gero study guide.docx

**[Ageism]** Ageism ------ - **For older people, ageism is associated with a shorter lifespan, poorer physical and mental health, slower recovery from disability, and cognitive decline** **Addressing implicit bias on an individual level** - **Actively engage in reducing implicit bias...

**[Ageism]** Ageism ------ - **For older people, ageism is associated with a shorter lifespan, poorer physical and mental health, slower recovery from disability, and cognitive decline** **Addressing implicit bias on an individual level** - **Actively engage in reducing implicit bias** - **Develop awareness** - **Provide person centered care/individualization** - **Perspective taking empathy** - **Expand your social circle** - **Use multiple strategies** **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** **[Aging Trends (2-3)]** Demographic trends ------------------ - **For the first time in US history older adults are projected to outnumber children by 2035** Population/baby boomer characteristics -------------------------------------- - **Social** - **Achieving higher levels of education** - **Staying in the workforce longer** - **More informed health care consumer, demand quality care** - **Interested in technology** - **Increased geographical mobility** - **27% of adults \> 60 live alone** - **Women \> men, 79 men: 100 women** - **Ratio becoming more balanced due to increasing life expectancy among men** - **Health** - **80% of older adults have at least one chronic health condition** - **Chronic conditions \> acute conditions** - **Less acute condition** - **More complications** - **Take longer to recover** - **Poorer health outcomes** - **Financial** - **Living on decreased, fixed income** - **Social security most common form of income** - **Most people do not have pensions** - **Medicare most common form of health insurance** - **As older adults age, poverty rates increase** - **Older women and person of color have highest risk of poverty** **[Healthy/Successful Aging (2-4) ]** **Life review** - **Reflection of the self** - **Self understanding, evaluation, discovery and identity maintenance** - **Validation of existing, letting go** **Erikson** - **The aging individual strives to accept the value of life experiencess** - **Integrity vs. despair, gerotranscendence -\> legacy building** **QOL theory** - **Metaphysically connected** - **Self esteem, self determination, cognition, purpose, optimism, life satisfaction** - **Spiritually connected** - **Prayer, worship, fellowship, meaning** - **Biologically connected** - **Functional capacity, physical comfort, health promotion, health maintenance** - **Connected to others** - **Social support, interpersonal dynamics, cultural dynamics** - **Environmentally connected** - **Socioeconomic status, transportation, assistive devices, safety, anesthetics** - **Connected to society** - **Personal social system** - **Global societal system** **[General Gerontological Nursing (6-10])** Gerontology principles ---------------------- - **Addresses the unique physiological, 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** Acute care Nursing approach --------------------------- - **Identify pts preferences for care. What do they want, how do they want it?** - **Implement 4 Ms** - **Assess and identify potential complication and safety risks** - **Prevention of complications** - **Promote independence** - **Monitoring of medications** - **Preparing for their return home** - **Education** - **Goals of care** - **Improve functional capacity** - **Maximize ADLS** - **Promote wellbeing and QOL** - Know the unique capacities and limitations of the individual - Focus on strengths and capabilities - Do with not for - Be patient OBRA ---- - **Improved conditions of nursing homes** - **Ombudsman program** - **Established resident bill of rights** - **Culture change** - **Requires compliance with federal regulations** - **Center for medicare and medicaid services** - **Comply with quality measures that evaluate nursing care** - **All residents must be assess with minimum data sheet** - **Assessment must be performed by an RN assessment coordinator** - **Established quality measures for all nursing homes** - **Moderate to severe pain report, falls with injury, vaccinations, presence of pressure injuries, UTI, indwelling catheters, etc.** - **Nursing homes must collect data and show continual quality assurance and performance improvement** - **Surveyed annually by state representatives funded by CMS** - **Review data on quality measures** Transitional care ----------------- - **A set of actions designed to improve coordination and continuity across settings** - **Benefits** - **Enhances pt experiences** - **Improves health outcomes and quality of life** - **Includes a broad range of services** - **Designed to improve safety** - **Shown to reduce hospital readmissions** - **Decreases care costs** - Common barriers in care transitions - 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 - Assisted living -\> minimal assistance with ADL - Skilled nursing -\> big impairment / rehab - Respite -\> short term care like vaycay - Rehab: sub acute 3 hr/day, long term 1hr/day, improve adl 4 Ms ---- - **Mobility: Ensure that older adults moves safely every day in order to maintain function and do what matters** - **Medication: polypharm, med reconcil, deprescribing** - **Mentation -\> mini cog, delirium -\> cam** - **Matters: know and align care with each older adults specific health outcome goals and care preferences including, but not limited to, end of life care, and across settings of care** SPICES ------ - **Sleep, problems with eating, incontinence, confusion, evidence of falls, skin breakdown** **[Comprehensive Geriatric Assessment (CGA) (5-7)]** Goals ----- - **Promotes function, independence, and quality of life** - **Helps to keep older adult in their home** - **Minimize functional and cognitive decline** Geriatric syndromes ------------------- - **Falls & frailty** - 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 Functional assessment --------------------- - **Systematic eval of the older person level of function and self care abilities** - **Person ability to complete ADLs and IADLs** - **Lawtons IADLs** - **Kratz 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** Advance directive ----------------- - **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 **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 Atypical presentations ---------------------- - **More common in adults over 85** - **Multiple comorbidities** - **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** - 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 **[Medication Safety & Polypharmacy (4-7)]** Age related changes ------------------- - **Changes in drug receptor sensitivity (pharmacodynamics)** - **Increased sensitivity, increases drug effects → anticholinergics, antihistamines, barbiturates, benzodiazepines, digitals and warfarin** - **Iatrogenic concerns** - **Side effects caused by treatment or medication** - **Can contribute to ADEs** - **Visual and hearing changes** - **Interferes with safe administration** - **Changes in cognitive function** - **Increases risk of anticholinergic effects, increased CNS adverse effects, confusion, forgetfulness** **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 **Polypharmacy** - **Over 5 meds** - Med reconciliation - Done at admission, discharge, transfer of floor or unit to unit - Risks - Increased hospitalizations - Development or worsening of geriatric syndromes - Adverse Drug Events - Duplication of drug therapy - Poor adherence - Cost - Decreased quality of life ADE - Risk factors - 6 or more chronic diseases - 12 or more medication doses/day - 9 or more medications - Low BMI - Age \>85 years - Creatinine clearance \ dec emptying time** - **Increased gastric pH due to decrease acid production -\> dec production + dec motility = juice sits and raises pH, effects how meds broken down** - **Can be altered by antacids, PPIs, anticholinergic medications** - **PPI play effect on smooth muscle, difficulty CNS/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** - **BB and digoxin sensitive** - **Sxs toxicity are confusion and restlessness** - **Cardiac arres, brady, hypotensive** - **Increase in body fat- increased volume of distribution results in prolonged half life for fat soluble medications** - **Secreted slowly, stays in body longer, more effective as it remains in body longer** - **Decrease in serum proteins (albumin)- increases toxicity of protein bound meds** - **Bind to protein molecules in body** - **Low protein can only bind few, rest is free in body, inc toxicity** - **Metabolism** - **Decreased liver blood flow and size- delays and decreased metabolism- increases half life. How do you adjust the dose?** - 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** - **Excretions** - **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 Anticholinergics ---------------- - **Pharmacokinetics and Pharmacodynamics increase sensitivity in older adults** - **Commonly prescribed and OTC medications** - **H~1~ first generation antihistamines- chlorpheniramine, diphenhydramine, meclizine** - **Antiparkinson- benztropine** - **Antimuscarinics- oxybutynin, tolterodine, atropine** - **Antipsychotics- chlorpromazine, thioridazine, clozapine, TCAs** - **Causes CNS and PNS symptoms and can aggravate other conditions- BPH, cardiac function** - **CNS- agitation, confusion, hallucinations** - **PNS- constipation, urinary retention, dry mouth, dry eyes, tachycardia, blurred vision** - **Increased risk with increased dose** Polypharmacy ------------ - **Individuals taking 5 + medications** - **30% of adults 65+ take 5 or more medications** - **People 65 yrs and older account for 33% of prescriptions but only 15% of the population** - **Includes supplements, herbals, and OTC** - **Regimens are increasingly complex** - Contributors ------------ - **Prescribing cascade** - **Multiple conditions** - **Increased number of OTC medications** - **Recent or frequent hospitalizations** - **Uncoordinated care** - Risks ----- - **Increased hospitalizations** - **Development or worsening of geriatric syndromes** - **Adverse Drug Events** - **Duplication of drug therapy** - **Poor adherence** - **Cost** - **Decreased quality of life** - Prevention ---------- - **Prevent the use of Potentially Inappropriate Medications (PIMs)** - **Beers Criteria, STOPP/START** - **Deprescribing** - **Patient communication and education** - **Medication reconciliation, brown bag** - **Medication management interventions** Adherence --------- - **Challenges with adherence** - **Complicated regimen, polypharmacy** - **Visual impairment** - **Language, culture, education level, beliefs about benefits** - **Health literacy, multiple pharmacies** - **ADEs, lack of immediate response** - **Promoting adherence** - **Listen to patient, establish trust, education** - **Assess specific challenge for the individual** - **Financial- resources** - **Complexity** - **Lack of understanding** - **Keep current list of medications and bring it with them** - **Medication organizers** - **Use an activity as a reminder (ex. Take meds after walking dog in morning)** - **Set alarms, sticky notes** - **Establish routine** - **Keep medications visible** **[Musculoskeletal (4-7)]** Age related changes ------------------- msk --- - **Aging changes start at the basic cellular level** - **Cell number reduces, leaving decreased number of functional cells** - **Lean body mass decreases** - **Total body fat increases** - **Total body fluid volume decreases -\> concern older adult and dehyd** - **\*\*\* Sarcopenia: Reduced muscle mass, strength, and function** - can lead to pain, impaired mobility, self care deficits, and increased risk of falls - Self care deficit: \*RISK FOR IMPAIRED MOBILITY\* **Skeletal** - Thinning disks and shortening vertebrae Why people lose height - Flattening of the lordotic curve; change in posture and gait People hunched over - Diminished calcium absorption - Decreased bone mineral density and mass - Bones become stiff, weaker, and more brittle - Decreased elasticity of ligaments and tendons. Erosion of cartilage. Joint degeneration - Risk for Falls! Health promotion ---------------- **Assessment** - **Mobility** - **Establish baseline** - **Assess impact on quality of life** - **Health History, Medication Review** - **Physical Exam- musculoskeletal & neurological** - **Functional assessment: ADLs, IADLs** - Ambulation and Mobility ----------------------- - **1. Falls efficacy scale- older adult's self-rated confidence** - **Scores \> 70 indicate fear of falling** - **2. 30-second chair stand test- assesses strength and endurance** - **Below average scores have increased risk of falls** - **3. Timed up and go test (TUG)-assesses balance and walking ability** - **The longer it takes, the greater assistance needed with mobility and increased risk of falls** - Physical Consequences of untreated impaired mobility - Skin breakdown, pressure injuries - Loss of calcium - Joint contractures, joint pain - Loss of muscle mass - Reduced circulation - Risk for falls - Risk for infection - Constipation Get them up and moving to promote peristalsis - **Falls** - **Community dwelling adults- annually, STEADI** - **On hospital admission- facility fall assessment** - **Acute Fall** - **Do not move- assess for injury and head trauma** - **Call rrt** - **Vital signs** - **If no injury, assist to chair/bed** - **Ask for older adult's perspective** - **Assess the environment** - **Review medications** - **Notify provider/family** - Write "Found patient on bathroom floor" - If you actually witnessed patient fall write "witnessed patient fall" and then describe what happened and what pt was doing before falling - **Frailty** - **Multiple screening tools, no gold standard** - **Frailty Index, 3 or more of the following** - **Unintentional weight loss: 10% or \>** - **Weakness: grip strength \< 20%** - **Slowness: walking (15 feet), slowest 20% by sex and height** - **Exhaustion: self-reported** - **Low level of physical activity** - **Assess these areas both outpatient and inpatient** - **Requires interdisciplinary care** - **Can get delirium** - **Osteoarthritis** - **Persistent usage related pain in several joints** - **Morning stiffness that lasts less than 30 minutes** - **Pain with increased activity** - **May present with crepitus, decreased ROM** - **Heberden's and Bouchard's nodes** - **Radiographs- joint-space narrowing, osteophytes** - **More common in post menopause women** - **Common w obesity, repetitive moevements, previous injury** - **Osteoporosis** - Genetics - Age (older than 50 and postmenopausal) - Gender (females greater than males) - Race (Caucasian or Asian) - Family history - Smaller body frame (less than 58 kg) - Nutrition - Low calcium intake - Low vitamin D intake - Inadequate calories - Lifestyle - Sedentary lifestyle - Cigarette smoking - Excessive alcohol consumption (more than three glasses per day) - Medications - Corticosteroid therapy for more than 3 months - Antiepileptics - Heparin therapy - Thyroid hormones - parathyroid - Three factors that contribute to development of Osteoporosis - Failure to reach peak bone mass in early adulthood - Increased bone resorption - Decreased bone formation - Calcium and vit d - Osteopenia precursor - **Bone Health Risk Assessment** - **Identify and manage risk factors.** - **Focus on prevention** - **Dual-Energy X-Ray Absorptiometry (DXA Scan) measures bone mineral density (BMD) at the proximal femur (preferred location)** - **Recommended for healthy women \>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)** - **Pain, especially back pain** - **History of fractures** - **Hip fracture** - **Often found on the floor, lying with injured leg shortened and externally rotated** - **Coordinated Hospital Care** - **Expedites ED to OR** - **Reduces postoperative complications** - **On hospital admission assessment** - **Cognitive baseline- delirium most common post op complication** - **Pain- more common to administer nerve block** - **Skin** - **Nutrition** - **Engage family and caregivers** - **Risks** - 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 Interventions ------------- - **Mobility** - **Early mobility & walking** - **Hospital interventions** - **Physical activity & exercise** - **Resistance training** - **increases muscle mass** - **Promotes anti-inflammatory effects** - **Consider a range of options** - **Based on interests** - **Be creative- Wii Fit games, yoga, Tai Chi** - **Pace throughout the day** - **Stress reduction** - **Reduce pain from osteoarthritis** - **Frailty** - **Physical activity- Overarching Intervention for Prevention and Management** - **Address strength, endurance, and balance** - **3x/week 30-45 minutes** - **Enjoyable, based on preferences** - **Promotes social interaction** - **Nutrition** - **Increase caloric intake** - **Protein** - **Open and honest communication** - **Trajectory of frailty** - **Facilitate transitions** - **Advance directives** - **Osteoarthritis** - ***Nonpharmacological*** - **Low impact exercise- walking, swimming, resistance training, tai chi** - **Treat pain if preventing exercise -\> Celebrex** - **Weight loss** - **Heat (for stiffness) and cold compress (for inflammation)- patient preference** - **Physical therapy- ROM, strengthening exercises, ambulatory assistive devices** - **Occupational therapy- ADL assistive devices, hand brace, adaptive silverware** - **Proper footwear -\> if they are worn out/ fit right** - ***Pharmacological*** - **Topical analgesic- Capsaicin, Diclofenac gel** - **Applied 2-4 times/day to the affected area.** - **Relief may require 4-6 weeks of application** - **Acetaminophen (1^st^ line of treatment)** - **Inconclusive evidence in regards to efficacy. Can be used as an adjunct to NSAIDs.** - **Older person's preference.** - **Max dose 3g(3,000mg)/24 hours** - **NSAIDs- (2^nd^ life of treatment) Ibuprofen, Naproxen sodium, Celebrex** - **GI side effects, take with PPI if history of GI bleed and to reduce GI side effects** - **Avoid ibuprofen if on ASA** - **Caution with renal insufficiency** - Glucosamine/Chondroitin- limited evidence, d/c after 3 month trial if no improvement - CBD oil- topical or oral - Intra-articular steroid injections when synovial inflammation is present. Limited to 4 injections per year. - Intra-articular hyaluronic acid, Prolotherapy, Stem cell injection, Platelet-rich-plasma (PRP) - Many of these are experimental and not covered by insurance - If pain persists and gets worse or is significant functional loss - Refer to pain clinic- may progress to opioids - Refer to orthopedic surgeon for possible joint arthroplasty - **Osteoporosis** - **Prevention** - **Nutrition** - **Calcium supplementation** - **1000mg Men 50-70 years** - **1200mg Women 50-70 years** - **Vitamin D supplementation** - **600-1000 IU/day, upper limit of 4000 IU/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 osteoclast 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 Bisphosphonates** - **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 fracture** - 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 - Avoid flexion greater than 90 degrees - Avoid Adduction and internal rotation - Abductor pillow - Avoid crossing legs and lying on operative side +-----------------------------------+-----------------------------------+ | **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 | | +-----------------------------------+-----------------------------------+ **[Sleep (3-5)]** **\* disturbances aren't normal\* effects physical health brain and functional status** Age related changes ------------------- - **Decline in CNS neuropeptides, normally active during wakefulness and silent during** - **Flattened circadian rhythm** - **Impact: decreased time spent in deeper levels of sleep stage 3** - **Changes in suprachiasmatic nuclei (internal clock)** - **Briefer episodes of REM - stage 4** - **Possible decline in cortisol and melatonin rhythms** - **Greater number of arousals** - **Phase advanced syndrome** - **Reduced sensitivity to light at retinal level, disrupts circadian rhythms** - **Decreased quality of sleep - still need 7-8 hours** - **Increased fatigue during the day** **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 Sleep impairment ---------------- - **May be connected to mood, cognition and neurodegenerative disorders** - **May see memory deficits** - **Fragmented sleep patterns may be early signs of alzheimer's and parkinsons** - **Individuals with dementia often have** - **Increased sleep disruption** - **Fragmented sleep patterns** - **Decreased time in stage 3 (slow wave sleep)** - **No stage 4 (REM)** Contributing factors, interventions, and medication principles -------------------------------------------------------------- - 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 - Meds - ACE inhibitors- Nighttime cough - Beta-Blockers- Insomnia, nightmares - Antihistamines- daytime sleepiness, drowsiness - Antipsychotics-sedation - Opioids- Decreased slow-wave sleep, daytime fatigue - Herbal supplements Obstructive sleep apnea ----------------------- - **Risk factors** - **Obesity** - **Male** - **Decreased airway stability r/t ARC, muscle weakness** - **Decreased neuromuscular response to hypoxia** - **s/s** - **Snoring** - **Wakes up with a gasp or snorting noise** - **Observed pauses in breathing** - **Day time sleepiness** - **Tx** - Weight loss - CPAP - Surgical intervention 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** - Risk Factors - Peripheral neuropathy - Iron deficiency anemia - Uremia r/t renal failure - Smoking, alch, caffine, exercise - 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) Circadian rhythm disorders -------------------------- - **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 sleeping onset (WASO)** - **Normal sleep latency with frequent awakening** - **Can lead to chronic insomnia** - **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 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 **[Sensory (4 to 8)]** **Age related changes, safety interventions, Cataracts, Glaucoma, and Macular Degeneration, hearing loss- sensorineural vs. conductive, communication techniques** Age related changes ------------------- - **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** - ***Considerations -\> falls, home safety, medication safety, medication safety, driving issues*** Safety interventions -------------------- Home ---- - Adequate lighting ----------------- - Paint for contrast ------------------ - No rugs, basic patterns ----------------------- **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** - **Riving assessments by occupational therapist** Cataracts --------- - **By age 80 more than half of americans have had cataracts or have surgery for them** - **Development is slow and painless** - **May be unilateral** - **Opacities form and cloud the lens** - **Decrease the amount of light able to reach the retina, inhibits vision** - **Risk factors** - **Increased age** - **Smoking and alc** - **Obesity** - **Diabetes, hyperlipidemia, hypertension** - **Trauma to eye** - **Exposure to sun and uv** - **Long term corticosteroid meds** - **Causains** - **Symptoms** - **Blurry vision** - **Glare** - **Halos around objects** - **Double vision** - **Difficulty seeing contrasting colors** - **Poor night vision** - **Treatment** - **No med 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** - **Pt education and support** - **Implement preventive measures - reduce risk factors** Glaucoma -------- - **Result of optic nerve damage** - **Due to an increase in intraocular pressure** - **Caused by an obstruction of outflow of aqueous humor** - **Normal range = IOP 10-20 mmHg** - **Types** - **Open angle** - **Most common** - **Drainage of aqueous humor is slowed** - **Fluid is build up, increases IOP** - **Results in peripheral vision loss** - **Vision loss in 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 an urgent** A diagram of a type of glaucoma Description automatically generated - **Risk factors** - **Increased intraocular pressure** - **Older than 60 years** - **Leading cause of blindness in African descent** - **Family hx** - **Person hx of myopia, diabetes, hypertension and migraines** - **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.** - **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 Macular degeneration -------------------- - **Two forms ARMD; dry and wet** - **Results in loss of central vision** - **Dry** - **Most common** - **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** - **Responsible for severe, acute vision loss** - **Blood or serum leak from new formed blood vessels beneath the retina** - **Risk factors** - **Age \> 60** - **Cigs** - **Family hx** - **Increased exposure to uv** - **Caucasians and light colored eyes** - **Hypertension or cardiovascular disease** - **Lack of dietary intake of antioxidants and zinc** - **Symptoms** - **Blurry fuzzy vision** - **Straight lines appear wavy** - **Blind spot center of vision** - **Impacts reading, driving and recognizing faces** - **Diagnosis** - **Visual acuity** - **Pupil dilation** - **Fluorescein angiography - uses a dye to diagnose** - **Amsler grid** - **Health promotion/prevention** - **Routine eye exams** - **Sunglasses** - **Smoking cessation** - **Increased consumption of antioxidant rich foods** - **Manage cardiovascular disease** - **Treatment** - **Dry -\> none, use of low vison devices and adapting to changes** - **Wet** - **Injection -\> antiVEGf -\>** vascular endothelial growth factor, can stabilize or improve vision by blocking VEGF which is responsible for growth of new vessels. Ongoing administration - **Laser therapy** - **Photodynamic therapy** **Hearing loss** - **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** - **Risk factors** - **Age** - **Heredity** - **Long term exposure to excessive noise** - **Impacted cerumen** - **Ototoxic medication** - **Tumors and certain disease** - **Smoking** - **Head or ear injury** - **Hx of middle ear infection** - **Age related changes** - **The 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** - **Conduction 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** - **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 factor** - **Tx** - 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? - **Hyposmia- diminished sense of smell** - Hypogeusia, diminished taste Communication techniques ------------------------ - **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** **While you are studying things you should be thinking about:** - **The effects that ARC have on the older adult, contributory/risk factors, and challenges older adults may face in maintaining an active state** - **Signs and symptoms, unique features, and nursing care** - **Measures to promote health, the role nutrition plays** - **Measures to facilitate independence**