GERIATRIC SYNDROMES are common clinical conditions that don't fit into specific disease categories but have substantial implications for functionality and life satisfaction in older adults. Besides leading to increased mortality and disability, decreased financial and personal resources, and longer hospitalizations, these conditions can substantially diminish quality of life.1
According to a literature review, the five conditions most commonly considered geriatric syndromes are pressure ulcers, incontinence, falls, functional decline, and delirium. Malnutrition, eating and feeding problems, sleeping problems, dizziness and syncope, and self-neglect have also been classified as geriatric syndromes.2
This article discusses geriatric syndromes and their impact. It describes how to assess older adults for these syndromes and directs nurses to appropriate resources.
Geriatric syndromes will be an increasing concern for nurses because the population of older adults is growing exponentially. The number of those age 65 and older will more than double between 2000 and 2030, growing from 34.8 million to more than 70.3 million according to U.S. Census Bureau projections.1 The “old-old” adults—those age 85 and over—is the fastest growing group of all; their numbers will double between 1995 and 2030 and increase fivefold by 2050.1 About 82% of older adults have at least one chronic disease.1 These startling numbers will drive dramatic changes in healthcare and society.
Older adults face many challenges, including behavioral and social issues, problems with functionality and activities of daily living, and the wide range of settings where care is provided. A focus on geriatric competence, emphasizing the unique features of common health conditions in older adults, is crucial in nursing practice, education, and research.
Assessing older patients
Geriatric syndromes are often defined by isolating the shared risk factors associated with them, including older age, cognitive or functional impairment, and impaired mobility. Signs and symptoms of geriatric syndromes are many patients' chief complaint and are usually what lead older adults to seek healthcare. Patients who aren't treated successfully can consume an ever-increasing amount of resources, causing frustration among patients, caregivers, and healthcare providers. When searching for an answer to their problems, older adults may change healthcare providers or specialists, visit various EDs and clinics, and be hospitalized multiple times.2
When caring for older adults, perform comprehensive geriatric assessments to identify geriatric syndromes, especially for those older than 85.1 Besides using the Mini-Mental State Examination, apply geriatric assessment tools to assess:
* functional and instrumental (higher level functional) activities of daily living.
* gait and balance.
* visual acuity.
* fall risk.
* skin breakdown.1
The Hartford Institute for Geriatric Nursing websites offer many educational resources for practicing nurses, nurse educators, and researchers who assess and care for older adults. (See Tapping the Hartford Institute for Geriatric Nursing websites.) Review the “Try This” and “How to Try This” series available on these websites for 27 assessment tools considered best practice in nursing care of older adults. (See Finding “Try This” and “How to Try This” resources for assessment tools.) The “Try This” series, which is provided free through the John A. Hartford Foundation, demonstrates how to properly and effectively use these tools.
The “Fulmer SPICES: An Overall Assessment Tool for Older Adults,” one of the “Try This” tools, is an excellent beginning framework because it focuses on the six marker conditions that coincide with the five common conditions defined as geriatric syndromes. These six marker conditions are:
* S leep disturbances
* P roblems with eating and/or feeding
* I ncontinence
* C onfusion
* E vidence of falls
* S kin breakdown.
Although the SPICES tool isn't all-inclusive, it can lead nurses to critical areas that need more in-depth assessment. Nurses can use it to identify nursing problems or diagnoses specific to older adults and then develop a comprehensive care plan focusing on these problems. Additional assessment tools can be incorporated as more geriatric syndromes are identified.
Look for substantial evidence based on published research about how to manage geriatric syndromes and diseases common in older adults. This evidence may appear in practice guidelines, quality indicators, and evidence-based reports. Geriatric nursing protocols for best practice can stimulate nurses to practice with greater knowledge and skill and improve the quality of care for older adults.
Evidence-based practice is a framework for clinical practice that integrates the best-available scientific evidence with the expertise of clinicians and patient preferences and values to make decisions about healthcare.3 Evidence-based geriatric nursing protocols for best practice for pressure ulcers, incontinence, falls, functional decline, and delirium reflect assessment and intervention strategies by experts who've reviewed the evidence.
Look for journal articles and textbooks outlining evidence-based geriatric nursing protocols and online resources. One framework, Advancing Care Excellence for Seniors (ACES), was created by a partnership of the National League for Nursing (NLN) and Community College of Philadelphia with funding from the John A. Hartford Foundation, Laerdal Medical, and the Independence Foundation. The website http://www.nln.org/ACES introduces ACES as essential nursing actions to improve quality of life for older adults, coordinate care, decrease caregiver stress, and promote shared decision making.
Using the ACES framework, nurses assess function and expectations first, then coordinate care and manage clinical conditions using evolving knowledge about geriatric syndromes and the special needs of older adults. An interdisciplinary team can evaluate the risks and benefits of care decisions with the patients, families, and caregivers. The team makes recommendations based on the older adult's wishes, expectations, resources, strengths, and cultural traditions to treat geriatric syndromes, encourage adoption of healthy behaviors, and improve quality of life.1
Use best-practice exemplars of effective prevention programs to care for older adults. These exemplars incorporate an interdisciplinary team approach as well as a strong geriatric nurse-centered approach. Preventing falls and skin breakdown, reducing adverse drug events, and promoting oral health and adequate hydration can help prevent complications of geriatric syndromes.3 Proven preventive strategies for delirium, falls, and skin breakdown have been identified in the nursing literature and translated into clinical practice and policy initiatives.
Assessing relative risk is the first step in a patient's plan of prevention. Failing to identify, diagnose, or treat underlying causes of geriatric syndromes such as sensory deficits, fragility, and risks for skin breakdown, can adversely affect an older adult's health and longevity.3 Focusing on maintaining function, dignity, and individual control will promote health and quality of life.
Educating future nurses
Nursing students need intentional planned encounters using experiences such as simulation, unfolding case studies (as provided by the NLN's ACES framework), and clinical rotations in various settings such as hospitals, rehab centers, long-term-care facilities, and home-care and community settings. Best-practice geriatric nursing protocols must be introduced into nursing education, research, and practice settings. Nurses armed with knowledge about age-related changes and the use of proper assessment tools can play a vital role in improving geriatric standards of practice.
Nurses must also draw on other resources to meet the needs of older adults. Research has shown that interdisciplinary teams have dramatically improved geriatric patient care and outcomes. In The Institute of Medicine's report, Retooling for an Aging America: Building the Health Care Workforce, interdisciplinary collaboration was identified as a vital part of caring for the aging population.4 “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 optimal outcomes.”3
Nurses must recognize geriatric syndromes and apply best practices to the care of older adults to achieve the best outcomes possible.
Tapping the Hartford Institute for Geriatric Nursing websites
Hartford Institute for Geriatric Nursing: http://www.hartfordign.org.
Hartford Institute for Geriatric Nursing. ConsultGeriRN: http://www.consultgerirn.org.
Hartford Institute “Try This” Series: http://www.hartfordign.org/resources/Try_This_Series.
Hartford Geriatric Nursing Initiative: http://www.hgni.org.
Finding “Try This” and “How to Try This” resources for assessment tools
Tap into http://www.hartfordign.org/practice/try_this/ to find tools to explore these issues:
Issue 1: SPICES: An Overall Assessment Tool of Older Adults
Issue 2: Katz Index of Independence in Activities of Daily Living (ADL)
Issue 3: Mental Status Assessment of Older Adults: The Mini-Cog
Issue 4: The Geriatric Depression Scale (GDS)
Issue 5: Predicting Pressure Ulcer Risk
Issue 6.1: The Pittsburgh Sleep Quality Index (PSQI)
Issue 6.2: The Epworth Sleepiness Scale
Issue 7: Assessing Pain in Older Adults
Issue 8: Fall Risk Assessment
Issue 9: Assessing Nutrition in Older Adults
Issue 10: Sexuality Assessment for Older Adults
Issue 11.1: Urinary Incontinence Assessment in Older Adults: Part I—Transient Urinary Incontinence
Issue 11.2: Urinary Incontinence Assessment in Older Adults: Part II—Persistent Urinary Incontinence
Issue 12: Hearing Screening in Older Adults
Issue 13: Confusion Assessment Method (CAM)
Issue 14: The Modified Caregiver Strain Index (CSI)
Issue 15: Elder Mistreatment Assessment
Issue 16.1: Beers' Criteria for Potentially Inappropriate Medication Use in the Elderly: Part I—2002 Criteria Independent of Diagnoses or Conditions
Issue 16.2: Beers' Criteria for Potentially Inappropriate Medication Use in the Elderly: Part II—2002 Criteria Considering Diagnoses or Conditions
Issue 17: Alcohol Use Screening and Assessment
Issue 18: The Kayser-Jones Brief Oral Health Status Examination (BOHSE)
Issue 19: Horowitz's Impact of Event Scale: An Assessment of Post Traumatic Stress in Older Adults
Issue 20: Preventing Aspiration in Older Adults with Dysphagia
Issue 21: Immunizations for the Older Adult
Issue 22: Assessing Family Preferences for Participation in Care in Hospitalized Older Adults
Issue 23: The Lawton Instrumental Activities of Daily Living (IADL) Scale
Issue 24: The Hospital Admission Risk Profile (HARP)
Issue 25: Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)
Issue 26: The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults
Issue 27: General Screening Recommendations for Chronic Disease and Risk Factors in Older Adults