Transcript Document
1 PHYSIOLOGICAL BASIS FOR THE CARE OF THE ELDERLY CLIENT Neurological system 2 Scenario…. • J.H.’s granddaughter returns 3 months after her last visit. J.H. is more physically active now and her joint pain has improved. • J.H. has on 2 occasions driven on errands and forgotten how to return home. • The granddaughter states J.H. no longer complains of her joints hurting but she is even more mean and still won’t listen to her. • The granddaughter is exhausted and is afraid to leave J.H. alone. She has had to miss work several times. 3 Age related changes • Decreased number of neurons • Decrease in brain size • Decreased brain blood flow • Decrease in short term memory • Increased pain threshold • Increased reaction time • Decreased sensation to touch, pain 4 Assessing mental status is complex • Cognitive ability • Level of consciousness • Appearance, behavior • Speech and language • Mood • Affect • Perception • Thought content • Insight • Judgment 5 Common neurologic disorders of the elderly Dementia Depression Delirium 6 Delirium vs dementia • Delirium • Temporary mental confusion, agitation • Disorientation • Fluctuating consciousness • Delusions • Sleep-wake disturbances • May be caused by fever, intoxication, shock • Dementia • Deterioration of intellectual capacities • A syndrome, chronic and terminal • Caused by organic disease or brain disorder 7 Depression • Apathy is common in depression, not necessarily in dementia • Depression is common in dementia • Geriatric Depression Scale is invaluable! 8 Geriatric depression scale • > 5 suggestive of depression • > 10 depression very likely 9 THE SYNDROME OF DEMENTIA • Compromised ability to function at work or home • Decline in usual abilities • Not explained by other causes • Verified by history and cognitive assessment • Includes at least 2 of the following: • Inability to acquire new information • Impaired ability to manage complex tasks • Inability to recognize • Impaired language function • Changes in personality 10 Types of dementia Alzheimer’s Frontotemporal Dementia Lewy Body (Parkinson’s) Vascular 11 Comparison of types of dementia • Alzheimer’s • Most common form of dementia • Causes include genetics, environment, lifestyle • Vascular • Second most common form • Caused by cardiovascular factors • Lewy body • Protein bodies present in the brain • Can occur late in Parkinson’s disease • Frontotemporal • Personality change • Frontal brain atrophy occurring in mid-50s 12 Mild cognitive impairment vs dementia • Transition between normal aging and dementia • Memory problems without deficits in ADLs • Associated with increased risk of death • If found in conjunction with depression, risk of converting to AD is greater 13 Alzheimer’s disease • Before the 1950s, misidentified as alcoholism or • • • • some other presentation From ages 65 to 74, risk is about 2% Risk increases with age (42% at age 85) Risk increases with family history of AD Medical risks • Head trauma • Diabetes • Frailty • High cholesterol • Obesity • Low physical activity • Low vitamin D • Clinical depression 14 Incidence of Alzheimer’s disease • Twice as common in women • Common in people whose mothers had the disease (the “maternal effect”) • Age is greatest risk factor • Associated with low education level 15 Cultural considerations • Symptoms begin on average 7 years earlier in US Latinos than in non-Latino whites. • Affects African Americans 3 times more than European Americans. • Japanese American men have higher prevalence that Japanese men living in Japan. 16 Diagnosis of Alzheimer’s disease • No definitive diagnostic test • Physical examination • Formal mental status exam • Onset after age 40, most after age 65 • Postmortem examination of brain tissue is only way to confirm diagnosis 17 Prognosis of Alzheimer’s disease • Cognitive decline is inevitable • Average survival time from time of diagnosis is 7-8 years • May last more than 20 years 18 Signs and symptoms of Alzheimer’s • Brain changes may begin up to 20 years before symptoms are obvious • Loss of short term memory is often the first sign • Disease progresses gradually but may plateau for long periods of time • Distinct symptoms for early, intermediate and late stages. 19 Stage 1 dementia (mild) • Memory difficulties • Spatial disorientation Learning and retaining new information becomes difficult • Language difficulties (word finding) • Mood swings—hostility, irritability, agitation • Personality changes • Progressive difficulty with activities of normal living • Abstract thinking, insight, judgment impaired 20 Tasks at time of diagnosis • Preparation for progressive decline • Establishing DPAHC • Establish interventions to address functional impairment Tasks apply to both family and patient! 21 Stage 2 dementia (moderate) • Aphasia • Apraxia • Confusion, inability to initiate meaningful activities • Agitation • Insomnia • Remote memory reduced, but not lost • May require help with basic ADLs • Personality changes may progress • Behavior problems • Sense of time and place is lost; wandering • Risk of falls, accidents • Disorganized sleep patterns 22 Stage 3 dementia (severe) • Resistiveness to care • Incontinence • Eating difficulties • Motor impairment • Cannot walk, feed self, other ADLs • Unable to swallow • Recent and remote memory lost • Problems include… • Immobility • Pressure ulcers • Nutrition 23 Mental changes to anticipate • Changes create increasingly difficult behavior…. • Depression • Anxiety • Hallucinations • Paranoia due to • Confusion • Inherent personality • Unique coexisting mental disorder • Brain physiological changes 24 Goals of treatment of dementia Treatment is focused on 4 areas: • Maintain physical/functional abilities • Environmental measures • Drugs • Caregiver assistance 25 Patient safety • Evaluate home for safety • Signal monitoring systems for wandering • Unplug the stove, remove the car, confiscate the keys • Install alarms? • Ultimately requires assistance or change in environment • Patient care goals: • Prevent accidents • Manage behavior disorders • Plan for change as disease progresses • Transfer of responsibility… • From patient to family… • From family to others? 26 Drugs for Alzheimer’s disease • Limit drugs with CNS activity • Sedation worsens dementia • Antipsychotics may be used to control behavior disorders • Signs of depression treated with anti-depressants (preferably SSRIs—Paxil, Zoloft, Lexapro) • Mild to moderate disease—cholinesterase inhibitors (Donezepil [Aricept], Rivastigmine [Exelon]) • Moderate to severe disease— Memantine (Namenda) 27 Specific difficult behaviors • Resistiveness • Repetitiveness • Sexual inappropriateness • Aggression • Food refusal 28 Non-medication management of resistiveness • Task too difficult—break into small steps • Caregiver impatience—allow ample time • Can’t follow directions—simplify request • Modesty causes embarrassment—respect privacy • Fear of task—reassure, comfort, distract with music or conversation 29 Non-medication management of food refusal • Make meal times a measure of the day’s progression • Create an inviolable routine • Incorporate patient preferences • Eliminate any source of discomfort • Maximize dense calories • Use finger foods • Avoid dry foods • Keep patient upright 30 Non-medication management of inappropriate sexual behavior • Misinterpreting caregiver interaction—no mixed sexual messages • Decreased judgment, lack of social awareness—do not overreact, confront • Uncomfortable—check for irritants • Need for attention—increase basic need for touch and warmth, offer soothing objects • Self-stimulating—offer privacy, remove from inappropriate place 31 Antidisrobing clothing 32 Factors in caregiver burden Screaming Repetitive questions Verbal and physical aggression Reckless or careless behavior Personality clashes Not sleeping at night Wandering Suspiciousness Accusations Sexual actions Depression Resistance 33 Caregiver burden interventions • Design strategies for sharing responsibility • Emphasize importance of caring for oneself • Establish priorities • Education regarding disease • Support groups • Caregiver respite 34 Terminal stage of Alzheimer’s disease • Bedridden • Dysphagia • Eventually mute • Completely dependent • Risk of undernutrition, pneumonia, pressure ulcers • Eventual death usually from infection 35 Issues associated with terminal stage • Finding appropriate environment or facility • Address guilt associated with transfer • Important to discuss placement early on in process • Address four important concepts • CPR • (should not be offered) • Transfer to acute care facility • (not in patient’s interest) • Insertion of feeding tube • (does not enhance quality of life) • Treatment of infections • (does not promote comfort) 36 Common neurologic disorders of the elderly: Parkinson’s disease • Chronic, progressive neurologic disorder • Does not include cognitive impairment • Risk increases with age • More common in men, more often after 50s • Faint tremor in hand often 1st sign • Tremor decreases with purposeful movement (tremor at rest vs intention tremor) • Muscle weakness and rigidity • Characteristic gait • Related to loss of dopaminergic cells in the midbrain 37 Festinating gait • From Latin festinare (to hurry) • The patient’s speed increases in an unconscious effort to "catch up" with a displaced center of gravity • Patient has difficulty starting • Difficulty stopping after starting 38 Therapy for Parkinson’s disease • Directed at replacing dopamine • Levodopa is metabolic precursor of dopamine • Maintenance of function • Risk for falls is great 39 Secondary Parkinson’s disease • Symptoms are similar to Parkinson’s disease • Caused by certain medicines • Antipsychotics (haloperidol) • Metoclopramide • Phenothiazine medications • May be caused by another illness • AIDS • Encephalitis • Meningitis • Stroke • Confusion and memory loss may be more likely in secondary parkinsonism 40 Common neurologic disorders of the elderly: cerebrovascular accident • High risk in patients with HTN, severe arteriosclerosis, diabetes, gout, anemia, silent MIs, TIA, dehydration • Most caused by partial or complete cerebral thrombosis • Warning signs: • light-headedness • dizziness • headache • drop-attack • memory and behavior changes • Can occur without warning 41 Stroke risk factors • Prior stroke • Advanced age • Family history • Alcoholism • Male • Hypertension • Cigarette smoking • Hypercholesterolemia • Diabetes • Recreational drugs 42 Common neurologic disorders of the elderly: transient ischemic attack • Caused by any situation that reduces cerebral circulation: • Positioning • Anemia • Diuretics • Antihypertensives • Cigarette smoking • Lasts from minutes to hours • Resolves within < 24 hours • Symptoms are the same as CVA 43 Symptoms of TIA • Hemiparesis • Aphasia • Unilateral loss of vision • Diplopia • Vertigo • Nausea, vomiting • Dysphagia • Dependent on site of ischemic area! 44 Treatment of acute CVA Ischemic stroke • Maintain blood flow to brain • Aspirin • tPA • Surgical intervention • Carotid endartrectomy • Angioplasty and stents Hemorrhagic stroke • Stop bleeding • Surgical vessel repair • Clipping • Coiling (promotes clot) • AVM removal 45 Antithrombolytic therapy • Used for acute ischemic stroke (thrombus or embolus) • Blood pressure not decreased unless exceeds 220 systolic or 120 diastolic to promote perfusion of site • tPA (tissue plasminogen activator)— • protein involved in breakdown of clots • Most are not candidates for tPA; • Give ASA (81-325mg) within 24 to 48 hours 46 Common neurologic disorders of the elderly: seizures • Obtain accurate patient history • Prevent injury • Maintain airway • Suction equipment • Bite block • Prevent aspiration—side-lying position • Oxygen and IV access • Pad side rails • Observe seizure and document progression of symptoms 47 Observation during a seizure WHAT HAPPENED DURING THE EVENT • Alert or confused • Able to speak? Think? Remember? • Changes in seeing, hearing, smells, tastes, feelings? • Facial expression – staring, twitching, eye blinking or rolling, drooling • Changes in muscle tone or movements • Automatic, repeated movements – lipsmacking, chewing • Changes in color of skin, sweating, breathing • Loss of urine or bowel control PART OF BODY INVOLVED – where started, spread WHAT HAPPENED AFTER EVENT • Awareness of name, place, time • Memory for events HOW LONG IT LASTED 48 Formal evaluation • What is your nursing diagnosis for J.H.? • What is your desired outcome? • What are appropriate interventions pertinent to your desired outcome?