Week 3-5: Chronic Illness in the Older Adult

Consequences of Chronic Illnesses

• General Impact: Increased health risks, reduced functional status, family/caregiver strain, and high healthcare costs.

• Costliest Conditions: Arthritis, Heart Disease, Cancer, Diabetes Mellitus, Hypertension, Asthma, Chronic Kidney Disease.

• Nursing Goals: Delay functional decline, promote self-care, maintain quality of life and dignity.

Parkinson’s Disease

• General Characteristics & Pathophysiology:

  • Terminal neurodegenerative condition caused by dopamine depletion in the basal ganglia.

  • Confirmed clinically via Levodopa challenge test (symptom improvement confirms diagnosis).

• Cardinal Signs & Symptoms (TRAP):

  • T - Tremor: Resting ("pill-rolling"), aggravated by stress.

  • R - Rigidity: Cogwheel resistance to passive movement.

  • A - Akinesia / Bradykinesia: Slowness of movement, loss of facial expression, dysphagia/aspiration risk.

  • P - Postural Disturbances: Forward head tilt, shuffling/festinating gait.

  • Additional Manifestations: Lewy body dementia (15–20%15–20% of cases), hallucinations, constipation, sleep disturbances.

Parkinson’s Pharmacology

• Levodopa / Carbidopa (Sinemet): Take on an empty stomach; limit protein and Vitamin B6B6​ intake. Monitor for orthostatic hypotension and dyskinesia.

• COMT Inhibitors (Tolcapone): Increase dopamine levels for consistent symptom relief.

• MAO-B Inhibitors (Selegiline): Avoid tyramine-rich foods (aged cheeses, cured meats) to prevent hypertensive crisis.

• Dopamine Agonists: Pramipexole, Ropinirole.

Parkison’s Nursing Care

• ADL & Mobility: Allow extra time for meals; use adaptive utensils; teach "block turning" to prevent falls.

• Home Safety: Remove throw rugs, install elevated toilet seats/grab bars, simplify clothing using Velcro.

• Surgical Intervention: Deep Brain Stimulation (DBS) for severe, medication-resistant tremor.

Respiratory Disorders

• Chronic Obstructive Pulmonary Disease (COPD):

  • Persistent, irreversible airflow obstruction (Emphysema and Chronic Bronchitis).

  • Manifests after 50% loss of lung function.

  • Key Symptoms: Wheezing, chronic cough, dyspnea on exertion (DOE), sputum production, pursed-lip breathing, barrel chest, and accessory muscle use.

• Pneumonia:

  • Single most common infection in older adults (CAP, HAP, Aspiration, VAP).

  • Atypical Presentation: Often lacks fever; presents with altered mental status/confusion, dehydration, lethargy, and cough.

  • Recommended Vaccines: Influenza, Pneumococcal, COVID-19, and RSV.

Cardiovascular Disorders

• Diagnostic Indicators:

  • Troponin: Definitive diagnostic marker for acute Myocardial Infarction (MI).

  • BNP: Key marker for evaluating Heart Failure (HF) severity and fluid overload.

• Heart Failure Case Findings: Severe dyspnea, bilateral lung crackles, +4 lower extremity edema, and high BP (160/98 mmHg) indicate Decreased Cardiac Output secondary to Fluid Volume Excess and Increased Afterload.

• Antihypertensive Classes & Key Side Effects:

  • ACE Inhibitors (-pril): Persistent dry cough, hyperkalemia, life-threatening angioedema.

  • CCBs (-dipine): Peripheral edema, bradycardia, decreased myocardial contractility.

  • ARBs (-sartan): Angioedema, hyperkalemia.

  • Beta-Blockers (-olol): Bradycardia, hypotension, bronchoconstriction (contraindicated in asthma/COPD).

• Post-Surgical Red Flags:

  • Aortic Femoral Bypass: Report graft occlusion immediately if distal pulses are diminished (1+ or absent) with coldness, pallor, or severe pain.

  • Femoral Cardiac Catheterization: Assess for retroperitoneal bleeding/internal hemorrhage indicated by sudden hypotension (90/60 mmHg), tachycardia (120 bpm), and back/flank pain.

PAD- Vascular Disorder

(Think: not enough blood is getting DOWN to the legs):

• Cause: Atherosclerosis

• Skin: Thin, Shiny/taut, Hairless, Pale or cyanotic.

• Temperature: Cold

• Pulses: Decreased, weak, or absent

• Edema: None or minimal

• Pain:, Intermittent claudication → pain with walking/exercise. Rest pain may occur, Dangling/dependent position relieves pain.

• Ulcers:, Deep, Painful, Circular, "punched-out", Usually toes or heels

• Interventions: Keep legs dependent/down, Exercise/walking as prescribed, Avoid cold, Avoid nicotine/smoking, Protect feet from injury

PVD- Vascular Disorders

(Think: blood gets DOWN to the legs but has trouble getting BACK UP):

• Cause: Venous insufficiency, DVT

• Skin: Thickened/leathery, Bronze or brown discoloration, Stasis dermatitis.

• Temperature: Warm

• Pulses: Present

  • May be difficult to feel because of edema

• Edema: Significant/marked

• Pain: Dull aching, Heaviness, Leg elevation relieves pain

• Ulcers: Superficial, Painless or mildly painful, Irregular borders

  • Common near the medial malleolus/ankle

• Interventions: Elevate legs, Compression stockings when appropriate, Wound care, Weight management.

Lipid-Lower Pharmacology - Statins

1. Target outcomes include increased high-density lipoproteins (HDL) and reduced low-density lipoproteins (LDL).

2. Baseline and ongoing monitoring of liver enzymes is required.

3. Avoid grapefruit juice and grapefruit products due to CYP3A4 enzyme inhibition leading to drug toxicity.

4. Instruct client to immediately report unexplained muscle pain, tenderness, or weakness due to the risk of Rhabdomyolysis, which can cause acute kidney injury (AKI).

• Breakdown of muscle protein can get stuck in the nephron of the kidney and build up waste products.

Cerebrovascular Accidents (Stroke/CVA)

• Etiology & Classifications:

  • Ischemic (≈80%≈80%; ≈20%≈20% cardiogenic/Atrial Fibrillation) vs. Hemorrhagic (≈20%≈20%).

  • TIA: Temporary neurological dysfunction without acute infarction; warning sign for future stroke.

• BFAST Protocol: Balance loss, Facial drooping, Arm weakness, Speech difficulty, Time to call emergency services.

Interventions and Care for CVA

• Therapeutic Interventions:

  • tPA: Administered for acute ischemic stroke within 3–4.5 hours3–4.5hours of symptom onset.

  • Contraindications: Active bleeding, recent head trauma/surgery, severe hypertension (>185/110 mmHg>185/110mmHg), or hemorrhagic stroke on CT.

  • Anticoagulation: DOACs superior to Warfarin for long-term embolic stroke prevention in atrial fibrillation.

• tPA Response Evaluation:

  • Improving: Equal bilateral hand grasps (+3+3).

  • Unchanged: Persistent right facial droop or dysarthria.

  • Worsening: Visual changes (e.g., looking through a veil), progressive weakness, or new bleeding.

Osteoporosis

• Pathophysiology: Chronic metabolic disease where bone resorption exceeds formation, causing bone fragility and fractures.

• Risk Factors: Advanced age, female, low body weight (<127 lbs or 58 kg), postmenopausal estrogen deficiency, inadequate calcium/vitamin D, sedentary lifestyle, smoking, and excess alcohol.

• Clinical Manifestations: Asymptomatic early ("silent disease"); leads to height loss, kyphosis ("dowager's hump"), and spontaneous fractures.

• Hip Fracture S/S: External rotation of affected leg, limb shortening, severe pain, and muscle spasms.

• DXA Scan & Medication: DXA scan measures bone density (requires lying stationary for 20 minutes).

  • Alendronate (Fosamax) must be taken first thing in the morning with plain water on an empty stomach, remaining upright for at least 30 minutes post-dose to prevent severe esophagitis.

Gout (Gouty Arthritis)

• Pathophysiology: Hyperuricemia causes urate crystal deposition in joint tissues, causing severe inflammation (commonly first MTP joint / great toe).

• Management: Low-purine diet (restrict bacon, turkey, organ meats, sardines, alcohol); force fluid intake (2–3 L/day) to prevent uric acid renal stones.

• Pharmacology: Colchicine for acute attacks; Allopurinol for chronic prophylaxis (monitored via serum uric acid levels).

Osteoarthritis (OA)

• Pathophysiology: Noninflammatory, progressive cartilage loss with osteophyte formation (not a normal part of aging).

• Key Features: Asymmetrical; affects large weight-bearing joints (hips, knees) and DIP joints (Heberden's nodes) / PIP joints (Bouchard's nodes).

• Manifestations: Joint pain worsens with activity and improves with rest in early stages; morning stiffness resolves quickly (<30 minutes); crepitus present.

• Interventions: Weight loss, quadriceps strengthening, heat/cold therapy. Meds include Acetaminophen, NSAIDs (with Misoprostol for GI protection), and intra-articular corticosteroid or hyaluronic acid injections.

Rheumatoid Arthritis (RA)

• Pathophysiology: Chronic, systemic autoimmune disease causing symmetrical joint inflammation with periods of remission and exacerbation.

• Key Features: Symmetrical; affects small joints (hands, wrists); systemic signs (fatigue, low-grade fever, weight loss); deformities include Swan-neck, Boutonniere, and ulnar deviation.

• Manifestations: Morning stiffness lasting >60 minutes.

• Pharmacology: DMARDs (Methotrexate is first-line; requires CBC monitoring for bone marrow suppression and liver function tests; teratogenic); Hydroxychloroquine (requires eye exams every 6–12 months); short-term corticosteroids.

• Nursing Interventions: Use moist heat for morning stiffness; avoid placing pillows under knees to prevent severe, irreversible flexion contractures and DVT risk.

Benign Prostatic Hyperplasia (BPH)

• Pathophysiology & Risk Factors: Non-malignant enlargement of the prostate compressing the urethra, causing urinary retention, hydronephrosis, and post-renal AKI. Prevalent in men aged >50 years (50%) and >80 years (80%).

• Signs & Symptoms: Urinary frequency, nocturia, hesitancy, straining, weak stream, post-void dribbling, recurrent UTIs, and elevated PSA levels.

• Medical Management: Emergency catheterization for retention; Tamsulosin (relaxes smooth muscle), Finasteride (reduces prostate size), and Saw Palmetto (herbal; may mask PSA levels).

TURPs and CBI Use

• Surgical Approach: Transurethral resection of inner prostate tissue.

• CBI Management: Infuse isotonic solution via a 3-way Foley catheter to prevent clot obstruction and maintain patency; titrate flow rate to keep drainage light pink to clear.

• Nursing Interventions for Complications:

  • Clots / Dark Red Output (Grade IV--V): Increase CBI flow rate and perform manual sterile saline irrigation as ordered.

  • Bladder Spasms: Inspect drainage tubing for kinks or blockage before administering antispasmodics (e.g., Oxybutynin).

  • Prevent Bleeding: Avoid straining during bowel movements using stool softeners and a high-fiber diet.

  • DVT Prophylaxis: Apply SCDs, give low-dose heparin, and avoid prolonged sitting.

Electrolye Imbalances in Older Adults

• Hyponatremia (<136 mEq/L):

  • Causes: Diuretic therapy, SIADH, excessive hypotonic fluid replacement.

  • Signs & Symptoms: Confusion, altered LOC, muscle weakness, seizures.

  • Interventions: Sodium replacement, fluid restriction, seizure precautions.

• Hypernatremia (>145 mEq/L):

  • Causes: Dehydration/water deficit, Diabetes Insipidus.

  • Signs & Symptoms: Confusion, muscle twitching to weakness, dry mucous membranes.

  • Interventions: Sodium restriction, gradual hypotonic IV fluids, seizure precautions.

• Hypokalemia (<3.5 mEq/L):

  • Causes: Non-potassium-sparing diuretics, GI fluid loss (diarrhea, NG suctioning).

  • Signs & Symptoms: Muscle weakness, dysrhythmias (flattened T-waves, U-waves), constipation.

  • Interventions: Potassium supplementation (never give IV push), continuous cardiac monitoring.

• Hyperkalemia (>5.0 mEq/L):

  • Causes: Renal failure, packed RBC transfusions, Addison's disease.

  • Signs & Symptoms: Peaked T-waves, lethal ventricular dysrhythmias, flaccid paralysis.

  • Interventions: Kayexalate, IV regular insulin plus D50WD50​W, Calcium Gluconate, hemodialysis.

• Hypocalcemia (<9.0 mg/dL):

  • Causes: Hypoparathyroidism, end-stage renal disease, Vitamin D deficiency.

  • Signs & Symptoms: Neuromuscular excitability, tetany, positive Chvostek's/Trousseau's signs, prolonged QT interval, seizures.

  • Interventions: Oral/IV Calcium Gluconate, Vitamin D, seizure precautions.

• Hypercalcemia (>10.5 mg/dL):

  • Causes: Hyperparathyroidism, prolonged immobility, bone malignancy.

  • Signs & Symptoms: Decreased neuromuscular excitability, cardiac dysrhythmias, hypercoagulability, confusion to coma.

  • Interventions: Weight-bearing exercise, aggressive IV isotonic hydration, Calcitonin or Bisphosphonates.