Week 2: Older Adults II Flashcards
Do most analgesics cause sedation? What is the problem with that
Yes - increases the risk of falls and delirium
Do loneliness and emotional pain from loss decrease the ability to cope with pain?
Yes
Why might an older person underreport pain?
- cost of meds
- stigma (because pain is perceived as a normal burden of “old age”
- fear of addiction
What are common causes of pain?
- degenerative conditions (e.g osteoarthritis)
- pathological conditions (e.g herpes zoster, stroke, peripheral neuropathy)
Name 2 common NSAIDs (nonsteroidal anti-inflammatory drugs) for osteoarthritis pain?
naproxen or ibuprofen (advil
Name the most common analgesic for osteoarthritis pain? (not a NSAID)
Acetaminophen (tylenol)
What can be used for severe arthritis (unrelieved pain and extensive disability)?
Local anesthetic - corticosteroid injections (have hyaluronic acid that improves joint lubrication)
Long-acting narcotics
Joint replacement
Good to know:
What causes persistent pain in Herpes Zoster?
What can prevent PHN?
What is HZ and the symptoms of HZ?
- Postherpetic neuralgia (PHN) is a result of damaged nerves after a case of HZ (shingles) - tx pain with combination of antiviral meds, steroids, aspirin, and topical anaestheticsics.
- Use of antiviral drugs for HZ (acyclovir/famciclovir), lyrica and gabapentin can shorten the duration of HZ outbreak and prevent PHN.
- viral infection of the nerves - symptoms: itching, stinging, burning pain, erupting vesicles
What makes assessing pain difficult on a patient?
cognitive or communication impairment
What is the goal of pain management for older persons?
Promote comfort and maintain the highest level of functioning and well-being possible.
What are adjuvant meds?
Name a few that help with pain?
Adjuvantmedswere originally developed to treat other medical conditions but have been found to have pain-relieving quantities.
example:
- antidepressants (relieve nerve pain/insomnia)
- anticonvulsants (relieve neuropathic pain)
- corticosteroids (reduces inflammation)
- bisphosphonates (relives bone pain)
List the pharmacological interventions for pain?
- non-narcotics (for mild-moderate pain)
- e.g acetaminophen, NSADI (ibuprophen)
- narcotics (for mod-severe pain)
- e.g morphine, OxyContin, hydromorphone
With narcotics for pain management, what intervention is important for nurses to keep in mind?
Assess for side effects of narcotics (dizziness, sedation constipation)
What are some non-pharmacological interventions for pain performed by nurses?
- assistive devices (such as pillows forsupport)
- frequent rest periods
- pacing of activities (balance)
- rest
- encourage pt to journal/diary to track meds, pain intervals/intensity, what helps and for how long, etc
- analgesics 20-30 mins before activity/procedure -> decreases pain anxiety
- figure out from pt what worked in the past for pain?
- physical approaches: touch, cutaneous nerve stimulation, transcutaneous electrical nerve stimulation
- cognitive behavioural approaches: biofeedback, distraction, relaxation, meditation and imagery.
What aspects should a pain assessment cover?
- direct questions
- hx of pain
- description of pain (scale 1-10)
- use P (provocative)
Q (quality and quantity)
R (region and radiation)
S (severity (pain rating scale))
T (timing)
- use P (provocative)
- hx of med use (including rx meds, over-counter, herbs, supplements, street meds)
- functional changes
- social support
- non-verbal cues of pain
Is pain a natural consequence of aging?
NO
Does pain sensitivity and perception of pain decrease with age
No
Can older persons experience pain without obvious functional impairment or distress?
Yes
What are some age-related concerns that can contribute to poor nutrition in older persons?
- TASTE (taste buds decrease + taste cells shrink with aging)
- dentures - decrease the satisfaction of
food - bland food at LTC = decreased appetite
- dentures - decrease the satisfaction of
- SMELL (decreased sense of smell in aging leads to fewer messages sent to the brain about food) + no participation in cooking at LTC decreases appetite stimulation since pt’s can’t smell food that is cooking that usually stimulates appetite
- DIGESTIVE SYSTEM (age-related changes in the oral cavity, esophagus, stomach, liver, pancreas, gall bladder, and small and large intestines may influence nutritional status)
- REGULATION OF APPETITE (regulated by a combination of peripheral satiation system and a central feeding drive and is influenced by physical activity, functional limitations, smell, taste, mood, socialization, and comfort)
- changes in energy regulation mechanism and neurotransmitter regulation in aging can contribute to decreased appetite
- disease decreases appetite
- blockade of opioid receptors from opioids- can lead to decreased appetite
What supplements are important in old persons?
B vitamins (meat) (B12 particularly)
Vit K
Vit D (400 IU daily)
Calcium
To meet their nutritional goals, what should older persons eliminate or decrease from their diet?
- saturated/trans fat
- sugar
- salt
- alcohol
Fibre should be increased in older persons by how much?
What foods are good sources of fiber?
20-30 g/day
whole wheat, bran, fresh or dried fruits, vegetables
How does socialization impact food- intake?
- isolation can lead to overindulgence or disinterest in eating
- meds can affect dietary intake + make absorbing nutrients difficult leading to malnutrition
- ## alcohol misuse = depleted nutrients
Where do life-long eating habits develop from?
Tradition, ethnicity, religion, and socialization
What are some of the consequences of malnutrition?
- infections
- pressure ulcers
- anemia
- hypotension
- impaired cognition
- hip fractures
- increased mortality (increased risk of death) and morbidity (increased risk of disease)
What medications are mostly associated with malnutrition in older persons?
- digoxin (for heart failure)
- theophylline (for COPD)
- NSAIDS
- iron supplements
- psychoactive meds
What is poor dental health a risk factor for?
- dehydration
- malnutrition
- systemic diseases: aspiration pneumonia, joint dysfunctions, cardiovascular disease, poor glycemic control
- chewing/swallowing issues that affect adequate nutritional intake
What things need to be considered during a nutritional assessment of an older person? (9)
life-long eating habits ethnicity socialization income transportation housing food knowledge age-related changes (oral health changes int taste, smell, digestive system, and regulation of appetite) disease/illness (meds they take)
What interventions can be implemented by the nurse who is assessing a pt’s food intake?
- check for xerostomia (dry mouth - making chewing/swallowing harder)
- check dysphagia (difficulty swallowing -to avoid aspiration, seat pt at 90 degrees at bed)
- check for constipation/fecal impaction (critical to know when pt last had bowel movement)
- be careful w/ pts who are dependent or have a loss of function (when assisting make sure you are slow, at the right angle, not mixing foods)
- consider enteral feeding for unconscious or immobile pts
Function of water in our body?
- thermoregulation
- dilution of water-soluble meds
- facilitation of renal and bowel function
- metabolic processes
Dehydration is a geriatric syndrome for what common diseases?
- DM
- respiratory illness
- heart failure
Dehydration is a risk factor for what problems?
- delirium
- thromboembolic complications
- infections
- kidney stones
- constipation
- falls
- meds toxicity
- renal failure
- seizure
- electrolyte imbalance
- hyperthermia
- delayed wound healing
What are some risk factors for dehydration?
- decreased thirst mechanism
- meds that affect renal function and fluid function (e.g diuretics, laxatives, ACE)
- use of psychoactive meds that have anticholinergic effects (dry mouth, urinary retention, and constipation)
- functional deficits
- communication and comprehension problems
-oral problems - dysphagia
- depression
- hospitalization
- low body weight
diagnostic procedures that necessitate fasting
What does a dehydration assessment include?
- checking physical changes (dry mouth, yellow/dark urine, tachycardia, sunken eyes, oral problems, longitudinal furrows on the tongue, orthostasis, speech incoherence, weakness of extremities, dry axillae)
- labwork to check for dehydration - blood urea nitrogen (BUN); tests for sodium, creatinine, glucose, and bicarbonate.
- changes in body weight
What are some age-related changes in the bladder?
- decreased capacity
- increased irritability
- contractions during filling
- incomplete emptying
Why is urinary incontinence stigmatized and under-reported?
- embarrassment
- thought to be normal part of aging
- do not know successful tx are available
- lack of knowledge about UI
- men think it’s women who have incontinence (embarrassment/stigma)
- costly
What are the consequences of urinary incontinence (UI)?
physical: falls, skin irritation, infections, UTI, pressure ulcers
psychosocial: decreases self-esteem, increases risk of depression, anxiety, social isolation, and avoidance of sexual activity. Loss of dignity, loss of independence, and loss of self-confidence; feelings of shame/embarrassment.
economic: increased cost to stay dry/clean - briefs; med bills; therapy bills
List the types of urinary incontinence:
- Urge (overactive bladder - urgent need to void due to overactive bladder muscles that cause a sudden urge) most common in older persons
- Stress (involuntary loss during actions that increase intra-abdominal pressure e.g coughing, sneezing, exercise, bending) most common in women due to short urethras/poor pelvic tone
- Overflow (bladder issues -sphincter related?)
- Functional (can’t get to the bathroom fast enough due to environmental barriers, physical limitations, or severe cognitive impairment - balance, strength, wheelchair, etc)
- Mixed (stress & urge together)
- Reflex (automatic emptying - spinal injury)
- Total incontinence (unconscious - maybe during surgery, coma)
What does UI assessment consist of ?
- health hx
- targeted physical examination
- urinalysis
- determination of postvoid residual urine
- functional assessment
- cognitive assessment
- current strategies to control UI
- med review
- environmental review of home
What interventions can help with Urinary Incontinence?
- Behavioral: scheduled voiding, prompt voiding, bladder training (increasing interval between the urge to void and voiding), biofeedback, vaginal weight training, and pelvic floor muscle exercises.
- Lifestyle modifications: dietary factors (e.g increased fluid intake, avoidance of caffeine); weight reduction; smoking cessation; bowel management; and physical activity.
- Absorbent Products: protective undergarments and adult briefs.
- Urinary catheters: external (changed daily; intermittent (use when needed), or indwelling (only when abdolutely needed-no more than 30 days) catheters.
- Pharmocological:
~ Oxybutynin (most common urge UI med)
~ Alpha-adrenergic blockers and 5-alpha- reducatase inhibitors for benign prostatic hypertrophy
*antispasmodic (anticholinergic-macological) agents poorly tolerated by older adults because of anticholinergic adverse effects (sedation, weakness, dry mouth/eyes, constipatio, confusion)
Difference between asymptomatic bacteria and symptomatic UTIs?
The first doesn’t ABX whereas the second does.
Long-term catheter use can lead to?
- recurrent UTIs
- leading to urosepsis
- urethral damage/urethral erosion
- urethritis or fistula formation
- bladder stones
- cancer
Bowel incontinence is prevalent in individuals who have what conditions?
- DM
- IBS
- stroke
- MS
- Spinal cord injury
In terms of stages, how does sleep change for older persons?
- decreased stage 4 sleep (deep sleep = rest)
- decreased REM sleep
- increased stage 1 sleep (light)
What are some sleep patterns for older persons?
- more time in bed
- more awakenings
- prolonged sleep latency (amount of time it takes to fall asleep)
- increased wakefulness
- increased day time napping
- lighter sleep (due to less time in stage 4)
List a few sleep disorders:
- insomnia (subjective perception of insufficient or nonrestorative sleep)
- nocturia (waking up at night to urinate)
- sleep apnea
- restless leg syndrome
- REM sleep behavior disorder
What are some conditions that contribute to insomnia? What interventions can help?
- nocturia (avoiding caffeine/alcohol + fluids before bed + urinating before bed)
- GERD (elevating bed head to prevent coughing + PPI meds)
- anxiety/depression (relaxation techniques + SSRIs if needed)
- dementia (light therapy + daily activities + bedtime music)
- medication adverse effects
What interventions can be taken for sleep apnea?
- sleep study
- healthy weight
- avoidance of alcohol/sedatives
- cessation of smoking
- avoidance of supine sleep positions
- CPAP (continuous positive airway pressure)
- for mild sleep apnea–> dental appliance that moves the jaw forward keeping the throat open
What causes RLS (restless leg syndrome)?
- primary = genetics
- secondary = medical conditions such as anemia, end-stage renal disease, and pregnancy.
follow circadian rhythm so worse at night
What are the symptoms of RLS?
paresthesias (tingling, pricking, abnormal sensation without cause) creeping sensations crawling sensations tingling cramping burning sensations pain undesirable sensations
List a few things that can aggravate RLS?
List a few interventions that can help RLS?
Aggravate:
- antidepressants
- neuroleptic meds
- high BMI
- caffeine use
- tobacco use
- sedentary lifestyle
Helps:
- dopamine receptor agonists (e.g pramipexole, ropinirole)
- gabapentin (peripheral neuropathy)
- stretching of lower extremities
- mild to moderate physical activity
- hot baths
- relaxation techniques
- avoidance of alcohol
What is rapid eye movement behavior disorder?
it is the loss of normal voluntary muscle atonia during REM sleep and is associated with complex behavior while dreaming. i.e violent actions that could potentially harm them or their partner in bed.
Primary or secondary to neurodegenerative diseases such as PD, diffuse Lewy body disease, AD, progressive supranuclear palsy
What contributes to rapid eye movement behavior disorder?
What interventions can be implemented for RBD?
Contributes:
- caffeine + some meds (SSRIs; tricyclic antidepressants)
Interventions:
- neurological examination
- removal of aggravating meds
- counselling related to safety measures
- clonazepam, melatonin help RBD
What are the 2 major concerns for polypharmacy?
- increased risk for medication interactions
- adverse events
List an example of a medication interaction when looking at polypharmacy:
- tricyclic antidepressants decrease GI motility and interfere with the absorption of other meds
What common meds lead to adverse drug reactions?
anticoagulants antibiotics antineoplastic meds NSAIDs analgesics
Medication-induced delirium is a sign of?
Adverse drug reaction
Lethargy with the use of # of cardiovascular agents and antidepressants is a sign of?
Adverse drug reaction
Can decreased fluid intake of polypharmacy pts cause lithium toxicity?
Yes
Can leafy green vegetables counteract the anticoagulant effects of Coumadin and Aspirin?
Yes
What medications interfere with the body’s ability to regulate temperature? (i.e hot weather leading to heatstroke)
antipsychotics, stimulants, anticholinergics
What interventions can be implemented for polypharmacy pts?
check:
medication interactions
adverse drug reactions
misuse of meds
med administration
What are the 10 rights for medication administration?
right pt right dose right time right frequency right route right reason right documentaion right to refuse right pt education right evaluation
