Gero Midterm Study Guide.docx

**[HEALTHY AGING]** Healthy Aging "I believe the second half of one's life is meant to be better than the first half. The first half is finding out how you do it. And the second half is enjoying it."  \~Frances Lear Aging - Associated with changes in biological, physiological, environmental,...

**[HEALTHY AGING]** Healthy Aging "I believe the second half of one's life is meant to be better than the first half. The first half is finding out how you do it. And the second half is enjoying it."  \~Frances Lear Aging - Associated with changes in biological, physiological, environmental, psychological, behavioral, and social processes. - Many theories try to explain aging, no single answer - Everyone's aging experience is different - Can slow aging but it cannot be stopped **[\*\*Aging Theories\*\*]** - **Biological Theories**: Wear and Tear, Free Radical, Apoptosis - **Sociological Theories:** Disengagement, Activity - **\*Psychological Theories:** Erikson- ego integrity vs. despair, Gerotranscendence-legacy building - **Successful Aging Theories:** Neugarten- dependent on personality, coping & adaptation ability - No one theory fully explains the complex process of aging **[Applying Theories]** - Whether you are aware or not: theory guides every aspect of nursing practice - Aging theories: guide our interventions and promote healthy behaviors - Two Frameworks to Know - \*\*Register's Middle Range Nursing Theory for Generative Quality of Life (QOL) for the Elderly - Elizabeth register developed nursing theory looking at QOL for older adult - \*\*The WHO Health Aging Framework **WHO, Decade of Healthy Aging, 2021-2030 & Health Aging Framework** - Healthy Aging- functional ability that enables wellbeing in older age - Meet their basic needs to ensure adequate living - Learn, grow, and make decisions - Be mobile - Build and maintain relationships - Contribute to society - Dependent on intrinsic capacity and supportive environments - "Creating opportunities that enable people to be and do what they value throughout their lives" **Challenges to Healthy Aging/QOL** - Life Transitions - Changes in familial role and relationships - Loss of spouse, friends, other family members - Functional & mobility changes - Serious illness, cognitive decline - Stress, mental health **Reminiscence and life review as part of healthy aging** - Reflection of the self - Self-understanding and self-evaluation - Self-discovery and identity maintenance - Validation of existing - Letting go **[AGING TRENDS]** **US Population Projections** - Growth is slowing - 65+ population will almost double by 2060 - More Ethnically diverse - International Migration largest contributor to US population growth **Factors Influencing demographic changes** - Baby boomers - All baby boomers will be over 65 by 2030. Population over 85 to grow by 200% by 2060. - Advancing healthcare - Increasing life expectancy, living longer with chronic illness, lower infant mortality rates. - Changing Population - Decreased fertility rates, slowing growth of population, increasing ethnic diversity. **Characteristics of the Older Population: Social Characteristics** - Achieving higher levels of education - Age-related - Staying in the workforce longer - Bills, inc cost of living, ss/pensions are not increasing, boredom, less physically demanding jobs, not everyone is financially prepared to retire - More informed health care consumers, demand quality care - Interested in technology - As person gets into mid to late 80s, the wiring starts to change and they may not be as tech savvy as they used to be - Increased geographical mobility - Can get around/travel - 27% of adults \> 60 live alone - Women \> Men, 79 men:100women (right now, number will change as boys today outnumber girls) - Ratio becoming more balanced due to increasing life expectancy among men **Characteristics of the Older Population: Health Characteristics** - 80% of older adults have at least one chronic health condition - Chronic conditions \> acute conditions - Less acute conditions - More complications - Take longer to recover - Poorer health outcomes Pneumonia, UTI, flu acute illness **Characteristics of the Older Population: Financial Characteristics** - Living on decreased, fixed income. - Social Security most common form of income. - Not enough to live on - Most people do not have pensions. - Medicare most common form of health insurance. - Still needs supplement - As older adults age, poverty rates increase - Older women and persons of color have highest risk of poverty **Social Determinants of Health** - "Nursing has a clear mandate to ensure access to health and health-care by providing sensitive, empowering care to those experiencing inequities" (p. 219) - Conditions in which one is born, grows, lives, works, and ages are key determinants of health. - Impact of Social Determinants of Health accumulate over the course of one's lifetime - Intersectionality of ageism, racism, gender identity discrimination, and SDOH - Inequities contribute to poorer health outcomes and disparities as people age - Increased risk of geriatric syndromes **Societal Implications & Solutions: For an Aging Population** - Implications - Increased care needs/ nursing shortage - Change in where caregiving is provided - Get it back into home versus expensive hospital - Infrastructure to support an aging society - Increased healthcare expenditures - Care provider education, professional and family - Solutions - Address nursing shortage - Develop home-based care strategies - Create age friendly communities and healthcare, increase access - Develop policies to address increased expenses - Increase gerontology training and family education **[AGEISM]** "For older people, ageism is associated with a shorter lifespan, poorer physical and mental health, slower recovery from disability, and cognitive decline" (WHO, 2021, p. XVI) By the end of this content, you will be able to: - Assess one\'s own values and beliefs around ageism and implicit bias. - Discuss strategies to mitigate personal and systemic healthcare bias. What are some examples of aging myths? Myths of Aging - Depression and loneliness are normal in older adults - Older adults will get dementia - Older people are set in their ways and cannot learn new things - Older adults are a drain on society - Older people are cranky - Older adults have no interest in sex **Explicit Bias:** attitudes and beliefs that we have about a person or group on a conscious level. We are aware of these so they can be self-reported **Implicit bias:** unconscious attitudes that lie below the surface, but may influence our behaviors **Addressing Implicit Bias on an Individual Level** - Actively engage in reducing implicit bias - Develop awareness - education - Provide person-centered care/individuation - Perspective-taking/empathy - Expand your social circle - Use multiple strategies **Call to Action: Be aware of language and communication** - Do - Be person-centered, aging is unique for each individual - Use inclusive language - Focus on capabilities - Use preferred terms: older adults, older people. Ask! - Don't - Make generalizations or promote stereotypes - Treat them as "others" - Focus on disabilities - Use demeaning terms: honey, old, senior **Addressing Bias in the Healthcare System** - Non-judgmental - Seek understanding of: - Beliefs, values, traditions, and practices of various ethnic and racial groups - Do not stereotype, there is diversity within groups. - Unique health-related needs, experiences, and risks. Know their story. - Language barriers affecting communication. Preferred language. CLAS Standards - Advocacy- ongoing equitable and inclusive care - Cultural humility - "life-long process of self-reflection on one's personal values and self-critique of one's personal biases as they affect policy, education, practice and research" **Ethical, Personal, & Emancipatory Knowing** Call to Action: Changing the perspective on aging and the experience of aging - Aging is "the process of developing and maintaining the functional ability that enables well-being in older age" (World Health Organization, 2021). - Not merely the absence of disease - Shift from deficit model to strengths-based model - Value older adults' strengths, abilities, and capabilities **[COMPREHENSIVE GERIATRIC ASSESSMENT]** **Comprehensive Geriatric Assessment (CGA)** - Caring for older adults is complex due to normal age-related changes and multiple chronic conditions - Person centered, interprofessional approach - Completed annually, preferably with every patient encounter-outpatient - Adapted and modified for inpatient - Purpose of a CGA - Promotes function, independence, and quality of life - Help to keep older adult in their home - Minimize functional and cognitive decline **Comprehensive Geriatric Assessment: Components** - Physical Exam - Functional Assessment - Social Assessment - Psychological Assessment - Environmental Assessment - Spiritual Well Being - Sexuality and Intimacy Assessment - Advance Care Planning **Physical Exam** - Performed by primary care provider (MD, DO, NP, PA) - Many aspects performed by nurse or interdisciplinary team member - Medical & surgical history - Physical Exam- - Opportunistic exam - May need to conduct in multiple sessions - Bone Health- risk assessment **Nursing Assessment** - The gerontological nurse will use evidence-based instruments to identify risks, problems, and potential geriatric syndromes - Geriatric Syndromes - Multifactorial health conditions with impairments in multiple systems - Results in increased vulnerability to situational challenges, associated with decline and poor outcomes - Cannot be categorized in a specific disease category - Requires interdisciplinary, holistic care - Syndromes- frailty, falls, urinary incontinence, delirium, pressure ulcers A diagram of a disease Description automatically generated 4Ms and SPICES - **4Ms** - Mobility - Medication- polypharmacy, medication reconciliation, deprescribing - Mentation- cognitive impairment- MiniCog, delirium- CAM - What Matters- ask the older person! - **SPICES** - S - sleep - P - problems with eating - I - incontinence - C - confusion - E - evidence of falls - S - skin breakdown **Functional Assessment** - Systematic evaluation of the older person's level of function and self-care abilities. - Person's ability to complete ADLs and IADLs - Lawton IADLs - Katz ADLs - Mobility - Timed Up and Go (TUG) test - Cognitive Status - Mini-Cog, MMSE, MOCA, SLUMS - Medications and medication management - Purpose- to identify care needs and potential resources needed **Social Assessment** - Older adults who are socially engaged have improved health outcomes - Social history - Level of education, languages spoken, literacy, occupation, significant life events, are they a veteran? - Family history - Number of children, married? - Current circumstances - Who do they live with? Are they involved in church, community organizations? - Support system - Finances - Identify needs and provide community resources where available **Psychological Assessment** - Mental health history - Delirium- Confusion Assessment Method (CAM) - Dementia- screen and referral - Depression- geriatric depression scale (GDS) **Environmental Assessment** - Focused on safety - Prevention of falls - Home safety assessment - Flooring - Lighting - Steps & stairways - Electrical cords - Kitchens & bathrooms - Inpatient- situational assessment - Identify hazards - Fall prevention **Spiritual Well Being** - Personal search for meaning and purpose in life - Spiritual well being is connected to better outcomes - Religious and cultural assessment - Characteristics of Spiritual Distress - Dissatisfaction with personal past or present - Depression, Crying - Self-destructive behavior or threats - Fear - Feelings of abandonment - Feelings of hopelessness - Honor person's wishes **Sexuality and Intimacy** - Positive sexual relationships integral to maintaining health in later life - Need for intimacy doesn't decrease with age - Sexual issues may be a sign of underlying conditions - Assess relationship status and if the person is sexually active **Health Promotion and Prevention** - Educate about vaccine preventable diseases - [Seasonal influenza vaccine]: annually, - Adults 65yrs and older should receive the high dose flu vaccine - [Pneumococcal vaccine:] 65yrs and older, one dose of PCV15, then one year later receive one dose of PPSV23 or one dose PCV 20 - [Tetanus-Diphtheria Toxoid (Td)] booster every 10 years - [Shingles] (Shingrix) vaccine: 50yrs and older receive two doses 2-6 months apart - Immunocompromised older adults will have different dosing schedules **Screening Recommendations** - Breast cancer Women: every 2 years ages 50--74; none ≥ 75 years - Cervical cancer None for women over 65 if normal Pap smears and not at high risk for cervical cancer - Colorectal cancer Colonoscopy every 10 years; sigmoidoscopy every 5 years with FOBTs every 3 years or FOBTs every year age 50--75 years; no routine screening 76 to 85 years - Prostate cancer No PSA screening of all ages - Lung cancer Annual CT for ages 55--80 years with 30-pack/year history, currently smoke, or quit in past 15 years, stop after completing 15 years without smoking - Skin cancer None, evidence insufficient **Advance Care Planning** - Discussion that helps older adult reflect on: - Values, goals, and preferences - Conveys wishes for end-of-life care - Advance Directives include: Living wills, durable power of attorney (POA) for health care, & DNR - POA- identifies someone to make decisions for the older adult if they are unable to do so - Living Will- states wishes regarding treatment at end of life. They do not designate a healthcare decision maker. - Older adults should be encouraged to have advance directives in place to ease the burden on their family and to make their wishes known. - Complete when able to make decisions and not an urgent situation - Not a medical order **Physician Orders for Life Sustaining Treatment (POLST)** - Appropriate for someone at risk of medical emergency and at end-of-life (life expectancy 1-2 years) - Communicates what the patient's wishes are regarding treatment - CPR, mechanical ventilation, ICU, use of antibiotics, artificial nutrition & hydration - A medical order - Can be used in all settings **Do-Not-Resuscitate (DNR)** - Must be on chart as a provider order or POLST order - CPR is often not successful in older adults - Those who survive often suffer neurological damage and sternal injuries - Results in decreased quality of life - Advance Directives, CPR, and when appropriate POLST should be discussed with all older adults as part of their health care visits and planning **Care Planning** - Focus should be on: - Incorporating older adult's preferences - Incorporating strengths - Minimizing functional decline - Maximize independence - Safety and managing risks - Respecting the older adult's rights and autonomy **Atypical Presentations** - More common in adults over 85 - Multiple co-morbidities - Polypharmacy - Cognitive or functional impairment - Not recognizing atypical symptoms can result in increased morbidity and mortality, missed diagnosis, and increased ED visits and hospital admissions - Atypical presentations include - Vague presentation of illness - Altered presentation of illness - Non-presentation of illness **Vague presentation of illness** - Changes in behavior or function often early symptoms of acute illness - Changes may be subtle and need timely identification - Common presentation - Confusion - Falls - Incontinence - Self-neglect - Anorexia - Fatigue **Altered presentation of illness** - Infectious Diseases - Absence of fever - Falls, decreased appetite, confusion, change in functional status - Abdominal disorders - Absence of symptoms to mild discomfort - Constipation - Tachypnea and vague respiratory symptoms - Myocardial Infarction - Absence of chest pain - Vague symptoms of fatigue, nausea, decrease in functional status - Classic presentation: shortness of breath - Depression - Somatic complaints - Changes in appetite, vague GI symptoms, constipation, sleep disturbances **Non-Presentation of Illness** - Illnesses may go unrecognized in older adults for years. Due to: - Insidious nature and vague symptoms - Symptoms seen as normal aging - Reluctance of older adults to report symptoms - Communication barriers - Common "hidden" illness - Depression - Incontinence - Falling - Alcoholism - Dementia - Sexual dysfunction **[GEROTONOLOGICAL NURSING]** **Gerontological nursing** is: - Evidence-based specialty - Addresses the unique physiological, social, psychological, developmental, economic, cultural, spiritual, and advocacy needs of older adults. - Focuses on: - Process of aging and the protection, promotion, restoration, and optimization of health and functions - Prevention of illness and injury - Facilitation of healing - Alleviation of suffering through the diagnosis and treatment of human response - Advocacy in the care of older adults, carers, families, groups, communities, and populations. **Gerontological Nursing Principles** - Identify and highlight the strengths and abilities of older adults - Help maximize their independence and function - Minimize disability and functional decline - Improve or maintain quality of life - When appropriate, achieve a peaceful and dignified death. - Caregiver, teacher, leader, advocate, evidence-informed clinician **Gerontological Nursing Care Across Settings** Age Friendly Movement - Nurses play pivotal role: - Enhanced knowledge about aging - Promote age healthy systems and remove barriers - Expanded focus on health promotion and prevention in communities - Advocacy - WHO, Global Network of Age Friendly Cities and Communities - 2017 John A. Hartford Foundation & the Institute for Healthcare Improvement, Age Friendly Health Systems - Age Friendly Universities- collaborative out of Ireland **Age Friendly Communities** - Aging in place - Optimize health by addressing the following aspects of the community - Outdoor spaces - Transportation - Housing - Social participation - Respect and social inclusion - Civic participation & employment - Communication and information - Community support and health services **Nursing in Community Settings** - In the home - Home Health Care - Hospice - Adult Day Services - Community and Senior Centers - Adult Day Care Programs - Primary Care Providers - Community Care Models - PACE, LIFE centers - Senior Living Communities - Range of services, amenities, low-income housing **Age Friendly Health Systems** - Age Friendly Care - Follows evidence-based practices - Aligns with what matters to the older adult and their caregiver/s - 4Ms - What matters: know and align care with each older adult's specific health outcome goals and care preferences including, but not limited to EOL care and across settings of care - Medication: if meds are necessary, use Age-Friendly meds that do not interfere with other Ms - Mentation: prevent, identify, treat and manage dementia, depression, and delirium across settings of care - Mobility: ensure that older adults move safely every day in order to maintain function and do what matters - IHI Age Friendly - Being implemented across settings **Financing Healthcare for Older Persons** - 1965 Formation of the Administration on Aging; enactment of Older Americans Act - Introduction of Medicare and Medicaid. Centers for Medicare & Medicaid Services (CMS). - Medicare: federally funded, health insurance program. - Aged 65 and older - Qualify for Social Security due to disability - All ages with End-Stage Renal Disease Financing Healthcare for Older Persons - **MEDICARE** - Part A: Hospital, hospice, and some skilled health care (rehab). 2022 deductible \$1556 - Part B: Physician and nursing services, outpatient care, preventative care (x-rays, laboratory, etc.,). Covers some PT, OT, and equipment. Monthly premium, minimum of \$170 and goes up with incomes over \$91,000. Deductible (\$233 & 20% co-pay) - Part C: Medicare Advantage Plans (MA) -- private insurance plan approved by Medicare. Covers additional services. - Part D: Prescription Drug Plan available to everyone with Medicare. Purchase through private insurer. Most have monthly premium and copays. - Vision, dental, hearing, Rx drug plan - Catastrophic coverage - Medigap Plans: Supplement insurance sold by private insurance companies. Can pay for copays, deductibles. Only for Part A & B enrollees, not MA. Must enroll in initial 7-month period to not be charged for preexisting conditions. Financing Healthcare for Older Persons: **Medicaid** - Supported by federal and state funds. - Each state has different regulations and requirements - Provides insurance for individuals of all ages with limited income and resources- must meet state eligibility - Medicaid supplements Medicare for older individuals who are dually eligible and pays for most nursing home care. **Acute Care Setting** - Higher rates of hospitalization - Longer length of stay (LOS) - Increased risk of complications - Nosocomial Infections - Iatrogenic complications: Delirium, falls, pressure ulcers, dehydration, incontinence, constipation - Loss of mobility and functional status **Acute Care Gerontological Nursing Approaches** - Identify patient's preferences for care. Implement 4Ms - Assess & identify potential complications and safety risks - Prevention of complications - Promote independence - Monitoring of medications - Preparing for their return home - Education - How do we prevent complications and functional decline? **Caregiver, Advise, Record, Enable (CARE) Act** - Enacted in PA in 2015, currently in 40 states - Requires hospitals to identify a layperson caregiver - Include this caregiver in all healthcare decisions and discharge planning - Applies to all patients, no matter their age - Nurses have an opportunity to better prepare caregivers **Rehabilitative Care** - Can be in the sub-acute or long-term care environment - Sub-acute- 3 hours of therapy a day - Long-term- 1 hour of therapy a day - Eligibility - Eligible for 21 days of Medicare coverage with 3+ day stay in hospital. - Presence of increased incidence of falls, disability, or frailty - Goals of Care - Improve functional capacity - Maximize independence with ADLs - Promote well-being and QOL - Gerontological Nursing Approach - Know the unique capacities and limitations of the individual - Focus on strengths and capabilities - Do with not for - Be patient. Older person's take longer to recover during rehab but can have full recovery **Skilled Nursing Facility (SNF)/Nursing Home** - Only about 4% of older adults live in a nursing home - Reasons for nursing home admission - Functional ability determines the need for LTC placement - Progressive physical or cognitive impairment - Caregiving needs exceed the caregiver's abilities - A crisis/emergent circumstance - Rehabilitation **1987 OBRA, Nursing Home Reform Act/ Omnibus Budget Reconciliation Act** - Improved conditions of nursing homes - Ombudsman Program - Established resident bill of rights - Culture Change - Requires compliance with federal regulations - Centers for Medicare and Medicaid Services (CMS) - Comply with quality measures that evaluate nursing care - All residents must be assessed with standardized **Minimum Data Set (MDS)** - Assessment must be performed by a Registered Nurse Assessment Coordinator (RNAC) - Established **Quality Measures** for all nursing homes - Moderate to severe pain reports, falls with injury, vaccinations, presence of pressure injuries, UTI, indwelling catheters, incontinence, use of restraints, weight loss, increased dependency with ADLs, depressive symptoms, antipsychotic medication use - Nursing homes must collect data and show continual **Quality Assurance and Performance Improvement (QAPI)** - Surveyed annually by state representatives funded by CMS - Review data on quality measures - Average cost of Nursing Home in Philadelphia area \$120,000/year - Medicaid pays for majority of nursing home care - Finding a nursing home for your loved one: - Comparing Nursing Homes **Assisted Living** - Appropriate for individuals who need minimal assistance with ADLs - Combines independent apartments with - Provided meals - Medication management - ADL assistance as needed - No home maintenance - Scheduled social activities - Memory Care Units - Average cost in Philadelphia about \$60,000/year - Most care not covered by Medicare/Medicaid **Respite Care** - Form of short-term care, provided in a range of facilities - Provides temporary relief for family caregivers - Scaled to older adult's need (In-home care, Adult Day Services, Assisted Living, SNF) - Varies in length of time used - Often not covered by insurance **Care Transitions** - Anytime an individual transfers from one care setting to another - Older adults are more vulnerable to errors and disruptions in care - Common barriers: - lack of patient and family caregiver engagement - lack of collaboration among team members - Inadequate patient and family caregiver education - Poor continuity of care and communication - Gaps in services **Transitional Care** - A set of actions designed to improve coordination and continuity across settings - Benefits: - Enhances patient experiences - Improves health outcomes & quality of life - Includes a broad range of services - Designed to improve safety - Shown to reduce hospital readmissions - Decreases care costs **Promoting Successful Transitions** - Interdisciplinary approach - Active and early family engagement - Person centered care - Individualized patient and caregiver education - Communication between sending and receiving clinicians - Summary of care provided by sending institution - Reconciliation of medications **Models of Care for Older Adults** - Seek to provide interdisciplinary care across all settings - Often require nurses with specialty training in gerontology - Examples: - Transitional Care Model (TCM) - Program for all-inclusive care of the elderly (PACE) - CAPABLE- developed by our previous dean and nurse at John Hopkins - Acute Care for Elderly units (ACE) - Nurses improving care for health system elders (NICHE) **[POLYPHARMACY AND MEDICATION SAFETY IN THE OLDER ADULT]** Older adults have increased safety risks related to medications - Risks include - ARCs and impact on pharmacokinetics and dynamics - Polypharmacy - When they take a bunch of medications More than 5-6 - Chronic conditions - Start Low and Go Slow After a lot of observation and monitoring pt **Pharmacokinetics and Aging** - Absorption - Decreased GI motility Possible alteration in absorption of medication - Decreased emptying time - Increased gastric pH due to decrease acid production - Dec production + dec motility = gastric juice sits there and elevation in pH - Effects pharmacodynamics and how it is broken down - Can be altered by antacids, PPIs, anticholinergic medications - Protonix - PPIs -- anticholinergic effect dec acidity - Play an effect on smooth muscle - Difficulty CNS and PNS handle drugs - CNS -- confusion, memory loss, disorientation - Distribution - Decrease in body water decreases volume of distribution can increase concentration of water-soluble meds Increased toxicity - Beta blockers and digoxin are sensitive to elderly - s/s of toxicity: confusion, restlessness - could go into cardiac arrest, bradycardia, hypotensive - Increase in body fat increased volume of distribution results in prolonged half-life for fat soluble medications - In your system longer, slower to breakdown, longer to get out of the system, what should you do? - Going to be excreted slowly, in body longer. More effective med as it remains longer in body - Decrease in serum proteins (albumin)- increases toxicity of protein bound meds - Bind to protein molecules in body. Low protein, can only bind to so many. Rest are free in body and can build up to toxicity and really concentrated amounts - Metabolism (active med to less active) - Decreased liver blood flow and size delays and decreased metabolism increases half life. How do you adjust dose? - Up to a 35% reduction in hepatic blood flow - Look at pt LFT, start out with low dose and monitor pt. might monitor blood levels and inc slowly - Drug that normally starts at 100 mg in older adult you would start w 50 mg - Risk for Increased toxicity with first-pass drugs. - More stuff stays in body than we want it to - CYP450 slowed! Warfarin and phenytoin (Dilantin-seizure) levels will be higher - Interferes w metabolism and can slow it down - Increased risks with increase in number of meds - \*start w half of the dose and adjust the med as needed - Excretion - Decreased renal blood flow, decreased GFR (up to 50% by age 90) increased toxicity for renally excreted meds. NSAIDS decrease renal blood flow and function - GFR starts to change in your 40s - If unable to excrete med, buildup toxic effects - Seen a lot w NSAIDs **Other age related considerations** - Changes in drug receptor sensitivity (Pharmacodynamics) - Increased sensitivity, increases drug effects: anticholinergics, antihistamines, barbiturates, benzodiazepines, digitalis, and warfarin - Benadryl increased confusion - Decreased sensitivity, decreases drug effects: amphetamines, beta-blockers, quinidine - Iatrogenic Concerns -- SE from medications and other factors, just being in the hospital - Side effects caused by treatment or medication - Can contribute to ADEs - Adverse drug event - Visual and Hearing changes (ARC) - Interferes with safe administration - IV Lasix pushed quickly causes ADE - Push slow - - Changes in cognitive function - Increases risk of anticholinergics effects, increased CNS adverse effects - Confusion, forgetfulness \*Older adult is more sensitive\* BEER's criteria **Impact of Chronic Conditions** - Cardiac diseases - Impaired cardiac output- decreased distribution, metabolism, and excretion - Greater susceptibility to cardiac adverse effects - Kidney and liver diseases - Decreased drug clearance and metabolism - Neurological diseases - Impaired cerebral blood flow - Anticholinergics cause confusion ADEs - Greater sensitivity to CNS effects **What is polypharmacy?** - Individuals taking 5 + medications - 30% of adults 65+ take 5 or more medications - People 65yrs and older account for 33% of prescriptions but only 15% of the population - Includes supplements, herbals, and OTC - Regimens are increasingly complex - Med reconciliation - When we do them - At admission - Discharge - Transfer of floor or unit to unit Brown bag effect -- patient brings all of their meds w them to visit in a bag to you **Contributors to Polypharmacy** - Prescribing cascade -- ADR misinterpreted as new health condition - ACE-I cough - NSAIDS HTN - Multiple conditions - Increased number of OTC medications - Recent or frequent hospitalizations - Uncoordinated care - Seeing mult physicians and they don't know what the other is doing due to lack of communication **Risks of polypharmacy?** - Increased hospitalizations - Development or worsening of geriatric syndromes - Adverse Drug Events - Duplication of drug therapy - Poor adherence - Cost - Decreased quality of life **Prevention of Polypharmacy** - Prevent the use of Potentially Inappropriate Medications (PIMs) - Beers Criteria, STOPP/START - Deprescribing - Patient communication and education - Medication reconciliation, brown bag - Medication management interventions **Adverse Drug Events (ADE)** - Injury that results from a medication - Drug to drug interactions - Drug to disease interactions - Drug to food interactions **ADEs and the older adult** - 34.5% of ED visits related to ADEs - 35% of community dwelling - 40% of hospitalized **Potential risk factors for ADEs** - 6 or more chronic diseases - 12 or more medication doses/day - 9 or more medications - Low BMI - Age \>85 years - Creatinine clearance \65 and men \>70 - Younger with risk factors - Diagnostic with a t-score of ≤ -2.5 - Silent disease - Often not diagnosed until a fracture occurs - Possible symptoms - Kyphosis - Loss of height (\>4cm) - Ask how tall they were in their 40s - Pain, especially back pain - History of fractures **Prevention/Interventions** - Nutrition - Calcium supplementation - 1000mg Men 50-70 years - 1200mg Women 50-70 years - Vitamin D supplementation - 600-1000IU/day, upper limit of 4000IU/day - Goal: Serum Vitamin D 30ng/ml to reduce fracture risk - Exercise- weight bearing, strengthening, and core - Preserves bone density and improves balance to prevent falls - Cease smoking and excessive alcohol - Prevention of falls- limit injury if a fall were to occur **Pharmacological Interventions** - Antiresorptive Agents - Bisphosphonates- Risedronate, Alendronate, Ibandronate (Actonel, Fosamax, Boniva) PO, IV - Decreases osteoclastic activity - Side Effects: GI symptoms, esophagitis - Take on empty stomach or first thing in morning with 8oz water, remain upright and do not eat or drink anything for 30 minutes, 45 -- 60 minutes for Boniva - Selective Estrogen Receptor Modulators (SERMs)- raloxifene (Evista)- postmenopausal women - Less effective than Biphosphonates - Side Effects: thrombosis, hot flashes, and strokes - Anabolic Agents - Abaloparatide & Teriparatide- activate PTH1 which stimulates bone formation - Replacing bisphosphonates as first line therapy - Calcitonin (Calcimar)- less effective. Intranasally or subcutaneous administration **Hip Fractures** - Globally- hip fractures affect 18% of women and 6% of men - Osteoporosis with a fall the most common cause - Femoral Neck and Intertrochanteric most common types of fracture - Femoral neck can cause more complications due to interruption of blood supply to the femur - Stabilization through surgical intervention often required **Hip Fractures** - Femoral Neck Fracture -  - Intertrochanteric Fracture - A diagram of a hip joint Description automatically generated **Risks other than osteoporosis** - Excessive alcohol/ tobacco use - Sedentary lifestyle - Low body weight - Gender- female - Tall stature - Vision impairment - Cognitive impairment - Any condition/medication that increases risk of falls **Prevention** - Address risk factors - Lifestyle modifications - Physical activity, improve mobility - Prevent and manage osteoporosis - Decrease risk of falls **Hip fracture: Assessment** - Often found on the floor, lying with injured leg shortened and externally rotated - Coordinated Hospital Care - Expedites ED to OR - Reduces post-operative complications - On hospital admission assessment - Cognitive baseline- delirium most common postop complication - Can take weeks to months to return to normal - Pain- more common to administer nerve block - Skin - Nutrition - Engage family and caregivers **Surgical intervention & Postop Care** - Surgical Intervention - Preferably within 24 hours if medically stable - Rapid pain control - Improves mobility - Prefer spinal anesthesia to general anesthesia, reduces post-op complications - Prevent pressure injuries during surgery- pad bony prominences for surgical procedure - Post-Operative Care - Postop pain often not controlled in older patients - Scheduled short acting low dose opioid in conjunction with nonopioid - Neurovascular assessments- 6Ps - Pain, pallor (grey pale color/cap refill), paralysis, paresthesia, pulses, poikilothermia (checking temp of skin) - Increased risk for DVT/PE - Preventive interventions- compression devices, early mobilization, prophylaxis - Pain management, positioning, incentive spirometry (prevent pneumonia) , put oxygen on them, deep breathing and coughing - Establish pre fracture baseline w pt - Fatigue and pain that pt has - Give pt pain med and then in 30 min get them out of bed - Oxygen support- 2L NC while in bed for 3-4 days postop, increased risk for pneumonia - Early mobilization - Within 24 hours of surgery (Approximately 5% of muscle strength is lost each day of bedrest) and daily - Establish pre-fracture baseline and Individualize mobility goals - Barriers: fatigue and pain -- provide pain control and promote sleep - Mobilization is the responsibility of the entire multidisciplinary team - Decreases the risk for functional decline - Delirium Prevention - Constantly orient pt, give calendar, normalize environment, let them know they are in the hospital, why and that they are not at home - Continued nutrition support - Skin integrity prevention and management - Patient Education - Prepare for discharge/rehabilitation- engage family caregivers **Hip Precautions Post-Op** - Avoid flexion greater than 90 degrees - Avoid Adduction and internal rotation - Abductor pillow - Avoid crossing legs and lying on operative side **Total Joint Arthroplasty** - Joint replacements can last for 25 years or more - Elective surgery **Operative Care** - Preoperative - Patient and caregiver education prior to surgery (average LOS is often only 1 day) - Individualized plan of care - Nutrition considerations, increased carbohydrates - Decolonization of methicillin resistant bacteria (hibiclens wipes) - Regional block and abx before and after - Intraoperative - Regional anesthesia - Antibiotic prophylaxis - Postoperative - Same day ambulation - Discharge home rather than rehab - Outpatient physical therapy - Hip precautions for THA **[Age-Related MSK Changes:]** +-----------------------------------+-----------------------------------+ | **Change** | **Consequence** | +===================================+===================================+ | Decrease of 30-40% in muscle mass | Reduced strength of upper and | | | lower extremities | +-----------------------------------+-----------------------------------+ | Increased intramuscular and | Loss of muscle mass (sarcopenia) | | subcutaneous fat | | +-----------------------------------+-----------------------------------+ | Decline in tensile strength of | Increased risk of deconditioning; | | ligaments and tendons | a rapid loss of strength | +-----------------------------------+-----------------------------------+ | Stiffening of ligaments and | Reduced joint range of motion | | tendons | | | | | | Stiffer collagen in cartilage | | +-----------------------------------+-----------------------------------+ | Decreased bone density and bone | Osteopenia and osteoporosis | | remodeling | | +-----------------------------------+-----------------------------------+ | Increased bone loss | Increased risk for fractures | | | | | Decreased vitamin d absorption | | +-----------------------------------+-----------------------------------+ | Decreased in hand and foot | Increased risk for falls | | movement | | +-----------------------------------+-----------------------------------+ | Significant decline in one-legged | Management of ADLs and IADLs | | balance | becomes more challenging, | | | including dressing, bathing, | | Gait changes, including reduced | ambulating, doing household | | stride length and walking speed | chores, shopping and writing | | | | | Decreased grip strength | | | | | | Prescence of postural tremor | | +-----------------------------------+-----------------------------------+ **[SENSORY]** Sensory changes occur naturally and gradually throughout the aging process. Changes may greatly alter the capabilities of older adults to complete everyday activities, affecting quality of life and safety. - Sensory impairment can lead to: - Functional impairment - Injury - Social isolation - Depression **Normal Changes of Aging** - Graying and thinning of the eyebrows and eyelashes - Wrinkling of the skin surrounding the eyes - Decrease in musculature in eyelids - Ectropian- bottom lid sags outward - Entropian- Lid turns inward, eyelashes may contact eyeball causing irritation - Atrophy of lacrimal glands - Can lead to dry eye - Arcus Senilis: cloudy band of lipid deposits that appear as rings on the outer region of the corner **Age Related Changes and Functional Impact** - Thickening of the lens - Causes light to scatter, reduces space for aqueous humor to drain - Increased opacity & yellowing of the lens - Interferes with color discrimination - Hardening and decreased pliability of the lens - Impaired accommodation, Presbyopia- decrease in near vision - Decreased pupil diameter - Less light reaching the retina - Delayed pupillary reaction - Difficulty adapting to changes in light - Increased light sensitivity - More sensitive to glare - Decrease in tear production - Dry eyes - Overall- gradual decrease in visual acuity and depth perception **Vision- Assessment** - Ask about any changes in vision - Last eye exam - Inspect the eyes for any abnormalities - Movement of the eyelids - Abnormal discharge - Excessive tearing or dryness - Abnormally colored sclera - Abnormal or absent pupillary response - Assess overall appearance - PERRLA - Snellen chart- try in different levels of light **ARC Considerations: Risk for Injury** - Falls - Home safety - Medication Safety - Driving- Involvement in fatal crashes begins to increase at age 70 with highest numbers occurring in the 85+ population **Preventing Risks & Injuries** - Falls- previously discussed - Home Safety- home safety assessment as part of CGA - Provide adequate lighting in high-traffic areas - Motion sensors, puck lights on stairs, reduce glare by using table lamps and sheers on windows - Use paint to provide contrast - Can easily discriminate between walls, floors, and other structural elements of the environment, helps with depth perception - Use red-colored tape or paint on the edges of stairs and in entryways to provide warning and signal the need to step up or down - Flooring - Avoid reflective floors and complicated rug patterns - No throw rugs **Preventing Risks & Injuries** - Medication Safety - Use of pill organizers, large print labels, no child proof caps, medication delivery, prepackaged dosed medications (as previously discussed) - Education- potential side effects, red flags, when to call provider - Driving Safety - Loss of driving ability is associated with isolation, decreased quality of life, and poor health outcomes - Can negatively impact access to healthcare - Medications can further alter ability- opioids, benzodiazepines, antihistamines, antidepressants - Eye exams, discuss with provider - Promote risk reduction- do not drive at night, in bad weather, when taking certain medications, drive locally - AARP and AAA offer Smart Driver Programs - Driving assessments by occupational therapist - Decreased QOL **Hearing** - Age is the greatest risk factor for hearing loss - Individuals over 60 have highest risk - 50% of adults \>70 years old have some hearing loss - Hearing loss can start in one's 20s - Hearing loss can interfere with - Communication - Enjoyment of certain forms of entertainment - Safety - Social interactions - Independence **Hearing Loss: Risk Factors** - Age - Heredity - Long-term exposure to excessive noise - Impacted cerumen (earwax) - Ototoxic medication - Tumors and certain diseases - Smoking - Head or ear injury - History of middle ear infection **Age Related Changes related to Hearing** - Auricle tends to wrinkle and sag. - Decreased activity of ceruminous and apocrine glands - Drier and harder cerumen - Cerumen build up common - Can impair hearing if it becomes impacted (conductive hearing loss) - Inner ear changes - Atrophy of organ of Corti and cochlear neurons - Loss of sensory hair cells **Types of Hearing Loss** - Conductive hearing loss - Occurs when something is blocking the transmission of sound waves from the outer and middle ear - Age-related cause: impacted cerumen-reversible - Causes - external ear infection (otitis externa) - middle ear infection (otitis media) - perforation of the tympanic membrane - foreign bodies - Sensorineural hearing loss - Occurs when there is damage or atrophy to the inner ear nerves and organs resulting in distortion of sound. Not reversible - Age-Related Cause: - Presbycusis- atrophy of the inner ear nerves and organs - Affects Men \> Women - Occurs gradually, usually bilaterally - Impairs the ability to hear high-pitched tones first, then progresses - Can usually hear speech but cannot understand because words are distorted - Other causes of sensorineural hearing loss related to risk factors **Assessment of the Older Adult with Hearing Loss** - A thorough history and physical examination - Inspection of external ear and ear canal with otoscope - Discuss concerns with patient and family/caregivers - The whisper, Weber, and Rinne tests can be performed - Hearing Screening recommendations: - Asymptomatic: - Adults under 50yrs - screened every 10 years - Over 50 yrs- screened every 3 years - Symptomatic: checked more frequently based on provider recommendations **Hearing Aids** - Hearing aids amplify sounds and deliver them directly into the ear. - Medicare does not cover cost. - Inspect hearing aid: Are there any cracks? Does it turn off/on? Does the volume control work? - Cleaning: removed at bedtime, remove battery, cleaned with warm water and cotton cloth/pad. - Store in its case - Identify patients wearing hearing aids on admission to the hospital or nursing home - Make sure to document hearing aids: BIL? LT? RT? Communicating with Older Adults - Do not speak loudly to every older adult - Do: - Eliminate noise and distractions (turn off TV, close door, turn off phone) - Gain their attention before speaking (slight tap or touch on the shoulder, say their name and wait for them to look at you) - Keep room well lit - Stand 2-3 feet from individual - Face them and, if possible, keep face uncovered - Try to lower pitch of voice - Pause at the end of a sentence to allow time for processing - Speak slowly and clearly - Rephrase statement if patient does not understand - Use nonverbals and written communication if necessary - Ask for verbal or written response to evaluate understanding **Taste** - Age related changes - Hypogeusia, diminished taste - Decrease in number and function of taste buds - Usually occurs around 70 years of age - Taste also impacted by: - Decrease in saliva production - Decrease in olfactory sense - Poor oral condition - Certain medications - Smoking, respiratory infections - Assessment of the head and neck should be performed to rule out obvious deformity, injury, infection, or obstruction. - Assess mucous membranes for dryness, ulceration, or presence of candidiasis. **Taste** - Taste deficits can result in - Weight loss - Malnutrition - Impaired immunity - Exacerbation of medical illness - Interventions/Education - Use of seasonings, herbs, and flavor enhancers. - Separate foods on the plate - Vary textures, avoid bland foods - Good oral health care - Make meals social **Smell** - Hyposmia- diminished sense of smell - Age-related changes: reduction in number of sensory cells and neurotransmitters of olfactory mucosa and nerve damage. - Possible causes: - Upper respiratory infections - Allergies - Head trauma - Neurodegenerative diseases - Smoking **Physical Sensation** - Tactile sensation may diminish with age: - Slower conduction of nerve impulses - Diminished function of peripheral nerves - Decreased perception of pain, vibration, touch, pressure, varying textures, and temperature extremes - Other contributors include neuropathy, peripheral vascular disease, neurological diseases - Psychological benefits of touch: - Comfort - Lack of touch diminishes QOL Sensory Activity - Complete the following: - Each person will take 1 bag of supplies. - Each table will take 1 pair of goggles and three medicine bottles. - Empty bag of contents. - Place 1 cotton ball in each ear. - Take turns wearing the vision goggles. - With goggles on, try to read medication bottles and look around the room - View different colored paper through yellow vinyl strips. - Put on one examination glove, pick up sandpaper and hold in each hand. - Put on both examination gloves and open wrapped chocolate. - Using your thumb and one finger, hold your nostrils close and eat the piece of chocolate. - Debrief - How do you feel right now having completed the activity? - Recap of activity - What are your thoughts on how sensory changes would impact your everyday life? - How might this experience change how you work with an older adult in the hospital? - How might it change how you prepare an older adult for discharge from the hospital to home? **Causes of Visual Impairment in Older Adults** - 4.2 million people over 40 years are either legally blind (best corrected 20/200) or have low vision (best corrected 20/40). - Number is expected to increase - Visual impairment and blindness in the older person is often the result of four main causes: - Cataracts - Age-related macular degeneration (ARMD) - Glaucoma - Diabetic retinopathy **Cataracts** - By age 80 more than half of American have had cataracts or have had cataract surgery - Development is slow and painless - May be unilateral or bilateral. - Opacities form and cloud the lens - Decrease the amount of light able to reach the retina, inhibits vision. Diagram of a diagram showing the structure of the eye and the eye with cataract Description automatically generated **Cataract: Risk Factors** - Increased age - Smoking and alcohol - Obesity - Diabetes, hyperlipidemia, hypertension - Trauma to the eye or history of previous eye surgery - Exposure to the sun and UVB rays - Long-term corticosteroid medications - Caucasian race A. Simulation of vision with cataracts: **Symptoms** - Blurry vision - Glare - Halos around objects - Double vision - Difficulty seeing contrasting colors - Poor night vision **Treatment for Cataracts** - No medication to treat cataracts - Corrective lenses may be effective in the early phases - Surgery is the treatment of choice - Laser guided, Phacoemulsification preferred, ultrasonic emulsification of cataract - 1-3 weeks recovery, no heavy lifting, no straining, or bending - One eye done then the second, if needed, one month after - Eye patch to deter eye rubbing - Patient education and support - Implement preventive measures- reduce risk factors **Age Related Macular Degeneration (ARMD)** - Two forms ARMD: Dry and Wet - Results in loss of central vision - Dry -- the center of the retina detereoriates - Most common form of ARMD - Cause is unknown, possibly genetics and environment - Atrophy of light sensitive cells in the macular and drusen(cellular debris) accumulations - Usually one eye at a time - Vision loss is slow and gradual - Wet or neovascular exudate ARMD (leaky blood vessels grow under the retina) - Responsible for severe, acute vision loss - Microvascular leaking of blood or serum leaks from newly formed blood vessels beneath the retina **ARMD: Risk Factors** - Age \> 60 - Cigarette smoking - Family history of ARMD - Increased exposure to ultraviolet light - Caucasian race and light-colored eyes - Hypertension or cardiovascular disease - Lack of dietary intake of antioxidants and zinc - Consuming high doses of antioxidants (vitamins C, E, Beta-carotene) and zinc may decrease the risk by 25% and slow progression. **Symptoms** - Blurry/fuzzy vision - Straight lines appear wavy - Blind spot in center of vision - Impacts reading, driving and recognizing faces **Diagnosis** - Visual acuity test - Pupil dilation - Fluorescein angiography -- uses a dye to diagnose WMD - Amsler Grid **Health Promotion and Prevention** - Routine eye exams - Wearing UV protective lenses - Smoking cessation - Increased consumption of antioxidant rich foods - Manage cardiovascular disease Treatment for ARMD - Dry ARMD -- there is no treatment. Use of low vision devices and adapting to visual changes - Wet ARMD - Injections- antiVEGf - Vascular endothelial growth factor. Can stabilize or improve by blocking VEGF, which is responsible for growth of new vessels - Laser therapy - Photodynamic therapy **Glaucoma** - Result of optic nerve damage - Due to an increase in IOP (intraocular pressure) - Caused by an obstruction of outflow of aqueous humor - Normal range of IOP 10-20 mmHg - Types of Glaucoma - Open- Angle Glaucoma - Most common - Drainage of aqueous humor is slowed - Fluid builds up, increases IOP - Results in peripheral vision loss. - Vision loss is painless and gradual - Angle-Closure Glaucoma - Angle of the iris obstructs drainage of the aqueous humor - May occur suddenly due to infection, trauma - Symptoms include unilateral headache, visual blurring, nausea, vomiting, and photophobia - Uncommon & Urgent - A. Simulated glaucoma vision: **Glaucoma: Risk Factors** - Increased intraocular pressure - Older than 60 years of age - Leading cause of blindness in individuals of African descent - Family history of glaucoma, especially sibling - Personal history of myopia, diabetes, hypertension, and migraines **Glaucoma: Symptoms** - Often not reported until advanced stages of the disease. - Considered a "silent disease" - May notice blind spots in peripheral vision - Once vision is loss it cannot be regained - Diagnosed with visual exam - Patients over the age of 65 should be examined and screened for glaucoma at least every 1 to 2 years. **Glaucoma: Treatment** - Managing glaucoma involves lowering the IOP. - Medications (usually eye drops): - Beta-Blockers: (Betimol, Timolol, Istalol). decrease rate of fluid production. - Side effects: bradycardia, congestive heart failure, syncope, bronchospasm, depression, confusion, and sexual dysfunction - Prostaglandin analogues: (latanoprost, travoprost) improves drainage of fluid - Side effects: dizziness, hypertension - Other medications: Adrenergics, Miotics/cholinesterase inhibitors, Carbonic anhydrase inhibitors - Surgery- several different types of surgery - Focuses on maintaining patency of outflow channel, equalizes pressure - Cataract surgery also helps to decrease IOP - minimal recovery (1 day) - Avoid anticholinergics and Benadryl they can exacerbate glaucoma **Administration of Eye Drops** - Hygiene, gloves - Have older adult tip head backwards and look upwards. - Pull lower lid down slighty - Place drop into the eyelid pouch, not directly on eye - Do not contaminate eye dropper - Wait 3-5 minutes before additional drops are placed in the same eye - Provide patient with a tissue - Educate patient, must always administer eye drops. Should not miss doses. **Diabetic Retinopathy** - Diabetic retinopathy -- is a microvascular disease of the eye occurring in both type 1 and type 2 diabetes. - Damage to the ocular microvascular system impairs the transportation of oxygen and nutrients to the eye  **Diabetic Retinopathy** - Prevention: Tight glycemic control and managing hypertension and hyperlipidemia. - Symptoms: - Reduced acuity - Dark floating spots, cobweb like streaks - Diagnosed with an eye exam - Treatment: - Maintaining an average preprandial blood glucose of 80 to 120 mg/dl - Hemoglobin (HbA1c) of less than 7 - Anti-VEGF injections - Laser therapy or panretinal laser photocoagulation (PRP) - repairs leaking microaneurysms. - Does not reverse vision loss Refer for ophthalmic examinations after diagnosis of diabetes **[SLEEP AND THE OLDER ADULT]** **Impaired Sleep as a Geriatric Syndrome** - Sleep disturbances should not be seen as normal ARC - Not all older adults have issues with sleep - Multiple causative factors - Those 85 and older are at greatest risk - Negatively affects brain and physical health, and functional status **Sleep Architecture** - Fundamental physiologic process - Normal sleep is divided into 2 phases, NREM & REM, and 4 stages - Stage N1 - is light sleep - Transition period between wakefulness and sleep - Lasts around 5-10 minutes - Stage N2 - brain waves slow eye movement stops. - Body temp drops and HR begins to slow - Brain begins to produce sleep spindles - Lasts approx. 20 min - Stage N3 - Slow wave sleep, release of growth hormone - Muscles relax - BP and RR drops - Deepest sleep - Stage 4 REM- psychological restoration - Brain becomes more active - Body becomes relaxed and immobilized - Dreams occur - Eyes move rapidly - Sleep cycle- progression through 3 NREM stages ending in REM - Lasts 70-120 minutes - 4-6 cycles per night **Age Related Changes in Sleep** - Age Related Change - Decline in CNS neuropeptides, normally active during wakefulness and silent during sleep - Flattened circadian rhythm - Changes in the suprachiasmatic nuclei (internal clock) - Possible decline in cortisol and melatonin rhythms - Reduced sensitivity to light at retinal level, disrupts circadian rhythms - Impact - Decreased time spent in deeper levels of sleep Stage 3 - Briefer episodes of REM (stage 4) - Greater number of arousals - Phase Advanced Syndrome - Decreased quality of sleep -- still need 7-8 hours - Increased fatigue during the day **Additional Factors that Impact Sleep: Chronic Illness & Medication** - Can be both a symptom and/or a result of chronic illness - Cardiovascular disease, diabetes, chronic obstructive pulmonary disease, depression, and arthritis linked to sleep impairment - Many medications used to treat chronic conditions impact sleep - ACE inhibitors- Nighttime cough - Beta-Blockers- Insomnia, nightmares - Antihistamines- daytime sleepiness, drowsiness - Antipsychotics-sedation - Opioids- Decreased slow-wave sleep, daytime fatigue - Herbal supplements **Psychosocial Stressors** - Declining health or loss of loved one - Retirement - Onset of chronic illness - Declining health and function - Loss of independence - Change in living situation, environmental factors - Institutionalization - Be aware of poor coping mechanisms alcohol, nicotine, drug use **Sleep Impairment & Cognitive Function** - May be connected to mood, cognition, and neurodegenerative disorders - May see memory deficits - Fragmented sleep patterns may be early signs of Alzheimer's and Parkinson's - Individuals with dementia often have: - Increased sleep disruptions - Fragmented sleep patterns - Decreased time in Stage 3 (slow wave sleep) - No stage 4 (REM) **Depression, Pain, & Nocturia** - **Nocturia** - 60% of older adults wake 2+ times to void - Impacts quality of life - Can lead to insomnia - Less active during the day - Increased risk for falls - **Impaired sleep:** - Predicts incidences of chronic pain - Increases pain sensitivity - Osteoarthritis is associated with impaired sleep - Nighttime pain needs to be addressed - Ensuring restful sleep can lessen pain during the day **Sleep in Institutional Environment** - Nurses contribute to their patients' sleep disruption. HOW?? - Sleep deprivation in these settings may cause: - Delirium - Reduced activity - Reduced energy - Impaired healing - Longer recovery - What can nurses do to improve sleep? **Healthy Promotion of Sleep** - Sleep Hygiene - Sleep patterns are a learned behavior- establish a relaxing routine - Maintain consistent sleep schedule. Aim for 7-8 hours every night - Avoid caffeine & nicotine, limit fluids before bed - Make your bedroom sleep-friendly (dark, well-ventilated, and quiet). - Avoid alcohol as sleep medication - Eat a light snack before bed - Exercise regularly. - Get a few minutes of sunlight every day. - Get up and leave the bed if you cannot sleep after 20 minutes **Nursing Assessment** - Sleep is often not discussed, please ask about it! - Sleep issues are often dismissed as part of aging - Utilize a holistic approach. - The components of a sleep assessment should include - Health history - Physical examination, functional assessment, pain - Mental health assessment - How does it impact their quality of life? - Sleep journals, assess sleep hygiene, use validated scales - Referral based on findings **Common Sleep Disorders** - Circadian Rhythm Disorder - Chronic Insomnia - Sleep-Disordered Breathing - Restless Legs Syndrome **Circadian Rhythm Disorder** - Sleep Phase Advancement- most common - Early Sleep Times (6-9pm) - Early Awakening (2-5am) - Followed by daytime sleepiness - Sleep Onset Latency- increased, takes longer to fall asleep \>30 minutes - Wake After Sleep Onset (WASO)- normal sleep latency with frequent awakening - Can lead to chronic insomnia - Important to address with sleep hygiene education and assessment - Sleep hygiene education and assessment for underlying conditions/psychosocial circumstances **Chronic Insomnia** - Most common reported sleep disturbance - Prevalence- 25-51% of older adults - Obtain a detailed history, evidence-based sleep scales - Characterized by - Difficulty falling asleep - Difficulty staying asleep - Early morning awakening - Daytime sleepiness, impacts daily function - Occurs at least 3x per week for more than 1 month **Impact** - Impact of Untreated Insomnia - Increased risk of falls - Depression & anxiety - Suicide attempts - Heart disease - Cognitive impairment - Institutionalization - Decreased quality of life **Non-Pharmacological Therapies** - Cognitive Behavioral Therapy (CBT): Changes symptom related thoughts and gives sense of control - As effective as pharmacological treatment - Sleep hygiene - Stimulus control - Relaxation skills - Bright Light Therapy - Exposure to natural daylight or light therapy - Treats age-related issues and mood disorders - Mind Body Interventions - Tai Chi - Yoga **Pharmacological Treatment** - Treat the underlying cause of the sleep disturbance, if possible (pain, depression, apnea) - IF needed, prescription medication for sleep impairment - Recommended prescribing principles: - Use the lowest effective dose "START LOW, GO SLOW!" - Administer medications only 2--4 times/week. - Limit to short-term use only - D/C medications gradually **Pharmacological Treatment & Implications for Older Adult** - Nonbenzodiazepine receptor agonists (Zolpidem) -- increased risk for falls - Benzodiazepines (triazolam) -- oversedation, cognitive changes, falls , delirium - Antidepressants (Trazodone) -- low dose for sleep, anticholinergic effects - Melatonin -- daytime sleepiness, not FDA regulated - OTC (diphenhydramine) -- anticholinergic effects, oversedations with cognitive changes, falls, delirium \*Timoptic\* and PPI **Sleep Disordered Breathing (SDB)** - Decreased or cessation of breathing - Obstructive Sleep Apnea (OSA) -- more common - Narrowing or collapse of pharyngeal airway - Oxygen desaturation - Apneas lasting more than 10 seconds with continued respiratory effort - Central Nervous System Apnea - Brain fails to signal need for respiration - Apneas without respiratory effort - Prevalence of SDB between 13%-32% **OSA** - Risk Factors - Obesity - Male - Decreased airway stability r/t ARC, muscle weakness - Decreased neuromuscular response to hypoxia - Signs/Symptoms - Snoring - Wakes up with a gasp or snorting noise - Observed pauses in breathing - Day time sleepiness **Assessment & Treatment** - High risk or symptomatic individuals should be referred for further evaluation - Polysomnography sleep study needed for diagnosis - At home or in lab setting - May consists of EEG, EMG, measuring of REM, respirations, heart rate, oxygen saturation - Treatment - Weight loss - CPAP - Surgical intervention **Continuous positive airway pressure (CPAP)** - Delivers a constant pressure to the airway to maintain patency - Continuous delivery throughout inspiration and expiration - Individual must be breathing spontaneously - CPAP Delivery - Nasal- through prongs or small mask over nose - Full face mask - Nasopharyngeal- through a Nasopharyngeal tube, bypasses the nasal cavity - Adherence is often an issue **Restless Leg Syndrome** - Prevalence, 10%-35% among older adults - Diagnosis based on symptoms - Urge to move legs - Uncomfortable sensations - Increases during rest - Relieved by movement - Increases at night - Not explained by other conditions - Can result in - Insomnia - Sleep fragmentation with increased daytime sleepiness **Risk Factors & Treatment** - Risk Factors - Peripheral neuropathy - Iron deficiency anemia - Uremia r/t renal failure - Treatment - Correction of underlying conditions - Lifestyle modifications - Avoid- caffeine, cigarettes, & alcohol - Maintain regular sleep schedule - Mild-moderate exercise - Dopamine agonists (ropinirole)- increase dopamine levels - Anticonvulsants for painful symptoms (gabapentin, pregabalin)