse, along with leadership skill, in a
unique position to champion teamwork on their acute care unit.
BACKGROUND AND STATEMENT OF PROBLEM
The Importance of Fall and Injury Prevention in Acute Care
Many of the health care outcomes from falls, such as injury and/or functional decline,
typically strike those patients older than age 85 years and can be prevented. e most
serious outcome is a fatality. e National Center for Injury Prevention and Control
(NCIPC) tabulates fatal falls across the ages averaging more than 14,000 fatalities among
seniors. Fatal falls rank as the seventh leading cause of unintentional injury– fatality
among older adults (Centers for Disease Control and Prevention [CDC], NCIPC,
2007). e fatal fall incidence increases with age—those older than age 85 years being
the most vulnerable. Hospital in-patient falls are estimated to vary according to the unit,
with one study reporting 3.1 falls per 1,000 patient-days (Fischer et al., 2005). In this
study, bleeding or laceration occurred in 53.6%, fracture or dislocation in 15.9%, and
hematoma or contusion in 13%. Other serious injuries documented from falls included
hip fracture and traumatic brain injury (TBI), among others.
ASSESSMENT OF THE PROBLEM
Deciding Risk for a Serious Fall-Related Injury
“One look is worth a thousand words, but don’t forget to look more than once”
Diagnosis: Impaired consciousness
Important characteristics of level of alertness are the patient’s ability to sustain atten-
tion, and in determining if they are awake or not. If impairment exists in level of con-
sciousness, the patient is at risk for injury; thus, any postoperative surgical patient is at
greatest risk for injury from a fall. An important factor in determining a patient’s safety
within his or her environment will be if he or she can process information and execute
simple one-, two-, and/or three-stage commands. e ability to execute a command is
contingent on level of consciousness, behavior, and cognition.
Traditionally, level of consciousness is assessed and written as alert and oriented x 3,
referring to person, place, and time. e ability of the person to sustain attention can be
270 Evidence-Based Geriatric Nursing Protocols for Best Practice
gauged by observation of his or her ability (or not) to execute a command, for instance,
following instructions. is type of assessment is typically routine when the nurse rst
greets the patient and is beyond a simple assessment of whether or not the patient is awake,
“alert,” and oriented and can say, “Hello.” All of these determinations are critical factors in
the nurse’s judgment of patient safety. After the rst assessment, the nurse should reassess
the older patient frequently because level of consciousness can change quickly.
Critical Thinking Points
How many times do nurses reassess their own judgment and make changes accordingly
to their original impressions? Typically, in fall risk assessments, the reassessment is made
each shift and at the time of transition to another unit. Although a patient may “look
to be safe” resting in bed, they may be totally unsafe when they sit up on the side of the
bed or take a step to walk. erefore, the situational context is very important to note.
Consider these points: While patients are safe in bed, are they also safe to be unsu-
pervised alone? Are they safe to sit, transfer, or walk unassisted?
All of these nursing observations and ultimate clinical determination of patient
safety hinge on the older patient’s level of consciousness, level of alertness, as well as
behavior and current cognitive capabilities.
Level of consciousness is formally measured by use of standardized assessment tools
such as the Confusion Assessment Method and other such tools (see http://consultgerirn.
org/resources).
Diagnosis: Impaired Behavior, Affect, or Cognition
Observation of a patient’s behavior includes the patient’s aect, demeanor, and ability
to process stimuli in the environment. Agitated older adults are at risk for falls and
injury because attention to the normal environmental cues is blunted or lost altogether.
Depressed older adults may be at risk for impaired safety awareness and management
because of blunted responses or apathy as well as centrally acting medications used to
treat the depressants. Cognitive impairment should be evaluated because dementia is an
independent risk factor of falls (van Doorn et al., 2003).
For each of these four factors—consciousness, aect, behavior, and cognition— nurses
work with physicians to evaluate underlying causes and nd treatable solutions wherever
possible. Note that the root of many of the disturbances of consciousness, behavior, and
aect are due to some classic acute medical events such as hypotension, profound blood
loss, or toxicity from medications (see Table 15.1). If no identiable solution exists, pru-
dent and standard care (i.e., best practice) requires nurses to ensure the safety of patients
by instituting interventions related to improved monitoring and assistance with activities.
In the order of least to most restrictive, nurses employ various solutions until the patient is
no longer judged by the nurse to be at risk for a safety issue or in danger for a serious fall-
related injury (see Table 15.2). Note that research on these best practices for fall preven-
tion is slowly emerging, and the absence of research in this area does not justify not using
the intervention, because it may be a best practice intervention accepted as standard care.
Assess and Diagnose the Older Adult Patient’s Risk for Serious Injury
Fractures
ere are a few commonsense questions the acute care nurse must ask when determining
whether an elderly patient is at risk for serious injury (see Table 15.3). Serious injury is
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 271
TABLE 15.1
Medical Factors Associated With Risk to Fall Due to Impaired Safety Judgment
Summary of acute medical events, which can impair cognition, level of consciousness, or behavior
predisposing to impaired patient judgment and safety
Impaired level of consciousness
Volume depletion disorders
Dehydration
Acute internal bleeding
Medication toxicity
Infection/sepsis
Urinary track infections
Pneumonia
Intracranial mass/hemorrhage
Electrolyte imbalances
Diabetic ketoacidosis
Cerebral hypoxia
Impaired cognition (memory, short-term attention span)
Dementia
Untreated depression
Medication toxicity
Mental illness/developmental disability/mental retardation
Behavior agitation
Acute or chronic unmanaged pain
Medication toxicity
Depression
TABLE 15.2
Best Practice “Protective” Interventions for Patients With Impaired Level of
Consciousness, Cognition, or Behavior
Examples of best practice standard of care interventions (least to most restrictive)
Relocate patient bed to be near an observational port
Use of a personal or chair alarm
Dangle at bedside for 5 minutes before rising with assistance
Use of a sitter service, volunteer, or caregiver for one-on-one observation
Use of a bedpan as opposed to a bedside commode
Physicians orders for out of bed only with standby assistance
Physician orders for arm in arm assistance with ambulation
Physician orders for cane, walker, and standby assistance with ambulation
Out of bed for limited time with assistance only
Use of hipsters or protective hip wear
Use of helmets for the head, if at risk for head injury
dened as broken bones such as vertebral fractures, pelvic fractures, internal bleeding,
or fatality. All of the items listed in Table 15.3 are acute or chronic medical illnesses or
conditions giving rise to the possibility that an acute injury could result. One of the
most prevalent conditions increasing risk for serious injury in older patients, such as a
fracture, is the presence of osteoporosis. For many reasons, the true incidence of osteo-
porosis is unknown in the older population, especially in men (Kaufman et al., 2000)
who comprise a large percentage of the acute care hospital and long-term care beds.
272 Evidence-Based Geriatric Nursing Protocols for Best Practice
erefore, it is entirely conceivable that the older adult will fracture an extremity or ver-
tebrae with a fall, even though there is no documented diagnosis of osteoporosis. is
is because osteoporosis can be present, even though it has not formally been diagnosed.
Most older individuals with hip fractures have osteoporosis, yet ndings from a retro-
spective analysis of records of patients receiving hip fracture surgery appears that the
frequency of treating these high-risk older patients for osteoporosis is less than optimal;
women are oered treatment more than men (Kamel, 2004).
If osteoporosis has been diagnosed, then certain protective interventions should be
considered such as the use of hip protectors (Applegarth et al., 2009; Bulat, Applegarth,
Quigley, Ahmed, & Quigley, 2008). As indicated for those older persons without safety
judgment and are unable to transfer and ambulate independently, the use of low-height
beds and/or oor mats placed around the bedside will lessen the height of the fall, or
padding a hard surface to reduce the chance for injury. Treatment for osteoporosis needs
to be discussed, ranging from the use of medication agents to supplemental calcium and
vitamin D, although research ndings show a controversial association between vitamin
D and physical performance improvements in gait and balance (Annweiler, Schott,
Berrut, Fantino, & Beauchet, 2009). However, a recent meta-analysis found vitamin D
to be the only intervention shown to be eective in reducing falls among female stroke
survivors in an institutional setting (Batchelor, Hill, Mackintosh, & Said, 2010).
Other medical comorbidities that increase the risk of serious injury include bleeding
disorders and use of blood-thinning medications to prevent stroke. A risk versus benet
analysis should always be part of fall management decision making for patient safety
and prevention of injury (Quigley & Go, 2011). ose with thrombocytopenia require
monitoring of neurological status postfall in an eort to early identify a patient with
a looming internal bleed or developing hematoma. ese clinical conditions are very
serious and can be fatal if not assessed early.
Best Practice Interventions for Suspected Serious Injury
Head Trauma
Frequent neurological checks are done for several days following head injury in older
patients who are on blood thinners or who have coexisting medical conditions to detect the
development of serious conditions such as a subdural hematoma. In addition, vital signs,
assessing behavior, aect, cognition, and level of consciousness are all part of any assessment
TABLE 15.3
Medical Conditions Raising the Risk of Serious Injury/Internal Bleeding
Medical Conditions
Underlying osteoporosis
Current hip or vertebral fracture
Thrombocytopenia
Acute lymphocytic leukemia
Acute anemia or loss of blood volume
Any state of alerted level of consciousness “delirium,” lethargy, obtunded or comatose
Medications
Blood thinners
Thrombocytopenic agents
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 273
of the patient with head injury. Changes in speech, such as slurred speech, or subtle dimi-
nution in cognitive abilities (i.e., they no longer recognize you after recalling your name)
are signicant ndings postfall head injury that requires immediate attention.
Older patients who have unwitnessed falls or do not recall falling despite evidence to
the contrary should be monitored for head injury following the CDC guidelines for head
injury (see Resources). Traumatic brain injury caused by head injuries is a condition that
is preventable and, more importantly, readily recognizable. Subtle changes in cognition,
level of consciousness, or behavior postfall indicate underlying head trauma. Table 15.4
details best practice interventions in cases in which a head injury is suspected postfall.
Of all causes, falls are the leading cause of TBI (CDC, NCIPC, 2007), with older
adults age 75 and older having the highest rate of TBI-related hospitalization and death
(Langlois, Rutland-Brown, & omas, 2006). Groups at risk for the development of
TBI include men who are twice as likely to sustain a TBI—adults age 75 or older;
African Americans have the highest death rate from TBI (CDC, NCIPC, 2007). ere
is strong clinical reason to suspect that older adults in anticoagulants are at higher risk
for TBI, should then sustain a fall with head injury, but empiric research in this age-
group is lacking. Still, best practice approaches to care of older adults must include
a risk–benet evaluation of medications, such as Coumadin, Plavix, and/or aspirin,
among others, that place the older adult at increased risk for bleeding following a fall.
Additionally, use of helmets may be considered because they absorb trauma and reduce
impact to the head (Quigley & Go, 2011).
Why Do Older Adult Patients in an Acute Care Setting Fall and Who Is at Greatest Risk
The Value of Identifying Fall Type
Reasons for patient falls are tied directly to impairments in consciousness, cognition, behavior,
and acute and chronic types of medical conditions. Some of these risks are due to intrinsic
TABLE 15.4
Best Practice Interventions for Patients Suspected of a Serious Injury
Interventions
Notify the physician or health care professional immediately
Apply supplemental oxygen if indicated
Assess vital signs and pulse oximetry every 15 minutes
Prepare the patient for an x-ray of the extremity or CT scan of the head
Pad side rails if there is altered level of consciousness among those bedridden
Do not leave the patient alone; obtain a sitter or one-on-one assistance
Lower the height of the bed, use tab alarms or personal alarms
Maintain bed rest
Assess and maintain airway, breathing, and circulation
Assess and monitor pain (Does it increase over time or is it unrelieved?)
Maintain an NPO status unless ordered otherwise
For suspected injury to soft tissue, apply ice for swelling, follow the RICE principle
Prepare the patient for laboratory data, frequently a serum blood count, type and cross match,
bleeding time and serum electrolytes is ordered
Observe and monitor the injured site: Does the swelling increase? Is there an open fracture? Does the
tissue discolor is there loss of circulation?
Are there any coexisting symptoms, which worsen over time, such as headache, backache, pain in
the extremity, or experiences of dizziness or shortness of breath?
274 Evidence-Based Geriatric Nursing Protocols for Best Practice
factors, whereas others are due to extrinsic factors. e standard of care calls for assessment of
fall risk factors and then to develop intervention plan targeted toward these factors.
Environmental falls are potentially preventable because they encompass foresee-
able events, such as spills or improper shoe wear, which is correctable (Connell, 1996).
Important intrinsic risks to fall among older adults are summarized in Table 15.5, while
Table 15.6 lists some examples of age-related and associated conditions that cause falls.
Positive predictive validity of falls has also been used as evidence by the patient’s under-
lying history of falls, visual impairment, requiring toileting assistance, dependency in
transfer/mobility, balance disturbance, and cognitive impairment (Blahak et al., 2009;
Papaioannou, 2004; Tinetti, Williams, & Mayewski, 1986). Last, common extrinsic or
environmental factors, which represent preventable falls, are highlighted in Table 15.7.
Fall risk is formally assessed through administration of fall risk tools (see Table 15.8).
e National Center for Patient Safety recommends the Morse Falls Scale, but not
for long-term use (available at: http://www.va.gov/ncps/CogAids/FallPrevention/Index
.html#topofpage&page=page-4). e Stratify tool has also been widely used but
TABLE 15.5
Examples of Intrinsic Risks to Fall
Intrinsic Risks
Lower extremity weakness
History of falls
Gait deficit
*Balance deficit
Use of an assistive device
Visual deficit
Arthritis
Impaired activity of daily living (ADL)
Dependency in transferring/mobility
Depression
Cognitive impairment
*Delirium
Agitated confusion
*Older than age 80 years
Urinary incontinence/frequency
*Diabetes
Culprit medications: benzodiazepines, sedatives/hypnotics, alcohol, antidepressants, neuroleptics,
antiarrhythmics, digoxin, and diuretics.
*Polypharmacy
Note: * Indicates independent predictor of falls with prolonger lengths of stay and increased nursing home placement
(Corsinovi et al., 2009).
Sources: Corsinovi, L., Bo, M., Aimonino, N. R.., Marinello, R., Gariglio, F., Marchetto, C., . . . Molaschi, M.
(2009). Predictors of fall s and hospitalization outcomes in elerly patients admitted to an acute geriatric unit.
Archives of Gerontology and Geriatrics, 49(1), 142–145.
ECRI Institute. (2006). Falls prevention strategies in healthcare settings guide. Plymouth Meeting, PA: ECRI
Publishers.
Oliver, D., Daly, F., Martin, F. C., McMurdo, M. E. (2004). Risk factors and risk assessment tools for falls in hospital
inpatients: A systematic review. Age and Ageing, 33(2), 122–130.
Papaioannou, A., Parkinson, W., Cook, R., Ferko, N., Coker, E., & Adachi, J. D. (2004). Prediction of falls using
a risk assessment tool in the acute care setting. BMC Medicine, 2, 1.
Rubenstein, L. Z., & Josephson, K. R. (2002). e epidemiology of falls and syncope. Clinics of Geriatric Medicine,
18(2), 141–58.
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 275
TABLE 15.6
Medical Events and Diseases Associated with Falls in Older Adults
Age-related
Dizziness with standing from physiological age-related changes
Dizziness with head rotation from physiological age-related changes
Accidental/Environmental (see Table 15.7)
Slipping or tripping on a wet/slippery surface
Trip/slip
Lack of support from equipment or assistive device
Acute (Treatable) Sudden Symptoms
Mental confusion/delirium
Heart racing or skipping beats (arrhythmia)
Dizziness with standing up (orthostatic hypotension)
Dizziness with room spinning (vertigo)
Generalized weakness (infection, sepsis)
Involuntary movement of limbs accompanied by confusion, unresponsiveness, or absent facial
features (seizure)
Lower extremity weakness (electrolyte imbalance)
Gait ataxia associated with acute alcohol ingestion
Feeling faint or dizzy or unable to sustain consciousness (hypoglycemia)
Blacking out or loss of recall of fall event (syncope)
Unilateral weakness, sudden speech change, and/or facial droop (TIA/CVA)
Chronic (Manageable) Gradual or Recurrent Symptoms
Lower extremity numbness (neuropathy, diabetes, PVD, B
12
deficiency)
Lower extremity weakness (arthritis, CVA, thyroid disease)
Fatigue (anemia, CHF)
Dyspnea on exertion (emphysema, pneumonia)
Weakness (frailty, disuse, anemia)
Lightheadedness (carotid stenosis, cerebrovascular disease, emphysema)
Dizziness with standing (OH secondary to diabetes)
Dizziness with head rotation (carotid stenosis, hypersensitivity)
Dizziness with movement (labyrinthitis)
Forgetting the fall (dementia)
“I don’t know” responses (depression)
Lower extremity joint pain (arthritis)
Unsteadiness with walking (dementia, CVA/MID)
Poor balance (Parkinson’s disease)
Notes: TIA 5 transient ischemic attack; CVA 5 cerebrovascular accident; PVD 5 peripheral vascular disease;
CHF 5 congestive heart failure; OH 5 orthostatic hypotension; MID 5 multi-infarct dementia.
Sources: Gray-Miceli, D., Johnson, J. C., & Strumpf, N. E. (2005). A stepwise approach to a comprehensive post
fall assessment. Annals of Long-Term Care: Clinical Care and Aging, 13(12), 16–24.
Rubenstein, L. Z., & Josephson, K. R. (2006). Falls and their prevention in the elderly: What does the evidence
show? Medical Clinics of North American, 90(5), 807–824.
researchers report its use oers no added benet over nursing sta’s clinical judgment.
Oliver et al. (2010) recommend the Morse Fall Scale and the Stratify tool as the two
screening tools with best predictive properties for anticipated physiological falls.
e Veterans Administration VISN 8 Patient Safety Center has dened “inten-
tional falls” as those occurring from patients being pushed or falling to the ground
deliberately and these falls are usually not preventable. In other empirical research
directed at determining the various types of falls occur among older adults using a
276 Evidence-Based Geriatric Nursing Protocols for Best Practice
comprehensive postfall assessment (PFA) tool as the basis for determination, a broader
classication scheme has emerged consisting of eight dierent fall types observed: falls
due to acute illness, chronic diseases, medications, behavior, unknown, environment,
misjudgment, or poor patient safety awareness (Gray-Miceli, Ratclie, & Johnson,
2010). Fall risk screening tools identify the likelihood of an anticipated physiological
fall with known intrinsic and extrinsic fall risk factors. ese screening tools provide
rst level of assessment data as the basis for comprehensive assessment. Only through
comprehensive PFA can multifactorial, complex fall, and injury risk factors are dened
(Quigley, Neily, Watson, Wright, & Strobel, 2007). Fall risk assessment and PFA are
TABLE 15.7
Extrinsic Risks to Fall
Floor surfaces that are slippery, wet, extrashiny or uneven or cracked
Equipment that is faulty, nonsupportive, or collapsing when used, laden with
debris
IV poles, stretchers, or beds that are unsturdy or move away from the patient when
used for support
Poor lighting or extraglaring “blinding” bright lights
Bathrooms lacking grab rails, bars, or nonskid appliqués or mats
Physical restraints
Inappropriate shoe wear
TABLE 15.8
Listing of Some Empirically Tested Fall Assessment Tools
Name of Tool Author Setting Training
Time to
Administer Sensitivity
Assessment of high risk to fall Spellbring IP Y 17 minutes UK
Berg Balance Test Berg OP Y 15 minutes 77
Patient Fall Questionnaire Rainville IP Y UK UK
STRATIFY Oliver IP N UK 93
Fall Prediction Index Nyberg IP-CVA UK UK 100
Resident Assessment
Instrument
Morris NH Y 80 minutes UK
Post-Fall Index Gray-Miceli NH Y 22 minutes UK
Morse Fall Scale Morse IP Y , 1 minute 78
Fall Risk Assessment Tool MacAvoy IP N UK 93
Hendrich Fall Risk Model Hendrich IP N ,1 minute 77
Timed Get Up and Go Shumway-Cook OP Y ,1 minute 87
Tinetti Performance Oriented
Mobility Tinetti IP Y 20 minutes 80
Note. IP 5 inpatient; CVA 5 cerebrovascular accident; OP 5 outpatient; NH 5 nursing home; Y 5 yes; N 5 no;
UK 5 unknown.
Source: Adapted from ECRI Institute. (2006). Falls prevention strategies in healthcare settings. Plymouth Meeting, PA:
ECRI Publisher; Perell, K., Nelson, A., Goldman, R., Luther, S. L., Prieto-Lewis, N., & Rubenstein, L. Z. (2001).
Fall risk assessment measures: An analytic review. Journal of Gerontology, 56(12), 761–766.
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 277
two very dierent and distinct approaches for falls prevention. Fall risk assessment
tools oer limited types of inquiry typically streamlined focusing on ve or six areas
of inquiry, which are not a substitution or replacement for a comprehensive postfall
inquiry or assessment . Critical information is missing in these streamlined fall risk
assessment tools.
Patient-Specific Factors Linked to Fall Risk
Evidence from systematic reviews of fall risk factors in hospital inpatients supports the
following risk factors to be linked to falls: a recent fall, muscle weakness, behavioral
disturbance, agitation or confusion, urinary incontinence or frequency, use of “culprit”
medications(especially sedative/hypnotics), postural hypotension, syncope, and those
older than age 85 years (Oliver et al., 2010). In the acute care setting, fall risk tools have
been summarized in an analytic review by Perell and colleagues (2001; Scott, Votova,
Scanlan, & Close, 2007)
e nursing assessment of the older adult patient who falls does not stop with
administration of these assessment tools or other types of assessment. Rather, the assess-
ment is a dynamic and continuous process of quality improvement, which extends to
formulate an analysis of the information and situational context of the patient so that
corrective plans of action can unfold.
Physical Restraint Use Contributing to Fall Risk
Capezuti and colleagues (2002) cite physical restraint use as a contributor to risk for
falling, not a solution for fall prevention. Also noted by Capezuti et al. (2002), neither
physical restraints nor side rails have ever been shown to reduce falls or associated
injury. In fact, in the last 20 years, there have been numerous reports of restraint-
related injuries reported in the professional literature, by the U.S. Food and Drug
Administration, and e Joint Commission. Many of these injuries are due to patient
attempts to remove restraints or to ambulate while restrained (Agostini, Baker, &
Bogardus, 2001). e injuries include neurological injuries (DiMaio, Dana, & Bux,
1985), stress-induced complications (related to agitation secondary to restraint), and
strangulation (Dube, & Mitchell, 1986; Miles, 2002). e most common mechanism
of restraint-related death is by asphyxiation—the person is suspended by a restraint
from a bed/chair and the ability to inhale is inhibited by gravitational chest compres-
sion (DiNunno, Vacca, Costantinedes, & Di Nunno, 2003). Clearly, the risk of serious
injury or fatality due to physical restraint is substantial and must be considered when
deciding about using restraints. Serious direct injury from bedrails is usually related
to use of outmoded designs and incorrect assembly rather (Healey, Oliver, Milne, &
Connelly, 2008).
Medications Contributing to Fall Risk in Older Adults
“Culprit” drugs or medications implicated in increasing fall risk are those causing poten-
tially dangerous side eects including drowsiness, mental confusion, problems with
balance or loss of urinary control, and sudden drops in blood pressure with standing
( postural hypotension; Ensrud et al., 2002; Neutel, Perry, & Maxwell, 2002; Smith,
278 Evidence-Based Geriatric Nursing Protocols for Best Practice
2003). Classications of medications implicated in falls for older adults include psy-
chotropic agents (benzodiazepines, sedatives/hypnotics, antidepressants, and neurolep-
tics), antiarrhythmics, digoxin, and diuretics (Leipzig, Cumming, & Tinetti, 1999).
e risk of falls alone should not automatically disqualify a person from being treated
with warfarin (Garwood, & Corbett, 2008).
Postfall Assessment
Determination of why the fall occurred is of vital. e value of postfall assessment, if
performed properly and comprehensively using appropriately empirically tested tools,
is that underlying fall etiologies can be discerned so that appropriate plans of care can
be instituted. To simply perform a fall risk assessment or perform a PFA and document
the ndings without linking the risk or actual fall cause to a strategy is useless. Once the
type of fall is determined using a comprehensive postfall evaluation tool, the nurse can
put into motion an appropriate plan of care.
e purpose of the PFA is to identify the clinical status of the older adult, verify and
treat injuries, and to identify underlying causes of the fall whenever possible. Compo-
nents of the PFA are typically routinely performed by professional nurses in all patient
settings, although this evaluation may be skeletal or limited according to the complete-
ness of questions and examination included on the tool used. Few empirically published
tools for PFA exist, and previous research has shown that fall risk determination, using
short forms, asking 5–8 questions about risk, often replace (inappropriately) PFA in
institutionalized settings (Gray-Miceli, Strumpf, Reinhard, Zanna, & Fritz, 2004; Ray
et al., 1997; Rubenstein, Robbins, Josephson, Schulman, & Osterweil, 1990).
Evidence shows comprehensive PFA tools are useful and available to assist pro-
fessional registered nurses in performing a PFA, especially in institutionalized settings
(Gray-Miceli, Strumpf, Johnson, Draganescu, & Ratclie, 2006). In institutional set-
tings where teams are unavailable, comprehensive PFA may be carried out through
consultation with specialty-trained providers.
e PFA is a comprehensive, yet fall-focused history and physical examination
of the present problem (falling), coupled with a functional assessment, review of past
medical problems, and medications. Clinical fall prevention guidelines are very clear
about all of the necessary components for inclusion for patients who have fallen, which
include fall history; fall circumstance; medical problems; medication review; mobility
assessment; vision assessment; neurological examination, including mental status; and
cardiovascular assessment. In addition to this information, data are collected about
the patient’s physical status. Performing a comprehensive PFA allows the clinician to
identify intrinsic risks and recent causes of a fall such as orthostatic hypotension and/
or bradyarrhythmia or tachyarrhythmia associated with dizziness (Gray-Miceli et al.,
2006). In the hospital setting, certain components of a PFA can be elicited immediately
following a patient fall, with the decision to ask certain questions immediately depends
on the medical stability of the patient and nursing judgment.
The Immediate Postfall Assessment
As soon as possible, an assessment is made to determine the extent of any sustained
injuries. Before any intervention is taken, any sta member should remain with the
patient and call for help. During this time, the older adult patient is verbally reassured
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 279
and kept warm (but not moved) until help arrives. ere are many key observa-
tions to be noted about the fallen individual’s medical and psychological condition,
as well as condition of the environment. e medical stability of the patient deter-
mines the sequence of information gathered either immediately or in the interim
period, according to current standards of practice followed by licensed professionals.
For instance, if unconscious from a head injury sustained during the fall, neuro-
logical checks, vital signs with apical pulse rate, and pulse oxygenation are assessed
rst. Other assessments of gait or functional status are conducted after the patient
has stabilized. While this is being performed, or if shoes/slippers are worn, other
sta members can assess environmental spills. Information about the lighting and use
of assistive devices can be gathered. Any verbalizations made by the patient should
be noted about his or her condition. Critical observations made during the imme-
diate PFA (see Table 15.9) that should be communicated to the primary care provider
include observation or verbalizations of pain, extremity swelling, unstable vital signs,
discolored skin, temperature, laceration or contusions of the skin, loss of conscious-
ness, decreased range of motion, evidence of head or neck injury and abnormal or
erratic neurological responses, uncontrollable bleeding, and incontinence of bowel or
bladder at the time of the fall.
Interim Postfall Assessment
During the interim period of PFA and monitoring (anywhere from several hours to
days), the nurses continue to review, determine, and communicate pertinent ndings
from this assessment and its progression or resolution. Once the patient is medically
stable, fall risk assessment can be reassessed by the interdisciplinary team, revaluating
intrinsic and extrinsic risks so that a plan of care can be determined. Developing a plan
of care and requesting a change in physician orders for level of supervision required by
TABLE 15.9
Immediate Postfall Assessment
Actions Taken by Professional Nurses and Nursing Staff
If the older adult patient is found on the floor, remain with patient, summons additional help, proceed to:
Ask the older adult to explain what happened if possible
Ask the older adult how he or she is feeling and if there is pain
Control any bleeding (follow unit protocol) from injured site
Assess level of consciousness and perform neurological assessment including and pupillary checks
(according to unit protocol)
Gather and document vital signs: note the apical pulse rate and the supine blood pressure
Examine for signs of external injury to the head, spine, neck, and extremities
Determine oxygenation status
Determine finger stick glucose if hypoglycemia is suspected
If stable, sit the patient up with support and assess sitting blood pressure
Gather and review pertinent symptoms at the time of the fall
Immobilize an extremity if fracture is suspected
Reassure the older patient
If stable, assist with transfer to be or appropriate area for further evaluation
Diagnosis and treatment
Source: Reprinted with permission from ECRI. Gray-Miceli, D. (2006). Falls prevention strategies in healthcare settings,
Chapter 5, Patient Post fall Assessment: Plymouth Meeting: ECRI Publishing; Copyright Deanna Gray-Miceli, 2005.
280 Evidence-Based Geriatric Nursing Protocols for Best Practice
nursing sta of the older patient or specic activity restrictions depending on the fall
assessment ndings.
Longitudinal Postfall Assessment
Following a patient fall, the presence of injury may not be apparent until days or even
weeks later. When cognitive impairment exists, the accuracy of the historical accounts of
pain obtained immediately after the fall may be questioned. Observations of functional
status with attention to any subtle or blatant changes in mobility can signal an underlying
fracture or a looming unstable joint that was not previously reported. Likewise, during
a patient fall in which the older adult is cognitively intact, and then later develops, an
acute delirium should signal to the professional nurse the possibility of injury. In these
two instances, the standard of care warrants as part of the ongoing postfall assessment,
to monitor vital signs and neurological status for a period of several days or more, as
clinically indicated. Fall policy and procedures should reect this provision because any
change in patient condition warrants follow-through, documentation, and communica-
tion to senior level providers, other nursing sta, and family (see Table 15.10).
Overview of Effective Fall and Injury Prevention in Hospitals
Eective fall prevention programs in acute care hospitals are championed by nurses using
one or more approaches. Moving beyond traditional measures of fall rates to assessing
and measuring patient injury from falls provides more information and segmentation of
vulnerable patients so that a new level of intervention is applied. is process advances
the evidence related to falls into the quality management program for falls prevention.
Assessing risk for injury provides the evidence for nurses to provide specic interventions
to reduce injury (e.g., hip protectors, oor mats, and helmets) based on using existing
tools. e evidence is strong to support the benet of multifactorial fall prevention pro-
grams for injurious falls in acute care. System-level interventions with emerging evidence
of eectiveness emerge from the work of innovation: nurse champions, safety huddles,
teach-back strategies, postfall huddles, and interventions to reduce fall-related trauma.
TABLE 15.10
Critical Observations Made During the Immediate Postfall Assessment
Expressions or verbalizations of pain (facial grimacing, crying, screaming, agitation)
Changes in behavior or function, which may indicate pain
Swelling of an extremity (writs, arm leg) or head (hematoma, skull pain)
Unstable vital signs
Discolored cyanotic skin
Skin temperature (cold, clammy, diaphoretic)
Skin lacerations, contusions
Loss of consciousness (LOC), no response to stimuli or significant change in LOC
Changed range of motion of extremities
Evidence of neck, head, or spinal cord injury
Abnormal or erratic neurological responses, such as absent pupil response, fixed or dilated pupils,
seizures, or abnormal changes in posture
Source: Reprinted with permission from ECRI Institute. (2006). Fall prevention strategies in healthcare settings,
Chapter 5, Patient Post fall Assessment: ECRI Publishing.
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 281
Nurse Champions
Embracing nurse champions at the point of care, the Institute for Healthcare Improve-
ment’s (IHI) Transforming Care at the Bedside has partnered with the VISN 8 Patient
Safety Center to focus on acute care fall and injury prevention for the last 5 years.
Dedicated to building program capacity, infrastructure, and expertise, fall experts have
mentored and coached nurses from across acute care settings to address vulnerable older
adults are at greatest risk for loss of function or loss of life if any type of fall occurs. is
approach to nursing practice has been transformational (Boushon et al., 2008).
Teach Backs
Health literacy requires that providers evaluate the degree to which individuals learn
by assessing their capacity to obtain information, process, and understand basic health
information and services so that they can make informed health decisions (Institute of
Medicine, 2004). Teach backs identies what the patient learned by a return demon-
stration or feedback, and more importantly, what the patient had diculty learning, so
that the provider can ll that gap through ongoing education.
Comfort Care and Safety Rounds. Nursing sta are completing comfort care and safety rounds
as one of their tests of change. is intervention has emerging evidence of eectiveness
based on the results of researchers Meade, Bursell, and Ketelsen (2006), hourly rounds in
acute care reduced falls ( p 5 0.01), and by 60% 1 year later in the follow-up hospitals.
Safety Huddle Postfall
Safety huddles were patterned after the military’s “After Action Review” (AAR) process.
Safety huddles provide a mechanism for immediate knowledge transfer for learning from
errors and close calls. In a safety huddle, sta are instructed to immediately assess a
situation or event to understand what happened, what should have happened, what
accounted for the dierence, and what corrective action could be implemented to pre-
vent a similar event. is AAR mimics a modied root cause analysis. All sta received
a brochure explaining the AAR process and are instructed to perform a safety huddle
as soon as possible after becoming aware of a fall. Nurse managers or advanced practice
nurses coach sta in the safety huddle process through role playing and use of a brochure
and presentation that describes the process. e nurse managers lead the initial huddles,
and sta followed thereafter. Over time, sta begin to use safety huddles to examine other
patient safety situations and to ensure that falls precautions are consistently applied in
the shift-to-shift hand-o process. Incorporation into the hand-o process also provided
the opportunity for sta to reassess a patient’s status (Quigley et al., 2009).
Interventions to Reduce Trauma
Patients with risk factors for serious injury (osteoporosis or osteoporosis risk factors; anti-
coagulants for postoperative patients) should be automatically placed on high-risk falls
precautions and interventions to reduce risk for serious injury should be implemented.
Interventions to reduce the risk trauma and prevent injury include the following: place
a bedside mat on oor at side of bed unless contraindicated; use height-adjustable bed
(low-bed position to reduce distance from bed to oor); helmet use for patients at
risk for head injury (those on anticoagulants, patients with severe seizure disorder, and
282 Evidence-Based Geriatric Nursing Protocols for Best Practice
history of falling and hitting head); and dress with hip protectors for patients at risk for
hip fracture. ese interventions when combined create protective bundles. For exam-
ple, those patients at risk for hip fracture should be placed at high risk for falls and in
height-adjustable beds, wear hip protectors, have oor mats at bedside when in bed, and
receive comfort and safety rounds. ose patients at risk for hemorrhagic bleed should
be placed at high risk for falls and in height-adjustable beds, have oor mats at bedside
when in bed, and receive comfort and safety rounds. Helmets should be considered for
patients with history of head injury and falls, and on anticoagulants. All patients should
receive education about their fall and injury risks.
Program Evaluation
Many health systems use a specically designed incident report form for falls that collects
detailed literature-based data about fall occurrences (Elkins et al., 2004). For example,
these data might include time of day, location, activity, orthostasis, and incontinence.
From the analysis of the data, one can determine the type of fall, such as accidental,
anticipated physiological, and unanticipated physiological fall and severity of injury—
minor, moderate, or major/severe (Donaldson, Brown, Aydin, Bolton, & Rutledge,
2005). Analysis of data of this depth and scope enables clinicians, administrators, and
risk managers to prole the level of fall risk of their patients along with actual factors
contributing to the fall, as well as identifying overall patterns and trends surrounding
fall occurrence.
Fall Prevention Program
Fall prevention begins with an integrated/coordinated approach inclusive of fall risk
determination and PFA to identify risk factors. Accurate documentation should be pro-
vided in the plan of care, nursing and interdisciplinary notes, and other aspects of the
medical record such as the problem-list help to ensure communication and ongoing
monitoring. Review of fall-related information collected about a fall event or a person
deemed at risk for fall by the interdisciplinary team adds an important dimension to fall
care. e team oers input from their unique perspective of the fall circumstance and
how to best manage a fall or a patient at high risk for falls. e interdisciplinary team
consists of the medical provider, nurse, physical or occupational therapist, risk manager,
pharmacist, and other direct health care providers.
Hospital-based fall prevention programs have been described in the literature, but few
clinical trials have been conducted, demonstrating their eectiveness due to methodologi-
cal limitations associated with this complex fast-paced setting. One study examined the
eect of a program of fall prevention that includes multifactorial components of fall risk
assessment, a choice of interventions, patient education, and sta education, as well as
labels or “graphics alerting others to at risk patients.” Use of this model and its outcomes
were examined prospectively for 5 years by Dempsey (2004) who reported a signicant
reduction in fall rates. However, over time compliance deteriorated warranting further
nursing inquiry considering use of a process approach to increase nurse autonomy in fall
prevention.
Exemplary models of care also exist through the National Center for Patient Safety
at the United States Department of Veterans Aairs (available at: http://www.va.gov/
ncps/SafetyTopics/fallstoolkit/index.html). e Veterans Aairs, VISN 8 Patient Safety
Center of Inquiry, under the direction of an advanced nurse practitioner–nurse scientist,
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 283
spearheads an impressive program of fall prevention through its health care network
of inpatient hospitals. Fall prevention through best practice approaches are evaluated
and translated into standard practices among general falls prevention, interventions for
high-risk patients, and education of sta, patients, and families.
Models of care, serving as exemplars of the geriatric nurse-centered approach, realize
improvements in hospital lengths of stay and health outcomes as well as fewer iatrogenic
geriatric syndromes such as inpatient falls. Use of the Acute Care of the Elderly (ACE)
units; Nurses Improving Care for Healthsystem Elders (NICHE) program; and the
Geriatric Resource Nurse (GRN) model, which use a system-level quality improvement
approach, including educational programs for sta, realized a decrease fall rate by 5.8%
(Smyth, Dubin, Restrepo, Nueva-Espana, & Capezuti, 2001).
INTERVENTIONS FOR FALL PREVENTION AND MANAGEMENT
Instituting General Safety Measures
Hospitals and their sta have a legal responsibility and due diligence to ensure freedom
from environmental hazards and safety for all patients, sta, and visitors. Routine envi-
ronmental assessment using a checklist should include the unit, corridors, entrance, and
exits, as well as patient holding areas, patient rooms, and areas where patients are trans-
ported to (radiology, nuclear imaging, operating room). In each of these areas, an envi-
ronmental assessment is performed focusing on oor surfaces, furniture, hallways, steps,
device safety such as stretchers, wheelchairs, and other types of chairs, free of clutter,
bathrooms with appropriate grab rails, and routine assessment of equipment. Use of
a checklist signed by the designated employee allows for audit review of compliance,
serving as an internal benchmark of compliance.
As part of general safety, some facilities designate any older adult age 65 years and
older admitted to be on “safety precautions,” which can include various other safety
measures (presented in the succeeding text). Clinically, it is important to recognize, in
advance whenever possible, that if instructions are given to the patient for general safety
precautions, that the older adult is actually able to hear, understand, and demonstrate
that he or she can follow instructions. Simply “telling the older adult” to be careful or
to not get up without assistance is insucient in the face of an ongoing or new onset of
delirium or cognitive impairment. Rather, other safety measures need to be immediately
instituted, discussed with the team and the family caregiver, and incorporated as part of
the plan of care. Immediate options always include (a) increasing surveillance by either
staying with the patient continuously; (b) moving the patient to a closer location (pro-
vided there is sta constantly observing the patient); (c) providing a one-on-one type of
sitter service for continual surveillance; or (d) engaging the older patient in diversional
activities or other forms of therapeutic recreation. Sitter type services can be provided
by hospital sta, volunteers, or through private duty services. Discussion with family
caregivers and the interdisciplinary team are essential in these cases.
Early Mobility for Older Patients Who Fall
Early mobility, whenever the older patient is medically stable, is a fundamental and
basic aspect of care for all older adult patients to receive during their hospitalization. It is
a step toward the prevention of deconditioning, reduced mobility and immobility, and
other cascading problems that can result when less sedentary (for instance, orthostatic
284 Evidence-Based Geriatric Nursing Protocols for Best Practice
pneumonia or atelectasis). Early mobility as an intervention begins with the simple and
conscious decision by nursing to assist the patient out of bed to walk to the bathroom
whenever possible, rather than to use a bedpan or even a bedside commode that oers
little opportunity for mobility. Wearing proper footwear, corrective lenses, and clearing
a path that is clutter- and spill-free are essential. Use of a walking aid such as a standard
cane or walker may also be required; appropriate assistive devices can be ascertained
through an occupational or physical therapist consultation (Quigley & Go, 2011).
Another essential aspect for the older adult with comorbidities is for nurses to pre-
emptively ask the older patient, who is transitioning with your assistance, from sitting to
standing and then while walking, “How are you feeling”? Of concern is the detection of
symptoms such as lightheadedness, vertigo with rotational movement, or muscular sti-
ness. ese symptoms can be managed and monitored, if signicant enough to prohibit
mobility, once they are detected. Another concern exists for the older adult patient with
orthostatic hypotension. In this instance, gradual upright incline with assistance while
monitoring for symptoms of lightheadedness are important. Should an older adult experi-
ence symptoms or develop acute physiological evidence of a problem (for instance, near
syncope, syncope, or changes in heart rate or blood pressure), slowly easing him or her back
to a recumbent position and notifying the physician for further evaluation is warranted.
Mobility programs build upon the positive feedback that the patient is feeling and
objectively gaining strength each day is instituted. Checklist can monitor progress and
serve to validate to the patient his or her clinical progression. Care must be taken, how-
ever, to remind persons who are restricted from independent mobility to always wait
for assistance. Recommendations are to set a similar time each day and to use consistent
sta. An integral component of any mobility program is footwear of patients. A recent
study found patients who wore their own footwear signicantly improved participants’
balance compared to being barefoot; in fact, the greatest benet was seen in those indi-
viduals with the poorest balance (Horgan et al., 2009).
Some Best Practice Exemplars Used by Acute Care Hospitals
e dierence between environmental safety assessment and safety rounds is that safety
rounds are a regular, systematic observation by one or two key personnel of the hospital
unit; when assumed by the same personnel, hazards may be more quickly appreciated.
Further, they occur at regular points in time, such as every 2 or 4 hours around the clock
and also detect patients in need of assistance. is level of frequency is likely to detect
problems early so that intervention can ensure the prevention of environmental type of
falls. Use of checklist can help to ensure compliance and monitor for patterns of hazards
and types of hazards that need correction.
Many hospital-based fall prevention programs include toileting rounds. Toileting
rounds use nurse’s aides to regularly assess older adult patients for the need to urinate
and to provide the patient with assistance. e purpose of toileting rounds is to prevent
patients from incurring urinary accidents (and potential falls) by encouraging regular
voiding. In many circumstances, urinary accidents can lead to falls. Scenarios include
the older adult sensing a need to urinate, getting up out of bed unassisted, and incur-
ring a fall by an unrecognized physiologic mechanism (e.g., orthostatic hypotension).
Another scenario is in route to the bathroom; the older adult has a urinary accident on
the oor and slips and falls on the wet oor. By oering toileting rounds on a regular
basis, the potential for these occurrences are minimized, reducing fall rates as well as the
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 285
iatrogenic complications (e.g., hip fracture). Toileting is a fundamental element of basic
care that has an important place in the prevention of patient falls, but its importance is
underrecognized. In a study by Brown et al. (2000), urge incontinence (and not stress),
especially if occurring weekly or more often, increased risk of falls and nonspinal, non-
traumatic fractures in older White women living in the community.
Specific Nursing Interventions
Personal alarms are routinely used to alert nursing sta about impending falls or changes
in patient mobility status. Care should be taken when deciding to use these devices,
because they do not prevent a fall from occurring (Oliver et al., 2010); rather, they
heighten sta’s awareness by sounding an alarm, indicating a change in position has
occurred. ere are many commercial products available, but generally, they are of two
types, personal alarms clipped to the patient’s gown or chair and bed-chair pressure
sensors. Despite their widespread use, there is little evidence regarding their eective-
ness in reducing falls in an acute care hospital setting. Use of a bed sensor alarm was
studied in a geriatric rehabilitation unit with older adult patients, deemed by nurses to
be at increased fall for falling (Kwok, Mok, Chien, & Tam, 2006). In this study, the
availability of bed sensor devices neither reduced physical restraint use nor improved the
clinical outcomes of older adults with perceived fall risk. In a nursing home–based study,
however, use of the “NOC WATCH,” a nonintrusive monitor used with older adults at
high risk for falling (Kelly, Phillips, Cain, Polissar, & Kelly, 2002), reduced fall rate by
91%, thereby supporting other clinical trials using a randomized design. Falls may not
be the best indicator of the eectiveness of alarms, rather timeliness of rescue (Quigley,
& Go, 2011). Further, greater nurse surveillance capacity was signicantly associated
with better quality care and fewer adverse events (Kutney-Lee, Lake, & Aiken, 2009).
Both oor mats and use of low-rise beds have an important place in the armamen-
tarium of clinical interventions to prevent the occurrence of serious injury when a bed fall
occurs. Floor mats are simply placed surrounding the bed and serve to cushion the impact
of the fall. ey vary in thickness, and if portions of an area are uncovered, substantial
injury could still occur if a patient attempts to get out of bed and a bed fall ensues. Little, if
any, empirical research evidence exists regarding their eectiveness in preventing falls from
bed causing fractures to the hip or traumatic brain injury in acute care settings. However,
one observational cluster randomized trial in 18 nursing homes found that both types of
hip protectors (soft and hard), when worn correctly, had the potential to reduce the risk of
a hip fracture in falls by nearly 60% (Bentzen, Bergland, & Forsen, 2008).
A recent meta-analysis, however, reported that hip protectors are an ineective
intervention for those living at home and that their eectiveness in the institutional
setting is uncertain (Parker, Gillespie, & Gillespie, 2006).
Technological advances have occurred, oering sta and patients a greater variety of
solutions to the problem of falling. Improvements realized have occurred with walking
aides such as canes that “talk” and provide feedback to the user, balance retraining that
help patients learn about where their body is in space and to help learn how to compen-
sate for muscular impairments, and other types of equipment used at the bedside when
transitioning patients. Although these devices are available, research is evolving and
limited in terms of their eectiveness in fall prevention (Nelson et al., 2004).
An integral component of any fall prevention educational intervention for
hospitalized older adults or preparing for discharge home concerns their working
286 Evidence-Based Geriatric Nursing Protocols for Best Practice
knowledge of what their fall was due to and what can be done about it. Exploring the
older adult’s beliefs and attitudes are important and can lead to dispelling myths they
may hold about falling; for instance, they may believe it is a normal part of aging or that
nothing can be done about it. An older person’s view and conceptualization about their
falling is a starting point for a tailored educational intervention. A systematic review of
the literature of many studies examining older adults preferences, views, and experiences
in relation to fall prevention strategies reported several important ndings (McInnes, &
Askie, 2004): (a) In clinical practice, it is important to consult with individuals to nd
out what they are willing to modify; and (b) what changes they are prepared to make to
reduce their risk of falling, otherwise they may not attend fall prevention programs.
Mrs. S. is an 80-year-old White female admitted to the step-down rehabilitation unit
at the hospital following a 3-week admission for treatment of a community-acquired
pneumonia. Mrs. S. received intravenous (IV) antibiotics and uids for management
of the inltrate and associated dehydration. Mrs. S.’s hospitalization was complicated
by development of acute confusion, which escalated following use of IV theophylline
and use of Ventolin nebulizers. Mrs. S. also developed a deep vein thrombosis of the
leg, which was treated with IV heparin, and she now receives Coumadin. Mrs. S.’s fall
risk score was signicant for visual impairment due to a cataract, delirium, focal lower
extremity weakness due to osteoarthritis, chronic obstructive lung disease, osteoporo-
sis, and forgetfulness with short-term memory loss.
Prior to this hospitalization, Mrs. S. was functioning independently in her home,
until her son and daughter found her on the oor, mildly confused and disoriented,
complaining of dizziness. Mrs. S. was transported to the emergency room for further
evaluation. She was diagnosed with a right lung inltrate via chest x-ray; moderate-
to-severe dehydration. An IV line was started and she was treated with antibiotics and
admitted for observation. A 12-lead electrocardiogram showed a sinus bradycardia at
54 beats per minute. A CAT scan of the head was not performed; rather, Mrs. S. was
placed on observation and admitted to a medical–surgical unit.
After the 3-week long hospitalization, Mrs. S. is transferred via wheel chair to the
rehabilitation unit. During the admission assessment, you note Mrs. S.’s total fall risk
score increased by 4 points due to increased confusion/disorientation, periods of rest-
lessness, and reduced mobility. Mrs. S.’s vital signs are stable. You learn in the nursing
report that Mrs. S. needs constant supervision or she wanders o the unit. During the
physical examination, you are paged overhead and respond by going to the nursing
station. When you return to examine Mrs. S., she is gone. A second overhead page is
called “stat” for assistance on your unit. Apparently, Mrs. S. was found sitting on the
oor outside of the elevator, complaining of pain in her right hip and right ankle.
e immediate PFA shows possible loss of consciousness as Mrs. S. was observed
unresponsive for a few seconds. ere is evidence of a head injury with a laceration
and hematoma to the scalp as well as right lower leg pain and swelling. Mrs. S.’s blood
pressure sitting is 80/50, and her pulse rate is 60—regular, but weak. Ice is applied to
her scalp and her leg is immobilized. e physician is notied immediately and a stat
CASE STUDY
(continued)
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 287
CAT scan of the head is ordered, later conrming an acute intracranial bleed. Mrs. S.
is prepared for cranial surgery and then hip fracture repair the following day.
Case Study Discussion
1. What nursing actions should have been taken to prevent the fall and serious
injury?
Mrs. S. is at high risk for serious injury due to her fall risk screen score and use of an
anticoagulation medication, Coumadin. e standard of practice for caring for an
older adult hospitalized with increased risk for falls with serious injury requires the
nurse to recognize that this patient is likely to have impaired judgment and inability
to follow direction due to her disorientation, relocation to a new unit, and evidence
of restlessness. Because she is ambulatory, but forgetful, this creates a situation where
the patient needs constant supervision. Mrs. S. should be allowed to ambulate, but
only with 1:1 supervision and/or physical assistance whenever possible. e nurse
failed to recognize the importance of providing constant supervision to the patient.
Actions that should have been undertaken include constant supervision by support
sta, such as volunteers and/or a special assignment of a nurse’s aide to stay with the
patient. Family would need to be notied of this decision and to enlist their support
for considering a private duty nurses assistant. Acute confusion or delirium renders
Mrs. S. unsafe to make the necessary decisions or judgments about her care.
In terms of preventing serious injury, Mrs. S. could be oered a hip protector,
because they are indicated for older adults who are deemed at high risk for fracture.
Osteoporotic older adults who fall are likely to fracture an extremity or incur serious
injury. Use of a low-rise bed and oor mats should be used because she is at high risk
for falling from bed again. Her needs can be anticipated by regular rounds and by
oering the use of toilet that can help prevent urinary accidents and/or falls walking
toward the bathroom.
It is imperative that Mrs. S.’s mobility be allowed to continue to move freely
and ambulate provided she is supervised and/or assisted due to the disorientation.
Daily walking on the unit, in the patient’s room, and whenever possible to increase
mobility is essential.
2. How should the nursing assessment be focused?
Further assessment for reversible causes of delirium is warranted. Since the Ventolin
has precipitated acute confusion, this drug should be used sparingly and possibly
substituted with less “anticholinergic agents.” A pharmacy consultation, as part
of the interdisciplinary assessment, would be appropriate. Alternative respiratory
interventions for increased pulmonary secretions such as clapping, postural drain-
age deep breathing, and the use of an inspirometry could be instituted.
Further assessment of Mrs. S.’s falls (i.e., a fall evaluation) is clinically indicated.
She has had two falls recently: one at home and one at the hospital. e etiology of
these falls is not clear. e history of “being dazed” occurring in both falls warrants
additional workup. In the emergency room, the patient did not receive a CT scan of
her head. e fall evaluation includes, among other tests, a 24-hour Holter monitor.
A consultation with a geriatrician and/or neurologist is clinically warranted.
CASE STUDY (continued)
288 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Fall and serious injury prevention is a shared responsibility by all health care providers
and professionals caring for older adult patients. National recommendations exist to
guide practice and should be routinely incorporated into any fall prevention program
and practice policy. Some of the evidence-based research presented here can help clini-
cians make choices about which interventions may be the most ecacious or eec-
tive, bearing in mind that this choice changes with changes in the patient’s condition.
erefore, selecting the most appropriate intervention will always depend on what the
nursing and medical assessment determine the likely cause of the fall to be and the
medical stability of the patient at that time. Among older adults with advanced years of
age with complex illness and multiple comorbidities and geriatric syndromes, this deter-
mination becomes increasingly more challenging, but not impossible to determine. e
safety of older adults in the hospital and continuing upon discharge home depends on
continual assessment and reevaluation of their condition coupled with education, the
use of the most eective and safest technology, and the older adult’s knowledge and
willingness to participate in evidenced-based care.
Protocol 15.1: Fall Prevention
I. GOALS
A. Prevent falls and serious injury outcomes in hospitalized older adults.
B. Recognize multifactorial risks and causes of falls in older adults.
C. Institute recommendations for fall prevention and management consistent
with clinical practice guidelines and standards of care.
II. OVERVIEW. Falls among older adults are not a normal consequence of aging;
rather, they are considered a geriatric syndrome most often due to discrete multifac-
torial and interacting, predisposing (intrinsic and extrinsic risks), and precipitating
(dizziness, syncope) causes (Gray-Miceli, Johnson, & Strumpf, 2005; Rubenstein, &
Josephson, 2006). Fall epidemiology varies according to clinical setting. In acute care,
fall incidence ranges from 2.3 to 7 falls per 1,000 patient days depending on the unit.
Nearly one-third of older adults living in community fall each year in their home.
e highest fall incidence occurs in the institutional long-term care setting (nursing
home), where 50%–75% of the 1.63 million nursing home residents experience a fall
yearly. Falls rank as the 8th leading cause of unintentional injury for older Americans
and are responsible for over 16,000 deaths last year (Oliver et al., 2010).
III. BACKGROUND/STATEMENT OF THE PROBLEM
A. Denition
1. Fall: A fall is an unexpected event in which the participant comes to rest on the
ground, oor, or lower level (Prevention of Falls Network Europe, 2006).
(continued)
NURSING STANDARD OF PRACTICE
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 289
B. Fall Etiology
1. Fall risk factors include intrinsic risks of cognitive, vision, gait, or balance
impairment, high-risk/contraindicated medications, and/or the extrinsic risks
of assistive devices, inappropriate footwear, restraint, use of unsturdy furniture
or equipment, poor lighting, uneven or slippery surfaces (Chang et al., 2004).
2. Fall causes include, among others, orthostatic hypotension, arrhythmia,
infection, generalized or focal muscular weakness, syncope, seizure, hypo-
glycemia, neuropathy, medication.
IV. PARAMETERS OF ASSESSMENT
A. Assess and document all older adult patients for intrinsic risk factors to fall:
1. Advancing age- especially if over age 75
2. History of a recent fall
3. Specic comorbidities: dementia, hip fracture, Type 2 diabetes, Parkin-
son’s disease, arthritis, and depression
4. Functional disability: use of assistive device
5. Alteration in level of consciousness or cognitive impairment
6. Gait, balance, or visual impairment
7. Use of high-risk medications (Chang et al., 2004)
8. Urge urinary incontinence (Brown et al., 2000)
9. Physical restraint use (Capezuti et al., 2002)
10. Bare feet or inappropriate shoe wear
11. Identify risks for signicant injury due to current use of anticoagulants
such as Coumadin, Plavix, or aspirin and/or those with osteoporosis or
risks for osteoporosis (John A. Hartford Foundation Institute for Geriatric
Nursing, 2003)
B. Assess and document patient-care environment routinely for extrinsic risk fac-
tors to fall and institute corrective action:
1. Floor surfaces for spills, wet areas, unevenness
2. Proper level of illumination and functioning of lights (night light works)
3. Table tops, furniture, beds are sturdy and in good repair
4. Grab rails and bars are in place in the bathroom
5. Use of adaptive aides work properly and in good repair
6. Bed rails do not collapse when used for transitioning or support
7. Patient gowns/clothing do not cause tripping .
8. IV poles are sturdy if used during mobility and tubing does
C. Perform a PFA following a patient fall to identify possible fall causes (if pos-
sible, begin the identication of possible causes within 24 hours of a fall) as
determined during the immediate, interim, and longitudinal postfall intervals.
Because of known incidences of delayed complication of falls, including frac-
tures, observe all patients for about 48 hours after an observed or suspected fall
(ECRI Institute, 2006; Gray-Miceli et al., 2006; Panel on Prevention of Falls
in Older Persons, 2011).
1. Perform a physical assessment of the patient at the time of the fall, including
vital signs (which may include orthostatic blood pressure readings), neurologi-
cal assessment, and evaluation for head, neck, spine, and/or extremity injuries.
Protocol 15.1: Fall Prevention (cont.)
(continued)
290 Evidence-Based Geriatric Nursing Protocols for Best Practice
2. Once the assessment rules out any signicant injury:
a. obtain a history of the fall by the patient or witness description and
document
b. note the circumstances of the fall, location, activity, time of day and any
signicant symptoms
c. review of underlying illness and problems
d. review medications
e. assess functional, sensory, and psychological status
f. evaluate environmental conditions
g. review risk factors for falling (American Medical Directors Association, 2003;
ECRI Institute, 2006; John A. Hartford Foundation Institute for Geriatric
Nursing, 2003; Panel on Prevention of Falls in Older Persons, 2011).
D. In the acute care setting, an integrated multidisciplinary team (comprised of
the physician, nurse, health care provider, risk manager, physical therapist,
and other designated sta) plans care for the older adult, at risk for falls or
who has fallen, hinged upon ndings from an individualized assessment (Joint
Commission National Patient Safety Goals, 2006; ECRI Institute, 2006).
E. e process approach to an individualized PFA includes use of standardized mea-
surement tools of patient risk in combination with a fall-focused history and physical
examination, functional assessment, and review of medications (American Medical
Directors Association, 2003; John A. Hartford Foundation Institute for Geriatric
Nursing, 2003; Panel on Prevention of Falls in Older Persons, 2011) When plans
of care are targeted to likely causes, individualized interventions are likely to be
identied. If falling continues despite attempts at individualized interventions, the
standard of care warrants a reexamination of the older adult and their fall.
V. NURSING CARE STRATEGIES
A. General safety precaution and fall prevention measures that apply to all patients
especially older adults:
1. Assess the patient care environment routinely for extrinsic risk factors and
institute appropriate corrective action.
a. Use standardized environmental checklists to screen; document ndings
b. Communicate ndings to risk managers, housekeeping, maintenance
department, all sta and hospital administration if needed
c. Re-evaluate environment for safety (ECRI Institute, 2006)
2. Assess/screen older adult patient for multifactorial risk factors to fall on
admission, following a change in condition, upon transfer to a new unit,
and following a fall (ECRI Institute, 2006):
a. Use standardized or empirically tested fall risk tools in conjunction with
other assessment tools to evaluate risk for falling (Panel on Prevention
of Falls in Older Persons, 2011; Tinetti, Williams, & Mayewski, 1986)
b. Document ndings in nursing notes, interdisciplinary progress notes,
and the problem list.
c. Communicate and discuss ndings with interdisciplinary team members.
d. In the interdisciplinary discussion, include review and reduction or
elimination of high risk medications associated with falling.
Protocol 15.1: Fall Prevention (cont.)
(continued)
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 291
e. As part of fall protocol in the facility, ag the chart of use graphic or
color display of the patients risk potential to fall
f. Communicate to the patient, the family caregiver identied risk to fall,
and specic interventions chosen to minimize the patients risk
g. Include patient and family members in the interdisciplinary plan of care
and discussion about fall prevention measures.
h. Promote early mobility and incorporate measures to increase mobility, such
as daily walking, if medically stable and not otherwise contraindicated.
i. Upon transfer to another unit, communicate the risk assessment and
interventions chosen and their eectiveness in fall prevention.
j. Upon discharge, review fall risk factors and measures to prevent falls in
the home with the older patient and/or family caregiver. Provide patient
literature/brochures if available. If not readily available, refer to the
Internet for appropriate websites/resources.
k. Explore with the older patient and/or family caregiver avenues to main-
tain mobility and functional status; consider referral to home-based
exercise or group exercises at community senior centers. If discharge is
planned to a subacute or rehabilitation unit, label on the transfer form
the older adults mobility status at the time of discharge functional or
other forms of physical activity in the home to strength lower extremi-
ties or assist with gait/balance problems.
3. Institute general safety precautions according to facility protocol, which
may include:
a. Referral to a fall prevention program
b. Use of a low rise bed that measures 14 from oor
c. Use of oor mats if patient is at risk for serious injury such as osteoporosis
d. Easy access to call light
e. Minimization and/or avoidance of physical restraints
f. Use of personal or pressure sensors alarms
g. Increased observation/surveillance
h. Use of rubber-soled heeled shoes or nonskid slippers
i. Regular toileting at set intervals and/or continence program; provide
easy access to urinals and bedpans
j. Observation during walking rounds or safety rounds
k. Use of corrective glasses for walking
l. Reduction of clutter in trac areas
m. Early mobility program (ECRI Institute, 2006).
4. Provide sta with clear, written procedures describing what to do when a
patient fall occurs.
B. Identify specic patients requiring additional safety precautions and/or evalua-
tion by a specialist or:
1. those with impaired judgment or thinking due to acute or chronic illness
(delirium, mental illness)
2. those with osteoporosis, at risk for fracture
3. those with current hip fracture
4. those with current head or brain injury (standard of care)
(continued)
Protocol 15.1: Fall Prevention (cont.)
292 Evidence-Based Geriatric Nursing Protocols for Best Practice
(continued)
C. Review and discuss with interdisciplinary team ndings from the individual-
ized assessment and develop a multidisciplinary plan of care to prevent falls
(Chang et al., 2004).
1. Communicate to the physician signicantly postfall assessment ndings
(ECRI Institute, 2006).
2. Monitor the eectiveness of the fall prevention interventions instituted.
3. Following a patient fall observe for serious injury due to a fall and follow
facility protocols for management (standard of care).
4. Following a patient fall monitor vital signs, level of consciousness, neuro-
logical checks and functional status as per facility protocol. If signicant
changes in patient condition occurs, consider further diagnostic tests such
as plain lm x-rays, CT scan of the head/spine/extremity, neurological con-
sultation and /or transfer to a specialty unit for further evaluation (standard
of care).
VII. EVALUATED/EXPECTED OUTCOMES
A. Patients
1. Patient safety will be maintained.
2. Patient falls will be avoided.
3. Patients will not develop serious injury outcomes from a fall if it occurs.
4. Patients will know their risks for falling.
5. Patients will be prepared upon discharge to prevent falls in their homes.
6. Patient prehospitalization level of mobility will continue.
7. Patients who develop fall related complications such as injury, change in
cognition function will be promptly assess and treated appropriately as well
to reverse these aftermaths.
B. Nursing Sta
1. Nursing sta will be able to accurately detect, refer, and manage older adults
at risk for falling or who have experienced a fall
2. Nursing sta will integrate into their practice comprehensive assessment
and management approaches for fall prevention in the institution
3. Nursing sta will gain appreciation for older adults unique experience of
falling and how it inuencing their daily living, functional, physical and
emotional status
4. Nurses will educate older adult patients anticipating discharge about fall
prevention strategies
C. Family Caregivers
1. Family caregivers will benet from added knowledge about fall prevention
to become sensitized and more aware of simple strategies to prevent falls.
D. Health Care Organization
1. Health care organizations will realize reduced fall and injurious fall rates.
2. Health care organizations will realize the benets of fall prevention programs
that minimize liability.
3. Health care organizations will support budgetary lines for fall prevention
interventions directed to patients and health care sta.
Protocol 15.1: Fall Prevention (cont.)
Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 293
RESOURCES
Evidenced-based clinical practice guidelines for falls prevention
http://www.americangeriatrics.org/les/documents/health_care_pros/JAGS.Falls.Guidelines.pdf
Centers for Disease Control Guidelines for Head Injury
http://www.cdc.gov/concussion/pdf/TBI_Clinicians_Factsheet-a.pdf
Falls Prevention Strategies in Healthcare Settings
http://www.ecri.org
VISN 8 Patient Safety Center of Inquiry/Fall
http://www.patientsafety.gov/SafetyTopics/fallstoolkit/index.html
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VIII. FOLLOW-UP MONITORING OF CONDITION
A. Monitor fall incidence and incidences of patient injury due to a fall, comparing
rates on the same unit over time.
B. Compare falls per patient month against national benchmarks available in the
National Database of Nursing Quality Indicators.
C. Incorporate continuous quality improvement criteria into fall prevention program
D. Identify fall team members and roles of clinical and nonclinical sta (ECRI
Institute, 2006).
E. Educate patient and family caregivers about fall prevention strategies so they
are prepared for discharge.
IX. RELEVANT PRACTICE GUIDELINES
A. Panel on Prevention of Falls in Older Persons, Summary of the Updated
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D. ECRI Institute. (2006). Falls prevention strategies in healthcare settings,: Plymouth
Meeting, PA. 2006. Evidence Level VI.
Protocol 15.1: Fall Prevention (cont.)
294 Evidence-Based Geriatric Nursing Protocols for Best Practice
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http://archive.ahrq.gov/clinic/ptsafety/. Evidence Level VI.
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DiNunno, N., Vacca, M., Costantinedes, F., & Di Nunno, C. (2003). Death following atypical
compression of the neck. American Journal of Forensic Medicine and Pathology, 24(4), 364–368.
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Donaldson, N., Brown, D. S., Aydin, C. E., Bolton, M. L., & Rutledge, D. N. (2005). Leveraging
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Dube, A. H., & Mitchell, E. K. (1986). Accidental strangulation from vest restraints. Journal of the
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Elkins, J., Williams, L., Spehar, A., Marano-Perez, J., Gulley, T., & Quigley, P. (2004). Successful
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Ensrud, K. E., Blackwell, T. L., Mangione, C. M., Bowman, P. J., Whooley, M. A., Bauer, D. C., . . .
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cations and risk for falls in older women. Journal of the American Geriatrics Society, 50(10),
1629–1637. Evidence Level II.
Fischer, I. D., Krauss, M. J., Dunagan, W. C., Birge, S., Hitcho, E., Johnson, S., . . . Fraser, V. J.,
(2005). Patterns and predictors of inpatient falls and fall related injuries in a large academic
hospital. Infection Control Hospital Epidemiology, 26(10), 822–827. Evidence Level IV.
Garwood, C. L., & Corbett, T. L. (2008). Use of anticoagulation in elderly patients with atrial brilla-
tion who are at risk for falls. e Annals of Pharmacolotherpay, 42(4), 523–532. Evidence Level I.
Gray-Miceli, D., Johnson, J. C., & Strumpf, N. E. (2005). A stepwise approach to a comprehen-
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Evidence Level VI.
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falls. Western Journal of Nursing Research, 32(7), 932–948.
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properties of the Post-Fall Index. Clinical Nursing Research, 15(3), 157–176. Evidence Level III.
Gray-Miceli, D., Strumpf, N. E., Reinhard, S. C., Zanna, M. T., & Fritz, E. (2004). Current
approaches to postfall assessment in nursing homes. Journal of the American Medical Directors
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Kamel, H. K. (2004). Secondary prevention of hip fractures among hospitalized elderly: Are we doing
enough? e Internet Journal of Geriatrics and Gerontology, 1(1), 1–5. Retrieved from http://
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Kaufman, J. M., Johnell, O., Abadie, E., Adami, S., Audran, M., Avouac, B., . . . Reginster, J. Y.
(2000). Background for studies on the treatment of male osteoporosis: State of the art. Annals of
the Rheumatic Diseases, 59(10), 765–772,
Kelly, K. E., Phillips, C. L., Cain, K. C., Polissar, N. L., & Kelly, P. B. (2002). Evaluation of a non-
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Kutney-Lee, A., Lake, E. T., & Aiken, L. H. (2009). Development of the hospital nurse surveillance
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Kwok, T., Mok, F., Chien, W. T., & Tam, E. (2006). Does access to bed-chair pressure sensors reduce
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Langlois, J. A., Rutland-Brown, W., & omas, K. E. (2006). Traumatic brain injury in the United
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McInnes, E., & Askie, L. (2004). Evidence review on older people’s views and experiences of falls
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Meade, C., Bursell, M., & Ketelsen, L. (2006). Eects of nursing rounds on patients’ call light use,
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Miles, S. H. (2002). Deaths between bedrails and air pressure mattresses. Journal of the American
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298
16
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. complete a comprehensive pressure ulcer risk assessment
2. classify pressure ulcers using the correct staging denitions (check for applicability in
your clinical care setting or country)
3. develop a comprehensive, holistic plan to prevent pressure ulcers in individuals at risk
4. identify older adults at risk for skin tears
5. classify skin tears using the Payne–Martin classication system
6. develop a plan to prevent and treat skin tears
OVERVIEW
e skin is the largest external organ, so preserving its integrity is an important aspect
of nursing care. Performing a risk assessment and implementing a consistent prevention
protocol may avoid some losses of skin integrity including pressure ulcers or skin tears.
Although pressure ulcers and skin tears may look similar, they are dierent types of
skin injury; skin tears are acute traumatic wounds, whereas pressure ulcers are chronic
wounds. It is important, therefore, to assess the wound and to determine the correct
etiology so that the proper individualized treatment plan can be implemented.
BACKGROUND AND STATEMENT OF PROBLEM
Pressure Ulcers
Pressure ulcers are a signicant health care problem worldwide (Bolton, 2010). ey
have a signicant impact on health-related quality of life (HRQL; Gorecki et al., 2009).
In February 2009, the National Pressure Ulcer Advisory Panel (NPUAP; European
Pressure Ulcer Advisory Panel [EPUAP] & NPUAP, 2009), in conjunction with the
EPUAP, revised the classic 1989 pressure ulcer denition (“Pressure ulcers prevalence,”
1989) to eliminate the word friction in the denition (see Table 16.1). Pressure ulcers
Elizabeth A. Ayello and R. Gary Sibbald
Preventing Pressure Ulcers
and Skin Tears
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Preventing Pressure Ulcers and Skin Tears 299
TABLE 16.1
2009 International NPUAP-EPUAP Pressure Ulcer Definition
and Classification System
Pressure ulcer definition
A pressure ulcer is localized injury to the skin and/or underlying tissue, usually over a bony promi-
nence, as a result of pressure, or pressure in combination with shear. A number of contributing or
confounding factors are also associated with pressure ulcers; the significance of these factors is yet
to be elucidated.
NPUAP/EPUAP pressure ulcer classification system
Category/Stage 1: Nonblanchable redness of intact skin
Intact skin with nonblanchable erythema of a localized area, usually over a bony prominence.
Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented
skin may not have visible blanching.
Further description
The area may be more painful, firmer or softer, or warmer or cooler than adjacent tissue. Category 1
may be difficult to detect in individuals with dark skin tones. This may indicate an “at-risk” individual.
Category/Stage 2: Partial thickness skin loss or blister
Partial thickness, loss of dermis presenting as a shallow, open ulcer with a red or pink wound bed,
without slough. It may also present as an intact or open or ruptured serum-filled blister.
Further description
Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used
to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.
Category/Stage 3: Full thickness skin loss (fat visible)
Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not
exposed. Some slough may be present. It may include undermining and tunneling.
Further description
The depth of a Category 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput, and malleolus do not have (adipose) subcutaneous tissue and Category 3 ulcers can be
shallow. In contrast, areas of significant adiposity can develop extremely deep Category 3 pressure
ulcers. Bone or tendon is not visible or directly palpable.
Category/Stage 4: Full thickness tissue loss (muscle and bone are visible)
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present.
It often includes undermining and tunneling.
Further description
The depth of a Category 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput, and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow.
Category 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or
joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone or muscle is visible or
directly palpable.
Additional Categories for the United States
Unstageable/Unclassified: Full thickness skin or tissue loss depth unknown
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough
( yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Further description
Until enough slough and/or eschar are removed to expose the base of the wound, the true depth
cannot be determined, but it will be either a Category 3 or 4. Stable (dry, adherent, intact, without
erythema, or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and
should not be removed.
Suspected deep tissue injury—depth unknown
Purple or maroon localized area of discolored, intact skin or blood-filled blister caused by damage
of underlying soft tissue from pressure and/or shear.
(continued)
300 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 16.2
2009 Pressure Ulcer Prevalence by Stages in Acute Care
Type of Pressure Ulcer Number of Pressure Ulcers
Stage 1 or 2 4,985
Stage 3 or 4, eschar or unable to stage 876
DTI 642
Stage unspecified 86
Device-related 1,631
Note. DTI = deep tissue injury. Adapted from VanGilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009).
Results of the 2008–2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specic
analysis. Ostomy/Wound Management, 55(11), 39–45, (data p. 42).
are believed to develop as a result of the tissues’ internal response to external mechanical
loading (EPUAP & NPUAP, 2009).
e exact combination of pressure, ischemia, muscle deformation, and reperfu-
sion injury that leads to a pressure ulcer remains unclear (EPUAP & NPUAP, 2009).
Most pressure ulcers on adults are found on the sacrum, with heels being the second
most common site (VanGilder, Amlung, Harrison, & Meyer, 2009). Data in 2009 from
92,408 U.S. facilities reported an overall prevalence rate of 12.3%, with facility acquired
rate of 5.0% and 3.2% when Stage 1 ulcers are excluded (VanGilder, Amlung, Harrison,
& Meyer, 2009). is same study of 86,932 U.S. acute care facilities reported an overall
prevalence rate of 11.9%, with facility acquired rate of 5.0% and 3.1% when Stage 1
ulcers were excluded (VanGilder et al., 2009).
Table 16.2 summarizes the number of pressure ulcers by stages from this study
(VanGilder et al., 2009). e distribution of pressure ulcers has changed over the past
years, with the number of Stage 1 ulcers decreasing and the number of unstageable
pressure ulcers increasing to 15% as well as suspected deep tissue injury (sDTI) to 9%
(
VanGilder, MacFarlane, Harrison, Lachenbruch, & Meyer, 2010). Device-related pres-
sure ulcers account for 9.1% of ulcers, with ears being the most common location (see
Table 16. 3; VanGilder et al., 2009). In hospice patients, besides sacrum and heels, elbows
were a common site for ulcers with most ulcers occurring within 2 weeks prior to death
(Hanson et al., 1991).
In one hospital’s 10-bed palliative care unit, 5% of their patients
TABLE 16.1
2009 International NPUAP-EPUAP Pressure Ulcer Definition
and Classification System (continued)
Further description
The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as com-
pared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin
tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve
and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue
even with optimal treatment.
Note. NPUAP = National Pressure Ulcer Advisory Panel; EPUAP = European Pressure Ulcer Advisory Panel.
Adapted from Treatment of Pressure Ulcers: Quick Reference Guide, by European Pressure Ulcer Advisory Panel, &
National Pressure Ulcer Advisory Panel, 2009, Washington, DC: National Pressure Ulcer Advisory Panel. Copyright
2009 by the National Pressure Ulcer Advisory Panel. Reprinted with permission.
Preventing Pressure Ulcers and Skin Tears 301
developed a Kennedy terminal pressure ulcer (shaped like a pear, over the sacrum, bruise-
like discoloration with yellow and brown black; Brennan & Trombley, 2010).
Pressure Ulcer Risk Factors
No single factor puts a patient at risk for pressure ulcer skin breakdown. Nonnemacher
et al. (2009) are addressing the question of what combination of factors increase the
risk and they are exploring 12 factors that seem to have the most impact on predicting
pressure ulcer risk. Historically, pressure ulcers occur from a combination of intensity
and duration of pressure as well as from tissue tolerance (Bergstrom, Braden, Laguzza,
& Holman, 1987; Braden & Bergstrom, 1987, 1989). Immobility as seen in bedbound
or chairbound patients and those unable to change positions leading to shear, under-
nourishment or malnutrition, incontinence, friable skin, impaired cognitive ability, and
decreased ability to respond to one’s environment are some of the important identied
risk factors for pressure ulcers (Braden, 1998). True pressure ulcers need to be distin-
guished from moisture-associated dermatitis or surface injury in the buttocks region
caused by the contact irritation of local friction and moisture factors.
A study of 20 hospitals of patients waiting for surgery determined a higher incidence
of pressure ulcers for longer surgery waiting times or time in an intensive care unit (ICU;
Baumgarten et al., 2003). Most pressure ulcers, in one study of 84 surgical patients,
occurred within the rst three postoperative days (Karadag & Gümüskaya, 2006).
Patients With Hip Fracture and Pressure Ulcer Risk
In a study of nine hospitals, the cumulative incidence of Stage 2 or higher pressure ulcer
in older adults with hip fractures was 36.1% (Baumgarten et al., 2009). e less time
that patients waited to go to the operating room (OR) for their repair of a hip frac-
ture, the fewer the number of associated Level 4 pressure ulcers (Hommel, Ulander, &
orngren, 2003). e length of time on the OR table also increased the risk for pres-
sure ulcers in patients with hip fracture (Houwing et al., 2004). Campbell, Woodbury,
and Houghton (2010b) found that one-third of their sample of patients with hip frac-
ture developed Stage 2 or higher pressure ulcers. Implementation of a heel pressure
ulcer prevention program (HPUPP) for orthopedic patients in Canada resulted in com-
plete elimination of heel pressure ulcers compared to preimplementation level of 13.8%
(Baumgarten et al., 2008). However, this was not designed for sustainability after the
original study of a wedge-shaped lower leg positioner to lift the heel o the bed.
TABLE 16.3
Location of Device-Related Pressure Ulcers
Location Location Percentage of Device-Related Pressure Ulcer
Ears 20%
Sacral/Coccyx 17%
Heel 12%
Buttocks 10%
Adapted from VanGilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009). Results of the 2008–2009 International
Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specic analysis. Ostomy/Wound Management, 55(11),
39–45, (data on page 42).
302 Evidence-Based Geriatric Nursing Protocols for Best Practice
Critically Ill, Intensive Care Unit Patients and Pressure Ulcer Risk
In a case control study of medical patients in two hospitals, Baumgarten and col-
leagues (2008) found that the odds of developing a pressure ulcer were twice as high
for those having an ICU stay. In contrast, Shalin, Dassen, and Halfens (2009) found
a low incidence of pressure ulcers in their 121 ICU patients that they concluded were
caused by using foam and alternating air pressure mattresses. APACHE II scores, physi-
ological criteria and Glasgow Coma Scale to predict ICU outcomes with higher scores
having poorer outcomes, were higher in patients who developed pressure ulcers. In con-
trast, other researchers found no relationship between pressure ulcer development and
APACHE II scores (Kaitani, Tokunaga, Matsui, & Sanada, 2010). Shanks, Kleinhelter,
and Baker (2008) found that despite the consistent implementation of pressure ulcer
prevention protocols in their critically ill patients, the patients that developed more
hypotensive episodes were more likely to develop subsequent pressure ulcers.
Regulatory and Government Initiatives
Recent regulatory and government initiatives continuously support the importance
of pressure ulcer prevention. Beginning October 1, 2008, the Centers for Medicare
and Medicaid Services (CMS) no longer pay a higher diagnosis-related group (DRG)
for pressure ulcers acquired during hospitalization (CMS Hospital Acquired Condi-
tions, 2011). Recording of location and stage of any stage 3 and 4 pressure ulcers pres-
ent on admission (POA) is now holding clinicians legally responsible for establishing
the medical diagnosis accountable for documenting this information in the patient’s
medical record; otherwise, the hospital will not be reimbursed (Russo, Steiner, & Spec-
tor, 2006). Data from the Healthcare Cost and Utilization Project (HCUP) statistical
review reveal that over the past 11 years, pressure ulcers have increased in hospitalized
patients by 80%, even though the number of hospitalizations during this period of
1993–2006 only increased by 15% (CMS Hospital Acquired Conditions, 2011). In the
state of New Jersey (NJ), pressure ulcers, Stage 3 or 4, are now reportable in acute care
(NJ Department of Health and Senior Services, 2004). Pressure ulcers are one of the
12 targeted areas to reduce harm to hospitalized patients in the United States as part of
the Institute for Healthcare Improvement’s (IHI) “5 Million Lives Campaign” launched
in December 2006 (IHI, 2006). e former head of IHI is now the head of CMS. us,
at the beginning of the 21st century, appropriate risk assessment and preventative care
take on even more important meaning. Several successful initiatives to decrease pressure
ulcer incidence are reported in the literature (Lyder & Ayello, 2009; McInerney, 2008).
Nurses will nd the Agency for Healthcare Research and Quality (AHRQ) toolkit help-
ful in developing quality initiatives to decreased pressure ulcer incidence (Pancorbo-
Hidalgo, Garcia-Fernandez, Lopez-Medina, & Alvarez-Nieto, 2006).
ASSESSMENT OF THE PROBLEM
When To Do an Assessment
e assessment of the relative pressure ulcer risk is the rst step of any individual
patient or health care system plan for prevention. Some pressure ulcer clinical guide-
lines recommend that patients are assessed for pressure ulcer development on admission
to a facility, on discharge, whenever the patient’s condition changes, then reassessed
Preventing Pressure Ulcers and Skin Tears 303
periodically (EPUAP & NPUAP, 2009; Norton, McLaren, & Exton-Smith, 1962). e
IHI recommends daily pressure ulcer risk assessment (IHI, 2006).
Pressure Ulcer Risk Assessment Tools
Guidelines recommend that a comprehensive assessment for pressure ulcer risk include
a history and physical exam, skin inspection, and a pressure ulcer risk assessment calcu-
lation using a valid and reliable assessment tool. Both the Braden (Norton et al., 1962)
and Norton scale (Norton et al., 1962; Norton, McLaren, & Exton-Smith, 1975) are
considered reliable and valid. A study of 429 patients in acute care found the modi-
ed Braden scale to be a better predictor than the Norton scale (Kwong et al., 2005).
Although Kottner and Dassen (2010) found that the Braden scale was more valid and
reliable than the Waterlow scale, they do not recommend either of these scales for ICU
patients. Research to create new scales specic to ICU patients continues (Suriadi,
Sanada, Sugama, igpen, & Subuh, 2008).
e Braden scale created in 1987 (Bergstrom et al., 1987) as part of a research study
has six factors and is the most widely used in the United States. Sensory perception,
mobility, and activity address clinical situations that predispose the patient to intense
and prolonged pressure. Moisture, nutrition, and friction and shear address factors that
alter tissue tolerance for pressure. Each of the six categories is ranked with a numerical
score, with 1 representing the lowest possible subscore with the greatest risk. e sum of
the six subscores is the nal Braden scale score, which can range from 6 to 23.
A low Braden scale score indicates that a patient is at risk for pressure ulcers. e
original onset of risk score on the Braden scale was 16 or less (Braden & Bergstrom,
1987). Further research in older adults (Bergstrom & Braden, 1992) and in persons
with darkly pigmented skin (Lyder et al., 1998, 1999) support a score of 18 or less.
Research by Chan, Tan, Lee, and Lee (2005) also found that the total Braden scale
score was the only signicant predictor of pressure ulcers in hospitalized patients. In
2009, Chan, Pang, and Kwong (2009) found that using a modied Braden scale, with a
cuto score of 19 in 107 bed orthopedic department of an acute care hospital in Hong
Kong, 9.1% of patients developed pressure ulcers. In a retrospective study of intensive
care patients in Korea using a cuto score of 13, the Braden scale had low-to-moderate
positive predictive performance without a more comprehensive approach to patient-risk
assessment (Cho & Noh, 2010). Risk was associated with pressure ulcer development in
ICU patients where they had low Braden scale scores on the rst day of hospitalization
and low Glasgow scale scores (Fernances & Caliri, 2008).
Once risk is identied, either for overall score or in any low subscales (CMS, 2004),
prevention interventions need to be implemented. However, one study found that
despite identication of pressure ulcer risk using the Norton scale, only 51% of the
sample of the 792 patients, 65 years and older hospitalized patients, had a preventive
device in place (Rich, Shardell, Margolis, & Baumgarten, 2009).
DOES RACE MAKE A DIFFERENCE?
When it comes to severity of pressure ulcers, race may make a dierence. Ayello and
Lyder (2001) analyzed and summarized the existing data about pressure ulcers across
the skin pigmentation spectrum. Blacks have the lowest incidence (19%) of supercial
tissue damage classied as Stage 1 pressure ulcers, and Whites have the highest incidence
304 Evidence-Based Geriatric Nursing Protocols for Best Practice
at 46% (Barczak, Barnett, Childs, & Bosley, 2007). e more severe tissue injury seen
in Stages 2–4 pressure ulcers is higher in persons with darkly pigmented skin (Barczak
et al., 2007; Meehan, 1990, 1994). ree national surveys showed that Blacks had 39%
(Barczak et al., 2007), 16% (Meehan, 1990), and 41% (Meehan, 1994) higher inci-
dence of Stage 2 pressure ulcers compared to Caucasians. Subsequent studies by Lyder
and colleagues (1998, 1999) continue to support a higher incidence of pressure ulcers
in persons with darkly pigmented skin. Fogerty, Guy, Barbul, Nanney, and Abumrad
(2009) found that not only was there a higher prevalence of pressure ulcers, but also that
they occurred in younger African Americans as compared to Caucasians.
Inadequate detection of Stage 1 pressure ulcers in persons with darkly pigmented
skin may be because clinicians erroneously believe that dark skin tolerates pressure better
than light skin (Bergstrom, Braden, Kemp, Champagne, & Ruby, 1996), or that only
color changes indicate an ulcer (Bennett, 1995; Henderson et al., 1997; Lyder, 1996;
Lyder et al., 1998, 1999; Rich et al., 2009). Research has begun to validate these assess-
ment characteristics in the Stage 1 denition. In 2001, Lyder and colleagues (2001)
reported a higher diagnostic accuracy rate of 78% using the revised denition compared
with 58% with the original denition. Sprigle, Linden, McKenna, Davis, and Riordan
(2001) found changes in skin temperature; in particular, that warmth then coolness
accompanied most Stage 1 pressure ulcers.
Clinicians should pay careful attention to a variety of factors when assessing a client
with darkly pigmented skin for Stage 1 pressure ulcers. Dierences in skin over bony
prominences (e.g., the sacrum and the heels) as compared with surrounding skin may
be indicators of a Stage 1 pressure ulcer. e skin should be assessed for alterations in
pain or local sensation. In addition, a change of skin color should be noted by being
familiar with the range of skin pigmentation that is normal for your particular patient
(Bennett, 1995; Henderson et al., 1997).
INTERVENTIONS AND CARE STRATEGIES
Determining a patient’s risk for developing a pressure ulcer is only the rst step in pro-
viding best practice care. Once risk is identied, implementing a consistent protocol to
prevent the development of a pressure ulcer is essential. A nursing standard of practice
protocol for pressure ulcer prevention is presented to facilitate proactive interventions to
prevent pressure ulcers. A change in attitudes of health care professionals may be required
to facilitate prevention (Buss, Halfens, Abu-Saad, & Kok, 2004). Educating nursing
students (Holst et al., 2010) as well as nurses in an ICU unit resulted in decrease in pres-
sure ulcers (Uzun, Aylaz, & Karadag, 2009). Several clinical guidelines on preventing and
treating pressure ulcers exist (EPUAP & NPUAP, 2009; Wound, Ostomy, and Conti-
nence Nurses Society, 2010). Components of a pressure ulcer prevention protocol should
minimally include interventions targeting the following: skin care (including addressing
moisture and friction), pressure redistribution, repositioning, and nutrition.
Skin Care
Skin that is too dry or too wet has been associated with pressure ulcers. Although there
is limited research, dry skin is believed to predispose ulcer formation (Allman, Goode,
Patrick, Burst, & Bartolucci, 1995; Reddy, Gill, & Rochon, 2006). e type of cream
used on the skin for dierent parts of the body may make a dierence as evidenced
by a study of 79 patients treated with dimethyl sulfoxide cream who had an increase
Preventing Pressure Ulcers and Skin Tears 305
in pressure ulcers when this cream was used on the heels as compared to the buttocks
(Houwing, Van der Zwet, van Asbeck, Halfens, & Arends, 2008). Other researchers
(Stratton et al., 2005) found that a silicone-based dermal nourishing cream reduced the
proportion of hospital-acquired pressure ulcers to zero after 8 months. Each of these
creams are lubricating, adding an external ointment type of layer preventing insensible
losses. e stratum corneum has 10% moisture content and when this level goes below
a critical level, the skin integrity is lost with defects between the keratin layers (dry skin,
winter itch, eczema craquelé). e second way to moisturize the skin is with urea or
lactic acid preparations. ese are humectants that actually bind water to the stratum
corneum but will sting or burn when applied to open skin because of their hydro-
scopic properties. Skin can also be too wet with macerated stratum corneum, decreasing
the cutaneous barrier and subjecting aected individuals to increase risk of yeast and
bacterial infections.
Use of a soft silicone dressing on the sacrum of critically ill patients resulted in zero
pressure ulcers in one ICU (Brindle, 2010). Hydrocolloid dressings decreased pressure
ulcers from nasotracheal intubation (Huang, Tseng, Lee, Yeh, & Lai, 2009). When
hydrocolloid or lm dressings were applied to the skin under face masks, there were
fewer pressure ulcers (Weng, 2008).
Repositioning and Pressure Redistribution
Because immobility is a risk factor in the development of pressure ulcers in hospitalized
patients (Lindgren, Unosson, Fredrikson, & Ek, 2004), eorts must be implemented to
address pressure. Although repositioning patients is a key intervention to redistribute the
pressure and prevent pressure ulcers, the best frequency for turning and repositioning
as well as which support surface to use remains a challenge (Deoor, De Bacquer, &
Grypdonck, 2005; Norton et al., 1975; Young, 2004). Patients on a particular sup-
port surface may not have to be repositioned every 2 hours, depending on the persons’
tolerance to pressure. ere is no one repositioning timetable for all, it needs to be indi-
vidualized (EPUAP & NPUAP, 2009). e use of a wedge-shaped cushion rather than a
pillow may be more eective in decreasing pressure ulcers in some patients (Heyneman,
Vanderwee, Grypdonck, & Deoor, 2009).
Redistributing pressure is a key component of preventing pressure ulcers. When
compared to alternating pressure overlays, alternating pressure mattresses reduced
length of stay for hospitalized patients, thus, decreasing costs as well as the added
benet of delaying the time to when a pressure ulcer appeared (Iglesias et al., 2006;
Nixon et al., 2006). e incidence of heel pressure ulcers have been decreased when the
appropriate heel suspending device has been used to relieve pressure (Gilcreast et al.,
2005). In 2010, a prospective 150-patient, 6-month study by Campbell, Woodbury,
and Houghton (2010a), pressure ulcer incidence was 16% being signicantly lower
( p 5 .016) for those who received help with pressure relief interventions. In a single
study, when persons with a body mass index (BMI) greater than 35 were placed on
appropriate size low air loss equipment, no new pressure ulcers developed (Pemberton,
Turner, & Van Gilder, 2009). In Australia where real medical sheepskin is available,
one study that had some questionable methodology demonstrated that patients ran-
domly assigned to the real sheepskin mattress overlay during their hospital stay had a
9.6% incidence risk of pressure ulcers compared to the control group that had 16.6%
(Jolley et al., 2004). A similar increased attention to pressure redistribution also needs
to be brought into the OR.
306 Evidence-Based Geriatric Nursing Protocols for Best Practice
Nutrition
ere is lack of consensus about the best way to assess nutritional impairment but, gener-
ally, consultation by a dietician for nutritional status, determination of any unintended
weight loss, and evaluation of laboratory values such as serum albumin or prealbumin
should be considered. Cordeiro and colleagues (2005) found that the concentrations
of ascorbic acid and alpha-tocopherol were signicantly decreased in patients with
pressure ulcers or infection. In a randomized double blind study on the eect of daily
supplement with protein, arginine, zinc, and antioxidants versus water-based placebo
supplement in patients with hip fractures, the incidence of Stage 2 pressure ulcers
demonstrated a 9% dierence between the nutritionally supplemented group and the
placebo group (Houwing et al., 2003). e Cochrane Database reviewed the role of
nutrition in pressure ulcer prevention and treatment. e analysis of the database was
inconclusive because of the lack of high-quality trials (Langer, Schloemer, Knerr, Kuss,
& Behrens, 2003). When and how patients should be nutritionally supplemented to
prevent pressure ulcers remains unclear (Houwing et al., 2003; Reddy et al., 2006;
Stratton et al., 2005), but at times the literature is contradictory. e NPUAP nutri-
tional recommendations (EPUAP & NPUAP, 2009) for pressure ulcer prevention are
included in Protocol 16.1.
SKIN TEARS
Skin tears are traumatic wounds caused by shear and friction (O’Regan, 2002). is
skin injury occurs when the epidermis is separated from the dermis (Malone, Rozario,
Gavinski, & Goodwin, 1991). Because aging skin has a thinner epidermis, a atter
dermal-epidermal junction and decreased dermal collagen, older persons are more
prone to skin injury from mechanical trauma (Baranoski, 2000; Payne & Martin, 1993;
White, Karam, & Cowell, 1994). erefore, skin tears are common in older adults,
with more than 1.5 million occurring annually in institutionalized adults in the United
States (omas, Goode, LaMaster, Tennyson, & Parnell, 1999), although the incidence
in acute care is unknown. Skin tears are frequently located at areas of age-related pur-
pura (Malone et al., 1991; White et al., 1994).
Assessment of Skin Tears
e following areas should be assessed for skin tears: shins, face, dorsal aspect of hands,
and plantar aspect of the foot (Malone et al., 1991). Besides older adults, others with
thinning skin who are at risk for skin tears are patients on long-term steroid therapy,
women with decreased hormone levels, persons with peripheral vascular disease or
neuropathy (the decreased sensation making them more susceptible to injury), and
those with inadequate nutritional intake (O’Regan, 2002).
e three-group risk assessment tool was developed during a research study by
White and colleagues (1994). Because of its length, it is not always used clinically to
assess for risk of skin tears (White et al., 1994). Within the tool, there are three groups
delineated by level of risk: Groups 1, 2, and 3. Group 1 refers to a positive history
of skin tears within the last 90 days or skin tears that are already present. A positive
score in this group requires that the patient be put on a skin tear prevention protocol.
Group 2 requires four of the next six criteria to identify an increased risk: (a) decision-
making skills are either impaired or slightly impaired, or extensive assistance and total
Preventing Pressure Ulcers and Skin Tears 307
dependence for activities of daily living (ADLs) is noted; (b) wheelchair assistance
needed; (c) loss of balance; (d) bed or chair conned; (e) unsteady gait; and (f) bruises.
If a patient has a score of 4 or more items in Group 2, then implement a skin tear
prevention protocol. Group 3 includes the following 14 items requiring any ve for
an increased risk: (a) physically abusive; (b) resists ADL care; (c) agitation; (d) hearing
impaired; (e) decreased tactile stimulation; (f ) wheels self; (g) manually or mechani-
cally lifted; (h) contractures of arms, legs, shoulders, and/or hands; (i) hemiplegia and
hemiparesis; (j) trunk, partial, or total inability to balance or turn body; (j) pitting
edema of legs; (k) open lesions on extremities; (l) three or four discrete senile purpura
lesions on extremities; and (m) dry, scaly skin. An increased risk has also been identied
in individuals with a combination of three items in Group 2 and three items in Group
3. Positive responses to ve or more items in Group 3 or three items in both Groups 2
and 3 should also trigger the implementation of a skin tear prevention protocol (White
et al., 1994).
Several authors have suggested protocols to prevent skin tears (Baranoski, 2000;
Battersby, 1990; Mason, 1997; O’Regan, 2002; White et al., 1994). Lacking research in
acute care, some nursing home research supports the value of skin ulcer care protocols
to reduce the incidence of skin tears (Bank, 2005; Birch & Coggins, 2003; Hanson,
Anderson, ompson, & Langemo, 2005). After changing from soap and water to a
no-rinse, one step bed product, skin tears declined from 23.5% to 3.5% in one nurs-
ing home (Birch & Coggins, 2003). Hanson and colleagues (2005) also found that
skin tears could be reduced in two dierent nursing homes when sta was educated
in appropriate skin cleaning and protection strategies. A reduction in monthly aver-
age of skin tears from 18 to 11 after using longer lasting moisturizer lotion sleeves to
protect the arms, and padded side rails was reported in yet another nursing home study
(Bank, 2005). One study claims a decrease in skin tears when skin is treated with cream
(Groom, Shannon, Chakravarthy, & Fleck, 2010).
Interventions for Skin Tears
If a skin tear does occur, it is important to correctly identify it and begin an appropriate
plan of care. e Payne–Martin classication system (Payne & Martin, 1993) may be
used to describe skin tears. e three categories are the following:
n Category 1: A skin tear without tissue loss
n Category 2: A skin tear with partial tissue loss
n Category 3: A skin tear with complete tissue loss where the epidermal ap
is absent
e usual healing time for skin tears is 3–10 days (Krasner, 1991). Although
skin tears are prevalent in the older adult patient, there is no consistent approach
to managing these skin injuries (Baranoski, 2000; O’Regan, 2002). Research is just
beginning to provide evidence on which dressing is best to use for skin tears. One
study (Edwards, Gaskill, & Nash, 1998) compared the use of four dierent types
of dressings in treating skin tears in a nursing home: three occlusive (transparent
lm, hydrocolloid, and polyurethane foam) and one nonocclusive dressing of Steri-
strips covered by a nonadhesive cellulose-polyester material. e nonocclusive dress-
ing facilitated healing at a faster rate than the occlusive dressings. Another study by
omas and colleagues (1999) studied older adult skin tears in three nursing homes
308 Evidence-Based Geriatric Nursing Protocols for Best Practice
and identied that there was a higher rate of complete healing that occurred with
foam dressings compared to transparent lms.
Goals of care for skin tears include retaining the skin ap if present, providing a
moist, nonadherent dressing, and protecting the site from further injury (O’Regan,
2002). A consensus protocol for treating skin tears based on suggested plans of care
have been developed by several authors (Baranoski, 2000; Baranoski & Ayello, 2008;
Edwards et al., 1998; O’Regan, 2002) and can be found in Protocol 16.2.
Mr. Randy Gonnagetawound, age 70, has diabetes mellitus with several microvascular
and macrovascular complications. He was admitted to the hospital after a right-sided
cerebral vascular accident. Past history includes retinal hemorrhages, a previous myo-
cardial infarction, peripheral vascular disease, and a neuroischemic foot ulcer (healed
after a left femoral popliteal bypass, intravenous antibiotics, and plantar pressure
redistribution with deep toed shoe and orthotic). He is incontinent of feces and urine
and responds by nodding to verbal commands. e left arm and leg are paralyzed. He
has a gag reex but cannot swallow. His Braden score is 10.
Current Data
Physical exam: ere is an area of persistent erythema with bruising on the left buttock
along with a number of supercial nonpalpable purpuric lesions on the arms and legs.
Physical Assessment and Pertinent Admission History
General: Responds to verbal questioning but he cannot move his left side. Over the
past 3 days, he has been increasingly fatigued, completely bedridden. He can change
position only with movement of the right side.
Vital signs: Temperature 5 39.2 °C
Respiration: 10 per minute and regular Pulse: 88 and irregular
Blood pressure: 162/94
Weight: 195 lbs.
Height: 5 ft 9 in.
Abdominal: Intake has been limited to half bowl of cereal twice a day and piece of
toast and tea for lunch for the past 3 days. Last bowel movement was 3 days ago;
1 bowel sounds.
Cardiovascular: Irregular heartbeat, no S
3
S
4
at apex, 11 pedal edema, faintly pal-
pable pedal pulses; capillary rell prolonged at 8 seconds
Respiratory: Crackles over right lower lobe, coughing periodically, nonproductive
of mucous
Renal: Episodes of urinary incontinence for the past 3 days prior to admission
CASE STUDY 1
(continued)
Preventing Pressure Ulcers and Skin Tears 309
Integumentary: Skin is warm, dry, and translucent; tenting noted
Laboratory data: Hg 10, HCT 28, RBC: 3.2, WBC: 11,000 shift to the left. Albu-
min 3.0 g/dl, K: 3.1, BUN: 32 mg/100 ml, glucose and/or HbA1c not available
Medical Orders
D
5
W 1 ⁄ 2 NS with 10 mEq KCl at 100 cc/hr
Colace 100 mg PO tid
Pulse oximetry monitoring continuously
Metamucil 1 package QD
Bed rest
Multivitamin 1 tablet QD
Daily weights
Soft diet as tolerated
Mr. Gonnagetawound is a prime candidate for developing a pressure ulcer. His
low numerical score on the Braden scale (10) puts him at high risk. Immediate strate-
gies to prevent the occurrence of an ulcer are needed. Immobility is a leading risk fac-
tor for pressure ulcer development, so a major part of his plan of care needs to rst be
directed to initiate moving as much as possible. A physiotherapy consult is needed to
evaluate and recommend a plan of progressive exercise and activity. e plan should
be to get him out of bed and moving within the constraints of his limitations from
the stroke, as well as being in the chair rather than the bed. When in the chair, he
should have a gel cushion for pressure redistribution. He will need to be repositioned
every hour when in the chair. A Group 2, alternating low-air-loss mattress needs to
be placed on his bed. For the limited time, when he is in bed, he needs to be turned
and positioned. His skin should be assessed every shift to evaluate signs for early skin
injury.
A consult to a speech therapist is essential. A swallowing study is warranted to
determine his ability to safely take an oral diet. A nutritional consult with a dietician
will address his needs for appropriate calories, protein, and vitamins or minerals. A
toileting regimen needs to be implemented to address the fecal and urinary inconti-
nence. A discussion with the prescribing health care provider can explore whether he
should continue on the Colace and Metamucil. His skin needs cleansing after each
episode of incontinence. Use of a no-rinse bathing system is preferred here rather than
soap and water. is vulnerable skin needs protection by using one of the many skin
barriers available on the market.
Both Mr. Gonnagetawound and his family need instruction on why it is so impor-
tant to get him moving and why nutrition, skin care, turning, and repositioning are
so critical to his skin health.
Considering his general health, low hemoglobin, possibility of sepsis, and increase
capillary rell must also be monitored and addressed. It would be benecial to know
the HbA1c to determine blood sugar control and prevent long-term complications.
CASE STUDY 1 (continued)
310 Evidence-Based Geriatric Nursing Protocols for Best Practice
Mrs. Keri Sight, 88 years old, is admitted to the hospital from a long-term care facility
with a primary diagnosis of pneumonia, and secondary diagnosis of senile dementia
of the Alzheimer’s type with impaired communication skills. She has a history of
congestive heart failure and osteoporosis. She spends most of the day in a wheelchair
and needs two-person assistance for ambulation. Her skin is thin and dry, resembling
an onion; each arm and leg has a purpura area. She is 15 lbs. less than her ideal body
weight and has diculty swallowing. Laboratory values are as follows: total protein,
5.5 g/dl; albumin, 2.6 g/dl; and BUN, 28. She is verbally aggressive to the sta on
which she depends for assistance for her ADLs.
Assessment of Mrs. Sight on admission for skin integrity as well as pressure ulcer
risk needs to be done. Because she has four of the criteria from Group 2 of the skin
tear risk assessment tool developed by White and colleagues (1994; impaired deci-
sion-making skills caused by senile dementia, dependence for ADLs, wheelchair or
bed conned, unsteady gait), she is at risk for developing skin tears. Other factors
that would put her at risk are her thin, dry skin with four purpura present and poor
nutritional status. Her dependence on sta for ADLs and assistance coupled with her
dementia predispose her to skin injury during bathing and other ADLs. A compre-
hensive pressure ulcer risk assessment including her skin assessment, comorbidities,
and Braden scale score puts her at very high risk for developing pressure ulcers. A
pressure ulcer prevention protocol such as in Protocol 16.2 is implemented. e rest
of this case discussion will focus on her skin tear risk needs.
A skin tear prevention protocol needs to be implemented for Mrs. Sight imme-
diately. In order to achieve a safe environment for her, the sta must know how to
approach her with her dementia. To address her nutrition and hydration risk factors,
a dietary consultation should be performed. Her ability to safely swallow needs to be
evaluated by a speech therapist. After the swallowing evaluation, a plan to encourage
frequent uids and assist with eating should be implemented. To protect Mrs. Sight’s
skin from additional injury, avoid using hot water to bathe her and, instead, use one
of the nonrinse, soapless bathing products. Her family can be asked to bring in a soft
eece jogging suit for her to wear. e purpura areas on her arms and legs should be
covered with stockinet or some other soft nonadherent dressing or skin-protective
barrier product to further protect these areas. Her bed rails and the arms and legs of
her wheelchair should be padded. Sta should use the palm of their hands and a turn
sheet when repositioning Mrs. Sight in bed. Lotion can be applied twice a day to her
dry skin. Daily assessment of her skin including the ve minimal characteristics pro-
posed by CMS should be done (Rich et al., 2009).
CASE STUDY 2
SUMMARY
e skin is the largest organ, so pay attention to it. Although the research into prevention
strategies is limited, there is support for doing the appropriate risk assessment for these
two types of skin injuries: pressure ulcers and skin tears.
Preventing Pressure Ulcers and Skin Tears 311
General skin assessment is important for the early breakdown, protecting the skin
by using appropriate bathing techniques, products to minimize the eects of friction
and shear on the skin, and paying attention to nutritional status. In the case of pressure
ulcers, redistributing the pressure by turning and repositioning and appropriate use of
support surfaces is also critical. Immediate initiation of prevention protocols after risk
identication is key with each major abnormal risk factor correction part of the treat-
ment protocol. By doing so, you can prevent and treat skin integrity problems such as
skin tears and pressure ulcers.
Protocol 16.1: Pressure Ulcer Prevention
I. GOALS
A. Prevention of pressure ulcers (PU)
B. Early recognition of PU development and skin changes
II. BACKGROUND AND STATEMENT OF PROBLEM
A. Pressure ulcer 2009: Occurrence data reported for 2009 (VanGilder et al., 2009)
1. All U.S. facilities
Overall Prevalence: 12.3%
Facility acquired (FA) prevalence: 5.0 %
Prevalence excluding Stage 1: 9.0%
FA prevalence excluding Stage 1: 3.2%
2. Acute care
B. Etiology and/or Epidemiology
1. Risk factors (immobility, undernutrition or malnutrition, incontinence,
friable skin, impaired cognitive ability)
2. Higher incidence of Stage 2 and higher in persons with darkly pigmented
skin
III. PARAMETERS OF ASSESSMENT
A. Perform a complete skin assessment as part of the risk assessment policy and
practices (EPUAP & NPUAP, 2009, p. 27)
1. Inspect skin regularly for color changes such as redness in lightly pigmented
persons and discoloration in darkly pigmented persons (EPUAP & NPUAP,
2009, p. 28)
2. Look at the skin under any medical device (e.g., catheters, oxygen, airway
or ventilator tubing, face masks, braces, collars).
3. Palpate skin for changes in temperature (warmth) edema or hardness
4. Ask the patient if they have any areas of pain or discomfort over bony
prominences
B. Assess for intrinsic and extrinsic risk factors
C. Braden scale risk score—18 or less for older adults and persons with darkly
pigmented skin
NURSING STANDARD OF PRACTICE
(continued)
312 Evidence-Based Geriatric Nursing Protocols for Best Practice
IV. NURSING CARE STRATEGIES AND INTERVENTIONS
A. Risk Assessment Documentation
1. On admission to acute care
2. Reassessment intervals whenever the client’s condition changes and based
on patient care setting:
a. Based on patient acuity every 24–48 hours general units
b. Critically ill patients every 12 hours
3. Use a reliable and standardized tool for doing a risk assessment, such as the
Braden scale as part of a comprehensive risk assessment ( available at http://
www.bradenscale.com/braden.PDF)
4. Document risk assessment scores and implement prevention protocols
based on overall scores, low subscores, and the comprehensive assessment
of other risk factors.
5. Assess risk of surgical patients for increased risk of pressure ulcers including
the following factors: length of operation, number of hypotensive episodes,
and/or low-core temperatures intraoperatively, reduced mobility on rst
day postoperatively.
B. General Care Issues and Interventions
1. Culturally sensitive early assessment for Stage 1 pressure ulcers in clients
with darkly pigmented skin
a. Use a halogen light to look for skin color changes—may be purple hues
or other discoloration based on patient’s skin tone.
b. Compare skin over bony prominences to surrounding skin—may be
boggy or sti, warm or cooler.
2. Prevention recommendations:
a. Skin care (EPUAP & NPUAP, 2009)
i. Assess skin regularly.
ii. Clean skin at time of soiling—avoid hot water and irritating
cleaning agents.
iii. Use emollients on dry skin.
iv. Do not massage bony prominences as a pressure ulcer prevention
strategy as well as do not vigorously rub skin at risk for pressure
ulcers.
v. Protect skin from moisture-associated damage (e.g., urinary and/
or fecal incontinence, perspiration, wound exudates) by using
barrier products.
vi. Use lubricants, protective dressings, and proper lifting techniques
to avoid skin injury from friction and shear during transferring
and turning of clients. Avoid drying out the patient’s skin; use
lotion after bathing.
vii. Avoid hot water and soaps that are drying when bathing older adults.
Use body wash and skin protectant (Hunter et al., 2003).
viii. Teach patient, caregivers, and sta the prevention protocol
ix. Manage moisture by determining the cause; use absorbent pad
Protocol 16.1: Pressure Ulcer Prevention (cont.)
(continued)
Preventing Pressure Ulcers and Skin Tears 313
that wicks moisture.
x. Protect high-risk areas such as elbows, heels, sacrum, and back of
head from friction injury.
b. Repositioning and support surfaces
i. Keep patients o the reddened areas of skin
ii. Repositioning schedules should be individualized based on the
patient’s condition, care goals, vulnerable skin areas, and type of
support surface being used (EPUAP & NPUAP, 2009).
iii. Communicate the repositioning schedule to all the patient’s
caregivers.
iv. Raise heels of bedbound clients o the bed using either pillows or
heel-protection devices; do not use donut-type devices ( Gilcreast
et al., 2005).
v. Use a 30 degree tilted side lying position; do not place clients
directly in a 90 degree side lying position on their trochanter
vi. Keep head of the bed at lowest height possible.
vii. Use transfer and lifting devices (trapeze, bed linen) to move
patients rather than dragging them in bed during transfers and
position changes.
viii. Use pressure-reducing devices (static air, alternating air, gel, or
water mattresses; Iglesias et al., 2006; Hampton & Collins, 2005).
Use higher specication foam mattresses rather than standard hos-
pital mattress for patients at risk for pressure ulcers. If the patient
cannot be frequently repositioned manually, use an active support
surface (overlay or mattress).
ix. Use pressure redistributing mattresses on the operating table for
patients identied at risk for developing pressure ulcers.
x. Reposition chairbound or wheelchair-bound clients every hour. In
addition, if client is capable, have him or her do small weight shifts
every 15 minutes.
xi. Use a pressure-reducing device (not a donut) for chairbound
clients.
xii. Keep the patient as active as possible; encourage mobilization
xiii. Avoid positioning the patient directly on his or her trochanter
xiv. Avoid using donut-shaped devices
xv. Oer a bedpan or urinal in conjunction with turning schedules
xvi. Manage friction and shear:
a) Elevate the head of the bed no more than 30 degrees.
b) Have the patient use a trapeze to lift self up in bed.
c) Sta should use a lift sheet or mechanical lifting device to move
patient.
c. Nutrition
i. Assess nutritional status of patients at risk for pressure ulcers.
ii. For at-risk patient, follow nutritional guidelines for hydration
(continued)
Protocol 16.1: Pressure Ulcer Prevention (cont.)
314 Evidence-Based Geriatric Nursing Protocols for Best Practice
(1 ml/kcal of uid per day) and calories (30–35 kcal/kg of body
weight per day), protein 1.25–1.5 g/kg per day). Give high- protein
supplements or tube feedings in addition to the usual diet in persons
at nutritional and pressure ulcer risk (EPUAP & NPUAP, 2009).
iii. Manage nutrition
iv. Consult a dietitian and correct nutritional deciencies by increas-
ing protein and calorie intake and A, C, or E vitamin supplements
as needed (CMS, 2004; Houwing et al., 2003)
v. Oer a glass of water with turning schedules to keep patient
hydrated.
C. Interventions Linked to Braden Risk Scores (Adapted from Ayello & Braden
[2001])
Prevention protocols linked to Braden risk scores are as follows:
1. At risk: score of 15–18
a. Frequent repositioning turning; use a written schedule
b. Maximize patient’s mobility
c. Protect patient’s heels
d. Use a pressure-reducing support surface if patient is bedbound or chair-
bound.
2. Moderate risk: score of 13–14
a. Same as cited, but provide foam wedges for 30 degree lateral position.
3. High risk: score of 10–12
a. Same as cited, but add the following b and c.
b. Increase the turning frequency
c. Do small shifts of position
4. Very high risk: score of 9 or less
a. Same as cited but use a pressure-relieving surface.
b. Manage moisture, nutrition, and friction and shear.
V. EVALUATION AND EXPECTED OUTCOMES
A. Patient
1. Skin will remain intact.
2. Pressure ulcer will heal.
B. Provider or Nurse
1. Nurses will accurately perform PU risk assessment using standardized tool.
2. Nurses will implement PU prevention protocols for clients interpreted as at
risk for PU.
3. Nurses will perform a skin assessment for early detection of pressure ulcers.
C. Institution
1. Reduction in development of new pressure ulcers.
2. Increased number of risk assessments performed.
3. Cost-eective prevention protocols developed.
VI. FOLLOW-UP MONITORING OF CONDITION
A. Monitor eectiveness of prevention interventions.
B. Monitor healing of any existing pressure ulcers.
Protocol 16.1: Pressure Ulcer Prevention (cont.)
Preventing Pressure Ulcers and Skin Tears 315
Protocol 16.2: Skin Tear Prevention
I. GOALS
A. Prevent skin tears in older adult clients.
B. Identify clients at risk for skin tears (Mason, 1997)
C. Foster healing of skin tears by:
1. Retaining skin ap
2. Providing a moist, nonadherent dressing (Edwards et al., 1998; omas
et al., 1999)
3. Protecting the site from further injury
II. BACKGROUND AND STATEMENT OF THE PROBLEM
A. Traumatic wounds from mechanical injury of skin
B. Need to clearly dierentiate etiology of skin tears from pressure ulcers
C. Common in the older adult, especially over the areas of age-related purpura
III. PARAMETERS OF ASSESSMENT
A. Use the three-group risk assessment tool (White et al., 1994) to assess for skin
tear risk.
B. Use the Payne–Martin (Payne & Martin, 1993) classication system to assess
clients for skin tear risk.
1. Category 1: a skin tear without tissue loss
2. Category 2: a skin tear with partial tissue loss
3. Category 3: a skin tear with complete tissue loss where the epidermal ap is
absent
IV. NURSING CARE STRATEGIES AND INTERVENTIONS (Baranoski, 2000;
Baranoski & Ayello, 2008)
A. Preventing Skin Tears
1. Provide a safe environment:
a. Do a risk assessment of older adult patients on admission.
b. Implement prevention protocol for patients identied as at risk for skin
tears.
c. Have patients wear long sleeves or pants to protect their extremities
(Bank, 2005).
d. Have adequate light to reduce the risk of bumping into furniture or
equipment.
e. Provide a safe area for wandering.
2. Educate sta or family caregivers in the correct way of handling patients to
prevent skin tears. Maintain nutrition and hydration:
a. Oer uids between meals.
b. Use lotion, especially on dry skin on arms and legs, twice daily ( Hanson
et al., 1991).
c. Obtain a dietary consultation.
NURSING STANDARD OF PRACTICE
(continued)
316 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Protect from self-injury or injury during routine care:
a. Use a lift sheet to move and turn patients.
b. Use transfer techniques that prevent friction or shear.
c. Pad bed rails, wheelchair arms, and leg supports (Bank, 2005).
d. Support dangling arms and legs with pillows or blankets.
e. Use nonadherent dressings on frail skin.
i. Apply skin protective products (creams, ointments, liquid sealants,
etc.) or a nonadherent wound dressing such as hydrogel dress-
ing with gauze as a secondary dressing, silicone, or Telfa-type
dressings.
ii. If you must use tape, be sure it is made of paper, and remove it
gently. In addition, you can apply the tape to hydrocolloid strips
placed strategically around the wound rather than taping directly
onto fragile surrounding skin around the skin tear.
f. Use gauze wraps, stockinettes, exible netting, or other wraps to secure
dressings rather than tape.
g. Use no-rinse, soapless bathing products (Birch & Coggins, 2003;
Mason, 1997)
h. Keep skin from becoming dry, apply moisturizer (Bank, 2005; Hanson
et al., 1991)
B. Treating Skin Tears (Baranoski & Ayello, 2008)
1. Gently clean the skin tear with normal saline.
2. Let the area air dry or pat dry carefully.
3. Approximate the skin tear ap.
4. Use caution if using adherent dressings, as skin damage can occur when
removing dressings.
5. Consider putting an arrow to indicate the direction of the skin tear on the
dressing to minimize any further skin injury during dressing removal.
a. Skin sealants, petroleum-based products, and other water-resistant
products such as protective barrier ointments or liquid barriers may be
used to protect the surrounding skin from wound drainage or dressing,
or tape removal trauma.
b. Always assess the size of the skin tear; consider doing a wound tracing.
c. Document assessment and treatment ndings.
V. EVALUATION AND EXPECTED OUTCOMES
A. No skin tears will occur in at-risk clients.
B. Skin tears that do occur will heal.
VI. FOLLOW-UP MONITORING OF CONDITION
A. Continue to reassess for any new skin tears in older adults.
Protocol 16.2: Skin Tear Prevention (cont.)
Preventing Pressure Ulcers and Skin Tears 317
RESOURCES
Tools
Agency for Healthcare Research and Quality. (2011). Preventing pressure ulcers in hospitals: A toolkit for
improving quality of care.
http://www.ahrq.gov/research/ltc/pressureulcertoolkit/
Ayello, E. A. (2007). Try this: Best practices in nursing care to older adults. Predicting pressure ulcer risk.
Retrieved from the Hartford Institute for Geriatric Nursing, College of Nursing website;
http://www.consultgerirn.org/resources
Braden, B., & Bergstrom, N. (1988). Braden Scale for predicting pressure sore risk.
http://www.bradenscale.com/braden.PDF
Authoritative Sites
Agency for Healthcare Research and Quality. (2011). USDHHS supported clinical guidelines: Pressure
ulcers.
http://www.guideline.gov
National Pressure Ulcer Advisory Panel (NPUAP)
Pressure ulcer prevention and treatment, research, and policy information.
http://www.npuap.org/
Wound, Ostomy, and Continence Nursing Society (WOCN)
Guidelines, position statements, best practices, and much more.
http://www.wocn.org/
Other Related Professional Organizations
American Professional Wound Care Association (APWCA)
http://www.apwca.org/
European Pressure Ulcer Advisory Panel (EPUAP)
http://www.epuap.org/
World Council of Enterostomal erapists (WCET)
http://www.wcetn.org/
World Union of Wound Healing Societies (WUWHS)
http://www.wuwhs.org/
Wound Healing Society (WHS)
http://www.woundheal.org/
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trial of a prevention and treatment protocol for skin breakdown in two nursing homes. Journal
of Wound, Ostomy, and Continence Nursing, 30(5), 250–258. Evidence Level III.
Iglesias, C., Nixon, J., Cranny, G., Nelson, E. A., Hawkins, K., Phillips, A., . . . PRESSURE Trial
Group. (2006). Pressure relieving support surfaces (PRESSURE) trial: Cost eectiveness analy-
sis. British Medical Journal, 332(7555), 1416. Evidence Level II.
Institute for Healthcare Improvement. (2006). 5 million lives saved campaign: Pressure ulcers. Retrieved
from http://www.ihi.org/IHI/Programs/Campaign/. Evidence Level V.
Jolley, D. J., Wright, R., McGowan, S., Hickey, M. B., Campbell, D. A., Sinclair, R. D., &
Montgomery K. C. (2004). Preventing pressure ulcers with the Australian Medical Sheepskin:
An open-label randomized controlled trial. e Medical Journal of Australia, 180(7), 324–327.
Evidence Level II.
Preventing Pressure Ulcers and Skin Tears 321
Kaitani, T., Tokunaga, K., Matsui, N., & Sanada, H. (2010). Risk factors related to the development
of pressure ulcers in the critical care settings. Journal of Clinical Nursing, 19(3–4), 414–421.
Evidence Level IV.
Karadag, M., & Gümüskaya, N. (2006). e incidence of pressure ulcers in surgical patients:
A sample hospital in Turkey. Journal of Clinical Nursing, 15(4), 413–421. Evidence Level IV.
Kottner, J., & Dassen, T. (2010). Pressure ulcer risk assessment in critical care: Interrater reliability
and validity studies of the Braden and Waterlow scales and subjective rating in two intensive care
units. International Journal of Nursing Studies, 47(6), 671–677. Evidence Level III.
Krasner, D. (1991). An approach to treating skin tears. Ostomy/Wound Management, 32, 56–58.
Evidence Level VI.
Kwong, E., Pang, S., Wong, T., Ho, J., Shao-ling, X., & Li-jun, T. (2005). Predicting pressure ulcer
risk with the modied Braden, Braden, and Norton scales in acute care hospitals in Mainland
China. Applied Nursing Research, 18(2), 122–128. Evidence Level IV.
Langer, G., Schloemer, G., Knerr, A., Kuss, O., & Behrens, J. (2003). Nutritional interventions for
preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews, (4), CD003216.
Evidence Level I.
Lindgren, M., Unosson, M., Fredrikson, M., & Ek, A. C. (2004). Immobility—A major risk fac-
tor for development of pressure ulcers among adult hospitalized patients: A prospective study.
Scandinavian Journal of Caring Sciences, 18(1), 57–64. Evidence Level VI.
Lyder, C. H. (1996). Examining the inclusion of ethnic minorities in pressure ulcer prediction studies.
Journal of Wound, Ostomy, and Continence Nursing, 23(5), 257–260. Evidence Level IV.
Lyder, C. H., & Ayello, E. A. (2009). Annual checkup: e CMS pressure ulcer present-on- admission
indicator. Advances in Skin & Wound Care, 22(10), 476–484.
Lyder, C. H., Preston, J., Grady, J. N., Scinto, J., Allman, R., Bergstrom, N., & Rodeheaver, G.
(2001). Quality of care for hospitalized medicare patients at risk for pressure ulcers. Archives of
Internal Medicine, 161(12), 1549–1554. Evidence Level III.
Lyder, C. H., Yu, C., Emerling, J., Mangat, R., Stevenson, D., Empleo-Frazier, O., & McKay, J.
(1999). e Braden Scale for pressure ulcer risk: Evaluating the predictive validity in Black and
Latino/Hispanic elders. Applied Nursing Research, 12(2), 60–68. Evidence Level IV.
Lyder, C. H., Yu, C., Stevenson, D., Mangat, R., Empleo-Frazier, O., Emerling, J., & McKay, J.
(1998). Validating the Braden Scale for the prediction of pressure ulcer risk in Blacks and
Latino/Hispanic elders: A pilot study. Ostomy/Wound Management, 44(3A Suppl.), 42S–49S.
Evidence Level IV.
Malone, M. L., Rozario, N., Gavinski, M., & Goodwin, J. (1991). e epidemiology of skin tears in
the institutionalized elderly. Journal of the American Geriatrics Society, 39(6), 591–595. Evidence
Level IV.
Mason, S. R. (1997). Type of soap and the incidence of skin tears among residents of a long-term care
facility. Ostomy/Wound Management, 43(8), 26–30. Evidence Level IV.
McInerney, J. A. (2008). Reducing hospital-acquired pressure ulcer prevalence through a focused
prevention program. Advances in Skin & Wound Care, 21(2), 75–78. Evidence Level V.
Meehan, M. (1990). Multisite pressure ulcer prevalence survey. Decubitus, 3(4), 14–17. Evidence
Level IV.
Meehan, M. (1994). National pressure ulcer prevalence survey. Advances in Wound Care, 7(3), 27–30,
34. Evidence Level IV.
New Jersey Department of Health and Senior Services. (2004). Interim mandatory patient safety
reporting requirements for general hospitals. Patient safety reporting initiative. Retrieved from
http://www.state.nj.us/health/ps/documents/irr.pdf
Nixon, J., Cranny, G., Iglesias, C., Nelson, E. A., Hawkins, K., Phillips, A., . . . Cullum, N. (2006).
Randomised, controlled trial of alternating pressure mattresses compared with alternating pres-
sure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support sur-
faces) trial. British Medical Journal, 332(7555), 1413. Evidence Level II.
322 Evidence-Based Geriatric Nursing Protocols for Best Practice
Nonnemacher, M., Stausberg, J., Bartoszek, G., Lottko, B., Neuhaeuser, M., & Maier, I. (2009).
Predicting pressure ulcer risk: A multifactorial approach to assess risk factors in a large university
hospital population. Journal of Clinical Nursing, 18(1), 99–107. Evidence Level V.
Norton, D., McLaren, R., & Exton-Smith, A. N. (1962). An investigation of geriatric nursing problems
in hospitals. London, UK: Corporation for the Care of Old People. Evidence Level IV.
Norton, D., McLaren, R., & Exton-Smith, A. N. (1975). An investigation of geriatric nurse problems
in hospitals. Edinburgh, UK: Churchill Livingstone. Evidence Level IV.
O’Regan, A. (2002). Skin tears: A review of the literature. Journal of Wound, Ostomy, and Continence
Nursing, 39(2), 26–31. Evidence Level V.
Pancorbo-Hidalgo, P. L., Garcia-Fernandez, F. P., Lopez-Medina, I. M., & Alvarez-Nieto, C. (2006).
Risk assessment scales for pressure ulcer prevention: A systematic review. Journal of Advanced
Nursing, 54(1), 94–110. Evidence Level I.
Payne, R. L., & Martin, M. L. (1993). Dening and classifying skin tears: Need for common
language. Ostomy/Wound Management, 39(5): 16–26. Evidence Level IV.
Pemberton, V., Turner, V., & VanGilder, C. (2009). e eect of using a low-air-loss surface on the
skin integrity of obese patients: Results of a pilot study. Ostomy/Wound Management, 55(2),
44–48. Evidence Level IV.
Pressure ulcers prevalence, cost, and risk assessment: Consensus development conference statement—
e National Pressure Ulcer Advisory Panel. (1989). Decubitus, 2(2), 24–28. Evidence Level I.
Reddy, M., Gill, S. S., & Rochon, P. A. (2006). Preventing pressure ulcers: A systematic review. Jour-
nal of the American Medical Association, 296(8), 974–984. Evidence Level I.
Rich, S. E., Shardell, M., Margolis, D., & Baumgarten, M. (2009). Pressure ulcer preventive device
use among elderly patients early in the hospital stay. Nursing Research, 58(2), 95–104. Evidence
Level IV.
Russo, C. A., Steiner, C., & Spector, W. (2006). Hospitalizations related to pressure ulcers among adults
18 years and older, 2006. Retrieved from at http://www.hcup-us.ahrq.gov/reports/statbriefs/
sb64.jsp. Evidence Level IV.
Shahin, E. S., Dassen, T., & Halfens, R. (2009). Incidence, prevention and treatment of pressure
ulcers in intensive care patients: A longitudinal study. International Journal of Nursing Studies,
46(4), 413–421. Evidence Level III.
Shanks, H. T., Kleinhelter, P., & Baker, J. (2008). Skin failure: A retrospective review of patients with
hospital-acquired pressure ulcers. World Council of Enterostomal erapists Journal, 29(1), 6–10.
Evidence Level IV.
Sprigle, S., Linden, M., McKenna, D., Davis, K., & Riordan, B. (2001). Clinical skin tempera-
ture measurement to predict incipient pressure ulcers. Advances in Skin & Wound Care, 14(3),
133–137. Evidence Level IV.
Stratton, R. J., Ek, A. C., Engfer, M., Moore, Z., Rigby, P., Wolfe, R., & Elia, M. (2005). Enteral
nutritional support in prevention and treatment of pressure ulcers: A systematic review and
meta-analysis. Ageing Research Reviews, 4(3), 422–450. Evidence Level I.
Suriadi, Sanada, H., Sugama, J., igpen, B., & Subuh, M. (2008). Development of a new risk
assessment scale for predicting pressure ulcers in an intensive care unit. Nursing in Critical Care,
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an opaque foam dressing versus a transparent lm dressing in the management of skin tears in
institutionalized subjects. Ostomy/Wound Management, 45(6), 22–28. Evidence Level III.
Uzun, O., Aylaz, R., & Karadağ, E. (2009). Prospective study: Reducing pressure ulcers in intensive
care units at a Turkish medical center. Journal of Wound, Ostomy, & Continence Nursing, 36(4),
404–411. Evidence Level V.
VanGilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009). Results of the 2008–2009 Interna-
tional Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specic analysis. Ostomy/
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Preventing Pressure Ulcers and Skin Tears 323
VanGilder, C., MacFarlane, G. D., Harrison, P., Lachenbruch, C., & Meyer, S. (2010). e demo-
graphics of suspected deep tissue injury in the United States: An analysis of the International
Pressure Ulcer Prevalence Survey 2006–2009. Advances in Skin & Wound Care, 23(6), 254–261.
Evidence Level IV.
Weng, M. H. (2008). e eect of protective treatment in reducing pressure ulcers for non-invasive
ventilation patients. Intensive & Critical Care Nursing, 24(5), 295–299. Evidence Level III.
White, M. W., Karam, S., & Cowell, B. (1994). Skin tears in frail elders: A practical approach to
prevention. Geriatric Nursing, 15(2), 95–98. Evidence Level IV.
Wound, Ostomy, and Continence Nurses Society. (2010). Guideline for prevention and management
of pressure ulcers. Mt. Laurel, NJ: Author. Evidence Level I.
Young, T. (2004). e 30 degree tilt position vs the 90 degree lateral and supine positions in reduc-
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324
17
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. conduct a comprehensive medication assessment
2. specify four medications or medication classes having a high potential for toxicity in
older adults
3. describe ve reasons that older adults experience adverse drug events
4. delineate strategies to prevent common medication-related problems in older adults
OVERVIEW
One in seven Medicare beneciaries experienced an adverse event while hospitalized in
2008. Of those, 31% of the adverse events were related to medications (Levinson, 2010).
Nearly 1.9 million adverse drug events (ADEs) occur each year in older adults enrolled in
Medicare and 180,000 of those are life threatening or fatal (Gurwitz et al., 2003). ADEs
are common in older adults yet are potentially preventable (Safran et al., 2005).
Persons older than the age of 65 years experience medication-related events for seven
major reasons: (a) alteration in pharmacokinetics (i.e., reduced ability to metabolize and
excrete medications) and pharmacodynamics (Mangoni & Jackson, 2004; Rochon, 2010);
(b) polyphar macy (Gallagher, Barry, & O’Mahony, 2007; Hajjar & Kotchen, 2003); (c) incor-
rect doses of medications (more than or less than therapeutic
dosage; Doucette, McDonough,
Klepser, & McCarthy, 2005; Hanlon, Schmader, Ruby, & Weinberger, 2001; Sloane,
Zimmerman, Brown, Ives, & Walsh, 2002); (d) using medication for treatment of symptoms
that are not disease-dependent or - specic (i.e., self-medication or prescribing cascades; Neafsey
& Shellman, 2001; Rochon & Gurwitz, 1997); (e) iatrogenic causes such as ADEs and inap-
propriate prescribing (Fick et al., 2003; Pirmohamed et al., 2004; Rothberg et al., 2008);
(f) problems with medication adherence (Steinman & Hanlon, 2010); and (g) medication
errors (Agency for Healthcare Research and Quality [AHRQ], 2001; Doucette et al., 2005).
Reducing Adverse Drug Events
DeAnne Zwicker and Terry Fulmer
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Reducing Adverse Drug Events 325
Intrinsic factors such as advanced age, frailty, and polypharmacy place older adults at
greater risk for adverse outcomes. Older adults are the largest consumers of medications
with 82% taking at least one medication, 29%–39% taking ve or more drugs, and up
to 90% taking over-the-counter (OTC) drugs (Hanlon, Fillenbaum, Ruby, Gray, &
Bohannon, 2001; Kohn, Corrigan, & Donaldson, 2000). Older adults often combine
OTC medications with prescription medications yet do not report their OTC use to
health care providers. Likewise, providers often do not inquire about OTCs or herbal
remedies. Underreporting may lead to unrecognized adverse drug–disease or drug–drug
interactions (Astin, Pelletier, Marie, & Haskell, 2000; Rochon, 2010). ese factors
make it paramount that nurses identify older adults at risk for adverse events.
BACKGROUND AND STATEMENT OF PROBLEM
Adverse Drug Events
An ADE is an adverse outcome that occurs during normal use of medicine, inappropriate
use, inappropriate or suboptimum prescribing, poor adherence or self-medication, or
harm caused by a medication error. It is estimated that 35% of older persons experience
ADEs, almost half of which are preventable (Safran et al., 2005). Older adults are also
at signicant risk for further ADEs while in the hospital and after discharge. Acute drug
toxicity represents 2.5% of emergency department (ED) visits for unintentional injuries,
of which 42% resulted in a hospital admission (Budnitz et al., 2006; Hanlon et al., 2006).
Signicant morbidity and mortality are associated with ADEs, with the cost estimated
to be approximately $75–$85 billion annually (Budnitz et al., 2006; Fick et al., 2003;
Hanlon et al., 2001). ADEs are also associated with preventable adverse outcomes such
as depression, constipation, falls, immobility, confusion, hip fractures, rehospitalization,
anorexia, and death (Aspden, Wolcott, Bootman, & Cronenwett, 2007).
Iatrogenic Causes of Adverse Drug Events
Older adults’ susceptibility to ADEs is well documented in the literature on iatro-
genic events and medication errors (Gurwitz et al., 2003; Hohl et al., 2005). e term
iatrogenic, as it relates to ADEs, means any undesirable condition in a patient occurring
as the result of treatment by a health care professional, specically pertaining to an ill-
ness or injury resulting from a medication/drug or treatment. An iatrogenic medication
event is one that is preventable, such as the wrong dose of a medication given result-
ing in an adverse outcome. Adverse drug reactions (ADRs), inappropriate prescrib-
ing of high-risk medication to older adults, and medication errors are also considered
iatrogenic ADEs. In a systematic review, the most common preventable ADEs included
antiplatelet medications, diuretics, and anticoagulants. Prescribing problems, adherence
problems, and monitoring problems have been associated with preventable admissions
as well (Howard et al., 2007; Steinman & Hanlon, 2010). Frail older adults with mul-
tiple medical problems, memory issues, and multiple prescribed and nonprescribed
medications are at highest risk for ADEs (Rochon, 2010).
Adverse Drug Reactions
An ADR, a type of ADE, is any toxic or unintended response to a medication ( Committee
of Experts [COE] on Safe Medication Practices, 2005). e prevalence rate of hospital
admissions caused by ADRs has been reported between 5% and 35% (Gurwitz et al.,
326 Evidence-Based Geriatric Nursing Protocols for Best Practice
2003; Kohn et al., 2000). A recent systematic review reported 10.7% prevalence rate of
hospital admissions caused by ADRs in older adults; however, a confounding factor in
the accuracy is the dierent methods and studies employ to gather the data (Kongkaew,
Noyce, & Ashcroft, 2008). Among a community-dwelling population of older adults,
38% of ADRs were considered serious, life threatening, or fatal and 27% were considered
preventable (Gurwitz et al., 2005). Pirmohamed et al. (2004) reported that 70% of ADRs
were either possibly avoidable or denitely avoidable in a study of 18,820 older adults.
Twenty-nine percent of ADEs require evaluation by a physician, evaluation in the
emergency room, or hospitalization for clinical management (Hohl et al., 2005; Petrone
& Katz, 2005). A meta-analysis revealed that ADRs accounted for 6.7% of hospital
admissions and in-hospital ADRs; when extrapolated, they would be the fourth–sixth
leading cause of in-hospital mortality for all causes of death, which does not include ADRs
related to errors, nonadherence, overdose, or therapeutic failures (Lazarou, Pomeranz,
& Corey, 1998; Steinman & Hanlon, 2010). Drug–drug and drug–disease interactions
are the most common ADRs (Hansten, Horn, & Hazlet, 2001; Juurlink, Mamdani,
Kopp, Laupacis, & Redelmeier, 2003; Zhan et al., 2005). Drug–drug interactions
occur when one therapeutic agent either alters the concentration (i.e., pharmacokinetic
interactions) or the biological eect of another agent—pharmacodynamic interactions
(Leucuta & Vlase, 2006). Gray and Gardner (2009) reported that polypharmacy and
multiple prescribers tend to be key factors in these adverse reactions. Older adults with
multiple chronic medical problems requiring multiple medications are at high risk for
these interactions (Rochon, 2010).
Medication Errors
e Institute of Medicine (IOM) reported in 1999 that almost 7,000 hospital deaths
were associated with medication errors (Kohn et al., 2000). Medication errors occur fre-
quently, yet many hospitals still lack automated physician order entry systems that are
reported to decrease the number of medication errors (National Coordinating Council
for Medication Errors Reporting and Prevention [NCC MERP], 2001).
A medication error is dened by the COE on Management of Safety and Quality
in Health Care (COE, 2005) as any preventable event that may cause or lead to inap-
propriate medication use or patient harm while the medication is in the control of the
health care professional, patient, or consumer. Such events may be related to profes-
sional practice, health care products, procedures, and systems, including prescribing;
order communication, product labeling, packaging, and nomenclature; compounding,
dispensing, and distribution; administration, education, and use. A large percentage of
errors are caused by administration of the wrong medication or the correct medication
with the wrong dose or at the wrong time interval between dosing (Rochon, 2010).
ere are many reasons medication errors occur; however, it is beyond the scope of this
chapter. Information regarding the immense literature on medication errors is provided
in the Resources section of this chapter.
Adherence
Medication adherence (or compliance) with a medication regimen is generally dened
as “the extent to which a person’s medication-taking behavior corresponds with agreed
recommendations of a health care provider” (Sabaté, 2003, pp. 3). Seventy percent
of patients who begin taking a prescribed drug discontinue it within 1 year, with the
Reducing Adverse Drug Events 327
greatest drop-o rate at 6 months (Osterberg & Blaschke, 2005). A national survey
of 17,685 Medicare beneciaries older than age 65 years found that 52% do not take
medications as prescribed (Safran et al., 2005). Nonadherence was primarily associated
with a belief that the drug made them feel worse or was not helping (25%), or cost of the
medicine, resulting in a decision to skip or take a smaller dose (26%). Prescription drug
coverage signicantly impacted adherence, with 37% nonadherence among those with-
out coverage compared with 22% nonadherence beneciaries with coverage. Patients are
often reluctant to admit nonadherence; however, pill counts and rell history can aid in
determining this issue (Osterberg & Blaschke, 2005; Steinman & Hanlon, 2010).
Acute care nurses are ideally positioned to identify and aid in preventing ADEs in hos-
pitalized older adults and in transitions to other levels of care. Areas in which nurses must
be familiar are iatrogenic causes of ADEs such as ADRs, inappropriate medications, iden-
tifying system issues to reduce medicine errors, and risk of nonadherence in older adults.
Education of patient and families, recognizing inappropriate medications, and reinforcing
the need for drug monitoring are areas where nurses can make a dierence in aging persons
(Fick et al., 2003; Rochon, 2010). Nurses must take a proactive role in assuring patient
safety through interdisciplinary collaboration with patient and family, doctors, advance
practice nurses, and pharmacists to prevent adverse medication outcomes.
ASSESSMENT OF THE PROBLEM
Assessment Tools
Assessment tools are used to evaluate an older adult’s ability to self-administer medica-
tions (i.e., functional capacity assessment); assessment of the medication list for poten-
tial inappropriate medications, drug–drug or drug–disease interactions; and assessment
of renal function in collaboration with interdisciplinary team members. Commonly
used tools include the following:
n 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults:
Independent of Diagnoses or Condition (Fick et al., 2003). Used to assess medication
list for medications that should generally be avoided in older adults. (See http://
www.consultgerirn.org/resources, “Try is” series, issue number 16.1.)
n 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults:
Considering Diagnoses or Condition (Fick et al., 2003; see “Try is” series, issue
number 16.2). Used to assess for the presence of medications that may interact
adversely with a disease or condition a person has.
n Drug–Drug Interactions (Table 17.1). List of medications known to interact
with other medications. is may be performed by a computer or personal
digital assistant (PDA) program, such as Facts and Comparisons PDA program
to identify drug–drug and drug–disease interactions or “Physician Order Entry
(POE)” programs.
n Cockroft–Gault Formula (Table 17.2). Useful for estimating creatinine clearance
based on age, weight, and serum creatinine levels (Terrell, Heard, & Miller, 2006).
n Functional Capacity (activity of daily living [ADL], independent activity of daily
living [IADL], Mini-Cog/Mini-Mental State Exam [MMSE]). Used to assess
physical and cognitive ability to self-administer medications. (See Chapter 6,
Assessment of Physical Function, and Chapter 10, Dementia, respectively in this
text or visit http://www.consultgerirn.org.)
328 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 17.1
Common Drug–Drug Interactions
Drug 1 Drug 2 Interaction Adverse Effect(s)
Warfarin Diltiazem
1
Inhibits drug ↑ anticoagulation
(Coumadin) Verapamil
1
Metronidazole
1,3
metabolism Potential bleeding
Warfarin NSAID*
2,3
ASA
2
NSAID ↓ prostaglandin
Increases GI erosion
↓ platelet aggregation
GI bleed
Sulfa drugs
3
Macrolides
2
Unknown
Inhibits metabolism and clearance
↑ effects of war-
farin,
potential GI bleed
Acetaminophen
3
combined with
narcotic
Fluconazole
3
Cipro
2
Biaxin
2
↑ INR Bleeding
Digoxin Amiodarone
1,2
↓ renal or nonrenal
clearance of digoxin
Digoxin toxicity
Clarithromycin
1,2
Inhibits renal clearance of digoxin
Verapamil
1,2
↓ Impulse conduction and muscle
contraction
Potential
brady cardia or
heart block
Levothyroxine Calcium carbonate
1
L-thyroxine absorbs calcium
carbonate in acidic environment
Reduced
absorption of T
4
(L-thyroxin)
Glyburide Co-trimoxazole
2
Potentiates effect of sulfonylureas Hypoglycemia
ACE inhibitors Potassium-sparing
2
diuretics
Unknown Life-threatening
hyperkalemia
Diuretic NSAID*
1
↓ renal perfusion Renal impairment
Phenytoin4 Cimetidine,
erythromycin,
Not specified Increases levels
(Dilantin) clarithromycin,
fluconazole
of Dilantin within
1 week
Theophylline Quinolones ↓ liver metabolism of
theophylline
Theophylline
toxicity
Acetylcholinesterase
inhibitor
Anticholinergics
1
↓ ability to augment
acetylcholine level
Therapy less
effective
Note. ASA 5 aspirin; GI 5 gastrointestinal; INR 5 international normalized ratio; ACE 5 angiotensin-converting
enzyme. ere are many other common drug–drug interactions; this table is not intended to be all inclusive. Use of
computer devices is typically the best method for determining drug–drug interactions (see Resources section). *NSAID 5
nonsteroidal anti-inammatory agents: prescription and over-the-counter such as Toradol or ibuprofen respectively.
Adapted from
1
Cusak, B., & Vestal, R. E. (2000). Clinical pharmacology. In M. H. Beers & R. Berkow (Eds.), e Merck manual
of geriatrics (3rd ed., pp. 54–74). Whitehouse Station, NJ: Merck Research Laboratories. Evidence Level VI.
2
Feldstein, A. C., Smith, D. H., Perrin, N., Yang, X., Simon, S. R., Krall, M., . . . Soumerai, S. B. (2006). Reducing warfa-
rin medication interactions: An interrupted time series evaluation. Archives of Internal Medicine, 166(9), 1009–1015.
3
Ament, P. W., Bertolino, J. G., & Liszewski, J. L. (2000). Clinically signicant drug interactions. American Family
Physician, 61(6), 1745–1754. Evidence Level VI.
Reducing Adverse Drug Events 329
n Brown Bag Method (Nathan, Goodyer, Lovejoy, & Rashid, 1999). Method used
to assess all medications an older adult has at home including prescription from
all providers, OTCs, and herbal remedies. All medications at home are placed in
a bag and brought to hospital or other care setting. Should be used in conjunc-
tion with a complete medication history. (See Interventions and Nursing Care
Strategies or Protocol 17.1 for details on taking a complete medication history
and Table 17.3, which outlines medication history questions.)
n Drugs Regimen Unassisted Grading Scale (DRUGS) Tool. Standardized method
for assessing potential medication adherence problems. Used at transfer to other
levels of care (Edelberg, Shallenberger, & Wei, 1999; Hutchison, Jones, West, &
Wei, 2006).
ASSESSMENT STRATEGIES
Changes With Aging
Aging changes in pharmacokinetics and pharmacodynamics are important to consider
when assessing medications in older adults (Mangoni & Jackson, 2004; Rochon, 2010).
Pharmacokinetics is best dened as the time course of absorption, distribution across
compartments, metabolism, and excretion of drugs in the body. As the body ages, the
metabolism and excretion of many drugs declines and physiological changes require
dosage adjustment for some drugs (Cusak & Vestal, 2000). Pharmacodynamics is dened
as the response of the body to the drug that is aected by receptor binding, postreceptor
eects, and chemical interactions (Cusak & Vestal, 2000). Pharmacodynamic problems
occur when two drugs act at the same or interrelated receptor sites, resulting in addi-
tive, synergistic, or antagonistic eects. Many interactions of drugs are multifactorial,
with sequence of events that are both pharmacokinetic and pharmacodynamic (Spina &
Scordo, 2002). e following are changes that may occur with aging:
n Changes in drug absorption (i.e., increase gastric pH and decreased gastrointes-
tinal [GI] motility in an absorptive surface) once thought to be caused mainly
by aging changes are now thought to be caused by underlying disease states
(Mangoni & Jackson, 2004). ere may, however, be a change of absorption rate
in persons taking many medications, for example, uoroquinolones taken with
iron may impair absorption (Semla & Rochon, 2004).
TABLE 17.2
Cockroft–Gault formula for estimation of creatinine clearance (CrCl).
Formula for Men:
CrCl in milliliters per minute* 5
(140 2 age in years) (weight in kilograms)
72(serum creatinine in milligrams per deciliter)
Formula for Women: *Use above formula and multiply by 0.85
A creatinine clearance of , 50 ml/min places older adults at risk for adverse drug events and
virtually all people older than age 70 have a creatinine clearance of , 50 (Fouts, Hanlon, Pieper,
Perfetto, & Feinberg, 1997).
330 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 17.3
Complete Medication History*
Date Performed
Patient Name
Medication allergies and type of reaction (e.g., hives)
Prescription medications
Specifically ask about eye drops, topical creams, B
12
injections, or other injections (at home or at
medical office, how often). Recently discontinued medications and why.
Medication reconciliation performed and verified
Discrepancies found and reason(s)
Over-the-counter drugs
How often do you exceed the recommended dose on package?
Do you read the labels? Why or why not?
Do you ask a pharmacist or your provider about interactions with your prescriptions?
Ask specifically what patient is taking in the following classes:
Pain relievers
What have you tried, what works, and what does not? What pain do you take it for? How often?
Allergy medications
When do you take them? Year round? What season? Or When symptoms develop?
Sinus congestion/cold or cough medications (combined products with more than one ingredient?)
Heart burn medications, how often?
Diarrhea or constipation treatments, how often?
Sleeping medications, ask specifically diphenhydramine (Benadryl)
Eye drops—how often what do you take them for?
Herbal remedies (orally or as a tea) or Chinese medicine
- ginkgo biloba
- ginseng
- glucosamine
- St. John’s wort
- echinacea
Nutritional supplements
Ask how often?
Ask specifically about:
Calcium with vitamin D, vitamin E, C, or B’s
Megavitamins
Protein supplements such as Ensure, Boost, or protein bars
Vitamin drinks
Medications that have been stopped and why? (Did you discontinue or provider?)
Alcohol
Ask about type/amount per day
Smoking (what and how much; e.g., cigarette packs per day, how many years)
Past or annual immunizations, date last received
Pneumonia vaccine
Flu vaccine
Other
Regular lab tests—performed to evaluate medication levels or side effects (e.g., potassium level,
digoxin level, INR, liver toxicity, renal function). Inquire about those not drawn that should be based on
aforementioned medical list.
Use of memory aids—reminders to take medications (e.g., pill dispenser box)
Assess adherence: Consider using DRUGS tool (Edelberg et al., 1999; Hutchison et al., 2006).
Note.* Use in conjunction with brown bag method (see assessment tools). INR 5 international normalized ratio;
DRUGS 5 Drug Regimen Unassisted Grading Scale.
Reducing Adverse Drug Events 331
n Drug distribution changes associated with aging include decreased cardiac out-
put, reduced total body water, decreased serum albumin (which is more likely
to be related to malnutrition or acute illness than aging), and increased body
fat. Reduced total body water creates a potential for higher serum drug levels
because of a low volume of distribution and occurs with water-soluble drugs
(hydrophilic) such as alcohol or lithium. Decreased serum albumin results in
higher unbound drug levels with protein-bound drugs such as warfarin, pheny-
toin, digoxin, and theophylline. Lipophilic drugs (e.g., long-acting benzodiaz-
epines [BZDs]) are stored in the body fat of older persons and slowly leech out,
resulting in increased half-life and resulting in the drug staying around longer
(Gallagher et al., 2007).
n A signicant change in drug metabolism is a reduction in the cytochrome p-450
system, which aects metabolism of many drugs cleared by this enzyme system
(Cusak & Vestal, 2000; Mangoni & Jackson, 2004; Tune, 2001). Many classes
of drugs are cleared by the cytochrome p-450 enzyme system including car-
diovascular drugs, analgesics, nonsteroidal anti-inammatory drugs (NSAIDs),
antibiotics, diuretics, psychoactive drugs, and others (Mangoni & Jackson,
2004). Drugs such as beta-blockers that have a rst pass eect in the liver may
be eective in lower doses in older adults (Gallagher et al., 2007). For a list of
drugs cleared by this enzyme system see e Merck Manual of Geriatrics at http://
www.merckmanuals.com/mm_geriatrics. Metabolism may be aected by disease
states common in older individuals (e.g., thyroid disease, congestive heart fail-
ure [CHF], and cancer) or drug-induced metabolic changes (Cusak & Vestal,
2000). Several drugs are cleared by multistage hepatic metabolism, which is
more likely to be prolonged in older persons (Mangoni & Jackson, 2004). Some
drugs undergo hepatic metabolism then renal clearance. Such drugs (diazepam)
have enormously longer half-lives in the older adult because both systems are
impaired.
n Elimination or clearance of medications from the body may be slowed because of
decline in glomerular ltration rate, renal tubular secretion, and renal blood ow
that naturally decreases with age (Semla & Rochon, 2004). Decrease in clearance
prolongs drug half-life and leads to increase plasma concentrations (Gallagher
et al., 2007). A decrease in glomerular ltration is usually not accompanied by
an increase in serum creatinine because of decreasing lean muscle mass with age
and subsequent decline in creatinine production. Lack of dosage adjustment
for renal insuciency is a common reason for ADEs (Rochon, 2010). ere-
fore, serum creatinine is not an accurate measure of renal function in the older
adult. Instead, assessment of renal function using the Cockroft–Gault formula
(Table 17.2) should be calculated prior to initiation of renal clearing medica-
tions (Mangoni & Jackson, 2004; Semla & Rochon, 2004).
Beers Criteria
In 1999, the Centers for Medicare and Medicaid Services (CMS) incorporated the Beers
criteria into regulatory guidelines in long-term care (Lapane, Hughes, & Quilliam,
2007). Long-term care facilities can be cited if any of the drugs on the list are prescribed.
e Joint Commission (TJC) also adopted the criteria as a potential sentinel event
(2007) in hospitals.
332 Evidence-Based Geriatric Nursing Protocols for Best Practice
e Beers criteria address two key areas: (a) medications or medication classes that
should generally be avoided in persons aged 65 years and older; and (b) medications that
should be avoided in older persons with specic medical conditions. A severity rating of
high or low is given to each medication based on its potential negative impact on older
adults. e most recent Beers criteria, updated in 2003 by Fick et al., identies 48 medi-
cations or classes that should generally be avoided in persons older than 65 years, as well
as 20 specic medications that should not be used in the presence of specic conditions.
Inappropriate medications on the Beers list that resulted in ED visit for ADEs included
insulin, warfarin, and digoxin (Fu, Liu, & Christensen, 2004); these drugs are commonly
reported as high risk in other studies (see High-Risk Medications section). See “Try is”
series, issue numbers 16.1 and 16.2 at http://www.consultgerirn.org for Beers criteria.
Medications on the Beers inappropriate list have been shown to be associated with
poor health outcomes. Fick and colleagues (2003) reported that ambulatory older adults
prescribed with medications from the Beers list were more likely to be hospitalized
or evaluated in an emergency room than those not taking such medications. Other
studies report a positive association between potentially inappropriate drug prescribing
and ADRs in rst-visit older adult outpatients (Chang et al., 2005; Fu et al., 2004).
Although the Beers criteria for inappropriate medications are an excellent guideline
for assessing potential inappropriate medications, they need to be used in conjunction
with patient-centered care (Swagerty, Brickley, American Medical Directors Association
[AMDA], & American Society of Consultant Pharmacists [ASCP], 2005). A joint posi-
tion statement by the AMDA and ASCP points out that the Beers criteria are based on
consensus data (e.g., lower level of evidence) rather than on higher levels of evidence
such as systematic reviews or randomized controlled trials. Jano and Aparasu (2007)
found that use of inappropriate medications (Beers list) was associated with an increase
in ADRs and increased costs across settings; however, they suggest the predictive ability
of the criteria needs to improve.
Assessment for Potential Adverse Drug Reactions
ADRs commonly occur because of the number of medications taken (polypharmacy)
by older persons and their concomitant medical conditions. e severity of adverse reac-
tions increases because of changes in pharmacokinetics and pharmacodynamics in older
adults. Assessment for older adults’ risk of ADRs and potential drug–disease and drug–
drug interactions must be considered before initiating medications in the older adult.
Potential medication-related and patient-related risk factors for ADRs in older per-
sons were examined and reported by Hajjar and Kotchen (2003). A consensus panel of
four geriatric pharmacists and geriatric physician experts reviewed a list of evidence-based
risk factors compiled by two experts from the literature to ascertain older adult risk factors
for ADRs. e most prevalent risk factors identied are presented in Table 17.4.
e most preventable ADRs in the outpatient setting reported by Gurwitz and col-
leagues (2003) are cardiovascular medications followed by diuretics, nonopioids anal-
gesics, hypoglycemics, and anticoagulants. In 2005, the largest number of preventable
ADRs occurred at the prescribing or monitoring stages and includes wrong drug choices
or dosages, inadequate patient education, or clinically important drug–drug interac-
tions (Gurwitz et al., 2005). Monitoring for errors include inadequate evaluation of
drug levels and failure to respond to signs, symptoms, or abnormal lab levels indicative
of toxicity. Nurses can help to prevent ADRs in the acute care setting by monitoring
Reducing Adverse Drug Events 333
or recommending lab values, determining appropriateness of drugs and doses when
orders are written, and monitoring for signs and symptoms of toxicity. It is important
for nurses to understand that ADRs may be dicult to recognize as they often present
as atypical symptoms such as confusion, falls, lethargy, constipation, and depression
(Hanlon et al., 1997).
Drug–Drug Interactions
Concurrent use of more than one drug simultaneously, particularly those with similar
properties, can result in serious toxicities in older adults resulting in synergistic, addi-
tive, or antagonistic eects. For example, concurrent use of any two of the following
drugs: antiparkinsonian drugs, tricyclic antidepressants (e.g., amitriptyline), antipsy-
chotics (e.g., Haldol), antiarrhythmics (e.g., disopyramide), and OTC antihistamines
(e.g., diphenhydramine, chlorpheniramine) may cause or worsen dry mouth, gum
disease, blurred vision, constipation, urinary retention, and/or cognitive decits (Cusak
& Vestal, 2000).
TABLE 17.4
Risk Factors for Potential Adverse Drug Reactions in Older Adults
Medication-related factors
Class of medication
Anticholinergics
Benzodiazepines
Antipsychotics
Sedative/hypnotics
Non-ASA, non-COX-2 NSAIDs
TCAs
Opioid analgesics
Corticosteroids
Specific medication
Chlorpropamide
Theophylline salts
Warfarin salts
Lithium salts
Patient characteristics
Polypharmacy
Dementia
Multiple chronic medical problems
Renal insufficiency (CrCl ,50 ml/min)
Recent hospitalization
Advanced age (5 85 years of age)
Multiple prescribers
Regular use of alcohol (,1 fl oz/d)
Prior ADR
Note. ASA 5 acetylsalicylic acid; COX 5 cyclooxygenase; NSAlDs 5 nonsteroidal anti-inammatory drugs;
TCAs 5 tricarboxylic acid; CrCl 5 creatinine clearance; ADR 5 adverse drug reaction. From Hajjar, E. R.,
Hanlon, J. T., Artz, M. B., Lindblad, C. I., Pieper, C. F., Sloane, R. J., . . . Schmader, K. E. (2003). Adverse drug
reaction risk factors in older outpatients. e American Journal of Geriatric Pharmacotherapy, 1(2), 82–89. Reprinted
with permission from Elsevier. 61251.
334 Evidence-Based Geriatric Nursing Protocols for Best Practice
Little is known about the epidemiology of drug–drug interactions in clinical prac-
tice (Juurlink et al., 2003); however, studies indicate that drug–drug interactions are
a common cause of predictable ADEs (Hansten et al., 2001). Drug–drug interactions
have resulted in serious adverse events among several classes of medications. For exam-
ple, hypoglycemia resulted in around 900 patients out of 179,000 older patients treated
with glyburide along with co-trimoxazole, and 12 patients died. Digoxin toxicity was
experienced by more than 1,000 out of 230,000 patients admitted and 33 died while
hospitalized (Juurlink et al., 2003). ose with digoxin toxicity were 13 times more likely
to have received clarithromycin 1 week prior to hospitalization; suggesting avoidance of
concomitant use of digoxin and clarithromycin may have prevented the toxicity. In the
same study, concomitant prescribing of angiotensin-converting enzyme (ACE) inhibi-
tors and potassium-sparing diuretics 1 week before admission were observed in 622,285
older persons with ADRs. e researchers estimated that 7.8% of hospitalizations for
hyperkalemia could have been prevented if addition of potassium-sparing diuretics had
been avoided (Juurlink et al., 2003). In a retrospective review of the National Hospital
Ambulatory Medical Care Survey, Zhan and colleagues (2005) reported that older adults
with two or more prescriptions had at least one inappropriate drug–drug combination
present, and 6.6% of patients on warfarin were prescribed a drug with a potentially
harmful interaction. Other common drug–drug interactions reported in other research
are shown in Table 17.1.
Interactions With Over-The-Counter and Herbal Remedies
Drug interactions between prescription medications and herbal remedies or OTC med-
ications are often not reviewed during medication reconciliation, hospital admission,
or oce visits, yet 40% of all OTCs are consumed by older adults (Astin et al., 2000;
Kohn et al., 2000). In a survey of 1,001 older adults, up to 75% reported using OTCs
that increased as age increased. Twenty-three percent reported use of two or more OTCs
for chronic conditions in the past month; OTC use has increased over the last decade as
well as polypharmacy (Hanlon et al., 2001; Radimer et al., 2004; Sloane et al., 2002).
Community-dwelling older adults in the United States consume approximately
1.8 OTC medications per day (Hanlon et al., 2001). Herbal or dietary supplement
use such as ginseng, ginkgo biloba extract, and glucosamine is on the rise among older
adults, increasing from 14% in 1998 to 26% in 2002 (Kaufman, Kelly, Rosenberg,
Anderson, & Mitchell, 2002; Kelly et al., 2005). In a study examining community-
dwelling older adults’ use of prescription, OTC, and dietary supplements, 68% of older
adults used prescription medications concurrently with OTCs, dietary supplements, or
both (Qato et al., 2008). More than 50% of older adults used ve or more prescriptions,
OTC, or dietary supplements, concurrently. e prevalence rate of 5 or more prescrip-
tion medications increased steadily with age, and 1 in 8 older adults regularly used ve
or more dietary supplements. is substantially increases the risk of drug–drug inter-
actions in older adults (Qato et al., 2008). e researchers also reported 46 potential
drug–drug interactions with 11 classied as potentially of major severity, 28 classied
as moderate severity, and 7 as minor severity. Overall, 1 in 25 older adults (2.2 million)
were at risk for potential major drug–drug interactions. Half of all potential major
drug–drug interactions involved nonprescription medications (Qato et al., 2008).
e most commonly reported prescription or OTC medications, according to Qato
et al. (2008), included single or multicomponent products that were cardiovascular
Reducing Adverse Drug Events 335
drugs such as antihyperlipidemics, aspirin, hydrochlorothiazide, lisinopril, metoprolol,
and others; dietary supplements were primarily multivitamins or minerals. Alterna-
tive therapies included garlic, coenzyme Q, omega-3 fatty acids, and glucosamine-
chondroitin. In a review of herbal products and potential interactions with cardiovascular
(CV) diseases, Tachjian, Maria, and Jahangir (2010) described herbal remedies that
produce adverse eects on the CV system. ese include St. John’s wort, motherwort,
ginseng, ginkgo biloba, garlic, grapefruit juice, hawthorn, saw palmetto, danshen, echi-
nacea, tetrandrine, aconite, yohimbine, gynura, licorice, and black cohosh. Herbal
agents that interfere with digoxin levels include Chan Su, danshen, Asian and Siberian
ginseng, licorice, and uzara root. ose that may adversely interact with warfarin include
St. John’s wort, ginseng, ginkgo biloba, and garlic. Motherwort and BZDs together have
a synergistic sedative eect and can result in coma. Ginseng may have either a hypoten-
sive or hypertensive eect. Several other interactions are presented in this review.
St. John’s wort was reported as being in the top selling herbs in the United States
yet could potentially result in serious adverse reactions. Its eect on drug metabolism
induces the cytochrome p-450 enzyme system where many prescription medications are
metabolized. OTC and herbal supplements are typically not reported to medical pro-
viders as most consumers do not consider them medication and many health care pro-
viders do not ask about herbal remedies and OTC drugs (Astin et al., 2000; Gardiner,
Graham, Legedza, Eisenberg, & Phillips, 2006; Tachjian et al., 2010). Other concerns
are herbal products that lack scientic evidence of safety, lack regulatory oversight, and
there is an abundance of public misinformation (Tachjian et al., 2010). e implica-
tions for unidentied drug–drug and drug–disease interactions are astounding.
Medication Adherence
As individuals age, they may encounter diculties that decrease their ability to adhere
to medication regimens (e.g., vision impairment, arthritis, economics). Medication
adherence with older adults is complex and needs careful nursing assessment. ere are
a number of ways to assess for potential adherence-related problems (Bergman-Evans,
2006; Edelberg et al., 1999) as well as to ascertain if a patient is adhering to recom-
mended treatment (Rohay, Dunbar-Jacob, Sereika, Kwoh, & Burke, 1996). Barriers to
medication adherence include forgetting to take or limited organizational skills; belief
that the drug is either not needed, is ineective, or too many drugs are being taken;
patient has diculty taking such as opening bottles or swallowing; and cost (Steinman
& Hanlon, 2010). Several interventions are available in this systematic review but are
beyond the scope of this chapter. An array of devices can assist in enhancing adherence
behavior (Fulmer et al., 1999; Haynes et al., 2005; Steinman & Hanlon, 2010). See
Resources section for further information.
Reconciliation of Medications
Medication reconciliation (MR) conrms the patient’s current medication regimen and
compares this against the physician’s admission, transfer, and discharge orders to identify
and resolve discrepancies. Discrepancies between physician-acquired prescription medica-
tion histories and comprehensive medication histories at the time of hospital admission
were common, occurring in up to 67% of cases (Tam et al., 2005). Around 22% of medi-
cation discrepancies could have resulted in patient harm during their hospitalization and
336 Evidence-Based Geriatric Nursing Protocols for Best Practice
59% of the discrepancies could have resulted in patient harm if the discrepancy continued
after discharge (Sullivan, Gleason, Rooney, Groszek, & Barnard, 2005).
Poor communication of medical information at transition points of care (at admission,
transfer, and discharge) often results in medication errors, but appropriate strategies can
reduce the likelihood of errors (Santell, 2006). Adverse events were seen on transfer from
hospital to a nursing home in 20% of patients, particularly those readmitted to the nurs-
ing home (Boockvar et al., 2004). TJC has recommended standards for communicating
drug therapies to other levels of care and across the continuum (Nickerson, MacKinnon,
Roberts, & Saulnier, 2005). MR is often performed by pharmacists or nurses; however,
MR can be performed by a nurse with pharmacist collaboration or computer-based pro-
grams (Doucette et al., 2005; Gleason et al., 2004; Nickerson et al., 2005). Accuracy of
the list can mean the dierence between patient safety and patient harm.
e MR process includes comparison of medications on patient and family report
or admission and transfer documents with medication orders at the time of admission,
time of transfer to other units, or discharge to other levels of care. Barriers for nurses per-
forming MR reported in one study included lack of condence in existing institutional
safety systems, inconsistent practices (whether pharmacists are consulted or not), lack
of communication between health professionals, and stang concerns (MR is time con-
suming; Chevalier, Parker, MacKinnon, & Sketris, 2006). e brown bag method can
be used for corroborating medications (Nathan et al., 1999) with community-dwelling
older adults, when used in conjunction with a good medication or admission history.
At discharge, the pharmacist has been involved in identifying problems with drug
therapy and communicating with the community pharmacy, medical provider, or
admitting sta at the transitional site of care (Hanlon et al., 2001; Nickerson et al.,
2005). A systematic review across many health care settings and at home found that
interventions by clinical pharmacist showed a considerable reduction in drug-related
problems as well as reduced morbidity, mortality, and health care costs (Hanlon, Lind-
blad, & Gray, 2004). Many hospital pharmacies are now linked electronically to health
care providers and/or local pharmacies. Finally, discharge education and counseling
to patients including assessment of factors that might aect adherence has shown to
reduce ADEs (Hanlon et al., 2001) and methodologies known to enhance understand-
ing such as “teach back” especially low-literacy populations (Schillinger et al., 2003).
See Resources section for evidence-based information on medication reconciliation.
High-Risk Medications
Many studies have revealed common high-risk medications in older adults. Special
attention should be paid to drugs that carry a high risk of serious adverse eects such
as warfarin, hypoglycemic drugs, and digoxin that result in one-third of all emergency
room visits for ADEs (Steinman & Hanlon, 2010). Additionally, taking BZDs is an
independent risk factor for falls; diphenhydramine (Benadryl) may lead to impaired
cognition or urinary retention (in men); and antipsychotics may lead to falls, death,
or pneumonia (Steinman & Hanlon, 2010). Antipsychotics and other psychotropics
are also associated with an increased risk for falls (Rochon et al., 2007). Nurses should
become familiar with high-risk medications and medication classes prescribed for older
adults in order to aid in preventing ADEs. Many tools are available for the nurse to
assess for high-risk medications, for potential drug–drug, drug–disease, or drug–herbal
interactions. Common high-risk medications are discussed in the following sections.
Reducing Adverse Drug Events 337
Warfarin
Warfarin has been identied throughout many research studies as among the highest
risk medications taken by older persons (Gaddis, Holt, & Woods, 2002; Hanlon et
al., 2006). Warfarin leads to ED visits, preventable hospital readmission, and adverse
events after discharge (Alexopoulou et al., 2008; Budnitz et al., 2006; Howard et al.,
2007; Pirmohamed et al., 2004).
Together, polypharmacy and warfarin use consistently
increases the risk of ADRs (Hanlon et al., 2006).
Warfarin is highly bound (approximately 97%) to plasma protein, mainly albumin.
e high degree of protein binding is one of several mechanisms whereby other drugs
interact with warfarin (Olson et al., 2010). ose with malnutrition and low albumin
levels are at risk for unbound warfarin in the bloodstream and higher risk of bleed-
ing. Warfarin is metabolized by hepatic cytochrome P450 isoenzymes predominately
to inactive metabolites excreted in the bile; it is also excreted by the kidneys. Warfarin
metabolism may be changed in advanced age and in the presence of liver problems.
Drug interactions are extensive and includes (a) drugs that inhibit warfarin metabolism
and prolong prothrombin time (e.g., Cipro, phenytoin, amiodarone); (b) drugs that
inhibit vitamin K activity (e.g., cephalosporins and high-dose penicillins); (c) additive
eects with other anticoagulants such as aspirin, Lovenox, and others; and (d) drugs that
reduce the eectiveness of warfarin such as phenytoin, barbiturates, cholestyramine,
and others (Olson et al., 2010).
Fifty-eight percent of older persons do not report use of herbal supplements. Com-
monly used herbal remedies (ginkgo biloba and garlic) interact with warfarin to aug-
ment its anticoagulant eect and may lead to serious bleeding problems (Astin et al.,
2000; Miller, 1998). Many foods may interact with warfarin, specically those with
high vitamin K content such as chickpeas, spinach, and green tea (Miller, 1998). It is
imperative to identify older adults on warfarin who fall or are at risk for falling as their
risk of serious injury increases on warfarin. e risk of harm versus the benet must be
weighed and the nurse should clarify the risk versus benet with the primary prescriber
(Steinman & Hanlon, 2010).
Antihypertensive Agents
Hypertension aects approximately two thirds of individuals older than age 65 years
but only 27% of people have adequate control. Physiological changes of aging can alter
the pharmacokinetics and pharmacodynamics of cardiovascular drugs in older persons,
thus increasing the risk of ADEs (Nolan & Marcus, 2000). e antihypertensives, as
a class, tend to produce a variety of unintended eects including orthostatic hypoten-
sion (associated with diuretics and alpha-blockers), sedation and depression (associated
with some beta-blockers), confusion (associated with alpha-blockers), impotence, and
constipation (e.g., verapamil). Comprehensive and ongoing assessment for potential
adverse eects (e.g., routinely checking orthostatic blood pressure) is key to monitor-
ing drug ecacy and safety while hospitalized. Nurses should monitor for symptoms
such as dizziness and lightheadedness on standing. e use of four or more medications
should prompt the measurement of postural blood pressure (Tinetti & Kumar, 2010).
Particular attention should be given to the possible discontinuation or dose reduction
of medications known to increase orthostasis or fall risk.
Dose for dose, water-soluble compounds are more potent in aging persons, whereas
fat-soluble drugs (such as propranolol and carvedilol) can be expected to have an
338 Evidence-Based Geriatric Nursing Protocols for Best Practice
extended half-life because of their higher volume of distribution. Because of changes
in fat or lean body mass, older adults may require an increase in dosing intervals of
fat-soluble beta-blockers. Additionally, because of age-related changes that decrease the
integrity of the blood–brain barrier, it predisposes older adults to untoward events with
alpha-agonists. Bronstein and colleagues (2008) reported lipid soluble beta-blockers
that have marked antidysrhythmic eects more lethal (e.g., propranolol, oxprenolol).
e lethality signicantly increases when given with calcium channel blockers, cyclic
antidepressants, and/or psychotropics, even if the amount of beta-blocker is relatively
small (Bronstein et al., 2008).
Orthostatic hypotension is a serious problem that can aect older adults on con-
tinuous antihypertensive therapy. Sustained treatment renders them more susceptible to
diuretic-induced dehydration and orthostatic changes. Orthostasis may also be caused
by concomitant illness (e.g., infection). e known sequelae of orthostatic hypotension
in older adults include falls that is a true trauma and a medical emergency in physically
frail, anticoagulated, or functionally compromised older adults. Orthostatic hypoten-
sion is an independent risk factor for recurrent falls in nursing home residents (Ooi,
Hossain, & Lipsitz, 2000).
Psychoactive Drugs
Mental health disorders are not part of normal aging. Nearly 20% of persons older
than age 55 years experience mental disorders with the most common prevalence being
anxiety, severe cognitive impairment, and mood disorders, respectively. Mental disor-
ders are underreported and suicide rates are highest among older adults compared to
younger adults. Adults older than age 85 years have the highest suicide rates of all—
more than twice the national rate.
Sedative–hypnotic drugs signicantly increase risk for adverse events in older adults
and should generally be used sparingly and monitored very closely. BZDs, regardless
of half-life, have been associated with cognitive impairment, hip fractures, and falls
(Bloch et al., 2011; Hajjar et al., 2003). In a prospective study of 9,093 patients, older
adults who take BZDs are at greater risk for mobility problems and ADL disability, and
short-acting BZDs did not appear to improve safety benets over long-acting agents
(Gray et al., 2006). Higher plasma concentrations of sedatives and hypnotic are seen
because of increased volume of distribution as well as increased sensitivity, including
BZDs and opioids (Rochon, 2010). e likelihood of falls with fractures is more than
twice as high for the long-acting BZDs than short-acting agents. Likewise, Tamblyn,
Abrahamowicz, du Berger, McLeod, and Bartlett (2005) reported that 17.7% of older
persons given at least one prescription for BZDs at hospital discharge were treated for
at least one injury on follow-up visit of which fractures were the most common. In a
study of intubated ICU patients, lorazepam was identied as an independent risk factor
for development of delirium (Pandharipande et al., 2006). Oversedation, respiratory
depression, confusion, and other alterations in cognitive capacity, as well as falls, are
frequently associated with sedative-hypnotic drug use. (See Chapter 15, Fall Prevention:
Assessment, Diagnoses, and Intervention Strategies.)
Psychoactive medications include antidepressants (tricyclics, selective serotonin
reuptake inhibitors [SSRIs]), anxiolytic agents (e.g., diazepam, lorazepam), antipsy-
chotics (also referred to as neuroleptics), mood-stabilizing compounds (lithium), and
psychoactive stimulants. Psychoactive compounds are prescribed to stabilize mood,
Reducing Adverse Drug Events 339
agitated behaviors, and for therapeutic eects in clinical depression. Mood stabilizers
and psychoactive stimulants are known to have a relatively narrow therapeutic window
even in younger adults. Lithium, in particular, requires very close monitoring of levels
and signs of toxicity in older adults; it also interacts with many other drugs. Some unin-
tended interactions may be prevented if age-related changes are considered and careful
surveillance is part of routine care (Budnitz et al., 2006).
e half-life of psychoactive drugs is prolonged in older adults and, in general, this
class of drugs must be used with extreme caution to avoid inducing delirium, falls, and
other traumatic events. In a systematic review, medications strongly linked with falls
included sedatives, hypnotics, BZDs, and antidepressants (Woolcott et al., 2009). A sig-
nicant association between falls and psychotropic medications has also been reected
in two other meta-analyses (Bloch et al., 2011; Leipzig, Cumming, & Tinetti, 1999).
Drug classes determined to be a risk factor for falls included psychotropics, antidepres-
sants, BZDs, hypnotics, neuroleptics, and tranquilizers. Risk seemed to be more sig-
nicant for adults older than age 80 years in each of the classes. Drug classes that had
double the odds of traumatic falls included neuroleptics, antidepressants, and BZDs.
An extensive list of specic drugs for each class is listed in the review by Bloch et al.
(2011). Although antianxiety agents such as BZDs and sedative-hypnotics are gener-
ally overprescribed for older adults, the antidepressants are generally considered to be
underprescribed. It is estimated that almost 15% of older persons living in the commu-
nity, 5% in primary care, and 15%–25% in nursing homes have signicant depressive
symptoms (Spina & Scordo, 2002).
e SSRIs, as a class of antidepressants, have strikingly dierent side eects than
other antidepressants (e.g., tricyclics). is class does not cause cardiotoxicity or ortho-
static hypotension and does not have anticholinergic eects as do tricyclic antidepres-
sants. In general, these drugs tend to be a better choice of antidepressants in older
adults. e most common side eects are GI related (nausea, anorexia) that may be
ameliorated by starting with a low dose (half that for younger adults; e.g., uoxetine
5 mg) and slowly increasing (e.g., to 10 mg) after 1 week. A serious but uncommon
sequelae of SSRIs is serotonin syndrome. is syndrome may occur if more than one
antidepressant is prescribed with an SSRI or if concurrent use of St. John’s wort, a com-
monly self-administered OTC herbal remedy for depression.
e antipsychotics are often used inappropriately as rst-line treatment for persons
older than age 65 years presenting with agitation and behavioral problems associated
with dementia (Kindermann, Dolder, Bailey, Katz, & Jeste, 2002). Evidence-based
recommendations suggest the underlying cause of agitation should be determined (may
be caused by delirium or pain) and nonpharmacological interventions attempted prior
to administering antipsychotics such as Haldol (Zwicker & Fletcher, 2009).
Most antipsychotics are not U. S. Food and Drug Administration (FDA) approved
for agitation (without a psychotic diagnosis) and data on their eectiveness suggest
that the risk is greater than the benet (Leipzeig et al., 1999; Woolcott et al., 2009).
Antipsychotics must be used with extreme caution in this population, largely because
of the potential for development of abnormal, and often irreversible, involuntary move-
ments (extrapyramidal symptoms) associated with their administration and increased
risk for falls. e newer antipsychotics present a much lower risk of extrapyramidal
movement disorders than conventional antipsychotics. Unlike conventional antipsy-
chotics, the newer atypical ones (e.g., clozapine, risperidone, olanzapine, and quetiapine)
apparently provide several advantages with respect to both ecacy and safety.
340 Evidence-Based Geriatric Nursing Protocols for Best Practice
A major study examining the eectiveness of antipsychotic use in Alzheimer’s
disease concluded that the adverse eects are greater than the advantages of these thera-
pies (Schneider et al., 2006). In 2004, the FDA issued a warning against o-label use
of antipsychotics for dementia-related psychotic symptoms because of potential adverse
eects. Data from the CMS indicate that newer atypical antipsychotic medications,
compared to older antipsychotics, do not appear to be associated with an increased risk
of ventricular arrhythmias or cardiac arrest (Liperoti et al., 2005). Psychotropic medica-
tions are associated with an increased risk for falls (Gurwitz et al., 2005). Drug–drug
interactions with antipsychotics are common.
Anticholinergics
Medications with high anticholinergic properties must be used with great caution in
older adults because of adverse eects such as inability to concentrate to frank delirium,
agitation, hallucinations, blurred vision, slowed GI motility, decreased secretions, uri-
nary retention, tachycardia, impaired sweating, and constipation (Rochon, 2010; Spina
& Scordo, 2002; Terrell et al., 2006; Tune, 2001). Studies have reported that patients
with dementia are at higher risk for delirium associated with anticholinergics; however,
a recent study indicates that use of anticholinergic drugs is “independently
and speci-
cally” associated with a subsequent increase in delirium
symptom severity in older medi-
cal inpatients (Han et al., 2001).
Urinary retention, resulting from an anticholinergic, can be a lethal side eect in
a male with benign prostatic hypertrophy (BPH) and a history of UTIs; urosepsis and
death may result in men. Catterson and colleagues (1997) discussed the vicious cycle
of treatment and/or iatrogenesis that may occur with administration of anticholinergic
drugs. An illustrative example is an older adult with dementia and BPH who is admin-
istered diphenhydramine (Benadryl) for sleep and who is also taking oxybutynin
(Ditropan), both of which have anticholinergic properties. e additive eects of the
two medications may lead to urinary retention and agitation that may, in turn, lead to
treatment of the agitation with antipsychotics (which also have anticholinergic eects)
and exacerbate the problem and cascade of events further. Rochon (2010) refered to this
as the “prescribing cascade” that leads to cascade iatrogenesis.
Anticholinergic properties occur not only in antidepressant and antipsychotic
medications, as previously mentioned, but are also properties of most OTC antihis-
tamines and sleep aids, intestinal and bladder relaxants, corticosteroids, antihyperten-
sives, antiarrythmics and other cardiovascular drugs, and some antibiotics. See Tune
(2001) or Kemper, Steiner, Hicks, Pierce, and Iwuagwu (2007) for a list of medications
with anticholinergic eects. An anticholinergic risk scale (ARS) has been developed by
Rudolph, Salow, Angelini, and McGlinchey (2008) to identify older adults at highest
risk for adverse eects from anticholinergic drugs.
Cardiotonics
Digoxin is useful in treating CHF because of systolic dysfunction in the older adult but is
not the recommended treatment for CHF from underlying diastolic dysfunction in older
adults. Digoxin toxicity occurs more frequently in older adults, presents atypically, and
may result in death. Juurlink and colleagues (2003) reported that about 2.3% of cases of
digoxin toxicity could have been prevented in hospitalized older adults. Ahmed, Allman,
and Delong (2002) reported that digoxin is often prescribed inappropriately in hospital
Reducing Adverse Drug Events 341
patients. Classic symptoms of digoxin toxicity (nausea, anorexia, visual disturbance) may
occur; however, symptomatic cardiac disturbance and arrhythmias are more common in
the older adult and are not often thought to be caused by digoxin toxicity. Older adults
may experience toxicity symptoms even with normal plasma levels of digoxin (Flaherty,
Perry, Lynchard, & Morley, 2000). Many older people will have some reduction in renal
function with aging; therefore, monitoring for symptoms, especially atypical symptoms of
digoxin toxicity, and monitoring renal function and potassium levels is important.
Particular caution must be exercised when digoxin is prescribed with diuretics;
this combination can cause hypokalemia and exacerbate renal impairment that can
potentiate digoxin toxicity. Because the therapeutic window for digoxin is narrow and
because it is water-soluble (e.g., the drug has a smaller volume of distribution and, thus,
higher plasma concentration), correct and safe dosing of older adults is challenging.
e maximum recommended dose in older persons for treating systolic heart failure is
0.125 mg (Fick et al., 2003). Debilitated older adults who often have low serum albu-
min levels are at risk for higher plasma level and digoxin toxicity.
Despite the recommendation that ACE inhibitors (ACEIs) should be prescribed
for all patients with heart failure because of left ventricular or systolic dysfunction and
who have normal renal function (Packer et al., 1999), Sloane and colleagues (2002)
found that 62% of adults in assisted living residents (n 5 2,014) were not on an ACEI.
Monitoring of renal function and serum potassium should continue as the ACEI dose is
titrated up. Rarely do older patients on an ACE inhibitor need potassium supplementa-
tion, the combination of which can be lethal. Juurlink and colleagues (2003) reported
that 523 out of 1,222,093 patients on ACEIs were hospitalized with hyperkalemia; of
these patients, 21 died while hospitalized.
Hypoglycemic Agents
Hypoglycemic agents carry a high risk of serious adverse eects in older adults. Control
of blood glucose level is paramount to prevent microvascular and macrovascular com-
plications of diabetes. However, the use of general disease-specic evidence guidelines
for diabetic control can lead to overmedication in older adults. Tight glycemic control
in advance age or in older person with multiple comorbidities can result in greater harm
than benet (Greeneld et al., 2009; Steinman & Hanlon, 2010).
e American Geriatrics Society (AGS) has issued guidelines for improving the care
of older people with diabetes (Brown, Mangione, Saliba, Sarkisian, & California Health-
care Foundation [CHF]/American Geriatrics Society [AGS] Panel on Improving Care
for Elders with Diabetes, 2003). ey suggest that the risks of intensive glycemic con-
trol, including hypoglycemia, polypharmacy, and drug–drug and drug–disease interac-
tions, may signicantly alter the risk–benet equation. For frail older adults, persons with
limited life expectancy, and others in whom the risks of intensive glycemic control appear
to outweigh the potential benets, a less stringent target than the American Diabetes
Association (ADA) recommendation of 7% or 8% in frail older adult is appropriate. Oral
agents with shorter half-life are also recommended and insulin is less often recommended
because of vision changes and common arthritic conditions, unless it is provided in pre-
lled syringes. Metformin is not recommended for those older than age 80 years because
it may lead to metabolic acidosis. Blood pressure and lipid control, however, are recom-
mended to help reduce microvascular and macrovascular problems along with a daily low-
dose of aspirin (Greeneld et al., 2009; Steinman & Hanlon, 2010).
342 Evidence-Based Geriatric Nursing Protocols for Best Practice
Over-The-Counter Medications
Self-medication with OTC medications, herbal remedies, and dietary supplements
may lead to adverse drug–disease interactions and drug–drug interactions (Astin et al.,
2000; Rochon, 2010). Neafsey and Shellman (2001) found that 86% of sample of
168 older adults attending a hypertension clinic reported at least two or more self-
medication practices that could result in an adverse drug interaction. In the United
States, community- dwelling older adults take about as many OTC drugs as prescrip-
tion drugs (Hanlon et al., 2001). Salicylates, such as aspirin, are a signicant concern
regarding ADRs in older persons. In a study of 18,820 patients, 18% of all ADR hos-
pital admissions were aspirin-related and low dose aspirin was implicated most often
(Pirmohamed et al., 2004). In combination with alcohol, because of its water solubility,
age-related renal insuciency can worsen and result in chronic salicylate intoxication.
Cold remedies that include alcohol are a signicant source of drug potentiation in aging
adults. Indeed, alcohol consumption is frequently omitted from history taking of older
adults, even though it interacts with OTC and prescription medications in frank and
subtle ways to produce unintended drug harm.
e OTCs most commonly implicated in hospital admissions are low dose aspirin
and nonsteroidal anti-inammatory drugs (NSAIDs; Pirmohamed et al., 2004). e
FDA has been evaluating OTC ingredients and labeling of OTCs; however, it is a long-
range project and yet to be seen if the FDA will be more specic on safety issues that
relate to older adults. Astin and colleagues (2000) reported that 24% of seniors use
herbal remedies (the most common being ginkgo biloba and garlic), and 58% did not
report usage to their primary provider. Ginkgo biloba and garlic interact with warfarin
to augment its anticoagulant eect and may lead to bleeding (Miller, 1998); the poten-
tial adverse consequences are staggering.
INTERVENTIONS AND CARE STRATEGIES
Comprehensive Medication Assessment and Management
Medication assessment begins with a thorough drug history and assessment obtained
from the older adult or a reliable informant. Medication history errors occur in up
to 67% of patients at the time of admission to the hospital and increased up to 83%
when nonprescription drugs were included (Tam et al., 2005). is suggested a need
for systematic approach to accurate medication histories at the time of admission. No
studies provide a systematic approach to history taking, although specic aspects of the
medication assessment include the following evidence-based activities:
n Obtain a complete medical history and validate that the medication history is true (Lau,
Florax, Porsius, & De Boer, 2000), ascertaining the numbers and types of medica-
tions typically consumed, as well as an estimate of how long it has been taken.
n Nathan and colleagues (1999) recommended that older adults bring all their
medications and OTCs to provider or hospital or other health care setting
in a brown bag in order to document medication types, instructions for self-
administration, dates, and duration of the drug regimen. is method fosters
identication of multiple prescribers and dispensing pharmacies and can signal
polypharmacy and/or possible substance abuse, particularly regarding analgesics,
anxiolytics, and sedative hypnotics.
Reducing Adverse Drug Events 343
n Focused questions by the clinician should address nicotine and alcohol use,
as well as vitamins, herbal remedies, and OTC medications that are routinely
used (Astin et al., 2000; Lau et al., 2000). is information should be included
in the medication prole. (See Table 17.3 for a suggested medication history
or visit http://www.consumermedsafety.org/tools/Keeping_Track_of_Your_
Medications.pdf.)
n Ask detailed questions about OTC and “recreational” drugs, alcohol use, and
herbal or other folk remedies. Provide a list of herbal remedies and folk medi-
cines to choose from (Tachjian et al., 2010). Be specic about the actual amount
and under what circumstances these substances are used. Accurate information
can help explain symptoms that otherwise may not make sense. Evaluate for
duplicate medications or classes that occur because of unrecognized trade names
versus generic names, and OTCs with the same active ingredients in them, espe-
cially acetaminophen (Astin et al., 2000).
n Perform MR to verify actual medication regimen at hospital admission and dis-
charge and across the continuum of care (Gleason et al., 2004; Nickerson et al.,
2005; Tangalos & Zarowitz, 2006).
n Patients are often reluctant to admit to nonadherence; however, pill counts and
rell history can aid in determining this issue (Steinman & Hanlon, 2010).
Employ a medication discrepancy tool to facilitate discrepancy across settings
(University of Colorado Health Sciences Center, 2005).
n Monitor new symptoms and consider their likelihood of being caused by an
ADR before adding new medications to treat the symptom (Petrone & Katz,
2005; Rochon, 2010) prior to requesting a new medication to treat symptoms;
avoid the prescribing cascade.
n Attempt a trial of nonpharmacological interventions and treatments prior to request-
ing medication for new symptoms (e.g., agitation). Nurses often make these recom-
mendations when notifying primary provider for a new problem or symptom.
n Continually monitor for possible toxicity to those drugs with high prevalence rate
of toxicity (see Beers criteria; Beers, 1997; Beers et al., 1992). PDA technology
can help nurses assess high-risk medications such as facts and comparisons.
n Consider medications as the underlying cause when falls occur. Particularly,
consider recently added medications that are high risk for causing falls such as
diuretics and psychotropics.
n Collaborate with the interdisciplinary team to eect change in reducing the
numbers of ADEs and ADRs, many of which are preventable (Hanlon et al.,
2001). Although many studies describe and recommend an interdisciplinary
approach as the best method for improving drug treatment outcomes, most do
not delineate the specic role or function of the individual team members nor do
they measure outcomes of the team (Lam & Ruby, 2005; Williams et al., 2004).
Recommendations to consider for an interdisciplinary approach include a medi-
cation care team (nurse, pharmacist, primary physician/nurse practitioner, social
worker) with specic functions assigned to review medications at admission and
discharge utilizing evidence-based recommendations. Discharge interventions
may be performed by various team members including the following:
Reminder systems may be instituted by pharmacists in collaboration with
nurses as reported eective by Muir, Sanders, Wilkinson, and Schmader
(2001). A visual intervention (medication grid) was delivered to physicians to
344 Evidence-Based Geriatric Nursing Protocols for Best Practice
see if it could reduce medication regimen complexity, and researchers report
that the simple intervention had a signicant impact on medication regimen
complexity in older adults.
Pharmacist may also review (preferably using a computer-based program)
medication list at admission, when new medications are added and prior to
discharge for potential drug–drug interactions, drug–disease interactions,
and/or inappropriate medications for older adults.
Age-specic alerts sustained the eectiveness of drug-specic alerts to reduce
potentially inappropriate prescribing in older people and resulted in a
considerably decreased burden of the alerts (Simon et al., 2006).
Computerized physician order entry system has the potential to prevent an
estimated 84% of dose, frequency, and route errors. Anywhere from 28% to
95% of ADEs can be prevented by reducing medication errors through com-
puterized monitoring systems (AHRQ, 2001).
Medication interaction alerts may reduce the frequency of coprescribing of
interacting medications (Feldman et al., 2006).
Pharmacist may also function as the communicator of the hospital drug regimen
to community pharmacy, primary care provider, and/or other levels of care.
Social worker may review issues at home such as access to medications, costs,
caregiver support, and barriers to discharge interventions.
n Nurses and other interdisciplinary members need to be proactive participants in
reducing rehospitalization related to ADEs and implement discharge education
and counseling to patients including the following:
Assess cognitive and aective status to assure that memory problems or vegeta-
tive symptoms associated with depression are not interfering with the safe
use of prescription drugs (see Chapter 8, Assessing Cognitive Function, and
Chapter 9, Depression in Older Adults).
Assess abilities and limitations such as functional ability, including the ability
to read the medication label, to open the medication container, and consume
or self-administer the prescribed medication as intended (Curry, Walker,
Hogstel, & Burns, 2005; see Chapter 6, Assessment of Physical Function, and
Chapter 8, Assessing Cognitive Function). e plan of care should address
actual and potential problems and the need for reassessment at regular inter-
vals and after major medical events (e.g., cerebrovascular accident [CVA] or
delirium).
Devices to accommodate some impairments or barriers may be recommended.
For example, tamperproof lids are often dicult for older adults to remove,
particularly if there are arthritic changes. A simple request to the pharmacist
to provide a nonchildproof lid may improve the safe and eective use of pre-
scribed medication. Consult with occupational therapy.
Assess health literacy (Curry et al., 2005). Query whether the older person
understands what the drug is to be used for, how often it is to be taken,
circumstances of ingestion (e.g., with food), and other aspects of drug self-
administration that signal intelligent drug use; use teach-back method to ver-
ify understanding (Hutchison et al., 2006; Schillinger et al., 2003).
Assess for ability to recognize generic versus brand name medication and their use
(Curry et al., 2005). Ask the older adult to describe circumstances in which
the medication was not used or was used dierently than prescribed. If the
Reducing Adverse Drug Events 345
older adult cannot describe medication use, consider removing the drug or
provide written instruction for the home (Muir et al., 2001).
Assess beliefs, concerns, and problems related to the medication regimen. Ask
older adult if she or he believes that the drug is actually doing what it is
intended to do. If the medication is not useful, not creating symptom relief,
or causing adverse eects, consider removing it or replacing it with a more
acceptable substitute.
Discuss the impact of medication expenses. Many medications particularly those
that are new to the market can be prohibitively expensive, particularly for per-
sons on xed incomes. Discuss inuence of TV ads. Ask the older adult what
concerns they have about the costs and risks of administration (Curry et al.,
2005). In addition, discuss Medicare Part D concerns or confusion. Where
economic problems are identied, generic drugs and other avenues should be
explored to manage the cost issue.
Consider instrumental issues related to drug use, such as availability of family
members or other social supports to facilitate medication adherence, and who
monitors the need to change specic medications dictated by third-party
reimbursement and medication coverage plans.
n Patients should be given the necessary information and the opportunity to exer-
cise the degree of control they choose over health care decisions that aect them
and the necessary information to eectuate this. Patients who are informed and
are involved in decision making are less likely to make decisions that may lead to
ADRs, such as abruptly discontinuing a medication that should be tapered o
slowly (NCC MERP, 2001).
Mr. Jones is an 82-year-old male admitted 2 days ago for a surgical repair of a left hip
fracture he sustained when he fell as he was getting dressed at home. He is currently
preoperative on the surgery schedule for tomorrow morning. He has a history of multi-
infarct dementia, atrial brillation, hypertension, and was noted to have intermittent
runs of premature ventricular contractions on his last admission 3 months ago, but
has had no further cardiac symptoms since then. He was transferred to the orthopedic
unit yesterday from the ED at 6 a.m. after having spent the night for nursing observa-
tion. While in the ED, he received both Haldol 5 mg and Ativan 2 mg IV for severe
agitation. His wife says that when he is at home, he is usually able to make his needs
known but was “out of sorts” yesterday, very tired, and in noticeable pain after he
fell. She tells you he is now “out of his mind” compared to how he was when she rst
brought him to the ED and has become progressively worse cognitively.
e sta nurse from the day shift––giving you report––tells you he has not slept at all,
refused to eat anything, and that during her shift, he has become increasingly agitated and
combative. He was given Haldol 5 mg at 2 p.m. and is currently restrained. She reports he
was so agitated that they had to get security to help the sta. It is now 4:00 p.m. and you
are doing your assessment of Mr. Jones. You rst awaken him and assess his mental status,
CASE STUDY
(continued)
346 Evidence-Based Geriatric Nursing Protocols for Best Practice
talking to him in a calm, gentle voice. You note he is lethargic with an inability to sustain
attention. He is disoriented to place and time and cannot remember how old he is. He is
afebrile, with a blood pressure (BP) of 140/72, heart rate (HR) of 45 beats per minute
(bpm), and respiratory rate (RR) of 22 breaths per minute. Both of his upper extremities
are in soft restraints. He is on a cardiac monitor that indicates he has bradycardia with a
rate of 48 bpm; however, his rate increases to 57 bpm when he begins to wake up.
What Would You Do Next?
You decide to re-review his medication list and see what he is taking. His medications
are as follows:
Carvedilol CR 20 mg daily
Digoxin 0.125 mg daily
Amiodarone 400 mg daily
Warfarin 5 mg daily 3 5 years with normal INR
Aricept and Namenda (dose unknown) daily
You also look at his lab results and nd his blood counts and uid and electrolytes are
within normal limits except for potassium of 3.2 mEq/L.
You quickly notify the hospitalist and ask her to come and see the patient imme-
diately because of his low heart rate and change in mental status. When she gets to
the unit, you also ask her to discontinue the restraints and PRN Haldol and Ativan.
As you suspect, he is now overmedicated and, further, your calm voice seems to be
enough to prevent agitation. You are not only concerned that his agitation is caused
by untreated pain from his hip fracture but are also concerned about giving any pain
medication that he has not received since admission because of his lethargy. At pres-
ent, the patient is not showing nonverbal signs of pain.
CASE STUDY DISCUSSION
Initial Nursing Assessment and Interventions
You are on the right track, performing baseline vital signs, looking at a rhythm strip,
and comparing Mr. Jones’s vital sign results to prior readings. Your assessment, includ-
ing a review of his medications, lab results, considering a change in baseline mental
status, and considering pain as a reason for mental status change were the correct
assessment parameters, and each give clues about the potential underlying causes of
his current mental state. Untreated pain can cause delirium exhibited by agitation and
may cause a cancellation of the surgery—something that nobody wants. Had the gen-
tleman been treated for pain rather than agitation, he might have presented as com-
fortable and oriented, given that the correct medication and dosage were given. e
dose of Haldol was too high, and should be initiated at 0.5 mg (not 5 mg), although
it is not FDA approved for agitation nor benecial unless the patient is psychotic or
trying to harm another person or himself. e maximum dose is 3 mg/day for older
CASE STUDY (continued)
(continued)
Reducing Adverse Drug Events 347
adults. Demerol is contraindicated in older adults for pain and the best choice would
be morphine or a small dose of Dilaudid if morphine allergic.
You are also correct in your approach to a patient who is or has been agitated—
using a calm, soothing approach and removing the restraints that can exacerbate agi-
tation and are most often unacceptable in the practice setting and considered a poor
substitute for nursing care. Had his blood pressure been signicantly lower than his
baseline, calling rapid response would have been indicated and may still be depending
on how Mr. Jones presents over the next several hours.
Interventions
While waiting for the hospitalist to arrive on the unit, you continue to assess his vital
signs and mental status. Next, you access the bedside computer for the internet to try
to determine what the potential underlying causes are for Mr. Jones’s presentation.
You review the potential side eect of the medicines and discover that Carvedilol has
both alpha- and beta-blocking eects and was probably prescribed to address both his
hypertension as well as for rate control of the atrial brillation. Taking this drug with
digoxin and amiodarone can lead to a drug–drug interaction by an additive eect and,
therefore, lower the heart rate; fortunately, it is not seriously aecting his blood pressure
while he is in bed. Once he is stabilized, orthostatic blood pressure should be checked,
knowing that his pressure may drop upon standing, which could provoke an additional
fall. In addition, you learn that a common unknown side eect of the dementia medica-
tions (e.g., Namenda and Aricept) is bradycardia. Finally, you realize his low potassium
may also aect cardiac conduction. You remind the team that Mr. Jones fell at home,
and that is what brought him in for surgery. You suggest to the hospitalist that she may
want to ask the primary care physician about the risk and benets of continuing the
warfarin while Mr. Jones is at risk for falls. You also suggest that the surgeon be alerted
to Mr. Jones’s condition, in the event that Mr. Jones is not able to tolerate the surgi-
cal intervention in his current state of agitation, exhaustion, and with his potassium
depleted. You also determine a need to reconcile with his wife whether he was taking
any medications that may lower his potassium that may have been missed on the initial
reconciliation. You will ask her to bring his medications and OTCs in a brown bag.
Many nurses may say “this is the physician’s job” or “this is up to the pharmacist”
to determine the potential adverse eects of the drugs. However, nurses are at the
bedside 24 hours a day, and have a more comprehensive picture of how the patient is
responding to nursing care, medication, and therapies while admitted. Armed with
knowledge about geriatric syndromes and atypical presentation in older adults, nurses
can be pivotal and instrumental in the early identication of patients at risk. Addi-
tionally, the patient advocate that the role nurses play is a major component of the
safety and quality movement underway in care settings nationally. Of course, reaching
out for expert consultation from other team members will always enhance the plan
of care, but the more nurses learn about best practices for geriatric patients and the
geriatric resources available, the more it becomes a routine to identify risk factors for
ADEs and other geriatric syndromes discussed in this text. Nurses are key members of
the interdisciplinary team promoting a safe environment for patients.
CASE STUDY (continued)
348 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Nurses have the unique opportunity to intervene and improve safety by focusing on the
prevention of ADEs in older adults. Traditionally focused on “caring,” nurses have taken
the lead in implementing preventive strategies on behalf of the patient. Although acute
care nurses are not typically prescribers, unless they are advanced practice nurses (APNs)
with prescriptive authority, they have always reviewed and conrmed medication orders,
carried them out, and alerted the primary provider of concerns or problems with medi-
cations. Nurses have always ensured a culture of safety by advocating for their patients
and must continue to be proactive in doing so. Nurses are also responsible for identify-
ing wrong drugs, dosages, and so on prior to administering them. Given that nurses
are at the bedside 24/7, they can make medication suggestions to prescribers based on
their holistic knowledge of the patient and recognition of new symptoms. Nurses are
the primary source for providing discharge education and counseling to older adults at
discharge; therefore, they play a key role in preventing medication-related consequences
after discharge, including prevention of rehospitalization because of medication-related
problems. Consulting with experts on the interdisciplinary team and/or use of com-
puter programs can facilitate provision of accurate discharge information. Nurses are in
a pivotal position to take the lead in patient safety.
Protocol 17.1: Reducing Adverse Drug Events in Older Adults
I. GOAL: To proactively identify older adults at risk for adverse drug events (ADEs)
and reduce the likelihood of it.
II. OVERVIEW: ADEs whether from drug–drug or drug–disease interactions, inap-
propriate prescribing, poor adherence, or medication errors lead to serious or poten-
tially fatal outcomes for older adults. Around 31% of all adverse events in hospitals
are caused by medication-related problems. More than half of ADEs are potentially
preventable (Levinson, 2010; Rochon, 2010; Safran et al., 2005).
III. BACKGROUND
A. Denitions
1. Adverse drug event: Injury occurring during the patient’s drug therapy
whether resulting from appropriate care or from unsuitable or suboptimum
care. ADEs include adverse drug reactions (ADRs) during normal use of
medicine and any harm secondary to a medication error (COE Medication
Practices, 2007, pp. 1).
2. Iatrogenic ADEs: Any undesirable condition in a patient occurring as the
result of treatment by a health care professional; pertaining to an illness or
injury resulting from a medication.
3. Adverse drug reaction: Any noxious or unintended and undesired eect of a drug
that occurs at normal human doses for prophylaxis, diagnosis, or therapy.
NURSING STANDARD OF PRACTICE
(continued)
Reducing Adverse Drug Events 349
4. Drug–drug interactions: When one therapeutic agent alters either the concen-
tration (pharmacokinetic interactions) or the biological eect of another agent
(pharmacodynamic interactions; Leucuta & Vlase, 2006; Levinson, 2010).
5. Medication adherence: e extent to which a person’s medication-taking
behavior corresponds with agreed recommendations of a health care pro-
vider (Sabaté, 2003).
6. Drug–disease interactions: Undesired drug eects (exacerbation of a disease
or condition caused by a drug) that occur in patients with certain disease
states (e.g., beta-blocker given to patient with bronchospasm).
7. Pharmacokinetics: e time course of absorption, distribution across com-
partments, metabolism, and excretion of drugs in the body. e metabo-
lism and excretion of many drugs decrease and the physiological changes of
aging require dose adjustment for some drugs (Levinson, 2010).
8. Pharmacodynamics: e response of the body to the drug that is aected by
receptor binding, postreceptor eects, and chemical interactions. Pharma-
codynamic problems occur when two drugs act at the same or interrelated
receptor sites, resulting in additive, synergistic, or antagonistic eects. e
eects of two or more drugs together can be either additive (combination
of drugs “add up” to increase eect), synergistic (one agent magnies the
eect of the other), or antagonistic (one medication inhibits the eect of
the other).
9. Medication reconciliation: e process of comparing a patient’s medication orders
to all of the medications that the person has been taking (Santell, 2006).
B. Epidemiology
1. It is estimated that the majority of older adults older than age 65 years
(79%) are on medications, with 39% taking ve or more prescription
drugs and up to 90% taking over-the-counter (OTC) drugs (Hanlon et al.,
2001). Persons older than age 65 years consume more than one-third of all
prescription drugs and purchase 40% of all OTC medicines (Kohn et al.,
2000).
2. An estimated 35% of older persons experience ADEs and almost half of
these are preventable (Safran et al., 2005).
3. Prevalence of ADR-related hospitalizations ranges from 5% to 35%
(Gurwitz et al., 2005; Kongkaew et al., 2008). Drug toxicity admission was
2.5% in the emergency department (ED) with 42% being admitted to the
hospital for ADEs (Budnitz et al., 2006).
4. ADEs are estimated to cost the health care system $75–$85 billion annually
(Fick et al., 2003).
C. Etiology
Adults become increasingly susceptible to ADEs as they age. Physiological
changes characteristic of aging predispose older adults to experience ADEs
resulting in four times more hospitalizations in older versus younger persons.
Persons older than age 65 years experience medication-related problems for
seven major reasons:
1. Age-related physiological changes that result in altered pharmacokinetics
and pharmacodynamics (Mangoni & Jackson, 2004; Rochon, 2010).
Protocol 17.1: Reducing Adverse Drug Events in Older Adults (cont.)
(continued)
350 Evidence-Based Geriatric Nursing Protocols for Best Practice
2. Multiple medications (i.e., polypharmacy) that are often prescribed by mul-
tiple providers (Hajjar et al., 2003; Hanlon et al., 2001; Rochon, 2010).
3. Incorrect doses of medications (more than or less than a therapeutic dosage;
Astin et al., 2000; Hanlon et al., 2001; Sloane et al., 2002).
4. Medication consumption for the treatment of symptoms that are not dis-
ease dependent or specic (self-medication or prescribing cascades; Neafsey
& Shellman, 2001; Rochon, 2010).
5. Iatrogenic causes such as
a. ADRs including drug–drug or drug–disease interactions (Gurwitz et al.,
2005; Hohl et al., 2005; Petrone & Katz, 2005; Rothberg et al., 2008)
b. Inappropriate prescribing for older adults (Fick et al., 2003; Rochon, 2010)
c. Problems with medication adherence (Fulmer et al., 1999; Haynes
et al., 2005)
d. Medication errors (Doucette et al., 2005; Kohn et al., 2000; Rochon,
2010)
IV. ASSESSMENT TOOLS AND STRATEGIES
A. Assessment Tools
1. Use appropriate assessment tools as indicated for each individual’s needs
and specic setting:
a. “Beers Criteria for Potentially Inappropriate Medication Use in Older
Adults. Part I: 2002 Criteria Independent of Diagnoses or Conditions.”
“Beers Criteria for Potentially Inappropriate Medication Use in Older
Adults Part II: 2002 Criteria Considering Diagnoses or Conditions”
(Fick et al., 2003; see “Try is” series, issue numbers 16.1 and 16.2 at
http://www.consultgerirn.org/resources)
b. Common drug–drug interactions (see Table 17.1). List of some com-
mon known interactions.
c. Cockroft–Gault formula to estimate renal function (see Table 17.2).
d. Functional capacity (activity of daily living [ADL], independent activity
of daily living [IADL], Mini-Cog, or Mini-Mental State Exam [MMSE]):
assess ability to self-administer medications. (See Chapter 6, Assessment
of Physical Function, and Chapter 8, Assessing Cognitive Function; or
Resources section at http://www.consultgerirn.org/resources.)
e. Brown bag method (Nathan et al., 1999). Method used to assess all
medications an older adult has at home including prescriptions from all
providers, OTC medications, and herbal remedies (all medications are
to be brought in a brown bag). Should be used in conjunction with a
complete medication history (Table 17.3).
f. Drugs Regimen Unassisted Grading Scale (DRUGS) tool. Assessment of
self-administration ability (Edelberg et al., 1999; Hutchison et al., 2006).
B. Assessment Strategies
1. Comprehensive medication assessment should be performed at admis-
sion, discharge, and intervals in between (Petrone & Katz, 2005; Shekelle,
MacLean, Morton, & Wenger, 2001). Obtain a detailed medication history
and conrm its accuracy (Brown et al., 2003) detailing the type and amount
(continued)
Protocol 17.1: Reducing Adverse Drug Events in Older Adults (cont.)
Reducing Adverse Drug Events 351
of prescriptions; OTCs, vitamins, supplements, and herbal remedies (Hanlon
et al., 2001; Kaufman et al., 2002); and alcohol and illicit drugs using appro-
priate assessment tool (e.g., brown bag method; Nathan et al., 1999).
2. Asses for medication- and patient-related risk factors for ADRs (Table 17.4).
3. Assess renal function using Cockroft–Gault formula prior to administering
renal clearing drugs (Table 17.2).
4. Reconciliation of medications from home or other levels of care with medi-
cations ordered at admission and at discharge in consultation with a phar-
macist, geriatric expert, or computer-based program (Gleason, 2004; Joanna
Briggs Institute [JBI], 2006; Santell, 2006; Simon et al., 2006).
5. Review medication list using Beers criteria for potentially inappropriate medi-
cations, particularly those with high severity and for potential drug–drug and
drug–disease interactions (Fick et al., 2003; Rochon, 2010; Zhan et al., 2005).
6. At discharge from hospital, use appropriate tools to assess individual’s abil-
ity to self-administer medications:
a. Assess functional capacity: ADLs, IADLs, Mini-Cog. (See Chapter 6,
Assessment of Physical Function, and Chapter 8, Assessing Cognitive
Function, in this text.)
b. Assess individuals (at admission or initial encounter and at discharge)
who administer their own medicines with DRUGS tool to identify
potential areas of self-administration diculty (Edelberg et al., 1999;
Hutchison, et al., 2006).
V. INTERVENTIONS
A. Reducing ADEs (during and posthospitalization)
1. Patient empowerment. Patients should be given the necessary information
and the opportunity to exercise the degree of control they choose over
health care decisions that aect them. If patients are involved in decision
making, they are less likely to make decisions that may lead to ADRs such
as abruptly discontinuing a medication that should be tapered o (Aspden
et al., 2007; NCC MERP, 2001).
2. Comprehensive medication history on admission as indicated (Table 17.3).
3. Collaborate with the interdisciplinary team to eect change in reducing the
numbers of ADEs and ADRs, many of which are preventable ( Hanlon
et al., 2001).
4. Prescribing principles. Although bedside nurses are not involved in prescrib-
ing, they are involved in reviewing and signing o medications, thus should
be aware of prescribing principles. Monitoring for appropriate prescribing
and alerting the prescriber to potential problem areas helps reduce medi-
cation-related problems. Prescribing a medication is multifaceted: deciding
that a drug is truly indicated; choosing the best drug; determining appro-
priate dose for the individual; monitoring for toxicity and eectiveness;
and seeking consultation when necessary (Rochon, 2010). ese principles
support recommendations to:
a. Reduce the dose. “Start Low and Go Slow” or give the lowest possible dose
when starting a medication and slow upward titration to obtain clinical
Protocol 17.1: Reducing Adverse Drug Events in Older Adults (cont.)
(continued)
352 Evidence-Based Geriatric Nursing Protocols for Best Practice
benet; many ADEs are dose-related (Petrone & Katz, 2005; Rochon,
2010). Primary provider should be notied if the dosage ordered is higher
than the recommended starting dose (e.g., digoxin maximum dose , 0.125
mg for treatment of systolic heart failure; Fick et al., 2003).
b. Discontinue unnecessary therapy. Prescribers are often reluctant to stop
medications, especially if they did not initiate the treatment. is prac-
tice increases the risk for an adverse event (Rochon, 2010).
c. Attempt a trial of nonpharmacological interventions and treatments prior
to requesting medication for new symptoms (Rochon, 2010).
d. Recommend safer drugs. Avoid drugs that are likely to be associated with
adverse outcomes (review Beers criteria; Petrone & Katz, 2005).
e. Assess renal function using Cockroft–Gault formula (for renally cleared
drugs) to determine accurate dosage prior to prescribing such as many
routinely prescribed intravenous (IV) antibiotics. Dosage recommen-
dations are available based on this formula are presented in common
prescribing resources.
f. Optimize drug regimen. When prescribing medications, the focus should
be on risk versus benet where the expected health benet (e.g., relief
of agitation in dementia with psychosis) exceeds the expected negative
consequences (e.g., morbidity and mortality from falls that result in hip
fracture; Leipzig et al., 1999; Ooi et al., 2000; Rochon, 2010).
g. Initiation of new medication. Assess risk factors for ADRs, potential
drug–disease and drug–drug interactions, and correct drug dosages
(Doucette et al., 2005; NCC MERP, 2001; Petrone & Katz, 2005). See
Table 17.1 and Table 17.4.
h. Avoid the prescribing cascade. Avoid the prescribing cascade by rst con-
sidering any new symptom as being an adverse eect of a current medi-
cation prior to adding a new medication (Rochon, 2010; Rochon &
Gurwitz, 1997).
i. Avoid inappropriate medications. Review criteria for potential inappro-
priate medications, drug–disease interactions, and potential drug–drug
interactions (Fick et al., 2003).
j. Employ nonpharmacological approaches for symptoms (e.g., therapeutic activ-
ity kit for agitation; Zwicker & Fletcher, 2009).
B. Specic interventions for prevention of iatrogenic ADR (in hospital and after
discharge)
1. Consider any new symptom as a possible ADR before requesting or admin-
istering new medication for the symptom, avoiding the prescribing cascade
(Gurwitz et al., 2005).
2. Monitor medication orders for wrong drug choices (high-risk inappropriate
medications, drug–disease, and drug–drug interactions), wrong dosages, or
administration errors (Doucette et al., 2005; Gurwitz et al., 2005; Hanlon
et al., 1997). Consider use of technological handheld devices such as per-
sonal digital assistant (PDA) for quick access to Beers criteria, drug–drug
or drug–disease interactions, and geriatric assessment tools. (See Resources
section.)
(continued)
Protocol 17.1: Reducing Adverse Drug Events in Older Adults (cont.)
Reducing Adverse Drug Events 353
3. Improve prescribing practices by documenting indication for initiation
of new drug therapy, maintaining a current medication list, document-
ing response to therapy as well as the need for ongoing treatment, and
evaluating comorbidities (Merle, Laroche, Dantoine, & Charmes, 2005).
4. Institutional implementation of computer-assisted technology for
medication order entry (AHRQ, 2001). Identifying and reporting ADRs can
also be performed using computer-assisted national surveillance system.
5. Institutions must facilitate a culture of safety to reduce ADRs or ADEs
(Kohn et al., 2000).
C. Interventions at Discharge
1. Reconciliation of medications at admission and discharge helps to reduce ADR
or ADEs and rehospitalization (Gleason et al., 2004; Nickerson et al., 2005).
2. Assess abilities and limitations and health literacy in self-administration of medica-
tions using appropriate tools at discharge and recognize that self-administration
and nonadherence can induce ADRs (Curry et al., 2005; Merle et al., 2005).
3. Assess for adherence issues that may develop after discharge, which can help
to reduce ADEs and rehospitalization (Bergman-Evans, 2006; Edelberg
et al., 1999; Fulmer, Kim, Montgomery, & Lyder, 2000; Nickerson et al.,
2005). Recommend devices that can assist in enhancing adherence, behav-
ior, and interventions to address cost and other adherence issues.
4. Patient/Caregiver education. Provide patient and caregiver education using rel-
evant nursing content and principles including assessment of factors that might
aect compliance. Nurses are the primary source for providing education to
patients at discharge; therefore, their role is key to preventing medication-
related consequences after hospitalization, including rehospitalization (Curry
et al., 2005). Discharge education and counseling includes the following:
a. Education tailored to the age group and needs of the individual
( Bergman-Evans, 2006).
b. Educate the patient and caregiver about benets and risks and poten-
tial medication side eects (Rochon, 2010; Shekelle et al., 2001).
c. Teach safe medication management; use teach-back as a methodology
(Curry et al., 2005; Schillinger et al., 2003).
d. Consider an interactive computer program (personal education pro-
gram) designed for the learning styles and psychomotor skills of older
adults to teach about potential drug interactions that can result from
self- medication with OTC agents and alcohol (Neafsey, Strickler,
Shellman, & Chartier, 2002).
VI. EXPECTED OUTCOMES
A. Patients will
1. Experience fewer iatrogenic outcomes from medication-related events.
2. Demonstrate understanding of their medication regimens upon discharge
from the hospital.
B. Health care providers will
1. Use a range of interventions to prevent, alleviate, or ameliorate medication
problems with older adults.
Protocol 17.1: Reducing Adverse Drug Events in Older Adults (cont.)
(continued)
354 Evidence-Based Geriatric Nursing Protocols for Best Practice
2. Improve prescribing practices by documenting indication for initiation
of new drug therapy, maintaining a current medication list, and docu-
menting response to therapy as well as the need for ongoing treatment.
3. Evaluate nature and origins of medication-related problems in a timely manner.
4. Increase their knowledge about medication safety in older adults.
5. Increase referrals to appropriate practitioners for collaboration and medication
safety (e.g., pharmacist, geriatrician, geriatric/gerontological or psychiatric
clinical nurse specialist, nurse practitioner, or consultation-liaison service).
C. Institution will
1. Provide a culture of safety that encourages safe medication practices (Kohn
et al., 2000).
2. Provide education to health care providers regarding prevention, identica-
tion, and reporting of ADRs (Gurwitz et al., 2003).
3. Make information on ADRs accessible to patients (Gurwitz et al., 2003).
4. Enhance surveillance and reporting of ADRs using a national surveillance
system (Gurwitz et al., 2003). Consider use of computerized physician
order entry system (Gurwitz et al., 2003; JBI, 2006).
5. Track and report decreased morbidity and mortality caused by medication-
related problems.
6. Provide a system for medication reconciliation and follow-up its eectiveness
regarding rehospitalization rates caused by ADRs.
7. Review for careful documentation of iatrogenic medication and other iatro-
genic events for continuous quality improvement (CQI).
8. Provide ongoing education related to safe medication management for physi-
cians, other licensed independent providers, pharmacists, and nursing sta.
VII. FOLLOW-UP
A. Health care providers will
1. Provide consistent and appropriate care and follow-up in presence of a
medication-related problem.
2. Monitor and evaluate with physical exam and/or laboratory tests (as appro-
priate) on regular basis to ensure that the older adult is responding to ther-
apy as expected (Edelberg et al., 1999).
B. Institutions will
1. Provide ongoing assessment of sta competence in assessing and intervening
for prevention of ADEs.
2. Embed reduction of ADEs in the institution’s culture of safety.
VII. RELEVANT PRACTICE GUIDELINES
A. Bergman-Evans, B. (2004). Improving medication management for older adult
clients (NGC Guideline No. 003993). Iowa City, IA: University of Iowa Geron-
tological Nursing Interventions Research Center, Research Dissemination
Core. Retrieved from http://www.guideline.gov
B. Health Care Association of New Jersey. (2006). Medication management guide-
line. Hamilton, NJ: Author. Retrived from http://www.guideline.gov. Note:
Geared for posthospital institutions for adult patients.
Protocol 17.1: Reducing Adverse Drug Events in Older Adults (cont.)
Reducing Adverse Drug Events 355
RESOURCES
Medication Complexity
Steinman, M. A., & Hanlon, J. T. (2010). Managing medications in clinically complex elders: “ere’s
got to be a happy medium.” Journal of the American Medical Association, 304(14), 1592–1601.
Evidence Level I.
Medication Reconciliation
Bayoumi, I., Howard, M., Holbrook, A. M., & Schabort, I. (2009). Interventions to improve
medication reconciliation in primary care. e Annals of Pharmacotherapy, 43(10), 1667–1675.
Evidence Level I.
Jennings, B. (2008). Patient acuity. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-
based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.
http://www.ncbi.nlm.nih.gov/books/NBK2648/
Medication and Medical Error Prevention
Joanna Briggs Institute. (2006). Strategies to reduce medication errors with reference to older adults.
Nursing Standard, 20(41), 5.3–57.
National Coordinating Council for Medication Errors Reporting and Prevention. (2011). Medication
error reporting and prevention.
http://www.nccmerp.org/councilRecs.html
Herbal Remedies
Huang, S. M., Hall, S. D., Watkins, P., Love, L. A., Serabjit-Singh, C., Betz, J. M., . . . Center
for Drug Evaluation and Research and Oce of Regulatory Aairs. (2004). Drug interactions
with herbal products and grapefruit juice: A conference report. Clinical Pharmacology and
erapeutics, 75(1), 1–12.
http://www.ascpt.org
Huang, S. M., & Lesko, L. J. (2004). Drug-drug, drug-dietary supplement, and drug-citrus fruit and
other food interactions: What have we learned? Journal of Clinical Pharmacology, 44(6), 559–569.
http://www.jclinpharm.org
Medication Adherence
Haynes, R. B., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X. (2008). Interventions for enhancing
medication adherence [Audio podcast]. Cochrane Database of Systematic Reviews, (2), CD000011.
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Williams, A., Manias, E., & Walker, R. (2008). Interventions to improve medication adherence
in people with multiple chronic conditions: A systematic review. Journal of Advanced Nursing,
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Reducing Adverse Drug Events 359
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363
18
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. discuss transient and established etiologies of urinary incontinence (UI)
2. describe the core components of a nursing assessment for UI in hospitalized older
adults
3. discuss the importance of nurse collaboration within the interdisciplinary team in an
eort to best assess and document type of UI
4. develop an individualized plan of care for an older adult with UI
OVERVIEW
Despite evidence supporting urinary incontinence (UI) management strategies
(DuBeau et al., 2010; Fantl et al., 1996), nursing sta and laypersons often use con-
tainment strategies, such as adult briefs or other absorbent products, to manage UI.
In addition, individuals with UI erroneously believe that containing UI is a normal
consequence of aging (Bush, Castelluci, & Phillips, 2001; Dowd, 1991; Kinchen
et al., 2003; Milne, 2000; Mitteness, 1987a, 1987b), feel that UI is a dicult-to-
discuss personal problem (Bush et al., 2001), and prefer self-help strategies rather
than seeking professional advice (Milne, 2000). Personal care strategies are often the
result of information gained through lay media and personal contacts, not necessar-
ily from health care professionals (Cochran, 2000; Jeter & Wagner, 1990; Miller,
Brown, Smith, & Chiarelli, 2003; Milne, 2000). In comparison to nurses in other
health care settings, nurses in hospitals view incontinent patients more negatively
(Vinsnes, Harkless, Haltbakk, Bohm, & Hunskaar, 2001). erefore, attitudes and
beliefs regarding UI are important for the nurse to consider in an eort to best assess
and manage UI.
Annemarie Dowling-Castronovo and Christine Bradway
Urinary Incontinence
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
364 Evidence-Based Geriatric Nursing Protocols for Best Practice
BACKGROUND AND STATEMENT OF PROBLEM
UI aects more than 17 million adults in the United States and is most often dened as the
involuntary loss of urine sucient to be a problem (Fantl et al., 1996; National Association
for Continence, 1998; Resnick & Ouslander, 1990). Prevalence and incidence rates of UI
are viewed cautiously due to inconsistencies with denitions and measurements of both these
epidemiological statistics. In addition, variable or poorly articulated UI denitions (Abrams
et al., 2003; Palmer, 1988) as well as underreporting and underassessment of UI (Schultz,
Dickey, & Skoner, 1997) in the hospital setting can render data of questionable reliability.
Prevalence of UI in community-dwelling adult populations ranges from 8% to 46% (Anger,
Saigal, & Litwin, 2006; Diokno, Brock, Brown, & Herzog, 1986; Du Moulin, Hamers,
Ambergen, Janssen, & Halfens, 2008; Herzog & Fultz, 1990; T. M. Johnson et al., 1998;
Lee, Cigolle, & Blaum, 2009). For individuals with dementia, UI prevalence rates range
from 11% to 90%; higher prevalence rates reect institutionalized cognitively impaired
older adults (Brandeis, Baumann, Hossain, Morris, & Resnick, 1997; Skelly & Flint, 1995).
Although the highest prevalence rate occurs in institutionalized older adults, 15%–53% of
homebound older adults and 10%–42% of older adults admitted to acute care also suer
from UI (Dowd & Campbell, 1995; Fantl et al., 1996; McDowell et al., 1999; Palmer,
Bone, Fahey, Mamon, & Steinwachs, 1992; Schultz et al., 1997). Twelve percent to 36% of
older hospitalized adults develop acute UI (e.g., new-onset UI, meaning that these individu-
als were continent on hospital admission; Kresevic, 1997; Sier, Ouslander, & Orzeck, 1987);
for patients undergoing hip surgery, the incidence of acute UI ranges from 19% to 32 %
(Palmer, Baumgarten, Langenberg, & Carson, 2002; Palmer, Myers, & Fedenko, 1997).
In addition to being a common geriatric syndrome, UI signicantly aects health-
related quality of life (HRQOL; DuBeau, Simon, & Morris, 2006; Shumaker, Wyman,
Uebersax, McClish, & Fantl, 1994). e consequences of UI may be characterized
physically, psychosocially, and economically. For example, an episode of urge UI occur-
ring once weekly, or more frequently, has been associated with falls or fracture (Brown,
Sawaya, om, & Grady, 2000; Chiarelli, Mackenzie, & Osmotherly, 2009; Hasegawa,
Kuzuya, & Iguchi, 2010). Other physical consequences associated with UI include skin
irritations or infections, urinary tract infections (UTIs), pressure ulcers, and limitation
of functional status (Fantl et al., 1996; T. M. Johnson et al., 1998). UI is associated
with psychological distress (Bogner et al., 2002) including depression, poor self-rated
health, and social isolation or condition-specic functional loss (Bogner et al., 2002;
Fantl et al., 1996; T. M. Johnson et al., 1998), and poststroke UI is risk factor for poor
outcomes (Pettersen, Saxby, & Wyller, 2007). erefore, it is essential that nurses assess
and treat UI when addressing other health problems such as depression or falls.
Although there is conicting evidence regarding the role of UI as a predictor for nurs-
ing home placement, UI has been identied as a marker of frailty in community-dwell-
ing older adults (Holroyd-Leduc, Mehta, & Covinsky, 2004) and a predictor of 1-year
mortality among older adults hospitalized for an acute myocardial infarction (Krumholz,
Chen, Chen, Wang, & Radford, 2001). e negative psychosocial impact of UI aects
not only the individual but also family caregivers (CGs; Brittain & Shaw, 2007; Cassells
& Watt, 2003; Gotoh et al., 2009). Economically, the total direct cost for all inconti-
nent individuals is estimated to be more than $16 billion annually in the United States
(Landefeld et al., 2008; Wilson, Brown, Shin, Luc, & Subak, 2001; Wyman, 1997).
Nurses are in a key position to identify and treat UI, a quality indicator (“ Assessing
Care,” 2007), in hospitalized older adults. is chapter reviews the etiologies and con-
sequences of UI, with emphasis on the most common types of UI encountered in the
Urinary Incontinence 365
acute care setting. Assessment parameters and care strategies for UI are highlighted and
a nursing standard of practice protocol focused on comprehensive assessment and man-
agement of UI for hospitalized older adults is included.
ASSESSMENT OF THE PROBLEM
Adverse physiological consequences of UI commonly encountered in acute care settings
include an increased potential for UTIs and indwelling urinary catheter use, dermatitis,
skin infections, and pressure ulcers (Sier et al., 1987). Moreover, UI that results in func-
tional decline predisposes older individuals to complications associated with bed rest
and immobility (Harper & Lyles, 1988).
Etiologies of Urinary Incontinence
Continence is a complex, multidimensional phenomenon inuenced by anatomical, physi-
ological, psychological, and cultural factors (Gray, 2000). us, continence requires intact
lower urinary tract function, as well as cognitive and functional ability to recognize void-
ing signals and use a toilet or commode, the motivation to maintain continence, and an
environment that facilitates the process (Jirovec, Brink, & Wells, 1988). Physiologically,
continence is a result of urethral pressure being equal to or greater than bladder pressure
(C. P. Hodgkinson, 1965), of which angulation of the urethra, supported by pelvic muscles,
plays a role (DeLancey, 1994, 2010). Continence also requires the ability to suppress auto-
contractility of the detrusor (C. P. Hodgkinson, 1965). Micturition (urination) involves
voluntary as well as reexive control of the bladder, urethra, detrusor muscle, and urethral
sphincter. When the bladder volume reaches approximately 400 ml, stretch receptors in the
bladder wall send a message to the brain and an impulse for voiding is sent back to the blad-
der. e detrusor muscle then contracts and the urethral sphincter relaxes to allow urina-
tion (Gray, Rayome, & Moore, 1995). Normally, the micturition reex can be voluntarily
inhibited (at least for a time) until an individual desires to void or nds an appropriate place
for voiding. UI occurs as the result of a disruption at any point during this process. For
a comprehensive review, Gray (2000) provided a detailed analysis of voiding physiology.
Common age-associated changes, including a decrease in bladder capacity, benign prostatic
hyperplasia (BPH) in men, and menopausal loss of estrogen in women, can aect lower
urinary tract function and predispose older individuals to UI (Bradway & Yetman, 2002).
Despite these aging changes, UI is not considered a normal consequence of aging.
e two major types of UI are transient (or acute/reversible) and established (or
chronic/persistent; Newman & Wein, 2009). Transient UI is characterized by the sud-
den onset of potentially reversible symptoms. Causes of transient UI include delirium,
infections (e.g., untreated UTI), atrophic vaginitis, urethritis, pharmaceuticals, depres-
sion or other psychological disorders that aect motivation or function, excessive urine
production, restricted mobility, and stool impaction or constipation (e.g., that cre-
ates additional pressure on the bladder and can cause urinary urgency and frequency).
Hospitalized older adults are at risk of developing transient UI. Complicated by shorter
hospital stays, these individuals may also be at risk of being discharged without reso-
lution of transient UI and, thus, urine leakage persists and may become established
UI. However, transient UI is often preventable, or at least reversible (e.g., transient
UI precipitated by a UTI that resolves with successful treatment, or acute UI related
to diuretic therapy for heart failure exacerbation), if the underlying cause for the UI is
identied and treated (Ding & Jayaratnam, 1994; Fantl et al., 1996; Palmer, 1996).
366 Evidence-Based Geriatric Nursing Protocols for Best Practice
Kresevic (1997) reported that hospitalized older adults with new-onset UI were more
likely to be on bed rest, restrained, depressed, dehydrated, malnourished, and dependent
in ambulation when compared with their continent counterparts. Furthermore, the rela-
tive risk of developing new-onset UI was twofold for older adults with depression (OR
5 2.28), malnutrition (OR 5 2.29), and dependent ambulation (OR 5 2.55). Study
participants identied that being able to walk, having use of a bedpan or commode, and
nursing assistance fostered continence (Kresevic, 1997). Likewise, Palmer et al. (2002)
determined that in addition to mobility dependency, other risk factors for new-onset UI,
specic to a hip fracture population included: institutionalization prior to hospital, the
presence of confusion (identied by a retrospective chart review) preceding hip fracture,
and being an African American woman.
Established UI has either a sudden or gradual onset and is often present prior to
hospital admission; however, health care providers or family CGs may rst identify UI
during the course of an acute illness, hospitalization, or abrupt change in environment
or daily routine (Palmer, 1996). Types of established UI include stress, urge, mixed,
overow, and functional UI.
Stress UI is dened as an involuntary loss of urine associated with activities that
increase intra-abdominal pressure. Symptomatically, individuals with stress UI usu-
ally present with complaints of small amounts of daytime urine loss that occurs dur-
ing physical eort or exertion (e.g., position change, coughing, sneezing) that result in
increased intra-abdominal pressure. Stress UI is more common in women; however,
stress UI may also occur in men postprostatectomy (Abrams et al., 2003; Fantl et al.,
1996; Hunter, Moore, Cody, & Glazener, 2004; Jayasekara, 2009).
Urge UI is characterized by an involuntary urine loss associated with a strong desire
to void (urgency). Individuals with urge UI often complain of being unable to hold the
urge to urinate and leak on the way to the bathroom. is history is most helpful to
the identication of urge UI (Holroyd-Leduc, Tannenbaum, orpe, & Straus, 2008).
In addition to urinary urgency, signs and symptoms of urge UI most often include
urinary frequency, nocturia and enuresis, and UI of moderate to large amounts. Blad-
der changes common in aging make older adults particularly prone to this type of UI
(Abrams et al., 2003; Fantl et al., 1996; Jayasekara, 2009). Individuals with overactive
bladder (OAB) may complain of urgency, with or without UI, as well as urinary fre-
quency and nocturia. Assessment should focus on pathological or metabolic conditions
that may explain these symptoms (Abrams et al., 2003).
Mixed UI is dened as involuntary urine loss as a result of both increased intra-
abdominal pressure and detrusor instability (Fantl et al., 1996; Jayasekara, 2009). On
history, individuals describe symptoms of stress UI in combination with symptoms of
urge UI and OAB.
Overow UI is an involuntary loss of urine associated with overdistention of the blad-
der, and may be caused by an underactive detrusor muscle or outlet obstruction leading
to overdistention of the bladder and leakage of urine. Individuals with overow UI often
describe dribbling, urinary retention or hesitancy, urine loss without a recognizable urge, an
uncomfortable sensation of fullness or pressure in the lower abdomen, and incomplete blad-
der emptying. Clinically, suprapubic palpation may reveal a distended or painful bladder as
a result of urine retention, which may be acute or chronic. A common condition associated
with this type of UI is BPH. Neurological conditions such as multiple sclerosis and spinal
cord injuries or diabetes mellitus, which result in bladder muscle denervation, may also cause
overow UI (Abrams et al., 2003; Doughty, 2000; Fantl et al., 1996; Jayasekara, 2009).
Urinary Incontinence 367
Functional UI is caused by nongenitourinary factors such as cognitive or physical
impairments that result in an inability for the individual to be independent in voiding.
For example, acutely ill hospitalized individuals may be challenged by a combination
of an acute illness and environmental changes. is, in turn, makes the voiding process
even more complex, resulting in a functional type of UI (Fantl et al., 1996; B. Hodg-
kinson, Synnott, Josephs, Leira, & Hegney, 2008).
ASSESSMENT PARAMETERS
Nurse continence experts suggest that entry-level nurses demonstrate the ability to col-
lect and organize data surrounding urine control, and implement nursing interventions
that promote continence (Jirovec, Wyman, & Wells, 1998). Nurses play a critical role
in the basic assessment and management of UI in hospitalized older adults. Because UI
is an interdisciplinary issue, collaboration with other members of the health care team
is essential. It is not sucient for nurses to only identify and document the presence of
UI. Instead, the type of UI should be determined and documented based on a careful
history and focused assessment; urodynamic tests are not required as part of the initial
assessment of UI (DuBeau et al., 2010). Basic history and examination techniques are
presented here to assist the nurse in identifying the type of UI along with a nursing stan-
dard of practice protocol (see Protocol 18.1) to guide UI assessment and management.
History
When a patient is admitted to the hospital, nursing history should include questions to
determine if the individual has preexisting UI or risk factors (see Table 18.1) for UI. e
nurse should be alert for the following UI-associated risk factors specic to the hospital
setting: depression, malnourishment, dependent ambulation, being a resident of a long-
term care institution, confusion, and being an African American woman (Kresevic, 1997;
Palmer et al., 2002). erefore, the nurse should screen for depression, determine body
mass index (BMI), monitor albumin and total protein levels if available, consult with a
dietitian, and perform a validated assessment of both cognitive and functional status.
e nurse should include screening questions such as “Have you ever leaked urine?
If yes, how much does it bother you?” for all older adult patients. Although not validated
in the hospital setting, examples of screening instruments used in other settings include
the Urinary Distress Inventory-6 (UDI-6) and the Male Urinary Distress Inventory
(MUDI). e UDI-6 is a self-report symptom inventory for UI that is reliable and valid
for identifying the type of established UI in community-dwelling females (Lemack &
Zimmern, 1999; Uebersax, Wyman, Shumaker, McClish, & Fantl, 1995). e MUDI
is a valid and reliable measure of urinary symptoms in the male population (Robin-
son & Shea, 2002). Determining the degree of “bother” and the eect on HRQOL is
important and should include the perspective of both the patient and CG or signicant
other. Various instruments for quantifying bother and HRQOL exist (Abrams et al.,
2003; Bradway, 2003; Robinson & Shea, 2002; Shumaker et al., 1994).
Historical questions should focus on the characteristics of UI: time of onset, fre-
quency, and severity of the problem. Questions also should review past health his-
tory and address possible precipitants of UI such as coughing, uncontrollable urinary
urgency, functional decline, and acute illness (e.g., UTI, hip fracture). Nurses should
inquire about lower urinary tract symptoms such as nocturia, hematuria, and urinary
368 Evidence-Based Geriatric Nursing Protocols for Best Practice
hesitancy, as well as current management strategies for UI. e presence and rationale
for an indwelling urinary catheter should be documented (see Chapter 19, Catheter-
Associated Urinary Tract Infection Prevention).
A bladder diary or voiding record is recommended as a tool for obtaining objective
information about the patient’s voiding pattern, incontinent episodes, and UI severity
(Lau, 2009). ere are numerous voiding records available; for example, visit http://
consultgerirn.org/resources. Although the 7-day voiding record is the most evaluated
and recommended tool used to quantify UI and identify activities associated with
unwanted urine loss (Jeyaseelan, Roe, & Oldham, 2000), a 3-day voiding record has
TABLE 18.1
Risk Factors Associated With Urinary Incontinence
n Age (B. Hodgkinson et al., 2008; Holroyd-Leduc
et al., 2004; Shamliyan et al., 2007)
n Low fluid intake (Fantl et al., 1996)
n Caffeine intake (Holroyd-Leduc et al., 2004) n Environmental barriers (Fantl et al., 1996;
Offermans et al., 2009)
n Immobility/functional limitations (Fantl et al.,
1996; Holroyd-Leduc & Straus, 2004; Kresevic,
1997; Offermans et al., 2009; Palmer et al.,
2002; Shamliyan et al., 2007)
n High-impact physical activities
(Fantl et al., 1996)
n Impaired cognition (Fantl et al., 1996; Palmer
et al., 2002; Shamliyan et al., 2007)
n Diabetes mellitus (Fantl et al., 1996; Holroyd-
Leduc & Straus., 2004; Shamliyan et al., 2007)
n Medications (Fantl et al., 1996; Newman &
Wein, 2009; Offermans et al., 2009)
n Parkinson’s disease (Holroyd-Leduc &
Straus, 2004)
n Obesity (Fantl et al., 1996; Subak et al., 2005;
Subak et al., 2009)
n Stroke (Fantl et al., 1996; Holroyd-Leduc &
Straus, 2004; Meijer et al., 2003; Shamliyan
et al., 2007; Thomas et al., 2005)
n Diuretics (Fantl et al., 1996) n Chronic obstructive pulmonary disease
(Dowling-Castronovo, 2004; Holroyd-Leduc &
Straus, 2004)
n Smoking (Fantl et al., 1996) n Estrogen depletion (Fantl et al., 1996;
Holroyd-Leduc & Straus, 2004)
n Fecal impaction; fecal incontinence(Fantl et al.,
1996; Offermans et al., 2009)
n Pelvic organ prolapse (Shamliyan et al., 2007)
n Malnutrition (Kresevic, 2007) n Pelvic muscle weakness (DeLancey, 1994; Fantl
et al., 1996; Holroyd-Leduc & Straus, 2004;
Kegel, 1956)
n Depression (Kresevic, 2007) n Childhood nocturnal enuresis (Fantl et al., 1996)
n Delirium (Fantl et al., 1996; Offermans et al.,
2009)
n Race (Fantl et al., 1996; Holroyd-Leduc et al.,
2004; Palmer et al., 2002)
n Pregnancy/vaginal delivery/episiotomy
(DeLancey, 2010; Fantl et al., 1996; Holroyd-
Leduc & Straus, 2004; Nygaard, 2006; Shamli-
yan et al., 2007)
n Institutionalization prior to hospitalization
(Palmer et al., 2002)
n Treatment of prostate cancer including radical
prostatectomy and radiation therapy (Hunter et
al., 2004; Shamliyan et al., 2007)
n Arthritis and/or back problems (Holroyd-Leduc
& Straus, 2004)
n Hearing and/or visual impairment
(Holroyd-Leduc & Straus, 2004)
Urinary Incontinence 369
been recommended as more feasible in outpatient and long-term care settings (DuBeau
et al., 2010; Fantl et al., 1996). A voiding record completed for even 1 day may help
identify patients with bladder dysfunction or those requiring further referral. Advanced
practice nurses or urologic/continence specialists can assist nursing sta with interpreta-
tion and oer suggestions regarding nursing interventions based on information from
the voiding record.
Comprehensive Assessment
A wide variety of medications can adversely aect continence. Diuretics are the most
commonly known class of medications that contribute to UI due to polyuria, frequency,
and urgency. Medications with anticholinergic and antispasmodic properties may cause
mental status changes, urinary retention with or without overow incontinence, and
stool impaction. Various psychotropic medications (e.g., tricyclic antidepressants,
antipsychotics, sedative-hypnotics) have anticholinergic eects, contribute to immobil-
ity, and cause sedation and possibly delirium—each of which negatively aects bladder
control. Alpha-adrenergic blockers may cause urethral relaxation, whereas alpha-adren-
ergic agonists may cause urinary retention. Calcium channel blockers also may cause
urinary retention (Newman & Wein, 2009).
Nurses should document all over-the-counter, herbal, and prescription medications
on admission. Additionally, nurses must closely scrutinize new medications as possi-
ble causes if UI suddenly develops during the patient’s hospital stay. Medications that
may contribute to iatrogenic (i.e., hospital-caused) UI include diuretics and sedative-
hypnotics. Essentially, when a hospitalized patient develops transient UI, the nurse must
ask the question: Could a new medication be aecting this patient’s bladder control?
If the answer is yes, then the nurse reviews this nding with the prescribing practitioner
to learn if the contributing medication may be discontinued or modied.
Important components of a comprehensive examination include abdominal, genital,
rectal, and skin examinations. In particular, the abdominal examination should assess
for suprapubic distention indicative of urinary retention. Inspection of male and female
genitalia can be completed during bathing or as part of the skin assessment. e nurse
should observe the patient for signs of perineal irritation, lesions, or discharge. In women,
a Valsalva maneuver (if not medically contraindicated) or voluntary cough may identify
pelvic prolapse (e.g., cystocele, rectocele, uterine prolapse) or stress UI as a result of
increased intra-abdominal pressure with bearing down (Burns, 2000). Postmenopausal
women are especially prone to atrophic vaginitis. Signicant ndings for atrophic vagi-
nitis include perineal inammation, tenderness (and, on occasion, trauma as a result of
touch), and thin, pale genital tissues. During the genital examination, patients should
be instructed to cough or perform the Valsalva maneuver (sometimes referred to as a
bladder stress test) to determine if there is urine leakage, again caused by increased intra-
abdominal pressure, which may be attributed to stress UI (Holroyd-Leduc et al., 2008).
Digital rectal and skin examinations are essential in identifying transient causes of
UI such as constipation, fecal impaction, and the presence of fungal rashes. e “anal
wink” (contraction of the external anal sphincter) indicates intact sacral nerve innerva-
tion and is assessed by lightly stroking the circumanal skin. Absence of the anal wink
may suggest sphincter denervation (Burns, 2000) and risk of stress UI. In men, the
prostate gland should be palpated during the rectal examination because BPH may con-
tribute to urge or overow UI. A normal prostate gland is symmetrically heart-shaped,
370 Evidence-Based Geriatric Nursing Protocols for Best Practice
about the size of a large chestnut, and often described as “rubbery” or similar to the
tip of the nose. When enlarged, as with BPH, the examiner may palpate symmetrical
enlargement. Pain on palpation or asymmetrical borders may be indicative of prostatitis
or prostate cancer, respectively (Gray & Haas, 2000).
In some cases, diagnostic testing may provide additional information. e most
common diagnostic tests include urinalysis, urine culture and sensitivity, and postvoid
residual (PVR) urine (Dubeau et al., 2010). Urinalysis and urine cultures are used to
identify the presence of a UTI and bacterial agent responsible, which may contribute to
acute UI. A measurement of PVR may reveal incomplete bladder emptying. Two meth-
ods for accurately evaluating PVR are bladder sonography and sterile catheter insertion
after the patient has voided (see Table 18.2).
An additional diagnostic test such as a simple bedside urodynamic test, which pro-
vides information regarding detrusor activity, may be warranted in some cases (Burns,
2000; Newman & Wein, 2009). A simple bedside urodynamic test is most likely to be
performed by an advanced practice nurse or physician. It is done after a PVR has been
performed and measured via the sterile catheterization method. After the bladder is emp-
tied, the catheter is maintained in the bladder, and a 50-ml syringe (without plunger) is
connected to the catheter, with the center of the syringe in alignment with the symphysis
pubis. Sterile water is then instilled to ll the bladder. e uid level is monitored for
evidence of bladder contractions, which are reected in movement of the uid level.
Functional, environmental, and mental status assessments are essential components
of the UI evaluation in older adults. e nurse should observe the patient voiding, assess
mobility, note any use of assistive devices, and identify any obstacles that interfere with
appropriate use of toilets or toilet substitutes such as bedside commode.
INTERVENTIONS AND CARE STRATEGIES
Evidence demonstrates hospital nurses lack the knowledge necessary for evidence-based
incontinence care (Coey, McCarthy, McCormack, Wright, & Slater, 2007; Connor
& Kooker, 1996; Cooper & Watt, 2003); therefore, adapting this for the acute care
environment includes sta education. A brief, unit-based in-service followed by patient
rounds may be instrumental in identifying patients at risk for UI and those actually
experiencing UI. e North American Nursing Diagnosis Association (NANDA),
Nursing Interventions Classication (NIC), and Nursing Outcomes Classication
(NOC) provide structure for planning and evaluating UI assessment and manage-
ment (M. Johnson, Bulechek, McCloskey-Dochterman, Maas, & Moorhead, 2001).
Postvoid Residual (PVR; Shinopulos, 2000)
Instruct the patient to void. Postvoid (ideally within 15 minutes or less); measure the residual urine
remaining in the bladder by either:
n Bladder sonography (Scan): Noninvasive ultrasound of the suprapubic area identifies the residual
amount of urine, or
n Sterile catheterization
A PVR of greater than 100 cc is considered abnormal and requires further evaluation by a urology
specialist.
TABLE 18.2
Urinary Incontinence 371
However, there is no structured guidance for the assessment and management of tran-
sient UI. Nurses are likely to be the rst to identify, and perhaps prevent, transient UI.
Research is needed to understand the role nurses play in preventing UI (Sampselle,
Palmer, Boyington, O’Dell, & Wooldridge, 2004).
Treating Transient and Functional Causes of Urinary Incontinence
First, transient causes of UI should be investigated, identied, and treated. Individu-
als with a history of established UI should have usual voiding routines and continence
strategies immediately incorporated into the acute care plan, whenever possible. Nurses
play an essential role in the initiation of discharge planning and patient or CG teaching
regarding all aspects of UI. Teaching and discharge planning should begin at admission
as appropriate, reviewed continually, and revised as necessary.
e environment is vital in managing UI, particularly functional UI. Incontinent
older adults are often dependent on adaptive devices (e.g., walker) or CGs for assis-
tance with voiding, making them “dependently continent.” Call bells should be iden-
tied and within easy reach. If limited mobility is anticipated, nursing sta should
consider using an elevated toilet or commode seat, male or female urinal, or bed-
pan. Nurses should obtain referrals to physical and occupational therapy for ambula-
tion aids, gait training, further assessment of activities of daily living associated with
continence, and improved muscle strength. Physical and chemical restraints should
be avoided including side rails (see Case Study). Patients should be encouraged and
assisted to void before leaving the unit for tests (Fantl et al., 1996; Jirovec, 2000;
Jirovec et al., 1988; Palmer, 1996).
Toileting programs (e.g., individualized, scheduled toileting programs including
timed voiding; prompted voiding) have varied success rates (Colling, Ouslander, Had-
ley, Eisch, & Campbell, 1992; Eustice, Roe, & Paterson, 2000; Ostaszkiewicz, Johnston,
& Roe, 2004; Rathnayake, 2009c). Timed voiding has been promoted as a strategy for
managing UI in individuals who are not cognitively or physically able to participate in
independent toileting (Rathnayake, 2009c). A voiding record is essential for develop-
ing an individualized scheduled toileting or timed voiding program, which mimics the
patient’s normal voiding patterns and requires continual assessment and reevaluation
for successful outcomes. For example, if the initial scheduled toileting time is set for
8:00 a.m., yet at 6:30 a.m., the patient consistently attempts to independently void or
is noted to be incontinent, then the toileting time should be adjusted to 6:00 a.m. Evi-
dence is lacking regarding the eectiveness of timed voiding as a primary management
strategy for UI; however, it may be used based on the nurse’s judgment of the clinical
situation (Rathnayake, 2009c).
Prompted voiding requires the CG to ask if the patient needs to void, oer assis-
tance, and then oer praise for successful voiding (Eustice et al., 2000; Jirovec, 2000;
Ostaszkiewicz et al., 2004). In nursing home residents with UI, prompted voiding may
achieve short-term improvement in daytime UI and may be eective in reducing UI
in cognitively intact older adults (B. Hodgkinson et al., 2008; Rathnayake, 2009b).
Prompted voiding has not been studied in hospitalized patients.
Healthy Bladder Behavior Skills
Traditionally, nursing interventions for UI focus on containment strategies by means of
receptacles (e.g., bedpan, urinal, commode, urinary catheters) or by various absorbent
372 Evidence-Based Geriatric Nursing Protocols for Best Practice
products (e.g., sanitary napkin, adult brief, incontinent pad; Harmer & Henderson,
1955; Henderson & Nite, 1978; Palese et al., 2007). Various treatments beyond con-
tainment strategies include dietary management, pelvic oor muscle exercises (PFMEs;
Kegel, 1956), urge inhibition and bladder training (retraining) strategies, toileting
programs (e.g., individualized, scheduled toileting programs/timed voiding; prompted
voiding), pharmacological therapy, and surgical options (Fantl et al., 1996; B. Hodg-
kinson et al., 2008). ese treatments (excluding pharmacological and surgical options)
are viewed as healthy bladder behavior skills (HBBS). Although the recommendation
is to oer HBBS to all older adults with UI (Fantl et al., 1996; Teunissen, de Jonge,
van Weel, & Lagro-Janseen, 2004), it is unclear how to best incorporate HBBS in the
care of hospitalized older adults. Despite the fact that contemporary nursing practice
textbooks list and describe HBBS as nursing interventions (Kozier, Erb, Berman, &
Snyder, 2004; Newman & Wein, 2009; Taylor, Lillis, & LeMone, 2005), many of these
interventions have not been adequately examined in the acute care setting, and nurses
do not routinely implement these interventions in the acute care setting (Bayliss, Salter,
& Locke, 2003; Schnelle et al., 2003; Watson, Brink, Zimmer, & Mayer, 2003). Under-
reporting and underassessment are barriers to optimally addressing UI in the hospital
setting as reected in the study by Schultz et al. (1997), which reported that only 0.1%
of medical records captured the problem of UI present at the time of hospital admis-
sion. Accurate assessment and identication of type of UI is needed before care strate-
gies are initiated.
Prior to instituting HBBS, the nurse needs to assess the motivation of the patient,
informal CG, and nursing sta because behavior modication is a premise of HBBS
(Palmer, 2004). Examples of dietary management strategies include avoiding certain
foods and beverages known to be bladder irritants such as caeine, acidic foods or
uids, and NutraSweet (Gray & Haas, 2000). Some individuals with a BMI greater
than 27 may benet from a weight-loss program. For example, in one study, a weight
loss of 5%–10% signicantly decreased UI episodes for some obese women (Subak
et al., 2005).
If not contraindicated, the nurse recommends adequate uid intake, specically
water, and an increased intake of dietary ber to maintain bowel regularity. It is
important to work closely with older adults who fear that unwanted urine loss is a
result of increased uid intake. Education should focus on the adverse consequence
of inadequate uid intake such as volume depletion or potential for dehydration,
and that too little uid intake may result in concentrated urine, which, in turn,
may cause increased bladder contractions and increased feelings of urinary urgency.
Lastly, to manage and limit nocturia, patients may be advised to limit uid intake a
few hours before bedtime (Doughty, 2000; Fantl et al., 1996); however, this is ques-
tionable for older adults who do not have easy access to uids or have diminished
thirst sensation (DuBeau et al., 2010). In the hospital setting, the nurse must note
the schedule of diuretics. For example, many institutions schedule every 12-hour
diuretic dose times at 10 a.m. and 10 p.m. For some patients, it will be extremely
important that nurses navigate organizational processes to reschedule diuretic doses
to an alternate time such as 6 a.m. and 4 p.m. or 6 p.m. is simple strategy may
decrease nocturia, which, in turn, will likely decrease the risk of falls. Research that
examines which UI interventions best modify fall risk is needed (Wolf, Riolo, &
Ouslander, 2000).
Urinary Incontinence 373
For community-dwelling, cognitively intact older adults, PFME is at least as eec-
tive as pharmacological therapies in treating stress and urge UI (B. Hodgkinson et al.,
2008). PFME holds promise for the primary prevention of UI but requires additional
research (Hay-Smith, Herbison, & Morkved, 2002), particularly in the acute care set-
ting. PFMEs were developed to augment the strength, endurance, and coordination of
the pelvic muscles, which play a role in maintaining continence.
Integrating PFMEs into the plan of care requires an assessment of the patient’s
baseline understanding of PFMEs to identify knowledge decits. Ideally, PFMEs are
taught during a vaginal or rectal examination when the clinician manually assists the
patient to identify the pelvic muscles by instructing the patient to squeeze around the
gloved examination nger. is method allows for performance appraisal (Hay-Smith
et al., 2002); and together with weekly phone consults and monthly performance
appraisal, this method is known to improve UI outcomes for community-dwelling indi-
viduals (Tsai & Liu, 2009). Alternately, PFMEs may be verbally taught by instructing
the patient to gently squeeze or contract the rectal or vaginal muscles. Either teaching
method includes instructions to not squeeze the stomach, buttocks, or thigh muscles
(because this only increases intra-abdominal pressure) but to isolate the contraction of
the pelvic muscles.
Preferably, each exercise should consist of contracting for 10 seconds and relax-
ing for 10 seconds. Some patients may need to start with 3 or 5 seconds, and then
increase as their muscle becomes stronger. ere is no set “exercise dose” (Du Moulin,
Hamers, Paulus, Berendsen, & Halfens, 2005); however, it is usual practice to recom-
mend 15 PFMEs three times per day. For community-dwelling women with stress,
urge, or mixed UI, PFMEs (at least 24 per day for at least 6 weeks) should be included
in rst-line conservative management programs (Choi, Palmer, & Park, 2007; Syah,
2010). Patients may notice improvement in 2–4 weeks but not immediately. Nurses
should reinforce compliance and other HBBS and initiate a referral for discharge fol-
low-up with a continence specialist for PFME reinforcement via biofeedback, if avail-
able ( Bradway & Hernly, 1998). In a study of community-dwelling adults, PFME
instruction and reinforcement using biofeedback improved both UI outcomes and
concurrent depressive symptoms (Tadic et al., 2007); therefore, hospitalized patients
may benet from a referral to a continence nurse or other provider specializing in care
of individuals with UI (e.g., urologist, gynecologist, urogynecologist) for follow-up
after discharge.
Urge inhibition is based on behavioral theory and is another recommended HBBS
for treatment of urge UI (Teunissen et al., 2004), although the mechanism of how urge
inhibition works is not well understood (Gray, 2005; Smith, 2000). Urge inhibition
includes distraction techniques (e.g., reciting a favorite poem or song), relaxation tech-
niques, and rapid pelvic oor muscle contractions with the goal being to suppress the
urge to void until desirable (Smith, 2000).
Bladder training (retraining) is another behavioral technique used to treat urge UI
(DuBeau et al., 2010; Teunissen et al., 2004) and OAB, is often used in conjunction
with urge-inhibition techniques and Functional Incontinence Training (FIT; DuBeau
et al., 2010; Schnelle et al., 2003), and may be more eective if used in combination
with PFMEs or anticholinergic drugs (Rathnayake, 2009a). Bladder training requires
a baseline voiding record to determine the timing of voids and UI episodes. If uri-
nary frequency is present, the patient is instructed to lengthen the time between voids
374 Evidence-Based Geriatric Nursing Protocols for Best Practice
in an eort to retrain the bladder. When a strong urge to void occurs, the patient is
instructed to use urge-inhibition techniques to suppress urinary urgency. For example,
if the patient is not in a position to empty the bladder in a socially appropriate manner,
the nurse instructs the patient to quickly squeeze and relax pelvic oor muscles several
times to suppress the urge to void. is technique is sometimes referred to as “quick
icks” (Gray, 2005). Relaxation and distraction and urge inhibition techniques are also
benecial during bladder training.
In some instances (e.g., for patients experiencing incomplete bladder emptying
or overow UI), patients and sta can use Crede’s maneuvers (i.e., deep suprapubic
palpation) to facilitate bladder emptying. e Crede’s maneuver is used with caution
and requires manual compression over the suprapubic area during bladder emptying.
e Crede’s maneuver should be avoided if vesicoureteral reux (i.e., abnormal ow of
urine from the bladder back up the ureters) or overactive sphincter mechanisms are sus-
pected because it may dangerously elevate pressure within the bladder (Doughty, 2000).
In some cases, instructing patients to double void (i.e., after an initial void, instruct
patients to stand or reposition for a second void) also facilitates bladder emptying.
Additional Nursing Interventions
A causal link between UI and skin breakdown has not been adequately supported;
however, maintaining skin integrity is a goal of nursing care. Decomposition of urinary
urea by microorganisms releases ammonia and forms ammonium hydroxide, an alkali.
is alkali makes the protective “acid mantle” of the skin vulnerable and jeopardizes
skin integrity. If UI episodes persist despite management strategies, perineal skin care
interventions should focus on maintaining the integrity of the protective acid mantle of
the skin (Ersser, Getlie, Voegeli, & Regan, 2005; see Chapter 16, Preventing Pressure
Ulcers and Skin Tears).
Although absorbent products are commonly used for UI containment, there is
little evidence available to guide product selection and no evidence of how absorbent
products may interact with the acid mantle (Fader, Cottenden, & Getlie, 2008).
Community-dwelling women with light UI reported important characteristics of absor-
bent pads including the ability to hold and hide UI and ease of use (Getlie, Fader,
Cottenden, Jamieson, & Green, 2007). In hospitals, nursing sta reported problems
with quality and availability of absorbent products (Clayman, ompson, & Forth,
2005). Pertaining to reusable versus disposable absorbent products, there is no demon-
strable risk of cross-infection with reusable absorbent products when appropriate laun-
dering protocols are followed, and there are no clear cost savings with using one over
the other. Reusable products have limited acceptability among users (Fader et al., 2008),
and use of adult briefs is signicantly associated with an increased risk of infection
(Zimako, Stickler, Pontoppidan, & Larsen, 1996). Although bed pads contain urine,
consumer satisfaction is questionable, and there are no studies on the use of chair pads.
Although limited evidence exists, suggesting that disposable insert pads may be more
eective for women with UI than other absorbent products (Rathnayake, 2009d), there
is no clear evidence to suggest one absorbent product being superior to another, par-
ticularly in the acute care setting. Evidence does support pilot testing of absorbent prod-
ucts according to individual circumstances, including patient, family, and institutional
preferences, and oering a choice of products to women with UI (Dunn, Kowanko,
Paterson, & Pretty, 2002; Fader et al., 2008; Rathnayake, 2009d).
Urinary Incontinence 375
A student nurse received report on Mr. G, an 86-year-old man with history of Alzheimer’s
dementia who is hospitalized for delirium. e nurse was told that Mr. G. was “ pleasantly
confused,” required full assistance with personal care, and spent most of the day in a
Geri-chair. e student nurse performed an assessment that revealed the following:
Patient sleeping in bed with all side rails up, call bell within reach, no urinal in
sight.
PMH-CAD, Mild HTN, Mild osteoarthritis
PSH: None
Medications: diphenhydramine (Benadryl) 25 mg PRN for sleep, enalapril (Vaso-
tec) 5 mg PO OD for HTN, MVI 1 tab PO OD, donepezil (Aricept) 10 mg PO
OD for Alzheimer’s dementia
VS: 114/60, 72, 14, 98.0F
Alert and oriented to self; sleepy; no focal decits
Heart Rate: Regular
Breath sounds clear, slightly decreased at the bases
Abdomen: 1BS in all quadrants, soft, nontender, no suprapubic tenderness; left
quadrant slightly dull to percussion; no palpable masses
Dry adult brief in place
e student nurse learns from the patient’s wife (i.e., the primary CG at home)
that the patient has experienced occasional urinary leaking in the past but not to the
extent of needing “diapers.” He has a history of chronic constipation. With the nursing
instructor’s guidance, the student nurse assisted Mr. G. to a dangling position at the
side of the bed. After assessing and evaluating that the patient’s muscular strength was
strong, ambulation was attempted. e patient ambulated to the bathroom, the adult
brief was removed, and Mr. G. was prompted to void. He successfully voided and had
a bowel movement. He proceeded to wash his hands and returned to the bedside chair
(not the Geri-chair) and enjoyed breakfast. e adult brief was left o during the time
the student nurse was there to assist him. During this time, Mr. G. made one attempt
to initiate voiding and was successfully assisted by the student nurse.
e importance of ongoing nursing assessment was stressed as being vital to qual-
ity of care. Had the student nurse just transferred the patient to the Geri-chair, he
may not have eectively emptied his bowel and bladder. Mr. G.’s constipation was
addressed by providing appropriate uid and ber intake and by continuing with an
individualized toilet schedule as tolerated. e avoidance of diphenhydramine for the
older adults was also discussed because it is known to cause anticholinergic eects
including urinary retention. Diphenhydramine raises concerns about sedation as well,
which may alter Mr. G.’s response to the need to void.
Evidence suggests that prompted voiding and individualized toileting schedules
reduce the number of UI episodes (Eustice et al., 2000; Fink, Taylor, Tacklind, Rutks,
& Wilt, 2008; Ostaszkiewicz et al., 2004). In addition, prompted voiding in cognitively
impaired long-term care residents has demonstrated an increase in self-initiative toilet-
ing activities (Holroyd-Leduc & Straus, 2004). ese strategies have not been studied
in the hospital setting; however, this case study demonstrates that nursing interventions
used in other settings may also be benecial for acutely hospitalized older adults.
CASE STUDY
376 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Although acute care stays are generally short, UI is a signicant health problem that should
not be overlooked. Behavioral and supportive therapies and patient education should be
initiated by nurses if the patient is cognitively, physically, and emotionally able to partici-
pate. Evidence from long-term care and community settings suggests that nurse continence
experts play an essential role in improving the quality of continence care (Du Moulin et al.,
2005; McDowell et al., 1999; Watson, 2004). erefore, if patients remain incontinent at
discharge, hospital nurses have the responsibility to design a plan that includes referral to
a continence nurse specialist or other continence expert for follow-up.
Other than identifying UI as a risk for falls, there are no requirements specic
to UI from e Joint Commission (http://www.jointcommission.org/). Nevertheless,
it is recommended that a continuous quality improvement (CQI) criterion should
encompass critical elements in an eective and successful urinary continence program.
For example, quality indicators for UI in the vulnerable older adult population that
may be used in the hospital setting include documentation of (a) the presence of UI,
(b) the bothersome nature for the older adult and signicant other, (c) focused history
and physical examination, (d) documentation of urinalysis and/or culture, (e) PVR and,
if elevated to more than 300 cc, referral for evaluation of renal function; (f) type of UI;
(g) discussion of HBBS; (h) interdisciplinary evaluation for urodynamic evaluation and
pharmacological/surgical treatments; and (i) response to treatment (“Assessing Care,”
2007; Fung, Spencer, Eslami, & Crandall, 2007).
Nurses have a signicant role in improving the assessment and treatment of UI in
hospitalized older adults. It is recommended that nurses are particularly vigilant for
patients who are “admitted dry and become wet” during a hospitalization. ese patients
will particularly benet from evidence-based assessment and management. Moreover,
nurses can help to promote changes in attitudes toward UI and provide education on
individual, facility-wide, community, and national levels.
Protocol 18.1: Urinary Incontinence in Older Adults Admitted to Acute Care
I. GOAL
A. Nursing sta will utilize comprehensive assessments and implement
evidence-based management strategies for patients identied with urinary
incontinence (UI).
B. Nursing sta will collaborate with interdisciplinary team members to identify
and document type of UI.
C. Patients with UI will not have UI-associated complications.
II. OVERVIEW
UI aects approximately 17 million Americans (Fantl et al., 1996; Landefeld
et al., 2008; National Association for Continence, 1998; Resnick & Ouslander,
NURSING STANDARD OF PRACTICE
(continued)
Urinary Incontinence 377
1990). More than 35% of older adults admitted to the hospital develop UI
( Kresevic, 1997). In addition to medications, constipation/fecal impaction,
low uid intake, environmental barriers, diabetes mellitus, and stroke (Fantl
et al., 1996; Holroyd-Leduc & Straus, 2004; Meijer et al., 2003; Oermans,
Du Moulin, Hamers, Dassen, & Halfens, 2009; Shamliyan, Wyman, Bliss,
Kane, & Wilt, 2007; omas et al., 2005), immobility, impaired cognition,
malnutrition, and depression are additional factors specic to identifying older
adults at risk for UI in the hospital setting (Kresevic, 1997). Complications
of UI include falls, skin irritation leading to pressure ulcers, social isolation,
and depression (Bogner et al., 2002; Brown et al., 2000; Fantl et al., 1996;
T. M. Johnson et al., 1998; Morris & Wagg, 2007). Nurses play a key role in
the assessment and management of UI.
III. BACKGROUND
A. Denitions
UI is the involuntary loss of urine sucient to be a problem (Fantl et al.,
1996). UI may be transient (acute) or established (chronic). Types of estab-
lished UI include:
1. Stress UI is dened as an involuntary loss of urine associated with activities
that increase intra-abdominal pressure (Abrams et al., 2003; Fantl et al.,
1996; Hunter et al., 2004).
2. Urge UI is characterized by an involuntary urine loss associated with a strong
desire to void (urgency; Abrams et al., 2003; Fantl et al., 1996). An indi-
vidual with overactive bladder (OAB) may complain of urinary urgency,
with or without UI (Abrams et al., 2003).
3. Mixed UI is dened as a combination of stress UI and urge UI
(Jayasekara, 2009).
4. Overow UI is an involuntary loss of urine associated with overdistention of
the bladder, and may be caused by an underactive detrusor muscle or outlet
obstruction leading to overdistention of the bladder and overow of urine
(Abrams et al., 2003; Doughty, 2000; Fantl et al., 1996; Jayasekara, 2009).
5. Functional UI is caused by nongenitourinary factors, such as cognitive or
physical impairments that result in an inability for the individual to be
independent in voiding (Fantl et al., 1996; B. Hodgkinson et al., 2008).
B. Epidemiology
UI aects approximately 17 million Americans (Fantl et al., 1996; Landefeld
et al., 2008; National Association for Continence, 1998; Resnick & Ouslander,
1990). UI studies specic to the hospital setting demonstrate that UI is present
in 10%–42% of older adults (Dowd & Campbell, 1995; Fantl et al., 1996;
Kresevic, 1997; Palmer et al., 1992; Schultz et al., 1997); therefore, assessment
and implementation of an evidence-based protocol is essential.
IV. Parameters of Assessment
A. Document the presence or absence of UI for all patients on admission (DuBeau
et al., 2010).
B. Document the presence or absence of an indwelling urinary catheter.
(continued)
Protocol 18.1: Urinary Incontinence in Older Adults
Admitted to Acute Care (cont.)
378 Evidence-Based Geriatric Nursing Protocols for Best Practice
C. For patients with UI, the nurse collaborates with interdisciplinary team
members to:
1. Determine whether the UI is transient, established (stress/urge/mixed/
overow/functional), or both and document (DuBeau et al., 2010; Fantl
et al., 1996; Jayasekara, 2009; M. Johnson et al., 2001).
2. Identify and document the possible etiologies of the UI (DuBeau et al.,
2010; Fantl et al., 1996).
V. Nursing Care Strategies
A. General principles that apply to prevention and management of all forms
of UI:
1. Identify and treat causes of transient UI (DuBeau et al., 2010).
2. Identify and continue successful prehospital management strategies for
established UI.
3. Develop an individualized plan of care using data obtained from the
history and physical examination, and in collaboration with other team
members. Implement toileting programs as needed (Ostaszkiewicz et al.,
2004; Rathnayake, 2009c).
4. Avoid medications that may contribute to UI (Newman & Wein, 2009).
5. Avoid indwelling urinary catheters whenever possible to avoid the risk
of urinary tract infection (UTI; Bouza et al., 2001; Dowd & Campbell,
1995; Gould et al., 2009; Zimako et al., 1996).
6. Monitor uid intake and maintain an appropriate hydration schedule.
7. Limit dietary bladder irritants (Gray & Haas, 2000).
8. Consider adding weight loss as a long-term goal in discharge planning for
those with a body mass index (BMI) greater than 27 (Subak et al., 2005).
9. Modify the environment to facilitate continence (Fantl et al., 1996; Jirovec,
2000; Palmer, 1996).
10. Provide patients with usual undergarments in expectation of continence,
if possible.
11. Prevent skin breakdown by providing immediate cleansing after an incon-
tinent episode and utilizing barrier ointments (Ersser et al., 2005).
12. Pilot test absorbent products to best meet patient, sta, and institutional
preferences (Dunn et al., 2002), bearing in mind adult briefs have been
associated with UTIs (Zimako et al., 1996).
B. Strategies for specic problems:
1. Stress UI
a. Teach pelvic oor muscle exercises (PFMEs; DuBeau et al., 2010; B.
Hodgkinson et al., 2008).
b. Provide toileting assistance and bladder training PRN (whenever neces-
sary; DuBeau et al., 2010).
c. Consider referral to other team members if pharmacological or surgical
therapies are warranted.
2. Urge UI and OAB
a. Implement bladder training (retraining; DuBeau et al., 2010; Teunissen
et al., 2004).
(continued)
Protocol 18.1: Urinary Incontinence in Older Adults
Admitted to Acute Care (cont.)
Urinary Incontinence 379
b. If patient is cognitively intact and is motivated, provide information on
urge inhibition (Gray, 2005; Smith, 2000).
c. Teach PFMEs to be used in conjunction with bladder training, and
instruct in urge inhibition strategies (Flynn, Cell, & Luisi, 1994; Rath-
nayake, 2009a; Teunissen et al., 2004).
d. Collaborate with prescribing team members if pharmacological therapy
is warranted.
e. Initiate referrals for those patients who do not respond to the aforemen-
tioned strategies.
3. Overow UI
a. Allow sucient time for voiding.
b. Discuss with interdisciplinary team the need for determining a post-
void residual (PVR; Newman & Wein, 2009; Shinopulos, 2000). See
Table 18.2.
c. Instruct patients in double voiding and Crede’s maneuver (Doughty, 2000).
d. If catheterization is necessary, sterile intermittent catheterization is
preferred over indwelling catheterization (Saint et al, 2006; Terpenning,
Allada, & Kauman, 1989; Warren, 1997).
e. Initiate referrals to other team members for patients requiring pharma-
cological or surgical intervention.
4. Functional UI
a. Provide individualized scheduled toileting, timed voiding, or prompted
voiding (Eustice et al., 2000; Jirovec, 2000; Lee et al., 2009; Ostaszkiewicz
et al., 2004).
b. Provide adequate uid intake.
c. Refer for physical and occupational therapy PRN.
d. Modify environment to maximize independence with continence (Fantl
et al., 1996; Jirovec, 2000; Jirovec et al., 1988; Palmer, 1996).
VI. Evaluation of Expected Outcomes
A. Patients:
Will have fewer or no episodes of UI or complications associated with UI.
B. Nurses:
1. Will document assessment of continence status at admission and through-
out hospital stay. If UI is identied, document and determine type of UI.
2. Will use interdisciplinary expertise and interventions to assess and manage
UI during hospitalization.
3. Will include UI in discharge planning needs and refer PRN.
C. Institution:
1. Incidence and prevalence of transient UI will decrease.
2. Hospital policies will require assessment and documentation of continence
status (“Assessing Care,” 2007; Fung et al., 2007).
3. Will provide access to evidence-based guidelines for evaluation and
management of UI.
4. Sta will receive administrative support and ongoing education regarding
assessment and management of UI.
(continued)
Protocol 18.1: Urinary Incontinence in Older Adults
Admitted to Acute Care (cont.)
380 Evidence-Based Geriatric Nursing Protocols for Best Practice
VII. Follow-up Monitoring of Condition
A. Provide patient/caregiver discharge teaching regarding outpatient referral and
management.
B. Incorporate continuous quality improvement (CQI) criteria into existing pro-
gram (“Assessing Care,” 2007; Fung et al., 2007).
C. Identify areas for improvement and enlist multidisciplinary assistance in devis-
ing strategies for improvement.
VIII. Relevant Practice Guidelines
National Guideline Clearinghouse Guideline
Synthesis.http://www.guideline.gov/syntheses/index.aspx
Protocol 18.1: Urinary Incontinence in Older Adults
Admitted to Acute Care (cont.)
RESOURCES
Wound, Ostomy Continence Nurses Society
An international society providing a source of networking and research for nurses specializing in
enterostomal and continence care.
http://www.wocn.org
National Association for Continence (NAFC)
A not-for-prot organization dedicated to improving the lives of individuals with incontinence.
http://www.nafc.org/
e Hartford Institute for Geriatric Nursing
is website will bring the reader to the “Try is” series to share with hospital sta.
http://www.hartfordign.org/
Society of Urologic Nurse and Associates (SUNA)
An international organization dedicated to nursing care of individuals with urologic disorders.
http://www.suna.org/
GeroNurseOnline
Geriatric Resources and tools
http://www.geronurseonline.org
Click Resources tab in Urinary Incontinence topic.
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388
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. dene catheter-associated urinary tract infection (CAUTI)
2. understand the epidemiology of CAUTI
3. dene indications for indwelling urinary catheters (IUC)
4. identify evidence-based strategies and interventions for the prevention of CAUTI
5. understand how to engage an interdisciplinary team in the management of CAUTIs
OVERVIEW
Health care-associated infections (HAIs) have received increasing scrutiny over the last
decade and are now widely recognized as largely preventable adverse events related to
medical care. CAUTIs are the single most common HAI, accounting for 34% of all
HAIs (Klevens et al., 2007) and associated with signicant morbidity and excess health
care costs (Saint, 2000). CAUTI is disproportionately reported among older adults
(Fakih et al., 2010). Although once largely overlooked as part of the price of doing
business in hospitals, a signicantly changed regulatory environment has emerged that
will bring increased scrutiny to HAIs in general and CAUTIs in particular. Examples
of this oversight include process and outcome measurement and reporting and nan-
cial incentives to improve these measures. Since 2008, the Centers for Medicare and
Medicaid Services (CMS) no longer reimburses for additional costs required to treat
hospital-acquired urinary tract infections (UTIs; CMS, Department of Health and
Human Services [DHHS], 2007). Long-term care facilities also follow CMS regula-
tory guidance and their federal regulations (F-315 Tag) mandate that IUC use must
be medically justied and care rendered to reduce infection risk in all residents with or
without an IUC (CMS, DHHS, 2005). Enhanced public reporting and nancial incen-
tives gure prominently in the Patient Protection and Aordable Care Act of 2010;
19
Heidi L. Wald, Regina M. Fink, Mary Beth Flynn Makic,
and Kathleen S. Oman
Catheter-Associated Urinary Tract
Infection Prevention
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Catheter-Associated UTI Prevention 389
HAIs are singled out for inclusion in both types of initiatives (Patient Protection and
Aordable Care Act, 2010). erefore, it is imperative that health care professional sta
in various settings develop strategies and interventions to reduce IUC duration and
prevent CAUTIs, thus benetting both patient and nancial outcomes.
is paradigm shift occurs as the evidence base for the prevention of CAUTI is
evolving. After 25 years of stasis in the eld, multiple stakeholder organizations includ-
ing the Centers for Disease Control and Prevention (CDC) and several major profes-
sional societies have critically examined the literature on CAUTI prevention. Between
2008 and 2010, at least six evidence-based practice strategies, recommendations, and/
or guidelines for preventing CAUTI in hospitals and long-term care have been pub-
lished (Cottenden et al., 2005; Gould et al., 2009; Greene, Marx, & Oriola, 2008;
Hooton et al., 2010; Joanna Briggs Institute [JBI], 2000; Lo et al., 2008; see Resources
section). Prior to this proliferation of recommendations, the last evidence synthesis
for CAUTI prevention in the United States occurred in 1981. In addition, in 2009,
the CDC’s National Healthcare Safety Network signicantly revised the surveillance
denition for CAUTI (CDC, National Healthcare Safety Network, 2009). In light
of these rapid changes in the eld, the review of policies, procedures, practices, and
products is imperative for all health care facilities. In this chapter, we will review the
rationale for CAUTI prevention strategies, suggest an approach to implementing a
comprehensive CAUTI prevention program, and catalog the most important CAUTI
prevention strategies.
BACKGROUND AND STATEMENT OF PROBLEM
Health care-associated UTIs are frequent and costly, resulting in increased morbidity
and possible mortality in hospitalized older adults (Saint, 2000). ere are more than
500,000 hospital-acquired UTIs in the United States annually (Gould et al., 2009;
Klevens et al., 2007). At a mean cost of $589 per episode, this epidemic results in $250
million of excess health care costs each year (Tambyah, Knasinski, & Maki, 2002). Five
percent of UTIs lead to bacteremias, with signicantly increased mortality and costs.
e vast majority of UTIs are associated with the ubiquitous IUC, also known as a
Foley catheter named after urologist Frederick Foley who developed the modern device.
Urinary catheters are among the most widely used medical devices. Despite their utility
in acutely ill patients, they have many downsides, including the CAUTI. Other compli-
cations include delirium (Inouye, 2006), local trauma, encrustation, and restriction of
mobility (Saint, Lipsky, & Goold, 2002). erefore, the benets of managing urinary
output with an IUC must be weighed against the many risks.
Unfortunately, the indiscriminate use of IUCs is widespread. IUCs are used in
up to 25% of hospital admissions (Weinstein et al., 1999) and are more commonly
used in the older patient (Fakih et al., 2010). irty percent of Medicare patients
have IUCs during their hospital stay (Zhan et al., 2009) and older women are dis-
proportionately likely to have no clear indication for catheterization (Fakih et al.,
2010). Of Medicare patients undergoing elective surgery, 86% have an IUC (Wald,
Ma, Bratzler, & Kramer, 2008) and nearly 50% continue to have a catheter in place
beyond 48 hours postoperatively (Wald, Epstein, & Kramer, 2005). According to the
Infectious Diseases Society of America (IDSA), 21%–54% of all IUCs are inappro-
priately placed and are not medically indicated (Hooton et al., 2010). Only 25% of
attending physicians in teaching hospitals are aware that their patients have urinary
390 Evidence-Based Geriatric Nursing Protocols for Best Practice
catheters, and few hospitals have systematic methods for tracking which patients have
catheters placed (Saint et al., 2000; Saint et al., 2008). Clearly, interventions aimed
at evidence-based use of catheters are needed to prevent CAUTIs. To better under-
stand the potential approaches to prevention of CAUTIs, an understanding of CAUTI
pathogenesis is essential.
Catheter-Associated Urinary Tract Infection Pathogenesis
e urinary tract is normally a sterile body site; therefore, any positive urine culture
(dened in Table 19.1) can be considered a UTI. e IDSA distinguishes between
two categories of UTIs: the benign asymptomatic bacteriuria (ASB) and the clinically
important symptomatic UTI. Either of these conditions can occur in the presence of an
IUC (Hooton et al., 2010).
When a patient has an IUC, microorganisms can gain access to the urinary tract
on either the extraluminal surface of the IUC or intraluminal surface through breaks
in the catheter system (Figure 19.1). Extraluminal infection can occur early if bacteria
are introduced during insertion, but more commonly, extraluminal infection occurs
later (Maki & Tambyah, 2001). Once they gain access to the urinary tract, micro-
organisms can thrive in a “biolm” layer on either the extraluminal or intraluminal
surface of the IUC. e biolm, made up of bacteria, host proteins, and bacterial
slime, is thought to be important in the development of late CAUTIs. Because the
formation of a biolm and colonization with bacteria takes time, most CAUTI occurs
after 48 hours of catheterization and increases approximately 5% per day (Schaeer,
1986; Stamm, 1975).
e mechanisms described previously provide the rationale for evidence-based
care of IUCs and highlights three potential opportunities for intervention during
the use of IUCs (Figure 19.2). e rst opportunity is avoidance of catheters at the
time of the decision for insertion, the second is evidence-based product selection and
care practices regarding IUCs (including insertion and maintenance), and the third is
minimizing duration through timely removal. A fourth set of additional strategies for
CAUTI prevention includes education of providers and surveillance of processes and
outcomes. is set of strategies can be applied at any of the opportunities for interven-
tion. A comprehensive program to eliminate CAUTIs includes elements of each of the
aforementioned strategies.
TABLE 19.1
Definition of a Positive Urine Culture
1. Greater than or equal to 10
5
microorganisms/cc of urine with no more than two species of
microorganisms.
OR
2. Greater than or equal to 10
3
and less than or equal to 10
5
CFU/ml with no more than two
species of microorganism.
AND
A positive urinalysis:
n Positive dipstick for leukocyte esterase and/or nitrite
n Pyuria (urine specimen with 5 10 WBC/mm
3
or 5 3 WBC/high power field of unspun urine)
n Organisms seen on Gram stain of unspun urine.
CFU 5 colony forming unit; WBC 5 white blood cell.
Catheter-Associated UTI Prevention 391
Routes of entry of uropathogens to catheterized urinary tract.
FIGURE 19.1
Extraluminal
• Early, at insertion
• Late, by capillary action
Intraluminal
• Break in closed drainage
• Contamination of
collection bag urine
Source: Maki, D. G., & Tambyah, P. A. (2001). Engineering out the risk of infection with urinary
catheters. Emerging Infectious Diseases, 7(2), 342–347. Retrieved from http://www.cdc.gov/ncidod/eid/
vol7no2/makiG1.htm
Stages of catheter use and potential intervention strategies.
• Reminders and
stop orders
• Nursing-driven
removal protocols
• Audit and feedback
• Standardized order sets
Insertion Care Removal
1. Avoidance
2. Evidence-based
care practices and
product selection
3. Minimize duration
4. Education & Surveillance
• Protocols with explicit
criteria
• Utilize alternatives
(e.g., toileting regimens,
urinals, condom catheters,
commodes, absorbent
pads, intermittent
straight catheterization
with bladder scanner)
• Aseptic vs. sterile
insertion technique
• Routine meatal care
• Prevent urine reflux
• Maintain closed system
• Catheter material
• Catheter size
• Securement device
FIGURE 19.2
392 Evidence-Based Geriatric Nursing Protocols for Best Practice
ASSESSMENT OF THE PROBLEM
Surveillance Definition of Catheter-Associated Urinary Tract Infection Pathogenesis
A CAUTI is a UTI that occurs while a patient has an IUC or within 48 hours of its
removal. Although the clinical diagnosis of CAUTI is in the eye of the clinician, the
CDC has developed explicit surveillance criteria for CAUTI for use by infection control
practitioners. In brief, the patient must have the following symptoms:
1. A positive urine culture sent more than 48 hours after admission to the health care
facility (Table 19.1)
2. An IUC at the time of or within 48 hours prior to the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or tender-
ness, or a fever higher than 38 °C without another recognized cause; or a positive
blood culture with the same organism as in the urine
e CAUTI diagnosed within 48 hours of arrival to a location is attributed to the
prior location.
In nonbacteremic cases, this surveillance denition requires the patient have symp-
toms referable to the urinary tract or a fever without another cause. ASB is of ques-
tionable clinical signicance and should not be treated except in pregnant patients or
those undergoing urologic surgery (Nicolle et al., 2005). For the purposes of infection
control surveillance, new alterations in mental status do not meet the diagnostic crite-
ria for CAUTI.
CAUTIs are generally reported as infections per 1,000 catheter days on a given
patient care unit. More than half of all states require public reporting of hospital-
acquired infections, among them, many specify reporting of CAUTIs. Such reporting
of CAUTI rates is likely to increase.
Additional process measures that may be of interest include catheter days or hos-
pital days, catheter duration per episode of catheterization (may also be referred to as
dwell time), and proportion of catheterized or admitted patients from the emergency
department (ED) or operating room (OR). Since October 2009, the Surgical Care
Improvement Project collects a measure of postoperative catheter removal on post-
operative Day 1 or 2 and, as of October 2010, has expanded this measure to catheter
removal on catheterization Day 1 or 2 for all surgical patients (Surgical Care Improve-
ment Project, n.d.).
Indications for Indwelling Urinary Catheters
Avoidance of unnecessary IUCs may reduce CAUTI incidence with subsequent decreases
in length of stay, costs of hospitalization, and costs associated with CAUTI (Apisarn-
thanarak et al., 2007). Elpern et al. (2009) evaluated the inappropriate use of IUCs
among inpatients and found them to be more common in female, nonambulatory, and
medical ICU patients. Explicit criteria for appropriate insertion may result in signicant
reductions in catheter duration and CAUTI prevalence. e University of Colorado
Hospital developed and disseminated an algorithm for appropriate insertion of IUCs in
the ED based on guidance from the published literature (Figure 19.3).
Similar criteria can also be developed specically for the OR and postoperative
period. At the University of Colorado Hospital, a protocol for early postoperative
removal was developed and disseminated (Figure 19.4).
Catheter-Associated UTI Prevention 393
An IUC should not be used for routine care of patients who are incontinent, as
a means to obtain urine culture or other diagnostic tests in a patient who can void,
for prolonged postoperative duration without appropriate indications, or routinely in
patients receiving epidural anesthesia and analgesia (see Protocol 19.1).
INTERVENTIONS AND CARE STRATEGIES
It is estimated that 20%–69% of CAUTIs are preventable (Gould et al., 2009). Specic
interventions to prevent CAUTIs are summarized in the subsequent text and organized
regarding the four strategies illustrated in Figure 19.2. Many of these recommendations
Algorithm for appropriate insertions of indwelling urinary catheters.
Admission/Shift change assessment of Urine Output Management
Is there a need for an indwelling urinary catheter?
YES, the reason appears above.
Insert catheter
NO, the reason does not appear
above. (A catheter may not be
indicated for this patient.)
Re-evaluate continued need
each shift.
Consider removal if indications
no longer met.
Consider:
1. Straight Catheterization (for
Sterile specimen if needed)
2. Commode
3. Urinal
4. Bed pan
5. Incontinence Pads
6. Toileting with assistance
Please read the following criteria for appropriate use of Foley catheter
and check your reason for ordering the Foley catheter for this patient.
Drainage:
• Urinary obstruction (distal urinary tract)
• Urinary retention (not managed with intermittent
catheterization)
Monitoring:
• Alteration in the blood pressure or volume status
(unstable patient) requiring urine volume measurement.
• Accurate monitoring of intake and output in a patient
unable to cooperate with urine collection by other means.
Periprocedure:
• Preoperative insertion for emergency surgery
• Major trauma patients
• Placement by urology for procedure or surgery
Therapy:
• Continuous bladder irrigation
• Management of urinary incontinence with stage 3 or
greater pressure ulcerations
• Comfort care for the terminally ill
FIGURE 19.3
394 Evidence-Based Geriatric Nursing Protocols for Best Practice
are supported by low quality evidence and expert opinion. Further study may impact
these recommendations. A proposed approach to a comprehensive CAUTI intervention
follows.
Strategy 1: Avoidance
To reduce the incidence of CAUTI, it is important to rethink practice systems and
examine “why” behind the clinical indication for the IUC. Clearly identifying the need
for the IUC can assist in the avoidance of inserting an IUC when other options for
Algorithm for postoperative removal of indwelling urinary catheter placed
for surgery
Upon completion of surgery
Can the indwelling urinary catheter be removed?
Indications for Postoperative
REMOVAL of Indwelling Urinary
Catheter
Indications for Postoperative
MAINTENANCE of Indwelling Urinary
Catheter
Consider postoperative removal in OR or PACU
using one of the following alternatives
1. Toileting with Assistance
2. Bladder Scan to assess urine volume
3. Straight Catheterization
4. Incontinence Pads
Re-evaluate in PACU for indications for
continued device use
Drainage:
• Catheter inserted solely for
anticipated prolonged
duration of surgery
(> 2 hrs)
• Less than 1500 cc infused
intraoperatively; only small
volume infusions
anticipated postoperatively
Periprocedure:
• Catheter inserted solely for
deflation of urinary
bladder during surgery
Drainage: • Anticipated continuous
large volume infusions or
diuretics in the
postoperative period
Monitoring:
• Accurate postoperative
monitoring of urinary
output
Periproduce: • Urologic surgery or other
surgery on contiguous
structures of the
genitourinay tract
Therapy: • Need for prolonged
immobilization (e.g.,
potentially unstable
thoracic or lumbar spine,
multiple traumatic injuries
such as pelvic fractures)
• Prolonged effect of
epidural anesthesia
(inhibiting walking)
YES NO
FIGURE 19.4
Catheter-Associated UTI Prevention 395
elimination are available. e use of an algorithm (Figure 19.3) to guide the insertion
decision may be of assistance. To avoid catheterizations, alternative strategies for man-
aging urine output are necessary. Completing a systems evaluation of available equip-
ment to provide alternatives to IUC for urinary elimination is an important rst step
in reducing use. Developing toileting schedules incorporated with frequent nursing
sta rounding is another strategy that can be used to reduce urgency and incontinence
episodes.
If the patient is mobile or has limited mobility, alternatives to an IUC include the
use of a bedside commode with a toileting schedule (Gray, 2010), condom catheters for
male patients (Dowling-Castronovo & Bradway, 2008; Saint et al., 2006), moisture-
wicking incontinence pads (BioRelief, n.d.; Cottenden et al., 2005; Medline Ultrasorb
Underpad, n.d.), intermittent straight catheterization with the use of a bladder scanner
to determine bladder urine volume (Hooton et al., 2010; Saint et al., 2006; Saint et
al., 2009), as well as urinals and bedpans. Careful consideration of products and how
and where they are stocked is essential to success. For instance, commodes need to be
available in multiple sizes and need to include stable (not easy to tip) and bariatric com-
modes; urinals need to t snugly on bedrails.
For less mobile male patients, the condom catheter is an eective alternative to an
IUC. Research by Saint and colleagues (2006) found that the use of condom catheters
for elimination were eective in reducing CAUTIs (p 5 .04). In addition, the patients
in this study reported condom catheters to be more comfortable (p 5 2.02) and less
painful (p 5 .02) than an IUC. e authors did not report an increase in adverse
skin breakdown associated with the use of the condom catheter. Moisture-absorbing
or -wicking underpads for incontinence management are a newer alternative for the
acute care environment. Incontinence underpad products pull euent moisture and
urine away from the skin and can absorb up to 2 L of uid before becoming saturated
(Junkin & Selekof, 2008; Padula, Osborne, & Williams, 2008). For a full discussion of
incontinence management, please refer to Chapter 18, Urinary Incontinence.
Urinary retention postsurgery or after initial IUC removal may pose clinical care
challenges. To prevent IUC insertion or reinsertion, intermittent catheterization should
be considered as an avoidance strategy. e bladder scanner, which utilizes ultrasound
technology, is clinically benecial in determining urinary retention, reducing unneces-
sary intermittent catheterizations, enhancing patient comfort, and saving costs associ-
ated with inappropriate catheterizations and possible CAUTIs (Lee, Tsay, Lou, & Dai,
2007; Palese, Buchini, Deroma, & Barbone, 2010; Sparks et al., 2004).
Strategy 2: Evidence-Based Product Selection, Insertion, and Routine Care
If an IUC is determined to be clinically indicated, selection of the right catheter, proper
technique during insertion of the device, and evidence-based ongoing care management
are needed to reduce infection.
Catheter material remains an area of ongoing debate. Although antimicrobial
catheter materials have been shown to reduce catheter-associated bacteriuria ( Johnson,
Kuskowski, & Wilt, 2006), the impact of antimicrobial catheters on symptomatic
CAUTIs remains unproven. Research syntheses have failed to conclusively demonstrate
the eectiveness of silver-coated or antibiotic-impregnated catheters on prevention
of CAUTIs for short-term catheterization of adult patients versus standard materials.
ere is also insucient evidence to determine whether selection of a latex catheter,
396 Evidence-Based Geriatric Nursing Protocols for Best Practice
hydrogel-coated latex catheter, silicone-coated latex catheter, or all-silicone catheter
inuences CAUTI risk (Cottenden et al., 2005; Hooton et al., 2010; Parker et al.,
2009; Patient Protection and Aordable Care Act, 2010; Schumm & Lam, 2008). e
decision to use a silver-coated or antibiotic-impregnated catheter should be made with
the understanding that it does not substitute for a comprehensive CAUTI prevention
program.
Selecting the smallest IUC size, when possible, is an additional consideration to
reduce the risk of infection (Gould et al., 2009; Greene et al., 2008; Hooton et al.,
2010). e selection of a smaller catheter (e.g., less than 18 French) reduces irritation
and inammation of the urethra and reduces infection risk (Gray, 2010).
Placing an IUC is a fundamental skill for nurses; however, current evidence sup-
porting sterile versus aseptic technique for the procedure is inconclusive (Greene et
al., 2008; JBI, n.d.). Strict sterile technique involves using a sterile gown, mask, pro-
longed hand washing (more than 4 minutes), opening and using a sterile insertion kit,
donning sterile gloves, cleansing the urethral meatus and perineal area with an anti-
septic solution, and inserting the catheter using a no-touch technique (Gray, 2010).
Willson and colleagues (2009) reviewed the literature and found that most clinicians
employ an aseptic technique, which was most frequently dened as the use of sterile
gloves, sterile barriers, perineal washing using an antiseptic cleanser, and no-touch
insertion. Current recommendations suggest an IUC insertion be placed under asep-
tic technique with sterile equipment (Gould et al., 2009; Greene et al., 2008; Hooton
et al., 2010).
Once an IUC is placed, optimal management includes care of the urethral meatus
according to “routine hygiene” (e.g., daily cleansing of the meatal surface during bath-
ing with soap and water and as needed (e.g., following a bowel movement; Gould
et al., 2009; Greene et al., 2008; Hooton et al., 2010; Jeong et al., 2010; JBI, n.d.).
Meatal cleansing with antiseptics, creams, lotions, or ointments has been found to
irritate the meatus, possibly increasing the risk of infection (Jeong et al., 2010; Willson
et al., 2009).
Securing the IUC after placement to reduce friction from movement is an impor-
tant element of catheter management supported by current guidelines, researchers, and
expert opinion panels (Darouiche et al., 2006; Gould et al., 2009; Hooton et al., 2010;
Society of Urologic Nurses and Associates Clinical Practice Guidelines Task Force,
2006). Maintaining a closed catheter system is also supported by current guidelines
(Gould et al., 2009; Greene et al., 2008; Hooton et al., 2010) to eliminate the intro-
duction of microbes that occurs when breaking the prepackaged seals on the IUC.
A systems analysis should be conducted to purchase and stock the most commonly
needed IUC insertion and drainage bag kits to optimize the maintenance of a closed
system. Similarly, maintaining the urine collection bag below the level of the bladder
minimizes reux into the catheter itself preventing retrograde ow of urine (Gould
et al., 2009; Greene et al., 2008; Hooton et al., 2010). Establishing work ow protocols
to routinely empty the drainage bag frequently and prior to transport are important in
reducing urine reux and opportunities for CAUTI.
Strategy 3: Timely Removal
Developing systems that prompt health care providers to review the need for the IUC
and encourage early removal have been found to reduce IUC use and CAUTI rates
Catheter-Associated UTI Prevention 397
( Apisarnthanarak et al., 2007; Fernandez, Griths, & Murie, 2003; Loeb et al., 2008;
Meddings, Rogers, Macy, & Saint, 2010). Meddings and colleagues (2010) conducted a
systematic review and meta-analysis and found that urinary catheter removal reminders
and stop orders appeared to reduce CAUTI rates. Implementing systems that provide
physicians and nurses routine reminders to evaluate the need for the IUC were found
to reduce the CAUTI rate by 56% (p 5 .005). In this study, automatic stop orders were
found to reduce the rate of CAUTI by 41% (p , .001). Overall, urinary catheter use
and mean duration of catheterization were also decreased in several studies analyzed
(Meddings et al., 2010).
Other valid approaches to reducing catheter days include audit and feedback
(Goetz, Kedzuf, Wagener, & Muder, 1999) and nurse-prompted reminders to recom-
mend reevaluation of the need for the IUC and early removal (Apisarnthanarak et al.,
2007; Greene et al., 2008). Some hospitals have explored nurse-driven catheter removal
protocols (Wenger, 2010).
Multiple studies have examined outcomes associated with early removal of IUCs
after surgery. Early removal of IUCs after uncomplicated hysterectomy decreased rst
ambulation time and length of hospital stay (Alessandri, Mistrangelo, Lijoi, Ferrero, &
Ragni, 2006). Dunn, Shlay, and Forshner (2003) found that early removal postsurgery
was not associated with adverse events in patients and subjective pain was signicantly
less. Keeping the IUC as long as thoracic epidural analgesia is maintained may result in
a higher incidence of CAUTI and increased hospital stay. IUC removal on the morn-
ing after surgery while the thoracic epidural catheter is still in place does not lead to
urinary retention, infection, or higher rates of recatheterizations (Basse, Werner, &
Kehlet, 2000; Chia, Wei, Chang, & Liu, 2009; Ladak et al., 2009; Zaouter, Kaneva,
& Carli, 2009).
Strategy 4: Surveillance and Education
Ensuring leadership of organizations and systems are in place to eectively evaluate
and sustain practice change are essential to improving patient outcomes (Kabcenell,
Nolan, Martin, & Gill, 2010; Reinertsen, Bisognano, & Pugh, 2008). In particular,
surveillance is key to an eective infection control program. Metrics that are ame-
nable to performance measurement and feedback are discussed in the Assessment of
the Problem section and include process measures as well as outcomes. A 2005 sur-
vey demonstrated that only a minority of hospitals track urinary catheter use (Saint
et al., 2008).
Measurement must be accompanied by provision, knowledge, and skills to front-
line providers through appropriate education and training, which may be central
to a multicomponent CAUTI intervention. Huang et al. (2004) found that a mul-
tifaceted educational intervention incorporating the use of algorithms, automated
stop orders, and physician reminder prompts needed to be critically evaluated to
eectively decrease CAUTIs in all patients. Ongoing system evaluation, nursing
reeducation, practice reminders, and public reporting of unit-based CAUTI rate
data are strategies to inform the health care team of current practice outcomes and
eectiveness of CAUTI prevention strategies. Implementing systems that encompass
the whole health care team to question the need for the IUC and, when indicated,
ensuring proper care and early removal can be pivotal in reducing CAUTI rates
(Wenger, 2010).
398 Evidence-Based Geriatric Nursing Protocols for Best Practice
Approach to a Comprehensive Catheter-Associated Urinary Tract Infection Intervention
Evidence-based practice guidelines derived from valid, current research and other
evi dence sources can successfully improve patient outcomes and quality care.
However, simply disseminating scientic evidence is often ineective in changing
clinical practice. Learning how to implement ndings is critically important to
promoting high quality and safe care (Drekonja, Kuskowski, & Johnson, 2010).
To eectively facilitate the translation of best evidence into practice, processes
enhancing practice change must be embraced by the health care provider (Wallin,
Profetto-McGrath, & Levers, 2005). Understanding health care provider decisions,
experiences, practice processes, and barriers are considered essential elements that
must be explored to successfully implement practice change based on best evidence
(Titler & Everett, 2006).
Developing an interdisciplinary champion team and creating a multifaceted inter-
vention to implement evidence-based procedures for IUC insertion and maintenance
must be a priority in all practice settings. e ultimate goals are to reduce routine cath-
eter insertions, provide evidence-based catheter care, and prompt early removal when
possible, thus decreasing the risk of and prevention of CAUTI.
Steps used for protocol development at the University of Colorado Hospital are
highlighted in the subsequent text. Improved patient outcomes (decreased catheter
days, decreased CAUTIs) and decreased costs have been realized.
Protocol Development
1. Recruit an interdisciplinary champion team to include nurses (clinical educators,
OR registered nurses [RNs], ED RNs); physicians (hospitalists, infectious disease
ED medical doctors [MDs], surgeons, anesthesiologists); rehabilitation therapists
and transport personnel; infection control preventionists; and quality improve-
ment, central supply, and clinical informatics representatives.
2. Examine and synthesize the evidence (search, review, critique, and hold journal
clubs in various care areas to present the evidence).
3. Identify and understand product use, availability, and costs in your health care set-
ting. Rene product use based on the best evidence and cost analysis. Examine the
following:
n Urinary catheter materials, sizes, kits, and drainage bags
n Catheter securement device
n Urinals and bedpan availability
n Commodes (availability and size)
n Bladder scanners
n Alternatives (incontinence pads, condom catheters, etc.)
4. Identify barriers to optimal IUC care practices by surveying sta or holding focus
groups throughout your health care setting.
5. Update your policy and procedures related to indwelling catheter insertion and care
based on the evidence.
6. Consider breaking the project into manageable phases. Avoidance strategies may
require a dierent approach than care or removal strategies. For instance, avoidance
starts in the ED and OR, whereas removal occurs on inpatient oors.
Catheter-Associated UTI Prevention 399
7. Develop and use algorithms, decision aids, and factoid posters displaying evidence-
based caveats.
8. Update patient and family educational materials on the importance of prompt and
early removal of indwelling catheters.
9. Educate sta (including radiology, transport, rehabilitation therapy sta [PT,
physical therapist; OT, occupational therapist]) focusing on policy and pro-
cedure revision, insertion indication guidelines, insertion procedures, mainte-
nance and care, catheter bag placement, removal prompts, and bladder scanner
use and procedures.
10. Work with infection control and clinical informatics sta to audit and measure
outcomes. Provide feedback to sta. Potential measurable outcomes include the
following:
n CAUTIs/1,000 catheter days
n Catheter days and hospital days
n Postoperative catheter days and patient days
n Proportion of catheterized and admitted patients from ED or OR
11. Continually evaluate and update practice changes.
Mr. T is an 84-year-old male with a history of Alzheimer’s disease and incontinence
presenting to your hospital with failure to thrive. e patient arrives to the medical
oor with an IUC that was placed in the ED. Given the patient’s incontinence and
fall risk, the urinary catheter is left in place. ree days after admission while awaiting
placement in a skilled nursing facility (SNF), he develops fever and delirium and is
diagnosed with a UTI. is delays his transfer to the SNF.
Questions to Consider
1. Was the catheter placement medically indicated?
2. What could have been used as alternatives to indwelling catheter placement?
Discussion
Because incontinence and fall risk are not medically appropriate indications for a
urethral catheter, it should have been avoided in the ED or removed as soon as the
patient arrived to the oor. Alternatives to indwelling catheterization in this patient
would include a bedside commode with nursing assistance, incontinence pads or
diapers, or a condom catheter. Attentiveness to the appropriate medical indications
for catheter use, familiarity with catheter alternatives, and recognition of the clinical
and economic impacts may have prevented the infection and eased the placement of
this patient.
CASE STUDY 1
400 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
A rapidly changing evidence base and regulatory environment necessitates a renewed
focus on the prevention of CAUTI, which is informed by an understanding of CAUTI
pathogenesis and rational IUC use. Critical elements of a CAUTI prevention program
include maximizing catheter avoidance, ensuring evidence-based practice and product
use, and timely catheter removal. Additional strategies include sta education, continu-
ing monitoring of CAUTI incidence, and catheter use. Multicomponent interventions
have been used successfully in the prevention of CAUTIs.
Mrs. G is a 69-year-old alert female with a diagnosis of nonsmall cell lung cancer is
admitted for a thoracotomy. e patient is transferred from the postanesthesia care
unit (PACU) to the surgical intensive care unit (ICU) with an IUC that was placed
in the OR and a thoracic epidural for pain management with morphine and bupi-
vacaine infusion. Mrs. G is doing well 48 hours postoperatively, experiencing little
pain, and is able to cough and deep breathe. She is transferred out of the ICU to the
surgical oor with the urinary catheter and thoracic epidural still in place. When
prompted by nursing sta to write an order for urinary catheter removal, the surgeon
says he is waiting for the anesthesiology team to pull the epidural catheter before
removing the urinary.
Questions to Consider
1. Was the IUC placement surgically indicated?
2. When should the IUC be removed?
3. When the IUC is removed, what can be used as alternatives?
Discussion
e IUC was probably indicated because of length of surgery (more than 2 hours)
and need for accurate monitoring for intake and output. e misnomer that the IUC
needs to be in place as long as the thoracic epidural remains for pain management pur-
poses needs clarication. Multiple studies have supported IUC removal on the morn-
ing after surgery to decrease CAUTI risk (Basse et al., 2000; Chia et al., 2009; Ladak
et al., 2009; Zaouter et al., 2009). Early removal does not lead to urinary retention or
higher rates of recatheterization. Post-IUC removal, toileting with assistance, use of
a bedpan or urinal, placement of an incontinence pad or use of a bladder scanner for
post void residual volume assessment, and use of straight catheterization if indicated
are alternatives.
CASE STUDY 2
Catheter-Associated UTI Prevention 401
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention
I. GOALS: To ensure that nurses in acute care are able to:
A. Dene catheter-associated urinary tract infection (CAUTI)
B. Understand the epidemiology of CAUTI
C. Dene indications for indwelling urinary catheters (IUC)
D. Identify evidence-based strategies and interventions for the prevention of
CAUTI
E. Understand how to engage an interdisciplinary team in the management of
CAUTIs in your setting
II. OVERVIEW
A. CAUTIs are the single most common hospital-acquired infection (HAI),
accounting for 34% of all HAIs and associated with signicant morbidity and
excess health care costs.
B. Since 2008, the Centers for Medicare and Medicaid Services (CMS) no longer
reimburse for additional costs required to treat nosocomial urinary tract infec-
tions (UTIs).
C. Between 2008 and 2010, at least six evidence-based practice strategies, recom-
mendations, and/or guidelines for preventing CAUTI in hospitals and long-
term care have been published.
D. In light of these rapid changes in the eld, the review of policies, procedures,
practices, and products is imperative for all health care facilities.
III. BACKGROUND AND STATEMENT OF PROBLEM
A. Introduction
1. ere are more than 500,000 UTIs in the United States annually. At a
mean cost of $589 per episode, this epidemic results in $250 million of
excess health care costs each year.
2. Most UTIs are associated with the ubiquitous IUC, also known as a Foley
catheter.
3. According to the Infectious Diseases Society of America, 21%–54% of all
IUCs are inappropriately placed and are not medically indicated.
B. Denitions
1. Symptomatic UTI. A patient has at least one of the following signs or symp-
toms with no other recognized cause: fever (higher than 38 °C), urgency,
frequency, dysuria, or suprapubic tenderness and positive urine culture (see
Table 19.1).
2. Asymptomatic bacteriuria. A positive urine culture in a patient who does not
have symptoms referable to the urinary tract; may or may not be catheter-
associated.
3. CAUTI. A symptomatic UTI that occurs while a patient has an IUC or
within 48 hours of its removal.
NURSING STANDARD OF PRACTICE
(continued)
402 Evidence-Based Geriatric Nursing Protocols for Best Practice
C. Essential Elements
1. e urinary tract is normally a sterile body site. In the presence of an IUC,
microorganisms can gain access to the urinary tract on either the extralu-
minal surface of the IUC or intraluminal surface through breaks in the
catheter system.
2. Once bacteria gain access to the urinary tract, microorganisms can thrive
in a “biolm” layer on either the extraluminal or intraluminal surface of
the IUC.
3. Because the formation of a biolm and colonization with bacteria takes
time, most CAUTI occurs after 48 hours of catheterization and increases
approximately 5% per day.
4. e mechanisms described previously provide the rationale for evidence-
based care of IUCs. Four potential opportunities for intervention include
the following:
a. Avoid the use of catheters
b. Evidence-based care practices and product selection
c. Timely removal
d. Education and surveillance
IV. ASSESSMENT OF CAUTI
A. e Centers for Disease Control and Prevention (CDC) has developed explicit
surveillance criteria for CAUTI. In brief, the patient must have the following:
1. A positive urine culture (see Table 19.1) sent more than 48 hours after
admission to the health care facility
2. An IUC at the time of or within 48 hours prior to the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or
tenderness, or a fever higher than 38 °C without another recognized cause;
or a positive blood culture with the same organism as in the urine
B. Measures
1. Outcomes
a. CAUTIs/1,000 catheter days
2. Processes
a. Catheter days and hospital days
b. Postoperative catheter days and patient days
c. Proportion of catheterized and admitted patients from emergency
department (ED) or operating room (OR)
C. Indications for IUCs can be operationalized using algorithms or protocols.
V. NURSING CARE STRATEGIES
Twenty percent to 69% of CAUTIs are preventable through the application of evi-
dence-based care strategies.
A. Catheter Avoidance
1. Established insertion guidelines for ED and OR
2. Alternative strategies to manage urine output available:
a. Bedside commodes
b. Condom catheters
(continued)
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention (cont.)
Catheter-Associated UTI Prevention 403
c. Moisture-wicking incontinence pads
d. Intermittent straight catheterization
e. Bladder scanner for monitoring and assessment
f. Bedpans and urinals that are functional
3. Toileting schedules and frequent nursing rounds
B. Product Selection and Routine Care
1. Catheter material is controversial:
a. Antimicrobial catheter materials have been shown to reduce catheter-
associated bacteriuria (colonization), but impact on prevention of
symptomatic CAUTIs during short-term insertions is unproven.
b. ere is insucient evidence to determine whether selection of a latex
catheter, hydrogel-coated latex catheter, silicone-coated latex catheter,
or all-silicone catheter inuences CAUTI risk.
2. Select the smallest size possible (less than 18 French).
3. Use aseptic technique and sterile product during catheter insertion.
4. Routine urethral meatus cleansing with soap and water during bath and
after bowel movement.
5. Secure catheter to leg.
6. Maintain a closed system at all times.
7. Keep drainage bag below level of bladder.
8. Empty the bag when two-third full and before transport.
C. Timely Removal
1. Systems that prompt providers to review the need for the catheter and
encourage early removal. Examples include stop orders and reminder sys-
tems: audit and feedback, nurse-prompted reminders, and nurse-driven
removal protocols.
2. Measure of removal: Surgical Care Improvement Project (SCIP), SCIP-9
measure; catheter removal on postoperative Day 1 or 2.
D. Surveillance and Education
1. Measurement of processes and outcomes.
2. Ongoing system evaluation, nursing reeducation, practice reminders, and
public reporting of unit-based CAUTI rate data are strategies to inform the
health care team of current practice outcomes and eectiveness of CAUTI
prevention strategies.
VI. EVALUATION AND EXPECTED OUTCOMES
A. Plan of Care
1. Assessment that patient meets established insertion criteria
2. Adherence to prompts for early catheter removal
3. Standardized catheter care guidelines followed
B. Documentation
1. Dates of insertion and removal
2. Type of catheter (new indwelling, chronic indwelling, reinsertion, change
of device)
3. Reason for catheter insertion
4. Justication that catheter is still necessary
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention (cont.)
(continued)
404 Evidence-Based Geriatric Nursing Protocols for Best Practice
5. Post residual void after catheter removal if patient is unable to void in
6–8 hours; bladder volume; intervention.
C. Catheter Utilization
1. Monitor unit-specic CAUTI rates.
2. Monitor average catheter duration (catheter days).
3. Monitor SCIP postoperative catheter removal on catheterization Day 1 or 2.
4. Trend unit-specic IUC usage.
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention (cont.)
ACKNOWLEDGMENTS
e authors would like to thank the New York University (NYU) librarians for their
evidence-based search and Karis May for assistance with the formatting of this chapter.
RESOURCES
Association for Professionals in Infection Control and Epidemiology. (2008).Guide to the elimina-
tion of catheter-associated urinary tract infections (CAUTIs): Developing and applying facility-based
prevention interventions in acute and long-term care settings.
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/CAUTI_
Guide_0609.pdf
Centers for Disease Control and Prevention. (2009). Guideline for prevention of catheter- associated
urinary tract infections, 2009.
http://www.cdc.gov/hicpac/CAUTI/001_CAUTI.html
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection
Control Practices Advisory Committee. (2009). Guideline for prevention of catheter- associated
urinary tract infections 2009.
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009nal.pdf
Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C., . . . Nicolle,
L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in
adults: 2009 international clinical practice guideline from the Infectious Diseases Society of America.
http://www.idsociety.org/content.aspx?id=4430#uti
International Continence Society (International Consultation on Incontinence Committee [an inter-
national group of continence researchers])
http://www.icsoce.org
Joanna Briggs Institute
http://www.joannabriggs.edu.au/about/home.php
Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America
(SHEA-IDSA). (2008). Compendium of strategies to prevent healthcare-associated infections in
acute care hospitals.
http://www.shea-online.org/about/compendium.cfm
Wound, Ostomy, and Continence Nurses Society Evidence-Based Report Card (EBRC)
http://www.wocn.org/
Catheter-Associated UTI Prevention 405
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409
20
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader will be able to:
1. discuss the consequences of poor oral health
2. describe a thorough oral assessment in the older adult
3. describe the oral hygiene plan of care for nonintubated older adults
4. discuss nursing interventions for oral care
OVERVIEW
Poor oral health is associated with malnutrition, dehydration, brain abscesses, valvular
heart disease, joint infections, cardiovascular disease, pneumonia, aspiration pneumo-
nia, and poor glycemic control in type I and II diabetes (Abe et al., 2006; Adachi, Ishi-
hara, Abe, & Okuda, 2007; Azarpazhooh & Leake, 2006; Bingham, Ashley, De Jong,
& Swift, 2010; Coulthwaite & Verran, 2007; Ferozali, Johnson, & Cavagnaro, 2007;
Kelsey & Lamster, 2008; Lockhart et al., 2009; Sato, Yoshihara, & Miyazaki, 2006;
Sjögren, Nilsson, Forsell, Johansson, & Hoogstraate, 2008; Tran & Mannen, 2009;
Touger-Decker & Mobley, 2007). Oral health also aects nutritional status, ability
to speak, self-esteem, mental wellness, and overall well-being (Coulthwaite & Verran,
2007; Touger-Decker & Mobley, 2007; Gil-Montoya, Subirá, Ramón, & González-
Moles, 2008; Kanehisa, Yoshida, Taji, Akagawa, & Nakamura, 2009; Quandt et al.,
2010; Soini et al., 2006; Haumschild & Haumschild, 2009; Montero, López, Galindo,
Vicente, & Bravo, 2009; Naito et al., 2010). Many oral diseases are not part of the natu-
ral aging process but side eects of medical treatment and medications.
BACKGROUND AND STATEMENT OF PROBLEM
Plaque retention is a problem in older adults who have diculty in mechanically
removing plaque caused by diminished manual dexterity, impaired vision, or chronic
Linda J. O’Connor
Oral Health Care
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
410 Evidence-Based Geriatric Nursing Protocols for Best Practice
illness (Coulthwaite & Verran, 2007; Brown, Goryakin, & Finlayson, 2009; Hakuta,
Mori, Ueno, Shinada, & Kawaguchi, 2009; Ibayashi, Fujino, Pham, & Matsuda,
2008). An older adult’s functional ability and cognitive status aect their ability to
perform oral care and denture care. Dental plaque harbors microorganisms includ-
ing Streptococcus, Staphylococcus, gram-positive rods, gram-negative rods, and yeasts
(Coulthwaite & Verran, 2007). Dentures also have the potential to harbor Streptococ-
cus pneumoniae, Haemophilus inuenza, Escherichia coli, Klebsiella, and Pseudomonas
secondary to spending time in nonhygienic environments (Coulthwaite & Verran,
2007). Dentures have been seen thrown in with patients’ clothing, thrown in a wash-
basin or other container with bathing items, and so forth, instead of being properly
cleaned and stored in a denture cup. Lack of good oral hygiene increases the risk for
development of secondary infections, extended hospital stays, and signicant negative
health outcomes.
Multiple medications produce side eects that aect the oral cavity. Cardiac medi-
cations can cause salivary dysfunction, gingival enlargement, and lichenoid mucosal
reactions. Steroid treatment can predispose a patient to oral candidiasis, and cancer
treatments can cause a plethora of oral conditions such as stomatitis, salivary hypofunc-
tion, microbial infections, and xerostomia.
e mouth reects the culmination of multiple stressors over the years and as the
mouth ages, it is less able to tolerate these stressors. With an increase in chronic disease
and medication usage as a person ages, the prevalence of root caries, tooth loss, oral
cancers, soft tissue lesions, and periodontal problems increases signicantly (Touger-
Decker & Mobley, 2007; Christensen, 2007; Saunders & Friedman, 2007). Many of
the oral health problems in the older adults could be avoided with routine preventive
care. Many older adults believe in the myth that a decline in their oral health is a normal
part of aging.
ASSESSMENT OF THE PROBLEM
Physical Assessment
e promotion of oral health through assessment and good oral hygiene is an essential
of nursing care. e oral assessment is part of the nurse’s head-to-toe assessment of the
older adult and is done on admission and at the beginning of each shift. e nurse
assesses the condition of the oral cavity, which should be pink, moist, and intact; the
presence of or absence of natural teeth and/or dentures; ability to function with or with-
out natural teeth and/or dentures; and the patient’s ability to speak, chew, or swallow.
Natural teeth should be intact, and dentures (partial or full) should t comfortably and
not be moving when the older adult is speaking. Any abnormal ndings such as dry-
ness, swelling, sores, ulcers, bleeding, white patches, broken or decayed teeth, halitosis,
ill-tting dentures, diculty swallowing, signs of aspiration, and pain are documented
by the nurse, and the health care team informed.
Poorly tting dentures can cause ulcerations and candidiasis (oral fungal infection,
masses, and denture stomatitis). Denture stomatitis presents as red, inamed tissue
beneath dentures, caused by fungal infections and insucient oral hygiene. Some oral
mucosal diseases that nursing may see are angular cheilitis (red and white cracked lesions
in the corners of the mouth, caused by inammation and a fungal infection), cicatricial
pemphigoid (produces red, inamed lesions on the gingival, palate, tongue, and cheek
Oral Health Care 411
tissues), Lichen planus (most common form presents as a lacy white appearance on the
tongue and/or cheeks), and Pemphigus vulgaris (red bleeding tissues result from trauma
but heal without scarring). Untreated lesions can develop into large, infected regions,
which require immediate medical attention. Dental professionals diagnose oral mucosal
diseases, but the nurse needs to be aware of any abnormal ndings and report them
immediately.
e nurse also needs to assess the patient for their functional ability and manual
dexterity to provide oral hygiene. e nurse needs to observe the older adult providing
their oral hygiene to make sure that it is eective. e primary focus for nurses is to
maintain the older adult’s function so that older adults may participate in their daily
care. Once the older adult provides their oral hygiene, the nurse must follow-up as
appropriate to complete the oral hygiene.
Assessment Tools
e Oral Health Assessment Tool (OHAT) is an eight-category screening tool that can
be used with cognitively intact or impaired older adults. e OHAT provides an orga-
nized, ecient method for nurses to document their oral assessment. e eight catego-
ries (lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness, and
dental pain) are scored from 0 (healthy) to 2 (unhealthy). Total scores range from 0 to 16;
the higher the score, the poorer the older adult’s oral health (Chalmers, King, Spencer,
Wright, & Carter, 2005). e OHAT may be implemented in any health care setting.
See Resource section for access to this tool.
INTERVENTION AND CARE STRATEGIES
e gold standard for providing oral hygiene is the toothbrush. Toothbrushes should
have soft nylon bristles (Pearson & Chalmers, 2004). It is the mechanical action
of the toothbrush that is important for plaque removal. If the older adult has any
decrease in their function or manual dexterity, the nursing sta needs to assess the
older adult’s ability to provide eective oral hygiene and provide assistance as needed.
Foam swabs are available in numerous facilities to provide oral hygiene. Research has
shown that foam swabs cannot remove plaque as well as toothbrushes (Pearson &
Hutton, 2002). Foam swabs may be used for cleaning the oral mucous of an eden-
tulous older adult.
Lemon-glycerin swabs or swab sticks are drying to the oral mucosa and cause ero-
sion of the tooth enamel. is, combined with decreased salivary ow and an increased
rate of xerostomia in the older adult, potentiates the corrosive eect of lemon-glycerin
swabs (Pearson & Chalmers, 2004). Lemon-glycerin swabs or swab sticks are detrimen-
tal to the older adult and are never to be used.
Commercial mouth rinses, which contain alcohol are very trying to the oral mucosa.
If an older adult is using a commercial mouth rinse with alcohol, a half-and-half mix-
ture (commercial mouthwash and water) is recommended. Toothpaste with uoride is
currently recommended by the American Dental Association to reduce cavities and can
also help to reduce periodontal disease.
e use of chlorhexidine in the geriatric patient is determined by the dentist. ere
are some side eects of chlorhexidine (bitter taste, change in the taste of food, mouth
irritation, staining of teeth, mouth, llings, and dentures) that may have negative
412 Evidence-Based Geriatric Nursing Protocols for Best Practice
outcomes for the older adult (Quagliarello et al., 2009). A good oral assessment by the
nurse each shift is essential for the geriatric patient on chlorhexidine and monitoring of
their nutritional intake.
Education of the nursing sta is imperative. Two of the major barriers cited by nurs-
ing sta are inadequate knowledge of how to assess and provide care and lack of appro-
priate supplies. Implementation of evidence-based protocols combined with ongoing
educational training sessions have been demonstrated to have a positive impact on oral
care being provided and on the oral health status of older adults (Touger-Decker et al.,
2007; Akar & Ergül, 2008; Dharamsi, Jivani, Dean, & Wyatt, 2009; Gluhak, Arnetzl,
Kirmeier, Jakse, & Arnetzl, 2010; Peltola, Vehkalahti, & Simoila, 2007; Preston, Kearns,
Barber, & Gosney, 2006; Reed, Broder, Jenkins, Spivack, & Janal, 2006; Ribeiro et al.,
2009; Young, Murray, & omson, 2008). Sta needs to be instructed on oral hygiene
and the proper care of dierent appliances. Dentures should be brushed before placing
them into a denture cup. Dentures should be removed at night, but some older adults
prefer to keep their dentures in continuously. It therefore becomes even more important
for the nurse to do an assessment of the oral mucosa. In the acute care and long-term
care setting, the older adult may not have dental adhesive and, therefore, there is a high
risk for food particles to get caught underneath of their dentures. It is important that
sta remember to take the dentures out after each meal, rinse them and the patient’s
mouth, and place the dentures back in. Complete denture care should be given morn-
ing, night, and as needed.
Education of nursing sta, older adults, and families is imperative. Nurses need to
be educated in oral assessment and nursing assistants need to be educated in observation
of the oral cavity and what to report to the nurse. Both nurses and nursing assistants
need to be educated in the proper techniques for providing oral hygiene and caring for
oral appliances. Patients and families need to be educated in the importance of good
oral health and hygiene and to dispel the oral health myths that exist about oral health
and aging in general.
Education focused on the importance of good oral health and hygiene in the older
adult, the myths about oral health and aging, evidence-based practice protocols, imple-
menting these protocols, and the appropriate products for providing oral hygiene to
their patients and residents must be provided to administrators. Without the proper
supplies, it is impossible for the nursing sta to provide the oral hygiene care the older
adult needs and to properly implement evidence-based protocols for oral health and
hygiene in the older adult.
Mrs. Smith, an 84-year-old female with a history of Alzheimer’s Type Dementia, was
admitted for recent decreased oral intake and percutaneous endoscopic gastrostomy
(PEG) placement. Mrs. Smith was alert, oriented to herself, pleasant, cooperative with
care, and able to follow simple directions. She lived at home with her family and
received care from a home health aide. e initial oral assessment was done on Day 2
of admission and found upper dentures and lower natural teeth, both covered with
CASE STUDY
(continued)
Oral Health Care 413
food particles. Her oral mucosa was noted to be dry. e upper dentures were dicult
to remove and caused her pain. e upper denture was being “kept in place” by a col-
lection of old food, which was found upon removal. e oral mucosa under the upper
denture was covered with sores and ulcers—bleeding, infected, and very painful. e
health team was notied; a dental consult was called; and an oral hygiene plan of
care was implemented. Mrs. Smith’s diet was changed to puree while her oral mucosa
was healing and the PEG placement was put on hold. Upon inquiry, it was learned
from the family that their long-time aide had just moved, and the new aide had been
with them only a few months. It was during this time that they noticed the decline
in Mrs. Smith’s nutritional intake. e family chose to hire a new aide, and both the
family and the new aide were educated on proper oral hygiene for Mrs. Smith. Once
Mrs. Smith’s oral mucosa had healed, the upper denture was replaced, and she was
returned to her regular diet. Her oral intake returned to baseline, and a PEG was no
longer required.
is case study illustrates how poor oral care often goes undetected, the impor-
tance of good oral care, the need for physical assessment by the nurse, and the
need for sta and family education. is patient was being admitted for an inva-
sive procedure secondary to poor oral health caused by poor oral care. Although
the family was involved in Mrs. Smith’s care (she had no contractures or skin
breakdown), her lack of oral care had gone unnoticed by them. e admitting
nurse documented that the patient had dentures on the admission form but did
not do a physical oral assessment. e nurse caring for the patient on Day 2 had
attended an oral health seminar and included the physical oral assessment in her
morning rounds. She also followed up with the nursing assistants to ensure that
oral care had been provided to the patient after each meal. e implementation of
an oral hygiene plan of care and education of nursing sta, family, and home care
sta ensured that Mrs. Smith received the oral care required for her oral mucosa
to heal, her nutritional status to return to baseline, and prevented the unnecessary
placement of a PEG.
SUMMARY
As previously stated, many of the oral health problems in the older adults could be
avoided with routine preventive care, but many older adults believe in the myth
that a decline in their oral health is a normal part of aging (Allen, O’Sullivan, &
Locker, 2009; Borreani, Jones, Scambler, & Gallagher, 2010; Gagliardi, Slade, &
Sanders, 2008; McKenzie-Green, Giddings, Buttle, & Tahana, 2009; Wyatt, 2009).
To dispel this myth and improve the oral health of older adults, it is imperative
that health care professionals provide continuing education to patients and families,
advocate for oral health prevention, and provide oral care to older adults in all set-
tings. Well-developed evidence-based oral care protocols and educational training
sessions have been demonstrated to have a positive impact on the oral health status
of older patients.
CASE STUDY (continued)
414 Evidence-Based Geriatric Nursing Protocols for Best Practice
Protocol 20.1: Providing Oral Health Care to Older Adults
I. OVERVIEW: e promotion of oral health through good oral hygiene is an essen-
tial of nursing care. e registered nurse (RN) or designee provides regular oral care
for functionally dependent and cognitively impaired older adults.
II. BACKGROUND:
A. Oral hygiene is directly linked with systemic infections, cardiac disease, cere-
brovascular accident, acute myocardial infarction, glucose control in diabetes,
nutritional intake, comfort, ability to speak, and the patient’s self-esteem and
overall well-being.
B. Denitions
1. Oral: refers to the mouth (natural teeth, gingival and supporting tissues,
hard and soft palate, mucosal lining of the mouth and throat, tongue,
salivary glands, chewing muscles, upper and lower jaw, lips).
2. Oral cavity: includes cheeks, hard and soft palate.
3. Oral hygiene: the prevention of plaque-related disease, the destruction of
plaque through the mechanical action of tooth brushing and ossing, or use
of other oral hygiene aides.
4. Edentulous: natural teeth removed.
III. PARAMETERS OF ASSESSMENT:
A. e RN conducts an oral assessment or evaluation on admission and every shift.
e nurse assesses the condition of:
1. e oral cavity: e oral cavity should be pink, moist, and intact.
2. e presence of or absence of natural teeth and/or dentures: Natural teeth
should be intact and dentures (partial or full) should t comfortably and
not be moving when the older adult is speaking.
3. Ability to function with or without natural teeth and/or dentures.
4. e patient’s ability to speak, chew, or swallow.
5. Any abnormal ndings such as dryness, swelling, sores, ulcers, bleeding,
white patches, broken or decayed teeth, halitosis, ill-tting dentures, dif-
culty swallowing, signs of aspiration, pain are documented by the nurse,
and the health care team informed.
B. Assessment Tool: e Oral Health Assessment Tool (OHAT). See Resources
section for tool.
IV. NURSING CARE STRATEGIES:
A. Oral Hygiene Plan of Care: Dependent Mouth Care of the Edentulous Patient
1. Oral care is provided during morning care, evening care, and as needed
(PRN).
2. Wash hands and don gloves.
NURSING STANDARD OF PRACTICE
(continued)
Oral Health Care 415
3. Remove dentures.
4. Brush dentures with toothbrush/toothpaste using up-and-down motion.
5. Clean the grooved area, which ts against the gum with the toothbrush.
Rinse with cool water.
6. Brush patient’s tongue.
7. Re-insert dentures.
8. Apply lip moisturizer.
B. Dependent Mouth Care: Patient With Teeth or Partial Dentures
1. Oral care is provided during morning care, evening care, and PRN.
2. Wash hands and don gloves.
3. Place soft toothbrush at an angle against the gum line. Gently brush teeth in
an up-and-down motion with short strokes using the toothbrush.
4. Brush patient’s tongue.
5. Apply lip moisturizer.
For partial dentures, follow procedure for full denture cleaning and insertion.
C. Assisted or Supervised Care
1. Oral care is provided during morning care, evening care, and PRN.
2. Assess what patient can do and provide assistance as needed.
3. Set up necessary items.
V. EVALUATION OF EXPECTED OUTCOMES
A. Patient
1. Will receive oral hygiene a minimum of once every 8 hours while in the
acute care or long-term care or home setting.
2. Patients and families will be referred to dental services for follow-up
treatment.
3. Patients and families will be educated on the importance of good oral
hygiene and follow-up dental services.
B. Professional Caregiver or RN will
1. Conduct an assessment or evaluation of the oral cavity on admission and
every shift.
2. Notify the physician and dentist of any abnormalities present in the oral
cavity.
3. Assess what each patient can do independently.
4. Observe aspiration precautions while providing care.
5. Provide oral care and dental care education to patients and families.
C. Institution
1. Will provide access to dental services as appropriate.
2. Will provide ongoing education to health care providers.
3. Will provide a yearly oral health and dental care in-service to health care
providers.
Protocol 20.1: Providing Oral Health Care to Older Adults (cont.)
416 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
Assessment Tools
Chalmers, J. M., King, P. L., Spencer, A. J., Wright, F. A., & Carter, K. D. (2005). e oral health
assessment tool—validity and reliability. Australian Dental Journal, 50(3), 191–199.
Related Professional Organizations
Academy of General Dentistry
http://www.agd.org
American Dental Association
http://www.ada.org
Government Information Agencies
National Institutes on Aging
http://www.newcart.niapublications.org
National Institute of Dental and Craniofacial Research
http://www.nidcr.nih.gov
Centers for Disease Control and Prevention
http://www.cdc.gov
Regulatory or Authoritative Sites
National Institute of Dental and Craniofacial Research
http://www.nidcr.nih.gov
American Dental Association
http://www.ada.org
Continuing Education Opportunities
http://www.Hartford IGN.org
Patient and Family Resources
American Dental Association
http://www.ada.org
National Institute of Dental and Craniofacial Research
http://www.nidcr.nih.gov
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419
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe older adults at risk for dehydration
2. identify key aspects of a hydration assessment
3. list specic interventions to promote hydration in older adults across care settings
4. identify outcomes of a hydration management program
OVERVIEW
A recent study using markers (serum sodium, osmolality, and blood urea nitrogen
[BUN]/creatinine ratio) for dehydration and volume depletion from the Established
Populations for Epidemiologic Studies of the Elderly (EPESE; Stookey, Pieper, &
Cohen, 2005) and National Health and Nutrition Examination Survey III (NHANES
III; Stookey, 2005) found that the prevalence rate for these conditions in communi-
ty-dwelling older adults could range from 0.5% to 60% depending on the markers
used. Another study found that 48% of older adults presenting with dehydration at
an emergency room (ER) unit were from the community (Bennett, omas, & Riegel,
2004). Maintaining adequate uid balance is an essential component of health across
the lifespan; older adults are more vulnerable to shifts in water balance—both overhy-
dration and dehydration—because of age-related changes and increased likelihood that
an older individual has several medical conditions. Dehydration is the more frequent
occurrence in older adults (Warren et al., 1994; Xiao, Barber, & Campbell, 2004). In
fact, avoidable hospitalizations for dehydration in older adults have increased by 40%
Janet C. Mentes
21
Managing Oral Hydration
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Note. Portions of this chapter were adapted with permission from Mentes, J. C., & Kang, S. (2010).
Evidence-based protocol: Hydration management. In M. G. Titler (Series Ed.), Series on evidence-based
practice for older adults. Iowa City, IA: University of Iowa College of Nursing Gerontological Nursing
Interventions Research Center, Research Translation and Dissemination Core.
420 Evidence-Based Geriatric Nursing Protocols for Best Practice
from 1990 to 2000, at a cost of $1.14 billion (Xiao et al., 2004), and is one of the
Agency for Healthcare Research and Quality’s 13 ambulatory care-sensitive conditions.
Not only will careful attention to hydration requirements of older adults help
prevent hospitalizations for dehydration but will also decrease associated conditions
such as acute confusion and delirium (Foreman, 1989; Mentes & Culp, 2003; Mentes,
Culp, Maas, & Rantz, 1999; O’Keee & Lavan, 1996; Seymour, Henschke, Cape, &
Campbell, 1980); adverse drug reactions (Doucet et al., 2002); infections (Beaujean et
al., 1997; Masotti et al., 2000); and increased morbidity associated with bladder cancer
(Michaud et al., 1999), coronary heart disease (Chan, Knutsen, Blix, Lee, & Fraser,
2002; Rasouli, Kiasari, & Arab, 2008), stroke (Rodriguez et al., 2009), and other throm-
boembolytic events (Kelly et al., 2004). Further, dehydration has been associated with
longer hospital stays for rehabilitation (Mukand, Cai, Zielinski, Danish, & Berman,
2003) and for readmission to the hospital (Gordon, An, Hayward, & Williams, 1998).
Even in healthy community-dwelling older adults, physical performance and cognitive
processing is aected by mild dehydration (Ainslie et al., 2002).
Oral hydration of older adults is particularly complex for a variety of reasons. In the
following review, issues of age-related changes, risk factors, assessment measures, and
nursing strategies for eective interventions for dehydration are addressed.
BACKGROUND AND STATEMENT OF PROBLEM
Water is an essential component of body composition. Intricate cellular functions such as
gene expression, protein synthesis, and uptake and metabolism of nutrients are aected
by hydration status. Organ systems, specically the cardiovascular and renal systems, are
particularly vulnerable to uctuating levels of hydration (Metheny, 2000).
Older individuals are at increased risk for hydration problems stemming from
several converging age-related factors including lack of thirst (Ainslie et al., 2002; Phillips,
Bretherton, Johnston, & Gray, 1991; Phillips et al., 1984); changes in body composi-
tion, specically loss of uid rich muscle tissue (Bossingham, Carnell, & Campbell,
2005); increasing inability to respond eciently to physiological stressful events where
dehydration results (Farrell et al., 2008; Rolls, 1998); and renal changes including a
reduced renal capacity to handle water and sodium eciently (Macias-Nuñez, 2008).
Additionally, personal, often lifetime hydration habits, may contribute to risk but have
not been explored in relation to underhydration. As a result, older adults are often at
risk for a chronic state of underhydration. Several studies (Bossingham et al., 2005;
Morgan, Masterson, Fahlman, Topp, & Boardley, 2003; Raman et al., 2004) of commu-
nity-dwelling older adults suggest that under normal conditions, older adults maintain
adequate hydration; however, when challenged by environmental stressors—physical
or emotional illness, surgery, or trauma—they are at increased risk for dehydration and
rapidly become dehydrated if they are already chronically underhydrated.
DEFINITIONS
Dehydration
Dehydration is the depletion in total body water (TBW) content caused by pathologic
uid losses, diminished water intake, or a combination of both. It results in hyper-
natremia (more than 145 mEq/L) in the extracellular uid compartment, which
draws water from the intracellular uids. e water loss is shared by all body uid
Managing Oral Hydration 421
compartments and relatively little reduction in extracellular uids occurs. us, circula-
tion is not compromised unless the loss is very large.
Underhydration
Underhydration is a precursor condition to dehydration associated with insidious onset
and poor outcomes (Mentes, 2006; Mentes & Culp, 2003). Others have referred to
this condition as mild dehydration (Stookey et al., 2005) or chronic dehydration (Bennett
et al., 2004).
ASSESSMENT OF THE PROBLEM
Assessment of hydration status consists of risk identication with attention to specic
populations at increased risk, assessment of hydration habits, and evaluation of specic
biochemical and clinical indicators.
Risk Identification
Risk for dehydration in ill or frail older adults across care settings has been more fre-
quently studied. Although there is no outstanding risk factor for dehydration, age, gender,
ethnicity, class, and number of medications taken, level of activity of daily living (ADL)
dependency, presence of cognitive impairment, presence of medical conditions such as
infectious processes, and a prior history of dehydration have all been associated with dehy-
dration in older adults (Mentes & Iowa-Veterans Aairs Nursing Research Consortium
[IVANRC], 2000). erefore, although single risk factors will be discussed, it is likely that
clusters of risk factors maybe more helpful in clinical settings (Leibovitz et al., 2007).
Increasing age is associated with increased likelihood of dehydration (Ciccone,
Allegra, Cochrane, Cody, & Roche, 1998; Lavizzo-Mourey, Johnson, & Stolley, 1988;
Warren et al., 1994). Ciccone and colleagues (1998) found that adults aged 85 years
and older were three times more likely to have a diagnosis of dehydration on admission
to an emergency department than adults ages 65–74 years. Older African American
and Black adults have higher prevalence rates of dehydration on hospitalization than
Caucasian adults (Lancaster, Smiciklas-Wright, Heller, Ahern, & Jensen, 2003; Warren
et al., 1994). Female gender has been associated with risk for dehydration in nursing
home residents (Lavizzo-Mourey et al., 1988); however, male hospitalized patients had
an increased risk for dehydration (Warren et al., 1994) and more recently, no gender
dierences were detected in a large database study (Xiao et al., 2004).
In general, individuals in long-term care (LTC) settings are considered to be at
increased risk, with one-third of residents experiencing a dehydration episode in a
6-month period (Mentes, 2006). However, many of the factors are also characteristic
of older adult hospitalized patients as well. See Protocol 21.1 for patient-focused and
sta and family issues that serve as risk factor for dehydration. e following discussion
will highlight at risk groups of patients, hydration habits, and clinical parameters that
indicate risk.
At-Risk Populations
Several groups of patients, based on medical diagnosis, are at increased risk. ese groups
include chronic mentally ill, surgical, stroke, and end-of-life patients.
422 Evidence-Based Geriatric Nursing Protocols for Best Practice
Chronic Mentally Ill Patients
Special consideration should be given to chronic mentally ill older adults (e.g., indi-
viduals with schizophrenia, bipolar disorder, obsessive-compulsive disorder) because
they may be at risk for hydration problems. eir antipsychotic medications may blunt
their thirst response and put them at increased risk in hot weather for dehydration and
heat stroke (Batscha, 1997). In addition, even small increases in their antipsychotic
medications may predispose them to neuroleptic malignant syndrome (NMS), of which
hyperthermia and dehydration are prominent features (Bristow & Kohen, 1996; Jacobs,
1996; Sachdev, Mason, & Hadzi-Pavlovic, 1997). In these individuals, risks for over-
hydration stem from a combination of the drying side eects of prescribed psychotro-
pic medications and the individual’s compulsive behaviors that result in excessive uid
intake (Cosgray, Davidhizar, Giger, & Kreisl, 1993).
Patients With Stroke
ere is increasing evidence that dehydration may play an important part in contributing
to early cerebral ischemia (Rodriguez et al., 2009), and in the early recovery from stroke
(Kelly et al., 2004). In fact, Kelly et al. (2004) found that dehydration in patients with
stroke was hospital acquired and led to poorer outcomes for recovering patients with
stroke. Dehydration, signied by increased serum osmolality, led to a 2.8- to 4.7-fold
increase in the risk of hospitalized patients with stroke acquiring a venous thromboem-
bolism (VTE). Hospitalized patients recovering from stroke should be carefully and
continuously monitored for dehydration. Another sequela of stroke is dysphagia that
can cause dehydration (Whelan, 2001). is appears to be related not only to the dys-
phagia resulting from the stroke but also the poor palatability of the thickened uids
oered to patients to prevent aspiration.
Surgical Patients
Prolonged nothing by mouth (NPO) status prior to elective surgery has been linked
to increased risk of dehydration and adverse eects such as thirst, hunger, irritability,
headache, hypovolemia, and hypoglycemia in surgical patients (Smith, Vallance, &
Slater,1997; Yogendran, Asokumar, Cheng, & Chung, 1995). Crenshaw and Winslow
(2002) have found that despite the formulation of national guidelines developed by the
American Society of Anesthesiologist Task Force on Preoperative Fasting, patients were
still being instructed to fast too long prior to surgery (Crenshaw & Winslow, 2002).
In fact, patients may safely consume clear liquids up to 2 hours of elective surgery using
general anesthesia, regional anesthesia, or sedation anesthesia.
End-of-Life Patients
Maintaining or withholding uids at the end of life remains a controversial issue.
Proponents suggest that dehydration in the terminally ill patient is not painful and
lessens other noxious symptoms of terminal illness, such as excessive pulmonary
secretions, nausea, edema, and pain (dehydration acts as a natural anesthetic; Fainsinger
& Bruera, 1997). Some suggest additional benet from the decreased need to stand up
to use the restroom and receive bedpans or diaper changes, which could be dicult or
painful for someone at the end of life.
Managing Oral Hydration 423
Opponents to this position suggest that associated symptoms of dehydration
such as acute confusion and delirium are stressful and reduce the quality of life for
the terminally ill older adult (Bruera, Belzile, Watanabe, & Fainsinger, 1996). Most
research that has been done with terminally ill patients with cancer has examined dis-
comforts of dehydration including thirst, dry mouth, and agitated delirium. However,
research has not demonstrated a link between biochemical markers of dehydration and
these various symptoms in terminally ill patients (Burge, 1993; Ellershaw, Sutclie,
& Saunders, 1995; Morita, Tei, Tsunoda, Inoue, & Chihara, 2001). It is suggested
that several confounding factors inuence the uncomfortable dehydration-like symp-
toms that accompany the end of life. ese include use and dosage of opiates, type
and location of cancer, hyperosmolality, stomatitis, and oral breathing (Morita et al.,
2001). On the other hand, Bruera et al. (1996) have determined that small amounts of
uids delivered subcutaneously via hypodermoclysis plus opioid rotation was eective
in decreasing delirium and antipsychotic use and did not cause edema in terminally ill
patients. A 2-day long pilot study of parenteral hydration in terminally ill patients with
cancer lead to statistically signicant decreases in hallucination, myoclonus, fatigue,
and sedation (Bruera et al., 2005). However, research suggests that articial hydration
does not prolong life (Bruera et al., 2005; Meier, Ahronheim, Morris, Baskin-Lyons, &
Morrison, 2001; Mitchell, Kiely, & Lipsitz, 1997).
erefore, it is recommended that maintaining or withholding uids at the end of life
be an individual decision that should be based on the etiology of illness, use of medica-
tions, presence of delirium, and family and patient preferences (Fainsinger & Bruera, 1997;
Morita et al., 2001; Schmidlin, 2008). Schmidlin (2008) recommended early discus-
sions with patients and family on their wishes as well as educating patients on the current
knowledge about articial hydration so that proper patient-centered care will be provided.
Hydration Habits
Hydration habits may indicate level of risk for dehydration in older adults. Some hydra-
tion habits may have developed over a lifetime, and others are adaptations to current
health status. Four major categories of hydration habits have been identied (Mentes,
2006). e categories include those older adults who “can drink,” “cannot drink,” “will
not drink,” and older adults who are at the “end of life.” For example, older adults who
can drink are those who are functionally capable of accessing and consuming uids
but who may not know what is an adequate intake or may forget to drink secondary
to cognitive impairment; older adults who cannot drink are those who are physically
incapable of accessing or safely consuming uids related to physical frailty or diculty
swallowing; older adults who will not drink are those who are capable of consuming
uids safely but who do not because of concerns about being able to reach the toilet
with or without assistance or who relate that they have never consumed many uids;
and older adults who are terminally ill comprise the end-of-life category. Understanding
hydration habits of older adults can help nurses to plan appropriate interventions to
improve or ensure adequate intake (Mentes, 2006).
Indicators of Hydration Status
A priority for nursing, regardless of clinical setting, is the prevention of dehydration.
Unfortunately, many of the standard tests for detection of dehydration only conrm
424 Evidence-Based Geriatric Nursing Protocols for Best Practice
a diagnosis of dehydration after it is too late to prevent the episode. In our fast-paced
nursing environments, it is dicult to monitor the uid intake of all our older patients.
Although controversial, the use of urine color and specic gravity has been shown to be
reliable indicators of hydration status (not dehydration) in older individuals in nursing
homes and a Veterans Administration Medical Center with adequate renal function
(Culp, Mentes, & Wakeeld, 2003; Mentes, Wakeeld, & Culp, 2006). Specically,
the use of urine color, as measured by a urine color chart, can be helpful in monitoring
hydration status (Armstrong et al., 1994; Mentes & IVANRC, 2000). e urine color
chart has eight standardized colors ranging from pale straw (number 1) to greenish brown
(number 8), approximating urine-specic gravities of 1.003–1.029 (Armstrong et al.,
1994). e urine color chart is most eective when an individual’s average urine color
is calculated over several days for an individual referent value. If the older person’s urine
becomes darker from his or her average color, further assessment into recent intake and
health status can be conducted and uids can be adjusted to improve hydration status
before dehydration occurs. Limitations in using urine indices to estimate specic gravity
include (a) certain medications and foods can discolor the urine (Mentes, Wakeeld et
al., 2006; Wakeeld, Mentes, Diggelmann, & Culp, 2002); (b) persons must be able
to give a urine specimen for a color evaluation; and (c) best results in the use of urine
color as an indicator has been documented in older adults with adequate renal function
(Mentes, Wakeeld et al., 2006).
Bioelectrical impedance analysis (BIA) is a measurement that has been used mostly
in the tness industry to estimate body composition, including body mass index (BMI),
TBW, and intracellular and extracellular water. Several nursing studies have used imped-
ance measurements to estimate TBW and intracellular and extracellular water (Culp
et al., 2003; Culp et al., 2004). Although mostly used in research, BIA is a noninvasive,
reliable method to estimate body water (Ritz & Source Study, 2001). Because TBW
is weight and body composition dependent, this measure is best used after a baseline
value of TBW, intracellular, and extracellular uid in liters has been documented. en,
deviations from the individual baseline can be noted.
Salivary osmolality is an emerging clinical indicator of hydration status, which is
sensitive in younger healthy adults (Oliver, Laing, Wilson, Bilzon, & Walsh, 2008) and
has been tested in a same sample of nursing home residents (Woods & Mentes, 2011).
Indicators of Dehydration
Dehydration is the loss of body water from intracellular and interstitial uid compart-
ments that is associated with hypertonicity (Mange et al., 1997). erefore, the most
reliable indicators of dehydration are elevated serum sodium, serum osmolality, and
BUN/creatinine ratio (See Table 21.1). e most common clinical assessments of dehy-
dration include the presence of dry oral mucous membranes, tongue furrows, decreased
saliva, sunken eyes, decreased urine output, upper body weakness, a rapid pulse (Gross
et al., 1992), and tongue dryness (Vivanti, Harvey, & Ash, 2010; Vivanti, Harvey, Ash,
& Battistutta, 2008). Decreased axillary sweat production as a clinical sign of dehydra-
tion has produced contradictory results, making it an unreliable indicator of dehydra-
tion (Eaton, Bannister, Mulley, & Connolly, 1994; Gross et al., 1992). Assessment of
sternal skin turgor as a sign of dehydration has been a mainstay in nursing practice;
however, it is also an ambiguous indicator for dehydration in older individuals, with
some researchers nding it unreliable because of age-related changes in skin elasticity
Managing Oral Hydration 425
(Gross et al., 1992) and others nding it reliable (Chassagne, Druesne, Capet, Ménard,
& Berco, 2006; Vivanti et al., 2008).
INTERVENTIONS AND CARE STRATEGIES
A hydration management intervention is an individualized daily plan to promote ade-
quate hydration based on risk factor identication that is derived from a comprehensive
assessment. e intervention is divided into two phases: risk identication and hydra-
tion management.
Risk Identification
Based on the collected assessment data, a risk appraisal for hydration problems is completed
using the Dehydration Risk Appraisal Checklist (Table 21.2; Mentes & Wang, 2010).
Hydration Management
Managing uid intake for optimal uid balance consists of (a) acute management of
oral intake and (a) ongoing management of oral intake.
Acute Management of Oral Intake
Any individual who develops a fever, vomiting, diarrhea, or a nonfebrile infection
should be closely monitored by implementing intake and output records and provi-
sion of additional uids as tolerated (Wakeeld et al., 2008; Weinberg et al., 1994).
Individuals who are required to be NPO for diagnostic tests should be given special
consideration to shorten the time that they must be NPO and should be provided with
adequate amounts of uids and food when they have completed their tests. For many
procedures, a 2-hour uid fast is recommended (“Practice Guidelines for Preoperative
Fasting,” 1999).
TABLE 21.1
Approximate Ranges of Laboratory Tests for Hydration Status
Test Value Ranges for
Impending Dehydration Dehydration
BUN/Creatinine ratio 20–24 . 25
Serum osmolality normal 280–300 mmol/kg . 300 mmol/kg
Serum sodium . 150 mEq/L
Urine osmolality . 1050 mmol/kg
Urine specific gravity 1.020–1.029 . 1.029
Urine color dark yellow greenish brown
Amount of urine 800–1,200 cc/day . 800 cc/day
Note. BUN 5 blood urea nitrogen. Armstrong et al., 1994; Armstrong et al., 1998; Mentes, Wakeeld, & Culp,
2006; Metheny, 2000; Wakeeld, Mentes, Diggelmann, & Culp, 2002; Wallach, 2000
Source: Adapted with permission from Mentes, J. C., & Kang, S. (2010). Evidence-based protocol: Hydration
management. In M. G. Titler (Series Ed.), Series on evidence-based practice for older adults. Iowa City, IA: the
University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Translation
and Dissemination Core.
426 Evidence-Based Geriatric Nursing Protocols for Best Practice
Any individual who develops unexplained weight gain, pedal edema, neck vein dis-
tension, or shortness of breath should be evaluated and closely monitored for overhydra-
tion. Fluids should be temporarily restricted and the individual’s primary care provider
notied. Specic attention should be focused on individuals who have renal disease or
congestive heart failure (CHF); however, Holst, Strömberg, Lindholm, and Willenheimer
(2008) found that a liberal uid prescription based on body weight could be oered to
patients with stable CHF. Older adults taking selective serotonin reuptake inhibitors
(SSRIs) should have their serum sodium levels and their hydration status monitored
carefully because they are at risk for hyponatremia and increasing uid intake may aggra-
vate an evolving hyponatremia (Movig, Leufkens, Lenderink, & Egberts, 1992).
Ongoing Management of Oral Intake
Ongoing management of oral intake consists of the following ve components:
1. Calculate a daily uid goal.
All older adults should have an individualized uid goal determined by a documented
standard for daily uid intake. ere is preliminary evidence that the standard sug-
gested by Skipper (1993)—of 100 ml/kg for rst 10 kg of weight, 50 ml/kg for next
10 kg, and 15 ml/kg for the remaining kilogram—is preferred (Chidester & Spangler,
1997). Table 21.3 provides examples of daily uid goal calculations.
TABLE 21.2
Dehydration Risk Appraisal Checklist
The greater the number of characteristics present, the greater the risk for hydration problems. Please
check all that apply.
r . 85 years r Female
Significant Health Conditions
r MMSE score , 24 (indicating cognitive
impairment)
r Semi-dependent in ADLs
r Dementia diagnosis r Repeated infections
r GDS score 6 (indicating depression) r History of dehydration
r Urinary incontinence
Medications
r Laxatives r Psychotropics: antipsychotics,
antidepressants, anxiolytics
r Diuretics
Intake Behaviors
r BMI , 21 or . 27 r Can drink independently but forgets
r Requires assistance to drink r Poor eater
r Has difficulty swallowing/chokes
Note. MMSE = mini-mental status examination; GDS 5 Geriatric Depression Scale; ADLs 5 activities of daily living;
BMI 5 body mass index. Mentes & Wang, 2010.
Source: Reprinted with permission from Mentes, J. C., & Kang, S. (2010). Evidence-based protocol: Hydration man-
agement. In M. G. Titler (Series Ed.), Series on Evidence-based practice for older adults. Iowa City, IA: the University of
Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Translation and Dissemina-
tion Core.
Managing Oral Hydration 427
Because this standard reects uid from all sources, to calculate a standard for uids
alone, 75% of the total calculated from the formula can be used. is formula allows
for at least 1,500 ml of uid per day as a minimum, which has been shown to be
well tolerated in older men aged 55–75 years (Spigt, Knottnerus, Westerterp, Olde
Rikkert, & Schayck, 2006). Other standards include the following:
n 1,600 ml/m
2
of body surface per day (Gaspar, 1988; Butler & Talbot, 1944);
more recently, Gaspar (1999) recommended 75% of this standard
n 30 ml/kg body weight with 1,500 ml/day minimum (Cherno, 1994)
n 1 ml/kcal uid for adults (National Research Council, 1989)
n 1,600 ml/day (Hodgkinson, Evans, & Wood, 2003)
2. Compare individual’s current intake to the amount calculated from applying the
standard to evaluate the individual’s hydration status.
3. Provide uids consistently throughout the day (Hodgkinson et al., 2003).
a. Plan uid intake as follows: 75%–80% delivered at meals and 20%–25% delivered
during nonmeal times, such as medication times and planned nourishment times
(Simmons et al., 2001).
b. Oer a variety of uids, keeping in mind the individual’s previous intake pattern
(Zembrzuski, 1997). Alcoholic beverages, which exert a diuretic eect, should not
be counted toward the uid goal. Caeinated beverages may be counted toward
the uid goal based on individual assessment because there is evidence that in indi-
viduals who are regular users, there are no untoward eects on uid balance and
that recommendations to refrain from moderate amounts of caeinated beverages
(250–300 mg, equivalent of two to three cups of coee or ve to eight cups of tea
may adversely aect uid balance in older adults (Maughan & Grin, 2003).
c. Fluid with medication administrations should be standardized to a prescribed
amount (e.g., at least 180 ml or 6 oz.) per administration time.
4. Plan for at-risk individuals
For those who are at risk of underhydration because of poor intake, the following strate-
gies can be implemented based on time, setting, and formal or informal caregiver issues:
a. Fluid rounds mid-morning and late afternoon, where caregiver provides addi-
tional uids (Robinson & Rosher, 2002).
b. Provide 2- to 8-oz. glasses of uid in morning and evening (Robinson & Rosher, 2002).
c. “Happy hours” in the afternoon, where patients can gather together for additional
uids and socialization (Musson et al., 1990).
d. “Tea time” in the afternoon, where patients come together for uids, nourishment,
and socialization (Mueller & Boisen, 1989).
e. Use of modied uid containers based on intake behaviors (e.g., ability to hold
cup and swallow; Mueller & Boisen, 1989).
TABLE 21.3
Calculating Daily Fluid Goals: Examples
70-kg (154-lb.) patient would have a fluid goal of 2,250 ml/day.
60-kg (132-lb.) patient would have a fluid goal of 2,100 ml/day.
50-kg (110-lb.) patient would have a fluid goal of 1,950 ml/day.
428 Evidence-Based Geriatric Nursing Protocols for Best Practice
f. Oer a variety of uids and encourage ongoing intake throughout the day for
those with cognitive impairment. Oer uids that the person prefers (Simmons
et al., 2001).
g. Oer encouragement to drink, family involvement in and support, and
coordination of sta communication about hydration issues (Mentes, Chang
et al., 2006).
5. Fluid regulation and documentation
a. Individuals who are cognitively intact, visually capable, and have adequate renal
function can be taught how to regulate their intake through the use of a color
chart to compare to the color of their urine (Armstrong et al., 1994; Armstrong
et al., 1998; Mentes, Wakeeld et al., 2006). For those individuals who are cog-
nitively impaired, caregivers can be taught how to use the color chart.
b. Frequency of documentation of uid intake will vary from setting to setting and
is dependent on an individual’s condition. However, in most settings, at least one
accurate intake and output recording should be documented and should include
the amount of uid consumed, intake pattern, diculties with consumption, and
a urine-specic gravity and color (Mentes & IVANRC, 2000).
c. Accurate calculation of intake requires knowledge of the volumes of containers
used to serve uids, which should be posted in a prominent place on the care
unit, because a study by Burns (1992) suggested that nurses overestimated or
underestimated the volumes of common vessels.
EVALUATION
Adherence to the hydration management guideline can be monitored by the frequency
of monitoring (to be determined by setting), as follows:
n Urine-specic gravity checks, preferably a morning specimen (Armstrong et al.,
1994; Armstrong et al., 1998; Hodgkinson et al., 2003; Wakeeld et al., 2002).
A value greater than or equal to 1.020 implies an underhydrated state and
requires further monitoring (Kavouras, 2002; Mentes, 2006).
n Urine color chart monitoring, preferably a morning specimen (Armstrong et al.,
1994; Armstrong et al., 1998; Wakeeld et al., 2002).
n 24-hour intake recording (output recording may be added; however, in settings
where individuals are incontinent of urine, an intake recording should suce;
Hodgkinson et al., 2003)
Expected improved health outcomes of consistent application of a hydration manage-
ment plan include the following:
n Maintenance of body hydration (Mentes & Culp, 2003; Robinson & Rosher,
2002; Simmons et al., 2001)
n Decreased infections, especially urinary tract infections (McConnell, 1984;
Mentes & Culp, 2003; Robinson & Rosher, 2002)
n Improvement in urinary incontinence (Hart & Adamek, 1984; Spangler et al.,
1984)
n Lowered urinary pH (Hart & Adamek, 1984)
n Decreased constipation (Robinson & Rosher, 2002)
n Decreased acute confusion (Mentes & Culp, 2003; Mentes et al., 1999)
Managing Oral Hydration 429
Mrs. Chung is an 87-year-old Chinese American woman who was admitted to the
hospital for observation secondary to an episode of dehydration. She has resided at
Sunny Days Assisted Living Facility for the past month. Sta describes her as ercely
independent despite experiencing some declines in her health recently. Her medical
diagnoses include hypertension, for which she receives a atenolol 25 mg daily and
enalapril 20 mg daily; status post-mild cerebrovascular accident (CVA) with residual
left-sided weakness, for which she is taking 80 mg of aspirin daily; osteoarthritis, for
which she takes Tylenol extra strength twice daily; and cataracts, for which she is
reluctant to have surgery. She is cognitively intact and requires only minor assistance
with bathing.
Prior to hospitalization, Mrs. Chung had become more withdrawn and con-
cerned about her health. Her family noticed that she has altered some of her daily
routines. For example, she eliminated her daily tea because she nds it dicult to
use the new microwave at the assisted care facility (ACF) to heat her water because
of unfamiliarity. She stays in her bed much of the day, complaining that she does not
have any energy. When questioned, she reluctantly admits that she has been having
more problems with her long-standing urinary incontinence and she is afraid to leave
her room because she is fearful that she will not be able to make it to a bathroom on
time. Consequently, she has further restricted the amount of uid that she consumes
on a daily basis.
Mrs. Chung is at high risk for dehydration given that she has recently begun to
restrict her uids because of unfamiliarity with the microwave to heat her water for
tea. Older adults from dierent cultures may wish to have their beverages served at
dierent temperatures. Especially when ill, ethnic older adults may prefer to have
warmed beverages. In addition, Mrs. Chung is “treating” her urinary incontinence by
restricting her uids, which places her at risk for dehydration and urinary tract infec-
tions. is scenario is not uncommon in older adults struggling to maintain indepen-
dence. One of the major reasons for admission to a nursing home is the presence of
urinary incontinence. Finally, there is some evidence that Mrs. Chung is depressed,
which would also place her at risk for dehydration often secondary to decreased food
and uid intake. Additional risk factors include her age (87 years old), gender, and
use of an angiotensin-converting enzyme (ACE)-inhibitor, which acts on the renin-
angiotensin-aldosterone (RAA) system.
Interventions to prevent dehydration in Mrs. Chung would include evaluating her
for a urinary tract infection and oering her an evaluation for her urinary incontinence
that could include use of medications, if indicated; use of behavioral strategies including
urge inhibition; and/or Kegel exercises. Education around the importance of maintain-
ing adequate uid intake to minimize urinary incontinence is indicated, which should
include a discussion about the amount of daily uids required and the provision of a
graduated cup to help her ascertain appropriate amounts. Helping her simplify the use
of the microwave and/or attendance at social events at the ACF where uids are provided
could be implemented. Lastly, an evaluation for depression maybe indicated if the previ-
ous interventions do not improve her mood.
CASE STUDY
430 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Dehydration in older adults is a costly yet preventable health problem. Best practices for
hydration management have been identied primarily in the nursing home population.
ey include providing access to uids at all times, regularly oering uids throughout
the day, assessing uid preferences and providing the uid of choice, and appropriate
supervision of personnel who will be providing the uids. Access to uids means that
fasting times for older adults are limited to the shortest time, uids are available at all
times, and that nursing personnel assess the ability to self-manage hydration in older
individuals. Regularly oering uids through uid rounds, a beverage cart, or other
novel means such as tea time is another principle of good hydration practices. Accom-
modating older peoples’ preferences for type of beverage and appropriate temperature
of beverage has been shown to increase uid intake. Lastly, appropriate supervision of
how much uid per day is required and how assistance is given to older adults who are
not capable of drinking themselves to ensure that required amounts are consumed is
also the key in maintaining adequate hydration. e hydration practices of healthier,
community-dwelling older adults are less well known and require further study.
Protocol 21.1: Managing Oral Hydration
I. GOAL: To minimize episodes of dehydration in older adults.
II. OVERVIEW: Maintaining adequate uid balance is an essential component of
health across the lifespan; older adults are more vulnerable to shifts in water balance,
both overhydration and dehydration because of age-related changes and increased
likelihood that an older individual has several medical conditions. Dehydration is the
more frequently occurring problem.
III. BACKGROUND AND STATEMENT OF THE PROBLEM
A. Denitions
1. Dehydration is depletion in total body water (TBW) content caused by
pathologic uid losses, diminished water intake, or a combination of both.
It results in hypernatremia (more than 145 mEq/L) in the extracellular uid
compartment, which draws water from the intracellular uids. e water
loss is shared by all body uid compartments and relatively little reduction
in extracellular uids occurs. us, circulation is not compromised unless
the loss is very large.
2. Underhydration is a precursor condition to dehydration associated with
insidious onset and poor outcomes (Mentes & Culp, 2003). Others have
referred to this condition as mild dehydration (Stookey, 2005; Stookey et al.,
2005) or chronic dehydration (Bennett et al., 2004).
NURSING STANDARD OF PRACTICE
(continued)
Managing Oral Hydration 431
(continued)
B. Etiologic Factors Associated With Dehydration
1. Age-related changes in body composition with resulting decrease in TBW
(Bossingham et al., 2005; Lavizzo-Mourey et al., 1988; Metheny, 2000)
2. Decreasing renal function (Lindeman, Tobin, & Shock, 1985)
3. Lack of thirst (Farrell et al., 2008; Kenney & Chiu, 2001; Mack et al., 1994;
Miescher & Fortney, 1989; Phillips et al., 1991; Phillips et al., 1984)
4. Poor tolerance for hot weather (Josseran et al., 2009)
C. Risk Factors
1. Patient characteristics
a. More than 85 years of age (Ciccone et al., 1998; Gaspar, 1999;
Lavizzo-Mourey et al. 1988)
b. Female (Gaspar, 1988; Lavizzo-Mourey et al., 1988)
c. Semi-dependent in eating (Gaspar, 1999)
d. Functionally more independent (Gaspar, 1999; Mentes & Culp, 2003)
e. Few uid ingestion opportunities (Gaspar, 1988, 1999)
f. Inadequate nutrient intake (Gaspar, 1999)
g. Alzheimer’s disease or other dementias (Albert, Nakra, Grossberg, &
Caminal, 1989, 1994)
h. Four or more chronic conditions (Lavizzo-Mourey et al., 1988)
i. Four medications (Lavizzo-Mourey et al., 1988)
j. Fever (Pals et al., 1995; Weinberg et al., 1994)
k. Vomiting and diarrhea (Wakeeld, Mentes, Holman, & Culp, 2008)
l. Individuals with infections (Warren et al., 1994)
m. Individuals who have had prior episodes of dehydration (Mentes, 2006)
n. Diuretics: thiazide (Wakeeld et al., 2008), loop and thiazide (Lancaster
et al., 2003)
2. Sta and family characteristics
a. Inadequate sta and professional supervision (Kayser-Jones, Schell, Por-
ter, Barbaccia, & Shaw, 1999)
b. Depression or loneliness associated with decreased uid intake as identi-
ed by nursing sta (Mentes, Chang, & Morris, 2006)
c. Family or caregivers not spending time with patient (Mentes, Chang et
al., 2006)
IV. PARAMETERS OF ASSESSMENT (Mentes & IVANRC, 2000).
A. Health History
1. Specic disease states: dementia, congestive heart failure, chronic renal dis-
ease, malnutrition, and psychiatric disorders such as depression (Albert et
al., 1989; Gaspar, 1988; Warren et al., 1994)
2. Presence of comorbidities: more than four chronic health conditions (Laviz-
zo-Mourey et al., 1988)
3. Prescription drugs: number and types (Lavizzo-Mourey et al., 1988)
4. Past history of dehydration, repeated infections (Mentes, 2006)
B. Physical Assessments (Mentes & IVANRC, 2000)
1. Vital signs
2. Height and weight
Protocol 21.1: Managing Oral Hydration (cont.)
432 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Body mass index (BMI; Vivanti et al., 2008)
4. Review of systems
5. Indicators of hydration
C. Laboratory Tests
1. Urine-specic gravity (Mentes, 2006; Wakeeld et al., 2002)
2. Urine color (Mentes, 2006; Wakeeld et al., 2002)
3. Blood urea nitrogen (BUN)/creatinine ratio
4. Serum sodium
5. Serum osmolality
6. Salivary osmolality
D. Individual uid intake behaviors (Mentes, 2006)
V. NURSING CARE STRATEGIES
A. Risk Identication (Mentes & IVANRC, 2000)
1. Identify acute situations: vomiting, diarrhea, or febrile episodes
2. Use a tool to evaluate risk: Dehydration Risk Appraisal Checklist
B. Acute Hydration Management
1. Monitor input and output (Weinberg et al., 1994)
2. Provide additional uids as tolerated (Weinberg et al., 1994)
3. Minimize fasting times for diagnostic and surgical procedures (“Practice
Guidelines for Preoperative Fasting,” 1999)
C. Ongoing Hydration Management
1. Calculate a daily uid goal (Mentes & IVANRC, 2000)
2. Compare current intake to uid goal (Mentes & IVANRC, 2000)
3. Provide uids consistently throughout the day (Ferry, 2005; Simmons,
Alessi, & Schnelle, 2001)
4. Plan for at-risk individuals
a. Fluid rounds (Robinson & Rosher, 2002)
b. Provide two 8-oz. glasses of uid, one in the morning the other in the
evening (Robinson & Rosher, 2002)
c. “Happy hours” to promote increased intake (Musson et al., 1990)
d. “Tea time” to increase uid intake (Mueller & Boisen, 1989)
e. Oer a variety of uids throughout the day (Simmons et al., 2001)
5. Fluid regulation and documentation
a. Teach able individuals to use a urine color chart to monitor hydration
status (Armstrong et al., 1994; Armstrong et al., 1998; Mentes, 2006)
b. Document a complete intake recording including hydration habits
(Mentes & IVANRC, 2000)
c. Know volumes of uid containers to accurately calculate uid consump-
tion (Burns, 1992; Hart & Adamek, 1984)
VI. EVALUATION AND EXPECTED OUTCOMES
A. Maintenance of body hydration (Mentes & Culp, 2003; Robinson & Rosher,
2002; Simmons et al., 2001)
B. Decreased infections, especially urinary tract infections (McConnell, 1984;
Mentes & Culp, 2003; Robinson & Rosher, 2002)
Protocol 21.1: Managing Oral Hydration (cont.)
(continued)
Managing Oral Hydration 433
RESOURCES
Evidence-based website for geriatric nursing sponsored by the Hartford Institute for Geriatric Nursing
http://www.consultgerirn.org
Hydration for Health sponsored by Danone Waters
http://www.healthyhydrationcoach.com/
University of Iowa Evidence-Based Protocols
http://www.nursing.uiowa.edu/centers/gnirc/protocols.htm
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terp, K. R. (2002). Energy balance, metabolism, hydration, and performance during strenuous hill
walking: e eect of age. Journal of Applied Physiology, 93(2), 714–723. Evidence Level III.
Albert, S. G., Nakra, B. R., Grossberg, G. T., & Caminal, E. R. (1989). Vasopressin response to
dehydration in Alzheimer’s disease. Journal of the American Geriatric Society, 37(9), 843–847.
Evidence Level III.
Albert, S. G., Nakra, B. R., Grossberg, G. T., & Caminal, E. R. (1994). Drinking behavior and
vasopressin responses to hyperosmolality in Alzheimer’s disease. International Psychogeriatrics,
6(1), 79–86. Evidence Level III.
Armstrong, L. E., Maresh, C. M., Castellani, J. W., Bergeron, M. F., Keneck, R. W., LaGasse, K. E.,
& Riebe, D. (1994). Urinary indices of hydration status. International Journal of Sport Nutrition,
4(3), 265–279. Evidence Level IV.
Armstrong, L. E., Soto, J. A., Hacker, F. T., Jr., Casa, D. J., Kavouras, S. A., & Maresh, C. M. (1998).
Urinary indices during dehydration, exercise, and rehydration. International Journal of Sport
Nutrition, 8(4), 345–355. Evidence Level IV.
C. Improvement in urinary incontinence (Spangler, Risley, & Bilyew, 1984)
D. Lowered urinary pH (Hart & Adamek, 1984)
E. Decreased constipation (Robinson & Rosher, 2002)
F. Decreased acute confusion (Mentes et al., 1999)
VII. FOLLOW-UP MONITORING OF CONDITION
A. Urine color chart monitoring in patients with better renal function (Armstrong
et al., 1994; Armstrong et al., 1998; Wakeeld et al., 2002)
B. Urine-specic gravity checks (Armstrong et al., 1994; Armstrong et al., 1998;
Wakeeld et al., 2002)
C. 24-hour intake recording (Metheny, 2000)
VIII. RELEVANT PRACTICE GUIDELINES
A. Hydration Management Evidence-Based Protocol available from the University
of Iowa College of Nursing Gerontological Nursing Interventions Research
Center, Research Dissemination Core. Author: Janet Mentes, revised 2010.
Protocol 21.1: Managing Oral Hydration (cont.)
434 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Beaujean, D. J., Blok, H. E., Vandenbroucke-Grauls, C. M., Weersink. A. J., Raymakers, J. A., &
Verhoef, J. (1997). Surveillance of nosocomial infections in geriatric patients. e Journal of
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Bossingham, M. J., Carnell, N. S., & Campbell, W. W. (2005). Water balance, hydration status,
and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition,
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cancer patients. Supportive Care in Cancer, 4(2), 147–150. Evidence Level IV.
Bruera, E., Sala, R., Rico, M. A., Moyano, J., Centeno, C., Willey, J., & Palmer, J. L. (2005). Eects
of parenteral hydration in terminally ill cancer patients: A preliminary study. Journal of Clinical
Oncology, 23(10), 2366–2371. Evidence Level III.
Burge, F. I. (1993). Dehydration symptoms of palliative care cancer patients. Journal of Pain Symptom
Management, 8(7), 454–464. Evidence Level IV.
Burns, D. (1992). Working up a thirst. Nursing Times, 88(26), 44–45. Evidence Level IV.
Butler, A. M., Talbot, N. B. (1944). Parenteral uid therapy. New England Journal of Medicine, 231,
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coronary heart disease: e Adventist Health Study. American Journal of Epidemiology, 155(9),
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hypernatremia in elderly patients: A case control study. Journal of the American Geriatrics Society,
54(8), 1225–1230. Evidence Level IV.
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Reviews, 52(4), 132–136. Evidence Level VI.
Chidester, J. C., & Spangler, A. A. (1997). Fluid intake in the institutionalized elderly. Journal of the
American Dietetic Association, 97(1), 23–28; quiz 29–30. Evidence Level IV.
Ciccone, A., Allegra, J. R., Cochrane, D. G., Cody, R. P., & Roche, L. M. (1998). Age-related dier-
ences in diagnoses within the elderly population. e American Journal of Emergency Medicine,
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patients at a state hospital. Clinical Nurse Specialist, 7(2), 55–61. Evidence Level V.
Crenshaw, J. T., & Winslow, E. H. (2002). Preoperative fasting: Old habits die hard. e American
Journal of Nursing, 102(5), 36–44; quiz 45. Evidence Level IV.
Culp, K., Mentes, J., & Wakeeld, B. (2003). Hydration and acute confusion in long-term care residents.
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rural nursing home residents. e Journals of Gerontology. Series A, Biological Sciences and Medical
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Level IV.
Managing Oral Hydration 435
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(2008). Eect of aging on regional cerebral blood ow responses associated with osmotic thirst
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436 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Mentes, J. C., & Iowa-Veterans Aairs Research Consortium. (2000). Hydration management pro-
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439
22
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. recognize factors that place the older adult at risk for malnutrition.
2. discuss methods to screen and assess nutritional status in the older adult.
3. utilize appropriate nursing interventions in the hospitalized older adult who is either
at risk for malnutrition or has malnutrition.
OVERVIEW
Nutritional status is the balance of nutrient intake, physiological demands, and meta-
bolic rate (DiMaria-Ghalili, 2002). However, older adults are at risk for poor nutrition
(DiMaria-Ghalili & Amella, 2005). Furthermore, malnutrition, a recognized geriatric
syndrome (Institute of Medicine [IOM], 2008), is of concern because it can often be
unrecognizable and impacts morbidity, mortality, and quality of life (Chen, Schilling,
& Lyder, 2001), and is a precursor for frailty in the older adult. Malnutrition in older
adults is dened as “faulty or inadequate nutritional status; undernourishment charac-
terized by insucient dietary intake, poor appetite, muscle wasting, and weight loss”
(Chen et al., 2001). In the older adult, malnutrition exists along the continuum of care
(Furman, 2006). Older adults admitted to acute care settings from either the commu-
nity or long-term care settings may already be malnourished or may be at risk for the
development of malnutrition during hospitalization. A diagnosis of malnutrition dur-
ing an acute care stay increases the cost of hospitalization estimated at US$1,726 per
patient (Rowell & Jackson, 2010). Bed rest is common during hospital stay, and the
associated loss of lean mass that accompanies bed rest can impact the already vulner-
able nutritional status of older adults (English & Paddon-Jones, 2010). e IOM notes
that although malnutrition is a problem in older adults, most health care professionals,
Rose Ann DiMaria-Ghalili
Nutrition
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Note: is chapter is based on the geriatric nursing protocol series. See http://consultgerirn.org/topics/
nFutrition_in_the_elderly/want_to_know_more
440 Evidence-Based Geriatric Nursing Protocols for Best Practice
including nurses, have little training concerning the nutritional needs of older adults
(IOM, 2008). erefore, it is imperative that acute care nurses carefully assess and
monitor the nutritional status of older adults to identify the risk factors of malnutrition
so that appropriate interventions are instituted in a timely fashion. e focus of this
nursing protocol is aimed at the discussion of nutrition in aging as it relates to risk fac-
tors, implications, and interventions for malnutrition in the older adults.
BACKGROUND AND STATEMENT OF PROBLEM
e prevalence rate of malnutrition in hospitalized older adults was 38.7% according
to a recent pooled analysis of studies based on the Mini-Nutritional Assessment tool
(MNA; Kaiser et al, 2010). In the same study, 47.3% of older adults were at risk for
malnutrition (Kaiser et al, 2010). In addition, a 1-day international audit on nutri-
tion in 16,455 hospitalized patients (median age, 66) found that more than half of the
patients did not eat their full meal provided, and decreased food intake was associated
with increased risk of dying (Hiesmayr et al., 2006). Preliminary ndings from the
rst U.S. national nutrition day in 2009 echo these results with 40% of hospitalized
patients eating half or less of their meal (NutritionDay in the US, 2011). Marasmus,
kwashiorkor, and mixed marasmus-kwashiorkor originally described the subtypes of
malnutrition associated with famine, and these terms eventually characterized disease-
related malnutrition. An international guideline committee was organized to develop
a consensus approach to dening adult (including older adults) malnutrition in clini-
cal settings (Jensen et al., 2010). Inammation is the cornerstone of the new adult
disease-related malnutrition subtypes and include “starvation-related malnutrition”
(without inammation), “chronic disease-related malnutrition” (with chronic inam-
mation of a mild-to-moderate degree; e.g., rheumatoid arthritis), and “acute disease or
injury-related malnutrition” (with acute inammation of a severe degree; e.g., major
infections or trauma; Jensen et al., 2010). Dening characteristics of this new diag-
nostic classication of disease-related malnutrition are under development. e new
malnutrition categories underscore the impact of a loss of lean body mass and skeletal
muscle associated with the catabolic nature of the inammatory process (Jensen et al.,
2010). Although sarcopenia is an age-related loss of muscle mass and muscle strength
(Rolland, Van Kan, Gillette-Guyonnet, & Vellas, 2010), bed rest during hospitaliza-
tion is also associated with a loss of lean body mass, which adversely impacts functional
capacity (Rowell & Jackson, 2010).
e risk factors for malnutrition in the older adult are multifactorial and include
dietary, economic, psychosocial, and physiological factors (DiMaria-Ghalili & Amella,
2005). Dietary factors include little or no appetite (Carlsson, Tidermark, Ponzer,
Söderqvist, & Cederholm, 2005; Reuben, Hirsch, Zhou, & Greendale, 2005; Saletti
et al., 2005), problems with eating or swallowing, eating inadequate servings of nutri-
ents (Margetts, ompson, Elia, & Jackson, 2003), and eating fewer than two meals a
day (Saletti et al., 2005). Limited income may cause restriction in the number of meals
eaten per day or dietary quality of meals eaten (Souter & Keller, 2002). Isolation is also
a risk factor as older adults who live alone may lose their desire to cook because of lone-
liness, and appetite often decreases after the loss of a spouse (Shahar, Schultz, Shahar,
& Wing, 2001). Impairment in functional status can place the older adult at risk for
malnutrition (Oliveira, Fogaca, & Leandro-Merhi, 2009) since adequate functioning
is needed to secure and prepare food (Sharkey, 2008). Diculty in cooking is related
Nutrition 441
to disabilities (Souter et al., 2002), and disabilities can hinder the ability to prepare or
ingest food (Saletti et al., 2005). Chronic conditions can negatively inuence nutri-
tional intake as well as cognitive impairment (Kagansky et al., 2005). Psychological
factors are known risk factors of malnutrition. For example, depression is related to
unintentional weight loss (Morley, 2001; omas et al., 2002). Furthermore, poor
oral health (Saletti et al., 2005) and xerostomia (dry mouth caused by decreased saliva)
can impair the ability to lubricate, masticate, and swallow food (Saletti et al., 2005).
Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia
(DiMaria-Ghalili & Amella, 2005). Change in taste (from medications, nutrient de-
ciencies, or taste bud atrophy) can also alter nutritional intake (DiMaria-Ghalili &
Amella, 2005).
Body composition changes in normal aging include increase in body fat, includ-
ing visceral fat stores (Hughes et al., 2004) and a decrease in lean body mass (Jans-
sen, Heymseld, Allison, Kotler, & Ross, 2002). Furthermore, the low skeletal muscle
mass associated with aging is related to functional impairment and physical disability
(Janssen I, Heymseld, & Ross, 2002).
e impact of malnutrition on the health of the hospitalized older adult is well
documented. In this population, malnutrition is related to prolonged hospital stay
(Pichard et al., 2004), increased risk of poor health status, recent hospitalization, and
institutionalization (Margetts et al., 2003). Additionally, low MNA scores are predictors
of prolonged hospital stays and mortality (Sharkey, 2008).
ASSESSMENT OF THE PROBLEM
Areas of nutrition status assessment in the hospitalized older adult should focus on iden-
tication of malnutrition and risk factors for malnutrition. e MNA (Guigoz, Lauque,
& Vellas, 2002) is a comprehensive two-level tool that can be used to screen and assess
the older hospitalized patient for malnutrition by evaluating the presence of risk fac-
tors for malnutrition in this age group (DiMaria-Ghalili & Guenter, 2008). e valid-
ity and reliability of the MNA for use in hospitalized older adult is well documented
(Salva et al., 2004). If a patient scores less than 12 on the screen, then the assessment
section should be completed in order to compute the malnutrition indicator score. e
screening section of the MNA is easy to administer and is comprised of six questions.
e assessment section requires measurement of midarm muscle circumference and
calf circumference. Although these anthropometric measurements are relatively easy to
obtain with a tape measure, nurses may rst require training in these procedures prior
to incorporating the MNA as part of a routine nursing assessment. Protocols should be
established to identify interventions to be implemented once the screening and assess-
ment data are obtained and should include consultation with a dietitian. See http://
consultgerirn.org/resources for Assessing Nutrition in Older Adults (Portable document
Format [PDF] le) for MNA In Nutrition topic and Resources section.
Additional assessment strategies include proper measurement of height and weight
and a detailed weight history. Height should always be directly measured and never
recorded via patient self-report. An alternative way to measuring standing height is
knee height
(Salva et al., 2004) with special calipers. An alternative to knee height
measures is a demi-span measurement, half the total arm span. (For directions on
estimating height based on demi-span measurement, see Appendix 2 in A Guide
to Completing the Mini Nutritional Assessment at http://www.mna-elderly.com/
442 Evidence-Based Geriatric Nursing Protocols for Best Practice
mna_guide.pdf). A calorie count or dietary intake analysis is a good way to quantify
the type and amount of nutrients ingested during hospitalization (DiMaria-Ghalili
& Amella, 2005). Laboratory indicators of nutritional status include measures of vis-
ceral proteins such as serum albumin, transferrin, and prealbumin (DiMaria-Ghalili
& Amella, 2005). However, these visceral proteins are also negative acute phase reac-
tants and are decreased during a stressed inammatory state, limiting the ability to
predict malnutrition in the acutely ill hospitalized patient. In spite of this, albumin
is a strong prognostic marker for morbidity and mortality in the older hospitalized
patient (Sullivan et al., 2005). As biomarkers of inammation are translated from
research to clinical practice, future nutritional assessment protocols will incorporate
inammatory markers.
INTERVENTIONS AND CARE STRATEGIES
e nursing interventions outlined in the protocol focus on enhancing or promoting
nutritional intake and range in complexity from basic fundamental nursing care strate-
gies to the administration of articial nutrition via parenteral or enteral routes. Prior to
initiating targeted nutritional interventions in the hospitalized older adult, it must rst
be determined if the older adult cannot eat, should not eat, or will not eat ( American
Society for Parenteral and Enteral Nutrition [ASPEN], 2002). Factors to consider
include the gastrointestinal tract (starting with the mouth) working properly without
any functional, mechanical, or physiological alterations that would limit the ability to
adequately ingest, digest, and/or absorb food. Also, does the older adult have any chronic
or acute health condition in which the normal intake of food is contraindicated? Or, is
the older adult simply not eating, or is the appetite decreased? If the gastrointestinal
tract is functional and can be used to provide nutrients then nutritional interventions
should be targeted at promoting adequate oral intake.
Nursing care strategies focus on ways to increase food intake as well as ways to
enhance and manage the environment to promote increased food intake. When func-
tional or mechanical factors limit the ability to take in nutrients, nurses should obtain
interdisciplinary consultations from speech therapist, occupational therapists, physi-
cal therapists, psychiatrists, and/or dietitians to collaborate on strategies that would
enhance the ability of the older adult to feed themselves or to eat. Oral nutritional
supplementation has been shown to improve nutritional status in malnourished hos-
pitalized older adults (Capra et al., 2007) and should be considered in the hospitalized
older adult who is malnourished or is at risk for malnutrition. When used, oral liquid
nutritional supplements should be given at least 60 minutes prior to meals (Wilson
et al., 2002). Specialized nutritional support should be reserved for select situations.
If the provision of nutrients via the gastrointestinal tract is contraindicated, then par-
enteral nutrition via the central or peripheral route should be initiated (ASPEN, 2002).
If the gastrointestinal tract can be utilized, then nutrients should be delivered via enteral
tube feeding (ASPEN, 2002). e exact location of the tube and type of feeding tube
inserted depends on the disease state, length of time tube feeding is required, and risk of
aspiration. Patients started on specialized nutritional support should be routinely reas-
sessed for the continued need for specialized nutrition support and transitioned to oral
feeding when feasible. Also, advance directives, if not completed, should be addressed
prior to initiating specialized nutrition support (see Chapters 28 and 29, Health Care
Decision Making and Advance Directives).
Nutrition 443
Mrs. V. H. is a 75-year-old female admitted to the hospital with a myocardial infarc-
tion and is on a telemetry unit for further workup prior to coronary artery bypass
grafting surgery. On admission, her standing height is 5 ft 8 in. and she weighs 140 lbs.
Her BMI is 21.33. Her past medical history is signicant for rheumatoid arthritis. She
describes herself as generally in good health up until she was admitted to the hospi-
tal. Medications include 400 mg of ibuprofen every 6 hours, prn. Mrs. V. H. is the
primary caregiver for her 80-year-old husband who has altered cognitive functioning
and is bedridden after a stroke 3 years ago. She complained of being tired and lack-
ing energy prior to admission. Her weight history is signicant for a 10 lb weight loss
in the past 3 months. Mrs. V. H. said she started taking oral energy drinks because
she was often too tired to cook a complete dinner for herself and lacked energy and
was concerned about weight loss. She reported regaining 2 lbs. after taking 3 cans
of an oral nutritional supplement per day for about 4 weeks. She reported having
more strength after regaining some of her weight back. Although she is married, she
is isolated because she does not have any social support systems to rely on. Her only
living relative is a cousin who is 70 years old and lives 60 miles away and visits twice a
month. During the assessment, Mrs. V. H. continually complained of being physically
exhausted from caring for her husband at home and being too tired to eat or cook a
nutritious meal for herself. She is worried about how she will care for her husband
upon discharge from surgery and hopes that she can recover in the same nursing home
that her husband was admitted to.
Although Mrs. V. H. does not have any chronic conditions or functional limi-
tations that may place her at risk for malnutrition, her social history is signicant.
As the sole caregiver for her disabled husband, she is isolated, tired, and has a decreased
appetite. She reports a history of unintentional loss of 10 lbs. in 3 months. Her MNA
score is 7 based on moderate loss of appetite, weight loss greater than 6.6 lbs. during
the last 3 months, goes out, has suered an acute disease, no psychological prob-
lems, and has a BMI of 21.33. Because her score is below 11, she is at risk for
malnutrition, and a complete assessment level of the MNA is performed. Her total
MNA assessment score is 17.5 based on an assessment score of 10.5 and a screening
score of 7.0, indicating she is at risk for malnutrition. Although she is on a regular
diet, she only takes in about 50% of her meals. Oral nutritional supplements are
ordered twice daily between meals. Consultations obtained from the social worker,
dietitian, and physical therapist.
CASE STUDY
SUMMARY
Hospitalized older adults are at risk for malnutrition. Nurses should carefully assess
and monitor the nutritional status of the older hospitalized patient so that appropriate
nutrition-related interventions can be implemented in a timely fashion.
444 Evidence-Based Geriatric Nursing Protocols for Best Practice
(continued)
Protocol 22.1: Nutrition In Aging
I. GOAL: Improvement in indicators of nutritional status in order to optimize
functional status and general well being and promote positive nutritional status.
II. OVERVIEW: Older adults are at risk for malnutrition with 39% to 47% of
hospitalized older adults are malnourished or at risk for malnutrition (Kaiser, 2010).
III. BACKGROUND/STATEMENT OF PROBLEM
A. Denition(s)
1. Malnutrition: Any disorder of nutritional status, including disorders
resulting from a deciency of nutrient intake, impaired nutrient metabolism,
or overnutrition.
B. Etiology and/or Epidemiology. Older adults are at risk for undernutrition because
of dietary, economic, psychosocial, and physiological factors ( DiMaria-Ghalili,
& Amella, 2005)
1. Dietary intake
a. Little or no appetite (Carlsso et al., 2005; Reuben et al., 2005; Saletti
et al., 2005).
b. Problems with eating or swallowing (Margetts et al., 2003).
c. Eating inadequate servings of nutrients (Margetts et al., 2003).
d. Eating fewer than two meals a day (Saletti et al., 2005).
2. Limited income may cause restriction in the number of meals eaten per day
or dietary quality of meals eaten (Margetts et al., 2003).
3. Isolation
a. Older adults who live alone may lose desire to cook because of loneli-
ness (Souter & Keller, 2002).
b. Appetite of widows decreases (Souter & Keller, 2002).
c. Diculty cooking because of disabilities (Margetts et al., 2003).
d. Lack of access to transportation to buy food (DiMaria-Ghalili &
Amella, 2005).
4. Chronic illness
a. Chronic conditions can aect intake (Margetts et al., 2003).
b. Disability can hinder ability to prepare or ingest food (Saletti et al., 2005).
c. Depression can cause decreased appetite (Kagansky et al, 2005;
Morley, 2001).
d. Poor oral health (cavities, gum disease, and missing teeth), as is xerostomia,
or dry mouth impairs ability to lubricate, masticate, and swallow food
(Saletti et al., 2005).
e. Antidepressants, antihypertensives, and bronchodilators can contribute
to xerostomia (dry mouth; DiMaria-Ghalili & Amella, 2005).
5. Physiological changes
a. Decrease in lean body mass and redistribution of fat around internal
organs lead to decreased caloric requirements (Janssen et al., 2002;
omas et al., 2002).
NURSING STANDARD OF PRACTICE
Nutrition 445
b. Change in taste (from medications, nutrient deciencies, or taste
bud atrophy) can also alter nutritional status (DiMaria-Ghalili &
Amella, 2005).
IV. PARAMETERS OF ASSESSMENT
A. General: During routine nursing assessment, any alterations in general assess-
ment parameters that inuence intake, absorption, or digestion of nutrients
should be further assessed to determine if the older adult is at nutritional risk.
ese parameters include
1. Subjective assessment including present history, assessment of symptoms,
past medical and surgical history, and comorbidities (University of Texas
School of Nursing, 2006).
2. Social history (University of Texas School of Nursing, 2006)
3. Drug-nutrient interactions: Drugs can modify the nutrient needs and
metabolism of older people. Restrictive diets, malnutrition, changes in eating
patterns, alcoholism, and chronic disease with long-term drug treatment are
some of the risk factors in older adults that place them at risk for drug- nutrient
interactions (National Collaborating Centre for Acute w Care, 2006).
4. Functional limitations (Pichard et al., 2004)
5. Psychological status (Pichard et al., 2004)
6. Objective assessment: physical examination with emphasis on oral exam
(see Chapter 20, Oral Health Care), loss of subcutaneous fat, muscle wast-
ing, and body mass index (University of Texas School of Nursing, 2006)
and dysphagia.
B. Dietary Intake: In-depth assessment of dietary intake during hospitalization
may be documented with a dietary intake analysis (calorie count; DiMaria-
Ghalili & Amella, 2005).
C. Risk Assessment Tool: e Mini-Nutritional Assessment (MNA) should be
performed to determine if older hospitalized patient is either at risk for malnu-
trition or has malnutrition. e MNA determines risk based on food intake,
mobility, body mass index, history of weight loss, psychological stress, or acute
disease, and dementia or other psychological conditions. If score is 11 points
or less, the in-depth MNA assessment should be performed (Guigoz et al.,
2002). See Resources section for tool or http://consultgerirn.org/resources for
Nutrition topic.
D. Anthropometry
1. Obtain an accurate weight and height through direct measurement. Do not
rely on patient recall. If patient cannot stand erect to measure height, then
either a demi-span measurement or a knee-height measurement should be
taken to estimate height using special knee-height calipers (Guigoz et al.,
2002). Height should never be estimated or recalled due to shortening of
the spine with advanced age; self-reported height may be o by as much as
2.4 cm (Guigoz et al., 2002).
2. Weight history: A detailed weight history should be obtained along with
current weight. Detailed weight history should include a history of weight
loss, whether the weight loss was intentional or unintentional, and during
(continued)
Protocol 22.1: Nutrition In Aging (cont.)
446 Evidence-Based Geriatric Nursing Protocols for Best Practice
what period. A loss of 10 lbs. over a 6-month period, whether intentional or
unintentional, is a critical indicator for further assessment (Boullata, 2004;
DiMaria-Ghalili & Amella, 2005).
3. Calculate body mass index (BMI) to determine if weight for height is
within normal range: 22–27. A BMI below 22 is a sign of undernutrition
(Boullata, 2004).
E. Visceral proteins: Evaluate serum albumin, transferrin, and prealbumin are
visceral proteins commonly used to assess and monitor nutritional status
(DiMaria-Ghalili & Amella, 2005). However, keep in mind these proteins are
negative acute-phase reactants, so during a stress state, the production is usu-
ally decreased. In the older hospitalized patient, albumin levels may be a better
indicator of prognosis than nutritional status (Salva et al., 2004).
V. NURSING CARE STRATEGIES: (DiMaria-Ghalili & Amella, 2005)
A. Collaboration
1. Refer to dietitian if patient is at risk for undernutrition or has under-
nutrition.
2. Consult with pharmacist to review patient’s medications for possible drug–
nutrient interactions.
3. Consult with a multidisciplinary team specializing in nutrition.
4. Consult with social worker, occupational therapist, and speech therapist as
appropriate.
B. Alleviate dry mouth
1. Avoid caeine; alcohol and tobacco; dry, bulk, spicy, salty, or highly acidic
foods.
2. If patient does not have dementia or swallowing diculties, oer sugarless
hard candy or chewing gum to stimulate saliva.
3. Keep lips moist with petroleum jelly.
4. Frequent sips of water.
C. Maintain adequate nutritional intake
Daily requirements for healthy older adults include 30 kcal/kg of body weight,
and 0.8 to 1 g/kg of protein per day, with no more than 30% of calories from
fat. Caloric, carbohydrate, protein, and fat requirements may dier depending
on degree of malnutrition and physiological stress.
D. Improve oral intake
1. Assess each patient’s ability to eat within 24 hours of admission (Jeeries,
Johnson, & Ravens, 2011).
2. Mealtime rounds to determine how much food is consumed and whether
assistance is needed (Jeeries et al., 2011).
3. Limit sta breaks to before or after patient mealtimes to ensure adequate
sta available to help with meals (Jeeries et al., 2011).
4. Encourage family members to visit at mealtimes.
5. Ask family to bring favorite foods from home when appropriate.
6. Ask about patient food preferences and honor them.
7. Suggest small frequent meals with adequate nutrients to help patients regain
or maintain weight (Capra, Collins, Lamb, Vanderkroft, & Wai-Chi, 2007).
(continued)
Protocol 22.1: Nutrition In Aging (cont.)
Nutrition 447
8. Provide nutritious snacks (Capra et al., 2007).
9. Help patient with mouth care and placement of dentures before food is
served (Jeeries et al., 2011).
E. Provide conducive environment for meals
1. Remove bedpans, urinals, and emesis basins from rooms before mealtime.
2. Administer analgesics and antiemetics on a schedule that will diminish the
likelihood of pain or nausea during mealtimes
3. Serve meals to patients in a chair if they can get out of bed and remain
seated.
4. Create a more relaxed atmosphere by sitting at the patient’s eye level and
making eye contact during feeding.
5. Order a late food tray or keep food warm if patients not in their rooms
during mealtimes.
6. Do not interrupt patients for round and nonurgent procedures during meal
times.
F. Specialized nutritional support (American Society for Parenteral and Enteral
Nutrition, 2002)
1. Start specialized nutritional support when a patient cannot, should not, or
will not eat adequately and if the benets of nutrition outweigh the associ-
ated risks.
2. Prior to initiation of specialized nutritional support, review the patient’s
advanced directives regarding the use of articial nutrition and hydration.
G. Provide oral supplements
1. Supplements should not replace meals but be provided between meals and
not within the hour preceding a meal and at bedtime (Capra et al., 2007;
Wilson, Purushothaman, & Morley, 2002).
2. Ensure that oral supplement is at appropriate temperature (Capra et al.,
2007).
3. Ensure that oral supplement packaging is able to be opened by the patients
(Capra et al., 2007).
4. Monitor the intake of the prescribed supplement (Capra et al., 2007).
5. Promote a sip style of supplement consumption (Capra et al., 2007).
6. Include supplements as part of the medication protocol (Capra et al., 2007).
H. Nothing by mouth (NPO) orders
1. Schedule older adults for test or procedures early in the day to decrease the
length of time they are not allowed to eat and drink.
2. If testing late in the day is inevitable, ask physician whether the patient can
have an early breakfast.
See American Society of Anesthesiologists (ASA) practice guideline regard-
ing recommended length of time patients should be kept NPO for elective
surgical procedures.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. e patient will experience improvement in indicators of nutritional status.
2. e patient will improve functional status and general well-being.
(continued)
Protocol 22.1: Nutrition In Aging (cont.)
448 Evidence-Based Geriatric Nursing Protocols for Best Practice
B. Provider
1. e provider should ensure that care provides food and uid of adequate
quantity and quality in an environment conducive to eating, with appropri-
ate support (e.g., modied eating aids) for people who can potentially chew
and swallow but are unable to feed themselves (Boullata, 2004).
2. e provider should continue to reassess patients who are malnourished or
at risk for malnutrition (Boullata, 2004).
3. e provider should monitor for refeeding syndrome (Boullata, 2004).
C. Institution
1. e institution will ensure that all health care professionals who are directly
involved in patient care should receive education and training on the impor-
tance of providing adequate nutrition (Boullata, 2004).
D. Quality Assurance/Quality Improvement (QA/QI)
1. Establish QA/QI measures surrounding nutritional management in aging
patients.
E. Educational
1. Provider education and training includes
a. Nutritional needs and indications for nutrition support
b. Options for nutrition support (oral, enteral, and parenteral)
c. Ethical and legal concepts
d. Potential risks and benets
e. When and where to seek expert advice (Boullata, 2004).
2. Patient and/or caregiver education includes how to maintain or improve
nutritional status as well as how to administer, when appropriate, oral liquid
supplements, enteral tube feeding or parenteral nutrition
VII. FOLLOW-UP MONITORING (Boullata, 2004)
A. Monitor for gradual increase in weight over time.
1. Weigh patient weekly to monitor trends in weight.
2. Daily weights are useful for monitoring uid status.
B. Monitor and assess for refeeding syndrome.
1. Carefully monitor and assess patients the rst week of aggressive nutritional
repletion.
2. Assess and correct the following electrolyte abnormalities: Hypophosphatemia,
hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia.
3. Assess uid status with daily weights and strict intake and output.
4. Assess for congestive heart failure in patients with respiratory or cardiac
diculties.
5. Ensure caloric goals will be reached slowly more than 3–4 days to avoid
refeeding syndrome when repletion of nutritional status is warranted.
6. Be aware that refeeding syndrome is not only exclusive to patients started
on aggressive articial nutrition, but may also be found in older adults with
chronic comorbid medical conditions and poor nutrient intake started with
aggressive nutritional repletion via oral intake.
(continued)
Protocol 22.1: Nutrition In Aging (cont.)
Nutrition 449
RESOURCES
American Dietetic Association
Position Statement: Nutrition Across the Spectrum of Aging:
http://www.eatright.org/About/Content.aspx?id=8374
Practice Paper: Individualized Nutrition Approaches for Older Adults in Health Care Communities:
http://www.eatright.org/About/Content.aspx?id=8373
Position Paper: Food and Nutrition Programs for Community-Residing Older Adults:
http://www.eatright.org/About/Content.aspx?id=6442451115
United States Department of Agriculture
Professional Development Tools: Older Adults
http://snap.nal.usda.gov/nal_display/index.php?info_center=15&tax_level=3&tax_subject=275&topic_
id=1336&level3_id=5216
Regulatory/authoritative sites
American Geriatrics Society
http://www.americangeriatrics.org
American Medical Directors Association: Clinical Tools and Products
http://www.amda.com/tools/index.cfm
American Society for Parenteral and Enteral Nutrition
http://www.nutritioncare.org/
Centers for Medicare and Medicaid Services
http://www.medicare.gov/Nursing/Campaigns/NutriCareAlerts.asp
VIII: RELEVANT GUIDELINES
A. American Society of Anesthesiologists. (1999). Practice guidelines for pre-
operative fasting and the use of pharmacologic agents to reduce the risk of
pulmonary aspiration: Application to healthy patients undergoing elective pro-
cedures: A report by the American Society of Anesthesiologist Task Force on
Preoperative Fasting. Anesthesiology, 90, 896–905.
B. National Collaborating Centre for Acute Care. (2006). Nutrition support in
adults: Oral nutrition support, enteral tube feeding and parenteral nutrition.
London, UK: National Institute for Health and Clinical Excellence. Clinical
guideline; no. 32. Electronic copies: Available in PDF from that National Insti-
tute for Health and Clinical Excellence (NICE) website.
C. American Society for Parenteral and Enteral Nutrition. (2002). Guidelines
for the use of parenteral and enteral nutrition in adult and pediatric patients.
JPEN. Journal of Parenteral and Enteral Nutrition, 26, 1SA–138SA. Note: ese
guidelines are undergoing revision.
D. University of Texas. (2006). Unintentional weight loss in the elderly. Austin, TX:
Author. Note: ese guidelines are located at http://www.guidelines.gov. However,
the companion document with full bibliography is not in the public domain.
Protocol 22.1: Nutrition In Aging (cont.)
450 Evidence-Based Geriatric Nursing Protocols for Best Practice
Practicing Physician Education in Geriatrics
http://www.gericareonline.net/
National Conference of Gerontological Nurse Practitioners
http://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3697
National Gerontological Nursing Association
http://www.ngna.org/
National Institutes of Health
http://www.nlm.nih.gov/medlineplus/nutritionforseniors.html
e Gerontological Society of America
http://www.geron.org/
United States Department of Health and Human Services
http://www.hhs.gov/
Mini-Nutritional Assessment
Nestle Nutrition Institute
http://www.mna-elderly.com/
Nutrition in the Elderly
ConsultGeriRN website of the Hartford Institute for Geriatric Nursing
http://consultgerirn.org/resources
Knee-height Measurement
Florida International University’s Long-term Care Institute Resource Materials
http://www.u.edu/%7Enutreldr/LTC_Institute/materials/LTC_Products.htm#7
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Guigoz, Y., Lauque, S., & Vellas, B. J. (2002). Identifying the elderly at risk for malnutrition. e Mini
Nutritional Assessment. Clinics in Geriatric Medicine, 18, 737–757. Evidence Level V.
Hiesmayr, M., Schindler, K., Pernicka, E., Schuh, C., Schoeniger-Hekele, A., Bauer, P, . . .
Ljungqvist, O. (2009). Decreased food intake is a risk factor for mortality in hospitalised patients:
e NutritionDay survey 2006. Clinical Nutrition, 28, 484–491. Evidence Level IV.
Hughes, V. A., Roubeno, R., Wood, M., Frontera, W. R., Evans, W. J., & Fiatarone Singh, M. A.
(2004). Anthropometric assessment of 10-y changes in body composition in the elderly. e
American Journal of Clinical Nutrition, 80, 475–482. Evidence Level IV.
Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce.
Washington, DC: National Academies Press. Evidence Level VI.
Janssen, I., Heymseld, S. B., Allison, D. B., Kotler, D. P., & Ross, R. (2002). Body mass index
and waist circumference independently contribute to the prediction of nonabdominal, abdomi-
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Janssen, I., Heymseld, S. B., & Ross, R. (2002). Low relative skeletal muscle mass (sarcopenia) in
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Jeeries, D., Johnson, M., & Ravens, J. (2011). Nurturing and nourishing: e nurses’ role in nutri-
tional care. Journal of Clinical Nursing, 20, 317–330. Evidence Level I.
Jensen, G. L., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, A., Grijalba, R. F, . . . Waitzberg, D.
(2010). Adult starvation and disease-related malnutrition: A proposal for etiology-based diag-
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Kagansky, N., Berner, Y., Koren-Morag, N., Perelman, L., Knobler, H., & Levy, S. (2005). Poor
nutritional habits are predictors of poor outcome in very old hospitalized patients. American
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Kaiser, M. J., Bauer, J. M., Rämsch, C., Uter, W., Guigoz, Y., Cederholm, T., . . . Sieber, C. C.
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453
23
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. assess the older adult for critical issues related to performance at mealtimes: physical
and cognitive functioning, aversion to eating, cultural/religious factors
2. modify the mealtime environment to one that promotes adequate intake and
normalizes social interaction
3. educate sta and caregivers to provide individualized assistance at meals while
preserving the independence and dignity of the person being assisted
OVERVIEW
Nutrition has long been recognized as a key element in promoting good health and
recovery from illness across the life span; this is especially true as an individual ages.
However, the process of eating and the entire ritual of meals, which together are largely
culturally determined, are given little attention when nutritional problems are identi-
ed. is is especially notable in a time when interest in food and its presentation has
become a national craze, with many claiming to be “foodies” and chefs raised to the
status of media stars (Food Network Chef Bios, 2011). However, in institutions, restric-
tive diets are sometimes barely palatable, the eating environment ranges from a cluttered
hospital room to a large, noisy dining room, and sta treat the meal as a task to complete
rather than a process to enjoy. is chapter will address both barriers and enablers to
overcoming mealtime diculties and evidence-based strategies to support that process.
BACKGROUND AND STATEMENT OF PROBLEM
Nutrition is critical to maintaining health, and nowhere is this more important than
among older adults. e ingestion of the proper balance of macronutrients and
Elaine J. Amella and Melissa B. Aselage
Mealtime Difficulties
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
454 Evidence-Based Geriatric Nursing Protocols for Best Practice
micronutrients results in a pattern of eating that persists into old age and aects an indi-
vidual’s risk for chronic illness, especially Type 2 diabetes, heart disease, osteoarthritis,
and some cancers (U.S. Centers for Disease Control and Prevention [CDC], 2009a).
When older persons with multiple morbidities are hospitalized, their nutritional status is
often compromised related to a complex interplay of issues from social isolation, depen-
dence on others whether at home or in a nursing home, to depression or dementia (Arora
et al., 2007). en, as a result of these barriers to nutritional health, they are more likely
to remain in hospital longer with higher rates of complications and mortality (Arora
et al., 2007). Within the revised Healthy People 2020, determinants of health beyond
individual behaviors are examined to include both the social environment, such as limi-
tations that make it challenging for older adults to stay at home; health services–related
factors such as accessibility to providers with needed expertise; and community factors
such as poverty, violence, and access to healthy food (U.S. Department of Health and
Human Services [USDHHS], 2011); these factors directly aect nutritional issues and
disproportionately aect minorities and targeted underserved groups. A good diet in old
age can be inuenced by multiple factors; one study found, not surprisingly, that higher
socioeconomic status, ingestion of regular fruits and vegetables since childhood, and not
smoking were primary predictors (Maynard et al., 2006). Of the top 10 causes of death
in the older cohort, a lifetime of good nutrition would positively improve nine causes:
heart disease, cancer, stroke, chronic lower respiratory disease, Alzheimer’s disease, diabe-
tes, inuenza/pneumonia, nephritic syndrome/nephritis, and septicemia, with accidents
being the outlier (CDC, 2009b). However, although the examination of nutrition and
maintenance of a healthy diet are primary assessment criteria, the issue of how older peo-
ple choose, prepare, serve, and ingest food, or others do it for them—the phenomenon
of meals—is often overlooked. Meal is dened as “the food served and eaten, especially
at one of the customary, regular occasions for taking food during the day, as breakfast,
lunch, or supper; one of these regular occasions or times for eating food” (Flexner &
Hauck, 1987). Meals are custom driven and contextually based; even the time that food
is eaten and what is eaten at each meal can be dictated by culture and habit.
Within a “foreign” environment such as a hospital or long-term care institution,
a dierent culture exists—one that focuses on patient safety and quality, which has
been broadly dened as preventing harm to patients and delivering quality health care
(Mitchell, 2008). e overarching concern for systems outcomes may override indi-
vidual needs; this has led in the long-term care environment to the “culture change”
movement that focuses on quality of life as well as quality of care (Koren, 2010). Deeply
embedded within this paradigm shift, which is championed by national lay and profes-
sional stakeholders, is a regard for mealtimes that reects the comforts of home (Pioneer
Network, n.d.). With a growing concern for shifting the paradigm away from solely a
concern for calories consumed to a comprehensive approach to the entire phenomenon
of eating, we need to explore the assessment and management of mealtimes through a
new lens using a model that asks the health care provider to examine the entire context
of meals for all older adults; the way that the meal assistance is rendered by caregivers,
if needed, especially in the face of acute exacerbations of chronic illness and cognitive
impairment; and health factors that may inuence the older adult’s functional and cog-
nitive capacity to independently eat. is model—change the context, change the care-
giving, change the person—has been adopted in three studies by the authors who trained
caregivers in long-term care and in the community to change meals as a mechanism to
promote quality of life and nutritional health (Amella & DeLegge, 2009; Amella &
Mealtime Diculties 455
Laditka, 2009; Aselage, 2011). Furthermore, the support of the routine and the famil-
iar was shown to be critical in older persons with cognitive impairments through the
work of nurse researchers who developed the Needs-Driven Dementia-Compromised
Behavior framework in the late 1990s that examined dysfunctional behavior from the
areas of background (personal) and proximal (environmental) factors among people
with dementia (Algase et al., 1996). is work guides many interdisciplinary interven-
tions for this compromised population today, including examination of mealtime issues
(Aselage & Amella, 2010).
ASSESSMENT OF THE PROBLEM
Recommendations for assessment of nutrition among older adults vary depending on
their place of residence (community, long-term care, or acute care) and their level of
independence; however, a systematic review of dierent instruments recently supported
the use of the Mini Nutritional Assessment (MNA) across sites and SCREEN II for
community-dwelling older adults (Phillips, Foley, Barnard, Isenring, & Miller, 2010).
However, the MNA has only one question that even indirectly deals with meals: “How
many full meals does the patient eat daily?” e individual is then asked: “Do you
normally eat breakfast, lunch, and dinner?” e following denition of a full meal
is given: A full meal is dened as an eating occasion when the patient “sits down”
to eat and consumes more than two items/dishes (Guigoz, Vellas, & Garry, 1997).
An alternative assessment instrument that has been used exclusively in the community,
SCREEN II, shows strong psychometrics, but does not address contextual issues beyond
“eating alone” (Keller, Goy, & Kane, 2005). Assessment of the entire process of eating
and mealtimes was divided into the following components by Aselage (2010) to eat-
ing behavior assessed by the Level of Eating Independence Scale (LEIS) and the Eating
Behavior Scale (EBS); feeding behavior assessed by the Edinburgh Feeding in Dementia
Scale (EdFED), Feeding Abilities Assessment (FAA), Self-Feeding Assessment Tool of
Osborn and Marshall, the McGill Ingestive Skills Assessment (MISA), Feeding Behavior
Inventory, the Feeding Traceline Technique (FTLT), Feeding Dependency Scale (FDS),
and the Aversive Feeding Inventory; and meal behavior assessed by the Meal Assistance
Screening Tool (MAST) and Structured Meal Observation. is critical appraisal of
instruments determined that most are primarily used in research, most are setting spe-
cic with an emphasis on either long-term care or rehabilitation settings—few have
been used in the community; are often lengthy and may not be practical in a clinical
setting. Only the EdFED, which has been used across acute and long-term care settings
and in the community, has strong psychometrics, and appears to be the most practical
across domains (Watson, 1994b; Watson, Green, & Legg, 2001); yet, it was designed
to evaluate individuals with dementia—clearly not all older persons having diculties
with meals, but in all likelihood a signicant portion.
e other standardized assessment instrument worth noting is the Minimum Data
Set (MDS) that, as of late 2010, underwent its third complete revision—MDS 3.0—to
improve accuracy and reliability of assessment and reporting (Centers for Medicare &
Medicaid Services [CMS], 2010). e MDS is administered to all residents of nurs-
ing homes in the United States receiving federal funding, and it may be a part of the
assessment information that ows between agencies during transitions—nursing home
to acute care. One of the foci of the MDS is determining the amount of assistance
required by an individual to perform various activities, as well as health problems that
456 Evidence-Based Geriatric Nursing Protocols for Best Practice
may result if key factors are not addressed. e MDS dedicates only two questions in
15 sections regarding health assessment to a mealtime-like issue. In the section Prefer-
ence for Customary and Routine Activities, the only relevant item is “How important
is it to you to have snacks available between meals?” and in the Functional Status sec-
tion, “Eating—includes eating, drinking (regardless of skill), or intake of nourishment
by other means” (e.g., tube feeding, total parenteral nutrition, intravenous uids for
hydration; CMS, 2010).
As an individual ages, the likelihood of functional impairment increases. With
increased frailty, loss of function follows a predictable pattern, with the ability to feed
oneself the last activity of daily living (ADL) to be lost (Katz, Downs, Cash, & Grotz,
1970; Katz, Ford, Moskowitz, Jackson, & Jae, 1963). e most recent national data
on disability showed that 19.7% of all older adults (65 years old and older) are chroni-
cally disabled, with 3.1% of those living in the community requiring assistance with
ve to six ADLs (Federal Interagency Forum on Age-Related Statistics, 2006). Although
self-feeding must be promoted for all persons for as long as possible, techniques for pro-
motion of independence at meals are often not used and may take too much time for
caregivers resulting in increased dependence at mealtimes. Interdisciplinary research-
ers developed individualized nutritional interventions based on regular assessment of
changing status over time; the treatment group was noted to have a declining appetite,
poor posture while eating, and inadequate oral care—all amenable to alterations to the
process of care with improved nutritional serological markers and depression compared
to the control group (Crogan, Alvine, & Pasvogel, 2006).
Assessment is not a static event especially when an older adult experiences the down-
ward spiral of a life-limiting cognitive or physical illness.
Dierent religious and cultural groups may have strict requirements for prepa-
ration and blessing of food before it can be consumed (Bermudez & Tucker, 2004).
erefore, assessment of these beliefs and preferences are vital. Individuals who follow
dietary restrictions for religious or cultural reasons may not eat when rules have not
been observed (Fjellström, 2004).
.
In general, most cultures promote the washing of
hands before meals; this may not be oered in institutional settings. Older adults who
have serious chronic illness should be consulted regarding preferences for food and
uid intake. ey should be asked about their wishes regarding treatment with articial
nutrition and hydration if not already documented in an advance directive. If the older
adult loses the capacity for decision making, the proxy for health care decisions should
be consulted rather than the provider assuming responsibility for the management of
nutritional care.
Finally, for some older adults, social determinants of health may limit their ability to
acquire and eat the foods they have preferred over a lifetime. For those individuals living
at or near the poverty line, or those who live in rural or economically depressed neigh-
borhoods, food insecurity and food deserts may be active concerns (Coates et al., 2006).
In 2008, among older adults living alone, 8.8% were categorized as food insecure and
3.8% were categorized as very low food insecure, meaning they may not be eating for
a whole day and this condition was present for 3 or more months (Coates et al., 2006;
Seligman, Laraia, & Kushel, 2010). Inability to obtain favorite foods because one lives
in an area only serviced by convenience-type stores with highly processed food (food
deserts), out of fear of violence, or because of poverty may result in meals that are no
longer appealing or congruent with lifelong cultural preferences. For these older adults,
referral to meal programs may be vital.
Mealtime Diculties 457
INTERVENTIONS AND CARE STRATEGIES
Nutritional Health
Assessment and management of nutritional health is covered in the Nutrition chapter
in this text; therefore, the reader is referred to that discussion. However, the professional
nurse is reminded that nutritional health is best assessed and managed through an inter-
disciplinary approach because it is a multifaceted issue. Minimally, the dietitian, provider
(physician, advanced practice nurse, physician assistant), dentist, speech and language
pathologist, occupational therapist, and patient/caregiver should be consulted when
designing a nutritional plan of care. e social worker or case manager may be key to
coordinating outside resources and should be part of discharge planning for obtaining
preferred, culturally appropriate, and healthy foods. Strategies that produced better meal-
time outcomes included “meal rounds” by a dietitian and food service supervisors work-
ing with unit sta, which allowed for early identication of residents at risk for nutritional
problems and early intervention, especially those with dysphagia and those needing assis-
tance at meals (Keller, 2006). Clearly, mealtimes are an opportunity for collaboration.
Cognitive Impairments
Cognitive decits impair the ability to eat and drink. Persons with severe cognitive impair-
ments may develop refuse-like or aversive behaviors that aect their ability to be assisted
at meals; this is signicantly associated with mortality (Amella, 2002; Mitchell et al.,
2009).
In a systematic review of the literature, the only intervention that was associated
with increased intake in this group was high-calorie supplements, although other nutri-
tional and social interventions only showed weak association (Hanson, Ersek, Gilliam,
& Carey, 2011).
However, as this disease moves toward later stages, the individual’s prior
wishes should be respected regarding food and uid and the focus is often placed on
quality of life (Amella, 2004). Watson developed a psychometrically sound instrument,
the EdFED, to measure the declining ability to consume food oered related to resis-
tance (Watson & Deary, 1997). Nurses can use the principles of this instrument to deter-
mine the stage of resistive eating behavior. In the earlier stages, more active behaviors are
displayed (e.g., the individual pushes food away or turns his or her head away from the
feeder). In later stages, passive behaviors occur, as the patient does not swallow and allows
food to fall from his or her mouth. In late-stage dementia, a primitive and less forceful
swallow pattern may develop. e upper airway is not well protected, making the use of
bottle or syringe-type feeding not only undignied but also ineective and unsafe.
Increasing Intake
Modifying mealtimes may result in positive nutritional outcomes—one of the most nota-
ble is increasing intake of food and uids. Interventions range from modifying a “thera-
peutic” diet (including favorite foods, promoting socialization, and a team approach) to
planning meals. Liberalization of diets is recommended by a major dietetic organization
when intake of micronutrients (e.g., sodium) or macronutrients (e.g., fats) cannot be sup-
ported and quality of life is primary, especially in those persons with life-limiting illnesses,
or who have consumed minimal nutrition (Dorner, Friedrich, & Posthauer, 2010).
Equivocal results can be found regarding what activities promote greater intake
at meals. Taylor and Barr (2006) reported that eating smaller more frequent meals
458 Evidence-Based Geriatric Nursing Protocols for Best Practice
increased intake of uids; however, it did not increase food intake. In a randomized
crossover design, researchers found that “smaller eaters” consumed more calories and
protein if breakfast and lunch meals were enhanced with higher caloric food and extra
protein (Castellanos, Marra, & Johnson, 2009). Additionally, in a quasi-experimental
study, eating in the dining room appeared to increase total consumption of calories but
did not inuence intake of protein, nor did it inuence weight gain (Gaskill, Isenring,
Black, Hassall, & Bauer, 2009; Wright, Hickson, & Frost, 2006). Some Acute Care for
the Elderly units include a dining room in their environmental modications in order
to improve the mealtime experience, increase observation of those with eating prob-
lems, and increase food intake.
Mealtimes can be a time to signicantly increase social exchange, as was demon-
strated through a bundled intervention including favorite foods, including chocolate;
moderate exercise; and oral care. However, it was social engagement and functional abil-
ity that increased in the treatment group, with social engagement associated most with
improvement (Beck, Damkjaer, & Sorbye, 2010). Furthermore, in an observational
study conducted in France that promoted caregiving sta sharing meals with nursing
home residents with dementia, compared to another nursing home that did not have
shared meals, weight of residents in the “treatment” facility was maintained and stas’
behavior toward residents improved (Charras & Frémonteir, 2010).
Feeding Assistance and Staff Training
Within recent years, more emphasis is being placed on preparing sta in nursing homes
to safely assist with meals; sadly, this has not occurred with equal vigor in acute care
where older adults may be the most medically vulnerable and require knowledgeable
sta to support meals. Under experimental conditions, it has been demonstrated that
feeding assistance makes a critical dierence for older adults with functional impair-
ment: When nursing home residents at risk for weight loss were assisted by trained
research assistants for 24 weeks, caloric intake increased and weight improved ( Simmons
et al., 2008). However, in the clinical world, most sta are uninformed regarding how
to assist with meals and use personal beliefs and preferences to guide their delivery of
meals (Lopez, Amella, Mitchell, & Strumpf, 2010). Very few elements of mealtime care
are formally developed and taught: Most sta see meals as a task to be accomplished
(Amella, 1999). e advent of formal paid dining assistant (DA) feeding programs in
nursing homes has been supported by state survey and certication bodies to improve
nutrition among residents and may include information regarding interpersonal com-
munication in general, altering the environment and working with families. However,
a careful review of an 8-hour New York State program revealed that very little time is
allocated for focus on these elements (New York State Department of Health, 2007).
Simmons has been working to develop and rene an interdisciplinary-informed DA
training program (Simmons & Schnelle, 2006), and recently with an interdisciplinary
team tested a 12-month implementation with follow-up, nding that trained DA sta
were just as eective as certied nursing assistants (CNAs) at recognizing problems and
assisting with meals (Bertrand et al., 2010). However this program also had a focus
on safety and the task of feeding. When CNAs were trained in feeding skills, and the
residents they assisted using those improved strategies were then evaluated using the
EdFED, the residents receiving the new strategies had better eating behavior and were
given more time to eat (Chang & Lin, 2005). In acute care, no training material could
Mealtime Diculties 459
be found for direct care workers regarding the alteration of environment, personalized
strategies, or methods to encourage eating.
In addition to lack of training regarding facilitation of meals and promotion of meal-
time independence, mealtimes may be poorly staed, especially in acute care settings
because personnel are often taking meal breaks at the same time as patients ( Crabtree,
Miller, & Stange, 2005; Xia & McCutcheon, 2006). However, when hospital nurses in
the United Kingdom decided to redesign meals on medical wards and address nutri-
tional needs of patients by taking breaks at other than mealtimes, patients actually
consumed more food (Dickinson, Welch, & Ager, 2008). When surveyed, CNAs and
licensed nurses identied lack of time and training, as well as “working short staed,”
as being related to residents not receiving enough food (Crogan, Shultz, Adams, &
Massey, 2001). Mealtimes are one of the most time-consuming activities of daily living
and, unfortunately, not reimbursed at the required levels. It has been reported that nurs-
ing home residents with low intake required 35–40 minutes of sta assistance despite
their level of dependency (Simmons & Schnelle, 2006); the amount of time taken to
support meals among acutely and critically ill older adults in hospital is not known.
Environment and Interaction
Because of the strong social and cultural components of eating, where one dines is some-
times as important as what one eats. Nurses should simply ask themselves, “Would I want
to eat my next meal where this person is eating?” If the answer is no, then steps should be
taken to improve the dining environment. Small changes in the dining environment may
make large improvements in a patient’s capacity and motivation to eat or be fed. Unfor-
tunately in institutions, the mealtime experience is often not focused on individual needs
(Sydner & Fjellström, 2005). Several patient-centered factors have been identied as criti-
cal to older adults: Each mealtime was seen as a unique process, and patients are central to
the process through their actions not only at meals but also during the time surrounding
meals, such as socializing while waiting (Evans, Crogan, & Shultz, 2005; Gibbs-Ward
& Keller, 2005; Wikby & Fägerskiöld, 2004). External factors such as decreased noise,
increased lighting, and playing of relaxing music at meals positively inuenced appetite
(Hicks-Moore, 2005; McDaniel, Hunt, Hackes, & Pope, 2001). Using contrasting colors
(foreground/background) in tableware and tablecloth, and placing dishes in similar posi-
tions may help persons with low vision be more independent (Ellexson, 2004). Proper
positioning using the appropriate, supportive chair (instead of eating in bed or sitting on
the bedside) or promotes good eating posture (Rappl & Jones, 2000). Encouraging the
family to eat with the patient can be benecial; this has been shown eective in nursing
homes to increase body weight and ne motor function in a randomized control trial
(Altus, Engelman, & Mathews, 2002; Nijs, de Graaf, Kok, & van Staveren, 2006). Meals
eaten in small groups—much like family dining—are considered an ideal method; how-
ever, this intervention had more aect on sta’s perception of meals and willingness to
spend time in the process of attending to meals (Kofod & Birkemose, 2004). Successful
completion of the meal is dependent on who assists or feeds the patient and the interper-
sonal process that the person uses to interact with the patient (Altus et al., 2002; Amella,
2002). Caregivers who are able to let the patient set the tempo of the meal and allow oth-
ers to make choices will be more eectual in increasing intake. ese studies point to a
need to patient-centered approaches that individualize mealtimes for patients and that the
responsibility for ensuring this occurs rests with a sensitive and well-trained sta.
460 Evidence-Based Geriatric Nursing Protocols for Best Practice
Mr. Jackson is an 82-year-old African American male who is admitted to a medical
unit after a short stay in the medical intensive care unit with a diagnosis of an isch-
emic stroke and treatment with tissue plasminogen activator—he appears to have little
residual eect, although is being closely observed because of multiple comorbidities.
He has a long history of heart failure, Type 2 diabetes, and “mild” vascular dementia.
His insulin has been discontinued, and he is now receiving a short-acting oral antidi-
abetic agent that is given at mealtimes, loop diuretic, angiotensin-converting enzyme
inhibitor, and a beta-blocker. Medications can cause a decrease in appetite so Mr.
Jackson needed to have a side eect prole for all drugs developed by the pharma-
cologist. Initially, Mr. Jackson’s appetite had not improved and his blood glucose was
lower than 80 mg/dl on several occasions requiring the change in antihyperglycemic.
Mr. Jackson tires easily so he has been eating in the hospital bed; he is becoming more
dependent in his cares and the sta is having to occasionally feed him. Within the past
48 hours, he has become incontinent and requires almost total care; his confusion is
increasing and he is sometimes unaware of his surroundings. e plan was for Mr.
Jackson to return to senior housing; however, his daughter now wants him to come
home. Other family members are worried that he is not eating suciently and may
need a feeding tube. ey all agree that they will help the daughter with caregiving but
are unable to come up with a plan that the case manager considers safe; she recom-
mends that Mr. Jackson be discharged to a nursing home. Mr. Jackson is a member of
the Seventh-Day Adventist church.
Mr. Jackson has several issues that require close monitoring, rst of which are his
two severe chronic illnesses—diabetes and heart failure, and superimposed delirium
with dementia. All of these conditions must be medically managed before discharge
can be attempted. However, these illnesses in conjunction with his change in mental
status are causing him to have unmet nutritional needs that should be addressed by
careful assessment and interventions.
To improve his declining intake, initially, the nurse should observe Mr. Jackson
during each meal over the course of the day, noting if his capacity to eat independently
or amount of assistance needed uctuates across the day, and if he would benet
from progressive assistance. Because of the history of dementia and possible new-onset
delirium, the EdFED could be used to note mealtime behaviors and see if he is amena-
ble to environmental changes—eating out of bed, receiving cuing and prompts, provi-
sion of better lighting and use of eyeglasses, and moving him to a more stimulating
environment such as the unit’s dayroom. Oral care should be regularly provided. With
his recently diagnosed stroke, the nurse should be especially observant of any signs of
dysphagia and inability to handle dining implements. Adaptive equipment may allow
him to be more independent. Consultation with the entire health care team, includ-
ing the provider, speech and language pathologist, dietitian, dentist, occupational
therapist, clergy, and case manager, is warranted to ensure that any unmet needs are
addressed. Sta needs to be familiar with his religious preferences, such as a vegetarian
diet with increased whole grain, fruits, and water instead of fruit juice.
Mr. Jackson should be allowed to rest before meals; rehabilitative therapies should
be planned away from mealtimes. During mealtimes, favorite music can be played and
CASE STUDY
(continued)
Mealtime Diculties 461
SUMMARY
In the past 5 years, a number of tailored interventions and bundled programs have
been developed that have been shown to increase the caloric and uid intake of older
adults in nursing homes and hospitals. However, most evidence relies on smaller quasi-
experimental or descriptive studies, some with crossover designs; most interventions are
of rather short duration and few studies examine sustainability of programs (Watson &
Green, 2006).
At this time, careful and regular assessment of the vulnerable older adult with multiple
chronic cognitive/mental and physical illnesses is still warranted because these are the
patients who are at highest risk for mealtime diculties. A team approach to nutritional
and mealtime issues is critical. Across all sites of care, attention must be paid to not just
what a person eats, but how he or she eats, where he or she eats, and with whom he or
she eats, because meals are powerful contributor to both health and quality of life.
Mr. Jackson can be assisted out of bed and supported in a therapeutic position. Family
members can be encouraged to visit at mealtimes and sta should be present at meals
to assist, but not rush him. Sta should also avoid performing tasks in the room while
Mr. Jackson is eating—they should not distract him.
As Mr. Jackson’s delirium begins to clear and with a more focused approach to
his mealtime needs and improved interaction, Mr. Jackson’s intake begins to improve.
e family and church members bring foods he once enjoyed, and the family agrees
that a stay in short-term rehab may be a better alternative to further address his medi-
cal needs and ensure needed social interaction as he recovers.
Protocol 23.1: Assessment and Management of Mealtime Difficulties
I. GOAL: To maintain or improve nutritional intake at meals and provide a quality
mealtime experience that fosters dignity and pleasure in eating, as well as respecting
cultural and personal preferences, for as long as possible.
II. OVERVIEW
Guiding Principles
A. e adequate intake of nutrients is necessary to maintain physical and emo-
tional health.
B. Mealtime is not only an opportunity to ingest nutrients but also to main-
tain critical social aspects of life.
NURSING STANDARD OF PRACTICE
(continued)
CASE STUDY (continued)
462 Evidence-Based Geriatric Nursing Protocols for Best Practice
C. e social components of meals will be observed, including mealtime
rituals, cultural norms, and food preferences.
D. Persons will be encouraged and assisted to self-feed for as long as possible.
E. Persons dependent in eating will be assisted with dignity.
F. e quality of mealtime is an indicator of quality of life and care of an
individual.
III. BACKGROUND
A. Denitions
1. Feeding is “the process of getting the food from the plate to the mouth. It is a
primitive sense without concern for social niceties” (Katz et al., 1970, p. 23).
2. Eating is “the ability to transfer food from plate to stomach through the
mouth” (Katz et al., 1970, p. 23). Eating involves the ability to recognize
food, the ability to transfer food to the mouth, and the phases of swallowing.
3. Anorexia is characterized by a refusal to maintain a minimally normal body
weight and has a physiological basis in the older adults ( Wilson, 2007).
4. Dehydration is a uid imbalance caused by too little uid taken in or too
much uid lost or both.
5. Dysphagia is “an abnormality in the transfer of a bolus from the mouth to
the stomach” (Groher, 1997, p. 2).
6. Apraxia is an inability to carry out voluntary muscular activities related to
neuromuscular damage. As it relates to eating and feeding, it involves loss of
the voluntary stages of swallowing or the manipulation of eating utensils.
7. Agnosia is the inability to recognize familiar items when sensory cuing is
limited.
B. Etiology
Mealtime diculties can have multiple causes from both physiological and
psychological origins. Health professionals need to consider multiple etiologies
and not assume that diculties are related only to increased confusion from a
cognitive decline.
1. Cognitive/neurological: Parkinson’s disease; amyotrophic lateral sclerosis;
dementia, especially Alzheimer’s disease; stroke
2. Psychological: depression
3. Iatrogenic: lack of adaptive equipment; use of physical restraints that limit
the ability to move, position, or self-feed; improper chair or table surface
or discrepancy of chair to table height; use of wheelchair in lieu of table
chair; use of disposable dinnerware, especially for patients with cognitive or
neuromuscular impairments
IV. PARAMETERS OF ASSESSMENT
A. Assessment of Older Adults and Caregivers
1. Rituals used before meals (e.g., hand washing and toilet use); dressing for
dinner
2. Blessings of food or grace, if appropriate
(continued)
Protocol 23.1: Assessment and Management of Mealtime Difficulties (cont.)
Mealtime Diculties 463
3. Religious rites or prohibitions observed in preparation of food or before
meal begins (e.g., Muslim, Jewish, Seventh-Day Adventist; consult with
pastoral counselor, if available)
4. Cultural or special cues—family history, especially rituals surrounding
meals
5. Preferences about end-of-life decisions regarding withdrawal or administra-
tion of food and uid in the face of incapacity, or request of designated
health proxy; ethicist or social worker may facilitate process.
B. Assessment Instruments
1. EdFED for persons with moderate to late-stage dementia (Watson, 1994a)
2. Katz Index of ADL for functional status (Katz et al., 1970)
3. Food diary/meal portion method (Berrut et al., 2002)
V. NURSING INTERVENTIONS
A. Environment
1. Dining or patient room—encourage the older adult to eat in dining room
to increase intake, personalize dining room; no treatments or other activi-
ties occurring during meals; no distractions
2. Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer,
atware, tablecloth, napkin) versus disposable tableware and bibs
3. Furniture: older adult seated in stable armchair; table-appropriate height
versus eating in wheelchair or in bed
4. Noise level: environmental noise from music, caregivers, and televi-
sion is minimal; personal conversation between patient and caregiver is
encouraged
5. Music: pleasant, preferred by patient
6. Light: adequate and non-glare-producing versus dark, shadowy, or glaring
7. Contrasting background/foreground: use contrasting background and fore-
ground colors with minimal design to aid persons with decreased vision
8. Odor: food prepared in area adjacent to or in dining area to stimulate appetite
9. Adaptive equipment: available, appropriate, and clean; caregivers and/
or older adult knowledgeable in use; occupational therapist assists in
evaluation
B. Caregiver/Stang
1. Provide an adequate number of well-trained sta
2. Deliver an individualized approach to meals including choice of food,
tempo of assistance.
3. Position of caregiver relative to elder: eye contact; seating so caregiver faces
older patient in same plane
4. Cueing: caregiver cues older adult whenever possible with words or gestures
5. Self-feeding: encouragement to self-feed with multiple methods versus
assisted feeding to minimize time
6. Mealtime rounds: interdisciplinary team to examine multifaceted process of
meal service, environment, and individual preferences
(continued)
Protocol 23.1: Assessment and Management of Mealtime Difficulties (cont.)
464 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
How to Try is: e Edinburgh Feeding Evaluation in Dementia Scale: Determining How Much
Help People With Dementia Need at Mealtime.
Dementia series: http://www.nursingcenter.com/prodev/ce_article.asp?tid=807225
e Mini Nutritional Assessment (MNA)
http://www.mna-elderly.com/
VI. EVALUATION/EXPECTED OUTCOMES
A. Individual
1. Corrective and supportive strategies reected in plan of care
2. Quality-of-life issues emphasized in maintaining social aspects of dining
3. Culture, personal preferences, and end-of-life decisions regarding nutrition
respected
B. Health Care Provider
1. System disruptions at mealtimes minimized
2. Family and sta informed and educated to patient’s special needs to pro-
mote safe and eective meals
3. Maintenance of normal meals and adequate intake for the patient reected
in care plan
4. Competence in diet assessment; knowledge of and sensitivity to cultural
norms and preferences for mealtimes reected in care plan
C. Institution
1. Documentation of nutritional status and eating and feeding behavior meets
expected standard
2. Alterations in nutritional status; eating and feeding behaviors assessed and
addressed in a timely manner
3. Involvement of interdisciplinary team (geriatrician, advanced practice
nurse, dietitian, speech therapist, dentist, occupational therapist, social
worker, pastoral counselor, ethicist) appropriate and timely
4. Nutritional, eating, and/or feeding problems modied to respect individual
preferences and cultural norms
5. Adequate number of well-trained sta who are committed to delivering
knowledgeable and individualized care
VII. FOLLOW-UP MONITORING
A. Providers’ competency to monitor eating and feeding behaviors
B. Documentation of eating and feeding behaviors
C. Documentation of care strategies, and follow-up of alterations in nutritional
status and eating and feeding behaviors
D. Documentation of stang and sta education; availability of supportive inter-
disciplinary team.
Protocol 23.1: Assessment and Management of Mealtime Difficulties (cont.)
Mealtime Diculties 465
e Alzheimer’s Association
e “Eating Well” video as part of web-based training programs, CARES: A Dementia Caregiving
Approach.
http://www.alz.org/in_my_community_professionals.asp
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469
24
Family Caregiving
Deborah C. Messecar
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader will be able to:
1. describe characteristics and factors that put family caregivers at risk for unhealthy
transitions into the caregiving role
2. identify key aspects of a family caregiving preparedness assessment
3. list specic interventions to support family caregivers of older adults take on their
caregiving duties
4. identify family caregiver outcomes expected from the implementation of this
protocol
OVERVIEW
Family caregivers are a key link in providing safe and eective transitional care to frail
older adults as they move across levels of care (e.g., acute to subacute) or across set-
tings (e.g., hospital to home; Bauer, Fitzgerald, Haesler, & Manfrin, 2009; Coleman
& Boult, 2003; Naylor, 2003). Frail older adults coping with complex chronic con-
ditions are vulnerable to problems with care as they typically have multiple pro-
viders and move frequently between and among health care settings. Incomplete
communication among providers and across health care agencies is linked to adverse
outcomes and an increased risk of hospital readmission and or length of hospital stay
(Bauer et al., 2009). Nurses in collaboration with family caregivers can bridge the
gap between the care provided in hospital and other settings and the care needed in
the community. Transitional care for frail older people can be improved if interven-
tions address family inclusion and education, communication between health care
workers and family, and interdisciplinary communication and ongoing support after
the transition.
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
470 Evidence-Based Geriatric Nursing Protocols for Best Practice
Helping Caregivers Take On the Caregiving Role
Helping the caregiver with the role acquisition process is a critical nursing function that
facilitates good transitional care. Indicators of a healthy assumption of the caregiving
role are those factors that either indicate a robust and positive role acquisition process
or signal potential diculty with assuming the caregiver role. When trying to ascertain
what those indicators might be, the following questions about the caregiver role acqui-
sition process can be posed: “What constitutes health during the role acquisition pro-
cess?” “What indicates a positive state of health during this process?” and “What threats
to health may occur as the process unfolds?” (Schumacher, 1995, p. 219). Because
the role transition process unfolds over time, identifying process indicators that move
patient and family members either in the direction of health or on the way to vulner-
ability and risk allow early assessment and intervention to facilitate healthy outcomes of
the caregiving role acquisition (Schumacher, 2005). If unhealthy role-taking transitions
can be identied, then they can either be prevented or ameliorated.
Who Is Likely to Be or Become a Caregiver?
Being a family caregiver is a widespread experience in the United States. Depending on
how family caregiving is dened, national surveys estimate that anywhere from 22.4 to
52 million people provide care for a chronically ill, disabled family member or friend
during any given year (National Alliance for Caregiving [NAC] & American Association
for Retired Persons [AARP], 2004; Opinion Research Corporation [ORC], 2005; U.S.
Department of Health and Human Services [USDHHS], 1998). Reecting an increasing
trend, 44% of all family caregivers of adults older than age 18 are men, 56% are women,
and the majority is older than the age of 45 (ORC, 2005). Among the primary family
caregivers of older disabled or ill adults older than age 65, the proportion of male caregiv-
ers is lower (about 32%), but this number has increased from prior years (Wol & Kasper,
2006). Primary family caregivers are children (41.3%), spouses (38.4%), and other family
or friends (20.4%; Wol & Kasper, 2006). e most common caregiver arrangement is
that of an adult female child providing care to an elderly female parent (USDHHS, 1998).
Many caregivers are older and are at risk for chronic illness themselves. Nearly 45% of all
primary caregivers are older than 65 years of age, with 47.4% of spousal primary caregiv-
ers being 75 years or older (Wol & Kasper, 2006). National surveys indicate a trend in
the United States of care recipients being older and more disabled, and more caregivers
acting as the primary source of care (an increase from 34.9% on 1989 to 52.8% in 1999)
without help from secondary caregivers (Wol & Kasper, 2006). Family and friends now
provide more than 80% of all long-term care services in the country.
Impact of Unhealthy Caregiving Transitions on Caregiver
Caregiving has documented negative consequences for the caregiver’s physical and
emotional health. Caregiving-related stress in a chronically ill spouse results in a 63%
higher mortality rate than their noncaregiving peers (Schulz & Beach, 1999). Stress
from caring for an older adult with dementia has been shown to impact the caregiver’s
immune system for up to 3 years after their caregiving ends (Kiecolt-Glaser et al., 2003).
Spouse caregivers who provide heavy care (36 or more hours per week) are six times
more likely than noncaregivers to experience symptoms of depression or anxiety; for
child caregivers, the rate is twice as high (Cannuscio et al., 2002). In addition to mental
Family Caregiving 471
health morbidity, family caregivers also experience physical health deterioration. Family
caregivers have chronic conditions at more than twice the rate of noncaregivers (NAC
& AARP, 2004; USDHHS, 1998). Family caregivers experiencing extreme stress have
also been shown to age prematurely. It is estimated that this stress can take as much as
10 years o a family caregiver’s life (Arno, 2006).
BACKGROUND AND STATEMENT OF PROBLEM
Definitions
Family Caregiving
Family caregiving is broadly dened and refers to a broad range of unpaid care pro-
vided in response to illness or functional impairment to a chronically ill or functionally
impaired older family member, partner, friend, or neighbor that exceeds the support
usually provided in family relationships (Arno, 2006).
Caregiving Roles
Caregiving roles can be classied into a hierarchy according to who takes on the bulk of
responsibilities versus only intermittent supportive assistance. Primary caregivers tend
to provide most of the everyday aspects of care, whereas secondary caregivers help out as
needed to ll the gaps (Cantor & Little, 1985; Pening, 1990; Tennstedt, McKinlay, &
Sullivan, 1989). Among caregivers who live with their care recipients, spouses account
for the bulk of primary caregivers, whereas adult children are more likely to be second-
ary caregivers. e range of the family caregiving role includes protective caregiving like
“keeping an eye on” an older adult who is currently independent but at risk, to full time,
round-the-clock care for a severely impaired family member. Health care providers may
fail to assess the full scope of the family caregiving role if they associate family caregiving
only with the performance of tasks.
Caregiver Role Transition
Caregiver role acquisition is a family role transition that occurs through situated interac-
tion as part of a role-making process (Schumacher, 2005). is is the process of taking
on the caregiving role at the beginning of caregiving or when a signicant change in the
caregiving context occurs. Role transitions occur when a role is added to or deleted from
the role set of a person—or when the behavioral expectations for an established role
change signicantly. Role transitions involve changes in the behavior expectations along
with the acquisition of new knowledge and skills. Examples of major role transitions are
becoming a new parent, getting a divorce, and changing careers. e acquisition of the
family caregiving role is a specic type of role transition that occurs within families in
response to the changes in health of family member who has suered a decline in their
self-care ability or health.
Indicators of Healthy Caregiver Role Transitions
e broad categories of indicators of healthy transitions include subjective well- being,
role mastery, and well-being of relationships. ese are the subjective, behavioral,
and interpersonal parameters of health most likely to be associated with healthy role
472 Evidence-Based Geriatric Nursing Protocols for Best Practice
transitions (Schumacher, 2005). Subjective well-being is dened as “subjective responses
to caregiving role transition” (Schumacher, 2005, p. 219). Subjective well-being includes
any pattern of subjective reactions that arise from assuming the caregiver role within the
boundary of the caregiving situation. Examples of some of the more important possible
threats to subjective well-being could include role strain and depression. Role mastery
is associated with accomplishment of skilled role performance and comfort with the
behavior required in a new health-related care situation. Examples of threats to role
mastery, which indicate a vulnerability and risk of unhealthy transitions are role insuf-
ciency and lack of preparedness. Well-being of relationships refers to the quality of the
relationship between the caregiver and older adult. Examples of threats to well-being of
relationships are family conict or a poor quality of relationship with the care receiver.
Family Caregiving Activities
Family caregiving activities include assistance with day-to-day activities, illness-related care,
care management, and invisible aspects of care. Day-to-day activities include personal care
activities (bathing, eating, dressing, mobility, transferring from bed to chair, and using the
toilet) and instrumental activities of daily living (IADL; meal preparation, grocery shop-
ping, making telephone calls, and money management; NAC & AARP, 2004; Walker,
Pratt, & Eddy, 1995). Illness-related activities include managing symptoms, coping with
illness behaviors, carrying out treatments, and performing medical or nursing procedures
that include an array of medical technologies (Smith, 1994). Care management activi-
ties include accessing resources, communicating with and navigating the health care and
social services systems, and acting as an advocate (Schumacher, Stewart, Archbold, Dodd,
& Dibble, 2000). Invisible aspects of care are protective actions the caregiver takes to
ensure the older adults’ safety and well-being without their knowledge (Bowers, 1987).
Caregiver Assessment
Caregiver assessment refers to an ongoing iterative process of gathering information
that describes a family caregiving situation and identies the particular issues, needs,
resources, and strengths of the family caregiver.
Risk Factors for Unhealthy Caregiving Transitions
Gender
Female caregivers are more likely to provide a higher level of care than men, which is
dened as helping with at least two activities of daily living (ADL) and providing more
than 40 care hours per week. Male caregivers are more likely to provide care at the lowest
level, which is dened as no ADL and devoting very few hours of care per week (NAC &
AARP, 2004; Pinquart & Sörensen, 2006). A number of studies have found that female
caregivers are more likely than males to suer from anxiety, depression, and other symp-
toms associated with emotional stress caused by caregiving (Mahoney, Regan, Katona,
& Livingston, 2005; Yee & Schulz, 2000); lower levels of physical health and subjective
well-being than caregiving men (Pinquart & Sörensen, 2006); and are at higher risk for
adverse outcomes (Schulz, Martire, & Klinger, 2005). In the pooled analysis from the
Resources for Enhancing Alzheimer’s Caregiver Health (REACH) trials, females had
higher initial levels of burden and depression (Gitlin et al., 2003).
Family Caregiving 473
Ethnicity
Rates of caregiving vary somewhat by ethnicity. Among the U.S. adult population older
than age 18, 17% of White and 15% of African American families are providing infor-
mal care, whereas a slightly lower percentage of Asian Americans (14%) and Hispanic
Americans (13%) are engaged in caregiving for persons older than the age of 50 (NAC
& AARP, 2004). However, in another national survey, which looked only at people
older than 70 years old, 44% of Latinos were found to receive informal home care
compared with 34% of African Americans and 25% of non-Hispanic Whites (Weiss,
González, Kabeto, & Langa, 2005). Ethnic dierences are also found regarding the
care recipient. Among people aged older than 70 years who require care, Whites are the
most likely to receive help from their spouses; Hispanics are the most likely to receive
help from their adult children; and African Americans are the most likely to receive help
from a nonfamily member (National Academy on an Aging Society, 2000).
Studies show that ethnic minority caregivers provide more care (Pinquart & Sörenson,
2005) and report worse physical health than White caregivers (Dilworth-Anderson,
Williams, & Gibson, 2002; Pinquart & Sörenson, 2005). African American caregivers
experience less stress and depression and get more rewards related to caregiving when
compared with White caregivers (Cuellar, 2002; Dilworth-Anderson et al., 2002; Gitlin
et al., 2003; Haley et al., 2004; Pinquart & Sörenson, 2005). However, Hispanic and
Asian American caregivers exhibit more depression than White caregivers (Gitlin et al.,
2003; Pinquart & Sörenson, 2005). In addition, formal services are rarely used by ethnic
minorities, which puts them at further risk for negative outcomes (Dilworth-Anderson et
al., 2002; Pinquart & Sörenson, 2005). A meta-analysis of three qualitative studies exam-
ined African American, Chinese, and Latino caregiver impressions of their clinical encoun-
ters around their care receiver’s diagnosis of Alzheimer’s disease (Mahoney, Cloutterbuck,
Neary, & Zhan, 2005). e primary issues identied in the analysis by Mahoney et al.
(2005) were disrespect for concerns as noted by African American caregivers, stigmatiza-
tion of persons with dementia as noted by Chinese caregivers, and fear that home care
would not be supported, were among Latino caregivers. ese ndings indicate a need for
greater culturally sensitive communications from health care providers.
Income and Educational Level
Low income is also related to being an ethnic minority and being “non-White,” and the
latter are risk factors for poorer health outcomes. Persons who become caregivers may
be more likely to have incomes below the poverty level and be in poorer health, inde-
pendent of caregiving (Vitaliano, Zhang, & Scanlan, 2003). Usually, educational level
has been combined with income in most caregiving studies, so there is a lack of data
on this variable. One study (Buckwalter et al., 1999) reported that caregivers who were
less educated tended to report slightly more depression than those who were better edu-
cated. is is consistent with the ndings from the REACH trial meta-analysis (Gitlin
et al., 2003). In the meta-analysis completed by Schulz et al (2005), caregivers with low
incomes and low levels of education were more at risk for adverse outcomes.
Relationship (Spouse, Nonspouse)
Past research conducted primarily among non-Hispanic White samples has shown that
caregiving outcomes dier between nonspouse (who are mostly adult children) and
474 Evidence-Based Geriatric Nursing Protocols for Best Practice
spouse caregivers (Pinquart & Sörensen, 2004). In some literature reviews, authors
noted that spousal caregivers have reported higher levels of depression than nonspouses
(Gitlin, Corcoran, Winter, Boyce, & Hauck, 2001; Pruchno & Resch, 1989); interven-
tion study found spouses reported less “upset” with the care receiver’s behavior than
nonspouses, who showed no decrease in “upset.” In a meta-analysis of caregiving stud-
ies, spousal caregivers beneted less from existing interventions than adult children
(Sörensen, Pinquart, & Duberstein, 2002).
Quality of Caregiver–Care Receiver Relationship
Disruption in the caregiver and care receiver relationship (Croog, Burleson, Sudilovsky,
& Baume, 2006; Flannery, 2002) and/or a poor quality of relationship (Archbold,
Stewart, Greenlick, & Harvath, 1990; Archbold, Stewart, Greenlick, & Harvath, 1992)
can make caregiving seem more dicult even if the objective caregiving situation (e.g.,
hours devoted to caregiving, number of tasks performed) does not seem to be too
demanding. Archbold et al. (1992) reported that the deleterious eects of lack of pre-
paredness on caregiver strain faded after 9 months; however, a poor relationship with the
care receiver remained strongly related to caregiver strain. Reporting a poorer quality of
relationship with the care receiver was associated with a 23.5% prevalence of anxiety and
10% prevalence of depression in Mahoney and colleagues (2005) descriptive study.
Lack of Preparedness
Most caregivers are not prepared for the many responsibilities they face and receive
no formal instruction in caregiving activities (NAC & AARP, 2004). According to a
national opinion survey, Attitudes and Beliefs About Caregiving in the United States,
58% of respondents say they are only somewhat or not at all prepared to handle health
insurance matters for an adult family member or friend, whereas 56% say they feel
unprepared to assist with medications. Moreover, 64% worry about selling the home of
a loved one and moving that person to another location or setting up a will or trust for
that person (ORC, 2005). Stewart, Archbold, Harvath, and Nkongho, (1993) reported
that although health care professionals were a caregiver’s main source of information
on providing physical care, the caregiver received no preparation on how to care for
the patient emotionally or deal with the stresses of caregiving. Lack of preparedness can
greatly increase the caregiver’s perceptions of strain, especially during times of transition
from hospital to home (Archbold et al., 1990; Archbold et al., 1992).
Baseline Levels of Burden and Depressive Scores
In a meta-analysis of 84 caregiving studies, Pinquart and Sörensen (2003) found that
caregivers have higher levels of stress and depression as well as lower levels of subjective
well-being, physical health, and self-ecacy than noncaregivers. e strongest nega-
tive eects of caregiving were observed for clinician-rated depression. Dierences in
perceived stress and depression between caregivers and noncaregivers were larger in
spouses than in adult children (Pinquart & Sörensen, 2003). Caregivers of care receivers
who have dementia (Pinquart & Sörensen, 2006) have more problems with symptom
management (Butler et al., 2005; Grande, Farquhar, Barclay, & Todd, 2004) and prob-
lematic communication (Tolson, Swan, & Knussen, 2002) and have also reported
increased burden, strain, and depression across studies.
Family Caregiving 475
Physical Health Problems
Vitaliano and colleagues’ (2003) quantitative review of 23 studies from North America,
Europe, and Australia examined relationships of caregiving with several health outcomes.
ey found that caregivers are at greater risk for health problems than are noncaregivers.
ese studies included 1,594 caregivers of persons with dementia and 1,478 noncare-
givers who were similar in age (mean 65.6 years old) and sex ratio (65% women, 35%
men). In this review, six physiological and ve self-reported categories were examined
that are indicators of illness risk and illness. e physiological categories included level
of stress hormones, antibodies, immune counts/functioning, and cardiovascular and
metabolic variables. Caregivers had a 23% higher level of stress hormones (adrenocor-
ticotropic hormone, catecholamines, cortisol, etc.) and a 15% lower level of antibodies
(Eipstein-Barr virus, herpes simplex, immunoglobulin G test) than did noncaregivers.
Comorbid medical illnesses are important because many caregivers are middle aged
to older adults, and they may be ill before they become caregivers. Interestingly, the
relationship between caregiver status and physiological risk was stronger for men than
women (Vitaliano et al., 2003).
ASSESSMENT OF THE PROBLEM
Although systematic assessment of the patient is a routine element of clinical practice,
assessment of the family caregiver is rarely carried out to determine what help the care-
giver may need. Eective intervention strategies for caregivers should be based on an
accurate assessment of caregiver risk and strengths. According to a broad consensus of
researchers and family caregiving organizations (Stewart et al., 1993), assessing the care-
giver should involve addressing the following topics. ese are applicable across settings
(e.g., home, hospital) but may not need to be measured in every assessment. Specic
topics may dier for the following:
n Initial assessments compared to reassessments (the latter focus on what has
changed over time)
n New versus continuing care situations
n An acute episode prompting a change in caregiving versus an ongoing need type
of setting and focus of services (Family Caregiver Alliance [FCA], 2006)
Caregiving Context
e caregiving context includes the background on the caregiver and the caregiv-
ing situation. e caregiver’s relationship to the care recipient (spouse, nonspouse)
is important because spouse and nonspouse caregivers have dierent risks and needs
(Gitlin et al., 2003; Sörensen et al., 2002). e caregiver’s various roles and responsi-
bilities can either take away from or enhance their ability to provide care. For example,
working caregivers may have to develop strategies to juggle family and work responsi-
bilities, so we need to know what their employment status is (work/home/volunteer;
Pinquart & Sörensen, 2006). e duration of caregiving (Sörensen et al., 2002) can
give the clinician clues about how new caregiving is for the caregiver, or alert the clini-
cian to possibility of caregiver exhaustion with the role. Questions about household
status such as how many people are in the home (Pinquart & Sörensen, 2006) and
the existence and involvement of extended family and social support (Pinquart &
476 Evidence-Based Geriatric Nursing Protocols for Best Practice
Sörensen, 2006) can give the clinician clues about how much support the caregiver
has readily available. Depending upon the type of impairment of the care receiver,
the physical environment of the home, or facility where care takes place can be very
important (Vitaliano et al., 2003). Determine what the caregiver’s nancial status
is—for example, are they getting by, or are they short of funds to provide for everyday
necessities (Vitaliano et al., 2003)? Ask about potential resources that the caregiver
could choose to use and list these (Pinquart & Sörensen, 2006). Explore the family’s
cultural background (Dilworth-Anderson et al., 2002) and look for clues on how to
use this as a resource.
Caregiver’s Perception of Recipient’s Health and Functional Status
List activities the care receiver needs help with; include both ADL and IADL (Pinquart
& Sörensen, 2003; Pinquart & Sörensen, 2006). Determine if there is any cognitive
impairment of the care recipient. If the answer to this question is “yes,” ask if there
are any behavioral problems (Gitlin et al., 2003; Sörensen et al., 2002). e presence
of mobility problems can also make caregiving more dicult—assess this by simply
asking if the care recipient has problems with getting around (Archbold et al., 1990; see
Chapter 6, Assessment of Physical Function).
Lack of Caregiver Preparedness
Does caregiver have the skills, abilities, or knowledge to provide care recipient with
needed care? To assess preparedness, use questions from the caregiving preparedness
scale (see http://consultgerirn.org/resources). e Preparedness for Caregiving Scale
(PCGS) was developed by Archbold and colleagues (1990, 1993). e concept of pre-
paredness was derived from role theory, in which socialization to a role is assumed to
be important for role enactment and performance. e questions prompt caregivers to
rate how well prepared they think they are for caregiving in four perspectives of domain-
specic preparedness: physical needs, emotional needs, resources, and stress. e clini-
cian can interview the caregiver or ask the caregiver to complete the scale like a survey.
e responses to the scale items can also be tallied and averaged for an overall score.
If pressed for time, the clinician can simply ask, overall, how well prepared the caregiver
thinks he or she is to care for a family member, and then follow this with more specic
questions if the response indicates preparedness is low. e PCGS was evaluated in a
longitudinal correlational study of family caregivers (N 5 103) of older patients with
chronic diseases (Archbold et al., 1990; Archbold et al., 1992). e scale has ve Likert-
type items with possible responses ranging from 1 (not at all prepared) to 4 (very well
prepared). Overall scores are computed by averaging responses to the ve items. Scores
range from 1.00 to 4.00—the lowest score correlating with least preparedness. Archbold
and colleagues (1992) reported internal reliability (Cronbach’s alpha) of 0.72 at 6 weeks
and 0.71 at the 9-month interview.
Quality of Family Relationships
e caregiver’s perception of the quality of the relationship with the care receiver is a
key predictor of the presence or lack of strain from caregiving (Archbold et al., 1990).
e quality of the relationship can be assessed using the Mutuality scale (Messecar,
Family Caregiving 477
Parker-Walsch, & Lindauer, in press) developed by Archbold and colleagues (1990,
1992). Mutuality is dened as the caregiver’s perceived quality of the relationship with
the care receiver. Questions include “How close do you feel to him or her?”and “How
much does he or she express feelings of appreciation for you and the things you do?”
An overall score can be obtained by calculating the mean across all items—or the ques-
tions can be used in an open-ended interview format where the clinician then probes for
more information and history about the relationship. is scale can also be completed
via self-administration and then reviewed by the clinician with the caregiver (interview
the caregiver apart from the care receiver). For this scale, there is no item that asks about
the relationship overall; instead, the items explore several key features of the relation-
ship such as conict, shared positive past memories, felt positive regard, and positive
reciprocity between the caregiver and care receiver. e questions open the door for the
clinician to probe in a gentle way the quality of the relationship. Caregivers rate how
they feel about the care recipient with possible responses ranging from 0 (not at all)
to 4 (a great deal). e caregiver’s mutuality score is computed by taking the average
of the scores on the 15 items. Internal reliability and consistency (Cronbach’s alpha)
of the scale was 0.91 at both 6 weeks and 9 months from discharge from the hospital
(Archbold et al., 1990).
Indicators of Problems With Quality of Care
Indicators of problems with the quality of care can include the following: evidence
of an unhealthy environment, inappropriate management of nances, and demon-
stration of a lack of respect for older adult. e nurse’s observations can be guided
by e Elder Mistreatment Assessment (Fulmer, 2002), which helps the nurse iden-
tify elder abuse and neglect issues (see Elder Mistreatment Assessment instrument at
http:// consultgerirn.org/resources). is assessment instrument comprised seven sec-
tions that reviews signs, symptoms, and subjective complaints of elder abuse, neglect,
exploitation, and abandonment (Fulmer, Paveza, Abraham, & Fairchild, 2000;
Fulmer, Street, & Carr, 1984; Fulmer & Wetle, 1986). ere is no “score,” but the
older adult should be referred to social services if there is evidence of mistreatment,
a complaint by the older adult, or if there is high risk or probable abuse, neglect,
exploitation, or abandonment of the older adult. Please also refer to Chapter 27,
Mistreatment Detection.
Caregiver’s Physical and Mental Health Status
e caregiver’s perception of their own health (Pinquart & Sörensen, 2006) is one of
the most reliable indicators of a physical health problem. Depression or other emo-
tional distress (e.g., anxiety) can be assessed using the Center for Epidemiological
Studies-Depression Scale (CED-S; see http://www.chcr.brown.edu/pcoc/cesdscale.pdf;
Pinquart & Sörensen, 2006; Sörensen et al., 2002). e CES–D was initially designed as
a screen for the community dwelling at risk for developing major depressive symptoma-
tology. It has been used widely in intervention studies with family caregivers where it has
been self-administered. e Brown University Center for Gerontology and Healthcare
Research created a set of end-of-life care toolkit instruments, which are available for use
on their site at no charge. For each of the 20 items, participants rate its frequency of
occurrence during the past week on a 4-point scale from 0 (rarely) to 3 (most of the time).
478 Evidence-Based Geriatric Nursing Protocols for Best Practice
Scores range from 0 to 60, with a higher score indicating the presence of a greater num-
ber and frequency of depressive symptoms. A score of 16 or higher has been identied
as discriminatory between groups with clinically relevant and nonrelevant depressive
symptoms (Fulmer et al., 2000; Radlo, 1977).
Burden or strain can be assessed using the modied Caregiver Strain Index
(CSI; see http://consultgerirn.org/resources Family Caregiving; Sullivan, 2002).
Pre-existing burden or strain places caregivers at greater risk and may prevent
them from beneting from interventions (Schulz & Beach, 1999; Sullivan, 2002;
Vitaliano et al., 2003). e modied CSI is a tool that can be used to quickly
identify families with potential caregiving concerns. It is a 13-question tool that
measures strain related to care provision. ere is at least one item for each of
the following major domains: employment, nancial, physical, social, and time.
Positive responses to seven or more items on the index indicate a greater level of
strain. Internal consistency reliability is high (Cronbach’s a 5 0.86) and construct
validity is supported by correlations with the physical and emotional health of the
caregiver and with subjective views of the caregiving situation. A positive screen
(7 or more items positive) on the CSI indicates a need for more in-depth assessment
to facilitate appropriate intervention.
Rewards of Caregiving
Although early family caregiving research focused almost exclusively on negative out-
comes of caregiving, clearly, there are many positive aspects of providing care. Spouses
can be drawn closer together by caregiving, which can act as an expression of love.
Child caregivers can feel a sense of accomplishment from helping their adult parents.
Caregivers should be encouraged to explore and list their perceived benets of caregiving
(Archbold et al., 1995). ese can include the satisfaction of helping family member,
developing new skills and competencies, and/or improved family relationships.
Self-Care Activities for Caregiver
Self-care activities can include things like setting aside time to exercise, getting time for
oneself, and obtaining respite. Even if the caregiver does not use this strategy, ask them
to think about strategies that would work for them. Caregivers need to be reminded that
self-care is not a luxury; it is a necessity. At a minimum, caregivers need to learn how to
put themselves rst, manage stress, socialize, and get help.
INTERVENTIONS AND CARE STATEGIES
Definitions
Psychoeducational Interventions
Psychoeducational interventions involve a structured program geared toward providing
information about the care receiver’s disease process and about resources and services, and
training caregivers to respond eectively to disease-related problems, such as memory
and behavior problems in patients with dementia or depression and anger in patients
with cancer. Use of lectures, group discussions, and written materials are always led by
a trained leader. Support may be part of a psychoeducational group, but it is secondary
to the educational content.
Family Caregiving 479
Supportive Interventions
is category subsumes both professionally led and peer-led unstructured support
groups focused on building rapport among participants and creating a space in which
to discuss problems, successes, and feelings regarding caregiving.
Respite or Adult Day Care
Respite care is either in-home or site-specic supervision, assistance with ADL, or skilled
nursing care designed to give the caregiver time o.
Psychotherapy
is type of intervention involves a therapeutic relationship between the caregiver and
a trained professional. Most psychotherapeutic interventions with caregivers follow a
cognitive behavioral approach.
Interventions to Improve Care Receiver Competence
ese interventions include memory clinics for patients with dementia and activity
therapy programs designed to improve aect and everyday competence.
Multicomponent Interventions
Interventions in this group included various combinations of educational interventions,
support, psychotherapy, and respite in Sorensen et al.’s (2002) meta-analysis. Individual
studies included after the 2002 meta-analysis include nursing management and inter-
disciplinary care interventions and REACH II.
Overview
Past reviews of caregiver interventions, such as support groups, individual counseling,
and education conrm that there is no single, easily implemented, and consistently
eective method for eliminating the stresses and/or strain of being a caregiver (Knight,
Lutzky, & Macofsky-Urban, 1993; Toseland & Rossiter, 1989). Sorensen and colleagues
(2002) performed a more recent meta-analysis on the eects of a second generation of
78 caregiver intervention studies. e most consistent signicant improvements in all
outcome domains (burden, depression, well-being, ability and knowledge, care receiver
symptoms) assessed in the meta-analysis resulted from psychotherapy and caregiver
psychoeducational interventions aimed at improving caregiver knowledge and abilities.
Multicomponent interventions, which combined features of psychotherapy and knowl-
edge or skill building, had the largest eect on burden and in addition, were eective for
improving well-being, ability, and knowledge. e eects of dierent types of interven-
tions on selected indicators of unhealthy caregiver transitions from the meta-analysis
and studies completed since 2002 are presented in Table 1.
Other studies of psychotherapy and psychoeducational interventions t the same
pattern of results (Akkerman & Ostwald, 2004; Burns et al., 2005; Coon, ompson,
Steen, Sorocco, & Gallagher-ompson, 2003; Hébert et al., 2003; Hepburn et al.,
2005; Mittelman, Roth, Coon, & Haley, 2004; Mittelman, Roth, Haley, & Zarit,
2004). All of these interventions address key negative aspects of caregiving: being
480 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 24.1
Effects of Different Types of Interventions on Indicators of
Unhealthy Caregiver Transitions
Type of Intervention Burden or Strain
Depression or Distress
or Lack of Well-being Lack of Preparedness
Psychoeducation Significant effect
(Sörensen et al., 2002)
Significant effect
(Sörensen et al., 2002)
Significant effect
(Sörensen et al., 2002)
Skill-building Decreased burden—
6 studies (Acton &
Winter, 2002)
Decreased
depression—6 studies
(Acton & Winter, 2002)
Increased
knowledge—9 studies
(Acton & Winter, 2002)
Significant reduction in
depressive symptoms
(Gallagher-Thompson
et al., 2003)
14% improved reaction
to CR symptoms
(Hébert et al., 2003)
Decreased bother,
anxiety, depression
(Mahoney et al., 2003)
Decreased depression
(Coon et al., 2003)
Decreased distress
(Hepburn et al., 2005)
Supportive
Interventions
Significant effect
(Sörensen et al., 2002)
Significant effect
(Sörensen et al., 2002)
Psychotherapy Significant effect
(Sörensen et al., 2002)
Significant effect
(Sörensen et al., 2002)
Significant effect
(Sörensen et al., 2002)
Decreased objective
burden
Decreased anxiety
(Akkerman &
Ostwald, 2004)
Some improved reaction
to CR symptoms (Burns
et al., 2005)
Respite Significant effect
(Sörensen et al., 2002)
Significant effect
(Sörensen et al., 2002)
Decreased
depression—3 studies
(Acton & Winter, 2002)
Focus on CR Significant effect
(Sörensen et al., 2002)
Multicompent—
added to this
category:
Large significant effect
(Sörensen et al., 2002)
Improved distress and
depression (Bass, Clark,
Looman, McCarthy, &
Eckert, 2003; Callahan
et al., 2006)
Significant effect
(Sörensen et al., 2002)
Nursing and
interdisciplinary
care management—
includes hospital
or rehabilitation
at-home and
primary care
Improved carer strain
(Burton & Gibbon,
2005)
Less burden (Crotty,
Whitehead, Miller, &
Gray 2003)
Decreased burden/
strain—2 studies (Acton
& Winter, 2002)
Less strain (Harris,
Ashton, Broad,
Connolly, &
Richmond, 2005)
(continued)
Family Caregiving 481
TABLE 24.1
Effects of Different Types of Interventions on Indicators of
Unhealthy Caregiver Transitions (continued)
Type of Intervention Burden or Strain
Depression or Distress
or Lack of Well-being Lack of Preparedness
REACH interventions
overall decreased bur-
den (Gitlin et al., 2003)
More strain after
intervention
(Wade, 2003)
Decreased burden
(Kalra et al., 2004)
Significant decrease in
depressive symptoms
(Eisdorfer et al., 2003)
Burden and strain were
responsive to interven-
tion (Schulz et al., 2005)
Decreased depression,
distress, anxiety—
4 studies (Acton &
Winter, 2002)
Decreased anxiety
and depression
(Kalra et al., 2004)
Decreased depression
(Mittelman, Roth, Coon,
et al., 2004)
Decreased reaction
ratings (Mittelman, Roth,
Haley, et al., 2004)
Clinically significant
decreases in depression
and anxiety (Schulz et
al., 2005)
Significant effect
(Sörensen et al., 2002)
Higher role rewards
(Li et al., 2003)
Caregiver affect
improved (Gitlin
et al., 2005)
Well-being worse in
control group (Burns
et al., 2003)
Focus on physical
or emotional health
of CG
Decreased
psychological distress
(King, Baumann,
O’Sullivan, Wilcox, &
Castro, 2002)
Decreased depression
& anxiety (Waelde,
Thompson, & Gallagher-
Thompson, 2004)
Note. CG 5 caregiver; CR 5 care receiver; REACH 5 Resources for Enhancing Alzheimer’s Caregiver Health.
482 Evidence-Based Geriatric Nursing Protocols for Best Practice
overwhelmed with the physical demands of care, feeling isolated, not having time for
oneself, having diculties with the care recipient’s behavior, and dealing with one’s own
negative responses.
ere are several characteristics across interventions that seem to have a moderating
eect on caregiving outcomes. Focusing the caregiver training exclusively on the care
receiver to alter their symptoms has almost no eect on the caregiver (Sörensen et al.,
2002). In the Sorensen (2002) meta-analysis, group interventions were less eective at
improving caregiver burden than individual and mixed interventions, which is consis-
tent with Knight et al. (1993) but inconsistent with the meta-analysis performed by
Yin, Zhou, and Bashford (2002). Length of an intervention appears to be important in
alleviating caregiver depression and care receiver symptoms. Caregivers do less well with
shorter interventions regarding depression because they lose the supportive aspects of
prolonged contact with a group or a professional before they can benet.
Characteristics of the caregiver are also associated with intervention eectiveness.
Some caregivers benet less from interventions than others do. For example, Sörensen
(2002) found that spouse caregivers beneted less from interventions than did adult
children. Table 2 presents caregiver characteristics associated with various indicators of
unhealthy caregiver transitions. .
Interventions With Little Effect
Some intervention approaches have been consistently disappointing, showing either no sig-
nicant eects or limited responses. In Lee and Cameron’s (2004) update of the Cochrane
database review, re-analysis of three trials of respite care found no signicant eects of
respite on any outcome variable. Interventions focused on medication management of the
care receiver’s dementing condition (Lingler, Martire, & Schulz, 2005) and/or targeted to
managing problematic behavior (Livingston, Johnston, Katona, Paton, & Lyketsos, 2005)
were similarly disappointing. A meta-analysis of habit training for the management of uri-
nary incontinence interventions showed that not only were there no signicant dierences
in incontinence between the intervention and control groups, but that caregivers found
the intervention labor intensive (Ostaszkiewicz, Johnston, & Roe, 2004).
In Acton and Winter’s (2002) meta-analysis of dementia, caregiving studies; small,
diverse samples; lack of intervention specicity; diversity in the length, duration, and
intensity of the intervention strategies; and problematic outcome measures led to nonsig-
nicant results for many tested interventions (Cooke, McNally, Mulligan, Harrison, &
Newman, 2001). ey also reported that two thirds of the interventions they examined
did not show any improvement in any outcome measures. eir analysis was hampered
by lack of detailed description of the interventions in the studies they examined. Study
limitations have also been a factor leading to disappointing results for some innovative
caregiving interventions for caregivers of care receivers with other long-term, debili-
tating illnesses. For example, interventions designed to teach arthritis management as
a couple (Martire et al., 2003), to decrease the gap between caregiver’s expectations
and care receiver’s actual functional abilities with skill-building and nurse-coached pain
management, all had disappointing results because of either small sample sizes or the
complexity of the problems they were designed to address (Martin-Cook, Davis, Hynan,
& Weiner, 2005; Schumacher et al., 2002). According to Price, Hermans, and Grimley
Evans (2000) modication interventions for wandering have never been adequately
tested because of the many aws identied in the existing published research; outcome
Family Caregiving 483
TABLE 24.2
Effects of Different Types of Caregiver Characteristics on Indicators of
Unhealthy Caregiver Transitions
Characteristics of
Caregiving Situation Burden
Depression or Lack of
Well-being Lack of Preparedness
CR has dementia Less effective
(Sörensen et al., 2002)
Less effective (Sörensen
et al., 2002)
Less effective
(Sörensen et al., 2002)
Adult child CGs Greater improvement
(Sörensen et al., 2002)
Greater improvement
(Sörensen et al., 2002)
Greater improvement
(Sörensen et al., 2002)
Nonspouses did better
(Gitlin et al., 2003)
Spouse CGs Smaller improvement
(Sörensen et al., 2002)
Smaller improvement
(Sörensen et al., 2002)
Smaller improvement
(Sörensen et al., 2002)
Wives with low mastery
and high anxiety
benefited the most
(Mahoney et al., 2003)
Cuban husbands
improved more on
depressive symptoms
(Eisdorfer et al., 2003)
Older CGs Greater improvement
(Sörensen et al., 2002)
No effects (Sörensen
et al., 2002)
Greater improvement
(Sörensen et al., 2002)
Higher risk for (Schulz
et al., 2005)
Higher risk for (Schulz
et al., 2005)
Greater improvement
well-being (Sörensen
et al., 2002)
Female CGs Greater improvement
(Sörensen et al., 2002)
Females benefit more
(Gallagher-Thompson
et al., 2003)
Greater improvement
(Sörensen et al., 2002)
Better improvement
(Gitlin et al., 2003)
Cuban daughters
improved more on
depressive symptoms
(Eisdorfer et al., 2003)
Higher risk for (Schulz
et al., 2005)
Higher risk for (Schulz
et al., 2005)
Ethnicity Sorensen et al.
(Sörensen et al., 2002)
Latinos benefit as much
(Eisdorfer et al., 2003)
Sorensen et al
(Sörensen et al., 2002)
Cuban husbands and
daughters improved
more on depressive
symptoms (Eisdorfer
et al., 2003)
Hispanics did better
(Gitlin et al., 2003)
Lower education Better improvement
(Gitlin et al., 2003)
Better improvement
(Gitlin et al., 2003)
Higher risk for (Schulz
et al., 2005)
Higher risk for (Schulz
et al., 2005)
Note. CR 5 care receiver; CG 5 caregiver.
484 Evidence-Based Geriatric Nursing Protocols for Best Practice
measurement has also been problematic. More distal outcomes, such as depression, per-
ceived stress, caregiver strain, and self-ecacy that are less directly related to the actual
intervention are less likely to change signicantly (Bourgeois, Schulz, Burgio, & Beach,
2002; Burgio, Stevens, Guy, Roth, & Haley, 2003) than outcomes that are more specic
to the intervention (Hebert et al., 2003).
Caregivers caring for care receivers who have conditions that worsen substantially
over time (dementia, Parkinson’s disease, stroke) have reported either less improvement,
no improvement, or increased strain after intervention (Sörensen et al., 2002; Forster et
al., 2001; Wright, Litaker, Laraia, & DeAndrade, 2001). Across many studies, Sörensen
et al. (2002) reported that interventions with caregivers of dementia patients are less
successful than for other caregivers. ey also noted that if levels of caregiving are rela-
tively high and cannot be reduced, as is the case for dementia caregivers, then burden
and depression are less amenable to change as well. A multidisciplinary rehabilitation
program for patients with Parkinson’s disease resulted in no improvement in depression
for caregivers after treatment (Trend, Kaye, Gage, Owen, & Wade, 2002). A meta-
analysis of hospital-at-home care for patients with stroke reported no evidence from
clinical trials to support a radical shift in the care of patients with acute stroke from
hospital-based care (Langhorne et al., 2000). Individual studies that examined other
psychoeducational and/or support and counseling interventions for stroke caregivers
(albeit with relatively small samples) found no signicant changes between the interven-
tion and control groups (Clark, Rubenack, & Winsor, 2003; Gräsel, Biehler, Schimdt,
& Schupp, 2005; Larson et al., 2005). Only an intensive, multicomponent skills train-
ing intervention signicantly decreased burden anxiety and depression for this category
of caregivers (Kalra et al., 2004). A number of family-based and symptom manage-
ment interventions for patients with cancer have also found no signicant interven-
tion eects (Hudson, Aranda, & Hayman-White, 2005; Kozachik et al., 2001; Kurtz,
Kurtz, Given, & Given, 2005; Northouse, Kershaw, Mood, & Schafenacker, 2005;
Wells, Hepworth, Murphy, Wujcik, & Johnson, 2003). In several of these studies, there
was a large dropout rate among the intervention participants because of the rapidly
deteriorating condition of the care receivers.
Resources for Enhancing Alzheimer’s Caregiver Health
e REACH project was designed to test promising interventions for enhancing fam-
ily caregiving for persons with dementia and overcome several of the limitations of
prior research (Schulz et al., 2003). More than 1,200 caregivers participated at six sites
nationwide. e sample was more diverse than most caregiving studies because of the
multisite design: participants were 56% White, 24% African American, and 19% Latino
(Wisniewski et al., 2003). Five sites participated in this trial nationwide. e following
ve interventions were tested:
1. A 12-month, computer-mediated automated interactive voice response intervention
designed to assist family caregivers managing care receivers with dementia (Mahoney,
Tarlow, & Jones, 2003).
2. A psychoeducational (skill-building) approach modeled after community-based support
groups tailored to be sensitive to ethnic groups tested (Gallagher-ompson et al., 2003).
3. A manual-guided care-recipient–focused behavior management skill training and
caregiver-focused, problem-solving training intervention tailored on cultural prefer-
ences of White and African American caregivers (Burgio et al., 2003).
Family Caregiving 485
4. A family therapy intervention designed to enhance communication between caregiv-
ers and other family members by identifying existing problems in communication
and facilitating changes in interaction patterns (Eisdorfer et al., 2003).
5. Two primary care interventions delivered more than a period of 24 months, which
included patient behavior management only and patient behavior management plus
caregiver stress and coping (Burns, Nichols, Martindale-Adams, Graney, & Lummus,
2003).
6. In-home occupational therapy visits designed to help families modify the environ-
ment to reduce caregiver burden (Gitlin, Hauck, Dennis, & Winter, 2005).
When the results from the REACH interventions were pooled, overall interventions
decreased burden signicantly compared to the control conditions (Gitlin et al., 2003).
Only the family therapy with computer technology intervention was eective for reduc-
ing depressive symptoms. Interventions were superior to control conditions on burden
for women and caregivers with lower education; on depression, Hispanics, nonspouses,
and caregivers with lower education had bigger responses.
REACH II followed up on REACH I, but unlike the rst set of studies, which
implemented a variety of interventions at six sites, REACH II implemented the same
two interventions at each of ve participating sites. Reach II specically implemented
a multicomponent intervention and tested new tools for assessing caregivers at risk for
adverse outcomes. Intervention participants received individual risk proles and the
REACH intervention through nine in-home and three telephone sessions for more
than 6 months. Caregivers receiving REACH II reported better self-rated health, sleep
quality, physical health, and emotional health than for those caregivers not receiving the
intervention. Findings supported using a structured, multicomponent skills training
intervention that targeted caregiver self-care behaviors as one of ve target areas. Over-
all, REACH II improved self-reported health status and decreased burden and bother
in racially and ethnically diverse caregivers of people with dementia (Elliott, Burgio,
& Decoster, 2010). An analysis of the ndings by sociodemographic groups indicated
that caregiver’s age and religious coping moderated the eects of the intervention for
Hispanics and Blacks. e older Hispanic and Black caregivers who received the inter-
vention reported a decrease in caregiver burden from baseline to follow-up (Lee, Czaja,
& Schulz, 2010). Findings from the REACH studies support use of multicomponent
interventions tailored for specic caregiving characteristics.
Aspects of Interventions That Improve Effectiveness
A key conclusion of the REACH trial and several of the meta-analyses (Gitlin et al.,
2003; Schulz et al., 2005; Sörensen et al., 2002) reviewed in this chapter was that
family caregiver interventions need to be multicomponent and tailored. Multicompo-
nent interventions have the potential to include a repertoire of various strategies that
target dierent aspects of the caregiving experience. In focus groups conducted during
a caregiving clinical trial, Farran and colleagues (2004) identied and catalogued the
information and skills caregivers reported they needed to respond to their own needs
or the caregiving process. is included care receiver issues such as managing dicult
behaviors, worrisome symptoms, personal care problems, and caregiver concerns such
as managing competing responsibilities and stressors, nding and using resources, and
handling their emotional and physical responses to care (Farran et al., 2004). Tailored
interventions are interventions that are crafted to match a specic target population,
486 Evidence-Based Geriatric Nursing Protocols for Best Practice
for example, spouse caregivers of patients with Alzheimer’s disease and their specic
caregiving issues and concerns identied through assessment (Archbold et al., 1995;
Horton-Deutsch, Farran, Choi, & Fogg, 2002). Interventions that are individualized or
tailored in combination with skill building demonstrated the best evidence of eective-
ness (Pusey & Richards, 2001). Among the psychoeducation interventions, some of the
most eective were predicated on a skills building approach (Gallagher-ompson et
al., 2003; Hepburn, Tornatore, Center, & Ostwald, 2001). Collaboration or a partner-
ship model with the caregiver is also a key component of making the tailoring process
more eective (Harvath et al., 1994). Programs that work collaboratively with care
receivers and their families and are more intensive and modied to the caregiver’s needs
are also more successful (Brodaty, Green, & Koschera, 2003).
Nursing Care Strategies
1. Identify content and skills needed to increase preparedness for caregiving.
Psychoeducational skill-building interventions include information about the care
needed by the care receiver and how to provide it, as well as coaching on how to
manage the caregiving role. Tasks associated with taking on the caregiving role
include dealing with change, juggling competing responsibilities and stressors, pro-
viding and managing care, nding and using resources, and managing the physical
and emotional responses to care (Acton & Winter, 2002; Farran, Loukissa, Perraud,
& Paun, 2003; Farran et al., 2004; Gitlin et al., 2003; Sörensen et al., 2002).
2. Form a partnership with the caregiver prior to generating strategies to address
issues and concerns.
e goal of this partnership is blending the nurse’s knowledge and expertise in health
care with the caregiver’s knowledge of the family member and the caregiving situ-
ation. Each party brings essential knowledge to the process of mutual negotiation
between the family and the nurse. Together, they develop ideas to address the issues
and concerns that are most salient for the caregiver and care receiver. One strategy
that can be used in the hospital setting is to interview the caregiver using the Family
Preferences Index developed by Li to assess family member’s preferences to partici-
pate in care while the older adult is hospitalized (Brodaty et al., 2003; Gitlin et al.,
2005; Harvath et al., 1994; Nolan, 2001).
3. Identify the caregiving issues and concerns on which the caregiver wants to work
and generate strategies.
Multiple strategies should be generated for each caregiving issue and concern. One of
the most important ndings from the review of literature on caregiving is that mul-
ticomponent interventions are superior to narrow, single-approach problem solving
(Acton & Winter, 2002; Gitlin et al., 2005; Sörensen et al., 2002). Several Level II
individual studies are presented in Table 1.
4. Assist the caregiver in identifying strengths in the caregiving situation.
Not all outcomes from caregiving are negative, and caregiving can be rewarding for
some caregivers who derive pride and satisfaction from the important role they are
lling. Incorporating pleasurable activities into the daily routine or incorporating
into some caregiving task something that is either fun or meaningful are ways of
enhancing caregiving. Even in really dicult situations, there may be some positive
benet derived such as satisfaction in meeting an important commitment and/or
recognition of personal growth (Archbold et al., 1995).
Family Caregiving 487
5. Assist the caregiver in nding and using resources.
Navigating the health care system is one of the most dicult skills caregivers have
to master (Archbold et al., 1995; Farran et al., 2004; Schumacher et al., 2002).
Caregivers rarely know how to translate a need that they have into a request for help
from the health care system. Learning how to speak to health care providers, how to
negotiate billing, and how to request help with transportation—all of these tasks can
be overwhelming. For some caregivers, Internet and other online sources of support
and information can be helpful.
6. Help caregivers identify and manage their physical and emotional responses to
caregiving.
We know that caregiving is sometimes associated with deterioration of the caregiver’s
health or signicant depression (Schulz et al., 2005). Generating strategies to take care
of the caregiver is just as important as the strategies for caring for the care recipient.
7. Use interdisciplinary approach when working with family caregivers.
Multicomponent interventions have the strongest record in terms of alleviating some
of the global negative consequences of caregiving. Involving a team of other health
professionals helps the nurse and family generate new ideas for strategies and brings
a fresh perspective to the idea-generating process (Acton & Winter, 2002; Farran et
al., 2003; Farran et al., 2004; Gitlin et al., 2003; Sorensen et al., 2002). Several Level
II studies are presented in Table 1.
Alison Walsh is the oldest of two children and the only one who still lives in the same
city as her widowed mother. She describes her relationship with her mother as very
strained and without much love—only discipline. Her mother, who recently suered
a stroke and is considered marginal for staying home by her neurologist, is expecting
that Alison will move in and take care of her. In fact, Alison’s mother has virtually no
resources for any other option. Alison’s mother is being discharged today from the
hospital. Alison says she would feel hard-pressed to take on all of the new care that
her mother will require, including having to do baths and do many, if not all, of her
ADL. In addition, she feels her relationship with her mother is so poor she does not
understand why she should have to be the caregiver at this time when she has her own
problems to deal with. Adding to her diculties, Alison has only one other sibling to
call on for help, and he lives more than 2,000 miles away in another city. Her husband
has health problems as well and his care takes considerable time.
As a child caregiver, Alison is at higher risk for depression or anxiety. e goal of inter-
vention with Alison will be to identify and address aspects of her caregiving situation ame-
nable to modication. e possible targets for intervention will vary from one caregiver to
another, and it is important that the approach be tailored. Addressing aspects of caregiving
that are strong predictors of unhealthy caregiver transitions such as a lack of preparedness,
stress and strain in the relationship, and overall burden can help the nurse tailor their
caregiver interventions. In this case study, only three parameters of assessment (lack of
preparedness, poor relationship quality, and need to nd rewards of caregiving) will be
addressed along with some suggested strategies for addressing the concerns indicated.
CASE STUDY
(continued)
488 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Outcomes Specific to Caregiving
e goal of the guideline is to reduce the likelihood of unhealthy transitions to the caregiv-
ing role by lowering caregiver strain, depression, and poor physical health for caregivers.
Indicators of problems with this include reports of depression and/or fatigue, increased
use of over-the-counter and prescription medications, increased use of health services,
neglect of own health, and substance abuse. Increased focus on the caregiver system as the
unit of service should increase the nurse’s condence in working with family caregivers.
Outcomes Specific to Patient
ese include improvement (where possible) in patient functional status, nutrition, and
hygiene. Improved symptom management for care recipients with signicant chronic
disease is also a desired outcome. is could include better pain management for care
recipients with cancer, improved glycemic control for care recipients with diabetes, and/
or diminished problematic behaviors for care recipients with dementia. e emotional
well-being of the care recipient should also be an outcome of interventions to aid the
caregiver. Decreased use of emergency services and increased use of formal care supports
are system outcomes we might expect.
First, in Alison’s case, caregivers may be reluctant to raise concerns about their
lack of preparedness to the nurse. ey may connect lack of preparedness with being
embarrassed about their own lack of understanding, or they may simply not know
what it is they do not know. For example, in Alison’s case, she may not realize that for-
mal resources could be taped to provide some of the personal care that she feels unable
or unwilling to perform. Exploration of her readiness to provide care will help Alison
raise her concerns so that they can be fully addressed.
Second, a lack of mutuality (the positive quality of the relationship between care-
giver and care recipient) is very predictive of future and sustained reported diculty
with caregiving. Alison has a dicult relationship with her mother now and a history
of a poor quality relationship from childhood. is puts her at risk for experiencing
more strain from caregiving. Alison is aware that her relationship with her mother is
dicult, but she may not realize how much this is adding to her strain. Alison will
need to think about strategies to get support and help to deal with her feelings.
ird, although in Alison’s situation there might not seem to be any rewards of
caregiving, it is important to ask about these anyway. ere are two very important
reasons for nurses exploring positive aspects of caregiving with the caregiver; caregiv-
ers want to talk about them, and these factors will be an important indicator of the
quality of care provided to the care recipient. Nurses need to encourage an increase in
positive aect (i.e., feelings such as gratitude, forgiveness, and the like) while at the
same time working on decreasing negative feelings like depression, anxiety, and guilt.
CASE STUDY (continued)
Family Caregiving 489
Protocol 24.1: Family Caregiving
I. GOAL: Identify viable strategies to monitor and support family caregivers.
II. OVERVIEW: Family caregivers provide more than 80% of the long-term
care for older adults in this country. Caregiving can be dicult, time-consuming
work added on top of job and other family responsibilities. If the caregiver suf-
fers negative consequences from their caregiving role and these are not mitigated,
increased morbidity and mortality may result for the caregiver. Not all outcomes
from caregiving are negative; there are many caregivers that report rewards from
caregiving.
III. BACKGROUND AND STATEMENT OF PROBLEM
A. Denitions
1. Family caregiving is broadly dened and refers to a broad range of unpaid
care provided in response to illness or functional impairment to a chroni-
cally ill or functionally impaired older family member, partner, friend, or
neighbor that exceeds the support usually provided in family relationships
(Schumacher, Beck, & Marren, 2006).
2. Caregiver role transitions: Caregiver role acquisition is a family role transition
that occurs through situated interaction as part of a role-making process.
is is the process of taking on the caregiving role at the beginning of care-
giving or when a signicant change in the caregiving context occurs. Role
transitions occur when a role is added to or deleted from the role set of a
person, or when the behavioral expectations for an established role change
signicantly (NAC & AARP, 2004).
3. Indicators of healthy caregiver role transitions: e broad categories of indi-
cators of healthy transitions include subjective well-being, role mastery, and
well-being of relationships. ese are the subjective, behavioral, and inter-
personal parameters of health most likely to be associated with healthy role
transitions (NAC & AARP, 2004).
4. Family caregiving activities include assistance with day-to-day activities,
illness-related care, care management, and invisible aspects of care. Day-
to-day activities include personal care activities (bathing, eating, dressing,
mobility, transferring from bed to chair, and using the toilet) and IADL
(meal preparation, grocery shopping, making telephone calls, and money
management; Walker et al., 1995). Illness-related activities include man-
aging symptoms, coping with illness behaviors, carrying out treatments,
and performing medical or nursing procedures that include an array of
medical technologies (Smith, 1994). Care management activities include
accessing resources, communicating with and navigating the health care
and social services systems, and acting as an advocate (Schumacher et al.,
2000). Invisible aspects of care are protective actions the caregiver takes
to ensure the older adults’ safety and well-being without their knowledge
(Bowers, 1987).
NURSING STANDARD OF PRACTICE
(continued)
490 Evidence-Based Geriatric Nursing Protocols for Best Practice
5. Caregiving roles can be classied into a hierarchy according to who takes on
the bulk of responsibilities versus only intermittent supportive assistance.
Primary caregivers tend to provide most of the everyday aspects of care,
whereas secondary caregivers help out as needed to ll the gaps (Cantor &
Little, 1985; Penning, 1990; Tennstedt et al., 1989). Among caregivers who
live with their care recipients, spouses account for the bulk of primary care-
givers, whereas adult children are more likely to be secondary caregivers.
e range of the family caregiving role includes protective caregiving like
“keeping an eye on” an older adult who is currently independent but at risk,
to full-time, round-the-clock care for a severely impaired family member.
Health care providers may fail to assess the full scope of the family care-
giving role if they associate family caregiving only with the performance
of tasks.
6. Caregiver assessment refers to an ongoing iterative process of gathering
information that describes a family caregiving situation and identies the
particular issues, needs, resources, and strengths of the family caregiver.
B. Etiology and/or epidemiology of risk factors associated with unhealthy
caregiving transitions
1. Just being a caregiver puts an individual at increased risk for higher levels
of stress and depression and lower levels of subjective well-being and phys-
ical health (Pinquart & Sörensen, 2006; Vitaliano et al., 2003).
2. Female caregivers on average provide more direct care and report higher
levels of burden and depression (Gitlin et al., 2003).
3. Ethnic minority caregivers provide more care, use less formal services, and
report worse physical health than White caregivers (Dilworth-Anderson et
al., 2002; Pinquart & Sörensen, 2006).
4. African American caregivers experience less stress and depression
and get more rewards from caregiving than White (Cuellar, 2002;
Dilworth-Anderson, 2002; Gitlin et al., 2003; Haley et al., 2004; Pinquart
& Sörensen, 2004).
5. Hispanic and Asian American caregivers exhibit more depression (Gitlin
et al., 2003; Pinquart & Sörensen, 2004).
6. Less-educated caregivers report more depression (Buckwalter et al., 1999;
Gitlin et al., 2003).
7. Spouse caregivers report higher levels of depression than nonspouse
caregivers (Pinquart & Sörensen, 2004; Pruchno & Resch, 1989).
8. Caregivers who have a poor quality relationship with the care recipient report
more strain (Archbold et al., 1990; Croog et al., 2006; Flannery, 2002).
9. Caregivers who lack preparedness for the caregiving role also increases
strain (Archbold et al., 1990; Archbold et al., 1992)
10. Caregivers of care recipients who have dementia (Pinquart & Sörensen, 2003).
IV. PARAMETERS OF ASSESSMENT
A. Caregiving context
1. Caregiver relationship to care recipient (spouse, nonspouse; Gitlin et al.,
Sörensen et al., 2002).
(continued)
Protocol 24.1: Family Caregiving (cont.)
Family Caregiving 491
(continued)
2. Caregiver roles and responsibilities
a. Duration of caregiving (Sörensen et al., 2002)
b. Employment status (work/home/volunteer; Pinquart & Sörensen, 2004)
c. Household status (number in home, etc.; Pinquart & Sörensen, 2004)
d. Existence and involvement of extended family and social support
(Pinquart & Sörensen, 2004)
3. Physical environment (home, facility; Vitaliano et al., 2003)
4. Financial status (Vitaliano et al., 2003)
5. Potential resources that caregiver could choose to use—list (Pinquart &
Sörensen, 2004)
6. Family’s cultural background (Dilworth-Anderson et al., 2002)
B. Caregiver’s perception of health and functional status of care recipient
1. List activities care receiver needs help with; include both ADL, and IADL
(Pinquart & Sörensen, 2004).
2. Presence of cognitive impairment—if yes, any behavioral problems (Gitlin
et al., 2003; Sörensen et al., 2002)?
3. Presence of mobility problems—assess with single question (Archbold et al.,
1990).
C. Caregiver preparedness for caregiving
1. Does caregiver have the skills, abilities, or knowledge to provide care
recipient with needed care (see Preparedness for Caregiving Scale at http://
consultgerirn.org/resources).
D. Quality of family relationships
1. e caregiver’s perception of the quality of the relationship with the care receiver
(see Mutuality Scale; Archbold et al., 1990; Messecar et al., in press).
E. Indicators of problems with quality of care
1. Unhealthy environment
2. Inappropriate management of nances
3. Lack of respect for older adult (see EAI at http://www.consultgerirn.org/
resources)
F. Caregiver’s physical and mental health status
1. Self-rated health: single item—asks what is caregiver’s perception of their
health (Pinquart & Sölensen, 2006).
2. Health conditions and symptoms
a. Depression or other emotional distress (e.g., anxiety; Pinquart &
Sörensen, 2003; Pinquart & Sörensen, 2006; Sörensen et al., 2002;
See http://www.chcr.brown.edu/pcoc/cesdscale.pdf.)
b. Reports of burden or strain (Schulz & Beach, 1999; Vitaliano et al., 2003;
See Caregiver Stain Index at http://www.consultgerirn.org/resources—
Family Caregiving topic)
3. Rewards of caregiving
a. List perceived benets of caregiving (Archbold et al., 1995)
b. Satisfaction of helping family member
c. Developing new skills and competencies
d. Improved family relationships
4. Self-care activities for caregiver
Protocol 24.1: Family Caregiving (cont.)
492 Evidence-Based Geriatric Nursing Protocols for Best Practice
V. NURSING CARE STRATEGIES
A. Identify content and skills needed to increase preparedness for caregiving (Acton
& Winter, 2002; Farran et al., 2003; Gitlin et al., 2003; Pusey & Richards,
2001; Sörensen et al., 2002).
B. Form a partnership with the caregiver prior to generating strategies to address issues
and concerns (Brodaty et al., 2003; Gitlin et al., 2003; Harvath et al., 1994).
C. Invite participation in care while in the hospital using the Family Preferences
Index, a 14-item approach to exploring caregivers’ personal choices for par-
ticipating in the care of hospitalized older adult family members to determine
preferences to provide care (Messecar, Powers, & Nagel, 2008).
D. Identify the caregiving issues and concerns on which the caregiver wants to
work and generate strategies (Acton & Winter, 2002; Gitlin et al., 2003;
Sörensen et al., 2002).
E. Assist the caregiver in identifying strengths in the caregiving situation (Archbold
et al., 1995).
F. Assist the caregiver in nding and using resources (Archbold et al., 1995; Farran
et al., 2004; Schumacher et al., 2002). Help caregivers identify and manage
their physical and emotional responses to caregiving (Schulz & Beach, 1999).
G. Use an interdisciplinary approach when working with family caregivers (Acton
& Winter, 2002; Farran et al., 2003; Farran et al., 2004; Gitlin et al., 2003;
Sörensen et al., 2002).
VI. EVALUATION OR EXPECTED OUTCOMES
A. Outcomes specic to caregiving transitions
1. Lower caregiver strain
2. Decreased depression
3. Improved physical health
B. Outcomes specic to patient
1. Quality of family caregiving
2. Care recipient functional status, nutrition, hygiene, and symptom management
3. Care recipient emotional well-being
4. Decreased occurrence of adverse events such as increased frequency of
emergent care
Protocol 24.1: Family Caregiving (cont.)
ACKNOWLEDGMENTS
e author wishes to gratefully acknowledge the assistance of Patricia Archbold and
Barbara Stewart, the developers of the Caregiver Preparedness and Mutuality scales for
their assistance in providing information and access to these valuable caregiving assess-
ment tools. is protocol also beneted from the perspective provided by Hong Li, the
developer of the Family Preference Index about the critical importance of involving
family caregivers early in the hospital care process to facilitate a healthy transition into
the caregiving role.
Family Caregiving 493
RESOURCES
CES-D
http://www.chcr.brown.edu/pcoc/cesdscale.pdf
Caregiver Strain Index
http://consultgerirn.org/uploads/File/trythis/try_this_14.pdf
Elder Assessment Instrument (EAI)
http://www.hartfordign.org/publications/trythis/issue15.pdf
Preparedness Scale
http://consultgerirn.org/uploads/File/trythis/try_this_28.pdf
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25
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe an older adult’s interest in sexuality
2. identify barriers and challenges to sexual health among older adults
3. discuss normal and pathological changes of aging and their inuence on sexual
health
4. identify interventions that may help older adults achieve sexual health
OVERVIEW
Sexuality is an innate quality present in all human beings and is extremely important to an
individual’s self-identity and general well-being (Wallace, 2008). Sexuality is dened as “a
central aspect of being human throughout life and encompasses sex, gender identities and
roles, sexual orientation, eroticism, pleasure, intimacy and reproduction (World Health
Organization [WHO], 2010).” Sexual health as a manifestation of sexuality is “a state of
physical, emotional, mental and social well-being related to sexuality (WHO, 2010).”
Sexual health contributes to the satisfaction of physical needs; however, it is often not as
apparent that sexual contact fullls many social, emotional, and psychological compo-
nents of life as well. is is evidenced by the fact that human touch and a healthy sex life
may evoke sentiments of joy, romance, aection, passion, and intimacy, whereas despon-
dency and depression often result from an inability to express one’s sexuality (Kamel &
Hajjar, 2003). When this occurs, sexual dysfunction, dened as impairment in normal
sexual functioning, may result (American Psychiatric Association [APA], 2000).
It is frequently assumed that sexual desires and the frequency of sexual encounters
begin to diminish later in life. Moreover, the notion of older adults engaging in sexual
activities has become taboo in today’s youth-loving society (Kamel & Hajjar, 2003).
Despite this stereotype, sexual identity and the need for intimacy do not disappear with
Meredith Wallace Kazer
Issues Regarding Sexuality
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Issues Regarding Sexuality 501
increasing age, and older adults do not morph into celibate, asexual beings. In a study
of 3,005 U.S. older adults, current sexual activity was reported in 73% of adults aged
57–64 years, 53% of adults aged 65–74 years, and 26% of adults aged 75–84 years
(Lindau et al., 2007).
BACKGROUND AND STATEMENT OF PROBLEM
Despite the persistence of sexual patterns throughout the lifespan, there is limited research
and information to assist nurses to assess and intervene to promote sexual health among
older adults. Lack of research literature and insucient clinical resources are a product of
the lack of societal recognition of sexuality as a continuing human need and a factor that
perpetuates lack of sexual assessment and intervention among the older population. In
addition to the lack of literature, there are several factors that further impact the sexual
health of older adults. ese factors include the presence of normal and pathological aging
changes, environmental barriers to sexual health, and special problems of the older adult
that interfere with sexual fulllment, such as cognitive impairment.
Nurses’ Views Toward Sexuality and Aging
Nurses’ hesitancy to discuss sexuality with older adults has a signicant impact on the
sexual health of this population. Gott, Hinchli, and Galena (2004) reported that
general practitioners do not discuss sexual health frequently in providing primary care
to older adults. eir study of 55 older men and women resulted in the nding that a
major factor aecting sexual discussion between patients and their physicians included
the hesitancy of discussing sexuality with a health care provider who was not the patient’s
age or sex. In this qualitative study, clients stated that sexuality discussions would be
more comfortable and forthcoming with health care providers who matched their sex
and age. Moreover, attitudes toward sexuality later in life, making jokes about sexuality,
shame or embarrassment and fear, perception of sexual problems as not serious, and
lack of knowledge regarding available interventions were also seen as barriers to sexual
discussion between older clients and health care providers (Gott et al., 2004).
General discomfort with discussing sexuality among nurses and lack of experience in
assessment and management of sexual dysfunction among older adults often prevents nurses
from addressing the sexual needs of this population. Moreover, the sexuality of older adults is
generally excluded from sparse gerontological curricula. Without education and experience
in managing sensitive issues around sexuality, health professionals are often not comfortable
discussing sexual issues with older adults. Health care providers may lessen discomfort with
addressing sexual issues by increasing their knowledge on the subject and routinely intro-
ducing this dimension of health into routine assessment and management protocols.
Nurses’ understanding of sexuality should be broadened beyond that of a relation-
ship between just men and women. Many clients within various health care systems are
gay or lesbian, bisexual, and transgender (GLBT) adults, and these alternative sexual
preferences require respect and consideration. In a focus group study, older gay and
lesbians reported extensive discrimination in accessing health care services by excluding
them from program planning (Brotman, Ryan, & Cormier, 2003). Discrimination
among GLBT older adults is especially seen in the development of residential services
to meet the needs of older adults. In a larger study of 400,000 GLBT adults, discrimi-
nation was seen among administrators, care providers, and other residents of retirement
care community (Johnson, Jackson, Arnette, & Koman, 2005).
502 Evidence-Based Geriatric Nursing Protocols for Best Practice
Normal and Pathological Aging Changes
e “sexual response cycle,” or the organized pattern of physical response to sexual
stimulation, changes with age in both women and men. After menopause, a loss of estro-
gen in women results in signicant sexual changes. is deciency frequently results in
the thinning of the vaginal walls and decreased or delayed vaginal lubrication, which
may lead to pain during intercourse (Lobo, 2007). Additionally, the labia atrophy, the
vagina shortens, and the cervix may descend downward into the vagina and cause fur-
ther pain and discomfort. Moreover, vaginal contractions are fewer and weaker during
orgasm, and after sexual intercourse is completed, women return to the prearoused stage
faster than they would at an earlier age. e result of these physiological age-related
changes in women is the potential for signicant alterations in sexual health that have
traditionally received little attention from research or individual health care providers.
e pain resulting from anatomical changes and vaginal dryness may result in the avoid-
ance of sexual relationships in order to prevent painful intercourse.
Men also experience decreased hormone levels, mainly testosterone, yet this seems
to have a limited impact on sexual functioning because only a minimal amount of tes-
tosterone is needed for the purposes of sex. is reduction in testosterone that has been
controversially labeled viropause or andropause and male menopause generally begins
between the ages of 46 and 52 years and is characterized by a gradual decrease in the
amount of testosterone (Kessenich & Cichon, 2001). e loss of testosterone is not
pathological and does not result in sexual dysfunction. However, men may experience
fatigue, loss of muscle mass, depression, and a decline in libido. As a result of normal
aging changes, older men require more direct stimulation of the penis to experience
erection, which is somewhat weaker as compared to that experienced in earlier ages.
As with postmenopausal women, orgasms are fewer and weaker in older men, the force
and amount of ejaculation is reduced, and the refractory period after ejaculation is
signicantly increased (Araujo, Mohr, & McKinlay, 2004).
Bodily changes such as wrinkles and sagging skin may cause both older women and
men to feel insecure about initiating a sexual encounter and maintaining emotionally
secure relationships. In addition, lack of knowledge and understanding among older
adults about sexuality is common because sexual education is rarely provided in formal
educational systems as the older adults developed and was rarely discussed informally.
Strict beliefs and values are likely to impact sexual action, freedom, and desires and
may result in sexual frustration and conict. Physical changes in the sexual response
cycle that occur with increasing age do not completely explain the extensive changes in
sexuality that occurs among older adults. Many individual psychosocial and cultural fac-
tors play a role in how older adults perceive themselves as sexual beings. Although sexual
disorders have not been well-addressed among the older population, they have been
dened and fall into four categories: hypoactive sexual desire disorder, sexual arousal
disorder, orgasmic disorder, and sexual pain disorders (Walsh & Berman, 2004).
In addition to normal aging changes and pathological sexual disorders, there are
a number of medical conditions that have been associated with poor sexual health
and functioning in the older population (Morle & Tariq, 2003). Rosen et al. (2009)
reported that the main predictors of sexual dysfunction are age, cardiovascular diseases,
and diabetes. One of the most frequently occurring medical conditions among older
adults includes cardiovascular disease. In a study of 2,763 postmenopausal women, the
presence of coronary heart disease was associated with lack of interest, inability to relax,
arousal and orgasmic disorders, and general discomfort with sex (Addis et al., 2005).
Issues Regarding Sexuality 503
Diabetes is a large problem among older adults, aecting approximately 14.7 million
individuals in the United States each year. Approximately, 40% of those with diabetes
are aged 65 years or older (Centers for Disease Control and Prevention [CDC], n.d.).
In a study of eight women aged 24–83 years, older women with diabetes reported lower
sexual function, desire, and enjoyment than their younger counterparts (Rocklie- Fidler
& Kiemle, 2003). Moreover, in a study of 373 men aged 45–75 years with Type II
diabetes, 49.8% of men reported mild or moderate degrees of erectile dysfunction (ED),
and 24.8% had complete ED (Rosen et al., 2009).
e presence of depression among older adults impacts sexual health, in that depres-
sion often causes a decline in desire and ability to perform with this disease and treat-
ment. Korfage et al. (2009) reported in a study of 3,810 men aged 57–78 years that men
with ED reported signicantly lower mental health than men without ED. e presence
of loss and depression should be assessed among older adults and considered for the
impact of these emotional and psychological factors on sexual health. (see Chapter 9,
Depression in Older Adults).
Other medical conditions occurring among older adults also have the potential
to impact sexual health. Older adults who have experienced strokes and subsequent
aphasias reported alterations in sexual health because of communication diculties
(Lemieux, Cohen-Schneider, & Holzapfel, 2001). Additionally, Parkinson’s disease
(PD) that is predominantly found in an older adult has the potential to negatively
impact sexual health. In a study of 444 older adults with PD, sexual limitations were
reported in 73.5% of the sample as a product of diculty in movement (Mott, Kenrick,
Dixon, & Bird, 2005). Benign prostatic hypertrophy (BPH) in older men may result in
altered circulation to the penis eecting erectile function and sexual arousal. Derogatis
and Burnett (2008) stated that sexual dysfunction is prevalent worldwide, and its occur-
rence and the frequency of symptoms that impact sexual health increase directly with
age for both men and women. Pathological changes of aging such as the conditions
discussed are major risk factors for sexual disorders.
Medications used to treat commonly occurring medical illnesses among older adults
also impact sexual function. Two of the major groups of medications include antide-
pressants and antihypertensives. Causative antidepressants include the commonly used
selective serotonin reuptake inhibitors (SSRIs). In a study of 610 women and 412 men,
59.1% of the individuals taking SSRI antidepressant medications reported sexual dys-
function (Montejo, Llorca, Izquierdo, & Rico-Villademoros, 2001). Although the use
of monoamine oxidase (MAO) inhibitors and tricyclic antidepressants has decreased in
favor of the SSRIs with lower side-eect proles, these medications also impact sexual
function by reducing sexual drive and causing impotence and erectile and orgasmic dis-
orders. Antihypertensives, angiotensin-converting enzyme (ACE) inhibitors, and alpha
and beta cell blockers also result in impotence and ejaculatory disturbances among older
adults (Alagiakrishnan et al., 2005). Antipsychotics, commonly used statin medications,
and H2 blockers also impact the sexual health of older adults.
Special Issues Related to Older Adults and Sexuality
Cognitively impaired older adults continue to have sexual needs and desires that present
a challenge to nurses. ese continuing sexual needs often manifest in inappropriate
sexual behavior. Sexual behaviors common to the cognitively impaired older adults
may include cuddling, touching of the genitals, sexual remarks, propositioning, grab-
bing and groping, use of obscene language, masturbating without shame, aggression,
504 Evidence-Based Geriatric Nursing Protocols for Best Practice
and irritability. In a study of 41 cognitively impaired older adults, 1.8% had sexually
inappropriate behavior manifesting in verbal and physical problems (Alagiakrishnan
et al., 2005). In a study that used computed tomography (CT) of the head to scan
10 patients with these problematic sexual behaviors, cerebral infarction was seen in six
of them, and severe disease in two others, supporting the organic basis for these symp-
toms ( Nagaratnam & Gayagay, 2002).
Masturbation is a method in which cognitively impaired men and women may
become sexually fullled. Nurses in long-term care facilities may assist older adults to
improve sexual health by providing an environment in which the older adult may mas-
turbate in private. Alkhalil, Tanvir, Alkhalil, and Lowenthal (2004) reported that the
use of gabapentin to decrease sexual behavior problems (such as inappropriate sexual
overtures and public masturbation) has demonstrated eectiveness anecdotally. Accu-
rate assessment and documentation of the ability of cognitively impaired older adults to
make competent decisions regarding sexual relationships with others while in long-term
care is essential. If the resident has been determined to be incapable of decision making,
then the health care sta must prevent the cognitively impaired resident from unsolic-
ited sexual advances by a spouse, partner, or other residents.
Environmental settings may also inuence sexuality among older adults. Normally,
engaging in sexual intercourse occurs within the privacy of one’s bedroom; however, for
some older adults, extended care facilities are the substitute for what one called home.
Residents of extended care facilities state that many of the obstacles they face regarding
their sexuality include lack of opportunity, lack of available partner, poor health, feeling
sexually undesirable, and guilt for having these sexual feelings. Furthermore, nega-
tive sta attitudes and beliefs regarding residents’ sexual activity bar the expression of
sexuality in long-term care settings (Hajjar & Kamel, 2004).
Twenty-ve percent of all HIV cases are developed in adults older than the age of
50 years, underscoring the signicant risk of HIV transmission in the older age group.
Older adults with HIV are more likely to be diagnosed late in the disease, progress more
quickly, and have a shorter survival (Martin, Fain, & Klotz, 2008). e use of antiretro-
viral medications among older adults may be complicated by multiple chronic comor-
bidities and treatments (Magalhães, Greenberg, Hansen, & Glick, 2007). Sherr et al.
(2009) conducted a study of 778 patients in an HIV clinic. Of the total population,
12% were aged older than 50 years. e ndings revealed that older patients reported
signicantly lower psychological and global burden and were more likely to take anti-
retrovirals than their younger cohorts. Health care providers are in a unique position to
assess and manage HIV among the older population, but greater education regarding
the risk for HIV in the older population is needed.
ASSESSMENT OF THE PROBLEM
A model to guide sexual assessment and intervention is available and has been well used
among younger populations since the 1970s. e Permission, Limited Information,
Specic Suggestion, Intensive erapy (PLISSIT) model (Annon, 1976) begins by rst
seeking permission (P) to discuss sexuality with the older adult. Because many sexual
disorders originate in feelings of anxiety or guilt, asking permission may put the client in
control of the discussion and facilitate communication between the health care provider
and client. is permission may be gained by asking general questions such as “I would
like to begin to discuss your sexual health; what concerns would you like to share with
Issues Regarding Sexuality 505
me about this area of function?” Questions to guide the sexual assessment of older
adults are available on many health care assessment forms. e next step of the model
aords an opportunity for the nurse to share limited information (LI) with the older
adult. In the case of older adults, this part of the model aords health care providers
the opportunity to dispel myths of aging and sexuality and to discuss the impact of
normal and pathological aging changes, as well as medications on sexual health. e
next part of the model guides the nurse to provide specic suggestions (SS) to improve
sexual health. In so doing, nurses may implement several of the interventions recom-
mended for improved sexual health, such as safe sex practices, more eective manage-
ment of acute and chronic diseases, removal or substitution of causative medications,
environmental adaptations, or need for discussions with partners and families. e nal
part of the model calls for intensive therapy (IT) when needed for clients whose sexual
dysfunction goes beyond the scope of nursing management. In these cases, referral to a
sexual therapist is appropriate.
Sexual assessments will be most eective using open-ended questions such as “Can
you tell me how you express your sexuality?” “What concerns you about your sexuality?”
“How has your sexuality changed as you have aged?” “What changes have you noticed
in your sexuality since you have been diagnosed or treated for disease?” “What thoughts
have you had about ways in which you would like to enhance your sexual health?” e
loss of relationships with signicant, intimate partners is unfortunately common among
older adults and often ends communication about the importance of self to the person
experiencing the loss. is greatly impacts the older adult’s sexual health. Asking the
older adult about past and present relationships in his or her life will help to aid this
assessment.
Barriers to sexual health should be assessed, including normal and pathological
changes of aging, medications, and psychological problems, such as depression. More-
over, lack of knowledge and understanding about sexuality, loss of partners, and family
inuence on sexual practice often present substantial barriers to sexual health among
older adults. Nurses should assess for presence of physiological changes through a health
history, review of systems, and physical examination for the presence of normal and
aging changes that impact sexual health. Older adults may view the normal changes of
aging and their subsequent impact on appearance as embarrassing or indicative of ill-
ness. is may result in a negative body image and a reluctance to pursue sexual health.
It is important for nurses to consider the impact of normal and pathological changes of
aging on body image and assess their impact frequently.
As discussed earlier, there are a number of medical conditions that have been asso-
ciated with poor sexual health and functioning including depression, cardiac disease,
diabetes, stroke, and PD. Eective assessment of these illnesses using open-ended health
history questions, review of systems, physical examination, and appropriate lab testing
will provide necessary information for appropriate disease management and improved
sexual function.
Assessing the impact of medications among older adults, especially those commonly
used to treat medical illnesses such as antidepressants and antihypertensives are essential.
Potential medications should be identied by reviewing the client’s medication bottles
and the client should be questioned about the potential impact of these medications on
sexual health. If the medication is found to impact on sexual health, alternative medica-
tions should be considered. e older adult should also be questioned regarding the use
of alcohol because this substance also has a potential impact on sexual response.
506 Evidence-Based Geriatric Nursing Protocols for Best Practice
INTERVENTIONS AND CARE STRATEGIES
Following a thorough assessment of normal and pathological aging changes, as well
as environmental factors, a number of interventions may be implemented to promote
the sexual health of older adults. ese interventions fall into several broad categories
including (a) education regarding age-associated change in sexual function, (b) com-
pensation for normal aging changes, (c) eective management of acute and chronic
illness eecting sexual function, (d) removal of barriers associated with diculty in ful-
lling sexual needs, and (e) special interventions to promote sexual health in cognitively
impaired older adults.
Client Education
e most important intervention to improving sexuality among the older population is
education. It is important to remember that sexuality was likely not addressed in formal
educational systems as the older adults developed and was rarely discussed informally.
Older adults may possess dated values that impact sexual action, freedom, and desires
and lead to both sexual frustration and conict. Masters (1986) reported in his seminal
work on the sexuality of older adults that older women were raised to believe that when
menstruation ceased, they would cease to be feminine. Knowledge is essential to the
successful fulllment of sexuality for all people.
e incidence of HIV and AIDS infection is rising among older adults, with 25%
of new cases resulting in adults older than the age of 50 years (Martin et al., 2008). is
underscores the signicant risk of HIV transmission in the older age group and the need
for eective teaching regarding safe sex practices. Teaching about the use of condoms to
prevent the transmission of sexually transmitted diseases is essential. In response to this
rise in HIV cases and the presence of other sexually transmitted diseases, it is essential
to provide older adults with safe sex information provided by the CDC.
Compensating for Normal Aging Changes
Assisting older adults to compensate for normal aging changes related to sexual dysfunc-
tion will greatly lessen the impact of these changes on sexual health. Among women,
the discussion of anatomical changes in sexual anatomy will help women to anticipate
these changes on sexuality. For example, the decreases in the size of the vagina and
increased vaginal dryness among women may require the use of articial water-based
lubricants or topical estrogen agents. In a multicenter, double-blind, randomized, pla-
cebo-controlled study, 305 women with symptoms of vaginal atrophy were treated
with a low-dose synthetic conjugated estrogen-A (SCE-A) cream twice weekly. e
results revealed that the cream signicantly reduced symptoms of vaginal atrophy and
pain during intercourse compared to the placebo (Freedman, Kaunitz, Reape, Hait,
& Shu, 2009). In men, delayed response and the increased length of time needed for
erections and ejaculations are among normal changes of aging, of which older adults
may not be aware. When older adults understand the impact of normal aging changes,
they then understand the need to plan for more time and direct stimulation in order
to become aroused.
One of the most important preventive measures older adults may undertake to
reduce the impact of normal aging changes on sexual health is to continue to engage
Issues Regarding Sexuality 507
in sexual activity. Planning for more time during sexual activities; being sensitive to
changes in one another’s bodies; the use of aids to increase stimulation and lubrication;
the exploration of foreplay, masturbation, sensual touch, and dierent sexual positions
along with education about these common changes associated with sex and aging may
help immensely. By doing so, changes in sexual response patterns are less likely to occur.
Eating healthy foods, getting adequate amounts of sleep, exercising, stress-management
techniques, and not smoking are also very important to sexual health.
Effective Management of Acute and Chronic Illness
Eective management of both acute and chronic illnesses that impair sexual health is
also important. Interventions that improve sexual health are frameworked within the
current interventions to treat disease. In other words, eective disease management
using primary, secondary, and tertiary interventions will not only eectively treat
the disease but also result in improved sexual health. Consequently, better glucose
control among diabetics enhances circulation and may increase arousal and sexual
response. Appropriate treatment of depression with medication and psychotherapy
will enhance desire and sexual response. Although treatment of depression may help
to improve libido and sexual dysfunctions such as orgasmic disorders, medications to
treat depression often impact sexual function by lowering libido and causing orgas-
mic disorders. As a potential alternative to treat libido problems during antidepres-
sant management, Seidman and Roose (2006) conducted a study of 32 depressed
patients with a mean age of 52 years. e sample was randomized to receive either
Enanthate (testosterone) 200 mg or sesame seed oil (placebo). Although self-reported
sexual functioning improved in both groups, no signicant dierences were found
between groups.
Oral erectile agents such as sildenal citrate (Viagra), vardenal HCl (Levitra), and
tadalal (Cialis) play a signicant role in the treatment of sexual dysfunction that occurs
with aging and are eective and well-tolerated treatments for ED in older men (Wespes
et al., 2007). In men treated for prostate cancer with radical prostatectomy, the use
of oral erectile agents to manage ED immediately following surgery is also gaining
increased support (Miles et al., 2007). Medications used to treat diseases may result in
sexual dysfunction among older adults (see http://www.netdoctor.co.uk/menshealth/
feature/medicinessex.htm for a list of these medications). ere are many medications
that may result in decreased sexual drive and impotence as well as orgasmic and ejacu-
latory disorders. ese medications are widely prescribed for many chronic illnesses
among older adults, including psychological disorders such as depression, hyperten-
sion, elevated cholesterol, sleep disorders, and peptic ulcer diseases. Moreover, because
of the hesitancy among older adults and nurses to discuss sexual problems, the eect of
these medications on sexual function is often not discussed in clinical settings. is may
result in either prolonged sexual dysfunction among the older adult or a noncompli-
ance with the medication. Recognition of the continuing sexual needs of older adults
among nurses is essential to beginning dialogue about sexual problems. Eective assess-
ment will uncover medications aecting older adult’s sexual function and lead to the
consideration of stopping the medication in favor of alternative disease management
strategies or substituting the medication causing the dysfunction with another one with
less sexual eects.
508 Evidence-Based Geriatric Nursing Protocols for Best Practice
Removal of Barriers to Sexual Health
One of the greatest barriers to sexual health among older adults lies within nurses’ per-
sistent beliefs that older adults are not sexual beings. Nurses should be encouraged to
open lines of communication in order to eectively assess and manage the sexual health
needs of aging individuals with the same consistency as other bodily systems and treat
alterations in sexual health with available evidence-based strategies.
An essential intervention to promoting sexual health in this population is to edu-
cate nurses regarding the continuing sexual needs and desires persisting throughout the
lifespan. Education regarding older adult sexuality as a continuing human need should
be included in multidisciplinary education and sta development programs. Educational
sessions may begin by discussing prevalent societal myths around older adult sexuality.
Nurses should be encouraged to discuss their own feelings about sexuality and its role in
the life of older adults. Moreover, the development of policies and procedures to manage
sexual issues of older adult clients is important throughout environments of care.
Environmental adaptations to ensure privacy and safety among long-term care and
community-dwelling residents are essential. Arrangements for privacy must be made
so the dignity of older adults is protected during sexual activity. For example, nurses
may assist in nding other activities for the resident’s roommate so that privacy may be
obtained or in securing a common room that may be used by the older adults for private
visits. Call lights or telephones should be kept within reach during sexual activity and
adaptive equipment such as positioning devices or trapezes may need to be obtained.
Interventions such as providing rooms for privacy and oering consultations for resi-
dents regarding evaluation and treatment of their sexual problems are a few of the many
ways this may be accomplished (Wallace, 2008). Roach (2004) suggested that nursing
home sta and administration work to develop environments that are supportive and
respectful of older resident’s continuing sexual rights and promote sexual health.
Families are an integral part of the interdisciplinary team. However, for older couples,
especially those in relationships with new partners, it is often dicult for families to
understand that their older relative may have a sexual relationship with anyone other
than the person they are accustomed to them being with. A family meeting, with a
counselor if needed, is appropriate in order to help the family understand and accept
the older adult’s decisions about the relationship.
Special Interventions to Promote the Sexual Health of Cognitively Impaired Older Adults
Cognitively impaired older adults continue to have sexual needs and desires but may
lack the capacity to make appropriate decisions regarding sexual relationships. Accurate
assessment and documentation of ability to make informed decisions regarding sexual
relationships must be conducted by an interdisciplinary team. If the older adult is not
capable of making competent decisions, participation in sexual relationships may be
considered abusive and must be prevented. On the other end of the spectrum, nurses
should not attempt to prevent sexual relationships and may play an important role in
promoting sexual health among older adults who are cognitively competent to make
decisions regarding sexual relationships. In these cases, nurses should implement all
necessary interventions to promote the sexual health of older adult clients.
Inappropriate sexual behavior such as public masturbation, disrobing, or making
sexually explicit remarks to other patients or health care professionals may be a warn-
ing sign of unmet sexual needs among older adults. A full sexual assessment should be
Issues Regarding Sexuality 509
Mrs. Jones is a highly functioning 79-year-old widow, recently admitted to a nursing
home with MCI. Mrs. Jones began a friendship with Mr. Carl, who is cognitively
intact and wheelchair bound. Mr. Carl is married to a woman who resides outside the
facility. e nursing sta has noticed more and more intimate touches among the two
residents and is concerned about Mrs. Jones’s competency to make the decision to par-
ticipate in this increasingly intimate relationship. Moreover, general concern about the
sexual relationship within a long-term care setting prevails among the nursing sta.
e rst step in this situation is to conduct a full assessment to determine Mrs.
Jones’s capacity to participate in this intimate relationship. e right to Mrs. Jones’s
autonomy is complicated by the presence of MCI and must be explored further. e
question remains, does Mrs. Jones have the decisional capacity to participate in an
intimate relationship?
e actual and projected outcomes of the intimate relationship would require
assessment to determine what nursing actions are required regarding this relation-
ship. If an assessment of Mrs. Jones nds that she is incapable of understanding the
consequences of her relationship with Mr. Carl, then she must be protected from
unsolicited sexual advances by a spouse, partner, or other residents. However, if the
assessment leads nurses to believe that Mrs. Jones and Mr. Carl understand the risks
and consequences of their relationship, then the right to autonomy prevails.
If clinicians determine that the older adults have the decisional capacity to con-
sent to a sexual relationship, then a comprehensive health history, review of systems,
and physical examination to determine normal and pathological changes of aging that
may play a role in this sexual relationship must be conducted. Appropriate lab work
for the potential presence of sexually transmitted diseases should be included. A care
plan focusing the need to promote sexual health for this couple should be developed.
Teaching regarding normal and pathological aging changes and the impact of these
changes, as well as medications on sexual function, should be conducted. Normal
changes of aging must be compensated for and diseases eecting sexual response
should be treated with medications that will not impact sexual health. Safety from the
transmission of sexually transmitted diseases and privacy should be provided for the
residents, ensuring that their dignity is respected at all times.
CASE STUDY
conducted using clear communication and limit setting in these situations. Following
this, a plan should be developed to manage this behavior while providing the utmost
respect and preserving the dignity of the client. Providing an environment in which
the older adult may pursue their sexuality in private may be a simple solution to a dif-
cult problem. Medication management for hypersexual behavior may be considered.
Tricyclic antidepressants and trazodone are two medications with antilibidinal and anti-
obsessive eects that may be safely used to treat hypersexual behavior (Wallace & Safer,
2009). Levitsky and Owens (1999) reported that antiandrogens, estrogens, gonadotro-
pin-releasing hormone analogues, and serotonergic medications may be successful when
other methods are ineective.
510 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
One of the most prevalent myths of aging is that older adults are no longer interested
in sex. It is commonly believed that older adults no longer have any interest or desire
to participate in sexual relationships. Because sexuality is mainly considered a young
person’s activity, often associated with reproduction, society does not usually associate
older adults with sex. In the youth-oriented society of today, many consider sexuality
among older adults to be distasteful and prefer to assume that sexuality among the older
population does not exist. However, despite popular belief, sexuality continues to be
important, even in the lives of older adults.
Although the sexual health of older adults has been largely ignored in the past
decades, evolving images of older adults as healthy and vibrant members of society
may result in a decrease in prevalence of myths of this population as nonsexual beings.
Changes in the societal image of older adults as asexual celibate beings will greatly
enhance removal of barriers to sexual health in the older population. Improved assess-
ment and management of normal and pathological changes of aging and appropriate
environmental adaptations and management of special issues of sexuality and aging will
also result in improved sexual health in the older population. Oral erectile agents also
play a substantial role in enhanced sexual health among older adults.
e fulllment of sexual needs may be just as satisfying for older adults as it is for
younger people. However, several normal and pathological changes of aging complicate
sexuality among older adults. Environmental changes may create further barriers to sex-
ual expression among older adults. Despite the many barriers to achieving sexual health
among an aging population, nurses are in a critical position to understand sexual needs
and capabilities in later life and assist older adults to develop compensatory strategies for
improving sexual health in order to have the best possible sexual life. If these strategies
and interventions are undertaken, increased awareness and acceptance of older adults’
sexuality will ultimately take place, and the concept of sex in old age will no longer be
such a shocking topic.
Protocol 25.1: Sexuality in the Older Adult
I. GOAL: To enhance the sexual health of older adults.
II. OVERVIEW: Although it is generally believed that sexual desires decrease with
age, researchers have identied that sexual desires, thoughts, and actions continue
throughout all decades of life. Human touch and healthy sex lives evoke sentiments of
joy, romance, aection, passion, and intimacy, whereas despondency and depression
often result from an inability to express one’s sexuality. Health care providers play an
important role in assessing and managing normal and pathological aging changes in
order to improve the sexual health of older adults.
NURSING STANDARD OF PRACTICE
(continued)
Issues Regarding Sexuality 511
III. BACKGROUND AND STATEMENT OF THE PROBLEM
A. Denitions
1. Sexuality. A central aspect of being human throughout life and encompasses
sex, gender identities and roles, sexual orientation, eroticism, pleasure, inti-
macy, and reproduction (WHO, 2010).
2. Sexual health. A state of physical, emotional, mental, and social well-being
related to sexuality (WHO, 2010).
3. Sexual dysfunction. Impairment in normal sexual functioning (APA, 2000).
B. Etiology and/or Epidemiology
1. Despite the continuing sexual needs of older adults, many barriers prevent
sexual health among older adults.
2. Health care providers often lack knowledge and comfort in discussing
sexual issues with older adults (Gott et al., 2004).
3. e older population is more susceptible to many disabling medical con-
ditions; a number of medical conditions are associated with poor sexual
health and functioning (Morle & Tariq, 2003), including depression, car-
diac disease, stroke and aphasia, Parkinson’s disease (PD), and diabetes that
make sexuality dicult.
4. Medications among older adults, especially those commonly used to treat
medical illnesses, also impact sexuality such as antidepressants (Montejo
et al., 2001).
5. Normal aging changes make sexual health dicult to achieve such as a
higher frequency of vaginal dryness in women and erectile dysfunction
(ED) in men (Kessenich & Cichon, 2001; Lobo, 2007).
6. Environmental barriers also present barriers to sexual health among older
adults (Hajjar & Kamel, 2004).
IV. ASSESSMENT
A. e Permission, Limited Information, Specic Suggestion, Intensive erapy
(PLISSIT) model (Annon, 1976) begins by rst seeking permission (P) to dis-
cuss sexuality with the older adult. e next step of the model aords an oppor-
tunity for the nurse to share limited information (LI) with the older adult.
What about SSIT?
B. Ask open-ended questions such as “Can you tell me how you express your
sexuality?” or “What concerns you about your sexuality?” and “How has your
sexuality changed as you have aged?”
C. Assess for presence of physiological changes through a health history, review
of systems, and physical examination for the presence of normal and aging
changes that impact sexual health.
D. Review medications among older adults, especially those commonly used to
treat medical illnesses that also impact sexuality such as antidepressants and
antihypertensives.
E. Assess medical conditions that have been associated with poor sexual health
and functioning including depression, cardiac disease, stroke and aphasia, PD,
and diabetes.
Protocol 25.1: Sexuality in the Older Adult (cont.)
(continued)
512 Evidence-Based Geriatric Nursing Protocols for Best Practice
V. NURSING CARE STRATEGIES
A. Communication and Education
1. Discuss normal age-related physiological changes.
2. Address how the eects of medications and medical conditions may aect
one’s sexual function.
3. Facilitate communication with older adults and their families regarding
sexual health as desired, including the following:
a. Encourage family meetings with open discussion of issues if desired.
b. Teach about safe sex practices.
c. Discuss use of condoms to prevent transmission of sexually transmitted
infections (STIs) and HIV.
B. Health Management
1. Perform a thorough patient assessment
2. Conduct a health history, review of systems, and physical examination
3. Eectively manage chronic illness
4. Improve glucose monitoring and control among diabetics
5. Ensure appropriate treatment of depression and screening for depression
(see Chapter 9, Depression in Older Adults).
6. Discontinue and substitute medications that may result in sexual dysfunction
(e.g., hypertension or depression medications).
7. Accurately assess and document older adults’ ability to make informed
decisions (see Chapter 28, Health Care Decision Making).
8. Participation in sexual relationships may be considered abusive if the older
adult is not capable of making decisions.
C. Sexual Enhancement
1. Compensate for normal changes of aging
a. Females:
i. Use of articial water-based lubricants
ii. Use of estrogen cream (Freedman et al., 2009)
b. Males:
i. Recognizing the possibility for more time and direct stimulation
for arousal caused by aging changes. Use of oral erectile agents for
ED (Wespes et al., 2007)
2. Environmental adaptations
a. Ensure privacy and safety among long-term care and community-dwell-
ing residents (Wallace, 2008).
VI. EXPECTED OUTCOMES
A. Patients will:
1. Report high quality of life as measured by a standardized quality of life
assessment.
2. Be provided with privacy, dignity, and respect surrounding their sexuality.
3. Receive communication and education regarding sexual health as desired.
4. Be able to pursue sexual health free of pathological and problematic sexual
behaviors.
Protocol 25.1: Sexuality in the Older Adult (cont.)
(continued)
Issues Regarding Sexuality 513
RESOURCES
American Foundation for Urological Disease, Inc.
http://www.urologyhealth.org/auafhome.asp
MedlinePlus
http://www.nlm.nih.gov/medlineplus/sexualhealthissues.html
National Institutes on Aging
http://www.nia.nih.gov/HealthInformation/Publications/sexuality.htm
Prentiss Care Networks Project
Care networks for formal and informal caregivers of older adults
http://caregiving.case.edu
World Health Organization
http://www.who.int/reproductivehealth/en/
Videos
A Rose by Any Other Name. (1976). Post Perfect Productions Backseat Bingo. Terra Nova Films
Freedom of Sexual Expression: Dementia and Resident Rights in Long-Term Care Facilities. Terra Nova Films.
e Heart Has No Wrinkles. Terra Nova Films.
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B. Nurses will:
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516
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe common patterns of substance use in older adults
2. recognize common substance use disorders diagnosed in older adults
3. outline screening steps for substance use disorders in older adults
4. discuss the stepwise assessment and rationale for identifying a substance use disorder
5. analyze intervention strategies for substance use disorders in older adults
6. list potential resources on substance-related disorders for older adults and their families
OVERVIEW
Alcohol and drug use among persons aged 50 years and older is increasing as more people
live longer, continue community living, and continue substance use habits established
in youth and middle adulthood. Approximately 57 million persons ages 50–64 years are
now living in the United States, and there are another 37.8 million persons aged 65 years
and older. e projected increase in persons aged 65 years and older is expected to reach
85 million older adults by 2050 (U.S. Census Bureau, 2008). Population growth pre-
dicts greater numbers of substance-related problems in older adults, and nurses should
be prepared to identify and intervene to address these issues (Han, Gfroerer, Colliver, &
Penne, 2009). e estimated one third of the older population who are minority group
members will also grow and because drug and alcohol use in ethnic minorities is grossly
understudied, nursing interventions must be adapted in culturally competent ways and
individualized to this group of older adults (Andrews, 2008; Grant et al., 2004).
BACKGROUND AND STATEMENT OF PROBLEM
Health care problems linked to substance abuse are costly to society with direct and
indirect economic costs of alcohol abuse and dependence, including costs of illness and
Madeline Naegle
26
Substance Misuse and
Alcohol Use Disorders
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Substance Misuse and Alcohol Use Disorders 517
crime, estimated at $184 billion in 1998. Another $143.4 billion in costs is attributed
to illicit and prescription drugs (National Institute on Alcohol Abuse and Alcoholism
[NIAAA], 2000). Nearly 22% of community-dwelling older adults use potentially
addictive prescription medication (Simoni-Wastila & Yang, 2006), and risks of psycho-
logical and/or physical dependence associated with this phenomenon are considerable
(Simoni-Wastila, Zuckerman, Singhal, Briesacher, & Hsu, 2005). is misuse of drugs
in older persons costs the United States $60 billion annually, a cost that is anticipated to
rise as the middle-aged population—high users of nonprescription pain relievers—grow
(Wu & Blazer, 2011).
e drug most commonly misused by older adults is alcohol, followed by tobacco
and psychoactive prescription drugs, with trends indicating an increase in the numbers
of older individuals using marijuana (Moore et al., 2009). High personal and medical
costs are linked to excessive use and abuse of alcohol, rather than moderate use. Among
persons older than 60 years seen in primary care, 15% of men and 12% of women regu-
larly drank in excess of the National Institute Alcohol Abuse and Alcoholism (NIAAA)
recommended levels (i.e., one drink per day and no more than three drinks on any
one occasion; Fink, Elliott, Tsia, & Beck, 2005). Heavy consumption has been shown
to decrease the likelihood that older people will use preventive medical services such
as glaucoma screening, vaccinations, and mammograms (Fink et al., 2005). Looking
to the future, of the estimated 57 million late middle-aged persons (50–64 years old),
14% are drinking heavily, with 9% of them “at-risk” drinkers, and 23% report binge
drinking (consumption of four to ve drinks on an occasion; Blazer & Wu, 2009;
Merrick et al., 2008).
e burden of disease derived from tobacco use continues to be heaviest among
older individuals and is the leading cause of premature death in older persons (Sachs-
Ericsson, Collins, Schmidt, & Zvolensky, 2011) who have smoked the longest and
have the most health problems. In 2004, 18.5 million Americans older than 45 years
smoked, (about 42% of all adult smokers) and in 2006, 9% of older Americans were
smokers (National Center for Health Statistics [NCHS], 2007). Smoking-related deaths
number 300,000 annually in this age group (Centers for Disease Control and Preven-
tion [CDC], 2010).
As baby boomers age, their lifetime illicit drug use is anticipated to continue at the
same levels, increasing the number of persons older than 55 years using illicit drugs
(marijuana and cocaine; National Institute on Drug Abuse [NIDA] 2010). Using sur-
vey research and modeling methods to project trends, the number of persons aged
50 years and older who use marijuana is projected to increase from 1.0% in 1999 to at
least 2.9% (3.3 million users) by 2020. Use of illicit drugs is expected to increase from
2.2% (1.6 million) to 3.1% (3.5 million) and nonmedical use of psychotherapeutic
drugs is projected to increase from 1.2% to 2.4% (Colliver, Compton, Gfroerer, &
Condon, 2006).
More older people in need of treatment, coupled with their reluctance to seek
assistance with mental health problems (fewer than 3% of older people visit a mental
health professional), suggest that nurses and health professionals caring for older adults
in all settings must be knowledgeable about substance use, abuse, and dependence
(Bartels et al., 2004). Psychiatric disorders often cooccur with alcohol abuse in older
adults with a prevalence rate ranging from 12% to 30% (Oslin, 2005) and depres-
sion, independently and as a consequence of excessive drinking, often occurs in male
smokers (Kinnunen et al., 2006).
518 Evidence-Based Geriatric Nursing Protocols for Best Practice
e metabolic changes of aging are key factors in health problems related to drug or
alcohol use, resulting in increased morbidity in advancing age. Older persons respond
dierently to alcohol because of decreased total body water, decreased rates of alcohol
metabolism in the gastrointestinal tract, and increased sensitivity to alcohol combined
with decreased tolerance (U.S. Department of Health and Human Services [USDHHS],
2004a). Consequently, more dramatic behavioral changes and adverse physical responses
are evident at lower doses of all drugs. Social and legal problems occur more frequently
and are more pronounced than in younger people, especially for older women (Center
for Substance Abuse Treatment [CSAT], 1998). Because the Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV) criteria may be less applicable to older
adults, these criteria must be interpreted and applied in an age-appropriate manner.
ASSESSMENT OF SUBSTANCE USE DISORDERS
Substance use and related disorders are categorized as use, misuse, abuse, and depen-
dence. Misuse is the most common disorder in older adults because of the high number
of prescription drugs used and more pronounced responses to any drugs—licit or illicit.
Older people tend to “self-medicate” with alcohol and other drugs to treat physical and
psychological symptoms associated with aging. Whether a problem is categorized as
abuse or dependence, potential health problems are linked to the substance used; the
length of time used, misuse, abuse, or dependence; and the social, legal, and health
consequences for the individual. For example, persons who drink four or fewer drinks
per year are considered abstinent and low-risk drinkers. For adults aged 65 years and
older, one drink daily is considered moderate consumption (USDHHS, 2005). Most
individuals who use and/or are dependent on alcohol, nicotine, and illicit drugs have
developed drinking patterns before the age of 60. One half to two thirds of older adult
alcoholics developed alcoholism or abuse patterns early in life. “Late-onset alcoholism”
and patterns of prescription drug abuse, marked by increased use of alcohol or over-
reliance on prescription drugs, are often linked to losses, chronic illness, psychological
traumas, and common stressors of advancing age. A common example is the change
from social use to risky drinking or drug misuse by people who have lost a spouse, part-
ner, or job; are estranged from family or are facing serious illness; or any combination
of situations mentioned.
Alcohol Use Disorders
e most common substance use disorders in older adults relate to alcohol consump-
tion, including interactions of alcohol with prescription and over-the-counter (OTC)
drugs (USDHHS, 2005).
At-Risk and Binge Drinking
“At-risk” drinking is a pattern that may not readily appear to cause alcohol-related
problems but may cause harmful consequences to the user or others with continued
use over time. Regular alcohol and tobacco use, for example, are linked to insomnia
(Tibbitts, 2008), a common complaint of older persons. Negative consequences of use
include accidents, health and/or mental health problems, or social and legal problems.
For people older than 60 years, continuing to drink the same amounts of alcohol that
did not appear to cause problems earlier in life later results in adverse consequences.
Substance Misuse and Alcohol Use Disorders 519
Such outcomes are determined by the individual’s response to alcohol, the use of pre-
scription drugs (alcohol interacts with at least 50% prescription drugs), and cooccur-
rence of other chronic medical or psychiatric disorders. Similarly, a decline in visual,
auditory, or other perceptual capacities make alcohol consumption hazardous. Heavy
drinking can result in ulcers, respiratory disease, stroke, and myocardial infarction, and
older persons are more vulnerable to these. Most adults decrease alcohol consumption
with age but signicant numbers continues heavy consumption at age 60 years and
older (Merrick et al., 2008).
Abuse of a substance is diagnosed when a maladaptive pattern of use, leading to
impairment or distress (legal, interpersonal, emotional, or mental), is evident. ese pat-
terns include failure to fulll role obligations and use of a drug in physically hazardous
situations, all occurring over a 12-month period (modied from American Psychiatric
Association [APA], 2000). Even when a person does not meet the DSM-IV-TR crite-
ria for abuse or dependence, alcohol consumption at levels of more than seven drinks
per week for persons older than 65 years can result in health consequences. Excessive
alcohol consumption may place the older individual at risk for falls, self-neglect, and
diminished cognitive capacity, and long-term alcohol use is related to the development
of common medical problems such as sleep disorders, restlessness and agitation, liver
function abnormalities, pneumonia, pancreatitis, gastrointestinal bleeding, and trauma
as well as chronic diseases, particularly neuropsychiatric and digestive disorders, diabe-
tes, cardiovascular disease, and pancreatic or head and neck cancer (Blow, 1998). Excess
alcohol use compromises health by interfering with the absorption and utilization of
prescribed drugs and nutrients.
Drug Dependence (Addiction)
Drug dependence is a maladaptive pattern of substance use that leads to impair-
ment or distress (legal, interpersonal, emotional, or mental) occurring in a 12-month
period (APA, 2000). Addiction is a chronic illness characterized by brief “slips” from
sobriety and “relapses,” returns to regular use of the substance. It has two components:
(a) physiological dependence, induced by certain drugs, particularly alcohol, tobacco,
benzodiazepines, barbiturates, amphetamines, and opioids, is evidenced in “ tolerance,”
the need for increasing amounts of a substance to achieve the desired eect and
“ withdrawal,” in a characteristic pattern of symptoms when use of a substance is sud-
denly stopped; craving accompanies withdrawal; and (b) psychological dependence, the
perceived need to use the drug. Psychological dependence occurs with both abuse and
dependence and is more dicult to resolve than physiologic dependence.
Illicit Drug Use
Illicit drug use is less prevalent in late adulthood than alcohol abuse or prescription drug
misuse. Recent trends in the “baby boomer” generation, however, suggest that this may
be changing. Marijuana use, for example, is now more prevalent among persons aged
55 years and older than among adolescents, and in 2000, more than half a million persons
aged 55 years and older reported illicit drug use (Substance Abuse and Mental Health
Services Administration [SAMHSA], 2001). Two recent studies, as well, indicate that
among persons older than 50 years reporting illicit drug use, toxicology screens on small
samples seen in urban emergency departments were positive for cocaine (63%), opiates
(16%), and marijuana (14%; Rivers et al., 2004; Schlaerth, Splawn, Ong, & Smith, 2004).
520 Evidence-Based Geriatric Nursing Protocols for Best Practice
Clinical observation suggests that older people are rarely asked about cocaine abuse despite
strong evidence of its associated cardiovascular risks. e result is inaccurate information
of the prevalence of illicit drug use among older adults (Chait, Fahmy, & Caceres, 2010).
Recovery From Drug or Alcohol Dependence
Many older persons are “in recovery” or have established long sobriety from the use
of alcohol, cocaine, heroin, or other drugs. e components of recovery have been
described by the Consensus Panel of the Betty Ford Institute (2007) as a lifestyle
voluntarily maintained by an individual that includes sobriety, varying levels of personal
health, and citizenship. Situations and life stressors may contribute to an individual’s
relapse to alcohol or drug use. Changes associated with aging, the numbers of losses
that increase with age, and the onset of chronic illness may all become “triggers,”
which pose a threat to recovery and increase the risk for a return to regular, maladap-
tive patterns of use (relapse). On a positive note, good treatment outcomes and rates
of recovery for older persons are higher than in any age group. Nurses can contribute
positively by supporting the patient’s attendance at self-help group meetings, con-
tinued involvement in treatment such as methadone maintenance and/or group or
individual psychotherapy.
In this chapter, the term drug applies to OTC medications, prescription medica-
tions, nicotine, alcohol, and illicit drugs. Herbs and food supplements are also used
frequently by older adults. Although knowing the chemical composition of drugs of
abuse is essential to understanding their eects on mind and body, this chapter focuses
primarily on drug misuse, and the eects and consequences of excessive use and use
in combination, for health as well as appropriate nursing assessment and intervention
strategies. Please refer to http://www.nih.nida.gov for a full listing of drugs of abuse and
their chemical properties.
Psychoactive Drug Misuse and Abuse
Drug misuse, dened as use of a drug for reasons other than for which it was intended,
occurs with increasing frequency with advancing age because (a) prescriptions for
multiple medications and cognitive changes, ranging from early signs of dementia,
can lead to medication misuse; (b) failure to discard expired medications; (c) trading
medications with friends and companions; and (d) combining both nonprescription
and prescription medications and alcohol. e most common resulting problems are
related to (a) overdose, (b) additive eects, (c) adverse reactions to drugs used, or
(d) drug interactions, especially with alcohol. Older adults are prescribed with more
than 33% of all prescription drugs, and the nonmedical use of prescription drugs
is increasing in persons older than 60 years (NIDA, 2007). Among older women
who misuse medications and alcohol as high as 30% developed such habits after
age 60 years (e National Center on Addiction and Substance Abuse [CASA] at
Columbia University, 1998).
e regular use of numerous drugs for multiple medical conditions (i.e., poly-
pharmacy) is complicated by the older adult’s use of alcohol or illicit drugs (Letizia
& Reinbolz, 2005). Prescription drug use or misuse contributes to falls and cognitive
impairment. In persons aged 18–70 years old treated for falls, 40% of men and 8% of
women tested positive for alcohol and/or benzodiazepines (9% and 3%, respectively),
or both (Boyle & Davis, 2006).
Substance Misuse and Alcohol Use Disorders 521
Abuse of psychoactive drugs is a growing health problem for older adults and the
few research ndings listed as factors correlating with drug abuse are isolation, history
of substance-related or mental health disorder, bereavement, chronic medical disor-
ders, female gender, and exposure to prescription drugs with abuse potential. Use of
illicit drugs by older adults is mostly limited to long-time addicts (Blow et al., 2000)
and marijuana users (SAMHSA, 2000). However, substance abuse by older adults,
1 in 4 of whom receive prescriptions for psychoactive drugs with abuse potential, is
becoming more common. Drugs—other than nicotine or tobacco—most commonly
abused are benzodiazepines, sedative hypnotics, and opioid analgesics (Barry, Oslin, &
Blow, 2001).
Smoking and Nicotine Dependence
Today’s older Americans have smoked at rates among the highest of any U.S. genera-
tion (American Lung Association [ALA], 2006), resulting in many health problems and
contributing to the estimated 438,000 American deaths annually caused by smoking.
In 2008, more than 17 million Americans older than 45 years smoked, accounting for
more than 22% of all adult smokers. By age group, the prevalence rate of smoking was
9.5% among those aged 65 years and older and 21.9% among those 45–64 years of age.
Vulnerability to the eects of smoking in an older adult varies, with men being
more than twice as likely as women to die of stroke secondary to smoking (ALA, 2006).
e risk of dying of a heart attack for men aged 65 years and older is twice that for
women smokers and 60% higher than for nonsmoking men of the same age. Smokers
also have signicantly higher risks than nonsmokers for Alzheimer’s disease and other
types of dementia, as well as visual problems (Whitmer, Sidney, Selby, Johnston, &
Yae, 2005).
Polysubstance Abuse
Polysubstance abuse, the misuse, abuse, or dependence of three or more drugs, is com-
mon in older adults. Prescription analgesics are frequently prescribed for chronic pain,
a common complaint in older persons, and depending on the class of drug, can induce
dependence. Older problem drinkers, as well, report more severe pain, greater disrup-
tion of activities caused by pain, and frequent use of alcohol to manage pain ( Brennan,
Schutte, & Moos, 2005). ese ndings underscore the importance of monitoring
drinking and medication use in patients who present with complaints of pain, especially
those with histories of any drug dependence, including alcohol and nicotine.
ASSESSMENT OF SUBSTANCE USE PROBLEMS
e nurse should review data collected on the most recent nursing and medical histories
and ndings of the most recent physical examination. When patients are using alcohol,
there may be deviations in standard liver function tests (LFTs) and elevations in gamma-
glutamyl transferase (GGT) and carbohydrate-decient transferrin (CDT) levels (Godsell,
Whiteld, Conigrave, Hanratty, & Saunders, 1995). Physical signs such as ecchymosis,
spider angiomas, ushing, palmar erythema, or sarcopenia may be evident. e patient
may have an altered level of consciousness, changes in mental status or mood, poor coor-
dination, tremor, increased deep tendon reexes, or a positive Romberg sign. Increased
lacrimal secretions, nystagmus, and sluggish pupil reactivity may also be noted in the
522 Evidence-Based Geriatric Nursing Protocols for Best Practice
examination (Letizia & Reinbolz, 2005). Patients who report use of marijuana and/or
other drugs should have toxicology tests to establish baseline use level. Findings can be
eectively used in a motivational interview and brief interventions and/or counseling.
Nurses need to assess and document frequent changes in drug using habits and
record these in substance use histories, dating from rst use to the current situation.
Ask if the individual ever experienced problems related to drug or alcohol use, sponta-
neously stopped using a drug or alcohol, or is in recovery and participating in self-help
programs such as Alcoholics Anonymous or Narcotics Anonymous.
In taking the patient history, ask about a history of smoking, alcohol use, OTC
medications, prescription and recreational drugs, herbal, and food and drink supple-
ment use. Record this information using the Quantity Frequency (QF) Index (Khavari
& Farber, 1978). Another helpful technique in assessing drug use is the “brown bag”
technique. Ask the client to bring in a brown bag containing all of the prescribed, OTC,
food supplements, and other legal or illicit drugs that he or she consumes weekly. Use
these to develop the history and to open a discussion about the implications of drug use
with the patient. Be sure to talk with the client about how using the drug is meaningful
or helpful (i.e., relieves pain, relieves feelings of loneliness, anxiety, or comfort).
Screening, brief intervention, and referral to treatment (SBIRT) has been found to
be eective with adults and older adults for smoking and alcohol use, and should be part
of the nursing evaluation (Schonfeld et al., 2010). Despite federal agency guidelines
supporting its use, it is rarely used with older adults. SBIRT has demonstrated ecacy
and feasibility in reducing patients’ alcohol consumption, decreasing dependence symp-
toms (Babor et al., 2007; SAMHSA, 2008), and improving general and mental health
(Madras et al., 2009) following its use by nurses and nurse practitioners.
SBIRT begins with screening an individual with a valid and population-appropriate
screening tool. When the patient scores positively for excess alcohol use or for smoking,
a brief 3- to 5-minute advice giving or counseling session is done by the health profes-
sional. Its components are as follows:
Screening: Short, well-tested questionnaire that identies risk (such as the Alcohol,
Smoking, and Substance Involvement Screening Test [ASSIST], the Short Michigan
Alcohol Screening Test—Geriatric version [SMAST-G], the Alcohol Use Disorder
Identication Test [AUDIT], the Drug Abuse Screening Test [DAST], etc.)
Brief Intervention: Short, structured conversations that feature feedback and options
for change
Referral: For in-depth assessment and/or diagnosis and/or treatment, if needed
Treatment: Between 1% and 10% may need some level of treatment—depending on
the health care setting
e brief intervention generally consists of recommendations to stop smoking
or to cut down on the amount of alcohol used. When the screening score indicates
dependence on alcohol or nicotine, the nurse refers the patient to specialty treatment,
providing him or her with the information needed to access a provider with expertise in
this area or a specialty health care agency.
Health providers, family members, and friends may overlook substance use by older
persons because no one reports the ways in which drug use is disrupting their lives,
because they feel that the patient has “earned it,” or patients and family do not see that
use causes health problems. Health professionals may be pessimistic that older per-
sons can change long-standing behaviors, so may not ask about drug and alcohol use.
Substance Misuse and Alcohol Use Disorders 523
Evidence suggests that many health professionals doubt the eectiveness of alcohol or
drug treatment (Vastag, 2003). In addition, health care providers often do not recognize
the association of drug use, smoking, or excessive alcohol use and health problems such
as chronic obstructive pulmonary disease (COPD), stroke, or depression. Recently,
dependence on alcohol and other drugs has been recognized as a chronic condition,
characterized by slips and relapses, and one that responds to treatment (McLellan,
Lewis, O’Brien, & Kleber, 2000). Interventions and treatment are now being matched
to stages of the disease such as acute phases, exacerbations, and stages of recovery.
Screening Tools for Alcohol and Drug Use
Screening for alcohol and other drug use is equally important in the community and
hospital setting. A QF Index such as the Khavari Alcohol Test (KAT) asks respondents to
report their (a) usual frequency of drinking, (b) usual amount consumed per occasion,
(c) maximum amount consumed on any one occasion, and (d) frequency with which
one consumes the maximum amount (Allen & Wilson, 2003). e KAT consists of the
four questions noted previously that are asked for each type of beverage (beer, wine,
spirits, liqueurs) and can be administered in 6–8 minutes (Khavari & Farber, 1978).
e amounts are then compared with NIAAA norms for persons older than 65 years,
which are one drink per day for men and women and no more than three drinks per
occasion. Additional questions such as (a) “Did you ever feel you had a problem related
to alcohol or other drug use?” and (b) “Have you ever been treated for an alcohol or
drug problem?” will yield an important additional information.
Short Michigan Alcohol Screening Test-Geriatric Version
e SMAST-G is an eective tool for screening older adults in all settings. e complete
drug use history can be obtained in the comprehensive assessment. e original instru-
ment from which this instrument was derived has a sensitivity of 93.9% and a specicity
of 78.1% (Blow et al., 1992). e SMAST-G that is composed of 10 questions is quickly
administered and short and has outcomes equal to the parent instrument. Each positive
response counts as 1 point.
Alcohol Use Disorders Identification Test
is 10-item questionnaire has good validity in ethnically mixed groups and scores
classify alcohol use as hazardous, harmful, or dependent. Administration: 2 minutes
(Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). e AUDIT has been found
to have high specicity in adults older than 65 years (Babor, Higgins-Biddle, Saunders,
& Monteiro, 2001).
Fagerström Test for Nicotine Dependence—Revised
is six-question scale provides an indicator of the severity of nicotine dependence: scores
less than 4 (low-to-moderate dependence); 4–6 (moderate dependence); and 7–10 (highly
dependent on nicotine). e questions inquire about rst use early in the day, amount
and frequency, inability to refrain, and smoking despite illness. is instrument has
good internal consistency and reliability in culturally diverse, mixed gender samples
(Pomerleau, Carton, Lutzke, Flessland, & Pomerleau, 1994).
524 Evidence-Based Geriatric Nursing Protocols for Best Practice
INTERVENTIONS AND CARE STRATEGIES
Because drug and alcohol use aects physical, mental, spiritual, and emotional health,
interdisciplinary collaboration is essential to providing the needed range of treatment
modalities for substance use disorders and related problems. Primary care providers,
psychologists, dentists, nurses, and social workers should all be equipped to detect and
refer a problem, and all dimensions of health should be addressed during treatment
and aftercare. e least intensive approaches to treatment for older adults should be
implemented rst and should be exible, individualized, and implemented over time.
Older persons are disinclined to seek or continue care with mental health or addictions
specialists. Brief interventions and motivational interviewing have been found eective
in producing short-term reduction in alcohol consumption for older persons and for
men and women. ere are some ndings that motivational interviewing is more eec-
tive with smoking than brief advices (Ballesteros, González-Pinto, Querejeta, & Ariño,
2004; Wutzke, Conigrave, Saunders, & Hall, 2002). Research ndings suggest that
once enrolled in treatment for dependence, however, older people treated for alcohol
or opioid dependence with medications such as naltrexone, methadone, or buprenor-
phine; and individualized, supportive, and medically based psychosocial interventions
have better outcomes than younger patients (Oslin, Pettinati, & Volpicelli, 2002; Satre,
Mertens, Areán, & Weisner, 2004).
Inpatient Hospitalization
Older adults who report using alcohol should be screened on admission to any care
facility. A small but important percentage of them will be at risk for the development
of acute alcohol withdrawal syndrome (AWS) on sudden cessation of drinking. Patients
at highest risk have (a) a history of consuming large amounts of alcohol, (b) coexisting
acute illness, (c) previous episodes of AWS or seizure activity, (d) a history of detoxi-
cation, and (e) intense cravings for alcohol (Letizia & Reinbolz, 2005). Symptoms of
withdrawal will be intense and of greater duration than in younger persons with onset
of withdrawal as early as 4–8 hours after the last drink and persisting up to 72 hours.
e clinical symptoms determine the need for detoxication and are essential to medi-
cal and nursing decisions. is clinical judgment is made following a history, including
history of drug and alcohol use, and physical and mental status assessments.
A 10- to 28-day period of acute care hospitalization in a mental health unit or
alcohol and drug treatment center is indicated for the older person addicted to alco-
hol, benzodiazepines, heroin, amphetamines, or cocaine when (a) living situations and
access to the drug makes abstinence unlikely, (b) there is a likelihood of severe with-
drawal symptoms, (c) comorbid physical or psychiatric diagnoses such as depression
and accompanying suicidal ideation or a chronic physical illness are present, (d) daily
ingestion of alcohol or a sedative hypnotic has been higher than recommended doses for
4 weeks or more, and (e) mixed addiction as in alcohol and benzodiazepines or cocaine
and alcohol is present. It is helpful if programs specically designed to meet the needs
of older persons are available (USDHHS, 2004a).
Ambulatory Care
Persons dependent on alcohol, tobacco, and heroin can be successfully withdrawn
in community-based care through the collaboration of a medical doctor or nurse
Substance Misuse and Alcohol Use Disorders 525
practitioner and family members and friends. Specialists in addiction should be sought
as supervisors or collaborators in the process. Older persons drinking at risky levels or
abusing alcohol or other drugs are generally treated in the community. Tobacco cessation
protocols are now available directly to consumers as well as to primary care providers
and mental health professionals.
Residential Treatment
Residential treatment is available in specialty care centers, therapeutic communities, and
some long-term care facilities. Programs designed specically for the older person are
benecial in their focus on the specic health care needs and challenges to abstinence
faced by older people. ese long-standing habits of use, a diminished social network,
and the risks of social isolation and cost and health implications of heavy alcohol and
prescription drug use make behavioral change particularly challenging.
Therapeutic Communities
erapeutic communities provide long-term (up to 18 months) treatment and are
abstinence-oriented programs. ey use 12-step models of individual and group coun-
seling, as well as participation in a social community, to address drug-related prob-
lems. For the isolated, older drug user with a history of frequent relapse, these are good
treatment options.
Pharmacological Treatment
Agents for pharmacological treatment of substance abuse and dependence are more
available but not all are appropriate for use with older adults. e best outcomes of
pharmacological interventions occur when they are used in combination with individual
and/or group counseling. Attendance at 12-step programs also supports adherence to
treatment regimens.
Alcohol Abuse amd Dependence Pharmacological Treatment
ere is strong evidence that naltrexone can decrease cravings and consumption in heavy
drinkers. It is available in liquid form for oral use and is now available in injectable,
long-acting form. It is marketed as Vivitrol or Vivitrex. ese extended-release formula-
tions of naltrexone act up to 28 days to decrease the euphoric eects of, and craving for
alcohol (Bartus et al., 2003). Evidence suggests that this treatment is well tolerated by
older people (Oslin et al., 2002). Contraindications for its use include renal problems,
acute hepatitis, or liver failure. Some study ndings stress the importance of psychoso-
cial interventions to improve adherence to pharmacological interventions for alcohol
dependence, a nding similar to those regarding smoking cessation (Mayet, Farrell,
Ferri, Amato, & Davoli, 2005). Acamprosate calcium (Campral), a recent addition to
prescription drug choices, has variable outcomes in reducing the craving for and con-
sumption of alcohol. Disulram (Antabuse) or to deter alcohol consumption produces
an elevation in vital signs and severe gastrointestinal symptoms if alcohol is ingested and
is poorly tolerated by alcoholics older than 55 years. In addition, it must be taken every
day if aversive eects on consumption are to occur, working with the patient’s family
members and support persons predicts the best outcomes with this medication.
526 Evidence-Based Geriatric Nursing Protocols for Best Practice
Opioid Dependence. e use of methadone, an opioid agonist, assists the opioid-dependent
person to focus on psychological and life problems. e drug buprenorphine—both an
opioid antagonist and agonist—is longer acting and now available. Both are dispensed
in institution-based clinic settings or by physicians specically credentialed to prescribe
and monitor buprenorphine. Evidence supports added benet of psychosocial treat-
ment for patient adherence to pharmacological treatment (Amato et al., 2008).
Smoking. Bupropion in doses of 75 mg with administration begun 2 weeks before the
smoker intends to quit has proved a helpful adjunct to smoking cessation. Nicorette
transdermal patches and nicotine gum are now available OTC and there is research sup-
port for their pharmacological contribution to smoking cessation. e best outcomes
with smoking cessation are a combination of individual or group psychosocial support
and the medications described previously (New York City Department of Health and
Mental Hygiene, 2002).
Models of Care
Individualized care plans should be developed for older adults at risk for substance
abuse or dependence in accord with the classes of drugs used and the mild, moderate,
or severe nature of the disorder. Individualizing care allows exibility for patient and
nurse. Evidence is emerging, however, on models of care for older adults with complex
health problems. For example, in one study, the integration of mental health into pri-
mary care increased access to mental health and substance abuse treatment for both
Black and White older adult patients who are oered both enhanced specialist services
and mental health services at primary care site (Ayalon, Areán, Linkins, Lynch, & Estes,
2007). Case management has also demonstrated eective outcomes with older adults
with multiple social, mental health, and physical needs with problems accessing com-
munity services, including substance abuse (Hesse, Vanderplasschen, Rapp, Broekaert,
& Fridell, 2007). Guidelines for all interventions should include the following:
n A nonjudgmental, health-oriented approach to substance-related problems.
Drug and alcohol use and abuse are highly stigmatized in American society, par-
ticularly in minority communities, leading to denial and/or rejection by family
members. Understanding addiction as a disease helps nurses and other providers
adopt attitudes and approaches similar to care for other chronic illness.
n A supportive, encouraging approach to the possibilities of changing use habits.
e patient or client is taught that change occurs in stages and that support and
assistance are available at each stage.
n Education of patient and family on the risks associated with drug misuse. Because
older persons use so many medications, the potential health consequences may
be minimized in the eyes of family members and care takers.
n Assessment of substance use in relation to life style, existing chronic illnesses, nutri-
tional patterns, sleep, exercise, sexual patterns, and recreation. Counsel the patient
and/or family about the eects of substances used on these areas of the patient’s life.
n Set the goal of “harm reduction” in the forms of decreased use and supervised use
if abstinence is not imperative or achievable.
n Monitor substance use patterns at each encounter or visit, documenting changes
and providing reinforcement of positive changes and/or movement toward
treatment.
Substance Misuse and Alcohol Use Disorders 527
n Enhance the involvement of members of the patient’s support system, includ-
ing family and friends identied by the patient, community-based groups,
support groups, appropriate clergy, or organizational groups such as senior
centers.
n Support the development of coping mechanisms, including modications in
social, housing, and recreational environments, to minimize associations with
settings and groups in which substance use and abuse are common (USDHHS,
2004a).
Counseling and Psychotherapy
Older persons tend to seek care from their primary care, medical specialist, or nurse/
nurse practitioner provider even regarding assistance with mental health and substance-
related problems. is practice derives from long-held beliefs that depression or anxiety
indicates weakness or lack of character.
Older persons, more than others, stigmatize the excess use of alcohol or use of an
illicit drug and problems with prescription drugs. Counseling done by the nurse using
a brief intervention model or supportive counseling is more readily acceptable to older
patients than referral to mental health or substance abuse clinics.
Optimally, short-term psychotherapy by a practitioner with education about abuse
and addiction is extremely helpful. e model of cognitive behavioral therapy, in particu-
lar, has demonstrated good outcomes with excessive drinking and marijuana use (Cooney,
Babor, & Litt, 2001). ese approaches assist the older person to modify behavior and to
deal with negative feelings and/or chronic pain that often motivate use.
Treatment Outcomes
Health care providers and older persons may feel pessimistic about the possibilities of
changing their substance use behavior. Health providers often do not intervene because
they believe that older people do not change. Treatment outcomes for older persons
with substance use problems, however, have been shown to be as good as or better than
those for younger people (USDHHS, 2004b). Good treatment outcomes, however,
can be compromised by inconsistency of follow-up and limited access to aftercare for
community-dwelling older adults.
Joseph and Mary P., both 71 years old, reside in a small, rural community where
Mr. P. owned the only pharmacy. Retired for 5 years, Mr. P. suers from arthri-
tis and Mrs. P. has mitral valve insuciency, which frequently results in cardiac
symptoms that are frightening but readily managed. She has also been treated for
generalized anxiety disorder for which she has been prescribed Paxil. e couple
enjoys a nightly cocktail hour at which Mr. P. consumes two scotch whiskies and
CASE STUDY
(continued)
528 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Two current trends are predicted to result in an increase in the already signicant num-
ber of men and women older than 55 years who experience various substance use disor-
ders: the growing numbers of older persons in America and the continuation of tobacco,
drug, and alcohol use patterns established earlier in life. Although most people decrease
the amount of alcohol and kinds of drugs they use with age, anywhere from 10% to
24% of older persons do not (USDHHS, 2004a). e most common of substance use
disorders is heavy drinking, especially by Caucasian men older than 65 years and liv-
ing alone (USDHHS, 2004a). e frequency of heavy drinking is closely followed by
smoking that causes the highest number of premature deaths among older people. e
high numbers of prescription drugs used by older adults pose serious problems related
to misuse and drug interactions. Health professionals are disinclined to query older
adults about substance use, with the result that problems become known in the context
of the diagnosis and treatment of other medical disorders. Nurses in daily contact with
institutionalized and community-dwelling older adults must be skilled in screening and
counseling on the use of nicotine, alcohol, prescription, illicit, and OTC drugs. Educat-
ing patient and family about health risks and referring patients to specialists and com-
munity resources are essential “best practices.”
Mrs. P. has “wine.” Recently, the visiting nurse who has been monitoring Mrs. P.’s
recovery from a recent episode of congestive heart failure received a phone call
from the couple’s daughter who stated that on her last three evening phone calls
to her parents, Mrs. P. sounded somewhat confused and her speech was slurred.
When the daughter questioned Mr. P. about their drinking, he became irritable
and defensive.
e visiting nurse made it a point to visit the P.’s in the early evening on her
way home. She found them enjoying their cocktails and took the opportunity to
conduct a drug and alcohol assessment, including making a list of all of their medi-
cations. e nurse diagnosed “drug misuse” because it appears that neither of them
considered how their continued alcohol use was aecting them. She conducted a
brief intervention, giving them feedback about their respective illnesses, pointed
out the pros and cons of modifying their drinking such as decreasing the gastric
distress Mr. P. experiences, and the benets of limited wine intake while taking par-
oxetine hydrochloride (Paxil). e nurse taught them (building on autonomy and
responsibility) about the relationship between physical changes and the eects of
alcohol on their sleep patterns, mood, and balance. She also pointed out that both
were consuming alcohol more than one daily drink and recommended that they
cut down to one standard drink per day (1.5 oz of spirits, 4–5 oz wine, or 12 oz
of beer). At rst, they seemed unhappy about the recommendation but both com-
mitted to attempting to do so. When she visited 2 weeks later, they had begun to
journal their drinking and both were recording consistent declines in the amount
of alcohol consumed.
CASE STUDY (continued)
Substance Misuse and Alcohol Use Disorders 529
Protocol 26.1: Substance Misuse and Alcohol Use Disorders
I. GOAL: Implement best nursing practices to care of older persons with drug, alcohol,
tobacco, or other drug misuse, abuse, or dependence.
II. OVERVIEW
A. Several factors increase the risks associated with alcohol and drug use for the
older individual, continuing drug use patterns that earlier in life were common-
place, can be potentially harmful. Constitutional risk factors include changes
in body composition such as decreased muscle mass, decreased organ eciency
(especially kidney and liver), and increased vulnerability of the central nervous
system (CNS).
B. Alcohol use in combination with other drugs or used excessively may result in
falls, impaired cognition, malnourishment, and decreased resistance to disease,
interpersonal, and legal problems.
C. At-risk drinking (more than one drink per day or more than three drinks
on one occasion) by older adults increases the likelihood of negative health
consequences.
D. Any smoking is considered drug abuse and places the person at risk for negative
health consequences: advancing age increases the likelihood of respiratory and
cardiovascular illnesses.
III. BACKGROUND AND STATEMENT OF THE PROBLEM
A. Denitions (APA, 2000)
1. Substance use disorders. A broad category of disorders on a continuum of
use or misuse of alcohol, tobacco, prescription, or illicit drugs and the
abuse or dependence on these drugs.
2. Substance abuse. A maladaptive pattern of substance use evidenced in
recurrent and signicant adverse consequences related to the repeated use
of substances. It is associated with repeated failure to fulll role obliga-
tions, use in situations where use is physically hazardous, and/or when it
results in legal and/or interpersonal problems.
3. Substance dependence. A maladaptive pattern of self-administering a drug that
results in the development of tolerance, withdrawal, and compulsive drug
taking behavior. Dependence is both physiological and psychological.
4. Drug misuse. Use of a drug for purposes other than that for which it was
intended.
5. Polysubstance-related disorder. Misuse, abuse, or dependence on three or
more drugs.
6. Tolerance. (a) A need for markedly increased amounts of a substance to
achieve intoxication or the desired eects or (b) a markedly diminished
eects with the continued use of the same amount of a substance.
7. Withdrawal. A characteristic group of signs and symptoms that has its
onset following the sudden cessation of consumption of a drug (including
alcohol and nicotine) that induces physiological dependence.
NURSING STANDARD OF PRACTICE
(continued)
530 Evidence-Based Geriatric Nursing Protocols for Best Practice
8. At-risk drinking. Dened as more than one drink per day, 7 days a week
or more than three drinks on any one occasion for persons 65 years and
older. For older adults, at-risk drinking increases the likelihood of negative
health consequences.
9. Relapse. Return to regular use of a substance in a maladaptive pattern.
10. Recovery. A lifestyle voluntarily maintained by an individual that includes
sobriety, varying levels of personal health, and citizenship. Recovery is
categorized as early (1–11 months), sustained (1–5 years), and beyond.
B. Etiology and/or Epidemiology: Of persons older than 50 years, 16.7% reported
drinking two or more drinks per day (risky drinking) and 19.6% reported
binge drinking on occasion. Among primary care patients older than 60 years,
15% of men and 12% of women regularly drank in excess of the NIAAA
recommended levels (one drink per day and no more than three drinks on any
one occasion).
1. e drugs used, abused, and misused most frequently by older adults
are nicotine, alcohol, and prescription drugs, particularly analgesics and
benzodiazepines.
2. Excessive drinking by individuals of all ethnic groups ages 65 years and
older is approximately 7%, down from 12% in persons ages 55–64 years.
3. Five hundred thousand persons ages 55 years and older reported monthly
use of illicit drugs in the National Household Survey on Drug Use, National
Institute on Drug Abuse.
4. Approximately 11% of women older than 59 years misuse psychoactive drugs.
C. Risk Factors (USDHHS, 2004a)
1. Family history of dependence on alcohol, tobacco, prescription, or illicit
drugs
2. Cooccurrence of addiction with dependency or abuse of another substance
dependence (i.e., alcohol and tobacco)
3. Lifelong pattern of substance use, including heavy drinking
4. Male gender
5. Social isolation
6. Recent and multiple losses
7. Chronic pain
8. Cooccurrence with depression
9. Unmarried and/or living alone
IV. PARAMETERS OF ASSESSMENT
A. Screening for alcohol, tobacco, and other drug use is recommended for all com-
munity-dwelling and hospitalized older adults. It is essential that the nurse
1. state the purpose of questions about substances used and link them to
health and safety,
2. be empathic and nonjudgmental; avoid stigmatic terms such as alcoholic,
3. ask the questions when the patient is alcohol- and drug-free,
4. inquire re: patient’s understanding of the question (Aalto, Pekuri, &
Seppä, 2003).
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
(continued)
Substance Misuse and Alcohol Use Disorders 531
B. Assessment and Screening Tools
1. e Quantity Frequency (QF) Index (Khavari & Farber, 1978): Review
all classes of drugs: alcohol, nicotine, illicit drugs, prescription drugs,
OTC drugs, and vitamin supplements, for each drug used. Record the
types of drugs, including the kinds of beverages; Frequency: the number
of occasions on which the drug is consumed (daily, weekly, monthly);
Amount of drug consumed on each occasion over the last 30 days.
e psychological function, what the drugs does for the individual, is
also important to identify. e QF Index tool should be part of the
intake nursing history. e brown bag approach is also useful. Ask the
patient to bring all drugs and supplements he or she uses in a brown bag
to the interview.
2. Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G):
Highly valid and reliable, this is a 10-item tool that can be used in all
settings. ree minutes for administration. is instrument is derived from
the MAST-G with a sensitivity of 93.6% and a positive predictive value of
87.2% (Blow et al., 1992).
3. e Alcohol Use Disorders Identication Test (AUDIT): is 10-item
questionnaire has good validity in ethnically mixed groups, and scores
classify alcohol use as hazardous, harmful, or dependent. Administration:
2 minutes. Sensitivity scores range from 0.74% to 0.84% and specicity
around 0.90% in mixed age and ethnic groups (Allen, Litten, Fertig, &
Babor, 1997). is instrument is highly eective for use with older adults
(Roberts, Marshall, & MacDonald, 2005). Its derivative, the Alcohol Use
Disorders Identication Test-Condensed (AUDIT-C), is composed of three
questions that have proved equally valid in detecting an alcohol-related
problem.
4. Fagerström Test for Nicotine Dependence (Pomerleau et al., 1994): is
six-question scale provides an indicator of the severity of nicotine depen-
dence: scores of less than 4 (very low); 4–6 (moderate), and 7–10 (very
high). e questions inquire about rst use early in the day, amount and
frequency, inability to refrain, and smoking despite illness. is instrument
has good internal consistency and reliability in culturally diverse, mixed
gender samples (Pomerleau et al., 1994).
C. Atypical Presentation
Men and women older than 65 years may have substance use and dependence
problems even though the signs and symptoms may be less numerous than
those listed in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
text rev.; DSM-IV-TR).
D. Signs of CNS Intoxication (i.e., slurred speech, drowsiness, unsteady gait,
decreased reaction time, impaired judgment, disinhibition, ataxia):
1. Assess by individual or collateral (speaking with family members) data col-
lection, detail the consumption of amount and type of depressant medica-
tions including alcohol, sedatives, hypnotics, and opioid or synthetic opioid
analgesics.
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
(continued)
532 Evidence-Based Geriatric Nursing Protocols for Best Practice
2. Obtain a blood alcohol level. Marked intoxication 5 0.3%–0.4%, toxic
eects occur at 0.4%–0.5%, coma and death at 0.5% or higher.
3. Assess vital signs and determine respiratory, cardiac, or neurological depression
4. Assess for existing medical conditions, including depression
5. Arrange for emergency room or hospitalization treatment as necessary
6. Obtain urine for toxicology, if possible
7. Assess for delirium that can be confused with intoxication and withdrawal
in the older adult.
E. At-risk drinking is regular consumption of alcohol in excess of one drink per
day for 7 days a week or more than three drinks on any one occasion.
1. Assess for readiness to change behavior using stages of change model
(Prochaska & DiClemente, 1992).
2. Is drinker concerned about amount or consequences of the drinking? Has
she or he contemplated cutting down?
3. Does she or he have a plan for cutting down or stopping consumption?
4. Has she or he previously stopped but then resumed risky drinking?
5. Personalized feedback and education on “at-risk drinking” results in a
reduction in at risk drinking among older primary care patients.
F. Treatment of acute alcohol withdrawal syndrome (guidelines are modi-
ed for other CNS depressant drugs such as barbiturates, heroin, sedative
hypnotics):
1. Assess for risk factors: (a) previous episodes of detoxication; (b) recent heavy
drinking; (c) medical comorbidities including liver disease, pneumonia, and
anemia; and (d) previous history of seizures or delirium ( Wetterling, Weber,
Depfenhart, Schneider, & Junghanns, 2006).
2. Assess for extreme CNS stimulation and a minor withdrawal syndrome
evidenced in tremors, disorientation, tachycardia, irritability, anxiety,
insomnia, and moderate diaphoresis. When these signs are not detected, life-
threatening situations for older adults often result. Withdrawal, occurring
24–72 hours after the last drink, can progress to seizures, hallucinosis,
withdrawal delirium, extreme hypertension, and profuse diarrhea from
4 to 8 hours and for up to 72 hours following cessation of alcohol intake
(delirium tremens [DTs]).
3. Assess neurological signs, using the Clinical Institute Withdrawal Assess-
ment for Alcohol, Revised (CIWA-Ar). is CIWA-Ar is a 10-item rating
scale that delineates symptoms of gastric distress, perceptual distortions,
cognitive impairment, anxiety, agitation, and headache (Sullivan, Sykora,
Schneiderman, Naranjo, & Sellers, 1989).
4. Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in
doses titrated to patient’s score on the CIWA-Ar, patient’s age and weight;
use one third to one half recommended dose (Amato, Minozzi, Vecchi, &
Davoli, 2010). Continue CIWA-Ar to monitor treatment response.
5. Provide emotional support and frequent reorientation in a cool, low stimu-
lation setting; monitor hydration and nutritional intake. Give therapeutic
dose of thiamine and multivitamins.
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
(continued)
Substance Misuse and Alcohol Use Disorders 533
G. Reported sleep disturbance, anxiety, depression, problems with attention and
concentration (acute care):
1. Assess for neuropsychiatric conditions using the mental status exam,
Geriatric Depression Scale, or Hamilton Anxiety Scale.
2. Obtain sleep history because drugs disrupt sleep patterns in older persons.
3. Assess intake of all drugs, including alcohol, OTC, prescription, herbal and
food supplements, and nicotine. Use “brown bag” strategy.
4. If positive for alcohol use, assess for last time of use and amount used.
5. Assess for alcohol or sedative drug withdrawal as indicated.
H. Smoking cigarettes or using smokeless tobacco:
1. Assess for level of dependence using the Fagerström test (see Screening Tools
for Alcohol and Drug Use section).
V. NURSING CARE STRATEGIES
A. At-risk drinking (consumption of alcohol in excess of one drink per day for
7 days a week or more than three drinks on any one occasion) or excess alcohol
consumption (more than three to four drinks on frequent occasions):
1. Conduct Screening, Brief Intervention, and as indicated, Referral to
Treatment: (SAMHSA, 2008)
a. Screen using the AUDIT-C, AUDIT, or SMAST-G
b. Feedback information to the client about current health problems or
potential problems associated with the level of alcohol or other drug
consumption.
c. Stress client‘s responsible choice about actions in response to the
information provided.
d. Advice must be clear about reducing his or her amount of drinking or
total consumption.
e. Recommend drinking according to NIAAA levels for older adults.
f. Provide a menu of choices to the patient or client regarding future
drinking behaviors.
g. Oer information based on scientic evidence, acknowledge the diculty
of change, and avoid confrontation. Empathy is essential to the exchange.
B. Support self-ecacy. Help client explore options for change.
1. Assist client in identifying options to solving the identied problem.
2. Review the pros and cons of behavior change options presented.
3. Help client weigh potential decisions by considering outcomes.
C. Smoking cigarettes or using smokeless tobacco
1. Apply the 5 A’s Intervention (Agency for Healthcare Research and Quality
[formerly the Agency for Health Care Policy and Research] Guidelines):
a. Ask: Identify and document all tobacco use.
b. Advise: Urge the user to quit in a strong personalized manner.
c. Assess: Is the tobacco user willing to make a quit attempt at this time?
d. Assist: If user is willing to attempt, refer for individual or group counseling
and pharmacotherapy. Refer to telephone “quitlines” in region or state.
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
(continued)
534 Evidence-Based Geriatric Nursing Protocols for Best Practice
e. Arrange referrals to providers, agencies, and self-help groups. Monitor
pharmacotherapy once quit date is established. e U.S. Food and Drug
Administration (FDA)-approved pharmacotherapies for smoking cessa-
tion are the following:
i. Bupropion SR (Zyban) and nicotine replacement products such as
nicotine gum, nicotine inhalers, nicotine nasal spray, and nicotine
patch. Nurse-initiated education about these medications is
essential.
ii. Zyban, for example, should not be combined with alcohol. Nurses
working with inpatients in a case management model were found
to produce outcomes in smoking cessation (Smith, Reilly, Hous-
ton Miller, DeBusk, & Taylor, 2002).
iii. Caring, concern, and provide ongoing support
2. Communicate caring and concern:
a. Encourage moderate intensity exercise to reduce cravings for nicotine
because 5 minutes of such exercise is associated with short-term reduc-
tion in the desire to smoke and tobacco withdrawal symptoms (Daniel,
Cropley, Ussher, & West, 2004).
b. Arrange: Schedule follow-up contact in person or by telephone within
1 week after planned quit date. Continue telephone counseling espe-
cially those using medications and nicotine patches (Boyle et al., 2005;
Cooper et al., 2004).
D. Alcohol Dependence
1. Assess patient for psychological dependence
2. Assess patient for (a) physiological dependence and (b) “tolerance.” Psycho-
logical dependence occurs with both abuse and dependence and is more
dicult to resolve.
3. Assess for need for medical detoxication (see alcohol withdrawal in
Inpatient Hospitalization section)
4. Refer patient and family to addictions or mental health nurse practitioner
or physician
5. Evaluate patient and family capacity to implement referral
6. On successful detoxication, monitor use of medications, interpersonal
therapies, and participation in self-help groups.
E. Marijuana Dependence: Little research on eective intervention for psycho-
logical dependence on marijuana is available. Some guidance can be found in
smoking cessation and self-help approaches.
1. Refer to steps for smoking cessation (see section C of Nursing Care
Strategies).
2. Refer patient to addiction specialist for counseling for psychological depen-
dence and/or treatment with cognitive behavioral therapy.
3. Refer to community-based self-help groups such as Narcotics Anonymous,
Alcoholics Anonymous, or Al-Anon.
4. Encourage development or expansion of patient’s social support system.
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
(continued)
Substance Misuse and Alcohol Use Disorders 535
F. Heroin or Opioid Dependence
1. Older long-term opioid users may continue use, relapse, and seek
treatment. Methadone or buprenorphine are current pharmacological
treatment options, eective in conjunction with self-help programs and/or
psychosocial interventions
2. Treatment with methadone, a synthetic narcotic agonist, suppresses with-
drawal symptoms and drug cravings associated with opioid dependence
but require daily dosing of 60 mg, minimum. It is dispensed only in state
licensed clinics.
3. Buprenorphine (Subutex or Suboxone), recently approved for use in oce
practice by trained physicians, is an opioid partial agonist–antagonist. Alone
and in combination with naloxone (Suboxone), it can prevent withdrawal
when someone ceases use of an opioid drug and then be used for long-
term treatment. Naloxone is an opioid antagonist used to reverse depressant
symptoms in opiate overdose and at dierent dosages to treat dependence
(CSAT, 2010).
a. Close collaboration with the prescriber is required because these drugs
should not be abruptly terminated, used with antidepressants, and
interact negatively with many prescription medications.
4. Naltrexone, a long-acting opioid antagonist, blocks opioid eects and is
most eective with those who are no longer opioid dependent but are at
high risk for relapse (Srisurapanont & Jarusuraisin, 2005).
5. Treatment of the older patient who has become addicted to Oxycontin or
other opioids should be done in consultation with an addictions specialist
nurse or physician.
a. It is recommended that prescribers avoid opioids and synthetic opioids
(Demerol, Dilaudid, and Oxycontin). Opioids have high potential for
addiction and Demerol has been associated with delirium in older adults
(CSAT, 2010).
b. Barbiturates should be avoided for use as hypnotics and the use of ben-
zodiazepines for anxiety should be limited to 4 months (USDHHS,
2004a).
G. Treatment and Relapse Prevention
1. Monitor pharmacological treatment such as naltrexone as short-term treat-
ment for alcohol dependence. e benets of this treatment are dependent
on adherence and psychosocial treatment should accompany its use (World
Health Organization [WHO], 2000). Methadone or buprenorphine should
be used for long-term treatment of opioid dependence.
2. Group psychotherapy in limited studies using a cognitive behavioral
approach has produced good outcomes with older adults (Payne &
Marcus, 2008).
3. Refer to community-based groups such as Alcoholics Anonymous, Narcotics
Anonymous, Al-Anon groups, and encourage attendance.
4. Educate family and patient regarding signs of risky use or relapse to heavy
or alcohol-dependent behavior.
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
(continued)
536 Evidence-Based Geriatric Nursing Protocols for Best Practice
5. Counsel patient to reduce drug use (harm reduction) and engage in
relationship healing or building, community or intellectually rewarding
activities, spiritual growth, and so on that increase valued nondrinking
rewards.
6. Counsel in the development of coping skills:
a. Anticipate and avoid temptation
b. Learn cognitive strategies to avoid negative moods
c. Make lifestyle changes to reduce stress, improve the quality of life, and
increase pleasure.
d. Learn cognitive and behavioral activities to cope with cravings and
urges to use.
e. Encourage development or expansion of patient’s social support system.
VI. EVALUATION AND EXPECTED OUTCOMES
A. Patient will have:
1. Improved physical health and function
2. Improved quality of life, sense of well-being, and mental health
3. More satisfying interpersonal relationships
4. Enhanced productivity and mental alertness
5. Decreased likelihood of falls and other accidents
B. Nurses will demonstrate:
1. Increased accuracy in detecting patient problems related to use or misuse of
substances.
2. More evidence-based interventions resulting in better outcomes.
C. Institution will have:
1. Increased number of referrals to ambulatory substance abuse and mental
health treatment programs.
2. Improved links with community-based organizations engaged in pre-
vention, education, and treatment of older adults with substance-related
disorders.
VII. FOLLOW-UP MONITORING OF CONDITION
A. Evaluate for increase in substance use or misuse associated with growing
numbers of aging adults.
B. Increase outreach to targeted vulnerable populations.
C. Document chronic care needs of older adults diagnosed with substance-related
disorders.
D. Monitor alcohol use among older adults with chronic pain.
E. Communicate ndings to all members of the caregiver team.
VIII. GUIDELINES
e National Quality Forum has published “Evidence-Based Practices to Treat
Substance Use Disorders.” ese guidelines are inclusive of primary care, the settings
in which most older adults seek treatment (National Quality Forum [NQF], 2007).
Protocol 26.1: Substance Misuse and Alcohol Use Disorders (cont.)
Substance Misuse and Alcohol Use Disorders 537
RESOURCES
Important Websites
Agency for Healthcare Research and Quality (AHRQ) Guidelines
AHRQ clinical practice guidelines are available to download.
http://www.ahrq.gov
American Lung Association
http://www.sonline.org
American Nurses Association
http://www.ana.org
American Psychiatric Association
http://www.apa.org
American Psychiatric Nursing Association
http://www.apna.org
Centers for Disease Control and Prevention
http://www.cdc.gov/tobacco/how2quit.htm
International Nurses Society on Addictions
http://www.intnsa.org/
National Institute of Mental Health
Download patient teaching materials for panic disorders, obsessive compulsive disorder, posttrau-
matic stress, acute stress, and general anxiety disorders
http://www.nih.nimh.gov
National Institute on Aging
Age page: Medications: Use them safely
http://www.nia.nih.gov/healthinformation/publications/medicine.htm
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
http://www.niaaa.nih.gov
National Institute on Drug Abuse (NIDA)
http://www.nida.nih.gov
New York City Department of Health and Mental Hygiene
http://www.nyc.gov/htm/doh/html
Assessment Tools
Alcohol Use Disorders Identication Test (AUDIT) Tool
Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development
of the Alcohol Use Disorders Identication Test (AUDIT): WHO collaborative project on early
detection of persons with harmful alcohol consumption—II. Addiction, 88(6), 791–804. Evi-
dence Level III.
Fagerström Test for Nicotine Dependence (FTND)
American Psychiatric Association. (2002). Fagerström test for nicotine dependence (FTND). Revised 1991.
American Psychiatric Association’s PsychNET 2002 http://www.apa.org/videos/fagerstrom.html
538 Evidence-Based Geriatric Nursing Protocols for Best Practice
FRAMES
Dyehouse, J., Howe, S., & Ball, S. (1996). FRAMES model in the training manual for nursing using
brief intervention for alcohol problems. Rockville, MD: U.S. Department of Health and Human
Services. Retrieved from Substance Abuse and Mental Health Association’s (SAMSA’s) pathways
courses: silence hurts:
http://pathwayscourses.samhsa.gov/vawp/vawp_supps_pg20.htm
Hartford Institute for Geriatric Nursing
Substance abuse
http://consultgerirn.org/resources
Quantity Frequency Index
Khavari, K. A., & Farber, P. D. (1978). A prole instrument for the quantication and assessment of
alcohol consumption. e Khavari Alcohol Test. Journal Studies on Alcohol, 39(9), 1525–1539.
SMAST
Naegle, M. A. (2003).Try this: Best practices in nursing care of older adults: Alcohol use screening
and assessment, Issue # 17. A series provided by e Hartford Institute for Geriatric Nursing.
Retrieved from New York University College of Nursing:
http://consultgerirn.org/uploads/File/trythis/try_this_17.pdf
Guidelines
Blow, F. C., Bartels, S. J., Brockmann, L. M., & Van Citters, A. S. (2005). Evidence-based practices for
preventing substance abuse and mental health problems in older adults. Older Americans Substance
Abuse and Mental Health Technical Assistance Center.
http://store.samhsa.gov/product/KAPT26
Michigan Quality Improvement Consortium. (2003/2005). Screening and management of substance
use disorders (p. 1, NGC:004548).
http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_5.aspx
e National Quality Forum is completing review for “Evidence-Based Practices to Treat Substance
Use Disorders.” ese guidelines are inclusive of primary care, the settings in which most older
adults seek treatment.
http://www.qualityforum.org/projects/substance_use_2009.aspx
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540 Evidence-Based Geriatric Nursing Protocols for Best Practice
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544
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able:
1. to educate nurses about elder mistreatment (EM)
2. to identify the factors that make older adults vulnerable for mistreatment
3. to highlight the ill eects EM may have on an older adults’ overall health status
4. to provide a framework for identifying, reporting, and managing cases of EM
OVERVIEW
Most nurses in the acute care setting have likely provided care for an older adult suf-
fering from elder mistreatment (EM) without knowing it. In a report published by the
United Nations (2007), it is estimated that the number of older adults worldwide is
expected to triple by the year 2050. Cases of EM are expected to become more prevalent
given the expected surge of older adults. In 2000, older adults comprised 13% of the
U.S. population. By 2030, it is predicted that adults older than 65 will increase to 20%
of the American population (Ebersole & Touhy, 2006). With a 274% increase since
1960, adults 85 years or older, commonly referred to as the “oldest old,” are the fastest
growing sector of the American population (Cowen & Cowen, 2002). e oldest old
are at the greatest risk for EM because of increased vulnerability and dependence on
caregivers for many aspects of care. is drastic increase in older adults may only serve
to exacerbate the issue of EM. Technological advances of the past century have made
it possible for those with chronic diseases to live longer; however, they require greater
assistance in activities of daily living (ADL) and management of care. Now, more than
ever before, it is imperative for nurses to become better educated about EM and its
complexities (Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009).
Nurses in the hospital setting serve an important role in recognizing EM because
they are often the rst health care professionals to perform a detailed medical history or
Billy Caceres and Terry Fulmer
Mistreatment Detection
27
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Mistreatment Detection 545
physical assessment. eir presence at the patient’s bedside aords nurses the opportu-
nity for direct contact with caregivers, rsthand observations of caregivers’ interactions
with patients, and identify red ags (Cohen, Halevi-Levin, Gagin, & Friedman, 2006).
ese factors place nurses in the unique and dicult role to assess, identify, and act in
cases of EM more often than other members of interdisciplinary health care teams.
Nursing has had a long history in ensuring high standards of care for older adults. e
identication of EM should not be the exception. In spite of this, nurses’ lack of training
and knowledge of the extent of EM and its presentation may hinder their ability to iden-
tify the signs of mistreatment. Abuse is often multifactorial; therefore, it is important to
recognize that it is an interplay between characteristics of the abused, the perpetrator,
and environmental factors (Killick & Taylor, 2009). Physical markers of abuse are often
incorrectly attributed to physiological changes in the elderly rather than EM (Wiglesworth
et al., 2009). Cases of EM can prove to be challenging for nurses as it is often complicated
by denial on the part of the perpetrator and older adult, refusal of services by victims, as
well as fears that an accusation of EM may actually worsen abuse. Serious ethical dilemmas
may arise because a nurse may struggle between his or her obligation to ensure the patient’s
well-being and uncertainty over presence of EM (Beaulieu & Leclerc, 2006). e develop-
ment of EM protocols that are grounded in evidence-based research is crucial to ensure
that EM cases are properly handled by nurses and other health care professionals.
BACKGROUND AND STATEMENT OF PROBLEM
Recent data suggest that in the United States, more than 2 million older adults suer
from at least one form of EM each year (National Research Council [NRC], 2003).
e National Elder Abuse Incidence Study estimated that more than 500,000 new cases
of EM occurred in 1996 (National Center on Elder Abuse [NCEA], 1998). A recent
study by Acierno and colleagues (2010) estimated the prevalence of EM within a 1-year
period to be approximately 11%. Although 44 states and the District of Columbia have
legally required mandated reporting, EM is severely underreported. ere is a lack in
uniformity across the United States on how cases of EM are handled. Cases of EM are
managed dierently state by state with varying methods of investigation and interven-
tion (Jogerst et al., 2003). NCEA (1998) estimates that only 16% of cases of abuse are
actually reported. In a systematic review, one-third of health care professionals included
believe they had detected a case of EM; however, only about 50% had actually reported
the case (Cooper, Selwood & Livingston, 2009). Similarly, another study found that
despite 68% of emergency medical services sta surveyed stating they felt they had
encountered a case of EM in the past year, only 27% had actually made a report (Jones,
Walker, & Krohmer, 1995). Despite mandatory reporting on the part of health care
professionals, it is believed that many are not reporting all cases of EM that they detect
(Killick & Taylor, 2009).
is creates several issues in terms of obtaining an accurate sense of the scope of EM
in the country and may have serious detrimental eects for the older adults suspected
of being victims of EM.
Conicting theories of causation and lack of uniform screening approaches have
further complicated EM detection. Understandably, it has been dicult for nurses to
adequately respond to cases of EM when they are unclear about its manifestations,
causes, and detection strategies. EM researchers agree that as the population continues
to age exponentially, cases of EM will reach epidemic levels.
546 Evidence-Based Geriatric Nursing Protocols for Best Practice
A lack of universally accepted denitions for dierent types of EM has hampered
eorts to ascertain what constitutes EM. In an eort to establish a clear consensus, the
NRC (2003) dened elder mistreatment as either “intentional actions that cause harm
or create serious risk of harm (whether harm is intended) to a vulnerable elder by a care-
giver or other person who is in a trust relationship to the elder,” or “ failure by a caregiver
to satisfy the elder’s basic needs or to protect himself or herself from harm.”
Types of Elder Mistreatment
Six types of mistreatment are generally included under the term EM. Table 27.1 describes
each form of EM as well as examples of each.
e use of the term mistreatment rather than abuse further underscores a crucial
feature of EM; that EM is the outcome of the actions abuse, neglect, exploitation,
or abandonment. Abuse and neglect can then be further classied as intentional or
unintentional. Intentional neglect might be seen as a conscious disregard for caretaking
duties that are inherent for the well-being of the older adult. Unintentional neglect
might occur when caregivers lack the knowledge and resources to provide quality care
(Jayawardena & Liao, 2006).
TABLE 27.1
Forms of Elder Mistreatment
Type of EM Definition Examples
Physical abuse The use of physical force that may
result in bodily injury, physical pain,
or impairment
Hitting, beating, pushing, shoving,
shaking, slapping, kicking, burning,
inappropriate use of drugs, and
physical restraints
Sexual abuse Any form of sexual activity or
contact without consent, including
with those unable to provide
consent
Unwanted touching, rape, sodomy,
coerced nudity, and sexually explicit
photographing
Emotional/
psychological
abuse
The infliction of anguish, pain,
or distress through verbal or
nonverbal acts
Verbal assaults, insults, threats, intimi-
dation, humiliation, harassment, and
enforced social isolation
Financial abuse/
exploitation
The illegal or improper use of an
elder’s funds, property, or assets
Cashing a person’s checks without
authorization or permission; forging a
signature; misusing or stealing money
or possessions; coercing or deceiving a
person into signing any document; and
the improper use of conservatorship,
guardianship, or power of attorney
Caregiver neglect The refusal or failure to fulfill any
part of a person’s obligations or
duties to an older adult, including
social stimulation
Refusal or failure to provide life
necessities such as food, water, clothing,
shelter, personal hygiene, medicine,
comfort, and personal safety
Self-neglect The behavior of an elderly person
that threatens his or her own
health or safety. Disregard of one’s
personal well-being and home
environment.
Refusal or failure to provide oneself with
adequate food, water, clothing, shelter,
personal hygiene, medication (when
indicated), and safety precautions
Source: Fulmer, T., & Greenbery, S. (n.d.). Elder mistreatment & abuse. Retrieved from
http://consultgerirn.org/resources
Mistreatment Detection 547
Neglect, whether intentional or unintentional, is recognized as the most commonly
occurring form of EM. NCEA (1998) revealed that neglect accounts for approximately
half of all cases of EM reported to Adult Protective Services (APS). About 39.3% of
these cases were classied as self-neglect and 21.6% attributed to caregiver neglect,
including both intentional and unintentional. More than 70% of cases received by APS
are attributed to cases of self-neglect with those older than 80 years thought to represent
more than half of these cases (Lachs & Pillemer, 1995).
ere is much debate as to whether self-neglect should be included as a type of
EM. Although other forms of EM occur because of the action or inaction of an outside
perpetrator, in self-neglect, the perpetrator and victim are one and the same (Anthony,
Lehning, Austin, & Peck, 2009). Several international studies studying perceptions of
EM identied caregiver neglect as the most common and accepted form of EM among
participants (Daskalopoulos & Borrelli, 2006; Mercurio & Nyborn, 2006; Oh, Kim,
Martins, & Kim, 2006; Stathopoulou, 2004; Yan & Tang, 2003). Subjects identied
family members as the caregivers more likely to be perpetrators. Shockingly, neglect was
seen as a “quasi-acceptable” form of abuse, whereas physical and emotional/ psychological
abuses were viewed as extreme and harsh.
Theories of Elder Mistreatment
e concept of vulnerability has been central to the discussion of EM. Fulmer and
colleagues (2005) conducted a study of older adult patients recruited through emer-
gency departments in two major cities. e goal was to identify factors within the older
adult–caregiver relationship that may predispose some older adults to be victims of
neglect over others. e theoretical framework of the study is the risk-and-vulnerability
model, which posits that neglect is caused by the interaction of factors within the older
adult or in his or her environment. e risk and vulnerability model adapted to EM
by Frost and Willette (1994) provides an appropriate model through which to examine
EM (Frost & Willette, 1994; Fulmer et al., 2005). Vulnerability is determined by char-
acteristics within the older adult that may make him or her more likely to be victims
of EM such as poor health status, impaired cognition, history of abuse, and so forth.
Risks refer to factors in the external environment that may predispose to EM. ese may
include characteristics of caregivers such as health status and functional status, as well as
a lack of resources and social isolation (Fulmer et al., 2005). It is the interaction between
risk and vulnerability that can predispose some older adults to EM (Killick & Taylor,
2009; Paveza, Vanderweerd, & Laumann, 2008).
e risk and vulnerability model as well as other theories from the literature on
family violence have been adapted from the health and social sciences literature in an
eort to nd probable theories for EM. However, there has been no clear consensus on
one theory that explains EM (Fulmer, Guadagno, Bitondo Dyer, & Connolly, 2004).
e development of assessment interventions and strategies that cross multiple theoreti-
cal frameworks is likely to be the most clinically appropriate strategy (NRC, 2003).
eories of EM include but are not limited to the following:
1. Situational theory: Promotes the idea that EM is a result of caregiver strain due to the
overwhelming tasks of caring for a vulnerable or frail older adult (Wolf, 2003).
2. Psychopathology of the abuser: Abuse is believed to stem from a perpetrator’s own
battle with psychological illness such as substance use, depression, and other mental
disorders (Wolf, 2003).
548 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Exchange theory: Speculates that the long-established dependencies present in the
victim–perpetrator relationship are part of the “tactics and response developed in
family life, which continue into adulthood” (Wolf, 2003).
4. Social learning theory: Attributes EM to learned behavior on the part of the perpetrator
or victim from either their family life or the environment; abuse is seen as the norm
(Wolf, 2003).
5. Political economy theory: Focuses on how older adults are often disenfranchised in
society as their prior responsibilities and even their self-care are shifted on to others
(Wolf, 2003).
Dementia and Elder Mistreatment
Older adults with dementia are particularly vulnerable to EM. As the population of older
adults increases, it is expected that so will the number of older adults with dementia
( Wiglesworth et al., 2010). It is estimated that older adults with dementia will rise from
4.5 million in 2000 to 13 million by the year 2050 (Hebert, Scherr, Bienias, Bennett,
& Evans, 2003). Because of the cognitive decits present in older adults with dementia,
it is particularly dicult to screen for EM. e older adult may not be able to give a
reliable history, and signs of EM may be masked or mimicked by disease ( Fulmer et al.,
2005). ose providing care for older adults with dementia are at particular risk for
caregiver strain and burnout. Disruptive behavior such as screaming or wailing, physical
aggression, or crying can be exhausting for caregivers in any setting (Lachs, Becker,
Siegal, Miller, & Tinetti, 1992).
One study reported that as many as 47% of older adults with dementia were victims
of some form of EM (Wiglesworth et al., 2010). e researchers used a combination of
two screening instruments as well as a caregiver self-report. Similarly, in a systematic review,
one-third of caregivers of older adults with dementia were willing to admit to some form
of EM, whereas 5% admitted to physical abuse (Cooper, Selwood, & Livingston, 2008).
In a community-based study of caregivers of older adults with dementia, 51% of caregivers
admitted to verbal abuse and 16% to physical abuse. However, only 4% admitted to neglect
(Cooney, Howard, & Lawlor, 2006). e ramications of these data are sobering. If 30%
will admit to EM, there is every reason to worry regarding EM in those who do not report.
Objective assessment alone cannot capture all cases of EM and, thus, a policy is
needed that incorporates both objective measures as well as a discussion with both the
older adult and caregiver (Cooper et al., 2008). Most caregivers are forthcoming with
admission of EM and many of them ask for help in developing coping strategies and
plans of care to provide better care for care recipients (Wiglesworth et al., 2010).
ASSESSMENT OF THE PROBLEM
e American Medical Association (AMA, 1992) released a set of guidelines and
recommendations in 1992 on the management of EM. e AMA urged providers that
all older adults should be screened for EM. Many hospitals already include EM screening
as part of the admission process for all patients older than 65 years old. Assessment of
EM is not an easy task. Subtle signs of EM are hard to identify and even harder to
substantiate (Anthony et al., 2009). Rates of reporting on the part of health care pro-
fessionals are still low due in large part to ageism in society and lack of education and
training on the assessment, detection, and reporting of EM. Unsubstantiated fears exist
Mistreatment Detection 549
that increasing education on assessment of EM will lead to higher rates of false positive
cases and, therefore, expense and disruption in the system. However, a systematic review
of 32 studies revealed that health care professionals educated about EM were not more
likely to detect EM cases but were more inclined to report detected cases than those that
had little or no education related to EM (Cooper et al., 2009).
e complexity and variability of most cases of EM makes it hard to describe what
a typical perpetrator or a victim looks like. ere is no correlation found between age,
gender, race, and any association with EM (Krienert, Walsh, & Turner, 2009). Hence,
it is dicult to describe who is a “typical” victim or perpetrator of EM. Some research
suggests that victims of EM are more likely to be unable to provide for self-care needs
on their own because of cognitive or physical decits and have a history of depres-
sion (Giurani & Hasan, 2000). In a small scale, victims of EM had lower scores on
cognitive screens using the mini-mental status exam (MMSE) and greater functional
decits as scored with the Katz Index of Independence in ADL. ey also had higher
rates of depression when screened with the Geriatric Depression Scale (GDS) scores
(Dyer, Pavlik, Murphy, & Hyman, 2000). ese studies support earlier ndings from a
longitudinal study on factors inuencing mortality of victims of EM (Lachs, Williams,
O’Brien, Pillemer, & Charlson, 1998). Others (Draper et al., 2008; Fulmer et al., 2005)
have also identied a link between childhood abuse among victims and physical and
sexual EM later in life. A lack of social support and social isolation increase the risk for
EM in older adults (Acierno et al., 2010; Dong & Simon, 2008; Fulmer et al., 2005).
Research suggests perpetrators are more likely to be family members, report greater
caregiver strain, live with the victim, have a history of mental illness and/or depression,
history of substance abuse, have lived with the victim for an extended time (approxi-
mately 9.5 years), have few social supports, and have a long history of conicts with the
victim (Cowen & Cowen, 2002; Giurani & Hasan, 2000; Wiglesworth et al., 2010).
In the clinical setting while conducting an EM screen, it is recommended to sepa-
rate the older adult from the caregiver and obtain a detailed history and physical assess-
ment (Heath & Phair, 2009). Special attention should be paid to both physical and
psychological signs of EM. Discrepancies between injury presentation or severity and
the report of how the injury occurred as well as discrepancies between explanations
from the caregiver and older adult should be paid close attention. Physically abused
older adults are more likely to have signicantly larger bruises and to know the cause
of their bruise. Further, these abused older adults are more likely to display bruising on
the face, lateral aspect of the right arm and the posterior torso (including back, chest,
lumbar, and gluteal regions; Wiglesworth et al., 2009). Other possible indicators of
physical abuse include bruises at various stages of healing, unexplained frequent falls,
fractures, dislocations, burns, and human bite marks (Cowen & Cowen, 2002).
It is important to distinguish that signs and symptoms of EM may vary depending on
the type of abuse. Table 27.2 provides strategies for assessment of each type of EM. Victims
of sexual abuse are more likely to be female and exhibit “genital or urinary irritation or
injury; sleep disturbance; extreme upset when changed, bathed, or examined; aggressive
behaviors; depression; or intense fear reaction to an individual” (Chihowski & Hughes,
2008, p. 381). Ageist attitudes among health care professionals may limit the amount of
cases of sexual abuse that are identied as older adults are rarely thought of as the usual vic-
tims of abuse (Vierthaler, 2008). Victims of nancial abuse are harder to identify; however,
they share similar traits such as social isolation, physical dependency, and mental disorders
as victims of emotional or psychological abuse and neglect (Peisah et al., 2009).
550 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 27.2
Assessment of Elder Mistreatment
Type of
Mistreatment
Questions Used to
Assess Type of EM
Physical Assessment and Signs
and Symptoms
Physical abuse Has anyone ever tried to hurt you in any
way?
Have you had any recent injuries?
Are you afraid of anyone?
Has anyone ever touched you or tried to
touch you without permission?
Have you ever been tied down?
Suspected evidence of physical abuse
(i.e., black eye) ask:
—How did that get there?
—When did it occur?
—Did someone do this to you?
— Are there other areas on your body
like this?
—Has this ever occurred before?
Assess for:
bruises (more commonly bilaterally
to suggest grabbing), black eyes,
welts, lacerations, rope marks,
fractures, untreated injuries, bleed-
ing, broken eyeglasses, use of
physical restraints, sudden change
in behavior.
Note if a caregiver refuses an
assessment of the older adult
alone.
Review any laboratory tests. Note
any low- or high-serum prescribed
drug levels.
Note any reports of being
physically mistreated in any way.
Emotional/
Psychological
abuse
Are you afraid of anyone?
Has anyone ever yelled at you or
threatened you?
Has anyone been insulting you and
using degrading language?
Do you live in a household where there
is stress and/or frustration?
Does anyone care for you or provide
regular assistance to you?
Are you cared for by anyone who
abuses drugs or alcohol?
Are you cared for by anyone who was
abused as a child?
Assess cognition, mood, affect, and
behavior.
Assess for:
agitation, unusual behavior, level of
responsiveness, and willingness to
communicate.
Delirium
Dementia
Depression
Note any reports of being verbally or
emotionally mistreated.
Sexual abuse Are you afraid of anyone?
Has anyone ever touched you or tried to
touch you without permission?
Have you ever been tied down?
Has anyone ever made you do things
you did not want to do?
Do you live in a household where there
is stress and/or frustration?
Does anyone care for you or provide
regular assistance to you?
Are you cared for by anyone who
abuses drugs or alcohol?
Are you cared for by anyone who was
abused as a child?
Assess for:
bruises around breasts or genital
area; sexually transmitted diseases;
vaginal and/or anal bleeding; or
discharge, torn, stained, or bloody
clothing/ undergarments.
Note any reports of being sexually
assaulted or raped.
(continued)
Mistreatment Detection 551
TABLE 27.2
Assessment of Elder Mistreatment (continued)
Type of
Mistreatment
Questions Used to
Assess Type of EM
Physical Assessment and Signs
and Symptoms
Financial abuse/
exploitation
Who pays your bills?
Do you ever go to the bank with
him or her?
Does this person have access to your
account(s)?
Does this person have power of attorney?
Have you ever signed documents you
did not understand?
Are any of your family members
exhibiting a great interest in your assets?
Has anyone ever taken anything that
was yours without asking?
Has anyone ever talked with you before
about this?
Assess for:
changes in money handling or bank-
ing practice, unexplained withdraw-
als or transfers from patient’s bank
accounts, unauthorized withdrawals
using the patient’s bank card, addi-
tion of names on bank accounts/
cards, sudden changes to any
financial document/will, unpaid bills,
forging of the patient’s signature,
appearance of previously uninvolved
family members.
Note any reports of financial exploi-
tation.
Caregiver neglect Are you alone a lot?
Has anyone ever failed you when you
needed help?
Has anyone ever made you do things
you did not want to do?
Do you live in a household where there
is stress and/or frustration?
Does anyone care for you or provide
regular assistance to you?
Are you cared for by anyone who
abuses drugs or alcohol?
Are you cared for by anyone who was
abused as a child?
Assess for: dehydration, malnutrition,
untreated pressure ulcers, poor
hygiene, inappropriate or inadequate
clothing, unaddressed health prob-
lems, nonadherence to medication
regimen, unsafe and/or unclean living
conditions, animal/insect infestation,
presence of lice and/or fecal/urine
smell, and soiled bedding.
Note any reports of feeling
mistreated.
Self-neglect How often do you bathe?
Have you ever refused to take
prescribed medications?
Have you ever failed to provide yourself
with adequate food, water, or clothing?
Assess for:
dehydration, malnutrition, poor
personal hygiene, unsafe living condi-
tions, animal/insect infestation, fecal/
urine smell, inappropriate clothing,
nonadherence to medication regimen.
Source: Fulmer, T., & Greenbery, S. (n.d.). Elder mistreatment & abuse. Retrieved from
http://consultgerirn.org/resources
Since the 1970s, a myriad of screening instruments have been developed to detect
cases of EM, but few are appropriate for inpatient older adults. Most have had limited
testing in the acute care setting and focus on in-home assessments or extensive questions
that are better suited for primary care settings.
e Elder Assessment Instrument (EAI) developed by Fulmer and colleagues (2004)
is a 41-item screening instrument that requires training on how to administer it but has
been proven eective in busy hospital settings (Perel-Levin, 2008). e current EAI-R
(revised in 2004) is considered more appropriate for inpatient and outpatient clinics
because it relies on objective assessment by the clinician such as general appearance,
assessment for dehydration, physical and psychological markers, or pressure ulcers as
well as subjective information received from the patient.
552 Evidence-Based Geriatric Nursing Protocols for Best Practice
e Hwalek-Sengstock Elder Abuse Screening Test (HS-EAST) is a 15-item instrument
that relies on self-report from older adults and is documented as appropriate for detecting
physical abuse, vulnerability, and high-risk situations. Some instruments focus on the care-
giver, but an advantage of HS-EAST is the focus on the older adult history. It is regarded as
appropriate for use in the hospital setting and can be easily administered by nurses (Fulmer
et al., 2004; Perel-Levin, 2008). If a positive screen is noted, detailed physical assessment
and medical history should be completed to substantiate possible abuse. Referral to experts
in trauma or geriatrics, either on or o site, should take place for the best available input.
In addition to these screening instruments for EM, there are a number of other reliable
and valid instruments that can aid nurses in identifying those at risk for EM. As discussed
previously, victims of EM tend to have lower functional and cognitive capabilities than
their counterparts. e Katz Index of Independence in ADL and/or the Lawton instru-
mental activities of daily living (IADL) scale may help in detecting older adults with func-
tional decits (Graf, 2007; Wallace, 2007). Similarly, with higher rates of depression in
victims of EM, the GDS may be a useful instrument for nurses to use in the hospital set-
ting. It is a 15-item screening instrument that is eective at distinguishing depressed older
adults (Kurlowicz & Greenberg, 2007). In the literature, perpetrators of EM often report
higher caregiver strain. e Modied Caregiver Strain Index (CSI) is a reliable and self-
administered instrument that can aid in assessing caregivers that may benet from inter-
vention strategies to alleviate stress involved with caregiving demands (Sullivan, 2007).
e process of identifying cases of self-neglect is oftentimes even more daunting
than other cases of EM. Assessing self-neglect is further complicated by a lack of stan-
dardized screening instruments or markers for detection (Dyer et al., 2006; Kelly, Dyer,
Pavlik, Doody, & Jogerst, 2008; Mosqueda et al., 2008). Several researchers are currently
developing screening instruments for self-neglect. However, their use in the acute care
setting is limited. Most require in-depth assessments of home life and are based mostly
on objective ndings from the health care professional. Nevertheless, data suggests that
detection of self-neglect in the hospital setting is unfortunately made easier because
by the time these cases reach the hospital, they are often very severe (Mosqueda et al.,
2008). Signs of self-neglect may include lack of adequate nutrition such as dehydration;
changes in weight; poor hygiene and appearance such as soiled clothing, uncombed hair,
debris in teeth; poor adherence to medical treatments such as unlled prescriptions;
refusing to perform dressing changes; poor glucose monitoring; and so forth (Cohen et
al., 2006; Naik, Teal, Pavlik, Dyer, & McCullough, 2008). Objective measures as well
as questioning of the older adult about health patterns and activities of self-care are also
important factors in detecting self-neglect because it can yield important information
about attitudes and opinions of the older adult.
INTERVENTIONS AND CARE STRATEGIES
Detailed screening of older adults at risk for EM is the rst step in identifying cases
of EM (Perel-Levin, 2008). ere are various screening instruments that can help in
revealing older adults and caregivers at risk for EM. Setting aside time to meet with
the older patient and their caregiver separately is an important aspect of the screening
process. is can highlight any inconsistencies in depictions of how injuries occur, allow
the nurse to develop a closer relationship with each, as well as express his or her willing-
ness to help each party.
Nurses should not work alone in detecting cases of EM but, instead, should include
professionals from other disciplines as much as possible. According to the literature,
Mistreatment Detection 553
when EM is suspected, the use of interdisciplinary teams with professionals from both
the acute care and community settings is the best approach to managing such cases
(Wiglesworth, Mosqueda, Burnight, Younglove, & Jeske, 2006). Institutions should
develop clear guidelines for practitioners to follow when cases of EM are identied
(Perel-Levin, 2008). Referral to appropriate community organizations is paramount
to ensure safe discharges for suspected victims of EM. Interdisciplinary teams work
best when they include team members with expertise in various disciplines including
nursing, social work, law, and so forth. It is this diversity of skills that allows for innova-
tive approaches to managing cases of EM (Jayawardena & Liao, 2006).
Educating older adults, sta, and caregivers about the nature of EM is key. It is
crucial to educate older adults that have the cognitive capacity to accept or refuse
interventions about patterns of EM such that abuse tends to increase in severity over
time (Cowen & Cowen, 2002; Phillips, 2008). For individuals who lack the cognitive
capacity to consent for interventions, it is important to report these cases to APS and
develop a plan for safe discharge. Older adults should receive emergency contact infor-
mation as well as community resources (Cowen & Cowen, 2002).
Interdisciplinary teams should also take into account the diculties caregivers may
experience in caring for adults with diminished functional and/or cognitive capacity and
provide these caregivers with support services and interventions of their own to assist them
in providing the best care they can (Lowenstein, 2009). Services should be oered not only
to victims of EM but also to their suspected perpetrators. Helping caregivers gain a better
understanding of proper care techniques may help alleviate cases of neglect in particular.
Because of the nature of hospital stays, most of the long-term interventions currently
occur in the community setting. A systematic review of interventions for EM revealed
that interventions tend to concentrate on the situational theory of abuse by focusing
on education, counseling, and social support for perpetrators of EM to better cope
with stressors of caregiving (Ploeg et al., 2009). However, even these community-based
interventions have shown mixed results in terms of eectiveness when studying factors
such as risk of recurrence of EM; levels of depression and self-esteem in older adults; and
levels of caregiver strain, stress, and depression in caregivers (Ploeg et al., 2009).
In the acute care setting, patients are assumed to have the autonomy to refuse medical
treatments and participate in care management as long as there are deemed to be able to
give informed consent. However, what can be done if the older adult is refusing to perform
activities deemed essential for their health and well-being? e answer, at the moment, is
very little because there is currently no rigorously tested screening instrument to assess
cognitive capacity in this population (Naik et al., 2008). Naik et al. (2008) discuss the
ethical dilemma that is present when an older adult is suspected of self-neglect. If the older
adult is deemed to have the cognitive capacity to make decisions about their own self-
care, there is very little that health care professionals can do to intervene. Interdisciplinary
health care teams are thought to be the most eective way of identifying self-neglect.
Although it may seem dicult and costly to implement interdisciplinary health care teams
to adequately treat this group of older adults, the costs of not connecting these individuals
to proper resources can be much greater as their health conditions can go undiagnosed and
untreated for longer time, therefore creating greater health care costs (Lowenstein, 2009).
ere is inherent diculty in evaluating the success of interventions implemented
in acute care organizations. e nature of discharges makes it dicult to learn about
outcomes in cases of EM. Not all suspected victims of EM will return to the same
institution for repeat visits, and condentiality issues can restrict information sharing
among health care professionals.
554 Evidence-Based Geriatric Nursing Protocols for Best Practice
Mr. Jack is an 89-year-old male admitted to a medical unit for dehydration. His
77-year-old wife is at his bedside. Upon initial assessment, the nurse notices Mr. Jack
is confused, weak, and pale. He is also underweight with a body mass index (BMI) of
16. When asked about his cognitive status, Mrs. Jack reports that he was diagnosed
with early dementia last year.
His vital signs are as follows: blood pressure of 88/46 mm Hg, heart rate of
123 beats per minute, respiratory rate of 26 breaths per minute, and a temperature of
101.8 °F. He is unable to verbalize a pain score; however, he does not appear to be in
any pain at this moment.
Upon performing an EM assessment, the nurse gathers the following information
from Mrs. Jack: Her husband has lost a total of 20 pounds in recent months and
has been refusing to eat for the past week. Mrs. Jack’s mobility is limited because of
multiple sclerosis and their neighbor who used to accompany them to appointments
has moved away. eir son, John, had to move in with them a year ago after he lost his
job. Mr. Jack and his son have never had the best relationship and often argue about
their living arrangements that have made them all very depressed. Also, John has
stopped searching for a job and drinks alcohol often. John refuses to take Mr. Jack to
see his primary care provider stating that these changes in his health are “just because
he’s so old.”
Mr. Jack is now on intravenous hydration and is being followed by a dietitian
regarding his nutrition. His vital signs and mental status have improved. Further testing
reveals Mr. Jack has an esophageal tumor, which may be the cause of his discomfort.
Discussion
is may be considered a case of neglect and/or psychological abuse. eir son knows
that his father’s health has been deteriorating and yet refuses to obtain him proper
medical attention. He also often argues with his father and may be abusing alcohol.
From Mrs. Jack’s report, there is no evidence of other forms of EM; however, the case
should be investigated further. Although the nurse has yet to meet John, there are a
number of signs to indicate that neglect or psychological/emotional abuse may be
occurring in this home. As a mandated reporter, the nurse should report this case if he
or she suspects any form of EM is present.
A number of risk factors are present in this family to alert the nurse to possible
EM. For example, Mr. Jack has cognitive decits because of dementia and is frail
because of his present cancer diagnosis. In addition, his wife has several functional
decits because of her multiple sclerosis; she reports feeling depressed by her current
situation and lacks a solid support system.
e nurse should discuss the case with Mr. Jacks’ medical team as well as his
social worker. e dietitian would be the good source of information for the family
about Mr. Jack’s nutritional needs. e nurse should collaborate with the family and
interdisciplinary team to identify community services for this family.
CASE STUDY
Mistreatment Detection 555
SUMMARY
With a rapidly aging population, it is likely that cases of EM will become more prevalent.
Although most research on EM has focused on EM in the community and long-term care
settings, the acute care setting is a good location for the identication of those at risk for
EM. EM prevalence is hard to estimate, yet most experts in the eld believe it is heavily
underreported because of various factors. As providers of care, it is nurses’ responsibility
to develop an understanding and appreciation for the complexities involved in detecting
and responding to cases of EM. e recognition of markers of EM is an important step
in guaranteeing that older adult patients are receiving high-quality care.
e dierent manifestations and types of EM often make it challenging for nurses
to determine the best course of action. However, the strategies included in this chapter
serve as a framework to help nurses navigate these types of situations. ese strategies
include best practices from the literature on EM that is applicable for acute care nurses.
Nurses serve as important advocates for older adults who may not be able to protect
themselves from EM. ey should encourage their institutions to develop guidelines for
managing suspected cases of EM as well as establishing interdisciplinary teams to decide
how to best respond in these circumstances. EM detection should be embedded within
admission and nursing assessments of older adults. ere is no telling how many older
adults and their caregivers may benet from a greater focus on EM. It is only through
education and the use of interdisciplinary teams to respond to EM cases that nurses can
ensure the safety and well-being of older adults in their care.
Protocol 27.1: Detection of Elder Mistreatment
I. GOAL: Identify best practices in identifying and responding to cases of EM
II. OVERVIEW: With the projected increase in the population of older adults world-
wide and the rise in medical and technological advances, it is anticipated that older
adults will be living longer. erefore, it is expected that cases of EM, although cur-
rently underreported, will be on the rise. As patient advocates and providers of care,
nurses serve an important function in the screening and treatment of cases of EM.
However, current data shows that nurses and other health care professionals are not
reporting all cases of EM they encounter either because of lack of knowledge about
manifestations of EM or how reporting and investigation by state agencies functions.
III. BACKGROUND/STATEMENT OF PROBLEM
A. Denitions
1. Elder mistreatment: “Intentional actions that cause harm or create serious
risk of harm (whether harm is intended) to a vulnerable elder by a care-
giver or other person who is in a trust relationship to the elder,” or “failure
by a caregiver to satisfy the elder’s basic needs or to protect himself or
herself from harm (NRC, 2003).” Conicting casual theories of EM:
NURSING STANDARD OF PRACTICE
(continued)
556 Evidence-Based Geriatric Nursing Protocols for Best Practice
2. Physical abuse: e use of physical force that may result in bodily injury,
physical pain, or impairment (NCEA, 2008).
3. Sexual abuse: Any form of sexual activity or contact without consent,
including with those unable to provide consent (NCEA, 2008).
4. Emotional/psychological abuse: e iniction of anguish, pain, or distress
through verbal or nonverbal acts (NCEA, 2008).
5. Financial abuse/exploitation: e illegal or improper use of an elder’s funds,
property, or assets (Naik et al., 2008).
6. Caregiver neglect: e refusal or failure to fulll any part of a person’s
obligations or duties to an older adult, including social stimulation
(NCEA, 2008).
7. Self-neglect: e behavior of an older adult that threatens his or her
own health or safety. Disregard of one’s personal well-being and home
environment (NCEA, 2008).
8. Risk-vulnerability model: Posits that neglect is caused by the interaction
of factors within the older adult and his or her environment. e risk
and vulnerability model adapted to EM by Frost and Willette (1994)
provides a good lens through which to examine EM. Vulnerability is
determined by characteristics within the older adult that may make him
or her more likely to be abused by caregivers such as poor health status,
impaired cognition, history of abuse, and so forth. Risks refer to fac-
tors in the external environment that may contribute to EM (Frost &
Willette, 1994; Fulmer et al., 2005).
9. Psychopathology of the abuser: Abuse is believed to stem from a perpetrator’s
own battle with psychological illness such as substance use, depression,
and other mental disorders (Wolf, 2003).
10. Exchange theory: Speculates that the long-established dependencies present
in the victim–perpetrator relationship are part of the “tactics and response
developed in family life, which continue into adulthood” (Wolf, 2003).
11. Social learning theory: Attributes EM to learned behavior on the part of
the perpetrator or victim from either their family life or the environment;
abuse is seen as the norm (Wolf, 2003).
12. Political economy theory: Focuses on how older adults are often
disenfranchised in society as their prior responsibilities and even their
self-care are shifted on to others.
28
B. Characteristics of Victims
1. Decreased ability to complete ADLs and more physically frail (Frost &
Willette,1994; Peisah et al., 2009; Dyer et al., 2000).
2. Cognitive decits such as dementia (Fulmer et al., 2005; Gorbien &
Eisenstein, 2005; Naik et al., 2008).
3. History of childhood trauma (Fulmer et al., 2005; Lachs et al., 1998).
4. Depression and other mental disorders, as well as an increased sense of
hopelessness (Dyer et al., 2000; Fulmer et al., 2005).
5. Social isolation and lack of support systems (Draper et al., 2008; Dyer et al.,
2000; Peisah et al., 2009).
6. History of substance abuse (Dyer et al., 2000; Peisah et al., 2009).
Protocol 27.1: Detection of Elder Mistreatment (cont.)
(continued)
Mistreatment Detection 557
C. Characteristics of Perpetrators
1. Family member in 80% or more of cases (Cowen & Cowen, 2002).
2. Long history of conict with the victim (Krienert et al., 2009).
3. Live with victim for an extended time (Wiglesworth et al., 2010).
4. Higher rates of caregiver strain (Wiglesworth et al., 2010).
5. History of mental illness (Wiglesworth et al., 2010).
6. Depression and other mental disorders (Wiglesworth et al., 2010).
7. Social isolation and lack of support systems (Wiglesworth et al., 2010).
D. Etiology and/or Epidemiology
1. Recent data suggests that in the United States, more than 2 million older
adults suer from at least one form of EM each year (NRC, 2003).
2. e National Elder Abuse Incidence Study estimates that more than half a
million new cases of EM occurred in 1996 (NCEA, 1998).
3. Even though 44 states and the District of Columbia have legally required man-
dated reporting, EM is severely underreported. ere is a lack in uniformity
across the United States on how cases of EM are handled (NCEA, 1998).
4. NCEA, (1998) estimates that only 16% of cases of abuse are actually reported.
5. e National Council on Elder Abuse revealed that neglect accounts for
approximately half of all cases of EM reported to APS. About 39.3% of
these cases were classied as self-neglect and 21.6% attributed to caregiver
neglect, including both intentional and unintentional (NRC, 2003).
6. Over 70% of cases received by APS are attributed to cases of self-neglect
with those older than 80 years thought to represent more than half of these
cases (Lachs & Pillemer, 1995).
IV. PARAMETERS OF ASSESSMENT
A. See Table 27.2.
V. NURSING CARE STRATEGIES
A. Detailed screening to assess for risk factors for EM using a combination of
physical assessment, subjective information, and data gathered from screening
instruments (Perel-Levin, 2008).
B. Strive to develop a trusting relationship with the older adult as well as the care-
giver. Set aside time to meet with each individually (Perel-Levin, 2008).
C. e use of interdisciplinary teams with a diversity of experience, knowledge,
and skills can lead to improvements in the detection and management of cases
of EM. Early intervention by interdisciplinary teams can help lower risk for
worsening abuse and further decits in health status (Jayawardena & Liao,
2006; Wiglesworth et al., 2010).
D. Institutions should develop guidelines for responding to cases of EM (Perel-
Levin, 2008; Wiglesworth et al., 2010).
E. Educate victims about patterns of EM such that EM tends to worsen in severity
overtime (Cowen & Cowen, 2002; Phillips, 2008).
F. Provide older adults with emergency contact numbers and community resources
(Cowen & Cowen, 2002).
G. Referral to appropriate regulatory agencies.
Protocol 27.1: Detection of Elder Mistreatment (cont.)
(continued)
558 Evidence-Based Geriatric Nursing Protocols for Best Practice
VI. EVALUATION AND EXPECTED OUTCOMES
A. Reduction of harm through referrals, use of interdisciplinary interventions
and/or relocation to a safer situation and environment.
B. Victims of EM express an understanding how to access appropriate services.
C. Caregivers take advantage of services such as respite care or treatment for mental
illness or substance use.
D. If possible, evaluate progress in relationships between caregiver and older adult
through screening instruments such as e Modied CSI and GDS.
E. Institutions establish clear and evidence-based guidelines for management of
EM cases.
VII. FOLLOW-UP MONITORING OF CONDITION
A. Follow-up monitoring in the acute care setting is limited compared to the
follow-up that may be performed in the community or long-term care settings.
VIII. RELEVANT PRACTICE GUIDELINES
A. American Medical Association. Diagnostic and treatment guidelines on elder
abuse and neglect. Chicago, IL: Auhtor.
B. Aravanis, S. C., Adelman, R. D., Breckman, R., Fulmer, T. T., Holder, E.,
Lachs, M., . . . Sanders, A. B. (1993). Diagnostic and treatment guidelines on
elder abuse and neglect. Archives of Family Medicine, 2, 371–388.
C. Jones, J., Dougherty, J., Schelble, D., & Cunningham, W. (1988). Emergency
department protocol for the diagnosis and evaluation of geriatric abuse. Annals
of Emergency Medicine, 17(10), 1006–1015.
D. Neale, A., Hwalek, M., Scott, R., Sengstock, M., & Stahl, C. (1991). Validation of
the Hwalek-Sengstock elder abuse screening test. Journal of Applied Gerontology,
10, 406–418.
E. Phillips, L. R., & Rempusheski, V. F. (1985). A decision-making model for
diagnosing and intervening in elder abuse and neglect. Nursing Research, 34(3),
134–139.
Protocol 27.1: Detection of Elder Mistreatment (cont.)
RESOURCES
Administration on Aging
http://www.aoa.gov/
Elder Mistreatment Assessment
http://consultgerirn.org/resources
Journal of Elder Abuse & Neglect
http://www.informaworld.com/smpp/title~content=t792303995~db=all
National Center on Elder Abuse
http://www.ncea.aoa.gov/ncearoot/Main_Site/index.asp
Mistreatment Detection 559
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562
28
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. dene informed consent and the supporting bioethical and legal principles
2. understand the role of culture in health care decision making
3. dierentiate between competence and capacity
4. understand the process of decisional capacity assessment
5. describe the nurse’s role and responsibility as an advocate for the patient’s voice in
health care decision making
OVERVIEW
Health care is about decisions. Until the latter half of the 20th century, patients were
told what health care interventions would benet them and they rarely questioned
the doctor’s instructions. e rise of the rights movement in most areas of society
promoted the idea that patients would benet from robust participation in decision
making aecting their health outcomes. Building on the well-established doctrine
of informed consent, as well as statutory and case law, all states came to require
that patient wishes and values be central to health care decisions. e result was a
greater degree of clinician–patient collaboration in planning and implementing care
decisions.
Although all health care activities require principled and thoughtful decision
making, treatment, and diagnostic interventions—because of their benet-burden-risk
calculus—typically require specic informed consent by or on behalf of the patient.
For this reason, the determination of decision-making capacity, authority, and standards
becomes a most pressing clinical issue when deciding about treatment or diagnostic
interventions.
Ethel L. Mitty and Linda Farber Post
Health Care Decision Making
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Health Care Decision Making 563
BACKGROUND AND STATEMENT OF PROBLEM
Ethical Principles and Professional Obligations
Core ethical principles that underlie the health care decision process and give rise to
clinician obligations include
n respect for autonomy: supporting and facilitating the capable patient’s exercise
of self-determination;
n benecence: promoting the patient’s best interest and well-being and protecting
the patient from harm;
n nonmalecence: avoiding actions likely to cause the patient harm; and
n distributive justice: allocating fairly the benets and burdens related to health
care delivery (Beauchamp & Childress, 2001).
ese principles and the professional obligations they create often give rise to conict
and tension for clinicians. For example, care providers have a duty to respect patients’
autonomy by honoring their decisions and protecting them from the harm of risky choices.
Care providers are also expected to provide care to patients who need it and be responsible
stewards of limited resources. Clinical, legal, and ethically valid decisions by or for patients
invoke a careful balancing of information, principles, rights, and responsibilities in light of
medical realities, cultural factors, and, increasingly, concerns about resource allocation.
Autonomy and Capacity
e well-settled right to determine what shall be done with one’s own body has two
equally important components: the right to consent to treatment and the right to refuse
treatment. Grounded in the ethical principle of respect for persons, this right to bodily
integrity is considered so fundamental that it is protected by the U.S. Constitution,
state constitutions, and decisions of the U.S. Supreme Court (Cruzan v. Director, 1990).
All persons are considered to have the potential for autonomy, expressed in the clinical
setting through informed decision making. e threshold question is whether they have
the capacity to act autonomously.
Respect for autonomy is widely considered to be the ethical principle most central
to health care decision making because of its emphasis on self-governance and choices
that reect personal values. is heightened emphasis on self-determination is largely
a Western phenomenon and not universally shared. Capable patients who are easily
confused or with diminished or uctuating capacity, or who are from cultures that do
not consider autonomy a central value, may not be capable of or comfortable with pure
autonomous decision making. Instead, they may involve trusted others in planning
their care, thus exhibiting assisted, supported, or delegated autonomy as their preferred
method of decision making. For these patients, autonomy may not be reected in self-
determined decision making about treatment, but in expressions of values and goals of
care. Drawing on the assistance or support of trusted others does not diminish the integ-
rity of the process. Voluntarily delegating decision-making authority to others is also an
autonomous choice but it is one that must be explicitly conrmed, not inferred.
Diminished or uctuating capacity is not a reason to ignore the patient’s voice but
is an indicator to attend more carefully to what is being communicated. e “what” and
“how” of the treatment may be a decision of others to make; the “why” in the patient’s
voice must be heard.
564 Evidence-Based Geriatric Nursing Protocols for Best Practice
Consent and Refusal
In the clinical setting, the principle of respect for autonomy is most clearly expressed in
the doctrine of informed consent and refusal (Beauchamp et al., 2001). Because thera-
peutic and diagnostic interventions typically involve a range of benets, burdens, and
risks, express consent is almost always required before they are implemented. Consent
should be a process over time rather than a single event or a signed document. Among
adults with a language barrier associated with education and/or ethnicity, comprehen-
sion might be limited (Fink et al., 2010). Providing adequate time for the informed
consent discussion(s) and the opportunity for “repeat back” by the patient of specic
facts might improve understanding. As an expression of autonomy, the consent process
can be solitary or, more likely, a collaborative process that includes consultation with
clinicians, family, and trusted others.
Capable patients or surrogates acting on behalf of patients without capacity are
engaged in a process, which is considered to include the following elements:
n Evidence of decisional capacity
n Disclosure of sucient information relevant to the decision in question
n Understanding of the information provided
n Voluntariness (a patient’s right to make health care choices free of any undue
inuence) in choosing among the options, and, based on these,
n Consent to or refusal of the intervention (Lo, 2000)
Education can improve decisional capacity to give safe, informed consent even for
clinically depressed older adults (Lapid, Rummans, Pankratz, & Appelbaum, 2004).
In one study, depressed patients’ involvement in health care decision making not only
increased the likelihood of their receiving treatment congruent with depression treat-
ment guidelines but also showed reduced symptoms of depression over an 18-month
period (Clever et al., 2006). “Framing” can be persuasive; a clinician’s emphasis on
the distinctions about the ecacy of a treatment and whether it would be curative or
palliative can inuence a patient’s decision even more than information given about the
disease or treatment options (Van Kleens, van Baarsen, & van Leeuwen, 2004).
Decision-Making Authority
Treatment decisions are typically made by capable patients based on their goals and
values in response to information they receive about their diagnosis, prognosis, and
therapeutic options. ese decisions are, thus, an expression of autonomy, reecting the
view that health care is not something that is done to patients; rather, it is a collabora-
tive endeavor in which patients and clinicians contribute to the shared goal of recovery,
rehabilitation, or palliation.
Readiness for decision making has a temporal, as well as a contextual, component.
Older adults and their caregivers, asked in focus groups why they had or had not been
involved in any advanced care planning (ACP), revealed considerable variability in their
readiness for discussion of dierent components of the ACP process such as advance
directive creation, communication with family and physicians, and consideration of
their treatment goals (Fried, Bullock, Iannone, & O’Leary, 2009). Participants iden-
tied barriers and benets to ACP and said that it was not the only way to prepare
for decline in health or death. Prior experience with health care decision making for
Health Care Decision Making 565
others inuenced older adults’ propensity to engage in ACP. Having an active role in
shared decision making is associated with enhanced cancer-specic quality of life, satis-
faction, and more likely use of adjuvant therapy for women with breast cancer but not
for men with prostate cancer (Hack et al., 2010; Mandelblatt, Kreling, Figeuriedo, &
Feng, 2006).
When patients are not capable of making decisions about their treatment, others are
asked to choose for them basing their decisions as much as possible on what is known
of the patients’ preferences or what is considered to be in their best interest. e deter-
mination of decision-making authority is among the most critical tasks in the clinical
setting. When patients lack the ability to make treatment decisions, authority to act on
their behalf must be vested in others—appointed agents, family, or other surrogates.
e threshold determination, then, is of the patient’s decisional capacity: an assessment
of an individual’s ability to make decisions about health care and treatment.
Decision Aids
Decision aids assist, guide, and support a decision-making process that requires con-
sideration of benets, burdens, risks, and options. Studies indicate that decision aids
lead to decisions that are value-based, more informed, less conicted, and charac-
terized by a process that is more participatory than passive compared to standard
decision-making approaches (O’Connor et al., 2009). Decision aids made a dierence
in physician– patient discussion about the use of adjuvant therapy for women with
breast cancer (Simino, Gordon, Silverman, Budd, & Ravdin, 2006); claried values
and options, and increased knowledge regarding breast and ovarian genetic testing
counseling ( Wakeeld et al., 2008); and improved men’s knowledge of the risks and
benets of prostate-specic antigen (PSA) testing (Watson et al., 2006). An “order
eect” was discerned regarding the sequence in which information was presented in
a decision aid to women with breast cancer (Ubel et al., 2010). e order of pre-
sentation of information about the risks and benets of tamoxifen inuenced their
perceptions. Bias was eliminated by the simultaneous presentation of information of
competing options and risks.
ASSESSMENT OF THE PROBLEM
Decision-Making Capacity
Although the terms capacity and competence are often used interchangeably, in the health
care setting, their distinctions go beyond semantics. Competence is a legal presumption
that an adult has the mental ability to negotiate various legal tasks such as entering into a
contract, making a will, and standing for trial (Beauchamp & Childress, 2001). Incom-
petence is a judicial determination that because a person lacks this ability, she should
be prevented from doing certain things (Beauchamp & Childress, 2001). Capacity is
a clinical determination that a person has the ability to understand, make, and take
responsibility for the consequences of health care decisions (Beauchamp & Childress,
2001). Because the legal system should rarely be involved in medical decisions, the
patient’s capacity for decision making is an assessment made by clinicians.
e importance of capacity determination resides in the presumption that adults have
decisional capacity and, absent contrary evidence, treatment decisions defer to patient
wishes. is deference usually extends to all decisions made by capable individuals,
566 Evidence-Based Geriatric Nursing Protocols for Best Practice
including those decisions that appear risky or ill advised. Capacity assessment is important
because patients who lack the ability to appreciate the implications of, and accept respon-
sibility for, their choices are vulnerable to the risks of decient decision making. Whereas
honoring the decisions of a capable patient demonstrates respect for the person, honoring
the decisions of a patient without capacity is an act of abandonment. us, clinicians have
an obligation to ensure that capable patients have the opportunity to make treatment
decisions that will be implemented and incapacitated patients will be protected by having
decisions made for them by others who act in their best interest.
Fullling this obligation requires that clinicians appreciate the characteristics of
decision-making capacity, the elements of which include the ability to
n understand and process information about diagnosis, prognosis, and treatment
options;
n weigh the relative benets, burdens, and risks of the care options;
n apply a set of values to the analysis;
n arrive at a decision that is consistent over time; and
n communicate the decision (Roth, Meisel, & Lidz, 1997).
Capacity assessment depends on interaction with the patient over time rather than
on specic tests. ere is no gold standard instrument or “capacimeter” that assesses
decisional capacity (Kapp & Mossman, 1996). e Mini-Mental Status Examination
(MMSE) estimates orientation, long- and short-term memory, and mathematical and
language dexterity. It is not a test of executive function (an assessment more likely to
capture reasoning and recall) and is, therefore, less helpful in gauging the patient’s ability
to understand the implications of a decision (Allen et al., 2003). It has been suggested,
however, that an MMSE score less than 19 or more than 23 might be able to distinguish
those with and without capacity for decision making (Karlawish, Casarett, James, Xie,
& Kim, 2005). e Assessment of Capacity for Everyday Decision-Making (ACED) is
a reportedly valid and reliable instrument to assess everyday decisional capacity in those
with mild-to-moderate cognitive impairment (Lai et al., 2008). Its use in facilitating
assessment of health care decision-making capacity has not been reported but could be
explored in future studies.
Although there is no consistent standardized denition of decisional capacity, there
is sucient evidence that safe and sucient decision making is retained in early stage
dementia (Kim, Karlawish, & Caine, 2002). Persons with mild-to-moderate dementia
can make or at least participate in making treatment decisions, but impaired mem-
ory recall might be a barrier to their demonstrating their understanding of treatment
options (Moye, Karel, Azar, & Gurrera, 2004). Standard assessment of appreciation of
diagnostic and treatment information should focus on the patient’s ability to state the
importance or implications of the choice on his or her future health. Specic neurop-
sychological tests (e.g., MacArthur Competence Assessment Tool, Hopemont Capacity
Assessment Interview) can predict decisional capacity for those with mild-to-moderate
dementia, although reasoning and appreciation might dier among those with mental
illness (Gurrera, Moye, Karel, Azar, & Armesto, 2006).
e standard of decision making most highly valued by a group of geriatricians, psy-
chologists, and ethics committee members was the ability to appreciate the consequences
of a decision, followed by the ability to respond “yes” or ”no” to a question; the standard
least supported was that the decision had to seem reasonable (Volicer & Ganzini, 2003).
Health Care Decision Making 567
Clinical Importance of Decisional Capacity
Accurate and useful capacity assessment depends on the recognition that capacity is
decision-specic rather than global. For example, a person with diminished capacity
may be able to decide what to have for lunch or when to shower without undue risk of
harm. Evidence also suggests that adults with mild-to-moderate mental retardation are
able to make and provide a rationale for their treatment decisions and evaluate the risks
and benets of treatment options (Cea & Fisher, 2003). Because most people have the
ability to make some decisions and not others, respect for autonomy requires clinicians
to identify the widest range of decisions each patient is capable of making. A note in the
chart saying, “Patient lacks decision-making capacity” arbitrarily precludes the individual
from making any decisions about anything when, in fact, the patient may only lack the
ability to make complex treatment decisions. Far more helpful would be an entry that
says, “Patient lacks the capacity to make decisions about participation in a drug study.”
Likewise, decisional capacity may not be constant but may uctuate, depending on the
patient’s clinical condition, medication, and/or time of day. Among gerontological nurses,
protecting the right of older adults with diminished capacity or physical function to make
those health care decisions that they can appropriately make is among their top practice
concerns (Alford, 2006). It is imperative for the protection of those with mild-to- moderate
dementia that their understanding and reasoning about treatments and interventions is peri-
odically assessed (Moye, Karel, Gurrera, & Azar, 2006). Approaching patients for discus-
sions and decisions, when they are at their most capable (e.g., during the patient’s “window
of lucidity”), enhances their opportunities to participate in planning their health care.
Whereas disagreement with a proposed care plan or refusal of recommended treat-
ment does not by itself demonstrate incapacity, risky or potentially harmful decisions
should be carefully scrutinized to protect vulnerable patients from the consequences of
decient decision making. Because appointing a health care agent requires a lower level
of capacity than that needed to make the often complex decisions the agent will make,
even patients with diminished capacity may be able to select the persons they want to
speak for them (Mezey, Teresi, Ramsey, Mitty, & Bobrowitz, 2002).
Decision Making in the Absence of Capacity
e more dicult clinical scenario is decision making on behalf of patients who have
lost or never had the capacity to make decisions for themselves. Two approaches have
been developed in response to the needs of incapacitated patients: advance directives
and surrogate decision making. Advance directives (see Chapter 29, Advance Directives)
include the living will (a list of interventions the patient does or does not want in speci-
ed circumstances) and the preferred directive, the health care proxy (the appointment
of a health care agent with the same decision-making authority as the patient).
It is estimated that only 19%–36% of the adult population in the United States has an
advance directive. As such, the majority of health care decisions for incapacitated patients
are made by surrogates. Absent explicit instructions from the patient and decisions by
others are based on either substituted judgment (when the patient’s wishes are known or
can be inferred) or the best interest standard (when the patient did not have or articulate
treatment preferences). Substituted judgment assesses what the patient would choose based
on prior statements and patterns of decision making. e best interest standard is the
surrogate’s evaluation of the proposed intervention’s benets and burdens to the patient.
568 Evidence-Based Geriatric Nursing Protocols for Best Practice
A health care surrogate may be any competent adult older than 18 years of age
who, although not specically chosen or legally appointed by a patient, assumes the
responsibility for making health care decisions on behalf of a person who does not
have the ability to do so. Informal surrogates are individuals, usually family or others
close to the patient, who are asked by the care team to participate in making treatment
decisions. Formal surrogates may be specied by state law in a hierarchy, typically in
descending order of relation to the patient. Most states accord considerable latitude to
surrogates, especially next of kin, in consenting to treatment. Decisions about limiting
treatment are more problematic and may be signicantly restricted, depending on the
state in which the patient is receiving care (see Resources, American Bar Association
Commission on Law & Aging for state guidelines).
Context of Health Care Decision Making
Individual treatment preferences can change as a patient’s health and functional status
changes (Fried et al., 2006). Previously unacceptable treatment states may become more
acceptable. For example, patients already experiencing pain are less likely to refuse a
treatment outcome that includes being in pain than patients who are not currently
experiencing moderate-to-severe pain (Fried et al., 2006). Additionally, patients may
have dierent treatment and comfort goals than those of their family caregivers and
professional providers (Steinhauser et al., 2000).
Just as there is the right to know one’s medical information, there is also a right not
to be burdened with unwanted information. Older adults from cultures that traditionally
shield patients from knowing about their illness may prefer to have information given to
and decision making assumed by a particular family member, the family as a group, or
trusted others. Although it is important to respect patient preferences and cultural tradi-
tions, a patient’s waiver of the disclosure obligation must be explicitly conrmed, not pre-
sumed. Because of the implementation of Health Insurance Portability and Accountability
Act of 1996 (HIPAA), many hospitals have a form for the patient to sign, designating the
preferred decision maker. Another approach is to ask, “When we have information about
your condition and decisions will need to be made, who would you like us to talk to?
Would you like to be part of those discussions? What would make you comfortable?”
Trust in professional health care providers is a critical element in health care, cer-
tainly in decision-making situations where information is given and questions have to be
answered. Various factors inuence information exchange and shared decision making
among providers and patients (Edwards, Davies, & Edwards, 2009). Providers are inu-
enced by their susceptibility or responsiveness to informed patients and patients’ interest
in decision making, limited knowledge of patients’ culture, and a tendency to stereo-
type patients rather than view them as individuals. Patients are inuenced by their per-
sonal motivation to obtain and use information, cultural identity and expression, health
literacy, and their ability to manage the possibility of receiving distressing information.
Of note, a shared inuence among providers and patients was sick-role expectation
(Edwards et al., 2009). African American patients have been shown to be signicantly
more likely than White patients to report low trust, unrelated to age or socioeconomic
status (Halbert, Armstrong, Gandy, & Shaker, 2006) of the U.S. health care system, and
have little interest in advance directive creation and ACP (Cox et al., 2006). is is not
to say, however, that Black and minority ethnic populations do not want to participate
in health care decision making, including decisions at the end of life.
Health Care Decision Making 569
Quality-of-Life Considerations in Decision Making
ere is almost universal acknowledgement of the patient’s desire to be comfortable
(i.e., relieved of pain and suering) and to achieve a sense of completion. Attitudes about
the importance of clergy, of being physically touched, and using all available technology
may dier among patients, families, and caregivers. Older adults with varying degrees of
functional impairment and past experiences with treatment decision making were more
interested in the outcome of a serious medical event than with the curative interventions
and with whether the intervention could restore or maintain their ability to participate
in activities they valued (Rosenfeld, Wenger, & Kagawa-Singer, 2000). Among older
adults with end-stage renal disease, the decision to begin dialysis was inuenced by their
family caregiving responsibilities, feeling that they had no other options, and that they
currently enjoyed life and were not ready to contemplate their death (Visser et al, 2009).
ose who rejected dialysis were more often male, older, and widowers in comparison
to those who accepted dialysis. ey imagined that they would experience a loss of
autonomy and a continuing trajectory of functional loss, have diculty getting to the
dialysis center, and have to start thinking about the future—a prospect that was unap-
pealing to them at the time. ese ndings speak to the contextual and temporal nature
of health care decision making as has been explored by others (Fried et al., 2009).
INTERVENTIONS AND CARE STRATEGIES
Assessing the patient’s orientation and understanding can provide critical informa-
tion about decision-making behavior in dierent circumstances as well as the ability
to articulate care wishes. Reporting that a patient is “disoriented to time and place” is
helpful only in establishing the context in which more focused and useful assessment of
decisional capacity should take place.
Documentation needs to be specic and descriptive. e entry should describe the
circumstances or interaction(s) that led to the conclusion about the patient’s ability to
make decisions. Because capacity is decision-specic, accurate and useful statements are
“Patient appears to lack the capacity to make decisions about discharge” “She is unable to
describe how she will cook or get to the bathroom at home” or “Patient lacks the capacity
to make decisions about surgery; he was unable to name the type of surgery, what the
surgery is supposed to correct, or what is involved or to be expected during recovery.”
Communicating information includes determining what the patient and/or
surrogate(s) need or want to know and what they understand. Having the relevant med-
ical facts available in lay language and avoiding jargon is essential. It is also important
to consider the participants in the decision making: Who should be present? What is
their relationship to the patient? What is their decisional authority? What information
is necessary; at what level of detail and how will it be used? When is the information
to be provided and over what period? (Popejoy, 2005) Language interpreters might be
the only health care sta who recognize that surrogate decision makers and the physi-
cian or health care professionals have diering interpretations of illness, treatment, and
health; disparate views about death and dying; and use language and a decision-making
framework dierently. An interpreter may realize that truth telling might not only be
perceived as disrespectful and dangerous but able to shorten the patient’s life span,
as believed in certain cultures. As such, an interpreter is more than a word-for-word
translator but, rather, can serve as a mediator, culture broker, patient advocate, witness,
educator, and participant who interpret fact and nuance.
570 Evidence-Based Geriatric Nursing Protocols for Best Practice
Mr. Peters is an 85-year-old man with advanced Alzheimer’s disease who has been
living in a nursing home for the past 6 months. When he stopped eating several weeks
ago, he was hospitalized for percutaneous endoscopic gastrostomy (PEG) tube inser-
tion to provide articial nutrition and hydration. He returned to the nursing home
briey but developed uncontrolled diarrhea and apparent abdominal discomfort. Two
days ago, his PEG tube fell out and he has been readmitted to the hospital for treat-
ment of the diarrhea and possible replacement of the PEG.
Mr. Peters opens his eyes and responds to painful stimuli but does not inter-
act and appears not to recognize family members. He is clearly incapable of par-
ticipating in discussions or decisions about his care. His close family includes his
son and granddaughter, who are visiting from California, and his grandson, Jason,
who has been very involved for several years in providing and deciding about
Mr. Peters’s care.
A clinical ethics consultation has been convened, including Mr. Peters’s family, his
two attending physicians, the house and nursing sta who have cared for him most
consistently, and the bioethicist. Discussion focuses on clarifying his condition and
probable clinical course, the goals of care, and his likely care preferences.
Jason describes his grandfather as very active and ercely independent until
age 78, when his dementia began. With his wife, he had raised Jason and, when
she died, he continued to raise the boy alone until Jason left for college. When the
dementia worsened several years ago, Jason arranged for his grandfather and a team
of 24-hour caregivers to move into an apartment next to his. at arrangement
continued until Mr. Peters required care that could best be provided in a skilled
nursing facility.
All three family members agree that, given Mr. Peters’s personality, values, and
lifetime behavior pattern, he would not have wanted to be maintained in his current
condition, certainly not dependent on articial nutrition and hydration. Nevertheless,
they express concern about the ethics, legality, and clinical eect of not replacing the
PEG tube, and are especially uncomfortable about whether it would be considered
“starving” him to death.
According to the care team, Mr. Peters’s advanced dementia is not reversible
and he will continue to deteriorate mentally and physically until death. e doc-
tors referred to the considerable literature demonstrating that, in patients with
advanced dementia, articial nutrition and hydration can cause gastrointestinal
(GI) distress, including nausea, bloating, gas, and diarrhea, which appears to have
happened to Mr. Peters. In the opinion of the care team, continued articial nutri-
tion and hydration would only contribute to the patient’s suering and prolong
the dying process. e doctors also explain that, far from suering, Mr. Peters
appears more comfortable because the PEG fell out and the diarrhea has stopped.
ey assure the family that the patient could be admitted to the nursing home’s
hospice unit where he will receive comfort care, including pain and other symp-
tom management. e bioethicist addressed the relevant ethical issues discussed in
subsequent texts.
CASE STUDY
(continued)
Health Care Decision Making 571
Discussion
e ethics analysis of this case focuses on decision making for an incapacitated
patient, promoting the patient’s best interest and protecting him from harm, and
forgoing life-sustaining treatment, specically articial nutrition and hydration, at
the end of life.
Surrogate decision making on behalf of patients lacking capacity uses the follow-
ing standards:
n e patient’s wishes as expressed directly through discussions with others or in
advance directives (health care proxy appointments or living wills)
n Substituted judgment (when the patient’s wishes are known or can be
inferred)
n e best interest standard (when the patient’s wishes are not known or infer-
able; Beauchamp & Childress, 2001).
Mr. Peters has not left any explicit instructions but, his family, knowing him
very well, is able to predict with condence what he would and would not have
wanted based on his characteristic patterns of behavior and decision making. In
this case, the family’s substituted judgment is consistent with what was considered
by the family and the care team to be in the patient’s best interest—protecting
him from continued articial nutrition and hydration that would have increased
his suering without providing benet and prolonged his dying. Framing this as
protecting the patient from the burdens and risks of an intervention rather than
depriving him of necessary treatment can make this decision more tolerable for
distressed families.
One of the most dicult surrogate decisions is forgoing life-sustaining treatment
and because providing nourishment is so intimately associated with love and nurturing,
forgoing articial nutrition and hydration is especially wrenching for families and care-
givers. Clinicians, ethicists, and courts have consistently agreed that articial nutrition
and hydration is a medical treatment, the benets, burdens, and risks of which should
be assessed like those of any other intervention.
Capable patients and the appointed health care agents of incapacitated patients
have a well-settled right to refuse any treatment, including those that are life-
sustaining. Absent capacity or advance directives, the family’s authority to make
end-of-life decisions, including forgoing articial nutrition and hydration depends
on the laws of the state in which the patient is treated. Many states permit family
and surrogates authorized by case or statutory law to make these decisions based
on substituted judgment or their assessment of the patient’s best interest in light
of the patient’s condition and prognosis. Other states require surrogates, even next
of kin, to provide explicit evidence that the patient would have refused articial
nutrition and hydration in order to authorize withholding or withdrawing the
interventions.
CASE STUDY (continued)
572 Evidence-Based Geriatric Nursing Protocols for Best Practice
Protocol 28.1: Health Care Decision Making
I. GOALS
To ensure nurses in acute care:
A. Understand the supporting bioethical and legal principles of informed consent.
B. Are able to dierentiate between competence and capacity.
C. Understand the issues and processes to assess decisional capacity.
D. Can describe the nurse’s role and responsibility as an advocate for the patient’s
voice in health care decision making.
II. OVERVIEW
A. Capable persons (i.e., those with decisional capacity) have a well-established right,
grounded in law and Western bioethics, to determine what is done to their bodies.
B. In any health care setting, the exercise of autonomy (self-determination) is seen in
the process of informed consent to and refusal of treatment and/or care planning.
C. Determination of decision-making capacity is a compelling clinical issue because
treatment and diagnostic interventions have the potential for signicant ben-
et, burden, and/or risk.
D. Honoring the decisions of a capable patient demonstrates respect for the person;
honoring the decisions of a patient without capacity is an act of abandonment.
III. BACKGROUND AND STATEMENT OF THE PROBLEM
A. Introduction
1. Core ethical principles that are the foundation of clinician obligation are
the following:
a. Respect for autonomy, benecence, nonmalecence, and distributive
justice.
b. Clinically, legally, and ethically valid decisions by or for patients requires
a careful balancing of information, principles, rights, and responsibili-
NURSING STANDARD OF PRACTICE
(continued)
SUMMARY
e notion of “ownership” of one’s body should apply to health care decision making even
at times of crisis. Even patients with diminished or uctuating decisional capacity should
not be denied the opportunity to make the specic health care decisions they are capable of
making. A vulnerable patient who lacks capacity, despite some social or conversational skills,
needs to be protected from the potentially harmful eects of uninformed, poorly reasoned,
and potentially risky health care decisions. It is suggested that the best way for nurses to learn
older adults’ informational needs, avoid paternalism, and promote their best interests is to
simply ask them (Tuckett, 2006). e ethical obligations that must be assumed by health
care professionals are skillfully assessing the clinical situation, the benets, burdens and risks
of the therapeutic options, the patient’s capacity to make and take responsibility for the
relevant decisions, and the surrogate’s need for information, guidance, and support.
Health Care Decision Making 573
ties in light of medical realities, cultural factors and, increasingly, con-
cerns about resource allocation.
c. Even capable patients, including those who are older adults, easily confused
or from cultures that do not consider autonomy a central value, as well as
patients with diminished or uctuating capacity, may not be capable of or
comfortable with exercising purely autonomous decision making.
d. Care professionals have an obligation to be alert to questionable or uc-
tuating capacity both in patients who refuse and those who consent to
recommended treatment. Capable individuals may choose to make their
own care decisions or they may voluntarily delegate decision- making
authority to trusted others. Delegation of decisional authority must be
explicitly conrmed, not inferred.
e. e context of decision making can include cultural imperatives and taboos,
perceptions of pain, suering and quality of life and death, education and
socioeconomic status, language barriers, and advance health care planning.
B. Denitions
1. Consent. e informed consent process requires evidence of decisional
capacity, disclosure of sucient information, understanding of the infor-
mation provided, voluntariness in choosing among the options, and, on
those bases, consent to or refusal of the intervention.
2. Competence. A legal presumption that an adult has the mental ability to
negotiate various legal tasks (e.g., entering into a contract, making a will).
3. Incompetence. A judicial determination that a person lacks the ability to
negotiate legal tasks and should be prevented from doing so.
4. Decisional capacity. A clinical determination that an individual has the ability
to understand and to make and take responsibility for the consequences of
health decisions. Because capacity is not global but decision- specic, patients
may have the ability to make some decisions but not others. Capacity may
uctuate according to factors, including clinical condition, time of day,
medications, and psychological and comfort status.
C. Essential Elements
1. Decisional capacity reects the ability to understand the facts, appreciate the
implications, and assume responsibility for the consequences of a decision.
2. e elements of decisional capacity: the ability to understand and process
information; weigh the relative benets, burdens, and risks of each option;
apply personal values to the analysis; arrive at a consistent decision; and
communicate the decision.
3. Standards of Decision Making
a. Prior explicit articulation: decision based on the previous expression of a
capable person’s wishes through oral or written comments or instructions.
b. Substituted judgment: decision by others based on the formerly capable
person’s wishes that are known or can be inferred from prior behaviors
or decisions.
c. Best interests standard: decision based on what others judge to be in the
best interest of an individual who never had or made known health care
wishes and whose preferences cannot be inferred.
Protocol 28.1: Health Care Decision Making (cont.)
(continued)
574 Evidence-Based Geriatric Nursing Protocols for Best Practice
IV. ASSESSMENT OF DECISIONAL CAPACITY
A. ere is no gold standard instrument to assess capacity.
B. Assessment should occur over time, at dierent times of day, and with atten-
tion to the patient’s comfort level.
C. e Mini-Mental Status Examination (MMSE) or Mini-Cog Test is not a test
of capacity. Tests of executive function might better approximate the reasoning
and recall needed to understand the implications of a decision.
D. Clinicians agree that the ability to understand the consequences of a decision is
an important indicator of decisional capacity.
E. Safe and sucient decision making is retained in early stage of dementia
(Kim et al., 2002) and by adults with mild-to-moderate mental retardation
(Cea & Fisher, 2003).
V. NURSING CARE STRATEGIES
A. Communicate with patient and family or other/surrogate decision makers to
enhance their understanding of treatment options.
B. Be sensitive to racial, ethnic, religious, and cultural mores and traditions regarding
end-of-life care planning, disclosure of information, and care decisions.
C. Be aware of conict resolution support and systems available in the care-
providing organization.
D. Observe, document, and report the patient’s ability to
1. articulate his or her needs and preferences,
2. follow directions,
3. make simple choices and decisions (e.g., “Do you prefer the TV on or o?”
“Do you prefer orange juice or water?”), and
4. communicate consistent care wishes.
E. Observe period(s) of confusion and lucidity; document the specic time(s)
when the patient seems more or less “clear.” Observation and documenta-
tion of the patient’s mental state should occur during the day, evening, and
at night.
F. Assess understanding relative to the particular decision at issue. e following
probes and statements are useful in assessing the degree to which the patient
has the skills necessary to make a health care decision:
1. “Tell me in your own words what the physician explained to you.”
2. “Tell me which parts, if any, were confusing.”
3. “What do you feel you have to gain by agreeing to (the proposed intervention)?
4. “Tell me what you feel you have to lose by agreeing to (the proposed
intervention)?
5. “Tell me what you feel you have to gain or lose by refusing (the proposed
intervention)?
6. “Tell me why this decision is important (dicult, frightening, etc.) to you.”
G. Select (or construct) appropriate decision aids.
Protocol 28.1: Health Care Decision Making (cont.)
(continued)
Health Care Decision Making 575
RESOURCES
American Bar Association (ABA)
http://www.americanbar.org
American Bar Association Commission on Law & Aging, Legislative Updates
See link for chart that summarizes the wide variation on how states allocate decisional authority in
the absence of patient capacity to make health care decisions, as well as legislative updates and
other relevant information.
http://www.americanbar.org/groups/law_aging.html
American Society of Bioethics and Humanities
http://www.asbh.org
e Hastings Center
http://www.thehastingscenter.org
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
http://www.hhs.gov/ocr/privacy/
e Oce for Civil Rights (OCR) enforces the HIPAA Privacy Rule
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
H. Help the patient express what he or she understands about the clinical situa-
tion, the goals of care, their expectation of the outcomes of the diagnostic, or
treatment interventions.
I. Help the patient identify who should participate in diagnostic and treatment
discussions and decisions.
VI. EVALUATION AND EXPECTED OUTCOME(S)
A. e number of referrals to the ethics committee or ethics consultant in situations
of decision-making conict between any of the involved parties.
B. e use of interpreters in communication of, or decision-making about, diag-
nostic and/or treatment interventions.
C. Plan of care: instructions regarding frequency of observation to ascertain the
patient’s lucid periods, if any.
D. Documentation
1. Is the process of the capacity assessment described?
2. Is the assessment specic to the decision at issue?
3. Is the informed consent and refusal interaction described?
4. Are the specics of the patient’s degree or spheres of orientation described?
5. Is the patient’s language used to describe the diagnostic or treatment inter-
vention under consideration recorded? Is the patient’s demeanor during this
discussion recorded?
6. Are the patient’s questions and the clinician(s) answers recorded?
7. Are appropriate mental status descriptors used consistently?
Protocol 28.1: Health Care Decision Making (cont.)
576 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Lo, B. (2000). Resolving ethical dilemmas: A guide for clinicians (2nd ed.). Philadelphia, PA: Lippincott
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Mandelblatt, J., Kreling, B., Figeuriedo, M., & Feng, S. (2006). What is the impact of shared decision
making on treatment and outcomes for older women with breast cancer? Journal of Clinical
Oncology: Ocial Journal of the American Society of Clinical Oncology, 24(30), 4908–4913.
Evidence Level IV.
Mezey, M., Teresi, J., Ramsey, G., Mitty, E., & Bobrowitz, T. (2002). Determining a resident’s
capacity to execute a health care proxy. Voices of decision in nursing homes: Respecting
residents’ preferences for end-of-life care. New York, NY: United Hospital Fund. Evidence
Level IV.
Moye, J., Karel, M. J., Azar, A. R., & Gurrera, R. J. (2004). Capacity to consent to treatment:
Empirical comparison of three instruments in older adults with and without dementia.
e Gerontologist, 44(2), 166–175. Evidence Level IV.
Moye, J., Karel, M. J., Gurrera, R. J., & Azar, A. R. (2006). Neuropsychological predictors of
decision-making capacity over 9 months in mild-to-moderate dementia. Journal of General
Internal Medicine, 21(1), 78–83. Evidence Level IV.
O’Connor, A. M., Stacey, D., Entwistle, V., Llewellyn-omas, D., Rovner, D., Holmes-Rovner,
M., . . . Jones, J. (2004). Decision aids for people facing health treatment or screening decisions.
Chichester, United Kingdom: John Wiley & Sons. Evidence Level I.
Popejoy, L. (2005). Health-related decision-making by older adults and their families: How clinicians
can help. Journal of Gerontological Nursing, 31(9), 12–18. Evidence Level V.
Rosenfeld, K. E., Wenger, N. S., & Kagawa-Singer, M. (2000). End-of-life decision making: A quali-
tative study of elderly individuals. Journal General Internal Medicine, 15(9), 620–625. Evidence
Level IV.
Roth, L. H., Meisel, A., & Lidz, C. W. (1997). Tests of competency to consent to treatment.
e American Journal of Psychiatry, 134(3), 279–284. Evidence Level VI.
Simino, L. A., Gordon, N. H., Silverman, P., Budd, T., & Ravdin, P. M. (2006). A decision aid
to assist in adjuvant therapy choices for breast cancer. Psycho-Oncology, 15(11), 1001–1013.
Evidence Level II. Steinhauser, K. E., Christakis, N. A., Clipp, E. C., McNeilly, M., McIntyre,
L., & Tulsky, J. A. (2000). Factors considered important at the end of life by patients, family,
physicians, and other care providers. Journal of the American Medical Association, 284(19),
2476–2482. Evidence Level IV.
Tuckett, A. G. (2006). On paternalism, autonomy and best interests: Telling the (competent) aged-
care resident what they want to know. International Journal of Nursing Practice, 12(3), 166–173.
Evidence Level V.
Ubel, P. A., Smith, D. M., Zikmund-Fisher, B. J., Derry, H. A., McClure, J., Stark, A., . . . Fagerlin,
A. (2010). Testing whether decision aids introduce cognitive biases: Results of a randomized
trial. Patient Education and Counseling, 80(2), 158–163. Evidence Level II.
Van Kleens, T., van Baarsen, B., & van Leeuwen, E. (2004). e medical practice of patient
autonomy and cancer treatment refusals: A patients’ and physicians’ perspective. Social Science
and Medicine, 8(11), 2325–2336. Evidence Level IV.
Visser, A., Dijkstra, G. J., Kuiper, D., de Jong, P. E., Franssen, C. F., Gansevoort, R. T., . . .
Reijneveld, S. A. (2009). Accepting or declining dialysis: Considerations taken into account
by elderly patients with end-stage renal disease. Journal of Nephrology, 22(6), 794–799.
Evidence Level IV.
Volicer, L., & Ganzini, L. (2003). Health professionals’ views on standards for decision-making
capacity regarding refusal of medical treatment in mild Alzheimer’s disease. Journal of the
American Geriatrics Society, 51(5), 1270–1274. Evidence Level IV.
578 Evidence-Based Geriatric Nursing Protocols for Best Practice
Wakeeld, C. E., Meiser, B., Homewood, J., Taylor, A., Gleeson, M., Williams, R., . . . Australian
GENetic testing Decision Aid Collaborative Group. (2008). A randomized trial of a breast/
ovarian cancer genetic testing decision aid used as a communication aid during genetic counseling.
Psycho-Oncology, 17(8),844–854. Evidence Level II.
Watson, E., Hewitson, P., Brett, J., Bukach, C., Evans, R., Edwards, A., . . . Austoker, J. (2006).
Informed decision making and prostate specic antigen (PSA) testing for prostate cancer:
A randomised controlled trial exploring the impact of a brief patient decision aid on men’s
knowledge, attitudes and intention to be tested. Patient Education and Counseling, 63(3),
367–379. Evidence Level II.
579
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. dierentiate between a durable power of attorney for health care and a living will
2. describe assessment parameters to ensure that older adults receive advance directive
information
3. identify strategies to ensure good communication about advance directives among
patients, families, and health care professionals
4. guide a discussion of the benets and burdens of various treatment options to assist
proxy treatment decision making
5. describe measurable outcomes to be expected from implementation of this practice
protocol
OVERVIEW
One of the most dicult situations health care professionals face is treatment deci-
sion making for those who can no longer communicate their treatment preferences.
Decision-making capacity of older adults may be diminished, uctuating, or lapsed.
e justication for advance care planning (ACP) is that a person with capacity can
prospectively state their wishes, values, and treatment preferences so that their authen-
tic voice will be heard when their capacity and/or ability to communicate has lapsed.
Approximately 30% of older adults do not have a relative, friend, or guardian who can
make health care decisions for them. e right to not complete an advance directive
(AD) must also be respected. Patients should be informed (and in some cases, reassured)
that neither providers nor the facility will abandon them or provide substandard care if
they elect not to formulate an AD.
Ethel L. Mitty
Advance Directives
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
29
580 Evidence-Based Geriatric Nursing Protocols for Best Practice
BACKGROUND AND STATEMENT OF PROBLEM
e Patient Self-Determination Act (PSDA, 1992), enacted in 1991, is the federal statu-
tory codication of an individual’s right to conduct health planning and decision mak-
ing in advance. Predicated on the Western philosophic tradition of individual freedom
and choice, and that self-determination is a moral right, the U.S. Supreme Court articu-
lated the requirement of “clear and convincing evidence” that an incompetent patient
would not want a specic treatment. Because few oral statements could meet this stan-
dard, written ADs were promulgated as constituting clear and convincing evidence.
ADs are value neutral and can be used to request as well as refuse treatment(s). ey
provide guidance for health care professionals and families. Importantly, ADs provide
immunity from civil and criminal liability for health care professionals and families
when an AD is followed in good faith. State statutes generally outline the conditions
under which an AD is legally valid and when it should be followed (see ADs by State
link in Resources section).
Quality-of-life concerns, the inuence of the family, and pragmaticism inuence
most adults’ decisions to create an AD (Crisp, 2007). Older adults who create ADs
feel that their physicians know their wishes and do not feel that the AD would be a
constraint on their care. ose who do not create an AD want their families to make
decisions for them and apparently fail to see the exibility that having an AD provides
(Beck, Brown, Boles, & Barrett, 2002). Among participants of the original Framing-
ham Heart Study, almost 70% discussed their end-of-life (EOL) care preferences and
ADs with someone but not necessarily with a physician or health care provider. More
than half had a health care proxy (HCP) or a living will (LW); slightly under half had
both. Most respondents wanted comfort care at the end of life but few wanted to forego
life-sustaining treatment (LST) interventions (e.g., ventilator, feeding tube) and would
endure a burdensome health status (e.g., intense pain, confusion, forgetfulness) to pro-
long life, rather than die (McCarthy et al., 2008).
Hospice patients who talk with their surrogate decision makers (i.e., proxy) about
their treatment wishes for their last week(s) of life have a higher rate of agreement with
their surrogate’s understanding of their treatment wishes than patients who do not have
these discussions (Engelberg, Patrick, & Curtis, 2005).
Although family surrogate decision making is more accurate than primary physi-
cians regarding older patients’ preferences for LST in hypothetical scenarios, having
an AD does not necessarily improve congruence between patients’ wishes and deci-
sions made by others (Coppola, Ditto, Danks, & Smucker, 2001). Substitute deci-
sion makers are not necessarily making treatment choices or decisions that represent
the patient’s preferences (Ditto et al., 2001; Mitchell, Berkowitz, Lawson, & Lipsitz,
2000). e evidence, to date, is inconclusive with regard to patient–surrogate informa-
tion sharing and decision making. Whereas a small study found that communication
between patients and their proxies improved the accuracy of proxies representations of
patient preferences (Barrio-Cantalejo et al., 2009), a meta-analysis of surrogate deci-
sion making found no improvement in accuracy of representing patient preferences as
a result of prior discussion between patient and proxy (Shalowitz, Garrett-Mayer, &
Wendler, 2006). However, lack of concordance between a patient’s stated wishes and
physician orders cannot simply be viewed as a denial of a patient’s rights; physicians
might be relying on additional information to guide their treatment decisions (Hardin
& Yusufaly, 2004).
Advance Directives 581
TYPES OF ADVANCE DIRECTIVES
Treating a patient without their explicit permission is battery. In most states, unless the
patient has severely limited the proxy’s decision-making scope, the proxy’s decision has
the same weight and power as the patient speaking on his or her own behalf. A proxy’s
power is no greater or less than the capable patient himself or herself. Vague or ambigu-
ous language in an AD (e.g., refusal of “heroic measures”) deprives the proxy as well
as providers the guidance needed to honor the patient’s wishes. ere are two types of
ADs: DPAHC (also called HCP) and LW.
Durable Power of Attorney for Health Care
e DPAHC allows an individual to appoint a relative, friend, or trusted other—called
a health care proxy, agent, attorney-in-fact, or surrogate—to make health care decisions
if the individual loses the ability to make decisions or communicate his or her wishes.
(An alternate agent should also be appointed.) A key presumption of HCP appoint-
ment is that the patient and proxy have discussed the patient’s treatment wishes. Older
adults with a DPHAC and an LW are less likely to die in a hospital or receive all care
possible in comparison to those without a DPAHC (Silveira, Kim, & Langa, 2010).
(Some states require the proxy’s signature on the AD as an attempt to assure that the
proxy is aware of his or her appointment and has accepted decision-making responsi-
bilities as the patient’s voice in care planning decision making.) Whereas an LW is in
eect at the end of life, the DPAHC springs into eect at any time that the patient has
a temporary (or permanent) absence of decisional capacity, as might be associated with
trauma, illness, or mental impairment (dementia, stroke, delirium). A proxy has the
legal authority to interpret the patient’s wishes based on the medical circumstances of
the situation and is not restricted to only deciding if LST can be withdrawn or withheld.
us, the proxy can make decisions as the need arises, and such decisions can respond
directly to the situation at hand rather than being restricted only to circumstances that
were thought of previously.
“Family consent laws” designate the order in which persons can make decisions for an
incapacitated patient who did not appoint a proxy; a spouse is usually rst, then adult chil-
dren, parents, and distant relatives. Decisions of family members acting in this capacity are
restricted in various ways by many states including the requirement that the patient must
be terminal or in a persistent vegetative state, comatose, and so forth. Disputes between
family members who bear the same relationship to the patient (e.g., two children) are not
uncommon and often very dicult to resolve. A proxy’s decision legally supersedes a deci-
sion made by a family member or nonproxy concerned party. is is not to say, however,
that a proxy’s decision is always easy and conict-free or that the burden is light.
Living Will
For adults who have no one to appoint as their proxy, completing an LW that out-
lines their wishes is preferable to not providing any information at all about their care
preferences. An LW is also helpful for those with a DPAHC who want to provide their
proxy some guidance about their treatment preferences and EOL care wishes, including
articial nutrition and hydration (ANH), ventilator support, and pain management.
An LW is a prospective declaration that provides specic instructions to health
care providers about particular kinds of health care treatments or interventions that an
582 Evidence-Based Geriatric Nursing Protocols for Best Practice
individual would or would not want in specic clinical circumstances, usually at the
end of life. All but three states (New York, Massachusetts, and Michigan) have detailed
statutes recognizing LWs. However, the usefulness of LWs is limited to those clinical
circumstances that were thought of before the person became incapable of making or
communicating decisions. If a situation occurs that the LW does not address, providers
and families may not know how to proceed and still respect the patient’s wishes. Hence,
it is recommended that individuals also appoint a proxy—a trusted other who knows
their values and wishes. When an individual completes both the LW and DPAHC, the
proxy or agent might not be obligated (in some states) to follow the wishes outlined in
the LW; the LW serves as a guide. When presented with the opportunity to complete a
“traditional” LW that limited LST in terminal illness and a “modied” LW with three
treatment options (i.e., limiting LST in critical illness; providing LST on a trial basis;
refusing LST and/or ANH in advanced dementia), almost 90% of hospitalized general
medical patients preferred the modied LW and a number of subjects subsequently
chose to create one (Abbo, Sobotka, & Meltzer, 2008).
Some states have a combined directive that includes elements of the LW and the
DPAHC. A section on organ donation (“anatomical gift”) has been added to the AD
document of some states that allows the individual to indicate if they wish to donate an
organ(s). However, in New York State, for example, the proxy cannot eect this wish
unless the proxy is also the identied decision maker for organ donation, a distinct statu-
tory authority separate from an HCP’s rights and responsibilities.
“Instructional or medical directives” have been suggested to compensate for the
deciencies of LWs. ey address specic clinical situations and interventions. Indi-
viduals must decide prospectively which interventions they would want in the face of
four scenarios: coma with virtually no chance of recovery; coma with a small chance
of recovery but restored to an impaired physical and mental state; advanced dementia
and a terminal illness; and advanced dementia. Among the interventions are cardiopul-
monary resuscitation (CPR), ANH, dialysis, invasive diagnostic tests, antibiotics, and
blood transfusion. e instructional/medical directive does not, however, address the
patient’s desired goals of care, willingness to allow a short-term intervention, or treat-
ment choices associated with stage of chronic illness or exacerbation.
Two other AD documents further the goals of ACP and are accepted in many
states: the physician order for life-sustaining treatment (POLST) and the Five Wishes
document. POLST originated in Oregon in 1995 and is a state-endorsed protocol to
honor an individual’s wish to die in a setting of his or her choice without unwanted
life-supporting interventions. It contains four separate categories of physician’s orders
that are based on patient–physician discussion: comfort measures, antibiotics, paren-
teral feeding, and CPR. Nursing home residents with POLST forms are more likely
to have documented restricted LST preferences as well as be less likely to be hospital-
ized if their POLST indicated comfort measures only. ere is no evidence of dif-
ferences in symptom assessment or management among residents with and without
POLST forms (Hickman et al., 2010). e POLST has greater specicity and accu-
racy in communicating EOL preferences in comparison to traditional ads (Bomba &
Vermilyea, 2006).
e Five Wishes document meets the legal requirements of ADs in almost all states
and is available in 26 languages. It combines the HCP, LW, instructional directions,
and proxy designation. Open-ended statements guide the individual to express their
thoughts and wishes about how they want to be physically and emotionally supported,
Advance Directives 583
the medical treatments they want and do not want, and the funeral arrangements and
eulogy they would like. e “values statements” embedded in the Five Wishes AD
generally do not explore or express the patient’s understanding of the benets and
burdens of various treatments, thereby making it dicult to act on the patient’s wishes
and preferences (Lo & Steinbrook, 2004).
Location of death (e.g., home or hospice rather than in acute care), less likelihood
of being on a respirator or having a feeding tube, fewer concerns with family/signicant
other being informed about what to expect, and good physician communication are
associated with ADs and quality EOL care (Bakitas et al., 2008; Detering, Hancock,
Reade, & Silvester, 2010; Teno, Grunier, Schwartz, Nanda, & Wetle, 2007). Patients
facing the need for EOL care for advanced illness, randomized to an advanced illness
coordinated care program, experienced increased satisfaction with care and commu-
nication, completed more ADs, and their surrogates reported fewer support problems
than patients receiving usual care (Engelhardt et al., 2006). As with another study (Teno
et al., 2007), there was no dierence in survival rates between the two groups. However,
unmet needs were for adequate pain management and emotional support for patient
and family (Teno et al., 2007).
Factors important to older patients with regard to their medical decision making
and ADs include their religious beliefs, dignity, physical comfort, dependency,
and nances (Hawkins, Ditto, Danks, & Smucker, 2005). Few patients want to
document their specic medical treatment preferences; they highly value verbal
communication. Spouse surrogates are less likely than child surrogates to believe that
recording wishes in advance is necessary. Most patients gave their surrogate leeway
in decision making. e spouse surrogate was more likely than the child surrogate to
feel that nancial issues were important. Patients had more condence in their child
surrogate understanding their wishes than their spouse surrogate understanding. e
eect of a recent hospitalization on a reduced desire to receive LSTs (e.g., CPR,
ANH) was noted during an interview conducted just after recovery but returned
to normal several months after hospitalization. ese results challenge assumptions
about the stability of treatment preferences and the temporal context during which
treatment decisions are made (Ditto, Jacobson, Smucker, Danks, & Fagerlin, 2006;
Hawkins et al., 2005).
Research Advance Directive
e notion of a research advance directive (RAD) has been suggested (National Bioethics
Advisory Commission, 1998). e conduct of research with participants suering from
a dementing illness is daunting with regard to obtaining informed consent. An RAD
must be executed while the individual still retains decisional capacity and must contain
a fairly detailed description of the person’s understanding of the research intention and
possible risks, benets, and burdens. e proxy decision maker must make a determi-
nation whether the person’s intention to participate in research is congruent with the
proposed research. A study involving patients with moderate dementia and their family
proxies sought to learn whether the patients wanted to retain decision making about
their participation in research in the future or allow their proxy to make the decision.
Although many, but not all, patients granted future decision making about research
participation to their proxies, it was also clear that proxies did not always want to make
research participation decisions (Stocking et al., 2006).
584 Evidence-Based Geriatric Nursing Protocols for Best Practice
Psychiatric Advance Directive
Psychiatric advance directives (PAD) are presumably written by individuals with deci-
sional competence. Given the opportunity to meet with a trained facilitator, adults with
psychotic disorders suciently increased their competence to make treatment decisions
within their PADs (Elbogen et al., 2007). Psychiatric outpatients want assistance to cre-
ate a PAD. Of these, most are female, non-White, have limited personal autonomy, a
history of self-harm or arrest, and a felt pressure to take medications (Swanson, Swartz,
Ferron, Elbogen, & Van Dorn, 2006). Completion of a PAD is associated with patients
with good insight and their need to keep their outpatient mental health treatment
appointment (Swanson et al., 2006).
Patient identication in their PAD of their preferred psychiatric medications pre-
dicted not only that it was likely to be prescribed but that medication adherence per-
sisted over time (Wilder, Elbogen, Moser, Swanson, & Swartz, 2010). Among mental
health professionals (i.e., psychiatrists, psychologists, social workers), most agree that
PADs would be helpful for patients with severe mental illness. However, their positive
attitude is supported by their knowledge that their respective state laws do not require
them to follow a directive that contained a patient’s refusal of appropriate mental health
treatment (Elbogen et al., 2006).
Oral Advance Directive
Although the courts prefer written ADs, oral advance directives are respected, espe-
cially in emergency situations, and can be persuasive in a judicial decision to withhold
an LST. Some states permit a patient to orally designate a proxy in discussion with
their physician, rather than execute a written AD (Lo & Steinbrook, 2004). In deter-
mining the validity of an oral AD, the court seeks information about whether the
statement was made on serious or solemn occasions, consistently repeated, made by a
mature person who understood the underlying issues, was consistent with the values
demonstrated in other aspects of the patient’s life (including the patient’s religion),
made before the need for the treatment decision, and specically addressed the actual
condition of the patient (Lo & Steinbrook, 2004). What might seem like an occa-
sional comment made by a patient (whether in a practitioner’s oce or at the bedside)
should be recorded for just such an occasion when “clear and convincing evidence”
is required. It has been argued that oral instructions explicated during conversation
with one’s physician can be taken to signify the patient’s genuine intent on having his
or her instructions followed.
Do Not Resuscitate Orders
Consent to CPR is presumed unless a physician writes a do-not-resuscitate (DNR)
order. Respecting (or not) a patient’s resuscitation wishes is a frequent cause of moral
distress for nurses. It has been suggested that CPR should not be instituted when it will
not oer a medical benet or when death is inevitable and expected. All states have a
Natural Death Act that recognizes the right of competent patients, in their written AD,
to refuse LSTs. Patients have a right to refuse CPR after they have been informed of the
risks and benets involved and may, in fact, request a DNR order. If the physician is
unwilling to write a DNR order to comply with the patient’s request, the physician has
a duty to notify the patient or family and assist the patient to obtain another physician.
Advance Directives 585
It is important that otherwise healthy hospitalized older adults who may benet from
CPR should not be denied this life-saving intervention.
For patients on a palliative home care program, their interest and willingness to
have a DNR order is associated with sleep and incontinence problems, acceptance
of their situation and nearness to death, and their wish to die at home. Once again,
the temporal nature of AD care preferences has to be factored in (Brink, Smith, &
Kitson, 2008).
Artificial Nutrition and Hydration
ANH poses ethical, legal, and cultural challenges. e U.S. Supreme Court, in 1990
(before the PSDA), established that competent patients have a “constitutionally pro-
tected liberty” to refuse unwanted medical treatment. e court further established
that ANH is no dierent than other forms of medical treatment. Many ethicists and
legal scholars hold that there is no legal dierence between forgoing and discontinuing
ANH. e legal evidence and procedures required to forgo or discontinue ANH vary by
state. Several states hold that proxies cannot make decisions about withholding unless
the patient specically directs, in the AD, that the proxy can make this decision on his
or her behalf. (e DPAHC document contains a statement and box to check, if the
patient wishes, that states: “My proxy knows my wishes.” Nothing has to be written
regarding precisely what those wishes are.) e LW statutes in some states regard ANH
as a medical treatment, whereas other states consider ANH a comfort measure (Gillick,
2006). Nurses need to be aware of their state law in this regard and, also, the extent to
which patients (and proxies) are correctly informed about the clinical benets and bur-
dens of ANH at the end of life and the caring/comfort treatment alternatives. Whether
or not to institute ANH or to withdraw it once started has the moral equivalence, for
many people, of “killing” the patient.
ASSESSMENT OF THE PROBLEM
A primary consideration in approaching a patient about AD creation is the person’s
capacity to not only make decisions about his or her health care but also to accept respon-
sibility for the consequences of the decision. “Competence” and “capacity” are not the
same, yet they are frequently used synonymously and interchangeably (see Chapter 28,
Health Care Decision Making). e law presumes competency unless shown other-
wise; only the court can rule that an individual is incompetent. Capacity is a clinical
determination and is not determined solely by a medical or psychiatric diagnosis or
test. Inability to make nancial decisions or communicate verbally does not preclude
the ability to communicate important information about one’s treatment preferences.
e determination that a patient lacks capacity is often made based on a mental status
assessment test—an inappropriate measure of decisional capacity. us, there is a grave
risk that individuals with communication disorders or those with mild dementia might
not have the opportunity to appoint an HCP or to execute an LW.
Decisional Capacity to Create an Advance Directive
e steps in determining whether a patient has sucient decisional capacity to create an
AD are similar to the basic elements of a valid consent and are based on observation of
a specic set of abilities. ese steps include (a) the patient appreciates and understands
586 Evidence-Based Geriatric Nursing Protocols for Best Practice
that he or she has the right to make a choice; (b) the patient understands the medical
situation, prognosis, risks, benets, and consequences of treatment consent (or refusal);
(c) the patient can communicate the decision; and (d) the patient’s decision is stable and
consistent over a period (Roth, Meisel, & Lidz, 1977).
Decision-making capacity is not an all-or-none, “on-o” switch. Not all health
decisions require the same level of decision-making capacity. Rather, capacity should be
viewed as “task specic.” An individual may be able to perform some tasks adequately
and may have the ability to make some decisions, but is unable to perform all tasks or
make all decisions. e notion of “decision-specic capacity” assumes that an individual
has or lacks capacity for a particular decision at a particular time and under a particular
set of circumstances (Meisel, 2002). Most older adults have sucient cognitive capability
to make some, but not all, decisions. An individual might have the requisite capacity
or understanding that they can choose someone to make health care decisions for them
when they no longer have the capacity to make treatment choices. e determination
of decisional capacity becomes more exacting in relationship to the complexity and risk
associated with the health care decision (Midwest Bioethics Center, 1996).
Appreciation of the consequences of an option or decision is a key component of
capacity determination. ere is no gold standard or “capacimeter” to assess. e mini-
mental status examination (MMSE) is a cognitive screen; it was not designed for, nor is
it applicable to, capacity determination (Mezey, Teresi, Ramsey, Mitty, & Bobrowitz,
2002). Bioethicists, legal scholars, and clinicians generally agree that a lower level of
capacity is needed to create a DPAHC in comparison to an LW (Mezey et al., 2002).
Objective assessment of capacity can avoid two types of mistakes. First, mistakenly pre-
venting persons who ought to be considered capacitated from directing the course of
their treatment and, second, failing to protect incapacitated persons from the harmful
eects of their decisions. Failure to take language barriers and hearing and visual decits
into account can result in the erroneous conclusion that a person lacks the capacity to
execute an AD. Residents with dementia who are White and have some higher educa-
tion are likely to have an AD that is primarily used to restrict, not request, many forms
of aggressive LST care at the end of life. Pain management and comfort care are rou-
tinely requested, however (Triplett et al., 2008).
Benefit–Burden Assessment
A benet–burden analysis considers the intended and unintended consequences of a
particular treatment, estimates the likelihood that the intended benet will occur, and
weighs the importance of the benet and burden to the patient. Patients are not neces-
sarily consistent in their treatment preferences, especially if the chance to avoid death
or the degree of burden is unclear. Many patients are in variable stages of readiness for
ACP that includes creation of an AD and communication with their families and physi-
cians about their treatment goals. Prior experience with health care treatment decision
making can inuence a patient’s perceptions of his or her readiness (Fried, Bullock,
Iannone, & O’Leary, 2009; Fried, O’Leary, Van Ness, & Fraenkel, 2007). e proxy
can be helped to infer how the patient would evaluate the benets and burdens based
on knowledge of the patient’s values, preferences, and past behavior. e nurse can
ask the proxy, “If [the patient] could join this discussion, what would he say?” “Faced
with similar situations in the past, how did he decide?” Higher congruence between
patient and proxy regarding patients’ EOL care preferences is associated with a nurse-led
Advance Directives 587
discussion intervention: patients were more knowledgeable about LSTs, less willing to
receive LSTs for a new serious medical event, and less willing to live in a state of poor
health (Schwartz et al., 2002).
e rationale for withholding or withdrawing a treatment is to eliminate a burden-
some intervention/treatment that is not producing the desired result. In those situations
where the proxy has scant knowledge about the patient for whom he or she must make
health care decisions (or there is no AD, proxy appointment, or person who speaks for
the patient), a decision is made on what would be in the patient’s best interest. Known
as the “reasonable person” or “best interest” standard, the decision relies on the notion
of what an average person in the patient’s particular situation would consider bene-
cial or burdensome. Questions that could move the process along would ask, “What
does [this patient] have to gain or lose as a result of this treatment?” In what ways will
[this patient] be better or worse o as a result of this treatment—or not having this
treatment?”
CULTURAL PERSPECTIVES ON ADVANCE CARE PLANNING
e notion of ACP and written directives is not universally acceptable. In some cul-
tures, for the close-knit family, an AD is intrusive, irrelevant, and a refusal if not a legal
denial of care. Many in the Black and ethnic minority populations do not view the
DPAHC as relevant, nor do they regard a DNR order as a summative value statement
(Cox et al., 2006). Disinterest in creating an AD because of a present-day, rather than
a future, orientation and an unwillingness to write, speak, or plan for one’s death are
pervasive cultural inuences on a decision not to create an AD. As well, deference to
physician decision making, the family’s role in protecting the patient from the burdens
of life and death decision making, and spiritual obligations or beliefs can exert a power-
ful inuence on the decision.
Studies indicate dierent LST preferences and decision-making contexts among
racial and ethnic groups (Cox et al., 2006). Overall, Asian and Hispanic patients prefer
family-centered decision making in contrast to White and African American patients’
preference for patient-directed decision making (Kwak & Haley, 2005). As many have
shown, White patients are more interested in and likely to discuss treatment prefer-
ences, execute an LW, refuse certain LST, and appoint an HCP decision maker than
Black or Hispanic patients (Hopp & Duy, 2000). AD completion is more concen-
trated among White patients with higher education and income levels than among
Black and Hispanic patients with low income levels and less than a high school educa-
tion (Mezey, Leitman, Mitty, Bottrell, & Ramsey, 2000). Latino patients in comparison
to White patients are less likely to complete an AD or communicate their preferences
even though there are no dierences between groups with regard to AD preferences
(Froman & Owen, 2005).
In contrast, African American patients are more likely to want LSTs to prolong life.
Some Black patients believe that having an AD is a legal way to deny access to treatment
and care, and tend to distrust the health care system more than Mexican Americans and
European Americans (Perkins, Geppert, Gonzales, Cortez, & Hazuda, 2002). Among
African American patients, spirituality and beliefs that are in conict with palliative
care goals, views of suering and death and dying, and mistrust of the health care sys-
tem negatively inuence their creation of an AD (Bullock, 2006; Gerst & Burr, 2008;
Johnson, Kuchibhatla, & Tulsky, 2008). An intervention study using same-race peer
588 Evidence-Based Geriatric Nursing Protocols for Best Practice
mentors to discuss ACP with dialysis patients demonstrated a signicant positive eect
on Black patients but not on White patients. Positive outcomes included increased
comfort in discussion, completion of ADs, and improved feelings of well-being (Perry
et al., 2005).
Cultural assimilation as well as cultural diversity make even a simplistic assump-
tion about why people do and do not create an AD extremely hazardous. When
patients and health care professionals are from dierent ethnic backgrounds, the value
systems that form the basis for AD decision making may conict, often leading to
distinct ethical and interpersonal tensions. Older Japanese American patients in the
United States prefer to make their own decisions about withholding LST, whereas
older Japanese patients residing in Japan defer decision making to their physicians
and families (Matsui, Braun, & Karel, 2008). Subtle themes pertain to elder Japanese
patients with regard to their feelings about being a burden to others, the family obli-
gation to support the dying person, and the overall usefulness of an AD as a means to
reduce conict, yet not be intrusive (Bito et al., 2007). High religiosity, a strong fam-
ily decision-making history, and a belief that the family should support the patient’s
wishes are negatively correlated with AD creation among many cultural groups in the
United States, such as patients who are Greek (Makridou, Efklides, Economidis, &
Peonidis, 2006), Bosnian (Searight & Gaord, 2005), Asian Indian (Doorenbos &
Nies, 2003), and Malaysian (Htut, Shahrul, & Poi, 2007). Predictors of AD comple-
tion for multiethnic urban seniors include what investigators called modiable factors,
such as an established relationship with a primary care physician and their doctor’s
willingness to start the discussion, being knowledgeable about ACP, recognition of
the family role in decision making, and prior experience with decision making about
mechanical ventilation (Morrison & Meier, 2004).
NURSES’ ROLES IN ADVANCE DIRECTIVES
All adult patients, regardless of their gender, religion, socioeconomic status, diagnosis,
or prognosis should be approached with information about and encouraged to discuss
ACP and ADs. ese conversations occur over time; they are not interviews, per se.
Discussion is always patient centered, not proxy or provider centered. Nurses can have a
major role in checking their patients’ knowledge about EOL treatment options and the
benets, burdens, and consequences of each option. Correct information/ knowledge
about the dierence between euthanasia and assisted suicide, treatment refusal, and
treatment withdrawal is associated with being college educated, being White, and
having prior experience as a proxy for another (Silveira, DiPiero, Gerrity, & Feudtner,
2000). Oncology nurses are knowledgeable about ADs but less so about the PSDA
and their respective state laws. ey lack condence in their knowledge and ability
to assist patients to create an AD (Jezewski et al., 2005). Interestingly, they view their
role as one of advocacy, especially for adequate pain management (even though it may
hasten death).
Patients say that they complete ADs to ease their family’s nancial and emotional
burden and to ease decision making. ey want to discuss EOL care and LWs, but
they expect providers to initiate these discussions. Community-dwelling older patients
attending a general medical clinic were more likely to create an AD when they received
AD information by mail in advance of their appointment, and their physician received
a reminder to discuss ADs, in comparison to patients whose physicians only received a
Advance Directives 589
reminder to document ADs (Heiman, Bates, Fairchild, Shaykevich & Lehmann, 2004).
Discussions of EOL care and ADs are a statistically signicant predictor of patient sat-
isfaction with their primary care physician (Tierney et al., 2001). Attitude, skills, and
knowledge about ACP among medical residents caring for hospitalized older adults
revealed that they had incomplete and often erroneous understanding of patients’
decision-making process, all of which inuenced their willingness to have such a dis-
cussion (Gorman, Ahern, Wiseman, & Skrobik, 2005). Training in ACP for medical
residents not only improved their knowledge in and comfort with discussion of Ads,
but also positively inuenced patient interest in creating an AD (Alderman, Nair, &
Fox, 2008). Case managers vary in their level of ACP knowledge and skills, reaction to
family involvement and patient receptivity, and in supporting their clients in creating an
AD (Black & Fauske, 2007). Directives that address hospitalization and ED treatment
are the most useful for physicians yet are not always available, especially in emergency
departments (Cohen-Manseld & Lipson, 2008; Weinick, Wilcox, Park, Griey, &
Weissman, 2008).
A pervasive myth among patients, and one inuenced by a history of abuse and
denial of health care, is that an AD means “do not treat” or, conversely, means being
kept alive against their wishes, with all manner of tubes and technology. Some patients
believe, erroneously, that a lawyer is needed to execute an AD and that each state has its
own specic AD document that must be used. It is partially correct that in the absence
of an AD “surrogate decision maker,” a family member is most often the designated
decision maker. is reects custom as well as recognition of the pivotal role of the fam-
ily in important decisions as well as the fact that a family member is most likely to be
aware of the patient’s values, wishes, and preferences. e reality in many cases is that
families disagree or might be ignorant of the patient’s wishes. Nurses are in a position to
identify pending family conict and act to mitigate the drastic eects of poor or delayed
treatment decisions.
e language of ADs can be confounding, especially for those with limited lit-
eracy. Randomized to a standard AD (12th-grade reading level) form and one which
was modied to address literacy needs (i.e., 5th-grade reading level; graphics), most
English- and Spanish-speaking patients preferred the modied form, which resulted
in higher AD creation among them (Sudore et al., 2007). Most community-dwelling
older adults know about treatment purposes but least about outcomes (Porensky &
Carpenter, 2008). Phrases such as “improvement” or “vegetable” were idiosyncratically
interpreted.
INTERVENTIONS AND CARE STRATEGIES
One way for a nurse to begin the discussion about ACP is by helping the patient and/or
proxy explore and express what quality of life means for the patient, the importance of
preservation of life, and how the patient’s illness (and death) will aect others (emotion-
ally, nancially, etc.). Some patients might want to focus on the quality of their living,
whereas others focus on the quality of their dying. Some patients might want to talk
about from whom and where they will receive care at the end of life. Some may abhor
their coming dependence on others; others may not like or want it, but will accept it.
Still others might opt for hospice care out of the home to distance their dependency
on family caregivers. Patients (and proxies) might need or want to talk about what they
each fear most and what will be important when dying.
590 Evidence-Based Geriatric Nursing Protocols for Best Practice
Communication About Advance Care Planning
Under state law and Joint Commission standards, patients have the right to have a
qualied interpreter translate and transmit discussion between themselves and their
health care professional. e interpreter may be the only person who recognizes that
patients and their families have a totally dierent “take” than the health care team on
words like “health” and “illness,” on what a treatment is supposed to do, and on what
dying is and what it is not. If “telling bad news” is prohibited (e.g., Navajo, Greece,
Korea, Horn of Africa nations), then it might be dicult to discuss EOL planning. It
should not be assumed that facility, family, or other interpreters are neutral and will
simply “translate” words. An interpreter is communicating fact and nuance, explana-
tion and rationale, and might inuence a treatment decision by virtue of attempting
a 1:1 word translation or a clumsy approximation of two distinct languages. In the
presence of conict about a treatment decision, or an unexpected decision, it may be
in the patient’s best interest to bring in another interpreter and repeat the exchange of
information and questions.
Mrs. R. is an 88-year-old female, widowed for 22 years, and with no next of kin who
lived alone prior to her admission to the nursing home 2 years ago, at which time
she consented to a DNR order. She has severe chronic obstructive pulmonary dis-
ease (COPD), chronic renal failure (blood urea nitrogen of 58), dementia mild/mod
(MMSE score of 20/30), is mildly depressed (by Geriatric Depression Scale score),
and is below her initial body weight (222 lbs). Mrs. R. now requires another person
for all personal care; she bruises easily. Her prognosis is poor; goals of care are symp-
tom management with comfort/palliative care. She has had multiple hospitalizations
for pneumonia; the latest was 10 weeks ago after which she had further weight loss
and developed a Grade II pressure ulcer on her right hip. She is receiving the standard
medications for COPD, antianxiety medication, a short-acting sleeping medication,
and appetite stimulants. Recent discussion about her quality of life by the interdis-
ciplinary team noted that she no longer attends parties, Sabbath candle lighting, or
discussions, all of which she used to enjoy. Mrs. R. seemed unable to make health care
decisions as of 6 months ago; her decisional capacity appears to uctuate in relation
to her oxygen saturation.
Five years ago, Mrs. R. created an LW that stipulated “aggressive comfort care,
including ventilator support.” ere are no verbal statements documented that might
indicate Mrs. R.’s feelings about being hospitalized if she has another COPD exacer-
bation, which is to be expected given the trajectory of this disease.
Two days ago, Mrs. R. began to have stertorous breathing, a nonproductive
cough, and episodes of diaphoresis. She appears exhausted; her solid food intake is
minimal, and she gets very dyspneic when taking small sips of uid. A chest x-ray was
equivocal and is to be repeated today. At present, her vital signs are as follows: tem-
CASE STUDY
(continued)
Advance Directives 591
perature, 100.8; pulse oximeter, 82%; pulse and blood pressure are within normal
limits. e nursing home has the resources to provide oxygen and IV uids including
antibiotics.
Discussion
e diculty of this case is an LW instruction written before the disease trajectory
had reached a terminal state, and that now might not be in Mrs. R.’s best interests;
aggressive intervention might be more burdensome than benecial. Whose voice will
articulate the benets and burdens of hospitalization or remaining in the nursing
home for palliative/terminal care? e nurse assistants feel she should be hospitalized;
their advocacy is based on 2 years of knowing her and feelings of great aection for
her. e clinical professional sta argue from prognostications about the likely out-
come of an aggressive intervention (e.g., ventilator support) and probable multiple
skin breakdowns if she is hospitalized. e standard of “substituted judgment” that
a proxy uses when deciding on behalf of a patient whose wishes and preferences are
known is not available to us. One could ask, “What would Mrs. R. choose if she could
join the discussion?” e “best interest” standard of decision making asks what we
think would promote Mrs. R.’s well-being. Can we bring her back to baseline (the sta-
tus at which sta knew and loved her)? At this point, the benet–burden assessment
becomes a critical part of the discussion.
Conict between the professional and paraprofessional sta has to be addressed.
For the nurses, administering morphine to provide respiratory comfort might well
hasten Mrs. R.’s death. Are we prolonging life or prolonging death? Are we treating
resident or institutional anxiety? What is quality of life? Is it a complex personal phe-
nomenon and judgment? A medical determination? To what extent can the facility
provide a reasonable quality of life, a degree of comfort and safety, that might meet
Mrs. R.’s interests at this time—dierent from that which the sta previously enjoyed
with her? What are the legal and ethical implications of departing from Mrs. R.’s AD?
What are the implications of morphine administration and of the principle of double
(i.e., unintended) eect?
After discussion with an ethics consultant at an interdisciplinary meeting that
included the nurse assistants involved in her care, a consensus decision was made not
to hospitalize Mrs. R. e decision was guided by the clinical facts, Mrs. R.’s prior
wishes (for “aggressive comfort care”), the likely trajectory of COPD, fact gathering,
values discussion, and reection about Mrs. R.’s condition after each hospitalization.
Mechanical ventilation was likely to be more of a burden than a benet at this point
in her illness; Mrs. R. could be made comfortable with judicious use of medication
and intensive nursing care. is case teaches us that ACP is not a static one-time
event. Whether a person’s wishes and preferences are stated through an AD document
or verbally, they must be periodically reviewed upon a person’s change of condition,
lifestyle, proxy, heart, and mind. e ability to reach consensus through mediation
that addressed each person’s concerns, but kept the discussion resident centered, was
key to arriving at a medically and ethically appropriate decision that focused on the
goals of care.
CASE STUDY (continued)
592 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
Discussions about care at the EOL should occur over time. Having such discussions
shortly after hospitalization for an acute event can blur the goals of ACP, focusing more
on resuscitation preferences than on the long range goals of care and treatment (Happ
et al., 2002). Notions of quality of life, confusion about what it looks and feels like,
and how to measure this complex phenomenon inuence EOL care preference inter-
ventions. Rather than discussing the technology of LST and EOL care, nurses can help
recenter the discussion on the patient’s wishes and preferences. It may be wiser and more
humane to discuss with patients, families, and proxies the acceptable state of health,
desired functionality, and the “valued life activities” that patients want. Construing
quality of life in this manner might be more meaningful and helpful.
An environment conducive to meaningful discussions about ADs and EOL care
requires an appropriate time and location. An emergency admission is not an appro-
priate time. Distribution without discussion, commonly done in hospital admis-
sion oces at the time of an elective admission, is not an appropriate time either.
(Nursing homes tend to wait 2 weeks before discussing ADs with a new admission.).
Many studies report that the most eective interventions for patient creation of an
AD is oral information provided over several interactive sessions (Bravo, Dubois, &
Wagneur, 2008; Tamayo-Velázquez et al., 2010) and the opportunity to ask questions
(Jezewski, Meeker, Sessana, & Finnell, 2007). Passive use of print material and lack
of opportunity to receive assistance in creating an AD does not elicit AD creation
(Ramsaroop, Reid, & Adelman, 2007). It is unlikely that education and information
about ADs will completely counteract the natural discomfort associated with discuss-
ing death and dying; this is generally as true for patients and families as it is for care
providers. Awareness of the patient and family’s spiritual and cultural “surround” as
well as the provider’s moral biases about LST can give rise to sensitive and realistic
discussion.
Protocol 29.1: Advance Directives
I. GUIDING PRINCIPLES
A. All people have the right to decide what will be done with their bodies.
B. All individuals are presumed to have decision-making capacity until deemed
otherwise.
C. All patients who can participate in a conversation, either verbally or through
alternate means of communication, should be approached to discuss and record
their treatment preferences and wishes.
D. Health care professionals can improve EOL care for older adult patients by
encouraging the use of ADs.
NURSING STANDARD OF PRACTICE
(continued)
Advance Directives 593
II. BACKGROUND
A. Education About Advance Directives
1. Patients uniformly state that they want more information about ADs.
2. Patients want nurses (and physicians) to approach them about ADs.
3. It is estimated that 19% to 36% of Americans have completed an AD.
B. Advance Directives
1. Allow individual to provide directions about the kind of medical care they do or
do not want if they become unable to make or communicate their decisions;
2. Provide guidance for health care professionals, families, and substitute decision
makers about health care decision making that reect the person’s wishes; and
3. Provide immunity for health care professionals, families, and appointed
proxies from civil and criminal liability when health care professionals
follow the AD in good faith.
C. Two Types of Advance Directives: DPAHC (also called HCP) and LW.
1. A durable power of attorney allows an individual to appoint someone, called
HCP, agent, or surrogate, to make health care decisions for him or her should
he or she lose the ability to make decisions or communicate his or her wishes.
2. A living will provides specic instructions to health care providers about
particular kinds of health care treatment an individual would or would not
want to prolong life. LWs are often used to declare a wish to refuse, limit,
or withhold LST.
D. Instructional or Medical Directive: intended to compensate for the weaknesses
of LWs. is kind of directive identies specic interventions that are acceptable
to a patient in specic clinical situations (e.g., POLST).
E. Oral Advance Directives (Verbal Directives): allowed in some states if there is
clear and convincing evidence of the patient’s wishes. Clear and convincing
evidence can include evidence that the patient made the statement consistently
and seriously, over time, specically addressed the actual condition of the
patient, and was consistent with the values seen in other areas of the patient’s
life. Legal rules surrounding oral advance directives vary by state.
III. ASSESSMENT PARAMETERS
A. All adult patients regardless of age (with the exception of patients with persistent
vegetative state, severe dementia, or coma) should be asked if they have an LW
or if they have designated a proxy.
B. All patients regardless of age, gender, religion, socioeconomic status, diagnosis,
or prognosis should be approached to discuss ADs and ACP.
C. Discussions about ADs should be conducted in the patient’s preferred language
to enable information transfer and questions and answers.
D. Discussions should be conducted with sensitivity to the patient’s stage of
wellness and illness, that is, to their temporal as well as physical status.
E. Patients who have been determined to lack capacity to make other decisions may
still have the capacity to designate a proxy or make some health care d ecisions.
Decision-making capacity should be determined for each individual based on
whether the patient has the ability to make the specic decision in question.
Protocol 29.1: Advance Directives (cont.)
(continued)
594 Evidence-Based Geriatric Nursing Protocols for Best Practice
F. If an LW has been completed or proxy has been designated:
1. e document should be readily available on the patient’s current chart.
2. e attending physician should know that the directive exists and has a copy.
3. e designated HCP should have a copy of the document.
4. e directive should be reviewed periodically by the patient, attending
physician/nurse, and the proxy to determine if it reects the patient’s
current wishes and preferences.
IV. CARE STRATEGIES
A. Nurses should assist patients and families trying to deal with EOL care issues.
B. Patients may be willing to discuss their health situation and mortality with a nurse or
clergyman rather than with a family member and should be supported in doing so.
C. Patients should be assisted in talking with their family/proxy about their
treatment and care wishes.
D. Patients should be assessed for their ability to cope with the information provided.
E. Nurses must be mindful of and sensitive to the fact that race, culture, ethnicity,
and religion can inuence the health care decision-making process. e fact
that patients from non-Western cultures may not subscribe to Western notions
of autonomy does not mean that these patients do not want to talk about their
treatment wishes, or that they would not have conversations with their families
about their treatment preferences.
F. Patient’s must be respected for their decision to not complete an AD and
reassured that they will not be abandoned or receive substandard care if they
do not elect to formulate an AD.
G. Nurses should be aware of the institution’s mechanism for resolving conicts
between family members and the patient or proxy or between the patient/
family and care providers and assist the parties in using this resource.
H. Nurses should be aware of which professional in their agency/institution is
responsible for checking with the patient that copies of the AD have been given
to their primary health care provider(s), to their proxy, and that the patient is
carrying a wallet-size card with AD and contact information.
V. EVALUATION OF EXPECTED OUTCOMES
To determine whether implementation of this protocol inuenced the type as well as
the number of ADs created, changes should be measurable and should contribute to
the facility’s ongoing quality improvement program. Look at:
A. As documented in the record
1. Whether patients are asked about ACP and directives
2. Whether patients do or do not have an AD
B. Of those patients with an AD, the percentage of ADs included in patient charts;
C. e use of interpreters to assist sta discussion of ADs with patients for whom
English is not their primary language;
D. e number of ADs completed in association with admission to, or receipt of
services from, the agency/institution;
E. e number of nurse referrals to the ethics committee of patient or sta
situations regarding ADs.
Protocol 29.1: Advance Directives (cont.)
Advance Directives 595
RESOURCES
American Nurses Association (ANA)
www.nursingworld.org
n Code for Nurses with Interpretive Statements
n Position statements on assisted suicide and active euthanasia, do-not-resuscitate, comfort
and relief, patient self-determination act
n Selected bibliographies on ethical issues such as EOL decisions, foregoing, nursing ethics
committees, and assisted suicide and euthanasia
e American Society for Bioethics and Humanities
www.asbh.org
n International Journal of Nursing Ethics
Caring Connections
A program of the National Hospice and Palliative Care Organization (NHPCO)
Includes Partnership for Caring, Inc. (formerly, Choice in Dying)
http://www.caringinfo.org
n Questions and Answers: Advance directives and EOL decisions, medical treatments and
your advance directives, articial nutrition and hydration and EOL decision making,
do-not-resuscitate orders and EOL decisions
n Video: Who’s Death Is It, Anyway? (PBS special)
Aging With Dignity
Five Wishes
www.agingwithdignity.org/ve-wishes.php
Washington State Medical Association
Physician’s Orders for Life-Sustaining Treatment (POLST)
http://www.wsma.org/patient_resources/polst.cfm
American Association of Colleges of Nursing
End-of-Life Nursing Education Consortium (ELNEC)
www.aacn.nche.edu/elnec/curriculum.htm
Physician Education Research Center
End of Life/Palliative Education Resource Center (EPERC)
www.eperc.mcw.edu/EPERC/FastFactsandConcepts
Advance Directives, by State
http://www.noah-health.org/en/rights/endoife/adforms.html
http://www.caringinfo/stateaddownload
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Gerst, K., & Burr, J. A. (2008). Planning for end-of-life care: Black-White dierences in the
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Gillick, M. R. (2006). e use of advance care planning to guide decisions about articial nutrition
and hydration. Nutrition in Clinical Practice, 21(2), 126–133. Evidence Level V.
Gorman, T. E., Ahern, S. P., Wiseman, J., & Skrobik, Y. (2005). Residents’ end-of-life decision
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(2002). Advance care planning and end-of-life care for hospitalized nursing home residents.
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Hawkins, N. A., Ditto, P. H., Danks, J. H., & Smucker, W. D. (2005). Micromanaging death:
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A comparison of method to communicate treatment preferences in nursing facilities: Traditional
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Hopp, F. P., & Duy, S. A. (2000). Racial variations in end-of-life care. Journal of the American
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Htut, Y., Shahrul, K., & Poi, P. J. (2007). e views of older Malaysians on advanced directive and
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598 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Matsui, M., Braun, K. L., & Karel, H. (2008). Comparison of end-of-life preferences between
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Advance Directives 599
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600
30
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. identify factors that inuence an older adult’s ability to survive and rehabilitate from
a catastrophic illness
2. list examples of atypical presentation of illness in critically ill older adults
3. describe geriatric-specic assessment and physical examination of critically ill older
adults
4. identify nursing interventions that decrease critically ill older adults’ risk for adverse
medical outcomes
OVERVIEW
More than half (55.8%) of all intensive care unit (ICU) days are incurred by patients
older than the age of 65, and this number is expected to increase to unprecedented
levels over the next 10 years as the population ages (Angus et al., 2000). For example,
it is projected that by the year 2020, more than 350,000 older adults will annually
require acute mechanical ventilation for more than 4 days (Zilberberg, de Wit, Pirone,
& Shorr, 2008). Although older adults are an extremely heterogeneous group, they
share some age-related characteristics and are susceptible to various geriatric syndromes
and diseases that may inuence ICU treatments and outcomes (Milbrandt, Eldadah,
Nayeld, Hadley, & Angus, 2010; Pisani, 2009).
Ideally, the goals of providing nursing care to the critically ill older adult include
restoring physiologic stability, preventing complications, maintaining comfort and
Michele C. Balas, Colleen M. Casey, and Mary Beth Happ
Comprehensive Assessment and
Management of the Critically Ill
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Note: is chapter has been adapted from the American Association of Colleges of Nursing, “Preparing
Nursing Students to Care for Older Adults: Enhancing Gerontology in Senior-Level Undergraduate
Courses” curriculum module. Assessment and Management of Older Adults with Complex Illness in the
Critical Care Unit, prepared by Michele C. Balas, Colleen M. Casey, and Mary Beth Happ.
Comprehensive Assessment and Management of the Critically Ill 601
safety, and preserving or preventing decline in preillness functional ability and quality
of life (QOL). ere is evidence, however, suggesting that many critically ill older
adults are at risk for poor outcomes. Once hospitalized for a life-threatening illness,
older adults suer from high ICU, hospital, and long-term crude mortality rates and
are at risk for deterioration in functional ability, cognitive impairment, and postdis-
charge institutional care (de Rooij, Abu-Hanna, Levi, & de Jonge, 2005; Esteban et al.,
2004; Ford, omas, Cook, Whitley, & Peden, 2007; Hennessy, Juzwishin, Yergens,
Noseworthy, & Doig, 2005; Hopkins & Jackson, 2006; Kaarlola, Tallgren, & Pettilä,
2006; Marik, 2006; Wunsch et al., 2010). Older age is also one of the factors that may
lead to physician bias in refusing ICU admission (Joynt et al., 2001; Mick & Ackerman,
2004); the decision to withhold mechanical ventilation, surgery, or dialysis (Hamel
et al., 1999); and an increased frequency of do-not-resuscitate orders (Hakim et al.,
1996). Despite these ndings, most critically ill older adults demonstrate resiliency,
report being satised with their QOL postdischarge, and, if needed, would reaccept
ICU care and mechanical ventilation (Guentner et al., 2006; Hennessy et al., 2005;
Kleinpell & Ferrans, 2002).
BACKGROUND AND STATEMENT OF PROBLEM
Chronologic age alone is not an acceptable or accurate predictor of poor outcomes after
critical illness (Milbrandt et al., 2010; Nagappan & Parkin, 2003). Factors inuencing
an older adult’s ability to survive a critical illness include severity of illness, nature and
extent of comorbidities, diagnosis, the need for mechanical ventilation, complications,
preadmission of cognitive and functional status, malnutrition, and patient preference
(de Rooij et al., 2005; Marik, 2006; Wunsch et al., 2010). Other less well investigated
variables include senescence, vasoactive drug use, ageism, decreased social support, and
the critical care environment (Ford et al., 2007; Mick & Ackerman, 2004; Tullmann
& Dracup, 2000). e onset of new geriatric syndromes for an older hospitalized adult
such as urinary incontinence, infection, delirium, or falls are also harbingers of unde-
sirable events that can often be prevented with appropriate and timely ICU nursing
interventions (for more information, visit http://www.geronurseonline.org). is chap-
ter presents strategies and rationale for comprehensive assessment of critically ill older
adults to guide optimal care management.
ASSESSMENT OF PROBLEM AND NURSING CARE STRATEGIES
Assessment of Baseline Health Status
Comprehensive assessment of a critically ill older adult’s preadmission health status,
functional and cognitive ability, and social support systems helps the nurse identify risk
factors that make the older adult susceptible to cascade iatrogenesis (Creditor, 1993),
the development of life-threatening conditions, and frequently encountered geriatric
syndromes.
Preexisting Cognitive Impairment
Several anatomic and physiologic changes occur in the aged central nervous system
(see Table 30.1; Miller, 2009). e additive eect of chronic illness (e.g., diabetes, hyper-
tension, or coronary artery disease [CAD]) coupled with common aging changes and acute
602 Evidence-Based Geriatric Nursing Protocols for Best Practice
TABLE 30.1
Age-Associated Changes by Body System in the Older ICU Patient
System Age-Associated Changes
Respiratory Decrease in chest wall compliance, rib mobility, lung size and elasticity, ventilatory
response to hypoxia and hypercapnia, strength of respiratory muscles, PaO
2
level, mucociliary clearance, total lung capacity (minimal), forced vital capacity,
forced inspiratory and expiratory volume, peak and maximal expiratory flow rate,
tidal volume (slight), diffusing capacity, and maximal inspiratory and expiratory
pressure
Increases in residual volume, closing volume, A/A gradient, ventilation/perfusion
(VQ) imbalance, and chest wall stiffness
Physical assessment findings: possible kyphosis and an increased anteroposte-
rior diameter of the chest upon auscultation, a few bibasilar crackles that clear
with deep breathing and coughing
Gastrointestinal Decrease in number of mucus-secreting cells, mucosal prostaglandin concen-
trations, bicarbonate secretion, transit time of feces, pepsin and acid secretion,
gastric emptying, and thinning of smooth muscle in gastric mucosa; decrease in
the number and velocity of peristaltic contractions in esophagus, enteric nervous
system neurons, capacity to repair gastric mucosa, calcium absorption, lean
muscle mass and strength, daily energy expenditure, intracellular water, number
of hepatocytes, and overall weight and size of liver (compensatory increase in cell
size and proliferation of bile ducts), hepatic blood flow, and metabolism of and
sensitivity to drugs
Increase in body fat, changes to interstitial tissue (predisposing to soft tissue
injury and increasing the time and course for mobilization of extracellular water)
Genitourinary Increase in proportion of sclerotic nephrons or glomeruli, functional unit
hypertrophy, afferent and efferent arteriole atrophy, collagen in the bladder,
benign prostatic hypertrophy (men), hypertrophy of bladder muscle, thickening
of the bladder
Decline in number of functioning nephrons, glomerular filtration rate, renal
tubular cell function and number, renal blood flow, and creatinine clearance;
ability to conserve sodium and excrete hydrogen ions; ability to excrete
salt and water loads, ammonia, and certain drugs in the activity of the
renin-angiotensin system and end-organ responsiveness to antidiuretic
hormone, tone of sphincters, and alterations in estrogen cause further
changes in urethral sphincter of women
Skin Decrease in surface area between dermis and epidermis, subcutaneous and
connective tissue, number of eccrine and sebaceous glands, sebum amount,
vascular supply to dermis, epidermal turnover, skin turgor, moisture content, and
dermal thickness
Physical assessment findings: thin, fragile, wrinkled, loose, or transparent, dry,
flaky, rough, and often itchy skin
Neurologic Decrease in size of brain/brain weight, number of neurons and dendrites,
length of dendrite spines, cerebral blood flow, neurotransmitters or their
binding sites, in dopaminergic function, visual acuity and depth perception
(secondary to anatomic and functional changes to the auditory and vestibular
apparatus) and proprioception, balance and postural control, and tactile and
vibratory sensation
Increase in liposuscins, neuritic plaques, neurofibrillary bodies, ventricle size, and
sulci widening
Physical assessment findings: decreased papillary response to penlight, decrease
in near and peripheral vision, loss of visual acuity to dim light, evidence of muscle
wasting and atrophy, presentation of a benign essential tumor, slower and less
agile movement as compared to younger adults, diminished peripheral reflexes,
and a decreased vibratory sense in the feet and ankles
(continued)
Comprehensive Assessment and Management of the Critically Ill 603
TABLE 30.1
Age-Associated Changes by Body System in the Older ICU Patient (continued)
System Age-Associated Changes
Cardiovascular Decrease in number of myocytes and pacemaker cells, ventricular compliance,
rate of relaxation, baroreceptor sensitivity, vein elasticity, compliance of arteries,
response of myocardium to catecholamine stimulation, resting heart rate, heart
rate with stress, and cardiac reserve
Increase in myocardial collagen content, amyloid deposits, myocardial irritability,
stiffening of the outflow tract and great vessels (causing resistance to vascular
emptying), ventricular hypertrophy (slight), pulse wave velocity, time required to
complete the cycle of diastolic filling and systolic emptying, vein dilation, and
valvular stiffening
Physical assessment findings: Upon auscultation, many healthy older adults
display a fourth heart sound (S
4
), an aortic systolic murmur, higher systolic blood
pressure with a widening pulse pressure, and a slower resting heart rate.
Immune/
hematopoietic
Change in T-cell populations, products, and response to stimuli; defects in B-cell
function; mix of immunoglobulins change (i.e., IgM decreases, IgG and IgA
increase) and decline in neutrophil function
Note. ICU 5 intensive care unit; IgG 5 immunoglobulin G; IgA 5 immunoglobulin A; IgM 5 immunoglobulin M.
Source: Based on Bickley & Szilagyi (2008); Marik, Vasu, Hirani, & Pachinburavan (2010); Menaker & Scalea
(2010); Miller (2009); Pisani (2009); Rosenthal & Kavic (2004); and Urden, Stacy, & Lough (2002).
pathology may, however, place older adults at higher risk for some commonly encoun-
tered ICU syndromes such as delirium (McNicoll et al., 2003; Pisani, Murphy, Van Ness,
Araujo, & Inouye, 2007). High rates of preexisting cognitive impairment (31%–42%) are
reported in older adults admitted to both medical and surgical ICUs (Balas et al., 2007;
Pisani, Redlich, McNicoll, Ely, & Inouye, 2003). Unfortunately, this cognitive impair-
ment is often unrecognized by both the older adults family and health care providers (Balas
et al., 2007; Pisani et al., 2003). Relatives or other caregivers should be asked for baseline
information about memory, executive function ( problem solving, planning, organization
of information), and overall functional ability in daily living prior to the critical care admis-
sion (Kane, Ouslander, & Abrass, 2004; see Chapter 8, Assessing Cognitive Function).
Because knowledge of an older adult’s preadmission cognitive status may also assist in treat-
ment decisions, ICU clinicians should consider familiarizing themselves with dementia
screening tools such as the Informant Questionnaire on Cognitive Decline in the Elderly
(IQCODE) that were specically designed for proxy administration (Jorm, 1994).
Psychosocial Factors
Critical illness often renders older adults physically unable to eectively communicate
with the health care team. e inability to communicate may stem from multiple factors
including physiologic instability, tracheal intubation, and/or sedative and narcotic use
(Happ, 2000, 2001). Family members, or signicant others, are therefore a crucial
source for obtaining important preadmission information such as the older adult’s past
medical and surgical history, drug and alcohol use, nutritional status, home environment,
infectious disease exposure, medication use, religious preference, and social support
systems. Further, the lack of presence of family or a signicant other threatens the nurse’s
ability to obtain accurate data about the person, which is often needed to make urgent,
important care management and end-of-life discussions. (See Chapters 28, Health Care
Decision Making, and Chapter 29, Advance Directives).
604 Evidence-Based Geriatric Nursing Protocols for Best Practice
Functional Ability
Although most older adults report having at least one chronic condition, they remain
relatively independent (Administration on Aging, 2009). Assessing preadmission func-
tional status is essential when caring for critically ill older adults because many studies
have found it to be an important prognostic indicator in this population (Marik, 2006;
Mick & Ackerman, 2004; Tullmann & Dracup, 2000). Both the Katz Index of Inde-
pendence in Activities of Daily Living (KATZ ADLs; Katz, Ford, Moskowitz, Jackson,
& Jae, 1963) and the Functional Independence Measure (FIM; Kidd et al., 1995)
have been recommended for use with an older population (Kresevic & Mezey, 2003;
see Chapter 6, Assessment of Physical Function). Upon admission to the ICU, nurses
should also investigate whether the older adult uses glasses, hearing aids, or other devices
to perform their ADLs. Having these assistive devices available to the older adult while
they are in the ICU is important to enhance communication and rehabilitation.
Assessment and Interventions During ICU Stay
Although a full discussion of the physiologic changes that accompany common aging is
beyond the scope of this chapter, in the following sections we hope to provide readers
with (a) an overview of the major age-related changes to organ systems and description
of how these changes often manifest on physical exam (Table 30.1); (b) a discussion of
atypical presentations of some common ICU diagnoses; and (c) a description of inter-
ventions that may decrease the risk of untoward medical events for critically ill older
adults (also see Protocol 30.1). Common nursing interventions that benet multiple
organ systems will only be discussed in the rst section in which the intervention is
introduced. ese interventions include encouraging early, frequent mobilization or
ambulation; obtaining timely and appropriate consults (e.g., physical, occupational,
speech, respiratory, nutritional therapy); providing proper oral hygiene and adequate
pain control; securing and ensuring the proper functioning of tubes or catheters; main-
taining normothermia; deep vein thrombosis prophylaxis; and reviewing and assessing
medication appropriateness. e importance of these interventions and vigilance to
these elements of nursing care cannot be overstated.
Respiratory System
Because of a decrease in respiratory reserve with aging (Table 30.1; Pisani, 2009), an
older ICU patient’s respiratory status can become the most tenuous component of his
or her recovery. Common pulmonary changes in aging elevate an older adult’s risk for
aspiration, atelectasis, pneumonia, and acute lung injury (Menaker & Scalea, 2010;
Nagappan & Parkin, 2003; Pisani, 2009; Rosenthal & Kavic, 2004; Urden, Stacy, &
Lough, 2002). ese risks are further heightened in older adults who undergo tho-
racic or abdominal surgery; sustain rib fractures or chest injury; receive narcotics or
sedatives; have tubes that bypass the oropharyngeal airway; or who are weak, decondi-
tioned, dehydrated, and have poor oral hygiene (Menaker & Scalea, 2010; Nagappan
& Parkin, 2003; Rosenthal, 2004; Rosenthal & Kavic, 2004; Urden et al., 2002).
Preexisting pulmonary disease and manipulations of the abdominal and thoracic
cavities may further lead to unreliability of traditional values associated with central
venous pressure (CVP) and pulmonary artery occlusion pressures (PAOPs; Rosenthal
& Kavic, 2004). Consequently, it is important to discuss with the ICU team any
Comprehensive Assessment and Management of the Critically Ill 605
unusual preexisting or acute inuences on these hemodynamic parameters so that
accurate trends can be monitored.
Caring for the older adult who requires mechanical ventilation is particularly
challenging. Although debate exists about whether age inuences outcome in this popu-
lation, evidence suggests that chronic ventilatory dependency disproportionately aects
older patients, whether as a complication of a critical illness or as a result of a chronic
respiratory system limitation (Esteban et al., 2004; Kleinhenz & Lewis, 2000; Zilberberg
et al., 2008). Patients who require 4 or more days of mechanical ventilation are more
likely to die in the hospital, or if they survive, to spend a considerable amount of time in
an extended care facility upon discharge, experience an increased risk of hospital readmis-
sion, suer from continued morbidity, and experience a decreased QOL ( Chelluri et al.,
2004; Daly et al., 2009; Douglas, Daly, Brennan, Gordon, & Uthis, 2001; Douglas,
Daly, Gordon, & Brennan, 2002; Douglas, Daly, Kelley, O’Toole, & Montenegro,
2007; Douglas, Daly, O’Toole, Kelley, & Montenegro, 2009; Oeyen, Vandijck, Benoit,
Annemans, & Decruyenaere, 2010). ese patients and their family members often
experience symptoms of depression and posttraumatic stress disorder following discharge
from the ICU (Douglas, Daly, Kelley, O’Toole, & Montenegro, 2005; Douglas, Daly,
O’Toole, & Hickman, 2010; Griths, Fortune, Barber, & Young, 2007; Jubran et al.,
2010). ese potential consequences should be included as part of a discussion of treat-
ment options and postdischarge follow-up with older adults and their families.
e aforementioned ndings also highlight the need for the ICU team to aggres-
sively pursue means of early ventilator liberation. A protocol that paired spontaneous
awakening trials (SATs) with spontaneous breathing trials (SBTs) was recently found to
improve mechanically ventilated patients’ outcomes (Girard et al., 2008). In this study,
patients treated with both SATs and SBTs spent more days breathing without assistance,
were discharged from intensive care and the hospital earlier, and, at any instant during
the year after enrollment, were less likely to die than were patients in the control group
(Girard et al., 2008). It has also been suggested that even more benet may be accrued
by adding SATs and SBTs to protocols of early mobilization of mechanically ventilated
patients (Bailey, Miller, & Clemmer, 2009; King, Render, Ely, & Watson, 2010; Morris
et al., 2008). Finally, recent advances in techniques and applications of noninvasive
ventilation provide an exceedingly useful means of managing respiratory compromise,
thus potentially avoiding mechanical ventilation, in the older adult population (Muir,
Lamia, Molano, & Cuvelier, 2010).
Older patients with preexisting obstructive or restrictive lung disease who are
mechanically ventilated either in the ICU or in long-term care facilities are also at
increased risk for ventilator-assisted pneumonia (VAP; Buczko, 2010). To minimize this
complication, nurses should aggressively exercise standard VAP precautions, including
elevating the head of the bed to at least 30 degrees, providing frequent oral care, main-
taining adequate cu pressures, using continuous subglottic suctioning, avoiding the
routine changing of ventilator circuit tubing, assessing the need for stress ulcer and
deep venous thrombosis (DVT) prophylaxis, turning the patient as tolerated, providing
optimal hygiene, and advocating for weaning trials as early as possible (American Asso-
ciation of Critical Care Nurses [AACN], 2004; American oracic Society [ATS] &
Infectious Diseases Society of America [IDSA], 2005; Dezfulian et al., 2005; Institute
for Healthcare Improvement [IHI] & 5 Million Lives Campaign, 2008; Krein et al.,
2008). Several studies have also reported that early tracheostomy may be of benet in
decreasing VAP in older critically ill patients (Menaker & Scalea, 2010).
606 Evidence-Based Geriatric Nursing Protocols for Best Practice
Nurses should consider that older adults with common respiratory pathology often
do not present with symptoms traditionally considered “hallmarks of infection”—fever,
chills, and other constitutional symptoms. In fact, the typical signs of pneumonia— fever,
cough, and sputum production—can be absent in older adult, with only 33%–60%
of older patients presenting with a fever (Bellmann-Weiler & Weiss, 2009). Instead,
older patients with either sepsis or pneumonia can often present with acute confu-
sion, tachypnea, and tachycardia (Girard & Ely, 2007). is vague symptomatology can
delay diagnosis, and importantly antibiotic administration, leading to poorer outcomes
(Iregui, Ward, Sherman, Fraser, & Kollef, 2002).
Cardiovascular System
Because so many older adults live with hypertension, peripheral vascular disease, or
CAD, individual responses to treatment can dramatically dier depending on the sever-
ity of their illness and any preexisting comorbidities. Even the “disease-free” older adult
may experience a decrease in their ability to respond to stressful situations because of
many changes that accompany cardiovascular aging (see Table 30.1; Pisani, 2009).
Cardiovascular-associated aging changes ultimately render the myocardium less
compliant and responsive to catecholamine stimulation, can cause ventricular hyper-
trophy, and predispose the older adult to the development of several dierent types
of arrhythmias (Nagappan & Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al.,
2002). During times of stress, an older adult achieves an increase in cardiac output by
increasing diastolic lling rather than increasing heart rate (Nagappan & Parkin, 2003;
Rosenthal & Kavic, 2004; Urden et al., 2002). e practical implication of this nd-
ing is that older adults often require higher lling pressures (i.e., CVPs in the 8–10 cm
range, PAOPs in the 14–18 cm range) to maintain adequate stroke volume and may be
especially sensitive to hypovolemia (Rosenthal & Kavic, 2004). However, overhydra-
tion of the older adult should also be avoided because it can lead to systolic failure, poor
organ perfusion, and hypoxemia with subsequent diastolic dysfunction (Rosenthal &
Kavic, 2004). Careful monitoring of hemodynamic and uid status is therefore essential
to optimize the older patient’s cardiac status.
Cardiac complications are among the highest causes of mortality in the elderly sur-
gical patient (Menaker & Scalea, 2010). Although many of the randomized controlled
trials of beta-blocker therapy are small, the weight of evidence, in aggregate, suggests that
the use of preoperative beta-adrenergic blockade decreases the incidence of postoperative
cardiac complications and death in patients considered high risk (Fleisher et al., 2007).
High cardiovascular risk includes older adults with unstable coronary syndromes,
decompensated heart failure, signicant arrhythmias, previous myocardial infarction,
and even patients with diabetes mellitus and renal insuciency (Fleisher et al., 2007).
Certain other drugs commonly used in the ICU setting to treat cardiac conditions may
prove to be either not as eective (e.g., isoproterenol and dobutamine) or more eective
(e.g., afterload reducers) in the older adult population (Rosenthal & Kavic, 2004).
Symptoms of a myocardial infarction and congestive heart failure may be blunted in
critically ill older adults (Menaker & Scalea, 2010; Pisani, 2009), requiring the need to
monitor for nonspecic and atypical presentations in this patient population, including
shortness of breath, acute confusion, or syncope (Miller, 2009). Worsening clinical
status or diculty weaning from mechanical ventilation should prompt the ICU team
to investigate the possibility of myocardial ischemia in this population (Pisani, 2009).
Comprehensive Assessment and Management of the Critically Ill 607
Neurologic System
e central and peripheral nervous system changes that accompany aging may partially
explain why older adults often present to emergency departments or the ICU with acute
neurologic symptoms. ese acute neurologic changes may represent an atypical pre-
sentation of an acute illness, including alterations caused by infection, an imbalance of
electrolytes, or drug toxicity. A thorough physical examination, with follow-up testing,
must be conducted to accurately diagnose the etiology of an older adult’s neurologic
changes as well as a thorough review of medication use.
Age-related changes to the neurologic system, when coupled with acute pathology
and the ICU environment, may increase a critically ill older adult’s risk for cognitive
dysfunction, falls, restraint use, oversedation, alterations in body temperature, and
anorexia. Most importantly, these changes also elevate the risk of delirium that occurs
in up to 70% of older adults admitted to an ICU (Balas et al., 2007; Kresevic & Mezey,
2003; Peterson et al., 2006) and is associated with increased morbidity, mortality,
length of hospital stay, and poor functional outcomes (Balas et al., 2007; Balas, Happ,
Yang, Chelluri, & Richmond, 2009; Ely et al., 2001). Pain, sleep deprivation, visual
impairment, illness severity, prior cognitive impairment, dehydration, comorbidities,
laboratory abnormalities, multiple medications, chemical withdrawal syndromes, infec-
tions, fever, windowless units, and ICU length of stay may place the critically ill older
adult at risk for delirium (Morandi, Jackson, & Ely, 2009). Although management of
delirium in hospitalized patients is discussed more fully in Chapter 11, clinicians must
be particularly aware of the interconnectedness of delirium, mechanical ventilation, and
immobility in the critical care environment. Nurse-led interdisciplinary, multicompo-
nent strategies such as the awakening and breathing coordination, delirium monitoring/
management, and early mobility (ABCDE) bundle proposed by Vasilevskis et al. (2010)
have the potential to decrease delirium rates and subsequent poor outcomes in the older
adult population.
In addition to the physical barriers to speech imposed by mechanical ventilation,
older adult patients are at greater risk for impaired communication than their younger
counterparts because of preexisting vision, hearing, and cognitive or language impair-
ments ( Bartlett, Blais, Tamblyn, Clermont, & MacGibbon, 2008; Happ & Paull, 2008;
Patak et al., 2009). Accurate interpretation of patient messages, including pain and
symptom descriptions, may be dicult and frustrating for patients and care providers.
Partnering with speech-language pathologists on tools and techniques to facilitate
patient comprehension and communication can improve this process (Bartlett et al.,
2008; Happ & Paull, 2008).
Achieving adequate pain control for critically ill older adults is of utmost impor-
tance, both related to and independent of its relationship to delirium; however, the
nurse also needs to avoid oversedation and undertreatment of pain in this population
because both are associated with multiple negative outcomes, including distress, delir-
ium, sleep disturbances, and impaired mobility (Graf & Puntillo, 2003; Rosenthal &
Kavic, 2004). Several tools exist to assess a critically ill patient’s level of sedation and
delirium status. e Richmond Agitation and Sedation Scale (RASS; Ely et al., 2001;
Sessler et al., 2002) and the Confusion Assessment Method-ICU (CAM-ICU; Ely et
al., 2001) are two of the most common tools in the critical care setting (see Resources
section for additional information on these tools and Practice Protocol for interven-
tions to reduce delirium).
608 Evidence-Based Geriatric Nursing Protocols for Best Practice
Gastrointestinal System
Common age-related changes to the gastrointestinal (GI) system can predispose older
ICU patients to complications during their ICU stay, ranging from altered presentation
of illness to issues of medication eectiveness (Table 30.1). Older adults also experience
changes in their body composition (i.e., decrease in lean body mass) and energy use that
can potentiate the eect of medications on these GI system changes.
Ironically, although many conditions aecting the GI system are more common in
older adults (e.g., constipation, undernutrition and malnutrition, gastritis), their presence
is not fully explained by the aging processes (Rosenthal & Kavic, 2004). When assessing
the GI function of a critically ill older adult, it is important for the nurse to realize that age
may blunt the manifestations of acute abdominal disease. For example, pain may be less
severe, fever may be less pronounced or absent, and signs of peritoneal inammation, such
as muscle guarding and rebound tenderness, may be diminished or even absent (Bickley &
Szilagyi, 2008). Because of changes in the secretion of gastric enzymes, the stomach wall
of older adults can be more susceptible to acid injury, especially in the face of critical ill-
ness. e practice of routine stress ulcer prophylaxis in the critically ill patient, part of the
VAP bundle and common in many ICUs, however, has more recently been challenged as a
potential contributor to pneumonia with more narrow indications that has been assumed,
even in mechanically ventilated patients (Herzig, Howell, Ngo, & Marcantonio, 2009;
Logan, Sumukadas, & Witham, 2010; Marik, Vasu, Hirani, & Pachinburavan, 2010).
Delayed gastric emptying may predispose older adults to abdominal distension,
nausea, vomiting, aspiration, and constipation. is delayed motility is especially true in
the postoperative period when many older adults are immobile and receiving narcotics.
Many older adults take multiple medications, which along with age-related changes such
as altered thresholds for taste and smell, a hypersensitive hypothalamic satiety center, and
oropharyngeal atrophy, can inhibit their intake of solids and liquids (Rosenthal & Kavic,
2004). is baseline GI functionality, in combination with their critical illness, must
be proactively addressed. e nurse needs to be alert for ill-tting dentures, swallowing
diculties, silent aspiration, and the possibility of decreased saliva production (caused
by either salivary dysfunction or the use of drugs such as sympathomimetics). ese
alterations can lead to insucient mastication and can combine with other risk factors
that put the older ICU patient at risk for aspiration. Aspiration should be considered a
life-threatening situation requiring immediate nursing intervention.
Older adults facing stress from illness, injury, or infection are also at high risk for
protein–calorie malnutrition, as evidenced by low serum albumin and prealbumin lev-
els, a decline in hepatic function, decreased muscle mass and strength, and dysfunction
in those tissues with high cell turnover (Nagappan & Parkin, 2003; Rosenthal & Kavic,
2004). ese changes lead to a breakdown in barrier function, increased susceptibility to
infection, delayed wound healing, uid shifts, deconditioning, and further impairment
in absorption of essential nutrients (Rosenthal, 2004). us, early enteral or parental
nutritional support is crucial while taking advance directives into consideration.
Reductions with age in the activity of the drug-metabolizing enzyme system and
blood ow through the liver inuence the liver’s capacity to metabolize various drugs
(Kane et al., 2004; Urden et al., 2002). Splanchnic blood ow is further compromised
in states of shock or even mild hypotension. ese changes may predispose older adults
to adverse drug reactions (Urden et al., 2002). For example, drugs such as warfarin
that work directly on hepatocytes may reach their therapeutic eect at lower doses
Comprehensive Assessment and Management of the Critically Ill 609
TABLE 30.2
High-Risk Medications Commonly Used in Older ICU Patients
Drug Severity Rating
†
Potential Adverse Effects
*Amiodarone
(Cordarone)
High May provoke torsades de pointes and QT interval
problems. Lack of efficacy in older adults.
*Clonidine
(Catapres)
Low Orthostatic hypotension, CNS adverse effects
*Diazepam (Valium) High Increased sensitivity to benzodiazepines; long half-life in
older patients (can be several days); prolonged sedation;
increasing risk of falls and fractures; short- and intermediate-
acting benzodiazepines preferred
Digoxin (Lanoxin) Low Decreased renal clearance may lead to increased risk of
toxic effects; dose should not exceed .0.125 mg/day
except when treating atrial arrhythmias
*Diphenhydramine
(Benadryl)
High Strong anticholinergic effects, confusion, oversedation;
can also cause dry mouth and urinary retention; aggravates
benign prostatic hypertrophy and glaucoma; use smallest
possible dose
*Ketorolac (Toradol) High Peptic ulceration, GI bleeding, perforation; GI effects can
be asymptomatic
*Meperidine
(Demerol)
High Active metabolite accumulation may cause CNS toxicity,
tremor, confusion, irritability; other narcotics preferred
*Promethazine
(Phenergan)
High Highly anticholinergic; confusion, oversedation; can also
cause dry mouth, urinary retention; aggravates benign
prostatic hypertrophy and glaucoma
Propofol (Diprivan) Unrated Lipophilic drug; decreased clearance in older adults related
to increased total body fat
Cimetidine
(Tagamet) and
Ranitidine (Zantac)
Low CNS effects, confusion
†
Severity Rating—Adverse eects of medications rated as high or low severity based on the probability of event
occurring and signicance of the outcome (Beers, 1997; Bonk et al., 2006)
*Identied in Bonk et al. (2006) as seven most commonly prescribed Beers medications used in older hospitalized patients.
CNS 5 central nervous system; GI 5 gastrointestinal.
Source: Adapted from Bonk, Krown, Matuszewski, & Oinonen (2006);
and Fick, Cooper, Wade, Waller, Maclean, & Beers (2003).
( Rosenthal & Kavic, 2004). Common pharmacologic agents used in the critical care
setting and their common side eects often experienced by the gerontologic patient are
given in Table 30.2 (see Chapter 17, Reducing Adverse Drug Events).
Finally, many older adults have diabetes and even those older adults without preex-
isting diabetes may experience elevated blood glucose levels as a result of medications
and a stress response to critical illness. erefore, glycemic control in the older ICU
patient may be more dicult because of a declining glucose tolerance associated with
aging. Although initial studies indicated tight control of blood sugar, with blood glu-
cose levels 80–110 mg/dL, optimized recovery, and outcomes (Humbert, Gallagher,
Gabbay, & Dellasega, 2008; Van den Berghe et al., 2001), more recent study has
revealed that this tight control actually increases mortality (Van den Berghe, Bouillon,
& Mesotten, 2009).
610 Evidence-Based Geriatric Nursing Protocols for Best Practice
Genitourinary System
Preservation of the older adult’s preadmission renal status is one of the goals of ICU care.
Common age-related changes in the genitourinary (GU) system decrease the older adult’s
ability to excrete ammonia and drugs, diminish their capacity to regulate uid and acid–
base balance, and often impair their ability to properly empty their bladder (Nagappan &
Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al., 2002). e coupling of these com-
mon age-related changes with conditions commonly seen in the ICU environment such as
hypovolemia, shock, sepsis, and polypharmacy render the older adult at increased risk for
acute renal failure, metabolic acidosis, and adverse drug events (Yilmaz & Erdem, 2010).
e increased prevalence in the older population of asymptomatic bacteriuria also exacer-
bates an older ICU patient’s infection risk related to Foley catheter use (Richards, 2004).
e nurse must take into consideration an older patient’s baseline cardiovascular
status relative to their renal function. If an older patient was typically hypertensive prior
to hospitalization, for example, this patient’s renal vasculature may be accustomed to a
higher-than-normal pressure to perfuse the kidneys. Furthermore, common indicators
of dehydration, such as skin turgor, should be considered an unreliable sign in an older
adult, related to their loss of subcutaneous tissue (Sheehy, Perry, & Cromwell, 1999).
Although the Cockcroft–Gault formula (see Chapter 17, Reducing Adverse Drug
Events) has been derived to estimate creatinine clearance in the healthy aged, care must
be taken when applying this formula to critically ill older patients or to those patients
on medications that directly aect renal function (Rosenthal & Kavic, 2004). Finally,
the nurse should be especially cognizant of medications known to contribute to renal
failure including aminoglycosides, certain antibiotics, and contrast dyes, and closely
monitor laboratory results as warranted (Urden et al., 2002).
Immune and Hematopoietic System
e changes that occur in the aged immune and hematological system mainly involve
altered T- and B-cell functioning and a decrease in hematopoietic reserve (Nagappan
& Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al., 2002; see Table 30.1). e
consequences of these changes include an increased susceptibility to infection, increases
in autoantibodies and monoclonal immunoglobulins, and tumorigenesis (Rosenthal
& Kavic, 2004). ese common aging changes coupled with the stress, malnutrition,
and number of invasive procedures seen in the critical care environment may heighten
the older adult’s risk for a nosocomial infection. Furthermore, because an older adult’s
ability to mount a febrile response to infection diminishes with age (related to a decline
in hypothalamic function), the older patient may even be septic without the warning
of a fever (Urden et al., 2002) and instead may exhibit only a decline in mental status.
Close assessment of other nonfebrile signs of infection (i.e., restlessness, agitation,
delirium, hypotension, and tachycardia) is essential and warranted.
Although recent research suggests that giving blood more liberally to patients may
be associated with worse patient outcomes, these ndings may not necessarily apply
to the older adult population for several reasons: (a) the chronic anemia often seen in
aging, (b) the exclusion of many older adults from previous clinical trials, (c) research
ndings that suggest higher transfusion triggers in older patients with acute myocar-
dial infarction actually decrease mortality, and (d) the association of low hemoglobin
levels with increased incidence of delirium, functional decline, and decreased mobility
(Rosenthal & Kavic, 2004).
Comprehensive Assessment and Management of the Critically Ill 611
Skin and Wounds
Older adults are at high risk for skin breakdown in the ICU setting because of loss of
elastic, subcutaneous, and connective tissues; a decrease in sweat gland activity; and a
decrease in capillary arterioles supplying the skin with age (Bickley & Szilagyi, 2008;
Urden et al., 2002; see Table 30.1). Because the skin changes that occur in older adults
can cause diculty with thermoregulation, can heighten the risk for skin breakdown
and IV inltrations, may delay wound healing, and make hydration assessment di-
cult, the nurse should make every eort to prevent heat loss, carefully monitor hydra-
tion status, and conduct thorough skin assessments (Bickley & Szilagy, 2008; Urden
et al., 2002; see Chapter 16, Preventing Pressure Ulcers and Skin Tears).
Ned Saunders is a 71-year-old man who fell o a ladder while stringing holiday lights
and suered serious complications, including adult respiratory distress syndrome
(ARDS), after laminectomy. He required a second back surgery (revision of the lamine-
ctomy) during the same hospital stay and developed a Clostridium dicile (C. dicile)
infection and nutritional problems secondary to the severe diarrhea. Infection with
antibiotic-resistant organisms necessitated the use of isolation protocol. Tracheostomy
placement occurred on the 17th ICU day and progressive weaning trials began.
Preadmission
Mr. Saunders was a former smoker and his past medical history included mild chronic
obstructive pulmonary disease and hypertension. His medications prior to admission
were albuterol inhaler, two pus every 6 hours, and hydrochlorothiazide 50 mg for
blood pressure. He smoked a half pack per day for 30 years. A retired school teacher,
Mr. Saunders was slightly overweight but active around the house and enjoyed
an active social life, especially dancing with his wife at local dance halls. He was a
“social drinker,” as reported by his wife, having three to four glasses of wine per week.
Mr. Saunders was completely independent in all ADLs before this hospitalization.
Mini-Mental State Examination (MMSE) score on admission before surgery was 29.
CAM-ICU (for delirium) on admission to the ICU was positive for delirium.
Psychosocial
Mr. Saunders was unable to focus attention for more than 5 seconds at a time and was
intermittently agitated during the early stages of ICU stay. Delirium was treated with
around-the-clock dosages of IV haloperidol. He also received fentanyl patch for pain
and lorazepam (dose and frequency taken) as needed for anxiety and sedation. Eorts
were made to minimize and taper the use of the benzodiazepine (lorazepam) in an
attempt to clear the delirium.
Anxiety and communication diculties were identied by nurses as problems
possibly inuencing his “mental state” during ventilator weaning. Communication
CASE STUDY
(continued)
612 Evidence-Based Geriatric Nursing Protocols for Best Practice
was inhibited by respiratory tract intubation, cognition problems, and lack of dentures
and eyeglasses. Because his thinking was unclear, nurses used visual cues in the form
of written words, gestures, and pictures to augment their messages to Mr. Saunders.
ey cued him to use a simple communication board and asked yes/no questions
by categories (e.g., family, your body, comfort needs) whenever possible. After the
tracheostomy procedure was completed, his wife was advised to bring in his dentures
to improve lip reading. He began using a tracheostomy speaking valve after 5.5 weeks
of hospitalization.
e patient’s wife was his sole support. ey had no children or close relatives.
A reserved woman, she remained positive when at the patient’s bedside. Nurses
coached her to use touch and encouragement at the bedside. Mrs. Saunders asked
the therapists to teach her range-of-motion exercises and she performed these during
afternoon visits. She provided calm and distracting talk during weaning trials, reading
get-well cards from friends.
Cardiac
Mr. Saunders remained in a sinus tachycardia through most of the hospitalization
with occasional premature ventricular contractions. His hemoglobin and hematocrit
dropped to 10 mg/dL and 36 percent respectively during the hospitalization with
no identied source of bleeding. He received one unit of packed red blood cells and
diuretics before weaning trials were resumed.
Respiratory
Mr. Saunders progressed from dependence on mechanical ventilation in assist con-
trol mode (FiO
2
5 40%, continuous positive airway pressure [CPAP] 5 5 cmH
2
O,
PS [pressure support] 5 10 cmH
2
O) to tracheostomy mask oxygen at 50% FiO
2
over
a 10-day period.
Gastrointestinal
Nutritional balance was particularly challenging with Mr. Saunders because of the
impaired absorption of nutrients during C. dicile infection. Nutrition or dietitian
consult should be obtained. e infection was treated with IV vancomycin. A jejunos-
tomy tube was placed for continuous tube feeding and caloric requirements adjusted
frequently with careful attention to albumin levels. Vancomycin drug levels must also
be monitored.
Skin
Meticulous attention to wound healing at the back surgery site and t of “turtle shell”
to prevent friction or skin tears.
CASE STUDY (continued)
(continued)
Comprehensive Assessment and Management of the Critically Ill 613
SUMMARY
Nurses in the acute care setting must recognize and respond to the many factors that
inuence a critically ill older adult’s ability to survive and rehabilitate from a catastrophic
illness. In order to identify some of these risk factors, it is essential that the nurse per-
form a comprehensive assessment of each older adult’s preadmission health status, func-
tional and cognitive ability, and social support systems. It is equally important that the
nurse understand the implications of common aging changes, comorbidities, and acute
pathology that interacts with and heightens the risk of adverse and often preventable
medical outcomes. e application of evidence-based interventions aimed at restoring
physiologic stability, preventing complications, maintaining comfort and safety, and
preserving preillness functional ability and QOL are crucial components of caring for
this extremely vulnerable population.
Rehabilitation
Mr. Saunders received early physical therapy, beginning as passive range during the
most critical phase of his illness and progressing to active range of motion and chair
sitting. His mobility was limited by the protective “turtle shell” appliance required for
healing of his spine during any out-of-bed activity. A daily chair-sitting period was
arranged, requiring coordination between physical therapy and nursing. e team
initiated speech and swallowing rehabilitation (i.e., speech and swallowing evaluation)
beginning with lollipops to reestablish swallowing.
Discharge Planning
Mr. Saunders’s progress was slow and his respiratory status was still tenuous at the end
of his ICU stay. He required signicant physical rehabilitation following his critical
illness. A long-term acute care hospital (LTACH) was the best choice for continued
care and rehabilitation. As Mr. Saunders’s respiratory status and speaking ability
improved, his anxiety diminished. Because Mr. Saunders had multiple risk factors
for delirium, the exact cause of the delirium was unknown at discharge. Attention
to normalizing the uid and electrolyte balance, reestablishing and maintaining
normal sleep–wake cycles, and gradually withdrawing the use of benzodiazepines
continued as care was transferred to the LTACH. His mental status improved
as evidenced by less frequent periods of inattention and confusion. Short-term
memory problems persisted and required frequent cueing and reminders from sta
and his wife.
CASE STUDY (continued)
614 Evidence-Based Geriatric Nursing Protocols for Best Practice
Protocol 30.1: Comprehensive Assessment and Management of the Critically Ill
I. GOAL: To restore physiologic stability, prevent complications, maintain comfort
and safety, and preserve preillness functional ability and quality of life (QOL) in older
adults admitted to critical care units.
II. OVERVIEW: Caring for an older adult who is experiencing a serious or life-
threatening illness often poses signicant challenges for critical care nurses. Although
older adults are an extremely heterogeneous group, they share some age-related char-
acteristics that leave them susceptible to various geriatric syndromes and diseases. is
vulnerability may inuence both their ICU utilization rates and outcomes. Critical
care nurses caring for this population must not only recognize the importance of per-
forming ongoing, comprehensive physical, functional, and psychosocial assessments
tailored to the older ICU patient, but also must be able to identify and implement
evidence-based interventions designed to improve the care of this extremely vulner-
able population.
III. BACKGROUND
A. Denition
Critically ill older adult. A person, age 65 or older, who is currently
experiencing, or at risk for, some form of physiologic instability or alteration
warranting urgent or emergent, advanced, nursing/medical interventions and
monitoring.
B. Etiology and Epidemiology
1. More than one half (55.8%) of all ICU days are incurred by patients older
than the age of 65 (Angus et al., 2000).
2. Older adults are living longer, are more racially and ethnically diverse,
often have multiple chronic conditions, and more than one quarter report
diculty performing one or more ADLs. ese factors may aect both the
course and outcome of critical illness.
3. Once hospitalized for a life-threatening illness, older adults often:
a. Experience high ICU, hospital, and long-term crude mortality rates
and are at risk for deterioration in functional ability and postdischarge
institutional care (de Rooij et al., 2005; Esteban et al., 2004; Ford et al.,
2007; Hennessy et al., 2005; Hopkins & Jackson, 2006; Kaarlola et al.,
2006; Marik, 2006; Wunsch et al., 2010)
b. Older age is also a factor that may lead to:
i. Physician bias in refusing ICU admission (Joynt et al., 2001; Mick
& Ackerman, 2004)
ii. e decision to withhold mechanical ventilation, surgery, or dialy-
sis (Hamel et al., 1999)
iii. An increased likelihood of an established resuscitation directive
(Hakim et al., 1996)
c. Most critically ill older adults
i. Demonstrate resiliency
ii. Report being satised with their QOL postdischarge
NURSING STANDARD OF PRACTICE
(continued)
Comprehensive Assessment and Management of the Critically Ill 615
iii. Would reaccept ICU care and mechanical ventilation if needed
(Guentner et al., 2006; Hennessy et al., 2005; Kleinpell & Ferrans,
2002)
d. Chronologic age alone is not an acceptable or accurate predictor of poor
outcomes after critical illness (Nagappan & Parkin, 2003; Milbrandt
et al., 2010).
e. Factors that may inuence an older adult’s ability to survive a cata-
strophic illness include the following:
i. Severity of illness
ii. Nature and extent of comorbidities
iii. Diagnosis, reason for/duration of mechanical ventilation
iv. Complications
v. Others
a) Prehospitalization functional ability
b) Vasoactive drug use
c) Preexisting cognitive impairment
d) Senescence
e) Ageism
f) Decreased social support
g) Critical care environment (de Rooij et al., 2005; Ford et al., 2007;
Marik, 2006; Mick & Ackerman, 2004; Tullmann & Dracup,
2000; Wunsch et al., 2010)
IV. PARAMETERS OF ASSESSMENT
A. Preadmission: Comprehensive assessment of a critically ill older adult’s preadmission
health status, cognitive and functional ability, and social support systems helps iden-
tify risk factors for cascade iatrogenesis, the development of life-threatening condi-
tions, and frequently encountered geriatric syndromes. Factors that the nurse needs
to consider when performing the admission assessment include the following:
1. Preexisting cognitive impairment: Many older adults admitted to ICUs
suer from high rates of unrecognized, preexisting cognitive impairment
(Balas et al., 2007; Pisani et al., 2003).
a. Knowledge of preadmission cognitive ability could aid practitioners in:
i. Assessing decision-making capacity, informed consent issues, and
evaluation of mental status changes throughout hospitalization
(Pisani, Inouye, McNicoll, & Redlich, 2003)
ii. Making anesthetic and analgesic choices
iii. Considering one-to-one care options
iv. Weaning from mechanical ventilation
v. Assessing fall risk
vi. Planning for discharge from the ICU
b. Upon admission to the ICU, the nurse should ask relatives or other
caregivers for baseline information about the older adult’s:
i. Memory, executive function (e.g., ne motor coordination, plan-
ning, organization of information), and overall cognitive ability
(Kane et al., 2004)
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
(continued)
616 Evidence-Based Geriatric Nursing Protocols for Best Practice
ii. Behavior on a typical day; how the patient interacts with others;
their responsiveness to stimuli; how able they are to communicate
(reading level, writing, and speech); and their memory, orientation,
and perceptual patterns prior to their illness (Milisen, DeGeest,
Abraham, & Delooz, 2001)
iii. Medication history to assess for potential withdrawal syndromes
(Broyles, Colbert, Tate, Swigart, & Happ, 2008)
c. Psychosocial factors: Critical illness can render older adults unable to
eectively communicate with the health care team, often related to phys-
iologic instability, technology that leaves them voiceless, and sedative and
narcotic use (Happ, 2000, 2001). Family members are therefore often a
crucial source for obtaining important preadmission information. Upon
ICU admission, the nurse needs to determine the following:
i. What is the older adult’s past medical, surgical, and psychiatric
history? What medications was the older adult taking before com-
ing to the ICU? Does the older adult regularly use illicit drugs,
tobacco, or alcohol? Do they have a history of falls, physical abuse,
or confusion?
ii. What is the older adult’s marital status? Who is the patient’s sig-
nicant other? Will this person be the one responsible to make
decisions for the older adult if they are unable to do so? Does the
older adult have an advanced directive for health care? Is the older
adult a primary caregiver to an aging spouse, child, grandchild, or
other person?
iii. How would the older adult describe his or her ethnicity? Do they
practice a particular religion or have spiritual needs that should be
addressed? What was their QOL like before becoming ill?
d. Preadmission functional ability and nutritional status: Limited pread-
mission functional ability and poor nutritional status are associated
with many negative outcomes for critically ill older adults (Marik, 2006;
Mick & Ackerman, 2004; Tullmann & Dracup, 2000). erefore, the
nurse should assess the following:
i. Did the older adult suer any limitations in the ability to perform
their ADLs preadmission? If so, what were these limitations?
ii. Does the older adult use any assistive devices to perform his or her
ADLs? If so, what type?
iii. Where did the patient live prior to admission? Did he or she live
alone or with others? What was the older adult’s physical environ-
ment like (house, apartment, stairs, multiple levels, etc.)?
iv. What was the older adult’s nutritional status like preadmission?
Does he or she have enough money to buy food? Does he or she
need assistance with making meals and obtaining food? Does he
or she have any particular food restrictions or preferences? Where
he or she using supplements and vitamins on a regular basis? Does
he or she have any signs of malnutrition, including recent weight
loss or gain, muscle wasting, hair loss, or skin breakdown?
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
(continued)
Comprehensive Assessment and Management of the Critically Ill 617
B. During ICU stay: ere are many anatomic and physiologic changes that occur
with aging (see Table 30.1). e interaction of these changes with the acute
pathology of a critical illness, comorbidities, and the ICU environment leads
not only to atypical presentation of some of the most commonly encountered
ICU diagnoses, but may also elevate the older adult’s risk for complications.
e older adult must be systematically assessed for the following:
1. Comorbidities and common ICU diagnoses
a. Respiratory: chronic obstructive pulmonary disease, pneumonia, acute
respiratory failure, adult respiratory distress syndrome, and rib fractures/
ail chest
b. Cardiovascular: acute myocardial infarction, coronary artery disease,
peripheral vascular disease, hypertension, coronary artery bypass graft-
ing, valve replacements, abdominal aortic aneurysm, dysrhythmias
c. Neurologic: cerebral vascular accident, dementia, aneurysms, Alzheimer’s
disease, Parkinson’s disease, closed head injury, transient ischemic attacks
d. Gastrointestinal (GI): biliary tract disease, peptic ulcer disease, GI
cancers, liver failure, inammatory bowel disease, pancreatitis, diarrhea,
constipation, and aspiration
e. Genitourinary (GU): renal cell cancer, chronic renal failure, acute renal
failure, urosepsis, and incontinence
f. Immune/hematopoietic: sepsis, anemia, neutropenia, and thrombocy-
topenia
g. Skin: necrotizing fasciitis, pressure ulcers
2. Acute pathology: thoracic or abdominal surgery, hypovolemia, hypervolemia,
hypothermia/hyperthermia, electrolyte abnormalities, hypoxia, arrhythmias,
infection, hypotension/hypertension, delirium, ischemia, bowel obstruction,
ileus, blood loss, sepsis, disrupted skin integrity, multisystem organ failure
3. ICU/environmental factors: deconditioning, poor oral hygiene, sleep depri-
vation, pain, immobility, nutritional status, mechanical ventilation, hemo-
dynamic monitoring devices, polypharmacy, high-risk medications (e.g.,
narcotics, sedatives, hypnotics, nephrotoxins, vasopressors), lack of assistive
devices (e.g., glasses, hearing aids, dentures), noise, tubes that bypass the
oropharyngeal airway, poorly regulated glucose control, Foley catheter use,
stress, invasive procedures, shear/friction, intravenous catheters
4. Atypical presentation: Commonly seen in older adults experiencing the
following: myocardial infarction, acute abdomen, infection, and hypoxia
V. NURSING CARE STRATEGIES
A. Preadmission: Based on their preadmission assessment ndings, the nurse
should consider the following:
1. Obtaining appropriate consults (i.e., nutrition, physical/ occupational/
speech therapist)
2. Implementing safety precautions
3. Using pressure-relieving devices
4. Organizing family meetings
5. Providing the older adult with a consistent primary nurse
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
(continued)
618 Evidence-Based Geriatric Nursing Protocols for Best Practice
B. During ICU: Nursing interventions that may benet:
1. Multiple organ systems:
a. Encouraging early, frequent mobilization/ambulation
b. Providing proper oral hygiene
c. Ensuring adequate pain control
d. Reviewing/assessing medication appropriateness
e. Avoiding polypharmacy/high-risk medications (see Table 30.2)
f. Securing and ensuring the proper functioning of tubes/catheters
g. Actively taking measures to maintain normothermia
h. Closely monitoring uid volume status.
2. Respiratory
a. Encourage and assist with coughing, deep breathing, incentive spirome-
ter use; use alternative device when appropriate (e.g., positive expiratory
pressure [PEP])
b. Assess for signs of swallowing dysfunction and aspiration
c. Closely monitor pulse oximetry and arterial blood gas results
d. Consider the use of specialty beds
e. Advocate for early weaning trials and extubation as soon as possible
f. Exercise standard VAP precautions (AACN, 2004; ATS & IDSA, 2005;
Dezfulian et al., 2005; IHI & 5 Million Lives Campaign, 2008; Krein
et al., 2008):
i. Keep the head of the bed elevated to more than 30 degrees.
ii. Provide frequent oral care.
iii. Maintain adequate cu pressures.
iv. Use continuous subglottic suctioning devices.
v. Do not routinely change ventilator circuit tubing.
vi. Assess the need for stress ulcer and deep venous thrombosis (DVT)
prophylaxis.
vii. Turn the patient as tolerated.
viii. Maintain general hygiene practices.
3. Cardiovascular
a. Carefully monitor the older adult’s hemodynamic and electrolyte status.
b. Closely monitor the older adult’s ECG with an awareness of many con-
duction abnormalities seen in aging. Consult with physician regarding
prophylaxis when appropriate.
c. Advocate for the removal of invasive devices as soon as the patient’s condi-
tion warrants. e least restrictive device may include long-term access.
d. Recognize that both preexisting pulmonary disease and manipulations of
the abdominal and thoracic cavities may lead to unreliability of traditional
values associated with central venous pressures (CVPs) and pulmonary
artery occlusion pressures (PAOPs; Rosenthal & Kavic, 2004).
e. Because of age-related changes to the cardiovascular system, the nurse
should acknowledge (Rosenthal & Kavic, 2004):
i. Older adults often require higher lling pressures (i.e., CVPs
in the 8–10 cm range, PAOPs in the 14–18 cm range) to
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
(continued)
Comprehensive Assessment and Management of the Critically Ill 619
maintain adequate stroke volume and may be especially sensitive
to hypovolemia.
ii. Overhydration of the older adult should also be avoided because it
can lead to systolic failure, poor organ perfusion, and hypoxemia
with subsequent diastolic dysfunction.
iii. Certain drugs commonly used in the ICU setting may prove to be
either not as eective (e.g., isoproterenol and dobutamine) or more
eective (e.g., afterload reducers).
4. Neurologic/pain
a. Closely monitor the older adult’s neurologic and mental status.
b. Screen for delirium and sedation level at least once per shift.
c. Implement the following interventions to reduce delirium:
i. Promote sleep, mobilize as early as possible, review medications
that can lead to delirium, treat dehydration, reduce noise or pro-
vide “white noise,” close doors/drapes to allow privacy, provide
comfortable room temperature, encourage family and friends to
visit, allow the older adult to assume their preferred sleeping posi-
tions, discontinue any unnecessary lines or tubes, and avoid the
use of physical restraints, using least restraint for minimum time
only when absolutely necessary.
ii. Maximize the older adult’s ability to communicate his or her needs
eectively and interpret his or her environment.
a) Promote the older adult wearing glasses, hearing aids, and
other appropriate assistive devices.
b) Face the patients when speaking to them, get their attention
before talking, speak clearly and loud enough for them to
understand, allow them enough time (pause time) to respond
to questions, provide them with a consistent provider (i.e., a
primary nurse), use visual clues to remind them of the date and
time, and provide written or visual input for a message (Garett,
Happ, Costello, & Fried-Oken, 2007).
c) Provide the older adult with alternate means of communica-
tion (e.g., providing him or her with a pen and paper, using
nonverbal gestures, and/or using specially designed boards
with alphabet letters, words, or pictures; Garett et al., 2007;
Happ et al., 2010).
d) Provide translators/interpreters as needed.
d. Provide adequate pain control while avoiding oversedation or underse-
dation. For a full discussion, see Chapter 14, Pain Management.
5. Gastrointestinal
a. Monitor for signs of GI bleeding and delayed gastric emptying and motility.
i. Encourage adequate hydration, assess for signs of fecal impaction,
and implement a bowel regimen.
ii. Avoid use of rectal tubes.
b. Advocate for stress ulcer prophylaxis.
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
(continued)
620 Evidence-Based Geriatric Nursing Protocols for Best Practice
c. Provide dentures as soon as possible.
d. Implement aspiration precautions.
i. Keep the head of the bed elevated to a high Fowler’s position,
frequently suction copious oral secretions, bedside evaluate swal-
lowing ability by a speech therapist, assess phonation and gag
reex, monitor for tachypnea.
e. Advocate for early enteral/parenteral nutrition.
f. Ensure tight glucose control.
6. Genitourinary
a. Assess any GU tubes to ensure patency and adequate urinary output.
If the older adult should experience an acute decrease in urinary out-
put, consider using bladder scanner (if available), rather than automatic
straight catheterization, to check for distension.
b. Advocate for early removal of Foley catheters. Use other less invasive
devices/methods to facilitate urine collection (i.e., external or condom
catheters, oering the bedpan on a scheduled basis, and keeping the
nurse’s call bell/signal within the older adult’s reach).
c. Monitor blood levels of nephrotoxic medications as ordered.
7. Immune/hematopoietic
a. Ensure that the older adult is ordered appropriate DVT prophylaxis
(i.e., heparin, sequential compression devices)
b. Monitor laboratory results, assess for signs of anemia relative to patient’s
baseline
c. Recognize early signs of infection—restlessness, agitation, delirium,
hypotension, tachycardia—because older adults are less likely to develop
fever as a rst response to infection.
d. Meticulously maintain infection control/prevention protocols.
8. Skin
a. Conduct thorough skin assessment.
b. Vigilantly monitor room temperature, make every eort to prevent heat
loss, and carefully use and monitor rewarming devices.
c. Use methods known to reduce the friction and shear that often occurs
with repositioning in bed.
d. In severely compromised patients, the use of specialty beds may be
appropriate.
e. Techniques such as frequent turning, pressure-relieving devices, early
nutritional support, as well as frequent ambulation may not only pro-
tect an older adult’s skin, but also promote the health of their cardiovas-
cular, respiratory, and GI systems.
f. Closely monitor IV sites, frequently check for inltrations and use of
nonrestrictive dressings and paper tape.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Hemodynamic stability will be restored.
2. Complications will be avoided/minimized.
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
(continued)
Comprehensive Assessment and Management of the Critically Ill 621
3. Preadmission functional ability will be maintained/optimized.
4. Pain/anxiety will be minimized.
5. Communication with the health care team will be improved.
B. Provider
1. Employ consistent and accurate documentation of assessment relevant to
the older ICU patient.
2. Provide consistent, accurate, and timely care in response to deviations identi-
ed through ongoing monitoring and assessment of the older ICU patient.
3. Provide patient/caregiver with information and teaching related to his or
her illness and regarding transfer of care and/or discharge.
C. Institution: includes quality assurance/quality assessment (QA/QI)
1. Evaluate sta competence in the assessment of older critically ill patients.
2. Utilize unit-specic, hospital-specic, and national standards of care to
evaluate existing practice.
3. Identify areas for improvement and work collaboratively across disciplines
to develop strategies for improving critical care to older adults.
VII. RELEVANT PRACTICE GUIDELINES
Clinical practice guidelines for the sustained use of sedatives and analgesics in the crit-
ically ill adult. Task Force of the American College of Critical Care Medicine (ACCM)
of the Society of Critical Care Medicine (SCCM), American Society of Health-System
Pharmacists (ASHP), and American College of Chest Physicians ACC/AHA 2006
guideline update on perioperative cardiovascular evaluation for noncardiac surgery:
Focused update on perioperative beta-blocker therapy: A report of the American
College of Cardiology/American Heart Association Task Force on Practice Guide-
lines. Developed in collaboration with the American Society of Echocardiography,
American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardio-
vascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions,
and Society for Vascular Medicine and Biology.
Protocol 30.1: Comprehensive Assessment and Management
of the Critically Ill (cont.)
ACKNOWLEDGMENTS
e authors would like to acknowledge the continual support and commitment to
improving nursing care of older adults provided by the John A. Hartford Founda-
tion. Case study provided by the “Study of Ventilator Weaning: Care and Commu-
nication Processes” database using composite patient information and pseudonyms
(R01-NR007973).
RESOURCES
e Richmond Agitation and Sedation Scale (RASS) and e Confusion Assessment Method-ICU
(CAM-ICU)
http://www.icudelirium.org/delirium/training-pages/CAM-ICU%20trainingman.2005.pdf
622 Evidence-Based Geriatric Nursing Protocols for Best Practice
Training manual includes information for administering both the RASS and the CAM-ICU.
Copyright © 2002, E. Wesley Ely and Vanderbilt University
http://geronurseonline.org
Hartford Institute for Geriatric Nursing
http://www.consultgerirn.org/resources
Topics relevant to this chapter include the following:
n Brief Evaluation of Executive Dysfunction: An Essential Renement in the Assessment of
Cognitive Impairment
n Decision Making and Dementia
n Recognition of Dementia in the Hospitalized Older Adult
n Beers’ Criteria for Potentially Inappropriate Medication Use in the Elderly Assessing Pain in
Older Adults
n KATZ Index of Independence in ADL
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628
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader will be able to:
1. describe the older adult with heart failure who is at risk for hospital re-admission
2. conduct a comprehensive cardiac history
3. identify three physical ndings that may be associated with uid overload in the
older adult patient with heart failure
4. name three key symptoms associated with uid overload in the older adult patient
with heart failure
5. dene cardiovascular stability in relation to the ve key indicators
6. plan monitoring strategies to reduce uid overload in the older adult with heart failure.
OVERVIEW
Heart failure (HF) is the most common cause of hospital admission in the older adult
(Funk & Krumholz, 1996; Krumholz, Wang, et al., 1997). Hospitalizations for HF
account for approximately 50% of all cardiovascular hospital admissions (Krumholz,
Wang, et al., 1997; Lloyd-Jones et al., 2010) e evidenced-based literature demon-
strates that as many as half of these admissions are readmissions and are preventable
(Lloyd-Jones, et al., 2004; Rich et al., 1995; Ross et al., 2008). Early identication
of patients at risk for rehospitalization during the hospital stay provides opportunity
for interventions to impact the readmission rate. e epidemic growth in HF preva-
lence is commensurate with an aging population and has stimulated a focus of research
to identify those patients at high risk for hospitalization and readmission. Symptoms
Judith E. Schipper, Jessica Coviello, and
Deborah A. Chyun
Fluid Overload: Identifying and
Managing Heart Failure Patients
At Risk for Hospital Readmission
31
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Note: is chapter was adapted from the American Association of Colleges of Nursing Preparing
Nursing Students to Care for Older Adults: Enhancing Gerontology in Senior-Level Undergraduate
Courses curriculum module, Assessment and Management of Hypertension and Heart Failure, prepared
by Deborah A. Chyun and Jessica Coviello.
Fluid Overload: Identifying and Managing Heart Failure Patients 629
of HF compel patients to seek medical aid; however, evidence to date has shown HF
patients postpone seeking medical assistance 12 hours to 14 days before recognition of
these changes as harmful to bodily functioning (Koenig, 1998; Rich MW & Kitman
DW, 2005). e delay causes further deterioration in cardiac status requiring acute
hospitalization. is chapter presents the complex nature and pathophysiology of HF
symptoms, with nursing management strategies to reduce hospital re-admission rates. A
detailed protocol for nursing practice of the aging population is presented highlighting
the nursing assessment and management of HF.
BACKGROUND AND STATEMENT OF PROBLEM
HF is a public health problem aecting an estimated 5.8 million Americans yearly
(Lloyd-Jones et al., 2010; om et al., 2006). Cardiovascular disease (CVD), which
includes hypertension (HTN) and HF, valvular heart disease and arrhythmias, along
with the atherosclerotic disease that causes coronary heart disease (Hay et al., 1993),
stroke, and peripheral vascular disease (PVD), is the major contributor to mortality and
comorbidity in older adults. CVD accounts for 40% of all deaths in those aged 75 to
85 years, and 48% of all deaths in those 85 years and older (Lloyd-Jones et al., 2010;
om et al., 2006). Acute or chronic HF is the leading cause of hospital admission in
patients older than 65 years of age with readmission rates to acute care facilities averag-
ing 17.2% nationally in 1996 now increased to 23.6% in 2010 (Funk & Krumholz,
1996; Lloyd-Jones et al., 2010). Risk of readmission has been shown to be four times
higher in older adults aged 80 years and older, higher in ethnicities other than Whites,
and higher with lower economic status (Giamouzis et al., 2011).
e prevalence of HF increases with age, and more than 75% of those aected are
older than 65 years of age. Development of HF is higher with male sex, lower level
of education, low levels of physical activity, cigarette smoking, overweight, diabetes
mellitus (DM), HTN, valvular heart disease, left ventricular hypertrophy (LVH) and
atherosclerosis of the coronaries or CHD. HTN is a precursor in 75% of individuals
diagnosed with HF (om et al., 2006). Both the incidence and prevalence of HF
continues to increase as the population ages.
Risk Factors for Developing Heart Failure in Older Adults
e primary clinical risk factors for developing HF are advancing age, male sex, HTN,
myocardial infarction (MI), DM, valvular heart disease, and obesity. HTN is the most
common cause of HF in patients without CHD, accounting for 24% of the cases of
HF (Ho et al., 1993). HTN is also extremely common in type 2 DM, as it occurs in
40% to 60% of older adults with type 2 DM (Hypertension in Diabetes Study Group,
1993). Women with DM are at extremely high-risk for developing HF (Levy, Larson,
Vasan, Kannel, & Ho, 1996). Individuals with HTN and DM often develop HF with
preserved systolic function or so-called diastolic HF rather than systolic dysfunction
(Piccini, Klein, Gheorghiade, & Bonow, 2004).
Other related clinical risk factors of HF include smoking, dyslipidemia of genetic and
dietary etiology; sleep disordered breathing, chronic kidney disease, albuminuria, seden-
tary lifestyle, low socioeconomic status, and psychological stress. Toxic substances such
as chemotherapeutic agents (anthracyclines, cyclophosphamide, 5-FU, trastuzumab),
illicit drugs (amphetamines, cocaine), medications (nonsteroidal anti-inammatory
630 Evidence-Based Geriatric Nursing Protocols for Best Practice
drugs [NSAIDs], thiazolidinediones [TZDs], alcohol) can precipitate HF (Schocken
et al., 2008).
DM is a CVD equivalent and, as such, is an important contributor to HF. Women
and those individuals treated with insulin are at the greatest risk. In a sample of older
Medicare patients with type 2 DM, 22% had a diagnosis of HF, and this prevalence
increased with advancing age (Bertoni et al., 2004). In addition, the presence of type 2
DM is associated with higher HF-related morbidity and mortality. After MI or coronary
revascularization procedures, individuals with type 2 DM also have a high morbidity
and mortality, which is largely caused by the development of HF. An earlier analy-
sis of outcomes in Medicare patients 1 year after a MI revealed that 11% of patients
without DM had HF, whereas 17% of patients with DM on oral agents and 25% of
those treated with insulin were admitted for HF (Chyun, Vaccarino, Murillo, Young,
& Krumholz, 2002).
e initial diagnosis of HF is most often an acute index event requiring hospitaliza-
tion. Patients at risk for re-admission after initial diagnosis of HF include the following
(Bertoni et al., 2004; Chyun et al., 2002; Lewis et al., 2003):
n Age 70 years and older, and even more so for age 80 years and older
n Newly diagnosed HF with hospitalization (Krumholz, Parent, et al., 1997)
n Low systolic blood pressure (SBP; Pocock et al., 2006)
n Increased heart rate (Stefenelli, Bergler-Klein, Globits, Pacher, & Glogar, 1992;
Triposkiadis et al., 2009) or arrhythmia atrial brillation (Koitabashi et al., 2005)
n Hospitalizations for any reason in the last 5 years (Kossovsky et al., 2000)
n Social isolation (Faris, Purcell, Henein, & Coats, 2002)
n HF related to acute MI or uncontrolled HTN
n History of alcohol abuse (Evangelista, Doering, & Dracup, 2000)
n HF with acute infection
n HF with an exacerbation of a comorbidity; anemia with hemoglobin of less than
12 (Young et al., 2008), kidney disease (Metra et al., 2008), COPD (Braunstein
et al., 2003; Mascarenhas, Lourenço, Lopes, Azevedo, & Bettencourt, 2008),
and sleep apnea (Kasai et al., 2008)
n History of depression or anxiety (Faris et al, 2002; Rumsfeld et al., 2003)
n Nonadherence to diet, uid intake, or medications
Pathophysiology of Heart Failure
Understanding the pathophysiology of HF provides insight into the rationale for treat-
ment. Dened, heart failure is the inability of the heart to pump blood sucient to
metabolic needs of the body or cannot do so without greatly elevated lling pressures
(Miller & Piña, 2009). e inability of the left ventricle to eject blood suciently rep-
resents systolic HF and is diagnosed with a measurement of ejection fraction (EF) less
than 50%. Diastolic dysfunction and failure are the result of inadequate lling of the
left ventricle. Diastolic HF is also more descriptively named HF with preserved systolic
function because the EF is essentially normal: approximately 60%. e symptoms of
HF are directly related to impairment in the lling and ejecting of the blood in the left
ventricle (Owan et al., 2006).
All of the risk factors and disease entities listed previously can cause direct damage
to the myocardium, as in MI and toxic exposure, or subject it to increased level of
wall stress, as in HTN or valvular lesions. Such insult initiates compensatory actions
Fluid Overload: Identifying and Managing Heart Failure Patients 631
by the heart that are mediated by the neurohormones of the sympathetic nervous
system (SNS) and the renin angiotension aldosterone system (RAAS), which are
active both systemically and directly in the myocardium. Rather than oering ben-
et, the SNS ( epinephrine and norepinephrine) and RAAS (angiotensin II vasopres-
sin, aldosterone) hormones promote cardiac remodeling and hypertrophy, causing
dilatation of the ventricle and buildup of brous tissue that weakens the cardiomyo-
cytes. ese changes occur during compensated (asymptomatic) as well as decom-
pensated (symptomatic) failure. e overexpression of neurohormones causes salt
and water retention and vasoconstriction, which in turn produce increased hemody-
namic stress on the left ventricle. ese factors are cyclical unless treated. Untreated,
there is further disruption of left ventricle architecture and performance (Miller &
Piña, 2009).
Because this process begins without symptoms, for patients at risk, it is essential to
identify factors that are a hazard to cardiovascular health and initiate treatment before
signicant damage to the myocardium occurs. e American College of Cardiology/
American Heart Association Task Force (ACC/AHA) developed guidelines to classify
HF in 4 stages (2005):
Stage A is considered a pre-HF stage or an “at-risk” stage. It includes patients with
HTN, atherosclerotic disease, DM, obesity, metabolic syndrome, those using cardio-
toxic substances, or those with a family history of cardiomyopathy
Stage B includes asymptomatic individuals with previous MI, LVH, decreased EF, and
asymptomatic valvular disease
Stage C includes individuals with known heart disease and symptoms—shortness of
breath, fatigue, and reduced exercise tolerance—or those who are now asymptomatic
after eective treatment for their heart disease,
Stage D includes individuals with refractory HF requiring the use of specialized inter-
ventions and includes patients with marked symptoms at rest despite maximal
medical therapy.
Atherosclerosis and ischemia in CHD is the most common etiology of HF in the
United States, followed closely by HTN alone and valvular disease, although thyroid
dysfunction and excessive alcohol intake may also lead to HF. In the absence of known
CVD, systolic function of the heart remains relatively unchanged in older adults, as
does exercise tolerance. Diastolic dysfunction, however, is predominately a disease of the
elderly and may be present even in the absence of HTN or hypertrophic cardiomyopathy,
which are also known to contribute to diastolic failure (Bhatia et al., 2006; Olsson
et al., 2006; Yancy, Lopatin, Stevenson, De Marco, & Fonarow, 2006). e archetypical
patient presenting with diastolic HF is 70 to 80 years of age, female, obese, diabetic, and
often has atrial brillation (Coats, 2001). Diastolic dysfunction is characterized by an
exaggerated heart rate (HR) with activity, which is often one of the rst clinical ndings.
e severity of symptoms varies among patients and may not correlate to left ventricular
ejection fraction (LVEF; Brucks et al., 2005).
HTN, CHD, and hypertrophic cardiomyopathy are all abnormalities that are
exacerbated by tachycardia underscoring the importance of avoiding a high heart
rate in all older individuals. Diastolic abnormalities caused by HTN, aortic stenosis
or CHD may precipitate HF. Patients with either systolic or diastolic HF are at risk
for uid overload. Although discussed as two separate entities, many older adults have
components of both systolic and diastolic dysfunction.(Gheorghiade et al., 2010)
632 Evidence-Based Geriatric Nursing Protocols for Best Practice
ASSESSMENT OF THE PROBLEM
For older adults diagnosed with HF, the health history and physical assessment is
directed at monitoring symptoms and assessing cardiovascular function. For the nurse
assessing and managing the patient with HF, it is important to note that the recogni-
tion of uid overload is not always straightforward. Unlike the classic picture of HF
observed in younger adults, the symptoms of uid overload can be subtle and elusive in
older adults (Coviello, 2004). Once symptoms become pronounced in the older adult,
the nurse has a challenging task to resolve the HF, especially if it is of a long-standing
duration (Giamouzis et al., 2011). Monitoring parameters must be established where
the patient and nurse actively identify subtle changes and seek intervention as early as
possible (Grady et al., 2000).
The Health History
HF has both symptomatic and nonsymptomatic phase. When symptoms occur, they are
related to intravascular and interstitial uid overload and inadequate tissue perfusion.
Symptoms become evident with exertion and in severe HF, even at rest. e New York
Heart Association functional capacity is another important method for classifying the
HF patient according to how much activity patients are able to do without symptoms
(see Table 31.1). Classifying patients in this way oers evidence of the extent of volume
overload and activity limitation caused by symptoms, which then leads the nurse to real-
ize a level of disease. Patients, with proper treatment, can improve their functional status
and classication from a NYHA Class III to II or even I; however, they do not reclaim
earlier stages. For example, a Stage C patient does not return to Stage B.
Both patients and providers frequently attribute symptoms of uid overload to
aging. When symptoms occur during exertion, senior patients may simply decrease
their activities to prevent symptoms, yet when asked, they report activity from a mem-
ory of months earlier. Because of inaccurate reporting of activity, HF in older adults is
often dicult to recognize and, therefore, goes untreated. us, the nurse should rou-
tinely ask questions related to activity-limiting dyspnea. A key indicator in establishing
a baseline for functional capacity is to ask the patient what their maximal asymptomatic
activity is now, what it was 6 months ago, and what it was 1 year ago. Other important
questions include “How far can you walk without getting short of breath”? “What is the
activity that commonly produces shortness of breath”? “Do you experience shortness of
TABLE 31.1
New York Heart Association Functional Capacity Classification
Class I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue,
palpitation, dyspnea, or angina.
Class II Slight limitation of physical activity. Ordinary physical activity results in fatigue, palpitation,
dyspnea, or angina.
Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary of physi-
cal activity results in fatigue, palpitation, dyspnea, or angina.
Class IV Unable to carry on any physical activity without discomfort. Symptoms present at rest.
With any physical activity, symptoms increase.
Source: Adapted from: American Heart Association. (1994). Revisions to classication of functional capacity and
objective assessment of patients with disease of the heart. Circulation, 90, 644–645.
Fluid Overload: Identifying and Managing Heart Failure Patients 633
breath when simply sitting?” “Do you wake at night feeling short of breath?” Repeating
these questions in subsequent interviews will help monitor changes in activity associ-
ated with treatment or with suspected uid gain. Is the patient physically capable of
performing activities of daily living?
HF is a pathophysiological process in which left ventricular dysfunction occurs
independently from symptom development (Brucks et al., 2005). Symptom expression
is dependent upon compensatory mechanisms and the length of time HF has been
present. Patients with acute HF, as seen with MI, may be more symptomatic because
their compensatory mechanisms have not fully developed. In comparison, the patient
with long-standing HF may have severe dysfunction but may not become symptomatic
at all until they eat a high-sodium meal and develop uid overload rapidly, oftentimes
overnight. In this case, compensatory mechanisms are now exhausted and as a result,
fail. e window of opportunity to successfully intervene is narrow, as is the margin
of error. Treatment for uid overload in this case must be swift and brisk but gentle
enough to maintain BP (Grady, et al, 2000). Nurses need to be aware of the importance
of both early recognition and early intervention in the patient with uid overload. A few
hours delay in providing treatment can mean the dierence between successful manage-
ment at home or need for hospital admission with variable outcomes.
Knowledge of the past medical history will help to anticipate problems related to
other conditions because their presence may complicate assessment and management of
HF. Cardiac risk factors; levels of physical activity; and control of lipids, HTN, obesity,
DM, and smoking need to be determined. Older adult responses to HF medications
and treatment are variable. In addition, other drugs commonly used in this age group,
such as nonsteroidal anti-inammatory agents, can actually exacerbate uid overload
by increasing sodium retention. Previous questions related to cardiovascular functional
capacity may have already provided some information, but additional information on
musculoskeletal and neurological function is important.
Assessment of additional symptoms is also important. Orthopnea is the most sensi-
tive and specic symptom of elevated lling pressures, and it tends to reliably parallel
lling pressures in patients with this symptom (Ankler et al., 2003; Stevenson & Per-
lo, 1989). Nocturnal or exertional cough is often a dyspnea equivalent and should not
be confused with the cough from an angiotensin-converting enzyme (ACE) inhibitor,
which is not associated with activity or position. Individual patients generally exhibit
reproducible patterns of uid overload. ese should be documented, be made avail-
able to all on the care team, and be used in patient education and subsequent moni-
toring. Questions related to symptoms and function should be part not only of the
initial assessment, but also of subsequent visits as a means of surveillance (Stevenson &
Perlo, 1989).
e clinical presentation of HF may include a variety of symptoms reective of
pulmonary congestion and decreased cardiac output. e questions related to health
history are important to include and/or observe during the health encounter. Although
the presence of any one symptom is sucient to warrant consideration of HF when
they occur with other physical ndings, orthopnea, paroxysmal nocturnal dyspnea, and
progressive dyspnea on exertion are virtually diagnostic of uid overload.
e presence of other comorbidities among older adults, such as DM, renal dys-
function, and liver disease, along with systemic physiological changes associated with
aging, further complicate the assessment and management of HF in the older adult.
Co morbidities should also be carefully assessed by reviewing laboratory data. DM may
634 Evidence-Based Geriatric Nursing Protocols for Best Practice
necessitate monitoring of blood glucose since wide variations in glucose can aect isch-
emic threshold. Renal and liver disease may aect pharmacodynamics of drugs used
to treat HF. Anemia, a common medical condition in older adults, aects oxygen-
ation, activity tolerance, and subsequent uid balance (Young et al., 2008). e pres-
ence of chronic obstructive pulmonary disease (COPD), as well as other comorbidites,
may necessitate special precautions when assessing and managing oxygen therapy and
beta-blockers.
Since over use of salt in the diet may precipitate uid overload, a comprehensive
dietary history is absolutely essential. e nurse should include specic questions about
what the patient eats at meal and who prepares those meals. Additionally, does the
patient use the salt shaker or salt substitutes at the table or in cooking? A review of foods
high in sodium on a printed list often reveals foods the patient is eating but previously
did not admit to. For instance, important dietary questions related to use of canned
products or deli meats, which contain higher amounts of sodium should be included.
A list of the sodium and the potassium content of a variety of foods, including fruits
and vegetables, can be helpful in providing the information necessary for the patient
to make appropriate daily choices. Because assessment of nutritional status is critical
to elicit accurate uid and sodium intake, it is prudent in the acute care setting for the
older adult to have a dietary consultation. Additionally, since cachexia is a harbinger of
a downward spiral in patients with HF, questions need to be included on the health his-
tory related to appetite and weight loss (Evangelista et al., 2000; Lavie, Osman, Milani,
& Mehra, 2003).
Current prescription and over-the-counter medication taking should be assessed,
along with any alternative therapies. Many older adult who are eligible for aspirin, beta-
blockers, and ACE inhibitors do not receive these medications despite the important
role that these agents have in reducing CHD-related morbidity and mortality (Anker
et al., 2003; Colucci et al., 1996; Colucci et al., 2007; Packer, Bristow, et al., 1996;
Packer, 1998; Schocken et al., 2008).
Included in the health history should be questions related to medication adherence
and the patient’s decision to either take or not to take medications (Grady et al., 2000;
Riegel et al., 2009). Understanding a patient’s rationale to selectively not take certain
medications at certain times will help reveal ways for the nurse to intervene. Patients
may wish to adjust their diuretic dose so that they can function socially during the day.
is is not an adherence issue but a sound decision based on the patient’s rationale as
to how to t the medication regimen into their lifestyle. e interview can reveal if
“nonadherence” has such a rationale. If a cause is not found, other issues need to be
explored such as cost, number of medications, and/or the frequency of the doses. Ways
to simplify the drug regimen should be explored.
Psychosocial factors, personal beliefs and behaviors, along with cultural and envi-
ronmental inuences, all contribute to management of chronic disease. e impor-
tance of depression and social support has been well documented in the older adult;
therefore, all of these factors need to be assessed (Davos et al., 2003; Faris et al., 2002).
e nursing assessment in individuals with HF should identify the individual’s response
to treatment, which can then be used to assist the individual in subsequent management
of symptoms and the underlying condition, health promotion and disease prevention
activities, and chronic disease management. Awareness of the patient’s own perception
of why they sought medical care and a detailed analysis of the symptoms will assist in
assessing the individual’s or caregiver’s ability to identify symptoms, their knowledge
Fluid Overload: Identifying and Managing Heart Failure Patients 635
regarding their condition, its prognosis, and general health beliefs, along with their
prior ability to manage this or other medical conditions.
The Physical Assessment of the Older Adult With Fluid Overload
Physical assessment of the patient with suspected uid overload includes inspection;
palpation; and auscultation of the peripheral vasculature, heart, lungs, abdomen, and
extremities. Orientation, functional limitations, and mental clarity are observed during
examination of vital signs, which include height and weight and waist circumference.
A patient’s height and baseline weight are important indicators of both nutritional
and uid status. e importance of daily weights should be emphasized in the hospital
setting and, each day with each weight, a reinforcement of the need to not only continue
this practice at home, but to record the daily weight in a log as well. Weights should
subsequently be taken by the patient daily, typically the rst thing in the morning upon
arising, before breakfast, and with no clothes or wearing light clothing to avoid false
uctuations (Grady et al., 2000; Riegel et al., 2009; Riegel, Naylor, Stewart, McMurray,
& Rich, 2004). is provides the best baseline for consistency. Hospitalized patients
with HF have a weight measurement each day. With each daily weight, give reinforce-
ment again of the importance and also the signicance of weight gain and actions to
take with 3 to 5-lb weight gain. A 2-lb. weight gain overnight or a 3-lb weight gain in a
week is an indication that medical management must change. Measurement of a senior’s
waist circumference is also important to determine at baseline, since many times, this
is the location for uid accumulation (Grady et al., 2000). Once height and weight
are measured, a body mass index (BMI) should be calculated. Research has shown that
higher BMIs (25–30 kg/m
2
) are associated with longer survival (Horwich et al., 2001;
Lavie et al., 2003; Pickering et al., 2005; Pickering et al, 2008).
A thorough evaluation of the blood pressure (BP) should be performed. A variety
of environmental factors can inuence BP determination; therefore, the room should
be of a comfortable temperature, the patient as relaxed as possible, and a 5-minute
rest before taking the rst reading. Clothing that covers the area where the cu will be
placed should be removed, and the individual should be seated comfortably, with legs
uncrossed, with the back and arm supported; the middle of the cu on the upper arm
should be at a level of the right atrium (Sansevero, 1997). e initial BP reading should
be taken in both arms. Proper cu size is critical to obtaining an accurate measurement.
Obese individuals with large arm circumference need to have the appropriate cu size
for accuracy. Conversely, thin, cachectic patients will also have inaccurate reading with
a standard cu. e bladder length should be 80% of the arm circumference and width
at least 40%. e midline of the bladder should be placed above the brachial artery,
2 to 3 cm above the antecubital fossa, where the artery should have rst been palpated.
When using the auscultatory method, which remains the “gold standard” for BP mea-
surement, palpating the radial pulse rst while inating the cu will identify the point
at which the pulse disappears. For the subsequent auscultatory measurement, the cu
should then be inated to at least 30 mmHg above this point. e rate of deation is
also extremely important with a rate of 2 to 3 mmHg/second recommended. e rst
and last audible sounds are the SBP and diastolic BP (DBP) respectively. Two readings,
taken 5 minutes apart should be averaged and if there is greater than 5 mm Hg dier-
ence, additional readings should be obtained (Pickering et al., 2005; Pickering et al.,
2008; Sansevero, 2007).
636 Evidence-Based Geriatric Nursing Protocols for Best Practice
Pseudohypertension is a rare phenomenon resulting from noncompressibility of thick-
ened arteries and will result in the recording of falsely high BP when indirect methods are
used. A high BP over time without any indication of end-organ damage, and treatment
of the BP creates symptoms of hypotension such as dizziness, confusion, and decreased
urine output points to this diagnosis. is tendency for peripheral arteries to become
rigid with aging may result in a need to increase cu pressure in order to compress the
artery. If suspected, an intra-arterial reading has been suggested to avoid overmedication
with antihypertensives; however, this is an extreme measure and is rarely done. Most
providers, who treat HTN in the elderly, consider 160/90 as a hypertensive BP and will
treat gently with appropriate antihypertensives and pull back on treatment if symptoms
of hypotension or orthostasis occur. Isolated systolic HTN is also common in the older
adult and is dened by a SBP greater than 140 and a DBP of less than 90 mm Hg. Care
must be taken not to overtreat in this population, especially if aortic stenosis or other
valvular disease is present. Older adults are also more likely to exhibit white-coat HTN,
where the BP may be elevated over 140/90 mm Hg in the presence of a health care
worker and an actual reading at home is usually 135/85 mm Hg. erefore, assessment
of the BP not only requires careful attention to technique but also consideration of the
physiological abnormalities associated with aging. Home BP monitoring has been sug-
gested as a means for patients to partner with their providers to provide care. For those
patients who are unable for whatever reason, 24-hour ambulatory BP monitoring is
available to more accurately assess BP uctuations during the day (Arzt et al., 2006).
In addition, the standing BP should be assessed because older adults have a ten-
dency for postural hypotension. Orthostatic hypotension is diagnosed when the SBP
falls by at least 20 mm Hg or the DBP by 10 mm Hg within 3 minutes. e presence
of orthostatic hypotension may also reveal early dehydration in a patient who is usually
otherwise stable (Arzt & Bradley, 2006). Because dehydration is the second most com-
mon admission for the older adult with HF, with falling following closely behind,
standing BPs should be part of the routine assessment. In addition, patients should
be assessed for dehydration whenever a condition exists where uid loss could occur.
is includes not only with vomiting or diarrhea but also with diaphoresis caused by
extremes in temperature and humidity.
Inspection is the rst step of the physical assessment. General inspection of the
periphery includes the following:
n Observing color of the skin and mucous membranes.
n Inspecting the patient’s nails, including nail beds, and the angle between the base
of the nail and the skin of the cuticle (normally less than 160 degrees). An angle
of 180 degrees is called clubbing; the distal phalanx appears rounded. Clubbing
is associated with chronic hemoglobin desaturation.
n If cachexic, check dependent areas for decubiti.
n Hair on distal extremities—adequate arterial perfusion.
Palpation of the extremities occurs following inspection of the skin color for tempera-
ture and turgor as well as the color of the nail beds. Capillary rell of the nail should be
assessed by compressing the nail for 2 to 3 seconds and then releasing. Note the time elapsed
until the original color returns. Normally, the nail bed is pink; capillary rell occurs within
2 to 3 seconds. A pale or cyanotic nail with delayed capillary rell may indicate decreased
peripheral perfusion. e peripheral pulses should be palpated bilaterally, including radial,
femoral, pedal, and posterior tibial pulse. Note pulse rate, rhythm, and symmetry.
Fluid Overload: Identifying and Managing Heart Failure Patients 637
Respiratory rate and eort should be assessed prior to auscultation of the lungs. If
possible, oxygen saturation during rest and activity should be recorded. Patients whose
oxygen level desaturates during activity to 86% or lower may require oxygen support
at home. In addition, surveillance of oxygen saturation during sleep may be required if
the patient or family reports diculty with sleep at night. It is not uncommon to see
sleep apnea in patients with HF (Bennett & Sauvé, 2003; Cormican & Williams, 2004;
Kaneko, Hajek, Zivanovic, Raboud, Bradley, 2003; Lanfranchi & Somers, 2003; Maisel,
2001a; Manseld et al., 2003). Use the diaphragm of the stethoscope to assess the lungs.
Listen in all the lobes for diminished sounds, crackles, wheezes, or rhonchi. Lung sounds
are an important part of the assessment, particularly in patients with a history of HF.
e cardiovascular assessment begins by locating the apex and apical pulse by feel-
ing for the point of maximal impulse (PMI). In systolic HF, the PMI is displaced lat-
erally and indicates the heart is dilated. Assessment of apical pulse rate and regularity,
with attention to fullness and amplitude, also are important. Heart sounds should be
ascertained with both the diaphragm and the bell of the stethoscope. Note the presence
of S1 and S2 and of extra sounds, S3 gallop, S4, murmurs, clicks, or rubs. If extra heart
sounds are present, also examine the carotid arteries by listening on both sides of the
neck with the bell. Bruits sound like murmurs, so it is important to dierentiate between
the two. Some aortic murmurs will radiate into the neck and may even be audible when
auscultating the lungs posteriorly. Always listen to the heart before listening for extra
sounds in the neck. In addition, the carotids should not be palpated bilaterally because
this can lead to dysrhythmias and decreased blood ow to the brain
Jugular veins are assessed best with the patient in semi-Fowler’s position but if the
patient is severely dyspneic, Fowler’s position may be necessary. With the patient’s head
in straight alignment, observe the jugular neck veins for the presence of jugular venous
distention (JVD). Turning the head slightly to the left and shining a penlight angularly
on the vein allows for easier visualization of JVD and a and v waves, particularly in obese
patients. e jugular venous pulse waves will vary with respiration and decrease during
inspiration. e jugular vein is compressible and varies with the angle of the neck.
In the absence of pathology, venous distention is not present. Jugular venous distention
is the most sensitive sign of elevated lling pressures and is present with uid overload,
cor pulmonale, or high venous pressure (Stevenson, et al. 1989).
e abdomen should then be examined. First, auscultate for bowel sounds in a
distended abdomen to assess for other pathology-causing distention. Next, palpate to
determine if the abdomen is soft and nontender. A protuberant abdomen with bulg-
ing anks suggests the possibility of ascites. Because ascitic uid characteristically sinks
with gravity while gas-lled loops of bowel oat to the top, percussion gives a dull note
in dependent areas of the abdomen. Look for such a pattern by percussing outward in
several directions from the central area of tympany. Map the area between tympany and
dullness. To palpate the liver, place your hand behind the patient, parallel to and sup-
porting the right 11th and 12th ribs and adjacent soft tissues below. Remind the patient
to relax. By pressing your left hand forward, the patient’s liver may be felt more easily by
the other hand. Patients who are sensitive to palpation can rest their hand on your pal-
pating hand. Note any tenderness. If at all palpable, the edge of the liver is soft, sharp,
and regular. e liver can be enlarged in HF because of congestion. To further assess for
volume excess, place the patient in semi-Fowler’s position at the highest level at which
the jugular neck pulsations remain visible. Firmly apply pressure with the palmar sur-
face of the hand over the right upper quadrant of the patient’s abdomen for 1 minute.
638 Evidence-Based Geriatric Nursing Protocols for Best Practice
A 1-cm rise in the jugular distention called hepatojugular reux conrms the presence
of uid overload. Hepatojugular reux may be associated with or without tenderness.
Patients may also complain of a feeling of fullness.
e presence of peripheral edema, a symptom that can be related to uid over-
load from cardiac renal disease or PVD, should be evaluated. Edema can also occur in
response to medications such as calcium channel blockers. Dependent parts of the body
such as the feet, the ankles, and the sacrum are the most likely locations to nd edema.
e presence and location of edema and whether it is pitting or nonpitting should be
assessed. Depress an edematous area over a bony prominence for 5 to 15 seconds, then
release. Grading scale for edema is as follows:
0 5 no pitting
11 5 trace
21 5 moderate, disappears in 10 to 45 seconds
31 5 deep, disappears in 1 to 2 minutes
41 5 very deep, disappears in 3 to 5 minutes
e neurological assessment cannot be overlooked because changes in heart rate
and rhythm, a decrease in cardiac output, and side eects of cardiac medications may
cause signicant changes in mental status. e nurse can observe and assess the patient’s
mood, thought processes, thought content, abnormal perceptions, insight, judgment,
memory, and retention throughout the exam from intake of history and throughout
treatment. Because depression is common among both the older adult and the chroni-
cally ill, signs of depression should be assessed (Koenig, 1998; Maisel, 2001b). Examples
of signs of depression include feelings of hopelessness and sadness (also see Chapter 9,
Depression). e time, the day, and the year as well as orientation to place should be
included. Memory of hospitalization, teaching that occurred while hospitalized; subse-
quent events postdischarge can be addressed depending on whether the patient is hos-
pitalized or being seen as an outpatient (Grady et al., 2000; Wang, FitzGerald, Schulzer,
Mak, & Ayas, 2005).
To summarize, the physical examination ndings consistent with HF include the
following:
n JVD
n Basilar crackles, bronchospasm and wheezing
n Displaced apical impulse
n Presence of S3 or S4; heart murmur
n Elevated heart rate and BP
n Hepatomegaly/splenomegaly
n Hepatojugular reux
n Elevated heart rate and BP
n Temperature of extremities, warm versus cool
Laboratory and Diagnostic Studies
e initial laboratory evaluation of patients presenting with symptoms of HF should
include complete blood count, serum electrolytes including calcium and magnesium,
blood urea nitrogen, serum creatinine, fasting blood glucose, glycosylated hemoglo-
bin A1c (HbA1c), lipid prole, liver function tests, thyroid stimulating hormone, and
Fluid Overload: Identifying and Managing Heart Failure Patients 639
urinalysis. B-type natriuretic peptide (BNP) is useful in the evaluation of symptomatic
patients presenting in the urgent care setting in whom the clinical diagnosis of HF is
uncertain (Cygankiewicz et al., 2009; Huang et al., 2007; Hunt et al., 2005). A base-
line BNP in the patient with a conrmed diagnosis of HF in the compensated state
can provide a comparison measurement when both the presence of uid overload is
suspected. A BNP level below 100 indicates a very low probability of HF; however,
a level between 100 to 400 pg/mL should raise suspicion of HF. Levels greater than
400 pg/mL have a 95% probability of HF and congestion caused by volume overload
(Cygankiewicz et al., 2009; Hunt et al., 2005) and response to therapy. Electrolyte
abnormalities are common in the older adult, particularly in individuals on chronic
diuretic therapy. Of critical importance is the serum potassium whose level should not
drop below 3.8 mmol/l. Renal function, as well as electrolyte levels, should remain cur-
rent and repeated whenever a patient has to increase diuretic therapy for longer than
3 days because of uid overload. Anemia is frequently observed and may contribute to
hypoxia, myocardial ischemia, and uid overload.
e index episode or rst acute HF is most often ischemic in etiology. Cardiac
enzymes assist in determining the presence of acute MI when an acute uid overload
event occurs (Bertoni et al., 2004; Chyun et al., 2002; Lewis et al., 2003). Older adults
may have a MI in the total absence of symptoms or with atypical symptoms. All of these
factors make a review of diagnostic tests results very important.
A 12-lead electrocardiogram (ECG) and chest x-ray (PA and lateral) should be per-
formed initially in all patients presenting with symptoms of HF. A baseline ECG is
vital so that ST and T waves; axis changes; prolongation in PR, QRS, and QT inter-
vals can be assessed for indication of ongoing ischemia and response to medications.
A new onset arrhythmia heralded by an episode of uid overload is not uncommon.
e excess volume in HF can cause a stretch of the atrium, which, in turn, can pre-
cipitate atrial brillation, a common arrhythmia in patients with chronic HF. Two-
dimensional echocardiography with Doppler should be performed during the initial
evaluation to assess LVEF, LV size, wall thickness, and valve function. Radionucleotide
ventriculography (MUGA scan) can be performed to assess ventricular volumes, LVEF,
and myocardial perfusion abnormalities although the current advanced technology of
echocardiography makes the radionucleotide method of MUGA unnecessary. Cardiac
catheterization should be performed on patients presenting with symptoms of HF who
have angina or signicant ischemia or who have known, suspected, or at high-risk for
CHD, unless the patient is not eligible for revascularization of any kind.
Halter monitoring may be considered in patients presenting with HF who have a
history of MI and/or syncope and are being considered for an electrophysiology study
to document an inducible ventricular tachycardia. In addition, other candidates for elec-
trophysiology include those with an LVEF of 30% or less with a QRS complex duration
that exceeds 120 ms. Patients who meet this criteria may receive biventricular pacemaker
in combination with an automatic implantable debrillator in order to prevent sudden
death from ventricular arrhythmia (Prystowsky & Nisam, 2000), as well as improve
cardiac output (Bonds et al., 2010; Chobanian et al., 2003; Glant & Raz, 2010).
INTERVENTIONS AND CARE STRATEGIES
Initial goals in the acute management of HF are to alleviate symptoms and improve oxy-
genation, improve circulation, and correct the underlying causes of the HF. Longer term
640 Evidence-Based Geriatric Nursing Protocols for Best Practice
goals are to improve exercise tolerance and functional capacity, and through treatment
improve ventricular function thereby reducing admission and readmission rates and
decreasing morbidity and mortality. e management of HF follows standard ACC/
AHA Task Force expert consensus recommendations, including intensive treatment of
co-existent HTN, CHD, and renal disease (Chobanian et al., 2003). Importantly, opti-
mal treatment of HTN is critical to both the prevention and treatment of HF. Although
the level at which medication should be started is still debated (Lee, Lindquist, Segal, &
Covinsky, 2006), the goal BP should be 130/80 mm Hg (Baruch et al., 2004).
ere are key prognostic indicators of 4-year mortality for older adults diagnosed
with HF. Patients with renal dysfunction, pulmonary disease, a BMI of less than
25 kg/m
2
, diabetes, HTN, and cancer, as well as those who continue to smoke have
a greater risk of mortality. ose with a functional decit in activities of daily living
(ADLs; diculty bathing, managing nances, walking several blocks, or pushing or
pulling heavy objects) combined with one or more of the earlier mentioned factors
are at greater risk not only for mortality but additionally the need for hospitalization.
A chart review and history during hospitalization should then include not only the
standard accepted cardiac risk factors but also the key indicators as listed previously.
Detecting these additional prognostic indicators can aid in developing interventions
that can aect quality of life and survival (Carson, Tognoni, & Cohn, 2003). Goals for
therapy should include reaching goals for fasting blood sugar and HbA1c, BP, choles-
terol, and HF therapy through the use of evidenced based standards of care.
In Stage A, HF, HTN, and lipid disorders are treated with lifestyle modication
and medication as indicated to achieve guideline recommended goals for BP and cho-
lesterol. Smoking cessation assistance, in the form of counseling and medication, is
oered at every interaction with a patient that smokes. A goal of increasing activity or
exercise should be mutually established with patients. For some, this may be as little as
standing and sitting during television commercials, whereas for others, it may mean a
walk before or after dinner or more for others. e control of metabolic syndrome is
achieved through lifestyle modication. Alcohol is a simple sugar, and in excess con-
tributes to the development of insulin resistance and diabetes, increasing cardiovas-
cular risk. Illicit drug use must be identied, treatment oered and encouraged. Both
ACE inhibitors and angiotension-receptor blockers (ARBs; Maggioni et al., 2005) treat
HTN and HF but, importantly, have been shown to prevent cardiovascular events, cere-
brovascular events, and progression of renal disease. eir use is especially important in
patients with vascular disease or in those with DM.
In Stage B, these same cited measures are used with ACE inhibitors, ARBs, and
beta-blockers used in certain patients. All ACE inhibitors are indicated in HF; however,
there are only two ARBs with evidence strong enough to be indicated in HF. Valsartan
and candesartan, both ARBs, obtained recognition for benet in HF in their respec-
tive studies (Cohn, 1999; Cohn & Tognoni, 2001; Ostergren, 2006; Packer, 1998;
Packer, Bristow, et al., 1996; Packer, Colucci, et al., 1996; Shah, Desai, & Givertz,
2010). In Stage C, dietary sodium restriction is added to this regimen, and as a symp-
tomatic stage, diuretics are needed to be added to treat the uid retention that causes
symptoms, along with ACE inhibitors or ARB and beta-blockers. Carvedilol and meto-
prolol, in extended release form, are the two drugs in the beta-blocker category that
are indicated in the treatment of HF (Barrella & Della Monica, 1998; Carmody &
Anderson, 2007; Colucci et al., 1996; Colluci et al., 2007; Goldstein & Hjalmarson,
1999; Hjalmarson et al., 2000; Hjalmarson & Fagerberg, 2000; Naylor et al., 1994).
Fluid Overload: Identifying and Managing Heart Failure Patients 641
In certain patients, aldosterone antagonists, ARBs, and/or digitalis are used and are
eective (Baruch et al., 2004; Carson et al., 2003; Cohn & Tognoni, 2001; Maggioni
et al., 2005). Hydralazine in combination with isordil or other nitrates are benecial in
the African American population (Rich & Nease, 1999). Most of the Stage C patients
qualify for a biventricular pacemaker and/or implantable debrillators to treat life-
threatening arrhythmias. In Stage D, patients under the age of 70 without signicant
comorbidities may be oered options such as cardiac transplant or left ventricular assist
device (LVAD, VAD). A trial of inotrope therapy, such as milrinone or dobutamine,
may serve as a temporary boost to end-stage patients and may lead to treatment as
palliative therapy, oering patients at end of life an improved quality and ability to
be with their family. Palliative care oers the end-stage patient comfort that aords
the patient a quality of life in an environment where the patient can be at ease rather
than the frequent and recurrent hospital visits on an emergent basis. While the LVAD
rst was designed as a bridge to transplant, VADs are now oered as a bridge to deci-
sion about transplant. Additionally, the LVAD as destination therapy is a palliative
measure, again oering the patient a quality of life their heart is able to give. Hospice
care is also oered to the end-stage HF patient who is not a candidate for any further
therapy. e nurse has an important role in assisting the individual and their caregivers
in understanding the disease process and treatment options, including end-of-life care
(Coviello, Hricz-Borges, & Masulli, 2002).
Open and honest discussion regarding the chronic, progressive nature of HF must
begin early in the disease process since the natural history of HF involves declining
physical as well as psychological functioning. Although depression is commonly seen
in the older adult, as well as individuals with CVD, there are few studies that have
addressed this important problem in older adult with HF (Faris et al., 2002). In a
study of patients at Duke University over the age of 60, Koenig found 107 patients
of 342 depressed patients had HF, with 36.5 % having a major depression and 25.5%
having a minor depression (Koenig, 1998). Because pharmacotherapy and behavioral
interventions have demonstrated eectiveness, all older individuals should be screened
for depression and treated appropriately. Early discussions related to the goals of care
and advanced directives with frequent revisiting of patient understanding of the disease
course and patient preferences as the illness progresses ensures patient and care partner
participation in decision making. A multidisciplinary team including a spiritual and/or
a psychological representative should be developed to oer support for all involved: the
patient, family, and all involved in the care of the patient.
e benets of the multidisciplinary team to provide care to HF patients have been
discussed for the last several years. In most cases, this has been related to the use of
the team approach to help keep patients stable in order to prevent hospital re-admis-
sions (Naylor, 2006; Naylor et al., 2004; Naylor & Keating, 2008). Comprehensive
transitional care interventions have been shown not only to reduce costs and cardiac
outcomes, but also have a benecial eect on hospitalization for comorbid conditions
(Chriss et al., 2004; Coviello et al., 2002; Dickson et al., 2008; Naylor et al., 2009;
Riegel et al., 2004). In the case of the patient in end-stage HF, a multidisciplinary team
either for inpatient or outpatient management can provide cost-eective service provid-
ing patients with their last wishes in the environment that they choose (Grady et al.,
2000; Riegel et al., 2006).
Once the initial history and physical assessment have been completed, an individual-
ized care plan to monitor and treat uid overload should be implemented. e care plan
642 Evidence-Based Geriatric Nursing Protocols for Best Practice
should include teaching that begins early in the hospital stay while the patient’s memory
of a decompensated state is fresh. e teaching of principles of HF self-care relies on
the patient ability to learn to recognize the beginnings of decompensation. Techniques
to prevent a congested state and manage self-care to maintain euvolemia, are crucial to
begin as early as possible (Cavallari et al., 2004; Lancaster, Smiciklas-Wright, Heller,
Ahern, & Jensen, 2003; Riegel et al., 2009; Taylor et al., 2004). A 3-lb weight gain in 1
to 2 days or a 5-lb weight gain in the course of the week is reason to alter diuretic dosage
for up to 3 days. If the patient returns to baseline weight before the 3-day period, they
may reduce their dose back to standard daily dose (Grady et al., 2000). Patients can be
taught how to regulate their diuretic doses based on their symptoms and weight. e
nurse and patient can construct a self-care algorithm that gives them a sound “recipe” to
follow if uid overload occurs. e important factor here is early recognition and swift,
brief action. Clear guidelines as to when to contact caregivers, if they are not living with
the patient, should also be provided. Consideration should be given to the patient’s
baseline functional capacity, as well as renal function. Diuretics are used in both systolic
and diastolic HF to relieve congestive symptoms by promoting the excretion of sodium
and water and by decreasing cardiac lling pressures, thereby decreasing preload. ey
should be used eectively but cautiously in the elderly with diastolic dysfunction, where
maintaining an adequate cardiac output is heavily preload dependent in order to avoid
syncope, falls, or confusion.
A double dose of oral diuretics for up to 3 days is usually well tolerated in both sys-
tolic as well as diastolic HF. When diuretics are used, serum potassium levels should be
monitored because of an increased risk of hypokalemia with loop diuretics and of hyper-
kalemia with potassium-sparing agents especially if renal impairment exists. Patients
should be forewarned about signs of hypokalemia such as profound weakness. Loop
diuretics may be useful for patients who are volume sensitive or who have a tendency to
retain uid because of renal impairment. Aldosterone antagonists, as potassium sparing
diuretics, abate some degree of hypokalemia, resulting from loop diuretics; however,
serum potassium levels should be monitored. In some patients, ACE inhibitors can
cause hyperkalemia and in combination with aldosterone inhibitors this may be exacer-
bated. Recent evidence suggests that many individuals, particularly African Americans,
may still require potassium supplementation (Gonseth, Guallar-Castillón, Banegas, &
Rodríguez-Artalejo, 2002). In addition, dehydration is an important problem in older
adults taking diuretics and appears to be an even greater concern in African Americans
(McKelvie et al., 2002), making assessment of hydration status an important nursing
concern (Arzt & Bradley, 2006).
Use of diuretic agents increases the risk for sudden loss of urinary control (urinary
incontinence) in older adults, a very common, potentially reversible geriatric syndrome
(http://consultgerirn.org/resources and select “Try is Urinary Incontinence Assess-
ment”). Practice with an older adult population requires frequent monitoring and detec-
tion of symptoms related to the onset of urinary incontinence, which is often signaled
by symptoms of urinary frequency, urgency, or nocturia. ese symptoms may actually
be present in the older adult from other coexisting comorbidities. Nocturia is particu-
larly evident in patients with heart disease because the supine position increases vascular
return and precipitates frequent rising at night to urinate. Nighttime falls in the older
adult most often occur when the patient wakes to travel to the bathroom. Pre- existing
comorbidities such as visual impairment or osteoarthritis of the hip and or knees, as well
as prostate hypertrophy in men, make safety strategies a priority in urgent bathroom
Fluid Overload: Identifying and Managing Heart Failure Patients 643
requirements. Overall, management considerations for the older adult with heart dis-
ease and a new development of urinary incontinence or falls include re- evaluation of
medication regimen, activity considerations, and the use of additional adaptive aides to
assist in avoidance of preventable events. Use of a nighttime bedpan, urinal, or com-
mode with frequent toileting rounds and reduction of nighttime uids all are possible
and worthwhile solutions. Furosemide, as the most commonly used diuretic, has a half-
life of 6 hours. Inpatients who are a falling risk, timing the completion of diuresis before
bedtime can decrease nocturia.
Beta-blockers are useful in the management of diastolic HF because of their inhibi-
tion of the SNS and resultant negative chronotropic eect, which decreases heart rate
and increases time for diastolic lling. Beta-blockers are benecial in the treatment
of systolic HF (Cohn, 1999; Colucci et al., 1996; Colucci et al., 2007; Goldstein &
Hjalmarson, 1999; Hjalmarson & Fagerberg, 2000; Packer, 1998; Packer, Bristow, et al.,
1996; Packer, Colucci, et al., 1996; Ostergren, 2006; Shah et al., 2010) and are initiated
in a euvolemic state after symptoms have resolved. ese agents should be initiated at
low doses and titrated up to optimal tolerated dose. Use of beta-blockers in combina-
tion with ACE inhibitors has demonstrated both an improvement in LVEF and func-
tional capacity once optimized. Although beta-blockers may potentially worsen insulin
resistance, mask hypoglycemia or aggravate orthostatic hypotension in older individuals
with DM, these agents have been shown to contribute to improved outcomes. ere-
fore, careful monitoring for adverse eects is required with beta-blocker treatment to
realize the benecial eects of this important medication.
Digoxin increases contractility and decreases heart rate. It is not routinely indicated;
however, it may be useful in those patients with persistent symptoms despite diuretic
and ACE inhibitor therapy and in those patients who also have atrial brillation. Blood
levels of digoxin should be monitored for toxicity and interactions with other medica-
tions such as amiodarone, verapamil, and vasodilators. Quinidine is no longer indicated
or used therapeutically. e narrow therapeutic range for potassium is extremely impor-
tant to monitor to prevent hypokalemia, which can precipitate arrhythmias in older
adult patients with HF who are predisposed to both atrial and ventricular arrhythmias.
Other medications that have a positive inotropic eect are dopamine and dobutamine.
Both of these drugs can improve contractility and subsequent cardiac output; however,
they also increase myocardial oxygen demand. Milrinone is a phosphodiesterase inhibi-
tor that has been shown to be benecial in the management of the hospitalized patient
with HF, providing a positive inotropic eect, as well as a vasodilation (see Chapter 17,
Adverse Drug Events, for potential sequelae to several CV medications).
Vasodilators are also useful in the treatment of systolic and diastolic failure through
reduction in preload. As with diuretics, they should be used cautiously in those with
diastolic HF. Hydralazine and isosorbide reduce both preload and afterload, relieving
symptoms and improving exercise tolerance. is combination is commonly used when
patients do not tolerate ACE therapy. African Americans, in particular, had reduction in
morbidity and mortality with hydralazine/nitrate combination (Piepoli, Davos, Francis,
& Coats, 2004). Morphine sulfate, often used in an emergent situation, also has a
peripheral vasodilating eect and is useful with pulmonary edema or in patients with
breathlessness at end of life.
With appropriate titration of these medications, an improvement in both left ven-
tricular function and functional capacity can be achieved. Medications to treat HTN
and lipid abnormalities may not be well tolerated, and the potential for side eects and
644 Evidence-Based Geriatric Nursing Protocols for Best Practice
drug interactions is increased in the setting of polypharmacy. Both anti-hypertensive
agents as well as lipid-lowering agents should be used in the lowest doses possible to
bring about the desired goal for treatment.
Patients and caregivers need to understand the warning signs of HF and recurrent
MI such as chest pain, pressure, shortness of breath, indigestion, nausea, dizziness, pal-
pitations, confusion, weakness, and weight gain. A clear plan for obtaining immediate
medical attention should be developed. is is especially important if the older person
lives alone; some type of “medical alert” system may be needed. Telemonitoring may be
an option for some patients to consider. Understanding and ability to follow the medi-
cation regimen is paramount. A thorough assessment of the patient and their caregivers
is therefore vital. e older individual may be on multiple medications and the schedule
may be confusing. e need to maintain cardiac medications must be stressed and the
risk of the patient abruptly discontinuing beta-blocker, nitrates, and anti-arrhythmics
must be assessed. All medications should be reviewed with the patient and their caregiv-
ers, stressing desired eects, common side eects, and possible interactions with over-
the-counter medications (http://consultgerirn.org/resources and select Geriatric Topics
“Medication”). e nurse should also review what to do if medications are accidentally
omitted or become too costly to maintain. Long-term management of HF requires a
multidisciplinary team approach (Lloyd-Jones, et al., 2004) and disease management
programs have been eective in reducing re-admission rates (Exercise-based rehabili-
tation for heart failure [database on the Internet], 2006). Furthermore, even though
many of these individuals are debilitated, exercise training has been shown to improve
functional ability (Masoudi et al., 2005; Nesto et al., 2004; Pharmacotherapy of hyper-
tension in the elderly [database on the Internet], 2006). Referral to inpatient cardiac
rehabilitation is an important stepping-stone to reconditioning patients so they can
better function at home when discharged.
Optimization of the medication for HF, coupled with activity progression can enhance
the patient’s capacity for ADLs and quality of life. An active patient may notice early
signs of uid overload when unable to accomplish standard activities done the previous
week. erefore, questions related to activity tolerance can provide insight for the nurse
who monitors the patient. e patient with gradual uid gain will rst notice a change
in their level of fatigue, which will translate into a change in their daily routine. Previous
experience with uid overload will also reveal to the nurse the patient’s own unique signs
and symptoms because not every patient has the same indicators. It is not only important
to assess these factors directly with the patient during the interview but to also reinforce
that these symptoms are important for the patient to monitor as well (Grady et al., 2000).
In addition to changes in weight, deviation from the baseline functional ability is an early
clue, even before peripheral edema or lung congestion is present.
e prevention and treatment of HF in patients with DM requires optimal manage-
ment of co-existent HTN, CHD, and left ventricular dysfunction. Additionally, control
of hyperglycemia is an important issue because the presence of HF aects the choice of
medications used to treat type 2 DM. Although insulin and insulin secretagogues are
considered safe for use in individuals with HF, TZDs are contraindicated, and metformin
should be used only cautiously with careful monitoring of renal function (Hope-Ross,
Buchanan, Archer, & Allen, 1990). Decreased clearance of metformin in individuals
with HF caused by hypoperfusion or renal insuciency can lead to potentially dangerous
lactic acidosis. TZDs are associated with uid retention, pedal edema, and weight gain,
particularly when used in conjunction with insulin, and contribute to HF (Yusuf et al.,
Fluid Overload: Identifying and Managing Heart Failure Patients 645
2000). Careful clinical assessment and ongoing monitoring should be implemented in
the presence of known structural heart disease or a prior history of HF.
Adequate control of BP is also essential in the management of HF. Treatment of
older persons with HTN has been shown to reduce CVD morbidity and mortality
(Di Bari et al., 2004). An important nursing consideration is to monitor for adverse
eects of medications used to manage HF, as well as HTN, along with patient and care-
giver education. ACE inhibitors are important in the management of systolic HF and
may also be helpful in diastolic failure. In the Heart Outcomes Prevention Evaluation
Study (Wing et al., 2003), ACE inhibitors prevented cardiac events in high-risk patients
without HF or known low EFs (Brenner et al., 2001). In addition, ACE inhibitors have
a renal protective benet that is extremely important in preventing the development
or worsening of HF, especially in patients with DM. Recent evidence suggests that use
of ACE inhibitors is associated with a larger lower extremity muscle mass, which may
have benet in wasting syndromes and prevention of disability (Riegel, Lee, Dickson,
& Carlson, 2009) and that they are particularly ecacious in older adults (Bonow et al.,
2006). ARBs are also used widely for the prevention and treatment of HF, particularly
when patients are unable to use ACE inhibitors because of the development of cough
(Bonow et al., 2006). Renal function and hyperkalemia should be assessed when using
both classes of agents, especially in the presence of underlying renal dysfunction.
CTG is a 72-year-old woman with a history of diet-controlled glucose intolerance
and HF with normal renal function. She is seen in the geriatric clinic with a 3-day
history of poor appetite, nausea, and occasional vomiting. She complains of a con-
stant feeling of fullness. She was last hospitalized 3 months ago because of uid over-
load related to newly diagnosed HF. Her diuretic was increased 6 weeks ago for mild
ankle swelling. She denies recent lower extremity swelling, orthopnea, or paroxysmal
nocturnal dyspnea. Her blood sugars have been well controlled in the 90–130 range
without hypoglycemic episodes. She denies fever, chills, cough, or urinary symptoms.
She says she never misses her medications. Up until 5 days ago, she was able to walk
30 minutes a day without diculty. She had noticed a gradual increase in fatigue over
the last 10 days and found herself too tired to attend several social and church events
in the evening. When asked what her daily weights have been, she confessed that since
she had been feeling so good she had abandoned this as a daily practice. Concerned,
however, about her recent symptoms, she weighed herself this morning and found
that she had gained 6 pounds since she last weighed herself 2 weeks ago. Although she
has been compliant to her medications for HF which include the following:
Coreg 6.25 mg twice a day
Altace 5 mg daily
Aldactone 12.5 mg daily
Lasix 20 mg daily
Imdur 15 mg daily
CASE STUDY
(continued)
646 Evidence-Based Geriatric Nursing Protocols for Best Practice
She has not taken a double dose of Lasix with the additional weight gain as shown
in her self-care action plan. She had been unaware of that weight gain because she had
not been weighing herself. In addition, she had attended two social events 2 weekends
ago that included eating out. Her self-care action plan had shown that she should
increase her diuretic for 1 day following eating out the day before.
On physical examination, her BP is 132/86 with a heart rate of 88 bpm. She is
afebrile. She has ne crackles in the lower bases bilaterally. ere is 11 edema. Heart
sounds demonstrate S1, S2, and S3. Her apical impulse is displaced to the left. ere
is jugular neck vein distention. Her abdominal girth has increased 2 inches since her
last visit.
Lasix was increased to 40mg for a maximum of 3 days. If at any point during
the 3 days her weight returned to baseline, she was instructed to return to her usual
dose of Lasix. She was advised of the importance of daily weights in order to maintain
her baseline weight. She was referred back to her self-care action plan for changes in
diuretic depending upon her daily weight and the maintenance of her low-sodium
diet in light of her social schedule. She will return to the clinic in 1 week.
Discussion
is patient exemplies the need for educational reinforcement in a newly diagnosed
patient with HF, who is just learning how to incorporate a self-care action plan. Like
many patients who have had to take antibiotics in the past, compliance can wane
when the patient feels well. Assessment of self care knowledge and ability should
be ongoing throughout the hospital stay, but is critical at the time of discharge in
order to provide appropriate focus in outpatient care and support. e use of a tool
to quantify knowledge and ability of self-care such as the Self-Care in Heart Failure
Index is useful to identify patients who have continued needs for assistance after dis-
charge (Riegel, Lee, Dickson, & Carlson, 2009). It is important to make contact with
a newly diagnosed patient with HF fairly frequently in order to address questions that
might inuence the self-care decision making of the patient.
SUMMARY
Hospital admissions can be reduced in older adults with HF
1. When care is spent in identifying the patients’ own unique signs and symptoms of
uid overload.
2. By creating monitoring parameters for the nurse in the form of the history and the
physical assessment.
3. By creating monitoring parameters for the patient in the form of a self-care algo-
rithm with clear guidelines for self-care action.
4. By achieving goals for clinical stability.
CASE STUDY (continued)
Fluid Overload: Identifying and Managing Heart Failure Patients 647
Protocol 31.1: Heart Failure: Early Recognition, and Treatment
of the Patient At Risk for Hospital Readmission
I. GOAL: To reduce the incidence of hospital readmission of older adult patients with
heart failure (HF).
II. OVERVIEW
A. HF is the most common cause of hospitalization of adults over the age of 65
(Krumholz et al., 1997; Funk & Krumholz, 1996) and is the cause of func-
tional impairment and ultimate morbidity and mortality as well as signicant
hospital costs (Lloyd-Jones et al., 2010; om et al., 2006).
B. Hospitalization can be prevented by identifying the high-risk HF patients, early
recognition of sign and symptoms of decompensation, and timely initiation or
regulation of medical therapy (Lloyd-Jones et al., 2004; Rich et al., 1995; Ross
et al., 2008).
C. Recognition of risk factors and routine monitoring for potential HF decom-
pensation should be part of comprehensive nursing care of older adults (Lloyd-
Jones et al., 2004; Rich et al., 1995; Ross et al., 2008).
III. BACKGROUND AND STATEMENT OF PROBLEM
A. Denition
HF is the inability of the heart to pump blood sucient to metabolic needs
of the body or cannot do so without greatly elevated lling pressures (Miller
& Pina, 2009). Acute HF can develop swiftly or over the preceding weeks as
the primary initial event. Acute decompensated HF is the result of chronic HF
(Brucks et al., 2005).
B. Etiology and Epidemiology
1. Prevalence and incidence: ere are over 5.8 million individuals with HF
in the United States and approximately half a million new cases every year
(Lloyd-Jones et al., 2010; om et al., 2006).
2. Etiology: Deciency in myocardial pump function as a result of nonischemic
progressive cardiomyopathy or more prevalent ischemic causes such as
coronary heart disease and MI with a resulting development of signs and
symptoms such as edema, dyspnea, and orthopnea (Bertoni et al., 2004;
Chyun et al., 2002; Lewis et al, 2003).
3. Risk factors: Predisposing age (70 years old and older), severity of illness,
comorbidities such as HTN, coronary artery disease, diabetes, valvular heart
disease, and obesity. Additionally, cognitive impairment, depression, sen-
sory impairment, uid and electrolyte disturbances, and polypharmacy also
impose an increased risk (Ho et al., 1993; Hypertension in Diabetes Study
Group, 1993; Levy et al., 1996; Piccini et al., 2004). Precipitating: High-
sodium diet, excess uid intake, sleep disordered breathing, chronic kidney
disease, anemia, cardiotoxims such as chemotherapeutic agents, NSAIDS,
illicit drugs, or alcohol (Schocken et al., 2008). Environmental factors: low
socioeconomic status, psychological stress (Schocken et al., 2008).
NURSING STANDARD OF PRACTICE
(continued)
648 Evidence-Based Geriatric Nursing Protocols for Best Practice
4. Outcomes: HF has a downward trajectory that through preventative mea-
sures can be delayed; however, not without considerable impact on quality
of life (Grady et al., 2000).
IV. PARAMETERS OF ASSESSMENT
A. Assess at initial encounter and every shift
1. Baseline: Health history NYHA classication of functional status and stage
of HF, cognitive and psychosocial support systems (Brucks et al., 2005)
2. Symptoms: dyspnea, orthopnea, cough, edema; Vital signs: BP, HR, RR
(Pickering et al., 2005; Pickering et al., 2008; Sansevero, 1997). Physical
assessment with signs: rales or “crackles”; peripheral edema, ascites, or
pulmonary vascular congestion of chest x-ray (Stevenson & Perlo, 1989)
3. Medications review – Optimal medical regimen according to ACC/AHA/
HFSA guideline unless contraindicated (Brenner et al., 2001; Riegel et al.,
2009; Wing et al., 2003)
4. Electrocardiogram/telemetry review: Heart rate, rhythm, QRS duration, QT
interval (Bertoni et al., 2004; Chyun et al., 2002; Chyun et al., 2003)
5. Review echocardiography, cardiac angiogram, muga scan, cardiac CT or
MRI for left ventricle and valve function: left ventricular ejection fraction
(LVEF; Bertoni et al., 2004; Chyun et al., 2002; Lewis et al., 2003)
6. Laboratory value review (Cygankiewicz et al., 2009; Huang et al., 2007;
Hunt et al., 2005)
Metabolic evaluation: Electrolytes (hyponatremia, hypokalemia), thyroid
function, liver function, kidney function
Hematology: Evaluation for anemia: Hemoglobin, hematocrit, iron,
iron-binding capacity, and B12 folic acid
Evaluation for infection (fever, WBCs with dierential, cultures)
7. Impaired mobility/deconditioned status: physical therapy or structured cardiac
rehabilitation inpatient or outpatient
B. Sensory impairment—vision, hearing—limitations in ability for self-care
(Davos et al., 2003; Faris et al., 2002)
C. Signs and symptoms—assess for changes in mental status every shift (Davos
et al., 2003; Faris et al., 2002)
V. NURSING CARE STRATEGIES
A. Obtain HF/cardiology and geriatric consultation (Rich et al., 1995; Naylor,
2006; Naylor & Keating, 2008; Naylor et al., 2004).
B. Eliminate or minimize risk factors
1. Administer medications according to guidelines and patient assessment
(Brenner et al., 2001; Riegel et al., 2009; Wing et al., 2003)
2. Avoid continuous intravenous infusion especially of saline (Cavallari et al.,
2004; Lancaster et al., 2003; Riegel et al., 2009; Taylor et al., 2004).
3. Maintain euvolemia once uid overload is treated. Prevent/promptly treat
uid overload, dehydration, and electrolyte disturbances. Maximize oxygen
delivery (supplemental oxygen, blood, and BP support as needed (Cavallari,
et al., 2004; Lancaster, et al., 2003; Riegel et al., 2009; Taylor, et al., 2004).
Protocol 31.1: Heart Failure: Early Recognition, and Treatment
of the Patient At Risk for Hospital Readmission (cont.)
(continued)
Fluid Overload: Identifying and Managing Heart Failure Patients 649
4. Ensure daily weights accurately charted (Grady et al., 2000; Riegel et al.,
2004; Riegel et al., 2009).
5. Provide adequate nutrition with a 2-g sodium diet (see Chapter 22, Nutrition).
6. Provide adequate pain control (see Chapter 14, Pain Management).
7. Use sensory aids as appropriate.
8. Regulate bowel/bladder function.
D. Provide self-care education with maintenance and management strategies
(Masoudi et al., 2005; Nesto et al., 2004; Pharmacotherapy for Hypertension
in the Elderly, 2006)
1. Activity recommendation as appropriate to functional status. Assess for
safety in ambulation hourly rounds with encouragement to toilet.
2. Facilitate rest with schedule of diuretic medications for limited nocturia.
3. Maximize mobility: limit use of urinary catheters.
4. Communicate clearly; provide explanations.
5. Emphasize purpose and importance of daily weights.
6. Dietician referral for educational needs re-sodium.
E. Identify care partners. Reassure and educate
1. Foster care support of family/friends
2. Assess willingness and ability of care partner to assist with self-care: dietary
needs of sodium restriction, daily weight logging, symptom recognition,
and medical follow-up.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Absence of symptoms of congestion
2. Hemodynamic status remains stable (prior to acute decompensation)
3. Functional status returned to baseline (prior to acute decompensation)
4. Improved adherence to medical and self-care regimen
5. Discharged to same destination as prehospitalization
B. Health Care Provider
1. Regular use of self-care heart failure index screening tool
2. Increased detection of symptoms before acute decompensation
3. Implementation of appropriate interventions to prevent/treat volume
overload
4. Improved nurse awareness of patient/caregiver self-care condence and
ability
5. Increased management using guideline-directed therapy
C. Institution
1. Sta education and interprofessional care planning
2. Implementation of HF specic treatments
3. Decreased overall cost
4. Decreased preventable readmission and length of hospital stay
5. Decreased morbidity and mortality
6. Increased referrals and consultation to above-specied specialists
7. Improved satisfaction of patients, families, and nursing sta
Protocol 31.1: Heart Failure: Early Recognition, and Treatment
of the Patient At Risk for Hospital Readmission (cont.)
(continued)
650 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
American Association of Heart Failure Nurses
http://aahfn.org/
Heart Failure Society of America
http://www.hfsa.org
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Na
1
5 sodium; BUN/Cr 5 blood urea nitrogen/creatinine ratio; BP 5 blood pressure;
HR5heart rate; RR respiratory rate; Hgb/Hct 5 hemoglobin and hematocrit;
SpO
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Protocol 31.1: Heart Failure: Early Recognition, and Treatment
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Anker, S. D. (2003). Body mass and survival in patients with chronic heart failure without
cachexia: The importance of obesity. Journal of Cardiac Failure, 9(1), 29–35. Evidence
Level IV.
Di Bari, M., van de Poll-Franse, L. V., Onder, G., Kritchevsky, S. B., Newman, A., Harris T. B., . . .
Pahor, M. (2004). Antihypertensive medications and dierences in muscle mass in older per-
sons: e Health, Aging and Body Composition Study. Journal of the American Geriatrics Soci-
ety, 52(6), 961–966. Evidence Level IV
Dickson, V. V., Deatrick, J. A., & Riegel, B. (2008). A typology of heart failure self-care management
in non-elders. European Journal of Cardiovascular Nursing, 7(3),171–81. Evidence Level IV.
Evangelista, L. S., Doering, L. V., & Dracup, K. (2000). Usefulness of a history of tobacco and alco-
hol use in predicting multiple heart failure readmissions among veterans. e American Journal
of Cardiology, 86(12),1339–1342. Evidence Level III.
Exercise-based rehabilitation for heart failure [database on the Internet]2006.QM
Faris, R., Purcell, H., Henein, M. Y., & Coats, A. J. (2002). Clinical depression is common and
signicantly associated with reduced survival in patients with non-ischaemic heart failure. Euro-
pean Journal of Heart Failure, 4(4), 541–551. Evidence Level III.
Funk, M., & Krumholz, H. M. (1996). Epidemiologic and economic impact of advanced heart
failure. Journal of Cardiovascular Nursing, 10(2), 1–10. Evidence Level V.
Gheorghiade, M., Follath, F., Ponikowski, P., Barsuk, J. H., Blair, J. E., Cleland, J. G., . . . Filippatos,
G. (2010). Assessing and grading congestion in acute heart failure: A scientic statement from
the acute heart failure committee of the heart failure association of the European Society of Car-
diology and endorsed by the European Society of Intensive Care Medicine. European Journal of
Heart Failure, 12(5), 423–433. Evidence Level VI.
Giamouzis, G., Kalogeropoulos, A., Georgiopoulou, V., Laskar, S., Smith, A. L., Dunbar, S., . . .
Butler, J. (2011). Hospitalization epidemic in patients with heart failure: Risk factors, risk predic-
tion, knowledge gaps, and future directions. Journal of Cardiac Failure, 17(1), 54–75. Evidence
Level V.
Glandt, M., & Raz, I. (2010). Pharmacotherapy: ACCORD blood pressure and ACCORD lipid:
How low can we go? Natural Reviews, Endocrinology, 6(9), 483–484. Evidence Level II.
Goldstein, S., & Hjalmarson, A.. (1999). e mortality eect of metoprolol CR/XL in patients with
heart failure: Results of the MERIT-HF trial. Clinical Cardiology, 22(Suppl. 5), 30–5. Evidence
Level V.
Gonseth, J., Guallar-Castillón, P., Banegas, J. R., & Rodríguez-Artalejo, F. (2004). e eective-
ness of disease managament programmes in reducing hospitla re-admission in older persons
with heart failure: A systematic review and meta-analysis of published reports. European Heart
Journal, 25(18),1570–1595. Evidence Level I.
Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Stevenson, L. W., & Young,
J. B. (2000). Team management of patients with heart failure: A statement for healthcare
professionals from e Cardiovascular Nursing Council of the American Heart Association.
Circulation, 102(19), 2443–2456 Evidence Level VI
Fluid Overload: Identifying and Managing Heart Failure Patients 653
Hay, P., Sachdev, P., Cumming, S., Smith, J. S., Lee, T., Kitchener, P., & Matheson, J. (1993). Treat-
ment of obsessive-compulsive disorder by psychosurgery. Acta Psychiatrica Scandinavica, 87(3),
197–207. Evidence Level III,
Hjalmarson, A., & Fagerberg, B. (2000). MERIT-HF mortality and morbidity data. Basic Research
in Cardiology, 95(Suppl. 1), 198–103. Evidence Level V.
Hjalmarson, A., Goldstein, S., Fagerberg, B., Wedel, H., Waagstein, F., Kjekshus, J., . . . Deedwania,
P. (2000). Eects of controlled-release metoprolol on total mortality, hospitalizations, and well-
being in patients with heart failure: e Metoprolol CR/XL Randomized Intervention Trial in
congestive heart failure (MERIT-HF). MERIT-HF study group. Journal of the American Medical
Association, 283(10), 1295–1302 . Level I.
Ho, K. K., Pinsky, J. L., Kannel, W. B., & Levy, D. (1993). e epidemiology of heart failure: e
Framingham study. Journal of the American College of Cardiology, 22(4 Suppl. A), 6A–13A. Level V.
Hope-Ross, M., Buchanan, T. A., Archer, D. B., & Allen, J. A. (1990). Autonomic function in
Holmes Adie syndrome. Eye (Lond), 4( Pt. 4), 607–612. Evidence Level V.
Horwich, T. B., Fonarow, G. C., Hamilton, M. A., MacLellan, W. R., Woo, M. A., & Tillisch, J. H.
(2001). e relationship between obesity and mortality in patients with heart failure. Journal of
the American College of Cardiology, 38(3), 789–795. Evidence Level IV.
Huang, D. T., Sesselberg, H. W., McNitt, S., Noyes, K., Andrews, M. L., Hall, W. J., . . . Moss,
A. J. (2007). Improved survival associated with prophylactic implantable debrillators in elderly
patients with prior myocardial infarction and depressed ventricular function: A MADIT-II
substudy. Journal of Cardiovascular Electrophysiology, 18(8), 833–888. Evidence Level II.
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., . . .
Riegel, B. (2005). ACC/AHA 2005 Guideline update for the diagnosis and management of
chronic heart failure in the adult. Circulation, 112(12), e154–e235. Evidence Level I.
Hypertension in Diabetes Study Group. (1993). HDS: 1: Prevalence of hypertension in newly pre-
senting type 2 diabetic patients and the association with risk factors for cardiovascular disease
and diabetic complications. Journal of Hypertension, 11, 309–17. Evidence Level III.
Kaneko, Y., Hajek, V. E., Zivanovic, V., Raboud, J., & Bradley, T. D. (2003). Relationship of
sleep apnea to functional capacity and length of hospitalization following stroke. Sleep, 26(3),
293–297. Evidence Level II.
Kasai, T., Narui, K., Dohi, T., Yanagisawa, N., Ishiwata, S., Ohno, M., . . . Momomura, S. (2008).
Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous
positive airway pressure. Chest, 133(3),690–696. Evidence Level II.
Koenig, H. G. (1998). Depression in hospitalized older patients with congestive heart failure. General
Hospital Psychiatry, 20(1), 29–43. Evidence Level III.
Koitabashi, T., Inomata, T., Niwano, S., Nishii, M., Takeuchi, I., Nakano, H., . . Izumi, T. (2005).
Paroxysmal atrial brillation coincident with cardiac decompensation is a predictor of poor
prognosis in chronic heart failure. Circulation Journal, 69(7), 823–830. Evidence Level III.
Kossovsky, M. P., Sarasin, F. P., Perneger, T. V., Chopard, P., Sigaud, P., & Gaspoz, J. (2000). Unplanned
readmissions of patients with congestive heart failure: Do they reect in-hospital quality of care or
patient characteristics? e American Journal of Medicine, 109(5), 386–390. Evidence Level III.
Krumholz, H. M., Parent, E. M., Tu, N., Vaccarino, V., Wang, Y., Radford, M. J., & Hennen, J.
(1997). Readmission after hospitalization for congestive heart failure amoung Medicare bene-
ciaries. Archives of Internal Medicine, 157(1), 99–104. Evidence Level IV.
Krumholz, H. M., Wang, Y., Parent, E. M., Mockalis, J., Petrillo, M., & Radford, M. J. (1997).
Quality of care for elderly patients hospitalized with heart failure. Archives of Internal Medicine,
157(19), 2242–2247. Evidence Level II.
Lancaster, K. J., Smiciklas-Wright, H., Heller, D. A., Ahern, F. M., & Jensen, G. (2003). Dehydra-
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Evidence Level IV.
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and implications. Respiratory Physiology & Neurobiology, 136(2–3), 153–165. Evidence Level VI.
654 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Mascarenhas, J., Lourenço, P., Lopes, R., Azevedo, A., & Bettencourt, P. (2008). Chronic obstructive
pulmonary disease in heart failure. Prevalence, therapeutic and prognostic implications. American
Heart Journal, 155(3), 521–525. Evidence Level IV.
Masoudi, F. A., Inzucchi, S. E., Wang, Y., Havranek, E. P., Foody, J. M., & Krumholz, H. M. (2005).
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(EXERT). American Heart Journal, 144(1), 23–30. Evidence Level II.
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Evidence Level III.
Miller, A. B., & Piña, I. L. (2009). Understanding heart failure with preserved ejection fraction: Clinical
importance and future outlook. Congestive Heart Failure, 15(4), 186–192. Evidence Level V.
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Naylor, M., & Keating, S. A. (2008). Transitional care. American Journal of Nursing, 108(9 Suppl.),
58–63.
Naylor, M. D. (2006). Transitional care: A critical dimension of the home healthcare quality agenda.
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Fluid Overload: Identifying and Managing Heart Failure Patients 655
Naylor, M. D., Feldman, P. H., Keating, S., Koren, M. J., Kurtzman, E. T., Maccoy., . . . Krakauer, R.
(2009). Translating research into practice: Transitional care for older adults. Journal of Evaluation
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Naylor, C. J., Griths, R. D., & Fernandez, R. S. (2004). Does a multidisciplinary total parenteral
nutrition team improve patient outcomes? A systematic review. Journal of Parenteral and Enteral
Nutrition, 28(4), 251–258. Evidence Level I
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(2004). iazolidinedione use, uid retention, and congestive heart failure: A consensus state-
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and without left ventricular systolic dysfunction: Results from the candesartan in heart
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Ostergren, J. B. (2006). Angiotensin receptor blockade with candesartan in heart failure: Findings
from the Candesartan in Heart failure—assessment of reduction in mortality and morbidity
(CHARM) programme. Journal of Hypertension, 24(1), S3–S7. Evidence Level II.
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Trends in prevalence and outcome of heart failure with preserved ejection fraction. e New
England Journal of Medicine, 355(3), 251–259. Evidence Level II.
Packer, M. (1998). Beta-blockade in heart failure. Basic concepts and clinical results. American
Journal of Hypertension, 11(1 Pt 2), 23S–37S. Evidence Level V.
Packer, M., Bristow, M. R., Cohn, J. N., Colucci, W. S., Fowler, M. .B., Gilbert, E. M., & Shusterman,
N. H. (1996). e eect of carvedilol on morbidity and mortality in patients with chronic heart
failure. U.S. Carvedilol Heart Failure Study Group.. e New England Journal of Medicine,
334(21), 1349–1355. Evidence Level I.
Packer, M., Colucci, W. S., Sackner-Bernstein, J. D., Liang, C. S., Goldscher, D. A., Freeman, I., . . .
Shusterman, N. H. (1996). Double-blind, placebo-controlled study of the eects of carvedilol in
patients with moderate to severe heart failure. e PRECISE trial. Prospective randomized evalua-
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Pharmacotherapy for hypertension in the elderly [database on the Internet]. (2006). Evidence
Level V.
Piccini, J. P., Klein, L., Gheorghiade, M., & Bonow, R. O. (2004). New insights into diastolic
heart failure: Role of diabetes mellitus. American Journal of Medicine, 116(Suppl. 5A), 64S–75S.
Evidence Level V.
Pickering, T. G., Hall, J. E., Appel, L. J., Falkner, B. E., Graves, J., Hill, M. N., . . . Roccella, E. J.
(2005) Recommendations for blood pressure measurements in humans and experimental ani-
mals: Part 1: Blood pressure measurement in humans: A statement for professionals from the
Subcommittee of Professional and Public Education of the American Heart Association Council
on High Blood Pressure Research. Circulation, 111, 697–716. Evidence Level VI.
Pickering, T. G., Miller, N. H., Ogedegbe, G., Krako, L. R., Artinian, N. T., & Go, D. (2008).
Call to action on use and reimbursement for home blood pressure monitoring: Executive sum-
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Evidence Level VI.
Piepoli, M. F., Davos, C., Francis, D. P., & Coats, A. J. (2004). Exercise training meta-analysis of
trials in patients with chronic heart failure (ExTraMATCH). British Medical Journal, 328(7433),
189. Evidence Level II
Pocock, S. J., Wang, D., Pfeer, M. A., Yusuf, S., McMurray, J. J., . . .Granger, C. B. (2006).
Predictors of mortality and morbidity in patients with chronic heart failure. European Heart
Journal, 27(1), 65–75. Evidence Level IV.
656 Evidence-Based Geriatric Nursing Protocols for Best Practice
Prystowsky, E. N., & Nisam, S. (2000). Prophylactic implantable cardioverter debrillator trials:
MUSTT, MADIT, and beyond. Multicenter Unsustained Tachycardia Trial. Multicenter
Automatic Debrillator Implantation Trial. American Journal of Cardiology. 86(11),1214–1215.
Evidence Level I.
Rich, M. W., Beckham, V., Wittenberg, C., Leven, C. L., Freedland, K. E., & Carney, R. M.
(1995). A multidisciplinary intervention to prevent the readmission of elderly patients with
congestive heart failure. e New England Journal of Medicine, 333(18), 1190–1195. Evidence
Level II.
Rich, M. W., & Kitman, D. W. (2005). ird pivotal research in cardiology in the elderly (PRICE-III)
symposium: Heart failure in the elderly: Mechanisms and management. American Journal of
Geriatric Cardiology, 14(5), 250–261. Evidence Level V.
Rich, M. W., & Nease, R. F. (1999). Cost-eectiveness analysis in clinical practice: e case of heart
failure. Archives of Internal Medicine, 159(15), 1690–1700. Evidence Level IV.
Riegel, B., Dickson, V. V., Hoke, L., McMahon, J. P., Reis, B. F., & Sayers, S. (2006). A motivational
counseling approach to improving heart failure self-care: Mechanisms of eectiveness. Journal of
Cardiovascular Nursing, 21(3), 232–241. Evidence Level II.
Riegel, B., Lee, C. S., Dickson, V. V., & Carlson, B. (2009). An update on the self-care of heart
failure index. Journal of Cardiovascular Nursing, 24(6), 485–497. Evidence Level II.
Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., . . . Whellan, D. J.
(2009). State of the science: Promoting self-care in persons with heart failure: A scientic statement
from the American Heart Association. Circulation, 120(12), 1141–1163. Evidence Level VI.
Riegel, B., Naylor, M., Stewart, S., McMurray, J. J., & Rich, M. W. (2004). Interventions to
prevent readmission for congestive heart failure. Journal of the American Medical Association,
291(23), 2816.
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H. M. (2008). Statistical models and patient predictors of readmission for heart failure: A sys-
tematic review. Archives of Internal Medicine, 168(13), 1371–1386. Evidence Level I.
Rumsfeld, J. S., Havranek, E., Masoudi, F. A., Peterson, E. D., Jones, P., Tooley, J. F., . . . Spertus, J. A.
(2003). Depressive symptoms are the strongest predictors of short-term declines in health status
in patients with heart failure. Journal of the American College of Cardiology, 42(10), 1811–1817.
Evidence Level III.
Sansevero, A. C. (1997). Dehydration in the elderly: Strategies for prevention and management.
Nurse Practitioner, 22(4), 41–42, 51–67, 63–66. Evidence Level VI.
Schocken, D. D., Benjamin, E. J., Fonarow, G. C., Krumholz, H. M., Levy, D., Mensah, G. A., . . .
Hong, Y. (2008). Prevention of heart failure: A scientic statement from the American Heart
Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular
Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research
Interdisciplinary Working Group; and Functional Genomics and Translational Biology
Interdisciplinary Working Group. Circulation, 117(19), 2544–2565. Evidence Level VI.
Shah, R. V., Desai, A. S., & Givertz, M. M. (2010). e eect of renin-angiotensin system inhibitors
on mortality and heart failure hospitalization in patients with heart failure and preserved ejec-
tion fraction: A systematic review and meta-analysis. Journal of Cardiac Failure, 16(3), 260–267.
Evidence Level I.
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dierent stages of congestive heart failure. European Heart Journal, 13(7), 902–907. Evidence
Level III.
Stevenson, L. W., & Perlo, J. K. (1989). e limited reliability of physical signs for estimating
hemodynamics in chronic heart failure. Journal of the American Medical Association, 261(6),
884–888. Evidence Level II.
Taylor, A. L., Ziesche, S., Yancy, C., Carson, P., D’Agostino, R., Jr, Ferdinand, K., . . . Cohn,
J. N. (2004). Combination of isosorbide dinitrate and hydralazine in blacks with heart failure.
e New England Journal of Medicine, 351, 2049–2057. Evidence Level II.
Fluid Overload: Identifying and Managing Heart Failure Patients 657
om, T., Haase, N., Rosamond, W., Howard, V. J., Rumsfeld, J., Manolio, T., . . . Wolf, P. (2006).
Heart disease and stroke statistics—2006 update: A report from the American Heart Associa-
tion Statistics Committee and Stroke Statistics Subcommittee. Circulation, 113(6), e85–e151.
Available from http://circ.ahajournals.org. Evidence Level IV.
Triposkiadis, F., Karayannis, G., Giamouzis, G., Skoularigis, J., Louridas, G., & Butler, J. (2009).
e sympathetic nervous system in the heart failure physiology, pathophysiology, and clinical
implications. Journal of the American College of Cardiology, 54(19),1747–1762. Evidence Level I.
Wang, C. S., FitzGerald, J. M., Schulzer, M., Mak, E., & Ayas, N. T. (2005). Does this dyspneic
patient in the emergency department have congestive heart failure? Journal of the American
Medical Association, 294(15), 1944–1956. Evidence Level V.
Wing, L. M., Reid, C. M., Ryan, P., Beilin, L. J., Brown, M. A., Jennings, G. L., . . . West, M. J.
(2003). A comparison of outcomes with angiotensin-converting—enzyme inhibitors and diuret-
ics for hypertension in the elderly. e New England Journal of Medicine, 348(7), 583–592.
Evidence Level II.
Yancy, C. W., Lopatin, M., Stevenson, L. W., De Marco, T., & Fonarow, G. C. (2006). Clinical presen-
tation, management, and in-hospital outcomes of patients admitted with acute decompensated
heart failure with preserved systolic function: A report from the Acute Decompensated Heart
Failure National Registry (ADHERE) database. Journal of the American College of Cardiology,
47(1), 76–84. Evidence Level I.
Young, J. B., Abraham, W. T., Albert, N. M., Gattis Stough, W., Gheorghiade, M., Greenberg,
B. H., . . . Fonarow, G. C. (2008). Relation of low hemoglobin and anemia to morbidity and
mortality in patients hospitalized with heart failure (insight from the OPTIMIZE-HF registry).
e American Journal of Cardiology, 101(2),223–230. Evidence Level II.
Yusuf, S., Sleight P., Pogue, J., Bosch, J., Davies, R., & Dagenais, G. (2000). Eects of an
angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.
e Heart Outcomes Prevention Evaluation Study Investigators. e New England Journal of
Medicine, 342,145–153. Evidence Level I.
658
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. recognize the incidence and prevalence of U.S. statistics on malignancy in the older
adult
2. identify three common malignancies in the older adult
3. recognize three common comorbidities in the older adult with cancer
4. identify three common cancer-related emergencies in the older adult
5. identify three assessment instruments useful in the assessment of the older person
6. identify three important elements of a health history specic to the older patient
with cancer
7. identify three important elements of a physical examination specic to the older
patient with cancer
8. dene clinical parameters of frailty of an older adult with cancer
OVERVIEW
e probability of developing a malignancy increases with age. In the years between
1975 and 2007, the National Cancer Institute (NCI) Surveillance, Epidemiology,
and End Results (SEER) Program found that the mean age of a cancer diagnosis is
66 years old (NCI, 2010). According to the Centers for Disease Control and Preven-
tion (CDC), the number of people aged 65 years and older are expected to increase
from 12.4% in 2000 to 19.6% in 2030 (National Center for Health Statistics, 2006).
Older people diagnosed with cancer are often resilient; however, they are also faced
with issues associated with diminished identity, suering, and social isolation (Hughes,
Closs, & Clark, 2009) especially when hospitalized. Acute care nurses must appreci-
ate that cancer is common in older adult patients and be aware of potential health
limitations and emergencies associated with the diagnosis and treatment of malignancy.
Janine Overcash
32
Cancer Assessment and
Intervention Strategies
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Cancer Assessment and Intervention Strategies 659
is chapter will present assessment strategies and instruments that can be used in
an acute care setting and detail potential medical emergencies associated with cancer
disease process and treatment.
ASSESSMENT OF THE OLDER HOSPITALIZED PATIENT
Comorbid Conditions
A diagnosis of cancer may be only one of several comorbidities and it is important to
understand how the malignant and nonmalignant conditions aect the older adult’s
health. An acute health crisis may be the result of the culmination of several comorbidi-
ties interacting with the cancer diagnosis and treatment (Reiner & Lacasse, 2006). Older
adults with cancer, those with multiple comorbidities (Koroukian, 2009), and those
who are hospitalized more than 120 days are likely to die in the hospital ( Kozyrskyi,
Black, Chateau, & Steinbach, 2005). Additionally, the timing of diagnosis of comorbid
conditions between 6 and 18 months prior to a diagnosis of cancer have been associ-
ated with lower survival (Shack, Rachet, Williams, Northover, & Coleman, 2010). e
more severe the comorbidity, the less opportunity of survival at 1 year and 5 years after
a diagnosis of cancer (Iversen, Nørgaard, Jacobsen, Laurberg, & Sørensen, 2009). For
patients who are diagnosed with the comorbid condition of diabetes, there is a twofold
risk of recurrence or development of a new breast cancer as compared to people who
do not have diabetes (Patterson et al., 2010). Existence, management, and severity of
comorbid conditions are a principle aspect of the acute nursing assessment. Unmanaged
or uncontrolled comorbid conditions have the potential to modify cancer treatment
plans and outcomes.
Comprehensive Geriatric Assessment
e comprehensive geriatric assessment (CGA) can predict completion of chemo-
therapy and pending mortality in older patients diagnosed with cancer (Aaldriks et
al., 2010). e CGA is a 2-year prognostic predictor of mortality (Pilotto et al., 2007)
in gastrointestinal patients and has been used to determine the comorbid condition
severity and extent of geriatric conditions (Koroukian, 2009). e American Geriat-
rics Society (2008) recommendations suggests that CGA is an important component
of care for older persons who have or are at risk for functional limitations. Older
patients receiving acute care can benet from the CGA by revealing health concerns
and creating a baseline for care management strategies (Mion, Odegard, Resnick, &
Segal-Galan, 2006).
CGA used in oncology has been found to inuence cancer treatment decisions in
terms of dosing, delaying treatment, and other health considerations (Chaibi et al.,
2010). No one denition of a CGA exists. A CGA can be developed to include screen-
ing instruments necessary to meet the needs of a particular older patient population
(Panel on Prevention of Falls in Older Persons, American Geriatrics Society, & British
Geriatrics Society, 2011). e instruments that commonly make up the CGA and that
guide screening practices in many health care domains are all found on http://www
.consultgerirn.org and other chapters in this text. Whereas a CGA may be relevant
to primary care settings, understanding such issues as medication history and polyp-
harmacy, caregiver situation, and emotional condition are also important to an acute
assessment.
660 Evidence-Based Geriatric Nursing Protocols for Best Practice
A CGA can include various laboratory tests as well, in addition to self-report
and performance evaluations. Laboratory data such as C-reactive protein can predict
morbidity or mortality and help identify individual risk factors (Chundadze et al.,
2010; Pal, Katheria, & Hurria, 2010). Serum 25(OH)D will assess vitamin D levels to
determine if falls or muscle weakness can be a risk factor (Dhesi et al., 2004). Serum
albumin levels at 3.3 mg/dl at admission, serum creatinine levels at 1.3 mg/dl or higher,
history of heart failure, immobility, and advanced age are all predictors of inpatient
mortality (Silva, Jerussalmy, Farfel, Curiati, & Jacob-Filho, 2009). Other mortality risk
factors in older hospitalized patients are red blood cell and platelet transfusions that
increase the opportunity for venous and arterial thrombotic events (Khorana et al.,
2008). Another predictor of inpatient mortality while hospitalized is being uninsured
or underinsured (Allareddy & Konety, 2006). It is important to consider inpatient risk
factors for mortality and conduct assessments to anticipate potential problems before
they become a crisis.
Assessment for the existence of a caregiver that will be available in the home follow-
ing discharge is another important element of the CGA. For many older patients with
cancer, lack of a caregiver can be a problem and can impact health and medical treat-
ment. Older patients who are married tend to take advantage of preventative health care
services compared to those older persons who live with an adult child who often do not
receive preventative health services (Lau & Kirby, 2009).
Assessment of the older patient should occur upon admission to the hospital and
prior to discharge to understand trends in health and functional and behavioral ability.
Discharge planning should include interventions based on the CGA ndings and com-
munication is vital with outpatient providers to continue to address the limitations that
may aect the health, quality of life, and independence of the older person with cancer.
Developing a Comprehensive Geriatric Assessment for Hospitalized Patients
e following are instruments that can identify functional, physical, emotional, medi-
cation history, and cognitive impairment in the acute care patient and are generally
included in a CGA (see related chapters):
A. Assess for emotional distress
1. e Geriatric Depression Scale (GDS; Yesavage et al., 1982–1983)
2. e SF-12 Tool (Ware, Kosinski, & Keller, 1996). e SF-12 is a general health-
related quality-of-life instrument that is widely used in research and clinical assess-
ment. Two summary scores are the culmination of the measures from the mental
health aspect and the physical health domain. e SF-12 is simple to administer
and provides the clinician with a measure of emotional and physical health.
B. Assessment for cognitive limitations
1. e Mini-Cog test is used in the assessment of cognition (Borson, Scanlan, Brush,
Vitaliano, & Dokmak, 2000; Borson, Scanlan, Chen, & Ganguli, 2003). e
instrument is comprised of the clock drawing test and recall.
2. Assess the number and indications of medications. Look for medications with the
same indications and potential harmful interactions and consider any diculty
with cancer treatment agents. For more information on polypharmacy screening,
visit http://www.consultgerirn.org and select “Try is: Beers’ Criteria for Poten-
tially Inappropriate Medication Use in the Elderly.”
Cancer Assessment and Intervention Strategies 661
C. Assess for geriatric syndromes such as urinary incontinence, falls, or depression
(for more information, visit http://www.consultgerirn.org/resources and select
“Try is: Urinary Incontinence Assessment in Older Adults,” “Fall Risk Assessment,”
or “e Geriatric Depression Scale”).
D. Assess functional status and potential for falls
1. Ask the patient if a fall had been experienced within the last year.
a. e physical performance test battery (Simmonds, 2002) has age-related norms
and is a valid and reliable tool used with patients with cancer.
b. e 6-minute walk that assesses the speed and ability to ambulate for the entire
time (Enright et al., 2003).
c. e Timed Up and Go test help considers rising from a chair, walking 3 m, and
returning to the chair in a sitting position (Podsiadlo & Richardson, 1991).
d. Assessment of physical status can take place on observation of gait (Tinetti,
1986) using the Gait Assessment Scale (Tinetti, Mendes de Leon, Doucette, &
Baker, 1994).
e. Berg Balance Scale (BBS) is a 14-item scale developed for use in a clinical
setting (Berg, Wood-Dauphinee, Williams, & Maki, 1992). e BBS can be
helpful in predicting falls and functional status problems.
E. Assess the ability to perform self-care activities
1. Activities of Daily Living (ADL) Scale (Katz, Downs, Cash, & Grotz, 1970)
2. Instrumental Activities of Daily Living (IADL) Scale (Lawton & Brody, 1969)
Health History
e subjective information obtained from the older adult is a critical factor in the devel-
opment of the plan of care. Respect and condence are not only prudent but standard
practice for the acute care nurse and can set the stage for a productive health-centered
dialogue. e nurse should assess the reason(s) for seeking care (chief complaint) and
include the family and support person(s). e following are issues that should be con-
sidered when conducting a health history of the older adult with cancer:
A. Assess history of present illness regarding cancer diagnosis, cancer stage at diagno-
sis, cancer stage currently, and cancer treatment (surgical, chemotherapy, radiation
therapy, hormonal therapy).
B. Assess past medical history as related to a diagnosis of cancer (include dates of diag-
nosis and treatments and regular oncological assessment continue).
C. Assess family medical history of malignancy and ages on diagnosis (some families
have strong familial histories of malignancy and perhaps younger generations should
consider genetic counseling).
D. Assess regular cancer screening examinations.
E. Assess for common geriatric syndromes (issues such as incontinence or falls that have
many motivating factors).
Physical Examination
Conducting a physical examination of an older adult must orchestrate an understand-
ing of normative aging changes and knowledge of pathology likely for an older adult.
e physical examination is also an opportunity to teach about the importance of self-
examination (breast and skin exams) and provide relevant health information. When
662 Evidence-Based Geriatric Nursing Protocols for Best Practice
older adults perceive the physical examination as informative and understandable, they
are more likely to be more satised with their health care encounter (Foxall, Barron, &
Houfek, 2003).
Physical examination provides objective information to the nurse that is synergistic
to self report measures. Self-report measures are instruments such as the IADL assess-
ment (Lawton & Brody, 1969) and ADL (Katz et al., 1970) that focus on tasks vital to
independent living. It has been shown that self-report instruments tend to overestimate
abilities (Kuriansky, Gurland, & Fleiss, 1976; Naeim & Reuben, 2001), and objective
assessments such as observing gait or balance may produce more realistic data.
Functional status, and not chronological age, is an important indicator of cancer
treatment tolerance (Balducci & Yates, 2000; Garman & Cohen, 2002). Changes
in functional status may help determine cancer treatment tolerance or disease pro-
gression (Chen et al., 2003; Given, Given, Azzouz, & Stommel, 2001; Reiner &
Lacasse, 2006). Assessment of physical function and recognition of patients with
physical deciency can also identify those patients who have an increased risk of
hospitalization (Wyrwich & Wolinsky, 2000). It is important to conduct a functional
assessment at regular intervals while the patient is receiving acute care to look at
trends throughout the cancer treatment process. Patients may show functional com-
promise during periods following cancer therapy and become more functionally apt
when not receiving treatment.
Physical examination and functional status assessment can help reveal a clinical
presentation of frailty. Fried et al. (2001) suggests that frail can, in part, be dened as
follows:
1. Older than age 85
2. Dependent in one or more ADLs
3. e presence of one or more geriatric syndromes
Older adults who are considered frail are more likely to receive palliative cancer
treatment as compared to those not considered frail and receive curative therapy
( Balducci & Yates, 2000).
A complete head-to-toe assessment including the general elements of subjective
and objective physical exam, accompanied with the CGA assessment instruments and
performance evaluations, provide the infrastructure to develop a reasonable treatment
plan. Assessment of the older adult with cancer is a vital, dynamic component of care
for the interdisciplinary health care team.
MEDICAL EMERGENCIES ASSOCIATED WITH CANCER AND CANCER TREATMENT
A diagnosis of cancer can lead to medical emergencies such as electrolyte imbalances,
unstable fractures, and neutropenia leading to infection. It is important to obtain
cancer-related history and physical information concerning the type of treatment and
the exact diagnosis with metastasis (spread of the malignancy from the original site). It is
also important for the acute care nurse to know the cycle of chemotherapy administration
for a particular patient. Often, chemotherapy such as doxorubicin and cyclophamide
are given four times, 3 weeks apart. As the chemotherapy proceeds, various issues such
as nausea and vomiting, low white cell counts (neutropenia), and mouth sores may
occur and be present upon acute evaluation. e following are considered oncological
emergencies and require acute care.
Cancer Assessment and Intervention Strategies 663
Hypercalcemia
Hypercalcemia is a reasonably common complication associated with multiple myeloma,
breast, and lung cancers. e most common cause of hypercalcemia is malignancy
(Fisken, Heath, Somers, & Bold, 1981) and generally found in 3%–5% of emergency
admission patients (Lee et al., 2006). Nonmalignant causes are hyperparathyroidism
and renal failure. When hyperthyroidism is associated with hyperparathyroidism and
malignancy, survival is much greater as compared to hypercalcemia caused by malig-
nancy alone (Hutchesson, Bundred, & Ratclie, 1995). It is important to measure
parathyroid hormone in patients with hypercalcemia in order to predict time of survival
(Hutchesson et al., 1995).
Hypercalcemia is dened as calcium concentration of more than 10.2 mg/dl
(Lee et al., 2006). Signs and symptoms of hypercalcemia are often not evident in
patients with mild or moderate hypercalcemia (calcium levels of 10.3–14.0 mg/dl).
Gastrointestinal discomfort, changes in level of consciousness, and general nonspecic
discomfort can be experienced in cases of moderate hypercalcemia. Other signs and
symptoms are lethargy, confusion, anorexia, nausea, constipation, polyuria, and poly-
dipsia ( Halfdanarson, Hogan, & Moynihan, 2006).
Treatment of hypercalcemia depends on the severity. iazide diuretics should
be discontinued. Hydration must be maintained to diminish risk of exacerbation of
hypercalcemia. Severe hypercalcemia should be considered a medical emergency. Intra-
venous normal saline and loop diuretics should be implemented but will only last as
long as the treatments are infusing. Bisphosphonates can help reduce bone reabsorption
resulting in reduced serum calcium levels (Budayr et al., 1989). Calcitonin also can
be administered subcutaneous or intramuscularly and can also reduce calcium levels
( Halfdanarson et al., 2006).
Tumor Lysis Syndrome
Tumor lysis syndrome (TLS) is caused when a tumor breaks down and intercellular ions,
nucleic acids, proteins and their metabolites release into the extracellular space (Del Toro,
Morris, & Cairo, 2005). e syndrome develops when chemotherapy or radiation ther-
apy causes hyperkalemia, hyperuricemia, and hyperphosphatemia, which can enhance
the risk for renal failure and reduced cardiac function (Cantril & Haylock, 2004). As
chemotherapy agents become more eective, the risks increase for TLS. Agents including
cisplatin, etoposide, urarabine, intrathecal methotrexate, paclitaxel, rituximab, radia-
tion therapy, interferon alpha, corticosteroids and tamoxifen can cause TLS (Davidson
et al., 2004; Lin, Lucas, & Byrd, 2003).
Hyperphosphatemia and hypocalcemia can occur about 24–48 hours following
the rst chemotherapy administration. Signs and symptoms such as muscle cramps,
anxiety, depression, confusion, hallucinations, cardiac arrhythmia, and seizures can
result (Cantril & Haylock, 2004). Untreated TLS can lead to renal failure (Davidson
et al., 2004).
Hyperkalemia is created by a release of potassium from the debilitation of the tumor
cells. High serum potassium levels can cause severe arrhythmias and sudden death
(Cairo & Bishop, 2004).
Hyperuricemia (uric acid more than 10 mg/dl) can result in acute obstruction
uropathy and cause hematuria, ank pain, hypertension, edema, lethargy, and restless-
ness (Cairo & Bishop, 2004; Cantril & Haylock, 2004). Hydration, administration
664 Evidence-Based Geriatric Nursing Protocols for Best Practice
of allopurinol, and diuresis are generally the rst-line treatment (Cantril & Haylock,
2004). Treatment with rasburicase has been found to be eective in the treatment and
prevention of hyperuricemia and TLS (Annemans et al., 2003).
e signs and symptoms associated with TLS include decreased urine output,
seizures, and arrhythmias. Electrolytes must be assessed to determine presence of
hyperkalemia, hyperuricemia, and hyperphosphatemia. Electrocardiograms should be
obtained to assess arrhythmia.
Spinal Cord Compression
Spinal cord compression is not uncommon and can occur when metastasis spreads to
the vertebral bodies and invades the spinal cord. e area of the spinal column in the
thoracic area is the most common location and must be recognized immediately to
prevent critical, irreversible damage (Halfdanarson et al., 2006). Spinal cord compres-
sion can lead to paraplegia and long-term neurological decits (Hirschfeld, Beutler,
Seigle, & Manz, 1988).
Signs and symptoms are numbness and tingling in the extremities, upper thorax,
and back pain (Lowey, 2006). Pain can radiate or localize and may seem chronic, which
may disguise the emergent spinal cord compression and delay critical treatment. Bowel
and bladder dysfunction can also result.
Diagnosis is often made with magnetic resonance imaging (MRI) and com-
puted tomography (CT) and sometimes plain radiographic lms of the aected
area. Treatment is often initiated with glucocorticoids followed by either radiation
therapy and/or surgery. Surgery has been debated but many agree that it is reason-
able in conjunction with radiation therapy and sometimes chemotherapy (McLain &
Bell, 1998; Schmidt, Klimo, & Vrionis, 2005). Nurses have the ability to recognize
the signs and symptoms of this debilitating and often lethal oncological emergency
(Bucholtz, 1999).
Neutropenic Fever
Neutropenic fever is an oncological medical emergency that is caused by the diminish-
ment of neutrophils by various chemotherapeutic agents. Neutropenia is considered
present when the neutrophil count is less than 1.0 3 10
9
/L and severe neutropenia is
neutrophil counts less than 0.5 3 10
9
/L (Halfdanarson et al., 2006).
Generally, fever is the presenting sign; however, skin rashes and mucositis may also
be present. For some patients, neutropenic fever can occur after the rst cycle of chemo-
therapy and patients who have undergone aggressive surgery with bowel resections are
at enhanced risk (Sharma, Rezai, Driscoll, Odunsi, & Lele, 2006).
An instrument has been developed to help screen for the likelihood of neutropenia
and the identication of patients who are likely to benet from prophylaxis granulocyte
colony-stimulating factors (G-CSFs; Donohue, 2006). G-CSF works to elevate white
blood cell counts necessary in ghting infection. A great amount of nursing literature
exists on the denition, prevention, and management of neutropenic fever. Preven-
tion of neutropenia and neutropenic fever should be proactive in the administration
of G-CSFs in patients who are considered at high risk for neutropenia (Krol et al.,
2006). An older cancer patient receiving myelotoxic chemotherapy (cyclophosphamide,
doxorubicin, vincristine, and prednisolone) is considered high risk and should receive
prophylactic G-CSF administration (Repetto et al., 2003).
Cancer Assessment and Intervention Strategies 665
SUMMARY
Acute care of the older patient requires nurses’ health assessment skills to be proactive in
detecting and addressing limitations that can result from a cancer diagnosis and treat-
ment. Nonmalignant comorbidities and geriatric syndromes play a role in the diagnosis
and treatment of cancer and should be assimilated into the critical thinking involved in
developing the nursing plan of care. Careful health assessment and evaluation are criti-
cal to the acute care nurse in understanding the disease progress, treatment tolerance,
and the presence of oncological emergencies. Nurses working in acute settings must
be acquainted with principles of geriatric care that should be applied to patients with
any type of diagnosis and not limited to malignancy. Understanding normative aging
changes versus pathology can help facilitate a specialized plan of care with enhanced
health and independence as the intended patient outcomes.
A 76-year-old White woman presents to the emergency department with delirium and
trauma to her left hip. e patient’s daughter reports that the patient fell in the bath-
room several hours earlier. She has a diagnosis of breast cancer and is currently undergo-
ing chemotherapy and has received four cycles of Adriamycin and cyclophosphamide.
She also has a history of osteoarthritis, hypertension, and gastric reux disease. Present-
ing signs and symptoms are delirium, cracked mucus membranes, low blood pressure
(BP) at 88/42, and tachycardia.
Situations such as dehydration are not uncommon in an older person undergoing
chemotherapy. Patients may have vomiting or diarrhea and become dehydrated as
a result. Seniors have less functional reserve and are, therefore, more likely to suer
from complications of cancer treatment (Balducci, 2006). Older adults require
careful examination and intervention in order to maintain and enhance health and
independence.
1. In this clinical scenario, which geriatric syndromes are present?
Answer: Falls, delirium, pain associated with trauma, functional status limitations,
and ambulatory diculty
Rationale: is patient has multiple geriatric syndromes and is at risk for further
deconditioning. It is important to recognize the geriatric syndromes present and
anticipate any additional injuries. Ensure caregiver support and help facilitate a
plan for care while at home.
2. In this clinical scenario, which oncological emergency is this patient at greatest risk
to develop?
Rationale: Based on the signs and symptoms of dehydration, hypercalcemia is of
concern. Hydrate to prevent hypercalcemia and to reduce signs and symptoms of
dementia. Falls are also of concern because the risk of future falls is associated with
prior falls. Dehydration in an older adult patient with cancer can be associated
with many problematic health and functional limitations.
CASE STUDY
666 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
e National Comprehensive Cancer Network oers clinical practice guidelines, including senior
adult oncology.
http://www.nccn.org/professionals/physician_gls/default.asp
e American Geriatric Society oers clinical guidelines in using the CGA in the older person.
http://www.americangeriatrics.org
e Oncology Nursing Society oers recommendations for practice of the oncology patient.
http://www.ons.org
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Lowey, S. E. (2006). Spinal cord compression: An oncologic emergency associated with metastatic
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McLain, R. F., & Bell, G. R. (1998). Newer management options in patients with spinal metastasis.
Cleveland Clinic Journal of Medicine, 65(7), 359–366. Evidence Level IV.
Mion, L., Odegard, P. S., Resnick, B., & Segal-Galan, F. (2006). Interdisciplinary care for older adults
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Naeim, A., & Reuben, D. (2001). Geriatric syndromes and assessment in older cancer patients.
Oncology (Williston Park, NY), 15(12), 1567–1577, 1580; discussion 1581, 1586, 1591.
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(2010). Medical comorbidities predict mortality in women with a history of early stage breast
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Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients.
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Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short-Form Health Survey: Construction
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Development and validation of a geriatric depression screening scale: A preliminary report.
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670
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. identify the objectives common to all geriatric acute care models
2. describe the various types of models employed in North American hospitals
3. understand the evidence to support implementation of geriatric acute care models
OVERVIEW
Advances in geriatric science, coupled with the increasing older adult patient popula-
tion, have led to the development of several geriatric models of care across all health care
settings. Acute care models addressing the unique needs of older hospitalized patients
began with the comprehensive geriatric assessment (CGA) programs rst developed in
the 1970s (Rubenstein, 2008).
Geriatric acute care models aim to facilitate improved overall outcomes by promoting
a rehabilitative approach while preventing adverse events that occur more commonly in
older patients. Also known as geriatric syndromes, these are clinical conditions in older
persons that do not t into discrete disease categories (Rubenstein, 2008) and include
functional decline, pressure ulcers, fall-related injury, undernutrition or malnutrition,
urinary tract infection, and delirium (see Chapter 12, Iatrogenesis). ese syndromes
or complications contribute to prolonged hospital stays as well as increased likelihood
for rehospitalization, institutionalization, emergency department usage, and postacute
rehabilitation therapy services. ese complications rarely occur alone; the interrela-
tionships among these various syndromes during hospitalization is well documented
(Inouye, Studenski, Tinetti, & Kuchel, 2007; Rubenstein, 2008).
Acute care models attend to the age-specic vulnerabilities (i.e., frailty, comorbidi-
ties, cognitive impairment) of older hospitalized patients. ese models also address the
Elizabeth Capezuti, Marie Boltz, and Cynthia J. Nigolian
33
Acute Care Models
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Acute Care Models 671
role of institutional factors that determine sta practices and the physical environment
that can contribute to iatrogenic complications. us, the overall goals of acute geriatric
models of care are (a) prevention of complications that occur more commonly in older
adults and (b) address hospital factors that contribute to complications ( Capezuti,
Boltz, & Kim, in press). is chapter provides an overview of care delivery issues that
are addressed by acute models of care for older adults and a description of the most
commonly employed hospital models.
GERIATRIC ACUTE CARE MODEL OBJECTIVES
ere are several geriatric acute care models, each with their own approach to pre-
vent complications and address institutional/sta practices that can contribute to
complications. All of these models, however, share a common set of general objectives
( Hickman, Newton, Halcomb, Chang, & Davidson, 2007; Hickman, Rolley, &
Davidson, 2010). e six general objectives of geriatric acute care models are discussed
herein.
Educate Health Care Providers in Core Geriatric Principles
Many health care providers have not received in their basic or continuing education
the core geriatric care principles such as recognition of age-specic factors that increase
the risk of complications (Berman et al., 2005; Wald, Huddleston, & Kramer, 2006).
All acute care models require a coordinator with advanced geriatric education; however,
successful implementation depends on direct care sta with the knowledge and com-
petencies to deliver evidence-based care to older patients. us, the coordinator or a
clinician with geriatric specialization will facilitate sta learning via individual patient
consultation, in-service group education, unit rounds, journal clubs, web-based discus-
sion groups, conferences, and other internal institutional educational venues (Fletcher,
Hawkes, Williams-Rosenthal, Mariscal, & Cox, 2007; Smyth, Dubin, Restrepo,
Nueva-Espana, & Capezuti, 2001).
Target Risk Factors for Complications
e ideal method to prevent complications is by timely screening of potential geriatric
syndromes, early identication, and subsequent reduction of risk factors. Some of the
models focus on a particular syndrome; however, because of the interrelationship of
shared risk factors, reduction of one complication will aect the prevention of other
geriatric syndromes. To properly identify risk factors, standardized assessment tools
known to be valid and reliable for older adults is recommended. e Hartford Institute
for Geriatric Nursing website includes the “Try is” and “How To Try is” series of
assessment instruments (ConsultGeriRN, n.d.). At the institutional level, incorporating
these risk assessments into routine everyday practice requires hospital policies, proce-
dures, and protocols that will promote usage such as embedding these tools within the
health care record.
Incorporate Patient or Family Choices and Treatment Goals
Informed patient’s choices are essential whether they are decisions about activity level
and medication use to more complex issues such as advance directives.
672 Evidence-Based Geriatric Nursing Protocols for Best Practice
Family members of patients who can no longer participate in decision making must
often deal with the complicated balance between quality-of-life considerations and
potential length of life. e decision to employ life-sustaining treatments consistent with
patients’ preferences is typically and unfortunately only considered when the patient is
hospitalized (Somogyi-Zalud, Zhong, Hamel, & Lynn, 2002). For this reason, many
geriatric models work collaboratively or in conjunction with palliative care programs.
Employ Evidence-Based Interventions
e high proportion of complications in older hospitalized patients is partly attributed
to the lack of evidence-based geriatric care practices. ere is tremendous variability
in the adoption of geriatric protocols (Neuman, Speck, Karlawish, Schwartz, & Shea,
2010). Issues with overuse or inappropriate medications (e.g., overuse of psychoactive
drugs), unnecessary restraints, inadequate detection of cognitive or aective changes
(e.g., delirium, depression), and poor pain control are examples of hospital factors that
can lead to adverse outcomes. us, geriatric acute care models promote the use of stan-
dardized evidence-based protocols described in this book.
Promote Interdisciplinary Communication
e detection of management of geriatric syndromes are not limited to medical inter-
vention but require other disciplines such as nursing, pharmacy, social work, and physi-
cal and occupational therapy to address the complex interaction of medical, functional,
psychological, and social issues leading to these complications. Most importantly, it is
the communication of the various disciplines’ input that is facilitated by geriatric care
models that is essential.
Emphasize Proactive Discharge Planning
Older hospitalized patients are more likely to experience delays in discharge, greater emer-
gency service use hospital readmission, and rehabilitation in an institution or at home
(Coleman, Min, Chomiak, & Kramer, 2004). Hospital readmission for older patients is
most likely associated with medical errors in medication continuity ( Coleman, Smith,
Raha, & Min, 2005; Foust, Naylor, Boling, & Cappuzzo, 2005), diagnostic workup,
or test follow-up (Forster, Mur, Peterson, Gandhi, & Bates, 2003). Geriatric acute
care models address the posthospital care environment and the care transition following
hospital discharge by promoting coordination among health care providers, facilitating
medication reconciliation, preparing patients and their caregivers to carry out discharge
instructions, and making appropriate home care referrals (Bowles, Naylor, & Foust,
2002; Flacker, Park, & Sims, 2007; Moore, McGinn, & Halm, 2007). Two of the six
models consider the care transition as the primary focus of their programs.
ACUTE CARE MODEL TYPES
Although there are several types of geriatric acute care models that are used in U.S. hos-
pitals, all address both common health problems and care delivery issues. Most consider
all geriatric syndromes, whereas others target specic ones such as delirium. e models
are implemented in various degrees from a hospital-wide to unit-based approach or
some focus on specic processes of hospitalization such as discharge planning.
Acute Care Models 673
Geriatric Consultation Service
e consultants in a geriatric service may include a geriatrician, a geropsychiatrist, a
geriatric clinical nurse specialist, or an interdisciplinary team of geriatric health care
providers to conduct a CGA or evaluate a specic condition (older adult mistreat-
ment), symptom (wandering), or situation (adequacy of spouse to care for patient
at home). Some hospitals will require that all patients who are screened at high risk
for geriatric-related complications or are admitted from a homebound program or
a nursing home will receive a geriatric consult (Agostini, Baker, Inouye, & Bogar-
dus, 2001), whereas most are requested by another primary service for an individual
patient. ese consultation services have been associated with reduced length of stay
(Harari, Martin, Buttery, O’Neill, & Hopper, 2007); however, it is dicult to evalu-
ate any consultation service because their recommendations may not be followed or
the hospital may not have the resources or sta to adequately implement the recom-
mendations (Allen et al., 1986).
Acute Care for the Elderly Units
ese discrete geriatric units provide CGA delivered by a multidisciplinary team with
a focus on the rehabilitative needs of older patients. Team rounds and patient-centered
team conferences are considered essential. e core team includes a geriatrician, clini-
cal nurse specialist, social worker, as well as specialists from other disciplines providing
consultation—occupational and physical therapy, nutrition, pharmacy, audiology, and
psychology. Geriatric evaluation and management (GEM) units developed in the U.S.
Department of Veterans Aairs (VA) system have documented signicant reductions in
functional decline and suboptimal medication use as well as return to home postdis-
charge and, more recently, decreased rate of nursing home placement among hospital-
ized veterans on GEM units compared to general medical units (Phibbs et al., 2006).
ere have been mixed outcomes in nonveteran populations with some demonstrating
improved drug prescribing (Spinewine et al., 2007) and reduced mortality (Saltvedt,
Mo, Fayers, Kaasa, & Sletvold, 2002), whereas others showing no dierences in clinical
outcomes compared to usual medical units (Kircher et al., 2007).
Since the 1990s, acute care for the elderly (ACE) units have been implemented
in non-VA hospitals. An interdisciplinary team consisting of sta with geriatric exper-
tise work collaboratively using strategies such as team rounds and family conferences.
Most ACE units have made physical environment adaptations to address age-related
changes (e.g., ooring to reduce glare), support orientation (writeboards indicating sta
names, discharge goals), and promote sta observation (e.g., alarmed exit doors, com-
munal space for meals). Led by geriatricians and/or geriatric advanced practice nurses
(GAPNs), the interdisciplinary team facilitates care coordination and identication of
modiable risk factors for geriatric syndromes and prevents avoidable discharge delay.
Compared with other medical units, patients hospitalized on ACE units demon-
strate reduced incidence of delirium (Bo et al., 2009) and have maintained prehospital
or improved functional status at discharge of patients and fewer were discharged to
nursing homes without increases in hospital or postdischarge costs (Landefeld, Palmer,
Kresevic, Fortinsky, & Kowal, 1995). ese positive outcomes are attributed to pro-
cesses of care more likely found in ACE units: less restraint use, early mobilization,
fewer days to discharge planning, and less use of high-risk medications (Counsell
et al., 2000). Recently, more hospitals are using ACE units for those at highest risk for
674 Evidence-Based Geriatric Nursing Protocols for Best Practice
age-related complications, with ACE sta providing consultation to export ACE prin-
ciples throughout the health system. is mobile-ACE approach facilitates reaching a
greater number of hospitalized older adults.
Nurses Improving Care for Healthsystem Elders
A national program aimed at system improvement to achieve positive outcomes for hos-
pitalized older adults, Nurses Improving Care for Healthsystem Elders (NICHE) seeks
to improve the quality of care provided to older patients and improve nurse competence
by “modifying the nurse practice environment with the infusion of geriatric-specic:
(a) core values into the mission statement of the institution; (b) special equipment,
supplies, and other resources; and (c) protocols and techniques that promote interdisci-
plinary collaboration” (Boltz et al., 2008b, p. 283). NICHE includes several approaches
that promote dissemination of evidence-based geriatric best practices into hospital care.
e system-level approach of NICHE provides a structure for nurses to collaborate with
other disciplines and to actively participate in or coordinate other geriatric acute care
models. A NICHE coordinator acts in a leadership role by facilitating, teaching, and
mentoring others and changing systems of care (Fletcher, Hawkes, Williams-Rosenthal,
Mariscal, & Cox, 2007). In some hospitals, a GAPN functions in this role as well as
providing direct clinical consultation for evaluating and managing patients. e geriat-
ric resource nurse (GRN) model is foundational to NICHE; it is an educational inter-
vention whereby the NICHE coordinator or the GAPN prepares sta nurses as the
clinical resource person on geriatric issues to other nurses on their unit (Lee, Fletcher,
Westley, & Fankhauser, 2004). e GRN model provides sta nurses, via education
and role modeling (e.g., nursing bedside rounds) by a geriatric APN or NICHE coor-
dinator, with content focusing on care management for geriatric syndromes (Lopez et
al., 2002; Mezey, Quinlan, Fairchild, & Vezina, 2006). Application of evidence-based
practice at the bedside is facilitated by organizational strategies such as incorporation of
institution-wide clinical protocols provided in this book.
e GRN model fosters professional development and enhanced work satisfaction
for nurses who feel that they have institutional support to provide quality care. ese
supports include geriatric-specic resources (continuing education, equipment, and
specialty services), interdisciplinary collaboration, as well as patient, family, and nurse
involvement in treatment-related decision making. Evaluation in NICHE hospitals
have reported improved clinical outcomes, rate of compliance with geriatric institu-
tional protocols, cost-related outcomes, and improved nurse knowledge (Pfa, 2002;
Swauger & Tomlin, 2002; Turner, Lee, Fletcher, Hudson, & Barton, 2001). e GRN
model is associated with positive outcomes such as reduced delirium in a NICHE ortho-
pedic unit (Guthrie, Schumacher, & Edinger, 2006) and reduced complications among
hospitalized older adults with dementia (Allen & Close, 2010). In studies aggregat-
ing results from several NICHE hospitals, NICHE implementation is associated with
improved processes of care (Fulmer et al., 2002; Mezey et al., 2004) as well as higher
nurse perceived quality of care (Boltz et al., 2008a).
NICHE also promotes implementation of ACE model. e ACE model within
NICHE emphasizes nurse-driven protocols and geriatric continuing education of all
nursing sta. Similar to other ACE units, study of a NICHE-ACE unit found lower fall
and pressure ulcer rates and lower length of stay when compared to overall hospital rates
(LaReau & Raphelson, 2005).
Acute Care Models 675
The Hospital Elder Life Program
e Hospital Elder Life Program (HELP) is an intervention program using clinicians
(geriatric specialists of various disciplines) working together as an interdisciplinary team
with trained volunteers that target risk factors for delirium (mental orientation, thera-
peutic activities, early mobilization, vision and hearing adaptations, hydration and feed-
ing assistance, and sleep enhancement). Protocols based on several well-designed clinical
trials are employed to reduce incidence of new delirium and, among those who did
develop delirium, reduce total number of episodes and days with delirium, functional
decline, costs of hospital services, and use of long-term nursing home services (Inouye,
Baker, Fugal, Bradley, & for the HELP Dissemination Project, 2006; Inouye, Bogardus,
Baker, Leo-Summers, & Cooney, 2000; Inouye et al., 1999). e program depends on
well-trained and supervised volunteers in patient care interventions ( Bradley, Webster,
Schlesinger, Baker, & Inouye, 2006b) that are coordinated by Elder Life Specialists.
e Elder Life Nurse Specialist typically has advanced geriatric nursing education and
will supervise the implementation of nursing-related assessments and tracking of delir-
ium risk factor protocol adherence.
Transitional Care Models
Transitional care models aim to specically address the needs of older adult patients with
complex medical and social needs and their caregivers to navigate the health care system
across settings. Two models with demonstrated positive outcomes include the advanced
practice nurse (APN) transitional care model (Naylor & Keating, 2008) and the care
transitions coaching or care transitions intervention (Coleman, Parry, Chalmers, &
Min, 2006; Coleman et al., 2004). (ese are described in more detail in Chapter 34,
Transitional Care.)
Combination and Specialty Geriatric Acute Care Models
In some hospitals, a combination of geriatric models is implemented such as a geriatric
consultation team and transitional care (Arbaje et al., 2010) or inpatient geriatric assess-
ment and intensive home care (Buurman, Parlevliet, van Deelen, de Haan, & de Rooij,
2010). In others, a core geriatric interdisciplinary team provides direct consultation as
well as screens patients for other related services such as palliative care, rehabilitative
services, or pain management programs. Some hospitals have developed dual-function
units such as merging an ACE unit with a palliative care (Gelfman, Meier, & Morrison,
2008; Tomasovic;aa, 2005), stroke (Allen et al., 2003), or oncology (Flood, Brown,
Carroll, & Locher, 2011) unit as well as incorporating a “delirium room” within an
ACE unit (Flaherty et al., 2003) or a geriatric assessment unit within an emergency
department (Pareja et al., 2009).
Others have developed programs that incorporate geriatric comanagement with
other specialties such as rehabilitation, orthopedics, trauma, and oncology (Allen et al.,
2003; Gelfman et al., 2008; Kammerlander et al., 2010). ese programs have dem-
onstrated increased detection of and reduced incidence of delirium, as well as reduced
length of stay, readmission rates, morbidity, and mortality (Flaherty et al., 2003; Flood
et al., 2011; Milisen et al., 2001; Pareja et al., 2009). Programs promoting collabora-
tion between hospitalists and geriatric consultation team have resulted in lower length
of hospital stay (Sennour, Counsell, Jones, & Weiner, 2009), although preliminary
676 Evidence-Based Geriatric Nursing Protocols for Best Practice
evidence suggests that hospitalists leading transitional care teams (Better Outcomes
for Older Adults through Safer Transitions [BOOST]) can prevent postdischarge
complications and readmissions within 30 days and increases the patients’ condence
in self- management (Dedhia et al., 2009). Administered by the Society of Hospital
Medicine, the BOOST program provides technical support to optimize the hospital
discharge process and diminish discontinuity and fragmentation of care ( Williams &
Coleman, 2009).
New Model Approaches
e availability of geriatric clinicians is essential to implementing any model; how-
ever, there is a signicant shortage of fellowship-trained geriatricians, geriatric psy-
chiatrists, master’s prepared geriatric nurse specialists, as well as specialists in other
disciplines (Committee on the Future Health Care Workforce for Older Americans,
2008). is is especially true for hospitals located in rural areas as well as small hospi-
tals without the nancial capacity to employ geriatric specialists (Jayadevappa, Bloom,
Raziano, & Lavizzo-Mourey, 2003). Some hospitals are working with other hospitals
in their health system or in their region to create learning collaboratives or “knowl-
edge networks” by using web-based and other long-distance communication strate-
gies. us, a geriatrician (Malone et al., 2010) or a GAPN (Capezuti, 2010) can
participate in “virtual” rounds with sta in another location (Friedman, Mendelson,
Kates, & McCann, 2008; Pallawala & Lun, 2001) to foster communication; that is,
the e-geriatrician or e-APN has access to a system-wide electronic health record such
as the ACE Tracker and the TeleGeriatric system (Pallawala & Lun, 2001) or similar
web-based assessment tool (Gray & Wootton, 2008). In this way, collaboration and
mentoring of professional colleagues is facilitated while enhancing the care provided
to older adults.
SUMMARY
Despite dierences in approaches or foci, all models share common goals. e model
employed in a hospital or health system is based on the unique needs of that hospi-
tal’s patient population, the resources available (geriatric clinicians, bed size, volunteers,
etc.), and especially the senior administrator’s commitment to geriatric program-
ming. Because there is currently no direct reimbursement for many components of
these models, administrators are motivated by the model’s alignment to the institu-
tion’s strategic plan or mission, consumer or community satisfaction, and costs savings
(such reduced costly and nonreimbursable complications; Adunsky et al., 2005; Boult
et al., 2009; Bradley, Webster, Schlesinger, Baker, & Inouye, 2006a; Hart, Frank,
Homan, Dickey, & Kristjansson, 2006; Kammerlander et al., 2010; Siu, Spragens,
Inouye, Morrison, & Le, 2009). Although all of the models have demonstrated posi-
tive outcomes, only a small number (approximately 500) have been implemented in
U.S. acute care facilities. Most are located in academic or teaching hospitals. Expan-
sion to more than 3,000 hospitals that serve a high proportion of older adults may
depend on advancing the unique contributions of each within an integrated model that
will enhance the hospital experience of the older patient (Capezuti & Brush, 2009;
Marcantonio, Flacker, Wright, & Resnick, 2001).
Acute Care Models 677
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a comparison of home care referral decisions. Journal of the American Geriatrics Society, 50(2),
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Buurman, B. M., Parlevliet, J. L., van Deelen, B. A., de Haan, R. J., & de Rooij, S. E. (2010). A ran-
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Evidence Level II.
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678 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Evidence Level IV.
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Evidence Level IV.
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Jayadevappa, R., Bloom, B. S., Raziano, D. B., & Lavizzo-Mourey, R. (2003). Dissemination and
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LaReau, R., & Raphelson, M. (2005). e treatment of the hospitalized elderly patient in a spe-
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Lee, V., Fletcher, K., Westley, C., & Fankhauser, K. A. (2004). Competent to care: Strategies to assist
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680 Evidence-Based Geriatric Nursing Protocols for Best Practice
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Marcantonio, E. R., Flacker, J. M., Wright, R. J., & Resnick, N. M. (2001). Reducing delirium after
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Mezey, M., Quinlan, E., Fairchild, S., & Vezina, M. (2006). Geriatric competencies for RNs in hos-
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Acute Care Models 681
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682
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader will have gained knowledge on the challenges
and opportunities associated with transitional care and should be able to:
1. describe various transitional care models
2. identify potential for nurse-led and advanced practice nurses (APN)-led transi-
tional care
3. identify essential elements of successful transitional care
OVERVIEW
Persons with continuous complex care needs frequently require care in multiple settings.
e American Geriatrics Society (2003) denes transitional care as “a set of actions
designed to ensure the coordination and continuity of health care as patients transfer
between dierent locations or dierent levels of care within the same location.” (p. 556).
Representative locations include (but are not limited to) hospitals, subacute and post-
acute nursing facilities, the patient’s home, primary and specialty care oces, and long-
term care facilities (Coleman & Boult, 2003). During transitions between settings, this
population is particularly vulnerable to experiencing poor care quality and problems
of care fragmentation. For example, among Medicare patients, 20% were hospitalized
within 30 days and 34% were rehospitalized within 60 days (Jencks, Williams, &
Coleman, 2009). Despite how common these transitions have become, the challenges of
improving care transitions have historically received little attention from policy makers,
clinicians, and quality improvement entities (Coleman, 2003), until recently. With hos-
pital readmission now heralded as a quality indicator, there is more incentive to correct
transition-related problems. e enactment of the Patient Protection and Aordable
Care Act (PPACA) in 2010 (see relevant practice guidelines in this chapter) will help
formalize and implement transitional care services with federal funding.
Fidelindo Lim, Janice Foust, and Janet Van Cleave
Transitional Care
34
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
Transitional Care 683
Many factors contribute to gaps in care during critical transitions. Poor commu-
nication, incomplete transfer of information, inadequate education of older adults and
their family caregivers, limited access to essential services, and the absence of a single-
point person to ensure continuity of care all contribute transition-associated problems
(Naylor, 2002; Naylor & Keating, 2008). e practice of nursing is closely tied to health
illness transitions in a person’s lifetime. e quality of the outcomes during these tran-
sitional events is largely determined by the degree of care coordination among health
care environments and proactive involvement of the patient and their families in the
process, wherein a nurse plays a pivotal role. Success in implementing evidence-based
transition care strategies will help curtail preventable rehospitalizations and save health
care dollars.
is chapter reviews issues associated with transitional care mainly from the
acute care setting and presents evidence-based transitional care models (TCMs)
as well as strategies to enhance outcome performance. e authors searched the
CINAHL, Cochrane databases of systematic Reviews, Medline/PubMed, PsycINFO
and Evidence-Based Resources from the Joanna Briggs Institute using combinations
of the following terms: research, ages 65 years or older, care transitions, case man-
agement, critical pathways, continuity of patient care, patient transfer, patient dis-
charge, discharge planning and discharge education, and readmission and transfer.
e articles search are rated by level of evidence according to Stetler and colleagues’
(1998) and Melnyk and Fineout- Overholt’s (2005) Level of Evidence guidelines.
e search period was 2000 to 2010.
BACKGROUND AND STATEMENT OF PROBLEM
In 2004, older adults represent 50% of hospital days; 60% of all ambulatory adult
primary care visits; 70% of all home care visits; and 85% of residents in nursing homes
(National Center for Healthcare Statistics, 2004). Of the 1.5 million current residents
in U.S. Nursing Homes, nearly one half (48.2%) were admitted from a hospital or
health care facility other than a nursing home or assisted-living-type facility (Centers for
Disease Control and Prevention [CDC], 2009). In 2007, older adults aged 65 years and
older accounted for just 13% of the U.S. population, but 37% of the hospital discharges
(CDC, 2007). erefore, the likelihood of older adults being in a state of transition
between care environments is very high.
Transitions are considered high-stress events for patients, their families, and care
providers alike. Evidence suggests that transitions are particularly vulnerable to break-
downs in care and, thus, there is a need for transitional care services ( Naylor & Keating,
2008). Two especially problematic areas are medication discrepancies and poor post-
hospital follow-up with primary care providers. Forster, Mur, Peterson, Gandhi, &
Bates (2003) found that nearly 20% of recently discharged medical patients experi-
enced an adverse event during the rst several weeks at home. Of these, 66% involved
medications and were the most common type of adverse event (Forster et al., 2003).
Corbett, Setter, Daratha, Neumiller, & Wood, (2010) found in a study on home medi-
cation discrepancies that the problems were astoundingly widespread, with 94% of the
participants having at least one discrepancy. e average number of medication dis-
crepancies identied was 3.3 per patient during hospital to home transition (Corbett et
al., 2010). Another major area of breakdown is patient follow-up visits after discharge.
For example, one study reported that among Medicare patients rehospitalized within
684 Evidence-Based Geriatric Nursing Protocols for Best Practice
30 days, up to 50% did not have documentation of physician follow-up visits postdis-
charge ( Coleman, 2003). Patients and their caregivers are often unprepared for transi-
tions and are overwhelmed by discharge information. Poor preparation of the patient
and their informal caregivers for their next level of care interface, be it the home or
another facility, compromises overall patient safety. Follow-up visits after discharges
provide opportunities to reinforce discharge education and monitor for changes in
conditions. e lack of incentives and accountability make these transfers particu-
larly susceptible to medical errors (Nurses Improving Care for Healthsystem Elders
[NICHE], 2010).
e 2001 Institute of Medicine (IOM) landmark report Crossing the Quality
Chasm: A New Health System for the 21st Century, pointed out that the health care
delivery system is poorly organized to meet the challenges at hand. e delivery of care
is often overly complex and uncoordinated, requiring steps and patient “hand os”
that slowdown care and decrease rather than improve safety (IOM, 2001). Increasingly,
patients are being discharged home or to other health care environments with both
complex and complicated treatment plans with limited; timely follow-through by
professionals, causing undue stress to the patient and their informal caregivers once
they leave the hospital. Levine, Halper, Peist, & Gould (2010) has described informal
caregivers’ essential role and called for more proactive involvement of them as partners
during transitions, especially when they could be the major source of continuity for
the patient. e stress of caregiving is likely to be exacerbated during episodes of acute
illness (Naylor & Keating, 2008), readmissions and transfers to various health care
environments.
Health care disparity and lack or inadequate access to transition care resources will
be more pronounced in the disenfranchised segment of older adults, namely those who
are living alone, undomiciled, suering from mental illness, victims of elder abuse and
neglect, the uninsured, and those lacking in legal status.
ASSESSMENT OF THE PROBLEM
e lack of sustained transition care programs outside of funded randomized controlled
trials (RCTs) is largely caused by the almost nonexistent third-party reimbursement of
transition care services, although its necessity have been well described in the literature
(Naylor & Keating, 2008). However, this pattern is about to be rectied with the enact-
ment of Public Law 111–148, known as the PPACA. is groundbreaking legislation
oers signicant provisions and funding for creating community-based transition care
services starting from 2011 to 2015 (PPACA, 2010).
Coleman, Smith, et al. (2004) identied four major content areas that patients
and caregivers who recently underwent posthospital care transitions expressed as most
essential and most needed: medication self-management, a patient-centered health
record, primary care and specialist follow-up, and knowledge of “red-ags” warning
symptoms or signs indicative of a worsening condition. Similarly, Miller, Piacentine, &
Weiss (2008) identied posthospital diculties faced by adults during the rst 3 weeks
at home. Among those patients who had diculty coping, pain was the most frequent
stressor, followed by managing complications and recovery challenges. ese recently
discharged patients also described relying on family or friends for emotional support,
and were concerned about being a burden.
Transitional Care 685
A study that compared the referral decisions of hospital clinicians with those of
nurses with expertise in discharge planning and transitional care, found that transi-
tional care nurses (TCNs) judged that 96 of 99 of the control group patients discharged
without home care had unmet discharge needs that may have beneted from a postdis-
charge referral (Bowles, Naylor, & Foust, 2002). In investigating patient perceptions of
the quality-of-discharge instruction by assessing inpatients’ ratings of care and service
in the United States between 1997 and 2001 (n 5 4,901,178), Clark and colleagues
(2005) found that patient satisfaction with discharge instructions decreased signi-
cantly each year (p , 0.001). ey point out that patients gave lower ratings to the
quality-of-discharge instruction than to the overall quality of their hospital stay, and
that U.S. hospitals (in general) are not meeting e Joint Commission (TJC) standards
for patient education and discharge.
In a Sentinel Event Alert publication in January, 2006, TJC reported that from
September 2004 to July 2005, the United States Pharmacopeia (USP) received
2,022 reports of medication reconciliation errors. Of those reports, 66% occurred
during the patient’s transition or transfer to another level of care, 22% occurred dur-
ing the patient’s admission to the facility, and 12% occurred at the time of discharge
(Cumbler, Carter, & Kutner, 2008). e report added that of those medication errors
causing death or major injury, about 63%, at least part, are related to breakdown in
communication.
e most common example of communication breakdown is when systems of care
fail to ensure that the essential elements of the patient’s care plan that were developed
in one setting are communicated to the next team of clinicians (e.g., preparation for the
goals of care delivered in the next setting, arrangements for follow-up appointments and
laboratory testing, and reviewing the current medication regimen; Coleman, 2003).
Language and health literacy issues and cultural dierences exacerbate the communi-
cation breakdowns encountered in health care transition (Naylor & Keating, 2008).
For example, a review of literature noted direct communication between hospital and
community physicians was relatively rare (3%–20%), and available discharge summaries
at the rst primary care visit were low (12%–34%; Kripalani et al., 2007). Additionally,
discharge summaries did not always have essential information (e.g., medications,
diagnostic results) when available.
INTERVENTIONS AND CARE STRATEGIES
Various TCMs have been described in the literature, and several RCTs have tested inter-
ventions. Key outcome variables from these RCTs include rehospitalization rate, cost
reduction, patient satisfaction, and quality of care. Specic features of the two well-
known evidence-based models are summarized in Table 34.1.
The Two Leading Examples of Transition Care Interventions:
The Advanced Practice Nurses Transitional Care Model (Naylor & Keating, 2008; Naylor et al., 2004;
Naylor et al., 2009)
e TCM developed at the University of Pennsylvania provides a comprehensive in-
hospital planning and home follow-up for chronically ill, high-risk older adults hos-
pitalized for common medical and surgical conditions (Naylor & Keating, 2008).
686
TABLE 34.1
Transition Care—Strategies for Implementation
Model
Transition
Interface Target Population Implementation Primary Provider
Duration of
Follow-Up
Transitional Care
Model (TCM;
Jencks et al.,
2009; Naylor,
2002; Naylor &
Sochalski, 2010;
Naylor et al.,
2009; Naylor
et al., 2004)
Hospital to
home
Home to
hospital
65 years or older, high-risk,
cognitively intact older
adults with a variety of
medical and surgical
conditions (e.g., CHF and
comorbidities)
Initial APN visit within 24 hours of hospital admission.
APN visits at least daily the index hospitalization.
APN home visits (one within 24 hours of discharge),
weekly visits during the first month (with one of these
visits coinciding with the initial follow-up visit to the
patient’s physician).
Bimonthly visits during the second and third months.
Additional APN visits based on patients’ needs and
APN telephone availability 7 days per week.
If a patient was re-hospitalized for any reason during
the intervention period, the APN resumed daily
hospital visits to facilitate the transition from hospital
to home.
Use of care management strategies foundational to
the quality-cost model of APN transitional care model,
including identification of patients’ and caregivers’
goals, individualized and collaborative plan of care.
Implementation of an evidence-based protocol,
guided by national heart failure guidelines.
APN in a “ manager
coordinator” role
From admission
to 3 months
postdischarge
Care Transitions
Intervention
(Coleman, 2003;
Coleman, Smith,
et al., 2004;
Coleman et al.,
2006; Coleman,
Min, et al., 2004)
Hospital to
home and
hospital
to skilled
nursing
facility
65 years or older with
least 1 of the following
diagnoses: stroke,
congestive heart failure,
coronary artery disease,
cardiac arrhythmias, COPD,
diabetes mellitus, spinal
stenosis, hip fracture,
peripheral vascular disease,
deep venous thrombosis,
and pulmonary embolism.
The transition coach first met with the patient in the
hospital before discharge
Arrange a home visit, ideally within 48 to 72 hours
after hospital discharge. For those patients transferred
to a skilled nursing facility, the transition coach
telephoned or visited at least weekly).
The home visit involved the transition coach, the
patient, and the caregiver. The primary goal of
the home visit is to reconcile all of the patient’s
medication regimens (e.g., pre-hospitalization and
posthospitalization medications).
APN “ transition
coach” in a
supportive role
From admission
to 28 days
postdischarge
687
Transition coach imparted skills on how to effectively
communicate care needs during subsequent
encounters with health care professionals.
The patient and transition coach rehearsed or
role-played effective communication strategies.
The transition coach reviewed with the patient any
red flags that indicated a condition was worsening
and provided education about the initial steps to take
to manage the red flags and when to contact the
appropriate health care professional.
Following the home visit, the transition coach
maintained continuity with the patient and caregiver
by telephoning three times during a 28-day
posthospitalization discharge period. The first
telephone call generally focused on determining
whether the patient had received appropriate services
(e.g., whether new medications had been obtained or
durable medical equipment had been delivered).
In the two subsequent telephone calls, the transition
coach reviewed the patient’s progress toward
goals established during the home visit, discussed
any encounters that took place with other health
care professionals, reinforced the importance of
maintaining and sharing the personal health record
and supported the patient’s role in chronic illness
self-management.
688 Evidence-Based Geriatric Nursing Protocols for Best Practice
e heart of the model is the TCN, who follows patients from the hospital into their
homes and provides services designed to streamline plans of care, interrupt patterns of
frequent acute hospital and emergency department (ED) use, and prevent health status
decline. Although the TCM is nurse led, it is a multidisciplinary model that includes
doctors, other nurses, social workers, discharge planners, pharmacists, and other mem-
bers of the health care team, all of whom implement tested protocols uniquely focused
on increasing the ability of patients and their caregivers to manage their care (Naylor
et al., 2009).
is model involves APNs who assume a primary role in managing patients and
coordinating the transition from hospital to home and vice-versa. APNs implement
a comprehensive discharge planning and home follow-up protocol. When compared
with the control group, members of the intervention group had improved physical
function, quality of life, and satisfaction with care. People in the intervention group
had fewer rehospitalizations during the year after discharge, resulting in a mean savings
in total health care costs of $5,000 per patient (Naylor & Keating, 2008). An RCT
using the TCM for older adults hospitalized with heart failure showed increase in the
length of time between hospital discharge and readmission or death, reduced total
number of rehospitalizations and decreased health care costs (Naylor et al., 2004;
NICHE, 2010).
The Care Transitions Intervention Model (Coleman, Parry, Chalmers, & Min, 2006)
Coleman and colleagues (2006) developed this model through the Division of Health
Care Policy and Research at the University of Colorado Health Sciences Center in
Denver.
is model involves a specialized nurse or “transition coach,” who teaches patients
self-management skills and ensures their needs are met during transition. e transi-
tion coach helps the patient self-manage medications, maintain patient-centered health
records, complete follow-up care with their primary physician, and learn how to rec-
ognize and respond to red ags that indicate their condition is worsening. Providing
patients with support and tools to participate in their transition care using this model
has been shown to reduce hospital readmissions and associated costs (Coleman et al.,
2006; NICHE, 2010). An RCT found that patients who received this intervention had
lower all cause rehospitalization rates through 90 and 180 days after discharge compared
with control patients. At 6 months, mean hospital costs were approximately $500 less
for patients in the intervention group compared with controls (Coleman et al., 2006;
Naylor & Keating, 2008)
Other transition models that have been described in the literature include the
following:
Community-based transitions—hospital at home and day hospital models (Naylor &
Keating, 2008).
Transitions within settings—acute care for elders (ACE) and professional–patient
partnership model (Naylor, & Keating, 2008).
Hospital-to-home transition—geriatric oating interdisciplinary transition team ( Geri-FITT)
model (Arbaje et al., 2010) and chronic care model (2011)
Multi-setting transitions—Florida’s Medicare Quality Improvement Organization (FMQAI;
2010). It is one of Medicare’s Quality Improvement Organization (QIOs).
Transitional Care 689
Naylor and Sochalski (2010) describes the core features of transitional care, which can
be used as a guide for program planning and implementation to include the following:
A. A comprehensive assessment of an individual’s health goals and preferences; physical,
emotional, cognitive, and functional capacities and needs; and social and environ-
mental considerations.
B. Implementation of an evidence-based plan of transitional care.
C. Transition care that is initiated at hospital admission but extends beyond discharge
through home visit and telephone follow-up.
D. Mechanisms to gather and appropriately share information across sites of care.
E. Engagement of patients and family caregivers in planning and executing the plan of care.
F. Coordinated services during and following the hospitalization by a health care pro-
fessional with special preparation in the care of chronically ill people, preferably a
master’s-prepared nurse.
Whichever model is adopted by the institution and stakeholders, sta training is of
vital importance. Competency in cross-site collaboration is critical to the management
of patients with complex acute and chronic illnesses; however, very few clinicians have
any formal training in this area (Coleman, 2003).
Starting January 1, 2011 the government has established support of community-based
transition programs under the PPACA, section 3025. is 5-year program comes with a
500 million dollar funding with the primary aim in implementing improved care transi-
tion services to high-risk Medicare beneciaries. By “high risk,” the law aims to dedicate
transition care services to patients with multiple chronic conditions or other risk factors
associated with a hospital readmission or substandard transition into posthospitalization
care. Target populations are those diagnosed with cognitive impairment, depression, and a
history of multiple readmissions (PPACA, 2010). To qualify for funding, the transition care
program proposal must meet the following criteria (PPACA, 2010):
A. Initiates care transition services for a high-risk Medicare beneciary not later
than 24 hours prior to discharge.
B. Arranges timely postdischarge follow-up services to provide the beneciary and
the primary caregiver with information regarding responding to symptoms that
may indicate additional health problems or a deteriorating condition.
C. Provides the high-risk Medicare beneciary and the primary caregiver with assis-
tance to ensure productive and timely interactions between patients and post-
acute and outpatient providers.
D. Assesses and actively engages with the high-risk Medicare beneciary and
the primary caregiver through the provision of self-management support and
relevant information that is specic to the beneciary’s condition.
E. Conducts comprehensive medication review and management, including, if
appropriate, counseling and self-management support.
F. Provide services to medically underserved populations, small communities, and
rural areas.
ese criteria reect the ndings from the RCTs implementing Naylor’s TCM
(Naylor & Keating, 2008; Naylor et al., 2004) and the Care Transitions Intervention
model by Coleman (Coleman, Smith, et al., 2004). e adaptation of these best prac-
tice models into legislation is a ne example of research translated into practice.
690 Evidence-Based Geriatric Nursing Protocols for Best Practice
Lin Kwon Ying is a 70-year-old widow who lives alone in an apartment in Chinatown.
He was mostly independent up until 5 months ago when he started to develop
shortness of breath, increasing fatigue, and cough. He has had three admissions for
congestive heart failure (CHF) exacerbation. His medical–surgical history includes
hypertension (HTN), arthritis, peptic ulcer disease, and GI bleeding. He is back in
the hospital for another CHF exacerbation, a small left pleural eusion, and a left
leg deep venous thrombosis. Although cognitively intact, Mr. Ying does not speak
English and his family is very much involved in his care. A relative is present during
most of the day and evening while he is in the hospital. Most of his relatives have poor
English prociency. Mr. Ying is scheduled for discharge home the next day after being
in the hospital for 6 days. His current medications have been satisfactorily reconciled,
with the addition of enoxaparin (low-molecular–weight heparin) injection for 7 days
and to check with his primary care provider for possible oral anticoagulation. He is
to continue taking prehospitalization medications such as metoprolol, esomeprazole,
multivitamins, and furosemide. e family reports that Mr. Ying uses Chinese lini-
ment to ease his joint pains. He is described by his family as an obedient patient who
will do whatever his doctor recommends although he has received little advice or
“teachings” during his previous CHF admissions. He cannot recall being informed
what lifestyle changes are required of him.
Factors such as Mr. Ying’s rehospitalization, a diagnosis of CHF, language
barrier, family involvement, being cognitively intact, and a complex plan of care
(e.g., self-injection of enoxaparin) indicate that he is an ideal candidate to receive
dedicated transitional care services. If transition care service were available in the
current institution, he would have been referred for a consult upon his admission.
An assessment would have been made by an advanced practice TCN or “coach,”
preferably in the presence of the informal caregiver and a sta translator. From this
transition care evaluation, a multidisciplinary plan of care with emphasis applying
best practices, on family involvement and patient teaching by the sta nurses would
be drawn up. e hando report would mention Mr. Ying’s status as a transition care
patient and a disease-specic clinical pathway (in his case CHF) would be imple-
mented and followed through during rounds and discharge planning.
To satisfy TJC standards, all his medication should have been reconciled within
24 hours of his admission and the record placed in a prominent location in his chart.
e challenge is to create a medication reconciliation record written in Mr. Ying’s own
language (Mandarin) that he can take with him upon discharge.
At the bedside level, the nurses (mostly bilingual Chinese) provided random
or “ambush” teachings when they saw Mr. Ying consuming Chinese food brought
from home that they considered high in sodium. No dedicated patient teachings
were delivered and no printed materials in the patient’s language were provided. How
best to standardized patient teachings in acute care transitions is an ongoing chal-
lenge. Sta often reports not having the time to teach the patient and their family.
Patient education must be held as an essential and independent nursing intervention.
e facility must provide adequate training, not only for the licensed independent
practitioners (nurses, NPs, MDs, and social workers), but also of the auxiliary sta
CASE STUDY
(continued)
Transitional Care 691
SUMMARY
High-quality transitional care is especially important for older adults with multiple
chronic conditions and complex therapeutic regimens, as well as for their family care-
givers (Naylor & Keating, 2008). Nurses must recognize their critical role in safe transi-
tions. Breakdown in communication is often cited as one of the major cause of poor
quality transitions that may lead to untimely rehospitalization, injury, and poor patient
satisfaction. Clinicians and institutions must actively collaborate and communicate
to ensure an appropriate exchange of information, coordination of care across health
care settings among multiple providers (IOM, 2001). e current evidence indicates
that hospital discharge planning for frail older people can be improved if interventions
address family inclusion and education, communication between health care workers
and family, interdisciplinary communication, and ongoing support after discharge
(Bauer, Fitzgerald, Haesler, & Manfrin, 2009). In addition, evidence supports the need
for close follow-up posthospitalization including home visits, telephone calls, and timely
primary care provider visits. is provides opportunities to reinforce previous patient
and family education, especially medications, and monitoring of condition changes
(Naylor et al., 2004; Coleman et al., 2006; Rich et al., 1995).
As more and more evidence on the value of transitional programs in improving
health outcomes emerge, we hope to see sustainable adaptation of best practice models
such as patient-care technicians and other sta members with direct patient contact.
Repetition and reinforcement with use of traditional printed media can easily be
achieved. Numerous online patient teaching materials are now available. e institu-
tion could translate these materials into various languages based on local needs. In
Mr. Ying’s case, his ability to self-inject enoxaparin should be assessed, reinforced, and
documented. During hando, the nurse would include the patient’s teaching needs
and the follow-up needed, focusing on health promotion content, follow-up appoint-
ments, telephone numbers to call for questions, or report changes in condition.
Depending on the TCM applied, Mr. Ying would receive a home visit from the
APN transition care coordinator or “coach” within 24 hours postdischarge with an
individualized and explicit plan of care; including following up on medications, avail-
ability of equipment, and self-report of any “red-ag” signs for CHF exacerbation
or pulmonary embolism. On his rst visit to his primary care provider, he would
be accompanied by his transition care coordinator/coach. In this visit and in future
encounters with health care providers, Mr. Ying would be encouraged and provided
with the skills necessary for self-advocacy and self-management of his condition. Suc-
cess would depend on various factors such as patient readiness, literacy, and longitudi-
nal follow-up. From the evidence-based models mentioned in this chapter, follow-up
varies from Day 1 of hospitalization to up to 3 months postdischarge. Patient follow-up
must also address patients’ and informal caregivers’ satisfaction with the care received.
Additionally, the postacute TCN could also coordinate referrals to relevant, local com-
munity organizations to provide greater continuity and longer term support.
CASE STUDY (continued)
692 Evidence-Based Geriatric Nursing Protocols for Best Practice
in transition care as nurse-sensitive quality indicator of health care delivery. With the
full implementation and evaluation of the PPACA community-based transition pro-
gram legislation, we can expect to gain the benets of evidence-based transition care
interventions for the ever-growing older adult population.
Protocol 34.1: Transitional Care
I. GOAL
A. Nurses will assume a proactive role in transitional care across health care
settings.
B. Nurses will identify barriers to successful transitions and oer sustainable
solutions.
C. Increase coordination of care during transitions across health care settings
amongst all members of the health care system, including the family and infor-
mal caregivers.
II. OVERVIEW
A. Evidence that both quality and patient safety are jeopardized for patients under-
going transitions across care settings continues to expand (Coleman, Mahoney,
& Parry, 2005).
B. Care transitions are clinically dangerous times, particularly for older adults
with complex health problems (Corbett et al., 2010).
C. Problems encountered with poor transition process can lead to unplanned
readmission and ED visits (Jacob & Poletick, 2008).
D. Transitions are particularly vulnerable to breakdowns in care and, thus, have the
greatest need for transitional care services (Naylor & Keating, 2008; Coleman
et al., 2006).
E. Family caregivers play a major—and perhaps the most important—role in
supporting older adults during hospitalization and especially after discharge
( Naylor & Keating, 2008).
III. BACKGROUND AND STATEMENT OF PROBLEM
A. Denition
Transitional care: e American Geriatrics Society (2003) denes transi-
tional care as “a set of actions designed to ensure the coordination and conti-
nuity of health care as patients transfer between dierent locations or dierent
levels of care within the same location. Representative locations include (but
are not limited to) hospitals, subacute and postacute nursing facilities, the
patient’s home, primary and specialty care oces, and long-term care facilities.
Transitional care, which encompasses both the sending and the receiving
aspects of the transfer, is based on a comprehensive plan of care and includes
logistical arrangements, education of the patient and family, and coordina-
tion among the health professionals involved in the transition.” (Coleman &
Boult, 2003)
NURSING STANDARD OF PRACTICE
(continued)
Transitional Care 693
Transitional care encompasses a broad range of services and environments
designed to promote the safe and timely passage of patients between levels of
health care and across care settings (Naylor & Keating, 2008).
B. Etiology and/or Epidemiology
1. Situations likely to result in failed transitions include poor social support,
discharge during times when ancillary services are unavailable, uncertain
medication reconciliation, depression, and patients’ cognitive limitations
(Cumbler et al., 2008).
2. Medication errors related to medication reconciliation typically occur at the
“interfaces of care”—when a patient is admitted to, transferred within, or
discharged from a health care facility (Sentinel Event Alert, 2006).
3. Hospital discharge practices are placing an increasing burden of care on the
family caregiver (Bauer et al., 2009).
4. RCTs of transitional care interventions has been shown to reduce hospital
readmissions and health care costs (Arbaje et al., 2010; Coleman et al.,
2006; Naylor et al., 2004).
5. APN interventions in transition care has consistently resulted in improved
patient outcomes and reduced health care costs (Naylor, 2002).
IV. PARAMETERS OF ASSESSMENT
A. Patient population who are most likely to benet from transition care inter-
ventions are those who are diagnosed with one or more of the following
diseases: CHF, chronic obstructive pulmonary disease, coronary artery dis-
ease, diabetes, stroke, medical and surgical back conditions (predominantly
spinal stenosis), hip fracture, peripheral vascular disease, cardiac arrhyth-
mias, deep venous thrombosis, and pulmonary embolism (Coleman, Min,
Chomiak, & Kramer, 2004).
B. Upon admission to an acute care setting, starting at the ED; patient evaluation
must include referral of vulnerable older adults for transitional care services.
C. Compliance with TJC standards in medication reconciliation will be used as
one of the quality indicators and predictor in overall patient safety.
V. NURSING CARE STRATEGIES
A. General guidelines that may be adapted in implementing transition care strate-
gies based on the TMC are as follows (Bowles et al., 2002):
1. e TCN as the primary coordinator of care to assure consistency of pro-
vider across the entire episode of care.
2. In-hospital assessment, preparation, and development of an evidence-
based plan of care.
3. Regular home visits by the TCN with available, ongoing telephone sup-
port (7 days per week) through an average of 2 months postdischarge.
4. Continuity of medical care between hospital and primary care physicians
facilitated by the TCN, accompanying patients to rst follow-up visits.
5. Coordinate a timely appointment with patient’s primary care provider.
6. Comprehensive, holistic focus on each patient’s needs including the reason for
the primary hospitalization as well as other complicating or coexisting events.
(continued)
Protocol 34.1: Transitional Care (cont.)
694 Evidence-Based Geriatric Nursing Protocols for Best Practice
7. Active engagement of patients and their family and informal caregivers
including education and support.
8. Emphasis on early identication and response to health care risks and
symptoms to achieve longer term positive outcomes and avoid adverse
and untoward events that lead to readmissions.
9. Multidisciplinary approach that includes the patient, family, informal and
formal caregivers, and health care providers as part of a team.
10. Physician–nurse collaboration across episodes of acute care.
11. Communication to, between, and among the patient, family and informal
caregivers, and health care providers.
B. Successful and safe transitions demands active patient and informal caregiver
involvement. To improve patient advocacy and safety, the nurse can:
1. Promote the “Speak Up” initiative by the TJC in 2002. e brochure
“Planning Your Follow Up Care” lists patient-centered and safety-focused
questions to be asked by the patients from their health care provider before
they are discharged from the hospital (Joint Commission on Accreditation
of Health Care Organization, 2002).
2. Encourage family involvement and direct them to the “Next Steps in Care”
website (see resources).
3. Provide the patient a complete and updated medication reconciliation
record. e record should include medications the patient was taking prior
to admission, medications prescribed during hospitalization, and medica-
tions to be continued upon discharge (Sentinel Event Alert, 2006).
4. Implement evidence-based interventions to reduce transition-related medi-
cation discrepancies (Corbett et al., 2010). Encourage the patient to carry
their medication list (e.g., a copy of recent medication reconciliation from
a recent hospital admission) and to share the list with any providers of care,
including primary care and specialist physicians, nurses, pharmacists and
other caregivers (Sentinel Event Alert, 2006).
Critical Elements of Successful Transitions
A. Team approach and preferably nurse led (APN or specialized nurse; Coleman
et al., 2006; Naylor & Keating, 2008)
B. Active and early family involvement across transitions (Almborg, Ulander,
ulin, & Berg, 2009; Bauer et al., 2009; Naylor & Keating, 2008)
C. Proactive patient roles and self-advocacy (Coleman et al., 2006)
D. High-quality and individualized patient and family discharge instructions
(Clark et al., 2005)
E. Apply interventions for improving comprehension among patients with low
health literacy and impaired cognitive function (Chugh, Williams, Grigsby, &
Coleman, 2009), such as the National Patient Safety Foundation’s “Ask Me 3”
campaign available at: http://www.npsf.org/askme3/
F. Patient and informal caregiver empowerment through education
G. Commence interventions well before discharge (Bauer et al., 2009)
(continued)
Protocol 34.1: Transitional Care (cont.)
Transitional Care 695
Coleman identied elements of eective and successful transitions as follows
( Coleman, 2003):
A. Communication between the sending and receiving clinicians regarding a com-
mon plan of care
B. A summary of care provided by the sending institution (to the next care inter-
face providers)
C. e patient’s goals and preferences (including advance directives)
D. An updated list of problems, baseline physical and cognitive functional status,
medications, and allergies
E. Contact information for the patient’s caregiver(s) and primary care practitioner
F. Preparation of the patient and caregiver for what to expect at the next site of care
G. Reconciliation of the patient’s medication prescribed before the initial transfer
with the current regimen
H. A follow-up plan for how outstanding tests and follow-up appointments will be
completed
I. An explicit discussion with the patient and caregiver regarding warning symp-
toms or signs to monitor that may indicate that the condition has worsened
and the name and phone number of who to contact if this occurs.
Barriers to Successful Transitions
Coleman identied barriers to eective care transitions at three levels: the delivery
system, the clinician, and the patient (Coleman, 2003).
A. e Delivery System Barriers
1. e lack of formal relationships between care settings represents a barrier to
cross-site communication and collaboration.
2. Lack of nancial incentives promoting transitional care and accountabil-
ity in fee-for-service Medicare. Although such incentives exist in Medicare
managed care, most plans do not fully address care integration.
3. e dierent nancing and contractual relationships that facilities have
with various pharmaceutical companies impede eective transitions. As
patients are transferred across settings, each facility has incentives to pre-
scribe or substitute medications according to its own medication formulary.
is constant changing of medications creates confusion for the patient,
caregiver, and receiving clinicians.
4. Neither fee-for-service nor managed care Medicare has implemented qual-
ity or performance indicators designed to assess the eectiveness of transi-
tional care.
5. e lack of information systems designed to facilitate the timely transfer of
essential information.
B. e Clinician Barriers
1. e growing reliance on designated institution-based physicians (i.e., “hos-
pitalists”) and productivity pressures have made it dicult for primary care
physicians to follow their patients when they require hospitalization or
short-term rehabilitation.
(continued)
Protocol 34.1: Transitional Care (cont.)
696 Evidence-Based Geriatric Nursing Protocols for Best Practice
2. Nursing sta shortages have forced an increasing number of acute hospitals
to divert patients to other facilities where a completely new set of clinicians,
who often do not have timely access to the patients’ prior medical records,
manages them. Skilled nursing facility (SNF) sta are also overwhelmed
and do not have the time or initiative to request necessary information.
3. Clinicians do not verbally communicate patient information to one another
across care settings.
C. e Patient Barriers
1. Lack of advocacy or outcry from patients for improving transitional care
until they or a family member is confronted with the problem rsthand.
2. Older patients and their caregivers often are not well prepared or equipped
to optimize the care they will receive in the next setting.
3. ey may have unrealistic expectations about the content or duration of the
next phase of care and may not feel empowered to express their preferences
or provide input for their care plan.
4. Patients may not feel comfortable expressing their concern that the primary
factor that led to their disease exacerbation was not adequately addressed.
Evaluation/Expected Outcomes
Clinician outcomes
A. Increase nurse involvement in leading transition care teams.
B. Enhance sta training of transitional care by a multidisciplinary team.
C. Include patient’s transitional care needs during in-hospital “hand o”.
D. Improve medication reconciliation throughout all transition interfaces.
Patient outcomes
A. Improve patient satisfaction, increase involvement with their care during hos-
pitalization and transitions of care across health care settings.
B. Increase feeling of empowerment in making health care decision.
C. Reduce rehospitalization and ED visits because of primary disease and
c omorbidities.
Informal caregiver outcomes
A. Improve informal caregiver satisfaction and exercise proactive roles during
transitions across health care settings.
B. Increase informal caregiver participation in all transitions interface.
Institutional outcomes
A. Adopt evidence-based TCMs and provide logistic support.
B. Provide orientation and on-going education on transitional care strategies.
C. Introduce transitional care content into nursing core curriculum both in
baccalaureate and graduate levels.
VI. FOLLOW-UP MONITORING
A. Institute comprehensive and multidisciplinary transition care planning as soon
as the patient is admitted and sustained throughout hospitalization.
(continued)
Protocol 34.1: Transitional Care (cont.)
Transitional Care 697
B. Identify transition care team members and perform periodic role re-assessment,
including roles of informal caregivers.
C. Incorporate continuous quality improvement criteria into transition care pro-
grams such as monitoring for rehospitalization of targeted older adult, quality
of discharge instruction, and medication reconciliation.
D. Develop ongoing transitional care educational programs for both formal and
informal caregivers, using high-tech and traditional media.
E. Provide orientation and ongoing education on procedures for reconciling med-
ications to all health care providers, including ongoing monitoring (Sentinel
Event Alert, 2006).
F. Periodic “debrieng” of high-risk discharges as quality improvement strategy.
G. Improve recognition of condition changes or adverse events caused by medications.
H. Increase patient and caregivers’ knowledge concerning action steps if condition
worsens including who to contact and 24-hour contact information.
VII. RELEVANT PRACTICE GUIDELINES
A. Ongoing chart and medical records review of patients being considered for discharge
or awaiting transition should reect the quality indicators (QI) outlined in the Assess-
ing Care of Vulnerable Elders (ACOVE) under the Continuity and Coordination of
Care QI heading (Assessing Care of Vulnerable Elders-3 Quality Indicators, 2007).
B. TJC National Patient Safety Goals (NPSG, eective July 2011) related to tran-
sitions of care include the following:
NPSG.03.06.01—Maintain and communicate accurate patient medication infor-
mation. e elements of performance (EP) include the following: (TJC, 2010)
1. Obtain information on the medications the patient is currently taking when
he or she is admitted to the hospital or is seen in an outpatient setting. is
information is documented in a list or other format that is useful to those
who manage medications.
Note 1: Current medications include those taken at scheduled times and
those taken on an as-needed basis.
Note 2: It is often dicult to obtain complete information on current medi-
cations from a patient. A good faith eort to obtain this information
from the patient and/or other sources will be considered as meeting the
intent of the EP.
2. Dene the types of medication information to be collected in non–24-hour
settings and dierent patient circumstances.
Note 1: Examples of non–24-hour settings include the ED, primary care,
outpatient radiology, ambulatory surgery, and diagnostic settings.
Note 2: Examples of medication information that may be collected include
name, dose, route, frequency, and purpose.
3. Compare the medication information the patient brought to the hospital
with the medications ordered for the patient by the hospital to identify and
resolve discrepancies.
Note: Discrepancies include omissions, duplications, contraindications,
unclear information, and changes. A qualied individual, identied by
the hospital, does the comparison.
(continued)
Protocol 34.1: Transitional Care (cont.)
698 Evidence-Based Geriatric Nursing Protocols for Best Practice
4. Provide the patient (or family as needed) with written information on the
medications the patient should be taking when he or she is discharged from
the hospital or at the end of an outpatient encounter (e.g., name, dose,
route, frequency, purpose).
Note: When the only additional medications prescribed are for a short dura-
tion, the medication information the hospital provides may include
only those medications.
5. Explain the importance of managing medication information to the patient
when he or she is discharged from the hospital or at the end of an outpa-
tient encounter.
Note: Examples include instructing the patient to give a list to his or her pri-
mary care physician; to update the information when medications are
discontinued, doses are changed, or new medications (including over-
the-counter products) are added; and to carry medication information
at all times in the event of emergency situations.
Standard PC.04.02.01 (Provision of Care; U.S. Department of Health and
Human Services Agency for Healthcare Research and Quality, 2011).
When a [patient] is discharged or transferred, the [organization] gives
information about the care, treatment, and services provided to the [patient]
to other service providers who will provide the [patient] with care, treatment,
or services.
At the time of the patient’s discharge or transfer, the hospital informs other
service providers who will provide care, treatment, or services to the patient
about the following:
1. e reason for the patient’s discharge or transfer
2. e patient’s physical and psychosocial status
3. A summary of care, treatment, and services it provided to the patient
4. e patient’s progress toward goals
5. A list of community resources or referrals made or provided to the patient
C. Project Better Outcomes for Older Adults through Safe Transitions (BOOST)–
www.hospitalmedicine.org/BOOST - provides a “toolkit” for quality improve-
ment based on best practices, provides technical support to hospitals implementing
the toolkit, and provides mentoring to promote long-term sustainability of tran-
sitional care programs (Chugh et al., 2009).
D. Position Statement of e American Geriatrics Society Health Care Systems
Committee on Improving the Quality of Transitional Care for Persons with
complex care needs must be considered in developing practice guidelines
( Coleman et al., 2003)
E. e National Transitions of Care Coalition (NTOCC) developed the guide-
book Improving on Transitions of Care: How to Implement and Evaluate a Plan
(http://www.ntocc.org/Portals/0/ImplementationPlan.pdf). is book is in-
tended for institutions ready to make changes in the processes their facilities
use to send and receive patients. It includes an educational component about
transitions of care, implementation manual, and evaluation methodology that
(continued)
Protocol 34.1: Transitional Care (cont.)
Transitional Care 699
relates to nursing home to emergency department (ED)/hospital and vice-
versa. is implementation and evaluation plan aims to empower institutions
to take the rst step at measuring their own performance in transitions of care
and identify areas for improvement (National Transitions of Care Coalition,
2008). Guidelines on hospital to home and ED to home transitions are also
available from the NTOCC website:
http://www.ntocc.org/Portals/0/ImplementationPlan_HospitalToHome.pdf
http://www.ntocc.org/Portals/0/ImplementationPlan_EDToHome.pdf
F. e PPACA addresses community-based transition program under section 3026
of the law. e law provides incentive for hospital to establish and cultivate part-
nerships with community-based organizations to implement evidence-based
transition care intervention. Proposals and programs must meet the criteria
stipulated in the law (see Intervention/Care Strategies above). is criteria will
lend itself to evaluation of relevant practice guidelines (Patient Protection and
Aordable Care Act, 2010).
Protocol 34.1: Transitional Care (cont.)
ACKNOWLEDGMENT
With gratitude to Nigel Morgan and Malvina Kluger for their assistance in reviewing
the manuscript.
RESOURCES
Administration on Aging
http://www.aoa.gov/
e American Geriatrics Society Transitional Care Information Page
http://www.healthinaging.org/public_education/pef/transitional_care.php
e Care Transitions Program: Eric Coleman. MD
http://www.caretransitions.org
Centers for Medicare and Medicaid Services
Value Project: Transitional Care Weekly Learning Sessions
http://www.cfmc.org/value/co/index.htm
Centers for Medicare and Medicaid Services: Patient Discharge Checklist
http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf
Institute for Healthcare Improvement (IHI)
Provides educational resources on transitional care and medication reconciliation including samples
of a reconciliation tracking tool and a medication reconciliation ow sheet.
http://www.ihi.org/ihi
e Joint Commission: “Speak Up” Initiative: Planning Your Follow-Up Care
http://www.jointcommission.org/PatientSafety/SpeakUp/speak_up_recovery.htm
700 Evidence-Based Geriatric Nursing Protocols for Best Practice
Meals on Wheels Association of America
http://www.mowaa.org/
National Cancer Institute Transitional Care Planning
http://www.cancer.gov/cancertopics/pdq/supportivecare/transitionalcare/patient
National Transitions of Care Coalition: Transition Care Advocacy Group
http://www.ntocc.org/
e Next Steps in Care: Family Caregivers and Health Professionals Working Together. United
Hospital Fund.
http://www.nextstepincare.org/
NICHE –Transitional Care Models
http://www.nicheprogram.org/niche_encyclopedia-geriatric_models_of_care-transitional_models
Partnership for Clear Health Communication and National Patient Safety Foundation “Ask Me 3”
campaign
http://www.npsf.org/askme3/
Promising Practices: APN Transitional Care
http://promisingpractices.ghtchronicdisease.org/programs/detail/apn_transitionalcare_model
Robert Wood Johnson Foundation’s (RWJF) Speaking Together Toolkit
is toolkit provides advice to hospitals on improving the quality and accessibility of their language
services for limited English procient populations.
http://www.rwjf.org/qualityequality/product.jsp?id=29653
Transition Care Model: Mary Naylor, PhD, R.N
http://www.nursing.upenn.edu/research/ncth/Pages/default.aspx
Visiting Nurse Associations of America
http://vnaa.org/vnaa/siteshelltemplates/homepage_navigate.htm
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703
Index
AAN. See American Academy of Neurology
AAR. See After Action Review
AASM. See American Academy of Sleep
Medicine
abdomen assessment, HF, 637–638
absorption, of drugs, 329
abuse. See elder mistreatment
accrediting standards, restraint use, 230
ACE inhibitors (ACEIs), 341, 640, 643, 645
ACE units. See acute care for the elderly units
ACED. See Assessment of Capacity for
Everyday Decision-Making
acetaminophen, 253
acetyl cholinesterase inhibitors, 169
ACP. See advance care planning
activities of daily living (ADLs)
ADEs, 327
assessment, 92–93
CGA, 661
dementia, 165–166
physical function protocol, 97–100
acute care for the elderly (ACE) units, 673–674
acute care models
objectives, 671–672
overview, 670–671
summary, 676
types, 672–676
acute care settings, functional decline. See
also functional decline; hospitals,
hospitalization; intensive care units
hospitalization, 106–107
interventions, care strategies, 108–112
physical design, 108
policy, procedure, 107
social climate, 107
acute care settings, restraints. See restraints
acute pain, 246, 258. See also pain, pain
management
acute sensory loss, 62
AD. See Alzheimer’s disease
ADCS-ADL. See Modied Alzheimer’s
Disease Cooperative Study--Activities
of Daily Living Inventory
addiction. See drug misuse; substance
misuse, abuse
ADEs. See adverse drug events
adjuvant drugs, pain management, 253–254
ADRs. See adverse drug reactions
ADs. See advance directives
adult day care, 479
Adult Protective Service (APS), 547
advance care planning (ACP), 564–565,
587–588, 590. See also advance
directives
advance directives (ADs)
absence of capacity, 567
assessment, 585–587
background, 580
case study, 590–591
cultural perspectives, 587–588
dementia, end-of-life care, 173
interventions, care strategies, 589–590
nurses’ roles, 588–589
overview, 579
protocol for, 592–594
summary, 592
types of, 581–585
Advanced Practice Nurses Transitional Care
Model, 685–689
adverse drug events (ADEs)
assessment strategies, 329–342
assessment tools, 327–329
background, 325–327
Beers criteria, 331–332
case study, 345–347
dened, 325, 348
high-risk medications, 336–342
iatrogenesis, 203–204, 325–326
interventions, care strategies, 342–345
medication assessment, management,
342–345
medication history questions, 329–330, 342
overview, 324–325
preventing, 216–217
protocol for, 348–354
summary, 348
704 Index
adverse drug reactions (ADRs)
assessment for, 332–335
dened, 348
iatrogenic causes, 325–326
aect, fall prevention, 270–271
After Action Review (AAR), 281
Agency for Healthcare Research and Quality
(AHRQ )
iatrogenesis, 201
Keeping Patients Safe: Transforming the
Work Environment of Nurses, 216
pressure ulcers, 302
age-related health changes
atypical presentation of disease, 35–36
cardiovascular system, 24–25
case study, 36
cognition, 33–34
gastrointestinal system, 30–31
genitourinary system, 27–29
ICU patients, 602–603
immune system, 34–35
introduction to, 23–24
musculoskeletal system, 31–33
nervous system, 33–34
oropharyngeal system, 30–31
physiological sleep, 75–76
protocol for, 37–43
pulmonary system, 25–27
renal system, 27–29
sensory, 48–68
sexual, 502–503, 506–507
vaccination, 34–35
aging, older adults
dehydration, 421
delirium, 187–188
demographics, 246, 683
depression, 138–140
drugs to avoid, 254
fall incidence, 169
iatrogenesis, increased risk, 201–202
malnutrition, 440–441
medication changes, 329–331
pain, 246
UI, 365
agnosia, 462
AGREE instrument, 2–6
AGS. See American Geriatric Society
AHRQ. See Agency for Healthcare Research
and Quality
alcohol misuse. See also substance misuse, abuse
disorders, 518–519
HF, 640
pharmacological treatment, 525
recovery, 520
screening tools, 523
Alcohol Use Disorders Identication Test
(AUDIT), 523, 531
alcohol withdrawal syndrome (AWS), 524
Alzheimer’s disease (AD), 164, 484–485. See
also dementia
AMA. See American Medical Association
ambulation assessment, 93–94
ambulatory care, substance misuse, 524–525
American Academy of Audiology, 57
American Academy of Neurology (AAN),
168
American Academy of Sleep Medicine
(AASM), 76
American College of Cardiology, 631, 640
American Dental Association, 411
American Diabetes Association (ADA), 341
American Geriatric Society (AGS)
CGA, 659
diabetes guidelines, 341
NSAID protocols, 203
pain management guidelines, 251, 253
transitional care, 682
American Heart Association, 631, 640
American Medical Association (AMA), 548
American Nurses Association, 2, 230
American Society of Anesthesiologists, 422
analgesics, 252–254
anatomical gift, 582
andropause, 502
angiotension-receptor blockers (ARBs), 640
ANH. See articial nutrition and hydration
anorexia, 462
anosmia, 61
anthropometry, 445–446
anticholinergics, 340
antidepressants, 146. See also psychoactive
drugs
antihypertensive agents, 337–338
antipsychotics. See psychoactive drugs
anxiolytics. See psychoactive drugs
apraxia, 462
APS. See Adult Protective Service
ARBs. See angiotension-receptor blockers
Aricept. See donepezil hydrochloride
articial nutrition and hydration (ANH),
585
Assessing Nutrition in Older Adults, 441
Assessment of Capacity for Everyday
Decision-Making (ACED), 566
Index 705
assisted autonomy, 563
atrial brillation, 206
at-risk drinking, 518–519, 530`. See also
alcohol misuse
Attitudes and Beliefs About Caregiving, 474
attorney-in-fact. See advance directives;
durable power of attorney for health
care; surrogates
atypical presentation of disease, 35–36, 42
AUDIT. See Alcohol Use Disorders
Identication Test
autonomy, decision making, 563
AWS. See alcohol withdrawal syndrome
Baltimore Longitudinal Study of Aging, 23
baroreceptor function, 24–25
battery, 581. See also elder mistreatment
Beers criteria, 331–332
behavior, fall prevention, 270–271
Behavioural Risk Factor Surveillance System
(BRFSS), 75
benet-burden analysis, 586–587
benzodiazepines (BZDs), 170, 336, 338–339
beta-blockers, 643
Better Outcomes for Older Adults through
Safer Transitions (BOOST), 676
Betty Ford Institute, 520
BIA. See bioelectrical impedance analysis
binge drinking, 518–519. See also alcohol
misuse
bioelectrical impedance analysis (BIA), 424
biologic therapies, depression, 146
bladder diary, 368
bladder training, 372–374
blood pressure (BP), 24–25, 635, 645
bone loss, 32
BOOST. See Better Outcomes for Older
Adults through Safer Transitions
BP. See blood pressure
BPHQ-9. See Brief Patient Health
Questionnaire-9
Braden scale, 303, 314
brand name drugs, ADEs, 344–345
BRFSS. See Behavioural Risk Factor
Surveillance System
Brief Patient Health Questionnaire-9
(BPHQ-9), 143
Brown Bag Method, 329
Brown University Center for Gerontology
and Healthcare Research, 477
buprenorphine, 526, 535
bupropion, 526
burning mouth syndrome, 61
BZDs. See benzodiazepines
C. dicile. See Clostridium dicile
CABSI. See catheter-associated bloodstream
infection
call bells, 371
CAM. See Confusion Assessment Method
cancer
case study, 665
CGA, 659–660
CGA, developing, 660–662
comorbid conditions, 659
health history, 661
medical emergencies, 662–664
overview, 658–659
pain management, 252
physical examination, 661–662
summary, 665
capacity. See also decision making
absence of, 567–568
ADs, 585–586
assessing, 565–566
dened, 563, 573
importance of, 567
NYHA classication, 632
cardiotonics, 340–341
cardiovascular disease (CVD), 629. See also
heart failure
Cardiovascular Health Study, 75
cardiovascular system. See also heart failure
age-related changes, 24–25
age-related changes, protocol, 37–38
HF assessment, 637
ICU care, 606, 618–619
care quality. See Quality Assessment
Care Transitions Intervention Model,
686–689
caregiver role transitions, acquisitions. See
also family caregiving
dened, 471, 489
unhealthy, 472–475
unhealthy, interventions, 479–482
caregivers, caregiving. See also nurses
assessment of, 472
characteristics, 483
context of, 475–476
dementia, 169, 178
neglect, 546–547, 551, 556
personal health status, 477–478
706 Index
preparedness, 476
rewards of, 478
self-care, 478
caregiving, families. See family caregiving
case studies
ADEs, 345–347
ADs, 590–591
age-related health changes, 36
cancer, 665
CAUTI, 399–400
cognitive function assessment, 127–128
critical illness, care, 611–613
delirium, 190–192
dementia, 174–175
depression, 149–150
EM, 554
excessive sleepiness, 81–83
falls, fall prevention, 286–287
family caregiving, 487–488
functional decline, 112–113
health care decision making, 570–571
HF, 645–646
mealtime diculties, 460–461
nutrition, 443
oral health care, 412–413
oral hydration, 429
pain management, 257
physical function assessment, 96
pressure ulcers, 308–309
sensory changes, 67–68
sexuality, 509
skin tears, 310
substance misuse, abuse, 527–528
transitional care, 690–691
UI, 375
cataracts, 55
catheter-associated bloodstream infection
(CABSI), 207, 210–211
catheter-associated urinary tract infection
(CAUTI)
assessment, 392–393
background, 389–391
case studies, 399–400
interventions, care strategies, 393–399
overview, 388–389
pathogenesis, 390–391
protocol for, 401–404
summary, 400
surveillance, education, 397
CAUTI. See catheter-associated urinary tract
infection
CBT. See cognitive behavioral therapies
CDC. See Centers for Disease Control and
Prevention
CDT. See Clock Drawing Test
Center for Epidemiologic Studies Depression
Scale (CES-D), 143
Centers for Disease Control and Prevention
(CDC)
cancer statistics, 658
CAUTI prevention, 389, 402
HAI, 206
NNIS, 208
Centers for Medicare & Medicaid Services
(CMS)
Beers criteria, 331
P4P initiatives, 15
pressure ulcer policy, 302
quality reporting, 14
restraint use, 229–231, 238, 239
UTI treatment, 388
central auditory processing disorder, 59
CES-D. See Center for Epidemiologic
Studies Depression Scale
CGA. See comprehensive geriatric assessment
chemotherapy, 662–664. See also cancer
chlorhexidine, 411
chronic dehydration, 421. See also oral
hydration
CINAHL (Cumulative Index to Nursing and
Allied Health Literature), 5–6
clearance/elimination of medication, 331
clinical outcomes, Quality Assessment,
14 –15
clinical practice guidelines (CPGs)
AGREE instrument, 2–6
evidence levels, 7–8
introduction to, 1
search steps, 8
summary of, 8–9
terms, 1–2
Clock Drawing Test (CDT), 167, 177
Clostridium dicile (C. dicile), 208
CMS. See Centers for Medicare & Medicaid
Services
cochlear implants, 60
Cochrane Database, Review
Cochrane Handbook for Systematic Reviews
of Interventions, 5–6
delirium, 189
nutrition, pressure ulcers, 306
Cockcroft-Gault Formula, 39, 327, 329, 331,
610
caregivers, caregiving (cont.)
Index 707
cognition
ADEs, 344
age-related changes, 33–34
age-related changes, protocol, 41–42
fall prevention, 270–271
impairments, eating, 457
sexuality, 503–504, 508–509
support for, acute care setting, 108–109
cognition, functional assessment
background, 123
capacity, 95, 565–566
case study, 127–128
cautions for, 126–127
delirium, 123–124
dementia, 123–124, 166–167
depression, 123–124
how to use, 123–125
impairment, 601–603
interventions, care strategies, 125–127
overview of, 122
protocol for, 129–131
reasons for, 123
summary, 128
when to use, 125–126
cognitive behavioral therapies (CBT), 147
comfort care, fall prevention, 281
community-based transitions, 688
competence, 565, 573, 585. See also capacity;
decision making
comprehensive geriatric assessment (CGA),
659–662, 670
computerized physician order entry (CPOE),
217
condom catheters, 395
conductive hearing loss, 58
Confusion Assessment Method (CAM), 188
consciousness, fall prevention, 269–271
consent, 564, 573. See also advance
directives; decision making
consultation service, 673
contrast sensitivity, 53–54
Cornell Scale for Depression in Dementia
(CSDD), 143
counseling, substance abuse, 527
CPGs. See clinical practice guidelines
CPOE. See computerized physician order entry
creatinine clearance, 327, 329
Crede’s maneuvers, 374
Creutzfeld-Jakob disease, 164. See also
dementia
Criteria for Potentially Inappropriate
Medication Use in Older Adults, 327
critical care settings, restraints. See restraints
critical illness, care
age-associated changes, 602–603
background, 601
baseline health status assessment, 601–604
case study, 611–613
high-risk medications, 609
ICU stay assessment, interventions,
604 – 611
overview, 600–601
protocol for, 614–621
summary, 613
critical thinking, fall prevention, 270
critically ill older adult, 614
Crossing the Quality Chasm: A New Health
System for the 21st Century (IOM), 684
CSDD. See Cornell Scale for Depression in
Dementia
CSI. See Modied Caregiver Strain Index
culprit drugs, fall risk, 277–278
culture, religion
ACP, 587–588
health care decision making, 563, 568–569
mealtimes, 456
Cumulative Index to Nursing and Allied
Health Literature (CINAHL), 5–6
CVD. See cardiovascular disease
DAFA. See Direct Assessment of Functional
Abilities
decision making
aids, 565
authority, 564–565
background, 563–565
case study, 570–571
context of, 568
interventions, care strategies, 569
overview, 562
problem assessment, 565–569
protocol for, 572–575
quality-of-life considerations, 569
summary, 572
decisional capacity. See capacity
dehydration. See also oral hydration
dened, 420–421, 430
indicators of, 424–425
mealtimes, 462
prevalence of, 419–420
Dehydration Risk Appraisal Checklist,
425–426
delegated autonomy, 563
708 Index
delirium
assessment, 188–189
background, 186–188
case study, 190–192
cognitive function assessment, 123–124
dened, 129, 186–187, 193–196
etiology, epidemiology, 187–188
interventions, care strategies, 189–190
overview, 186
protocol for, 193–196
summary, 193
dementia
background, 164–165
behavioral assessment, 167–168
capacity, 566
caregiver assessment, 169
caregiver education, 172
case study, 174–175
cognitive assessment, 123–124, 166–167
dened, 129
diagnostics, 168
EM, 548
end-of-life care, 173
history taking, 165
interventions, care strategies, 169–173
overview, 163
pain reporting, 249
pharmacological interventions, 169–171
protocol for, 176–179
summary, 175
dementia with Lewy bodies (DLB), 164–165
dentures, 410
depression
assessment, 143–144
background, 136–140
caregiving, 472, 474
case study, 149–150
cause, risk factors, 140–143
cognitive function assessment, 123–124
course of, 138
dened, 129, 136
interventions, care strategies, 144–147
major, 136–147
medical vs. iatrogenic causes, 144–145
minor, 137
minorities, 141–143
misunderstandings of, 139
overview, 135–136
physical illness associations, 141–142
protocol for, 151–154
psychosocial approaches, 147–149
screening tools, 143
severity of, 138–139
sexuality, 503
summary of, 150
treatment ecacy, 140
detached retina, 55
dexmedetomidine, 189
diabetes mellitus (DM)
care improvement, 341
diabetic neuropathy, 62
diabetic retinopathy, 55
ETDRS, 53
HF, 630
sexuality, 503
Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV-TR)
major depression, 136–137, 144
substance misuse, 518, 519
diagnostic procedures, iatrogenesis, 204
diet. See mealtime diculties
digoxin, 340–341, 643
dimethyl sulfoxide cream, 304–305
Direct Assessment of Functional Abilities
(DAFA), 92
discharge planning, 672. See also transitional
care
disease, atypical presentation, 35–36, 42
diuretics, 269, 372, 642–643
DLB. See dementia with Lewy bodies
DM. See diabetes mellitus
DNR. See do-not-resuscitate
donepezil hydrochloride (Aricept), 169
do-not-resuscitate (DNR), 584–585
DPAHC. See durable power of attorney for
health care
drug metabolism, 331
drug misuse. See also substance misuse, abuse
addiction, 519
dened, 520
illicit drugs, 519–520
opioid abuse, 526, 535
psychoactive drugs, 520–521
recovery, 520
screening tools, 523
drug-disease interactions, 327, 349. See also
adverse drug events
drug-drug interactions, 327–328, 333–334,
349. See also adverse drug events
drugs. See also adverse drug events;
medication(s); pharmacological
therapies
adjuvant, 253–254
aging changes, 329–331
Index 709
to avoid in older adults, 254
causing depression, 144–145
dementia, 169–171
distribution, 331
fall risk, 277–278
nutrition, 445
Drugs Regimen Unassisted Grading Scale
(DRUGS) Tool, 329
DSM-IV-TR. See Diagnostic and Statistical
Manual of Mental Disorders, fourth
edition
durable power of attorney for health care
(DPAHC), 581
dwell time, 392
dysgeusias. See taste
dysphagia, 31, 462
EAI. See Elder Assessment Instrument
early mobility, 283–284
Early Treatment Diabetic Retinopathy Study
(ETDRS), 53
eating, 462. See also mealtime diculties;
nutrition
eating behavior, 455
EBP. See evidence-based practice
ECT. See electroconvulsive therapy
edema, 638
Edinburgh Feeding in Dementia Scale
(EdFED), 455
education
acute care models, 671
caregiving, 473
dementia, 172
family caregiving, 478
health literacy, ADEs, 344
sexual, 506
Elder Assessment Instrument (EAI), 551
elder mistreatment (EM)
assessment, 548–552
case study, 554
dened, types, 546–547, 555–556
interventions, care strategies, 552–553
overview, 544–545
perpetrator characteristics, 557
problem background, 545–548
protocol for, 555–558
summary, 555
victim characteristics, 556
Elder Mistreatment Assessment, 477,
548–552
elderly. See aging, older adults
electroconvulsive therapy (ECT), 147
electronic medical record (EMR), 217, 676
elimination/clearance of medication, 331
ELNEC. See End-of-Life Nursing Education
Consortium
EM. See elder mistreatment
emotional/psychological abuse, 546, 550,
556
EMR. See electronic medical record
end-of-life care. See advance directives
End-of-Life Nursing Education Consortium
(ELNEC), 213
environment for eating, 459, 463
EPESE. See Established Populations for
Epidemiologic Studies of the
Elderly
Epworth Sleepiness Scale (ESS), 78, 84
equianalgesia, 253–254
erectile agents, 507
ESS. See Epworth Sleepiness Scale
Established Populations for Epidemiologic
Studies of the Elderly (EPESE), 419
established UI, 365. See also urinary
incontinence
ETDRS. See Early Treatment Diabetic
Retinopathy Study
ethical issues, 232, 563. See also decision
making
ethnicity. See race, ethnicity
evidence process, 3–5
evidence-based practice (EBP)
acute care models, 672
dened, 1–2
evidence levels, 7–8
evidence process search, 3–5
excessive sleepiness
aging, physiological changes, 75–76
assessment, 78–80
background, 75
case study, 81–83
consequences of, 75
dened, 83–84
interventions, care strategies, 81
overview of, 74–75
primary causes, 76–77
protocol for, 83–86
secondary causes, 77–78
sleep history, 78–79
sleep hygiene measures, 80
summary, 83
exchange theory, 548, 556
Exelon. See rivastigmine tartrate
710 Index
exercise
depression treatment, 147
functional decline, acute care setting, 109
pelvic oors, 372–373
eyes, 52–55
Faces Pain Scale (FPS), 249
Fagerström Test for Nicotine Dependence,
523, 531
falls, fall prevention
assessment, 269–283
assessment tools, 76, 274
background, 269
case study, 286–287
CGA, 661
culprit drugs, 277–278
fall type identication, 273–277
interventions for, 283–286
intrinsic, extrinsic risks, 273–274, 276
medical events, diseases associated with, 275
overview, 268–269
PFA, 278–279
program, 282–283
protocol for, 288–293
restraint alternatives, 235–237
summary, 288
family caregiving
activities, 472
assessment, 475–478
case study, 487–488
denitions, 471–472, 489
interventions, care strategies, 478–487
nursing care strategies, 486–487
overview, 469–471
prevalence of, 470
protocol for, 489–492
summary, 488
unhealthy transitions, 470–475, 479–482
family consent laws, 581
family goals, acute care models, 671–672
Family Preferences Index, 486, 492
FAQ. See Functional Activities Questionnaire
FDA. See Food and Drug Administration
feeding, 462. See also mealtime diculties;
nutrition
feeding behavior, 455
fever, atypical symptoms in aging, 35
FFC. See function-focused care
nancial abuse/exploitation, 546, 551, 556
Five Wishes document, 582–583
uid intake, 425–428. See also oral hydration
uid overload. See heart failure
Foley catheter, 389. See also indwelling
urinary catheter
Foley, Frederick, 389
Folstein’s Mini-Mental State Examination
(MMSE), 123–125, 129–130
Food and Drug Administration (FDA)
antipsychotics, 339–340
OTC regulation, 342
restraint device hazards, 230
FPS. See Faces Pain Scale
fractures, pressure ulcers, 301
fractures, risk diagnosis, 270–272
frail, dened, 662
framing, 564
Framingham Heart Study, 580
frontotemporal dementia, 164. See also
dementia
Functional Activities Questionnaire (FAQ),
166, 177
functional capacity. See capacity
functional decline. See also physical function
assessment
assessment, 90–91, 95, 106–108
background, 105–106
case study, 112–113
critical care initiatives, 111
FFC, 111–112
interventions, care strategies, 108–112
overview, 104–105
patient risk factors, 105–106
protocol for, 113–117
summary of, 113
Functional Independence Measure, 604
functional mobility programs, 110
functional UI, 367, 371–374. See also urinary
incontinence
function-focused care (FFC), 111–117
fundus exam, 52–53
galantamine hydrobromide (Reminyl), 169
GAPNs. See geriatric advanced practice
nurses
gastrointestinal system
age-related changes, 30–31
age-related changes, protocol, 40
ICU care, 608–609, 619–620
gay, lesbian, bisexual, transgender (GLBT),
501
G-CSFs. See granulocyte colony-stimulating
factors
Index 711
GDS. See Geriatric Depression Scale
GEM units. See geriatric evaluation and
management units
gender, caregiving, 472
generic drugs, ADEs, 344–345
genitourinary system
age-related changes, 27–29
age-related changes, protocol, 39–40
ICU care, 610, 620
geriatric acute care models. See acute care
models
geriatric advanced practice nurses (GAPNs),
673–674
Geriatric Depression Scale (GDS), 143
CGA, 660
dementia, 168, 177
EM, 549, 552
geriatric evaluation and management (GEM)
units, 673
geriatric syndromes, 211–213, 670. See also
acute care models
Get Up and Go test, 94
glaucoma, 55
GLBT. See gay, lesbian, bisexual, transgender
Goldman VI4e kinetic perimetry visual eld
testing, 54
government initiatives, pressure ulcers, 302
granulocyte colony-stimulating factors
(G-CSFs), 664
guideline, dened, 1–2
Haldol, 170
handheld audioscope, 58
HAP. See hospital-acquired pneumonia
Hartford Center for Geriatric Nursing, 211,
671
HBBS. See healthy bladder behavior skills
HCP. See durable power of attorney for
health care
HCUP. See Healthcare Cost and Utilization
Project
head trauma, 272–273
health care, decision making. See decision
making
health care proxy. See advance directives;
surrogates
health care quality, dened, 13–14
health changes, age-related. See age-related
health changes
Health Insurance Portability and Account-
ability Act of 1996 (HIPAA), 568
health literacy, ADEs, 344
Healthcare Cost and Utilization Project
(HCUP), 202, 302
healthy bladder behavior skills (HBBS),
371–373
Healthy People 2020
food, nutrition, 454
iatrogenesis, 214
sensory changes, 48–49
hearing
aids, 59–60
assessment, 57
change implications, 59–60
changes, normal/common, 49, 58–59
intervention, care strategies, 57–58
nursing actions, referrals, 65
Hearing Handicap Inventory for the Elderly-
Screen (HHIE-S), 57
heart failure (HF)
assessment, 632–639
background, 629–631
case study, 645–646
health history, 632–635
interventions, care strategies, 639–645
laboratory, diagnostic studies, 638–639
overview, 628–629
pathophysiology, 630–631
physical assessment, 635–638
protocol for, 647–650
risk factors, 629–630
summary, 646
hedges, dened, 6
HELP. See Hospital Elder Life Program
hematopoietic system, 610, 620
hepatojugular reux, 638
herbal remedies
drug interactions, 334–335
medical history, 343
warfarin, 337
heroin dependence, 535
HF. See heart failure
HHIE-S. See Hearing Handicap Inventory
for the Elderly-Screen
high-risk falls, 281. See also falls, fall
prevention
high-risk medications, 336–342, 609
hip fractures, pressure ulcers, 301
HIPA A. See Health Insurance Portability
and Accountability Act of 1996
HIV, sexuality, 504, 506
Hospital Elder Life Program (HELP), 675
Hospital Quality Initiative, 15
712 Index
hospital-acquired infection (HAI)
CAUTIs, 388–389
iatrogenesis, 206–208
nursing strategies for, 208–210
hospital-acquired pneumonia (HAP), 207
hospitalization, HF. See heart failure
hospitals, hospitalization. See also acute care
settings, functional decline
EM, 553
fall, injury prevention, 280–285
functional decline, 106–107
hospital-to-home transition, 688
hypo’s of, 205
malnutrition, 440–441
meals, 454
pressure ulcer incidence, 301
sleep disturbances, 78
substance misuse, 524
UI, 366
hospitals, restraints. See restraints
Housing Enabler instrument, 108
How to Try is series, 211
HS-EAST. See Hwalek-Sengstock Elder
Abuse Screening Test
Humphrey Visual Field Test, 54
Hwalek-Sengstock Elder Abuse Screening
Test (HS-EAST), 552
hydration. See oral hydration
hydration habits, 420, 423
hypercalcemia, 663
hyperkalemia, 663
hyperphosphatemia, 663
hypersexual behavior, 509
hypertension (HTN)
HF, 629–631, 636, 640
hypertensive retinopathy, 55
medications, 337–338
hyperthyroidism, 663
hyperuricemia, 663–664
hypoglycemic agents, 341
hypo’s of hospitalization, 205
hyposmia, 61
IADLs. See independent activities of daily
living; instrumental activities of daily
living
iatrogenesis
ADEs, 203–204, 325–326
assessment, 203–208
background, 201–203
dened, 200
endogenous, exogenous risk factors,
202–203
geriatric syndromes, 211–213
HAI, 206–208
interventions, care strategies, 208–211
knowledge, attitudes, beliefs, 213–214
national, organization priorities, 214–218
overview, 200–201
summary, 218
iatrogenic disturbance pain (IDP), 212
ICUs. See intensive care units
IDP. See iatrogenic disturbance pain
IHI. See Institute of Healthcare
Improvement
illicit drugs. See drug misuse
illness, critical. See critical illness, care
immediate postfall assessment, 278–280. See
also falls, fall prevention
immune system
age-related changes, 34–35
age-related changes, protocol, 42
ICU care, 610, 620
immunizations. See vaccinations
immunosenescence, 34
income, caregiving, 473
incompetence, dened, 573
independent activities of daily living
(IADLs), 327. See also activities of
daily living
Individualized Sensory Enhancement of the
Elderly (I-SEE), 63
indwelling urinary catheter (IUC). See also
catheter-associated urinary tract
infection
avoidance, 394–395
indications for, 392–393
removal, 394, 396–397
selection, insertion, care, 395–396
use of, 388–390
infection. See also catheter-associated
bloodstream infection; catheter-
associated urinary tract infection;
hospital-acquired infection; surgical
site infection; urinary tract infection
minimizing, quality improvement
initiatives, 210–211
oral health care, 410
respiratory concerns, 606
Informant Questionnaire on Cognitive Decline
in the Elderly (IQCDE), 126, 130
informed consent, 562, 564. See also decision
making
Index 713
injury prevention, 280–285
injury risk assessment, 270–272
insomnia, 74, 76–77. See also excessive
sleepiness
Institute of Healthcare Improvement (IHI),
208–209, 215, 302
Institute of Medicine (IOM)
Crossing the Quality Chasm: A New Health
System for the 21st Century, 684
To Err is Human: Building a Safer Health
System, 201, 211, 214
excessive sleepiness, 75
medication error statistics, 326
nurses’ hours, 216
quality of care denition, 13–14
instructional, medical directives, 582
instrumental activities of daily living
(IADLs), 92–93. See also activities of
daily living
intensive care units (ICUs). See also critical
illness, care
age-related health changes, 602–603
assessment, interventions, 604–611
delirium, 187
pressure ulcer risk, 302
restraint use, 231, 234–235
statistics, 600
intentional falls, 275. See also falls, fall
prevention
interdisciplinary teams. See also nurses
acute care models, 672
CAUTI interventions, 398
depression, 148
EM education, 553
HF, 640
sexual health, 508–509
interim postfall assessment, 279–280. See
also falls, fall prevention
IOM. See Institute of Medicine
IQCDE. See Informant Questionnaire on
Cognitive Decline in the Elderly
I-SEE. See Individualized Sensory
Enhancement of the Elderly
e Joint Commission (TJC)
ACP communication, 590
Beers criteria, 332
communicating drug therapies, 336
communication breakdowns, 216
discharge, 685
HAI reduction, 208
iatrogenesis, 206
pain, 247
restraint use, 230–231, 238
jugular venous distention (JVD), 637
KAT. See Khavari Alcohol Test
Katz Index of Independence in Activities of
Daily Living (Katz ADL index)
EM, 549, 552
function assessment, 92, 604
Keeping Patients Safe: Transforming the Work
Environment of Nurses (AHRQ), 216
Khavari Alcohol Test (KAT), 523
kwashiorkor, 440
left ventricular assist device (LVAD, VAD), 641
legal issues, capacity vs. competence, 565
legal issues, restraint use, 230–231
lemon-glycerin swabs, 411
liability, restraint use, 230
life-sustaining treatment (LST)
ADs, 581–584
cultural preferences, 587–588
prevalence of, 580
Lighthouse for the Blind Near Vision
Screener, 53
limits, dened, 6
literature searches. See also AGREE
instrument
broad topics, 5–6
evidence process, 3–5
limits, hedges, publication types, 6
precision, recall, 6
steps, 8
lithium, 338–339
living will (LW), 581–583
longitudinal postfall assessment, 280. See also
falls, fall prevention
longitudinal studies, 23
LST. See life-sustaining treatment
LVAD. See left ventricular assist device
LW. See living will
macular degeneration, 55
magnet facilities, restraint use, 230
major depression, 136–147. See also
depression
Male Urinary Distress Inventory (MUDI), 367
malnutrition. See nutrition
714 Index
marasmus, 440
marijuana use, 519, 534. See also drug misuse
masturbation, 504
MDS. See Minimum Data Set
meal behavior, 455
meal, dened, 454
mealtime diculties. See also nutrition
assessment, 455–456
background, 453–455
case study, 460–461
feeding assistance, 458–459
interventions, care strategies, 457–459
overview, 453
protocol for, 461–464
summary, 461
medical devices, restraints, 237–238, 240
Medicare Care Management Performance
Demonstration, 15
Medicare Health Care Quality
Demonstration, 15
medication adherence, 326–327, 335, 349
medication error, 326
medication reconciliation (MR), 335–336,
343, 349
medication(s). See also adverse drug events;
drugs; pharmacological therapies
adherence, 326–327, 335, 349
error, 326
expenses, 345
fall risk, 277–278
high-risk, 336–342
high-risk, ICU use, 609
history questions, 329–330, 342
MR, 335–336, 343, 349
oral health care, 410
sexuality, 503, 507, 509
transitional care errors, 685
UI, 269
MEDLINE, 5
memantine (Namenda), 169–170
Ménière’s disease, 59
mentally ill patients, dehydration, 422
e Merck Manual of Geriatrics, 331
methadone, 526, 535
MID (multi-infarct dementia). See vascular
dementia
mild dehydration, 421. See also oral
hydration
milrinone, 643
Mini-Cognitive (Mini-Cog)
ADE assessment, 327
assessing cognitive function, 125, 129–130
CGA, 660
dementia, 167, 177
Mini-Mental State Examination (MMSE)
ADE assessment, 327
capacity assessing, 566, 586
cognitive function assessment, 123–125,
129–130
dementia, 166, 177
EM, 549
Minimum Data Set (MDS), 455–456
Mini-Nutritional Assessment tool (MNA),
440–441, 445, 455
minor depression, 137. See also depression
minorities. See race, ethnicity
mixed marasmus-kwashiorkor, 440
mixed UI, 366. See also urinary incontinence
MMSE. See Mini-Mental State Examination
MNA. See Mini-Nutritional Assessment tool
Modied Alzheimer’s Disease Cooperative
Study--Activities of Daily Living
Inventory (ADCS-ADL), 166
Modied Caregiver Strain Index (CSI), 169,
478, 552
monitoring cognitive functioning, 123
mood-stabilizing compounds. See
psychoactive drugs
Morse Falls Scale, 274–275
MR. See medication reconciliation
MRSA. See Staphylococcus aureus
mucosal diseases, 410–411
MUDI. See Male Urinary Distress Inventory
multi-infarct dementia (MID). See vascular
dementia
multi-setting transitions, 688
musculoskeletal system, 31–33, 41
Mutuality scale, 476–477
naltrexone, 525, 535
Namenda. See memantine
National Cancer Institute (NCI), 658
National Center for Injury Prevention and
Control (NCIPC), 269
National Center on Elder Abuse (NCEA), 545
National Database of Nursing Quality
Indicators, 18
National Elder Abuse Incidence Study, 545
National Eye Institute (NEI), 54
National Health and Nutrition Examination
Survey (NHANES)
excessive sleepiness, 75
hearing impairment statistics, 57
Index 715
oral hydration, 419
peripheral sensation statistics, 62
vision statistics, 51
National Health Services, 2
National Institute of Alcohol Abuse and
Alcoholism (NIAAA), 517, 523
National Nosocomial Infections Surveillance
(NNIS), 208
National Pressure Ulcer Advisory Panel
(NPUAP), 298, 306
National Quality Forum, 230
National Research Council (NRC), 546
Natural Death Act, 584
NCEA. See National Center on Elder Abuse
NCI. See National Cancer Institute
NCIPC. See National Center for Injury
Prevention and Control
near vision, 53
Needs-Driven Dementia-Compromised
Behavior framework, 455
neglect, 546–547, 551. See also elder
mistreatment
NEI. See National Eye Institute
nervous system, 33–34, 41–42
neurological system, 33–34, 607, 619
neuropathic pain, 258. See also pain, pain
management
Neuropsychiatric Inventory (NPI), 168
neutropenic fever, 664
New York Heart Association (NYHA), 632
NHANES. See National Health and
Nutrition Examination Survey
NIAAA. See National Institute of Alcohol
Abuse and Alcoholism
NICHE. See Nurses Improving Care for
Healthsystem Elders
nicotine dependence, 521, 526. See also
substance misuse, abuse
NNIS. See National Nosocomial Infections
Surveillance
NOC WATCH, 285
nociceptive pain, 258. See also pain, pain
management
nocturnal myoclonus. See periodic leg
movement disorder
nonopioid medications, 253
nonpharmacological therapies, 254–256
nonsteroidal anti-inammatory drugs
(NSAIDs), 253
Norton scale, 303
NOSCA. See Nurses’ Observation Scale for
Cognitive Abilities
NPI. See Neuropsychiatric Inventory
NPUAP. See National Pressure Ulcer
Advisory Panel
NRC. See National Research Council
NRS. See numerical rating scale
NSAIDs. See nonsteroidal anti-inammatory
drugs
numerical rating scale (NRS), 249
nurses. See also caregivers, caregiving;
iatrogenesis; interdisciplinary teams
ADs, 588–589
assessing substance problems, 521–523
EM recognition, 544–545
fall prevention, 281, 285–286
family caregiving, 469–470, 486–487
feeding assistance, 458–459
geriatric syndrome management,
211–213
iatrogenesis prevention, 215–216
knowledge, attitudes, beliefs, 213–214
oral health care, 412
sexuality views, 501
UI interventions, 374
Nurses Improving Care for Healthsystem
Elders (NICHE), 12, 674
Nurses’ Observation Scale for Cognitive
Abilities (NOSCA), 126
Nursing: Scope and Standards of Practice
(American Nurses Association), 2
nutrition. See also mealtime diculties
assessment, 441–442
background, 440–441
case study, 443
interventions, care strategies, 442
mealtimes, 457
overview, 439–440
pressure ulcers, 306, 313–314
protocol for, 444–449
summary, 443
NYHA. See New York Heart Association
obstructive sleep apnea (OSA), 74, 76
OH AT. See Oral Health Assessment Tool
older adults. See aging, older adults
olfactory sense. See smell
opioids
abuse, 535
pain management, 253
treatment, 526
oral advance directives, 585
Oral Health Assessment Tool (OHAT), 411
716 Index
oral health care
assessment tools, 411
background, 409–410
case study, 412–413
interventions, care strategies, 411–412
overview, 409
physical assessment, 410–411
protocol for, 414–415
summary, 413
oral hydration
assessment, 421–425
background, 420
case study, 429
dehydration, underhydration, 420–421
evaluation, 428
hydration habits, 420, 423
interventions, care strategies, 425–428
management, 425–428
overview, 419–420
protocol for, 430–433
risk identication, 421–423
status indications, 423–425
summary, 430
oral intake, 425–428. See also oral hydration
organ donation, 582
organizations, iatrogenesis prevention, 215–216
oropharyngeal system, 30–31, 40
orthopnea, 633
orthostatic hypotension, 338
OSA. See obstructive sleep apnea
osteoporosis, 31–32, 271–272
OTCs. See over-the-counter drugs
overow UI, 366. See also urinary incontinence
over-the-counter drugs (OTCs)
ADEs, 324
interactions, 334–335
medication history, 343
P4P/VBP. See pay-for-performance/value-
based purchasing
PAD. See psychiatric advance directive
pain, pain management
assessment, 248–250
background, 246–247
case study, 257
dened, 248, 258
iatrogenesis, 212–213
ICU care, 607, 619
improving, 256
interventions, care strategies, 250–256
nonpharmacological, 254–256
observed indicators, 249–250
overview, 246
patient knowledge, 214
pharmacological, 251–254
protocol for, 258–263
summary, 257
Parkinson’s disease (PDD), 164. See also
dementia
parosmia, 61
Patient Protection and Aordable Care Act
(PPACA), 682, 689
Patient Self-Determination Act (PSDA), 580
patient-initiated device removal, 234, 240
patients, decision making. See decision
making
patients, harm. See iatrogenesis
Patients’ Rights Condition of Participation,
230
pay-for-performance/value-based purchasing
(P4P/VBP), 11, 14
Payne-Martin classication system, 307
PDD. See Parkinson’s disease
P-E Fit. See person-environment Fit
Pelli-Robson Contrast Sensitivity, 54
pelvic oor muscle exercises (PFMEs),
372–373
Performance Improvement. See also Quality
Assessment
background, 11–12
measuring performance, 17–20
objectives, 11
program implementation, 20–21
periodic leg movement disorder (PLMD), 77
peripheral edema, 638
peripheral neuropathy, 62
peripheral sensation
assessment, interventions, care strategies,
62–63
changes, common/normal, 51, 62
I-SEE, 63
nursing actions, referrals, 65–66
Permission, Limited Information, Specic
Suggestion, Intensive erapy
(PLISSIT), 504, 511
persistent pain, 246–247, 258. See also pain,
pain management
person-environment (P-E) Fit, 108
PFA. See postfall assessment
PFMEs. See pelvic oor muscle exercises
phantom limb pain, 62
phantosmia, 61
pharmacodynamics, 329, 349
Index 717
pharmacokinetics, 329, 349
pharmacological therapies. See also drugs;
medication(s)
dementia, 169–170
pain management, 251–254
substance misuse, 525–526
physical abuse, 546, 550, 556. See also elder
mistreatment
physical function assessment. See also
functional decline
background, problem, 90
case study, 96
as clinical measure, 105
dementia, 165–166, 168
direct patient assessment, 93
information use, 95
instruments for, 91–93
interventions, care strategies, 95
overview, 89
problem assessment, 90–91
protocol for, 97–100
specic assessments, 93–95
physical pain relief modalities, 255
physical therapy, 109
Physician Group Practice Demonstration, 15
physician order for life-sustaining treatment
(POLST), 582
PICO, 4
pin-hole test, 53
Pittsburgh Sleep Quality Index (PSQI), 79, 84
plaque retention, 409–410. See also oral
health care
PLISSIT. See Permission, Limited
Information, Specic Suggestion,
Intensive erapy
PLMD. See periodic leg movement disorder
PLST. See Progressively Lowered Stress
reshold
political economy theory, 548, 556
POLST. See physician order for life-
sustaining treatment
polypharmacy, 332
polysubstance abuse, 521. See also substance
misuse, abuse
positive urine culture, 390
postfall assessment (PFA), 276–280
postvoid residual (PVR), 370
PPACA. See Patient Protection and
Aordable Care Act
Premier Hospital Quality Incentive
Demonstration, 15
Preoperative Fasting, 422
presbycusis, 49
presbyopia, 49
pressure ulcers
acute care stages, 300
assessment, 302–303
background, 298–302
case study, 308–309
dened, classication, 299–300
device related, 300–301
interventions, care strategies, 304–306
overview, 298
prevention protocol, 311–316
risk factors, 301
summary, 310–311
progressive dementia, 164. See also dementia
Progressively Lowered Stress reshold
(PLST), 172–173
proprioception, 63
protocol, dened, 1–2
proxies. See advance directives; surrogates
PSDA. See Patient Self-Determination Act
pseudoaddiction, 212
pseudohypertension, 636
PSQI. See Pittsburgh Sleep Quality Index
psychiatric advance directive (PAD), 584
psychoactive drugs, 338–340, 520–521. See
also drug misuse; drugs; medication(s)
psychoeducation interventions, 478
psychological pain relief modalities, 255
psychopathology of the abuser, 547, 556
psychosocial approaches, depression, 147–149
psychosocial factors, critical illness, 603
psychotherapy, 479, 527
psychotropic medications, 170. See also
drugs; medication(s)
publicly reported quality measures, 14–15
publishing wedge, 7
pulmonary system
age-related changes, 25–27
age-related changes, protocol, 38
HF assessment, 637
ICU care, 604–606, 618
pure tone audiometry, 58
PVR. See postvoid residual
Quality Assessment
addressing challenges, 16–17
background, 11–12
clinical outcomes, 14–15
interventions, care strategies, 15–20
measuring performance, 15–20
718 Index
objectives, 11
program implementation, 20–21
quality care dened, 13–14
Quantity Frequency (QF) Index, 522, 531
race, ethnicity
caregiving, 473
decision making, 568
dehydration, 421
depression, 141–143
pressure ulcers, 303–304
vision, 51
RAD. See research advance directive
RAND report, fall prevention, 268
randomized controlled trials (RCTs),
684–689. See also transitional care
recommendation, dened, 1–2
recovery, 520, 530
refusal, 564
RefWorks, 6, 8
regulations, pressure ulcers, 302
regulations, restraint use, 230
relapse, 519–520, 530
relationship, caregiving, 473–474, 476–477
reliability, measuring performance, 18–19
religion. See culture, religion
Reminyl. See galantamine hydrobromide
renal system, 27–29, 39–40
repeat back, 564
research advance directive (RAD), 583
residential treatment, substance misuse, 525
Resources for Enhancing Alzheimer’s
Caregiver Health (REACH), 472,
484–485
respiratory function. See pulmonary system
respite care, family caregiving, 479
restless leg syndrome (RLS), 74, 77
restorative care. See function-focused care
restraints
administrative responsibilities, 232–233
alternatives to, 235–238
background, legal issues, 230–231
ethical issues, 232
fall risk, 277
iatrogenesis, 204–205
interventions, care strategies, 233–235
overview, 229–230
protocol for use, 239–242
summary, 238
use prevalence, rationale, 231–232
ringing in the ear. See tinnitus
Rinne test, 58
risk, vulnerability model, 547, 556
rivastigmine tartrate (Exelon), 169
RLS. See restless leg syndrome
Robert Wood Johnson Foundation, 215
role transitions, 471–472. See also family
caregiving
Rosenbaum Pocket Eye Screener, 53
safety huddles, 281
safety rounds, fall prevention, 281
salt, HF, 634
sarcopenia
age-related health changes, 32
nutrition, 440
protocol for, 41
SATs. See spontaneous awakening trials
SBIRT. See screening, brief intervention,
referral to treatment
SBTs. See spontaneous breathing trials
SCREEN II, 455
screening, brief intervention, referral to
treatment (SBIRT), 522
screening cognitive functioning, 123
search strategies. See literature searches
SEER. See Surveillance, Epidemiology, End
Results Program
selective serotonin reuptake inhibitors
(SSRIs)
ADEs, 339
depression, 146
sexuality, 503
SelfCARE(D), 143
self-neglect, 546–547, 551–552, 556. See also
elder mistreatment
self-reported pain, 249. See also pain, pain
management
Semmes-Weinstein Monolament test, 63
sensitivity, measuring performance, 18
sensorineural hearing loss, 59
sensory changes
actions, referrals, 64–66
background, 48–49
capacity assessment, 94–95
case study, 67–68
expected outcomes, 66
follow-up monitoring, 66
history assessment, 63–64
interprofessional care, 66–67
intervention, care strategies, 56–63
Quality Assessment (cont.)
Index 719
normal, 49–51
nursing assessments, 63–67
physical exam, 64
problem assessment, 51–56
serious injury. See injury
serotonin-norepinephrine reuptake inhibitors
(SNRIs), 146
sexual abuse, 546, 550, 556. See also elder
mistreatment
sexual dysfunction, 500
sexual health, 500, 508
sexual response cycle, 502
sexuality
assessment, 504–505
background, 501–504
case study, 509
dened, 500
interventions, care strategies, 506–509
overview, 500–501
protocol for, 510–513
summary, 510
Short Michigan Alcohol Screening Test-
Geriatric Version (SMAST-G), 523,
531
side rails, 238. See also restraints
situational theory, 547
skin care, 304–305, 611, 620
skin tears
assessment of, 306–307
case study, 310
dened, 306
interventions for, 307–308
overview, 298
summary, 310–311
sleep, sleepiness. See excessive sleepiness
SMAST-G. See Short Michigan Alcohol
Screening Test-Geriatric Version
smell
change implications, 61–62
changes, common/normal, 49–50, 61–62
interventions, care strategies, 60
nursing actions, referrals, 65
smoking dependence, 521, 526. See also
substance misuse, abuse
SNRIs. See serotonin-norepinephrine
reuptake inhibitors
social learning theory, 548, 556
Society for Critical Care Medicine, 230
specicity, measuring performance, 18
speech paucity, 59
spinal cord compression, 664
spontaneous awakening trials (SATs), 605
spontaneous breathing trials (SBTs), 605
SSI. See surgical site infection
SSRIs. See selective serotonin reuptake
inhibitors
St. John’s wort, 335
standards of practice, dened, 2
Staphylococcus aureus (MRSA), 208
State Boards of Nursing, 214
stereopsis, 54
stomatitis, 410
STOP-Bang Questionnaire, 79–80
stress UI, 366. See also urinary incontinence
stroke, dehydration, 422. See also heart
failure
subjective well-being, 472
substance misuse, abuse
background, 516–518
case study, 527–528
disorder assessment, 518–521
interventions, care strategies, 524–527
models of care, 526–527
overview, 516
problem assessment, 521–523
protocol for, 529–536
screening tools, 523
summary, 528
suicide, 138–139
supported autonomy, 563
supportive interventions, 479
surgical procedures, dehydration, 422
surgical procedures, iatrogenesis, 205–206
surgical site infection (SSI), 207, 210
surgical wound dehiscence, 206
surrogates, 567–568, 580. See also advance
directives; durable power of attorney
for health care
Surveillance, Epidemiology, End Results
Program (SEER), 658
swabs, 411
Sweet 16, 125, 129–130
systolic blood pressure, 24, 37–38. See also
blood pressure
tacrine hydrochloride (Tacrine), 169
tailored interventions, 485–486
taste
altering diseases, 61–62
change implications, 61–62
changes, common/normal, 50–51, 61–62
interventions, care strategies, 60
nursing actions, referrals, 65
720 Index
TBW. See total body water
TCAB. See Transforming Care at the Bedside
TCAs. See tricyclic antidepressants
TCMs. See transitional care models
TCNs. See transitional care nurses
teach backs, fall prevention, 281
temporal arteritis, 55
therapeutic communities, 525
tinnitus, 59
TJC. See e Joint Commission
TLS. See tumor lysis syndrome
To Err is Human: Building a Safer Health
System (IOM), 201, 211, 214
toileting programs, 371, 372
tolerance, 519, 529
toothbrushes, 411
total body water (TBW), 420. See also oral
hydration
Transforming Care at the Bedside (TCAB),
215
transient UI, 365, 371–374. See also urinary
incontinence
transition coach, 688
transitional care
assessment, 684–685
background, 683–684
case study, 690–691
dened, 682, 692–699
interventions, care strategies, 685–689
overview, 682–683
protocol for, 692–699
summary, 691–692
transitional care models (TCMs), 675, 683,
685–689
transitional care nurses (TCNs), 685
transitions within settings, 688
tricyclic antidepressants (TCAs), 146
tuberculosis, atypical symptoms, 36
tumor lysis syndrome (TLS), 663–664
tuning fork tests, 58
UDI-6. See Urinary Distress Inventory-6
UI. See urinary incontinence
ulcers, pressure. See pressure ulcers
underhydration, 421, 430. See also oral
hydration
United Nations, EM, 544
United States
OTC drug use, 334
substance misuse statistics, 516–517
vision denitions, 51
United States Department of Health and
Human Services (USDHHS), 214
University of Colorado Hospital, 392, 688
urge inhibition, 372–373
urge UI, 366. See also urinary incontinence
Urinary Distress Inventory-6 (UDI-6), 367
urinary incontinence (UI)
assessment, 365–367
assessment parameters, 367–370
background, 364–365
case study, 375
etiologies, 365–367, 377
HF, 642–643
interventions, care strategies, 370–374
overview, 363
protocol for, 376–380
risk factors, 367–368
summary, 376
urinary tract infection (UTI), 207, 365. See
also catheter-associated urinary tract
infection
urine color chart, 424
USDHHS. See United States Department of
Health and Human Services
UTI. See urinary tract infection
vaccinations, 34–35
VAD. See left ventricular assist device
VaD. See vascular dementia
validity, measuring performance, 18
vancomycin-resistant enterococcus (VRE),
208
VAP. See ventilator-associated pneumonia
vascular dementia (VaD), 164. See also
dementia
vasodilation, 643
ventilator-associated pneumonia (VAP),
209–210
verbal descriptor scale, 249
VFQ. See Visual Function Questionnaire
vibratory sense, 63
viropause, 502
visceral proteins, 446
vision
assessment, 51–54
change implications, 56
changes, normal, 49
eye conditions, 55
eye examination, 52–54
history questions, 52
intervention, care strategies, 56–57
Index 721
nursing actions, referrals, 64–65
testing, 53
VFQ, 54
Vistech Contrast Sensitivity Test, 54
visual elds, 54
Visual Function Questionnaire (VFQ), 54
voiding record, 368–339
VRE. See vancomycin-resistant enterococcus
Walking for Wellness program, 110
warfarin, 337
Waterlow scale, 303
Weber test, 58
weight, HF, 635
well-being of relationships, 472
whisper test, 58, 94
WHO. See World Health Organization
withdrawal, 519, 529
World Health Organization (WHO), 208,
251–253
wounds, ICU care, 611
xerostomia, 61
Zarit Burden Interview (ZBI), 169
EVIDENCE-BASED
GERIATRIC NURSING
PROTOCOLS
FOR BEST PRACTICE
F O U R T H E D I T I O N
MARIE BOLTZ
ELIZABETH CAPEZUTI
TERRY FULMER
D
EANNE ZWICKER
E D I T O R S
A R DI S O ’ M E A R A
Ma n agi n g Ed i to r
11 W. 42nd Street
New York, NY 10036-8002
www.springerpub.com
9 780826 171283
ISBN 978-0-8261-7128-3
Evidence-Based Geriatric Nursing
Protocols for Best Practice
F O U R T H E D I T I O N
Marie Boltz, PhD, RN, APRN-BC • Elizabeth Capezuti, PhD, RN, FAAN •
Terry Fulmer, PhD, RN, FAAN • DeAnne Zwicker, DrNP, APRN-BC • EDI TOR S
Ardis O’Meara, MA • M A NAGI NG EDI TOR
“Now more than ever, nurses are called upon to lead efforts to embed evidence-based practice in daily operations. As
the IOM report states, ‘nurses have key roles to play as team members and leaders for a reformed and better-integrated,
patient-centered health care system.’ The process of implementing sweeping change in health care will likely take years;
however, nurses must start pragmatically and focus on these critically important protocols that have demonstrated improved
outcomes for older adults. Simply stated, ‘Pick this book up and use it.’”
—Susan L. Carlson,
MSN, APRN, ACNS-BC, GNP-BC, FNGNA
President, National Gerontological Nursing Association
From the Foreword
“As a gerontological clinical educator/research nurse, I will often use this as a reference. The format and the content are
good, and the explanations of how to best use the evidence simplify the process of sifting through mountains of information
to figure the best practice.”
—Doody’s, Score: 97; 5 Stars
O
ne of the premier reference books for geriatric nurses in hospital, long-term, and community settings, this
fourth edition has been thoroughly updated to provide the most current, evidence-based protocols for care
of common clinical conditions and issues in elderly patients. Designed to improve the quality, outcomes, and
cost-effectiveness of health care, these guidelines are the result of collaboration between leading practitioners and
educators in geriatric nursing and New York University College of Nursing.
Protocols for each clinical condition have been developed by experts in that particular area, and most have been
systematically tested by over 300 participating hospitals in “Nurses Improving Care for Health System Elders”
(NICHE). Evidence is derived from all levels of care, including community, primary, and long-term care. A
systematic method in compliance with the AGREE appraisal process was used to rate the levels of evidence for each
protocol. Protocols are organized in a consistent format for ease of use, and each includes an overview, evidence-
based assessment and intervention strategies, and an illustrative case study with discussion. Additionally, each
protocol is embedded within chapter text, which provides the context and detailed evidence for the protocol. Each
chapter contains resources for further study.
K EY FE AT UR ES :
• U
pdated to provide a wide range of evidence-based geriatric protocols for best practices
• Contains new chapters on function-focused care, catheter-associated urinary tract infections, mistreatment
detection, acute care models, and transitional care
• Illustrates application of clinical protocols to real-life practice through case studies and discussion
• Edited by nationally known leaders in geriatric nursing education and practice, who are endorsed by the
Hartford Institute for Geriatric Nursing and NICHE
• Encompasses the contributions of 58 leading practitioners of geriatric care
• Written for nursing students, nurse leaders, and practitioners at all levels, including those in specialty roles
EVIDENCE-BASED
GERIATRIC NURSING
PROTOCOLS
FOR BEST PRACTICE
BOLTZ • C APEZU TI •
FULMER • ZW ICKER •
O’ME A R A
F O U R T H E D I T I O N
