Geriatrics Guide

Notable Contributors: Melanie Zuo, M.D. | Nasiya Ahmed, M.D.

Key Points:

ACE Units are general medical units specifically for older adults. These units typically have the following components:

• An inter-professional team: physician, advance practice nurse, physician assistant, physical therapist, occupational therapist, speech therapist, nutritionist, social worker, pharmacist and nurses.
• Focus on functional ability: daily PT/OT starting on the day of admission.
• Discharge planning: Starts on admission day with goal of returning to the community.
• A thorough pharmaceutical review: usually in conjunction with a pharmacist to check dosages, therapeutic levels, side effects, and drug interactions.
• A prepared environment designed to facilitate physical and cognitive function: large clocks and calendars, handrails, raised toilet seats, and other environmental modification to assist the older patient.

Additional ACE Unit Facts:

• First started in 1989 at the University Hospitals of Cleveland
• Clinical and cost-effective benefits include:
• Fewer medications at discharge
• Reduced prevalence and duration of delirium
• Decreased length of stay
• Decreased re-admission rate
• Decreased nursing home placement
• Better functional capacity including improved ambulation and ability to perform instruments of daily living
• Better pain satisfaction scores
• Cost savings are realized by increased discharges to home versus long-term care, decreased length of stay, and decreased readmissions.

Supplemental Files:

Acute Care for the Elderly Handout

Complications of Hospitalization Video

Understanding Restraints and Restraint Alternatives Video

References:

Ahmed, N.N. & Pearce, S. E. (2010). Acute Care for the Elderly: A Literature Review. Population Health Management:13 (4): 219-225.

Ahmed, N., Taylor, K., McDaniel, Y., Dyer, C.B. (2012). The role of an acute care for the elderly unit in achieving hospital quality indicators while caring for frail hospitalized elders. Population Health Management: 15(4): 236-240.

Flood, K., MacLennan, P., McGrew, D. , et al.(2013). Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions. Journal of the American Medical Association, 173(11):981-987.

Fox, M,T., Sidani, S., Persaud, M., Tregunno, D., Maimets, I., Brooks, D., & O'Brien, K. (2013). Acute Care for Elders Components of Acute Geriatric Unit Care: Systematic Descriptive Review. Journal of the American Geriatrics Society: 61(6): 939–946.

Landefeld, C.S., Palmer, R.M., Kresevic, D.M., Fortnsky, R.H., & Kowal, J. (1995). A Randomized Trial of Care in a Hospital Medical Unit Especially Designed to Improve the Functional Outcomes of Acutely Ill Older Patients. New England Journal of Medicine; 332:1338-1344.

Key Points:

Patients have the right to manage their own health care decisions, to accept or refuse medical treatment, and ultimately make advance directives. The Agency for Healthcare Research and Quality, in a 2011 report, noted that less than 33% of older adults have completed advance directives and often these advance directives are not part of the electronic medical record. Learn more about advance directives and tips on how to have discussions with older adults about these documents.

Supplemental Files:

Advance Care Planning Handout

References:

Agency for Healthcare Research and Quality (2011). Elders' preferences for end-of-life care are not captured by documentation in their medical records. Research Activities. https://archive.ahrq.gov/news/newsletters/research-activities/jun11/0611RA25.html

Crosby, J.T. (2015). Advance Care Planning Discussions: A step-by-step guide with verbal options. Annals of Long-Term Care (September): 28-32.

House, T. & Lach, H.W. (2014). Advance directives in hospitalized patients: A retrospective cohort study. The Journal for Nurse Practitioners 10 (7): 465-471.

Tulsky, J. (2015). Beydon advance directives, importance of communication skills at the end of life. Journal of American Medical Association 294(3):359-366.

Key Points:

Persons with Intellectual Development Disabilities (IDD) are aging at a rapid rate. Adults with intellectual disabilities have intellectual functional limitations that occur prior to the age of 18 years. Adults with developmental disabilities have functional limitations in 3 or more areas of life activity (self-care, language, mobility, self-direction, capacity for independent living). Constipation is a major medical conditions that commonly is seen among persons with IDD and may lead to serious complications.

Supplemental Files:

Aging Persons with Intellectual Developmental Disorders (IDD): Constipation Handout

Aging Persons with Intellectual Developmental Disorders (IDD) Powerpoint Presentation

References:

Health Guidelines for Adults with an Intellectual Disability. Available at: http://www.intellectualdisability.info/how-to-guides/articles/health-guidelines-for-adults-with-an-intellectual-disability

Lewis SJ, Heaton KW (1997). Stool Form Scale as a Useful Guide to Intestinal Transit Time. Scand. J. Gastroenterol. 32 (9): 920–4. doi:10.3109/00365529709011203.PMID 9299672

Office of Training and Professional Development (2011, October 15). The Fatal Four: Constipation: A Major Challenge that Impacts People with Developmental Disabilities. Division of Developmental Disabilities Services 4(9), pp 1-2.

Schalock, RL, Borthw9ck-Duff, SA, Bradley VJ, et al. (2010). Intellectual Disability: Definition, Classification and Systems of Supports. (11th ed). Washington DC: American Association on Intellectual and Developmental Disabilities.

Smith, MA, & Escude, CL (2015). Intellectual and Developmental Disabilities. The Clinical Advisor, February:49-58.

Key Points:

Comprehensive Geriatric Assessment (CGA) is a mainstay in the assessment, evaluation and development of a plan of care in older adults. Aging adults have several unique features including multi-comorbidities, diminishing physiologic reserves, aging organ systems which may influence functional independence and changing social-economic status. The comprehensive geriatric assessment is an overall biopsychosocial approach to meet the holistic needs of older adults.

Supplemental Files:

Comprehensive Geriatric Assessment Handout

References:

Borenstein, JE, Aronow HU, Bolton LB, Dimalanta MI, Chan, E, Palmer K, Zhang, X, Rosen B, & Braunstein, GD. (2015). Identification and team-based interprofessional management of hospitalized vulnerable older adults. Nursing Outlook, on-line, 1-9. http://dx.doi.org/10.1016/j.outlook.2015.11.014.

Dyer, C.B., & Ostwald, S. (2011). Ageing and health: Managing co-morbidities and functional disability in older people. In E. Stuart-Hamilton (Ed.), An introduction to gerontology (pp. 87-125). Cambridge, UK: Cambridge University Press.

Flood, KL, MacLennan, PA, McGrew, D, Green, D, Dodd, C, & Brown, CJ (2013). Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Internal Medicine, 173(11), 981-987.

Interprofessional Education Collaborative (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

Ward, K.T., & Reuben, D.B. (2012). Up To Date. Comprehensive Geriatric Assessment. Retrieved from http://www.uptodate.com/contents/comprehensive-geriatric-assessment.

World Health Organization (WHO). (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health Organization. Retrieved September 17, 2013 from https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice.

Key Points:

Conditions of the Cervical Spine

Supplemental Files:

Conditions of the Cervical Spine Handout

References:

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