Geriatric Case Management

Geriatric Case Management
Linda N. Schoenbeck
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
  • List various methods of identifying high-risk geriatric patients for case management.
  • Assess for and identify common geriatric problems.
  • Assess and identify care needs of the geriatric patient.
  • List available tools to aid in assessment of geriatric patients.
  • Describe comprehensive geriatric assessment and when such assessment is useful.
  • Identify steps of the geriatric placement process.
  • Identify community resources to assist with common problems.
  • List common payment and insurance issues and resources.
IMPORTANT TERMS AND CONCEPTS
  • Assessment
  • Activities of Daily Living (ADLs)
  • Altered Mental Status (AMS)
  • Comprehensive Geriatric Assessment
  • Delirium
  • Dementia
  • Elder Abuse
  • Elder Depression
  • Instrumental ADLs (IADLs)
  • PRA Plus
  • Prediction of Repeat Admissions (PRA)
  • Psychological Health Assessment
  • Screening
  • SF-36 and SF-12
▪ INTRODUCTION
A. The population that is older than 65 years of age is growing.
B. Just 4% of the population was older than 65 years at the beginning of the century; now the proportion of elderly individuals exceeds 12%.
C. By the year 2030, the older population will be more than double (71.5 million).
D. Eighty-five percent of those over 65 years of age have at least one chronic condition, and many will have multiple conditions, such as hypertension (49.2%), arthritic symptoms (36.2%), and all types of heart disease (31.1%), any cancer (20.0%), and diabetes (15%).
E. In 1997, more than half the older population (54%) reported having at least one disability of some type (physical and nonphysical). Over one third reported at least one severe disability.
F. The fastest growing segments of the population, the oldest old (people greater than 85 years of age), accounted for about 12% of all elderly people in 2000 and is projected to account for 19% by 2040.
G. Expertise in the case management of geriatric patients is critical for case managers owing to:
  • Numbers of patients seen in this category; and
  • Diversity of health care delivery sites and services attending to this group
H. Case management of the geriatric patient differs from that of other patient populations.
I. Demographics (2003)
  • More than 10.5 million Americans (30.8%) older than 65 years of age live alone.
  • Eighty percent of those living alone are women.
  • Nearly half of persons aged 75 or older live alone.
  • Older women, the very old, and the minority elderly population have, on average, the lowest incomes among the older population.
  • In 2000, 4.5% (1.56 million) of the 65+ population lived in nursing homes.
  • Functional disability has increased. Almost 76.3% of institutionalized Medicare beneficiaries needed help with three or more activities of daily living (ADLs). Ninety-three percent of all Medicare beneficiaries needed help with one or more ADLs.
  • About one fourth of all nursing home costs are paid out of pocket by individuals and their families.
  • Women compose more than two-thirds (71.6%) of the total nursing home population.
  • Approximately half of all residents are age 85 and older.
J. In the United States, the growing population of elderly people will have enormous effects on the distribution of health care.
▪ KEY DEFINITIONS
A. Abuse—The willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting pain or mental anguish, or the willful depreciation by a caretaker of goods or services that is necessary to avoid physical harm, mental anguish, or mental illness (Abyad, 1996).
B. Multidimensional assessment or comprehensive geriatric assessment (CGA)—A comprehensive assessment that includes evaluation of a patient in several domains: physical, mental, socioeconomic, functional, and environmental status.
C. Neglect—The failure to provide the goods or services that are necessary to avoid physical harm, mental anguish, or mental illness (Abyad, 1996).
D. Pain assessment—A comprehensive assessment of pain in the geriatric patient should include intensity, character, frequency, location, duration, aggravating and alleviating factors, medical history, thorough analgesic medication history and side effects (if any), ADLs, and psychological function. A quantitative evaluation of pain should also be recorded by the use of a standard pain scale. Patients with cognitive, language, or sensory impairments should be evaluated with scales that are tailored for their needs and disabilities (American Geriatrics Society, 1998).
E. Predictor of repeat admissions (PRA)—A valid and reliable tool for identifying high-risk seniors (age 65 years or greater) who have a statistically higher probability of repeat hospital admission; developed by Chad Boult and associates from the University of Minnesota.
F. Screening—The process by which a health care provider institutes specific criteria to select potential recipients of case management. A screening questionnaire can be administered to a defined population of individuals (i.e., new enrollees into a Medicare risk plan) to identify those at high risk for an adverse health event who may be candidates for case management (HMO Work Group on Care Management, 1996).
▪ COMMON GERIATRIC PROBLEMS
A. Numerous problems can occur in the geriatric population and are characterized by the following:
  • Frequent occurrence
  • Under-recognition and under-treatment
  • Multiple causes
  • Impact on the individual’s ability to function
B. This list is not all-inclusive or comprehensive but represents common issues.
  • The issues above, along with others, are presented to serve as reminders to case managers working with the geriatric population.
  • Many of the issues presented here can manifest themselves in a variety of ways and can also be the precipitating cause of other problems. For this reason, the case manager must be aware of these issues.
  • Many case managers do not see the individuals they are charged with managing, or they do not complete in-depth assessments.
  • Discussing these issues should familiarize the case manager with the key points for each problem so that he or she can appropriately intervene.
  • Regardless of the case management setting, the case manager can ensure that the problems presented here are adequately assessed and the issues addressed appropriately.
C. Altered mental status (AMS)
  • AMS is an umbrella term linked to a variety of other descriptors of mental status, including confusion, delirium, obtundation, stupor, and coma.
  • A great deal of elder assessment depends on the assessment of a person’s mental state to some degree (Gallo, Reichel, and Anderson, 1988).
  • Changes in mental status can be very subtle and often go unrecognized.
  • There are several types and causes of cognitive decline; dementia is not the only cause.
  • Case managers who work with geriatric patients should familiarize themselves with the different causes of and risk factors relating to cognitive decline.
  • AMS can be the cause of many other problems identified by case managers:
    • Nonadherence to treatment plans or medications, or both
    • Injuries such as falls and burns
    • Nutritional deficits
    • Agitation or aggressive behavior
    • Depression
    • Social isolation
    • Fluid and electrolyte disturbances
    • Infections
    • Chemical withdrawal
    • Chemical intoxicants
  • Delirium and dementia can be confused. Although both are AMS, delirium is a sudden change in mental functioning and/or acute confusion—sudden being the key word. Dementia is an acquired loss of intellectual functioning that occurs over a long period of time.
  • A baseline assessment of mental status using a standardized tool can help identify and track the progression of mental status.
    • Standardized tools
      • There are several tools that test mental status.
      • One of the most popular is the Short Portable Mental Status Questionnaire for the Assessment of Organic Brain Disease in the elderly population (Pfeiffer, 1975).
      • Another popular questionnaire is the Folstein Mini-Mental Status Examination (Folstein, Folstein, and McHugh, 1975).
      • The confusion assessment method may also be used to determine and distinguish dementia from delirium.
      • Several other tests are available to identify and quantify the presence of cognitive deficits.
      • The choice of instrument depends on the case manager’s practice setting.
      • The case manager may not be the one who actually administers the test, but he or she should be aware of the availability of the various tools and recommend their use when appropriate.
D. Urinary incontinence
  • Although the urinary system is affected by changes in aging, incontinence should not be thought of as an inevitable part of aging.
  • Assessment for incontinence or the risk of incontinence should be multifaceted and cover the following factors (Miller, 1999):
    • Risk factors influencing elimination, such as prostate surgery
    • Social risk factors such as being able to read bathroom signs when out of the home
    • Signs and symptoms of actual dysfunction, such as leaking urine
    • Whether incontinence is acknowledged. Ask when the problem began, and what has been done about it.
    • Fears about incontinence that include changing activities because of the need to go to the toilet
    • Behavioral signs, such as a urine odor or use of pads
    • Environmental factors that may contribute to incontinence, such as having to go upstairs to use the bathroom
    • Drug side effects
    • Delirium or hypoxia
    • Excessive fluid intake
    • Impaired mobility
    • Physiologic factors—history of prostectomy, atrophic vaginitis, glycosuria
  • Incontinence is often unreported and can have a significant impact on the life and functioning of the older adult.
  • It is important for case managers to assess for and arrange interventions directed at resolving and/or improving the problem.
E. Safety issues
  • Falls
    • Multiple risk factors are associated with falls in the elderly (Miller, 1999).
      • Age-related changes such as:
        • Vision and hearing changes
        • Osteoporosis
        • Slowed reaction time
        • Altered gait
        • Postural hypotension
        • Nocturia
      • Medical problems
      • Psychosocial factors such as depression
      • Medications
      • Environmental factors
      • Any combination of the abovementioned items
      • Fear of falling or post-fall anxiety syndrome are also well recognized as negative consequences of falls
    • The case manager should assess for the presence of the abovementioned risk factors, especially if there is a history of previous falls.
    • As the case manager conducts the overall assessment of the individual, he or she should think about the possibility of falls and whether any of the information collected puts the individual at greater risk.
    • The fall assessment tool should include history of falls, confusion, impaired judgment, mobility status, cooperation, medications, physiological factors that may influence mobility or lack of mobility, mobility aids, to mention a few.
    • Resources are available to help the case manager with the assessment.
      • The physical therapist can assess the individual’s gait and balance.
      • A thorough home safety evaluation can identify environmental concerns.
      • A thorough history from the primary care physician that includes medications and health conditions can assist with identifying medical risk factors.
    • The case manager should tailor the interventions directed at preventing falls to the specific risk factors.
    • Although creating a safe environment is a good overall intervention, it will not fully address the risk of falls if the medication the person is taking makes him or her dizzy.
  • Elder abuse and neglect
Tags:
Jul 14, 2016 | Posted by in PEDIATRICS | Comments Off on Geriatric Case Management

Full access? Get Clinical Tree
Get Clinical Tree app for offline access