SIGN Vol 19, Issue 6 Nov/Dec 2012

President's Message
Keeping the Passion Alive


For those of you who joined me at the 27th Annual NGNA Convention in Baltimore, you know the inspiration, energy and passion that was present.  Regardless of your role as a gerontological nurse, finding ways to re-energize, gain new knowledge and remember why you commit yourself to influence improved nursing care for older persons is critical.  NGNA’s annual convention is an important opportunity to do this; but don’t forget, networking locally with your gerontological and interprofessional colleagues is powerful as well.
At Convention, I was reminded of two things.  First, our appreciation for the leadership and legacy of those NGNA members who have blazed the trail for our organization, and remain active participants in meeting our mission.  You know who you are.  Without you freely sharing your wisdom, resources and time, NGNA would not be the organization that it is today.  
Second, I was reminded that the “new guard” is arriving on a regular basis.  From the enthusiastic involvement of students, to the number of  members who are dipping their toes into committee involvement for the first time, and all others who are putting forth their names for leadership and Fellows opportunities -  all of you are the vital sources for NGNA to continue to meet our mission, improving nursing care given to older adults.  
I am so appreciative of the current state of scientific knowledge, the evidence-based practice tools and relevant health policy information I heard at our Baltimore meeting.  Equally important was the ability to fill up my “passion tank” and be reminded in such a vivid way of the extraordinary influence my gerontological nursing colleagues have on the world.  
Take a moment to think of ways to fill up your “passion tank.” The world needs us to lead the way for improving health care for older persons!
Warm regards,
 Convention Planning Committee Update

Submitted by Jane Hannah Herin MSHS, BSN, RN BC, PHN, CDE, CHES, FNGNA

Our 2012 annual convention was held in the “Charm City” of Baltimore, Maryland.  If you missed this event, you missed a great time.  NGNA hosted  230 participants, including 36 students. The students took part in student informational sessions, poster sessions and assisted in moderating general and concurrent sessions. They were also able to attend concurrent and general sessions, for the full convention experience. Our four pre-convention programs were well attended, and included topics of medication management, transitional care, geropalliative care and Deb Conley’s pre certification class.   

During our opening session,  we listened to a very enthusiastic Barbara Resnick, PhD, who discussed her research and experience in physical activity. This was followed by a reception with great Italian food, along with some special Maryland crab cakes.  The opening reception  was partially sponsored by University of Maryland, George Mason University, and Johns Hopkins University.  We all had the opportunity to view the posters and talk with the presenters, while reviewing the exhibitor booths and exhibits.  

Dr. Keela Herr was the keynote speaker,and received this year’s NGNA Lifetime Achievement Award. She brought us pain assessment tools which were developed in her many years of research.  Pharmacist Nicole Brandt shared key information on reviewing older adults’ medications – teaching us that ‘more is not necessarily better.’ We also had the opportunity to pick up the latest Beer’s list of medications to avoid or use with care.

Casey Shillam gave her presentation to a standing room only crowd.  Her Future of Nursing: Campaign for Action: Nurses Shaping Policies for the Care of Older Adults was something that we all need to consider for our facilities.  The consumer session was again a special treat -  they just get better and better each year.  This presentation was given by  two sisters, a playwright and an actress, who gave a performance reading about issues of older adults.

Karen Armacost gave an interesting concurrent session on partnerships with medical religious communities, and how we as health professionals can build healthy communities. During a general session, George Taler, a Baltimore-area physician, described his take on Health Care Reform and how we need to change the course of care for patients and providers.

Other features included committee meetings, a student networking session, a fellows informational session, a new member/first time attendee orientation, and the NGNA  membership meeting.

Our awards luncheon gave us an opportunity to give recognition to our fellow nurses. Our Distinguished Service Award was presented to Martha Sparks, a very well deserved recipient (who also happened to be my convention roommate!). The Excellence in Gerontological Nursing Award (APRN) went to Claudia Chaperon, PhD and the RN Excellence in Gerontological Nursing Award to Erin Ament.

The winner of the Judith Braun Excellence in research award was Todd Monroe, PhD for his poster, titled Assessing Advanced Cancer Pain in People with Dementia at End-of-Life. The winner of the Innovations in Practice award went to Linda Bub for her poster, titled The 3D Room: Educating Nurses on Delirium in their Practice Environment.  Six outstanding nurses were inducted as NGNA Fellows:  Sheila Delp, MSN; Sarah Jean Fisher, MSN; Melodee Harris, PhD; Linda Hassler, MS; Jeanne St. Pierre, MN; and Sharon Wexler, PhD.

Nicole Ortiz and Rachel Mjones were the winners of the Mary Opal Wolanin Scholarship – graduate and undergraduate, respectively.  Kelley Isringhaus was the recipient of the Cindy Shemansky Travel Scholarship.

Dr. Jonathan Zenilman gave us the latest information on MRSA and how to avoid contracting it.  Dr. Robin Remsburg  discussed her project of training for more nursing educators.  Sociologist Dr. Laura Gitlin gave a very poignant reveal and discussion of family caregivers of older adults.

Todd Monroe and Abby Parish discussed their research study on the effect of geriatric training or certification for employees.  Jane Marks and Reba Cornman discussed their project which engaged students in interdisciplinary geriatric educational opportunities. 

We had several groups of research presentations on such diverse topics as elder suicide prevention, certification for LTC nurses, educational needs of older adults with HIV, spirituality and caregiving. Others included behavior changes in medication administration, and caregivers perception among Taiwanese of chronic illness, pressure ulcer prevention, improving students’ skills and perceptions of older adults, preoperative assessment of older adults having cancer surgery, and the Geriatric Nursing Education Consortium.

We had 60 participants attend the Maryland Crab Feast, and they had a great time sampling Maryland’s famous cuisine. I spent a quieter but great time at Chiapparelli’s Italian Restaurant with a ‘Table for 8’ group. The silent auction was fun for everyone, and the 50/50 (totaling $1830!) was won by Joanne Alderman.  

I would like to thank the Baltimore/DC NGNA chapter for providing the Baltimore welcome bags and to Johns Hopkins University for sponsoring the conference syllabus. Thank you again for coming to Baltimore, and I look forward to seeing you at next year’s convention, which will take place at the Hilton Clearwater in beautiful Clearwater, Florida. The 2013 Convention Planning Committee will soon be reserving speakers and planning events for next year. It will be here before we know it!  


The following NGNA members were honored at the 2012 Awards Luncheon, which took place during the annual convention at the Sheraton Inner Harbor Hotel in Baltimore, Maryland. Congratulations to these deserving award winners!

Distinguished Service Award
Martha B. Sparks, PhD, GCNS-BC, FNGNA
Excellence in Gerontological Nursing Award – APRN 
Claudia Chaperon, PhD, APRN, GNP-BC
Excellence in Gerontological Nursing Award – RN
Erin Ament, RN
Judith Braun Excellence in Research Award
2012 Finalists:
Todd Monroe, PhD, RN-BC
Assessing Advanced Cancer Pain in People with Dementia at End-of-Life
Nancy B. Lerner, DNP, RN
RN Staffing and Quality in Nursing Homes
Award Presented To: Todd Monroe, PhD, RN-BC
Innovations in Practice Award
2012 Finalists:
Linda Bub, MSN, RN, GCNS-BC
The 3D Room: Educating nurses on delirium in their practice environment
Susan J. Gordon, ACNP-BC, GNP-BC, FGNLA
Bedside Coaching to Improve Nurses’ Recognition of Delirium
Sheila B. Delp, RN,MSN,GCNS-BC
Telephone Calls After Discharge to Assess and Clarify Discharge Instructions
Transitioning Elders Across the Continuum of Healthcare: Let the STARS (Safety, Teamwork, Advocacy, Rounding, & SPICES) Guide Older Adults to a Safe Harbor
Award Presented To: Linda Bub, MSN, RN, GCNS-BC
Recognition of Scholarship Recipients
Mary Opal Wolanin Scholarship
Graduate Student Recipient:  Nicole Ortiz
Undergraduate Student Recipient:  Rachel Mjones
Cindy Shemansky Travel Scholarship
Kelley Isringhaus, RN
Best Poster
EBP Category: Suzanne Fehr, RN-BC, MS, NE-BC and Joselin Bodaghi
Zero Pressure Ulcers
Research Category: Carol Enderlin, PhD, RN and Janet Rooker, MNSc., RNP
Excessive Daytime Sleepiness, Sleep Quality and Mood in Community-Dwelling Older Women with and without Breast Cancer
Student Poster: Ted Bailly, BSN, RN and Karen Yancopoulos
Student Perceptions of Older Adults: Outcomes of an Aging Sensitivity Program, A Qualitative Inquiry
Student Leadership Award
Graduate Student Recipient: Shalome Tomelli
Undergraduate Student Recipients: Claire Knaplund (recognized at convention); Lauren Schulze
Conferment of 2012 NGNA Fellows:
Sheila Delp, MSN, RN, GCNS-BC, ACNS-BC
Sarah Jean Fisher, BA, RN-BC, MSN
Melodee Harris, PhD, APN, GNP-BC
Linda J. Hassler, RN, MS, GCNS-BC
Jeanne St. Pierre, MN, RN, GCNS-BC
Sharon Wexler, PhD, RN, BC
Please welcome your 2013 NGNA Board of Directors – both new and returning members!
Nanci McLeskey, MCG, MDiv, RN-BC, FNGNA
Mary Rita Hurley, RN, MPA
Caryl Mayo, MS, RN, FNGNA
Jean M. Gaines, RN, Ph.D.
Melodee Harris, Ph.D., APN, GNP-BC
Joanne Alderman, MSN,RN,BC,APRN, FNGNA
Elizabeth "Ibby" Tanner, Ph.D., RN, FNGNA
Linda Hassler, RN, MS, GCNS-BC, FNGNA

NGNA Members Inducted as Fellows of American Academy of Nursing

The American Academy of Nursing has announced that 176 nurse leaders have been inducted as Fellows during the Academy’s 39th Annual Meeting and Conference on October 13, 2012 in Washington, DC. The 2012 class of inductees is composed of the nation’s top nursing professionals, which include scholars, educators, and executives.

The following NGNA members were honored as Fellows of the American Academy of Nursing:
Judith Hertz, PhD, RN, FNGNA
Kristine Williams, PhD, RN, BC
Rowena Elliott, PhD, RN, CNN
Susan Loeb, PhD, RN

Selection criteria for Fellowship status includes evidence of significant contributions to nursing and health care, along with sponsorship by two Academy Fellows. Selection is also based on the impact that the nominees’ careers have had on health care and health policies.

NGNA member Susan Loeb focuses her research efforts on older adults who are aging and dying in our nation’s prisons. “I was so touched… it was heartening to learn that so many others were interested in and care about this particularly vulnerable and often invisible group of elders,” she shared after her induction as a Fellow.

Judi Hertz was also honored. “I appreciated the nomination and support of Robin Remsburg, past NGNA President and my presidential mentor, as well as the presence, warm wishes and interactions from and with all  NGNA members who were in attendance (and some who were not in attendance but sent special notes and greetings).  This was, indeed, one of the most humbling while simultaneously inspiring and exciting events in my professional life,” she recalled.

Pictured are Amy Cotton, Judi Hertz and Susan Loeb at the AAN awards ceremony. Along with Amy are her sponsors, Jean Wyman and Robin Remsburg. Robin also sponsored Judi Hertz, and they are pictured together here. Kitty Buckwalter, Judi’s co-sponsor, is not shown. Susan is pictured with her sponsors, Dr. Therese Richmond and Dr. Janice Penrod.

Join us as we congratulate these five ladies! All of you are exemplary models of our industry, who have gone above and beyond to contribute to developments in gerontological nursing. NGNA is proud to have such strong leaders in our organization.

Donating to NGNA: Leave a Legacy with Planned Giving

NGNA continues to successfully provide education, networking opportunities, and industry updates to gerontological nurses over the past years and continues to enhance these benefits in the years to come. As you know, our volunteers and the overall commitment of our members help to make this possible. However, we are able to thrive as an organization as a result of the financial commitment that we have received from many of our members.

As the year draws to a close, please remember NGNA in your year-end gifts.  There are several ways to donate. You may donate to our Mission Advancement , Research, or Scholarship funds online. Click the links to donate now.

NGNA members seeking opportunities to advance NGNA’s mission over the long term, may wish to consider Planned Giving as a component of their charitable giving goals. Your Planned Gift will help secure the future of NGNA, its members, and most importantly the patients that you serve.  Please contact the NGNA National Office at 800-723-0560 to discuss your planned giving options.

Your contributions in time and money are greatly appreciated and help NGNA to advance the practice of gerontological nursing.  We wish you continued success in the year to come.

Infection, Aging and Immunity

Submitted by Carol A. Enderlin, PhD, RN; Janet L. Rooker, MNSc, RNP; and Susan C. Ball, PhD, RN, GNP-BC, University of Arkansas for Medical Sciences, College of Nursing

Although infectious diseases have been replaced by chronic diseases as the leading cause of death among older persons in the United States, influenza, pneumonia and septicemia remain among the top ten in Americans 65 years and older. In 2002, infections resulted in approximately 85,500 deaths among older adults, and the impact may be under-representative due the interaction between chronic and infectious diseases (Gorina, Hoyert, Lentzner, & Goulding, 2006).
Gerontologic nurses routinely encourage older adults to take proactive measures to safeguard their health, such as receiving recommended vaccinations for influenza and pneumonia. Yet approximately one-third have not received influenza or pneumococcal vaccination as needed (Centers for Disease Control and Prevention (CDC), 2011), and those who do still remain at a higher risk of infection than their younger counterparts due to normal aging and decline of the immune system, traditionally termed “immunosenescence.” Chronic disease, especially, multiple comorbidities, further impairs their immunity (Castle, Uyemura, Fulop, & Makinodan, 2007). The interplay between healthy aging and other factors has recently supported alternative terminology, “senescent immune remodeling,” as perhaps more descriptive of this ongoing and complex immune process. 
Gerontological nurses must not only strive to improve vaccination rates of older adults, but to increase their understanding of normal changes in older adults’ ability to fight infection. Further, knowledge of currently recommended vaccination for older adults, and of interventions which may boost immune responsiveness to vaccination is foundational to health promotion and disease prevention in this population. Consequently, changes associated with the aging immune system, recommended vaccination schedules, and potentially immune-supportive interventions will be reviewed in this article.
Immunosenescence is defined as “impairment in immunity as a result of age-associated changes in function in a variety of cells: it is a phenomenon of decreased function, involving changes to both innate and adaptive immunity and a dysbalance between the two arms, “ (Pawelec et al., 2010). Senescent immune remodeling describes more broadly the “complex and continuous remodelling of the immune system with age,” (Kumar, Rani, Tchigranova, Lee, & Foster, 2012). Both terminologies refer to changes in innate and adaptive immunity with increased aging, which are influenced by individual and environmental factors.
Innate immunity involves an immediate cellular immune response to microorganisms and a complement cascade, which respond aggressively against pathogens without the necessity of prior exposure. Changes in innate immunity associated with aging include impairment of neutrophil, monocyte, macrophage and natural killer cell function. These changes in innate immunity result in decreased mobilization of protective cells, engagement, engulfment, destruction of pathogens, and activation of adaptive immunity (Fulop et al., 2010).
Adaptive (acquired) immunity involves delayed antigen and memory responses to specific previously encountered pathogens (Castle et al., 2007). Alterations of adaptive immunity with increased aging are particularly characterized by T-cell deregulation (Fulop et al., 2010).  Thymic involution (progressive degeneration with aging) (Mitchell, Meng, Nicholson, & Aspinall, 2006) and chronic antigenic stimulation (often to cytomegalovirus or CMV) are thought to instigate many of the immune changes found with increased age (Pawelec, Derhovanessian, Larbi, Strindhall, & Wikby, 2009).  Functional thymopoiesis of aging (production of blood cells by the thymus) results in decreased naive T-cells (Goronzy, Lee, & Weyand, 2007), while chronic antigenic stimulation by CMV results in preferential expansion of CMV-specific T-cells in excess of naive T-cells (Fulop et al., 2010). These changes in adaptive immunity result in the decreased ability to mount an effective antibody response to previously encountered antigens (Fulop et al., 2010), as well as to effectively recognize and respond to new antigens such as influenza or vaccinations (Haynes & Maue, 2009).
Impact of the Aging Immune System on Risk of Infection
Partially as a result of changes in the aging immune system, older adults have increased susceptibility to bacterial infectious diseases such as pneumonia and bacteremia, to the reactivation of latent viral infections such as Herpes Zoster, and to infection by opportunistic organisms (Castle et al., 2007; Gavazzi & Krause, 2002; Kumar et al., 2012). Although less susceptible to viruses in general, older adults are more vulnerable to newly encountered viruses (Haynes & Maue, 2009; Gavazzi & Krause, 2002). Clostridium difficile and methicillin-resistant Staphylococcus aureus may also contribute to morbidity and mortality in compromised older adults (Boraschi et al., 2010).
Chronic diseases contribute to the risk of infections; for example, congestive heart failure is associated with pneumonia (Kumar et al., 2012). Although the precise connection between certain chronic diseases and increased vulnerability to infection is not always clear, low-grade inflammation has become increasingly recognized as a possible link between immune system aging and age-associated chronic diseases including cancer (Fulop et al., 2010). A few limited human studies have identified an immune risk phenotype or profile (IRP) which predicts mortality in elderly adults, based on biomarkers of immune aging (immune signatures) such as prior CMV infection and related immune changes such as T-cell differentiation and production of pro-inflammatory mediators (Pawelec, Larbi, & Derhovanessian, 2010).
Pharmacologic Immune Interventions
In the previous century nursing was largely devoted to the treatment of acute infectious disease, but nursing care of older adults in this century will increasingly focus on prevention and management of chronic diseases, and promotion of immunity. Although new immunomodulators (substances that alter the immune response) are being investigated, the standard pharmacologic methods currently available are vaccinations against some of the most common infections. These are recommended for all older adults and especially those with chronic diseases. Rare exceptions to these recommendations include specific immunodeficiency disorders or treatment-related immunosuppression. Immunization recommendations for older adults are summarized in Table 1.
Non-pharmacologic Immune Interventions
Although not yet as well understood or widely recommended as vaccinations, there are several areas of non-pharmacologic intervention which may boost the immunity of older adults. Regular activity/exercise and adequate sleep may interact with immune status and positively influence the response to vaccination. 
Activity/Exercise. Some studies of exercise in healthy older adults have demonstrated improved innate and adaptive immune function, including enhanced vaccination responsiveness. However, care must be used in generalizing the findings due to differences in design, purpose, type of exercise or level of activity, and gender of study participant.
In general, studies have found very limited effects of exercise on Natural Killer Cell (NKC) activity (Haaland, Sabljic, Baribeau, Mukovozov, & Hart, 2008). However, a few studies have reported increased acute or chronic NKC effects for older women participating in resistance training exercise (Flynn et al., 1999; McFarlin, Flynn, Phillips, Stewart, & Timmerman, 2005). Greater NKC cytotoxic function at baseline was also reported in highly conditioned compared to inactive older women (Nieman et al., 1993), and post-aerobic exercise in older women (Flynn et al., 1999). Greater NKC concentration has also been reported in older male exercisers (mixed types of exercise) compared to sedentary controls (Yan et al., 2001),
Some studies have reported greater lymphocyte proliferation (Nieman et al., 1993; Shinkai et al., 1995), and lymphocytes expression of CD25 (IL-2 receptor) thought to reflect lymphocyte responsiveness to immune activating signals, in active versus inactive older adults (Gueldner et al., 1997). Greater numbers of CD8+ T cells producing IL-2 were also reported in active compared to inactive older adults (Ogawa, Oka, Yamakawa, & Higuchi, 2003).  Additionally acute exercise-induced increases in circulating CD8+ T cells were reported in response to both aerobic (Woods et al., 1999) and resistance training exercise (McFarlin et al., 2005).
There is some evidence of a general immune-protective effect of exercise.  Healthy, community-dwelling older adults participating in moderate intensity exercise reported a reduced number of upper respiratory tract infections (URTI) versus participants doing calisthenics only. In comparison, the most highly-conditioned exercisers at baseline had the lowest number of URTI’s (Nieman et al., 1993). Physical activity was also inversely associated with the risk of community acquired pneumonia in women, but not in men (Baik et al., 2000).
Finally, some studies have reported exercise enhancement of vaccination responsiveness. A positive relationship was found between physical activity and initial response to the H3N2 (but not H1N1) component of the influenza virus vaccine in older adults (Schuler, Leblanc, & Marzilli, 2003). Older adults participating in moderate endurance exercise have also exhibited higher antibody titers compared to sedentary older adults (Kohut et al., 2004). In terms of specific exercise type, cardiovascular (aerobic) but not flexibility exercise demonstrated significantly improved influenza vaccination response in healthy, previously sedentary older adults (Woods et al., 2009).
The few studies in frail older adults have failed to demonstrate an enhanced immune response to exercise (Flynn et al., 1999; Kapasi, Ouslander, Schnelle, Kutner, & Fahey, 2003; Raso, Benard, DA Silva Duarte, & Natale, 2007). This may be attributed to a shorter-term length of the exercise intervention, and/or to a lower intensity and shorter duration of exercise (Senchina & Kohut, 2007). Lack of immune response may also be due to irreversible immune alterations which accompany frailty.
In summary, moderate intensity exercise appears to boost immunity in healthy community-dwelling older adults (Senchina & Kohut, 2007). Currently, aerobic exercise seems the most effective type of exercise to improve immunity (Haaland et al., 2008). Exercise may concurrently improve chronic disease-related health status, which may further decrease risk of infection. And, while exercise in frail older adults has not yet  demonstrated immune benefits, further research is needed to determine an optimal exercise prescription in this population.
Sleep. Increasing understanding of sleep and circadian rhythms over the past century has revealed that function of the immune system is dependent upon sleep and the sleep-wake cycle. Components of the innate immune response, such as NKCs who respond rapidly to pathogens, peak during wakefulness. Components of the adaptive immune response, such as naïve T-cells whose response evolves more slowly, peak during nocturnal sleep.  The endocrine environment during early sleep also promotes the migration of naïve T-cells to lymph nodes, and the formation of immunological memories (Besedovsky, Lange, & Born, 2012).  Thus, nocturnal sleep appears to be a time when the body can redirect its energy to develop a pathogen-specific response to invasion, a response which is supported by studies of sleep and vaccination.
Several studies have explored the effect of sleep on response to vaccinations. These have consistently demonstrated that sleep enhances the adaptive immune response, supporting a theorized role of sleep in immunological memory formation and maintenance (Besedovsky et al., 2012). Doubled immune-boosting effects at 4 weeks were found for those with a single normal night of sleep after vaccination compared to subjects who stayed awake the night after vaccination; and, the results were sustained at one year post-vaccination (Lange, Perras, Fehm, & Born, 2003; Lange, Dimitrov, Bollinger, Diekelmann, & Born, 2011). The immune response to influenza vaccine also demonstrated a decrease after 6 days of sleep restriction (Spiegel, Sheridan, & Van, 2002). Although these responses to sleep and vaccination were studied in healthy adults, their findings may have important implications for older adults already at risk for sub-optimal immune responses to vaccination.
The potential impact of sleep on overall ability to fight infection is also important. Poor sleep efficiency (per cent of time asleep while in bed attempting to sleep) has been associated with increased susceptibility to respiratory syncytial virus (the common cold) (Cohen, Doyle, Alper, Janicki-Deverts, & Turner, 2009). In humans, even mild prolonged sleep loss (from 8 to 6 hours per night for 8 days) was associated with increased pro-inflammatory cytokines (Vgontzas et al., 2004), and more prolonged sleep loss with inflammation similar to that of persons at risk for developing cardiovascular disease (Mullington, Haack, Toth, Serrador, & Meier-Ewert, 2009; Mullington, Simpson, Meier-Ewert, & Haack, 2010).
In summary, chronic sleep deprivation can increase susceptibility to infection,  decrease the ability to fight infection, and increase vulnerability to chronic diseases which are risk factors for infection. Because older adults experience normal changes in sleep with aging, as well as sleep problems associated with chronic disease, many experience poor sleep which may leave them more vulnerable to infection. Consequently, promotion of improved sleep, especially in older adults with chronic disease and multiple co-morbidities, may improve their immunity and help prevent infection.
Gerontological nurses are in a prime position to promote health and infection prevention in older adults, through recommending and improving access to vaccinations. Regular exercise participation and good quality of sleep are also areas where nurses can assess and intervene to promote optimal immunity. Because immunity appears resistant to improvement once frailty occurs, it is imperative that gerontological nurses be proactive by partnering with older adults to maintain their immunity to infectious diseases.
About the Authors
Carol Enderlin was a 2006-2008 John A. Hartford predoctoral scholar, and currently teaches undergraduate and graduate research for evidence based practice with a personal research focus of symptoms in older adults with cancer. She is the current co-chair of the NGNA Education/Evidence Based Practice Committee, chair of the Aging Research Interest Group for the Southern Nursing Research Society, co-chair of the Arkansas State Genetics Health Committee, board member and fellow of the Arkansas Geronotological Society, and past president of Gamma Xi Chapter of Sigma Theta Tau International, Honor Society of Nursing.

Carol A. Enderlin PhD, RN (first author)
Clinical Assistant Professor
And Continuing Education Coordinator
Fellow, Arkansas Gerontologic Society
UAMS College of Nursing
4301 W. Markham St., Slot 529
Little Rock, AR 72205

Janet L. Rooker, MNSc, RN (co-author)
Clinical Assistant Professor
Adult-Gerontological Acute Care Practicum Coordinator
UAMS College of Nursing
4301 W. Markham St., Slot 529
Little Rock, AR 72205
Susan C. Ball, PhD, RN, GNP-BC (co-author)
Clinical Assistant Profess
Coordinator, Family Psychiatric mental Health Nurse Practitioner Program
UAMS College of Nursing
4301 W. Markham St., Slot 529
Little Rock, AR 72205

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“As Needed” Medications: Helpful Yet Harmful

Submitted by Kerry Jordan MSN, APN, ACNS-BC, CNL-BC; Laura Hall, MSN, RN, CNL-BC; reviewed by Alyce S. Ashcraft PhD, RN, CNE, ANEF

The Institute of Medicine’s (2001) report, Crossing the Quality Chasm: A New Health System for the 21st Century, lists improvement in safety as one of its primary aims in the redesign of healthcare environments, with a focus of avoidance of injuries from care that is intended to help.  Safety is also a major focus of The Joint Commission on Certification of Health Care Organizations (2010).  Their National Patient Safety Goals reinforce the need for further study of “as needed” medications, especially in the care of dementia patients because of their multiple effects, including increased falls (Woolcott, Richardson, Wiens, Patel, Marin, Khan, & Marra, 2009) and functional decline (King, 2006).
This brief describes the results of a performance improvement (PI) project that examined administration of “as needed” medication on a geriatric transitional care unit.  We retrospectively reviewed documentation for the following information:
  1. Why were “as needed” medications administered?
  2. Was documentation descriptive of the circumstances leading to the medication administration?
  3. Were non-pharmacologic measures attempted prior to medication administration?
  4. What protective measures (related to falls and functional decline) were taken after the medications were given?
  5. What were fall rates and functional scores prior to and after medication administration? 
Functional decline is common in hospitalized elders, with estimates indicating that 34-50% of elders lose some functional abilities during acute hospital stays (Inouye, Bagardus, Baker, Leo-Summers, & Cooney, 2000). Falls among hospitalized in-patients are common as well, ranging from 2.3 to 7 falls per 1,000 patient-days. Although fall rates are a concern for any patient, there is evidence that fall rates resulting in serious injury are highest among the elderly and those on geriatric psychiatric units (Fischer, Krauss, Donagan, Birge, Hitcho, & Jounson et. al, 2005).

Incidence of falls and functional decline in hospitalized elders is multifactorial, with evidence suggesting the use of psychotropic medications contributes to both events. Three meta-analyses examining studies over the last 30 decades demonstrated statistically significant increases in fall rates with the use of both benzodiazepines and neuroleptics. Odds ratios in these analyses ranged from 1.39-1.59. (Leipzig, et. al., 1999; Woolcott et. al., 2009; & Bloch, Thibaud, Dugue, Breque, Rigaud, & Kemoun, 2011). Although less robust, evidence linking functional decline to psychotropic medications exists as well. Peron, Gray, & Hanlon (2011) reviewed 19 studies between the years 1986-2011, finding four studies linking the use of benzodiazepines to functional decline despite methodological inconsistencies in the research.

Protocols for dementia care have addressed the use of psychotropic medication, which include both benzodiazepines and antipsychotics. Although these protocols vary in their recommendations, certain criteria are consistent across protocols, including psychotropics not being used as the initial intervention for psychiatric behaviors unless  the patient poses an immediate harm to themselves or others (Alzheimer’s Association, 2006; American Psychiatric Association, 2007; Cotter & Evans, 2007; Dettmore, Kolanowski, & Boustani, 2009; Elioupoulas, 2005; Hartford Institute, 2008; Registered Nurses Association of Ontario, 2005).
In this PI project, 25 patient charts on a geriatric transitional care unit were retrospectively reviewed over a 39 day period. Of the 25 charts reviewed, 17 revealed the administration of at least one “as needed” psychotropic medication. A total of 42 “as needed” medications were given to the 17 patients at various times. Data was collected on all “as needed” psychotropic medications that were given to the patients during their hospital stay. Nursing notes were examined for documentation of reasons for medication administration, behavioral therapies, and interventions attempted prior to medication administration, and pre- and post- medication fall scores and functional status levels.
Behaviors or actions that required “as needed” psychotropic medication administration were documented 100% of the time and included the following states: (a) anxious/restless (62.5%), (b) hallucinations/paranoia/delusions (10.71%), and (c) combative/ argumentative (26.79%). Documentation did not show behavioral interventions or therapies were the first mode of treatment for this cohort. Documentation of behavioral interventions or therapies attempted prior to medication administration occurred 31% of the time.  “Redirection” was documented as the behavioral intervention used a majority of the time. Pain was assessed and a spouse called on two other occasions. Findings also reflected that Haldol was administered for behavioral problems other than hallucinations, paranoia, and delusions such as anxiousness and restlessness. 
Findings from data collection revealed an increase in fall scores post medication administration compared to pre- medication administration.
A paired samples T- test demonstrated a statistically significant increase in mean fall scores from pre- administration (M=19.29, SD=5.85) to postadministration [M=24.53, SD = 6.83, t(16) = -4.66. p < .000 (2 tailed)]. The mean difference in pre-test  post-test scores was -5.24, with a 95% confidence interval (-7.616, -2.855).
Findings regarding the functional status of patient’s pre -medication administration compared to post- medication administration were inconclusive. This was in part due to fragmentation of documentation. A complete activities of daily living (ADL) functional assessment was performed on each patient on admission for a baseline assessment, but was not performed again during the patient’s stay. Although parts of ADL functioning, such as toileting, mobility, and hygiene were documented at various times, and in various places in the chart, documentation was sporadic and poorly described. As a result, we were unable to successfully gather data for functional status.
Four major areas needing improvement emerged as a result of this PI project. First, nurses on the unit were resorting to pharmacological treatment for neuropsychiatric behaviors associated with dementia prior to attempting non-pharmacologic therapies. Based on this finding, we recommended nurses be trained in evidence-based protocols related to psychotropic “as needed” medication use. We also suggested implementation of a protocol that would require using and documenting three behavioral therapies prior to resorting to medications, except when the patient is a potential harm to themselves or others.

Second, nurses were giving antipsychotic medications for behaviors that did not demonstrate psychosis. It was not clear why this was being done. Nurses may have lacked knowledge about the appropriate use of antipsychotics or may have inappropriately assessed a patient.  Antipsychotic use in the presence of dementia is dangerous, not only because of the potential for falls and functional decline, but because these medications cause a host of other serious side effects (Jeste, Blazer, Casey, Meeks, Salzman, Schneider, 2008). We recommended further analysis be done to identify the cause(s) of inappropriate antipsychotic use on the unit to guide selection of an appropriate recommendation.

A third area to address is the process issue associated with tracking functional status of patients on the unit. Given that all patients who came to the transitional care unit were elderly,  coupled with the high risk for functional decline in hospitalized elders, we made the case for functional decline as an essential component of nursing assessment. As a result, we recommended assessment protocols be changed to incorporate a full functional assessment using a standardized instrument every 24 hours.

Lastly, because increased fall scores increased with “as needed” psychotropic use, additional precautions to prevent falls were instituted. 

Although data from this performance improvement project is not gerneralizable due to limited sample size and the specialized nature of the unit, “as needed” medication administration is common on a variety of hospital units. Given the potential consequences of harm to patients, investigation of patterns of administration and effects of “as needed” medication, especially  in  elders, is an important area of nursing practice to monitor. 

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