Ch3 common health problems of older adults

Question 1

Geriatric syndromes

Answer 1

major health issues associated with late adulthood in community and inpatient settings

Question 2

Stages of late adulthood

Answer 2

65-74-young old
75-84-middle old
85-99 old old aka advanced older adult population (fastest growing)
100 + -elite old

Question 3

frailty

Answer 3

geriatric syndrome in which older adult has unintentional weight loss, weakness and exhaustion, and slowed physical activity including walking. At higher risk for adverse outcomes

Question 4

Nurses supporting older adults

Answer 4

nurses need to support older adults’ self esteem and feelings of independence by encouraging them to maintain as much control as possible over their lives, to participate in decision making and to perform as many tasks as possible.

Question 5

Health promotion

Answer 5

older adults need to practice health promotion and illness prevention to maintain or achieve a high level of wellness. Teach them the importance of promoting wellness and strategies for meeting this outcome.

Question 6

Health protecting behaviors

Answer 6

• yearly flu vaccine
• pneumococcal vaccine
• shingles vaccine
• tetanus immunization and get a booster every 10 years
• wear seat belts
• use alcohol in moderation or not at all
• avoid smoking, if you do smoke dont do it in bed
• install and maintain working smoke detectors and/or sprinklers
• Create hazard free environment to prevent falls-remove hazards like scatter rugs, waxed floors.
• use medications, herbs, and nutritional supplements according to you primary health providers prescription
• avoid over the counter meds unless your PCP directs you to use them

Question 7

Health enhancing behaviors

Answer 7

• Have a yearly physical exam-more often if health problems occur
• reduce dietary fat to not more than 30% of calories, saturated fat should provide less than 10% of calories
• increase daily dietary intake of complex carbohydrate-and fiber containing food to five or more servings of fruits and vegetables and six or more servings of grain products
• increase calcium intake to between 1000 and 1500 mg daily
• Take a vitamin D supplement every day if not exposed to sunlight daily
• Allow at least 10-15 min of sun exposure 2 or 3 times weekly for vit D intake; avoid prolonged sun exposure
• Exercise regularly 3-5 times/week
• manage stress thru coping mechanisms that have been successful in the past
• Get together with people in different settings to socialize
• Reminisce about your life thru reflective discussions or journaling

Question 8

Common health issues and geriatric syndromes that often affect older adults in the community

Answer 8

• decreased Nutrition and hydration
• decreased Mobility
• stress, loss, and coping
• accidents
• drug use and misuse
• inadequate Cognition
• substance use
• elder neglect and abuse

Question 9

Nutrition /hydration

Answer 9

• older adults need increased dietary intake of calcium and vitamins D, C, A because aging changes disrupt the ability to store, use, and absorb these substances.
• older adults who have sedentary lifestyle and decreased metabolic rate reduction in total caloric intake is required to maintain an ideal body weight.
• if these needs are not met underweight or overweight/obesity can occur.
• aging may cause decrease in taste/smell.may result in overuse of salt/sugar
• teach older adults how to balance diets with healthy food selections-remind to substitute herbs/spices to season food and vary textures.
• tooth loss/poor fitting dentures/poor dental care/calcium loss can cause older adult to avoid important nutritious foods. may choose mashed potatoes/ice cream type foods, lacks fiber, nutrients
• needs to choose nutritious soft foods otherwise constipation, vitamin deficiencies and other problems may occur.
• extensive use of prescribed and OTC meds, herbal supplements, may decrease appetite, affect food tolerances and absorption and cause constipation.

Question 10

Constipation

Answer 10

-Constipation can reduce quality of life-cause pain, depression, anxiety, and decreased social activities. can lead to bowel obstruction- Constipation is common among older adults-caused by many risk factors like foods/drugs/ and diseases

Question 11

Factors that contribute to decreased nutrition and constipation among older adults

Answer 11

• Reduced income, -chronic disease,
• fatigue,
• decreased ability to perform ADLs -“Fast food” is inexpensive, requires no preparation. Older adults can become overweight or obese when they consume a diet high in fast food.
• older adults may reduce their intake of food to near-starvation levels due to lack of transportation, the necessity of traveling to obtain such services (SNAP,food banks, meals on wheels), -inability to carry large or heavy groceries prevent use of services
• some are too proud to accept free services.
• Many senior centers and homeless shelters offer meals and group social activities.
• loneliness, depression, boredom, responding to these by not eating=weight loss
• lose incentive to prepare or eat balanced diets, older men who live alone are at high risk of undernutrition

Question 12

Nursing action:constipation

Answer 12

educate to:
increase fiber and fluids, exercise, avoid risk factors for constipation
-adults need 35-50g of fiber/day
drink at least2liters/day (unless medically contraindicated)
-some use “Colon cocktail”-equal parts prune juice, applesauce, psyllium (e.g metamucil) to daily diet-1-2 tbsp of mixture daily
-use stool softener if colon cocktail does not relieve/ prevent constipation
-for opiate induced constipation drug therapy may be prescribed

Question 13

Nursing action:nutrition

Answer 13

-Perform nutritional screening for older adults in the community who are at risk for decreased NUTRITION—either weight loss or obesity.
-Ask the person about unintentional weight loss or gain, eating habits, appetite, prescribed and OTC drugs, and current health problems.
-Determine contributing factors for older adults who have or are at risk for poor NUTRITION
(transportation issues or loneliness)
-Based on these assessment data, develop and implement a plan of care in collaboration with the registered dietitian, pharmacist, and/or case manager to manage these problems.

Question 14

Geriatric failure to thrive

Answer 14

a complex syndrome including under-nutrition, impaired physical functioning, depression, and cognitive impairment

Note: drug therapy, chronic diseases, major losses, and poor socioeconomic status can cause these same health problems. Consider these factors when screening for GFTT

• for at risk patients collaborate with patient, family, to plan referral to PCP for extensive evaluation.
• Early supportive intervention can help prevent advanced levels of deterioration

Question 15

Dehydration in older adult

Answer 15

People older than 65 years are also at risk for dehydration because they have less body water content than younger adults. In severe cases they require emergency department visits or hospital stays. Incontinence may actually increase because the urine becomes more concentrated and irritating to the bladder and urinary sphincter.

Nursing action: Older adults sometimes limit their fluid intake, especially in the evening, because of decreased MOBILITY, prescribed diuretics, and urinary incontinence. Teach older adults that fluid restrictions make them likely to develop dehydration and electrolyte imbalances (especially sodium and potassium) that can cause serious illness or death. Teach importance of drinking 2 liters/day of water plus other fluids as desired. Remind to avoid excess caffeine and alcohol as they can cause dehydration

Question 16

Decreased mobility:

Exercise

Answer 16

• Exercise and activity are important for older adults. Promotes and maintains mobility and overall health.
• Physical activity can help keep the body in shape and maintain an optimal level of functioning. Regular exercise has many benefits for older adults in community-based settings.

Question 17

Benefits of regular exercise for older adults

Answer 17

The major advantages of maintaining appropriate levels of physical activity include:

Decreased risk for falls

• Increased muscle strength and balance
• Increased MOBILITY
• Increased sleep
• Reduced or maintained weight
• Improved sense of well-being and self-esteem
• Improved longevity
• Reduced risks for diabetes, coronary artery disease, and dementia

Question 18

Nursing actions: exercise

Answer 18

• Assess history of exercise and health concerns
• remind them to check with their health care provider to implement a supervised plan for regular physical activity.
• Teach older adults about the value of physical activity.

Question 19

Exercise for older adult

Answer 19

• Homebound older adults: Focus on functional ability like ADLs.
• For others-teach importance of exercise
• resistance exercise maintains muscle mass.
• Aerobic exercise such as walking improves strength and endurance.
• One of the best exercises is walking at least 30 minutes, 3 to 5 times a week.
• many senior centers and community centers offer exercise programs for older adults. For those who have limited MOBILITY, chair exercises are provided.
• Swimming is a good way to exercise but does not offer the weight-bearing advantage of walking.
• Weight bearing helps build bone, an especially important advantage for older women to prevent osteoporosis .
• Teach older adults who have been sedentary to start their exercise programs slowly and gradually increase the frequency and duration of activity over time under the direction of their primary health care provider.

Question 20

Stress loss and coping-effects

Answer 20

• Stress can speed up the aging process over time,
• can lead to diseases that increase the rate of degeneration.
• can impair the reserve capacity of older adults and lessen their ability to respond and adapt to changes in their environment.

Question 21

Frequent sources of stress and anxiety for the older population include:

Answer 21

note: later years of life can be a time of especially high risk for stress

• Rapid environmental changes that require immediate reaction
• Changes in lifestyle resulting from retirement or physical incapacity
• Acute or chronic illness
• Loss of significant others
• Financial hardships
• Relocation

Question 22

Reactions to stress

Answer 22

How people react to these stresses depends on their personal coping skills and support networks.
Losses may leave them without support.

A combination of poor physical health and social problems can leave older adults susceptible to stress overload, which can result in illness and premature death.

Question 23

Adapting to old age

Answer 23

depends largely on :

• personality traits
• coping strategies
• establishing and maintaining relationships
• close stable intimate relationships
• some may return to work for socialization and income
• retire at 55-65 live till 80 retirement funds deplete for many
• Fortunately most older adults are relatively healthy and live in and own their own homes.

Question 24

medicare/medical care

Answer 24

Although US government Medicare Part A pays for inpatient hospital care, older adults pay for Medicare Part B to reimburse for 80% of most ambulatory care services, Medicare Part D for prescription drugs, and a private Medi-Gap insurance (e.g., United Health or Blue Cross/Blue Shield) to cover the costs not paid for by Medicare. The premiums for these insurances are very expensive and may still require that older adults pay out-of-pocket copayments for health care services and prescription drugs.

In other developed countries part of or all older-adult care is provided for publicly by the federal government. For example, in Canada all acute and primary health care provider care is paid for publicly. In Germany all older-adult care, including long-term care, is paid for by the government.

Question 25

Facilities

Answer 25

Physical and/or mental health/behavioral health problems may force some to relocate to a retirement center or an assisted-living facility, although these facilities can be very expensive.

Others move in with family members or to apartment buildings funded and designated for seniors.

Older adults usually have more difficulty adjusting to major change when compared with younger and middle-age adults.

Being admitted to a hospital or nursing home is a traumatic experience.

Question 26

Relocation stress syndrome

Answer 26

Older adults often suffer from relocation stress syndrome, also known as relocation trauma. Relocation stress syndrome is the physical and emotional distress that occurs after the person moves from one setting to another. Examples of physiologic behaviors are sleep disturbance and increased physical symptoms such as GI distress. Examples of emotional manifestations are withdrawal, anxiety, anger, and depression.

Question 27

nursing interventions that may help decrease the effects of relocation.

Answer 27

• Provide opportunities for the patient to assist in decision making.
• Carefully explain all procedures and routines to the patient before they occur.
• Ask the family or significant other to provide familiar or special keepsakes to keep at the patient’s bedside (e.g., family picture, favorite hairbrush).
• Reorient the patient frequently to his or her location.
• Ask the patient about his or her expectations during hospitalization or assisted-living or nursing home stay.
• Encourage the patient’s family and friends to visit often.
• Establish a trusting relationship with the patient as early as possible.
• Assess the patient’s usual lifestyle and daily activities, including food likes and dislikes and preferred time for bathing.
• Avoid unnecessary room changes.
• If possible, have a family member, significant other, staff member, or volunteer accompany the patient when leaving the unit for special procedures or therapies.

Question 28

Accidents

Answer 28

accidents comm in older adults

falls most common

Motor vehicle crashes increase as well because of physiologic changes of aging or chronic diseases such as Alzheimer’s disease or peripheral neuropathy.

Question 29

Fall prevention

Answer 29

Most accidents occur at home.

Teach older adults about the need to be aware of safety precautions to prevent accidents such as falls.

Incapacitating accidents are a primary cause of decreased MOBILITY and chronic pain in old age.

Question 30

fallophobia (fear of falling)

Answer 30

Some people develop fallophobia (fear of falling) and avoid leaving their homes. This reaction is particularly common for those who have previously fallen and/or have osteoporosis (bone tissue loss). Osteoporosis is especially common in older thin Euro-Caucasian women who typically have a stooped posture (kyphosis), which can cause problems with balance

Question 31

Home modifications to prevent falls

Answer 31

Collaborate with the older adult, family, and significant others when recommending useful changes to prevent injury.

Safeguards such as handrails, slip-proof pads for rugs, and adequate lighting are essential in the home.

Avoiding scatter rugs, slippery floors, and clutter is also important to prevent falls.

Installing grab bars and using nonslip bathmats can help prevent falls in the bathroom.

Raised toilet seats are also important, especially for those who have hip and knee arthritis.

Remind older adults to avoid going out on days when steps are wet or icy and to ask for help when ambulating. To minimize sensory overload, advise the older adult to concentrate on one activity at a time.

Question 32

CHanges in sensory perception and mobility

Answer 32

Changes in SENSORY PERCEPTION and MOBILITY can create challenges for older adults in any environment.

presbyopia (farsightedness that worsens with aging) may make walking more difficult; the person is less aware of the location of each step.

disorders that affect visual acuity such as macular degeneration, cataracts, glaucoma, or diabetic retinopathy.

Teach the person to look down at where he or she is walking and have frequent eye examinations to update glasses or contact lenses to improve vision. Drug therapy or surgery may be needed to correct glaucoma or cataracts.

reduced sense of touch reduces the awareness of body orientation
Decreased reaction time
peripheral neuropathy/arthritis affects mobility and sensory perception

encourage the use of visual, hearing, or ambulatory assistive devices. High costs and a fear of appearing old sometimes prevent older adults from obtaining or using hearing aids, eyeglasses, walkers, or canes.

for fall risk individuals: choose interventions that help prevent falls and possible serious injury. For example, for those in the community, tai chi exercise or yoga for seniors is very helpful to improve balance and MOBILITY and decrease the fear of falling, especially among older women

Question 33

driving safety

Answer 33

Motor vehicle crashes are a major cause of accidents and death among the older-adult population.

many states require more freqiuent testing for older drivers

reaction time and ability to multitask decreases

some have insomnia =fall asleep while driving

health problems and treatments can contribute to crashes

peripheral neuropathy-decreased sensation of pedal

hypertension drugs can cauise orthostatic hypotension

many older adults feel losing ability to drive loses indipendence
PCP can recommend driving refresher courses and to avoid high risk driving conditions-wet/icy

Question 34

Recommendations for Improving Older Adult Driver Safety

Answer 34

• Discuss driving ability with the patient to assess his or her perception.
• Assess physical and mental deficits that could affect driving ability.
• Consult with appropriate primary health care providers to treat health problems that could interfere with driving.
• Suggest community-based transportation options, if available, instead of driving.
• Discuss driving concerns with patients and their families.
• Remind the patient to wear glasses and hearing aids if prescribed.
• Encourage driver-refresher classes, often offered by AARP (formerly the American Association of Retired Persons).
• Consult a certified driving specialist for an on-road driving assessment.
• Encourage avoiding high-risk driving locations or conditions such as busy urban interstates and wet or icy weather conditions.
• Report unsafe drivers to the state department of motor vehicles if they continue to drive.

Question 35

Drug use and misuse

Answer 35

Drug therapy for the older population can be another major health issue. Because of the multiple chronic and acute health problems that occur in this age-group, drugs for older adults account for about one third of all prescription drug costs.

Question 36

polymedicine

Answer 36

The term polymedicine has been used to describe the use of many drugs to treat multiple health problems for older adults.

Question 37

polypharmacy

Answer 37

Polypharmacy is the use of multiple drugs, duplicative drug therapy, high-dosage medications, and drugs prescribed for too long a period of time.

Question 38

drug issues

Answer 38

Older adults commonly take multiple nonprescription or over-the-counter (OTC) drugs such as analgesics, antacids, cold and cough preparations, laxatives, and herbal/nutritional supplements, often without consulting a health care provider. Therefore this population is at high risk for adverse drug events (ADEs) directly related to the number of drugs taken and the frequency with which they are taken. Drug-drug, food-drug, drug-herb, and drug-disease interactions are common ADEs that often lead to hospital admission.

Question 39

Effects of Drugs on Older Adults

Answer 39

dont tolerate standard dosage
physiologic changes related to aging make drug therapy more complex and challenging. These changes affect the absorption, distribution, metabolism, and excretion of drugs from the body. Even common antibiotics can lead to temporary memory loss or acute confusion. More commonly, antibiotic therapy can cause a Clostridium difficile infection,

Question 40

absorption

Answer 40

Age-related changes that can potentially affect drug absorption from an oral route include an increase in gastric pH, a decrease in gastric blood flow, and a decrease in GI motility. Despite these changes, older adults do not have major absorption difficulties because of age-related changes alone.

Question 41

distribution

Answer 41

Age-related changes that affect drug distribution include smaller amounts of total body water, an increased ratio of adipose tissue to lean body mass, a decreased albumin level, and a decreased cardiac output. Increased adipose tissue in proportion to lean body mass can cause increased storage of lipid-soluble drugs. This leads to a decreased concentration of the drug in plasma but an increased concentration in tissue.

Question 42

metabolism

Answer 42

Drug metabolism often occurs in the liver. Age-related changes affecting metabolism include a decrease in liver size, a decrease in liver blood flow, and a decrease in serum liver enzyme activity. These changes can result in increased plasma concentrations of a drug. Monitor liver function studies and teach older adults to have regular physical examinations.

Question 43

excretion

Answer 43

Changes in the kidneys can also result in high plasma concentrations of drugs. The excretion of drugs usually involves the renal system. Age-related changes of the renal system include decreased renal blood flow and reduced glomerular filtration rate. These changes result in a decreased creatinine clearance and thus a slower excretion time for medications. Consequently serum drug levels can become toxic, and the patient can become extremely ill or die. Monitor renal studies, especially serum creatinine and creatinine clearance, when giving drugs to older adults!

A creatinine clearance test measures the glomerular filtration rate of the kidneys. A commonly used formula for calculating creatinine clearance for men rather than directly measuring it is:

(140-age in years)xlean body weight in kg divided by serum creatinine in mg/dl x72

For women, use this formula and multiply the answer by 0.85. A normal creatinine clearance for men is 107 to 139 mL/min and for women 87 to 107 mL/min. Values decrease as a person ages.

Question 44

Chronic diseases

Answer 44

When chronic disease is added to the physiologic changes of aging, drug reactions have a more dramatic effect and take longer to correct. Often a lower dose of a drug is necessary to prevent ADEs. The policy of “start low, go slow” is essential when health care providers prescribe drugs for older adults. The physiologic changes of aging are highly individual. Alterations in drug therapy should always be individualized according to the actual physiologic changes present and the occurrence and severity of chronic disease.

Question 45

common adverse drug events in older adults

Answer 45

• Edema
• Severe nausea and vomiting
• Anorexia
• Dehydration
• Dysrhythmias
• Fatigue
• Weakness
• Dizziness
• Syncope
• Urinary retention
• Diarrhea
• Constipation/impaction
• Hypotension
• Acute confusion

Question 46

Self-Administration of Drugs

Answer 46

Most people older than 65 years take their own medications. Because the risk for drug toxicity is considerably increased in the older population, help patients assume this task responsibly.

Teach patients and their caregivers, providing clear and concise directions and developing ways to help them overcome difficulties with self-administration.

risk of making errors in self administration or dont adhere to drug regimen for several reasons
First they may simply forget. In the rush of daily activities, they may not take their drugs or may take them too often because they cannot remember when or whether they have taken the medications

helpful to associate pill takling with daily events like a meal. keep calendar or chart. Pill boxes or egg cartons. large print on drug label

Writing the drug regimen on the top of the bottle with large letters and numbers is helpful for some older adults. Colored labels or dots can also be applied. Easy-open bottle caps help older adults with limited hand mobility or strength.

Question 47

other reasons for drug errors

Answer 47

A second reason for drug errors is poor communication with health care professionals. These problems result from poor explanations that are not understood because of educational limitations, language barriers, or difficulty with hearing and vision. Health care professionals often presume that their patients have learned the information if they have taught them about the drugs. Help older adults plan their drug therapy schedules as needed.

varying ways that older adults take their medications. Many people older than 65 years use a multitude of complementary and integrative therapies. Some add to their drug regimen by taking OTC drugs, which can interact with prescription drugs and cause serious problems. For example, a patient receiving warfarin (Coumadin, Warfilone) for anticoagulation may take ibuprofen (Motrin) regularly for arthritis or garlic for hypertension. Because ibuprofen and garlic can inhibit clotting, this combination can cause serious bleeding. When obtaining a drug history, ask patients about all OTC drugs, including herbal and food supplements.

some avoid taking their prescribed drugs . fear of dependency or cost, also side effects not desireable (example diuretics -=incontinence)

may think that two pills are twice as effective and therefore it is better to take two rather than just one. Some older adults take drugs that are left over from a previous illness or one that is borrowed from someone else. Teach patients to take their medications exactly as prescribed by their health care providers.

Question 48

medication assessment and health teaching

Answer 48

interviewed regarding their medication use and include these questions:

• Do you take five or more prescription medications?
• Do you take herbs, vitamins, other dietary supplements, or OTC medications?
• Do you have your prescriptions filled at more than one pharmacy?
• Is more than one health care practitioner prescribing your medications?
• Do you take your medications more than once a day?
• Do you have trouble opening your medication bottles?
• Do you have poor eyesight or hearing?
• Do you live alone?
• Do you have a hard time remembering to take your medications?

The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults assessment tool, simply known as the Beers criteria, is also very useful in screening for medication-related risks in older adults who have chronic health problems. The tool lists multiple medications and related concerns.

Question 49

Examples of Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Answer 49

• meperidine (Demerol)
• cyclobenzaprine (Flexeril)
• digoxin (Lanoxin) (Should not exceed 0.125 mg daily except for atrial fibrillation)
• ticlopidine (Ticlid)
• fluoxetine (Prozac)
• amitriptyline (Elavil)
• diazepam (Valium)
• promethazine (Phenergan)
• ketorolac (Toradol)
• short-acting nifedipine (e.g., Procardia)
• ferrous sulfate (Iron) (Should not exceed 325 mg daily)
• chlorpropamide (Diabinese)
• diphenhydramine (Benadryl)

Question 50

nursing safety priority

drug alert

Answer 50

To reduce drug-related risks in older adults, perform a medication assessment every 6 months or more often if an acute illness or exacerbation of a chronic disease occurs. Be sure to:

• Obtain a list of all medications taken on a regular and as-needed basis; include OTC and prescribed drugs, herbs, and nutritional supplements. If a list is not available, ask the older adult or family to gather all ointments, pills, lotions, eyedrops, inhalers, injectable solutions, vitamins, minerals, herbs, and other OTC medications and place into a bag for review.
• Highlight all medications that are part of the Beers criteria; highlight any medication for which the indication for its use is not clear, is inappropriate, or could be discontinued (e.g., duplicative drug).
• Collaborate with the older adult, family, pharmacist, and primary health care provider if appropriate to determine the need for medication changes. Suggest once-a-day dosing if possible.
• Give older adults verbal and written information (at the appropriate reading level) regarding any change or new medication prescribed.
• Promote adherence to the drug therapy regimen exactly as prescribed; remind older adults to check with their primary care provider if they want to change their regimen or add an OTC medication or natural product (nutritional or herbal supplement, or probiotic).
• Encourage lifestyle changes and other nonpharmacologic interventions to help manage or prevent health problems.
• Remind older adults not to share or borrow medications.

Question 51

Inadequate Cognition

Answer 51

Older adults are usually mentally sound and competent. Some changes in COGNITION have been identified as age related and are linked to specific cognitive functions rather than intellectual capacity. These changes include a decreased reaction time to stimuli and an impaired memory for recent events. However, severe cognitive impairment and psychosis are not common.

Question 52

Competence: legally competent

clinically competent

Answer 52

Two forms of competence exist: legal competence and clinical competence. A person is legally competent if he or she is:

• 18 years of age or older
• Pregnant or a married minor
• A legally emancipated (free) minor who is self-supporting
• Not declared incompetent by a court of law

A person is clinically competent if he or she is legally competent and can make clinical decisions. Decisional capacity is determined by a person’s ability to identify problems, recognize options, make decisions, and provide the rationale supporting the decisions. Selected behavioral/mental illnesses often affect both legal and clinical competence.

Question 53

Guardian

Answer 53

If a court determines that an older adult is not legally competent, a guardian is appointed to make health care decisions. Guardians may be family members or a person who is not related to the patient. When no one is available, a guardian may be appointed from a local Area Agency on Aging, an organization with comprehensive services and resources for older adults.

Question 54

Nurses actions

Answer 54

Nurses are in a unique position to teach older adults about ways to promote cognitive health.

Cognitive training (e.g., learning a new skill), physical activity, social engagement, and NUTRITION are the most helpful interventions to prevent cognitive changes in older adults.

In some communities online cognitive training is playing a role in helping to improve memory in older adults

As older adults age, they are at increasing risk for cognitive impairments—depression, delirium, and dementia, often referred to as the 3Ds.

Question 55

Veterans’ Health Considerations

Patient-Centered Care

Answer 55

Many older veterans of the Korean and Vietnam wars also suffer from chronic pain, depression, post-traumatic stress disorder (PTSD), and severe anxiety. Substance use, especially alcoholism, is common among young and older veterans. Alcoholism can contribute to cognitive decline and may be used as a coping mechanism for loss. As a result, many of today’s homeless population are veterans of previous and more recent wars.

Question 56

Depression

Answer 56

Depression is the most common mental health/behavioral health problem among older adults in the community.

increases when admitted to hospital or nursing home

Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations. It can be primary or secondary and can range from mild to severe or major.

Question 57

primary depression

Answer 57

As a primary problem, depression is thought to result from a lack of the neurotransmitters norepinephrine and serotonin in the brain

Question 58

secondary depression

Answer 58

Secondary depression, sometimes called situational depression, can result when there is a sudden change in the person’s life such as an illness or loss. Common illnesses that can cause secondary depression include stroke, arthritis, and cardiac disease. It is often underdiagnosed by primary health care providers and is therefore undertreated.

Question 59

screening tools

Geriatric depression scale

Answer 59

Families and nurses are in the best position to suspect depression in an older adult. Several screening tools are available to help determine if the patient has clinical depression. The Geriatric Depression Scale—Short Form (GDS-SF) is a valid and reliable screening tool and is available in multiple languages. The patient selects “yes” or “no” to 15 questions, or a nurse or other health care professional can ask the patient the questions. A score of 10 or greater is consistent with a possible diagnosis of clinical depression (Fig. 3-3). These patients are then evaluated more thoroughly by the health care provider for treatment.

Question 60

Without diagnosis and treatment, depression can result in:

Answer 60

• Worsening of medical conditions
• Risk for physical illness
• Alcoholism and drug use
• Increased pain and disability
• Delayed recovery from illness
• Suicide (especially in Euro-Caucasian men between 75 and 85 years of age)

Question 61

signs of depression/treatments

Answer 61

Older adults with depression may have early-morning insomnia, excessive daytime sleeping, poor appetite, a lack of energy, and an unwillingness to participate in social and recreational activities. The primary treatment for depression usually includes drug therapy and psychotherapy, depending on the severity of the problem. Selective serotonin reuptake inhibitors (SSRIs) are the first choice for drug therapy but take 2 to 3 weeks to work. They act by increasing the amount of serotonin and norepinephrine at nerve synapses in the brain.
Reminiscence or reflective therapies also help older adults overcome feelings of depression and despair.

Question 62

Nursing Safety Priority image

Drug Alert

Answer 62

Tricyclic antidepressants should not be used for older adults because they have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence. For older adults who may be prescribed this group of drugs, question the primary health care provider and request an SSRI or other treatment.

Question 63

Dementia

Answer 63

Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline, sometimes referred to as chronic confusion. This syndrome represents a global impairment of intellectual function and is generally chronic and progressive. There are many types of dementia, the most common being Alzheimer’s disease. Multi-infarct dementia, the second most common dementia, results from a vascular disorder.

Question 64

Delirium

Answer 64

Whereas dementia is a chronic, progressive disorder, delirium has an acute and fluctuating onset. It is often seen among older adults in a setting with which they are unfamiliar, including both acute and long-term care (Kalish et al., 2014). Delirium is characterized by the patient’s inattentiveness, disorganized thinking, and altered level of consciousness (either hypoalert or hyperalert). In addition to cognitive changes, some patients have physical and emotional manifestations and may become psychotic.

Question 65

types of delirium

Answer 65

The types of delirium are hyperactive, hypoactive, and mixed. Hyperactive patients may try to climb out of bed or become agitated, restless, and aggressive. Hypoactive patients are quiet, apathetic, lethargic, unaware, and withdrawn. They often move very slowly and stare. Patients with hypoactive dementia are often not diagnosed. Mixed delirium patients have a combination of hyperactive and hypoactive manifestations.

Question 66

at risk for delirium

Answer 66

Identify patients who are at risk for delirium; high-risk patients are usually the late old and those with alcoholism and/or disorders of major body organs. Some hospitals offer programs to prevent delirium and loss of function in high-risk patients such as the Hospital Elder Life Program (HELP)

Question 67

Causes of delirium

Answer 67

Some of the many factors that can cause delirium are:

• Drug therapy (especially anticholinergics, opioids, and psychoactive drugs)
• Fluid and electrolyte imbalances
• Infections, especially urinary tract, pneumonia, and sepsis
• Fecal impaction or severe diarrhea
• Surgery (especially fracture hip repair and post-transplant)
• Metabolic problems such as hypoglycemia
• Neurologic disorders such as tumors
• Circulatory, renal, and pulmonary disorders
• Nutritional deficiencies
• Hypoxemia (decreased arterial oxygen level)
• Mechanical ventilation
• Relocation
• Major loss
• Critical care setting

Many patients have more than one of these factors as causes for their delirium.

Question 68

Nursing Safety Priority image

Action Alert

Answer 68

Delirium is a major predictor of morbidity and mortality (Kalish et al., 2014). For example, acutely confused patients who are discharged from the hospital are at an increased risk for functional decline, falls, and incontinence at home. Therefore carefully assess older patients in any setting for acute confusion so it can be managed.

Question 69

screening for delirium

Answer 69

A number of tools have been developed for point-of-care screening for delirium, including the Confusion Assessment Method (CAM), Delirium Index (DI), NEECHAM Confusion Scale, and Mini-Cog. The CAM is a short and easy-to-use tool that consists of nine open-ended questions and a diagnostic algorithm for determining delirium (Table 3-3). This screening tool is easily adaptable for computerized point-of-care charting.

Question 70

The Confusion Assessment Method (CAM)

Answer 70

1. Acute onset and fluctuating course (e.g., Is there evidence of an acute change in mental status from the patient’s baseline?)
2. Inattention (e.g., Does the patient have difficulty focusing attention or keeping track of what is being said?)
3. Disorganized thinking (e.g., Is the patient’s thinking and conversation disorganized or incoherent?)
4. Altered level of consciousness (e.g., Is the patient lethargic, hyperalert, or difficult to arouse?)

The diagnosis of delirium by the CAM is the presence of features 1 and 2 and either 3 or 4.

Question 71

preventing/managing delerium

Answer 71

Collaborate with the interprofessional health care team to remove or treat risk or causative factors for acute confusion. (treat UTI give oxygen)

To help prevent and manage delirium, use a calm voice to frequently reorient the patient. For example, playing tapes of soothing music may have a calming effect. Providing a doll or stuffed animal with which to “fidget” may prevent the patient from removing important medical tubes or equipment. Some nurses believe that providing dolls and stuffed animals is treating the adult like a child, but this intervention can sometimes be very effective when used for therapeutic purposes. If the patient has a favorite item such as an afghan blanket or a picture, ask the family or significant others to provide it for the same purpose.

The most difficult challenge is caring for a patient who is experiencing both problems at the same time.(dementia and delirium)

Question 72

substance use

Answer 72

Excessive substance use (both alcohol and illicit drugs) increases the risk for falls and other accidents; affects mood and COGNITION; and leads to complications of chronic diseases such as diabetes mellitus, hypertension, and heart disease. Isolation, depression, and delirium can result from substance use. The National Institute on Aging (NIA) recommends that people older than 65 years have no more than one alcoholic drink a day or seven drinks in a week (NIA, 2012). Illicit drugs such as cannabis (marijuana) should be avoided unless they are needed for therapeutic use.

Question 73

screening tests

Answer 73

The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) is often used by nurses and other health care professionals in ambulatory care settings to detect alcohol use or alcoholism. The 10 yes/no question test is available in English and Spanish and can be either self-administered or administered by a clinician. Examples of questions on the tool are:

• Do you drink to take your mind off your problems?
• When you feel lonely, does having a drink help?

A “yes” answer is worth one point. A total score of two or more points indicates that the person has a problem with alcohol.

Other screening tools for alcohol use in older adults include the CAGE questionnaire, the Alcohol-Related Problems Survey (ARPS), and the Short ARPS (shARPS). The acronym CAGE comes from 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 to get rid of a hangover (eye-opener)?

Question 74

elder abuse and neglect

Answer 74

Some older adults are more vulnerable to these problems than others, especially widows who may have difficulty being assertive. Elder abuse and neglect is a serious problem that affects many older adults each year. Older people who are neglected or abused are often physically dependent from one or more disabilities. The abuser is often a family member who becomes frustrated or distraught over the burden of caring for the older adult. Unfortunately only a few cases of elder abuse are reported.

Question 75

neglect

Answer 75

Prolonged caregiving by a family member is a common new role for adult children, usually women. This new role may result in role fatigue, conflict, and strain. As a result, neglect can occur when a caregiver fails to provide for an older adult’s basic needs such as food, clothing, medications, or assistance with ADLs. The caregiver refuses to let other people such as nursing assistants or home care nurses into the home. Whether intentional or unintentional, neglect accounts for almost half of all cases of actual elder abuse.

Question 76

physical abuse

Answer 76

Physical abuse is the use of physical force that results in bodily injury, especially in the “bathing suit” zone (abdomen, buttocks, genital area, upper thighs). Examples of physical abuse are hitting, burning, pushing, and molesting the patient. Sedating the older adult is also abusive.

Question 77

financial abuse

Answer 77

Financial abuse occurs when the older adult’s property or resources are mismanaged or misused; this is more common than physical abuse.

Question 78

emotional abuse

Answer 78

Emotional abuse is the intentional use of threats, humiliation, intimidation, and isolation toward older adults.

Question 79

assess

Answer 79

Carefully assess the patient for signs of abuse such as bruises in clusters or regular patterns; burns, commonly to the buttocks or the soles of the feet; unusual hair loss; or multiple injuries, especially fractures. If the older adult is too weak or has no other resources or support systems, he or she may not admit that abuse is occurring. Neglect may be manifested by pressure injuries, contractures, dehydration or malnutrition, urine burns, excessive body odor, and listlessness. Depression and dementia are common in community older adults who are abused or neglected.

Be sure to screen for abuse and neglect of older adults using an appropriate assessment tool. Table 3-4 lists tools that can be used by nurses and other health care professionals to screen for elder abuse and neglect. The older adult should be referred to the appropriate service when there is:
• Evidence of mistreatment without sufficient clinical explanation

• Report by an older adult of being abused or neglected
• A belief by the health care professional that there is a high risk for or probable abuse, neglect, abandonment, or exploitation

Question 80

legal aspect

Answer 80

All states in the United States and other Western countries have laws requiring health care professionals to report suspected elder abuse. In the community, if physical abuse or neglect is suspected, notify the local Adult Protective Services agency or other advocate organization. In a hospital or nursing home, notify the social worker or ombudsman, who then will investigate the case and report the problem to the appropriate agency.

Question 81

Examples of Elder Abuse Screening Tools

Answer 81

• Elder Abuse Suspicion Index
• Elder Assessment Instrument
• Indicators of Abuse Screen
• Questions to Elicit Elder Abuse
• Hwalek-Sengstock Elder Abuse Screening Tool
• Caregiver Abuse Screen
• Brief Abuse Screen for the Elderly
• Vulnerability to Abuse Screening Scale

Question 82

Health Issues for Older Adults in Hospitals and Long-Term Care Settings

Answer 82

Forty percent of adults in critical care settings are over 65 years of age; 60% of medical-surgical patients in hospitals are also over 65 (Ellison et al., 2015). Older adults who are admitted to hospitals and long-term care settings such as nursing homes have special needs and potential health problems. Many of these problems are similar to those seen among community older adults as discussed in this chapter. Since 1996 the Hartford Institute for Gerontological Nursing has worked to ensure that all hospitalized patients 65 years of age and older be given quality care.

Question 83

Cultural/Spiritual Considerations

Patient-Centered Care

Answer 83

The health of Hispanic older adults continues to lag behind that for non-Hispanic whites due to a number of factors such as language barriers, inadequate health insurance, and lack of health care access. To add to this health disparity, most nurses and other health care professionals are not educated in the language or culture of Hispanic older adults. Some older Hispanic patients may have beliefs and values that conflict with traditional Western health care views. Many have strong religious and spiritual beliefs. For example, traditional Catholicism is practiced among most Hispanic elders in the Southwestern United States. Be respectful of these differences and incorporate them into your patient’s plan of care. Become educated about the Hispanic culture and learn to speak basic medical Spanish to foster communication and trust

Question 84

Gender Health Considerations

Patient-Centered Care

Answer 84

Significant health disparities are also associated with the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) older-adult population. Compared with heterosexual adults, LGBTQ older adults are at an elevated risk for disability from chronic disease and mental distress (Fredriksen-Goldsen, 2011). When admitted to the hospital or nursing home, they may hide their gender identity and/or sexual orientation from the nurse and primary health care providers because of fear of rejection or discrimination or lack of adequate health care.

Do not assume that your older patients or visitors are heterosexual. Establish a safe and trusting relationship with the patient and discuss sexual orientation and gender identity in a private setting to emphasize confidentiality. Do not force patients to answer any questions with which they feel uncomfortable. Teach direct caregivers such as nursing assistants that they may observe patients with sexual organs that conflict with the patient’s gender identity. If this situation occurs, remind them not to be offensive or judgmental but, rather, to carry out the task as planned.

Question 85

hospital care

Answer 85

Nurses may not be aware that the needs of older adults differ from those of younger adults. Some health care systems have designated Acute Care of the Elderly (ACE) units with geriatric resources nurses and geriatric clinical nurse specialists. The patients are cared for by geriatricians who specialize in the care of older adults.
Other hospitals have developed interprofessional health programs system-wide to meet the special needs of older patients. The incentive for these new programs is the Nurses Improving Care for Healthsystem Elders (NICHE) project, which continues to generate evidence-based practice guidelines for older adult care.

The purpose of all of these programs and units is to focus on the special health care issues or geriatric syndromes seen in the older population

Question 86

Fulmer SPICES framework

Answer 86

The Fulmer SPICES framework was developed as part of the NICHE project and identifies six serious “marker conditions” that can lead to longer hospital stays, higher medical costs, and even deaths. These conditions are:

• Sleep disorders
• Problems with eating or feeding
• Incontinence
• Confusion
• Evidence of falls
• Skin breakdown

Other problems such as depression and constipation are also common in older hospitalized patients. Rather than being fully comprehensive, this classic, well-known SPICES framework is intended to be an easy tool that has been called geriatric vital signs (Fulmer, 2007).

Question 87

Problems of Sleep,

Answer 87

Sleep disorders are common in hospitalized patients, especially older adults. Adequate rest is important for healing and for physical and mental functioning. Pain, chronic disease, environmental noise and lighting, and staff conversations are a few of the many contributing factors to insomnia in the acute and long-term care setting

Assess the patient and ask how he or she is sleeping.
If the patient is not able to answer, observe for restlessness and other behaviors that could indicate lack of adequate rest. Manage the patient’s pain by giving pain medication before bedtime.
Attempt to keep patients awake during the day to prevent insomnia. Keep staff conversations as quiet as possible and away from patients’ rooms.
Dim the lights to make the patient area as dark as possible.
Avoid making loud noises such as slamming doors. Postpone treatments until waking hours or early morning if they can be delayed safely. If possible, place a “Do Not Disturb” sign on the patient’s door to avoid unnecessary interruptions in sleep.

Question 88

problems with nutrition-eating and feeding

Answer 88

Problems with eating and feeding prevent the older patient from receiving adequate NUTRITION. Malnutrition is common among older adults and is associated with poor clinical outcomes, including death.
Nurses need to perform nutritional screenings on the first day of patient admission, including a thorough nutritional history and weight, height, and body mass index (BMI) calculation.

Collaborate with the registered dietitian about the patient’s nutritional status as needed to achieve health goals. Consider cultural preferences and determine which foods the patient likes. Manage symptoms such as pain, nausea, and vomiting. If the patient has difficulty chewing or swallowing, coordinate a plan of care with the speech-language pathologist and dietitian. If there are no dietary restrictions, encourage family members or friends to bring in food that the patient might enjoy.

Question 89

Urinary and bowel ELIMINATION issues

Answer 89

Urinary and bowel ELIMINATION issues vary in type and severity and may be caused by many factors, including acute or chronic disease, ADL ability, and available staff. Assess the patient to identify causes for incontinence or retention. These problems are not physiologic changes of aging but are very common in both the hospital and long-term care setting. Place the patient on a toileting schedule or a bowel or bladder training program, if appropriate. Delegate this activity to unlicensed assistive personnel and supervise them

Question 90

Confusion, Falls, and Skin Breakdown

Answer 90

Acute and chronic confusion affect many older patients in both the hospital and nursing home. Whereas chronic confusion states such as dementia are not reversible, acute confusion, or delirium, may be avoidable and is often reversible when the causes are resolved or removed (see Table 2-1). For example, avoiding multiple drugs and promoting adequate sleep can help prevent acute confusion. Help the patient by reorienting him or her to reality as much as needed. Keep the patient as comfortable as possible (e.g., provide interventions to control pain)

Question 91

falls-hospital or nursing home

Answer 91

The most common accident among older patients in a hospital or nursing home setting is falling. A fall is an unintentional change in body position that results in the patient’s body coming to rest on the floor or ground. Some falls result in serious injuries such as fractures and head trauma. The Joint Commission’s National Patient Safety Goals (NPSGs) require that all inpatient health care settings use admission and daily fall risk assessment tools and a fall reduction program for patients who are at high risk.

Question 92

assessment

Answer 92

Assess all older patients for risk for falls. Many evidence-based assessment tools such as the Morse Fall Scale, STRATIFY, and the Hendrich II Fall Risk Model (HIIFRM) have been developed to help the nurse focus on factors that increase an older person’s risk for falling. Some of these tools also recommend selected interventions, depending on the patient’s fall risk score (Swartzell et al., 2013). Chart 3-4 lists some of the common risk factors that should be assessed and evidence-based, collaborative interventions for preventing falls in high-risk patients. A recent history of falling is the single most important predictor for falls.

Question 93

Best Practice for Patient Safety & Quality Care image

Assessing Risk Factors and Preventing Falls in Older Adults

Answer 93

Assess for the presence of these risk factors:

• History of falls
• Advanced age (>80 years)
• Multiple illnesses
• Generalized weakness or decreased mobility
• Gait and postural instability
• Disorientation or confusion
• Use of drugs that can cause increased confusion, mobility limitations, or orthostatic hypotension
• Urinary incontinence
• Communication impairments
• Major visual impairment or visual impairment without correction
• Alcohol or other substance use
• Location of patient’s room away from the nurses’ station (in the hospital or nursing home)
• Change of shift or mealtime (in the hospital or nursing home)

Question 94

For patients at a high risk for falls:

Answer 94

For patients at a high risk for falls:

• Implement all assessments and interventions listed previously.
• Relocate the patient for best visibility and supervision.
• Encourage family members or significant other to stay with the patient.
• Collaborate with other members of the health care team, especially the rehabilitative services.
• Use technologic devices such as mattress sensor pads and chair alarms to alert staff to patients getting out of bed.
• Use low beds or futon-type beds to prevent injury if the patient is at risk for falling out of bed.

Question 95

Implement these nursing interventions for all patients, regardless of risk:

Answer 95

Implement these nursing interventions for all patients, regardless of risk:

• Monitor the patient’s activities and behavior as often as possible, preferably every 30 to 60 minutes.
• Teach the patient and family about the fall prevention program to become safety partners.
• Remind the patient to call for help before getting out of bed or a chair.
• Help the patient get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring patients.
• Teach patients to use the grab bars when walking in the hall without assistive devices or when using the bathroom.
• Provide or remind the patient to use a walker or cane for ambulating if needed; teach him or her how to use these devices.
• Remind the patient to wear eyeglasses or a hearing aid if needed.
• Help the incontinent patient to toilet every 1 to 2 hours.
• Clean up spills immediately.
• Arrange the furniture in the patient’s room or hallway to eliminate clutter or obstacles that could contribute to a fall.
• Provide adequate lighting at all times, especially at night.
• Observe for side effects and toxic effects of drug therapy.
• Orient the patient to the environment.
• Keep the call light and patient care articles within reach; ensure that the patient can use the call light.
• Place the bed in the lowest position with the brakes locked.
• Place objects that the patient needs within reach.
• Ensure that adequate handrails are present in the patient’s room, bathroom, and hall.
• Have the physical therapist assess the patient for mobility and safety.

Question 96

nocturia

Answer 96

Toileting-related falls are very common, especially at night. Older patients often have nocturia (urination at night) and get out of bed to go to the bathroom. They may forget to ask for assistance and may subsequently fall as a result of disorientation in the darkness in an unfamiliar environment. In some cases they may crawl over the side rail, which can make the fall more serious. Because of this, side rails are used far less often in both hospitals and nursing homes. In both settings side rails are classified as restraints unless the use of rails helps patients increase mobility.

Question 97

restraint

Answer 97

A restraint is any device or drug that prevents the patient from moving freely and must be prescribed by a health care provider. In 1990 the US government enforced a law that gives nursing home residents the right to be restraint free. Removing physical restraints from nursing home residents has reduced serious injuries, although falls and minor injuries have increased in some cases. Mattresses placed on floors next to patient beds or “low beds” have helped reduce injury.

Hospitals have also reduced the use of physical restraints. The Joint Commission has specific standards that limit the use of physical restraints in hospitals and nursing homes. Although not appropriate, chemical restraints (psychoactive drugs) such as haloperidol (Haldol) have sometimes been used in place of physical restraints.

Experts agree that older adults should not be placed in a physical restraint or sedated just because they are old. Use alternatives before applying any type of restraint

Question 98

using restraint

Answer 98

However, if all other interventions (e.g., reminding patients to call for assistance when needed; asking a family member to stay with patients) are not effective in fall prevention, a physical restraint may be required for a limited period. Applying a restraint is a serious intervention and should be analyzed for its risk versus its benefit. Check the patient in a restraint every 30 to 60 minutes and release the restraint at least every 2 hours for turning, repositioning, and toileting. Physical restraints such as vests have caused serious injury and even death. If restraint is needed, use the least restrictive device first. Be sure to follow your facility policy and procedure for using restraints.

Question 99

Using Restraint Alternatives

Answer 99

• If the patient is acutely confused, reorient him or her to reality as often as possible.
• If the patient has dementia, use validation to reaffirm his or her feelings and concerns.
• Check the patient often, at least every hour.
• If the patient pulls tubes and lines, cover them with roller gauze or another protective device; be sure that IV insertion sites are visible for assessment.
• Keep the patient busy with an activity, pillow or apron, puzzle, or art project.
• Provide soft, calming music.
• Place the patient in an area where he or she can be supervised. (If the patient is agitated, do not place him or her in a noisy area.)
• Turn off the television if the patient is agitated.
• Ask a family member or friend to stay with the patient at night.
• Help the patient to toilet every 2 to 3 hours, including during the night.
• Be sure that the patient’s needs for food, fluids, and comfort are met.
• If agency policy allows, provide the patient with a pet visit.
• Provide familiar objects or cherished items that the patient can touch.
• Document the use of all alternative interventions.
• If a restraint is applied, use the least restrictive device (e.g., mitts rather than wrist restraints, a roller belt rather than a vest).

Question 100

chemical restraints

Answer 100

Chemical restraints are often overused in hospital settings. Examples include:

• Antipsychotic drugs
• Antianxiety drugs
• Antidepressant drugs
• Sedative-hypnotic drugs

The most potent group of psychoactive drugs is the anti­psychotics. These drugs are appropriate only for the control of certain behavioral problems such as delusions, acute psychosis, and schizophrenia. Typical antipsychotic drugs include haloperidol (Haldol, Peridol) and thiothixene (Navane). These drugs should not be used to treat anxiety or induce sedation.

Question 101

Closely monitor older adults receiving antipsychotics for adverse drug events (ADEs). Assess patients for:

Answer 101

• Anticholinergic effects, the most common problem, causing constipation, dry mouth, and urinary retention
• Orthostatic hypotension, which increases the patient’s risk for falls and fractures
• Parkinsonism, including tremors, bradycardia, and a shuffling gait
• Restlessness and the inability to stay still in any one position
• Hyperglycemia and diabetes mellitus, which occur more with drugs such as risperidone (Risperdal) and quetiapine (Seroquel)

Question 102

skin breakdown

Answer 102

Skin breakdown, especially pressure injuries, is a major TISSUE INTEGRITY problem among older adults in hospitals and nursing homes. In some cases these wounds cause death from infection. Therefore prevention is the best approach. The Joint Commission’s NPSGs require that all health care agencies have a program to prevent agency-associated pressure injuries. The program should include these evidence-based interventions:

• Nutritional support
• Avoidance of skin injury from friction or shearing forces
• Repositioning and support surfaces
• A plan to increase MOBILITY and activity level when appropriate
• Skin cleaning and use of moisture barriers

Question 103

assessment

Answer 103

Assess older adults for their risk for pressure injuries, using an assessment tool such as the Braden Scale for Predicting Pressure Sore Risk (see Chapter 25). Implement evidence-based interventions to prevent agency-acquired pressure injuries and maintain TISSUE INTEGRITY. Coordinate these interventions with members of the interprofessional health care team, including the dietitian and wound care specialist.

Question 104

Nursing Safety Priority

Action Alert

Answer 104

Supervise unlicensed assistive personnel (UAP) for frequent turning and repositioning for the patient who is immobile. Assess the skin every 8 hours for reddened areas that do not blanch. Remind UAP to keep the skin clean and dry. Use pressure-relieving mattresses and avoid briefs or absorbent pads that can cause skin irritation and excess moisture.

Question 105

skin tears

Answer 105

Skin tears are also common in older adults, especially the old-old group and those who are on chronic steroid therapy. Teach UAP to use extreme caution when handling these patients. Use a gentle touch and report any open areas. Avoid bruising because older adults have increased capillary fragility.

Question 106

Care Coordination and Transition Management

Answer 106

Some older adults and their families experience a breakdown in communication and coordination of care when transitioning from the hospital or long-term care (LTC) setting (nursing home) to the home setting. If the transition is not optimal, older adults experience high readmission rates and an increase in visits to the emergency department or primary health care provider’s office.

Care was not coordinated among health care professionals, which led to confusion for the older adult and family caregivers. To help prevent these problems, the authors recommended that a system be in place to address patients’ communication needs. The system should include follow-up phone calls after discharge to home and having one case manager to coordinate care during and after the transition from the inpatient agency to home. A home care nurse or other health care professional can serve as a “health coach” to ensure understanding of discharge instructions, consistent follow-up appointments, and a designated emergency contact for the patient and family. Discharge instructions should be easy to read, in large print, and accurate. Continuity of care for high-quality transition between settings is essential to achieve positive outcomes for older adults.