• Common Restrictive Diets:– Low/no sugar (Diabetes)– Low fat (Elevated cholesterol)– Low sodium (Congestive heart failure)– Combination of above (High blood pressure)

• Associated with poor intake• May be seen in specific ethnic groups

– Decreased meat intake– Other dietary preferences and restrictions

Chronic Diseases and Restrictive Diets

Dental Problems: Tooth Loss

• Most common causes of tooth loss: Inability or unwillingness to access and

pay for preventive/restorative treatment Loosening of teeth from periodontal

disease Removal of healthy teeth in preparation

for dental prosthesis

• Leads to diminished chewing efficiency and reduced range of preferred foods

Dental Problems: Removable Dentures

• Can aid in speech• Restores facial contours• Less likely to restore

ability to chew (restriction in range of foods)

• Requires frequent professional adjustment

• Not covered by Medicare < 10% of older persons have dental insurance

Screening for Under-nutrition or Malnutrition

Can use a combination of: Serial body weight Weight loss over the past months/yrs Nutrition history: appetite, # of meals/day,

taste & amount of food eaten Laboratory Values: Low serum cholesterol

and/or albumin

Cultural Competency & Frailty

• There is a need to include significant family members in health care discussions.

• It is important to educate both the patient and significant family members regarding the impact of frailty, nutrition and prevention strategies.

Cultural Competency & Frailty

• Family members instrumental in assuring preventive measures and treatment plans are implemented.

• Family members can also be a part of the problem, particularly regarding nutrition.

• By educating family members you:– make them a part of the solution– increase your understanding of potential barriers

to treatment.

Cultural Competency & Frailty

• Many older ethnic minorities lack formal education.

• May have difficulty understanding words, concepts and procedures discussed in a medical setting.

• Important to use words that are easily understood and provide examples. – Reduce carbohydrates– Reduce your intake of cereals, rice and breads

Nutrition Team Challenge

• You are a team gathered together by the CEO of your hospital.

• The CEO tells you that a recent survey by the nutrition department demonstrated a large proportion of your hospital’s patients were having eating difficulties and poor nutrition during the hospital stay and this was negatively impacting on their functional status after discharge.

Nutrition Team Challenge

• Move importantly (to the CEO) this group was having higher 30-day readmission rates.

• Your task is to define potential reasons for the eating difficulties and develop some potential solutions for the problem of eating difficulties and poor nutrition during hospitalization among the older adults admitted to your hospital.

Consequences of Frailty: Falls

• One-third of community-dwelling persons

age > 65, fall each year; less than half talk to their healthcare provider about it.

• In approximately half of the cases, falls are recurrent

• Rates increase – With age– During the month after hospital discharge

Falls Incidence: Community

• In next 17 seconds, an older adult will be treated in hospital ED for fall related injuries.

• 10-15% of falls result in injury requiring medical attention

• Functional deterioration including:– Fear of falling / loss of confidence

• 40-73% of recent fallers• 20-46% without recent fall

– Self-limitation of activities

Falls Morbidity: Community

• Unintentional injury, 5th leading cause of death in those > 65 years– Majority due to falls– Especially in those > 85 years

• Deaths often related to consequences after the fall, not the fall itself– Hospitalization– Decreased activity

Falls Mortality: Community

• Leading cause of injury-related visits to emergency departments in US

• In 2009, 2.2 million nonfatal fall injuries treated in emergency departments.

• Direct medical costs of falls: $28.2 billion in 2010 dollars.

• Numbers expected to climb as population ages

Falls Cost: Community

• Focus of most fall research • Falls in community-dwelling older adults tend

to be multifactorial in nature• As number of risk factors increases, so does

risk of falls

Fall Risk Factors : Community

Occurrence of Falls According to Number of Risk Factors

(Tinetti, 1988)

Number of Risk Factors

Most Common Risk Factors for Falls (AGS Guidelines, 2011)

Muscle weakness 10/11 4.4 1.5-10.3

History of falls 12/13 3.0 1.7-7.0

Gait deficit 10/12 2.9 1.3-5.6

Balance deficit 8/11 2.9 1.6-5.4

Use asst device 6/12 2.6 1.2-4.6

Visual deficit 6/12 2.5 1.6-3.5

Arthritis 3/7 2.4 1.9-2.9

Cognitive impairment

4/11 1.8 1.0-2.3

Risk factor Significant/total Mean RR-OR Range

Ambulatory Devices-Unilateral

Device Benefits Drawbacks Clinical situations

Straight cane

• Assists with balance and proprioception

• Reduced weight bearing on opposite side

• May not provide enough support

• Doesn’t stand up on its own making it difficult to carry objects and open doors

• Osteoarthritis of knee or hip

• Peripheral neuropathy

Quad or 4-point cane

• More stable than straight cane

• Allows greater weight bearing on device

• Heavier than single point cane

• Increased base of support may increase risk of tripping over device

• Stroke with hemiparesis

Ambulatory Devices-BilateralDevice Benefits Drawbacks Clinical situations

Two-wheeled Rolling Walker

• Easier to advance than standard walker

• Allows smoother, faster gait pattern

• Less stable than standard walker

• Turns less smooth than rollator due to fixed wheels

• Deconditioning

• Parkinson’s dz

Standard “Pick-up” Walker

• Very stable • Allows non-weight

bearing movement

• Must be lifted requiring strength/ coordination

• Gait pattern and turns not smooth due to lack of wheels

• Hip fracture; non-weight bearing

• After amputation

Rollator or 4-wheeled walker

• Allows for smoother, faster gait

• Large wheels: turns easy; good outside

• Seat for resting

• Less stable than standard or rolling walker

• Requires increased coordination due to brakes

• More expensive than other walkers

• Cardiopulmonary dz

• Peripheral neuropathy with balance difficulty

• Rodriguez O, Ruiz J, Phancao F. "Assistive Devices" Learning Object. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/379

• van Zuilen M, Rodriguez O, Paniagua M, Mintzer M. Choosing the Appropriate Assistive Device: A Card Sorting Activity. MedEdPORTAL; 2008. Available from: www.mededportal.org/publication/823

Resources for Teaching about Assistive Devices

• Psychotropics, any: RR 1.73 (1.52-1.97)– Neuroleptics: 1.50 (1.25-

1.79)– Sedative/hypnotics: 1.54 (1.40-

1.70)– Antidepressants: 1.66 (1.40-1.95)– Benzodiazepines: 1.48 (1.23-1.77)

• Diuretics: 1.08 (1.02-1.16)

• Anti-arrhythmics (Ia) : 1.59 (1.02-2.48)• Digoxin: 1.22

(1.05-1.42)

Medications and Falls

• Multifactorial assessment of risk factors and management of risk factors identified

• Adaptation/Modification of home environment• Exercise, particularly balance, strength, and

gait training• Withdrawal/Minimization of psychoactive

medications• Withdrawal/Minimization of other medications• Management of postural hypotension• Management of foot problems and footwear

[A]

[A][A]

[B]

[C][C][C]

Recommended InterventionsLevel of

Evidence

Falls in the Hospital Setting

CMS “Never” Events

• “Never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. 

• Patient death or injury associated with a fall while being cared for in a healthcare facility considered a “never” event.

Hospital Risk Factors

• Several factors consistently reported– Gait instability– Agitated confusion– Urinary incontinence/ frequency– Falls history– Medications especially sedative/hypnotics

Multifaceted Interventions: Hospitals• A recent meta-analyses showed rate ratio of

0.82 (95% CI 0.68-0.997) for falls• No significant effect on # of fallers or fractures• Multifaceted interventions included:

– risk assessment – removal of physical restraints– medical/diagnostic approaches– changes in physical environment – medication review– exercise– care planning– hip protectors

Results of Meta-Analysis

• A recent meta-analyses of 13 studies showed a rate ratio of 0.82 (95% CI 0.68-0.997) for falls but no significant effect on number of fallers or fractures– Study included historical controls

• A second study that used only prospective controlled trial designed studies found no conclusive evidence that fall prevention programs reduced falls.

Coussement J, et al. J Am Geriatr Soc, 2008

Frailty and Disability

Nagi’s Disablement Model

Active Pathology• Normal cellular processes and homeostatic efforts to return

to normal state are interrupted

Impairment• Loss or abnormality at the organ or tissue level

Functional Limitation • Have physical or mental limitation at the individual level

Disability • Have physical or mental limitation in a social context (i.e.

socially defined roles or tasks)

Active Pathology

ImpairmentFunctional Limitation

Disability

Criticism of Early Disablement Models

• Presented response to disease or illness as a static process with a linear progression through the disablement process.

• It was recognized the interaction between disease and disability is more complex, particularly for older persons.

ICF Model

• International Classification of Functioning, Disability and Health (ICF) released by World Health Organization (WHO)in 2001 by WHO.

• Describes decreases in function as consequence of dynamic interaction between various health conditions and contextual factors.

• Disability is defined as any decline at any of these levels.

Health ConditionDiseases, disorders,

injuries or aging

ActivityExecution of a task or

action

Body Functions & Structures

Physiologic functions and anatomical parts of body

ParticipationApplication to a real

life situation

Environmental FactorsPhysical, social and attitudinal

environment in which people live

Personal Factors Characteristics of person not part of health

condition or illness

International Classification of Functioning, Disability and Health

Model Used to Discuss Frailty

• We could describe an older woman who has a history of osteoarthritis of the knees and hypertension who presents to rehabilitation after a hip fracture. She lives alone in a second floor apartment and has a daughter who lives six hours away. The patient has a large circle of friends and regularly attends social gatherings at the local senior center.

Health ConditionNew hip fracture

Osteoarthritis Hypertension

Activity

Unable to walk long distances or

climb stairs

Body Functions and Structures

Impairment of ambulation due to hip fracture and

knee pain

ParticipationMissing social

events/ friends Worried about remaining in

apartment alone

Environmental Factors

Lives in second floor apartment

Lives alone, no available caregiver

Personal Factors Great attitude

Large circle of friends

Case Development

• As a team develop a case of a frail person with at least 3 issues contributing to their difficulty in an ICF domain.

• Break the case down by domain/problem to fit into the ICF model.

• After completing your case we will swap cases and develop potential solutions for the problems raised.