GERIATRIC RESOURCE. ASITENCIALES LEVELS

For proper health care to the elderly, it is essential to proper coordination of different stakeholders involved. It involves a multidisciplinary.

Although much progress has worked and, in Spain there is still some way to coordinate and ensure effective strategies for the correct approach.

-       Primary

-       General Hospital

-       Geriatric Unit

PILLARS IN WHICH IS BASED ASSISTANCE FOR ELDERLY

Pillars that support elderly care:

1. Interdisciplinary work

a.       Physicians

b.      Nursing

c.       Social Workers

d.      Occupational Therapists

e.       Psychologists

2. Correct use of the levels of care
3. Suitable expertise

Finally I found very interesting comment I read an article that was published in 2006 in Rev Esp of Geriatrics and Gerontology (SEGG). This is a 2003-2005 SEGG report on the level of adequacy of resources in general hospitals geriatric Spanish.

I quote some conclusions:

• The group of people over 80 years has grown in the period 2003-2005, 8.3%, double the geriatric care resources (4%).

• Only 36% of Spanish public hospitals have resources specific to the elderly patient.

• Maintain the lack of equity in the Spanish territory where regional inequalities are accentuated.

• Cantabria and the Basque Country are still without some kind of geriatric care in their hospitals.

• Andalusia and Extremadura only have a 9% and 11%, respectively, geriatric care in their hospitals.

• Castilla-La Mancha, Madrid, Catalonia and Aragon are communities with a more comprehensive geriatric care in their general hospitals.

In conclusion, this study makes clear that specialized geriatric care Spanish public hospitals is inadequate. It raises a number of weaknesses and improvement measures to implement. In particular, strikes me that, at least, Aragon appears as one of the communities most comprehensive geriatric hospital.

BIBLIOGRAPHY:

Elisabeth Schröder-Butterfill, Oxford Institute of Ageing

‘PILLARS OF THE FAMILY’ – SUPPORT PROVIDED BY THE ELDERLY IN INDONESIA”                                            2007

Available on http://www.ageing.ox.ac.uk/files/workingpaper_303.pdf

Harvey Jay Cohen, M.D., John R. Feussner, M.D., Morris Weinberger, Ph.D., Molly Carnes, M.D., Ronald C. Hamdy, M.D., Frank Hsieh, Ph.D., Ciaran Phibbs, Ph.D., Donald Courtney, M.D., Kenneth W. Lyles, M.D., Conrad May, M.D., Cynthia McMurtry, M.D., Leslye Pennypacker, M.D., David M. Smith, M.D., Nina Ainslie, M.D., Thomas Hornick, M.D., Kayla Brodkin, M.D., and Philip Lavori, Ph.D.

“A Controlled Trial of Inpatient and Outpatient Geriatric Evaluation and Management” 2002

Available on http://www.nejm.org/doi/full/10.1056/NEJMsa010285

Abizanda Soler, P.*; Gallego Moreno, J.*; Sánchez Jurado, P.* y Díaz Torres, C.** 

“Instrumentos de Valoración Geriátrica Integral en los servicios de Geriatría de España: uso heterogéneo de nuestra principal herramienta de trabajo”               2000

Available on http://www.elsevier.es/sites/default/files/elsevier/pdf/124/124v35n5a10017927pdf001.pdf

HEALTH EDUCATION IN THE GERIATRIC PATIENT

The maintenance of health and functional independence are the most important aspects of health promotion in older adults.

The activities of health education, which should cover the whole life of all citizens, are able to establish barriers to the development of disease and its complications. Monitoring activities of prevention programs and health promotion adapted to comprehensive care of older people healthy should be a common practice in primary care activities.

PREVENTION OBJECTIVES GERIATRICS

The general objectives of geriatric prevention are equivalent to those raised in other ages:

-       Reduce mortality caused by acute and chronic diseases.

-       Maintaining functional independence of the person as much as we can

-       Increase active life expectancy

-       Improving quality of life

It is possible to significantly decrease the incidence, prevalence and severity of disease, disability and dependence in the elderly. We need to know these terms:

-       Dependency: functional consequences of disability with changes in l activity, causing difficulty performing some APRA or some instrumental or basic tasks, needing the help of a person. There are situations of disability that technical support does not cause dependence, ie, are independent with such assistance if you need technical assistance from a person.

-       Disability: partial or total reduction of the ability to perform an activity or function within normal as a result of deficiency / disease, disability will be closely related to age and gender (more women older)

This is because women live longer presents as many socioeconomic risk factors (loneliness, widowhood, income declines, ...) and more disabling diseases.

In my opinion the goal of health promotion in the elderly population is to maintain the highest degree of autonomy and prevent the onset of disease. Sets a top priority to improve the quality of life, which includes promoting behaviors that favor a style of living. However, in elderly disease prevention has special features. In many cases the disease are already present and perhaps more important than the classic goals of reducing mortality and increasing life expectancy, are the goals of preventing and delaying functional decline, avoid dependency and maintain independence and quality of life .

As future nurses we have to keep in mind that through health education, is to ensure that older people could evacuate lifestyle habits that can lead to detrimental impact their quality of life, while replacing them with others that have demonstrated healthier. The health education is essential in this age, having proven effective for improving the quality of life of elderly. This will not only be for the benefit of elderly patients, but also their family and social environment.

Finally I want to emphasize that health education requires more than simply offering information and knowledge, getting changes in attitudes and lifestyles. Eliminate the risk factors that cause the conditions is a necessary measure to maintain good health.

Acquiring good habits is the best step to take to stay healthy. Through health education may get a better quality of life.

BIBLIOGRAPHY:


 Dr. Phillip G. Clark, Program in Gerontology and Rhode Island Geriatric Education Center
«Values in Health Care Professional Socialization: Implications for Geriatric Education in Interdisciplinary Teamwork» 1997
 Available on: http://gerontologist.oxfordjournals.org/content/37/4/441.short

Gopal K Ingle and Anita Nath
«Geriatric Health in India: Concerns and Solutions»  2008
Available on: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2763704/

Uchino, Bert N.; Cacioppo, John T.; Kiecolt-Glaser, Janice K."The relationship between social support and physiological processes: A review with emphasis on underlying  mechanisms and implications for health.»   2012
Available on: http://psycnet.apa.org/?fa=main.doiLanding&doi=10.1037/0033-2909.119.3.488

PALLIATIVE CARE

Palliative care is the way to deal with advanced, incurable disease that aims to improve the quality of life of patients facing illness and their families, through the prevention and relief of suffering by means of early diagnosis, assessment the timely adequate treatment of pain and other problems both physical and psychosocial and spiritual

In my opinion the mission of hospice nurses must go beyond providing direct assistance to physical needs only. Rather care plans from the continuity, flexibility, accessibility.

It poise and accompany in daily life of the patient and his family, the family integrates the act of caring. Supports from the listener, must be sensitive and are awaiting the details that give comfort to the patient.

Major concerns of any healthcare professional when communicating with the patient

Death and dying cause health professionals and caregivers in psychological reactions that lead directly and indirectly to prevent patient communication terminal (away).

To ensure proper communication, the nurse must overcome:

-          Anxiety generated disclose bad news

-          Afraid to provoke an overreaction in the patient

-          Fear of an over identification (similarities with patients for age, sex, study, children of the same age ...)

-          Fear of lack of response to certain questions:

o   Is it wrong right?

o   How am I going to die?

o   How long do you think I have to live?

o   Why to me how young I am?

o   Why me if I've never done wrong to anyone?

Basic principles of communication

-          Communication speed adapted to the rate of uptake of each person

-      Never reported in the same session: diagnosis, treatment, prognosis. Ongoing process, not an instantaneous act

-          If at any time the patient does not want to receive information on your situation, remember if you change your mind we will be available

-          When a patient does not wish to receive information, is that it has detected at least that something is wrong

-          Many times the patient does not seek answers to certain questions, but relief

-          Never remove the hope but also generate

-          Spain, 50-70% of patients with cancer want they receive their diagnosis. Progressive increase in numbers in younger populations

-          Northern European Sick demand higher levels of information, while in Spain and Greece less detailed information is preferred

How to communicate:

1. Strategy communication theoretical Buckman Bad News: it consists of 6 stages, unable to advance to the next if you have not passed the previous
1. Stage 0: chances are that the result shows a complementary exploration malignancy

Have you considered that there is the possibility that the result is not good?

2. Step 1: Prepare the environment. Diagnosis of certainty and not suspected

3. 2nd stage: What does the patient? Before reporting, figure out what you know so far

What you have said so far the doctors have you visited?

4. Stage 3: What does the patient know? What does and what does not, and how far you want to know

You want to talk about all this is happening?

5. Stage 4: sharing information. Just get here if the patient has a desire to be informed.

Gradual process of assimilation time, especially if it is asymptomatic.

6. 5th stage: responding to the patient's feelings. If we will not be able to support you emotionally afterwards, best delegate responsibility to other professional. With certainty diagnosis and prognosis overshadowed, staff often cling to "there are still possibilities." This creates hope and false expectations

When the patient hears that there is still hope, are forced to eat, to get out of bed ... when you see that still does not improve, ends on the grounds that to blame

7. Stage 6: Plan of care. Objectives:

                                                              i.      Support

                                                            ii.      Relief of symptoms

                                                          iii.      Listen to fears and concerns

                                                          iv.      Sometimes we do not recognize their true symptoms to avoid being branded a "soft" or non-recognition of their disease worsening

Main stages of grief

1. Denial phase. Denying oneself or the environment that loss has occurred.

2. Phase of anger and indifference. Euphoria or anger at being unable to prevent the loss.

3. Negotiation Phase. Negotiate with yourself or the environment, understanding the pros and cons of the loss.

4. Emotional pain phase. You experience sadness and grief over the loss.

5. Acceptance phase. Loss is assumed, but never forgotten.

BIBLIOGRAPHY: 

1. Martin M. Evers, BS, Diane E. Meier, MD, and R. Sean Morrison, MD
«Assessing Differences in Care Needs nd Service Utilization in Geriatric Palliative Care Patients» 2002
Available on: 
http://www.net/publication/11363113_Assessing_differences_in_care_needs_and_service_utilization_in_geriatric_palliative_care_patients/file/32bfe50f97944856de.pdf

2. Lukas Radbruch; Julia Downing; Guide to pain Management in Low-Resource Settings; Chapter 8 Principles of Palliative Care;   http://www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=12167

3.- HOFFMAN, Gloria Basic Geriatric Nursing 5th Edition. Elsevier 2012. 

INCONTINENCE IN THE ELDERLY

We speak of urinary incontinence when you lose urine involuntarily and objective, producing this in a time and place unsuitable and quantity or often enough to be a problem hygienic, social and psychic to the person suffering and a possible limitation of their activity and relationship.

Although UI is a common symptom that accompanies many processes, and affects the entire population range by far is more common among children and adults, sesgándose for distribution to women if we present sex. When we correct UI cases suffered illness, will be among those with neurological processes.

It is not clearly defined the prevalence of this disease, differing greatly depending on the population studied, their scope or assumed UI concept for quantification. In different studies, it is established that approximately 10-20% of those older than 65 years may have it, a figure that would rise to 35-40% if we refer to the hospital environment-institutionalized

 IU NURSE ASSESSMENT

Anamnesis

We must make an individualized assessment, both the characteristics of incontinence, and the impact that this comes in the elderly and its intone.

Although the history is usually very useful, especially for filial to the UI, this is not defining, having objectified and quantified (some authors, however, estimate a correlation between the clinical urodynamic bladder instability around 50 -80%)

We will pick the time of onset of incontinence, type, intensity and frequency of the episodes, triggering events and concomitant symptoms and diseases, traumatology and surgical history or genito-urinary and gynecological. It is essential to collect drug history

It is often useful for 3-4 days employment records incontinence, also known as bladder diaries or records of frequencies, which guide us about the intensity, urgency, triggers, schedule, etc.. Although logically its effectiveness will depend on the cooperation of the affected or their caregivers

Physical Examination

Neurological examination: primarily cognitive assessment and lower limbs (Mini-Mental, march, muscle tone, motor function, sensation, anal and bulbocavernosus reflex ...)

The nurse should assess abdominal distension and bladder. Anal sphincter tone, fecalota, prostate. Exploration Pelvic controversial in older children looking genital atrophy.

Investigations

In all cases, the nurse must assess and / or request elemental analysis and urine culture. We highlight the lack of consistency between asymptomatic bacteriuria and UTI in the elderly. Also discard analytically some endocrinological causes of polyuria by glucose, electrolytes, calcium and serum creatinine. In the male may be useful quantification of prostate specific antigen (PSA).

Finally and in summary we can say that nursing diagnoses related to urinary elimination eight. Undoubtedly, the nursing diagnoses formulated with NANDA taxonomy understand that the big problem is competition urinary incontinence is nursing, the 8 diagnoses, six of us talk about incontinence (functional, stress, urge, and emergency risk, total and reflects), out of this concept are twofold: first diagnosis "general": Impaired Urinary Elimination, and the urinary retention, (which in turn is closely related reflex incontinence).

The mechanism of urinary continence is basically reduced to a set of pressures where, if the system maintains a sphincter pressure higher than that at that moment is in the bladder, no urination occurs. If this situation is reversed in a conscious and voluntary urination call it, and if it is involuntary or unconscious, is called incontinence.

In my opinion this is a serious problem that affects a lot of elderly people and they must have our understanding as professionals we are.

BIBLIOGRAPHY:

-    Kathryn L. Burgio, PhD; Julie L. Locher, MA; Patricia S. Goode, MD; J. Michael Hardin, PhD; B. Joan McDowell, PhD, CRNP; Marianne Dombrowski, DO; Dorothy Candib, MD

      « Behavioral vs Drug Treatment for Urge Urinary Incontinence in Older Women» 1998http://jama.jamanetwork.com/article.aspx?articleid=188273 

- McDowell BJ, Burgio KL, Dombrowski M, Locher JL, Rodriguez E

     An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients.   1992

      Available on: http://europepmc.org/abstract/MED/1556364

- Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; and Scott Miller, MD, Urologist in private practice in Atlanta, Georgia. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., 
"Stress Incontinence" 2012 
Available on: http://www.nlm.nih.gov/medlineplus/ency/article/000891.htm

CONSTIPATION AND FECAL INCONTINENCE.

CONSTIPATION

It is defined as excessively dry stool output, low (less than 50g/day) or infrequent (less than two bowel movements per week).

Epidemiology

The prevalence of constipation increases especially after age 60, and is more common in women than in men. Represents a major geriatric syndromes because of its prevalence, its serious complications and their significant impact on the quality of life of elderly. Only 5% of the elderly have fewer than three bowel movements a week.

Etiology

Causes of constipation in a patient are numerous and, in many cases, several causes coexist simultaneously:

-          Mechanical: obstructive, neoplastic, postoperative changes, volvulus, hernias.

-          Functional: diverticula, low fiber diet, anal fissure, anal prolapse, hemorrhoids, irritable bowel syndrome.

-          Pharmacological: laxatives, antidepressantstricyclics, calcium antagonists, antacids, opiates.

-          Metabolic and Endocrine: diabetes, uremia,hypokalemia, hypercalcemia, hypomagnesemia, hypothyroidism.

-          Neurological trauma, CNS disorders (Parkinson's disease, dementia, stroke and depression).

Treatment and recommendation nurse

Dietary treatment should be the first therapeutic step in the management of constipated patients. A diet rich in fiber is associated with an increased frequency and weight of stools.

Fiber works by increasing stool bulk, for bacterial growth, and decreasing intestinal transit time by stimulating bowel motility.

To achieve normal bowel function is advised to eat a moderate amount of vegetable fiber (of 10 60g/day) and plenty of water (1-2 liters / day) and physical exercise regularly. In order to check the response to dietary treatment should be eating about 30g of fiber or fiber 14.4 g of crude a day, for a month, along with a diet rich in fruits and vegetables and plenty of water.

In order to improve constipation, insoluble fiber (consisting of cellulose, hemicellulose and lignin) is more soluble than the (pectin, gums and mucilages), since the first captures more water, which results in a further increase in fecal mass and acceleration of intestinal transit.

Besides, insoluble fiber produces far less flatulence than soluble, suffering only partial fermentation in the colon (the soluble ferment completely).

Ostomy

Surgical creation of a temporary or permanent opening which brought about the exterior digestive tract through the abdominal wall.

Start working after 3-6 days after surgery.

Elderly iliostomizado: general advice

Causes:

-          Tumors

-          Ulcerative Colitis

-          Crohn's Disease.

Main differences colostomates elderly:

-          Increased chance of complications nutritional level (volume evacuated).

-          Impaired nutrient absorption.

-          You need to increase fluid intake because most of the water is absorbed in the intestine.

-          Risk of dehydration, increase the amount of water intake

Old man with gastrostomy: general advice. PEG

-          Start with water tolerated and when you can spend a nutritional formula either crushed diet kitchen.

-          Tolerance has to be gradual and cautious.

PEG (percutaneous endoscopic gastrostomy)

-          The first day absolute diet, serum scheduled as needed and schedule (Performing Control Rx)

-          Second day, liquid / glucose 5%. PEG + 1250 ml Serum IV scheduled.

-          Third day, tickets for PEG 1450ml (BCP Formulas) + cover needs with serum.

Fecal Incontinence

Fecal incontinence is not part of normal aging, representing one of the geriatric syndromes that impact on quality of life of elderly and more overhead to the caregiver, with a great impact, not only physical (pressure ulcers, urinary infections ... ) but also economic (derived from spending that generates high intake of geriatric care absorbent and additions) and psychosocial (causing a progressive deterioration in personal and social relationships of patients).

In my opinion there are the main nursing interventions:

1.    Medication Management. (To facilitate the safe and effective use of medicines prescribed and counter).

2. Prescribe medication. (Prescribe medication for a health problem).

3. Bowel management. (Establishment and maintenance of a regular pattern bowel movement).

4. Intestinal Training. (Help the patient in the education of the intestine to evacuate at specified intervals).

5. Management of Constipation / impaction. (Prevention / relief of constipation / impaction).

6. Stages in the diet. (Institute the necessary restrictions on the diet with subsequent progression same as tolerated).

7. Management of nutrition. (To help provide a balanced diet of solids and liquids).

8. Liquid handling. (To maintain fluid balance and prevention of complications resulting from abnormal fluid levels or unwanted).

9. Monitoring fluids. (Collection and analysis of patient data to regulate the acid-base balance).

BIBLIOGRAPHY: 

- Romero Y, Evans JM, Fleming KC, Phillips SF; Constipation and fecal incontinence in the elderly population;Mayo Clin Proc. 1996 Jan;71(1):81-92., available in: http://www.ncbi.nlm.nih.gov/pubmed/8538239

- Livestrong; [quoted the 6/05/13 and available in: http://www.livestrong.com/article/149464-causes-of-elderly-fecal-incontinence/

- FelixW. Leung, Satish S.C. Rao; Fecal Incontinence in the Elderly; Gastroenterol Clin N Am 38 (2009) 503–511, available in: http://xa.yimg.com/kq/groups/21126260/478307167/name/incontin%C3%AAncia+fecal.pdf

INSTABILITY AND FALLS

The elderly generally have more difficulty maintaining stability, which is manifested by the existence of a gear or senile cautious start (flexion, rigid posture, short and slow steps, block rotation, balance, wide support base, steps lower short arm swing)

Furthermore, with aging are lost or reflex normal protective responses against falls, as the extension of hands and arms.

WHO defines the fall as a result of any event which tumbles down the person against his will.

It is one of the most important geriatric syndromes by its high incidence and the impact on quality of life of the elderly.

The main trigger fall risk are:

-       Older than 75 years

-       Altering the stability and gait

-       Previous falls

-       Number of drugs consumed: 4 or more

-       Frail elderly

-       Living outside the family

-       Muscle weakness

-       Deficit gait and balance

-       Cognitive impairment (mental confusion))

-       Polymedication

-       Decreased vision

-       Chronic diseases (osteoporosis), acute (hypoglycemia, orthostatic hypotension)

-       History of falls

NURSING CARE PLAN

Pain

Related to fracture. It manifests as a verbal communication of discomfort.

The pathognomonic sign is the shortening and external rotation of the limb.

Nursing interventions (NIC) à

-       Environmental Performance: comfort

-       Performance at the pain

-       Administration of analgesics

-       Decreased anxiety

Result Criteria (NOC) à

-       Pain Management

-       Comfort level

-       Anxiety control

-       Acceptance: health

Care:

-       Recognize the presence of pain

-       Handle gently the affected limb, resting on pillows

-       Administer prescribed analgesia, placing the patient in a comfortable position and functional. The correct body alignment increases the comfort of the elderly

-       Help in frequent changes of position and pressure-relieving discomfort related

Impaired physical mobility

Related decreased strength, presence of pain, fear of falling snow.

It is manifested by difficulty in changing position in bed, changes in gait.

Nursing interventions (NIC)

-       Help self-care

-       Promoting exercise

-       Teaching activity / exercise prescribed

-       Exercise therapy: muscle control

-       Exercise therapy: ambulation

-       Exercise therapy: balance

-       Fall prevention

Result Criteria (NOC)

-       Active joint movement

-       Novel mobility

-       Personal Care: AVD

-       Level of pain

-       Ambulation: walking

Nursing:

-       Instruct the elderly and help in repositioning and transfer activities and

-       Instruct patient to practice isometrics quads and glutes, and flexion and extension of the unaffected limb, strengthening the muscles needed for walking

-       Start walking with short, frequent walks, and progressively increase the distance as tolerated by the patient to the activity

-       Instruct on the safe use of assistive devices and monitor the progress.

Risk of injury

Related to the lack of safety education, physiological or perceptual deficit

Nursing interventions (NIC)

-       Fall prevention

-       Physical Restraint

-       Security: Security

Result Criteria (NOC:

-       Safeguards: Personal

-       Security check: preventing falls

-       Risk Control

-       Security State: falls

-       State security: physical injury

Care:

- Install handrails in bed 

To sum up I want to say that falls are one of the greatest threats to senior health, and they can be life threatening. Each year, one third of people over 65 suffer a fall, and one third of these falls cause injuries requiring medical treatment. Even low-level falls (e.g., slipping while stepping off a curb or on a tile floor) can be life threatening in people over 70. These people are 3 times more likely to die from such injuries as younger people (Spaniolas et al., 2010). Fall-related injuries, particularly those requiring hospitalization, are the most frequent cause of developing new or worsening disability (Gill et al., 2010).

PREVENTING FALLS

Patients and families need to know how to prevent falls. The CDC recommends the following four essentials:

·         Encourage exercises that improve balance and coordination, such as Tai Chi.

·         Make the home or other environment safer.

·         Ask the healthcare provider to review all medications.

·         Take the patient in for a vision check.

To make the home safer, remove tripping hazards such as throw rugs from stairs and floors; place often-used items within easy reach so that a step stool is not needed; install grab bars next to the toilet and in the tub or shower; place non-stick mats in the bathtub and on the shower floor; add brighter lighting and reduce glare by using lampshades and frosted bulbs; and add handrails and lights on all staircases.

Seniors should wear shoes that offer good support and have thin, non-slip soles. They should avoid wearing slippers and socks (without shoes) and going barefoot.

BIBLIOGRAPHY:

1. GEORGE F. FULLER, COL, MC, USA; Falls in the elderly; Am Fam Physician. 2000 Apr 1;61(7):2159-2168. Available in: http://www.aafp.org/afp/2000/0401/p2159.html

2. HOFFMAN, Gloria Basic Geriatric Nursing 5th Edition. Elsevier 2012.

3. Tinetti ME; Instability and falling in elderly patients; Semin Neurol. 1989 Mar;9(1):39-45.