Gero Exam 2 Flashcards

Question

Malnutrition RIsk Factors

Answer 1

- age related change in taste or smell - oral health status (do they have their dentures) - chronic diseases and the side effects of medications - lifelong eating habits (integrate what they like and do not like) - socialization (some people are loners so they just buy snack foods or things for sandwiches = suggest steamable vegetables) - income impacts them buying proper food (they shop on a budget so they choose cheaper items that are packaged or canned) - 40-60% of elderly in long term care patients are malnutritioned (often due to the diets we give them - figure out what they like and do not like)

Answer 2

*Difficulty swallowing (dysphagia) - Just because they have dysphagia, does not mean they cannot eat *About 20% of those over 50 *Up to 60% of LTC residents (have dysphagia) - Labored swallowing = slow to swallow - Coughing/choking = sit up patients (make sure they can clear secretions) - Increased oral secretions makes patients nervous to swallow so it builds up in their mouth — Make sure they swallow saliva (they are afraid to swallow because salvia is thin) - Make sure they have not pocketed food in their cheek - Make sure they have no chest pain due to acid reflux (position patient properly)

Answer 3

*Supervise all meals *Seated and rested before eating *Sitting up at 90 degrees *Don’t rush meals *Alternate solids and liquids *Chin-tuck swallow *Thickened liquids and pureed foods - Thickened food for patients = easier to swallow - Thicken liquids if needed (some come already thickened) and see if they need a puree diet *Avoid sedatives (ativan or benadryl) – may impair cough reflex - and makes them sleepy; if they have to have medications try to feed them before *Keep suction readily available *Oral care - most patients want their teeth cleaned before they eat (helps them to eat because they can taste) - Do proper oral care and make sure they do not have pain in their throat or mouth

Answer 4

*Prevent death from inadequate intake *Reduce aspiration pneumonia - they still might have oral liquids or food *Improve nutritional status *Provide comfort at end-of-life

Answer 5

*Do not improve QOL (quality of life) - just gives proper nutrients needed *Do not prolong survival in dementia *Associated with increased agitation, use of restraints, & worsening pressure injuries *50% of patients die within 6 months of insertion *Are associated with infection, GI symptoms and abscesses *Are popular r/t convenience & labor costs

Answer 6

Adequate fluid consumption & maintenance of fluid balance essential to health

Answer 7

o Physiological changes in body water content o Impaired thirst sensation o Medications - At high risk for dry mouth/dehydration: medications [anticholinergics, antidepressants, MAOBs for antiparkinson, antihistamines (benadryl or zyrtec), antihypertensive (enderlol), diuretics (lasix), antispasmodics which is a muscle relaxer (zanaflex)] o Functional impairments - impaired movement o Chronic illness - HIV positive pts, diabetes, hep C o Emotional illness o High environmental temperatures - temperature outside

Answer 8

o Water/body ratio decreases, making you more susceptible to dehydration o Requiring the need of daily care as we are less able to handle day-to-day tasks o Needing assistance with food and fluids can significantly reduce self-hydration o Increased incontinence results in the need to replenish our fluids more often o Cognitive impairment can mean that we may forget to keep ourselves hydrated o With increased age brings a diminished thirst sense o The need for multiple medications can increase the onset of dehydration o Increase likelihood of acute illnesses, can result in our body being dehydrated Solutions: - put liquids in front of patients and remind them to drink (some might not even remember they did not drink all day) especially with incontinence patients - they will decrease drinking because they do not want to have to go to the restroom as often

Answer 9

o Able to drink - they might just not want to drink o May not know what’s adequate o Possible cog impairment o Encourage & make fluids accessible

Answer 10

o Physical incapable to ingesting or accessing fluids o Dysphagia prevention o Swallow evaluation o Safe drinking techniques

Answer 11

o Highest risk for dehydration o Able to drink but refuses o Offer frequently o Prevent incontinence

Answer 12

o Terminally ill o Could be any of previous 3 (Can, Can't, or Won't drink) o Refer to advanced directives with regard to hydration wishes

Answer 13

*Skin turgor (unreliable r/t skin changes) *Weight *Mucous membranes *Speech changes *Tachycardia *Decreased UOP *Dark urine *Weakness *Dry axilla *Sunken eyes o Many of these signs are often unreliable in older people. Look at big picture. Dehydration generally confirmed with lab testing. - look at patient first (lab tests will give definitive answer if the patient is dehydrated)

Answer 14

At least 1500 mL/day (1.5 Liters or more)

Answer 15

*At least 1500 mL/day (1.5 Liters or more) *Fluid quality - Water is BEST *Offer often - offer fluids more often that food (fluids are more important than food) *Make readily available - cup poured on the nightstand (keep fluids within reach) *Encourage with meds - encourage them to drink the whole drink with it *Provide preferred fluids - Stay away from carbonation - Dairy free or lactose free (soy based is a good option) - 100% juice if you cannot get them to drink - If they want coke “If you drink the same amount of water then I will give you a coke” - Watch them drink to make sure they are drinking *Verbal reminders

Answer 16

Loss of moderate to large amount of urine before getting to the toilet; inability to suppress urge to urinate - when you have been holding it too long (fall hazard if they have to rush to the bathroom)

Answer 17

Loss of small amount of urine with activities that increase intra abdominal pressure (coughing, sneezing, exercising, lifting, bending) - more common in women, but can occur in men after prostate surgery

Answer 18

Lower urinary tract intact, but individual unable to reach toilet due to environmental barriers, physical limitations, cognitive impairment, lack of assistance, difficulty managing belts/zippers/getting a dress up and down/getting undergarments down, or sitting on a toilet

Answer 19

*Scheduled & Prompted voiding - put them on a schedule every 2 hours (we always have a reserve in the bladder even if they think they do not need to go) *Pelvic floor muscle exercises (Kegels) *Thorough assessment of continence - when did this start? Is it related to anything? (meds, cognitive function, surgery, life changes) *Lifestyle Modifications - discrete briefs; some patients prefer pull-ups rather than diapers *Medications - anticholinergics or antimuscarinics *Urinary catheters – last resort - because risk of UTI (internal) - Condom catheters (they will say large, but they need a small; make sure that you grab the shaft firmly and use adhesive because acid in urine breaks down adhesive) - Purewick (make sure they actually need it because it vibrates and sometimes they just want action); make sure inner thigh and outer thigh is not getting irritates (may need towel in between) - Change every 8 hrs for external catheters

Answer 20

o Most common cause of sepsis in older adults - First urine from foley we send to lab to make sure it was clear and then if there's an infection we remove foley, put on antibiotics, and insert again and make sure it is sterile o Often asymptomatic o Cognitively impaired may not report symptoms o Atypical Symptoms: Mental status change (#1 sign in older adults with or without a foley), Decreased appetite, and Incontinence o Normal for older adults to have asymptomatic, uncomplicated bacteria in urine. - Tell them to not hold urine if they need to urinate (retaining urine is not good)

Answer 21

o Reduction in bowel movement frequency or difficulty in forming or passing of stool o 40% of older experience constipation: More common in women - due to extra organs in abdominal area - make sure to auscultate for bowel sounds and determine why if abnormal (lack of fiber or meds) - they will get distended and not want to eat or do anything

Answer 22

o Impaction, obstruction, cognitive dysfunction, delirium, falls, increased morbidity & mortality o Increased risk for bowel cancer

Answer 23

Increase physical activity *Increases motility (walk with the patient) Proper positioning *Squatting, leaning forward (physiology) - Have patients sit up for 30 minutes first to prevent swallowing or dysphagia issues, then lay patient on their left side, and then when their stomach starts cramping sit them on the toilet Toileting regimen *Normalizes bowel function *Attempt BM after breakfast or dinner (gastrocolic reflex) *Allow at least 10 minutes for BM - do not rush them (you have to stand there with them) Increase dietary fiber *Know foods high in fiber - wheat, green leafy, dry fruit, dry beans, vegetables, bran, cereal, bananas, peas, lentils, leafy greens, pear, avocado, raspberries, almonds, cooked black beans, air-popped popcorn, cooked pearled barley - Patients who are in bed who have a high fiber diet can cause skin breakdown if they are immobile Increase fluid intake – at least 1.5L per day

Answer 24

o Bulk-forming (fiber) - psyllium (Metamucil) o Emollients – docusate sodium o Osmotic - polyethylene glycol (PEG), milk of magnesia, lactulose o Stimulant – bisacodyl, senna Enemas o Last resort o Don’t use on regular basis o May alter fluid and electrolyte status o Sodium phosphate enemas contraindicated in older - Have used syrup as enema (anything slippery)

Answer 25

*Common in incapacitated and those in institutions o Increased incidence with narcotics - Dualadid, morphine, percocet, lortab - slows GI system down *Manifestations & complications o Malaise, urinary retention, increased temp, incontinence, cognitive decline, hemorrhoids (occurs from bearing down trying to have a BM - inside of rectum and can be prolapsed onto the outside), intestinal obstruction.

Answer 26

*First prevent! *Removal of impaction - nurses do not disimpact patients (MDs are responsible because we are messing with the vagus nerve); can take several days for it to all come out and sometimes have to have surgery to have it removed o Digital removal of hard stool from rectum o Use copious lubricant o May take several days o Don’t dis-impact too much o Often very painful

Answer 27

*NREM (75% of night) o Stage 1-4 *REM (25% of night) - most important part of sleep

Answer 28

*Most changes in sleep begin >50 y/o *Less time in Stage 3-4 o Stage 3-4 = Feeling rested and refreshed *More time awake or Stage 1 *REM critical for elders – brain replenishment - Instruct patients to wait to go to sleep until the sun goes down (make sure naps are not deep sleep); if they sleep too much during the day it can cause confusion between night and day

Answer 29

*Barometer for health *Aging associated with: o Decreased sleep efficiency & total time o Sleep disorders - sun downers - turn all lights on and close shades before it gets dark to avoid cognitive impairment o Circadian rhythm responses diminished o Increase in stage one of sleep – less REM o Longer to fall asleep o Frequent awakenings o Increased napping during day o Frequency of leg movement increased *Must assess sleep patterns! – Poor sleep is NOT inevitable but indicator of health status *Older need just as much sleep as younger - sometimes it is their medications making them sleep, not their bodies telling them to sleep; many older adults do not sleep as much as we do *Pittsburgh Sleep Quality Index - assessment tool

Answer 30

Biorhythm and sleep o Age related changes in the body’s perception of light-dark cycle and circadian sleep-wake rhythm Sleep Cycle o Changes in sleep cycle that reduce amount of deep sleep and time spent in REM sleep *Sleep deprivation and fragmented sleep can adversely affect cognitive, emotional, and physical functioning as well as quality of life

Answer 31

*Disturbed sleep in the presence of adequate opportunities and circumstances *Medications and substance - Causes o Drugs and ETOH (10-15% of insomnia) - alcohol can cause them to wake up due to AE of ETOH (throwing up, having to urinate, headaches) *Eliminate underlying cause if possible - Cluster medications so they we do not have to wake them up as often (teach them to do the same thing at home)

Answer 32

o Difficulty falling asleep >1 month - “I have to count sheep to fall asleep” o AND impairment in daytime functioning r/t poor sleep o Primary (just have it bc you have it) vs. comorbid (other problem that lead to insomnia like HTN, diabetes, drugs)

Answer 33

*Maximize comfort *Bedroom is for two things – both start with S (sex and sleep) *Avoid or limit naps < 2 hours *Exercise (not before bedtime) and outdoor time *Bedtime routine *Limit tobacco, caffeine and ETOH – in evening - try to get them to smoke during the day and not at night if they will not quit *Manage GERD - make sure they stay up 30-45 minutes after they eat *Avoid screen time just before bed - 30 minutes before bed *If can’t fall asleep o Go to another room until feeling sleepy

Answer 34

*Older should avoid sleep aids, in general - some people get addicted and some do not work at all in elderly o Especially Benzodiazepines *OTC medications o Diphenhydramine (benadryl) *Preferred Sleep RX – benzodiazepine receptor agonist (zolpidem) or melatonin receptor agonist (ramelteon) o Lowest dose (start at ½ dose) o Short-term o Zolpidem – High ED visits for adverse drug events *Always remember SAFETY - Ambien can cause adverse effects (can make you wide awake)

Answer 35

*Periods of no breathing while sleeping S/S: o Excessive daytime sleepiness o Snoring, gasping, choking - often people who snore do not know they have sleep apnea o Headache, irritability o Symptoms often blamed on age! *Assess with Epworth Sleepiness Scale

Answer 36

*70% of men; 56% of women > 65 y/o o Cause: Decline in tone of upper airway muscles *Linked to: heart failure, cardiac dysrhythmias, stroke, T2DM, OP & death *Limit/stop ETOH & sedatives, weight loss, smoking, CPAP - When they have to get on a CPAP machine there are different options for claustrophobic patients

Answer 37

*2.5 hours weekly of moderate aerobic - ex: swimming pools for aerobics in LTC *Muscle strengthening activities at least 2 days per week o All major muscle groups - key to keep patients mobile and decrease fall risk

Answer 38

Continuous movement involving large muscle groups that is sustained for a minimum of 10 minutes; should make your heart beat faster Ex: Biking, swimming and other water based activities, dancing, brisk walking, lifestyle activities that incorporate large muscle groups (pushing a lawn mower, climbing stairs)

Answer 39

Activities that involve moving or lifting some type of resistance and work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, arms) Ex: Lifting weights, calisthenics, working with resistance bands, pilates, exercises that use the body’s own weight for resistance (push-ups, sit-ups), heavy gardening (digging, shoveling), washing windows or floors

Answer 40

(flexibility) a therapeutic maneuver designed to elongate shortened soft tissue structures and increase flexibility Ex: yoga, ROM exercises

Answer 41

Movements that improve the ability to maintain control of the body over the base of support to avoid falling Ex: Tai chi, exercises such as standing on one foot, walking heel to toe or backward or sideways, leg raises, hip extensions (can be done holding on to a chair), standing up from a sitting position without using your hands

Answer 42

*Know the NO’s *Don’t exercise when: o SBP (systolic BP) > 200 mm Hg o DBP (diastolic BP) > 100 mm Hg o Resting HR > 120 bpm o For 2 hrs after a big meal - to avoid cramping in abdomen and legs (can cause safety issues)

Answer 43

*Skin becomes drier, less elastic, cooler *Subcutaneous tissue on dorsum and sides of foot thins *Plantar fat pad shrinks and degenerates *Toenails become brittle, thicken, less resistant to fungal infections - cut toenails straight across *Degenerative joint disease decreases range of motion - Assess pads of feet, in between toes, and nails for discoloration and capillary refill - teach diabetic patients to check (or family/caregiver) due to loss of nerve feeling in feet

Answer 44

Thick, compacted skin often from prolonged pressure. Pad and protect area is BEST. Proper fitting shoes.

Answer 45

Bony deformities – great toe or fifth toe from chronic squeezing or hereditary. Custom shoes, surgery, or steroid injection.

Answer 46

Permanently flexed toe (clawlike). Custom shoes or surgery. - Common in older white population

Answer 47

Yellow, brown, opaque, brittle and thick nails. Difficult to treat – costly & limited effectiveness.

Answer 48

*If DM - Must have annual foot exam by healthcare provider (podiatrist) - some may need to go more often *Care of toenails o Best cut after bath or soaking 20-30 min – softens nails - Check water with elbow (closest to diabetic feet feeling) for proper temperature o Clip straight across *Proper fitting footwear (orthotic shoe is paid for by medicare, wide or narrow shoes) *Orthotic shoes as needed (medicare and medicaid will pay for them)

Answer 49

*Geriatric Syndrome: (malnutrition) o ¹∕₃ over 65 y/o fall each year o 10% sustain serious injury *Falls are a SYMPTOM of a problem *Consequences of Falls o Hip fractures o Traumatic brain injury o Fallophobia — Fear of falling causing limitations in function - catch them and let them slide down you because you are less susceptible to injury than them - sentinel event when there are falls in the hospital (patient changes from one status to another) and sometimes you have to go to court for it to figure out if it could've been prevented

Answer 50

Assessment Tools o Hendrich II Fall Risk Model o Morse Fall Scale Major risk factors o Orthostatic hypotension o Cognitive impairment o Impaired vision and hearing o Medications o Environmental factors o Weakness and frailty - assess risk for falls in ALL patients

Answer 51

Fall risk reduction programs *Fall bundles o Arm bands (“fall risk” bracelet), signs, education, risk assessment, footwear (make sure it is non-skid socks or non-skid shoes), assisted toileting *Environmental modifications *Assistive devices - educate on how to use and have them within reach (walkers/canes) *Safe client handling *Wheelchairs - most slide or roll out of wheelchair *Alarms/motion sensors - always determine where the alarm is going off

Answer 52

*Device to limit movement to prevent harm - Wanderguard (ankle bracelets) that sets off alarm if they walk past a certain area (sometimes put on wrist if it does not fit ankle) *Consequences of restraints in older adults o Do not effectively prevent falls, wandering, or removing medical equipment o Probably exacerbate the problem o Restrain-related death: Asphyxiation o Pressure ulcers, agitation, cognitive decline, depression - Check for pressure ulcers in restraints

Answer 53

*Not simply a part of the bed *Type of restraint (four side rails up is a form of restraint — you can have 2 or 3 side rails up) o If two full length or four half length up (four side rails is a form of restraint and can increase fall risk) - If in arm or ankle restraints (2 point or 4 point) you need to monitor and check underneath and have to take them off to assess — make sure they can go to the bathroom, exercise, get something to drink, etc - Give them an activity to do (folding towels or folding paper) to be able to keep them out of restraints *Research evidence does not show side rails reduce falls or injury *Some evidence that they increase injuries! *Centers for Medicare and Medicaid (CMS) o Require documentation of need for side rails - Document all restraints (if you have all 4 side rails up you need to document WHY) - Document on time; they often need a 1 to 1 sitter (PCA or nurse will have to be pulled out of staffing) - Rarely use vests in the hospital because they can cause strangulation - Violent patients in restraints = document every 15 minutes - Regular patients in restraints = document every 30 min-hour

Answer 54

*The goal for care in the older especially *Should not be used to manage behavior symptoms - Used for when there is a safety problem (pulling out IV) *Treat underlying problem *Practice with the evidence!

Answer 55

*Occurs suddenly and often without warning *Stroke, myocardial infarction (heart attack), hip fracture, infection (can fix and get rid of)

Answer 56

*Managed rather than cured *Always present but not always visible - can be at bay *Most common chronic condition in persons over 65 is arthritis, followed by hypertension

Answer 57

1) Hypertension 58% 2) High Cholesterol 47% 3) Arthritis 31% 4) Ischemic Heart Disease (or CAD) 29% 5) Diabetes 27% 6) Chronic Kidney Disease 18% 7) Heart Failure 14% 8) Depression 14% 9) Alzheimer's Disease and Dementia 11% 10) Chronic Obstructive Pulmonary Disease 11% 80% have at least 1 chronic condition 68% have 2 or more chronic conditions

Answer 58

No S/Sx (no signs and symptoms)

Answer 59

S/Sx & diagnosis PRESENT - trying to see if we can make it go away

Answer 60

Life-threatening situation - not just treating the symptoms, but treating the disease

Answer 61

Active illness requiring hospitalization - many pts in the hospitals are in this phase

Answer 62

Controlled illness course/symptoms

Answer 63

Not controlled but not requiring/desiring hospitalization - if they client is compliant then they can be sent home if they record their medications and reactions; non-compliant pts stay in the hospital

Answer 64

Progressive decline - the things we are doing are not working; body is fighting against us; possibly in hospice or palliative if interventions are no longer working

Answer 65

o Immediate weeks/days/hours before death - palliative/hospice care often happens on the floor now (keep them comfortable with pain medications — higher doses than normally considered safe and respiratory drive is not as important); educate the pt and the family

Answer 66

*Majority of health problems in late life are chronic - may be life long and have to teach them lifetime adaptations and how to live with chronic disease *Acute phase of illness management - stabilizes physiological processes and promote recovery during acute phase *Other phases of management - to maximize and extend period of stabilization at home with help from family and home health *Maintaining stable phases is central in managing chronic illness *Primary care nurse is the coordinator of multiple resources needed to promote quality of life along the trajectory - Impacts identity and impacts caregivers and family (set up home health and see if they need any other help at home which is planned on admission for discharge)

Answer 67

*Incidence increases with age *Normal age-related decreases in reserve capacity are depleted and not able to compensate - cannot fight off infection the same way = lose reserves that we normally have (may need to take tylenol around the clock whereas we might take a couple tylenol for the same infection) *Combination of geriatric syndromes

Answer 68

*The formal diagnosis is made in the presence of at least three of the following: (ask questions to determine if it is a normal aging problem or something else) o Unintentional weight loss (failure to thrive) o Self-reported exhaustion o Weak grip strength o Slow walking speed o Low activity - not as active as they usually can indicate a bigger underlying problem, not just necessarily aging ex: not gardening, going to the gym, eating like they usually do

Answer 69

*Hypertension *Heart failure

Answer 70

*HTN is a complex disease with a core defect of vascular dysfunction that leads to target organ damage. *HTN is the MOST COMMON chronic condition in people > 65 yo. *In short: 60 yrs or older BP is OK if LESS THAN 150 SBP OR 90 DBP - Once you are dx with HTN it may read 170/90 then you have to look at chart to see trend (it might not be high for them) - Teach them how to take BP at home (ask what type of cuff they are using at home because it can differ readings) - We do not want to drop their BP fast in hypertensive patients (a drop in 10 mmHg is a good amount to indicate trending down)

Answer 71

*Weight reduction (5-20 mmHg reduction) - key to everything *DASH diet (8-14 mmHg reduction) *Lower sodium intake (2-8 mmHg reduction) *Increase physical activity (4-9 mmHg reduction) - anything will help *EtOH in moderation (2-4 mmHg reduction) - they will not just stop drinking their glass of beer/wine *LOSE WEIGHT - biggest key (especially if they have big gut girth — get them moving as much as possible)

Answer 72

*Most common cause or hospitalization, re-`hospitalization, and disability for those over 65 yo *Heart cannot keep up with workload *Results in insufficient oxygen delivery to body

Answer 73

*Results from damage from hypertension and CHD *Ventricles ENLARGE and DILATE *Results in weaker muscle *Also related to : o EtOH abuse o Drug abuse o Chronic hyperthyroidism o Valvular disease o Some chemotherapy medications o Radiation therapy near heart (breast cancer, for example)

Answer 74

Left-side - Pump Failure to body *Systolic – decreased contractility – can’t squeeze *Diastolic – decreased filling – can’t relax *Think DYSPNEA

Answer 75

Right-side – Pump Failure to lungs *Results from Left-side failure *Think EDEMA – but also ascites (also heart murmurs)

Answer 76

Congestive Heart Failure - (also Acute Decompensated) *Swelling, edema, fluid in lungs (pulmonary edema) *Must remove fluid - Look for tachycardia, S3/S4 gallop, crackles in the lung fields, dependent edema (all the fluid has to be moved out of the body to help with the healing process) ex: ankles/fingertips swollen

Answer 77

- Activity (paced tolerance) - exercise (water aerobics) - taking medications (calcium channel blockers are usually contraindicated for CHF patients) - supplemental oxygen - sodium limited - weigh patients daily (in the morning, at the same time, before they do anything, same clothes) - sometimes need a fluid restrictions

Answer 78

*Complete assessment of all risk factors and existing disease *Lifestyle changes *Medication regimen tailored to specific disease process and patient needs *Focus on symptom management and prevention of exacerbations of disease - Educate patients on what they are taking, how they should take it, why they are taking it - Refer them to social work/case management for medication financial assistance (some pharmaceuticals have coupons)

Answer 79

ACE (-pril) & ARB (losartan) Vasodilation - Reduces cardiac preload and afterload, increase cardiac function/output, facialted H2O excretion, reduce stiffness ACEs = captopril, lisinopril - Can cause angioedema more commonly in African Americans (-pril will be discontinued) and can be taking for years before it happens ARBS = losartan

Answer 80

Reduce fluid retention - Furosemide/thiazide = loop diuretic - Spironolactone = potassium sparing

Answer 81

Improve contractility of heart muscle (-lol) - Increase heart contractility (watch HR because it will drop first before BP)

Answer 82

*Progressive disease – over 10-20 yrs *Think DOPAMINE – Dopamine is lost or inhibited o Dopamine regulates nerve impulses for MOTOR function *More common (slightly) in men than women *Onset approximately 60 years *Considered a terminal diagnosis - Neurodegenerative disorder that reduces neurons in a certain parts of the brain

Answer 83

- Progressive (worsens over time) neurodegenerative disease (loss of neurons in the brain) - Dopamine neurons reduced (they produce dopamine) - Dopamine is needed to make normal movements - Substantia nigra is the portion of the brain that makes dopamine - Signs: Shakiness (tremor), stiffness (felt when bending joints and is not as smooth = rigid), slowed down movements, problems with balance (unstable standing or difficulty walking — seen later in the disease development) - Parkinsonism or parkinsonism syndrome (symptom complex) are caused by parkinson's disease (primary parkinsonism) - Psychiatric problems (depression), memory loss, concentration lost, problems with smell - Causes are idiopathic = unknown - 15% have family hx is caused by a mutation in gene (either increases chance = more likely or causes parkinson's) - Risk factors: exposure to pesticides, cleaning chemicals, age, concussions, gender (males more likely), regularly breathing heavy metals (copper etc) - Tx: medications to treat symptoms which increase dopamine or stimulate dopamine production; may have surgery if medication no longer working by deactivating parts of the brain that cause symptoms - Goal is high quality life for as long as possible - Average age >65, but 5-10% occurs at 50 (early onset)

Answer 84

1. Cogwheel Rigidity *Small jerking movements when affected muscles stretched *Muscle rigidity - arms, leg, neck involved 2. Bradykinesia/Dyskinesia - All skeletal muscles are included *Difficulty starting, continuing, and or coordinating movements *Shuffling *May become frozen (Akinesia) (no movement at all) 3. Resting/Non-intention tremors - Jaw, hands, feet, tongue, face, neck, tongue *Fine, rhythmic, purposeless tremors o Disappear with sleep and purposeful movements *Pills rolling, small handwriting, low monotone voice - Posture is stooped over, small and slow steps when initiating moment often with tremors and shuffling; patient will turn en bloc (like a statue moving around) - At risk for falls, fractures, and social isolation

Answer 85

*Postural abnormalities (stooped posture) *Altered gait (slow start, short steps, “shuffle”) Autonomic Dysfunction *Seborrhea (seb-o-REE-ik) dermatitis - common and mainly on scalp scaly patching, red skin, stubborn dander they cannot get rid of - May affect oily places on the body (face, side of nose, eyebrows, chest, ears, eyelids) *Hyperhidrosis of face and neck (excessive sweating of face and neck) *Heat intolerance *Postural hypotension *Constipation - Complications Autonomic Dysfunction: skin breakdown, dizziness, falls, and impaction Cognitive and Psychological Dysfunction *Dementia - many PD patients will develop dementia due to dopamine not being produced *Memory loss, lack of problem solving, decreased intellect *Anxiety - not sure why all these changes are happening to them *Depression - because they are embarrassed to go out bc of symptoms *Sleep/wake reversal *Visual disturbances *Psychosis - Complications of Cognitive And Psychological Dysfunction: loss of function, loss of social skills, and social isolation

Answer 86

Complications in late stages can be fatal *Pressure ulcers *Pneumonia *Aspiration *Falls (neurologically impacting musculoskeletal system) Parkinsonian Crisis – Major complication *Precipitated by emotional stress or sudden withdrawal of meds - some PD medications can mimic PD symptoms so we need to educate that the meds are decreasing symptoms, but not making them go away) Manifestations *Severe exacerbation of tremors, rigidity, and bradykinesia *Anxiety *Sweating *Tachycardia *Hyperpnea Treatment and interventions *Respiratory/cardiac support prn *Non-stimulating environment *Psychological supports *Restarting medications (make sure they take it at the same time each day)

Answer 87

*Early assessment and symptom management (catch it early) *Surgical procedures o Ablation o Deep brain stimulation o Stem Cell transplantation (experimental) *Drug therapy focuses on mimicking or slowing dopamine breakdown

Answer 88

*Lift toes when walking *Widen legs while walking (wide turns around wall - turn away from wall) *Small steps while looking forward *Tight corner manipulation *Swing arms with walking to improve balance and ROM *Carry bag to counterbalance is necessary *Facial exercises *Read aloud *Speak slowly with purpose and concentrated articulation

Answer 89

*Preservation of functional ability and quality of life *Increased independence and ADLs *Prevent complications and excess disability *Coping mechanisms *Increased socialization (encourage them to go to the dining hall if they are in LTC facility) *Support groups for patient and family *Physical therapy and balance training *Increase strength and ROM *Occupational therapy with adaptive equipment

Answer 90

*Levodopa (Lardopa), carbidopa-levodopa (Sinemet) (produces more dopamine in brain & most commonly given), amantadine (Symmetrel) *Improves manifestations of motor dysfunction *Levodopa converted to dopamine in brain Carbidopa prevents conversion of dopamine in peripheral tissues = Synergistic effect (Arising between two or more agents that produce an effect greater than the individual effect) *Amantadine increases CNS response to dopamine *SEs: N/V/D, arrhythmias, blurred vision, darkening of sweat and urine, dyskinesias, postural hypotension, hallucinations and vivid dreams *Levodopa avoided in those with h/o TIA, angina, melanoma, Narrow Angle glaucoma Client Education *Weeks to months to take effect *Decrease protein intake (high protein decreases action/effectiveness of meds) *Avoid foods with pyridoxine o Pork, beef, avocado, beans, oatmeal *Antiemetics and PPIs/H2RA prn (helps with side effects) *Interventions to decrease postural hypotension *Teach to report increased symptoms and cardiac SEs (sweating or heart feels like it is racing) - adjust meds if needed

Answer 91

*Selegiline (Eldepryl), rasagiline (Azilect) *Inhibits enzymes that inhibit and/or breakdown dopamine *Often used synergistically with Levodopa *SEs: N/V, dizziness, insomnia, postural hypotension, HTN at high doses *Contraindicated with Prozac and Demerol Client Education *Take at same time each day *Report insomnia (may need to switch time of day taking medication) *Interventions to prevent postural hypotension *Skin exams – risk of melanoma (needs to be thorough) *Avoid foods containing Tyramine (decreases effect of medication)

Answer 92

*Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip) (cheaper version) *Mimic effects of dopamine in brain *Often used synergistically with Levodopa *SEs – similar to Levodopa Client Education *Same teaching as Levodopa *Don’t stop abruptly (has to be tapered off if you stop taking) *May cause compulsive behavior (ex: acting out; shopping spree) - Avoid pyridoxine foods (pork, beans, avocado) and foods high in protein

Answer 93

*Tolcapone (Tasmar), entacapone (Comtan) *“The Capones” *Inhibit COMT, which breaks down dopamine *Used synergistically with Levodopa/Sinemet *Monitor LFTs *Interacts with warfarin, so monitor INR closely *Not to be used with MAOBIs Client Education *Take with food *No ETOH or sedatives *Interventions to prevent postural hypotension *Don’t stop abruptly (have to taper off) *Report muscle control changes, jaundice, dark urine, hallucinations (weird dreams or seeing things that aren't there)

Answer 94

*Benztropine (Cogentin), trihexyphenidyl (Artane) *Block the excitatory action of acetylcholine *May be used synergistically with Levodopa/Sinemet *Used early in disease or when Levodopa not tolerated *Help prevent PD symptoms of drooling, tremors, rigidity *Know those anticholinergic SEs ! - Report SE: can't pee, cant see, can't shit, can spit, visual disturbances when lights are low, halo around light, new redness in the eyes, nausea/vomiting with severe eye pain after *Assess for glaucoma S/S and photophobia *Not used with any other meds with anticholinergic effects (antihistamines, TCAs, etc.) - With TCAs (amitriptyline or nortriptyline can not be mixed with these); we do not mix with anything that is going to dry you out Client Education *Avoid activity which promotes fluid loss (saunas, hot worx, excessive exercising) *Don’t stop abruptly

Answer 95

Gastroesophageal reflux disease (GERD) *Older adult symptoms: Persistent cough, Asthma exacerbations, Laryngitis, Intermittent chest pain Goal of therapy is to prevent exacerbation of symptoms *Lifestyle and diet changes *Medication management – PPI’s - esomeprazole or pantoprazole [Protonix] Most serious complication – Aspiration Pneumonia - leave pts in upright position after eating and do not lay them flat while they are eating

Answer 96

*Osteoporosis *Osteoarthritis *Rheumatoid arthritis

Answer 97

Non-modifiable *Female gender *Northern European ancestry *Advanced age *Family history of osteoporosis Modifiable *Low body weight (underweight) *Low calcium intake *Estrogen deficiency *Low testosterone *Inadequate exercise or activity *Use of steroids or anticonvulsants *Excess coffee or alcohol intake *Current cigarette smoking

Answer 98

*For women, fastest overall loss of bone mineral density is 5 to 7 years immediately after menopause - Stature is an indicator of OP due to bone reabsorption (the osteoclasts breakdown in the bone resulting in a shift of calcium from the bones to the blood) - Bone formation = osteoblasts forming bone mass such as osteocytes - highest bone mass = Average age 30 - Imbalance starts at age of 40 - Menopause accelerates OP due low bone mass of osteopenia and decrease of estrogen

Answer 99

*Most serious health consequence of osteoporosis is morbidity and mortality resulting from falls *20-24% of adults with hip fractures die within one year *One in five will require long term care (if they fall and survive) *Only 15% will be able to walk unassisted six months post fracture *Women with osteoporotic fractures have increased incidence of other major complications *Vertebral fractures often not recognized - Silent - they do not know they have a fracture until x-ray, but they keep reporting pain in different areas *Several new treatment options available: kyphoplasty/vertebroplasty

Answer 100

Diagnosis *DEXA scan – dual energy-ray absorptiometry - put feet in machine and it tests bone density - Insurance usually pays for (most commonly used) *T-Score: (not used as often) o Osteopenia – diagnosis -1 to -2.5 o Osteoporosis – diagnosis if greater than -2.5 USPSTF Currently (but under review): (U.S. Preventative Services Task Force (USPSTF) *Recommends screening women 65 and older for OP

Answer 101

*Weight bearing and resistance training *Adequate calcium and vitamin D intake *Education about fall prevention *Pharmacological therapy to prevent bone loss o Bisphosphonates – Teaching!! Upright for 30 min!

Answer 102

- MOA: inhibits osteoclastic activity and bone reabsorption - Poor bioavailability - Bone reuptake = 20-80% - Rapidly excreted via the kidneys - Only given in AM - Given 30 min before first food/drink intake - Only given with water (6-8 oz) - Cannot be crushed or chewed - Hypokalemia is most common SE - SE: hypophosphatemia, abdominal pain, musculoskeletal pain, nausea, vomiting, gas

Answer 103

*Normal soft and resilient cartilaginous lining in joint becomes thin and damaged *Joint space narrows and bones of joint rub together, causing joint destruction (bone on bone = no cartilage) *Diagnosis is made clinically *Most common symptoms are stiffness with activity and pain with activity relieved by rest - They can inject gel into joints to act as cartilage

Answer 104

*Neck – cervical spine *Lower back – lumbar spine *Hips *Hands *Fingers *Thumbs *Knees

Answer 105

Heberden’s node – DIP – Distal Interphalangeal Joint *Only in OA

Answer 106

Bouchard’s node – PIP – Proximal Interphalangeal Joint *In OA and RA

Answer 107

*Goals of therapy are to control pain and minimize disability (control pain so they can get up and move around) Non-pharmacological therapy *Weight loss can help – 1 lb of weight places 4 lb of pressure on knees *Exercise - “Motion is the Lotion” o Strength and flexibility – support the joints o Water exercise *Physical therapy *Hot/Cold therapy – patient preference *Adaptive devices o Cane – Relieves hip pressure by 60% o Shoe lift for back pain o Knee brace for stability

Answer 108

Pharmacological therapy *Acetaminophen – 4 Gram MAX/day *NSAIDs - COX2 (selective NSAID) *Joint injections – Intra-articular o Steroids - Inflammation o Hyaluronic Acid - Lubrication *Acupuncture *Surgical intervention – Knee/Hip o Arthroscopy (used to visualize and diagnose the joint problem) o Total Joint Replacement (can have partial joint replacement)

Answer 109

Chronic, progressive, systemic inflammatory autoimmune disease *Primarily synovial joints *Inflammation destroys surrounding cartilage & eventually bone - they often have a hard time moving and walking so they are in intense therapy Systemic *can affect any organ system i.e. vasculitis, anemia, splenomegaly, pulmonary nodules, pericarditis Focus of research includes *Genetic factors *Environmental triggers in genetically vulnerable population *Hormonal triggers

Answer 110

*Complete physical and laboratory assessment *Pharmacological therapy o Pain management o DMARDs (disease-modifying anti-rheumatic drugs) - methotrexate o Biological response modifier - “-mab” *Exercise and physical therapy *Environmental modifications (living in industrial area and may be breathing in heavy metals - esp females) *Assistive devices

Answer 111

Osteoarthritis *Older adults *May be unilateral - Knee, hip, spine, hand *DIP & PIP *Usually NO MCP *Shorter period of morning stiffness *Pain with activity Rheumatoid *Women > Men *Symmetrical – hands & feet common *MCP & PIP *Usually NO DIP *Prolonged morning stiffness > 30 min *Pain > with inactivity

Answer 112

DIP – distal joint, closest to fingertip PIP – proximal joint, middle joint of fingers.

Answer 113

*Diabetes Mellitus – altered presentation *Hyperthyroid *Hypothyroid

Answer 114

*Disorder of glucose metabolism Type I *Absolute deficiency of insulin production due to autoimmune destruction of pancreatic β cells Type II *Combination of relative insulin deficiency and insulin resistance *Genetics, lifestyle, and aging influence development of diabetes

Answer 115

*Dehydration *Confusion, delirium *Decreased visual acuity *Incontinence *Weight loss & anorexia (polyphagia in younger) *Fatigue, nausea *Delayed wound healing *Paresthesias

Answer 116

- Poor wound healing because they do not have the glucose to support them *Peripheral neuropathy with loss of sensation *Evidence of increased pressure (redness, bony deformity) *Peripheral vascular disease (diminished or absent pedal pulses) *History of ulcers (bedsores indicate poor wound healing) *History of amputation *Severe nail pathology (brittle or lines all through nail bed)

Answer 117

*Screening and early identification of diabetes *Prevent complications (ex: bed sore and wounds) *Assessment of end organ status *Medication management o Oral agents (metformin) o Insulin therapy *Assessment of self-care ability *Nutrition (what they can and cannot have) *Exercise (in moderation) *Close monitoring of residents in long-term care environment (turning patients, cushioned wheelchairs, checking toes and bottom for problems)

Answer 118

- Thyroid = gland in your neck crossing the trachea, just below the larynx with two main lobes that lie on either side of trachea - Thyroid Function: controls metabolic rate, oxygen consumption, and energy production of the body; influences physical and mental growth, neuro system activity, fluid and electrolyte balance, reproduction; requires vitamins and is the resistance of infection; metabolizes fat/protein/carbs in body; controls secretions of the body; controlling by stimulating the suppression of mechanical hypothalamus, pituitary, and thyroid gland

Answer 119

T3 and T4 are called the “thyroid hormones”. Abnormalities of these lead to hyper and hypothyroidism Thyrocalcitonin (calcitonin) *Decreases calcium loss from bone *Balances Parathyroid hormone (PTH) Tetraiodothyronine or Thyroxine (T4) *Produced by follicular cells if thyroid gland *T4 converted to T3 in peripheral tissues - More prevalent in the blood Triiodothyronine (T3) *4-5 times stronger than T4 - T3 is more potent - more rapid metabolic action and is present in the blood in very small amounts - Longer half life Thyroid Stimulating Hormone (TSH) *Produced by pituitary gland Thyrotropin Releasing hormone (TRH) *Produced by hypothalamus

Answer 120

Thyrotropin-releasing hormone stimulation test (TRH) o TRH injected and TSH measured to assess thyroid function Radioactive Iodine uptake (RAI) o Direct test of thyroid function o Radioactive iodine absorbed by thyroid and thyroid can be visualized assessing for nodules Thyroid scan o Similar to RAI, but iodine not used. Radioactive isotopes given orally and taken up by thyroid and visualized on scan (Make sure the patient or you are not pregnant) *T3 and T4 lab values *Hormones, steroids, ASA, foods containing iodine should be avoided for 7 days before testing. (salt needs to be non-iodine)

Answer 121

-intolerance to heat -fine, straight hair -bulging eyes -facial flushing -enlarged thyroid -tachycardia -increased systolic BP -breast enlargement -weight loss -muscle wasting -localized edema -menstrual changes (amenorrhea) -increased diarrhea -tremors -finger clubbing

Answer 122

*Most severe form thyrotoxicosis Causes o Autoimmune disorder (Grave’s disease) *most common o Multinodular goiter (Toxic goiter) o Women affected more often, 5-7:1

Answer 123

*Graves disease most common form in older adults *Also caused by toxic goiter (appears as swollen neck), iodine ingestion or iodine-containing foods, contrast agents, & medications *Onset often abrupt (can occur overnight) - often have to remove thyroid when pts wait too long to come in *Thyroxine increases myocardial oxygen consumption o Increases risk for Afib and angina in person with CHD o Can cause heart failure o Most common complication – AFIB – 27% of older adults with hyperthyroidism

Answer 124

Many symptoms non-specific in older adults *Unexplained Afib *Heart failure *Constipation *Anorexia *Muscle weakness Older Adults often present with *Tachycardia *Tremors *Weight loss *Apathetic Thyrotoxicosis – slowed movement and depressed affect

Answer 125

Anti-thyroid agents – blocks thyroid hormone production o Methimazole (Tapazole), Propylthiouracil (PTU) - SE: Rash, hypothyroidism, neuropathic problems, drowsiness Methimazole - Assess thyroid function tests closely and monitor INR if on warfarin (can lower INR if taken with warfarin) - Report swelling of lymph nodes - Give at same time every day with food PTU - Can cause lupus-like symptoms - Assess thyroid function tests - Do not give with potassium ionizing drugs bc it will affect absorption

Answer 126

Iodides – inhibit thyroid hormone secretion o Saturated solution of potassium iodide (SSKI) - Increase vascular of thyroid gland - Given during thyroid storm or for a short period of time* - SE: nausea, vomiting, confusion, hypothyroidism, diarrhea, abdominal pain, weakness, acne - Given with full glass of water or juice (NOT milk) - Use straw to avoid teeth staining (dark color liquid medication) - Report any GI disturbances - Avoid foods high in iodine - Increase regular fluid intake

Answer 127

Beta Blockers – manage tachycardia, anxiety, & tremors

Answer 128

Radioactive Iodine (RAI) – shrinks thyroid gland o Most common for Graves disease o Can be used alone or prior to surgery o Absorbed by thyroid and radiation destroys tissue o Teach radiation precautions

Answer 129

*Surgical removal of part or all of thyroid *Reserved for severe case or large goiters *Review Pre-op & Post-op care - PRE-OP Care: Give all antithyroid medication; give potassium iodine solution 10 days before to decrease thyroid hormone production; reduce anxiety and risk for thyroid storm - POST-OP Care: HOB = semi-fowler (priority - we do not want blood pooling in throat and have to sit up to check dressing), check dressing (especially on the back of neck for pooling of blood), assess respiratory status and airway edema, trach tray/suction/oxygen at bedside at all time, rest voice to avoid nerve injury, look for hypocalcemia for damage or removal of parathyroid gland = (trousseau = BP cuff bp blown up and watch for 3 minutes for abduction/twitching of fingers and chvostek’s sign = facial twitching due to nerve damage or low calcium)

Answer 130

*Life-threatening (we cannot do anything about it if it gets too late) *Exaggeration of hyperthyroid symptoms *Treatment: Cool with ice, ↓ levels of TH, replace fluids & electrolytes, give O2 (usually on a face mask), stabilize cardiac function. Avoid ASA (aspirin) (increases TH) - Cooling blanket or ice pack under armpits, groin, around feet to cool them off

Answer 131

*Women affected more often 5:1 *Ages 30-60 *Slow onset *Causes: Primary & Secondary *S/S: Think SLOW Metabolic - Thyroid fails to produce adequate TH and remains low (low T3 & T4) and TSH remains elevated - Hypothalamus and pituitary gland creates and release TSH - S/S: Thyroid gland may become hypertrophic (may need to be removed), can have genetic or congenital effects - Causes: Tx for hyperthyroidism can cause hypothyroidism (why we monitor levels closely); Iodine deficiency can cause hypothyroidism and a decrease of TH production - medications: Amiodarone and anabolic steroids, lithium, beta blockers Secondary Hypothyroidism - The pituitary TSH is deficient or peripheral resistance to the thyroid hormone (have to give medications to raise it)

Answer 132

-Hair loss -Apathy -Lethargy -Dry skin (coarse and scaly) -Muscle aches and weakness -Constipation -Intolerance to cold -Receding hairline -Facial and eyelid edema -Dull-blank expression -Extreme fatigue -Thick tongue -Slow speech -Anorexia -Brittle hair and nails -Menstrual disturbances Late Changes -Subnormal temp -Bradycardia -Weight Gain -Decreased LOC -Thickened Skin -Cardiac Complications

Answer 133

*Most frequent cause chronic autoimmune thyroiditis *Also radioiodine treatment, surgery, medications (Amiodarone), pituitary/hypothalamic abnormality Vague S/S – often subtle *Slowed mentation *Gait disturbances *Fatigue *Weakness *Cold intolerance

Answer 134

Diagnosis *TSH, T3, T4, FT4` *PE and hx; Cardiac studies to assess for complications Treatment *Thyroid replacement therapy *Review: Levothyroxine (Synthroid) Nursing Care *Prevent: chilling (getting too cold), constipation (hydrate, stool softener, high fiber diet, lower dose of sedatives and opioids), skin breakdown, infection *Assess: cardiac complications (and report), edema, tachycardia (and report even if it goes up to 105-110), skin (increase turning to prevent) — report subtle changes!! *Lifelong levothyroxine therapy (given on empty stomach — one hour before first meal or 3 hours after; often given early in the morning and given as your last thing on night shift) *Warning: levothyroxine can cause digoxin toxicity

Answer 135

*Rare & Life-threatening complication with HIGH mortality rate Causes *Untreated or uncontrolled hypothyroidism *External stressors including surgery, trauma, infection, excessive exposure to cold temps Manifestations *Hypothermia, Mental function ranges from depression to unconscious, Respiratory depression (hypoventilation), hypotension, Bradycardia Treatment *Supportive measures and stabilization of vitals *Treat underlying cause *Thyroid hormone replacement – must be slow r/t toxicity with rapid replacement

Answer 136

Most common non-skin cancer in men *1 in 5 (black) & 1 in 6 (white) chance of developing *Usually detected by screening Manifestations *General urinary complaints, retention, hematuria, back pain *Cachexia, bone tenderness, lower lymphedema, adenopathy Screening when asymptomatic should be individualized based on personal and family history *Uncertainties, Risks, Benefits Screening methods *Digital Rectal Exam (many men avoid screening due to digital exam) - most common exam *Prostate-Specific Antigen (PSA) - Can be curable if caught early enough; all men need, especially those with family hx of PC

Answer 137

American Cancer Society *50 y/o for men at average risk who have at least a 10-year life expectancy *40 or 45 y/o for African Americans and men who have had a first-degree relative diagnosed with prostate cancer before age 65 *40 y/o for men with several first-degree relatives who had prostate cancer at an early age USPSTF *Men aged 55 to 69 years *Recommends against PSA screening in men aged 70 and older (need to have digital rectal exam instead)

Answer 138

PSA *No PSA level guarantees the absence of prostate cancer. *The risk of disease increases as the PSA level increases, from about 8% with PSA levels of ≤1.0 ng/mL to about 25% with PSA levels of 4-10 ng/mL and over 50% for levels over 10 ng/mL Digital Rectal Exam (DRE) *Examiner-dependent; serial examinations over time are best *Most patients diagnosed with prostate cancer have normal DRE results but abnormal PSA readings Biopsy *Biopsy establishes the diagnosis *False-negative results often occur, so multiple biopsies may be needed before prostate cancer is detected

Answer 139

*Active surveillance *Watchful waiting *Radical prostatectomy (surgical removal) - will come home with a foley so you need to teach them foley care — how to clean *Radiation therapy (if the whole prostate is not removed) *Hormone therapy (if the whole prostate is not removed)

Answer 140

A. Crackles over lower lung fields B. 3+ edema in both feet C. S3 gallop in cardiac sounds

Answer 141

Prozac (Fluoxetine)

Answer 142

Elderly woman during winter

Answer 143

“I should call the doctor for nervousness or an increased pulse.”

Answer 144

*Acquiring *Storing *Sharing *Using information

Answer 145

*Language - how they hear the language being spoken, how they understand that part of the language *Thought - how they process, how they create in the brain, how they express, are they understanding what you are saying *Memory - what they store and are remembering (remember long term better than short); they will remember what happened before they will remember what you said; they remember day and time, but not what you said to them *Executive function o Organization – gather info - they might have issues/cognitive dysfunction and not even notice bc their brain is misfiring; we have to start asking questions and letting pts know about any cognitive dysfunction o Regulation – evaluate & change behavior *Judgment - they make rash decisions (do not know right from wrong or good vs bad - see all as the same) *Attention - short attention span and do not want to listen; keep them focused; make sure they are paying attention and understand the information you are giving them; cue them in *Perception - ask them questions and make sure they are understanding what you are saying

Answer 146

When we use these cognition components in combination with the different actions the output results are usually dealing with… *Orientation - will see in body language that they do not know what is going on *Problem solving - might have to set up mind mapping to make them understand *Psychomotor ability - make sure we are watching for rational decision making (they can be rash) *Reaction time *Social intactness - watch how they socialize; question why if they decrease social interaction

Answer 147

*Neuron loss – most pronounced in cerebral cortex *Brain atrophy – decreased weight *Dendrites atrophy o Impaired synapses o Changed transmission of dopamine, serotonin & acetylcholine *However – NOT consistent with deteriorating mental function *SLOWING is NORMAL *IMPAIRMENT is NOT NORMAL

Answer 148

Three components: *Immediate recall - they should be able to repeat it back immediately after *Short term memory - a few days to a few weeks ago *Remote or long-term memory - years ago (middle-age or childhood age) Memory retrieval *Recall of newly encountered information decreases with age (ex: changing environment from home to nursing home can impact them remembering things from the past; be patient and allow them to adjust) *Memory declines noted for complex tasks and strategies - due to slow decline and improper neuron firing

Answer 149

Learning in Late Life *Basic intelligence remains unchanged with increasing years - processing may speed up, but recall may decline; we have to adjust to their changes, not them to us (we need to not have abrupt changes, need a smooth systematic way to introduce change) Cognitive Assessment *True evaluation of cognition requires formal focused assessment - includes one or more assessment tools (ex: CAM); make sure the pt is stable before doing IGACs because certain questions might trigger them (ease into it and tell them you might be asking sensitive questions, explain to them what you are doing ex: do not say just “when was the last time you thought about killing yourself” — ease into it); Explain to caregivers what you are doing *Complete assessment, including laboratory workup, should be performed to rule out any medical causes of cognitive impairment

Answer 150

*Nearly 20% over 55 y/o experience mental health disorders that are not part of normal aging *Underreported and not well researched o Racially and culturally diverse (and general avoidance of seeking answers or help; they need to get help - does not mean meds, might mean just talking with someone) *Common mental disorders in late life are: o Depression & anxiety o Mood disorders o Alcohol abuse and dependence *Can be affected by cognitive and affective functioning earlier in life - Educate pts on the emotions they may be feeling; assure them that conversation is confidential (ask caregiver to leave bedside so pts can be more open ex: divert by asking “can you please step out while we clean them up?”)

Answer 151

Assessment *Risk factors of life transition, loss, and loss of social support - once they lose a loved one/spouse you will see a decline → broken heart syndrome where they die not too long after (find a support group for widows if needed) *History of ability to cope with stress and life events *Assessment of cognitive function and/or impairment *Assessment of substance abuse and suicide risk Interventions *Enhancing characteristics of hardiness, resilience, and resourcefulness *Enhancing functional status and independence *Promoting sense of control *Fostering social supports and relationships *Education regarding available resources

Answer 152

Attitudes and Beliefs *Stigma - talk to pts before you label anything (anxiety/depressed label) *Myth that it is normal Availability and Adequacy of Mental Health Care *Access *Ability to pay - gero age can have medicare and medicaid, but are unaware of what their insurance covers Cultural and Ethnic Disparities *Poverty *Language - use language line to translate if needed *Cultural understanding - some cultures do not want to seek help

Answer 153

*Not part of the normal aging process *Life events and stressors may contribute to development of anxiety disorders - being the matriarch/patriarch of the family who have to cook or work etc (increases stress and anxiety) Associated with: *Excessive healthcare use - overwhelmed with all their current health issues *Decreased physical activity and functional status *Substance abuse - may misuse regular prescribed medications or OTC meds; can see pts hospital/doctor hopping (educate on misuse of medications and EtOH) EtOH and caffeine with some meds can increase anxiety level *Decreased life satisfaction *Increased mortality rates

Answer 154

Therapeutic relationship between patient and health care provider is the foundation for any intervention. Assessment *Difficult to diagnose in older adults *Denial - nothing is wrong or their fault *Coexisting medical conditions can mimic anxiety *Common side effect of certain drugs - may need to take at night and educate them - Caffeine, nicotine, hypnotics, antihistamines, anticholinergics, beta-blockers, OTC cold/cough medicine, steroids, acetylcholine, antihypertensive, withdrawal from drugs and alcohol, and digoxin can all exacerbate anxiety *Drug and alcohol withdrawal also cause anxiety symptoms *Generalized Anxiety Disorder (GAD-7) Interventions *Treatment choices depend on symptoms, specific anxiety diagnosis, comorbid medical conditions, and current medications Pharmacological *Antidepressants—SSRI’s (selective serotonin uptake inhibitors) first line of treatment - Lexapro, Celexa, Zolaf, Prozac, Paxil (first line) *Short acting benzodiazepines - Ativan or xanax (should be used as short term treatment <3 months) *Non-benzodiazepine anxiolytic agents - Buspar (takes longer to therapeutically work = weeks-month); should be taken daily not be PRN; can take more long-term compared to benzos Non-pharmacological Interventions *Cognitive behavioral therapy (CBT) *Meditation *Yoga

Answer 155

*Not a normal part of aging *Most common mental health problem of late life - bc of all they have been through in life and friends are passing away (baby boomer who have experienced all the setbacks in the world) *1 in 10 older adults visiting a physician suffers from depression *Depression and illness are like to co-occur *R/T medical conditions and med side effect - ex: mood stabilizers; may be better to take at night if it is a daily med that causes depression

Answer 156

*Major source of morbidity in older adults Associated with… *Increased disability *Delayed recovery from illness and surgery *Excessive use of health services *Cognitive impairment *Decreased quality of life *Increased suicide and non-suicide related death Etiology - Multifactorial *Health and chronic conditions *Gender - more often in men than females — bc they are closed off from others and have cognitive decline; women are more likely to not know how to pay the bills so lights/water turned off when living alone *Developmental needs *Socioeconomics *Environment *Personality *Losses *Functional decline

Answer 157

*Comorbid medical conditions strongly related to depression in older people - DM/HTN or chronic conditions that are regulated by food (require specialized diet) that they are unable to afford *More somatic complaints – physical symptoms *Hypochondriasis – Constant complaining & criticism *Decreased energy and difficulties completing ADL’s *Social withdrawal *Decreased libido *Preoccupation with death *Memory problems *Strong association of depression with dementia

Answer 158

Assessment *Depression screening scale, H&P (history & physical), functional and cognitive assessment, medication review, laboratory analysis, comorbid conditions *GDS short form (geriatric depression scale) Interventions *Treatment should begin promptly - yoga, reading, meditation *Combination of pharmacologic therapy and psychotherapy and counseling - BEST Medications for depression *SSRI’s *Tailored to specific patient needs *Trials of alternate medications and psychotherapy required in many patients *ECT therapy (electrodes on pts brain to shock in different parts of the brain); pts are under anesthesia to not feel shocks; not guaranteed to work; used for major depression and bipolar disorder; can be used in conjunction with other treatments o Safe therapy for older patients at risk for harm due to suicidal ideation, psychotic depression, or severe malnutrition o Efficacy rates ranging from 60%–80%

Answer 159

*Older adults account for 13% of population but 20% of suicide deaths *Higher than any other age group *Older widowers most vulnerable *Men have HIGHER suicide rates *Up to 75% of older adults who die from suicide visited physician within one month of death o Depression screening important for all older adults - ask probing questions (how do you feel? Do you have thoughts of hurting yourself? Do you have a plan? What is your plan?) o Recognition of warning signs and risk factors for suicide - changes in appearance from pt’s normal (subtle changes)

Answer 160

Assessment *ANY reference to ending life must be taken seriously *Establish trusting and respectful relationship *Behavioral cues – goodbyes, giving away possessions Interventions *If suicide risk suspected, ask direct questions - use open and close ended questions; do not feel bad about asking questions, we need to for them to be safe; there are subtle changes we need to recognize; get social work/case workers involved if needed - We ask these questions 2-3x while they are in the hospital o Have you ever thought about killing yourself? o How often have you had these thoughts? o Do you have a plan to carry it out/How would you do it? - ask follow up questions as needed *High risk patients need to be hospitalized *Moderate and low risk treated as outpatients o Adequate social support o No access to lethal means

Answer 161

Alcohol *Often a coping mechanism in old age to deal with loss, anxiety, depression, chronic illness *Most severe abuse seen in ages 60-80 Gender issues *Late onset alcohol abuse associated with illness, retirement, loss of spouse *White men 4 times more likely to abuse alcohol *Number and impact of older female drinkers expected to increase Drug effects *Prescription and OTC medications have many adverse effects when combined with alcohol - Can decrease effect or increase effect of meds - Mixing meds at home - taking them all at once when they have forgotten for a few days (misuse) Physiology *Age related changes in water and body fat cause higher blood alcohol levels *Liver and kidney function interferes with alcohol metabolism and excretion *Increased risk of gastrointestinal bleeding (and other GI issues)

Answer 162

Assessment *Screening for alcohol and drug use *Comorbid conditions may mask decline caused by alcohol Interventions *Must address quality of life and adapted to meet needs of older adult *Treatment focuses on cognitive and behavioral approaches *Screening for alcohol and drug abuse *Education and counseling about alcohol and prescription, OTC, and illicit drug use *Referral to specialists and community resources - there are faith based groups; social workers/case workers can help you Acute alcohol withdrawal *Life threatening emergency *Detoxification should be done in inpatient setting - it should not be at home or outpatient so we can monitor more closely (need to balance normal meds with what they are detoxing from) - You cannot take them abruptly off alcohol/drugs so we may give them alcohol in the hospital to slowly wean them off (ex: a can of beer a day) Substance abuse concerns *Misuse of prescription and OTC medications *Polypharmacy effects exacerbated with alcohol use *Inappropriate prescribing and ineffective monitoring of controlled substances - going to different doctors for pain meds and not knowing they cannot add them together

Answer 163

Delirium - Onset: Sudden - Hrs to Days - Memory: Impaired - Variable - Duration: Hours - Days - Reversible: Yes - Usually - Psychomotor Activity: Usually - Hyper OR Hypo - Perceptual Disturbances: Yes - Speech: Incoherent/confused Dementia - Onset: Slowly developing - Years - Memory: Memory loss - esp. new events - Duration: Years - Reversible: No - progressive - Psychomotor Activity: Not until later in dx - Perceptual Disturbances: Not until later in dx - Speech: Early - word searching, Late - Mute (blank stare bc they are trying to process)

Answer 164

*May affect up to 42% of hospitalized adults and 87% of older adults in intensive care units - out of their normal/taking new meds - Some meds can cause delirium, but can be reversed once the body gets used to meds or you lower the dose/change the meds *Associated with ↑ length of stay, ↑ use of healthcare services post discharge, and morbidity, mortality, and institutionalization, independent of age and comorbid illnesses *Significant distress for patient and family - educate family *Medical emergency o Cognitive changes in older people often labeled as confusion by nurses and physicians; frequently accepted as part of normal aging - try to not change nurses every shift to decrease confusion (keep the same people caring for them to decrease confusion) o Delay in treatment contributes to negative outcomes with delirium

Answer 165

*Acute Illness *Infections *Medications *Invasive Equipment *Metabolic disturbances *Dehydration *Alcohol or Drug Abuse *Sensory Impairments *Unrelieved Pain *Surgery *Hip Fracture *Cognitive Impairment

Answer 166

Assessment *Confusion Assessment Method (CAM & CAM-ICU) o Documentation should focus on specific indicators of altered mental status rather than “confused” *Will lead to more appropriate prevention, detection, and treatment to prevent negative outcomes Interventions *Prevention *Managing risk factors *HELP program o Deliberate interventions to prevent delirium *Pharmacological treatment- Careful!!! (monitor for delirium and explain to pt that this might happen at first, but will decrease as pts body adjusts to meds — educate pt on this) *Communication - Speak slowly, clearly, and on their eye level

Answer 167

*Irreversible state that progresses over years in decline *Clinical features of syndrome of dementia include at least one of the following: (all include loss of something) o Aphasia – partial or total loss of the ability to articulate ideas or comprehend spoken or written language o Apraxia – partial or total loss of the ability to perform coordinated movements or manipulate objects in the absence of motor or sensory impairment o Agnosia – loss of the ability to interpret sensory stimuli, such as sounds or images o Disturbances in executive functioning – Attention (short), decision making (poor judgment and family will have to help you make decisions), consciousness, memory, problem solving

Answer 168

Degenerative dementias *Alzheimer’s disease (AD) – 50-70% of all dementias *Parkinson dementia (PDD) *Dementia with Lewy bodies *Frontotemporal lobe dementia Vascular cognitive impairment *Vascular dementia *Mixed primary neurodegenerative disease and vascular dementia Other dementias *Creutzfeldt-Jakob disease *HIV-related dementia

Answer 169

- 2nd most common type of progressive dementia after AD - protein deposits lewy bodies in the brain that develop in CNS in the region that impacts movement (no motor control), thinking, and memory

Answer 170

Degenerative disorder caused by progressive nerve cell loss in temporal (behind ear) and frontal lobe (area behind forehead)

Answer 171

impacts the vascular system

Answer 172

- occurs spontaneously - inherited or transmitted through the contact of infected tissues ex: during transplant or eating contaminated meat - causes personality changes, anxiety, depression, memory loss within the first few months - many lapse into coma - no effective treatment exists so the focus is to alleviate pain and relieve symptoms

Answer 173

- brain disorder that slowly destroys thinking and memory skill and eventually unable to do simple tasks *Development of neurofibrillary tangles in brain consisting of protein tau and extracellular deposits of amyloid-β peptides o Loss of connections between nerve cells and death of these nerve cells - memory loss, dementia, and progressive failing of the brain function o Research is ongoing to determine cause *Most common form of dementia *Sixth leading cause of death and third most expensive medical condition (80% of those with dementia are diagnosed with AD)

Answer 174

- Synapse stops firing and the nerve cells die out - Conglomeration of beta amyloid protein = amyloid plaque on the brain = oligomers - Beta oligomers can flow into synapse and short-circuit nerves and cause memory problems; as they build = plaque is created - Beta-amyloid is a normal thing in the body, but AD is an imbalance of production and breakdown - WBCs work to break down Beta-amyloid accumulation, but not fast enough naturally - Nasal spray vaccine to reduce beta-amyloid has been successful in mice

Answer 175

Two types *Early onset (between ages 30-60) o Affects about 5% of persons with AD o Results from genetic mutations of three genes o Genetic testing available for at risk individuals *Late onset (after age 60) o Does not run in families o Probable combination of lifestyle, environmental factors, and genetic mutation

Answer 176

Diagnosis—New guidelines issued in 2011 *Preclinical o Early cognitive decline before overt symptoms are present 5-20 yrs - Changes in brain are starting to happen and there are no significant clinical symptoms - CNF fluid through lumbar puncture (lay pt flat for hrs after and monitor for residual h/a and may need a blood patch) or PET scan can see amyloid plaque *Mild Cognitive Impairment - Mild cognitive changes: difficulty managing money issues, increased forgetfulness (appointments and social engagements), lost train of thought, decision making process becomes overwhelming, trouble finding their way around previously familiar places, impulsive behavior, depression, irritability, aggression, anxiety, loss of empathy o Amnestic MCI o Multiple domain MCI o Single non-memory MCI o Approximately 12% of persons over age 70 have MCI and are 3-4 times more likely to develop AD *Alzheimer’s Dementia—most advanced stage o Multiple deficits present - severe memory loss, cannot find words they want to use, visual/spatial issues (do not understand personal space), impaired reasoning and judgment, need full time assistance with ADLs (unable to function on their own) - may need aide or at home nurse, loss of awareness of experience and surroundings, cannot eat/swallow properly, very vulnerable to infections (pneumonia) - not cleaning hands properly etc., safety is key with these pts, changes in physical ability (cannot walk, do not know how to sit down), decreased ability to communicate Educate family that they need 24 hour care (at home or in a facility) at this stage — Safety is the priority!

Answer 177

*Regular monitoring of disease progression and response to therapy *Caregivers also need ongoing education about the disease as well as assessment of own coping mechanisms and self-care behaviors Pharmacological treatment *Cholinesterase inhibitors (CI) - block normal breakdown of acetylcholine by blocking enzyme cholinesterase which is responsible for breaking down acetylcholine in synapses - aerosil (most commonly given for AD) = slows progression *Directed toward symptom management *Does not affect neuronal decline - slows progression, not a cure Important to assess and treat for depression *If present will cause excess disability

Answer 178

Person-centered care *How to enhance well-being and quality of life *Treating the person, not the disease - listen to the pt *Establish connections and sense of security *Special skills and attitudes necessary to nurse the person with dementia *Maintain function and prevent excess disability o PLST (Progressively Lowered Stress Threshold) model *Care is structured to decrease stressors and provide a safe and predictable environment - try to keep the staff the same as much as possible (introduce new staff slowly) o NDDH (Need-Driven Dementia-Compromised Behavior) model *Care is structured to enhance understanding of behavior as expression of need Usually a locked unit; avoid abrupt changes *Care is optimized by manipulating factors that precipitate behavior - ex: do not sit pts together at meals who do not like each other

Answer 179

Assessment *View all behavior as meaningful and expression of needs o Focus on reasons for Behavioral & Psychological Symptoms of Dementia *Remember: You must enter the patient’s reality and not attempt to reorient them to actual reality. They cannot be reoriented due to the deterioration within the brain. - you can trigger more problems bringing them to reality

Answer 180

*Assessment of reversible causes of behavior Non-Pharmacological treatment *Environmental modifications *Light therapy - a light box that is directed at the pt; light is 30x more bright than the lights in the room; done at the same time each day for the same amount of time to help them with knowing day from night (helps with sleep disorder); many pts with sundowners leading into dementia get this type of therapy *Sensory Stimulation - folding things, making bracelets, or little activities for them to use their hands and feel useful and like they are accomplishing something throughout the day *Validation therapy - enter their reality and develop a sense of trust and reduce anxiety (builds trust and a sense of security to reduce their anxiety *Animal-assisted therapy *Activity and exercise *Distraction *Reminiscence activities *Social contact

Answer 181

*Address Safety - Priority! *Structure daily living to maximize abilities - we only change if they want to change *Monitor general health *Support advance care planning and directives *Educate and support caregivers

Answer 182

Pharmacological treatment *If patient is danger to self or others *Non-pharmacological interventions not effective then use pharmacological *Risk/benefit of medication has been considered Providing Care for ADL’s - Give them a washcloth and let them help bathe even if they are not helpful and promote/encourage them *Perceptual disturbances and misinterpretation of reality can cause much distress for patient and caregiver during this time *Can be perceived as an attack by a stranger - introduce new people slowly *See the world from the patient’s perspective *Alternative bathing methods as tolerated

Answer 183

Pts more alert and can be more engaged/less depressed

Answer 184

Wandering *Difficult problem to manage *May be a soothing mechanism *Not well understood o Risk: Falls, elopement, injury, and death Things to do - Put car keys away, keep the house locked (do not lock them in their bedroom or in a confined area) *Music, exercise, refreshments, social interaction *Camouflage doorways, enclosed areas for walking, electronic bracelets, *60% will wander and become lost at some point…

Answer 185

*Almost 2/3 of unpaid caregivers for Americans with AD are women *70% with dementia live at home (make sure the home is safe and educate caregivers - Everything needs to be on the pts level so they do not climb on top of things or drop things on their heads Caregivers: *Lower self-related health scores *Fewer health-promoting behaviors *Higher rates of depression and anxiety *Higher morbidity and mortality *Sleep disturbances *Higher number of illness-related symptoms Review caregiver role strain issues - give time to caregivers to avoid role strain (sleep disturbances) because they are often still working - may be already going through a grieving process bc their parents are not mentally there - use same sitters if possible (home health nurses)

Answer 186

*Grief over multiple losses that occur *Physical demands and duration of caregiving *Exacerbated when care recipient demonstrates behavioral issues and impairments in ADL’s *Resource availability

Answer 187

Magician *See the world through their eyes *Use tricks to augment behavior Detective *Investigate clues r/t behaviors Carpenter *Tools to individualize care - help them build things/arts and crafts to bring them to reality and let them use their hands Jester *Use humor *Spread joy *Relationships

Answer 188

*Focus on communication, behavior, and relationships - with pt and caregivers *Individuals are aware of their diagnosis and need support to share their feelings and needs *Caregivers need support to deal with changing role, changing couple relationships, anger, frustration, uncertainty about the future, burden, and depression

Gero Exam 2 Flashcards

(214 cards)