Chapters 11 & 12 - Foundations of Gerontology: Theories of Aging, Care of the Frail Elder & Prescribing to the Elderly Population

Question 1

What are the living arrangements for elders?

Answer 1

• Only 25% of the population > 95 living in LTC
• The majority of elderly live with a spouse or other relative
• 75% of men live with spouses
• 39% of women live with spouses
• 33% of elderly live alone

Question 2

Common threads among developmental tasks of aging

Answer 2

• Adjust to decreasing physical strength and health
• Adjust to retirement and reduced income
• Adjust to death of a partner
• Establish affiliation with peers
• Adapt to social rules
• Establish satisfactory physical living arrangements

Question 3

What are the stages in the Transtheoretical Model of Change

Answer 3

• Precontemplation – no intention to make change within the next 6 months
• Contemplation – intending to change within 6 months
• Preparation – ready to take action, already have taken some action
• Action – have made specific overt modifications that attains a criterion sufficient to reduce risk of disease
• Maintenance – working to prevent relapse

Question 4

Competency

Answer 4

• The law presumes all adults are competent to make decisions
• Only a court can declare a person as incompetent and appoint a guardian
• Impaired judgement does not make a person incompetent
• When obtaining informed consent the patient: has knowledge of diagnosis, understands nature and purpose of procedure, understands benefits/risk/side effects, understands reasonable alternatives

Question 5

Theories of elder abuse

Answer 5

• Cycle of learned abuse
• Caregiver stress
• Pathophysiology of abuser – psychologic issue, substance abuse, etc.
• Physical/mental impairment of the elder

Question 6

Organ systems most affected by the age-related decline

Answer 6

• Neurological
• Cardiovascular
• Musculoskeletal
• Lower urinary

Question 7

Atypical presentation of illness in the elder

Answer 7

• Because of the weakness of the 4 organ systems most affected by age-related decline (neurologic, musculoskeletal, cardiovascular, lower urinary) the strain of illness or disease in any body system tends to manifest in one of these four
• In the geriatric patient, the organ system associated with a particular abnormality or problem is less likely to be the source of the problem in the younger adult
• Diseases usually present at an earlier stage as a result of normal, age-related decline in compensatory mechanisms

Question 8

What is dementia (general)?

Answer 8

• A syndrome characterized by deterioration of or impairment in mental, behavioral, or emotional functions despite a state of clear consciousness. The persistent stable/progressive nature of the impairment distinguishes it from delirium
• Types – Alzheimer’s dementia, vascular dementia, Parkinson’s dementia, Lewy Body dementia, Pick’s disease, subcortical dementia

Question 9

What is Alzheimer’s dementia?

Answer 9

• Most common type of dementia
• Patients are very animated (either happy or angry) and as the disease progresses, the more extreme the animation
• Confabulation is characteristic as well as paranoia (especially as disease progresses)
• 10% > 65 years, 25% > 75 years, 50% > 85 years old

Question 10

What is vascular dementia?

Answer 10

• Second most common type of dementia
• Almost half of vascular dementia cases also have an Alzheimer’s component
• Multi-infarct dementia (MID), dementia with cerebrovascular disease (DCVD)
• Tends to have a more flat mood

Question 11

What is delirium?

Answer 11

• Acute event characterized by global impairment, alteration in sleep-wake cycle, and alteration in psychomotor behavior
• Its acute and global nature distinguishes it from dementia
• Patient safety is primary concern
• Management should include simple firm communications, reality orientation, validity of feelings, a visible clock, and the presence of a familiar person if possible
• Drug-therapy as indicated for safety – short-acting, low anticholinergic properties

Question 12

What is Parkinson’s Disease?

Answer 12

• Degenerative CNS disorder resulting from an imbalance of dopamine and acetylcholine (too little dopamine, too much acetylcholine)
• Characterized by any combination of tremor, rigidity, and bradykinesia
• Resting tremor (e.g., “pill rolling”) often disappears with purposeful movement
• Pharmacologic options focus around trying to increase amount of dopamine
• Carbidopa-Levodopa (Sinemet) – gold standard, treats symptoms
• Others: selegiline, dopamine agonists, COMT inhibitors

Question 13

General facts about falls

Answer 13

• Falls represent a significant source of morbidity and mortality in the elderly
• Multiple falls are associated with increased risk of death
• Biggest risk factor for falls = previous fall
• Age-related risk factors: female, chronic medical conditions, cognitive impairment, ADL dependence, impaired vision/hearing, polypharmacy, environmental hazards, gait and balance disorders

Question 14

Non-pharmacologic interventions to falls

Answer 14

• Review mediations; assess doses, eliminate high-risk drugs
• Prevention/treatment of osteoporosis
• Recommend proper footwear
• Obstacle-free, well-lit environment
• Raise chair heights, seat heights, add arm rests
• Physical therapy as indicated
• Counsel avoidance of quick position change

Question 15

General facts about pressure ulcers

Answer 15

• Pressure ulcers occur when tissues are compressed and vascular pressure is exceeded
• Significant contributing factors include friction, shear, and nutritional debilitation
• Other contributing factors – moisture, advanced age, low BP, smoking, elevated body temperature, dehydration
• Differential dx – conditions that mimic pressure ulcers, fungal and yeast infections, malignancy, venous and arterial ulcers, neuropathic ulcers

Question 16

Staging of pressure ulcers

Answer 16

• Stage 1 – non-blanchable erythema of intact skin; induration may be present
• Stage 2 – epidermal or dermal skin loss, may appear as intact blister
• Stage 3 – full thickness skin loss, deep crater without undermining
• Stage 4 – full-thickness skin and tissue loss; through fascia, muscle, bone, or supporting tissue visible

Question 17

What is Beers Criteria?

Answer 17

• Lists of certain medications that you should think about that may not be the safest or best option for older adults
• Helps guide clinicians away from potentially harmful treatments

Question 18

Normal age-related physical changes: skin

Answer 18

• Loss of skin turgor – d/t decreased subQ tissue, can also be abnormal (ex: dehydration)
• Senile keratoses – benign overgrowths, look like barnacles
• Senile lentigo – hyperpigmented macules
• Decreased perspiration and poor temperature regulation

Question 19

Normal age-related physical changes: head/neck

Answer 19

• Arcus senilis – white/gray opaque ring in corneal margins
• Eyes become dry
• Thickening of tympanic membrane – plays into difficulty hearing
• Decreased salivary gland activity

Question 20

Normal age-related physical changes: chest/lungs

Answer 20

• Increased AP diameter; COPD can also cause this
• Decreased inspiratory reserve volume – may be SOB easier, may take longer to recover
• Decreased strength of respiratory muscles – decreased effective coughing

Question 21

Normal age-related physical changes: cardiovascular

Answer 21

• Decreased HR and stroke volume
• Sclerosis and thickening of valves – aortic sclerosis very common
• EKG abnormalities – non-specific ST changes (importance of baseline)

Question 22

Normal age-related physical changes: GI

Answer 22

• Decreased salivation
• Poor relaxation of esophageal sphincter – increased rick for GERD and aspiration issues
• Decreased gastric acid/pancreatic enzyme secretions – can’t break things down very easily
• Reduced mobility and peristalsis – constipation and impaction risk
• Decreased hepatic metabolism – may change the way certain liver-metabolized drugs work

Question 23

Normal age-related physical changes: GU

Answer 23

• Decreased bladder capacity – higher risk of infection
• GFR naturally decreases leading to higher BUN and creatinine
• Decreased vaginal secretions
• Enlarged prostate
• Decreased renal function – reduced ability to concentrate or dilute urine

Question 24

Normal age-related physical changes: musculoskeletal

Answer 24

• Development of bony prominences
• Decreased bone and muscle mass
• Degenerative joint disease – osteoarthritis very common
• Complications from falls is leading cause of death from injury in patients > 65

Question 25

Normal age-related physical changes: neurological

Answer 25

* Decreased/delayed deep tendon reflexes | * Slowed reaction time

Question 26

Which of the following is a true statement with respect to the standard of living among elderly Americans? a. The socioeconomic standard of living is higher than it ever was in this population b. Elderly men have a higher poverty rate than elderly women c. The majority of elderly reside in some sort of assisted living facility, which has increased the standard of living of the entire demographic d. Changes in tax law have actually decreased the standard of living for the elderly, even though they are making more money than ever

Answer 26

a. The socioeconomic standard of living is higher than it ever was in this population

Question 27

You are the NP assessing an 87-year-old male. He is oriented but does not engage in conversation. The patient’s caregiver insists on answering all questions and becomes upset with you when you ask the patient to answer directly. The caregiver says that the patient is stupid and does not know anything. You should further assess for? a. Mild cognitive impairment b. Dementia c. Substance abuse d. Psychological abuse

Answer 27

d. Psychological abuse

Question 28

The continuum of care for the elderly patient ranges from health promotion for healthy, community dwelling elderly to terminal care for dying individuals. Which type of program requires functional abilities? a. Adult day care b. Senior centers c. Home health care d. Life care communities

Answer 28

b. Senior centers

Question 29

Which of the following is not a true statement with respect to decision making for the impaired person? a. Only a court can declare a person incompetent b. Impaired judgement does not make a person incompetent c. Living wills are generally only honored if a person is terminally ill d. If a patient is not declared incompetent, then he or she can give informed consent

Answer 29

d. If a patient is not declared incompetent, then he or she can give informed consent

Question 30

There are a variety of physiological theories of aging. Which one is based upon the concept of the senescence factor? a. Programmed theory b. Error theory c. Cross-link theory d. Free radical theory

Answer 30

a. Programmed theory

Question 31

Ageism results in a variety of misconceptions and stereotypes about the lifestyle of many elderly persons. All of the following statements are true except: a. Almost 25% of the elderly over 85 years of age require assistance with IADLs b. Most elderly live with a spouse or other family member c. Stereotypes about aging have resulted in fiscal policy benefits helpful to elders d. The number of older men in the workforce has increased in recent years

Answer 31

d. The number of older men in the workforce has increased in recent years

Question 32

During a routine assessment for shoulder pain, a patient reveals that he has become increasingly concerned about the physical losses of aging. His life always revolved around his ability to engage in physical work and recreation and now he cannot do the things he has always enjoyed. This realization has made him “cranky”, depressed, and angry with the world. His children have remarked on his personality change. You realize that this patient may be having difficulty accepting the inevitability of death as described by: a. Erikson b. Peck c. Levinson d. Butler

Answer 32

c. Levinson

Question 33

One particularly engaged patient has decided that she wants to do everything she can to minimize the physiologic effects of aging. She asks if taking vitamins, particularly vitamin E, will really help with the aging process. Which theory of aging implies that vitamins might delay the process? a. Free radical theory b. Somatic mutation theory c. Immunologic theory d. Programmed theory

Answer 33

a. Free radical theory

Question 34

An elderly patient tells you that he does not want to get the flu shot this year because last year he got it and developed the flu anyway. You know that this is most likely due to the fact that aging physiology: a. Increases humoral immunity b. Accelerates the production of antibodies c. Impairs the effectiveness of cellular immunity d. Reduces IgE levels

Answer 34

c. Impairs the effectiveness of cellular immunity

Question 35

Which of the following statements is true with regard to disease prevention in the older adult? a. Diseases are usually more difficult to treat because they present much later b. Normal age-related changes do not alter the way an illness presents c. Diseases usually present at an earlier stage due to impaired compensatory systems d. A mild decline in memory and information processing is not a normal finding

Answer 35

c. Diseases usually present at an earlier stage due to impaired compensatory systems

Question 36

When evaluating illness symptoms in an elderly patient, the nurse practitioner knows that diseases often present in a fashion different from the young and middle-aged population as a result of: a. Comorbid dementia b. Increased physiologic response to illness c. Normal age-related decline d. Increased compensatory mechanisms

Answer 36

c. Normal age-related decline

Question 37

Patient education for the elderly should include particular care to extreme environmental and weather conditions because: a. Repeated exposure to extremes of temperature may impact cognition in later years b. Aging physiology deceases the ability to respond to thermal stress c. Elderly people frequently neglect self-care d. The lower socioeconomic standard makes it difficult to pay energy bills

Answer 37

b. Aging physiology deceases the ability to respond to thermal stress

Question 38

An abrupt and global change in mental status of an elderly person is most likely due to: a. A UTI b. Alzheimer’s dementia c. Depression d. Multi-infarct dementia

Answer 38

a. A UTI

Question 39

Normal age related changes of the elderly that can affect medications

Answer 39

* % body weight decreases – more at risk for dehydration * Lean muscle mass decreases * % body fat increases – highly lipophilic drugs (like benzos) will have longer half-lives * Relative kidney weight decreases – more prone to nephrotoxicity * Relative hepatic blood flow decreases – decreased liver blood flow = meds stick around longer

Question 40

What are common meds in the older adult that are highly protein bound?

Answer 40

* Warfarin – 99% protein-bound, daily warfarin dose is significantly lower as age increases * Phenytoin * Valproic acid * Diazepam

Question 41

Why should anticholinergic drugs be avoided in the elderly?

Answer 41

* Due to increased risk of confusion, urinary retention, visual disturbance, constipation, and hypotension * Adverse effects could lead to polypharmacy and delirium

Question 42

What are the anticholinergic side effects?

Answer 42

* Dry as a bone (DRY MOUTH) * Red as a beet (flushing) * Mad as a Hatter (confusion) * Hot as a hare (hyperthermia) * Can't see (vision changes) * Can't pee (urinary retention) * Can't spit (dry mouth) * Can't shit (constipation)

Question 43

Meds with significant anticholinergic effects in the elderly

Answer 43

* 1st generation antihistamines – diphenhydramine (Benadryl), hydroxyzine (Atarax), etc. * SSRIs – paroxetine * TCAs – amitriptyline, nortriptyline

Question 44

Statin therapy – high-intensity vs. moderate-intensity statin therapy

Answer 44

• High-intensity – avoid in those > 80 years old, impaired renal function, frail, multiple comorbidities o Ex: atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily • Moderate-intensity – preferred in those with risks to high-intensity o Atorvastatin 10-20 mg, rosuvastatin 5-10 mg, or simvastatin 20-40 mg daily

Question 45

Consequences of long-term PPI use

Answer 45

* Rebound hypersecretion – explains why there are reports of increased symtoms following discontinuation; consider tapering med followed by every other day use and an antacid for symptoms * Potential decreased absorption of select micronutrients requiring an acidic stomach environment – iron, vitamin B12 * Increased fracture risk * Impaired magnesium absorption