Krehký senior v domácej a ústavnej ošetrovateľskej starostlivosti

title: Frail Senior in Home and Institutional Nursing Care type: Applied Papers language: English published: 21 Dec 2017 updated: 06 Apr 2018 category: Nursing author: PhDr. Katarína Zrubáková, PhD., PhDr. Mária Novysedláková, PhD., Bc. Jana Kučíková source: https://www.prohuman.sk/osetrovatelstvo/krehky-senior-v-domacej-a-ustavnej-osetrovatelskej-starostlivosti

Frailty Senior in Home and Institutional Nursing Care Frailty is a concept closely linked to aging. At the age of 65–70, it is present in 35% of the population; at 85–89, it occurs in 26% of people, with its prevalence increasing with age and being more common in women (Hoozová, 2014). Frailty is one of the key characteristics of geriatric patients. From the perspective of geriatrics, frailty is perceived as a non-specific vulnerability of the organism caused by its involution, the consequence of which is generally a decline in health potential (Kalvach, Holmerová et al., 2008, Extermann, 2010). The term frail senior is not synonymous with a disabled/sick senior; it is rather associated with a high risk of loss of function (Hudáková, Obročníková, 2009). Despite this, some authors continue to understand frailty as one among many geriatric syndromes, equivalent to falls, delirium, and incontinence, and do not emphasize it as an overarching, summary, or otherwise key concept (Extermann, 2010). The frailty syndrome and its phenotype are determined by the presence of at least three of five basic characteristics: unintentional weight loss (minimum 4.5 kg per year), subjective perception of fatigue, muscle weakness (sarcopenia), low handgrip strength, slow/shuffling gait, and low level of physical activity/hypomobility (Hudáková et al., 2017).

In nursing terminology, frailty is one of the functional categories determining the degree of dependency (Hoozová, 2014, Bodáková, 2011, Bóriková, Tomagová, Žiaková, 2014). A frail senior has a chronic risk of falls, worsening cognitive functions, is psychologically unstable, depressed, has decompensated chronic disease, experiences problems with instrumental activities of daily living (IADL), requires assistance from family or caregivers, and seeks protected environments (Kalvach et al., 2012, Cheng, 2017). When determining the diagnosis, food intake, nutritional status, mobility, muscle strength, the degree of cognitive deficit, and depression are assessed. Laboratory evaluation of inflammatory and metabolic parameters, self-sufficiency, and self-care—ADL, IADL, FIM—is conducted. For identifying frailty, screening scales are used: the Frailty Index (70 variables, determines the risk category of the senior in terms of institutionalization and death), the Clinical Frailty Scale (Canadian Study of Health and Ageing, 2005), the Clinical Frailty Scale (CFS), Identification of Seniors at Risk (ISAR) (Hudáková et al., 2017, Kalvach, 2012, Warnier et al., 2016), and the criteria for senior frailty according to Morley et al. (2011): F (Fatigue), R (Resistance—problems, inability), A (Ambulation—inability to walk one block home), I (Illness—presence of comorbidities), L (Loss of weight) (Ilinca, Calciolari, 2015).

Treatment of the frail senior must be comprehensive and requires cooperation between the physician, nurse, family, caregiver, social worker, and other professionals depending on the current health status of the senior. It includes screening and active follow-up of frail geriatric patients, optimization of the geriatric hospital regimen, and coordination of community services. Long-term physiotherapy, use of supportive devices and occupational therapy measures, protection of dignity, and individual measures based on the specific situation and problems of the senior are important (Kalvach et al., 2008, Rockwood, 2005, Hegyi, Krajčík, 2010, 2015, Berková et al., 2013).

The nurse is an important member of the team at all levels of senior care. She participates in the prevention, diagnosis, and treatment of the frail senior. She performs procedures independently based on the physician's indication and in cooperation with other team members—physiotherapist, nutrition assistant, nutritional therapist, occupational therapist, healthcare assistant, social worker, psychotherapist, etc. (Touhy, Jett, 2010).

The basis of preventive measures is patient education and identification of risk factors for the development of geriatric frailty. Preventive measures focus on modifiable risk factors, which include: supporting nutrition and physical activity, maintaining muscle strength, preventing isolation, keeping the senior in a natural environment, and regular assessment of functional and health status. In elite/fit seniors, it is essential to support individual and group physical activity and exercise. The nurse assesses the current health, psychological status, and functional capacity of the senior. The most common diagnoses associated with geriatric frailty include: activity intolerance (00092), impaired mobility (00090), impaired walking (00088), impaired physical mobility (00085), lack of recreational activities (00097), chronic pain (00133), imbalanced nutrition: less than body requirements (00002), decreased fluid volume (00027), fatigue (00093), self-care deficit (00108, 00109, 00102, 00110), anxiety (00146), risk-prone health behavior (00188), etc. (NANDA International, 2015–2017).

Nursing Interventions in Home and Institutional Care

Nursing interventions in the home environment focus on:

• monitoring the current condition of the patient and the family member/caregiver; it is important to maintain a system of regular visits.
• Adjusting the social environment when inappropriate conditions exist in the senior's household.
• Nutritional support, primarily for enteral nutrition—most commonly administration of food via PEG.
• Nursing rehabilitation.
• Activation, motivation of the frail senior, cognitive rehabilitation, and stimulation.
• Education of the senior/family members.
• Documentation of care.

In institutional care (healthcare and social facilities), interventions for frail seniors as part of nursing care include:

• Regular monitoring of the current health and psychological status of the senior.
• Optimization of the treatment regimen.
• Prevention of maladaptive syndrome.
• Nutritional support, regular assessment of nutritional status, reduction of malnutrition, intake of balanced nutrition, fluid intake. Attention is also given to swallowing disorders and patients with cognitive dysfunction, and weight is regularly checked.
• Patient activation, nursing rehabilitation, positioning, passive and active exercises, verticalization, respiratory gymnastics, conditioning exercises, use of compensatory devices, cognitive rehabilitation.
• Identification of current psychosocial and spiritual needs.
• Motivation, education, and social contact; promoting a sense of security, safety, self-realization, and hope.

Nursing Care for Frail Seniors in Clinical Practice

We investigated how nursing care for frail and long-lived seniors is provided in the home environment and in healthcare and social institutions through field research. The research is part of the KEGA project Possibilities of Interdisciplinary Cooperation in the Implementation of Non-pharmacological Treatment of Seniors in Institutional Facilities. The project aims to identify the most commonly used non-pharmacological treatment procedures in senior therapy. To determine which diagnoses they are most frequently used for and how team care is implemented in institutional facilities. In the pilot study, we found that non-pharmacological treatment procedures are often used in the treatment of frail seniors, so we focused subsequent research activities in this area.

Research Objectives To determine what preventive and therapeutic interventions nurses implement for frail seniors.

Sub-objectives To determine what knowledge nurses have about geriatric frailty. To determine how nurses assess the current health status of frail seniors. To compare interventions implemented in the home environment and in institutional facilities.

Research Sample 100 nurses working with seniors at the Central Military Hospital SNP FN Ružomberok, home care agencies in Ružomberok, Dolný Kubín, Liptovský Mikuláš, Poprad, and Social Services Facility in Poprad. Ward head nurses and home care agency managers (8). Respondent selection was intentional.

Research Methods The main method was a self-constructed questionnaire divided into areas—nurses' knowledge, assessment of seniors, preventive interventions, and therapeutic interventions. Complementary methods included: unstructured interviews, documentation analysis, and comparison.

Research Results Area: Nurses' Knowledge of Frailty Syndrome The questionnaire contained several items focused on nurses' knowledge of the syndrome. Questions addressed the general definition, the term geriatric frailty, and categories of seniors at risk for frailty syndrome. We found that the term was familiar to 25 nurses, 65 had heard of it, and 10 had not heard of it. Nurses also defined the term orally or in writing in their own words—the most frequent responses are presented in Table 1.

Table 1 Definition of the Term Geriatric Frailty

When asked which seniors are most at risk for the syndrome, nurses responded: long-lived seniors, over 85 years (72%), oncologically ill (20%), polymorbid geriatric patients (8%).

Area: Assessment of Seniors' Health Status

This area included questions focused on methods and tools for assessing the health and functional status of seniors. We focused on assessment of dependency, energy, weight, BMI, use of assessment tools, and monitoring symptoms that help diagnose the syndrome. Upon evaluation, we found that: 58% of nurses assess dependency (38% answered no), 30% of nurses use a scale from 0–10 to assess energy, 45% only sometimes, 45% calculate BMI, 30% sometimes. Negative responses were given regarding weight loss assessment—78% of nurses gave a negative answer. Nurses use standard assessment tools, but not tools specifically developed for frail seniors. The most commonly used tools are shown in Graph 1.

Graph 1 Use of Assessment Tools

The next section focused on monitoring the health status of seniors. We recorded positive responses regarding fluid intake monitoring (85 nurses check) and monitoring of dietary habits (96 nurses pay attention to seniors' nutrition). Table 2 presents the problems that nurses observe in frail patients.

Table 2 Problems Accompanying Frailty Syndrome

Area: Nursing Interventions Interventions were divided into preventive and therapeutic. For preventive interventions, the nurses' responses are presented in Table 3. Responses are listed by frequency—the response most frequently written in the questionnaire or given by nurses during personal communication.

Table 3 Preventive Interventions

When providing nursing care for frail seniors, nurses most frequently added these interventions:

• fall prevention.
• Support for self-sufficiency, improving independence, assistance with self-care activities.
• Improving nutrition and hydration.
• Assistance in meeting needs.
• Rehabilitation.
• Education.
• Adapting interventions to the patient's condition.
• Supporting cognitive functions.

In the last table, we present a comparison of responses from home care agency nurses and those working in healthcare and social institutions.

Table 4 Comparison of Nurse Interventions

Discussion

The dominant problem in relation to nursing care for seniors is the syndrome of age-related frailty and vulnerability. This refers to a set of symptoms implying a continuum of health and functional status that is the opposite of vitality (Hudáková et al., 2017, p. 29). Frail seniors are of interest to practical geriatric medicine, nursing, and social work. They represent the group of seniors with the highest risk of adverse outcomes—from falls and dependency on care to higher mortality (Ilinca, Calciolari, 2015). Internationally, significant attention is devoted to the treatment and nursing care of frail seniors, with clinical trials being conducted and care models being tested—for example, in Canada, integrated care systems, shared care models, and home care models are used (Frank, 2015). Clinical trials are testing tools for assessing the risk and presence of frailty syndrome, as well as areas of focus for preventive and therapeutic nursing interventions, particularly in primary care and the home environment (Van Hout, 2010). In the Slovak Republic, we have not encountered such activities. In conducting our own research, we defined four objectives, and after evaluating the collected results using methodological triangulation, we determined what knowledge nurses have about the syndrome, which tools they use in assessing seniors' health status, and what interventions they most frequently implement. Among the most important findings are: nurses have encountered the term frail senior; knowledge was mainly held by nurses with higher education and 2–10 years of work experience. When assessing health status, they are limited by documentation options. Among assessment tools, the Barthel Index and nutritional screening (particularly at the Central Military Hospital in Ružomberok) were most commonly used, while the dominant hand grip strength test was least frequently reported. Nurses used universal tools applicable to seniors with various diagnoses, in contrast to foreign studies, where primarily ISAR, FRAIL, TRST (Triage Risk Stratification Tool), and the Fa Index were used (Warnier et al., 2016, Dapp et al., 2014, Dapp et al., 2012), which are focused on assessing frailty syndrome.

Preventive activities are primarily implemented by nurses in long-term care. In the home environment, nurses are limited by insurance. A problem in implementing preventive and therapeutic interventions is the need for repeated visits. The effectiveness of care significantly depends on the help and cooperation of family members and the availability of social services. In acute care, nurses focus more on treatment and prevention of complications.

Conclusion

Effective care for frail seniors is one of the main challenges of geriatrics in the 21st century (Fulmeková, Masariková, Lehocká, 2012). It requires adequate interdisciplinary cooperation in both the home environment and institutional facilities. Through field research and analysis of other research studies and professional publications, we identified deficiencies in the individual care of frail seniors, in the coordination of interventions (primarily nurse–physiotherapist, nurse–nutrition assistant, nurse–social worker), and the absence of screening examinations for persons over 70 years of age, as well as persons with chronic disease and significant weight loss (more than 5% in the past six months). It is therefore important to eliminate these shortcomings and, based on evidence from clinical practice, implement preventive and therapeutic interventions in our facilities and community care that help eliminate the health and functional deficit of frail seniors. This will reduce the burden on families in the home environment and support the quality of care in institutional facilities.

Authors: PhDr. Katarína Zrubáková, PhD., PhDr. Mária Novysedláková, PhD., Bc. Jana Kučíková Faculty of Health Sciences, Catholic University in Ružomberok References

BERKOVÁ M. et al. Issues of senior age: senile frailty, sarcopenia, and disability. In Practicus. Vol. 12, No. 2, 2013. pp. 13–17. ISSN 1213-8711. BODÁKOVÁ, D. Frailty syndrome—characteristics. In Palliative Medicine and Pain Treatment. Vol. 4, No. 2, 2011. pp. 52–54. ISSN 1337-6896. BÓRIKOVÁ, I., TOMAGOVÁ, M., ŽIAKOVÁ, K. Measuring instruments in gerontological nursing. Multimedia support for teaching clinical and health disciplines. 2014. Online. Available at: https://portal.jfmed.uniba.sk/clanky.php?aid=251. DAPP, U. et al. Long-term prediction of changes in health status, frailty, nursing care and mortality in community-dwelling senior citizens. In BMC Geriatrics. Vol. 14, Iss. 1, 2014. pp. 141–144. ISSN 1471-2318. DAPP, U. et al. Resources and risk in old age. In Zeitschrift für Gerontologie und Geriatrie. Vol. 45, Iss. 4, 2012. pp. 262–270. ISSN 0948-6704. EXTERMANN, M. Educational book: Age and vulnerability of patient. American Society of Clinical Oncology, 2010. FRANK, C. Models of primary care for frail patients. In Canadian Family Physician. Vol. 61, Iss. 7, 2015. pp. 601–606. ISSN 0008-350X. FULMEKOVÁ, M., MASARYKOVÁ, L., LEHOCKÁ, Ľ. Geriatric patient and quality of life. In Practical Pharmacy. 2012, Vol. 2, No. 1, pp. 26–28. ISSN 1338-3132. HEGYI, L., KRAJČÍK, Š. Geriatrics. Bratislava: Herba, 2010. 608 pp. ISBN 978-80-89171-73-6. HEGYI, L., KRAJČÍK, Š. Geriatrics for the General Practitioner. 3rd ed. Bratislava: Herba, 2015. 408 pp. ISBN 978-80-89631-31-5. HOLMEROVÁ, I., JURAŠKOVÁ, B., ZIKMUNDOVÁ, K. et al. Selected Chapters from Gerontology. Prague: Gerontological Center, 2007. 145 pp. ISBN 978-80-254-0179-8. HOOZOVÁ, J. Frailty: a common topic for geriatricians and palliative care physicians. In Oncology. 2014, Vol. 9, No. 6, pp. 349–354. ISSN 1339-4215. HUDÁKOVÁ, A. et al. Evaluation of functional abilities of seniors. In Geriatrics. Vol. XXIII, No. 1, 2017. pp. 28–31. ISSN 1335-1850. HUDÁKOVÁ, A., OBROČNÍKOVÁ, A. Disability and frailty—new phenomena in geriatrics. In: Nurse and Physician in Practice: Journal for Nurses, Physicians and Other Health Professionals. Vol. 8, No. 7–8, 2009. pp. 42–43. ISSN 1335-9444. CHENG, M.H. Frailty as a Risk Factor for Falls Among Community Dwelling People. In Journal of Nursing Scholarship. Vol. 49, Iss. 5, 2017. pp. 529–536. ISSN 1527-6546. ILINCA, S., CALCIOLARI, S. The patterns of health care utilization by elderly Europeans: frailty and its implications for health systems. Health Services Research. 2015, Vol. 50, Issue 1, February, pp. 305–320. KALVACH, Z., HOLMEROVÁ, I. Geriatric frailty—an important clinical phenomenon. In Medical Practice. 2008, 5 (2), pp. 66–69. KALVACH, Z. et al. Geriatric Syndromes and the Geriatric Patient. Prague: Grada, 2008. 336 pp. ISBN 978-80-247-2490-4. KALVACH, Z. et al. The Frail Patient and Primary Care. Prague: Grada, 2012. 400 pp. ISBN 978-80-247-4026-3. NANDA International. NANDA—Nursing Diagnoses. Definitions and Classification 2015–2017. Prague: Grada, 2016. 464 pp. ISBN 978-80-2475-412-3. ROCKWOOD, K., HOGAN, D., MACKNIGHT, CH. Conceptualisation and measurement of frailty in elderly people. Drugs and Aging. Vol. 17, Iss. 4, October 2000. pp. 295–302. ROCKWOOD, K. et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. Vol. 173, Iss. 5, 2005. pp. 489–495. TOUHY, T., JETT, K. Gerontological Nursing. Healthy Aging. Mosby Elsevier, 2010. 483 pp. ISBN 978-0-323-05701-1. Van HOUT, H.P.J. et al. Prevention of adverse health trajectories in a vulnerable elderly population through nurse home visits. In Journals of Gerontology. Vol. 65A, Iss. 7, 2010. pp. 734–742. ISSN 1079-5006. WARNIER, R.M.J. et al. Validity, reliability and feasibility of tools to identify frail older patients in inpatient hospital care. In Journal of Nutrition, Health and Aging. Vol. 20, Iss. 2, 2016. pp. 218–230. ISSN 1279-7707.