Gero Bundle NSG 334
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This 50 page Bundle was uploaded by Brieanna Phipps on Monday May 2, 2016. The Bundle belongs to NSG 334 at University of North Carolina - Wilmington taught by Dr. Arms in Spring 2016. Since its upload, it has received 16 views. For similar materials see Gerontology in Nursing and Health Sciences at University of North Carolina - Wilmington.
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Date Created: 05/02/16
1. Primary, secondary and tertiary and the differences Primary Prevention is prevention of disease before it occurs: exercise, smoking cessation, stress management, active social engagement. Secondary prevention is early detection of a disease: Health screenings. Tertiary Prevention is rehab and restoration of health 2. Classifications of Old Young Old (6574) Middle Old (7584) Old, Old (8599) Centenarians “Elite Old” (100109) Supercentenarians (>110) 3. Cultural demographics and projected growth patterns • In 2010 12.6% of the population(38 million) are older than 65 years old. Of these 42.4% are men and 57.8% are older women. • By 2030, almost 1 in 5 Americans (72 million) will be 65 years or older. • Age group 85 years and older is now the fastest growing segment of the US population • At present, about 3.1% of the population are at least 100 years old, the total number is expected to increase by more than 400% by 2030, majority will be women. • Between now & 2050, the 85+ age group will double to 23.1% of the over 65 age group • Projections by 2050: o HispanicAmerican elders are projected to grow 322% • FASTEST GROWING DIVERSE GROUP o AsianAmerican elders will increase by 301% ▪ longest life o African American elders will increase by 128% o NonHispanic White will decline from 84% to 64% • Women now comprise the majority of the older population. • In the United States the ratio of men to women over the age of 65 is 49 men to every 100 women. • Projections by the United Nations, show that by 2050 there will be more people 60 years and older than people younger than 15 years (referring to the world population not just the United States). • Experts predict that the number of older people in the developing world will double in the next 20 years. • In 2015, 67% of the world’s older people will live in developing countries • Japan has longest life expectancy, U.S. second 4. Aging theories (module 2 ppt, chapter 3) BIOLOGICAL THEORIES OF AGING ■ Suggest that aging is the result of predictable cellular death ■ Programmed Theorytelemeres shorten as we get older and that’s why we age. Immunity theory programmed accumulation of damage and decline in the function of the immune system (immunosenescence) Explains the increase in Autoimmune Disorders as we age (because of cellular errors in the immune system that lead to an autoaggressive phenomenon in which normal cells are misidentified as alien and are destroyed by body’s own immune system) T lymphocytes show more signs of “aging” than B lymphocytes ■ Pacemaker theor Neuroendocrine Control (changes in hormones as we age) ex. menopause and estrogen decrease versus child bearing age) Programmed decline in the functioning of the nervous, endocrine, and immune systems. Cells lose ability to reproduce (replicated senescence) ■ biological clock theory – sleep/wake cycle, as we age we don’t secrete as much melatonin and we don’t sleep as much. Error Theories Propose aging is the result of an accumulation of random errors in the synthesis of cellular DNA and RNA. With each replication, more errors occur until the cells are no longer able to fully function, and the changes become visible. Wear and Tear theory cells “wear out” after years of use. (striated muscle, heart muscle, muscle fibers, nerve cells, and the brain are irreplaceable when destroyed by wear and tear or mechanical/chemical injury) Crosslinkage theory loss of proteins; collagen Cellular glucose attaches to protein, either by glycosylation or by glycation. Once attached, a chain reaction or bonding or “crosslinking” between the protein and the glucose causing them to become stiff and thicknew crosslinked proteins referred to as AGEs “advanced glycation end products” ■ Free radical theory (Oxidative stress) – random errors occur due to damage from free radicals. As we age, these accumulate and damage occurs faster than body can repair. Mitochondrial DNA seems to be the most affected by these changes (#9) PSYCHOLOGICAL THEORIES OF AGING Social Aging Role Theory Age norms: socially and culturally constructed expectations of what is deemed as acceptable behavior The ability of an individual to adapt to changing roles over the life course is a predictor of adjustment to personal aging. In successful aging: as one role is completed, another one takes its place that is valued comparatively. Resistance to role changes indicates poor adjustment to ones own aging Activity Theory “use it or lose it” Theorists saw activity as necessary to maintain life satisfaction and positive selfconcept Disengagement Theory Older Adult withdraws from roles Transfer of roles and disengagement was originally seen as necessary for the maintenance of social equilibrium Now is not necessarily viewed as a positive thing for society Continuity The (Havinghurst and Albrecht, 1953) Consistent pattern of behavior; substitute one role for a similar one as they age (SEE BELOW) Successful aging is associated with ones ability to maintain and continue previous behaviors and roles or to find suitable replacements Agestratification theory Social aging can be best understood by considering the individual as a member of an age group with similarities to others in the group ■ Modernization theory According to this theory, the status and value of elders are lost when their labors are no longer considered useful, kinship networks are dispersed, the information they hold is no longer pertinent to the society in which they live, and the culture in which they live no longer reveres them In part due to advancing technology, urbanization, and mass education DEVELOPMENTAL THEORIES OF AGING ■ Er s eightstage model Middle age: Generativity (accomplished, giving back) vs. stagnation (unhappy w/ life) “how can I contribute to society?” Older Adult: Ego integrity( satisfied with life) vs. despair (regrets, estranged family) “did I live a meaningful life?” ■ Havig s Developmental Tasks of Later Maturity (60 & >) 1. Adjusting to decreasing physical strength and health 2. Adjusting to retirement and reduced income 3. Adjusting to death of a spouse 4. Establishing an explicit affiliation with one’s age group 5. Meeting social and civil obligations 6. Establishing satisfactory physical living arrangement ■ Ma s hierarchy of needs (p. 41) Basic needs safety/security belonging self esteem self actualization 5. Preventable risk factors for Older Adults (Module 3 ppt, chapter 2) ■ CURRENTLY REDUCE LIFE EXPECTANCY IN THE US (PREVENTABLE) ■ Smoking ■ High BP ■ Elevated Blood Glucose ■ Overweight/obesity ■ Fall prevention ■ Medicare Prevention screenings https://mymedicare.gov/ o Estimates are that 90% of OA never receive routine screening tests. o 60% don’t receive routine preventative health services. ■ Screenings recommended for OA Primary prevention: ▪ Bone mineral density (DEXA) osteopenia (osteoporosis W>Men) ▪ BP, BS annually ▪ Fasting Lipids annually ▪ BMI –annually ▪ Smoking cessation counseling (annually) motivational interview do they want to quit, a quit date, 1 piece of gum=1 cigarette (patches come off at night) chantix increase suicide risk ▪ Vaccines • Yearly Flu vaccine • Pneumococcal vaccine – once but if given before 65, then 1 more 5 years later. • Zoster vaccine – once at 60 • Tetanus Booster (every 10yrs) • PPD Secondary Prevention: ▪ Mammograms – every 2 yrs 5075 yrs old ▪ Pap smears – none if hysterectomy. Every 3 years until 75 (flexible) ▪ Colonoscopy – every 10 yrs starting at 50 ▪ Fecal Occult Blood Test annually ▪ Hearing / vision – annually ▪ Depression / alcohol – annually ▪ Abdominal Aortic Aneurysm – annually in smokers starting at 65 6. Wellness and healthy aging Healthy Aging: “Achieving highest level of personal wellness no matter the health condition.” “Process of slowing down, physically and cognitively, while resiliently adapting and compensating in order to optimally function and participate in all areas of one’s life” (p. 23) o Functional independence o Self Care management of illness o Positive outlook o Personal growth and social contribution Healthy lifestyles are more influential than genetic factors in helping older people avoid the deterioration traditionally associated with aging. Preparation for healthy aging begins in the prenatal period and is fostered through social and physical environments that promote healthy development and healthy behaviors at every stage of life. (p.30) Senescence: Progressive deterioration of the body systems that can increase the risk of mortality as the individual gets older. Otherwise known as BIOLOGICAL AGING **Know Senescence and its definition** Wellness: Is: the best achievable balance between one’s environment, internal and external, one’s emotional, spiritual, cultural & physical processes. Wellness has been conceptualized as having seven dimensions: physical, emotional, spiritual, intellectual, environmental, occupational, and social. o Educational Wellness: ▪ Recognizes awareness and acceptance of one’s feelings as well as the ability to form interdependent relationships; feeling positive and enthusiastic about oneself and one’s life and the ability to cope effectively with stress. o Spiritual Wellness: ▪ Recognizes the search for meaning and purpose in our lies and the taking of time to reflect and connect with the universe o Intellectual Wellness: ▪ Includes expanding one’s knowledge and skills throughout life, discovering new skills and interests, and challenging oneself through creative, stimulating mental activities o Environmental Wellness: ▪ Calls for caring for precious resources and creating living spaces and practices that respect and support the environment. o Occupational Wellness: ▪ Includes doing something that you love, contributing your unique gifts, skills, and talents to work that is personally meaningful and rewarding and balancing work with leisure time. o Social Wellness: ▪ Recognizes the importance of staying engaged in meaningful activities and relationship and building a better world for current and future generations. The wellness approach suggests that every person has an optimal level of functioning for each position on the wellness continuum to achieve a good and satisfactory existence (wellbeing). (See Figure 21) 3 Components to Successful Aging: 1. Low probability of disease & diseaserelated disability 2. High cognitive and physiological functional capacity 3. Active engagement with life Healthy Behaviors: Promote health & prevent disability o Minimize loss of independence associated with illness o Hold off functional decline o “SelfManagement” – physical activity, nutrition, tobacco & alcohol use, safety measures related to falls and driving o Immunizations o Mental health – “GDS” – Geriatric Depression Scale http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf Recommended Health Screenings: Primary Prevention: Bone mineral density (DEXA) BP, BS annually Fasting Lipids BMI Smoking cessation counseling Vaccines o Yearly Flu Vaccine o Pneumococcal Vaccine – usually once but if given before 65, then 1 more 5 years later o Zoster vaccine – once at 60 o Tetanus Booster o PPD (Tuberculosis skin test) Secondary Prevention: Mammograms: every 2 yrs. (5075 yrs. old) Pap smears: none if hysterectomy OR every 3 years until 75 Colonoscopy: Every 10 yrs. Starting at 50 FOBT (Fecal Occult Blood Test): Annually Hearing/Vision: Annually Depression/Alcohol: Annually Abdominal Aortic Aneurysm: Annually in Smokers starting at 65 What are the implications for the community, state, nation, healthcare system of maximizing an older adult’s health & wellness? *THINK COST SAVINGS* KEY CONCEPTS: Wellness is a concept, not a condition; Human adaptation to the most individually satisfying level in response to existing internal and external conditions Older people rate their health in terms of The ability to function Preventable risk factors reduce life expectancy in US: 4.9 yrs. In men, 4.2 yrs. In women A nurse with a wellness focus: designs interventions to enhance: o Health promotion and o Disease prevention across the continuum of care. Physiological Changes: are cumulative. 3 are especially important: 1. Loss or decrease in compensatory reserve 2. Progressive loss in the efficacy of the body to repair damaged tissue 3. Decreased functioning of the immune system “Immune Theory” Immunity Theory: presents aging as a programmed accumulation of damage and decline in the function of the immune system, or immunosenescence. The damage is the result of oxidative stress (see p. 35, 36): The ability of lymphocytes to withstand oxidative stress appears to be a key factor in the aging phenotype The T cells are thought to be responsible for hastening the agerelated changes caused by autoimmune reactions as the body battles itself. Cellular errors in the immune system have been found to lead to an auto aggressive phenomenon in which normal cells are misidentified as alien and are destroyed by the body's own immune system. This phenomenon is used to explain the increase in autoimmune disorders as we age Aging Process: is a wholly unique experience Intrinsic (genetics) & Extrinsic (environment) Factors o Normal changes can mask early signs of potentially reversible disease processes 7. Atypical presentations in the Older adult patient Atypical presentation: as opposed to a younger person. UTI in older person would present different: confusion, fatigue and change in daily functioning. No fever (thermoregulation is different, they may be taking anti inflammatory which prevents fevers, inflammation). *** if you wait for a febrile response you waited too long!!!!! Also increased WBC in older adult is a LATE SIGN of infection! OA: will have atypical presentation: New onset or increased confusion (delirium) Falling Incontinence A change in ability to function daily **Dehydration is most common cause of electrolyte imbalance in the Older Adult** EYES: normal Prysbiopia – eye can no longer focus on near objects Arcus Senilis – blue ring around the pupils Entropion – eyelid turns inward, rubbing against the eye Ectropion weakening of the connective tissue of the eyelid, which causes the lid to turn out. Pupils smaller (normal) CATARACTS is pathological Cardiac Normal: S4 normal S3 = pathologic – fluid overload, CHF Presbycardia – normal Sacropenia – decreased muscle –Normal OA: pathologic Osteoporosis pathologic Anemia – pathologic Decreased kidney/GFR function is Normal ½ life of drugs are prolonged possibly leading to toxicity **MUST MEASURE CrCl*** Lithium is excreted by kidneys so effected by kidney function and fluid levels Kidney Disease/Failure is pathologic BUN: shows fluid balance ELEVATED: means dehydration LOW: means excess fluid Creatinine Clearance (CrCl): **Is the BEST REFLECTION of what our kidneys are doing **Magic # is 60! Meds will NOT CLEAR from kidneys if LESS THAN 60 = Pathologic Liver mass and Hepatic blood flow decreases as you get older slower metabolism of meds Stomach: delayed emptying of stomach is normal as we age Decreased gastric acid production – normal (PH GOES UP!!!!) Slower intestinal motility – normal Dry mouth delays buccal absorption = Dry mouth in older adults is normal Changes in Thyroid = Pathologic High TSH = hypothyroidism Low TSH = hyperthyroidism Increased adipose tissue = normal *Lipid soluble drugs stored in adipose tissue can lead to toxicity with “normal” dosing in older adults. Diprivan (propoful) – anesthetic can get stored up in body; usu. Used for intubation & ICU – Michael Jackson Benzos – same effect Decreased body water = Normal Digoxin – Water soluble drug = drug levels can be increased (increases heart contractility) Protein Levels – decrease slightly = normal Malnutrition; acute illness o Low Albumin Levels: ▪ Increase drug levels of protein bound drugs ▪ More circulating (free) drug in blood Warfarin (Coumadin) are protein bound meds See additional info at http://consultgerirn.org/topics/atypical_presentation/want_to_know_mor e 9. Ageism and Elderspeak Ageism is the systematic stereotyping of, and discrimination against, people because they are old. Ageism is found crossculturally, it is essentially prevalent in the United States where aging is viewed with depression, fear, and anxiety. Ageism can be detrimental to older adults and can contribute to a shorter life span, where as a more positive view can contribute to a longer life span. Ageism can affect health professionals as well and it is important for nurses to be aware of their own attitudes and beliefs about aging and the effect that this attitude can have on their patients. Elderspeak is a form of ageism in which younger adults alter their speech, based on the assumption that all older people have difficulty understanding and comprehending. Examples of this include speaking more slowly, using limited vocabulary, and using pet names. 9. Psychosocial theories – Erickson Erickson proposed that successful mastery of one task was necessary for successful movement to the next stage of maturity. Erickson’s task of middle age is generativity, or that which establishes oneself and contributes in meaningful ways for the future and future generations. Failure to accomplish this stage results in stagnation. What has been called the “final task” of the stage of late life is that of ego integrity as opposed to despair. Ego integrity implies a sense of completeness and cohesion of the self. In later years Erickson modified his earlier work and modified his “either/or” stance of the tasks to the recognition of the balance of each of the tasks and felt that the goal was to achieve balance between the two goals rather than absolute resolution. 10.. Normal age related changes vs. pathology and associated labs (chart) Integumentary System: Decreased elastin causing thin skin (wrinkling) Adipose tissue redistributes to waist line/hips Dry Skin – decreased eccrine, apocrine, and sebaceous glands Decreased proliferative potential – delays wound healing and vitamin D production Increased pressure ulcer probability Vascular lesions common (Seborrhea Keratosis) “Age Spots” – changes in pigmentation, accumulation of discoloration, decreased melanocytes/photoprotection Decreased response to injury/thermoregulation – decreased corresponding blood vessels Musculoskeletal System: Sarcopenia (generalized loss of skeletal mass) – decreased lean body mass Decrease of height – shrinking of vertebral discs/loss of bone mass (altered bone remodeling) Decreased range of joint motion – joint degeneration with arthritic changes Muscle atrophy – especially with disuse Increased postural sway – difficulty maintaining balance Cardiovascular System: Decreased cardiac output – resting cardiac output maintained Presbycardia (stiffening of the heart) – valve stiffening alters cardiac conductivity, arterial stiffening causes decline in peripheral/vital organ perfusion, veins thicken Increased risk for conduction disturbances (MI) and tachyarrhythmia, decreased HR response to stress S4 Sound – agerelated change Decreased renin, angiotensin, and aldosterone production Decreased baroreceptor sensitivity (potential postural hypotension) and loss of arterial elasticity (potential isolated systolic hypertension/left ventricular hypertrophy) *Ejection fraction: <40% heart failure diagnosis, <35% severe cardiac arrhythmias *S3 Sound: pathologic fluid overload Respiratory System: Total lung capacity decreases with aging – loss of elastic recoil (increased ventilation/perfusion mismatch) Decreased airway clearance – decreased cough/laryngeal reflexes & decline in mucociliary clearance Increased AP diameter – stiffening of chest wall, declining chest muscle strength Decreased number of alveoli – arterial hypoxemia (reduced PO2 levels) Decreased ciliary action – higher aspiration risk and respiratory infection Genitourinary System: Endocrine System: Older adults are less sensitive to insulin *Diabetes is pathologic disease (NOT normal) *Hypothyroidism/Hyperthyroidism ARE pathologic, although common. Digestive System: Decreased saliva secretion – taste buds decrease in number Tooth enamel and dentin erode (tooth loss/gum erosion) Decreases esophageal and gastric mobility (increased emptying time) Liver decreases in weight, size, and blood flow (drug clearance) Decreased acid production (achlorhydria) Slower absorption of proteins, fats, minerals, and some vitamins *Gallstones – increased occurrence Immune System: Decreased speed & strength of immune response Decreased neuroendocrine regulation of immune activities 11. Hearing impairment in the older adult Third most prevalent chronic condition (foremost communicative disorder) Conductive hearing loss (cerumen impaction) Sensorineural hearing loss: inner ear (most common in OA) *Presbycusis – loss of hearing d/t age related changes in both ears (NORMAL) Tinnitus: *Ototoxic medications: Aminoglycosides, Loop Diuretics (Lasix), Baclofen, Propranolol, Antineoplastic, high doses of ASA 13. Healthy People 2020 Box 23 (p. 24) HEALTHY PEOPLE 2020 SUMMARY OF OBJECTIVES ? Increase the proportion of older adults who use the Welcome to Medicare benefit ? Increase the proportion of older adults who are up to date on a core set of clinical preventative services ? Increase the proportion of older adults with one or more chronic health conditions who report confidence in managing their conditions ? Reduce the proportion of older adults who have moderate to severe functional limitations ? Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisuretime physical activities ? Increase the proportion of the health care workforce with geriatric certification ? Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for longterm services and supports ? Reduce the proportion of unpaid caregivers of older adults who report an unmet need for caregiver support services ? Reduce the rate of emergency department visits due to falls among older adults ? Increase the number of States, the District of Columbia, and Tribes that collect and make publicly available information on the characteristics of victims, perpetrators, and cases of elder abuse, neglect, and exploitation 12. Cultural proficiency “ To address health disparities and inequities, it is necessary not just to become competent but to become culturally proficient health care providers and organizations, that is, able to move smoothly between the world of the nurse and the world of the patient (and in this case, the world of the elder). Nurses should become aware of and understand the considerable problems that many older women in general, and men and women from ethnically distinct groups, encounter in pursuit and receipt of health care and the considerable disparities in health outcomes. Through this awareness, more compassionate and relevant care can be provided. By increasing awareness, nurses learn of their personal biases, prejudices, attitudes, and behaviors toward persons different from themselves in age, gender, sexual orientation, social class, economic situations, and many other factors. Through increased knowledge, nurses can better assess the strengths and challenges of the older adult and know when and how to effectively intervene to support rather than hinder cultural strengths. Skills in cultural competence include putting cultural knowledge to use in assessment, communication, negotiation, and intervention. ” (p. 66) BOX 56 (p. 67) MOVING TOWARD CULTURAL SENSITIVITY & HEALTHY AGING ? Become familiar with your own cultural perspectives, including beliefs about disease etiology, treatments, and factors leading to outcomes. ? Examine your personal and professional behavior for signs of bias and the use of negative stereotypes. ? Remain open to viewpoints and behaviors that are different from your expectations. ? Appreciate the inherent worth of all persons from all groups. ? Develop the skill of listening to both nonverbal and verbal communication. ? Develop sensitivity to the clues given by others, indicating the paradigm from which they face illness and aging. ? Learn to negotiate, rather than impose, strategies to promote healthy aging consistent with the beliefs of the persons to whom we provide care. A collectivist culture is one in which people tend to view themselves as members of groups (families, work units, tribes, nations), and usually consider the needs of the group to be more important than the needs of individuals. 13. Older adults in prison Module 2 Slides 45 – 47 MItka, M. (2004). Aging prisoners stressing health care system. 10% of prison population less then or equal to 50 years old (in 2008) o Expected to grow (30 % in 2030) On average they have 3 chronic conditions (if over the age of 55) 1hypertension 2hyperlipidemia 3diabetes o Prior to incarceration – impoverished lives Stressful prison life (they have to protect themselves) o A 50 year old inmate may have a physiological age that is 10 to 15 years older because inmates usually age faster due to abuse, illicit drugs and alcohol, and limited life time access to preventive care/health services o Nutritional issues from physical activity limitations o Lack of privacy to talk with PCP Cost o Tight budgets ▪ Perinmate basis (does not consider needs of individual prisoners) o 3 X more expensive to provide care to older inmate compared to younger. o Hard to legislate for more money (we’re economic hard times) Providing quality care o Computerized programs – tracks appts so physician and nursing time is not wasted o Introducing hospice care PMH Role o Of the population of 55 years old that average 3 chronic conditions – 20 % of these people have mental illness 14. Teaching the Older adult Basic intelligence does not change with age. Most older adults have hobbies, desire to travel, volunteer, and are involved in the community. Some, however, may experience learning barriers: memory impairment vision and/or hearing loss cultural differences education level (many of the older adults today may not even have a high school diploma which could result in low literacy skills) Nursing: make sure the older adult is ready to learn, or else the teaching will not be effective identify any cultural factors that could affect client learning assess memory and cognitive abilities before teaching. Use past experiences to help them connect new learning to what they already know. Ask for feedback to ensure they understood. Focus on a single topic at a time in order to help them concentrate and take a break if the client gets tired or distracted. assess for any sensory deficits. They may need assistive devices. *Vision impairment: use material with large print and contrasting colors. *Hearing impairment: sit in front of the client in order to maintain eye contact and allow them to read your lips. Speak slowly, concisely, and avoid high pitched tones. make sure to provide enough time for client to respond. minimize environmental distractions family members or friends can be present, they can reinforce the teaching take into account the client’s reading level, use appropriate vocabulary. Printed materials should be written for an 5th grade reading level. respond to topics that the client is interested in provide feedback 15. Communicating with the older adult Opportunities for social interaction may be more limited as a result of loss of family & friends, illnesses, and hearingvisioncognitive impairments. This can lead to a decline in communication skills. *Avoid yes/no questions and “why” questions* Neurological Disorders Receptionperceptionarticulation Anomia – word retrieval Aphasia – impaired ability to process language global aphasiaaren’t comprehending speaking one word language Broca’s aphasiaaware and comprehending but expressive speech isn’t fluent Wernickesnot aware and sequences does not make sense. Dysarthria – weakness or incoordination of speech muscles white boards and pictures can be used to enhance communication be patient, clarify, and provide feeback o Includes glaucoma screening Depression/alcohol (annually) Abdominal aortic aneurysm (annually in smokers starting at 65) Other Screenings: All Persons (from table – not included on pp) Serum Cholesterol o Routine in men >35 and women >45 o Q 5 years, more frequent for people at risk Fecal occult blood/rectal exam o Annually DM o Q 3 years, more for those at risk (no upper age limit suggestion) Obesity o BMI >30 o Counseling and behavioral interventions Digital rectal exam o Annually for men PSA (ProstateSpecific Antigen) o Offer to men >50 or at risk men >40 (not recommended for men >75) 16. Transitions of care across the continuum How do you determine what level of care an older adult needs? • This depends on their level of daily functioning o Determined objectively by using Katz IADL screening • Independent living means the person can do all IADLs themselves or has hired a care giver to assist them. Having this caregiver allows them to remain in the independent living setting. o A person does not necessarily have to be able to cook but must have community resources such as meals on wheels to provide adequate food. Meals are eaten in the privacy of each person’s apartment. There is not a dining room. • A person in an assisted living facility (ALF) needs some assistance with ADLs and IADLs but is able to feed themselves and is mobile enough to get from their apartment to the dining room. In ALF, patients may have a small kitchenette but typically eat most meals in a main dining room with other residents. • In Skilled Nursing Facilities (SNF), residents have at least deficits in 2 different areas of ADLs. For example, a person meets criteria if they need assistance with bathing and toileting. Persons in the PACE program also have to meet this criteria. • PACE – (patient all inclusive care of the elderly) to keep them out of a nursing home. eligible for medicare and Medicaid. • CCRC continuing care retirement community. (all levels of care for a person) • TRANSITIONS OF CARE is where most mistakes are made • up to 2/3 of hospitalization transfers are avoidable • rehospitalizations usually are Congestive Heart Failure, medication discrepancies and relocation stress syndrome (depression from changes) • ex talk to them, music, give pt control, window of time. • Relocation Stress Syndromephysiological and psychological disturbance as a result of change in one’s environment • confusion • delirium • depression • PT MUST have some control over the environment*** move from rehab to ALF or SNF (skilled or Long term) to memory care give patient control, bring pics from home. 17. Medicare 100% federal A: hospital visit B: Outpatient C: Private health plans D: Drug Coverage >65 yrs old (also the Blind, End Stage Renal, and Total Disabled) BET** KEY IS PREVENTION!! more sick=more money **you can sign up 3 months before your birth month, on your birth month, and three months after your birth month. (7 months) at age 62 you can sign up for SS (lesser rate if you draw early) Medicaid: (for low income children, preg women, permanently disabled and persons>65) 50% state 50% federal Eligibility determined by each county 18. Gero Pharmacy SEE MOD 4!!! 19. Stroke 1 Ischemic or Hemorrhagic (MUST KNOW) CT scan to determine. **** if hemorrhagic CANT have thrombolitic agents FAST – facial droop, arm, speech, time LEFT HEMISPHERE STROKE : speech, warnicies, language understood RIGHT HEMISPHERE STROKE : over estimate abilities, lack of awareness, sequences of task. ex, pants on before underwear pg 284 in book NSG 334 This is to be used as a guide only and does not represent everything you will be tested on. Any and all materials in Modules Falls, 5, 6, 7 and 8 can be part of the test. BOOK CHAPTERS 10,1218, 2023, 26, 245247 CODE OF ETHICS – (mod 7 and 8) Definitions in Book o moral principals are incorporated o Advocacy, autonomy, beneficence, nonmalefience, confidentiality, fidelity, justice, sanctity of life, reciprocity, veracity, informed consent, fiduciary responsibility FIRE SAFETY o Night time o Deaths > in men (may go back in to get others or things) o Smoke inhalation > burns o 80 and older have 3x higher risk of dying in a home fire. o smoke detectors (not by windows) HOME SAFETY o Clutter, cords, rugs o Space heaters o environment outside the home too FALLS (Chpt 12) (well lit, clear even walkways) SIGNIFICANT PROBLEM – women fall more, men have higher mortality rate : 1 in 3 OA fall annually; leading cause of morbidity and mortality for older adults (67% mortality in 1 year after hip fracture) (up to 86% from hip fracture now) post surgical complications (MI, PE, stroke, fat embolism) Patients get so scared to fall again they won’t get out of wheelchair again • consequences: fractures (increase frailty & mortality), TBI, fallaphobia • The impact of falls and being at risk for falls is larger than the impact of most other chronic conditions, namely heart problems, diabetes, respiratory conditions, and arthritis, among others. Some of the strongest predictors of falling include advanced age, gender, stroke, sciatica, arthritis, and vision/hearing problems. Medicare will not pay for hip fracture if it happens in the hospital (1 of 10 they wont cover) Intrinsic – what’s within the person body or medical history medications they take that cause falls (gait, instability, cog impairment, visual impairment) sensory deficit, medications, BB meds with ortho hypotension, sleep meds and pain meds. History of a fall!! text book page 460 table 121 Extrinsic environmental (not clear pathways) standing on step stool, not wearing no slip socks, reckless wheelchair use, all 4 rails up on bed, (Pg 470 book) nursing assessment** internal/external rotation of the leg o did they fall or elder abuse (unilateral bruise or bilateral bruise) DEMENTIA (umbrella for dementias) related to a decline in the brain’s level of Ach which is essential to learning and memory (Acetylcholinesterase: enzyme that naturally decreases acetylcholine in the brain & Cholinesterase inhibitor: block the enzyme increases the acetycholine (which helps keep the memory that they have)); glutamate overactivity causes neurodegeneration and atrophy of the brain, will kill the healthy neurons! o Memory BREW (memory, behavioralapraxia, recognitionagnosia, executive functioning, wordsaphasia o AlzheimersMOST COMMON (6080%); memory, visualspatial and language disturbances, indifference, delusions, agitation, behavioral changes Increasing age is #1 RISK!! (family history) increased BP, elevated blood sugar (100125), smoking, diabetes. (diagnosed with 2 fasting blood sugars of 126 or Hem A1C over 6) not on test Older African American Males highest risk. Daily Touching and Bathing can exacerbate pain responses bc they have FEAR of what you are doing. Can’t cognitively understand! Resistance causes tension and pain in muscles. Symptoms of AD: •Aphasia – disruption of language functioning •Receptive predominantly (frontal, temporal) •Apraxia – Disturbance in organization of voluntary action (dressing, eating) •Agnosia – Disorganization of perception and recognition (parietal lobe) •Amnesia – Dysfunction of memory processes (temporal lobe – hippocampus) •Alogia – poverty of speech Diagnosis: The clock drawing tests visualspacial skills – they usually can’t drive if they can’t do this. Animal naming give them one minute to tell you any type of animal that they can think of (they should be able to tell you more than 11) make sure they can go out of a specific are (farm animals, wild animals, zoo animals) Stages: Global deterioration scale has 7 scales – basically breaks the 3 main stages into early and late stages. Most people are placed in a nursing facility in the midlate moderate stages (wandering). Family can’t keep them safe at home. Understand that an early moderate stage and a late moderate stage is a big difference! Lifelong learning is protective so a person was still functional and didn’t realize. They didn’t have much long after the disease was diagnosed because it was already severe. Wandering with dementia: Finger foods can really help them if they don’t want to sit down Have a family dining have staff sit down with them and have dinner with them. o Frontoremporal Dementia personality changes, executive dysfunction, disinhibition, impulsivity, progressive loss of speech o Lewy Body Dementia Visual hallucinations, elusions, falls, syncope, parkinsonism, fluctuating memory, sensitivity to antipsychotic medications; these hallucinations don’t have to be frightening, they can be comforting (children playing outside window, loved ones who came back), parkinson’s kind of go hand in hand. These patients are highly sensitive to antipsychotic meds (it will energize them and cause them to become aggressive) o Vascular dementia (2 most common) stepwise deterioration, prominent aphasia, motor dysfunction, mood or behavior changes, severe depression symptoms; post stroke, doesn’t have to be a stroke but HTN, etc. Patients and families tend to delay treatment because it is hard to diagnose. There is a lot of fluctuation in this course so it’s hard to recognize this. o HIV/AIDS r/t dementia: Early diagnosis is extremely paramount. o Differences between dementia, delirium and pseudodementia are in patient presentation. A person with Dementia will try to answer all your questions and confabulate. A person with delirium will not be able to focus, concentrate and will have waxing and waning levels of consciousness. A person with pseudodementia will present with a blunted affect and say, "I don't know" in response to questions. Answering questions for this person is just too overwhelming for them. o LOBES: o Frontal lobe: The frontal lobe is what determines our personality, behavior, reasoning. Children with attention deficit disorder: their frontal lobe isn’t developed. Frontal temporal dementia this can change the person completely because it can affect their behavior and personality. o Temporal lobe: hippocampus and amygdala Amygdala where we store the fight or flight, where our fears and anxieties are held. People who go through an environment with a lot of yelling and abusive relationships their amygdalas are bigger than they should, if they go through psychotherapy and take medications their amygdala will go back to its regular size. Hippocampus shrinks with dementia, this is what affects our memories. “May your hippocampus be with you” o •Cognitive functions that remain stable: •Attention span, language skills, communication skills, comprehension, visual perception SHOULD NOT CHANGE!!! IF IT DOES IT IS PATHOLOGICAL. o •Cognitive functions that decline: •Verbal fluency, logical analysis, selective attention (ability to multitask), object naming (knowing what you want to say but the word isn’t in your brain but will come back), complex visuospatial skills (driving) It is very important to recognize what they may be dealing with, don’t hurry them or rush them and treat them how they want to be treated. Also give them positive reinforcement. Dementia + Chronic Illness: Any chronic illness along with dementia will increase their length of stay in a hospital. It has to do with the dementia and the increased risk of them having delirium in a hospital setting where they can easily become disoriented. Those different transports within a hospital cause a higher risk of a delirium as well (moving different rooms, taking down to a CT, etc) Costs: The Sandwich Generation (who are raising parents who are aging and taking care of their children as well) As a nurse be able to recognize caregiver burden and realize when they need respite care. ELDER ABUSE o Vast majority of abuse and neglect (89.3%) occur in the domestic setting o “Typical” elder who is abused is a Caucasian female > 80 yrs old o Typical abuser: Adult child (32.6%), Family member (21.5%), Spouses (11.3%) o CHARTS IN BOOK o Persons with cognitive impairment are more prone to be abused. Happens out of caregiver burden, frustration, etc. o Mostly occurs in home, typically the adults child. o Signs of abuse: Tend to be bilateral, falls would be unilateral Role as a nurse: as a nurse we are mandated reporters! (social services or adult protective serv) People who are in restraints are more likely to become injured and possibly die. Abuse is not always recognized sexual abuse is also possible, emotional abuse isolation, not allowing them to talk to people, humiliating them. Financial Exploitation when person steals the OA’s money and finances. Neglect self neglect is also classified here. (Malnutrition, ask about ADL’s) walk through musculoskeletal range of motion. TIPSHEET: ELDER ABUSE Types of elder abuse ■ Physical abuse (use of force resulting in pain, bruises, injury, or other impairment) adult children who are the care giver or spouses. Cognitive assessment, does she know, and do the bruises correlate. Report from EMS of how they found her… (unilateral) and should be uniform of same stage of healing. PAIN LEVEL and MEDICATIONS (watch for headache, TBI, irritability) pupil reactions are diff per eye with neuro prob. You have to call Adult Protective Services you can not pass it along to Social Worker. ■ Sexual abuse (nonconsensual physical contact that is sexual in nature, rape, assault, exposure, nudity, etc) ■ Emotional/psychological abuse (verbal and/or nonverbal aggression that results in distress of the victim) Elder abuse risk factors ■ Clinical Shortterm memory impairment Dementia Depression Physical dependence, manifested by deficits in activities of daily living Substance abuse (by patient or caregiver) ■ Situational Social isolation Poor social functioning Recent bereavement, especially loss of partner DELIRIUM characterized by an acute or subacute onset with symptoms developing over a short period of time (hours to days) LIFE THREATENING ORTHO surgery is the most common cause of Delirium o Symptoms fluctuate over the course of the day, worsening at night Altered Changes in Cognition Acute Onset Changes in Consciousness attention Reduced awareness Memory, thinking, Onset hours to days and Reduced ability to of environment disorientation and changes the symptoms fluctuate maintain, shift or in perceptual awareness over the course of a day focus attention o Delirium happens rapidly, hours to days, can be experiencing delusions (a fixed false belief) you don’t want to tell them it’s not there. TELL THEM YOU WILL KEEP THEM SAFE. o Usually caused by something else and once you fix that cause it will go away. As long as it is caught early enough! Nurses are responsible to recognize this and bring it to the attention to the doctor. o Medical FRAT (medical, fluctuating symptoms, recent onset, attention, thinking) o Risk Factors: Age (over 65years old) Dementia Multiple medications Sensory impairment (visual/hearing) Dehydration Chronic physical illness Substance use (including alcohol) Depression Neurological impairment Functional disability o Nursing Interventions: Talk to your patient, orient them (simple sentences), and get them hydrated, dehydration will lead to a delirium Patient is trying to communicate by getting out of bed…. seen as combative Getting the patient up and out of bed (using the bathroom, doing normal daily function is pivotal) Recognizing it is the biggest problem! o Delirium does NOT cause dementia o But a person who is already diagnosed with dementia is more likely to go into a delirium. o Delirium can look like a hyperactive state (the person will attend to all environmental stimuli) or a hypoactive state (tend to stay attend to their inner thoughts, they have a running connotation in their heads “they are out to get me” they have a lot of paranoia) – it is very important to recognize that this person is fearful and may be combative because they are trying to tell you what they need and what they want. SUBSTANCE ABUSE IN OA’S o BY 2020, the number of people >50 yrs old with substance abuse problems will DOUBLE. o Alcohol is most commonly abused substance (now a powdered form of alcohol) o 1/3 of all hospital admissions are related to alcohol abuse o ½ of MVA are alcohol related o isolation causes drinking more, lost track of day, self neglect and malnutrition o Women should not have more than 7 drinks per week or more than 3 a day o Men should not have more than 14 a week or more than 4 a day o Binge drinking is more than 5 drinks per occasion o Substance abusers are 20% more likely to die by suicide o Men who are widowed are 4x more likely to abuse ETOH o 12 0z beer = 5 oz wine = 1 shot of liquor (all beer and wine are not equal) o Screening CAGE, SMASTG (aimed more for OA), sleep, appetite, balance (apraxia), cognition, memory, interaction with medications, CNS depressant o Physiology & complications decreased metabolism and excretion 2 to renal and liver failure, decrease in lean muscle and total body water, increase body fat, decrease alcohol dehydrogenase breaks down alcohol slower, Werkicke’s encephalopathy (thiamine deficiencybanana bag), Korsakoffs syndrome (caused by chronic alcoholism, dementia like state ataxia, nystagmus, confabulation) o ALCOHOL WITHDRAWL CAN BE FATAL!!! LOSS & GRIEF o The number of losses increase with age health, normal changes in everyday life, life transitions (moving, retirement), loved ones through death, independence o Grief Anticipatory grief “a dress rehersal” avoidance of dying person unintentionally to prepare Acute grief a crisis Chronic grief grieving that takes time Complicated Grief chronic grief complicated by obstacles interfering with its evolition towards reestablishment of equilibrium Disenfranchised grief loss cannot be publicly acknowledges or mourned 5 Stages of grief DENIAL, ANGER, BARGAINING, DEPRESSION, ACCEPTANCE o Mourning: more public display of grief (open casket) o Normal for older adult MALES to move on almost immediately after passing of spouse. Female adult children don’t agree with this and WOMEN move on sometimes but its approved more to MEN DEATH & DYING: The dying process (ARTICLE) o CV system Dehydrated, hypoxia, mottled skin o Respiratory system Dyspnea, pulmonary congestion, tachypnea, “airhunger” (cured with morphine), ꜜ protein levels shift osmotic pressure – 3 spacing & congestion o GI Gag reflex weakens, Loss of appetite o Musculoskeletal system o Muscle weakness: mouth droops, difficulty swallowing o Renal, Dehydration, incontinence o Other signs & symptoms, Pain, agitation, “Transitional withdrawal” o INTERVENTIONS: care, control, composure, communication, continuity, closure o “death vigil” reconciliation, family’s wishes, signs and implications, communicating with the dying patient, family surrounding dying patient o signs of death decreased consciousness or delirium mottling of skin (honeycomb) decreased pulse/respirations “deaths rattle” INTIMACY and SEXUALITY o Changes in sexual identity, HIV still common (>50% of OA are active) New Hanover county is #7 in HIV disease in the state. o can just mean touch not intercourse for intimacy (hug from a friend) not always sexual o Age related changes vs pathology (ED & vaginal dryness)early signs of HTN and Diabetes, also increases exposure to HIV for women o Sexually inappropriate bx in facilities (older adult men) o NSG interventions education to everyone, set boundaries, what medications can help—SSRI’s (decreases libido and decreases ability to orgasm) May need to use this as education. HIV o Approximately 1/3 of HIV infected persons are over 50 o In next 5 years: o Es
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