Ch. 36 & 4 Flashcards
alzheimer’s disease
- unknown cause
- most common type of dementia
alzheimer’s disease: pathophysiology
structural changes in the brain
risk factors of alzheimer’s
- age: over 65
- gender: females
- genetics: familial history
there is a higher incidence and prevalence of alzheimer’s after age
65
alzheimer’s can affect anyone older than age
40
how many people are affected by alzheimer’s in the U.S.?
> 6 million (over 65 years)
is there a proven way to prevent alzheimer’s?
no- there is no proven way to prevent AD
what may contribute to alzheimer’s?
chronic health problems
- diabetes
- acrosclerosis
alzheimer’s: health promotion
- diet
- exercise
- stop drinking and smoking
alzheimer’s assessment: history
- onset (gradual onset of symptoms),
- duration,
- progression,
- course of sx
- functional assessment
alzheimer’s assessment: physical assessment
- 3 clinical stages (early, middle, late)
- changes in cognition
- attention and concentration
- judgement and perception,
- learning and memory,
- communication and language,
- information processing
alzheimer’s assessment includes
- history
- physical assessment
- psychosocial assessment
- laboratory and imaging assessment
alzheimer’s assessment: laboratory and imaging assessment
- brain tissue examination at autopsy is only definitive diagnosis
- diagnosis based on patient history and clinical presentation and imaging:
- PET scan
- MRI, CT scan
- genetic testing
what is the only definitive diagnosis of alzheimer’s?
brain tissue examination at autopsy
- therefore cannot “definitively” be diagnosed until after death
the priority collaborative problems for patients with alzheimer’s disease include:
- decreased memory and cognition r/t neuronal degeneration in the brain
- potential for injury or falls r/t wandering or inability to ambulate independently (think fires)
- potential for elder abuse by caregivers r/t patient’s prolonged progression of disability and the patient’s increasing care needs
the priority for interprofessional care of a patient with alzheimer’s is
safety
planning and implementation: what do we do as nurses for patients with alzheimer’s?
- manage memory and cognitive dysfunction
- nonpharmacologic interventions
- drug therapy
- prevent injuries and accidents
- prevent elder abuse
drug therapy for alzheimer’s includes
- cholinesterase inhibitors: donepezil
- NMDA receptor antagonist: memantine
care coordination and transition management of alzheimer’s includes
- home care management
- self-management education
- health care resources
alzheimer’s: home care management
- respite care
- caring for caregiver
alzheimer’s: self-management education
- emphasize mobility
alzheimer’s: health care resources
- Safe Return Program
evaluation of care for a patient with alzheimer’s includes:
- evaluating expected outcomes
- did the patient achieve these outcomes or do you need to revise the plan of care?
parkinson’s disease
- progressive neurodegenerative disease
what (neurologically) causes parkinson’s?
degeneration of the substantia nigra leads to decrease in dopamine levels in brain and affects mobility
parkinson’s disease is separated in ___ stages
5 stages
- stage 1 is mild progressing to stage 5 which is completely dependent
the 4 cardinal symptoms of parkinson’s
- tremor
- muscle rigidity
- bradykinesia (slow movement/speed)
- postural instability
parkinson’s: etiology (causes)
- environmental and genetic factors
- exposure to chemicals and metals
- older than 40 years old
- familial tendency
how many new cases of parkinson’s are seen annually in people over 50 years old?
60,000 new cases
how many people live with parkinson’s?
1 million
what is the prevalence of parkinson’s in men compared to women?
50% more men than women have PD
parkinson’s assessment includes
- history
- physical assessment
- laboratory and imaging assessment
parkinson’s assessment: history
- when symptoms started
parkinson’s assessment: physical assessment
- resting tremors in upper extremities
- rigidity assessment
- facial expression (“masklike”)
- emotional changes (depression)
- speech changes (slower, monotone, slurred, nonverbal)
- bowel and bladder changes (constipated/incontinent)
parkinson’s assessment: laboratory and imaging assessment
- no specific diagnostic tests
- may do a CSF, MRI, or SPECT
- autopsy
appearance of a patient with parkinson’s
- blank facial expression
- forward tilt to posture
- short, shuffling gait
- tremor
- slow, monotonous, slurred speech
planning and implementation: what do we do as nurses for patients with parkinson’s?
- promote mobility
- surgical management
- nonsurgical management- need to collaborate with multiple disciplines to plan care
- manage cognitive dysfunction
nonsurgical management of parkinson’s
- exercise and ambulation
- self-management
- injury prevention
- nutrition
- communication
- psychosocial support
- drug therapy
drug therapy for parkinson’s
- levodopa with carbidopa is often the first drug used
- dopamine receptor agonsits: ropinirole, pramipexole, bromocriptine
- catechol O-methyltrasferases (COMTs): entacapone
- monoamine oxidase B inhibitors: selegiline
what is often the first drug used for parkinson’s?
levodopa with carbidopa
dopamine receptor agonists used for parkinson’s
- ropinirole
- pramipexole
- bromocriptine
cetechol O-methyltrasferses (COMTs) used for parkinson’s
- entacapone
monoamine oxidase B inhibitors for parkinson’s
- selegiline
anticholinergics can be used in management of
parkinson’s disease- severe tremors and rigidity
- Benzotropine
anticholinergics should be used cautiously in older adults because
side effects of acute confusion, urinary retention, and dry mouth
BEERS CRITERIA
tool used to improve medication safety in older adults
- created by American Geriatric Society (AGS)
- medications that need to be used with caution due to severe side effects
what drug class do we give parkinson’s patients that is on BEERS?
- anticholinergics are on the BEERS CRITERIA list to try to avoid
parkinson’s: long-term drug therapy regimens often cause
- delirium
- cognitive impairment
- decreased effectiveness of the drug
- hallucinations
preventing drug tolerance/toxicity with parkinson’s meds
- reduce med dose
- change meds or frequency of administration
- take “drug holiday” especially in the use of levodopa therapy
“drug holiday” means
an agreed cessation of medication for a period of time
surgical management of parkinson’s disease
- last resort
- stereotactic pallidotomy
- deep brain stimulation
- experimental research- Fetal tissue transplantation (human deceased fetus or pig)
care coordination and transition management of parkinson’s includes
- home care preparation
- health care resources
evaluation of a patient with parkinson’s includes
- improve mobility to provide self-care and not experience complications of impaired mobility
- maintain safety and an acceptable quality of life
major subgroups of late adulthood
- baby boomers: 65-78 years
- in-betweens: 79-99 years
- centenarians: 100 years +
social determinants of health in older adults
- limited income
- housing
- lack of access to health care to treat chronic health conditions
- lack of social support
geriatric assessments
- understanding of geriatric subgroup
- functional assessment
- assessment of health protecting behaviors
- assessment of common health issues
health protecting behaviors
- vaccinations
- influenza
- pneumococcal
- shingles
-tetanus (booster every 10yrs)
- seat belts
- moderate alcohol use
- avoid smoking
- smoke detectors/sprinkler in home
- medications/herbs/supplements are prescribed
- avoid OTC meds unless prescribed
- hazard free environment: no scatter rugs, waxed floors, good lighting
health enhancing behaviors
- yearly physicals
- exercise 3-5x/week
- low fat diet
- Ca and Vit D supplements
8 common health issues that affect older adults
- inadequate nutrition and hydration
- decreased mobility
- stress and coping
- falls
- drug use or misuse
- mental health/cognition problems
- substance use disorder
- elder neglect and abuse
older adult problems: inadequate nutrition and hydration
- sedentary lifestyle
- reduced metabolic rate
- reduction in total caloric intake
- inappropriate/unbalanced foods (ie. desserts/sweets)
- diminished sense of taste, smell
- tooth loss, poorly fitting dentures
- reduced income
- chronic disease, fatigue
- decreased ability to perform ADLs
- “fast food” consumption that leads to obesity
- inability to carry large or heavy groceries
- loneliness
basic metabolic rate declines an average of _____ per decade
BMR declines 1-2% per decade
basic metabolic rate: there is a more rapid decline at age ___ for men and age ___ for women
- 40 years for men
- 50 years for women
aging process and nutrition
- gradual loss of functioning body cells and reduced physical activity
- kilocalories = energy
- carbohydrate, fat, and protein
recommendation & daily amount: grains
- half of all grains consumed should be whole grains
- 6 oz/daily
recommendation & daily amount: vegetables
- vary the types of vegetables you eat
- 2.5 cups/daily
recommendation & daily amount: fruits
- eat a variety of fruits
- go easy on juices
- 2 cups/daily
recommendation & daily amount: milk
- eat low-fat or fat-free dairy products
- 3 cups/daily
recommendation & daily amount: meat and beans
- eat lean cuts, seafood, and beans
- avoid frying
- 5.5oz/daily
recommendation & daily amount: oils
- most fat should be from fish, nuts, vegetable oils
- limit solid fats: butter, margarine, lard
- keep consumption of saturated fats, trans fats, and sodium low
- choose foods low in added sugar
recommendation & daily amount: water/liquids
- 8 or more servings/daily
- may include low- and non-fat milk, vegetable or fruit juice, water, soup
assisted feeding suggestions
- make no negative remarks about food being served
- identify the food being served
- allow at least 3 bites of each item before serving the next food
- allow time to chew and swallow
- give liquids throughout meal
medications that may affect nutritional status
- BP meds
- antacids
- anticoagulants
- laxatives
- diuretics
- decongestants
benefits of regular exercise
- decreased risk for falls
- increased mobility
- increased sleep
- reduced or maintained weight
- improved well-being and self-esteem
- decreased depression sx
- improved longevity
- reduced risk for DM, CAD, and dementia
older adult problems: stress and coping are often caused by
- rapid environmental changes
- changes in lifestyle
- acute or chronic illness
- loss of significant other
- financial hardship
adapting to older adulthood includes
- relationships with others
- work or retirement
- medicare coverage options
- programs
- relocation stress syndrome
adapting to older adulthood: programs
- national aging in place council
- village to village network
- AARP Livable Communities
- Administration for Community Living
relocation stress syndrome
nursing diagnosis characterized by symptoms such as anxiety, confusion, hopelessness and loneliness
- commonly happens shortly after moving from a private residence to a nursing home/assisted-living facility
fallophobia
a fear of falling, which causes one to avoid leaving home
factors that increase the likelihood of falls
- presbyopia: the loss of eyes ability to focus on nearby objects
- reduced sense of touch
- decreased reaction time
- peripheral neuropathy
- arthritis
most common cause of injury-related death, ages 65-74
car accident/driving
driving safety may be affected by
- health problems
- medications
assessing risk factors to prevent falls
- fall history
- advanced age (>80yr)
- multiple illnesses
- generalized weakness
- gait and postural stability
- drug assessment
- urinary incontinence
- communication/visual impairment
- alcohol/substance abuse
- change of shift/mealtime in hospital/nursing home
improving driving safety includes
- assessing for physical/mental deficits
- discuss driving concerns with patient
- recommend strategies for maintaining safety when driving
- driving refresher courses
- avoid high-risk conditions (ie. wet roads)
- use vehicle safety features (ie. large-print digital readouts)
older adult problems: dug use and misuse
- polypharmacy
- drugs, food, herb, disease interactions
- intolerance to standard drug dosages
- physiologic changes affect absorption, distribution, metabolism, excretion
effects of meds on older adults
- often intolerant of standard doses
age-related changes (meds)
- affect absorption
- affect metabolism and excretion
- reduced liver blood flow and serum enzyme activity
- reduced renal blood flow causing a decreased creatinine clearance can result in slow excretion and cause high toxic serum drug levels
self-administration of drugs
medication assessment
- assess medication use per Healthy People 2030
- highlight all drugs that are part of Beers criteria
- assess for duplicate drugs
- collaborate with patient, family, pharmacist, and primary health care provider
- obtain complete drug list (OTC, prescribed, herbs, supplements)
medication health teaching
- give verbal and written information
- remind not to share/borrow drugs
- promote adherence to drug therapy regimen exactly as prescribed
when may a guardian be appointed to an older adult?
if an older adult is not legally competent
as older adults age, their risk increases for cognitive impairments of the 3 D’s:
- depression
- dementia
- delirium
what 3 conditions are not associated with aging (hint: start with letter D)
- depression
- dementia
- delirium
one of the most common mental health problems among older adults
depression
depression
- mood disorder having cognitive, affective, and physical manifestations
- primary or secondary
geriatric depression scale- short form (GDS-SF)
an evaluative form that scores you on depression
treatment of depression
- drug therapy
- psychotherapy
**reminiscence and music therapies are also useful with older adults
dementia
syndrome involving slow, progressive cognitive decline (also known as chronic confusion)
- global impairment of intellectual function; generally chronic and progressive
- types: alzheimer’s disease & multi-infarct dementia
delirium
- acute state of confusion, fluctuating onset
- usually short-term, reversible within 1 month or less
- can include physical and emotional manifestations (including psychosis)
older adults in unfamiliar settings often experience
delirium
- very agitated, anxious, restless, disoriented in a new environment
common causes of delirium
- drug therapy (side effects)
- fluid and electrolyte imbalances (dehydration/sodium)
- infections (UTI- most common)
- severe diarrhea (dehydration)
- surgery (anesthesia)
- metabolic problems
- neurological, circulatory, renal, pulmonary disorders (liver/kidney issues- drug levels build up)
- nutrition deficiencies
- hypoxemia (not enough blood perfusion to brain)
screening tools for delirium
- confusion assessment method (CAM)
- delirium index (DI)
- NEECHAM Confusion Scale
- Mini-Cog
interventions for delirium
- collaborate with interprofessional team
- remove or treat risk or causative factors
- use calm voice to frequently reorient
- music (soft)
- doll or stuffed animal (to hug)
elder neglect and abuse
- all 50 states have laws requiring health care providers to report suspected elder abuse
elder abuse can be
- verbal (how they are spoken to)
- physical (bruises, broken bones)
- financial (caretaker stealing money from elderly)
elder neglect (and common signs)
the most common form of elder abuse, not getting ADLs/basic needs met
- malnourished
- dehydrated
- not eating
- unkept appearance- dirty/smelly vs clean
- coming in with pressure ulcer (from home)
- not taking medication
substance use disorder
- excessive use (alcohol or illicit drugs)
- impairs cognition
what may result from substance abuse disorders?
- isolation, depression, delirium can result
substance abuse tools
- SMAST-G
- CAGE questionnaire
- ARPS
- short ARPS (shARPS)
SMAST-G (short michigan alcoholism screening test- geriatric version)
- 10 yes/no questions
- each “yes” answer = 1 point
- total score of 2 or more points = individual has problem with alcohol
examples of SMAST-G questions
- Do you drink to take your mind off of your problems?
- When you feel lonely, does having a drink help?
CAGE test
- four questions:
- Have you ever tried to cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)
the majority of older adults live ___
in the community
what % of adults are living in nursing homes?
10%
do most older adults >65 years take their own medications?
yes
what is important to use to assist with safe med administration for older adults?
- pill boxes (family members or visiting nurses can fill boxes, separated by AM/PM and days of the week)
most common type of elder abuse?
neglect accounts for almost half of all elder abuse cases
early stage alzheimer’s
- mild phase
- lasts up to 4 years
- not major symptoms
- subtle changes: more forgetful than usual
- still pretty independent
middle stage alzheimer’s
- more disoriented
- start wandering
- more forgetful (short term memory)
late stage alzheimer’s
- start to lose their long term memory
- completely dependent for ADLs
- can become non-verbal
- usually end up in nursing home for safety reasons- need to be watched so that they do not inevitably harm themself
psychosocial assessment of patient with alzheimer’s disease
- depression is common in people diagnosed with alzheimer’s
respite care
- where a nurse can come in and take care of the patient so that the caregiver can have a break, go to a wedding, get out of the house for a few hours, etc.
what are your priorities when you have a patient with parkinson’s
- airway
- aspiration (difficulty swallowing)
- falls & injuries (r/t rigidity of muscles, gait, posture)
if a parkinson’s patient is prescribed an MAO inhibitor, what is an important teaching point for your patient?
avoid eating aged cheese, smoked foods, red wine
**no charcuterie board
if you have a patient that drinks daily/is an alcoholic/starting to come off, you want to ask
when was your last drink?
- within 72 hours, they will start going through withdrawal: agitation, delirium, etc.
primary depression
- results from a lack of neurotransmitters norepinephrine and serotonin in the brain
secondary depression
aka situational depression
- results when there is a sudden change in the person’s life such as illness (stroke, arthritis, cardiac disease) or loss (death in the family, friend, pet)
per the Joint Commission, a patient with delirium will or will not be placed in restraints?
will not
SOMA bed
- mesh covering that goes over the bed
- ordered by MD, renewed every 24 hours
- keeps patient with delirium safe in bed
