EXAM 2 STUDY GUIDE

Balanced diet from my plate

•  50% fruits and vegetables

• 25% grains, whole grains

• 25% protein

  • Nuts, beans

  • Fish, lean meats, poultry

  • Low dairy products such as milk, cheese, yoghurt

Other diets to consider

• DASH

• Mediterranean 

• Mediterranean Dash intervention

Wound healing & nutrition

•  Poor nutrition (low protein and vitamins) cause slowed wound healing (which has increased frequency in older adults)

Safe feeding practices

 Preventing aspiration in patients with dysphagia 

• Brain speech therapy consultation

• Work closely with dietician

• Consider modified textured food and drinks

• Sit person at 90 degrees during all oral intake and for 1 hour after

• Have person swallow twice before the next mouth full

Safe feeding practices: box 15.12 ph 194

Mini Nutritional Assessment

•  A 6 category assessment that looks at nutritional status of older adults

• Based on

  • food intake

  • weight loss

  • mobility

  • stress or illness

  • neuropsychological stress of acute disease

Mini Nutritional Assessment: Food intake

• 0= severe decrease in food intake

• 1 = moderate decrease 

• 2 = no decrease 

Mini Nutritional Assessment: weight loss

• 0 = weight loss greater than 3 kg/6.6 lb,

• 1 = does not know

• 2 = weight loss 1–3 kg/2.2–6.6 lb 

• 3 = no weight loss 

Mini Nutritional Assessment: mobility

• 0 = bed or chair bound

• 1 = able to get out of bed/chair but does not go out

• 2 = goes out 

Mini Nutritional Assessment: stress or illness

• 0 = yes

• 2 = no 

Mini Nutritional Assessment: neuropsychological stress of acute disease

• 0 = severe dementia or depression

• 1 = mild dementia

• 2 = no psychological problems 

Mini Nutritional Assessment: BMI or calf circumference

• 0 = BMI less than 19

• 1 = BMI 19 to less than 21

• 2 = BMI 21 to less than 23

• 3 = BMI 23 or greater 

Mini Nutritional Assessment: scores

• 12-14= normal nutritional status

• 8-11= at risk for malnutrition

• 0-7= malnourished 

Fluid recommendations for older adults & age-related changes affecting hydration status 

• Fluid recommendations for older adults

  • 1500 mL/day

Fluid recommendations for older adults & age-related changes affecting hydration status 

• Thirst sensation diminishes

• Creatinine clearance declines

• Kidneys less able to concentrate urine

• Total body water decreases

• Loss of muscle mass and increase in fat

Signs of dehydration

• CONFUSION

• Skin turgor is NOT a reliable indicator in older adults

Signs of dehydration: Look for

• Dry mucous membranes in mouth and nose

• Furrows on tongue

• Orthostatic blood pressure and pulse changes

• Speech incoherence

• Rapid pulse

• Decreased urine output

• Extremity weakness

• Dry axilla

• Sunken eyes

• delirium

GERD symptoms in older adults present as

atypical

GERD symptoms in older adults

• Persistent dry cough

• Asthma exacerbations

• Laryngitis

• Intermittent chest pain

• Abdominal pain may occur within 1 hr of eating

• Heartburn & regurgitation

UTIs in adults

• Persons may be cognitively impaired and nurses often rely on nonspecific signs and symptoms

UTIs in adults: Symptoms

• CONFUSION

• Lack of appetite

• Change in behavior

UTIs in adults: Diagnosis

• Painful urination

• Lower abdominal pain/tenderness

• Blood in urine

• New or worsening urinary urgency or frequency

• Incontinence

• Fever

• Lab evidence

UTIs in adults: Clinical Manifestations

• Non localized abdominal comfort

• Cognitive impairment

• Generalized deterioration

• Afebrile

Incontinence and their impact on the older adult: types

• Urinary

• Fecal

Urinary Incontinence and their impact on the older adult: Urinary types

• transient (acute)

• Established (chronic)

Urinary Incontinence and their impact on the older adult: transient

• Sudden onset

• Present 6 months or less

• Usually caused by treatable factors

  • UTI

  • Delirium

  • Constipation

  • Stool impaction

  • Increased urine production

Urinary Incontinence and their impact on the older adult: established

• Sudden or gradual onset

• Characterized as

  • Stress

  • Urge

  • Overflow

  • Functional 

  • Mixed

• Table 17.1 pg 214

Urinary Incontinence and their impact on the older adult: established table 17.1

Fecal incontinence and their impact on the older adult: types

• Urge incontinence

• passive incontinence

• Highly associated with UI

• Common in women 50+ d/t obstetrical trauma

Fecal incontinence and their impact on the older adult: urge incontinence

• Most common

• Individuals feel a strong urge to have a bowel movement but cannot stop it before reaching a toilet

Fecal incontinence and their impact on the older adult: passive incontinence

• Leakage of stool occurs without the individual being aware of it

Urinary incontinence and their impact on the older adult

• Affects quality of life and has physical, psychosocial and economic consequences

• Associated with increased risk for falls, fractures, and hospitalizations

• Affects self esteem and increases risk for

  • Depression

  • Anxiety

  • Dignity

  • Autonomy

  • Social isolation

  • Skin breakdown

  • Sexual activity

• Increases risk for admission to nursing home in those over 65 years of age

• Psychosocial impacts affects the person and his or her family caregivers

Urinary incontinence treatment: pharmacotherapy

• Anticholinergics or antimuscarinic agents

  • Oxybutynin/ditropan

  • tolterodine/detrol LA

Urinary incontinence treatment: nonpharmacotherapy

• Lifestyle modifications

  • Decrease caffeine & alcohol intake

  • Weight loss

• Behavioral

  • Scheduled voiding

  • Bladder retraining

  • Pelvic floor muscle exercises

• Nonsurgical devices

  • Disposable briefs

  • Penile clamps

  • Pessary

• Surgical

  • Indicated for stress incontinence

  • Most common procedures colposuspension and slings

Fecal incontinence treatment: pharmacotherapy

• Alternative treatments

  • Miralax

  • Colace

• Antidiarrhea and fiber therapy

• May consider surgery

Fecal incontinence treatment: nonpharmacotherapy

• Fluid and diet

• Physical activity

• Positioning

  • Squatting or sitting

• Toileting regimen

• Box 17.16 pg 226

Fecal incontinence treatment: nonpharmacotherapy box 17.16

Normal age related changes in urinary

• Age related loss of nephron &, kidney mass

• Loss of the ability to concentrate urine generally lead ot little change in  the body’s ability to maintain adequate fluid homeostasis

• Renal disease or urinary tract obstruction can amplify age related decline in function

• Urinary incontinence and frequency should NEVER be considered a normal part of aging

Normal age related changes in urinary: kidneys

• Decrease size and function

• Decrease in renal blood flow and glomerular filtration rate

• Diverticula of renal tubes and distal portion of nephron

• Decreased glucose reabsorption

• Decline in renal activation of vitamin D decreases intestinal absorption of calcium, now MORE vitamin D is needed to counteract diminishing renal function

• Ability to concentrate urine creases; hyperkalemia more common; sudden large changes in pH or fluid load can quickly lead to hypervolemia or hypovolemia → these changes can cause a high risk for adverse events if individuals are exposed to changes in environment … or to functional restrictions that limit ability to obtain adequate fluids

  • High temperatures

  • Renal toxic medications

Normal age related changes in GU

• Less tone and elasticity

• Loss of bladder holding capacity

• Total bladder capacity decreased to 300 mL from 600mL

• Urge to void occurs at lower bladder volume (160 to 300)

• Weakened contractions during emptying, which can lead to postvoid residual and increased risk for bladder infection

• More urine produced at night may be due to changes in circadian rhythm, output, medications, or be an indicator of sleep apnea

• Increased collagen content, changes in gap junctions, space between myocutes, & changes in sensitivity of sensory afferents, all of which may contribute to involuntary bladder contractions and overactive bladder symptoms

Normal age related changes in GI: small intestine

• Villi become broader, shorter and less functional

  • Blood flow decreases

• Proteins, fats, minerals (including calcium), vitamins (especially B12), and carbs (especially lactose) are absorbed more slowly and in lesser amounts

Normal age related changes in GI: large intestine

• Slowed peristalsis

• Blunted response to rectal filling

• Increased collagen deposition leading to dysmotility

• Fibro fatty degeneration

• Increased thickness of the internal anal sphincter

Normal age related changes in skin

Skin concerns: xerosis

• Extremely dry cracky skin

• Seen primarily on the extremities, mostly legs, but may affect trunk and face

• Prevention and treatment (Box 14-2 pg 166; prevention and treatment)

Xerosis prevention treatment

• Evaluate for dehydration, nutritional deficiencies, systemic diseases, and open lesions

  • Diabetes

  • Hypothyroidism

  • Renal disease

• Maintain environment of 60% of humidity

• Promote adequate fluid intake (minimum 1,500 mL daily)

  • Contraindicated in CHF

• Creams, lubricants, emollients should be applied to towel-patted dry, damp skin immediately after a bath

  • Vaseline

  • Get out of the bath → do not DRY skin. Pat and leave moisture for skin to absorb

• Use only lukewarm water for bathing and avoid long duration baths

Skin concerns: scabies

• Causes intense itching

• Contagious, easily transmitted through close physical contact; intimate or casual

• Scabies with thick crust contain large number of mites and eggs

• Treated with prescribed lotions and creams; clothes and linens need to be washed in hot, soapy water and dried with high heat; rooms cleaned and vacuumed

  • Permethrin

    • Disinfect the whole damn room

• Contact isolation precautions

  • GOWN UP!!!

Scabies treatment

• Treated with prescribed lotions and creams; clothes and linens need to be washed in hot, soapy water and dried with high heat; rooms cleaned and vacuumed 

Skin concerns: skin cancer

• Cancer of the skin is the most common cancer

• Caucasian populations are at a higher risk

• Danger signs

  • Remember ABCDE (Box 13.8 pg 162)

Skin concerns: skin cancer ABCDE

• Asymmetry of a mole (not regularly round or oval)

• Border is irregular

• Color variation (black, brown, tan, blue, red, white, or a combination)

• Diameter > size

• Elevated

Skin concerns: basal cell cancer

• Most common malignant skin cancer

• Mainly in older persons

• Slow growing

Skin concerns: squamous cell cancer

• Aggressive and high incidence of metastasis

• Fairskin or chronic immunosuppression

Skin concerns: purpura

• Bruise

• Commonly seen on dorsal forearm and hands

• Persons on blood thinners are more susceptible

• Don't try to repeatedly put in IVs

  • Can lead to hematoma

Skin concerns: seborrheic keratoses

• Benign growth

• Mainly seen on trunk, face , scalp and neck

• waxy , raised, stuck on appearance

• Flesh colored or pigmented, various sizes

Skin concerns: actinic keratoses

• Precancerous

• Related to exposure to uv light

• Risk; increased age, fair complexion

• Rough scaly sandpaper patches

• Pink to reddish brown with erythematous base

• Should be monitored by dermatologist every 6-12 months

Skin concerns: herpes zoster

• Preceded by itching, tingling, rash along dermatome prior to outbreak of vesicular lesions

• Infectious until it crusts over

Skin concerns: herpes zoster treatment

• Analgesics

• calamine lotion

• antiviral agents ASAP

• shingles vaccine if greater than 50 years

  • Velcysclevier ?

  • Gabapentin analgesic

• GET EM VACCINATED

Skin concerns: herpes zoster complications

• Postherpetic neuralgia, eye involvement (med emergency)

  • Can go blind

Skin concerns: pressure injuries

• 70% of Pis occur in older adults

• Major cause of morbidity and mortality

• Most frequently occur on the posterior aspects of the body

• Persons with peripheral vascular disease at greatest risk for development of heel ulcers

• Risk factors

  • Prolonged pressure / immobilization

  • BRADEN SCALE

    • What ratings

      • What they mean

  • Anemia

  • Disease / tissue factors

  • Multiple organ system disease or comorbid complications

Skin concerns: healthy skin promotion

• Prevent sunburn if at all possible

• Use a good quality sunscreen when outdoors, even in the winter

• Dehydration increases the risk of skin injury

• DO NOT use soaps that are heavily perfumed

Skin concerns: pruritus

• Not a disease but a symptom

• May result from systemic disease such as

  • chronic renal failure

    • CKD: build up of waste under the disease

  • biliary disease

  • hepatic disease

    • Hepatic disease: bilirubin

Physical activity education: category of exercise types that improves daily activities

Physical activity education: functional status

falls assessment instruments

• The National Center for Patient Safety recommends the Morse Fall Scale, except for LTC

• Hendrich II Fall Risk Model which has been developed and validated with skilled nursing and rehabilitation populations.

• For outpatient you want to use Timed Up & GO (TUG)

falls assessment purpose

• Identify clinical status of a person

• verify and treat injuries

• identify underlying causes

• assist with risk reduction intervention.

Post fall assessment

• Determining why it occurred is vital & provides information on underlying fall etiologies so that appropriate plans of care can be instituted

• Fall-focus history, fall circumstances, medical problems, medication review, mobility assessment, vision and hearing assessment, neurological examination, and CV examination.

Fall interventions

• Adaptation or modification of home environment

• Withdrawal or minimization of psychoactive medications

• Withdrawal or minimization of other medications

• Detection and prevention of delirium

• Management of orthostatic hypotension

• Continence programs such as promoted

• Management of foot problems and footwear

• Exercise, particularly balance, strength, and gait training

• Staff and patient education

Fall prevention

• Outdoor grounds and indoor floor surfaces checked for spills, wet areas, and unevenness

• Hallways, doorways have clear paths free of clutter, equipment

• Proper illumination and functioning of lights, including night lights

• Tabletops, furniture and beds are study and in good repair

• Grab rails and non skid appliques or mats are in place in the bathroom (toilet and shower)

•  Appropriate shoe wear is available and used

• Adaptive aids area available, work properly, and are in good repair

• Bed rails do not collapse when used for transitioning or support

• Bed wheels lock

• Patient gowns/clothing does not cause tripping

• IV poles are saturday is used during ambulation and tubing does not cause tripping

Diabetes labs

• Blood glucose

• HbA1C

• Lipids

• Assess serum creatinine and eGFR yearly

Diabetes: Lab BG

• Blood glucose:

  • Hypoglycemia: blood glucose < 60

  • Hyperglycemia: blood glucose 200–600 or higher

Diabetes: HbA1C

• Goal: < 7.0%

• Frail older adults: < 8.0–8.5%

• Assess HbA1c every 3 months

Diabetes: Lipids

• Cholesterol < 200 mg/dL

• LDL < 100 mg/dL

• HDL > 40 mg/dL men / > 50 mg/dL women

• Triglycerides < 150 mg/dL

Diabetes management

• Focus on prevention, early identification, and delaying complications

• Minimize cardiovascular risk

• Low carbohydrate and sodium diet

• Regular exercise

• No smoking

• Monitor weight and BP every visit

• Inspect feet every visit

• Review self-monitoring glucose record each visit

• Dilated eye exam yearly

• Comprehensive foot exam by podiatrist yearly

• Influenza vaccination yearly

• Pneumococcal vaccination as recommended

Diabetes first line agents

• Metformin is listed as preventative or first-line therapy

  • Does not cause hypoglycemia or weight gain

  • Contraindicated with advanced renal disease: GFR < 30

  • Use caution with reduced hepatic function or CHF

Diabetes hyperglycemia symptoms

• Blood glucose 200–600 or higher

• Harder to detect in older adults because they may tolerate higher glucose levels

• Increases risk for hyperosmolar hyperglycemic non-ketotic coma

• Body tries to remove excess glucose through urine, which can cause life-threatening dehydration

• Consider this in older adults with diabetes who are difficult to arouse

Diabetes activity education

• Exercise improves tissue sensitivity to insulin and promotes cardiac health

• Walking is inexpensive and beneficial, but consider safety

• See health care provider before starting an intense exercise program

• If taking insulin, exercise must be regular, and blood sugar should be checked before and after to avoid hypoglycemia

Diabetes: things the pt is at risk for

• Heart disease

• MI

• Stroke

• Dementia

• Depression

• Functional disability

• Peripheral neuropathy

• Gastroparesis

• Sexual dysfunction, impotence, erectile dysfunction

• Blindness

• Amputation

• Kidney failure

• Hyperosmolar hyperglycemic non-ketotic coma

• Life-threatening dehydration with severe hyperglycemia

Basic hyper/hypothyroidism labs

• TSH (Thyroid-Stimulating Hormone):

  • Normal range: 0.5-5.0 units/mL

  • Treatment typically recommended when TSH ≥10 units/mL

  • For persons over age 80: treatment considered when TSH >7.5 units/mL

• Free T₄ (Thyroxine):

  • Normal range: 0.8-1.8 ng/dL

• Free T₃ (Triiodothyronine):

  • Normal range: 2.3-4.2 pg/mL

Hyperthyroidism signs

• Most often caused by Grave’s disease with multinodular or uninodular goiter

• Can result from iodine or iodine-containing substances, such as seafood, contrast agents, or amiodarone

• Onset is usually abrupt

• Manifestations are often atypical in older adults

• May not be diagnosed until the person has:

  • Unexplained atrial fibrillation

  • Heart failure

  • Dementia

• Other possible findings:

  • Depression

  • Weight loss

  • Dyspnea

  • Constipation

  • Anorexia

  • Muscle weakness

Hyperthyroidism treatment

•  anti-thyroid medication or ablative therapy

Hyperthyroidism labs

•  low TSH and elevated free T4

Hypothyroidism signs

• Fatigue

• Weakness

• Depression

• Dry skin

• Mental slowness

• Drowsiness

• Constipation

Hypothyroidism treatment

• thyroid stimulating/replacement medication

Hypothyroidism labs

• Thyroid gland does not produce enough T3/T4

• Labs: increased TSH and low T3/T4

• Onset is insidious

• Most commonly caused by chronic autoimmune thyroiditis / Hashimoto’s disease

• Can be caused by radioiodine treatment, subtotal thyroidectomy, or medications such as amiodarone

age related changes of immune system: gout

age related changes of immune system: management and education

osteoporosis risk factors

• Highest risk → post menopausal caucasian women

• Results from gradual loss of cortical and trabecular bone and microarchitectural deterioration

• Primary OP is likely a sign of normal aging particularly in postmenopausal women who DO NOT take hormone replacement therapy.

• Secondary may be caused by

  • Dietary deficiencies in calcium and vit D

  • Medications such as corticosteroids

  • Autoimmune disorders

    • RA

    • Lupus

    • Hashimoto's thyroiditis

osteoporosis education

• MEdicare coverage for bone density scan (DEXA) every 2 years at NO COST

  • Women whose provider determines she is estrogen deficient and at risk for osteoporosis, based on her medical history and other findings

  • A person whose xray shows possible OP, osteopenia, or vertebral fractures

  • A person who has been diagnosed with primary hyperparathyroidism

  • A person who is being monitored to see if the OP drug therapy is effective

s/s of OA

• Stiffness with inactivity

• Pain with activity relieved by rest

• Stiffness greatest in the morning but resolves within 20-30 minutes after movement begins

• On exam, subluxation and joint instability may be found and crepitus is common

• As disease advances, spinal stenosis develops in the lumbar region and osteophytes develop in the joints of the fingers

s/s of GOUT

• Person complains of intense pain in the affected joint or joints, often awakening one from sleep

• Joint is bright red, hot, and too painful to touch

• Pain of gout may be very responsive to oral anti-inflammatories such as NSAIDs and a short course of corticosteroids or colchicine

s/s of RA

• Three variations

  • Monocyclic

    • One episode lasting 3-5 years

  • Polycyclic

    • Intensity of symptoms varies over time

  • Progressive

    • Increase in severity and present all the time

• Affects joints and systems as a whole

  • Pain, fatigue, malaise, weakness, and fever MAY be present

• Characterized by symmetrical polyarticular limitations affective five or more joints

• Usually affects the small joints of the wrist, ankle, and hand although it can affect the large joints such as the knee

OA non-pharmacological treatment

• NO CURE

• Focus on

  • Managing pain and inflammation

  • Preventing disability

  • Maintaining and improving joint function

• Rest and joint protection

  • Immobilization should not exceed 1 week, use assistive devices

• Heat and cold applications for pain and stiffness

• Ice for inflammation & heat for stiffness

• Nutritional therapy & exercise → weight reduction is helpful

• Complementary & alternative therapies → acupuncture, yoga, and glucosamine chondroitin

• Diet

  • Red meat, poultry and fish should be limited to 4-6oz daily

  • Organ meats such as hearing, anchovies, mackerel

OA: Pharmacological treatment

• Mild to moderate pain

  • Tylenol 500 mg up to 4x a day

    • 2,000 mg daily MAX to prevent hepatic toxicity

  • Topical agent

    • Zostric

    • capsaicin cream

      • blocks pain signals locally

  • Topical salicylates

  • Other OTC

    • Bengay

      • local relief

  • Ibuprofen 200 mg up to 4x a day

• Athroplasty

  • Reconstruction or replacement of a joint

• NSAIDs

  • Ibuprophen

    • 200 mg up to 4x daily

    • Critical

      • Always screen for renal, GI, or CV comorbidities

    • Naproxen

  • Naproxen

• COX-2 inhibitors

  • Celecoxib

  • Celebrex

GOUT treatment

• Mainly NSAIDs

• Goal during an acute gout attack: stop the attack as quickly as possible.

• Medications mentioned:

  • NSAIDs

  • Colchicine

  • Short course of corticosteroids

  • Sometimes injection of long-acting steroids into the joint

• After the acute attack, the goal is to prevent:

  • Another attack

  • Systemic spread of disease

  • Development of chronic gout

• The document also mentions allopurinol under gout education.

Gout education

• Encourage hydration because dehydration can cause a gout flare-up and kidney stones, which may lead to kidney failure.

  • Exception: be careful with hydration in heart failure.

• Decrease/limit high-purine foods:

  • Red meat

  • Chicken

  • Fish

  • Organ meats

  • Meat, poultry, and fish: limit to 4–6 oz daily

  • Herring, anchovies, mackerel

• Limit or avoid:

  • Alcohol

  • Foods sweetened with high-fructose corn syrup

• Encourage movement.

RA treatment

• Treatment can begin as early as possible providing greatest chance the joints can be preserved

• Use of Disease modifying anti-rheumatic drugs (DMARDs) as soon as diagnosis is made

  • Methotrexate/hydroxychloroquine

  • Plaquenil

• Athroplasty

  • Reconstruction or replacement of a joint

• NSAIDs or COX-2 inhibitors

  • Celecoxib

  • Celebrex

• Diet

  • Mat, poultry and fish should be limited to 4-6oz daily

  • Organ meats such as hearing, anchovies, mackerel

  • Limit or avoid alcohol

  • Limit or avoid foods sweetened with high fructose corn syrup

Therapeutic touch

• Can serve as a means of providing sensory stimulation, reducing anxiety, relieving physical and psychological pain, and comforting the dying as well as sexual expression

• Hands on healing and energy based interventions have been found in cultures throughout history, dating back at least 5000 years

• Can satisfy “touch hunger: of older adults

• Powerful tool to promote comfort and well being when working with older adults

• Can serve as a means of providing

  • Sensory stimulation

  • Reducing anxiety

  • Relieving physical and psychological pain

  • Comforting the dying

HIV/AIDS in older adults

• Growing in 50y+

• 37% of people in the US with HIV are over 50

• LArgest increase in HIV diagnosis from 2008-2010 was among 65 years and older

• The compromised immune system of an older person makes him or her more susceptible to HIV/AIDs

• Sexually active older men and women do not routinely use condoms

High risk factors (BOX 33.3, pg 458)

HIV/AIDs assessments

• Thorough sex and drug use/assessment screening should be conducted with attention to HIV risk factors

• Many symptoms such as fatigue, weakness, weight loss, and anorexia are common to other disease conditions and may be attributed to normal aging

• Many IS guidelines recommend HIV testing among high risk groups regardless of age but routine screening recommendations differ, and some have a cutoff age of 65 years.

• Medicare covers annual screening for HIV for those at risk or who ask for a test

HIV/AIDS interventions

• Antiretroviral therapy can be more complicated if there are chronic illnesses, comorbidities and polypharmacy

• Guidelines of those 60-80 with HIV are limited due to not studied in clinical/pharmacokinetic trials

• Disease stage summary of care

  • box 33.4 pg 459

• Misinformation about HIV is more common in older adults

• Educational materials and programs aimed at older adults need to be developed that include information about what HIV/AIDS is, how its transmitted, risk reduction counseling, symptoms of which to be aware and the treatments that are available