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I ‘ _ . . . ‘ - .. . . ; - - . ..' . ‘. 1 .. ‘ . . . ' ' .. ' ' ' ' . ~ . . .‘ n ' - ..t . - . . ._ : . ‘ . - ” ~~<' - _ ' . . . ' - . . . . I. ._ - ‘ a . .1 . ' ‘ f I - . " _ _ . .. theDegeefMS _A o. _ c ‘ . , - ... h . ‘ .._ MSULUVAN * L1""???"’1."- ‘ LIBRARY Michigan State University PLACE IN RETURN BOX to remove this checkout from your record. To AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE JWtZNzSZOUS i r ! JW 73 0.92505 6/01 c:/CIRC/DateDue.p65-p. 15 ————f¥i’ ’i"”77’ " ”” ””’*"_' “““—————‘*h‘—“ A FOCUSED NUTRITION AND MEDICATION ASSESSMENT OF THE OLDER ADULT IN PRIMARY CARE: IMPACT ON FUNCTIONAL STATUS by Jacquelyn M. Sullivan A SCHOLARLY PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1998 ABSTRACT A FOCUSED NUTRITION AND MEDICATION ASSESSMENT OF THE OLDER ADULT IN PRIMARY CARE: IMPACT ON FUNCTIONAL STATUS By Jacquelyn M. Sullivan In 1996thefirstofthe “babyboomers”tumed SO anditisestimated that by 2030 the population of people 65 and older will be approximately 20%anditispmjectedtherewfllbeadecreaseinavailableresomcesto provide care for these individuals. Therefore, emphasis needs to be placed on prevention and health maintenance with the older adult to help them maintain independenceandtommdmizetheuseofavailableresomces. One methodto dothisisthroughassessmgtheolderadiflt’sabflitymcareforthemselvesmd in seeking early interventions when needed. This scholarly project is an enhanced protocol that was developed to assess the older adult’s current ability to provide self-care. Two additional factors that influence the older adult’s ability to provide self-care, nutrition and medication, were added to basic fimctional status questions. This protocol is based upon General Systems Theory, which allows the health care provider to have a more person-centered holistic view of the older adult. This protocolwasdesignedtobeusedinaprimarycaresettingandtofimctionas abaselineassessmentofthe olderadult’scmrentabilitytocarefor themselves including nutritional status and medication usage. ACKNOWLEDGMENTS This scholarly project owes its conception to the excellent program that Iris Boettcher, MD. has developed in geriatric rehabilitation and that I was able to participate in and contribute to for a few short years. It is this program that has helped me to see the potential that exists for the older adult. I also wish to thank the members of my scholarly project: Linda Keilman, RN, Joan Predko, RN and Laura Struble, RN. Linda has made my experience a positive one by giving me coaching and support and telling me to “take a deep breath and relax!” Joan has walked down this whole long road with me and never made me feel abandoned when my frustration and anxiety became overwhelming. Laura provided enthusiasm for this project and many helpful ideas. I also wish to thank my friends, Susan Wainstock and Paula Spahr for providing me support throughout this whole process. And finally, to my mother, Lois, and my sister, Kathleen, I extend my appreciation for the encouragement they have provided to me. TABLE OF CONTENTS LIST OF TABLES . LIST OF FIGURES INTRODUCTION . The Problem. Pmpose of the Study CONCEPTUAL FRAMEWORK LITERATURE REVIEW. thctional Status . Body System Aging Changes Neuromuscular System Cardiopulmonary System . Sensory Changes Nutrition . Medication Use . Functional Nutritional & Medication Assessment Tools Summary THE PROTOCOL . Overview . . Assessment of Self-Care . Medications . Nutrition Limitations . Analysis IMPLICATIONS . Research Education Practice APPENDIX LIST OF REFERENCES . iv 10 10 11 ll 13 15 16 18 21 26 28 28 28 29 29 29 30 32 32 32 32 34 35 LIST OF TABLES Table 1. Comparison of Functional, Nutritional & Medication Assessment Tools 22 LIST OF FIGURES Figure 1. Open System Figure 2. Adaptation of an Open System INTRODUCTION W The population of people over the age of 65 in the United States in 1996 was 12.8% (US. Census Bm'eau, 1997). The estimated growth of this population in the 1990’s has slowed somewhat due to the small number of babies born during the Great Depression of the 1930’s (American Association of Retired Persons, 1997). However, the first of the “baby boomers” turned 50 in 1996 and it is estimated that by 2030 the population of individuals 65 years and older will be approximately 20% (AARP, 1997). There will be a significant increase seen in 2010 when the first of the “baby boomers” reaches the age of 65. National figures show that approximately 4% of the 65 and older population live in long term care (LTC) facilities (U .8. Census Bureau, 1997). That means the majority of 65 and older population is living in the commrmity. It is estimated that 30% of the 65 and older population lives alone. The remainder live with a spouse (48% of the women and 77% of the men), or with other relatives or non-relatives (AARP, 1997). As the individual ages, they tmdergo many physical changes. These physical changes can interact with the individual’s environment and leave them vulnerable to the development of many diseases that may efi'ect their ability to continue living independently. To be successful at aging, the individual and their health care provider must understand what is “normal” and what is “abnormal” aging systems changes. They must also be able to identify the factors that influence the ability to provide self-care. Two areas that influence the individual’s ability to live independently are nutritional status and the medications that they consume. 1 2 As will be demonstrated later, both an individual’ 5 nutritional status and their medication usage are closely tied to the older adult’s ability to care for themselves in a community setting. Both factors, if not identified and monitored, can lead to the development or worsening of any disease process. This then eventually could result in the hospitalization of the individual (Ebley, Hogan & Fung, 1997). It is estimated that up to 88% of people over 65 are at moderate to high risk for malnutrition (Jackson, 1998). Malnutrition has been called a “silent crisis” among America’s older adults (Cope, 1996). Warning signs of malnutrition are often missed by both the older adult and their health care provider. The result then is a slow insidious compromise of the individual’s physiologic reserves (Cope, 1996). This contributes to the development of disease processes that often require hospitalization. Kresivic, Mezey and the Niche Faculty (1997) have reported a 20% - 40% decline in frmction during hospitalization of the older adult. Changes with aging will also influence the pharmokinetics of medications that may be taken. Falling is often associated with adverse drug reactions (Cumming, Miller, Kelsey, Davis, Arfl_. . s _ o I . _ \ m — I — — \ _ . I . ~ \ _ .w _ I I ~ \ _ .m - I s d I I s \ _ a _ I I x x _ a I I \ s .m — I I, \\ \ — o — I \ _ c _ II \ . . I \ _ _ II \\ _ u I x n . II \\ _ _ < _ 'l'l'l'lIl'l'I'I'I'I'I'lII'I'II'l'|'|IIII|III'L E OR: @588 6 A system is a sum of all of its parts and cannot be identified or examined by its parts, but rather holistically. A change in one subsystem will cause a change in the system as a whole. Changes in the environment and within the system will affect each other. The system attempts to maintain homeostasis as it reacts to interactions through a feedback loop. The system will evaluate how the interaction has afl‘ected its equilibrium and attempt to adapt (Figure l). The individual is balanced at the center of their subsystems which are balanced within their environment. F igrue 1 illustrates an open system (dotted lines) that is in negentrophy. Changes in either the individual, their subsystem or their environment may result in an area becoming ofi‘ balanced. The feedback mechanism however, will allow the system to retmn to its balanced state as it adapts to this change. Application of this theory for the APN provides a more wholistic look at the individual and their environment. The older adult is a whole system composed of many subsystems. He/she is distinct from the environment in which they exist. Interactions with this environment, as well as some of its subsystems, will cause changes in the older adult that they will attempt to control to maintain homeostasis (Figure 2). The older adult is the center of their subsystem. The subsystems include normal age changes, nutrition, medications and the ability to care for self (fimctional status). The older adult and these subsystems exist in an environment that includes the APN/PCP. Changes in the subsystem that will aflect the environment of the older adult are normal system changes that occur with aging. The older adult Continual Feedback Through Systems 7 13.2.2": 02am VICE—um.» \ >U<>ZOMU VIEW—40m zcwmm 1 _ . . u " II 5m szaoz 33.9552 222522. 3.2.». \ _ . II \\| I I'll \\ _ . I \\ II \ _ _ II \\ II \\ _ " II \ II \ n _ I ~ I s . . II . I \ . " II " 05mm >85 " \ n . I _ _ s . . I I s s . — I I x \ - I s — I I’ \\ \ - . I I s s . I I \ s — I I .I \ — _ I s _ _ I s . I s _ I x _ . II \s . u I, x u _ < _ f 8 attempts to adapt to these changes to maintain equilibrium and the ability to continue living in harmony in their chosen environment. Some older adults maintain an open system and do an adequate job of adapting the environment to these system changes. A study conducted by Williamson and Fried (1996) found that many olderadultshadadaptedtosystemchangesfi'omaginginwaysthattheydid not perceive as afi‘ecting their functional status. For example, they were still able to do their own grocery shopping and did not perceive it as a problem thattheyhadtoleanonthe shoppingcartastheyproceededthroughthestore and make fiequent rest stops to continue the activity. They had adapted to the change in their systems by aging and possible disease to maintain equilrbrium in their environment based upon a feedback loop. Eventually however, the older adults will not be able to compensate for these changes and the result is generally a decline in frmction that jeopardizes their ability to live independently. Another subsystem of the older adult that would effect their environment is the normal system changes that afl’ect nutritional status. The development of a sub-clinical or clinical malnutrition will cause chaos in the individual as evidenced by the development of a disease process and/or impairment in flmctional status. Outside environmental intervention would most likely be required to bring equilibrium back into the system. This is also true for any interaction between the subsystems, such as medications and nutrition. These two subsystems can interact and afiect the environment of the older adult. Conversely, the environment could act on these subsystems and that will also affect the equilibrium of the system. An example of this is the polyplmrmacy effect of medications ordered by the APN not only causing 9 adverse drug reactions, but also interfering in the older adults nutritional status. If the older adult has a closed system, they become very isolated and resistive to change. These individuals are generally seen by the PCP/APN during some crisis event. Even then, they may be resistive to any intervention by the outside environment. These individuals will continue a downward spiral with death being the eventual outcome. General Systems theory as applied to the APN becomes people centered (Beckman, Fernandez & Coulter, 1996). The emphasis is on the individual and their environment rather than the subsystem of presenting symptoms. The APN assumes the role of facilitator and teacher in collaboration with the older adult to help them maintain their goal of independent living. This is accomplished through actively listening to what the older adult is saying. The older adult then needs to actively participate in discovering interventions to help maintain system equilibrium. General Systems Theory very clearly illustrates the principle behind the development of this protocol. As will be demonstrated shortly, normal age changes, medications and nutrition are subsystems of the older adult that interact closely with the individual to influence their ability for self-care. One subsystem alone cannot be analyzed to get a true picture of the older adult. All subsystems and the environment must be viewed as a whole to identify potential problems and develop early interventions. I In developing this protocol, it is important to know the current knowledge of factors that may influence the older adult’s ability to live independently. The following literature review will define self—care (functional status) and show how normal aging changes, medications and 10 nutrition may influence the older adult’ s ability to provide self-care. It will also review current tools being used by the PCP to assess these areas. LITERATURE REVIEW Emcfionalfitams F rmctional status refers to an individual’ 3 ability to accomplish necessary or desired tasks (Bonder & Wagner, 1994). Activities of Daily Living (ADL’s) are defined as those tasks necessary for self-care: bathing, grooming, locomotion, toileting, transferring, dressing and feeding. Instrumental Activities of Daily Living (IADL’s) are the more complex tasks necessary for self-care: taking medications, using a telephone, preparing a meal, grocery shopping, housekeeping, and balancing a checkbook. ADL and IADL activities are classified according to complexity. Feeding oneself is a low complexity task compared to toileting oneself, where the individual must not only recognize the need to use the toilet, but must be able to transfer on and off the toilet while manipulating clothing. Grocery shopping would be classified as an even higher complex task as it involves the cognitive ability to prepare a shopping list, the motor fimction of transport to the store and shopping for the desired items, and the ability to manage money to pay for the purchases. Nationally, approximately 40% of older adults reported having at least one area of ADL’s and IADL’s where they required assistance (Williamson & Fried, 1996). In the Provena-United Samaritans Medical Center service area, a study completed by the author reported approximately 67% of the population surveyed needed some assistance with ADL’ s or IADL’s (Geriatric Care Committee, 1997). Functional decline in the older adult can 1 1 be caused by a myriad of factors. The influence of normal aging changes, nutritional status and medication usage on fimctional status will be reviewed. WWW As the individual ages, the body tmdergoes many normal changes. It is important for the PCP/APN to recognize what these normal changes are so that appropriate interventions can be initiated toward the abnormal changes. By doing so early, there will be a conservation of resources and a prevention of decline in the older adult. The older adult may show some physical or cognitive decline with these normal body system changes, but they should not impact frmctional ability. These changes however, leave the older adult with very little reserve so that any rmtoward event could tip the scales into a frmctional decline (Krach, DeVaney, DeTurk & link, 1996). Normal age changes that occur in the older adult that may impact ADL’s and IADL’s are in the neuromuscular system, the cardiopulmonary system and sensory changes. The normal declines seen with aging will vary from individual to individual and progress along a continuum with the greatest decline seen in the oldest old (Krach et al, 1996). Aging changes are in the absence of any disease process. Nemrscularfiysrem Changes in the neuromuscular system that may affect functional status are in the areas of muscle strength, posture, balance, gait, coordination and speed of movement (Bond & Wagner, 1994). Strength is the amount of force that can be exerted by a muscle and involves not only the muscle tissue itself, but also the neurons innervating it. As an individual ages, there is evidence of a loss of lean skeletal muscle mass, sometimes up to 30% (Miller, 1995). A 12 relationship between loss of lean skeletal muscle mass and the subsequent loss of muscle strength, especially in hand grip, has been reported (Miller, 1995; Richards & Palmiter, 1997). Motor neuron rmits innervate the skeletal muscle fibers and are responsrble for controlling the contraction time, resistance to fatigue and enzyme activity. As an individual ages, there is evidence of an overall loss of motor neuron imits which would efi‘ect the response time and coordination of the muscle to a stimuli. There is also evidence of disuse syndrome playing a role in exaggerating some of the effects of aging on muscle strength. Bedrest, for example, is associated with a loss of strength of from 1% to 5% per day (Schwartz & Buchner, 1994). Physical activity and exercise help to maintain overall muscle strength (Shumway-Cook, Gruber & Baldwin, 1997 ). Overall motor fimction is coordination between the motor cortex and other areas in the brain like the basal ganglia, and the muscles themselves (Mitchell, Hodges, Muwaswes & Walleck, 1988). With aging there is also a loss of motor fibers, a replacement of lost muscle mass with fatty tissue, and a slowing of nerve conduction velocities. As a result, the individual may see a minor loss of fine motor skills, a decrease in coordination, and a increase in reaction time (Miller, 1995). Proprioception is the ability to maintain an upright position without falling (Nichols, 1996). Proprioception depends upon the use of balance, posture and movement. In response to gravity, the body constantly responds to subtle shifts in weight and alignment. This is called postln'al sway. Due to the increase in reaction time as the individual ages, postural sway increases (Bonder & Wagner, 1994). This, and changes in the basal ganglia with 13 aging, may cause the individual to develop a wider base of support with movement and a more head forward position with gait. Balance and coordination require an integration of many muscle groups and afferent and efferent pathways (Wilson, 1992). With aging there is a decrease in the afferent feedback to the central cortex that affects postural stability. This influences dynamic balance or the ability to keep the body upright with movement (Woollacott & Tang, 1997). All of these normal changes in the neuromuscular system may influence the older adult’s functional status. For example, the loss in strength in hand grip could make it difficult for the older adult to open up jars of food or the child-proof cap on medication bottles. The lengthening of reaction time and changes in postural sway may effect their balance and gait, thus limiting their ability to get to the grocery store or prepare a meal. Candianulmonmsrzsmm With aging there are structural and firnctional changes to the cardiopulmonary system that may also affect ADL and IADL activity. As the individual grows older, there is a gradual stiffening of the ventricular walls of the heart (Leuckenotte, 1996). This will impede contraction and will subsequently result in a decrease in the overall cardiac output. The body attempts to compensate for this structural change by a longer ejection phase and delaying diastole. As a result functionally, the heart will contract less frequently and with less force. This will affect the heart’s response to exertion and an increased demand for oxygen (Dean, 1997). With aging there is a stiffening and thickening of the arterial system related to an increase in collagen and a decrease in elastin (Lakatta, 1994). 14 This results in a decrease in the ability of the arterial walls to stretch and recoil in response to variations in blood volume. This also means a decrease in the blood volume that can be stored in the arterial system. There are changes in the peripheral baroreceptors and chemoreceptors with aging. This will aflect the body’s ability to adjust heart rate and blood pressure in response to stressors (Dean, 1997). There is a calcification of the costal cartilage with aging that result in a stiffening of the thoracic cage. This results in a decrease in chest compliance and an increase in dead space ofup to ahnost one halfthe inspiratory tidal volume (Lueckenotte, 1996). This increase in dead space results in less air being available for gas exchange (Leuckenotte, 1996). There are structural changes that occur in the alveoli that result in a decreased number, or a decrease in surface area, available for gas exchange. And finally, there is a decrease in chest muscle strength as part of the overall decrease in skeletal muscle strength. This will result in a decrease in the inspiratory and expiratory efl‘ort. All of these structural and functional changes to the pulmonary system cause it to be less responsive to the body’s demand for an increase in oxygen (Dean, 1997). This may mean that when the older adult performs an ADL or IADL activity, they may feel short of breath and fatigue more easily. This may cause a reluctance to perform that activity, which would lead to an eventual frmctional decline. SensonLChanges There are many sensory changes that an individual undergoes as they age. The two that may efi‘ect the older adult’s overall nutritional status are a change in taste and smell. As the individual ages, there is a decrease in the number of firnctioning taste buds and therefore a decrease in taste (Cope, 1996). It appears that the sweet and salt taste buds deteriorate before the bitter and sour. With aging, there are neurological changes in the olfactory system resulting in a diminished capacity to smell odors. These two senses work together to adversely affect the nutritional status in the older adult, as something must smell good and taste good to trigger appetite (Yen, 1996). Another sensory change that may efi‘ect the older adult’s nutritional status and medication usage is in vision. There are several changes that occur in the eye as part ofnormal aging. Two tlurt may afi‘ect functional status are light sensing threshold and color perception. The rods and cones of the lens rmdergo neurological degeneration as part of the normal aging process (Michaels, 1996). This means that adaptation fi'om a light to dark environment is delayed. Other changes in the lens are the development of opacities in the lens nucleus, a yellowing of the lens and a loss of luteal pigment in the macular area (Leukencotte, 1997). This afi‘ects color perception with the loss of ability to see greens and blues as well as reds or yellows. This overall loss of visual acuity could mean difficulty in reading the label on a medication bottle, or being rmable to distinguish between the colors of difi‘erent medications. It also could be diflicult reading labels in the 15 l6 grocery store or in the kitchen because of low lighting or glare from too bright lighting. II . . Successful aging and the declines in frmction and prevention of disease have been closely related to diet and nutrition (Chapman, Ham & Pearlman, 1996). As previously mentioned, the age-related changes in taste and smell will afl'ect the older adult’s appetite. Due to these alterations, the older adult may not eat a well-balanced meal. There are additional age related changes that may also affect the nutrition of the older adult. Basal metabolism is related to the metabolism that moms in lean muscle mass. As lean muscle mass decreases with aging, the energy requirements diminish by approximately 100 calories per decade (Gidden & Shenkin, 1997). As the energy requirements decrease, it becomes more difficult for the older adult to meet their micronutrient requirements through diet alone. Micronutrients include vitamins, minerals, essential fatty acids, and essential amino acids. Vitamins and minerals are also affected by the normal age related changes seen in the gastrointestinal (GI) system. For example, there is diminished absorption of Vitamin B12, calcium, iron, folic acid and zinc due to the decrease secretion of hydrochloric acid in the stomach of some adults over the age of 70 (Leuckenotte, 1996). This leaves the older adult vulnerable to multiple diseases that would afi'ect fimctional status, for example: pernicious anemia, iron deficiency anemia and osteoporosis. Low blood levels of certain vitamins have also correlated to poor performance on memory testing and abstract thinking (Chapman, Ham & Pearhnan, 1996). 17 The macronutrients are protein, fat, carbohydrates and water. Protein and water are affected by normal system changes. A decrease in gastric secretions of up to 80% may occur in people over the age of 60 (Leuckenotte, 1996). A decrease in hydrochloric acid production is a normal system change. There is also a decrease in the digestive enzyme pepsin that may be related to the decrease in hydrochloric acid production (Cope, 1996). Pepsin is important in the breakdown of proteins into amino acids and is converted from its inactive form in an acidic environment (Watson, 1997). As the individual ages, protein breakdown may be less efiicient. Protein is measm'ed by the serum albumin level, which has a slightly lower value in the older adult to reflect this normal change (Jackson, 1998). Immune fimction has also been shown to depend upon adequate micro and macronutrients (Chapman et al, 1996). Astheindividual ages,thetotalbodywaterisdiminished. This isa result of a bltmted response to vasopressin (anti—diuretic hormone) by the renal system (Leuckenotte, 1996). Also, for rmknown reasons, the thirst response to dehydration becomes bltmted as the individual ages (Mentes & Buckwalter, 1997). Dehydration has been linked to the development of acute confusion, which is a transient brain dysfrmction (Mentes & Buckwalter, 1997 ). If not prevented, the outcome for the older adult is poor, resulting in hospitalization, increased mortality and often discharge to a higher level of care (Mentes & Buckwalter, 1997 ). Another nutritional concern in the older adult is obesity. With aging, lean body mass is replaced with fatty tissue. This and the diet of most Americans that is composed of up to 50% dietary fat, leaves the yormger old (those rmder the age of 75) with a tendency toward obesity (Leuckenotte, 18 1996). There has been much documentation showing a relationship between obesity and the development of Type 2 diabetes, hypertension, degenerative joint disease and cardiovascular disease (Jackson, 1998). I I l' . II Medications, both prescription and over the cormter (OTC), that the older adult uses can affect ADL and IADL performance. The older adult accounts for 25% - 30% of all prescription medications and 40% of all OTC medications (Leuckenotte, 1996; Swonger & Burbank, 1995). Adverse drug reactions can occur in up to 50% of older adults taking medications in an outpatient setting (Hanlon, Schmader, Koronkowski, Weinberger, Landsman, Samas & Lewis, 1997). Adverse drug reactions can be severe enough to result in hospitalization of up to 30% of this population (Hanlon et al, 1997). There are several reasons why the older adult is susceptible to adverse drug reactions. Pharmokinetics of medications are altered due to normal body system changes in the GI, hepatic and renal systems. There is a decrease in hydrochloric acid production and a decrease in protein synthesis with aging (Schwartz, 1994). Some medications require an acidic environment for metabolism and some medications bind with protein for distribution (Swonger & Burbank, 1995). If the appropriate environment is unavailable, then the dosage of medication administered will not be efi‘ective. There is also a delay in gastric emptying with aging which may cause a delay in drug absorption and delay of onset of drug action (Leuckenotte, 1996). 19 There are normal age related changes in the liver that will affect hepatic protein synthesis. This may then afi‘ect the liver metabolism of some medications (Swonger & Burbank, 1995). The loss of lean body mass with aging has been described. Some medications depend upon lean body mass for distribution. If the lean body mass is not present for distribution, then medication is circulating in the system and the result may lead to adverse drug reactions. The renal system is very important for the excretion of many of these medications. Due to changes in renal arterial perfusion, glomerular filtration becomes less eficient (Schwartz, 1994). As a result, there is competition for excretion sites. This then may mean an extension of the half-life of the medication (Swonger & Burbank, 1995). Many of the adverse drug reactions occur in the older adult because very few clinical trials of medications include people over the age of 65 (Hanlon et al, 1997). Often these individuals are experiencing multiple disease processes and for that reason are excluded from clinical trials. There is little documentation into recommended dosage, rate and route of delivery to prevent adverse drug reactions except in post-clinical applications (Schuster, 1997). In addition to not being included in clinical medication trials, many older adults experience polypharrnacy (Schuster, 1997). Due to the multiple diseases many older adults experience, they may see more than one health care provider. Each health care provider may prescribe medications, many times in ignorance of other clinicians this person may be seeing, and what medications they may be taking (Hunter, Florio & Langbery, 1996; Lee, 20 1996). These multiple medications can leave the older adult vulnerable to drug-drug interactions. Adverse drug reactions are many times treated by the PCP with another medication, thus potentiating “polypharmacy”. The number of medications that an older adult takes has been linked to an increase in falls (Miller, 1996). Another problem with polypharmacy is the drug interactions that may occur that will afl‘ect the nutritional status of the older adult (Lewis, Frongillo & Roe, 1995). One example of this are antacids that afl‘ect the absorption of folate, phosphate and calcium, and anti-inflammatory agents, such as aspirin, that afiea the absorption of Vitamin C, folate and iron (Leuckenotte, 1996). Both medications are available to the older adult OTC and could potentiate the nutritional effect of a prescription medication, such as hydralazine, which also efi'ects absorption of folate. These medications, in combination, may effect the overall nutritional status of the older adult and leave them vulnerable to the development of a macrocytic anemia (Lewis, Frongillo & Roe, 1995). Another adverse medication effect that could influence nutrition is dry mouth. 50% of commrmity dwelling older adults take one or more medications that can lead to dry mouth (University of Michigan, 1996). Saliva is important for clearing plaque and bacteria fi'om dental and oral mucosa with its flushing action and in lubricating food so that it may be swallowed. If dry mouth is a problem for the older adult, they may develop dental caries and its subsequent sequela, or have difficulty swallowing their food. Both, if they occur, will affect the overall nutritional status of the individual. 21 The older adults who “shop” around for the best price for their prescriptions are at an even greater risk from the effects of polypharmacy, as they have removed a safeguard mechanism (Hanlon et al, 1997). Dealing with more than one pharmacy leaves no one having the knowledge of all the medications that are being taken and interceding, if necessary, to prevent adverse drug reactions. The normal body system changes that occur with aging and their influence on ftmctional status have been reviewed. The effects of medication usage and nutritional status as they relate to flmctional status have also been reviewed. Next the current tools used by the PCP/APN to assess frmctional and nutritional status and medication usage will be reviewed. E'lll”lll[l"! I] Functional assessment tools are a systematic method to objectively evaluate the level at which an individual is performing in many different areas (Mitchell et al, 1988). Functional assessment tools have become very useful to the health care team when dealing with the older adult. The tools used by health care team members assesses ADL and/or IADL status. Some tools are all encompassing and look at the social support, mental health and economic resources available or utilized by the older adult. Some tools are used as self-reports, although some tools require performance evaluation and specific settings to be utilized. Table 1 lists the more well known tools currently in use for assessing ADL, IADL activity, medications and nutrition. The Katz Index of ADL was developed in 1963 and is still widely used today. This tool evaluates the frmctional dependence or independence of the individual in six categories: bathing, dressing, toileting, transferring, Hugo _ 008318: c». 35983.. Zen—.505»— Ea 32383358333. Hoe—m <9: 3 ado. 0210qu .3? 08:88.2: manage.“ mo=uwauon >Ur {II—Ur 2:530: 32:832.». 5.6 was” 0». >91 53 x x weave; Hen—ax 33 x x 35325. Enough—once Enema—«Boa 92V 33 x x msmnawsaema. >o=<5nm _ woo x x cm 08:. FEE 052. >Bano§m ”808.0: an menace Gum x x x x 02:2 239—va 3:: 25:22.». 50¢ x x x x >mmomm8oa 022.85“ 25120:». Ier. 53 x x 23 continence and feeding. The older adult’ s actual performance of a task score this tool rather than their potential ability to perform the task (Bonder & Wagner, 1994). For example, the individual is scored as dependent if they refuse to perform the task, even if they are able to do so. Although this tool was designed as a performance tool, the primary care provider often uses it as a self-report tool (Bonder & Wagner, 1995; Judge, Schechtrnan, Cress & the FICSIT group, 1996; Krach et al, 1996; Sinofl‘ & Ore, 1997). No studies appear in the literature that show how this use influences the reliability and validity of the tool. Ifused as a self-report tool of fimction, it takes 5 - 10 minutes to complete. If used as a performance tool, the time for completion could be up to thirty (30) minutes and obviously could not easily be completed in the primary care providers office. Another popular tool to measure ADL fimction is the Barthel Index that was developed in 1965 and measures ten items of self-care and mobility. It was designed as a performance evaluation measurement; however, it is also being used in the primary care setting as a self-report tool. A study conducted by Sinofi‘ and Ore (1997) showed limitations in this tool as a self- report evaluation in people over the age of 75 and recommended a performance appraisal be utilized. This tool measm'es feeding, transferring, grooming, toileting, bathing, arnbulating on a level surface, ascending and descending stairs, dressing and continence of bowel and bladder. The individual is scored as either being independent or requiring assistance with each item. A total score of 100 indicates independence in all items. The tool may also be utilized for showing gains or losses in individual tasks, rather than a cumulative score. Again, this tool is designed as a performance 24 evaluation and if used as such, it is difficult to administer outside of a rehabilitation setting. The Functional Independence Measurement (FIM) expands areas of the Barthel Index to include communication and social cognition. This eighteen (18) item tool was developed in 1987 by a joint task force of the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation (Johnston, Findley, DeLuca & Katz, 1991). Along with self-care management, sphincter management, transfers and locomotion, this tool also assesses the individual’s ability to communicate (comprehension and expression) and social cognition, as expressed by social interaction, problem solving and memory. This tool is scored on a seven-item scale that ranges from total independence to total dependence. A score of 126 means total independence on all eighteen items assessed (Heinemann, Linacre, Wright, Hamilton & Granger, 1994). Generally, a score of 80-100 indicates the ability to live in a community setting with some assistance. This tool is designed to look only at a cumulative score and therefore a gain in one area and loss in another area may not be reflected in the overall score. Time to administer this performance tool is approximately forty minutes. This tool is being used in some acute care settings to predict discharge disposition (Mauthe, Haaf, Hayn & Krall, 1996). No studies are in the literature that document how the reliability of the tool is affected when used as a self-report. The Instrumental Activities of Daily Living was developed by the Philadelphia Geriatric Center in 1969. Also known as the Lawton Scale of Instrumental Activities of Daily Living, this tool includes nine items: using the telephone, walking distances, shopping for groceries, preparing meals, doing housework, doing handiwork, doing larmdry, taking medications and 25 managing money. This tool is scored by self-report on ability to carry out the task. Some items are gender specific, such as preparing meals and doing handiwork. Items are marked on a three-point scale of performing independently, performing with some help or rmable to perform. This scale can be completed in approximately five minutes. The Older Americans Research and Service Center (OARS) is a tool developed in 197 8 at Duke University (Duke University, 197 8). This 105-item tool covers five broad areas: social resornces, economic resorn'ces, physical health, mental health and ADL’s. The OARS tool has frequently been utilized as separate evaluation tools, e. g. OARS Social Resource tool, as opposed to administering the entire questionnaire. Scoring is done in each domain and then a cumulative score is derived. This questionnaire takes a minimmn of one horn to administer. None of the comprehensive assessment tools looks at nutrition as it relates to functional status. The OARS does ask the individual what medications they take by classification as part of the physical health assessment portion. The Mini Nutritional Assessment tool was developed in 1994. This tool helps to evaluate the risk of malnutrition to allow early intervention for the individual (Vellas & Guigoz, 1995). There has only been one study to date that has demonstrated reliability of this tool (Vellas & Guigoz, 1995). There are five areas that are evaluated: anthropometric measurements (height and weight); biological measurements (albumin and cholesterol); the individuals perception of their nutritional health; a global assessment that looks at lifestyle, number of medications taken and mobility; and a dietary assessment that looks at the number of meals per day, food and fluid intake 26 and ability to feed self. This approximately thirty item questionnaire takes about fifteen minutes to complete. It is scored as indicating no risk to high risk for malnutrition. Another nutritional screening assessment is the Determine Nutritional Health (Nutrition Screening Initiative, 1991). This was developed in 1991 as part of the Public Awareness Checklist in conjunction with the US. National Screening Initiative. This ten item questionnaire is designed to be completed by the individual. If they score as a high nutritional risk, they are encouraged to bring the form in to their PCP. The PCP then completes a Level I and Level II screening that encompasses Body Mass Index (BMI), eating habits, frmctional status, living environment, anthropometric measurements, number of medications taken and mental status. This screening assessment has poor specificity (Vellas & Guigoz, 1995). Summary All ADL and IADL activity requires movement. The neuromuscular system is an integral part of performance of these activities. Changes in strength with aging may afl‘ect the ability to perform such activities as medication administration and meal preparation. Changes in coordination, proprioception and balance may afiect the locomotion of the older adult and their ability to grocery shop or prepare meals. Changes in the aging cardiopulmonary system affects the body’s ability to respond to an increase in tissue demand for oxygen. This may leave the older adult feeling short of breathe and weak when they wish to perform some more complex motor activities, such as getting to and fi'om the grocery store and arnbulating around the store to make their purchase. 27 Some sensory changes may affect the ability of the older adult to eat a well balanced meal. Normal system changes with aging affect the ability to meet the micro and macronutrient requirements. Immune function has been linked to insufficient micronutrients and acute confusion can be caused by inadequate hydration. The development of disease processes fiom insufficient nutrition will add a burden to the older adults ability to maintain ADL and IADL fiurction. With the older adult accounting for the consumption of a significant portion of prescription and OTC medications, they become more susceptible to adverse drug reactions. Cognitive changes are a common reaction which may affect IADL and eventually ADL activity. Some adverse drug reactions can also impair the nutritional status of the older adult. All of these will affect the ADL and IADL activity of the older adult. Current methods to determine ADL and IADL activity were reviewed. Many tools are being used as assessments through self-report although they were not designed as such, therefore, the reliability and validity of the tool comes in question. The Determine Nutritional Help Assessment is a self-report that depends upon the individual bringing the results to the primary care provider for fiuther evaluation if they score as a high risk for malnutrition. No tool or screening combined ADL, IADL, medications and nutritional assessment. The literature review has shown the connection between these areas and how vital they are in helping the older adult to continue to live independently in the community. THE PROTOCOL Quarries: The protocol consists of two parts. The first part (Appendix A) is a brief, inexpensive, easy to administer form that can serve as a baseline to the APN/PCP of the older adult’ 3 ability to care for self. It includes an area of data collection on nutritional status and medication usage that is currently not available to the APN/PCP in one format. This protocol is designed to be used in the primary care setting. It will serve as a reminder of their appointment and will be mailed to the client to be completed prior to their scheduled appointment and returned at the time of the visit. It is designed to fit on one sheet of paper. It will be printed in larger font, to accommodate any vision problems and on white paper with black ink. Instructions are simple and important areas are in bold print. It should be sent to any person over the age of 65 at least on an annual basis. Assessmenmeelffiare Items for assessment in this areas were adapted fiom ADL and IADL activity that were evaluated in the Katz Index of ADL, the Barthel Index, FIM and OARS. Items were arranged in order of descending complexity. A study by Judge et al (1996) showed that IADL activity decline will appear before ADL performance decline. Many IADL activity involves higher cognitive frmction and declines in this area can start the evaluation process to prevent further declines. A question was included in this section to ask about usual activity to try to compensate for any gender bias in IADL activity. Since many older adults may adapt to a change in fimction and not recognize it as an inability to perform independently, a section was included to try and identify any adaptive behavior that is currently being used by the 28 29 older adult. This may again alert the APN/PCP to the need for some intervention immediately or in the near future. Asking about specific assistive equipment that is being used is also another method to gather a holistic image of the older adult. Medications This portion of the protocol asks the older adult to bring all prescriptive and OTC medications in on their visit. This is an effective method for the APN/PCP to see exactly what has been prescribed for the older adult and what OTC medications they may be using. With many medications now available in OTC and prescriptive strength, the potential for adverse drug reactions has increased. This section will also serve as a double check into IADL activity of taking medications and allow for interventions if necessary. Because this form is mailed to the home, the older adult should be able to provide a “real-time” recall of intake for a typical day. This should be more effective than trying to do a recall in the office when other information may be of more concern to the older adult. From the recall, the APN/PCP should get an idea if nutritional needs are being met. Again, this will also be a double check to the APN/PCP into IADL fimction of grocery shopping and meal preparation. This portion of the protocol will provide the APN/PCP the opportunity to investigate any potential causes that may effect the older adult’s ability to live independently. With regular review into self-care ability, nutrition and medications, the APN should be able to identify potential or actual problems 30 early and to seek interventions. This will help the older adult to maintain balance within their subsystems and within their environment. One barrier to this may be the educational level of the older adult. Although language was kept simple, it still does require rmderstanding of the written word. This may present a problem with an older adult with a cognitive deficit or literacy problem. Although designed to be a reminder of their appointment, this form may not make its way back into the primary care setting. Information can still beobtainedatthetime ofthe visit, althoughdietrecallmaynotbeaccurate and another trip to the primary care setting may be necessary for medication review. Analxsis The second portion of this protocol is the analysis by the PCP/APN of the data that has been collected. Any identification by the older adult of assistance/adaptation in an IADL or ADL activity needs further in depth questioning. The PCP/APN will be determining the cause of the need for assistance/adaptation. For example, if the older adult states that they need assistance with meal preparation, the PCP/APN should investigate whether the need is from a cognitive decline that makes it rmsafe to be around cooking surfaces; whether there is an inability to see adequately to prepare a meal; or whether reaching for equipment in the kitchen causes dizziness and the older adult has a fear of falling. The identification of assistance or adaption in IADL and /or ADL activity will lead into an analysis of nutrition and medication usage. Using the above example, it would be important for the PCP/APN to evaluate all the 3 1 medications that the older adult is on as a potential cause of cognitive impairment or dizziness. The PCP/APN should evaluate the medications that are known to cause impairment in the older adult’s cognitive frmction such as benzodiazepams, antihypertensives, antidepressants or sedative/hypnotics (Cummings et al, 1991; University of Michigan, 1996). It is also important for the PCP/APN to be aware of any medications in combination that may afiect the older adult’s frmctional status, for example, hydralazine and antacids in combination affecting folate absorption. The same analysis needs to occur with the diet/fluid recall. This information needs to be combined with the anthropometric data that is routinely gathered with each oflice visit. Again using the same example, if the older adult needs assistance with meal prepartion then malysis must include how balanced of a meal that the individual is consuming. It is unportanttodetermmeiftheyhaveanadequatefluidintake,adequatepmtein intake and adequate intake of essential vitamins and minerals. Change in cognitive frmction can occur with deficits in any of these areas. It then becomes necessary for the PCP/APN to determine whether they wish further laboratory work-up such as pre-albumin level, 812 level and/or folate to finther pinpoint a nutritional cause to a cognitive decline. This self-report questionaire puts all the information in one place for the PCP/APN to begin the analysis into the self-care ability of the older adult. No other tool crurently used in primary care gets this data together in one place. IMPLICATIONS Research Identification of problems and development of interventions with the older adult rely heavily upon self-report. There are very few studies out that demonstrate the reliability of self-report in this cohort. Although not economically practical, performance appraisal with the older adult will many times give a more accurate pictm'e of adaptation. Further research is needed into cost-effective methods to investigate reliable means to determine self-care. Early intervention of maladaptive behavior can prevent fimctional decline and allow for continued independent living. Education ' As was stated previously, the older adult population is growing and will comprise a significant portion of the APN/PCP’s practice. It is important therefore, that the APN/PCP become aware of the normal age changes and how they can work with nutrition and medication to efl‘ect independent living. At the same time, it is important that the older adult be educated that loss of frmction is not a normal part of aging and that interventions should be sought if they are experiencing this. By having both the older adult and their health care provider aware of how all these systems interact with each other, amoreproactive healthcare environmentwill existthatwill facilitate Practise This protocol moves the focus of the APN/PCP and the older adult fi'om “treating diseases” to “health maintenance”. By looking at not only self-care items, but factors that may impede self-care, the focus becomes holistic and people-centered. The older adult and the APN develop a 32 33 relationship of mutuality and respect for each other with a common goal and outcome. It is important with the older adult that their whole enviroment is evaluated rather than “presenting symptoms”. This cohort of people are very complex and very easily sent into a decline in frmction. At the same time it takes them longer to recover. It becomes imperative that the PCP/APN recognize normal aging changes and how this will impact other systems of the older adult that can quickly impact their fimctional status. This self-report questionaire and the subsequent analysis by the PCP/APN of the data gathered provides much of the information in one place. It not only provides the opportrmity for the PCP/APN to analyze the information, but also provides a jump ofl‘ point for educating the older adult, thus making this truly a participative effort in health maintainance. APPENDIX A PLEASE COMPLETE THIS FORM AND BRING IT TO YOUR NEXT OFFICE VISIT ON AT . NAME: DATE: DDYOUGETl-IEIICOMPLETINGTHISFORM? CIRCLE THE ACTIVITY THAT YOU NEED HELP WITH GroceryShop Usethetoilet Movefrombedorchair CookMeals Dim/Undrecsumerbody Bathe/shower Cleanhmnelqmrtrnem DraflUndrerslowerbody Bnrshteethlcombhair Balancecheckbook/paybills Clinbstairs Feedself Takeyourmedicine Walkdistancesoutsideot‘yourhome LIST ANY ACTIVITY ABOVE THAT YOU MAY NEED HELPWITH THAT YOU HAVE NOT NORMALLY DONE (e4. balm: yut' mg CIRCLETHEACI'IVI'I‘Y THATYOUDONOTNEDHEIPWMBUTTHATYOU MAY HAVECHANGEDORMODHEDHOWYOUNOWDOITMbathedyattiednhnotBthe tub/shower). GroceryShop Usethetoilet Movefrombedorchair CookMeals DredUndresupperbody Bathe/shown Cleanhouselapartmem DredUndrecslowerbody Brushteeth/combhair Balancecheckhort/pybills Clinirstairs Feedself Takeyourmedicine Walkdistanoesoutsideofyourhome DO YOU USE ANY OI" THE FOLLOWING? DWheelchair DCrutch(s) DBrace Where? 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