Are falls, wounds, and skin Breakdown in long-term care always a result of poor care? Here is the perspective of a Geriatric Nurse Practitioner.
Our objectives:
Define 3 causes of weight loss in older adults
Identify 3 areas of care frequently cited in lawsuits regarding care of older adults
State the percentage of weight loss that is considered an abnormal loss
Abstract: This activity will discuss three conditions commonly named as a result of negligent or substandard care in older adults from the unique perspective of a provider specializing in Geriatrics. Situations in which a decline has occurred despite good care are explored. Several perspectives are shared to make a case that the change is the result of a decline or advancement of a chronic condition rather than poor care. Two case scenarios are shared depicting a change in condition and highlighting the importance of collaborating with caregivers and staff as well as determining the individual’s priorities to develop a plan of care consistent with their wishes.
Event such as falls, wounds and weight loss may appear to be due to neglect but there are situations that these changes in condition are a result of advancement of disease or generalized decline. The care of older adults is complex due to the number of chronic conditions as well as the changes that occur with age.
As a Geriatric Nurse Practitioner working in long term care much of my time is spent differentiating a decline in function versus an acute change in condition. When working with older adults in a skilled nursing or assisted living facility, staff and family members are a vital part of helping to determine an acute change versus a general decline. The staff or family may notice a change over a few days or months.
Another complexity of working with older adults is determining goals of care regarding their preferences and treatment options. The presence of chronic illness often plays a role in decisions regarding the quality of life they desire. Sometimes older adults are no longer deemed able to make their own decisions and communication occurs with a surrogate decision maker. Even when individuals make their own decisions their family members are often involved in their care, both the older adult and their family appreciate family involvement in the discussions regarding change of condition.
Wounds, falls and weight loss are commonly the focus of lawsuits in long term settings with care below the standard or neglect sited as the cause however these areas may be the result of an overall decline in the patient’s condition. As a provider working in long term care, at each visit or medical update, time is spent determining if the concern is an acute change or it is a consistent finding. Has there been a change in lab values or weight? Is the weight trending up or down? Is the trend due to a condition such as heart failure? Are there other conditions contributing to a weight loss such as trouble swallowing? If there is swallowing difficulty is it due to a condition such as Parkinson’s disease or a history of a stroke? Is it possible the individual has an infected tooth causing them to eat less, or are they depressed or suffering from memory loss which causes disinterest in eating or do they just not care for the food? If the individual fell, was there a cause that can be determined? Did they need to use the restroom, are they suffering from an infection? Did they have an acute change of condition causing weakness? If the individual has developed a wound, is this a new finding? Have they had wounds in the past? Has there been a change in condition preventing them from repositioning as they usually would such as pain from a broken bone or increased sleepiness due to a medication or infection?
Weight loss in long-term care
A trigger for a weight loss is usually 5 % of the body weight. The most common causes of weight loss in older adults is cancer, an issue with the intestinal system or a psychiatric condition. Medications and interactions between them can also be a factor (Gaddey H. MD, 2014 ) Some medications can interfere or alter the taste of food causing a decrease in food intake.
There are no specific guidelines for the management of weight loss. The goal for management is to treat the underlying cause. The provider can order blood work and urinalysis to look for an infection. There are screening tools available to evaluate for depression or cognitive changes. Depression and dementia have both been shown to contribute to unintentional weight loss. Weight loss evaluation can require an assessment of a dentists, dietitians, speech therapists, physiotherapists, occupational therapists, or social worker (McMinn, 2011) If a work up does not reveal an acute finding it is acceptable to monitor the weight for three to six months. If an underlying cause is found, steps can be made to correct the cause. Discussions regarding life prolonging measures of treatment should be discussed and documented. Appetite stimulants and nutrition through devices such as a feeding tube are not without side effects and risks, the interventions offered and chosen should be discussed with the patient and or their decision maker and documented.
Falls while in long-term care
Older adults are at higher risk for injury from falls for several reasons. They may be taking medications that cause an increased risk for bleeding or may cause dizziness. As people age the brain shrinks. With more room between the brain and skull there is a higher impact to the brain with a fall which may cause a severe brain injury and bleeding. Persons with dementia are 4–5 times more likely to experience falls (Datta, 2018). Many older adults use a device such as a walker to help their gait be steadier but those with dementia may forget to use the device or may use it incorrectly. Some medications pose increased risk for falls, these medication classes include antipsychotics, antidepressants, and sedatives–hypnotics, particularly benzodiazepines Common side effects are sedation, impaired balance, and decreased coordination. While there has been a push to reduce the use of antipsychotics in nursing homes, nearly one-third of nursing home residents with dementia receive antipsychotic medications with the common side effects of sedation, impaired balance, and decreased coordination. (Datta, 2018) Environmental hazards such as wet floors, poor lighting, unstable furniture, clutter account for 16% to 27% of falls in nursing homes (Datta, 2018)
Long-term care wounds
Skin, the body’s largest organ can become overwhelmed with the burden of disease even with appropriate prevention interventions. The Wound and Ostomy Nursing Society (WOCN) have provided a position addressing avoidable versus unavoidable pressure ulcers.
“Unavoidable” means that the resident developed a pressure ulcer, even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions, and revised the approaches as appropriate” (483.25c/TagF314).
WOCN Position Statement
The statement also discussed there are clinical circumstances when pressure ulcer prevention interventions may be medically contraindicated. An individual may need to have their head elevated to promote good aeration of the lungs. This does put additional pressure on the buttock area which puts them at greater risk for skin breakdown but without adequate oxygenation the individual will not survive.
The position statement also discusses the very controversial concept that individuals have a right to refuse recommended treatment such as repositioning, particularly if it causes discomfort. The presence of pressure ulcers is most often an indication of deterioration of the individual’s medical conditions.
A study in 2016 performed by University of Washington School of Nursing was undertaken to determine if residents in facilities providing consistent high-quality care still developed pressure ulcers despite their good care. The study of 20 residents were from facilities located in 7 counties in Western Washington and Orange County, along with a single site in Wisconsin. The results from the study determined residents who developed advanced stage pressure injuries despite the consistent good quality care were older, had limited mobility and dementia. Other comorbid conditions included urinary or fecal incontinence, and infections. The pressure injuries were relatively small and had little-to-no undermining, exudate, or edema. (Baker, 2016)
Once determining if the concern is an acute change or a decline in a chronic condition the next step is to determine with the older adult and their family/ decision maker what they wish to do about this change. The treatment choices and interventions they feel is acceptable to undergo is different for everyone. The decisions made should be documented and shared with the care team then implemented.
Scenarios
Care scenario of Gladys Night
Gladys Night is an 86-year-old woman who has chronic conditions of Parkinson’s disease, dementia, and hypertension with a history of CVA. Gladys has a mild weakness in her right side. She is on a diet of soft foods with thickened liquids with the consistency of nectar. The dietician has sent an update that Gladys has had a 3-pound weight loss over the past two weeks and a 6-pound weight loss over the past month. Glady’s current weight is 117 pounds. One year ago, Gladys weighed 135 lbs.
This weight loss is despite the staff feeding Gladys her meals and nutritional supplements three times a day. A review of the records reveals Gladys’s intake varies from 15-40% of most of her meals. The dietician is asking for the provider’s recommendations and orders. At this point, the chart would be reviewed to see if recent blood count, electrolytes, or urinalysis have been collected and if there is any indication of an underlying cause of the weight loss such as an infection. Gladys had a full panel of blood work and urinalysis 2 months ago which did not reveal any concerns, A review of Glady’s medication was performed to see if there have been any recent changes or if one of her medications may affect Gladys’s taste or appetite. The nurses were consulted and asked if they have noted any concerning changes with Gladys. The nurse has noticed a steady decline but no alarming changes with her. Gladys is on two medications with potential adverse effects, the first one is oxybutynin, a medication given to help with urinary incontinence however Gladys has been incontinent for years and is dependent on others to change her so she really is not benefiting from this medication. The adverse effects of the medication include dry mouth, constipation, nausea, and daytime sleepiness. The second medication is omeprazole (Prilosec) used to prevent or treat stomach ulcers. Gladys has never had a stomach ulcer and a review of the records indicate she was placed on the medication several years ago after her husband passed away when she was having some stomach upset. Adverse effects include abdominal pain, diarrhea, nausea, vomiting, dizziness, constipation, altered taste, and a higher risk of intestinal infection. Both medications are felt to pose more risk than benefit for Gladys.
Once all the information is gathered about Gladys, it is time to discuss the concern of the weight loss, review the lab work and discuss recommendations regarding the two medications as well as options for the desired course of action. Gladys is not able to make her own decisions, her daughter Kelly has been made her decision-maker. Kelly visits Gladys often, particularly at mealtime so she can help encourage Gladys to eat. Kelly has noted Gladys is declining over the past few months. She sleeps more and talks less. Gladys no longer feeds herself and no longer participates in activities. Kelly states Gladys used to be on a medication to help her appetite, but she gained weight a desired side effect) and was taken off the medication.
Kelly was asked what Glady’s goals would be regarding supporting her nutritionally. Would she want a feeding tube or appetite stimulants? Would she want comfort measures such as palliative care or hospice? Would she want lab work repeated to evaluate for an infection? While discussing all of the information gathered and options for care, Kelly agreed to stop the two medications with adverse side effects to see if it helped improve Glady’s appetite, Kelly did not want to place Gladys on any medication to stimulate her appetite and she definitely did not feel Gladys would want her life prolonged with the placement of a feeding tube. She is aware Gladys’s condition is declining, she just wishes to keep her comfortable and to continue supporting her the same way. She does not feel ready for evaluation of Palliative or Hospice at this time.
Care scenario of Frank Smith
Frank Smith is a 76-year-old patient in a long-term care facility. He has lung disease, high blood pressure, and kidney disease. Frank has been feeling tired for several months but really has no other complaints. Frank has been eating fairly well but has been losing weight steadily and over the past 6 months, he lost 30 pounds. The blood work over the past 6 months indicates a very high platelet count which was felt to be due to acute myeloid leukemia. Frank and the nurse practitioner had several conversations to discuss Frank’s wishes. Frank did not wish to pursue an evaluation by a blood specialist for his elevated platelet count and did not wish to have any aggressive treatment. Today Frank really cannot eat anything, he does not wish to go to the hospital. Frank’s family was alerted and came to the nursing facility. Frank son’s and a daughter-in-law came to see Frank and requested that he be transferred to the hospital. Frank again insisted he did not wish to go. The nurse practitioner helped Frank talk with his family and offered an intervention of Intravenous fluids to see if perhaps correcting Frank’s dehydration may make him feel well enough to eat. Frank agreed but insisted that he did not want any heroic measures including CPR or mechanical ventilation. Frank’s sons were not aware of Frank’s wishes but did agree to honor them. Paperwork was filled out to document Frank’s preference for “do not resuscitate” status. Orders were written for no hospitalization. Frank was given IV fluids and felt a bit better the next day however he continued to decline and did pass away with his family at his bedside several days later. Frank and his family were very grateful for the interventions and assistance of the nurse practitioner in helping Frank define and express his wishes and have control over his last days.
This article has discussed just a few of the complexities in caring for older adults and speak to the specialized body of knowledge and experience required to navigate care. It serves as a testament to the fact that a geriatric nurse practitioner brings unique focus and perspective in determining if the standard of care has been met and if the perceived breach of care is due to a decline in patient condition.
References
Attar M, A. Y. (2021, May 6). Common Types of Falls in the Elderly Population, Their Associated Risk Factors and Prevention in a Tertiary Care Center. Cureus, 13(5).
Baker, M. W. (2016, sept/ oct). Full-Thickness and Unstageable Pressure Injuries that Develop in Nursing Home Residents Despite consistently Good Quality Care. Journal of Wound Ostomy Continence Nurs., 43(5), 464-470.
Berkowitz, D. B. (2000, January). Are we improving the quality of nursing home care: The case of pressure ulcers. Journal of American Geriatric Society, 48(1), 59-62.
Congess .gov. (2015). Retrieved from Code of ethics with interpretive statements.
Datta, A. D. (2018, December 25). What Factors Predict Falls in Older Adults Living in Nursing Homes: A Pilot Study. Journal of Functional Morphology and Kinesiology, 2-8.
Enderlin, C. R. (2015). Summary of factors contributing to falls in older adults and nursing implications. Geriatric Nursing Journal, 36, 397-406.
Gaddey H. MD, H. K. ( 2014 , May 1). Unintentional Weight Loss in Older Adults. American Family Physician, 89(9), 718-722. Retrieved from https://www.aafp.org/journals/afp.html?cmpid=_van_188
McMinn, J. S. (2011, March 29). Investigation and management of unintentional weight loss in older adults. BMJ. Retrieved from https://www.bmj.com/content/342/bmj.d1732
Wound and Continence Nurses Society. (2009). Position Statement on Avoidable Versus Unavoidable Presure Ulcer. Journal of Wound, Ostomy and Continence Nursing, 36(4), 378-381.
About the Author
Dana Beyers GNP- BC
I have been a nurse for 33 years. Much of my nurse clinical experience includes working on a hospital telemetry unit caring for patients requiring cardiac monitoring as well as patients requiring mechanical ventilation. I also have experience working as a nursing supervisor and charge nurse.
In 2009 my affinity for older adults lead me to become a Board-Certified Geriatric Nurse Practitioner. My preferred clinical practice environment is long term care as it allows for autonomy as well as opportunities to provide guidance for patients and their family regarding the complex health care needs that develop with patients of advanced age.