Ch3 common health problems of older adults Flashcards

Question

Facilities

Answer 1

Physical and/or mental health/behavioral health problems may force some to relocate to a retirement center or an assisted-living facility, although these facilities can be very expensive. Others move in with family members or to apartment buildings funded and designated for seniors. Older adults usually have more difficulty adjusting to major change when compared with younger and middle-age adults. Being admitted to a hospital or nursing home is a traumatic experience.

Answer 2

Older adults often suffer from relocation stress syndrome, also known as relocation trauma. Relocation stress syndrome is the physical and emotional distress that occurs after the person moves from one setting to another. Examples of physiologic behaviors are sleep disturbance and increased physical symptoms such as GI distress. Examples of emotional manifestations are withdrawal, anxiety, anger, and depression.

Answer 3

* Provide opportunities for the patient to assist in decision making. * Carefully explain all procedures and routines to the patient before they occur. * Ask the family or significant other to provide familiar or special keepsakes to keep at the patient's bedside (e.g., family picture, favorite hairbrush). * Reorient the patient frequently to his or her location. * Ask the patient about his or her expectations during hospitalization or assisted-living or nursing home stay. * Encourage the patient's family and friends to visit often. * Establish a trusting relationship with the patient as early as possible. * Assess the patient's usual lifestyle and daily activities, including food likes and dislikes and preferred time for bathing. * Avoid unnecessary room changes. * If possible, have a family member, significant other, staff member, or volunteer accompany the patient when leaving the unit for special procedures or therapies.

Answer 4

accidents comm in older adults falls most common Motor vehicle crashes increase as well because of physiologic changes of aging or chronic diseases such as Alzheimer's disease or peripheral neuropathy.

Answer 5

Most accidents occur at home. Teach older adults about the need to be aware of safety precautions to prevent accidents such as falls. Incapacitating accidents are a primary cause of decreased MOBILITY and chronic pain in old age.

Answer 6

Some people develop fallophobia (fear of falling) and avoid leaving their homes. This reaction is particularly common for those who have previously fallen and/or have osteoporosis (bone tissue loss). Osteoporosis is especially common in older thin Euro-Caucasian women who typically have a stooped posture (kyphosis), which can cause problems with balance

Answer 7

Collaborate with the older adult, family, and significant others when recommending useful changes to prevent injury. Safeguards such as handrails, slip-proof pads for rugs, and adequate lighting are essential in the home. Avoiding scatter rugs, slippery floors, and clutter is also important to prevent falls. Installing grab bars and using nonslip bathmats can help prevent falls in the bathroom. Raised toilet seats are also important, especially for those who have hip and knee arthritis. Remind older adults to avoid going out on days when steps are wet or icy and to ask for help when ambulating. To minimize sensory overload, advise the older adult to concentrate on one activity at a time.

Answer 8

Changes in SENSORY PERCEPTION and MOBILITY can create challenges for older adults in any environment. presbyopia (farsightedness that worsens with aging) may make walking more difficult; the person is less aware of the location of each step. disorders that affect visual acuity such as macular degeneration, cataracts, glaucoma, or diabetic retinopathy. Teach the person to look down at where he or she is walking and have frequent eye examinations to update glasses or contact lenses to improve vision. Drug therapy or surgery may be needed to correct glaucoma or cataracts. reduced sense of touch reduces the awareness of body orientation Decreased reaction time peripheral neuropathy/arthritis affects mobility and sensory perception encourage the use of visual, hearing, or ambulatory assistive devices. High costs and a fear of appearing old sometimes prevent older adults from obtaining or using hearing aids, eyeglasses, walkers, or canes. for fall risk individuals: choose interventions that help prevent falls and possible serious injury. For example, for those in the community, tai chi exercise or yoga for seniors is very helpful to improve balance and MOBILITY and decrease the fear of falling, especially among older women

Answer 9

Motor vehicle crashes are a major cause of accidents and death among the older-adult population. many states require more freqiuent testing for older drivers reaction time and ability to multitask decreases some have insomnia =fall asleep while driving health problems and treatments can contribute to crashes peripheral neuropathy-decreased sensation of pedal hypertension drugs can cauise orthostatic hypotension many older adults feel losing ability to drive loses indipendence PCP can recommend driving refresher courses and to avoid high risk driving conditions-wet/icy

Answer 10

* Discuss driving ability with the patient to assess his or her perception. * Assess physical and mental deficits that could affect driving ability. * Consult with appropriate primary health care providers to treat health problems that could interfere with driving. * Suggest community-based transportation options, if available, instead of driving. * Discuss driving concerns with patients and their families. * Remind the patient to wear glasses and hearing aids if prescribed. * Encourage driver-refresher classes, often offered by AARP (formerly the American Association of Retired Persons). * Consult a certified driving specialist for an on-road driving assessment. * Encourage avoiding high-risk driving locations or conditions such as busy urban interstates and wet or icy weather conditions. * Report unsafe drivers to the state department of motor vehicles if they continue to drive.

Answer 11

Drug therapy for the older population can be another major health issue. Because of the multiple chronic and acute health problems that occur in this age-group, drugs for older adults account for about one third of all prescription drug costs.

Answer 12

The term polymedicine has been used to describe the use of many drugs to treat multiple health problems for older adults.

Answer 13

Polypharmacy is the use of multiple drugs, duplicative drug therapy, high-dosage medications, and drugs prescribed for too long a period of time.

Answer 14

Older adults commonly take multiple nonprescription or over-the-counter (OTC) drugs such as analgesics, antacids, cold and cough preparations, laxatives, and herbal/nutritional supplements, often without consulting a health care provider. Therefore this population is at high risk for adverse drug events (ADEs) directly related to the number of drugs taken and the frequency with which they are taken. Drug-drug, food-drug, drug-herb, and drug-disease interactions are common ADEs that often lead to hospital admission.

Answer 15

dont tolerate standard dosage physiologic changes related to aging make drug therapy more complex and challenging. These changes affect the absorption, distribution, metabolism, and excretion of drugs from the body. Even common antibiotics can lead to temporary memory loss or acute confusion. More commonly, antibiotic therapy can cause a Clostridium difficile infection,

Answer 16

Age-related changes that can potentially affect drug absorption from an oral route include an increase in gastric pH, a decrease in gastric blood flow, and a decrease in GI motility. Despite these changes, older adults do not have major absorption difficulties because of age-related changes alone.

Answer 17

Age-related changes that affect drug distribution include smaller amounts of total body water, an increased ratio of adipose tissue to lean body mass, a decreased albumin level, and a decreased cardiac output. Increased adipose tissue in proportion to lean body mass can cause increased storage of lipid-soluble drugs. This leads to a decreased concentration of the drug in plasma but an increased concentration in tissue.

Answer 18

Drug metabolism often occurs in the liver. Age-related changes affecting metabolism include a decrease in liver size, a decrease in liver blood flow, and a decrease in serum liver enzyme activity. These changes can result in increased plasma concentrations of a drug. Monitor liver function studies and teach older adults to have regular physical examinations.

Answer 19

Changes in the kidneys can also result in high plasma concentrations of drugs. The excretion of drugs usually involves the renal system. Age-related changes of the renal system include decreased renal blood flow and reduced glomerular filtration rate. These changes result in a decreased creatinine clearance and thus a slower excretion time for medications. Consequently serum drug levels can become toxic, and the patient can become extremely ill or die. Monitor renal studies, especially serum creatinine and creatinine clearance, when giving drugs to older adults! A creatinine clearance test measures the glomerular filtration rate of the kidneys. A commonly used formula for calculating creatinine clearance for men rather than directly measuring it is: (140-age in years)xlean body weight in kg divided by serum creatinine in mg/dl x72 For women, use this formula and multiply the answer by 0.85. A normal creatinine clearance for men is 107 to 139 mL/min and for women 87 to 107 mL/min. Values decrease as a person ages.

Answer 20

When chronic disease is added to the physiologic changes of aging, drug reactions have a more dramatic effect and take longer to correct. Often a lower dose of a drug is necessary to prevent ADEs. The policy of “start low, go slow” is essential when health care providers prescribe drugs for older adults. The physiologic changes of aging are highly individual. Alterations in drug therapy should always be individualized according to the actual physiologic changes present and the occurrence and severity of chronic disease.

Answer 21

* Edema * Severe nausea and vomiting * Anorexia * Dehydration * Dysrhythmias * Fatigue * Weakness * Dizziness * Syncope * Urinary retention * Diarrhea * Constipation/impaction * Hypotension * Acute confusion

Answer 22

Most people older than 65 years take their own medications. Because the risk for drug toxicity is considerably increased in the older population, help patients assume this task responsibly. Teach patients and their caregivers, providing clear and concise directions and developing ways to help them overcome difficulties with self-administration. risk of making errors in self administration or dont adhere to drug regimen for several reasons First they may simply forget. In the rush of daily activities, they may not take their drugs or may take them too often because they cannot remember when or whether they have taken the medications helpful to associate pill takling with daily events like a meal. keep calendar or chart. Pill boxes or egg cartons. large print on drug label Writing the drug regimen on the top of the bottle with large letters and numbers is helpful for some older adults. Colored labels or dots can also be applied. Easy-open bottle caps help older adults with limited hand mobility or strength.

Answer 23

A second reason for drug errors is poor communication with health care professionals. These problems result from poor explanations that are not understood because of educational limitations, language barriers, or difficulty with hearing and vision. Health care professionals often presume that their patients have learned the information if they have taught them about the drugs. Help older adults plan their drug therapy schedules as needed. varying ways that older adults take their medications. Many people older than 65 years use a multitude of complementary and integrative therapies. Some add to their drug regimen by taking OTC drugs, which can interact with prescription drugs and cause serious problems. For example, a patient receiving warfarin (Coumadin, Warfilone) for anticoagulation may take ibuprofen (Motrin) regularly for arthritis or garlic for hypertension. Because ibuprofen and garlic can inhibit clotting, this combination can cause serious bleeding. When obtaining a drug history, ask patients about all OTC drugs, including herbal and food supplements. some avoid taking their prescribed drugs . fear of dependency or cost, also side effects not desireable (example diuretics -=incontinence) may think that two pills are twice as effective and therefore it is better to take two rather than just one. Some older adults take drugs that are left over from a previous illness or one that is borrowed from someone else. Teach patients to take their medications exactly as prescribed by their health care providers.

Answer 24

interviewed regarding their medication use and include these questions: * Do you take five or more prescription medications? * Do you take herbs, vitamins, other dietary supplements, or OTC medications? * Do you have your prescriptions filled at more than one pharmacy? * Is more than one health care practitioner prescribing your medications? * Do you take your medications more than once a day? * Do you have trouble opening your medication bottles? * Do you have poor eyesight or hearing? * Do you live alone? * Do you have a hard time remembering to take your medications? The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults assessment tool, simply known as the Beers criteria, is also very useful in screening for medication-related risks in older adults who have chronic health problems. The tool lists multiple medications and related concerns.

Answer 25

* meperidine (Demerol) * cyclobenzaprine (Flexeril) * digoxin (Lanoxin) (Should not exceed 0.125 mg daily except for atrial fibrillation) * ticlopidine (Ticlid) * fluoxetine (Prozac) * amitriptyline (Elavil) * diazepam (Valium) * promethazine (Phenergan) * ketorolac (Toradol) * short-acting nifedipine (e.g., Procardia) * ferrous sulfate (Iron) (Should not exceed 325 mg daily) * chlorpropamide (Diabinese) * diphenhydramine (Benadryl)

Answer 26

To reduce drug-related risks in older adults, perform a medication assessment every 6 months or more often if an acute illness or exacerbation of a chronic disease occurs. Be sure to: * Obtain a list of all medications taken on a regular and as-needed basis; include OTC and prescribed drugs, herbs, and nutritional supplements. If a list is not available, ask the older adult or family to gather all ointments, pills, lotions, eyedrops, inhalers, injectable solutions, vitamins, minerals, herbs, and other OTC medications and place into a bag for review. * Highlight all medications that are part of the Beers criteria; highlight any medication for which the indication for its use is not clear, is inappropriate, or could be discontinued (e.g., duplicative drug). * Collaborate with the older adult, family, pharmacist, and primary health care provider if appropriate to determine the need for medication changes. Suggest once-a-day dosing if possible. * Give older adults verbal and written information (at the appropriate reading level) regarding any change or new medication prescribed. * Promote adherence to the drug therapy regimen exactly as prescribed; remind older adults to check with their primary care provider if they want to change their regimen or add an OTC medication or natural product (nutritional or herbal supplement, or probiotic). * Encourage lifestyle changes and other nonpharmacologic interventions to help manage or prevent health problems. * Remind older adults not to share or borrow medications.

Answer 27

Older adults are usually mentally sound and competent. Some changes in COGNITION have been identified as age related and are linked to specific cognitive functions rather than intellectual capacity. These changes include a decreased reaction time to stimuli and an impaired memory for recent events. However, severe cognitive impairment and psychosis are not common.

Answer 28

Two forms of competence exist: legal competence and clinical competence. A person is legally competent if he or she is: * 18 years of age or older * Pregnant or a married minor * A legally emancipated (free) minor who is self-supporting * Not declared incompetent by a court of law A person is clinically competent if he or she is legally competent and can make clinical decisions. Decisional capacity is determined by a person's ability to identify problems, recognize options, make decisions, and provide the rationale supporting the decisions. Selected behavioral/mental illnesses often affect both legal and clinical competence.

Answer 29

If a court determines that an older adult is not legally competent, a guardian is appointed to make health care decisions. Guardians may be family members or a person who is not related to the patient. When no one is available, a guardian may be appointed from a local Area Agency on Aging, an organization with comprehensive services and resources for older adults.

Answer 30

Nurses are in a unique position to teach older adults about ways to promote cognitive health. Cognitive training (e.g., learning a new skill), physical activity, social engagement, and NUTRITION are the most helpful interventions to prevent cognitive changes in older adults. In some communities online cognitive training is playing a role in helping to improve memory in older adults As older adults age, they are at increasing risk for cognitive impairments—depression, delirium, and dementia, often referred to as the 3Ds.

Answer 31

Many older veterans of the Korean and Vietnam wars also suffer from chronic pain, depression, post-traumatic stress disorder (PTSD), and severe anxiety. Substance use, especially alcoholism, is common among young and older veterans. Alcoholism can contribute to cognitive decline and may be used as a coping mechanism for loss. As a result, many of today's homeless population are veterans of previous and more recent wars.

Answer 32

Depression is the most common mental health/behavioral health problem among older adults in the community. increases when admitted to hospital or nursing home Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations. It can be primary or secondary and can range from mild to severe or major.

Answer 33

As a primary problem, depression is thought to result from a lack of the neurotransmitters norepinephrine and serotonin in the brain

Answer 34

Secondary depression, sometimes called situational depression, can result when there is a sudden change in the person's life such as an illness or loss. Common illnesses that can cause secondary depression include stroke, arthritis, and cardiac disease. It is often underdiagnosed by primary health care providers and is therefore undertreated.

Answer 35

Families and nurses are in the best position to suspect depression in an older adult. Several screening tools are available to help determine if the patient has clinical depression. The Geriatric Depression Scale—Short Form (GDS-SF) is a valid and reliable screening tool and is available in multiple languages. The patient selects “yes” or “no” to 15 questions, or a nurse or other health care professional can ask the patient the questions. A score of 10 or greater is consistent with a possible diagnosis of clinical depression (Fig. 3-3). These patients are then evaluated more thoroughly by the health care provider for treatment.

Answer 36

* Worsening of medical conditions * Risk for physical illness * Alcoholism and drug use * Increased pain and disability * Delayed recovery from illness * Suicide (especially in Euro-Caucasian men between 75 and 85 years of age)

Answer 37

Older adults with depression may have early-morning insomnia, excessive daytime sleeping, poor appetite, a lack of energy, and an unwillingness to participate in social and recreational activities. The primary treatment for depression usually includes drug therapy and psychotherapy, depending on the severity of the problem. Selective serotonin reuptake inhibitors (SSRIs) are the first choice for drug therapy but take 2 to 3 weeks to work. They act by increasing the amount of serotonin and norepinephrine at nerve synapses in the brain. Reminiscence or reflective therapies also help older adults overcome feelings of depression and despair.

Answer 38

Tricyclic antidepressants should not be used for older adults because they have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence. For older adults who may be prescribed this group of drugs, question the primary health care provider and request an SSRI or other treatment.

Answer 39

Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline, sometimes referred to as chronic confusion. This syndrome represents a global impairment of intellectual function and is generally chronic and progressive. There are many types of dementia, the most common being Alzheimer's disease. Multi-infarct dementia, the second most common dementia, results from a vascular disorder.

Answer 40

Whereas dementia is a chronic, progressive disorder, delirium has an acute and fluctuating onset. It is often seen among older adults in a setting with which they are unfamiliar, including both acute and long-term care (Kalish et al., 2014). Delirium is characterized by the patient's inattentiveness, disorganized thinking, and altered level of consciousness (either hypoalert or hyperalert). In addition to cognitive changes, some patients have physical and emotional manifestations and may become psychotic.

Answer 41

The types of delirium are hyperactive, hypoactive, and mixed. Hyperactive patients may try to climb out of bed or become agitated, restless, and aggressive. Hypoactive patients are quiet, apathetic, lethargic, unaware, and withdrawn. They often move very slowly and stare. Patients with hypoactive dementia are often not diagnosed. Mixed delirium patients have a combination of hyperactive and hypoactive manifestations.

Answer 42

Identify patients who are at risk for delirium; high-risk patients are usually the late old and those with alcoholism and/or disorders of major body organs. Some hospitals offer programs to prevent delirium and loss of function in high-risk patients such as the Hospital Elder Life Program (HELP)

Answer 43

Some of the many factors that can cause delirium are: * Drug therapy (especially anticholinergics, opioids, and psychoactive drugs) * Fluid and electrolyte imbalances * Infections, especially urinary tract, pneumonia, and sepsis * Fecal impaction or severe diarrhea * Surgery (especially fracture hip repair and post-transplant) * Metabolic problems such as hypoglycemia * Neurologic disorders such as tumors * Circulatory, renal, and pulmonary disorders * Nutritional deficiencies * Hypoxemia (decreased arterial oxygen level) * Mechanical ventilation * Relocation * Major loss * Critical care setting Many patients have more than one of these factors as causes for their delirium.

Answer 44

Delirium is a major predictor of morbidity and mortality (Kalish et al., 2014). For example, acutely confused patients who are discharged from the hospital are at an increased risk for functional decline, falls, and incontinence at home. Therefore carefully assess older patients in any setting for acute confusion so it can be managed.

Answer 45

A number of tools have been developed for point-of-care screening for delirium, including the Confusion Assessment Method (CAM), Delirium Index (DI), NEECHAM Confusion Scale, and Mini-Cog. The CAM is a short and easy-to-use tool that consists of nine open-ended questions and a diagnostic algorithm for determining delirium (Table 3-3). This screening tool is easily adaptable for computerized point-of-care charting.

Answer 46

1. Acute onset and fluctuating course (e.g., Is there evidence of an acute change in mental status from the patient's baseline?) 2. Inattention (e.g., Does the patient have difficulty focusing attention or keeping track of what is being said?) 3. Disorganized thinking (e.g., Is the patient's thinking and conversation disorganized or incoherent?) 4. Altered level of consciousness (e.g., Is the patient lethargic, hyperalert, or difficult to arouse?) The diagnosis of delirium by the CAM is the presence of features 1 and 2 and either 3 or 4.

Answer 47

Collaborate with the interprofessional health care team to remove or treat risk or causative factors for acute confusion. (treat UTI give oxygen) To help prevent and manage delirium, use a calm voice to frequently reorient the patient. For example, playing tapes of soothing music may have a calming effect. Providing a doll or stuffed animal with which to “fidget” may prevent the patient from removing important medical tubes or equipment. Some nurses believe that providing dolls and stuffed animals is treating the adult like a child, but this intervention can sometimes be very effective when used for therapeutic purposes. If the patient has a favorite item such as an afghan blanket or a picture, ask the family or significant others to provide it for the same purpose. The most difficult challenge is caring for a patient who is experiencing both problems at the same time.(dementia and delirium)

Answer 48

Excessive substance use (both alcohol and illicit drugs) increases the risk for falls and other accidents; affects mood and COGNITION; and leads to complications of chronic diseases such as diabetes mellitus, hypertension, and heart disease. Isolation, depression, and delirium can result from substance use. The National Institute on Aging (NIA) recommends that people older than 65 years have no more than one alcoholic drink a day or seven drinks in a week (NIA, 2012). Illicit drugs such as cannabis (marijuana) should be avoided unless they are needed for therapeutic use.

Answer 49

The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) is often used by nurses and other health care professionals in ambulatory care settings to detect alcohol use or alcoholism. The 10 yes/no question test is available in English and Spanish and can be either self-administered or administered by a clinician. Examples of questions on the tool are: * Do you drink to take your mind off your problems? * When you feel lonely, does having a drink help? A “yes” answer is worth one point. A total score of two or more points indicates that the person has a problem with alcohol. Other screening tools for alcohol use in older adults include the CAGE questionnaire, the Alcohol-Related Problems Survey (ARPS), and the Short ARPS (shARPS). The acronym CAGE comes from four questions: * Have you ever tried to cut down on your drinking? * Have people annoyed you by criticizing your drinking? * Have you ever felt bad or guilty about your drinking? * Have you ever had a drink first thing in the morning to settle your nerves to get rid of a hangover (eye-opener)?

Answer 50

Some older adults are more vulnerable to these problems than others, especially widows who may have difficulty being assertive. Elder abuse and neglect is a serious problem that affects many older adults each year. Older people who are neglected or abused are often physically dependent from one or more disabilities. The abuser is often a family member who becomes frustrated or distraught over the burden of caring for the older adult. Unfortunately only a few cases of elder abuse are reported.

Answer 51

Prolonged caregiving by a family member is a common new role for adult children, usually women. This new role may result in role fatigue, conflict, and strain. As a result, neglect can occur when a caregiver fails to provide for an older adult's basic needs such as food, clothing, medications, or assistance with ADLs. The caregiver refuses to let other people such as nursing assistants or home care nurses into the home. Whether intentional or unintentional, neglect accounts for almost half of all cases of actual elder abuse.

Answer 52

Physical abuse is the use of physical force that results in bodily injury, especially in the “bathing suit” zone (abdomen, buttocks, genital area, upper thighs). Examples of physical abuse are hitting, burning, pushing, and molesting the patient. Sedating the older adult is also abusive.

Answer 53

Financial abuse occurs when the older adult's property or resources are mismanaged or misused; this is more common than physical abuse.

Answer 54

Emotional abuse is the intentional use of threats, humiliation, intimidation, and isolation toward older adults.

Answer 55

Carefully assess the patient for signs of abuse such as bruises in clusters or regular patterns; burns, commonly to the buttocks or the soles of the feet; unusual hair loss; or multiple injuries, especially fractures. If the older adult is too weak or has no other resources or support systems, he or she may not admit that abuse is occurring. Neglect may be manifested by pressure injuries, contractures, dehydration or malnutrition, urine burns, excessive body odor, and listlessness. Depression and dementia are common in community older adults who are abused or neglected. Be sure to screen for abuse and neglect of older adults using an appropriate assessment tool. Table 3-4 lists tools that can be used by nurses and other health care professionals to screen for elder abuse and neglect. The older adult should be referred to the appropriate service when there is: • Evidence of mistreatment without sufficient clinical explanation * Report by an older adult of being abused or neglected * A belief by the health care professional that there is a high risk for or probable abuse, neglect, abandonment, or exploitation

Answer 56

All states in the United States and other Western countries have laws requiring health care professionals to report suspected elder abuse. In the community, if physical abuse or neglect is suspected, notify the local Adult Protective Services agency or other advocate organization. In a hospital or nursing home, notify the social worker or ombudsman, who then will investigate the case and report the problem to the appropriate agency.

Answer 57

* Elder Abuse Suspicion Index * Elder Assessment Instrument * Indicators of Abuse Screen * Questions to Elicit Elder Abuse * Hwalek-Sengstock Elder Abuse Screening Tool * Caregiver Abuse Screen * Brief Abuse Screen for the Elderly * Vulnerability to Abuse Screening Scale

Answer 58

Forty percent of adults in critical care settings are over 65 years of age; 60% of medical-surgical patients in hospitals are also over 65 (Ellison et al., 2015). Older adults who are admitted to hospitals and long-term care settings such as nursing homes have special needs and potential health problems. Many of these problems are similar to those seen among community older adults as discussed in this chapter. Since 1996 the Hartford Institute for Gerontological Nursing has worked to ensure that all hospitalized patients 65 years of age and older be given quality care.

Answer 59

The health of Hispanic older adults continues to lag behind that for non-Hispanic whites due to a number of factors such as language barriers, inadequate health insurance, and lack of health care access. To add to this health disparity, most nurses and other health care professionals are not educated in the language or culture of Hispanic older adults. Some older Hispanic patients may have beliefs and values that conflict with traditional Western health care views. Many have strong religious and spiritual beliefs. For example, traditional Catholicism is practiced among most Hispanic elders in the Southwestern United States. Be respectful of these differences and incorporate them into your patient's plan of care. Become educated about the Hispanic culture and learn to speak basic medical Spanish to foster communication and trust

Answer 60

Significant health disparities are also associated with the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) older-adult population. Compared with heterosexual adults, LGBTQ older adults are at an elevated risk for disability from chronic disease and mental distress (Fredriksen-Goldsen, 2011). When admitted to the hospital or nursing home, they may hide their gender identity and/or sexual orientation from the nurse and primary health care providers because of fear of rejection or discrimination or lack of adequate health care. Do not assume that your older patients or visitors are heterosexual. Establish a safe and trusting relationship with the patient and discuss sexual orientation and gender identity in a private setting to emphasize confidentiality. Do not force patients to answer any questions with which they feel uncomfortable. Teach direct caregivers such as nursing assistants that they may observe patients with sexual organs that conflict with the patient's gender identity. If this situation occurs, remind them not to be offensive or judgmental but, rather, to carry out the task as planned.

Answer 61

Nurses may not be aware that the needs of older adults differ from those of younger adults. Some health care systems have designated Acute Care of the Elderly (ACE) units with geriatric resources nurses and geriatric clinical nurse specialists. The patients are cared for by geriatricians who specialize in the care of older adults. Other hospitals have developed interprofessional health programs system-wide to meet the special needs of older patients. The incentive for these new programs is the Nurses Improving Care for Healthsystem Elders (NICHE) project, which continues to generate evidence-based practice guidelines for older adult care. The purpose of all of these programs and units is to focus on the special health care issues or geriatric syndromes seen in the older population

Answer 62

The Fulmer SPICES framework was developed as part of the NICHE project and identifies six serious “marker conditions” that can lead to longer hospital stays, higher medical costs, and even deaths. These conditions are: * Sleep disorders * Problems with eating or feeding * Incontinence * Confusion * Evidence of falls * Skin breakdown Other problems such as depression and constipation are also common in older hospitalized patients. Rather than being fully comprehensive, this classic, well-known SPICES framework is intended to be an easy tool that has been called geriatric vital signs (Fulmer, 2007).

Answer 63

Sleep disorders are common in hospitalized patients, especially older adults. Adequate rest is important for healing and for physical and mental functioning. Pain, chronic disease, environmental noise and lighting, and staff conversations are a few of the many contributing factors to insomnia in the acute and long-term care setting Assess the patient and ask how he or she is sleeping. If the patient is not able to answer, observe for restlessness and other behaviors that could indicate lack of adequate rest. Manage the patient's pain by giving pain medication before bedtime. Attempt to keep patients awake during the day to prevent insomnia. Keep staff conversations as quiet as possible and away from patients' rooms. Dim the lights to make the patient area as dark as possible. Avoid making loud noises such as slamming doors. Postpone treatments until waking hours or early morning if they can be delayed safely. If possible, place a “Do Not Disturb” sign on the patient's door to avoid unnecessary interruptions in sleep.

Answer 64

Problems with eating and feeding prevent the older patient from receiving adequate NUTRITION. Malnutrition is common among older adults and is associated with poor clinical outcomes, including death. Nurses need to perform nutritional screenings on the first day of patient admission, including a thorough nutritional history and weight, height, and body mass index (BMI) calculation. Collaborate with the registered dietitian about the patient's nutritional status as needed to achieve health goals. Consider cultural preferences and determine which foods the patient likes. Manage symptoms such as pain, nausea, and vomiting. If the patient has difficulty chewing or swallowing, coordinate a plan of care with the speech-language pathologist and dietitian. If there are no dietary restrictions, encourage family members or friends to bring in food that the patient might enjoy.

Answer 65

Urinary and bowel ELIMINATION issues vary in type and severity and may be caused by many factors, including acute or chronic disease, ADL ability, and available staff. Assess the patient to identify causes for incontinence or retention. These problems are not physiologic changes of aging but are very common in both the hospital and long-term care setting. Place the patient on a toileting schedule or a bowel or bladder training program, if appropriate. Delegate this activity to unlicensed assistive personnel and supervise them

Answer 66

Acute and chronic confusion affect many older patients in both the hospital and nursing home. Whereas chronic confusion states such as dementia are not reversible, acute confusion, or delirium, may be avoidable and is often reversible when the causes are resolved or removed (see Table 2-1). For example, avoiding multiple drugs and promoting adequate sleep can help prevent acute confusion. Help the patient by reorienting him or her to reality as much as needed. Keep the patient as comfortable as possible (e.g., provide interventions to control pain)

Answer 67

The most common accident among older patients in a hospital or nursing home setting is falling. A fall is an unintentional change in body position that results in the patient's body coming to rest on the floor or ground. Some falls result in serious injuries such as fractures and head trauma. The Joint Commission's National Patient Safety Goals (NPSGs) require that all inpatient health care settings use admission and daily fall risk assessment tools and a fall reduction program for patients who are at high risk.

Answer 68

Assess all older patients for risk for falls. Many evidence-based assessment tools such as the Morse Fall Scale, STRATIFY, and the Hendrich II Fall Risk Model (HIIFRM) have been developed to help the nurse focus on factors that increase an older person's risk for falling. Some of these tools also recommend selected interventions, depending on the patient's fall risk score (Swartzell et al., 2013). Chart 3-4 lists some of the common risk factors that should be assessed and evidence-based, collaborative interventions for preventing falls in high-risk patients. A recent history of falling is the single most important predictor for falls.

Answer 69

Assess for the presence of these risk factors: * History of falls * Advanced age (>80 years) * Multiple illnesses * Generalized weakness or decreased mobility * Gait and postural instability * Disorientation or confusion * Use of drugs that can cause increased confusion, mobility limitations, or orthostatic hypotension * Urinary incontinence * Communication impairments * Major visual impairment or visual impairment without correction * Alcohol or other substance use * Location of patient's room away from the nurses' station (in the hospital or nursing home) * Change of shift or mealtime (in the hospital or nursing home)

Answer 70

For patients at a high risk for falls: * Implement all assessments and interventions listed previously. * Relocate the patient for best visibility and supervision. * Encourage family members or significant other to stay with the patient. * Collaborate with other members of the health care team, especially the rehabilitative services. * Use technologic devices such as mattress sensor pads and chair alarms to alert staff to patients getting out of bed. * Use low beds or futon-type beds to prevent injury if the patient is at risk for falling out of bed.

Answer 71

Implement these nursing interventions for all patients, regardless of risk: * Monitor the patient's activities and behavior as often as possible, preferably every 30 to 60 minutes. * Teach the patient and family about the fall prevention program to become safety partners. * Remind the patient to call for help before getting out of bed or a chair. * Help the patient get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring patients. * Teach patients to use the grab bars when walking in the hall without assistive devices or when using the bathroom. * Provide or remind the patient to use a walker or cane for ambulating if needed; teach him or her how to use these devices. * Remind the patient to wear eyeglasses or a hearing aid if needed. * Help the incontinent patient to toilet every 1 to 2 hours. * Clean up spills immediately. * Arrange the furniture in the patient's room or hallway to eliminate clutter or obstacles that could contribute to a fall. * Provide adequate lighting at all times, especially at night. * Observe for side effects and toxic effects of drug therapy. * Orient the patient to the environment. * Keep the call light and patient care articles within reach; ensure that the patient can use the call light. * Place the bed in the lowest position with the brakes locked. * Place objects that the patient needs within reach. * Ensure that adequate handrails are present in the patient's room, bathroom, and hall. * Have the physical therapist assess the patient for mobility and safety.

Answer 72

Toileting-related falls are very common, especially at night. Older patients often have nocturia (urination at night) and get out of bed to go to the bathroom. They may forget to ask for assistance and may subsequently fall as a result of disorientation in the darkness in an unfamiliar environment. In some cases they may crawl over the side rail, which can make the fall more serious. Because of this, side rails are used far less often in both hospitals and nursing homes. In both settings side rails are classified as restraints unless the use of rails helps patients increase mobility.

Answer 73

A restraint is any device or drug that prevents the patient from moving freely and must be prescribed by a health care provider. In 1990 the US government enforced a law that gives nursing home residents the right to be restraint free. Removing physical restraints from nursing home residents has reduced serious injuries, although falls and minor injuries have increased in some cases. Mattresses placed on floors next to patient beds or “low beds” have helped reduce injury. Hospitals have also reduced the use of physical restraints. The Joint Commission has specific standards that limit the use of physical restraints in hospitals and nursing homes. Although not appropriate, chemical restraints (psychoactive drugs) such as haloperidol (Haldol) have sometimes been used in place of physical restraints. Experts agree that older adults should not be placed in a physical restraint or sedated just because they are old. Use alternatives before applying any type of restraint

Answer 74

However, if all other interventions (e.g., reminding patients to call for assistance when needed; asking a family member to stay with patients) are not effective in fall prevention, a physical restraint may be required for a limited period. Applying a restraint is a serious intervention and should be analyzed for its risk versus its benefit. Check the patient in a restraint every 30 to 60 minutes and release the restraint at least every 2 hours for turning, repositioning, and toileting. Physical restraints such as vests have caused serious injury and even death. If restraint is needed, use the least restrictive device first. Be sure to follow your facility policy and procedure for using restraints.

Answer 75

* If the patient is acutely confused, reorient him or her to reality as often as possible. * If the patient has dementia, use validation to reaffirm his or her feelings and concerns. * Check the patient often, at least every hour. * If the patient pulls tubes and lines, cover them with roller gauze or another protective device; be sure that IV insertion sites are visible for assessment. * Keep the patient busy with an activity, pillow or apron, puzzle, or art project. * Provide soft, calming music. * Place the patient in an area where he or she can be supervised. (If the patient is agitated, do not place him or her in a noisy area.) * Turn off the television if the patient is agitated. * Ask a family member or friend to stay with the patient at night. * Help the patient to toilet every 2 to 3 hours, including during the night. * Be sure that the patient's needs for food, fluids, and comfort are met. * If agency policy allows, provide the patient with a pet visit. * Provide familiar objects or cherished items that the patient can touch. * Document the use of all alternative interventions. * If a restraint is applied, use the least restrictive device (e.g., mitts rather than wrist restraints, a roller belt rather than a vest).

Answer 76

Chemical restraints are often overused in hospital settings. Examples include: * Antipsychotic drugs * Antianxiety drugs * Antidepressant drugs * Sedative-hypnotic drugs The most potent group of psychoactive drugs is the antipsychotics. These drugs are appropriate only for the control of certain behavioral problems such as delusions, acute psychosis, and schizophrenia. Typical antipsychotic drugs include haloperidol (Haldol, Peridol) and thiothixene (Navane). These drugs should not be used to treat anxiety or induce sedation.

Answer 77

* Anticholinergic effects, the most common problem, causing constipation, dry mouth, and urinary retention * Orthostatic hypotension, which increases the patient's risk for falls and fractures * Parkinsonism, including tremors, bradycardia, and a shuffling gait * Restlessness and the inability to stay still in any one position * Hyperglycemia and diabetes mellitus, which occur more with drugs such as risperidone (Risperdal) and quetiapine (Seroquel)

Answer 78

Skin breakdown, especially pressure injuries, is a major TISSUE INTEGRITY problem among older adults in hospitals and nursing homes. In some cases these wounds cause death from infection. Therefore prevention is the best approach. The Joint Commission's NPSGs require that all health care agencies have a program to prevent agency-associated pressure injuries. The program should include these evidence-based interventions: * Nutritional support * Avoidance of skin injury from friction or shearing forces * Repositioning and support surfaces * A plan to increase MOBILITY and activity level when appropriate * Skin cleaning and use of moisture barriers

Answer 79

Assess older adults for their risk for pressure injuries, using an assessment tool such as the Braden Scale for Predicting Pressure Sore Risk (see Chapter 25). Implement evidence-based interventions to prevent agency-acquired pressure injuries and maintain TISSUE INTEGRITY. Coordinate these interventions with members of the interprofessional health care team, including the dietitian and wound care specialist.

Answer 80

Supervise unlicensed assistive personnel (UAP) for frequent turning and repositioning for the patient who is immobile. Assess the skin every 8 hours for reddened areas that do not blanch. Remind UAP to keep the skin clean and dry. Use pressure-relieving mattresses and avoid briefs or absorbent pads that can cause skin irritation and excess moisture.

Answer 81

Skin tears are also common in older adults, especially the old-old group and those who are on chronic steroid therapy. Teach UAP to use extreme caution when handling these patients. Use a gentle touch and report any open areas. Avoid bruising because older adults have increased capillary fragility.

Answer 82

Some older adults and their families experience a breakdown in communication and coordination of care when transitioning from the hospital or long-term care (LTC) setting (nursing home) to the home setting. If the transition is not optimal, older adults experience high readmission rates and an increase in visits to the emergency department or primary health care provider's office. Care was not coordinated among health care professionals, which led to confusion for the older adult and family caregivers. To help prevent these problems, the authors recommended that a system be in place to address patients' communication needs. The system should include follow-up phone calls after discharge to home and having one case manager to coordinate care during and after the transition from the inpatient agency to home. A home care nurse or other health care professional can serve as a “health coach” to ensure understanding of discharge instructions, consistent follow-up appointments, and a designated emergency contact for the patient and family. Discharge instructions should be easy to read, in large print, and accurate. Continuity of care for high-quality transition between settings is essential to achieve positive outcomes for older adults.