Geriatrics is the medical specialty serving patients 65 and older. Usually multidisciplinary, the geriatric team may consist of primary care providers specializing in geriatrics, diabetes educators, psychologists, medical social workers, pharmacists, and support staff. The goal is to keep patients functional at their highest level throughout their elder years. This might mean the difference between a patient living independently, semi-independently, or in a skilled nursing facility.
Let’s say your next patient is a 75-year-old female admitted to the ER for confusion. Vitals are HR 98, BP 102/60, RR 20, SpO2 96, T 98 oral. The patient arrives by ambulance from home. Her clothing is wet with foul smelling urine. She is not oriented to person or place. Her affect is flat. Tenting is elicited on her hands. Skin is warm. You note she has lately been to the ER several times for falls and failure to thrive.
What to do for your patient? After the work up, the patient is diagnosed with a UTI and dehydration. Confusion is often seen in the elderly as the first sign of a UTI. Of course the foul smelling urine and new incontinence were the giveaway. This patient is going to need more than a course of antibiotics and fluid. Although she lives with family, the recent visits to the ER make it clear that the family is overwhelmed. A quick conversation with the daughter confirms this fact. You suggest a geriatric consult to the ER provider and she agrees.
Some inclusionary factors for a geriatric referral are age 65 and older, increased utilization of services, changing/increasing needs, decreased functioning, confusion or dementia, failure to thrive/weight loss, falls, and age related health problems. Our ER patient meets several of these criteria. If the patient has a PCP, coordination with that provider would be necessary. Geriatrics will often do a consult to see if the patient is the right fit. It looks like our patient and her family could use the services of a multidisciplinary team.
Active addiction/alcoholism, recent suicide attempt, acute psychosis, or untreated mental health issues would require different referrals. Substance abuse problems, active mental health issues, or suicide attempts would need to be addressed by addiction services and/or mental health services and the patient stabilized before geriatrics could assess age related changes to memory or dementia. These issues would cloud the clinical picture and make diagnosis of cognitive impairment impossible.
The geriatric primary care provider is part of an interdisciplinary team. Because of this, our patient will have access to a range of services that are can be outside of the ability of the primary care provider to manage. Having everyone under the same roof, steps away, using the same electronic record system, allows for an integration of care that would be impossible using outside specialists. Our patient will get a referral from the ER after the ER provider consults with the patient’s primary doctor if she has one.
The patient will be scheduled for a geriatric consult as soon as her condition has stabilized.
Meet the Geriatric Team
Dr. Nirmala Gopalan, MD, is the site manager for the Santa Clara Valley Medical Center Downtown Geriatric Clinic in San Jose, CA.
“On the patient’s initial visit, I’m looking for inclusionary factors. Does this patient need us? There are a lot of elderly patients whose health care needs are well met by their PCP. The ideal patient to come aboard our service meets the inclusionary factors, has a desire to onboard to our services, and is looking for quality of life, not just disease care.”
Ginny Estupian, PhD, is the geriatric clinic psychologist at Santa Clara Valley Medical Center and works closely with Dr. Gopalan. “My role on the team can be divided into two parts; providing individual therapy and neuropsychological evaluations.”
“When I conduct individual therapy, I focus on reducing troublesome mood symptoms such as depression and anxiety. I may focus on helping the patient cope with chronic health conditions that exacerbate their mood such as COPD, chronic pain, diabetes, and cognitive changes. I help the client understand the relationship between the sleep, pain, mood triad, and we focus on improving one or more of those areas. Mood symptoms can improve by learning coping skills, engaging in age-appropriate exercise, or simply processing how they feel about their overall health.”
“The second part of my role is conducting neuropsychological evaluations. I assess for changes in cognition that may occur due to Alzheimer’s disease, vascular disease, or other age-related conditions. Findings from neuropsychological testing are discussed with the multidisciplinary team, then discussed with the patient and family in order to coordinate ongoing care that meets the specific needs of each client.”
Carol Lee, PharmD, is a pharmacist for Santa Clara Valley Geriatrics Clinic. “The first thing I do with the new patient is go over the medication. I’m looking for appropriateness, contraindications, drug interactions, compliance…”
“I look at the patient in terms of the 5 Ms of geriatrics: Mind, Mobility, Medications, Multi-complexity, and Matters Most. Does the patient have dementia, cognitive decline, delirium, or depression? Can the patient tell me why he or she is on this medication? Is the patient an active participant in care or is someone else managing it? Age is just a number. Patients have a wide variability in ability. We don’t prejudge, we assess.”
“Can the patient navigate the pharmacy system? Are they having difficulty with refills or medication timing? Our pharmacy can set up automatic refills, home delivery, blister packs, and other services to assist our patients.”
“Another thing I asses for our patient population is herbal supplements. I educate them on the pros and cons of taking supplements and over the counter medications. The patient needs to weigh if they are getting benefit or detriment from them. I go over each one with them, looking for interactions.”
“Finally, polypharmacy has to be addressed. Some patients have been to many doctors over the years or have seen multiple specialties and they can have a lot of medication burden. Having the patient’s care totally within our system, on the same electronic charting system, and doing a medication reconciliation with each visit helps me to drill down to exactly what the patient is taking, what we can toss, and what we can keep. The patient has health goals, that’s what ‘matters most.’ The proper medicine, and nothing extra, is my job with the geriatric patient.”
Danette Flippin, MSW, MSG, also at Santa Clara Valley Medical Center Geriatric Clinic, looks at not just the whole patient, but at the patient’s support system.
“When assessing the new patient I always think in terms of biopsychosocial and spiritual assessment. Starting with the patient, I ask what is this patient’s level of functioning in the world? What are the physical, cognitive, emotional, and psychological abilities that allow this patient to address needs or to cope with challenges? What deficits are preventing healthy coping or access to health care, or engagement with community support?
“Simultaneously, as a medical social worker, I am looking at the patient’s environment and support systems such as family, friends, social/senior networks, church communities, etc. What is important to this person as they navigate the later stages of their life cycle, place meaning and address the existential questions and factors in their lives?
“When we look at an older adult, we are assessing the well-being of the caregiver as well. The patient and family centered approach is key to assessing, identifying problems, and integrating helpful, successful interventions. When all the information is in place I form a plan on how best to serve this person, not this person’s diseases.”
As we each progress through the stages of life, it’s good to know there are resources available. Not every elder patient needs the services of a geriatric specialty clinic, but the ones that do definitely get value. Don’t forget to evaluate your geriatric patients for specialized care.
Leopold Linton faulted the omelet he ate during a flight five years ago to Jamaica, his country of origin. He was sick to his stomach by the time he arrived at the airport in Black River on a Tuesday. By Friday, he was admitted to the hospital, where a doctor informed him he had full-blown AIDS.
While shocking, the news actually solved the mystery of why his health had deteriorated so rapidly during the previous year. He’d felt weak, lost weight, and soaked his bed sheets at night with sweat. He rarely saw his doctor, so he surmised his diabetes was out of control. His trip back home, in fact, was prompted by a gut feeling he was dying, although he didn’t know why. “I might as well spend my last days where it’s warm,” he remembers thinking.
Linton started antiretroviral therapy in Jamaica, allowing him to return in 2010 to the Washington DC region, his home for the past 40 years. He is now happily receiving care at Whitman-Walker Health, DC’s preeminent health care provider for low-income people with HIV/AIDS.
At 68, Linton received his AIDS diagnosis as a senior citizen. He joins the growing ranks of people over 50 grappling with HIV/AIDS—a population that includes long-term survivors, the newly diagnosed, and the newly infected. Thanks to groundbreaking antiretroviral drugs developed in the mid-1990’s, HIV has gone from being a death sentence to a lifelong, chronic illness like diabetes, where treatment adherence can prolong life expectancy. The CDC estimates that by 2015, 50% of people with HIV in the United States will be in this age group, presenting unique challenges and opportunities for nurses.
Nurses: Front and Center
As HIV shifts from being a fatal illness to a manageable one, experts say HIV care will become a routine element of primary health care. Nurses will be on the front lines in the expanded effort to test seniors, educate them about risk factors, and motivate them to stay in treatment if they test positive.
“When it comes to retention and keeping people in care, nurses are so important,” says Wayne E. Dicks, MPH, a training coordinator with the Pennsylvania/MidAtlantic AIDS Education Training Center based at Howard University. “They need to be understanding and compassionate.”
Nurses, in fact, were at the heart of Whitman-Walker’s restructuring of its health care delivery system five years ago. The goal was to be more medically—rather than social service—oriented, says Justin Goforth, RN, BSN, Director of the Medical Adherence Unit at Whitman-Walker Health.
During the epidemic’s early days, HIV/AIDS care was palliative, focusing on getting patients basic necessities like food, shelter, and end-of-life pain medication since they weren’t expected to survive. A case management system was established at Whitman-Walker, but staffed with social workers and activists who had passion for the cause but little medical training, according to Goforth, who has been HIV positive since 1992.
With the antiretroviral revolution came the need for medical expertise—especially from those who could speak in plain language to patients about comorbidities and non-infectious, age-related illnesses exacerbated by HIV and, in some cases, HIV medications. Comorbidities include heart and kidney disease, high blood pressure, cognitive impairments, depression, and non-AIDS related cancers affecting the anus, prostate, and colon.
“Every time a new comorbidity is added on and a new treatment is added on, the complexity of [a patient’s] whole regimen is affected,” Goforth says. “We have to sit down with them, and say, ‘OK, where are we going to fit this in? Does this have any contraindications with taking it at the same time as this other med?’ I’m not sure who would do this except a nurse.”
In 2008, Whitman-Walker replaced their social work staff with nurse case managers, each of whom oversees a 250 to 300 patient caseload. Support staff handles referrals to benefits, food, and housing assistance. And while each Whitman-Walker client is assigned a physician, doctors only have 15-minute timeslots to see patients—enough time to prescribe medications or order labs, but not enough to talk in detail about their HIV care regimen.
“We needed nurses as case managers because we’re going to need to be teaching people throughout their lifetime about what’s going in their bodies and why is this treatment something they need to commit to,” says Goforth. “And why they need to integrate it into their lives.”
Accelerated Aging with HIV
Diagnosed in 1989, Kermit Turner is an immaculately groomed retired IT professional who hasn’t let HIV slow him down. It’s hard to imagine the 59-year-old has had four near-death experiences from HIV-related infections between stretches of good health.
“I’m not the rocking chair type,” he says. “Yes, HIV is going on [in] your life, but HIV is not your entire life.”
Another Whitman-Walker client, Turner has battled pneumocystis pneumonia—the strain associated with early AIDS sufferers—in addition to a locked bowel and non-Hodgkin’s lymphoma. In 2011, his left lung was removed because of aspergillosis, a pulmonary disease caused by a fungus affecting people with weakened immune systems.
Turner experiences problems with vision and short-term memory. A sense of humor, he says, is an essential weapon against forgetfulness—and HIV.
“I’m the one with the Post-its about the Post-its,” Turner says.
Researchers are beginning to understand how HIV accelerates aging, and it has much to do with “immune senescence,” or aging of the immune system itself. A recent Israeli study published in the Rambam Maimonides Medical Journal attributed rapid aging among people with HIV to chronic inflammation of the immune system and the loss of CD4 cells, activated by the immune system to fight infections, rather than the amount of HIV virus—known as “viral load”—in a person’s blood.
Additionally, a research review published in the Journal of NeuroVirology found that the immune systems of HIV-infected individuals resemble those of non-infected people decades older, triggering heart disease, kidney disease, and diabetes much earlier.
In 2009, Jay Jones had a double-bypass after his chest pains and shortness of breath were misdiagnosed as asthma by an emergency room doctor. He was 48 at the time and experienced heart problems much earlier than members of his extended family with its history of heart disease. Living with HIV for 21 years, Jones, 52, tried several drug regimens, which his doctor told him were partially responsible for his coronary blockages.
“I was angry because they didn’t tell me this could be a result of taking medications,” the US Army veteran says. “I wondered if I should continue taking them.”
He continued his HIV therapy, but added blood cholesterol medication and started a more active lifestyle. His ability to surmount challenges posed by HIV, heart disease, and depression motivated him to start a second career as a minister at his son’s church in Washington, DC.
Sex and Stigma
Jones says once he’d overcome his internal stigma—for being HIV positive and same-gender loving—he was able to accept himself and the unconditional love of his former wife and children. Stigma and lack of HIV knowledge among medical staff remain powerful obstacles to HIV testing and care for people over 50.
“We’ve done an abysmal job doing sexual histories on the elderly,” says Frances Jackson, RN, BSN, MA, MSN, PhD, a professor emeritus at the Oakland University School of Nursing in Rochester, Michigan. “There’s still a level of discomfort in discussing sex lives with elderly people.”
Among the elderly, specific cultural and sexual identities must be considered. Mental health should be part of the conversation as seniors are prone to depression and feelings of isolation from their peers—especially if they test positive for HIV, experts say. Jackson says older heterosexual men and women may not use condoms because fertility is no longer a factor. Older gay men may feel rejected by younger gay men as sexual partners, leading them to recreational drug use to overcome their inhibitions, says Dicks.
“We need to do a better job with some of our questions,” he says.
Jackson suggests framing discussions about risk behaviors around what a patient’s personal goals are. “You can’t scare people into healthy behaviors,” says Jackson. “We have to meet people where they are. We have to tie it [to] what the individual wants out of their life.”
Jackson, who has practiced HIV/AIDS care for 30 years, remembers when medical staff hosed down hospital rooms where an AIDS patient had stayed. While such stories are less frequent today, the knowledge level of nurses in non-AIDS specialties feels “almost like we’re in the 1980’s again,” says Marion Smith, RN, BSN, a nurse case manager at Whitman-Walker Health.
In an oncology unit at a major urban hospital where she worked before her current position, Smith often heard nurses caution each other: “Be careful when you’re in that room because that person is positive.”
Smith says what’s needed is to normalize HIV for nurses and other medical staff no matter the context. Since HIV care is “continually evolving and changing,” health care managers need to “figure out how to keep people abreast about what’s happening,” she says.
Assumptions that seniors aren’t sexually interested or active, that they’re monogamous, that they’re heterosexual, and that they understand HIV risk factors are all barriers to testing and care, says Goforth.
“We have all this trauma instilled in us about what is HIV and we keep perpetuating that,” he says. “That keeps people . . . from thinking ‘I have good options about having a healthy life in case I am HIV positive.’”
The incidence of immunosuppressed elderly patients has increased over the past few years. Hospitals and rehabilitation centers are seeing patients with greater complications, which poses many risks. Patients face the dangers of mass infection, greater length of stay, isolation from friends and family, limited resources, and poor patient follow-up. These potential threats combined with Medicare cuts in an ever-changing health care system are putting our elderly in jeopardy.
Improving patient care is essential to this community by increasing education and providing better preventive programs and follow-up. Many elderly patients are discharged into a rehabilitation setting after spending some time in the hospital due to illness or trauma. Complications can be seen very early and vary from weakness and dehydration to cognitive and physical problems. In order for a patient to receive optimal care, problems need to be addressed accordingly.
Patients’ physiological changes can cause a simple illness to present differently and can make treatment difficult. In rehabilitation, patients require detailed assessments from the rehabilitation team, easy-to-follow instructions, a well-lit environment, minimal noise level, and a keen eye to notice changes in the patient. Evidence-based practice must include continuous education for staff, such as interventions for current disease processes, assessments of current medications and side effects, and an evaluation of support systems and community needs.
Elderly patients who suffer from dementia or delirium can also experience a positive rehabilitation experience by simply minimizing triggers that may cause anxiety. Patients need to feel comfortable in their new surrounding. Reorient the patient often and repeat instructions accordingly. Encourage safety and maintain an open dialogue with the patient and his/her family to enhance opportunities for teaching and learning.
Nurses need to be aware of changes that could cause a patient to become increasingly confused: fever, infection, dehydration, a change in room, poor eyesight, poor sleeping habits, or medications such as antidepressants. Confusion can also lead to falls, an increase in length of stay, and/or lawsuits. Within the past few years, the cost of falls has risen to $30 billion dollars. The statistics are shocking:
1 in 3 adults over the age of 65 will be treated for a hospital fall related injury
30% suffer complications such as infection and/or death
By the year 2020, the cost of falls will cost health insurances over $50 billion dollars
Immunocompromised patients may require longer hospitalization and rehabilitation. Premorbid conditions may present differently and can be difficult to treat. Family and caregivers must be taught to watch for signs and symptoms of infection and dehydration. Education is extremely important, particularly current medications and their side effects as well as proper follow-up. Patients can become lost for many different reasons: lack of support, decrease in income, lack of understanding of current disease process, or no means of getting to the doctor. Families must be encouraged in order to have a positive outcome.
Patients who have better access to community services fare better and are more likely to follow-up with doctor visits. They tend to keep a better dialogue with visiting nurses, require less hospitalization, and comply with medications and procedures. These patients gain an understanding of their disease process, identify possible risks, and seek medical help sooner.
Helping seniors remain independent for as long as possible is extremely important to their psyche. Community services range from town to town, availability, and cost. Coordinating care can be tricky, but a case manager is an essential source of information. Caregivers can arrange transportation, meals, social and physical programs, and even group events. Some programs are even specifically geared to gender, needs, race, or religious affiliation.
Staying active and being part of the community plays an important role in health. Daily fears of isolation, poor health, decrease in income, and loss of friends can contribute to an ailing health. In reality, caring for the elderly requires a community—nurses, doctors, family, friends—in order to maximize independence and decrease current challenges.
Rehabilitation can allow patients to regain communication skills, increase mobility and strength training, and gain emotional support. Rehabilitation programs offer patients and families the chance to learn, intervene, and reduce complications. These instructions are proactive in nature to prevent further accidents, injury, and acute hospital care. MN
As aging is inevitable, the need for specialized care also becomes inevitable. But what can you do if your access to quality elderly care is severely limited? Unfortunately, this is the case for many urban communities.
According to a study conducted at Brown University, the United States has lost 5% of its nursing homes (over a nine-year period), with closures being twice as likely to occur in minority neighborhoods. Not only does this leave families with fewer options, but it’s causing some moral dilemmas as well. Families are now finding themselves obliged to put their loved ones into low quality health care facilities. Also, the nursing homes may be farther away from their home communities, and if those elderly are from low income areas, their family and friends may not be able to afford the frequent trips to visit them.
What can be done to make sure additional nursing homes are not affected by the closures? Because polls have shown that people only go to nursing homes as a last resort, Dr. Mitchell H. Katz of the San Francisco Department of Health suggests that Medicare should help pay for assisted living and contribute other alternatives to nursing home care. If putting more money into new nursing homes is not an option, then the focus should be shifted towards other options like assisted living, home-based care, or community-based care. Katz says doctors should demand “high-quality nursing homes in the communities where people have lived and doctors should be more present” in order to raise the quality of care for the elderly.
A study done by the University of Iowa reports elderly African Americans living in nursing homes are more likely to suffer from bedsores. Bedsores usually develop if there is a lack of blood flow to an area of bones covered by a thin layer of skin, commonly found in the heels, elbows, and tailbone.
The study also showed nursing homes with predominately black residents lacked the resources needed for proper care, when compared to facilities with mostly white residents. The observational study was conducted with 2.1 million white nursing home residents and 346,808 black residents from 12,500 nursing facilities. From these residents, researchers found that 15% of black residents developed bedsores, while only 10% of white residents were affected.
Even though black residents seem to be more at risk, the study has determined that it is not necessarily caused by black residents receiving inferior-quality care, but a lack of staff resources to give the proper amount of care to their residents. Researchers discovered that even white residents placed in homes with mostly black residents were at a higher risk for bedsores.
If bedsores are not treated right away, they can become more serious and even life threatening. It is important that nursing home staff takes the proper steps in treating bedsores, or they can develop into sepsis. Failure to catch bedsores in their early stages has even found nursing home staff in negligence lawsuits.