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Care 4: Health Promotion for the Older Adult 2

Terms in this set (222)

age range for the "young old"
60-74 years old
age range for the "old"
75-84 years old
age range for the "old old"
85-100 years old
How old much someone be to be considered a "centenarian"?
older than 100 years old
common fears of the older adult
-losing health, ability to care for oneself
-running out of money
-not being able to drive (losing independence)
-being a burden to the family
-going to nursing home to die
leading causes of death in the US in the 1900
pneumonia, diptheria, influenza & tuberculosis were the leading causes of death
male's average life expectancy (2010)
81 yrs/males
female's average life expectancy (2010)
85 yrs/ females
leading cause of death today
Leading causes of death are heart disease, cancer, COPD, stroke, influenza, diabetes, Alzheimer's
characteristics of American population over 65 years old
-Currently 13.7% of population is over 65 years
-American's >65 years constitute the largest # of cognitively impaired individuals - also some of the most well off financially
-Half of all the people who have EVER reached the age of 65 are alive today
-70,000 people are over 100 years of age
-36% of health care $ go for the older adult, 47% of hospital days
-First baby boomers have started collecting social security
-Marriage & economic well-being impact longevity
-4.5% live below poverty level. Men $31,000, women $17,000
-Out of pocket medical expenses increased
population-based trends in the elderly
-Most elderly adults live in the community
-Florida, West Virginia, PA, IA, ND-highest # of older adults
-90% - at least one chronic health problem - 60% >1
-One in three - obese
-One in four - diabetes
-One in two - arthritis
-Persons over 85 often use as many as 12 different medications (the old-old)
-Aging does not always lead to disease or disability
-Ageism - profound prejudice against older adults - thing of the past in most places
What activities can lead to a longer lifespan?
activity
keeping healthy
purpose
positive attitude
concept of frailty in older adults
a dynamic syndrome of decreased musculoskeletal strength, unintentional weight loss, ADL impairment, increased risk for falls, and decreased physical endurance that makes the individual vulnerable to disease, disability & death
geriatric syndromes
common health conditions in older adults unrelated to a specific pathology - delirium, falls, incontinence, pressure ulcers, functional decline
healthy people 2020 goals
-increased older adults using prevention services
-increased physical activity
-increased proportion of HCS with geriatric certification
-increased services for caregivers
-decreased rate of pressure ulcers in hospital
-decreased rate of ED visit due to falls
-increased available information on characteristics of victims and perpetrators in cases of elder abuse, neglect & exploitation
What makes people grow old?
biologic theories of aging
-damage from free radicals
-wear and tear
-programmed aging
-stress
-auto-immune
damage from free radicals (biologic theory of aging)
-Damage to cells accumulates over time from oxygen metabolism
-Maybe a drug to slow metabolism would help
wear and tear (biologic theory of aging)
damage accumulates - failure of body's repair system
programmed aging (biologic theory of aging)
-biologic clock controls cell life span, neuro-chemical or immune or genetic control on # of cell divisions possible
stress (biological theory of aging)
genetic factors influencing the severity of the sympathetic response; catecholamines & cortisol released
auto-immune (biological theory of aging)
body attempts to destroy normal cells (can't distinguish from foreign cells)
psychosocial theories of aging
1. disengagement
2. activity theory
3. self-fulfilling theory/continuity theory
disengagement theory
the older adult and society withdraw from each other in a mutually sought and satisfying separation
activity theory
connection between activity and life satisfaction
self-fulfilling theory/ continuity theory
coping skills and goal achievement determine if they will successfully cope with later years
Erikson's task for older adult
ego integrity vs. despair
Is every older adult in Erikson's designated stage for their age?
not all elderly are going to be in that phase at that time; stroke patient may have cognitive impairments that puts him or her back at lower level (trust vs. mistrust)
Erikson's tasks for integrity
-Adjusting to declining health and physical strength
-Living on a fixed retirement income
-Adjusting to death of spouse, friends, self
-Making appropriate living arrangements
-Redefining one's relationship with children
-Accepting self as an aging person
-Finding ways to maintain a quality life
-Accepting life as lived
-Accepting aloneness
Erikson's tasks for despair
-Dissatisfied with life as lived
-Feeling frightened of what is to come
-Hopelessness
-Irritability
-Depression
Maslow's theory
-Must meet lower level needs before a person can meet the higher level.
+Physiological needs/Self preservation
+Safety and security/Self protection/identity
+Love and belonging/ Concern for family and friends
+Self-esteem/influencing events
+Self-actualization/ Philosophical & Historic Concerns, leaving a legacy (family traditions)
theory behind social security act (1935)
workers "pay it forward" anticipating they will reap the benefits when retired
When was the social security act developed? For what purpose?
Established in the depths of the Great Depression to provide benefits to elderly needy persons & prevent destitution and dependency in older age
What is dependent for a solid social security system?
payroll taxes collected from employers are immediately distributed to retirees; a burden is placed on future generations of workers & retirees because the fiscal integrity of the fund is in jeopardy. Benefits based on earnings while in the workplace.
What population does Medicare serve?
Medicare is the largest single payer for health care in the U.S. - covers everyone > 65 years that is eligible; federally funded program
characteristics of Medicare A
-hospital insurance, inpatient care, hospice, SNF, limited home health care - no monthly premium 80%/20% co-payment
characteristics of Medicare B
optional medical - Primary Care Provider visits, outpt care, PT & OT, premium approx. $115/month
characteristics of Medicare C
supplemental, covers deductibles & co-payments, premium approx. $174/month
characteristics of Medicare D
Pharmaceuticals - prescription drug plan; premium
What population does Medicaid serve?
jointly funded by federal & state govts using tax dollars; low income, needy persons; often used for NH costs after personal funds have been depleted
current state of Medicaid program
With recent health reform plan, number of enrollees increased due to federal mandate - states struggling to meet the demand
purpose of the Older Americans Act (1965)
makes sure services available for elderly
What are a few of the services available to older adults through the Older Americans Act (1965)?
-deliver community-based services to help keep elders in their homes
+senior centers
+senior employment
+volunteer programs
+nutrition programs
+health education/health promotion activities
+transportation services
+in-home care
+in-home services
+handy-man, mowing
+caregiver support
purpose of the National Institute on Aging
branch of NIH (some research began in 1994) that supports and conducts high-quality research on:
+Aging processes
+Age-related diseases
+Special problems and needs of the aged
What sort of information does the National Institute on Aging provide?
healthy aging, care giving, medications, dietary supplements, and diseases. Resources are available in both English and Spanish. Copies also are provided in PDF format where applicable. Print versions are available for online ordering.
Americans with Disabilities Act (1990)
-Law that prohibits discrimination based on disability
+Employment
+Reasonable Accommodations
+Designated parking areas
+New construction compliant - wheelchair access, restrooms, doorways, etc.
+Telecommunication (deaf, hard of hearing, speech impairments)
private and voluntary resources for the older adult
-Respite
-Parish nurses
-In-home care options
-Day care possibilities
purpose of the National Council on Aging (NCOA)
improve the life of older Americans through advocacy, public policy
American Association of Retired Persons (AARP)
-Largest nonprofit, nonpartisan, voluntary membership organization in the world; political action committee (PAC); membership is $16/year
purpose of the American Association of Retired Persons (AARP)
-enhance quality of life and promote dignity and purpose for older Americans,
-provide leadership for determining the role of the older adult in society,
-improve the image of aging
patient self-determination act (1990)
a federal law that requires hospitals to "provide written information" to adult inpatients concerning "an individual's right under state law to make decisions concerning medical care
advanced directives
required with every facility admission; allows individual to determine treatment wishes
living will
written instrument regarding CPR, Ventilators, Feeding tubes, Artificial Hydration
status of advanced directives and living will
-Can be changed or cancelled at any time
-Can be changed or cancelled at any time
function of Durable Power of Attorney for Health Care (DPOA)
makes medical decisions for person - usually trusted family member
health care proxy
person that makes medical decisions for person if they are incapable of doing so
What is important to teach the caregivers
Need knowledge of disease, treatment, respite care
Caregiver needs, social, medical, rest
Alternatives to home care
What is important to evaluate in the caregiver?
Evaluate to make sure the caregiver is in good health and manageable stress level as well (can be very stressful)
alternatives to home care
1. adult day care
2. independent living apartments
3. assisted living
4. nursing home facilities
5. skilled nursing care
6. hospice care
adult day care
alternative to home care in which there is a group setting 8 hours/day
assisted living
alternative to home care; required to need 3 services (personal care, med administration, housekeeping, etc.) Must be ambulatory, walker, or propel self in wheelchair, feed self, elimination controlled
nursing home facilities
alternative to home health; can cost $4,000-12,000/month; relocation syndrome; nursing home insurance
skilled nursing care
alternative to home care; requires 3 day hospital stay & skilled services - limited to 100 days maximum and usually less- PT, OT, wound care, IV meds; depends on progress of rehabilitation
hospice care
care of the dying
What services are provided in independent living apartments?
no healthcare provided
tips when choosing a nursing home
-Ask to see the latest state inspection report
-Determine the type of care such as rehab or custodial
-Is it state certified for Medicare or Medicaid
-Visit at meal time
-Ask about the staffing ratio
-Are there physical, occupational and speech therapy
-Cleanliness, sunshine, light not dark inside
-Services such as transportation
-Cost
relocation stress syndrome
-Physiological and/or psychological events following relocation (specifically into a nursing home); harder when change is sudden or not expected
result/ consequences of relocation stress syndrome
Anxiety, insecurity, fear, sleep disturbances, confusion, increased physical symptoms or illness, even death
tips on how to address relocation stress syndrome
-Have person be involved in the decision, visit
-Someone to greet them, buddy
-Orientation, involvement
-Family visit often first few weeks, then establish a pattern
-Bring and decorate with things from home
population-based outcomes for the older adult
-Population will have adequate nutrition
-Population will have adequate activity, exercise
-Population will have acceptable sleep and rest pattern
-Population will maintain preferred roles/relationships
-Population will maintain cognitive ability
-Population will remain safe from... (select appropriate)
Falls, crime, abuse, medication misuse, infection complications, MVA, etc.
assessments applicable to the older adult
-Assessments of functional ability (Katz &Lawton)
-Mini Nutritional Assessment
-Fall Risk Assessment
-Mini Mental State Exam
-Geriatric Depression Scale
-Caregiver Strain Assessment
-Pain, Sleep Scales
-Elder abuse
-Alcoholism
-Braden Scale
-SPICES
-Geriatric oral health
SPICES assessment tool
S=Sleep Disorders
P=Problems Eating or Feeding
I=Incontinence
C=Confusion
E=Evidence of falls
S=Skin breakdown
normal physical assessment findings in the older adult
- decreased lung expansion
- decreased reaction time
- exertional dyspnea
- decreased elasticity of the arteries
- increased skin fragility
- impaired balance
- decreased bone mass
-urinary urgency & frequency
- increased insulin resistance
- decreased immune response
- decreased thyroid function
- decreased gastric acidity
- decreased GI motility
- increased skin fragility
- decreased visual acuity
- increased tendency for indigestion
- decreased renal filtration
- prostate enlargement
role of the home heath care nurse when visiting client at home
-Assess the caregiver for strain and stress, other health problem
-Listen
-Teach about care, disease, age related changes for patient and self
-Discuss patient care
-Respite care options
-Support groups
-Alternatives and financing
-Social worker
nutritional assessment of the older adult
-Decreased appetite
-Digestive problems
-Chewing (denture fit)
-Swallowing
-Meal preparation
-Sensory changes taste, smell, vision
-Loneliness
-Geriatric oral health screening
-Cage Assessment for alcohol problems
-Assess for pocketing of food
-Albumin (long-term/past month) (3.5-5)
-Pre-albumin (shorter-term/past week)
-Cholesterol screening
-Decreased physical activity
-Fixed income
-Pain (influence appetite)
-Medications
-Lactose intolerance
-Ethnic and religious beliefs
-Finances (food stamps and pantries)
-Access and prepare food
-Dental referrals
-Review vitamin and mineral supplements
mini-nutritional assessment (MNA)
SCALES assessment tool (r/t to nutrition)
S--sadness, mood changes
C—cholesterol elevation
A—albumin
L—Loss/gain in weight
E—Eating problems
S—Shopping or preparing food
care management strategies when caring for one with dysphagia
HOB elevated (90%)
thickened foods
care management strategies when caring for one with GERD
Pepcid, Prilosec, etc.
care management strategies r/t to nutrition when caring for one with dementia
Finger foods, frequent feedings (4-6 times per day) (wandering around takes a lot of energy)
What does it mean to "liberalize a diet"?
remove any restrictions (let them eat what they want because they don't eat that much)
What happens to total body water and thirst as one ages?
decreased thirst, total body water decreases
dehydration presentation in the elderly
-weakness
-dry tongue
-rapid pulse
-sunken eyes
-confusion
-hypotension
-speech difficulties
-decrease blood pressure
What patients may be on fluid restriction?
chronic heart disease or renal failure
medications that alter fluids and electrolytes
diuretics, multiple meds (ACE-inhibitors)
end-of-life nutrition
removing food and fluids at the end of life; usually they lose their appetite; however, breathing through mouth (dry mouth); despite that, not a good idea to feed; fluid will fill up lungs to make process worse
effect of incontinence on fluids and electrolytes
voluntary decreased fluid intake to decrease nocturia fear - dehydration
assessment for dehydration in the older adult
-Intake less than 1500 ml
-Tongue furrows
-Dry mucous membranes
-Weight loss greater than 3%
-Constipation
-Disorientation
-Orthostatic hypotension
-Concentrated urine
-Cognitive changes (confused)
nursing interventions to treat dehydration
-Prevention is the most important
-Making water pitchers accessible
-Providing 8 oz of water minimum with meds unless otherwise ordered
-Avoid drinks with caffeine that dehydrate
-Identify what does the person like
-Do not say "would you like" rather "here is the glass of water that you need now"
-Open containers
What factors influence one's elimination pattern?
-decreased fluids & fiber
-decreased physical activity
-decreased privacy
What medications could affect elimination?
Medications - opioids, diuretics, etc.
What additional things do we woe about in terms of incontinence?
skin integrity issues with incontinence due to constant fluids
Is nocturia common in the older adult?
nocturia is "normal"; > 3 x/night is abnormal; disturbed sleep pattern related to nocturia of the older adult
care management strategies to achieve desired urinary elimination outcomes
-Bladder training
-Kegels for some kinds of incontinence
-Detrol
-Toileting schedule
care management strategies to achieve desired urinary fecal elimination outcomes
-toilet schedule
-prune juice
-the Bomb (coke, butter, prune juice)
-administer stool softeners
-bulk forming agents
-laxatives
relationship between activity and exercise to fecal elimination
physical immobility hastens aging and leads to decreased fecal elimination (decreased peristalsis)
barriers to exercise in the older adult
-knowledge
-motivation
-musculoskeletal strength
-balance
-fear of falling
-Pain, fatigue, mobility problems
-Sensory impairments (vision, kinesthetic)
-The big "M" (motivation)
-Cost (gym fee)
-Safety
-Musculoskeletal problems, rheumatoid arthritis
-Inappropriate blood pressure (low or high)
-Significant arrhythmias
What tasks are included in Katz ADLs?
-Bathing
-Dressing
-Toileting
-Transfers
-Continence
-Feeding
What tasks are included in Lawton's IADLs?
-Telephone
-Shopping
-Getting places
-Meals
-Housework
-Laundry
-Handyperson work
-Medications
-Money management
strategies to promote activity and exercise
-mall walking (flat, inside, air conditioned)
-weight training
-chair aerobics
-aquatic exercises (in pool) (easier to perform musckuloskeletal actions)
-Tai Chi
-Wii (hand eye coordination)
-Golf
evidence of improved activity
-improved sleep
-decreased constipation
-decreased cholesterol
-decreased blood pressure
-decreased depression
-improved digestion
-weight loss or gain
-↑socialization
-fewer falls
-Improved function/QOL
barriers to sleep in the older adult
-Physical discomfort (restless leg syndrome (RLS), sleep apnea syndrome, pain)
-External environment
-Emotional discomfort (anxious)
-Sleep pattern changes
+REM (deep sleep) preserved
+decrease in total number of hours needed
+decrease in slow wave activity (III & IV) (shorter duration)
+increase in nocturnal & early morning awakenings (more fragmented)
-shorter periods of sleep; naps
What can be done for the older adult who is having troubles sleeping?
do a sleep study
desired outcomes for the older adult related to good sleep/rest
-increased energy
- increased motivation to continue high quality life
-increase immune function
-increase cognitive function
-decrease falls
care management strategies for sleep in the older adult
-Sensory changes impact
-Avoid or Limit Daytime naps (make short 20-30 minutes)
-Decrease pain
-Increase physical activity
-Avoid caffeine after 4:00 p.m.
-Environmental strategies - red night light
-Safety with meds - discourage hypnotics, sedatives
-Assistance with emotional concerns (listen to patient: PM care)
-Sundown syndrome, REM problems - dementia (can get anxious, combative, confused)
-Establish sleep routine (reading: example))
-Pittsburgh Sleep Quality Index(PSQI)
seriousness of falls
falls in the older adults is associated with morbidity, mortality, functional decline; also Fear of Falling
What factors may lead to an increased likelihood of an older adult having a fall?
-history of falls
-alcohol use
-systolic blood pressure changes (orthostatic hypotension)
-medications: antipsychotics, antianxiety, antidepressants, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, cardiovascular, diuretics, hypoglycemics, hypnotics, narcotics
-Gait/Mobility, physical problems such as hemiparesis
-Balance, tremors, strength (shuffling)
-Incontinence
-Vision Status
-Cognitive Status: wandering, easily distracted, periods of restlessness, confusion, impaired judgment, altered perception, awareness of surroundings
-Fatigue, edema, improper footwear, assistive devices (proper use)
What fall risk assessments are used to assess for mobility and balance?
-Get up and go
-Timed get up and go
-Modified Romberg
-Fall Risk assessment tool
-Home fall prevention checklist
scoring of Get Up & Go
-score 1: able to rise in a single movement - No loss of balance with steps
-score 2: pushes up, successful in one attempt holds onto chair arms
-score 3: multiple attempts, but successful
-score 4: unable to rise without assistance during test - using the chair = needing assistance
fall prevention strategies
-Motion monitors in hospitals, LTCF
-Home safety evaluation by home health or OT
-Turn on lights before entering a room
-Use nightlights in bedroom, bathroom, hallways
-Avoid highly polished floors; proper shoes
-Handrails on both sides of stairs
-Immediately clean up spills
-Avoid clothes too big and can become entangled in them - e.g. slacks that are too long, night clothes
-Keep phone, call light, remote, water, near bed or chair
-Don't hurry to answer the phone, they will call back
-Lifeline or similar emergency call system
-Hip protectors (like football pads)
-Pets (can cause or prevent)
-Refer to physical and occupational therapy
-Move the patient closer to the nurse's station
-Do not leave alone in the bathroom (unless cognitively aware)
-Toilet on a regular schedule
-Use gait belts
-Non-skid footwear
-Motion sensors at home (alerts family)
-Proper lift techniques
-Sliding board
-Vision screening
What technology has been put in place to reduce falls?
motion monitors: when patient stands, pressure pad responds "Name, sit back down, you will be assisted in a moment."
4 P's that need to be checked when entering a patient's room
-Potty
-Position
-Pain
-Possessions
How do you define adult failure to thrive?
Progressive functional deterioration of a physical and cognitive nature. Ability to live with multisystem involvement diminishes.
signs and symptoms of adult failure to thrive
-anorexia
-weight loss
-no interest in family
-entertainment
-decreased activity
-fatigue
-balance issues
-dehydration
-decrease ADL
-exacerbations of illness
treatment for older adult experiencing adult failure to thrive
-assess for signs and symptoms
-use reminiscence
-touch
-antidepressants
-physical therapy
-pain management
concentrate on what person can still do (interventions)
effect of crime on the older adult
fear of crime leads to social isolation
common crimes that affect the elderly
-purse snatching
-theft
-identity or consumer fraud
-medical quackery
-charities that don't exist
-merchandise that doesn't arrive
-Email and calls (IRS or abduction of grandchild)
seriousness of elder abuse
Between 1 and 2 million Americans, age 60 or older, have been abused (it is estimated that only 1 in 6 cases are reported to the authorities)
types of abuse
physical
sexual
emotional
neglect
abandonment
financial
self neglect
situations in which we see elder abuse
-trauma
-unattended medical problems
-poor hygiene or dehydration
-evidence of failure to thrive
-substandard housing
-battering
-verbal abuse
-forced confinement
Who most typically abuses the older adult?
- Two-thirds of the perpetrators are family members.
- Mostly adult child or spouse
trigger for most cases of elder abuse
Stress is a trigger (tough on caregiver), usually not cause
What circumstances make adult children more likely to commit elder abuse?
- Dependent on elders for financial assistance.
- Dependent on housing.
What factors of the older adult may lead to increase abuse risk?
- Dementia
- Disruptive behaviors; problematic personality traits
- Significant assistance needs (incontinence)
What traits/characteristics/actions of the older adult have been reported to be particularly stressful for abusive caregivers?
- Verbal aggression
- Refusal to eat or take medications
- Calling the police
- Invading caregiver's privacy
- Vulgar habits
- Disruptive behavior
- Embarrassing public displays
- Physical aggression
Is it the nurse's place to determine whether or not elder abuse is taking place?
-Call Adult Protective Services
-Adult Services will decide if respite or something more is necessary
nursing strategies in the case of elder abuse
-Safety of patient is a priority
-Use least restrictive intervention
-Patient has the right to chose or not
-Support the caregiver
-Avoid blame
-Non-judgmental
-Confidentiality
-Encourage Advance Directives
characteristics of the older adult driver
↑ crash rate/mile
They generally drive less
assessing the older adult's ability to safely drive?
-Ask someone who has ridden with the driver "Do you feel safe?"
-Track Accidents (may not report because of afraid of losing insurance)
-Incidences when Getting lost
-Visual-spatial assessment
-MMSE (mini-mental status exam)
-Attention
-Visual fields
-Reaction time
-Muscle strength and joint flexibility
-55 Alive course with road test (how react)
When should the older adult consider stopping driving?
-Receiving more tickets or warnings
-Get lost on familiar roads
-Passengers feel unsafe
-Drive too slow
-Not stopping at stop signs
-Erratic moves
-Honked at frequently
-Missing traffic signs
-Experience preventable accidents
immunizations/screenings for the older adult
a. Influenza - annually
b. Pneumonia - 1 dose after 65 years, younger with chronic illness plus a booster after 65 years
c. Tetanus - every 10 years
d. Zostavax - shingles vaccine - (chickenpox) (may not be covered by insurance) (post-herpetic pain >40% over 60 years of age; painful
e. Screenings-mammography, colonoscopy, prostate, stool for occult blood , pap smears (not being done anymore if over 65 or without partner)
f. Tuberculosis testing (not generally tested; tested upon admission to facility (two-step))
g. Vision and auditory screenings yearly
influences of alcohol abuse in the elderly
May have genetic, environmental, biological influences
danger of alcoholism in the older adult
Physiological changes of aging influence metabolism , excretion, etc so may cut down or have problems with the same amount as used earlier
assessment of the older adult suspect of alcohol abuse
Assess blackouts, confusion, relationships, mood swings, GI problems, falls, arrests, malnutrition, nausea and vomiting, cheliosis, stomatitis, spider veins, hypertension, cardiomyopathy and dementia
What set of questions can be used to assess alcohol abuse in the older adult?
-Have you had to cut down on your drinking?
-Have others annoyed you by criticizing your drinking?
-Have you ever felt bad or guilty about your drinking?
-Have you ever had eye opener in the morning to get steady? (drink to get started in the morning)

+Two positive answers are considered alcohol abuse a problem.
nursing strategies for the older adult suspect of alcohol abuse
-Be supportive and non-judgmental
-Use CAGE screening tool
-Diet high calorie and high protein with vitamins
-May need vitamin B12 injections for neuropathy
-Medications for detoxification
-Safety issues (falls)
-Support groups such as AA
-In-patient and out-patient treatment (most insurance won't pay for much inpatient treatment)
cognitive changes seen in the older adult
decreased neurons
decreased brain size
change in neurotransmitters
ways to assess the cognitive functioning of the older adult
-Compared to others your age, how do you feel you are doing?
-Have you been having trouble with your memory?
-3 item recall in 1 min.
-MMSE
-Clock drawing
-Cognitive evaluation by Occupational Therapy (cognitive retraining done)
characteristics of benign forgetfulness
-Forgets, later remembers
-Loses things but can retrace
-Forgets minor events
-Forgets past events
-Can use memory aids
-May repeat stories overtime
-Knows self and important people
characteristics of pathological forgetfulness (dementia)
-Forgets & does not remember later
-Cannot retrace steps
-Forgets important events
-Forgets very recent events
-Cannot use reminders
-Repeats in a very short time
-Forgets important people
delirium
acute state of confusion, usually reversible once the cause has been identified & treated
causes of delirium
-electrolyte imbalances (sodium)
-cerebral anoxia
-hypoglycemia
-medications
-infections
-sensory overload
-pain meds (seen in ICU)
-new environments
depression in the older adult
reversible; thought to contribute to high suicide rates; persons with dementia may also experience depression
interventions for older adult with depression
-medications (may take a week or longer to work)
-get client involved
-group and individual therapy/ pastoral care
dementia
gradual impairment of brain function with actual irreversible changes to the brain, memory loss
forms of dementia
1. Alzheimers
2. vascular dementia
3. diffuse Lewy body disease
What cognitive changes do we see in the Alzheimer's patient?
senile plaques & neurofibrillary tangles; deficits in neurotransmitters;
advances to terminal illness
care management strategies of the older adult with dementia
-Encourage self-care
-Safe, familiar environment and use of memory aids
-Active mind activities & involvement (Suduko, sorting, coloring)
-Not always best to re-orient with dementias
-Allow cogitation (additional time to remember)
-Reminiscence and Life Review
-Touch - most untouched population
What can one do instead of reorientation in the patient with dementia?
distraction techniques (looking at pictures or doing an activity)
life review
the process by which people reflect on the events and experiences of their lifetimes; starting from beginning and walking through life
auditory challenges in the older adult
presbycusis
sensory overload or deficit
presbycusis
a gradual loss of sensorineural hearing that occurs as the body ages; loss of high pitched sounds
ways to examine the hearing of the older adult
Whispered voice & finger rub
importance of testing hearing of older adult
impacts understanding of instructions and socialization if hearing impairment present
visual changes in the older adult
-color perception
-presbyopia
-dry eye
-decreased ability to accommodate to darkness
-cataracts
-macular degeneration
-diabetic retinopathy
What colors may be hard or easy to see with changes in vision of the elderly?
-Blue, green, violet = trouble
-RED, ORANGE, YELLOW BEST
presbyopia
impaired vision caused by old age or loss of accommodation; farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
cataract
opaque clouding of the lens causing decreased vision
macular degeneration
deterioration of macula lutea of retina; patient notices loss of vision in center of visual field
characteristics of the rural elderly
-Have more chronic illness
-Increased exposure to pesticides in agriculture
-May not have paid into Medicare
-Reluctant to use welfare resources
-Less access to health care systems
-May not use health promoting behaviors
-Limited assisted living and nursing home care
-Need comprehensive care management
-Telehealth
-Informal help, church, family, friends
characteristics of the homeless elderly
-Little to no money (social security maybe?)
-Often decreased cognitive function
-Live alone—no family contact
-Fear Institutionalization (don't want to go to hospital)
-Health care is delivered through emergency room
-Admit to facilities that take Medicaid patients (not the highest of quality of facilities) (facilities don't get paid as much for Medicaid beds; therefore, cannot staff properly)
age related changes in heat and cold tolerance
-Decreased subcutaneous tissue
-Insufficient vasoconstriction
-Delayed and diminished shivering response
-Decreased peripheral circulation
-Impaired ability to adapt to heat
-Insufficient sweating mechanism
-Older adults core temperature ranges 95-97F

Therefore, aging results in a decreased ability to adjust to heat/cold
How do you identify hypothermia in the older adult?
-Temperature below 94F
-Bradycardia, irregular pulse
-Puffy face
-Cool skin
-Slurred speech
-Hypotension
-Slow, shallow respirations
-Decreased urinary output
-Muscle rigidity
-Cardiac dysrhythmias
-Coma
strategies for hypothermia
-education
-home temperature (some elderly will turn down to save money)
-winterize home (insulation and windows)
-Home Energy Assistance Program
-Clothing (layers)
-fluid intake - but consider co-morbidity issues with forcing fluids
How do you identify hyperthermia in the older adult?
-Temperature over 100
-Weakness and dizziness
-Headache
-Confusion, delirium***
-Arrhythmias
-Seizures
-Nausea and vomiting
-Bloody Stools
-Coma, shock
-Often fatal, sudden onset of temp 105
strategies for hyperthermia
-fans
-malls, theaters, libraries
-hat, umbrella
-cool packs, cool baths
causes of social isolation in the older adult
children become independent
spouse may die
grand-parenting role
retirement
-sensory changes or losses
-feelings of powerlessness (multiple losses or changes)
assessments/interventions for social isolation in the older adult
-Grief interventions are really the same as other age groups
-Watch for changes in mood and affect
-Geriatric Depression Scale
effect of social isolation in the older adult
-Drug use and abuse (includes prescription drugs)
-Alcohol use
-Gambling Addiction
-Depression & Suicide -
highest rate of suicide in elderly men (numerous losses may contribute)
strategies for coping with changes
-Maintenance of relationships (family, friends, senior center)
-Attending to healthy behaviors
-Staying active and independent (subsidized work programs, volunteering)
-Learn new skills
-Spiritual anchor
-Sense of humor
-Continue to have goals
-Take control of own health and future (finances)
-Pets (taking care of pet causes them to take care of themselves)
physical changes of the older adult related to sexuality
-Vaginal wall drier, decreased length & width
-Prostate increases
-Mobility limitations
-Illness of one or both partners
-Discuss prevention of STD's
-Changes in libido are common (changes in hormones)
myths about the sexuality of the older adult
-No interest
-Medical illness prevents
-Impotence is normal
What way can we show the elderly that we care for the older adult?
TOUCH (least touched group within population)
What form of Medicare covers the expense of medications?
Part D: covers portion of medication bill
polypharmacy
the simultaneous use of multiple drugs to treat a single ailment or condition
medication concerns for the older adult
-polypharmacy
-self adjustment of dosages (to extend use and decrease severity of side effects)
-confusion about when to take medications
-altered metabolism
-increased risk for falls with many medications
Beer's List of Medications
-list of medications that should NOT be used or used with caution in the elderly
possible reason why the older adult does not complain about pain
-Believe it is a normal part of aging
-Have been raised to be stoic, not complain
-Believe they will become addicted to pain medication
-May have physiological condition so they can't complain such as dementia or aphasia
-Other behaviors such as wandering may be indicative of pain (example dementia)
effects of physiologic aging on medication absorption
delayed gastric emptying; decreased gastric acidity
effects of physiologic aging on medication administration
higher percentage of fat; decreased total body water; decreased plasma albumin concentration
effects of physiologic aging on serum concentration of medications
Change in body composition & changes in serum concentration of water-soluble drugs; Change in fat mass affects concentration of fat-soluble medications
effects of physiologic aging on drug clearance of medications
-Altered liver metabolism
-Decreased renal excretion of drugs - slower GFR
medication management strategies of the older adult
-Assess ability to safely self-administer at home or a caregiver who can assist
-Costs
-Start low, go slow
-Limit OTC
-Teaching is important
-ID bracelets
-Lists of meds
What factors can influence the older adult's ability to safely self-administer medications?
-Caregiver who can prepare (med containers)
-Know what meds can be crushed if difficulty swallowing
-Document that promotes compliance
-Have someone check compliance
At what point in time is acute pain transitioned into chronic pain?
acute = less than 6 months
chronic = more than 6 months
What is the most reliable source for pain level of the older adult in long-term care?
CNA assessment more accurate than nurses; undertreatment of pain is signficant problem in LTCF
What is important to remember when giving pain medication to the older adult?
NSAIDs, acetaminophen, hydrocodone, oxycodone available lower dosage
What do you need to monitor for when giving analgesics to older adults?
Cheyne Stokes pattern more common (don't decrease opioids just because of this; check O2 sats)
signs of pain in dementia patients
watch for rubbing body part, rocking
caution when giving IM injection to the elderly
Do not give intramuscular meds to a person with a decrease in muscle mass
common side effects of administering opioids
Opioids cause constipation, nausea and vomiting, decreased respiratory rate, orthostatic hypotension, anorexia
What drug class can be used for neuropathic pain?
Anticonvulsants (Neurontin, Lyrica) are used for neruopathic pain
What drugs can be used if older adult is experiencing severe that is intolerable upon administration of NSAIDS or APAP?
Tramadol (Ultram) and Gabapentin moderate to severe pain when intolerance to NSAIDS or APAP
assessments to conduct when giving a non-steroidal anti-inflammatory
watch for ulcer disease, renal function
example of drug given in combination
Duragesic patches
non-pharmacological strategies to relieve pain in the older adult
-Massage
-Ice/heat
-Imagery
-Music therapy
-Repositioning the patient
-Distraction
supplements commonly given to the older adult
Ginkgo biloba
Ginseng
Saw palmetto
Echinacea
St. John's wort
Melatonin
use of Ginkgo biloba
memory (prolongs clotting)
use of Ginseng
energy (insomnia, cardiac disorders)
use of Saw palmetto
enlarged prostate
use of Echinacea
immunity
use of St. John's wort
depression (interacts with anti-depressants)
use and precautions taken with melatonin
May help sleep, but...
-Constricts blood vessels - stroke, heart attack
-Interferes with sleep if taken at wrong time of day
-Unsubstantiated claim that reverses effects of aging
Why are the elderly predisposed to infection?
Lymphocyte function declines as does the immune response
initial symptoms of infection in the elderly
Initial symptoms may present as confusion, anorexia, anemia, restlessness, hypertension
later signs of infection in the elderly
Later the elevated temperature, pulse and respirations occur
benefits of spirituality in the elderly
-Spirituality based on outlook on life helps person deal with challenges and losses of aging
-Have a "can do spirit" do not stress as much
-Believe God helps them make the right choices
-Trust courageously
-Remember gratefully (don't focus on bad memories)
-Hope realistically
-Feel one's life has had meaning
danger of acute care of the elderly
-75% elderly enter independent are not functionally independent on discharge, 15-90% are unstable
-Higher surgical risk with increasing age
-Nosocomial infections and pressure ulcers occur
management strategies for the acute care of the elderly
-Teaching, referrals, include family or caregiver
-Interdisciplinary effort for dismissal knowledge and placement
-Encourage independence in ADL's (ACE Units)
-Ethical decision making
hazards of the older adult when leaving the hospital
-Disturbed sleep
-Malnourished
-Pain/ other discomforts
-Decreased muscle strength
-Falls
-Infections
-Psychosocial distress
What does one need to know to die peacefully?
-You have been loved
-You have loved
-You have been forgiven
-You have forgiven
-Your life has meaning and was the best possible under the circumstances
legal and ethical issues surrounding the care of the older adult
-Advance directives, will, etc
-Restraint use
-Resuscitation
-Treat infection
-Enteral feedings (tube feedings)
-Transfer to more intensive treatment units
-Blood transfusions
tips for older adults on how to stay young
-Have no regrets. Elderly don't regret what we did but what we did not do.
-Laugh and find humor every day.
-Find the opportunity to change
-You have to have a dream or you will be bored. And most importantly
-Elderly are not growing old we are just growing up.
What legislation was passed in 1935 that affirmed the government's responsibility to care for its older citizens?
social security
Which theory of aging suggests that a biologic clock controls the number of cell divisions that a cell can make causing the aging process?
Programmed aging
The patient was receiving an oral antibiotic for an infection. The nurses noticed that the peak level of the antibiotic was not in therapeutic range. The physiological reason for
this was that:
Decreased GI motility delayed the peak effects of the oral drug
An 80 y/o man needs help with shopping, cooking, cleaning, laundry & minimal personal care. He is being assisted by a social services agency to find a place to live. Which is the most likely possibility?
assisted living
What type of problem occurs when an older person experiences changes in vision and hearing?
social isolation
What socioeconomic factor may influence the nutritional status of older patients?
Older patients may be forced to choose between food and medications due to a fixed income
Jane found her father on the floor one morning, very confused. The nurse asked Jane if her father had any signs of temp. elevation or
infection. The rationale for this is that:
Mental status changes from an infectious process or fever may be manifested as a fall
Of the following conditions that occur as the result of chronic pain, which is most common, yet treated
less often, in older adults?
Depression
The home health nurse observed Mrs. Ansel sitting in her chair rocking very slowly. She noticed that she had become more depressed than usual. Before this behavior had started, Mrs. Ansel had confided in the nurse that her daughter would call her names and make threats about putting her in a nursing home. The nurse assessed Mrs. Ansel's habitual rocking as a sign of:
emotional abuse
The defining characteristics for the nursing diagnosis of activity
intolerance seen in older adults are:
fatigue and weakness
THIS SET IS OFTEN IN FOLDERS WITH...