Registed Nurses' Association of Ontario

Assessment and Management of Frail Older Adults in Mississauga/Halton

Terra Codack
Saint Elizabeth

Goal: My overall goal was to learn about Frailty, how to assess it and what interventions are effective for the front line health care provider to assist clients and their caregivers to live with this condition.

Background: Canada’s population is aging at an accelerating rate. Older adults require services that are designed to meet their unique physical, emotional, intellectual and social needs. Of concern, is the system’s ability to support the needs of older adults and their families living with age related diseases (e.g. dementia, cognitive impairment, physical disease) or changes in situational circumstances (e.g. personal or physical loss of function, and support systems). It is anticipated that as care continues to shift from hospital to home, the need for home care will continue to rise. Recently the Living Well, Living Longer report highlighted the necessary resources and supports to enable older adults to live independently in their homes for as long as possible.

Methods: Knowledge of Frailty was gained through a number of methods including conducting a literature review, reviewing relevant best practice guidelines, and presentations and discussions with my Primary Mentor and other SE clinical experts such as our Geriatric Medical Advisor, Continence Care Nurse and the Program Development Leader for Dietetics. Additional knowledge and skills in undertaking assessment and developing appropriate interventions were gained through clinical placements.

• Dr. Fisher – Discussed B. Issacs 5 I’s – Intellectual Impairment, Immobility, Instability, Incontinence and Iatrogenesis. concept of frailty. Importance of comprehensive geriatric assessment, along with discussion of the key areas in a CGA. AHA! Moment – Our discussion regarding polypharmacy. It was interesting to learn that pharmaceutical companies complete testing on young “healthy” adults and not on those that are prescribed the medication.

• Laurie Bernick – NP Trillium Healthcare – Geriatric Outreach program. I had the opportunity to attend the Falls Prevention and Bone Strength Program. This program last 12 weeks and is offered through 3 area hospitals. The program includes discussion around diet, meds and exercise. The classes cover diet/meds and then exercise with a PT. Participants also have the opportunity to meet with the NP and OT each for 20-30mins. I had the opportunity to observe Laurie complete a geriatric assessment. It was a unique situation as the client did not see there was a problem and did not understand why, “this new person was here”. Daughter had stated the family doctor was suspecting dementia. AHA! Moment – Though the assessment was of the client, the daughter required support as well which Laurie provided.

• Joanne Chen – Interim Director of the Regional Geriatric Outreach Program. Discussed and learned about the Outreach Program. There are Geri-assessment clinics that have NP’s and MD’s available to complete the assessments. Outreach has access to Geriatric clients that are homebound. There is 1 referral form that is triaged by the team and decided if client can come into the clinic or requires a home visit. AHA! Moment – A geriatrician is on a consult basis only. A client needs to be referred by their primary physician and remains with their primary MD. A client may only see a geriatrician once or twice, for they do not remain on their service. The

HELP – program within the hospital setting is run by an Elder Life Specialist and assistant. The HELP program provides assistance, with prevention of delirium while in hospital and having visitors come by to help with activation initiatives such as walking or reading a book.

• Hospice Wellington – Palliative care for any disease process, not just cancer. Question – What role does a frailty score play in palliative care? Is it even required? Though there are older adults greater than 75 years within the residence, the assessment of frailty is not used to direct care. Interviewed a resident to speak about community resources available for older adults. Daughter stated they were not aware of resources other than CCAC and it would have been helpful to know of day programs especially for those with dementia.

• Trish Corbett – CNS for geriatric services Joseph Brant – Observed a geriatric assessment including a Mini-Mental exam was completed on an older patient admitted with delirium. Observed completion of the Mood Scale for a patient along with physical assessment. Discussed importance of orthostatic BP’s being assessed. AHA! Moment – Foley catheters and older adults are a No-No! Had the opportunity to review labs of a patient admitted. Urine analysis on arrival to ER was normal, by day 2 +1 bacteria and increased leukocytes by day 4 patient had a UTI. There is an increased for risk of a UTI especially within 3 days. If a patient has a foley catheter, CNS will advocate to have removed.

• Pat Ford – NP Geriatrics Team, St. Joseph’s Hamilton – Referrals are done for inpatients when the medical team requires the services of the geriatric team. Attended Geriatric Team rounds to discuss the clients that had been referred for assessment. After this was completed, we then reviewed the charts and lab results for those to be seen. AHA! Moment – older adults present atypically. Everything needs to be ruled out. Ca, B12, Lactate, Albumin being a few. Discussed medications and those that should not be prescribed to older adults. Pat does a “plotting tool” of medications and looks over the meds that the patient has taken in a 2 week period and compares to notes and observations of the staff to see if there is any correlation. AHA! Moment – The importance of a collaborative history. I was able to observe Pat speaking with the son of a patient and obtain this collaborative history. I wrote down all the questions that she asked. Some questions, I would not have even thought of but saw the importance of them being asked. Pat also presented a power point on Delirium which gave me a better understanding of the condition.

• Joan Reid – GEM Brampton Civic Hosp. – This placement was great in that I learned about the resources available for older adults out in the community. AHA! Moment – I attended the orientation given to new ER nurses re: care of the older adults. I was not aware that for every 24hrs an older adult stays in a stretcher/bed they lose approximately 2.5% of muscle mass. It is important to get the older adults up and walking if they are able. The CNS, who presented the topic, stated though it may seem easier, for the nurse, to insert a foley catheter or restrain someone, it is better to get the patient up as the longer the patient remains on the stretcher the greater the chance of delirium setting in.

• Completed the RNAO eLearning module – The 3 D’s. This was a wealth of information that gave me a better understanding of the importance of screening for a three and the importance of a collaborative history.

Deliverables: Based on my new knowledge, I developed an annotated bibliography and power point presentation on Frailty and Seniors’ Care that can be used for ongoing education and training for the Saint Elizabeth (SE) Clinical Practice Coaches (CPC) (educators) and other clinical champions in the Seniors’ Care program. This information could also be added to the SE online At Your Side Colleague (AYC) education for all staff including nurses, PSW, therapists, and supervisors, in order to promote greater understanding of frailty and the effective interventions that can promote wellbeing, independence and increased coping.

I also developed education regarding normal ageing, abnormal ageing due to frailty and common interventions. As well, a list of local resources was developed that can be utilized by the nurses when caring for clients in the home.

Conclusion: This fellowship was extremely valuable in my understanding of frailty, how frailty impacts the lives of our senior population and what we, as health care professionals can do to assist the frail elderly to live with this condition. I feel more confident in my ability to educate staff on how to complete a Mini-Cog, MOCA and SIGE CAPS and have a better understanding of the frailty score and how this will benefit older adults in the community. In role as Clinical Practice Coach with a specialty in Seniors Care, I will be able to utilize this new knowledge and skills in my ongoing practice by promoting a comprehensive geriatric assessment through education and consultation and mentorship with front line staff.

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