Care of the Older or Disabled Adult

Care of the Older or Disabled Adult
PHYSIOLOGY NORMAL CHANGES OF AGING There are a number of normal age-related changes that occur in all major systems of the body. These may present at different times for different people. It is important to be able to differentiate between normal and abnormal changes in elderly people and to educate patients and families about these differences. Vision Characteristics • Decreased visual acuity • Decreased visual fields, and thus decreased peripheral vision • Decreased dark adaptation • Elevated minimal threshold of light perception • Presbyopia (farsightedness) due to decreased visual accommodation from loss of lens elasticity • Decreased color discrimination due to the yellowing of the lens; short wavelength colors, such as blues and greens are more difficult to see • Increased sensitivity to glare • Decreased depth perception • Decreased tears Assessment Findings • Arcus senilis — deposits of lipid around the eye, seen as a white circle around the iris; causes no visual impairments • Cataracts — a clouding of the normally clear lens of the eye (This results in lens thickening and decreased permeability; noted on examination with the ophthalmoscope; results in fuzziness of vision and is like looking through wax paper. Cataracts cause blurring, sensitivity to light, and/or double vision.) • Macular degeneration — due to damage to macula that results in loss of central vision (Objects seem blurred, distorted, or are not seen.) • Glaucoma — increased intraocular pressure with tonometer testing (Results in blurring, colored “halos” around lights, pain or redness of eyes, loss of peripheral vision.) • Smaller pupil size • Complaints of decreased ability to read, discomfort from light, changes in depth perception, falls, collisions, difficulty handling small objects, difficulty with activities of daily living (ADL), and tunnel vision • Dry, red eyes • Vitreous floaters, which are lightning flashes in the visual field Nursing Considerations and Teaching Points • Make sure objects are in the patient's visual field, and do not move objects around. • Use large lettering to label medications and any distributed written information.

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Allow the person more time to focus and adjust to the environment. Avoid glare — may help to wear sunglasses. Use night-lights to help with dark adaptation problems. Use red and yellow to stimulate vision. Mark the edges of stairs and curbs to help with depth perception problems. Use microspiral telescopes or magnifying glasses and high-intensity lighting. Encourage yearly eye examination and/or refer for examination if visual changes persist (flashing lights in fields or “veil over the eye”). Encourage use of isotonic eyedrops as needed. Encourage use of low vision aids such as magnifying lens, light filtering lens, telescopic lenses, or electronic devices.

Hearing Characteristics • Approximately 30% to 50% of people older than age 65 have significant hearing loss. • Two major types of hearing disorders are common in the older population. o Sensorineural — progressive, irreversible bilateral loss of high-tone perception often associated with aging. Results in difficulty discriminating sounds. Sound waves reach the inner ear but are not properly transmitted to the brain. o Conduction deafness — results from blockage or impairment of the mechanical movement in the outer or middle ear (also a pathologic condition). Sound waves are not conducted to inner ear so that all sounds are muffled. • Hearing loss in elderly patients is usually a combined problem. The majority of the loss is due to auditory nerve changes or deterioration of the structures of the ear. There may also be nerve damage beyond the ear. Presbycusis and central deafness can result in permanent hearing loss; conduction deafness is reversible. • Usual progression from high-tone or high-frequency loss to a general loss of both high and low tones. • Consonants (higher pitched sounds) are not heard well. • Hearing loss increases with age and is greater in men. • Increase in the sound threshold (ie, greater sound needed to stimulate the older adult). • Decreased speech discrimination, especially with background noise. • Cerumen impaction, the most common cause of conductive hearing loss, is reversible. Assessment Findings • Increased volume of patient's own speech • Turning of head toward speaker • Requests of a speaker to repeat • Inappropriate answers, but otherwise cognitively intact • The person may withdraw, demonstrate a short attention span, and become frustrated, angry, and depressed

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Lack of response to a loud noise

Nursing Considerations and Teaching Points • Suggest hearing testing for further evaluation and consideration of an assistive device. • Face the person directly so he can lip read. • Use gestures and objects to help with verbal communication. • Touch the person to get his attention before talking. • Speak into the person's “good ear.” • Do not shout. Shouting increases the tone of the voice, and elderly people are unable to hear these high tones. • Speak slowly and clearly. • Suggest amplifiers on telephones and alarms. • Allow the person more time to answer your questions. • Evaluate the person's ear canals regularly and assist with cerumen removal. Cerumen removal is facilitated by: o Use of ceruminolytic agents, such as Debrox, 10 drops in the affected ear twice per day for 5 days, followed by flushing the ear with warm water via a 50-ml irrigation syringe or an electronic irrigation device. o Careful use of an ear spoon to mechanically remove cerumen. Smell Characteristics • Changes in smell are due to nasal sinus disease preventing odors from reaching smell receptors, a decrease in nerve fibers, chronic injury from infections, or bleeding. • Discrimination of fruity odors seems to persist the longest. • Generally, smells decrease in men more than in women. Assessment Finding • Inability to notice unpleasant odors, such as fires, body odor, or excessive perfume use • Decreased appetite Nursing Considerations and Teaching Points • At mealtime, name food items and give the person time to think of the smell/taste of the food. • Suggest use of stronger spices and flavorings to stimulate smell. Taste Characteristics • Taste buds decrease with age, especially in men. People over age 60 have lost half of their taste buds. By age 80, only one sixth of the taste buds remain. • Taste buds are lost from the front to the back (ie, sweet and salty tastes are lost first, whereas bitter and sour tastes remain longer)

Assessment Findings • Complaints that food has no taste • Excessive use of sugar and salt • Inability to identify the foods • Decrease in appetite and weight loss • Decreased pleasure from food Nursing Considerations and Teaching Points • Serve food attractively, and separate different types of foods. • Vary the texture of foods. • Encourage good oral hygiene. • Season food. Kinesthetic Sense Characteristics • With age, the receptors in the joints and muscles that tell us where we are in space lose their ability to function. Therefore, there is a change in balance. • Walking with shorter step length, less leg lift, a wider base, and tendency to lean forward. • With age, less ability to stop a fall from occurring. Assessment Findings • Alterations in posture, ability to transfer, and gait • Complaint of dizziness Nursing Considerations and Teaching Points • Position items within reach. • Give person more time to move. • Take precautions to prevent falls. • Suggest physical therapy with balance training after periods of prolonged immobility. Cardiovascular Characteristics • With age, the valves of the heart become thick and rigid as a result of sclerosis and fibrosis, compounding any cardiac disease already present. • Blood vessels also become thick and rigid, resulting in elevated blood pressure, which is present in half of the U.S. population over age 65. • Maximum heart rate and aerobic capacity decrease with age. • Slower response to stress. Once the pulse rate is elevated, it takes longer to return to baseline. • Decline in maximum oxygen consumption. • About 50% of older adults have an abnormal resting electrocardiogram. • Subtle changes in artery walls result in a less flexible vasculature. Assessment Findings

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Normal blood pressure is 120/80 mm Hg and below; blood pressure 121 to 129/81 to 89 mm Hg is considered prehypertension; 130 to 159/90 to 109 mm Hg is grade 1 hypertension; 160/110 mm Hg and above is grade 2 hypertension. Prolonged tachycardia may occur following stress.

Nursing Considerations and Teaching Points • Encourage regular blood pressure evaluation as well as lifestyle modifications and medication adherence, if indicated, for hypertension. • Encourage longer cool-down period after exercise to return to baseline cardiac function. • Encourage regular aerobic exercise: walking, biking, or swimming for 20 minutes at least three times per week. Pulmonary Characteristics • With age, there is a weakening of the intercostal respiratory muscles, and the elastic recoil of the chest wall diminishes. • There is no change in total lung capacity; however, residual volume and functional residual capacity increase. • Partial pressure of oxygen decreases with age due to ventilation_erfusion mismatches. However, elderly people are not hypoxic without coexistent disease. • There is a decrease in the mucous transport/ciliary system. Therefore, there is resulting decreased clearance of mucus and foreign bodies, including bacteria. Assessment Findings • Prolonged cough, inability to raise secretions • Increased frequency of respiratory infections Nursing Considerations and Teaching Points • Elderly people undergoing surgical treatment need special attention paid to deepbreathing exercises. • Teach measures to prevent pulmonary infections — avoid crowds during cold and flu season, wash hands frequently, report early signs of infection. • Avoid smoking and exposure to secondhand smoke. Immunologic Characteristics • The function of T-cell lymphocytes, such as cell-mediated immunity, declines with age due to involution and atrophy of the thymus gland. • Decreased T-cell helper activity; increased T-cell suppressor activity. • Declining B-cell function as a result of T-cell changes. Assessment Findings • More frequent infections • Increased incidence of many types of cancer

Nursing Considerations and Teaching Points • Teach people that they are at increased risk of infection, cancer, and autoimmune disease; therefore, routine follow-up and screening are essential. Neurologic Characteristics • There is gradual loss in the number of neurons with age, but no major change in neurotransmitter levels. • Some brain tissue atrophy is normal and does not relate to cognitive impairment. • Decreased muscle tone, motor speed, and nerve conduction velocity. • Decrease in gait speed of 1.6% per year after age 63, decreased step length, stride length, and arm swing. Assessment Findings • Decreased position and vibration sense • Diminished reflexes, possible absent ankle jerks • Complaint of falls and impaired balance • Wide-based gait with decreased arm swing Nursing Considerations and Teaching Points • Because of these changes in combination with sensory changes, fall prevention techniques are essential to teach to elderly people. o Environmental safety techniques include nonslip surfaces, securely fastened handrails, sufficient light, glare-free lights, avoidance of lowlying objects, chairs of the proper height with armrests, skidproof strips or mats in the tub or shower, toilet and tub grab bars, elevated toilet seats. o Home safety evaluations should be done on all community-dwelling elderly people to reduce the risk of falls. A home safety checklist can be obtained from:  National Safety Council: http://www.nsc.org. Musculoskeletal Characteristics • Declining muscle mass and endurance with age, although deconditioning may be an associated factor. • Decreased bone density, less so in men than in women. • Decreased thickness and resiliency of cartilage, with a resulting increase in the stiffness of joints. • Bone resorption exceeds bone formation, resulting in a decline in bone density. • Injuries to the cartilage accumulate with age. Assessment Findings • Muscle atrophy • Increased incidence of fractures • Complaint of joint stiffness in absence of arthritis

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Decrease bone density (less that 2.5 standard deviations below normal)

Nursing Considerations and Teaching Points • Early intervention to encourage regular exercise (including weight-bearing exercise) in the elderly population is important to prevent exacerbation of these normal changes. • Consideration of calcium and vitamin D intake and encourage decrease alcohol and nicotine use. Community and Home Care Considerations • Encourage older adults to engage in 20 minutes of continuous aerobic exercise, including walking, biking, or swimming, at least three times per week. • For older adults who will be exercising at < 80% of the maximum heart rate (220 -age), stress testing before starting an exercise program is not needed. • To help with adherence to the exercise program, older adults should be encouraged to exercise at a set time, to relieve pain before exercising, and to do an activity they enjoy. Provide positive reinforcement for those who do exercise, and continually reinforce the benefits of exercise (increased bone strength, cardiovascular fitness, decreased risks of falls, overall sense of well-being). Endocrine Characteristics • Decreased secretion of trophic hormones from the pituitary gland • Blunted growth hormone release during stress • Elevated vasopressin (antidiuretic hormone); exaggerated response to osmotic challenge • Elevated levels of follicle-stimulating hormone and luteinizing hormone because of reduced end-organ response • Normal insulin secretion at rest with an age-related decrease in secretion in response to a glucose load; this may be a function of weight or genetic factors Assessment Findings Usually asymptomatic Nursing Considerations and Teaching Points • Encourage routine screening for elevated blood glucose — both fasting and postprandial. • Provide dietary education about a well-balanced diet. Reproductive Characteristics • In women, menopause leads to decreases in the size of the ovaries and hormone production. This results in uterine involution, vaginal atrophy, and loss of breast mass. • With age there is increased risk in females of cystocele, rectocele, and uterine prolapse.

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In men, testosterone production and secretion decrease with age. However, serum levels may be in the low-normal range through age 80.

Assessment Findings • Vaginal dryness, painful intercourse • Atrophic vaginitis • Urinary incontinence Nursing Considerations and Teaching Points • Suggest the use of additional lubrication during sexual intercourse. • Advise sexually active older men that spermatogenesis may continue into advanced age. • Address advantages and disadvantages of hormone replacement therapy for symptomatic relief related to menopause. Renal and Body Composition Characteristics • Increased body fat and decreased lean muscle mass, even when weight remains stable. • Decreased renal function, measured by the glomerular filtration rate, or creatinine clearance. • Despite reduced total body creatinine due to decreased muscle mass in the older adult, serum creatinine often remains within normal range. This is because of decreased elimination of creatinine by the kidneys. • About 10% decline in creatinine clearance per decade after age 40; however, relatively unchanged serum creatinine. Assessment Findings • Usually asymptomatic • Increased incidence of anemia Nursing Considerations and Teaching Points • Be aware that although creatinine level may be within normal range, creatinine clearance may be decreased. To obtain an accurate creatinine clearance in an elderly person, the following formula should be used: (140 - age)(weight [kg])/ (72)(serum creatinine [mg/dL]). • Drugs that are cleared through the kidneys may be given in decreased dosage. Adverse effects and toxicity must be closely monitored. • Consider the advantages and disadvantages of drug management for anemia associated with renal disease. Skin Characteristics • Thinning of all three layers of the skin — epidermis, dermis, and subcutaneous tissue — leads to greater fragility of the skin and decreased ability of the skin to function as a barrier to external factors.

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Fewer melanocytes and decreased tanning. Less efficient thermoregulation of heat because of fewer sweat glands. Drier skin because the decreased number of sebaceous glands results in reduced oil production. Other changes in aging skin include reduced sensory input, decreased elasticity, and impaired cell-related immune response.

Assessment Finding • Dry, irritated skin Nursing Considerations and Teaching Points • Excessive use of soap, which can be drying to the skin, should be avoided. • Careful skin evaluation and lubrication are necessary to prevent fissures and breakdown. • Heat regulation needs to be controlled by proper clothing and avoidance of extreme temperatures. • Avoid direct application of extreme hot or cold to skin because damage may occur without feeling it. • Encourage use of sunscreen during all outdoor activities. Community and Home Care Considerations • Xerosis is a common problem for older adults. Treatment should include: o Drinking 2,000 mL of liquid daily. o Total body immersion in warm water (90° to 105° F [32.2° to 40.6° C]) for 10 minutes. o Use of nonperfumed soap without hexachlorophene. o Application of emollient, particularly those with alpha-hydroxy acids (Lac-Hytrin), after bathing and at bedtime. Hematopoietic Characteristics • Unchanged number of stem cells of all three cell lines; however, bone marrow cellularity is decreased by 33% during adult life. • Declining marrow activity, especially in response to stress, such as with blood loss or infection. Assessment Finding Asymptomatic Nursing Considerations and Teaching Points • Anemia and granulocytopenia are not normal consequences of aging and should be investigated. • Teach patients that there is no need to take oral iron unless there is an actual documented decrease in iron levels. • Encourage oral B12 and folate replacement to manage associated anemias.

Altered Presentation of Disease Characteristics • In part due to the physiologic changes that occur with aging, the manifestations of illness in the older patient are less dramatic than in younger patients. • Most elderly persons have at least one chronic condition. These coexisting conditions can complicate the evaluation of new symptoms. Assessment Findings • The classic indicators of disease are usually absent or disorders present atypically. Atypical Presentation of Disorders in the Older Adult DISORDER ATYPICAL PRESENTATION Acute intestinal o Abdominal pain may be absent. infection o May present with acute confusional state, leukocytosis, and acidosis. Appendicitis o Pain may be diffuse, not localized in right lower quadrant. Biliary disease o Confusion, declining function, and other nonspecific symptoms. o Abnormal liver function tests may be only sign. Heart failure o Initially may have change in mental status and fatigue. Hyperthyroidism o Apathy, palpitations, weight loss, weakness. Hypothyroidism o Present with weight loss. Myocardial infarction o Chest pain may be absent. o Syncope, dyspnea, vomiting, or confusion may be presenting symptoms. Perforated ulcer o Rigidity may be absent until late. Pneumonia o May present with confusion. o Fever and cough may be absent. Pulmonary embolism o May present with change in mental status. o May not have fever, leukocytosis, or tachycardia. Septicemia o May be afebrile. Systemic lupus o Pneumonitis, subcutaneous nodules, and erythematosus discoid lesions are more common presentation. o Malar rash, Raynaud's phenomenon, and nephritis are less common. Urinary tract o Confusion. infection • Older people are less likely to complain of new symptoms but rather attribute them to aging or existing conditions. Many elderly people minimize symptoms because of fears of hospitalization or health care costs. Nursing Considerations and Teaching Points

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Have a high index of suspicion for underlying illness if the older adult presents with an acute change in cognition, behavior, or function.

ASSESSMENT FUNCTIONAL ASSESSMENT Functional assessment is the measurement of a patient's ability to complete functional tasks and fulfill social roles, specifically addressing a person's ability to complete tasks ranging from simple self-care to higher-level activities. Purpose • Functional assessment is essential in the care of the elderly patient because it: o Offers a systematic approach to assessing elderly people for deficits that commonly go undetected. o Helps the nurse to identify problems and utilize appropriate resources. o Provides a way to assess progress and decline over time. o Helps the nurse evaluate the safety of the person's ability to live alone • Functional status includes the evaluation of sensory changes, ability to complete ADL, instrumental ADL, gait and balance problems, and elimination. Instruments to Measure Functional Ability • Functional status may be assessed by several methods: self-report, direct observation, or family report. Direct observation is the method of choice, when possible. • The instrument chosen should be based on the specific goal or purpose for the evaluation. For example, if the focus is on basic self-care and mobility, the Barthel index should be used. • See Box 9-1, page 172, for scales measuring functional ability: Katz Index for Activities of Daily Living and Instrumental Activities of Daily Living. Use these scales to determine how independent the older adult is, and repeat them periodically to compare level of functioning over time. See Selected References for reference to Barthel index, page 199. • Performance measures, such as the Tinetti Gait and Balance measure or the Chair Rise test, can be used to evaluate higher-level function.

Katz Index for Activities of Daily Living and Instrumental Activities of Daily Living ACTIVITIES OF DAILY LIVING 1. Bathing — Sponge bath, tub bath, or shower INSTRUMENTAL ACTIVITIES OF DAILY LIVING 1. Can you use the telephone? 0 = without help, including looking up numbers and dialing 2 = with some help (can answer phone or dial “O” in

0 = no assistance (gets in and out of tub by self) 1 = uses a device to get in or out of tub but able to bathe self 2 = requires partial assistance with bathing 3 = full bath required (unable to bathe) 2. Dressing — includes getting clothes from closet and drawers (under and outer garments and able to use fasteners) 0 = no assistance with getting clothes and dressing self 1 = able to get clothes and get dressed, except for assistance with shoes 2 = receives assistance with getting clothes or getting dressed 3 = requires complete assistance or stays partly or completely

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emergency, but need special help in getting the number or dialing) Why?__________________________________________ 3 = completely unable to use the telephone Can you get to places out of walking distance? 0 = without help (travels alone on buses, taxis, drives own car) 1 = with some help in transferring on and off (device and/or person) 2 = with help of someone while travelling 3 = totally dependent on specialized arrangements for travel (ie, ambulance) or doesn't travel at all Can you go shopping for groceries or clothing? 0 = without help taking care of all shopping needs (assuming had own transportation) 1 = able to take care of all shopping needs but requires companion to help 2 = requires assistance in preparation of shopping list as well as a companion to help with shopping 3 = totally dependent on another person for all shopping needs Can you prepare your own meals? 0 = without assistance (plan and cook full meals for yourself) 2 = with some assistance (can prepare some things but unable to cook a full meal) Why?__________________________________ 3 = totally unable to prepare meals Can you do your housework? 0 = without assistance (scrub floor, etc.) 2 = able to do light housekeeping but needs help with heavy work ie ___________________________________ 3 = unable to do any housework Can you take your own medicine? 0 = without assistance (correct doses, correct time) 1 = able if someone prepares it for you 2 = able to if someone prepares it for you and reminds you to take it 3 = require someone to prepare and give you your medication

7. Can you handle your own money? 0 = without assistance (able to pay bills, write checks) 2 = able to manage day-to-day buying but need help with managing check book and paying bills

undressed 3. Toileting — going to bathroom for bowel and urine elimination, self-cleaning and arranging clothes 0 = requires no assistance 1 = requires no assistance but uses device (cane, walker, wheelchair, bedpan at night, but able to empty in morning) 2 = receives partial assistance with going to the bathroom or in cleansing or arranging clothing 3 = receives full assistance or does not go to the bathroom 4. Transfer 0 = moves well in and out of bed and/or chair without assistance 1 = moves well in and out of bed and/or chair with device 2 = moves in and out of bed and/or chair with assistance

Why?_________________________________________ How long has this been going on?_________________ 3 = requires full assistance with money management _____________ Score Best score is 0, most independent; worst score is 18, most dependent.

3 = requires full assistance 5. Continence 0 = controls urination and bowel movements completely by self 1 = has occasional “accidents” 2 = supervision helps keep bowel or urine control or is incontinent 3 = catheter is used 6. Feeding 0 = able to prepare foods, serve and feed self without assistance 1 = requires help in preparation of food but is able to feed self 2 = requires help in preparation of food, cutting of meat, buttering 3 = receives full assistance or is fed partly or completely by tubes ____________ _ Score Best score is 0, most independent;

worst score is 18, most dependent. Adapted form Katz, S., et al. (1963.) Studies of illness in the aged, in the aged the index of ADL: A standardized measure of biologic and psychosocial function. Journal of the American Medical Association, 185,914-919. PSYCHOSOCIAL ASSESSMENT Altered Mental Status • Assessment of cognitive function to detect altered mental status involves examination of memory, perception, communication, orientation, calculation, comprehension, problem solving, thought processes, language, construction abilities, abstraction, attention, aphasia, and apraxia. • Assessment can be facilitated by use of the Folstein Mini-Mental State Examination. Assessment items include: o Orientation to time (year, season, date, day, month); 5 points. o Orientation to place (state, county, town, hospital, floor); 5 points. o Registration of 3 items; 1 point for repeating each item correctly. o Calculation by subtracting serial 7′s, starting with 100; 1 point for each correct up to 5 trials. Alternately spell “world” backwards; 1 point for each letter correct. o Recall of the three items registered earlier; 1 point for each correct. o Naming 2 items shown such as pencil and pen; 1 point each. o Repeating “No ifs, ands, or buts”; 1 point. o Following a 3-stage command: “Take this paper in your right hand, fold it in half, and put it on the floor”; 3 points. o Obeying the written command “Close your eyes”; 1 point. o Writing a sentence; 1 point. o Copying a complex polygon; 1 point. • Total possible score is 30. Score of 24 to 30 indicates intact cognitive function; 20 to 23, mild cognitive impairment; 16 to 19, moderate cognitive impairment; 15 or less, severe cognitive impairment. This scale can help to follow the elderly person's mental status over time and assess for acute and or chronic changes. • Although success on scales such as this has been associated with education and socioeconomic status, this scale continues to be used as an appropriate screening tool for abnormal cognitive function. • Assessment of altered mental status or behavior may elicit criteria that lead to a diagnosis of dementia. It is essential to differentiate dementia from delirium (which is treatable and reversible). o Delirium is abrupt in onset and is commonly due to an underlying medical condition such as cardiac decompensation, electrolyte imbalance, or urinary tract infection. Disorientation occurs early, and the behavior is variable hour to hour. There is a clouded, altered, or changing level of consciousness, short attention span, and disturbed sleep-wake cycle.

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Hallucinations are common. The condition is reversible with treatment of the underlying cause. Dementia has a gradual onset. Behavior is usually stable, and disorientation occurs late. Consciousness is not clouded, attention span generally is not reduced, day-night reversal of sleep-wake cycles can occur rather than hour-to-hour variation. Hallucinations do not occur until late.

Social Activities and Support • Social support for older adults is generally instrumental, informational, or emotional. The social environment is important with regard to recovery of acute medical problems and management of chronic illness. • Elicit information by asking such questions as: o How often do you socialize with others? o With whom do you socialize? o What type of activities do you get involved in? o Do you enjoy socializing? o Who can you call for help? o Do you know of any church or community groups you can call for help? Emotional and Affective Status Characteristics • Depression may occur for the first time in older age and has been related to the many changes that occur with aging: o The independence of one's children o The reality of retirement o The loss of roles, income, spouse, friends, family, homes, pets, functional ability, health, and ability to participate in leisure activities such as reading o Ageist messages from society supporting and encouraging the value of youth • Depression may also be caused by underlying illnesses such as Parkinson's disease and by drugs, such as antihypertensives, antiarthritics, and antianxiety agents. • Depression is usually difficult to identify in the elderly patient because the presentation is different than in younger people. Obtain the following information to assess for depression: o Complaints of insomnia, weight loss, anorexia, and constipation (vegetative symptoms) o Preoccupation with past life events o Decrease in concentration, memory, and decision making (dementia syndrome) o Other somatic complaints, such as decreased appetite, musculoskeletal aches and pains, chest pain o History of chronic illness or other health problems o Current medications

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Evaluate depression using the Geriatric Depression Scale as a screening tool (see Box 9-2, page 174). Suicide is sometimes associated with depression, with suicides being especially high in older white men. Assess for suicide risk. Pain is underdetected and undertreated in the elderly and may be contributing to depression. Assess pain by asking and observing the patient, and provide appropriate measures to make the patient more comfortable.

Geriatric Depression Scale (Short Form) Choose the best answer for how you felt over the past week. YES NO 1.Are you basically satisfied with your life? □ □ 2.Have you dropped many of your activities and interests? □ □ 3.Do you feel that your life is empty? □ □ 4.Do you often get bored? □ □ 5.Are you in good spirits most of the time? □ □ 6.Are you afraid that something bad is going to happen to you? □ □ 7.Do you feel happy most of the time? □ □ 8.Do you often feel helpless? □ □ Do you prefer to stay at home rather than going out and doing new 9. □ □ things? 10.Do you feel you have more problems with memory than most? □ □ 11.Do you think it is wonderful to be alive now? □ □ 12.Do you feel pretty worthless the way you are now? □ □ 13.Do you feel full of energy? □ □ 14.Do you feel that your situation is hopeless? □ □ 15.Do you think that most people are better off than you are? □ □ Total score ___________ The following answers count one point; scores 5 indicate probable depression. 1. No 2. Yes 3. Yes 4. Yes 5. No 6. Yes 7. No 8. Yes 9. Yes 10. Yes 11. No 12. Yes 13. No 14. Yes

15. Yes Yesavage, J. A., & Brink, T. L. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. Nursing and Patient Care Considerations • Treatment of depression should be given to older adults and includes drugs, psychotherapy and, in some cases, electroconvulsive therapy. • Complement other therapeutic measures by providing opportunities to increase the person's self-esteem. o Encourage participation in meaningful activities. o Compliment the person. o Help the person develop a sense of mastery. o Encourage reminiscence of meaningful past events. • Help the person identify and use social supports. • For behavioral problems (agitation, combative behavior, or wandering) consider options such as aromatherapy, music therapy, pet therapy, or massage. Motivation in Elderly Patients Characteristics • Motivation is an important variable in the elderly person's ability to recover from any disabling event and the ability to maintain his highest level of wellness. • It is possible to evaluate a persons's motivation to comply with a given treatment plan and adopt interventions to help to improve the elderly person's motivation. • Factors that influence motivation in a elderly patient include: o Needs such as hunger. o Past experiences, specifically with health care providers. o Negative attitudes toward aging. o Self-efficacy expectations, or the belief in one's ability to perform a specific activity. o Outcome expectations, or the belief that if a specific activity is performed there will be an expected outcome. o The cost of performing a specific activity in terms of time, money, pain, fatigue, or fear. o Internal factors, such as sensory changes, cognitive status, and medication adverse effects. o External factors, such as social norms (particularly if those norms conflict with treatment) and the influence of social supports. • Problems in motivation due to age-related differences include: o A shift from achievement motivation to conservative motivation. o Increasing difficulty in the establishment of rewards for elderly people, due to their many losses. o A tendency to see a task as being more difficult than a younger person would. o A tendency to become easily discouraged; the older adult may not initiate behavior as readily.

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Greater significance placed on the meaning of a task; it must be meaningful to the elderly person. o Evidence that elderly people do not do well on tasks if they are asked to do them rapidly, under a time limit, or in a stressful situation. o Increased importance placed on the cost of participating in an activity; fear of failing can be expressed either as increased anxiety or decreased willingness to take risks. o Increased need for elderly people to get approval for trying. The Motivation Wheel can be used to evaluate motivation in the older adult.
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The wheel of motivation. o Motivation is influenced by personal expectations (self-efficacy and outcome expectations), spirituality, goals, self-determination, social support, individual care, and physical sensations. o Motivation can be increased by strengthening self- efficacy and outcome expectations, spirituality, self-determination, by identifying appropriate goals, using social supports, individualized care, and decreasing any unpleasant sensations associated with an activity. Nursing and Patient Care Considerations • Strategies to improve motivation include:

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Establish whose motives are being discussed — the patient's, the family's, or the health care provider's; involve the patient in setting the goals. o Explore with the patient any indication of fear or other unpleasant sensation associated with the activity, such as pain or fatigue, and implement interventions to decrease these unpleasant sensations. o Evaluate the spokes of the wheel to consider the many factors that influence motivation and implement interventions as appropriate. o Encourage the patient to verbally express emotional factors associated with the activity. o Examine the setting for the desired behavior to occur. Is the environment too stressful, too dark, or too noisy? o Attempt to use role models. Elderly role models can change ageist attitudes and stimulate patients to perform the desired behavior. o Set small goals to be met either daily or each shift. This provides frequent rewards. o Do not be afraid to use yourself. Research has indicated that being nice, demonstrating caring, using humor, verbal encouragement and support can all help motivate the elderly person. Educate the older adult about the benefits of the activity, whether these are physical or psychological.
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HEALTH MAINTENANCE PRIMARY PREVENTION Primary prevention is the prevention of disease before it occurs. Primary prevention can be broken down into counseling, immunizations, and chemoprophylaxis. Counseling • Encourage smoking cessation. o Approximately 20% of people between ages 65 and 74 and 10% of those over age 75 still smoke cigarettes. o Tobacco use has been linked to heart disease; peripheral vascular disease; cerebrovascular disease; chronic obstructive pulmonary disease; cancer such as lung, bladder, and esophageal malignancies; and numerous other health problems that decrease the quality of life or cause premature death. o Although much damage has been done to the lungs and blood vessels by many years of smoking, elderly persons can still benefit from smoking cessation by increasing the quality of life. • Encourage physical activity. o It has been stated that less than 10% of those over age 65 are physically active and that almost 50% are sedentary. o It has been recommended that elderly people participate in regular activity, especially aerobic activities that promote cardiovascular fitness, such as walking, cycling, or swimming.

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Refer to a physical, occupational, or rehabilitation therapist. An individualized exercise prescription should be developed and cleared with the health care provider. Identify alcohol abuse in elderly people. o The consequences of alcoholism include liver disease, GI bleeding, and motor vehicle accidents. o Question elderly people about drug or alcohol abuse. Although street drug use is rare, prescription drug abuse may be occurring or ETOH may be used for pain. o Recognize the signs and symptoms of alcohol abuse in the elderly. o Refer for counseling. Evaluate and counsel on dental health. o Dental problems in elderly people include missing teeth, ill-fitting dentures, periodontal disease, and decayed teeth. o Dental problems commonly lead to poor eating habits, apathy, and fatigue. o Regular dental care should be encouraged to improve nutrition and the quality of life.
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Signs of Alcohol Abuse in Elderly Patients • Difficulty with gait and balance • Acute change in cognition • Frequent falls or accidents • Change in drinking patterns • Poor nutritional intake • Poor hygiene and self-care • Lack of physical exercise • Social isolation Immunizations Pneumococcal Pneumonia and Influenza • Pneumococcal pneumonia and influenza are significant causes of mortality and morbidity in elderly people. • It is recommended that the pneumococcal vaccine be given at least once to all people over age 65. Individuals immunized before age 65 may be candidates for revaccination, provided at least 6 or more years have passed since the last dose. • Two options are available for the prevention of influenza. o Annual influenza vaccine for all people over 65. o Antiviral agents are effective against influenza. These agents can be effective in ameliorating symptoms if given within 48 hours of onset of illness. Tetanus-Diphtheria • Tetanus-diphtheria immunization is an important but frequently forgotten component of health maintenance, especially in elderly people. o The mortality rate of tetanus exceeds 50% in those over age 65.

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Combined tetanus-diphtheria boosters should be given every 10 years, but even a booster given after 25 to 30 years will be effective. For those with no history of immunization or unknown immunization status, a primary series should be initiated, consisting of two doses of tetanus-diphtheria vaccine at least 4 weeks apart, followed by a third dose 6 to 12 months later.

Chemoprophylaxis • The risk and benefits of oral anticoagulation therapy should be considered for older adults at risk of cardiovascular disease, particularly stroke. o Contraindicated if patient is at risk for GI bleeding. o Should be discussed with older adults with regard to prevention of deep vein thrombosis, nonvalvular atrial fibrillation, cardiomyopathy, valvular heart disease, mechanical prosthetic heart valves, and acute myocardial infarction. • Calcium, vitamin D, and other agents such as selective estrogen receptor modulators or bisphosphonates may be considered for those at risk for osteoporosis. SECONDARY PREVENTION Secondary prevention is the detection of disease in an early stage, commonly for colorectal cancer, breast cancer, prostate cancer, uterine cancer, and tuberculosis screening. Implications of screening versus not screening should be discussed and patients should be helped to make appropriate decisions. Screening Recommendations • The recommendation for bowel cancer screening is for yearly stool samples for occult blood and sigmoidoscopy every 5 years after age 50. • Monthly breast self-examination, yearly breast examination by a health care provider, and yearly mammography are suggested for breast cancer screening for women over age 40. • Yearly screening for tuberculosis via skin test is recommended for the older adult at increased risk, such as the institutionalized or those with medical risk factors such as diabetes or immunosuppression. A two-step test is indicated in those over age 55 because of waning immunogenicity. If the initial test is negative, a second test is given 1 to 2 weeks later. • Yearly rectal examinations and blood test for prostate specific antigen (PSA) are recommended in men over age 50 to screen for prostate disease. • Annual examination with Papanicolaou (Pap) test is recommended in older women to rule out cervical or genital malignancies; after hysterectomy for noncancerous process, Pap test may be done every 3 to 5 years. • Yearly visual screening is important to assess for visual changes, glaucoma, and cataracts. TERTIARY PREVENTION

Tertiary prevention addresses the treatment of established disease to avoid complications and death. The major areas of focus for the older adult are preventing the complications of immobility and rehabilitation. Preventing Complications of Immobility Positioning • The goal of frequent position changes is to prevent contractures, stimulate circulation and prevent pressure sores, prevent thrombophlebitis and pulmonary embolism, promote lung expansion and prevent pneumonia, and decrease edema of the extremities. Changing position from lying to sitting several times a day can help prevent changes in the cardiovascular system known as deconditioning. • The recommendation is to change body position at least every 2 hours, and preferably more frequently in patients who have no spontaneous movement. Proper Body Alignment • Dorsal or supine position o The head is in line with the spine, both laterally and anteroposteriorly. o The trunk is positioned so flexion of the hips is minimized to prevent hip contracture. o The arms are flexed at the elbow with the hands resting against the lateral abdomen. o The legs are extended in a neutral position with the toes pointed toward the ceiling. o The heels are suspended in a space between the mattress and the footboard to prevent heel pressure. o Trochanter rolls are placed under the greater trochanters in the hip joint areas. • Side-lying or lateral position o The head is in line with the spine. o The body is in alignment and is not twisted. o The uppermost hip joint is slightly forward and supported by a pillow in a position of slight abduction. o A pillow supports the arm, which is flexed at both the elbow and shoulder joints. • Prone position o The head is turned laterally and is in alignment with the rest of the body. o The arms are abducted and externally rotated at the shoulder joint; the elbows are flexed. o A small, flat support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. o The lower extremities remain in a neutral position. o The toes are suspended over the edge of the mattress. Therapeutic Exercise • It has been reported that there is a daily loss of 1% to 1.5% of initial strength in an immobilized older adult.

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The goals of therapeutic exercise are to develop and retrain deficient muscles, to restore as much normal movement as possible to prevent deformity, to stimulate the functions of various organs and body systems, to build strength and endurance, and to promote relaxation. Perform passive range-of-motion (ROM) exercise. o Carried out without assistance from the patient. o The purpose is to retain as much joint ROM as possible, and to maintain circulation. o Move the joint smoothly through its full ROM (see Box 9-4, pages 178 to 181). Do not push beyond the point of pain. Perform active assistive ROM. o Carried out by the patient with the assistance of the nurse. o The purpose is to encourage normal muscle function. o Support the distal part and encourage the patient to take the joint actively through its ROM. o Give only the amount of assistance necessary to accomplish the action. Encourage active ROM. o Accomplished by the patient without assistance. o The purpose is to increase muscle strength. o When possible, active exercise should be done against gravity. o Encourage the patient to move the joint through the full ROM without assistance. o Make sure that the patient does not substitute another joint movement for the one intended. o Other active forms of exercise include turning from side to side, turning from back to abdomen, and moving up and down in bed. Assist with resistive exercise. o Carried out by the patient working against resistance produced by either manual or mechanical means. o The purpose is to increase muscle strength. o Encourage the patient to move the joint through its ROM while you or someone else provides slight resistance at first and then progressively increases resistance. o Weights may be used and are attached at the distal point of the involved joint. o The movements should be done smoothly. Teach isometric or muscle-setting exercise. o Involve alternately contracting and relaxing a muscle while keeping the part in a fixed position; performed by the patient. o The purpose is to maintain strength when a joint is immobilized. o Teach the patient to contract or tighten the muscle as much as possible without moving the joint. o The patient holds the position for several seconds, then relaxes.

Range of Motion

SHOULDER

ELBOW

WRIST

THUMB

FINGERS

ANKLE

TOES

HIP

KNEE

CERVICAL SPINE

Geriatric Rehabilitation and Restorative Care Characteristics • The primary goal is restoring the older adult to maximum functional level. • Multidisciplinary service involving input from the primary care provider; nursing personnel; physical, occupational, speech, and recreational therapists; social worker; psychologist; and dietitian. • Rehabilitation and restorative nursing involves developing a rehabilitation philosophy of care. o Patients are encouraged, and allowed sufficient time, to perform as much of their personal care as possible. o Goals are set with the patient rather than for the patient. o Prevention of further impairment is imperative. o Focus on skin and wound care, regaining or maintaining bowel and bladder function, independent medication use, good nutritional status, psychosocial support, an appropriate activity/rest balance, and patient and family education. Nursing and Patient Care Considerations

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Impaired cognitive function may have an impact on the quality of rehabilitation. o Assess for physical problems that may exacerbate cognitive dysfunction (eg, infection, drug adverse effects, metabolic or circulatory problems, or fatigue). o Provide innovative measures to encourage ambulation and increased function; provide frequent verbal cues and large print reminders; focus on basic self-care abilities. o Implement appropriate safety measures such as bed side rails, proper lighting, appropriate staffing, and avoidance of restraints. Disability has a tremendous impact on the patient's body image and requires an adjustment by the patient. Be aware of the stages of psychological reaction the patient may undergo. o Period of confusion, disorganization, and denial o Period of depression or anxiety and grief o Period of adaptation and adjustment Interventions in rehabilitation nursing include: o Provide an atmosphere of acceptance. o Identify and encourage positive coping patterns. o Encourage socialization and participation in group activities. o Give positive reinforcement and feedback about progress. o Involve families as much as possible. Use interventions suggested above to motivate the older adult to engage in functional activities and exercise.

Community and Home Care Considerations • Family or significant other caring for the older adult at home can have a major impact on the rehabilitation process. o Assist the family or significant other to face the reality of the patient's disability and to set appropriate goals. o Involve the family or significant other in decision making and in the patient's care in order for them to develop and practice the skill necessary for the patient to reach rehabilitation goals. o Help extend and enlarge the family's or significant other's skills by teaching problem solving, treatment needs of the patient, ways to communicate to health care providers, and the use of community resources. o Assess the level of caregiver fatigue or burnout. • For the older adult living independently: o Encourage adherence to a regular exercise program to maintain optimal function. o Exercise goals should be at least 20 minutes of continuous aerobic exercise (walking, biking, or swimming) three times per week.

Caregiver Strain Index Instructions given to the caregiver: I am going to read a list of things that other people have found to be difficult in caring for patients after they come home from the hospital. Would you tell me whether any of these apply to you? (Give the examples.) Score one point for “yes” and zero for “no.” 1. Sleep is disturbed (eg, because __________ is in and out of bed or wanders around at night). 2. It is inconvenient (eg, because helping takes so much time or it's a long drive over to help). 3. It is a physical strain (eg, because of lifting in and out of a chair). 4. It is confining (eg, because helping restricts free time or cannot visit). 5. There have been family adjustments (eg, because helping has disrupted routine or there has been no privacy). 6. There have been changes in personal plans (eg, had to turn down a job or could not go on vacation). 7. There have been other demands on my time (eg, from other family members). 8. There have been emotional adjustments (eg, because of severe arguments). 9. Some behavior is upsetting (eg, incontinence; __________ has trouble remembering things; __________ accuses others of taking things). 10. It is upsetting to find that __________ has changed so much from before (eg, __________ is a different person from before). 11. There have been work adjustments (eg, because of having to take time off). 12. It is a financial strain. 13. It has been completely overwhelming (eg, because of worry about __________ or concerns about how to continue to manage). Scoring: Total score of 7 or more suggests a greater level of stress. Robinson, B.C. (1983). Validation of a caregiver strain index. Journal of Gerontology, 38(3), 344–348. ©1983 The Gerontological Society of America. SPECIAL HEALTH PROBLEMS OF THE OLDER ADULT ALTERED RESPONSE TO MEDICATION Adults over age 65 consume 30% to 40% of all prescription drugs and an even higher proportion of the over-the-counter drugs consumed. Age-related changes predispose older adults to problems with medication adverse effects. Pathophysiology and Etiology • Drug absorption is affected by such age-related changes as: o Decreased gastric acid. o Decreased GI motility. o Decreased gastric blood flow. o Changes in GI villi. o Decreased blood flow and body temperature in rectum. • Drug distribution is affected by:

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Decreased body size. Decreased water content in the body. Increased total body fat. Drugs distributed in water have a higher concentration in elderly patients (eg, gentamicin [Garamycin]). o Drugs distributed in fat have a wider distribution and less intense but prolonged effect (eg, phenobarbital [Luminal]). Drug metabolism in the older adult: o Is altered by a decrease in liver size, blood flow, enzyme activity, and protein synthesis. o Requires more time than in younger adults. Therefore, there is increased drug activity time in drugs that are metabolized in the liver (eg, propranolol [Inderal], theophylline [Theo-Dur]). Excretion of drugs is altered in older adults due to the following renal changes: o Decreased renal tubular function and blood flow. o This causes a decrease in renal filtration and an increase in blood levels of drugs that are excreted through the kidneys (eg, cimetidine [Tagamet]).
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DRUG ALERT Drugs that may have severe adverse effects in elderly patients include anticholinergics (antihistamines, antidepressants), nonsteroidal anti-inflammatory drugs (NSAIDs), any drug with a long half-life, and drugs with action on the central nervous system (CNS). Nursing Assessment • Drug toxicities are different than they are in younger people. • Fewer symptoms may be identified, and they may develop slower; however, the reactions may be more pronounced and further advanced once they do present. • Behavioral adverse effects are more common in elderly people because the bloodbrain barrier becomes less effective; the first reaction to a drug is confusion. • Many potential drug adverse effects are not identified because they are attributed to old age; fatigue, confusion, anorexia, or indigestion as drug adverse effects may not be reported. • Allergic reactions to drugs increase with age due to a greater likelihood of earlier exposure. Nursing and Patient Care Considerations • Maintain awareness that the older adult is at greater risk for adverse medication reactions. o This risk increases from 6% when two drugs are taken to 50% when five different drugs are taken, and to 100% when eight or more medications are taken. • Assess patient's ability to follow medication regimen by evaluation of: o Cognition. o Ability to read drug labels.

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Hand and muscle coordination. Swallowing difficulty. Lifestyle patterns, specifically smoking and alcohol use. Cultural beliefs toward medication. Ability to afford medication. Caregiver involvement in medication administration; assess caregiver if indicated. Identify problems in the use of medications such as: o Lack of knowledge about drugs. o Multiple medications and difficult administration techniques. o Caregiver misunderstanding of medication use. Appropriate interventions for safe drug use include: o Obtain a complete drug history. o Reinforce verbal instructions with written instructions using large print and simple wording. If necessary, use color-coding rather than drug names. o Write what the drug is used for and what the adverse effects can be. o Make sure patient or caregiver can open the medication container. o Arrange medication schedules to coincide with regular activity, such as eating (if appropriate for that drug). Simplify the drug regimen as much as possible. o If necessary, arrange a check-off system using a chart to ensure compliance. o If possible, visibly evaluate all medications in the home, or ask patient to bring all medications for evaluation. o Encourage patient to discard all old or unneeded medications, and to check expiration dates. o Encourage patient to store medications in original containers and in a dry, dark place. o Encourage patient to avoid over-the-counter medication without checking with the primary care provider before use. o Encourage patient to report any drug adverse effects. o Work with patient to maintain a drug regimen that follows the principles for geriatric drug use; start dosages low and go slow, use only necessary medications, titrate the dose to the patient response, simplify the regimen, and have frequent reevaluations done regarding the medication regimen.
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Community and Home Care Considerations • Ask the patient or family to bring in all the patient's medications for clinic or office visits or whenever the patient goes to the hospital, in order to obtain an accurate medication history. • Ask the patient what vitamins, minerals, herbal supplements, and other over-thecounter products are being used. Many patients do not consider these medications and will not readily supply the information unless specifically asked.

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Alert patients and family members that many “natural” products sold over the counter still may cause adverse reactions and toxicity as well as interactions with other drugs. Warn patients and families that many complementary and alternative therapies (CAM) do not have proven effectiveness despite advertisements. CAM should be used as an adjunct to conventional therapy, and the patient should notify all health care providers of supplements and therapies being used.

ALTERED NUTRITIONAL STATUS Normal age-related changes, behavioral changes, and pathologic conditions may lead to malnutrition in the older adult. Pathophysiology and Etiology • Changes in the oral cavity, including loss of teeth, diminished saliva production, and difficulty with mastication, may cause decreased food intake. • A decrease in gastric secretion with reduced pepsin hinders protein digestion, and iron, vitamin B12, calcium, and folic acid absorption; there are no significant changes in the small or large bowel. • Sensory changes involving taste and smell cause anorexia. • Psychosocial factors including changes in living situation, widowhood, depression, loneliness, decreased choice of food for institutionalized elderly, need to adhere to special diets, economic status, and ability to obtain and prepare food all impact what is eaten. • Alcohol use interferes with the absorption of the B-complex vitamins. Additionally, alcohol is high in calories and low in nutritional value. • Medications can alter nutrition by directly decreasing absorption and utilization of nutrients. Indirectly, medications can result in anorexia, xerostomia, dysgeusia, and early satiety. • Dysphagia (difficulty swallowing), which commonly occurs after cerebral vascular accident, intubation, head and neck surgery, or related to Parkinson's disease and dementia, may cause decreased food intake. • With age, there is a decrease in energy needs because of a decrease in muscle mass (total caloric need decreases 30%). Nursing Assessment • Be alert for patients who complain of difficulty swallowing and difficulty managing saliva. Watch for coughing after swallowing, sounding “wet” after eating, and pocketing food in the cheeks. • Assess for absent or diminished gag reflex. • Assess for a 10% weight loss over 6 months (marasmus) or weight loss along with low serum albumin levels (kwashiorkor), which are signs of protein-energy malnutrition. • Determine if cholesterol level is below 150 mg/dL, which is the single best predictor of malnourishment. Nursing and Patient Care Considerations

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Educate older adult and family or significant other about basic nutritional requirements and on overcoming barriers that interfere with optimal nutrition. o The Required Dietary Allowances (RDA) for healthy older adults are the same as that for younger adults, with three exceptions: decreased caloric intake, decreased protein intake (1 g/kg), and decreased iron requirements for postmenopausal women. Encourage good mouth care. Encourage patients to avoid alcohol if possible; refer for counseling if necessary and compensate for the nutritional consequences of alcohol abuse with liquid supplements, B vitamins. Review all prescription and over-the-counter medications with patients, and evaluate the influence of these on nutritional status. If food procurement, preparation, and enjoyment are a problem, identify community resources to offer assistance in obtaining food and community meals. In institutional settings, environmental factors may influence food enjoyment. Encourage socialization when eating, and try to minimize the negative effects of disruptive people. Try to improve aesthetics. To compensate for age-related changes in taste and smell, encourage use of lowsodium food additives. Encourage proper body position (eg, sitting upright during mealtimes) and staying up for 30 minutes after eating to help with digestion. If possible, encourage five to six small meals per day rather than three large meals. If appropriate, encourage the family to bring in food favorites for the patient. Position food on the plate so that if there is visual neglect, or impairment, the patient is best able to see the food served. Identify patients with dysphagia and obtain a referral to a speech therapist. o Work with the speech therapist and primary health care provider to determine what consistency of food is safe for the patient to swallow. If the patient is unable to swallow thin liquids, slushes, puddings, or applesauce should be given to ensure adequate hydration. o Use good compensatory techniques if indicated. These include sitting upright, tucking and turning the head, placing the food on the unaffected side of the tongue, swallowing twice to clear the pharyngeal tract, tucking the chin to the chest, and bringing the tongue up and back and holding the breath to swallow. o Write out swallowing instructions for patient and family, and educate family regarding the importance of maintaining these precautions.

Community and Home Care Considerations • Encourage the older adult at home to eat a well-balanced diet to maintain an optimal nutritional state. • Suggest vitamin preparations with the fewest number of minerals and vitamins needed to prevent interactions and avoid megadoses. • Advise taking calcium, iron, and zinc at least 2 hours apart and taking vitamins at the same time daily.

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Advise taking calcium and iron on an empty stomach and taking fat-soluble vitamins (A, D, E, and K) with food.

URINARY INCONTINENCE Approximately 10 million Americans suffer from urinary incontinence, including 15% to 30% of community-dwelling elderly people and 40% to 70% of institutionalized elderly people. It is commonly not reported by elderly people because they consider it to be a normal age change, and there is a low expectation of benefit from treatment. Pathophysiology and Etiology • There are five basic types of urinary incontinence: o Stress — an involuntary loss of urine with increases in intra-abdominal pressure. Usually caused from weakness and laxity of pelvic floor musculature, or bladder outlet weakness. o Urge — involves leakage of urine because of inability to delay voiding after sensation of bladder fullness is perceived. This is associated with detrusor hyperactivity, CNS disorders, or local genitourinary conditions. o Overflow — due to a leakage of urine resulting from mechanical forces on an overdistended bladder. This results from mechanical obstruction or hypomobility of the detrusor muscle. o Mixed — symptoms of both stress and urge incontinence secondary to both an overactive detrusor and pelvic floor/urethral incompetence. o Functional — involves urinary leakage associated with inability to get to the toilet because of cognitive and/or physical functioning. Nursing Assessment • Identify reversible causes of incontinence using the DRIP acronym. o D — Delirium, especially new onset delirium o R — Restricted mobility, retention o I — Infection (especially sudden onset cystitis), inflammation (such as atrophic vaginitis or urethritis), impaction (fecal) o P — Polyuria (from poorly controlled diabetes or diuretic treatment), pharmaceuticals (including psychotropics, anticholinergics, alpha agonists, beta agonists, calcium channel blockers, opioids, alpha antagonists, and alcohol) • Evaluate lower urinary tract function. o Stress maneuvers are evaluated by asking the patient, with a full bladder, to cough three times while standing. Observe for leakage of urine. o Check for postvoid residual by inserting a 12 or 14 French straight catheter a few minutes after the patient voids. o Evaluate bladder filling by leaving the straight catheter in place and using a 50-mL syringe to fill the bladder with sterile water. Hold the syringe approximately 6 inches (15 cm) above the pubic symphysis. Continue to fill the bladder in 25-mL increments until the patient feels the urge to void. Observe for involuntary bladder contractions. These contractions are

detected by continuous upward movement of the column of fluid in the absence of abdominal straining. Nursing and Patient Care Considerations • For stress or urge incontinence, teach Kegel (pelvic muscle) exercises. o Tell the patient to first practice stopping the stream of urine while voiding to identify proper contraction of the pubococcygeal muscle; contraction will result in stopping flow, and relaxation allows flow. o Once proper contraction is verified, advise the patient to practice contraction for 3 seconds, then relaxation of the muscle for 3 seconds in sets of 15 three times per day. o The exercise can be practiced anywhere at any time because it involves contraction of an internal muscle; encourage the patient to try them sitting, standing, and lying down. The abdomen should be relaxed, and no movement should be visible by doing Kegel exercises. • Assist with biofeedback that involves the use of bladder, rectal, or vaginal pressure recordings to train patients to contract pelvic floor muscles and relax the abdomen. • Institute a behavioral training program, using bladder records, biofeedback, and pelvic floor exercises for patients with stress or urge incontinence. • Institute other interventions such as: o Bladder retraining — progressive lengthening or shortening of voiding intervals to restore the normal pattern of voiding; this is useful after period of immobility or catheterization. o Scheduled toileting — using a fixed toileting schedule to prevent wetting episodes for patients with urge or functional incontinence. o Habit training — involves using a variable toileting schedule based on the patient's pattern of voiding; also incorporates positive reinforcement. o Prompted voiding — includes regular prompts to void every 1 to 2 hours with positive reinforcement. o Appropriate use of incontinence aids such as pads or diapers. o Judicious use of medications to help control urge incontinence. These include oxybutynin (Ditropan XL, Oxytrol transdermal patch) and tolterodine (Detrol, Detrol LA). Contraindicated in urinary or gastric retention, myasthenia gravis, and uncontrolled glaucoma. Monitor carefully for anticholinergic effects — dry mouth, heat intolerance, urine retention, constipation, drowsiness, dry eyes, blurred vision. URINE RETENTION Urine retention is a common problem in the older adult, commonly related to neurologic or other underlying condition. Pathophysiology and Etiology • Frequently encountered in the acute care setting, postcatheterization, after stroke, in diabetics due to atonic neuropathic bladder, due to fecal impaction, and males with prostatic enlargement.

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The patient with urine retention may void small amounts or may be incontinent continuously due to overflow of urine. Patients with urine retention will usually have incontinence during the night. Urine retention may also be caused or aggravated by drugs with anticholinergic properties such as levodopa (Sinemet) or the tricyclic antidepressants, especially amitriptyline (Elavil).

NURSING ALERT Urine retention may cause urinary tract infection, which can lead to sepsis in the elderly patient. Nursing Assessment • Take a complete history and perform physical examination to rule out causes of urine retention. • Monitor for a distended bladder and perform postvoid catheterization; residual of greater than 30 mL of urine signals urine retention. Nursing and Patient Care Considerations • Remove fecal impaction to help patient regain bladder function. • If prostatic disease is suspected, appropriate referral is necessary. • Encourage male to use the standing position and female the sitting position to facilitate urinary flow; provide privacy. • Evaluate medication regimen and discuss with health care provider the necessity or substitution of offending medication. • If no underlying condition is suspected attempt intermittent catheterizations every 8 hours, in combination with regular voiding attempts by patient. If there is no response in 2 weeks (ie, no decrease in postvoid residuals), referral to a urologist may be necessary for medical management of the urine retention. FECAL INCONTINENCE Fecal incontinence is an inability to voluntarily control the passage of gas or feces. Although not as common as urinary incontinence, fecal incontinence afflicts 13% to 47% of hospitalized elderly patients and 10% to 30% of nursing home residents. It has been noted to affect 10.9 men and 13.3 women per 1,000 older adults living at home. Pathophysiology and Etiology • Fecal continence depends on normal rectal and anal sensation, rectal reservoir capacity, and internal and external sphincter mechanisms. • In institutionalized elderly patient, fecal impaction is a primary cause of fecal incontinence due to stool leaking around a fecal mass. • In the noninstitutionalized elderly patient, fecal incontinence is commonly associated with dysfunction of one of the anorectal continence mechanisms such as impaired contractile strength of the sphincters and lower rectal volume capacity. Stroke and spinal cord injuries cause loss of sensation in the rectal area.

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Often, no cause can be determined for the fecal loss, and it is believed that the incontinence may be due to a degenerative injury to the pudendal nerve.

Nursing Assessment • Perform a rectal examination to check for impaction or decreased rectal sphincter tone. • If the fecal incontinence is diarrheal in nature, stool evaluation for leukocytes, culture and sensitivity, ova and parasites, and Clostridium difficile evaluation may be indicated. Nursing and Patient Care Considerations • Increase dietary fiber in an attempt to add bulk to the stool to stimulate regular defecation, if there is no infection and no impaction present. • Try antidiarrheals such as loperamide, as directed, for managing diarrhea. • Try to set up a regular bowel evacuation pattern once an impaction is detected and removed. This includes regular toileting times set preferably after breakfast, and increased fluid and fiber intake. Use laxatives only as a last resort. • In the bedbound patient, increased fiber in the diet is contraindicated. These patients may require a bisacodyl (Dulcolax) suppository or an enema to help with rectal evacuation two to three times per week. • Treat those with neurogenic fecal incontinence, such as patients with spinal cord injuries and post-stroke, to induce fecal evacuation at regularly scheduled times. • Administer glycerin (Glycol) or bisacodyl (Dulcolax) suppository two to three times per week before breakfast (to use the normal gastrocolic reflex that starts after the first meal of the day) to help to induce a complete rectal evacuation and decrease stool incontinence. Community and Home Care Considerations • Explain to patient and family that it is not necessary to have bowel movement every day. • Advise avoidance of laxatives, which may induce diarrhea. • Encourage fibrous foods that stimulate the bowel to be eaten daily, preferably at breakfast, such as stewed prunes, citrus fruit, bran cereals. Make sure that help is available to toilet the patient when the urge to defecate is felt. • Recommend a homeopathic remedy to maintain regular bowel movements: 3 tbsp applesauce, 2 tbsp bran, and 1 tbsp prune juice mixed, refrigerated, and given at least 1 tbsp each morning. PRESSURE ULCERS Pressure ulcers (decubitus ulcers) are localized ulcerations of the skin or deeper structures. They most commonly result from prolonged periods of bed rest in acute- or long-term care facilities; however, they can develop within hours in the compromised individual.

Areas susceptible to pressure ulcers. Pathophysiology and Etiology Factors in the Development of Pressure Ulcers • Pressure of 70 mm Hg applied for longer than 2 hours can produce tissue destruction; healing cannot occur without relieving the pressure. • Friction contributes to pressure ulcer development by causing abrasion of the stratum corneum. • Shearing force, produced by sliding of adjacent surfaces, is particularly important in the partial sitting position. This force ruptures capillaries over the sacrum.

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Moisture on the skin results in maceration of the epithelium.

Risk Factors for Pressure Ulcers • Bowel or bladder incontinence • Malnourishment or significant weight loss • Edema, anemia, hypoxia, or hypotension • Neurologic impairment or immobility • Altered mental status, including delirium or dementia Nursing Assessment • Assess for risk factors for pressure ulcer development and alter those factors, if possible. • Assess skin of the older adult frequently for the development of pressure ulcers. • Stage the ulcer so appropriate treatment can be started. One commonly used staging system advocated by the National Pressure Ulcer Advisory Panel includes four levels:

Pressure ulcer staging. (A)Stage I-erythema; (B) Stage II-breakdown of the dermis; (C) Stage III-full thickness skin breakdown; (D) Stage IV-bone, muscle, and supporting tissue involved. o Stage I — nonblanching macule that may appear red or violet o Stage II — skin breakdown as far as the dermis o Stage III — skin breakdown into the subcutaneous tissue o Stage IV — penetrates bone, muscle, or joint Nursing and Patient Care Considerations Prevent Pressure Ulcer Development • Provide meticulous care and positioning for immobilized patients. o Inspect skin several times daily. o Wash skin with mild soap, rinse, and pat dry with a soft towel.

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Lubricate skin with a bland lotion to keep skin soft and pliable. Avoid poorly ventilated mattress that is covered with plastic or impermeable material. o Employ bowel and bladder programs to prevent incontinence. o Encourage ambulation and exercise. o Promote nutritious diet with optimal protein, vitamins, and iron. Teach older adult and family or significant other the importance of good nutrition, hydration, activity, positioning, and avoidance of pressure, shearing, friction, and moisture.
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Relieve the Pressure • Avoid elevation of head of bed greater than 30 degrees. • Reposition every 2 hours. • Use special devices to cushion specific areas, such as flotation rings, lamb's wool or fleece pads, convoluted foam mattresses, booties, elbow pads. • Use an alternating-pressure mattress or air-fluidized bed for patients at high risk to prevent or treat pressure ulcers. • Provide for activity and ambulation as much as possible. • Advise frequent shifting of weight and occasional raising of buttocks off chair while sitting. Clean and D_bride the Wound • Use normal saline for cleaning and disinfecting wounds. • Apply wet-to-dry dressings or enzyme ointments for d_bridement as directed; or assist with surgical d_bridement. Treat Local Infection • Avoid obtaining wound cultures because open wounds are always colonized with bacteria, unless there is evidence of systemic infection or progressive local infection such as cellulitis. • Apply topical antibiotics to locally infected pressure ulcer as prescribed. Cover the Wound • Cover the wound with a protective dressing, as this minimizes disruption of migrating fibroblasts and epithelial cells and results in a moist, nutrient-rich environment for healing to occur. o Polyurethane thin film dressings can be used for superficial low-exudate wounds. They are air and water permeable but do not absorb exudate. o Hydrocolloids can provide padding to wounds but can lead to maceration; they are not oxygen permeable. o Polyurethane foam/membrane dressings absorb exudate and are oxygen permeable. o Hydrogel dressings are multilayered and include properties of both hydrocolloids and polyurethane. (See Table 9-2 for comparison of selected occlusive dressings.) Comparison of Selected Occlusive Dressings

DRESSING EXAMPLESAPPROPRIATE USE ADVANTAGES TYPE Absorption Debrisan  Stage II-IV  Absorbs Hydrophilic ulcer with drainage drainage and deodorize Beads wound Hydrocolloid DuoDerm  Stage I-II  Provides ulcer padding  Easy to apply  Water impermeable  No skin excoriation PolyurethaneOp-Site,  Nondraining  Transpa Tegaderm wounds  Selfadhesive  Oxygen permeable PolyurethaneMitraflex membrane
   

Skin tears Tape burns Blisters Stage II ulcers Lowmoderate exudate wounds Skin tears Tape burns Blisters Stage II ulcers Lowmoderate exudate wounds

        



PolyurethaneEpi-Lock foam

    

Hydrogel

Vigilon, Biofilm



Stage I-III

   

Debriding enzyme

Elase, Travase



Stage III-IV



Good absorptive ability Good oxygen exchange Water impermeable May debride Good absorptive ability Good oxygen exchange Water impermeable May debride No skin excoriation No skin excoriation Transpa Some ability to absorb draina Easy to apply Acts

against devitalized tissu


Not appropriate for hard, dr eschar

OSTEOPOROSIS Osteoporosis is a condition in which the bone matrix is lost, thereby weakening the bones and making them more susceptible to fracture. Bone mineral density is 2.5 standard deviations below the peak bone density for young adult (T score -2.5). Decrease in bone density of 1.5 to 2.5 below young adult is termed osteopenia (T score -1.5 to -2.5). It is the most age-related metabolic bone disorder. Pathophysiology and Etiology • The rate of bone resorption increases over the rate of bone formation, causing loss of bone mass. • Calcium and phosphate salts are lost, creating porous, brittle bones. • Occurs most commonly in postmenopausal women. • Other factors include: o Age. o Inactivity. o Chronic illness. o Medications, such as corticosteroids, excessive thyroid replacement, cyclosporine. o Calcium and vitamin D deficiency. o Family history. o Smoking and alcohol use. o Diet — caffeine has been linked as a risk factor. o Race — Whites and Asians have higher risk incidence. o Body type — small frame/short stature, low body fat. Clinical Manifestations • Asymptomatic until later stages. • Fracture after minor trauma may be first indication. Most frequent fractures associated with osteoporosis include fractures of the distal radius, vertebral bodies, proximal humerus, pelvis, and proximal femur (hip). • May have vague complaints related to aging process (stiffness, pain, weakness). • Estrogen deficiency may be noted. Diagnostic Evaluation • X-rays show changes only after 30% to 60% loss of bone. • Dual-energy X-ray absorptiometry (DEXA) shows decreased bone mineral density (T score -2.5 or worse). • Serum and urine calcium levels normal. • Serum bone GLA-protein (a marker for bone turnover) is elevated. • Bone biopsy shows thin, porous, otherwise normal bone.

Management Management is primarily preventive. • Adequate intake of calcium — 1 to 1.5 g — may be preventive. • Adequate intake of vitamin D. o Vitamin D plays a major role in calcium absorption and bone health. With age there is decreased ability to take in vitamin D through the skin; therefore, replacement is recommended. Major food sources are daily products, egg yolks, fish, and liver. Daily intake should be between 400 and 800 IU. • Weight-bearing exercise (walking) throughout life. • Hormone replacement therapy (HRT) is no longer recommended for osteoporosis prevention or treatment because the risks outweigh the benefits. • Raloxifene (Evista), an estrogen receptor agonist, is an alternative to estrogen. Not as effective as estrogen, but does show some benefit in preserving bone density. No increase in risk of breast cancer. • Calcitonin (Miacalcin) administered by nasal spray may help to preserve bone density. Adverse effect is nasal burning and a runny nose. • Bisphosphonates, such as Risedronate (Actonel) and alendronate (Fosamax), bind to and inhibit osteoclast action, remain active on bone resorptive surfaces for 3 weeks, and do not impede normal bone formation. o Associated with improved bone density and decreased fracture rate. o They must be taken with fluid but not food, and patient must remain upright for 30 minutes after taking pill to prevent esophagitis. • Prevention of falls in elderly patients to prevent fractures. Complications • Fractures • Progressive kyphosis, loss of height

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Progressive kyphosis in osteoporosis. Chronic back pain from compression fracture

Nursing Assessment • Obtain history of risk factors for osteoporosis, history of fractures, and other musculoskeletal disease. • Assess risk for falls and fractures — sensory or motor problems, improper footwear, lack of knowledge of safety precautions, and so forth. See Table for assessment factors and interventions.

Assessment Factors and Interventions to Decrease Risk of Falls This chart supplies specific interventions you can use to decrease the risk and incidence of falls in older or disabled patients. KNOWN RISK SPECIFIC INTERVENTIONS TO DECREASE FACTORS INDIVIDUAL RISK History of falls o Identify the patient as being at risked for falls: May use sticker on chart or door, inform families of increased risk and other care providers. Fear of falling o Encourage patient to verbalize feelings. o Strengthen self-efficacy related to transfers and ambulation by providing verbal encouragement about capabilities and demonstrating to patient his ability to perform safely. Bowel and bladder o Set up regular voiding schedule (every 2 incontinence hours or as appropriate based on patient need). o Monitor bowel function and encourage sufficient fluids and fiber (eight 8-ounce glasses daily and 24 g of fiber). o Utilize laxatives as appropriate. Cognitive o Evaluate patient for reversible causes of impairment cognitive impairment or delirium and eliminate causes as relevant. o Monitor patient with cognitive impairment at least hourly with relocation of the patient such that nursing staff can observe and monitor regularly. o Encourage family member to hire staff or stay with patient continuously. o Utilize monitoring devices if available (ie, bed/chair or exit alarms) rather than restraints. Mood o Encourage verbalization of feelings o Evaluate patient's ability to concentrate and learn new information. o Encourage participation in daily activities. o Utilize alternative interventions, such as massage, aromatherapy, pet and plant therapy, and music or exercise. Dizziness o Monitor lying, sitting and standing blood pressures and continually evaluate for factors contributing to dizziness. o Encourage adequate fluid intake (eight 8ounce glasses daily). o Set up environment to avoid movements that result in dizziness or vertigo. o Decrease or avoid alcohol use. Functional o Encourage participation in personal care impairment, activities at highest level (ie, if possible encourage

immobility, impaired gait

o o o

Medications

o

o

Medical problems Environment

o

o o o o o

ambulation to bathroom rather than use of bedpan). Refer to physical and occupational therapy as appropriate. Facilitate adherence to exercise program when indicated. Maintain safe and appropriate use of assistive devices. Review medications with primary health care provider and determine need for each medication. Make sure that medications are being used at lowest possible dosages to obtain desired results. Work with primary health care provider to augment management of primary medical problem, such as Parkinson's disease, heart failure, or anemia. Remove furniture if patient cannot sit on it and have his feet reach the floor. Remove clutter. Make sure furniture and any assistive devices used are in good condition. Make sure lighting is adequate. Make sure safety bars are available in bathroom.

Nursing Diagnosis • Chronic Pain related to vertebral compression fractures in late stages of osteoporosis Nursing Interventions Reducing Pain • Administer opioid analgesics as ordered for acute exacerbations of pain. • Encourage replacement with non-opioid pain relievers as soon as possible to avoid drowsiness, possible addiction. • Assist with putting on back brace and ensure proper fit. Encourage use as much as possible, especially while ambulatory. • Encourage compliance with physical therapy appointments and practicing exercises at home to increase muscle strength surrounding bones and to relieve pain.

GERONTOLOGIC ALERT Be alert for alcohol use combined with other CNS depressants in elderly patients. With advanced age there is a reduction in lean body mass, an increase in body fat, a decrease in water content, and a decrease in the gastric alcohol dehydrogenase enzyme. This results in an increase in the blood alcohol level in older individuals compared to younger individuals per unit of alcohol consumed, especially in women. Alcohol use, particularly when combined with opioids or sedative hypnotics, is commonly associated with falls in these individuals. Patient Education and Health Maintenance • Encourage exercise for all age-groups. Teach the value of walking daily throughout life to provide stress required for strong bone remodeling. • Provide dietary education in relation to adequate daily intake of calcium 1,500 mg. Calcium can be obtained through milk and dairy products, vegetables, and supplements. Anyone with a history of urinary tract calculi should consult with health care provider before increasing calcium intake. • Encourage use of combined calcium and vitamin D replacement. Avoid massive doses of vitamin D however because this may be harmful. • Encourage young women at risk to maximize bone mass through nutrition and exercise. • Suggest that perimenopausal women confer with their health care provider about the need for calcium supplements and estrogen therapy. • Alert patients to resources such as the National Osteoporosis Foundation: http://www.nof.org. Community and Home Care Considerations • Encourage screening according to the U.S. Preventive Services Task Force (USPSTF) for all women over age 65 and women over age 60 at increased risk by DEXA of the femoral neck, with rescreening at approximately two-year intervals. • Identify women at high risk for osteoporotic fractures in the community — frail, elderly White or Asian women with poor dietary intake of dairy products and little exposure to sun — and provide education and safety measures to prevent falls and fracture. • Make sure that diet contains maximal calcium. Teach family and caregivers how to read labels, encourage dairy products, and add powdered milk to foods as possible. Use skim milk if cholesterol and fat intake is a consideration. • Make sure that supplements and other medications are being taken properly. o Patient teaching is critical in dosing of alendronate sodium (Fosamax) to prevent esophagitis. Patient must take this upon waking with 6 to 8 oz of water, at least 30 minutes before first food, and must remain upright for 30

• •

minutes after taking Fosamax. Risedronate may be better tolerated. Weekly dosing may increase adherence. o Calcitonin nasal spray dose is one spray in one nostril once per day; alternate nostrils each day. Teach strategies to prevent falls. Assess home for hazards (eg, scatter rugs, slippery floors, extension cords, adequate lighting). Obtain physical and occupational therapy consultations as needed to encourage use of walking aids when balance is poor and to improve muscle strength.

Evaluation: Expected Outcomes • Pain tolerable with non-opioid analgesics; no new fractures • Received screening and understands prevention measures ALZHEIMER'S DISEASE The most common form of dementia; characterized by progressive impairment in memory, cognitive function, language, judgment, and ADL. Ultimately, patients cannot perform self-care activities and become dependent on caregivers. Pathophysiology and Etiology • Gross pathophysiologic changes include cortical atrophy, enlarged ventricles, and basal ganglia wasting. • Microscopically, changes occur in the proteins of the nerve cells of the cerebral cortex and lead to accumulation of neurofibrillary tangles and neuritic plaques (deposits of protein and altered cell structures on the interneuronal junctions) and granulovascular degeneration. There is loss of cholinergic nerve cells, which are important in memory, function, and cognition. • Biochemically, neurotransmitter systems are impaired. • Cause unknown, but genetics and female gender are risk factors. Research is being conducted to locate specific genes involved in predisposition to Alzheimer's. • Viruses, environmental toxins, silent brain infarcts, and previous head injury may also play a role. Clinical Manifestations • Disease onset is subtle and insidious. Initially, a gradual decline of cognitive function from a previously higher level may be noticed. Short-term memory impairment is commonly the first characteristic in earliest stages of the disease. Patients are forgetful and have difficulty learning and retaining new information. In addition to memory impairment, at least one of the following functional deficits is present: o Language disturbance (word-finding difficulty) o Visual-processing difficulty o Inability to perform skilled motor activities o Poor abstract reasoning and concentration • Patients may have difficulty planning meals, managing finances, using a telephone, or driving without getting lost. Other classic signs include personality

•

•

•

changes such as irritability and suspiciousness, personal neglect of appearance, and disorientation to time and space. The following clinical manifestations are typical in the middle stage of Alzheimer's disease: o Repetitive actions (perseveration) o Nocturnal restlessness o Apraxia (impaired ability to perform purposeful activity) o Aphasia (inability to speak) o Agraphia (inability to write) With disease progression, signs of frontal lobe dysfunction appear, including loss of social inhibitions and loss of spontaneity. Delusions, hallucinations, aggression, and wandering behavior often occur in the middle and late stages. Patients in the advanced stage of Alzheimer's disease require total care. Symptoms may include: o Urinary and fecal incontinence. o Emaciation. o Increased irritability. o Unresponsiveness or coma.

Diagnostic Evaluation • Detailed patient history with corroboration by an informed source to determine cognitive and behavioral changes, their duration, and symptoms that may be indicative of other medical or psychiatric illnesses. • Noncontrast computed tomography (CT) scan to rule out other neurologic conditions. Magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) may be used. • Neuropsychological evaluation, including some form of mental status assessment, to identify specific areas of impaired mental functioning in contrast to areas of intact functioning. • Laboratory tests include complete blood count, sedimentation rate, chemistry panel, thyroid-stimulating hormone, test for syphilis, urinalysis, serum B12, folate level, and test for human immunodeficiency virus (HIV) to rule out infectious or metabolic disorders. • Commercial assays for cerebrospinal fluid (CSF) tau protein and beta-amyloid are available, but their use is limited. Genetic testing is available, but its use is controversial. Three disease genes and one gene indicating susceptibility have been identified. In families with a history of Alzheimer's disease, tests are available to confirm Alzheimer's disease or to provide information to at-risk family members regarding their likelihood for development of Alzheimer's disease. Management • Primary goals of treatment for Alzheimer's disease are to maximize functional abilities and improve quality of life by enhancing mood, cognition, and behavior. No curative treatment exists. Treatment includes pharmacologic and nonpharmacologic approaches.

•

•

• • • •

Cholinesterase inhibitors were the first treatment for cognitive impairment of Alzheimer's disease. These drugs improve cholinergic neurotransmission to help delay decline in function over time. o Donepezil (Aricept) is widely used in mild to moderate cases because it can be given once daily and is well tolerated; starting at 5 mg hs and increased to 10 mg after 4 to 6 weeks. o Galantamine (Reminyl) is given with food in dosage of 4 to 12 mg bid. Should be restarted at 4 mg bid if interrupted for several days. Dose should be reduced in cases of renal or hepatic impairment. o Rivastigmine (Exelon) is given 1.5 mg bid with meals and increased up to 6 to 12 mg per day. Memantine (Namenda), an NMDA-receptor antagonist, is the first of a new class approved for moderate to severe Alzheimer's. Dosage is 10 mg bid. The drug can be used with a cholinesterase inhibitor. Studies indicate that other drugs, such as estrogen and NSAIDs, have not proven helpful. Patients with depressive symptoms should be considered for antidepressant therapy. Behavioral disturbances may require pharmacologic treatment with anxiolytics, antipsychotics, or anticonvulsants. Nonpharmacologic treatments used to improve cognition include environmental manipulation that decreases stimulation, pet therapy, aromatherapy, massage, music therapy, or exercise.

DRUG ALERT Cholinesterase inhibitors were initially aimed at improving memory and cognition. These drugs, however, seem to have an important impact on the behavioral changes that occur in patients with cognitive impairment. Specifically, research studies have demonstrated that use of cholinesterase inhibitors improves the apathy, disinhibition, pacing, and hallucinations commonly noted in dementia. Be alert for drug interactions with NSAIDs, succinylcholine-type muscle relaxants, cholinergic and anticholinergic agents, drugs that slow the heart, and other drugs that are metabolized by the hepatic CYP2D6 or CYP3A4 pathways. Complications • Increased incidence of functional decline • Injury due to lack of insight, hallucinations, and confusion • Malnutrition due to inattention to mealtime and hunger or lack of ability to prepare meals Nursing Assessment • Perform cognitive assessment for orientation, insight, abstract thinking, concentration, memory, and verbal ability. • Assess for changes in behavior and ability to perform ADLs. • Evaluate nutrition and hydration; check weight, skin turgor, meal habits.

•

Assess motor ability, strength, muscle tone, and flexibility.

Nursing Diagnoses • Disturbed Thought Processes related to physiologic changes • Risk for Injury due to loss of cognitive abilities • Disturbed Sleep Pattern secondary to disease process • Caregiver Role Strain related to physical needs and behavioral manifestations of the disease process Nursing Interventions Improving Cognitive Response • Simplify the environment: reduce noise and social interaction to a level tolerable for the patient. • Maintain a strict routine, decrease the number of choices available to the patient, use pictures to identify activities. Use structured group activities. • Encourage participation in care as tolerated and provide positive feedback for tasks that are accomplished. • Provide rest periods between activities to reduce fatigue. • Avoid confrontations and arguments. Follow the patient's direction and individualize care as much as possible. • Maintain consistency in interactions and introduce new people slowly. Preventing Injury • Avoid restraints but maintain observation of the patient as necessary. • Provide for adequate lighting to avoid misinterpretation of the environment. • Remove unneeded furniture and equipment from the room. • Provide identification tag or MedicAlert bracelet. • Make sure patient has nonslip shoes or slippers that are easy to put on. • Encourage use of assistive safety devices, such as handrails and shower chairs. • Ensure physical activity as tolerated and ROM exercises to maintain mobility. Ensuring Adequate Rest • Administer antipsychotics to manage agitation. • Provide periods of physical exercise to expend energy. • Support normal sleep habits and bedtime ritual. o Keep regular bedtime. o Have patient change into pajamas at bedtime. o Allow desired bedtime activity, such as snack, warm noncaffeinated beverage, listening to music, or prayer. • Maintain quiet, relaxing environment to avoid confusion and agitation. Supporting Caregiver • Encourage caregiver to discuss feelings. • Encourage caregiver to maintain own health and emotional well-being. • Stress the need for relaxation time or respite care.

• • •

Assist the caregiver in finding resources, such as community or church groups, social service programs, or hospital-based support groups. Assess caregiver's stress and refer for counseling. Support decision to place patient in a nursing facility.

Community and Home Care Considerations • Encourage regular medical checkups with attention to health maintenance every 3 to 6 months to provide ongoing medical surveillance of patient and stamina of caregivers. Include influenza vaccine and ensure that patient has had pneumococcal pneumonia vaccine. • Discuss advance directives for patients and discuss long-term placement options in anticipation of future needs, to help family members adjust and plan arrangements. • Encourage patients to be involved in social and intellectual activities as long as possible, such as family events, exercise, and recreational activities, sharing the newspaper and other forms of media. • Assist caregivers to modify the home environment for safety, and advise families of safety hazards such as wandering and driving a car. Encourage use of door locks, electronic wander-alert guards, and registration with the “Safe Return” program through the Alzheimer's Association or local police department. • Remind family members of possible dangers around the house as patients becomes less responsible for behavior. Encourage caregivers to reduce the temperature of the hot water heater, remove dials from stove and other electrical appliances, remove matches and lighters, and safely store away tools and other potentially dangerous items. Patient Education and Health Maintenance • Encourage activities that provide physical exercise and repetitive movement but that require little thought, such as dancing, painting, doing laundry, or vacuuming. • Teach patient and family to eliminate stimulants and maintain good nutrition. • Discuss with the family the need to organize finances and to make advanced directive decisions and guardianship arrangements before they are needed to allow the patient input into the process. • Over-the-counter products, such as ginkgo biloba and vitamin E, are gaining popularity; however, their clinical benefits are inconclusive at this time, so families should be encouraged to discuss their use with the health care provider and not abandon conventional treatment. • For additional information, refer families to: o The Alzheimer's Association: http://www.alz.org. Evaluation: Expected Outcomes • Participates in ADL without confusion or agitation • Remains free from injury • Sleeps 6 to 8 hours at night with 1-hour rest period twice a day • Caregiver reports using support systems and community resources

LEGAL AND ETHICAL CONSIDERATIONS RESTRAINT USE See Procedure Guidelines and CNO Standards Guidelines • The following are the federal requirements for the use of restraints based on the 1987 Omnibus Budget Reconciliation Act. • These guidelines are useful for health care providers working with elderly people in all settings. o The resident has the right to be free from any physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience and not required to treat the resident's medical symptoms. o Physical restraints are any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the person cannot remove easily, which restricts freedom of movement or access to one's body (includes leg and arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, and gerichairs). o There must be a trial of less restrictive measures unless the physical restraint is necessary to provide life-saving treatment. o The resident or his legal representative must consent to the use of restraints. o Residents who are restrained should be released, exercised, toileted, and checked for skin redness every 2 hours. o The need for restraints should be reevaluated periodically. o The specific institution will have to develop policies and procedures for the appropriate use of restraints and psychoactive drugs. o Primary health care providers will have to write appropriate orders for restraints and psychoactive drugs. • The most frequently reported reason for nurses' use of restraints is to prevent patients from harming themselves or others. Specifically, they are used to prevent falls and prevent removal of catheters or I.V. lines. • Multiple studies have found that restraints actually increase the falls that occur, can result in patient strangulation, can increase patient confusion, can cause pressure ulcers and nosocomial infections, can decrease functional ability, and can result in social isolation. • In regard to the patient's personal and social integrity, restraints have resulted in emotional responses of anger, fear, resistance, humiliation, demoralization, discomfort, resignation, and denial. Alternative Interventions Instead of Restraints • Evaluate those patients who are considered to be in need of a restraint. Evaluation should include physical function (see page 171), cognitive status (see page 173), elimination history, history of falls, visual impairment, blood pressure (specifically evaluating for orthostatic hypotension), and medication use.

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Attempt to correct any problems identified in the evaluation, such as visual impairment or unsafe gait. Use the evaluation to determine patients at high risk of falling (ie, those with confusion, orthostatic hypotension, multiple medication regimens, and altered gait). Use interventions as alternatives to restraints as outlined below.

ADVANCE DIRECTIVES Based on the ethical principle of autonomy (a person's privilege of self-rule), advance directives provide a clear and detailed expression of a person's wishes for care. Advance directives may be limited to a single situation, such as a “living will” for the terminally ill, or may address a multitude of different scenarios in detail. Types of Advance Directives Living Wills • Living Wills were the first and most widespread type of advance directive. • They were proposed as a mechanism for refusing “heroic” or unwanted medical intervention for the dying person. • They allow a person to state in writing that certain life-sustaining treatments should be withdrawn or withheld when that person is dying and unable to directly communicate his or her wishes. • Living Wills only allow for the refusal of further treatment. They are not precise in terms of directives and focus only on the patient who is clearly terminally ill. Durable Power of Attorney for Health Care • This document appoints a person to act on behalf of another person, provides guidance for the proxy, and endures even when the maker is incapacitated. • The Durable Power of Attorney for Health Care (DPOA-HC) is always a written document. • The document states the preferences and perhaps even the values of its maker: It outlines the types of decisions the person would want to have made on his behalf. • Because no DPOA-HC can cover all situations, the document should name a person who has the task of ensuring that the patient's wishes are honored. The proxy has the responsibility to interpret the DPOA-HC and extrapolate its contents to situations not specifically covered. PROCEDURE GUIDELINES Safety Guidelines for Restraint Use PROCEDURE Nursing Action Preparatory phase 1. Select the least restrictive physical restraint. Rationale 1. Passive restraints such as geriatric chairs with trays are more desirable than active restraints (vests, leg, arm, wrist, hand

2.

Examine the restraint device to make 2. sure that it is not torn or damaged, and that it works properly and is the proper size for the patient.

restraints or seat belts). A damaged or improperly fitting restraint poses a significant safety risk because the patient could become suspended by the restraint, causing chest compression.

Proper position of the patient restraint in whellchair and bet. Straps of most vest-type restraints should cross in front of the patient. (Left) Safety vest. (Right) Budget vest. 3. If the restraint is being used in bed, 3. Side rails that are only one-half or threemake sure that full side rails can be quarters length of the bed may allow the placed in the up position. Obtain side patient to slip partially off the bed and rail covers if the patient's limbs could become suspended in the restraint. fit over, under, around, through, or between side rails. 4. Completely review manufacturer's 4. Complete information can be obtained instructions before applying the from Posey Co.: 800-44-POSEY; restraint. http://www.posey.com . Performance phase 1. Apply the restraint with the patient 1. Proper positioning helps prevent injury or positioned in the middle of the bed or falls. sitting with hips well to the back of chair. 2. Make sure the front and back of 2. Crossing the straps in the back or restraint are positioned appropriately applying a vest restraint backward may on the patient and that straps are result in serious injury or death. crossed in the front, unless the vest is

specifically designed with positioning slot in the back.

3.

Secure straps out of patient's reach to 3. the movable part of a spring bed frame (shown below) or wheelchair kick spurs (shown above). Use quickrelease knots.

Ensures that adjustment of bed position or siderails will not interfere with restraint. Quick-release knots allow timely intervention in emergency situations.

Follow-up phase 1. Monitor the patient frequently after restraint is applied. 2.

1.

3.

Use ancillary staff to sit with and try to 2. calm agitated or restless patients whenever possible, even if restraint has been consented to. Never use restraints on a toilet or 3. commode or in a motor vehicle. Do not send restraint home with patient.

Will detect loosening, which may cause injury or restriction caused by the restraint. Studies have shown that use of restraints only contributes to falls. Restraints are specifically designed to be used with hospital beds, wheelchairs, and geriatric chairs, and by those trained in their proper use. Misuse may result in injury.

Nursing and Patient Care Considerations • Nursing home or home health agency must: o Be provided with information about the state's laws and the facility's policies regarding advance directive.

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Be asked if they have advance directives. Have their advance directives placed in their medical record. Education of patients and families is essential in helping them to understand the difference between Living Wills or DPOA-HC and determining which document best suits their needs. Patients and families need to be educated about what is involved in undergoing various life-sustaining procedures so they can make a decision regarding their future treatment. Patients need to be informed that they can have more than one advance directive. That is, if a patient has a Living Will but is not terminally ill, he needs to be encouraged to obtain a DPOA-HC to ensure that health care wishes will be met in any situation.
o o

Community and Home Care Considerations • Information about completing advance directives can be obtained by contacting Choice in Dying, http://www.choices.org. • Instruct older adults that they will be allowed to record their wishes about various types of medical treatment, and let them appoint a proxy for if and when they are unable to make those decisions on their own. ADVOCACY FOR THE DISABLED There are an estimated 54 million Americans with disabilities, not all of whom are older adults. Disability may strike any age-group, ethnic or racial origin, and socioeconomic group. Nurses must not only provide skilled physical care to reduce complications and enhance the rehabilitation potential of disabled persons, they must also act as advocates to help these individuals transcend their disabilities to be as independent, functional and self-actualized as possible. Definition of Disability • A disability can be viewed as any restriction or lack of ability to perform activities in a manner, which is normal for most people. • Disability as a physical or mental impairment that substantially limits 1 or more major life activities. A person can also be disabled if there is a record of such impairment, or one is regarded as having such impairment. • Handicap is an outdated term; there should be no reason for an individual with a disability to be handicapped. A handicap is a disadvantage resulting from an impairment that limits or prevents fulfillment of a role. Techniques to Prevent Falls as Alternative to Restraints FOR ALL PATIENTS • Familiarize patient with environment (ie, identify call light or bell to ring, label the bathroom, kitchen, closet). • Have patient demonstrate ways to obtain help if needed. • Place bed in low position with brakes locked if possible, or mattress on the floor. • Make sure that footwear is fitted and non-slip and is used properly. • Determine appropriate use of side rails based on cognitive and functional status.

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Utilize night-light. Keep floor surfaces clean and dry. Keep room uncluttered and make sure that furniture is in optimal condition. Make sure patient knows where personal possessions are and that he can safely access them. Ensure adequate handrails in bathroom (commode, shower, and tub), room and hallway. Establish a care plan to maintain bowel and bladder function. Evaluate effects of medications that increase the patient's risk of falling. Encourage participation in functional activities and exercise at patient's highest possible level and refer to physical therapy as appropriate. Monitor patient regularly and encourage safe activities.

FOR PATIENTS AT HIGH RISK FOR FALLING WHEN AMBULATING INDEPENDENTLY • Use beanbag chairs or specially designed chairs that make independent transfer difficult. • Tilt the front of a chair upward by inserting a small to medium folded blanket under the anterior portion of the cushion. • Institute physical therapy and increased exercise activities to help strengthen muscles and improve function. • For the patient who interferes with treatment, evaluate the need for the invasive treatments. When such treatments are essential, use mittens or gloves rather than restraints. • For the patient who wanders, provide an exercise program or establish a bounded environment in which the person can ambulate freely. • For aggressive and agitated patients, be aware that restraints may only make the behavior worse. Provide a low-stimulus environment, consistent caregivers, and appropriate medications to help control the agitation. Music therapy has also been shown to decrease aggressive behavior. Problems for the Disabled • Psychosocial adaptation to a disability is an ongoing process that progresses through stages: shock, denial, depression, ambivalence, and adaptation. It may become stalled at one or more stages and not reach adaptation. • Caregiver and family strain due to loss of income, hopelessness, and physical and mental exhaustion from taking over roles and responsibilities from the disabled individual may impede successful rehabilitation. • Despite laws, disabled persons are still discriminated against when applying for jobs and educational programs. To get around the laws, employers and educational systems may list multiple physical requirements of a job or program that are meant to discourage disabled persons from applying, or that would prompt failure, even though these physical requirements may have nothing to do with the actual job.

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In addition to physical barriers at workplaces and educational institutions, disabled persons must overcome tremendous attitude barriers. Once a disability is known, stereotyping and prejudice may overshadow a person's potential.

Nursing Interventions for Advocacy • Become familiar with and assist patients with the medical forms. • Help individuals understand the eligibility for disability income if their medical condition lasts for 1 year or longer and they are unable to perform substantial employment. • Become aware of social services in your geographic area, both through government and charitable programs, such as public transportation that will transport individuals who use wheel chairs to medical appointments. • Assist patients in obtaining prescription drugs through discounted and free programs that may be available through pharmaceutical companies to those who do not have prescription coverage. Contact pharmaceutical companies directly (phone numbers and addresses listed in any Physician's Desk Reference [PDR]) for eligibility requirements and applications. • If your facility is not fully handicapped accessible, advocate for structural changes that allow access. • When providing care for a disabled person always ask if you can assist him or her and allow the individual to direct your assistance. Most individuals with disabilities know what works for them and what causes the least amount of discomfort. • Be aware that an individual with an acquired disability goes through an adjustment phase that can be compared with bereavement. Allow the individual time and respect for where they are in the process. Denial can last a year or more and they must be supported, not pushed, to move on in the process. • Be aware of your own biases and attitudes toward disabled individuals. Refrain from stereotyping. Also be aware that not all disabilities are visible, ie mental illness or impairment from a head injury. Treat all persons with respect and understanding. • Encourage sensitivity training in your facility for all employees to ensure compassionate care and polite interactions with all disabled individuals. • Utilize the following resources for additional information and support: o Disability Resources Monthly (DRM) Guide to Disability Resources on the Internet: http://www.disabilityresources.org o Youreable (products, services, and information for disabled persons): http://www.youreable.com o National Organization on Disability: http://www.nod.org o National Council on Disability: http://www.ncd.org o Association of Rehabilitation Nurses: http://www.rehabnurse.org o Exceptional Nurses (resource for nurses and students who are disabled): http://www.exceptionalnurse.com