age-friendly health care and systems 4ms overview
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Age-Friendly Health Care and Systems
4Ms Overview
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
What Age-Friendly health care is
Why it is important
Brief review of how to use the 4Ms
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
An Age-Friendly Health System
Where every older adult:
Gets the best care possible
Experiences no healthcare-related harms
Is satisfied with the health care they receive
Value is optimized for everyone!
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Age-Friendly Health Care: 4Ms
What Matters most to the person
Medications
Mobility
Mentation: dementia, delirium, depression
A framework: not a program, but a shift in how we provide care to older adults
4Ms Guide Quality Care
Lots of good reasons to use 4M framework!
Best practice acrosshealthcare settings
Focus on the person,not the disease
Focus on quality of life, not “more treatment” or acute care transfers
4Ms Guide Quality Care
Make care for older adults with multiple chronic conditions: Less fragmented
and burdensome
Better focused on What Matters most to older persons
Less frustrating for thehealthcare team
Source: Mary Tinnetti, 2016, AGS
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Critical Interactions Among 4Ms!
What Mattersis the “driver”!
Medications Mobility
Mentation• Dementia• Delirium• Depression
What Matters Most
Know and act on each older adult’s specific health outcome goals and care preferences across settings
Daily living and engagement
Outpatient care
Rehab/short stays
Transfers between settings
Acute care
End-of-life care
What Matters Most
Life & Living: What gives us joy, happiness,
meaning in living
Health:Our ongoing
health concerns
& conditions
Health Care:Treatment and
care of disease, illness, conditions
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What Matters: Life Outside Health
Explore life context, priorities, preferences . . .
What is important to you?
What brings you joy? Makes you happy? Makes life worth living?
What do you worry about?
What are some goals you hope to achieve before your next birthday?
What would make tomorrow a really great day?
What else would you like us to know about you?
What Matters: Anchor to Health
Consider health status and care needs New diagnosis, treatment decision
Change in health status
Change in residence or care location
Focus question on How treatment could facilitate or impede
abilities to do things enjoyed (everyday activities) or attain a goal (attend a meaningful event)
What Matters: Guiding Questions
Health OUTCOME goals
What is the one thing about your health care you most want to focus on so that you can do [desired activity] more often or more easily?
What are your most important goals now, and as you think about the future with your health?
What concerns you most when you think about your health and health care?
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What Matters: Varies with Needs
Hospitalization: What is the goal of acute care treatment? To do WHAT?
Post-Acute/Skilled care: To regain abilities to do WHAT?
Long-term stay: To maintain abilities to do WHAT?
End-of-life care: To best assure WHAT is achieved or avoided?
4Ms Key Actions
Focus on What Matters, then think about how Mobility, Medications, dementia, delirium, and depression may impact the person’s ability to do What Matters most!
Don’t make assumptions! Use 2 steps:
ASSESS each M: Screen & document
ACT ON each M: Manage, treat, intervene to promote wellness
Medications
ASSESS: Review high-risk Medications
Benzodiazepines
Opioids
Highly anticholinergic drugs
Sedatives and sleep medications
Muscle relaxants
Tricyclic antidepressants
Antipsychotics
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Medications
ACT ON: Use Age-Friendly Medicationthat does not interfere with
What Matters to the older person,
Mobility, or
Mentation
Medications
Deprescribe
Dose reductions
Discontinuation
Focus on person’s goals!
What Matters most
Desired health outcome
Mobility
ASSESS: Ensure that older adults move safely every day in order to maintain function and do What Matters
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Mobility
ACT ON
Ensure a safe environment
Set daily Mobility goals that support What Matters
Avoid high-risk Medications
Refer to PT
Regular exercise, no matter what level!
Mentation
Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care
Acute care: greater focus on delirium
Ambulatory care: greater focus on depression, dementia
Senior living: Pay attention to all 3Ds!
Mentation: Dementia
Check history related to cognitive function, diagnosis of dementia
ASSESS
Mini-Cog
SLUMS
MOCA
6-ItemScreener
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Mentation: Dementia
ACT ON Memory deficits do not rule
out making decisions aboutWhat Matters
Capacity to make MANY decisions endures
Ask about preferences
Focus on ABILITIES
Encourage person-FIRST approach, supported by family involvement
Mentation: Delirium
Consider common causes: infection, pain, hypoxia, dehydration, Medications
ASSESS
2-Item Ultra-Brief Delirium Screen (UB-2)
1 question confusion assessment
Delirium Observation Scale (DOS)
Confusion Assessment Method (CAM)
Mentation: Delirium
ACT ON
Treat/reverse underlying causes!
Assure safety
Gently re-orient
Promote hydration
Promote sleep
Increase ambulation Mobility
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Mentation: Depression
Anhedonia is common in late-life depression; sadness may not be prominent!
ASSESS
2-item Patient HealthQuestionnaire (PHQ-2)
9-item Patient HealthQuestionnaire (PHQ-9)
Geriatric Depression Scale
Mentation: Depression
ACT ON
Behavioral activation: schedule pleasant activities
Talking therapy: brief problem-solving therapy
Physical activity/exercise
Self-care: nutrition, sleep, pain management
Antidepressant Medication: many choices based on symptoms
4Ms Is a “Package,” not Silos!
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4Ms Series
Please also see our additional programs:
What Matters
Medication
Mobility
Mentation, including dementia, delirium and depression
Goal: Understand and use the framework to guide care of older people!
Work as a team to deliver high-quality care!
Summary
Being Age-Friendly and using the 4Ms makes good sense in all settings!
Acute care, hospitals
Ambulatory care, clinics
Senior living, home health
FOCUS on What Matters!
Reduce unwanted/unneeded care and treatment
Promote quality of life and living!
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Age-Friendly Health Care and Systems What Matters
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Brief review of 4Ms Age-Friendly health care Common care challenges
What Matters to older persons Person-centered vs. disease-focused Aligning care to each person’s goals and preferences Conversations across settings
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Acknowledgements
https://patientprioritiescare.org/http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
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https://www.acponline.org/clinical-information/clinical-resources-products/patient-priorities-care
Patient Priorities Care
An excellent resource for
learning how to have
conversations with older people
about WhatMatters and
aligning care to the person’s
priorities!
An Age-Friendly Health System
Where every older adult:
Gets the best care possible
Experiences no healthcare-related harms
Is satisfied with the health care they receive
Value is optimized for everyone!
Age-Friendly Health Care: 4Ms
What Matters most to the person
Medications
Mobility
Mentation: dementia, delirium, depression
A framework: not a program, but a shift in how we provide care to older adults
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4Ms Guide Quality Care
Lots of good reasons to use 4M framework!
Best practice acrosshealthcare settings
Focus on the person, not the disease
Focus on quality of life, not “more treatment” or acute care transfers
The Big Challenge
Needs of older adults with multiple chronic conditions vary!
One size does NOT fit all (or over time)
What made sense earlier may not make sense now
Priorities change
Where Is the Person NOW?
Source: Mary Tinnetti, 2016, AGS
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What Matters
Patients identify their health priorities
Clinicians translate these priorities into care options
All care aligned with these priorities
Source: Mary Tinnetti, 2016, AGS
What Matters
What Matters to older adults is the basis of Age-Friendly health care!
Change the conversation from
What is the matter?to
What matters to you?
What Matters to Older Adults
Know and align care with each person’s specific health outcome goals and care preferences across settings
Daily living and engagement
Outpatient care
Rehab/short stays
Transfers between settings
End-of-life care
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https://theconversationproject.org/
What Matters: Not Just End of Life
Discussing What Matters is critical to advance care planning
However, 4Msframework is not limited to end of life!
What Matters
Health outcome goals
Values & activities that motivate a person to sustain and improve health
Can help guide decision-making
E.g., babysitting grandchild, walking with friends, gardening, volunteering
Care preferences
Healthcare activities the person is willing and able (or NOT willing or able) to do or receive
Institute for Healthcare Improvement | ihi.org
I go for blood work every month. It’s not a bother.My medications
make me so tired I can hardly get out
of the chair, let alone get to
church.
I walk and do the exercises that my PT taught me every day.
Not helpful? Or helpful and doable?
Care Preferences
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What Matters Conversations
Ongoing communication and relationship building with older persons and caregivers Regular visits
Annual Wellness visits
New diagnosis
Life change
Ongoing management of chronic conditions
Inpatient visits
Advance care planning for end of life
What Matters Conversations
Team effort!
Nurses, nurse practitioners, nurse navigators
Physicians, physician assistants
Social workers, chaplains
Community health workers, trained volunteers
Identify, understand, and document WhatMatters so it can be acted on and updated across settings
Patient/Family Boards
Lots of creative ways to share What Matters
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What Matters Most
Life & Living: What gives us joy, happiness,
meaning in living
Health:Our ongoing
health concerns
& conditions
Health Care:Treatment and
care of disease, illness, conditions
What Matters: Life Outside Health
Explore life context, priorities, preferences . . .
What is important to you?
What brings you joy? Makes you happy? Makes life worth living?
What do you worry about?
What are some goals you hope to achieve before your next birthday?
What would make tomorrow a really great day?
What else would you like us to know about you?
What Matters: Anchor to Health
Health status and care needs New diagnosis, treatment decision
Change in health status
Change in residence or care location
Focus question on How treatment could facilitate or impede
abilities to do things enjoyed (everyday activities) or attain a goal (attend a meaningful event)
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What Matters: Guiding Questions
Health OUTCOME goals
What is the one thing about your health care you most want to focus on so that you can do [desired activity] more often or more easily?
If we could change one thing in your health or health care, what would it be? What would you be doing more of if we could accomplish this?
What concerns you most when you think about your health and health care?
What Matters: Guiding Questions
What are your fears or concerns for your family?
What are your most important goals if your health situation worsens?
What things about your health care do you think aren’t helping you, and you find bothersome or difficult?
Is there anyone who should be part of this conversation?
What Matters: Plan Ahead!
Keep it comfortable
Invite the person to talk about “What Matters” ahead of time
Ask one or more “What Matters” questions
Listen carefully!
Affirm your understanding
Incorporate “What Matters” information into the care plan and share with the team
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What Matters: Example
“As you know, you have several diseases and health problems that your other clinicians and I are trying to help you with. We know that people differ in what matters most to them in terms of their health and healthcare. Knowing what is most important to you helps me, and your other doctors and nurses, work with you to recommend the best care and treatment for you. You would have 1-2 sessions of about ½ hour with one our healthcare team members to help you identify what is most important to you about your health, what you think is working well about your current healthcare, and what you find difficult or unhelpful. If you agree, which I hope you will, we can set up a time that works for you to get started. This will help us take the best possible care of you. Any questions about this?”
© Mary Tinetti, Caroline Blaum, 2018, Patient Priorities Care. https://www.acponline.org/clinical-information/clinical-resources-products/patient-priorities-care
What Matters Varies
Priorities often change based on the setting of care
Hospitalization
Post-Acute/Skilled care
Long-term stay
End-of-life care
What Matters most may vary from the health issue!
Feeling safe & calm
Managing pain in order to walk again
Time with family
Talking with the chaplain
What Matters: Example
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What Matters: Shared Decisions
Work to reconcile differences Agree on information to inform the decision Person’s priorities, life context, family concerns
Burden of treatment, co-existing conditions
Health trajectory
Present trade-offs (unbiased)
Be realistic about benefits If person understands alternatives, then
accept decision
4Ms Start with What Matters
What Mattersis the “driver”!
Medications Mobility
Mentation• Dementia• Delirium• Depression
Summary: What Matters Most
Ongoing conversations
Aligns care with each person’s health outcome goals and care preferences
Goals change over time
Team effort: identify, understand, document
Conversation skills are developed with practice!
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Age-Friendly Health Care and Systems
Mentation: Dementia
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Overview of dementia Why it is important in 4Ms Brief review of screening Brief review of interventions
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Mentation
Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care
Acute care: greater focus on delirium
Ambulatory care: greater focus on depression, dementia
Senior living: Pay attention to all 3Ds!
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Mentation: Dementia
Cognitive status is important to having conversations aboutWhat Matters
Memory deficits do not rule out making decisions about What Matters
Consider how cognitive status does, or does not, impact the person’s ability to engage in meaningful conversations about goals and preferences
Mentation: Dementia
Brief Overview Permanent loss of cognitive abilities
caused by damage to brain cells NOT a “normal” part of aging The common end result of many entities Diseases Traumas Infections Drugs
Dementia: Common Features
Impairments in . . .
Thinking Ability to reason Judgement Problem-solving Language Memory Perception Impulse control
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Dementia Due to . . .
Alzheimer’s disease Vascular disease Frontotemporal
lobar degeneration Lewy body disease Traumatic brain
injury
HIV disease Prion disease Parkinson’s disease Huntington’s
disease Substance/
Medication use Another medical
condition
Dementia: Progressive Course
Early Confused Ambulatory Late
Months to years (-)
Cog
nit
ive
& f
un
ctio
nal
ab
ilit
ies
(+
)
Dementia: Common Features
Progressive loss of abilities results in many changes . . . Personality Behavior Emotion Function: social and physical
Interferes with doing What Matters most! Identification is essential to quality care
and living!
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Age-Friendly: Key Actions
ASSESS Consider risk factors, presentation Check history related to cognitive function,
history of dementia Screen for dementia
ACT ON your findings Refer for further evaluationManage symptoms Engage additional resources/supports
Mentation: Dementia
Assessment Tips* Normalize cognitive screening for patients
“I’m going to assess your cognitive health, just like
we check your blood pressure, or heart or lungs…”
Remember: Cognitive screening is part of Welcome to Medicare and Medicare Annual Wellness Visits!
*Source: Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (April 2019). Institute for Healthcare Improvement. www.ihi.org
Mentation: Dementia
Assessment Tips* Emphasize the older person’s strengths
when screening
Document and share findings with the team Consider and rule out delirium if cognitive
change is sudden (days to weeks)*Source: Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (April 2019). Institute for Healthcare Improvement. www.ihi.org
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Mentation: Delirium
Delirium Delirium
Dementia
Remember that delirium is part of Mentation, and can occur alone, or overlap with dementia!
Dementia: ASSESS
Many brief tools to screen for dementia
Mini-Cog
SLUMS
MOCA
6-ItemScreener
Select a tool that best fits your setting/practice!
Three item recall (3 pts)
Clock Drawing (2 pts)
Scoring: 0 to 5• 0-2 = concern for
cognitive functioning*• 3-5 = less concern
for dementia
*Mini-Cog is a screening tool! Further evaluation is needed to
diagnose dementia
https://mini-cog.com
Mini-Cog
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St. Louis University Mental Status (SLUMS) Examination
Scoring: 0 to 30• 27-30 = Normal • 21-26 = Mild
Neurocognitive Disorder
• 1-20 = Dementia
https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/slums_form.pdf
Montreal Cognitive Assessment Tool (MoCA)
Scoring: 0-30• 26-30 = Normal• 18-25 = Mild Cognitive
Impairment (CI)• 10-17 = Moderate CI• <10 = Severe CI
Note: Research for these severity ranges has not been established
https://www.mocatest.org
Six-Item Screener (SIS)
Scoring: 0-6• 4-6 = Normal• 1-3 = Assess
further
SIS is designed for brief screening that directs further assessment – not diagnosis
Med Care. 2002, Sept; 40(9):771-81.doi: 10.1097/00005650-200209000-00007
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Dementia: ACT ON
Taking action is guided by:
Care setting: acute care, ambulatory clinic, residential/nursing facility care
Stage of dementia: early, middle, late
Identified needs of the person Further evaluation/diagnosis Symptom management Social support, education, community
services, family support
Dementia: ACT ON
Not all cognitive impairment is dementia! Further evaluation, diagnosis is criticalMedication side effects can impair thinking
Depression can impact concentration / look like memory impairment
Delirium can mimic dementia
Consider all 4Ms!
Ask: What Matters Most
Life & Living: What gives us joy, happiness,
meaning in living
Health:Our ongoing
health concerns
& conditions
Health Care:Treatment and
care of disease, illness, conditions
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Dementia: ACT ON
What Matters most to the person?
Use the person’s priorities in communicating, decision-making, and planning! Consider: How does the person’s cognitive function
influence reaching his/her goals?
What support, assistance, or resources may be needed?
Who else may need to be involved?
Dementia: ACT ON
Encourage persons living with dementia to be engaged in discussions!
Dementia: ACT ON
Capacity to make many decisions endures Ask about preferences Focus on abilities
Family involvement re: goals of care is important, but person-FIRST is best!
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Dementia: ACT ON
Maximize function to do What Matters
Evaluate Medications Side effects, interactions Impact on function?
Maintain Mobility Ambulation, activity engagement Do What Matters most!
Encourage, support independence
Dementia: ACT ON
Emphasize the person – not the diagnosis Preserved abilities, not losses Individual tastes, interests, values Preferences for care & treatment Engagement in meaningful activities
What Matters!
Compensate for lost abilities Support, encourage Simplify, adapt
Dementia: ACT ON
Many online resources offer education and support for the person, family ADEAR: https://www.nia.nih.gov/health/alzheimers
National Institute on Aging: https://order.nia.nih.gov/view-all-alzhemer-pubs
Alzheimer’s Association: https://www.alz.org/
Alzheimer’s Society, Canada: https://alzheimer.ca/en/help-support/im-living-dementia
Alzheimer’s Society, UK: https://www.alzheimers.org.uk
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Dementia Friendly Communities
Another importantsocial movement Important overlap
with being Age-Friendly! Many resources for
being Dementia Friendly!
https://www.dfamerica.org/
Dementia Friendly Communities
https://dementiafriendsusa.org/
Summary: Dementia
Recognize cognitive decline/impairment
Apply screening tools
Discuss with team members
Refer for further evaluation
Assess interaction with all 4Ms
Support function: Doing What Matters!
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Age-Friendly Health Care and Systems
Mentation: Delirium
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Overview of delirium (a.k.a. acute confusion) Why it is important in 4Ms Brief review of screening Brief review of interventionsAcknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Mentation
Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care
Acute care: greater focus on delirium
Ambulatory care: greater focus on depression, dementia
Senior living: Pay attention to all 3Ds!
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Mentation: Delirium
Brief Overview Rates are high among older adults 10%-30% in emergency departments 15%-53% post-operatively 70%-80% in intensive care units Up to 60% in nursing homes Up to 83% at end of life
Delirium is often NOT recognized!
APA, DSM-5, 2013
Mentation: Delirium
Too often mistaken for dementia! Problematic in acute care settings Providers don’t know what “baseline” is ASSUME older person has dementia Lack of identification triggers downward spiral No interventions to treat symptoms Inappropriate Medication use Failure to communicate at discharge Persisting confusion that leads to disability, death
Identification is the key!
Mentation: Delirium
Key Signs & Symptoms
Disturbance in ATTENTION Reduced ability to direct, focus, sustain, and
shift attention; reduced orientation
RAPID ONSET of symptoms Change from baseline level
Symptoms FLUCTUATE in severity during the course of the day
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Delirium: Fluctuating Course
Morning Afternoon Night
(-)
S
ymp
tom
s
(+) De Lira = Latin for “Off the track”
Mentation: Delirium
Disturbance in COGNITIONMemory deficit Disorientation Language disturbance Visuospatial disturbance Perception: hallucinations, delusions,
illusions/misperceptions
Disturbances aren’t due to another neurocognitive disorder (like dementia)
Mentation: Delirium
Disturbance is the direct physical consequence of A medical condition Substance intoxication or withdrawal Toxin exposureMultiple causes (common in late life!)
Main Point Physical health problems trigger delirium & are often reversible
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Mentation: Delirium
Common associated features Sleep-wake cycle disturbance Daytime sleepiness Nighttime agitation Difficulty falling asleepWakefulness throughout the night
Rapid shifts in emotions Anxiety, fear, depression, irritability, anger Screaming, cursing, muttering, moaning
Mentation: Delirium
Predisposing factors Cognitive impairment/Dementia Multiple health problems Advanced age Dehydration Malnutrition Vision/hearing impairment Immobilization Functional impairments
So on a “good day” many older adults are at risk for delirium!
Mentation: Delirium
Physical causes of deliriumMedications* Infections Pain Electrolyte imbalanceMetabolic disturbance Hypoxia Sensory deficits
And every new health problem or change can tip the balance!
*Visit IA-ADAPT at https://igec.uiowa.edu/ia-adapt
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Delirium and Dementia
Remember! Delirium can overlap on dementia
Dementia
Delirium
Age-Friendly: Key Actions
ASSESS Consider risk factors, presentation Check history for new Medications, medical
conditions that may be the trigger Screen for delirium
ACT ON your findings Treat underlying health problemsManage symptoms, support function Educate person and family!
Mentation: Delirium
Assessment Tips Select & use the assessment approach
that best fits your setting & team Adjust your approach to avoid the sense of
being “tested” Engage & educate family about delirium Enlist their help to identify changes Is their loved one more confused than usual?
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Delirium: ASSESS
Many options to screen for delirium
2-Item Ultra-Brief Delirium Screen (UB-2)
1 question confusion assessment
Delirium Observation Scale (DOS)
Confusion Assessment Method (CAM)
Select a scale that best fits your team and care culture!
2-Item Ultra-Brief (UB-2) Delirium Screen
Fick D, Inouye S, Guess J, Ngo LH, Jones RN,Saczynski JS, Marcantonio ER. Preliminary development of an ultra-brief two-item bedside test for delirium. Journal of Hospital Medicine. 2015;10:645-650. DOI 10.1002/jhm.2418
https://www.nursing.psu.edu/wp-content/uploads/2019/03/UB-2-with-disclaimer-fick_Delirium-Pocket-Card_052118.pdf
Confusion Assessment Method (CAM)
Scoring: Delirium indicated by1) Presence of acute onset &
fluctuating discourse, AND
2) Inattention, AND EITHER
3) Disorganized thinking OR
4) Altered level of consciousness
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.
Items mirror diagnostic criteria for delirium
1. Acute onset
2. Inattention
3. Disorganized thinking (cognitive disturbance)
4. Altered consciousness
5. Disorientation
6. Memory impairment
7. Perceptual disturbance
8. Psychomotor disturbance
9. Altered sleep-wake
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Confusion Assessment Method (CAM)
Resources are available at the Iowa Geriatric Education Center website: https://igec.uiowa.edu/ia-adapt
Delirium Observation Scale (DOS)
Scoring: 0-13
• No = 0
• Yes = 1
• Score of three or more points indicates risk of delirium, need for further assessment
* Items 3, 8, and 9 are reverse-scored (Yes = 0, No = 1)
Gavinski K, Carnahan R, Weckmann M. Validation of the Delirium Observation Screening Scale (DOS) in a hospitalized older population. J Hosp Med. 2016;11(7): 494-497. doi: 10.1002/jhm.2580
13 items observed each of 3 shifts: day, evening, night
1) Dozes off during conversation or activities
2) Is easily distracted by stimuli from the environment
3) Maintains attention to conversation or action*
4) Does not finish question or answer
5) Gives answers that do not fit the question
6) Reacts slowly to instructions
7) Thinks he/she is somewhere else
8) Knows which part of the day it is*
9) Remembers recent events*
10) Is picking, disorderly, restless
11) Pulls IV tubes, feeding tubes, catheters, etc.
12) Is easily or suddenly emotional (frightened, angry, irritated)
13) Sees/hears things which are not there
Growing Evidence for 1 Question*
Is the person more confused today than
USUAL?If Yes, then assess further!
*Best used by family and direct care staff who know the person well and know what “baseline” is for the person
https://pubmed.ncbi.nlm.nih.gov/20837733/
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Delirium: ACT ON
Taking action is guided by the care setting
Hospital/Acute care: greater focus on discharge planning and communication with family and other providers Long-term care: greater focus on risk
factors and reoccurrence Home: greater focus on family
knowledge, involvement
Delirium: ACT ON
First and foremost . . . Identify & treat
reversible underlying causes! Infection Pain HypoxiaMedication side effects, interactions
Assure safety
Delirium: ACT ON
Increase ambulation Mobility Sit, stand, walk as soon as able Support, assist to be safe & successful
Promote hydration Dehydration both causes & contributes Encourage & monitor intake
Promote sleep (without Medications!)
Reassure emotional reactions
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Delirium: ACT ON
Re-orient with environmental cues Clocks, calendars, white boards
Promote sensory input Increase lighting, glasses, hearing aids
Document and communicate across levels of care! Include in discharge planning, transfers Reduce risk that confusion is “accepted” as
baseline and not addressed!
Delirium: ACT ON
Reduce risk of misperceptions Remove or disguise objects that are
misinterpreted Clutter Pictures Reflections
• E.g., insists someone is in the bathroom with them try covering the mirror
Reduce sounds that are misunderstood Voices, address systems, radio, television
Delirium: ACT ON
Adjust approaches Offer limited choices Provide “conversational” orientation “Would you like juice or milk with breakfast?” “Isn’t it a beautiful day for early November?
Thanksgiving will be here in no time!”
Provide guidance Educate: Family, patient, caregivers Explain: Reversible confusion related to
illness, stress; should resolve! Support: What to monitor, how to get help
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Delirium: ACT ON
Use Medication ONLY for severe agitation, fear, or psychotic symptoms that pose safety risks Behaviors that interfere with medical
treatment and recovery Psychotic symptoms/misbeliefs that are
troubling/upsetting to the person
Low dose, short-term, discontinue as soon as safety risk passes!
Summary: Delirium
Recognize changes from baseline Assess using standardized method Collaborate with team to identify and
treat underlying health problem(s) Assure person’s safety and comfort Assist person and family to understand
symptoms Monitor outcomes to assure full recovery
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Age-Friendly Health Care and Systems
Mentation: Depression
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Overview of depression Why it is important in 4Ms Brief review of screening Brief review of interventions
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Mentation
Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care
Acute care: greater focus on delirium
Ambulatory care: greater focus on depression, dementia
Senior living: Pay attention to all 3Ds!
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Mentation: Depression
Clinical depression changes thoughts and feelings that interfere with: Talking about What Matters Engaging in physical & social activitiesManaging other health conditions Enjoying friends, family, activities
Depression robs older people of their quality of life AND contributes to a downward spiral of disability
Mentation: Depression
Brief Overview Clinical depression is more than a
passing mood! Significant cluster of specific symptoms Persists over time Impairs function Contributes to dysfunction & disability Increases risk of self-harm, suicide
Mentation: Depression
Who wouldn’t feel that way?Being sad is understandable –
I mean, after all…Goodness, you have every RIGHT to be
depressed!
Too often UNrecognized and UNtreatedamong older people!
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Mentation: Major Depression
Two “hallmark” symptoms Depressed mood Sadness, discouragement, crying “Down in the dumps” – “Blues”
OR
Loss of ability to experience pleasure (a.k.a. anhedonia)Withdrawal, inactivity, isolation “Nothing is fun” – “Don’t care”
Mentation: Major Depression
Plus additional symptoms for 5 totalWeight loss or gain Sleep disturbance Insomnia or
hypersomnia Psychomotor agitation or retardation Fatigue, loss of energy Feelings of worthlessness, inappropriate guilt Loss of ability to think, concentrate, make
decisions Recurrent thoughts of death, suicidal ideation
Depression “Without Sadness”
Anhedonia present, but sadness is NOT Loss of ability to experience pleasure loss of interest, apathy, withdrawal, indifference, low motivation
Additional symptoms Physical: Sleep, appetite, energy, motor activity looks like PHYSICAL ILLNESS
Psychological: Problems thinking, concentrating looks like DEMENTIA
Often overlooked AS depression!
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Depressionand Dementia
Depression
Dementia
Remember, depression can occur alone, or may overlap with dementia!
Depression
30% with both!
Depression: Course
(+)
S
ymp
tom
s
(-)
Weeks to Months (up to 2 years)
Age-Friendly: Key Actions
ASSESS Consider risk factors, presentation Check history related to depression, history
of symptoms or treatment Screen for depression
ACT ON your findings Refer for further evaluation Treat symptoms Support function, refer to resources
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Mentation: Depression
Assessment Tips* Normalize depression screening for
patients
“I’m going to assess your mood, just like we check
your blood pressure, or heart or lungs…”
Remember: Depression screening is part of Welcome to Medicare and Medicare Annual Wellness Visits!
*Source: Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (April 2019). Institute for Healthcare Improvement. www.ihi.org
Depression: ASSESS
2-item Patient HealthQuestionnaire (PHQ-2) 9-item Patient Health
Questionnaire (PHQ-9) Geriatric Depression Scale GDS Short Form GDS Long Form
Don’t guess! Quantify symptoms using a standardized measure!
PHQ-9
Nine items mirror the diagnostic criteria for Major Depressive Disorder
PHQ-2 uses the first two (hallmark) symptoms required for diagnosis of MDD
PHQ-9 uses all nine symptoms
https://www.phqscreeners.com/
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PHQ-2: Rate Hallmark Symptoms
Screening: If unsure, just rate 2 symptoms1. Little interest or pleasure in doing things2. Feeling down, depressed, or hopeless
Score each item: 0=Not at all1=More than half the days2=Several days3=Nearly every day
Total Score: 0-6
Score of 3 or greater Complete the remaining items!
PHQ-9: Rate Remaining Symptoms
1.Little interest or pleasure in doing things
2.Feeling down, depressed or hopeless
3.Trouble falling or staying asleep, sleeping too much
4.Feeling tired or having little energy
5.Poor appetite or overeating
6.Feeling bad about yourself, feeling like a failure
7.Trouble concentrating on things, such as reading the newspaper or watching television
8.Moving or speaking slowly, or being restless and moving around more than usual
9.Thoughts that you would be better off dead or of hurting yourself in some way
PHQ-9: Scoring
Score items as before: 0=Not at all to 3=Nearly every day
Add scores for 9 items; Total score 0-27 Apply cut-points: 0-4 = depression is not significant 5-9 = mild depression 10-14 = moderate depression; any score over 10 is
considered clinically significant/worthy of treatment 15-19 = moderately severe depression 20-27 = severe depression
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Geriatric Depression Scale: Long Form
Scoring: 0-30• 0-9 = normal• 10-19 = mild• 20-30 = severe
GDS forms are considered public domain
Geriatric Depression Scale: Short Form
Scoring: 0-15
• >5 suggestive of depression
• >10 indicative of depression
• Scores of 5 or greater suggest need for further assessment
Depression: ACT ON
Taking action is guided by: Severity of depression symptoms Risk of self-harm Older person’s treatment preferencesMany older adults prefer non-drug treatments! Explore preferences Discuss options Focus on What Matters!
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Depression: ACT ON
Think about interactions among 4Ms Difficulty identifying What Matters due to
anhedonia? Sense that nothing is fun? Nothing matters?
Medication(s) triggering depression?
Mobility challenged due to fatigue, lack of energy?
Depression masked by dementia?
All of the above?
Depression: ACT ON
Two main treatment approaches: Behavioral/non-drug therapies Behavioral activation Talking therapy Physical activity/exercise Self-care Antidepressant Medication Many choices; selection based on symptoms Follow 4Ms advice! Only if preferred and safe!
“For mild to moderate depression, talking and behavioral therapies often works as well as medication. What would you like to try?”
Depression: ACT ON
Behavioral activation Schedule pleasant events Re-establish healthy routines Increase positive experiences Leads to improved mood and better
functioning
Individual, social, physical activities
Keep it simple! (Failure-free!)
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Depression: ACT ON
Physical exercise Engaging in physical activity for 20 minutes a day, 5x each week, decreases depression and improves health!
Break the cycle of “Do Less Feel Worse”
Depression: ACT ON
Counseling, talking therapy Often preferred as 1st line Don’t want more pills Don’t want “mind” pills in particular
May need to explain goals No couches, no talking about dreams or
“mother,” unless she is a current problem Usually problem-focused, brief, limited
number of visits
Depression: ACT ON
Antidepressant Medication Apply Age-Friendly practices! Select Medications based on their
side effect profile Avoid high-risk Medications: TCAs & MAOsMonitor side or adverse effects Start low, go slow, but keep going until
symptoms resolve! Educate the person to advance adherence!
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Depression: ACT ON
Promote adherence Antidepressants . . . Do NOT work immediately Are NOT addictingWill not make you “high” Need to be taken every dayMay take 12 weeks to get the full benefit Side effects may occur & should be reported
Just another “illness treatment”
Summary: Depression
Clinical depression is often masked and misunderstood Apply screening tools; assess severity Address causal/contributing factors Assess interactions with all 4MS Treat following person’s preferences Support function: Doing What Matters!
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Age-Friendly Health Care and Systems
Mobility
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Overview of Mobility in the 4Ms
Brief review of screening
Brief review of interventions
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
4Ms in Health Care & Systems
Lots of good reasons to use 4M framework! Best practice across
healthcare settings Focus on the person,
not the disease Focus on quality of
life, not “more treatment” or acute care transfers
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Mobility: Importance
Brief Overview Most health and life goals are activities
that require Mobility Central to What Matters most! Do what is important Get to get where you
want to go Contributes to quality
of life, living
Mobility: Importance
Medications Benzodiazepines Other psychoactives Anticholinergics Anticonvulsants Antihypertensives
Not silos! All 4Msinteract!
Mentation Delirium Dementia
Impaired Mobility, increased risk of falls is associated with
Mobility: Importance
Falls risks are largely preventable! Lower body weakness Vitamin D deficiency Difficulties with walking and balance Medication side effects Vision problems Foot pain or footwear choices Home hazards like uneven steps, clutter, or
rugs that can be tripped overhttps://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-programs-for-older-adults-2/
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Mobility: Importance
Value beyond fall reduction! Physical activity is a key
prevention strategy Heart health, lung functionManage painMaintain Mobility Increase function Enhance mood: stress, anxiety,
depression Promote sleep quality, appetite
Mobility
Ensure that older adults move safely every day in order to maintain function and do What Matters
Age-Friendly: Key Actions
ASSESS Identify & treat contributing factors
Screen for Mobility limitations
ACT ON your findings Support movement every day
Support Mobility goals to do What Matters
Refer to physical +/or occupational therapy
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Mobility
Assessment Tips Identify: Older adults at risk for
functional decline Assess: Baseline function at home/on a
“good day” and at admission Ask: What is needed to maintain
function? To prevent or treat complications of frailty or immobility? Who and what needs to be involved?
Mobility
Assessment Tips Remember! Team approaches are
essential to high quality 4Ms careMedications: providers, pharmacistsMentation: family, daily care providersMobility: all team members
All team members contribute to Gathering information Supporting Mobility goals
Mobility: ASSESS
Many tools to assess Mobility Get Up and Go Test (GUG) Timed Up and Go Test (TUG) Performance Oriented Mobility
Assessment (POMA) Johns Hopkins Highest Level of Mobility
(JH-HLM) Scale
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Get Up and Go Test
Rise from sitting position Walk 10 feet, turn, return to the chair Sit back down
https://fpnotebook.com/geri/exam/GtUpAndGTst.htm
Even if you don’t administer the TUG yourself, it’s good to know what observations are made as part of the assessment!
View an example at https://www.youtube.com/watch?v=j77QUMPTnE0
Scale Source: https://www.cdc.gov/steadi/pdf/TUG_test-print.pdf
Performance Oriented Mobility Assessment (POMA)
https://www.leadingagemn.org/assets/docs/Tinetti-Balance-Gait--POMA.pdf
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Johns HopkinsHighest Level of Mobility Scale
Google: JH HLM Scale
Which One Should We Use?
It’s less about the tool and more about using it Select tool that best
fits your setting Train staff to use it Use consistently!
Also assess & monitorcontributing factors
Mobility: ACT ON
Ensure a safe environment Identify, set daily
Mobility goals thatsupport What Matters Avoid high-risk Medications Regular exercise, no
matter what level!
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Mobility: ACT ON
Address factors that interfere with Mobility Pain Strength, balance, gait impairments Deconditioning due to immobility, bed rest Treatment-related “tethers” Catheters IV lines Telemetry, others that reduce movement
Refer to physical therapy!
AFHS Change Package, 2018, IHI
Mobility: ACT ON
Support to set a daily Mobility goal to do What Matters Build on strengths and abilities
Remember that variation in older adults is the “norm,” not the exception
Start where the person is!
Revise Mobility goals as needed Goals change with transitions in care, health status Hospital goal likely quite different from goals at
home!
Daily “ACErcise”
Example from IHI about exercise on the hospital ACE unit!
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Hospital Mobility Checklist
Once daily Mobility screen Ambulate 3 times a day Out of bed or leave room for meals Refer to PT: balance, gait, strength, gait
training, exercise Restraint-free Remove catheters and other tethers No high-risk Medications
Source: P. Mulhausen (9-2-2020). Promoting Health Aging: Mobility and the Age-Friendly Health System. Telligen AFHS Learning Collaborative. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/
Mobility: ACT ON
MyMobility PlanMySelf: plan to stay independentMyHome: plan to stay safe at homeMyNeighborhood: plan to stay mobile
https://www.cdc.gov/injury/features/older-adults-mobility/index.html
Mobility: ACT ON
Get a physical checkup yearly Review Medications with your provider Get a medical eye exam yearly Follow a regular exercise program to increase
your strength and balance
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Mobility: ACT ON
All exercise is good, but strength and balance help reduce falls!
Go4Life is now at https://www.nia.nih.gov/health/exercise-physical-activity
Mobility: ACT ON
Many Options! Regular exercise
need not be strenuous or time-consuming
Exercising with Chronic Conditions offers many good choices!
Visit Exercise and Physical Activity: https://www.nia.nih.gov/health/exercise-physical-activity
Home Mobility Checklist
Safety assessment Items in easy reach Trip hazards removed: rugs, cords Bright lights, lamps within easy reach, more! PT and/or OT consultation Supportive & adaptive equipment Physical activity program Vision referral, assessment No high-risk Medications
Adapted from P. Mulhausen (9-2-2020). Promoting Health Aging: Mobility and the Age-Friendly Health System. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/
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Mobility: ACT ON
Many evidence-based fall prevention programs! STEADI A Matter of Balance Stepping On Community Aging in Place –
Advancing Better Living for Elders(CAPABLE)
Stay Active and Independent for Life (SAIL)
Tai Chi (various versions)https://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-programs-for-older-adults-2/
Summary: Mobility
Mobility is often essential to doing What Matters most! Identify and treat factors that impair
Mobility Support individualized Mobility goals
across care settings to promoteHealthWell-beingFunction and Enjoyment in living!
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Age-Friendly Health Care and Systems Medications
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Overview of Medications in the 4Ms
Brief review of screening
Brief review of interventions
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Medications: Importance
Critical to health & well-being for many Treat acute and chronic illnesses Improve function, well-being Reduce suffering, distress Increase longevity
At the same time, risks are ever-present! Age-related changes in how drugs work Metabolism, distribution, excretion = drugs may
have a greater or different impact than expected Longer half-life = drugs are in the system longer
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Medications: Importance
Multiple chronic conditions lead to . . . Multiple specialty providersMultiple Medications that all have risks Drug-drug, drug-disease interactions Adverse side effects Unexpected effects
Over-the-counter drugs that are not reported Financial cost relative to other needs: What
Matters most!
Medications: Importance
Key Point Medications have both risks & benefits! 4Ms framework
emphasizes SAFEuse! Promote function,
well-being Do What Matters!
Medications: Importance
Medications impact other Ms! Mobility: increased risk of falling Mentation: directly cause depression,
delirium; increases confusion in dementia What Matters: may not be possible due to
drug burden Function Cost
All 4Ms interact! Not silos!
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Medications
If needed, use Age-Friendly Medicationthat does not interfere with
What Matters to the older person,
Mobility, or
Mentation across care settings
Age-Friendly: Key Actions
ASSESS Review for high-risk Medication use Annually or change of status Team approach using established criteria
ACT ON your findings Deprescribe, or do not prescribe high-
risk Medications Dose reduction, discontinuation Avoid in the first place!
Medications
Assessment Tips* Consider the setting or practice culture Resources that improve Medication reviews? High-risk Medications most often prescribed
in your setting? Best approach to championing deprescribing?
Goal: Don’t be overwhelmed with Medication reviews! Start where you are!
*Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. (2019). Institute for Healthcare Improvement. IHI.org
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Medications
Assessment Tips* Consider delirium and fall prevention
protocols already in use Guidance to avoid high-risk Medications Build on, extend drug review procedures
Incorporate drug reviews at discharge Not all Medications may be needed
(e.g., short-term uses for specific symptoms)
*Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. (2019). Institute for Healthcare Improvement. IHI.org
Medications: ASSESS
IHI: Review high-risk Medications Benzodiazepines Opioids Highly anticholinergic drugs Sedatives and sleep MedicationsMuscle relaxants Tricyclic antidepressants Antipsychotics
Engage, screen, assess current needsAge-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. (2019). Institute for Healthcare Improvement. IHI.org
Medications: ASSESS
IHI list is one of many Think about drug impact on function, quality
of life, risk to independence Sedation Cognitive impairment Unsteadiness Falls Injuries Unpleasant side effects, adverse reactions Drug-disease interactions
Explore resources for high-risk Medications
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Medications: ASSESS
High-Risk MedicationResources American Geriatrics
Society Beers Criteria® JAGS DOI: 10.1111/jgs.15767 GeriatricsCareOnline.org Pocket card: 8 pages
High-Risk Medications
Resources are available at the Iowa Geriatric Education Center website
See Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) for pocket cards like this
https://igec.uiowa.edu/ia-adapt
Medications: ASSESS
What Matters most to the person?
What is most important?
How do their Medications facilitate or impede doing What Matters?
How much is “enough”?
What is a burden? Sheer number, management? Cost?
Is it time to stop some?
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Medications: ACT ON
Focus on person’s goals Desired health outcome
Prescribe Age-FriendlyMedications Prevent problems
Avoid high-risk drugs
Deprescribe Dose reductions Discontinuation
Medications: ACT ON
Avoiding high-risk Medications is a top priority for ALL older adults Next most important: What Matters!What are the person’s health outcome goals?
Treatment preferences?
Does Medication burden interfere? If so, how? Too many pills to manage?
Too high a cost?
Too little benefit to justify?
Medications: ACT ON
Focus on PREVENTION Do not start a drug unless truly needed! Ask: Could a non-drug approach be
safer & as effective? Behavioral activation, physical activity,
talking therapy in depression? Promote sleep without drugs? Exercise or activity vs. opioids for pain?
Source: R Carnahan (Sept 2, 2020). Age-Friendly Medication Use in Older Adults. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/
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Medications: ACT ON
Use a time-limited trial then gradualdose reductions Assess need for continued use Stop drugs that don’t work! Avoid “prescribing cascades” Treating
side effects of one drug with another
Especially important with psych drugs! Antipsychotics for delirium, behavioral
symptoms in dementia; sleep aids
Source: R Carnahan (Sept 2, 2020). Age-Friendly Medication Use in Older Adults. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/
Medications: ACT ON
Engage & educate older adults At discharge As part of ambulatory care
Keep it simple, understandable Comprehensive list Person & family understand what each is for How to take, why to take How to monitor: Helping? Causing adverse
effects?
Medications: ACT ON
Engage & educate older adults Include information on high-risk Medications Discuss opportunities to Reduce number, dose Explore alternatives: drug and non-drug Discontinue
Use educational materials, brochures to promote knowledge, understanding
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Medications: ACT ON
Many good resourcesfor education HealthinAging.org Ten Medications to
Avoid, Use with Caution (2 pages) Consistent with IHI Types & names Provides reasons
Medications: ACT ON
Deprescribing Triggers Need for continued use
is unclear
Side effects
Prescribing cascades
Mobility problems, falls, other accidents
New cognitive impairment
Deprescribing Barriers Real need for drug
Lack of attention, time
Trust issues: person & provider
Person’s beliefs: Medsneeded for health
Cost of non-drug treatment
Time needed to taper (dependence)
Source: R Carnahan (Sept 2, 2020). Age-Friendly Medication Use in Older Adults. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/
Medications: ACT ON
https://professionals.optumrx.com/content/dam/optum3/professional-optumrx/resources/High_Risk_Medications_Elderly.pdf
Identify Alternatives
NCQA list Category
High-risk Meds
Alternatives
Work to select Age-Friendly options
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Medications: ACT ON
Tools to Deprescribe: Canadian Deprescribing Network – www.deprescribingnetwork.ca Deprescribing algorithms, videos for clinicians Deprescribing pamphlets for patients EMPOWER brochures for patients: stories, examples Templates:
pharmacist to prescribers; prescribers to patients
Many excellent resources!
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More from deprescribing.org
Need help to deprescribe?Check out the recent lecture series on the topic!
Visit the University of Iowa Carver College of Medicine Continuing Education site: https://uiowa.cloud-cme.com/course/search?P=4000&search=Medications%20and%20Deprescribing%20Series
Medications: ACT ON
Summary: Medications
Identify, document high-risk Medications
Use a team approach, starting “where you are” and then expanding
Address What Matters to the person
Educate and engage in decision-making
Use Age-Friendly Medications
Avoid prescribing and deprescribe high-risk Medications
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Age-Friendly and Dementia Friendly
Social Movements
Marianne Smith, PhD, RNAssociate Professor & Director of the
Csomay Center for Gerontological Excellence, University of Iowa,
College of Nursing
Goals for Today . . .
Briefly describe Age-Friendly Health Systems and 4Ms Age-Friendly Communities Dementia Friendly Communities
Briefly review similarities and overlaps
Encourage participation at all levels
Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Age-Related Social Movements
Change societal attitudes & practices Encourage & advance best practices Make life easier & better quality for older
adults Two main themes: Age-Friendly: Health Systems that provide
care & treatment, and also Communities Dementia Friendly Communities
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Age-Friendly Health Systems
Co-sponsored by the John A. Hartford Foundation Institute for Healthcare Improvement (IHI) Health systems, hospitals, outpatient, and
long-term services across the county
http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
Age-FriendlyHealth Systems
Achieve better health outcomes for older adults
Reduce unwanted care & treatment, risk of harm
Reduce fragmented, burdensome care
Focus on What Matters most to older people!
An Age-Friendly Health System
Where every older adult:
Gets the best care possible
Experiences no healthcare-related harms
Is satisfied with the health care they receive
Value is optimized for everyone!
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Age-Friendly Health Care: 4Ms
What Matters most to the person
Medications
Mobility
Mentation: dementia, delirium, depression
A framework: not a program, but a shift in how we provide care to older adults
The 4Ms Framework
Lots of good reasons to use 4M framework! Best practice across
healthcare settings Focus on the person,
not the disease Focus on quality of
life, not “more treatment” or acute care transfers
Start with What Matters Most
What Matters: Know and align care with each person’s specific health outcome goals & care preferences
Older persons identify their health priorities
Clinicians translate these priorities into care options
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What Matters Most
Life & Living: What gives us joy, happiness,
meaning in living
Health:Our ongoing
health concerns
& conditions
Health Care:Treatment and
care of disease, illness, conditions
Critical Interactions Among 4Ms
Medications: Use Age-Friendly Medications that do not interfere with What Matters to the older person or their Mobility or Mentation Mobility: Ensure that older adults move
safely every day to maintain function and do What Matters Mentation: Prevent, identify, and treat
dementia, delirium, and depressionacross care settings
Critical Interactions Among 4Ms
What Mattersis the “driver”!
Medications Mobility
Mentation• Dementia• Delirium• Depression
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126 systems 357 sites in 37 states(as of May 2019)
Age-Friendly on the Rise
Age-Friendly Health Systems
4Ms work well across care settings Institution-based care: Hospital, subacute,
skilled care, nursing home, residential Ambulatory/primary care Community-based organizations
Age-Friendly Communities
World Health Organization (WHO) initiative started in 2006
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Age-FriendlyCommunities WHO defines an AFC as a place that
“encourages active aging by optimizing opportunities for health, participation, and security in order to enhance quality of life as people age.”
AARP notes that “Age-Friendly Communities adapt their structures and services to be accessible to, and inclusive of, older people with varying needs and capacities.”
Source: N. Turner & L. Morken. (March 2016). Better Together: A Comparative Analysis of Age-Friendly and Dementia Friendly Communities, p. 3. AARP Research Report.
Age-Friendly Communities
AARP is the U.S. affiliate https://www.aarp.org/livable-
communities/network-age-friendly-communities/
“The common thread among the enrolled communities and states is the belief that the places where we live are more livable, and better able to support people of all ages, when local leaders commit to improving the quality of life for the very young, the very old, and everyone in between.”
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AARP: Age-Friendly / Livable Communities
Age-Friendly refers to livability for people of ALL ages, including older adults
AARP: Rooted in “Active Aging”
AF Health System vs. Community
Age-Friendly Health Systems focus on the person and system: What Matters most Age-Friendly Communities focus on
population aging: Environmental support Both focus on Maintaining function, independenceMaximizing physical, social, mental well-being Doing What Matters, which is often linked to
the larger environment
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Dementia Friendly Communities
Dementia Action Alliance Dementia Friends, UK Alzheimer’s Society, UK and Canada Dementia Friendly America Based on ACT on Alzheimer’s Minnesota Sponsored by National Association of Area
Agencies on Aging: https://www.dfamerica.org Includes Dementia Friends USA
State‐based, National, and International!
Dementia Friendly Communities
Understands that dementia can affect a person’s cognition, behavior, emotions, and physical abilities
Embraces the belief that EVERYONE has a role in recognizing people with dementia as part of their community AND supporting their independence, value, and inclusion
Increases awareness, promotes social inclusion, challenges stigma, & improves care and service
Community Capability:Adoption of
dementia friendly practices within and across all community
sectors (e.g., faith, business,
government, health care)
System Capability:Adoption of optimal
dementia care and supports in health, long‐term care, and community services
Person with Dementia—Well‐Being
Care Partner Efficacy
Care Partner Support and
Family Health
Dementia Friendly Communities
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Dementia Friendly America
10 Sectors of Community Engagement1) Transportation, housing, public services2) Businesses & employers3) Legal & advance planning4) Banks & financial services5) Neighbors & community members6) Independent living & community engagement7) Communities of faith8) Care throughout the continuum9) Memory loss support and services10) Emergency planning and first responders
Dementia Friendly America
Dementia Friendly America
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Dementia Friendly vs. Age-Friendly Communities
Considerable overlap in goals and approach. Both focus on Maintaining function, independenceMaximizing physical, social, mental well-being Broad stakeholder engagement
“A dementia friendly community is age-friendly, but an age-friendly community is not necessarily dementia friendly.”1
1. N. Turner & L. Morken. (March 2016). Better Together: A Comparative Analysis of Age-Friendly and Dementia Friendly Communities, p. 3. AARP Research Report.
Dementia Friendly vs. Age-Friendly
Doing What Matters is a common theme Support to older people to be successful! Facilitative social environment Facilitative physical environment Acceptance, respect, assistance Using the person’s priorities to guide care Focusing on strengths, abilities
EVERYONE has a role!
Summary
Many opportunities exist to change societal attitudes, beliefs, and practices! Healthcare systems: acute to residential Community settings: villages to cities
Support older people to live WELL Reduce unwanted care, burden Promote function, independenceMake life easier, better quality
Everyone has a role; how about you?
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