Exam 2: Gero Lecture 7 Flashcards
adult cognition is the process of?
acquiring
storing
sharing
using info
What are the adult cog components?
language
thought
memory
executive function: organization (gather info) and regulation (evaluate and change behavior)
judgement
attention
perception
what are the adult cog in action?
orientation
problem solving
psychomotor ability
reaction time
social intactness
what are the physiological changes?
neuron loss
brain atrophy
dendrites atrophy
however NOT consistent with deteriorating mental function
SLOWING IS NORM
IMPAIRMENT IS NOT NORM
most pronounced in cerebral cortex
neuron loss
decreased weight
acetylcholine impair
brain atrophy
impaired synapses
changed transmission of dopamine, serotonin, and acetylcholine
dendrites atrophy
what are the 3 components of memory?
immediate recall
short term memory
remote or long term memory
what is memory retrieval?
Recall of newly encountered information decreases with age
Memory declines noted for complex tasks and strategies
Cog function?
learning in late life
cognitive assessment
basic intelligence remains unchanged with increasing years
learning in late life
True evaluation of cognition requires formal focused assessment
Complete assessment, including laboratory workup, should be performed to rule out any medical causes of cognitive impairment
cognitive assessment
Nearly 20% over 55 y/o experience mental health disorders that are not part of normal aging
Underreported and not well researched
Racially and culturally diverse
Can be affected by cognitive and affective functioning earlier in life
mental health
Common mental disorders in late life are:
Depression & anxiety
Mood disorders
Alcohol abuse and dependence
what is the health promotion assessment?
Risk factors of life transition, loss, and loss of social support
History of ability to cope with stress and life events
Assessment of cognitive function and/or impairment
Assessment of substance abuse and suicide risk
what is the health promotion interventions?
Enhancing characteristics of hardiness, resilience, and resourcefulness
Enhancing functional status and independence
Promoting sense of control
Fostering social supports and relationships
Education regarding available resources
What are the factors influencing MH care?
attitudes and beliefs
availability and adequacy of MH care
cultural and ethnic disparities
what are attitudes and beliefs for MH care?
stigma and myth that is not norm
what is the availability and adequacy of MH care?
access and ability to pay
what are cultural and ethnic disparities for MH care?
poverty
language
cultural understanding
Not part of the norm aging process
life events and stressors may contribute to development of this disorder.
anxiety disorders
what are anxiety disorders associated with?
Excessive healthcare use
Decreased physical activity and functional status
Substance abuse
Decreased life satisfaction
Increased mortality rates
what is the anxiety assessment?
Difficult to diagnose in older adults
Denial
Coexisting medical conditions can mimic anxiety
Common side effect of certain drugs
Drug and alcohol withdrawal also cause anxiety symptoms
Generalized Anxiety Disorder (GAD-7)
what is are the interventions for anxiety?
Treatment choices depend on symptoms, specific anxiety diagnosis, comorbid medical conditions, and current medications
what are the pharmacological measures for anxiety?
Antidepressants—SSRI’s (selective serotonin uptake inhibitors) first line of treatment
Short acting benzodiazepines
Non-benzodiazepine anxiolytic agents
what are the Non-pharmacological Interventions for anxiety?
Cognitive behavioral therapy (CBT)
Meditation
Yoga
Therapeutic relationship between patient and health care provider is the foundation for any intervention.
Not a normal part of aging
Most common mental health problem of late life
1 in 10 older adults visiting a physician suffers from this
this and illness are like to co-occur
R/T medical conditions and med side effects
depression
Major source of morbidity in older adults
depression
what is depression associated with?
Increased disability
Delayed recovery from illness and surgery
Excessive use of health services
Cognitive impairment
Decreased quality of life
Increased suicide and non-suicide related death
what is the etiology for depression?
Multifactorial
Health and chronic conditions
Gender
Developmental needs
Socioeconomics
Environment
Personality
Losses
Functional decline
differing presentation of depression in elders?
Comorbid medical conditions strongly related to depression in older people
More somatic complaints – physical symptoms
Hypochondriasis – Constant complaining & criticism
Decreased energy and difficulties completing ADL’s
Social withdrawal
Decreased libido
Preoccupation with death
Memory problems
Strong association of depression with dementia
what is the depression assessment?
Depression screening scale, H&P, functional and cognitive assessment, medication review, laboratory analysis, comorbid conditions
GDS short form
what are the interventions for depression?
Treatment should begin promptly
Combination of pharmacologic therapy and psychotherapy and counseling - BEST
what meds are used for depression?
SSRI’s
Tailored to specific patient needs
Trials of alternate medications and psychotherapy required in many patients
What is ECT therapy?
Safe therapy for older patients at risk for harm due to suicidal ideation, psychotic depression, or severe malnutrition
Efficacy rates ranging from 60%–80%
describe suicide in older adults.
Older adults account for 13% of population but 20% of suicide deaths
Higher than any other age group
Older widowers most vulnerable
Men have HIGHER suicide rates
Up to 75% of older adults who die from suicide visited physician within one month of death
Depression screening important for all older adults
Recognition of warning signs and risk factors for suicide
what is the assessment for suicide?
ANY reference to ending life must be taken seriously
Establish trusting and respectful relationship
Behavioral cues – goodbyes, giving away possessions
what are the interventions for suicide?
If suicide risk suspected, ask direct questions
Have you ever thought about killing yourself?
How often have you had these thoughts?
Do you have a plan to carry it out/How would you do it?
High risk patients need to be hospitalized
Moderate and low risk treated as outpatients
Adequate social support
No access to lethal means
Alcohol use disorders?
Often a coping mechanism in old age to deal with loss, anxiety, depression, chronic illness
Most severe abuse seen in ages 60-80, white male use increase
Gender issues with sub abuse and alcohol use disorders?
Late onset alcohol abuse associated with illness, retirement, loss of spouse
White men 4 times more likely to abuse alcohol
Number and impact of older female drinkers expected to increase
what are the drug effects for substance abuse and alcohol use disorders?
Prescription and OTC medications have many adverse effects when combined with alcohol
what is the physiology for sub abuse and alcohol use disorders?
Age related changes in water and body fat cause higher blood alcohol levels
Liver and kidney function interferes with alcohol metabolism and excretion
Increased risk of gastrointestinal bleeding
Assessment for substance abuse?
Screening for alcohol and drug use
Comorbid conditions may mask decline caused by alcohol
what are the interventions for substance abuse?
Must address quality of life and adapted to meet needs of older adult
Treatment focuses on cognitive and behavioral approaches
Screening for alcohol and drug abuse
Education and counseling about alcohol and prescription, OTC, and illicit drug use
Referral to specialists and community resources
what is acute alc withdrawal?
Life threatening emergency
Detoxification should be done in inpatient setting
what are the sub abuse concerns?
Misuse of prescription and OTC medications
Polypharmacy effects exacerbated with alcohol use
Inappropriate prescribing and ineffective monitoring of controlled substances
Delirium –>
onset - sudden hrs to days
memory - impaired variable
duration - hours - days
reversible - yes usually
psychomotor activity - usually hyper or hypo
perceptual disturbances - yes
speech - incoherent/confused
Dementia –>
onset - slowly developing years
memory - memory loss esp. new events
duration - years
reversible - no progressive
psychomotor activity - not until later in dx
perceptual disturbances - not until later in dx
speech - early work searching. late-mute
May affect up to 42% of hospitalized adults and 87% of older adults in intensive care units
Associated with ↑ length of stay, ↑ use of healthcare services post discharge, and morbidity, mortality, and institutionalization, independent of age and comorbid illnesses
Significant distress for patient and family
Delirium
is a medical emergency
Cognitive changes in older people often labeled as confusion by nurses and physicians; frequently accepted as part of normal aging
Delay in treatment contributes to negative outcomes with this
delirium
What are risk factors for delirium?
acute illness
infections
meds
invasive equipment
metabolic disturbances
dehydration
alc or drug abuse
sensory impair
unrelieved pain
surgery
hip fracture
cog impair
What is the delirium assessment?
Confusion Assessment Method (CAM & CAM-ICU)
Documentation should focus on specific indicators of altered mental status rather than “confused”
Will lead to more appropriate prevention, detection, and treatment to prevent negative outcomes
what are delirium interventions?
Managing risk factors
HELP program
Deliberate interventions to prevent delirium
Pharmacological treatment- Careful!!!
Communication
what are the Delirium preventions? (box 29.9)
know the persons past
look at nonverbal signs, such as tone of voice, facial expressions, and gestures
speak slowly
be cam and patient
face the person and keep eye contact; get to the level of the person rather than standing over him/her
explain all actions
smile
use simple, familiar words
allow adequate time for response
repeat if needed
tell the person what you want him/her to do rather than what you so not want him/her to do
give one-step directions; use gestures and demonstrations to augment words
reassure persons safety
keep caregivers consistent
assume that comm and behavior are meaningful and an attempt to tell us something or express needs
do not assume that the person is unable to understand or experiencing cog impairment
Irreversible state that progresses over years in decline
dementia
Clinical features of syndrome of dementia include at least one of the following:
Aphasia – partial or total loss of the ability to articulate ideas or comprehend spoken or written language
Apraxia – partial or total loss of the ability to perform coordinated movements or manipulate objects in the absence of motor or sensory impairment
Agnosia – loss of the ability to interpret sensory stimuli, such as sounds or images
Disturbances in executive functioning – Attention, decision making, consciousness, memory, problem solving
What are degenerative dementias?
Alzheimer’s disease (AD) – 50-70% of all dementias
Parkinson dementia (PDD)
Dementia with Lewy bodies
frontotemporal lobe dementia
what is vascular cog impairment with dementia?
Vascular dementia
Mixed primary neurodegenerative disease and vascular dementia
what are other dementia types?
creutzfeldt-jakob disease
HIV-related dementia
Development of neurofibrillary tangles in brain consisting of protein tau and extracellular deposits of amyloid-β peptides
Loss of connections between nerve cells and death of these nerve cells
Research is ongoing
Most common form of dementia
Sixth leading cause of death and third most expensive medical condition
alzheimers disease (AD)
What are the 2 types of AD?
early onset (between 30-60)
late onset (after age 60)
what is early onset AD?
Early onset (between ages 30-60)
Affects about 5% of persons with AD
Results from genetic mutations of three genes
Genetic testing available for at risk individuals
what is late onset AD?
Late onset (after age 60)
Does not run in families
Probable combination of lifestyle, environmental factors, and genetic mutation
What are the alz disease diagnosis/stages?
preclinical
mild cog impair
alz dementia –> most advanced stage
what is preclinical AD?
Early cognitive decline before overt symptoms are present 5-20 yrs
what is mild cognitive impairment AD?
Amnestic MCI
Multiple domain MCI
Single non-memory MCI
Approximately 12% of persons over age 70 have MCI and are 3-4 times more likely to develop AD
what is Alzheimer’s Dementia—most advanced stage?
multiple deficits present
what is the treatment of AD?
Regular monitoring of disease progression and response to therapy
Caregivers also need ongoing education about the disease as well as assessment of own coping mechanisms and self-care behaviors
What is the pharm treatment of AD?
Cholinesterase inhibitors (CI)
Directed toward symptom management
Does not affect neuronal decline
Why is it Important to assess and treat for depression in AD?
If present will cause excess disability
What is the AD health promotion?
person-centered care
How to enhance well-being and quality of life
Treating the person, not the disease
Establish connections and sense of security
Special skills and attitudes necessary to nurse the person with dementia
Maintain function and prevent excess disability
PLST (Progressively Lowered Stress Threshold) model
Care is structured to decrease stressors and provide a safe and predictable environment
NDDH (Need-Driven Dementia-Compromised Behavior) model
Care is structured to enhance understanding of behavior as expression of need
Care is optimized by manipulating factors that precipitate behavior
What is the assessment side of health promo in AD?
View all behavior as meaningful and expression of needs
Focus on reasons for Behavioral & Psychological Symptoms of Dementia
Remember: You must enter the patient’s reality and not attempt to reorient them to actual reality. They cannot be reoriented due to the deterioration within the brain.
what are the general interventions for dementia?
Address Safety
Structure daily living to maximize abilities
Monitor general health
Support advance care planning and directives
Educate and support caregivers
what are the pharm treatment interventions for dementia?
If patient is danger to self or others
Non-pharmacological interventions not effective
Risk/benefit of medication has been considered
how do you provide care for ADLs in dementia?
Perceptual disturbances and misinterpretation of reality can cause much distress for patient and caregiver during this time
Can be perceived as an attack by a stranger
See the world from the patient’s perspective
Alternative bathing methods as tolerated
What is the nursing intervention care for AD?
Wandering
Difficult problem to manage
May be a soothing mechanism
Not well understood
Risk
Falls, elopement, injury, and death
Things to do
Music, exercise, refreshments, social interaction
Camouflage doorways, enclosed areas for walking, electronic bracelets,
60% will wander and become lost at some point…
Wandering interventions and Avoiding getting lost
What is the caregiving for persons with dementia?
almost 2/3 of unpaid caregivers for Americans with AD are women
70% with dementia live at home
what do you need to know about caregivers?
Lower self-related health scores
Fewer health-promoting behaviors
Higher rates of depression and anxiety
Higher morbidity and mortality
Sleep disturbances
Higher number of illness-related symptoms
what do you need to know about caregiving stress?
Grief over multiple losses that occur
Physical demands and duration of caregiving
Exacerbated when care recipient demonstrates behavioral issues and impairments in ADL’s
Resource availability
what are the 4 nursing roles?
magician: see the world through their eyes, use tricks to augment behavior
detective: investigate clues r/t behavior
carpenter: tools to individualize care
jester: use humor, spread joy, relations
What are the special considerations for caregiving in MCI, early-stage, and early onset dementia?
Focus on communication, behavior, and relationships
Individuals are aware of their diagnosis and need support to share their feelings and needs
Caregivers need support to deal with changing role, changing couple relationships, anger, frustration, uncertainty about the future, burden, and depression
