314 PRELIMS REVIEWER WK 1-5.docx

Gerontology - Study of aging and the aged - "gero" -- old age, "ology" -- study of older group Gerontophobia - Fear of aging Age discrimination - Emotional prejudice among the older adult Ageism - Dislike of aging/older adult Geriatrics - Medical care for the aged Gerontologic...

Gerontology - Study of aging and the aged - "gero" -- old age, "ology" -- study of older group Gerontophobia - Fear of aging Age discrimination - Emotional prejudice among the older adult Ageism - Dislike of aging/older adult Geriatrics - Medical care for the aged Gerontological Nursing - Gerontology within nursing practice Age groups/Sex Ratio - Young old -- ages 65 -- 74 - 100 females, 86 males - Middle old -- 75 -- 84 - 100 F, 72 M - Old old /very old frail elderly -- 85+ - 100 F, 49 M Demographics of Aging Life expectancy - US: 75.7 yrs old - Life span: 115 yrs - French women: 122 yrs (1994) factors that affect life expectancy: - Improved sanitation - Advances in med care - Implementation of preventive health services Centenarians - People who reach 100 yrs old - Impoverished, widowed, more disabled - Weight less - Few meds - Few chronic disease Feminization of Later life - Women - 55% of older population, longer life (average life span in US: 81 yrs) - Men in US: 75.2 yrs Situations of older adult in the Philippines A. Number of older people is growing - 7.7% of total population in 2025 - 2017 -- total popul: 104 256 076 - Life expectancy both sex: 68.5 yrs - Male: 65.3 - Female: 72 B. Older people need care/support - demand for health care - Suffer from degenerative /communicable diseases - Leading cause of morbidity: Infections C. Older people are struggle with poverty - 31.4 % were living in poverty - Older people are unemployed - Employed in: farming, forestry, fishing - male -- 63.6%, Female -- 37.4% Impacts of aging members in the family - sadness - resentment - relationship - work - self-time Theories of Aging Biological Theories I. Stochastic theories - Based on random events that cause cellular damage a. Free radical theory - Cellular injury damaged by free radical. - Exogenous free radical: - Tobacco smoke - Pesticide - Uv/radiation - Ozone/ selected meds Health teaching: - Decrease calories to lower weight - high in nutrients using antioxidants - Avoid inflammation - Minimize metals in the body that can trigger free radicals reactions. - Older adults are more vulnerable to free radicals. b. Orgel/error theory - Errors in DNA and RNA synthesis occurs with aging c. Wear and Tear theory - Cells wears out and cannot function with aging d. Connective tissue theory/Cross link theory - proteins impede metabolic processes trouble\ with getting nutrients to cells and removing cellular waste products II. Non-stochastic theories of aging - Based on the genetically programmed events that cause cellular damage a. Programmed theory - Cells divide triggers to apoptosis or cell death. - Ex: shortening of telomeres: distal appendages of chromosomes arm. "cellular fountain of youth" b. Gene/biological clock theory - genetically programmed aging code c. Neuroendocrine theory - Feedback system causes disease (problem with hypothalamus) - Inc insulin -- accelerates aging d. Immunologic/autoimmune theory - faulty immunological function Psychosocial theories of aging - explain aging in terms of behavior, personality and attitude change I. Sociological theories - changing roles, relationship, status and generational cohort impact the older adult's ability to adapt. a. Activity theory - Activity engagement and positive adaptation to satisfy late life b. Disengagement theory - withdrawal from society and relationships serves to maintain social equilibrium and promote internal reflection c. Subculture theory - sharing loss of status and societal negativity regarding the aged d. Continuity theory/Development - Personality influences role and life satisfaction and remains\ consistent throughout life i. Integrated ii. Armored defended -- uses emotional defense iii. Passive dependent -- relies on others iv. Unintegrated -- least successful type of aging Sociological Theories a. Age stratification theory - Society is stratified by age groups b. Person-Environment Fit theory - Lawton (1982) - Function is affected by ego strength, mobility, health, cognition, sensory perception and the environment. Psychological theories - Explain aging in terms of mental processes, emotions, attitudes,\ motivation, and personality development that is characterized by life stage transitions a. Human needs - Maslow's (1954)\ - Five basic needs motivate human behavior in a lifelong process toward need fulfilment(Self-actualization) b. Individualism theory - Jung (1960) - Personality consists of an ego and personal and collective\ unconsciousness that views life from a personal or external\ perspective. - Middle life crisis i. Person looks inward & value self ii. Accepts past accomplishments/limitations c. Stages of personality development - Erikson (1963) - Personality develops in eight sequential stages with corresponding life tasks. - Generativity (sense of care/responsibility) vs self-absorption or stagnation - Ego integrity vs Despair d. Life-course/lifespan development - \- Life stages are predictable and structured by roles, relationship,\ values and goals Nursing Implications - Aging and disease do not necessary go hand. - Have a clear understanding between age related changes and those that may be pathologic - Among biologic theories two concept have gained wide acceptance: - Limited replicative capacity of certain cells - Free radical may cause damage to cell Gerontological nurse can promote health: - Smoking cessation - Activity (sun exposure) - Nutritious diet, vit. C/E - Prev of atrophy of muscle - Deep breathing - Daily walking - Prev measures (annual influenza) - Recognize stress - Promote positive self esteem task - intellectual functioning remains intact in most older adults - Employing moslow's theory the nurse recognize essential needs must be met before self actualization - individuals enjoy feeling needed and respected. (reviewing person's lifetime through picture) - promoting interaction between older adult and young children - eyesight and manual dexterity diminish, many older adult enjoy the opportunity to cook or work in garden - provide deeper understanding on why older adults act the way they do - Helping older adult to adjust to limitation while accentuating positive attributes Physiologic Changes in Aging Integumentary - Decreased protection against trauma and sun exposure; protection against extreme temperature - Diminished secretion of natural oils and perspiration (impaired thermoregulation) - Loss of thickness, elasticity, vascularity and strength that may delay the healing process and increase the risk of skin tear and bruising - Loss of hair follicle along with thinning and graying - Increase hair density in the nose and ears particular in men w/c may clog external ear canal and impaired hearing - Higher incidence and malignant skin growths Subjective/Objective Data: - Skin is thin, wrinkled, saggy and dry - Graying of hair - Thick nails with longitudinal line - Complaint of bruises and intolerance to heat - Bone structure is prominent Nursing Management - Avoid excessive sun exposure; use sunscreen - Dress in accordance with the weather - Take short bath (5-10 mins) - Use gentle cleansers - Maintain safe indoor temperature - Gently pat (rather than rub) the skin to dry - Apply skin moisturizer immediately after drying - Use ointment or cream rather than lotion - Skin care products should unscented and alcohol free - If needed, use humidifier to add moisture - Wear fabrics such as cotton - Keep client hydrated if not contraindicated Musculo-Skeletal - Loss of bone density; More prominent in menopausal women - Loss of muscle strength and size - Degenerative joint cartilage Subjective/Objective Data - Height loss - Prone to fracture - Joint pains - Kyphosis and other spine deformities (scoliosis, lordosis) - Loss of muscle strength, flexibility and endurance Health Promotion Strategies - Exercise regularly (Range-of-motion) - Diet: High calcium diet, vitamin D - Limit phosphorus intake Respiratory System - Increase in lung rigidity and decrease in lung elasticity - Ribs become less mobile and chest wall compliance decrease - Diaphragm muscle strength decreases thus breathing requires effort - Increase lung residual volume; decrease lung vital capacity and cough efficiency Factors Affecting Lung Function - Lifestyle (smoking, sedentary, exposure to pollutants) - Obesity - Anesthesia and Surgery Subjective/Objective Data - Easily fatigued, breathlessness with sustained activity - Impaired healing tissue due to decreased oxygenation - Difficulty in coughing up secretion - Use of accessory muscle when breathing Health Promotion Strategies: - Lifestyle modification: smoking cessation, eating healthy foods, losing appropriate weight, exercise daily - Take adequate fluids to liquify thick secretions - Encourage patient to receive influenza vaccine annually - Avoid exposure to infection, pollutants and irritant by wearing protective equipments such as mask - Avoid known allergens - Ensure early diagnosis and treatment of resp. tract infection - Adhere to medical regimen for chronic respiratory illness Cardiovascular System - Heart valves becomes thicker; prone in valve stenosis, arteries lose their elasticity; prone in unstable blood pressure - Accumulation of calcium and fat deposits - Veins becomes tortuous - Decrease cardiac output and cardiac reserve - Left ventricular wall thickens - A and AV node become fibrotic with age - ECG (arrhythmias) - During stress stimulation heart rate increase move slowly Risk for Cardiovascular Diseases - Non-modifiable: Gender (prone to males), Genetics, Age - Modifiable: Lifestyle, Diet, Tobacco use - Subjective/Objective Data - Complaint of fatigue with increase activity - Increase heart rate recovery time - Normal BP \< or equals to 140/90 mmHg Health Promotion Strategies: - Lifestyle modification - Diet Modification: DASH Diet; Low salt and low fat diet - Stress management: - BP Control and weight control Reproductive System - Female- vaginal narrowing, decrease vaginal secretions, slower sexual response and arousal - Male- decrease size of penis and testes; slower sexual response and arousal; erectile dysfunction. Delayed achievement of orgasm Subjective/Objective Data - Female: Dysparenuia, vaginal bleeding following intercourse, delayed orgasm, vaginal itchiness and irritation - Male: delayed erection and achievement of orgasm, benign prostatic hyperplasia Health Promotion Strategy - May require vaginal estrogen replacement - Gynecology and Urology follow up - Use of lubricant during sexual intercourse - Pelvic floor exercise (kegel exercise) Genito-Urinary System - Male- Benign prostatic hyperplasia; enlargement of the prostate often non-malignant - Female- relaxed perineal muscles, urethral dysfunction Subjective/Objective Data - Urinary retention, incontinence, irritative voiding symptoms - Frequency, feeling of incomplete voiding - Bladder emptying urgency/ frequency syndrome drop of urine mostly when coughing Health Promotion Strategies - Seek referral to urology - Make an easy access to the toilet - Wear easily manipulated clothing - Drink adequate amount of fluids Gastrointestinal System - Decrease salivation, acuity of taste, motility of the GI tract - Delayed esophageal and gastric emptying; prone for acid reflux - Atrophy of gingival tissue = gingival retraction → loss of teeth - Lower esophageal sphincter pressure decreased = Potential for hiatal hernia andmaspiration - Abdominal wall is thinner and less taut, decrease in number and sensitivity of sensory - receptors - Atrophy of gastric mucosa, decrease in blood flow - Small intestine decreases in secretion of most digestive enzyme and motility - Liver decreased size and lower in position, decrease in protein synthesis, ability to regenerate decreased = Decrease drug metabolism - Large intestine to rectum has decreased anal sphincter tone and nerve supply to rectal area, decreased muscular tone, decreased motility = Increase in transit time, sensation to defecation decrease - Pancreatic duct distended, lipase production decreased, pancreatic reserve impaired = Impaired fat absorption, decreased glucose tolerance Subjective/Objective Data - Loss of teeth, use of dentures - Weight loss - Complaint of dry mouth, fullness, constipation, flatulence - Heartburn and indigestion - Abdominal discomfort - Diminished sense of taste; Food intolerance - Signs of anemia as result of cobalamin malabsorption decrease gastric emptying - More visible peristalsis, easier palpation of organs, less sensitivity to surface pain - Dysphagia - Fecal incontinence and impaction Health Promotion Strategies - Use of ice chips and adequate fluid intake - Oral care; Mouthwash - Well balanced diet; Eat high fiber and low fat diet - Limit laxatives and defecate on a regular basis - Correct administration of medication: 10 rights in medication Nervous System - Reduced speed of nerve conduction - Increase confusion with physical illness and loss of environment cues - Reduced cerebral circulation Subjective/Objective Data - Learning takes longer to process - Slower to react and respond to a stimuli - Altered level of consciousness (syncope) and frequent falls Health Promotion Strategies - Pace teaching - Enhance sensory stimulation - Encourage slow rising from resting position to prevent orthostatic hypotension Special Senses - Vision - diminished ability to focus on close objects - inability to tolerate glare; - difficulty adjusting to change of light intensity; - decrease ability to distinguish colors. - Eyelid lose tone and internal eye - Pupil decrease in size and loses to constrict - Hearing and Balance: - decreased hearing acuity (sensorineural hearing - Auditory canal narrows - Decrease vestibular sensitivity - Taste and Smell - decrease acuity to taste and smell - damage to cell anddiminished level of neurotransmitter - Xerostomia (dry mouth) is the most common change in the sense - Touch: - Sensitivity to light touch diminished in older adult Subjective/Objective Data - Complaint glare, poor night vision, blurred vision - excessive seasoning - May give inappropriate response - Prone to falls Health Promoting Strategies - Use of eyeglasses to aid for vision, Hearing aid if necessary - Enunciate words clearly; speak with low pitch voice; use nonverbal cues - Encourage use of lemon, spices and Herbs - Encourage patient to rise slowly before standing up - Notify physician of any pain, discharge redness, swelling, dizziness, ringing in ears or loss of hearing - See physician for early detection Pressure Ulcers/Injury - Scale that Assess Pressure Injuries Braden Scale: A screenshot of a computer Description automatically generated Norton Scale:  Basic Principle of Preventing Pressure Ulcer - Minimize: pressure, friction shearing and poor nutrition - Provide nutritional support - clear moist wound environment with adequate - circulation and oxygenation - Always turn patient at least every 2 hours CHANGES TO THE MIND Psychological changes can be influenced by: - General health status - Genetic factors - Educational achievement - Activity - Physical and Social changes - Sensory organ impairment can impede interaction with the environment and other people. - Feeling depressed and socially isolated may obstruct psychological function Personality - Drastic changes in basic personality normally do not occur at one age. Excluding pathologic processes - The alleged rigidity of older persons is more a result of physical and mental limitations than a personality change - Changes in personality traits May occur in response to events that alter self -attitude,such as retirement, death of spouse. Memory 3 Type of Memory 1. Short Term- lasting from 30 seconds to 30 minutes 2. Long Term- memories learned long ago 3. Sensory- obtained through the sensory organs and lasts only a few seconds - Retrieval of information from long -term memory can be slowed - Working memory function is reduced. - memory aids(mnemonic devices) Intelligence - Basic intelligence is maintained; one does not become more or less intelligent with age Learning - Learning ability is not seriously altered with age - other factors can interfere:motivation, attention span, delayed transmission of Information to the brain, perceptual deficits, and illness. - when old habits exist and must be unlearned, relearned, or modified Attention Span - decrease in vigilance performance (i.e. the ability to retain attention longer than 45 minutes). - easily distracted by irrelevant information and stimuli Nutrition in Geriatrics Nursing care of the older adult in wellness Comprehensive geriatric assessment - multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socio environmental situation of older people - Improved care and clinical outcomes - Greater diagnostic accuracy - Improved functional and mental status - Reduced mortality - Decreased use of nursing homes and acute care hospitals - Greater satisfaction with care Principal Domains to be Assessed: 1. Functional ability- Ability to do activities of daily living (ADLs) and instrumental ADLs (IADLs) - ADLs include eating, dressing, bathing, transferring between the bed and a chair, using the toilet, and controlling bladder and bowel - IADLs enable people to live independently and include preparing meals, doing housework, taking drugs, going on errands, managing finances, and using telephone 2. Physical health- History and physical examination should include problems common among older people problems with vision, hearing, continence, gait, and balance 3. Cognition and mental health- validated screening tests for cognitive dysfunction (eg,mental status examination) and for depression (eg, Geriatric Depression Scale, Hamilton Depression Scale) can be used 4. Socio Environmental situation- patient's social interaction network, available social support resources, special needs, and the safety and convenience of the patient's environment are determined KATZ INDEX - Clients are scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment MINI-MENTAL STATE EXAMINATION (MMSE) - Any score of 24 or more (out of 30) indicates a normal cognition. Below this, scores can indicate severe (≤9 points), moderate (10--18 points) or mild (19--23 points) cognitive impairment. Geriatric Depression Scale (GDS) Scoring Instructions: Score 1 point for each bolded answer. A score of \> 5 or more suggests depression. 1\. Are you basically satisfied with your life? Yes / No 2\. Have you dropped many of your activities and interests? yes/no 3\. Do you feel that your life is empty? yes/no 4\. Do you often get bored? yes/no 5\. Are you in good spirits most of the time? yes/no 6\. Are you afraid that something bad is going to happen to you? yes/no 7\. Do you feel happy most of the time? yes/no 8\. Do you often feel helpless? yes/no 9\. Do you prefer to stay at home, rather than going out and doing things? yes/no 10\. Do you feel that you have more problems with memory than most? yes/no 11\. Do you think it is wonderful to be alive now? yes/no 12\. Do you feel worthless the way you are now? yes/no 13\. Do you feel full of energy? yes/no 14\. Do you feel that your situation is hopeless? yes/no 15\. Do you think that most people are better off than you are? yes/no Gordon's 11 Basic functional Health Patterns of Older Adult A. Self-Perception/ Self-Concept Pattern - a sense of personal identity B. Roles/ Relationship Pattern - achievement of expected developmental tasks. C. Health Perception/ Health Management Pattern - management of any health problems D. Nutritional / Metabolic Pattern - dietary and other nutrition-related indicators E. Coping/ Stress-Tolerance Pattern - ability to manage difficult situations F. Cognitive/ Perceptual Pattern - self-management of pain, presence of communication difficulties, and deficits in sensory function. G. Value/ Belief Pattern - spiritual well-being H. Activity/ Exercise Pattern - health promotion that encourages the older adult to achieve the recommended 30 minutes daily of physical activity I. Rest and Sleep Pattern - sleep and rest patterns over a 24-hour period and their effect on function J. Sexuality/ Reproductive Pattern - older adult's behavioral expressions of sexuality. K. Elimination Pattern - encompasses bowel and bladder excretory functions 3 Factors influencing Nutritional risk in older adults i. Social - Isolation - Loneliness - Poverty (significant cause of weight loss) - dependency ii. Psychological - Depression - Anxiety - Dementia iii. Biological - COPD - Swallowing disorder (dysphagia) - Malabsorption, anorexia, stroke etc. Drug nutrient Interactions associated with poor appetite/weight loss - Digoxin, theophylline, metformin, various antibiotics, NSAID, psychotropic drugs such as fluoxetine, lithium, and phenothiazines A. Dehydration - at risk of dehydration caused by a decrease intake of fluids, loss of sodium, and increased fluid losses lead to electrolyte imbalance either hyper or hyponatremia - Confusion depression and dementia also contribute significantly to reduced food and fluid intake. Risk factors: - advance age 80y/o - female gender - residing in nursing home - infection - dementia 3 main forms: 1. Isotonic dehydration ( results from loss of sodium and water during GI illness) 2. Hypertonic Dehydration ( water losses exceed sodium losses, may occur with fever or limited fluid intake 3. Hypotonic dehydration ( may occur when sodium loss is higher than water loss, use of diuretics) Prevention - Provide fluids that adults like and enjoy drinking - Educate adults to drink fluids even if they are not thirsty - Identifying at risk older adults - Identify and treating treatable cause of dehydration - Measure the intake and output - Provide appropriately sized cups and glasses for older adults to handle and straws if necessary - Educating caregivers to offer small amounts of fluid each time they enter the room - Educating caregivers to encourage the older adult to drink 8 ounces of fluids between and each meal - Providing positive feedback to caregivers who provide fluid B. Micronutrient deficiency - vitamin d calcium and vitamins b12 deficiency - diet/supplementation C. Malnutrition - leads to anorexia of aging - state of being poorly nourished Two major markers of malnutrition - SARCOPENIA -- decline in skeletal muscle mass - CACHEXIA- loss of fat and muscle mass accompanied with anorexia D. Oral health - linked to tooth loss, pain, and discomfort, and can lead to poor food intake - Xerostomia is one of the most common causes of poor food intake in older adult. - reduced ability to taste food and may have cracked lips or a fissured tongue - Older adult are at risk for dental caries secondary to xerostomia - Older adult with dentures should be encouraged to remove daily E. Dysphagia - Swallowing disorder - Either identified as oropharyngeal or esophageal Causes: - Neuromuscular - muscular dystrophy, myasthenia gravis - neurological (stroke, Parkinson\'s disease, multiple sclerosis - weakened muscle, impaired coordination (in elderly) - Narrowing of the throat or esophagus - throat cancer, esophageal cancer - sacs or rings in the esophagus - gastric reflux (GERD) Complication - Choking - Pulmonary Aspiration - Poor nutrition Tx: - Muscle exercise - Change head/neck position - Soft food/thickened drinks - Surgery - Tube feeding Specialized nutritional support 1. Enteral nutrition 2. Parenteral nutrition Components of a healthy diet - The plates divides into quarters, with ¼ grains, ¼ protein, and remaining half for vegetables and fruits. - Older adults who are not eating close to these estimations might be inadequate - Fruits/vegetables (colored flesh, or packed in own juices or low NA) - Healthy oils - Herbs/spices (reduce need for salt) - Fluids - Grains (fiber/vit. B) - Dairy (protein/calcium) - Protein Pharma Geria Predictors Medication Response - General state of health - number and types of other medications taken - liver (sgpt), renal function - *creatinine* - presence of comorbidities or other diagnosed diseases Medication Error - Results from human knowledge based deficiencies and a lack of sophisticated systems to support and monitoring drug therapy. Medication Error Language 1. Adverse Drug reaction (ADR) - Any unintended response to drug when used to diagnose, treat, or prevent disease. - Difficulties in the ADL - Cognitive changes - Falls - Anorexia, nausea - Weight changes 2. Adverse Drug Event (ADE) - Any injury that results when medications are used - Both ADR's and medication error that lead to ADR - Too many/ wrong type of meds increase risk for ADE and non adherence. Factors that Contribute in Increasing Risk of ADE 1. Pharmacokinetic - What does the body do to the drugs Drug Absorption - does not usually contribute in drug response, less impact on pharmacokinetics - altered distribution into the peripheral circulation and tissues - decrease in plasma albumin levels with age - decrease in total body water, and intracellular water volumes Drug Distribution - Increase in body fat Hepatic Metabolism - age-related metabolism is not easily measured. - biotransformation occurs in liver (enzymatic activity alters and detoxifies the drug) Renal Excretion - the most important pharmacokinetic parameter that changes with age - changes is extremely variable - decline kidney function - requiring a decrease dose or extension of interval for certain drugs - SERUM CREATININE may be used as indirect estimate of renal function. - CREATINE CLEARANCE is an estimate of GFR and decreases with age. 2. Pharmacodynamic - What drug does to the body - Aging result in different response - Altered number of receptors or affinity. - Decreases in receptor binding. - Altered cellular response to the drug receptor- receptor interaction. - Organ pathologic condition. - Altered homeostatic mechanism. 3. Drug-Drug Interaction - Can alter pharmacokinetics/ dynamics - Alterations in hepatic metabolism as responsible - *Warfarin and aspirin = \^ bleeding* 4. Drug -- Food Interaction - *Theophylline and caffeine = \^ toxicity* - *Levodopa and clonidine = decrease antiparkinsonian effect* 5. Drug -- Disease Interactions - May exacerbate, c/i - *Aspirin, NSAID, atrophic gastritis = GI hemorrhage* Polypharmacy - Prescription, administration, or use of more medications that are clinically indicated in given patient. - *drug-drug interaction* - *ADE's and ADR's* - *Error of dosing* Prevention of Polypharmacy - Use of the same pharmacy to fill all prescriptions. - Notification to all prescribing clinicians of drug used. - Nurse obtaining a complete history of all drugs used. Federal Legislations 1. Omnibus Budget Reconciliation Act ( OBRA) 1987 - legislated the appropriate use of medications in institutionalized older persons. - *use of chemical restraint* - *use of unnecessary drugs* - Antipsychotic drugs should not be used unless necessary to treat a specific condition that is diagnosed and documented in the clinical record. 2. BEERS Criteria - Commonly used consensus criteria r/t inappropriate medications. - Developed in 1997, and adopted in 1999 by the Centers for Medicare and Medicaid Services - regulations of medications in nursing homes. - prescriptions for *long-acting benzodiazepines, persantine, propoxyphene* - long-term use of drugs that are to be used for short-term use only *( e.g. histamine blockers, short-acting benzodiazepines, oral antibiotics)* - High doses of drugs prescribed above dosage limitations *( Fe supplements, histamines blockers, antipsychotic agents).* Commonly Used Medications 1. Anxiolytic and Hypnotics - anxiety as significant problem associated with depression & dementia - according to the Beer's list, benzodiazepines with long half-lives should be avoided because of the increase toxicity. DAILY USE OF BOTH SHORT- AND LONG-TERM ACTING BENZODIAZEPINES - should be limited for less than 4 continuous months - should be limited unless an attempt at gradual dose reduction is unsuccessful - dose reduction should be considered after 4 months 2. Antidepressant - all antidepressant are generally equally effective and typically take effect in 2-4 weeks - tricyclic antidepressants avoided (anticholinergic and sedative side effect) - newer SSRI's are often considered the first choice (lack of TCA side effects) 3. Antipsychotics - valid and clear documentation of need exist - appropriate indications *(schizophrenia, paranoid states, and symptoms of psychosis such as hallucinations and delusion)* 3D's that may justify antipsychotic use: - Danger to the resident of others - Distress for the residents - Dysfunction of the resident, including interference with basic nursing care Conditions inappropriate - Wandering, Poor self-care, Restlessness - Impaired memory, Anxiety, Depression - Insomnia, Unsociability - Indifference to surroundings - Nervousness, Uncooperativeness - Agitated behavior when not a danger to other self or others If Receiving Antipsychotic Drugs - GRADUAL DOSE REDUCTION - DRUG HOLIDAYS-a patient stops taking a medication(s) for a period of time. - BEHAVIORAL PROGRAMMING unless contraindicated 4. PRN Neuroleptics - Are not to be used more than twice in a 7-day period without further assessment - purpose of titrating dosage for optimal response - for management of unexpected behaviors otherwise unmanageable. 5. Cardiovascular Medications - Older adults have an increased risk for orthostatic hypotension and dehydration - especially with volume-depleting agents and vasodilators 6. Antimicrobial - Dosing may need to be altered due to reduced renal elimination. Non-Prescription Agents - FDA'S 3 Main Criterias For Switching Prescribed Medication To Otc Status: 1. A record of established safety data for the prescription product is necessary. 2. The drug's expected use should be appropriate for OTC treatment. 3. The drug should lack undesirable property and not require special precautions when used without physician oversight. Non-Adherence / Compliance - Living alone without social support. - Visual or auditory impairments. - Increasing use of alcohol. - Socioeconomic factors. - Unpalatable bulk powders or large tablets. Nursing Management - if knowledge deficits are a problem, provide verbal education, reinforced with written instructions and allow time for clients feedback. - Encourage a client who "pharmacy shops" to have prescriptions filled at the same pharmacy each time. - Provide cues to assist remembering to take medications. - Reduce the impact of drug side effects. - Give adequate intake of fiber and fluid to reduce constipation. - Diuretics can be scheduled in the morning to reduce interruptions of activities and sleep. - Use of Isotonic liquids or sugar-free lozenges can help with dry mouth General Prescribing Principle 1. Encourage the discontinuation of one drug when another is added. 2. Consider reducing dosages - Weight is less than average. - Liver or renal function is decreased. - An individual experiences exaggerated responses to drug. 3. One drug should not be used to treat the side effect of another drug. - Better to change the offending drug. - Decrease the dosage in order to decrease the side effects. 4. ALTERNATIVES should be considered. 5. START SLOW, go SLOW. 6. TITRATE therapy. 7. Educate the client. 8. Review regularly. Measures to Manage Medication Correctly - Decreasing the number of pills to be taken in a day. - Establishing a routine for taking medications. - Preparing medications for the day in different containers. - Developing memory methods. - Scheduling in conjunction with other daily activities. - Using reminders such as telephone or e-mail. - Conduct a brown bag assessment. - Bring all medications including OTCs. Check - Outdated preparations - Unused or unfinished prescriptions - Overlap or duplication of medications [PROMOTING HEALTHY AGING] - An initiative of the US Department of Health and Human Services that set forth health care objectives designed to increase the quality and quantity of years of healthy life of Americans and to eliminate health disparities. - FOCUS: minimize the loss of independence associated with illness and functional decline Components of Health Promotion 1. Exercise - Reduction in Heart Disease, Diabetes, High Blood pressure, Colon CA, Depression, Anxiety, Excess weight, falling, bone thinning, muscle wasting and joint pain. Nursing Implication - Motivate the elderly - Advise the elderly to have continuous exercise. - Promote as a habit for the elderly. 2. Nutrition - Eating and drinking habits have been implicated in 6:10 leading cause of death in the elderly. - more prone to Obesity and Malnutrition. Nursing Implication - Proper Nutrition - Alcohol Consumption: Men twice a day, Women once a day. - Decrease Fats, Decrease Cholesterol Diet - Balance Caloric Intake - Daily Calcium, Vit. B12, Vit. D, Fruits and Vegetable 3. Mental Health - Decrease Income (50%) - Increase emotional losses - Physical losses - Caregiving responsibilities Nursing Implications - Life Review -- tool for preserving or enhancing the mental health of the older adults. (Life domains Autobiography, tape recording or videotape.) - Depression -losses that accompanying aging such as widowhood, chronic medical conditions and pain , and functional dependence. - Depression may lead to physical Decline. - Plays a significant role in suicidal behaviors. - Undetected in the elderly. 4. Model Health Promotion Programs for Older Adult - Programs that have received federal funding and foundation supports to evaluate their effectiveness and to encourage their replication. Health Wise - provides information and prevention tips on 190 common health problems. Chronic Disease Self Management Program - Founded by Nurse Researcher Kate Lorig. - Chronic Diseases: Self Management Program. Project Enhance - Enhance Fitness and Enhance Wellness Ornish Program For Reversing Heart Disease - Founded by Dr. Dean Ornish - Enhancement of Elderly Nutrition Benson's Mind/Body Medical Institute - Dr. Herbert Benson - Combination of Relaxation: Nutrition, Exercise, and - Reframing from Negative thinking patterns Strong For Life Model - exercised program for disabled and non - disabled older adults 5. Re-Engagement Instead of retirement - The likely alternative to retirement blessed with longevity, education, health and positive attitude towards remaining engaged. 6. Green House - Founded by Dr. William Thomas - An Innovative and home -like alternative to nursing homes. 7. Safety - Falls as leading cause of unintentional injury death in older adult. - Postural Instability - Decrease muscle Strength - Gait Disturbances - Decreased proprioception - visual/cognitive impairment - polypharmacy - Environmental conditions (Slippery surfaces, stairs, irregular surfaces, poor lightning, incorrect foot ware, obstacles in the pathways.) FALL-RISK ASSESSMENT: "I H ATE FALLING" - I -- nflammation of joints or joint deformity. - H -- ypotension (Orthostatic Blood pressure changes) - A -- uditory and Visual Impairments - T -- remors - E -- quilibrium problems. - F -- oot problems. - A -- rrythmias, heart block, valvular disease. - L -- eg Discrepancy - L -- ack of conditioning (General Weakness) - I -- llness - N -- utrition - G -- ait disturbance Disease Prevention - Helps prevent functional decline. Levels Of Disease Prevention - Primary Prevention -- completely prevent a disease from occurring. - Secondary Prevention -- early detection and management of disease. - Tertiary Prevention -- manage clinical disease to prevent them from progressing or to avoid complications of the disease. Quality of Life - How a person rates his or her life as satisfactory or not. - Degree of Satisfaction and Dissatisfaction with life - WHO (1994) - An individual's perception of his or her position in life in the context of their culture and value system where they live in and in relation to their goals, expectations, standards and concerns. Quality of Life Model - Physical Well Being - Functional Ability - Strength/Fatigue - Sleep/Rest - Nausea, Appetite and Constipation. - Psychological Well Being - Anxiety, Depression - enjoyment, leisure - pain distress, happiness, fear - cognition/attention. - Social Well Being - Caregiver burden - roles and relationship - affection/sexual function - appearance. - Spiritual Well Being - Suffering - meaning of pain - religiosity - transcendence. Quality Of Life Program - Active Aging - Integrated health and quality of life program. - Optimizing opportunities for health, participation in the community and safe living to enhance quality of life. - Center of Active Aging: Provide quality of life to the elderly. - Enhance Autonomy, Independence, and Activity - WHO's Determinants Of Health - Affects aging and the quality of life of individuals, communities and nations. 1. Behavioral Determinants Physical Activity - contributes to muscle strength, flexibility, balance, cardiovascular health - positive mood and improves cognition. Nutrition - powerful and modifiable lifestyle factors. - Increase in Vitamins and Minerals - increase in Vit. B6, B12, D, K and folic acids - anti-oxidants Vitamins A,C, E - Beta -Carotene, Selenium, Calcium and Iron. Smoking - single most important preventable risk factors that cause Premature Death. - 5 A's : Ask, Advise, Assess, Assist and Arrange. Alcohol Abuse and Alcoholism - increase effects of Alcohol - Four Steps in Treating Alcoholism - Identify individuals requiring treatment - Determine individual's readiness to discuss treatment. - assess individual's requiring detoxification. - Plan for post detoxification treatment in coordination with other professional. Medication Adherence - Non-Adherence to medication. - Invisible epidemic ▪ Promote Self -efficiency. ▪ Empower patients to become informed medication consumers. ▪ Avoid strategies that could intimidate. ▪ Help the patient to develop a lists of short term goal and long term goals. ▪ Plan for regular follow -up ▪ Implement a reward system. 2. Personal Determinants: - Biological - Genetic Impacts 3. Psychological Determinants: - Intelligence - Cognitive Capacity 4. Physical Determinants - Safe Housing 5. Social Determinants - Social Support - Violence and Abuse - Education and Literacy 6. Economic Determinants 7. Social Services Determinants Home Care - Consist of multiple health and social services delivered to recovering, chronically ill, or disabled individuals in their place of residence 3 Main Category of Home Care - Home care organization - Medicare-certified agencies include hospice and free standing - Facility based home health agencies Indication for Home Care - Have a skilled care need - Be homebound - Be unable to perform the skilled care alone and have no one in home to provide care - Require only intermittent care High Risk Indicators for Home Care - Unexpected readmission to hospital within 15-30 days - Frequent readmissions - Alteration of health care problems or management - Changes in mental status - Nonadherent behavior before or during hospitalization - Terminal or pre terminal condition - Seen in the hospital by physical, occupational or speech therapist. - After amputation - After hip or knee replacement - New assistive device - Foley catheter etc. - Enteral or parenteral feeding - Ostomies or tubes of any kind - Draining wounds - After wound debridement or irrigation and debridement of pressure injury - Pain management - Intravenous antibiotics - PIC line - IV chemo - Multiple medication or a major medication change - Ventilator dependence - Low air loss bed or other complex medical equipment Palliative Care - reducing the intensity of uncomfortable symptoms Hospice Care- - Medical care for people with an anticipated life expectancy of 6 months or less Community Based Services - indicates impairment does not necessarily indicate the need of for institutionalization, but it means older adult needs assistance Area agencies on aging - Older American act (OAA) of 1965 to remove barriers to independent living for older individuals and to ensure the availability of appropriate services for those in need Multipurpose senior centers - Services includes health promotion - Based on Section 4 of RA 7876, all cities and municipalities in the country are required to establish a senior citizens center with an area of 500 square meters. Adult day care services - for older adults who require some supervisions but who do not need continuous care Respite Care - for persons providing home care to ill - provided on a regular schedule (4 hours a week) or for longer time intervals Life Care Residences Philippines - Homemaker services- include such things as housecleaning, laundry, food shopping, meal preparation, and running errands - Nutrition services- provide older adults with inexpensive, nutritious meals at home or in group settings - Telephone monitoring and friendly visitors- allows communication line and visitation hours to senior residents - Personal emergency response system- home monitoring system that allow older person to obtain immediate assistance a small device worn on the body - Assisted Living- rental housing arrangement that provides room, meal, utilities, and laundry and housekeeping services for a group of residents. Characteristics of Adult Acute Care - Polypharmacy- inappropriate number of medication - Falls - 79 % of all adverse inpatient incidents are related to fall - 65 or older experience most fall - 10 % fall more than once during hospital stay Infection - UTI are second most frequent - GI tract infection Hazards of immobility - Prone to rapid loss of muscle 5 Nursing Homes in the Philippines for Different Elderly Needs a. RainTree Care - "premiere senior residence in the country" - specializes in caring for the elderly with dementia and Alzheimer's b. Life Care - the first and only assisted living facility in the Philippines, incorporates IT in assisting seniors in ADLs c. Mabuhaii Nursing Home - welcomes the elderly and their family to experience belongingness within the community. d. Golden Groves - Assisted Living provides 24/7 care e. Home Health Care - provides house calls with the help of its private duty caregivers - (service starts at Php 1,000 for a 7:00 a.m. to 7:00 p.m. duty), nurses (Php 1,500), physical therapists (Php 1,100/one-hour session), and doctors (Php 5,500). Nursing care of the older adult with chronic illness Disturbance in Sensory Function a. Presbyopia - loss of visual acuity; - reduced elasticity and stiffening of the muscle fibers - reduced pupil size - Sensitivity to glare - reducing peripheral vision. - fewer tears and drier - Visual limitations b. Presbycusis - reducing ability to hear s, sh, f, ph,and w. - Telephone conversations can be affected c. Presbyosmia - loss of olfaction (smell) d. Ageusia - loss of sense of taste Sensory Health Promotion Promote Vision by: - Routine and thorough eye examinations - Stress importance of annual eye exam - Evaluate financial ability - Review diet - Essential Fatty Acid healthy retinal function - Flavonoid improves night vision - Vitamin C promotes normal vision, reduce the risk of cataract - Vitamin E may aid in preventing cataracts; - Selenium - Vitamin B complex prevent elevated levels of homocysteine - Zinc Promote Hearing by: - treatment of ear infection, prevention of trauma of the ear - examine ear frequently for cerumen application - Avoid use of cotton tip applicator - Ear irrigation can help to remove cerumen accumulation - protect the older person - Provide health education about the effects of environmental noise on hearing ear plugs Common Visual Condition Among Geriatrics Patient: 1. Cataract- clouding of the lens Risk Factors: - excessive exposure to ultraviolet light; - Diabetes, smoking, high alcohol - consumption and eye injury Clinical manifestation: - vision is distorted, night vision decreased, and object appear blurred, - Glare from sunlight - Color of the pupil change from black to white Treatment: - Phacoemulsification; Surgery (can be done outpatient) - Post op care: Sunglasses, sheer curtain over windows furniture placed away from bright light, non strenuous activity within a day. - AVOID lifting heavy objects 2. Glaucoma- optic nerve is damaged from above normal intraocular pressure, Drugs with anticholinergic properties can exacerbate glaucoma due to their effects of dilating pupils. a. Acute Glaucoma (closed angle and narrow glaucoma) - sudden onset of severe unilateral eye pain with blurred vision Clinical manifestations: - severe eye pain, headache, nausea and vomiting Treatment: - Medication: mannitol, carbonic anhydrase - Iridectomy b. Chronic Glaucoma (open angle glaucoma) - More common - peripheral vision becomes slowly but increasingly impaired Clinical manifestations: - tired feeling in their eyes, headache, misty vision, or seeing - halos in the light, Cornea may have a cloudy appearances, and the iris maybe fixed and dilated Treatment: Iridectomy 3. Macular Degeneration - damage of macula - Common cause of blindness Clinical manifestation: Loss of central vision Treatment/Management: - Laser therapy - Magnifying glass high intensity reading lamps and other aids can prove helpful to this condition CHRONIC CONFUSION 4. Delirium - rapid onset of short-term memory - disoriented, confused, distorted thinking, incoherent speech Cause: - medication side effect, circulatory disturbances, dehydration, low or high blood pressure, low or high blood glucose, surgery, stress Clinical manifestation- - highly agitated - (illusions, hallucinations, exaggeration of personality features Recovery - disease can be reversed and normal mental status restored 5. Dementia - Irreversible impairment in cognitive function affecting memory language, sudden movements which can cause