3.2 Psychosocial Aspects of Aging and Frail Elderly

what is seen in cognitive decline?

• mental processing speed decline

• sensory-perceptual changes

  • sensitivity to visual contrast and sound

what is this test checking for?

cognitive decline

what are signs of memory decline?

• no definitive conclusions

• difficulty with multi-memory tasks

• frontal lob shrinkage

  • working memory decline

• long term memory less affected than short term memory

what is fluid intelligence?

the ability to process new general information that requires no specific knowledge

what is crystallized intelligence?

knowledge that must be learned or memorized

when does intelligence start to decline?

sixties or seventies

as we increase in age, fluid intelligence…

decreases

how is learning affected as we age?

• slower but once something is learned the rate of forgetting is no faster than young ones

• sensory deficits affect learning 

what is tested in the Mini Mental Status Exam?

• test of cognitive function among the elderly 

• includes orientation, attention memory, language, and visual spatial skills 

what is the single cutoff for the MMSE that is considered abnormal?

< 24

what value of the MMSE indicates increased odds of dementia?

<21

what value of the MMSE indicates decreased odds of dementia?

>25

what score range on the MMSE is indicative of no cognitive impairment?

24-30

what score range on the MMSE is indicative of mild cognitive impairment?

18-23

what score range on the MMSE is indicative of severe cognitive impairment?

0-17

elderly patients with college education who present with complaints of cognitive decline and score ___ on the MMSE are at greater risk of being diagnosed with dementia

< 27

what are the 3 Ds of confusion?

• delirium

• dementia

• depression

what causes delirium?

• medication interaction

  • benzos

• life-threatening illness

  • sepsis 

what is delirium?

• acute brain syndrome 

• confusion, changes level of consciousness, difficulty concentrating 

• difficulty with immediate recall, short term memory, maintaining attention 

• often have hallucinations

how long does delirium last?

• hours to weeks

• usually return to normal once the problem has been fixed 

symptoms of hyperactive delirium

• agitated

• mood swings

• angry 

• belligerent

• aggressive towards caregivers

symptoms of hypoactive delirium

• extreme drowsiness

• fatigue

• indifference 

how do you manage pts with delirium?

• hydration

  • want to help flush out meds if that is what is causing the problem

• calm and quiet environment

• low level of lightening without shadows, natural lighting 

• simple, clear instructions

• familiar objects, individuals

• visual hearing aids

• maximize all their senses

• avoid restraining agitated pt with delirium 

• avoid feeding into hallucinations → reorient 

what test is used to measure if a pt is in a state of delirium or not?

Confusion Assessment Method for the ICU (CAM-ICU) Flowsheet

what are the signs of dementia?

• enlarged ventricles, shrinkage cortex and hippocampus

• loss of memory 

• lose daily living skills

• personality changes

• develops over a number of years and slowly worsens 

why are pts with dementia at a higher risk of injury with falls?

cortex shrinkage, more room for the brain to move within the cranium

what are the types of dementia?

• Alzheimer’s Disease

• Vascular Dementia

• Vitamin B12 deficiency

• over- or under-active thyroid gland

• excessive alcohol use 

what percentage of dementia is Alzheimer’s?

70%

what percentage of dementia is vascular dementia?

17%

how do you manage pts with dementia?

• simplify 

• explain 

• reorient

• slow down 

• avoid change 

• one step at a time

• take care of yourself

what are the cognitive symptoms of depression?

• poor concentration

• low self-esteem

• indecisiveness

• guilt

• hopelessness

• inability to concentrate 

• suicidal ideations

what are somatic symptoms of depression?

• fatigue

• altered sleep patterns

• weight gain or loss

• tearfulness 

• agitation

• heart palpitations

• overall weakness

what are the affective symptoms of depression?

• sadness

• anxiety 

• irritability 

• fear

• anger

• depersonalization

• feelings of isolation 

what is the score cut off for depression on the Geriatric Depression Scale?

> 5 = depression 

what is another questionnaire that measures depression but is not specific to geriatric populations?

patient health questionnaire - 9 (PHQ-9)

how do you manage pts with depression?

• resistance training/group exercise

• referral to PCP → worsening depression needs to be treated ASAP

• be aware of the treatment plans and goals

• shift the pts focus to other situations

  • their dog or grandkids (something that makes them happy)

• motivation → emphasizing strength and positive feedback

what is fear of falling associated with?

• decreased satisfaction with life

• increased frailty

• increased depressed mood

• increased recent falls

• decreased mobility

• decreased social activities 

how does gait change with decline?

• reduced gait speed, stride velocity

• increased gait variability

• significantly longer anticipatory postural adjustment phase during gait initiation

• difficulty with dual task 

what is the biomedical definition of frailty?

disease and illness of the frail population (multiple diseases, numerous chronic conditions, require long-term hospital care)

what is the functional definition of frailty?

lose the ability to perform ADLs and need assistance

(institutionalized, dependent on others for ADL care, debilitated and could not survive without substantial help, need long-term help with basic ADLs)

what is the systems definition of frailty?

takes into account various interlocking physical, psychological, and social complexes 

(diminished ability to carry out practical. and social ADLs, have poor functioning in physical, cognitive, emotional, sensory, and social functions)

what factors influence frailty?

• financial

• cognitive 

  • level of education

• interpersonal 

• physical 

• psychological 

  • self rated 

• living arrangement 

what is an independent risk factor for admission to an institution?

cognitive impairment

who is eligible for home care?

• dr must certify that you are home bound

• leaving your home isn’t recommended because of your condition

• you condition keeps you from leaving home without help

• leaving home takes considerable and taxing effort 

• can only leave for dr appt, church or hair appointment 

what are the predictors and risk factors for institutionalization?

• physical function

• restricted mobility 

• social resources and support

• health perception

• socioeconomic status

• health-care system 

it is estimated that 60% of people older than 65 years and are dependent in __-__ ADLs reside in nursing homes

5-7 ADLs

independent mobility outside of the home has been found to be associated with lower risk of what?

institutionalization

low quantity of social relationships is associated with what?

increased risk of death and institutionalization

what is an iatrogenic illness?

• unintended and harmful condition resulting from a diagnostic or therapeutic intervention

• accidental injury occurring in an institutional setting 

what are the MSK problems associated with bed rest and immobility?

• muscle weakness and atrophy 

• dec endurance

• contracture

• osteoporosis

what are the cardiopulmonary problems associated with bed rest and immobility?

• inc heart rate

• dec cardiac output

• orthostatic hypotension

• venous thromboembolism 

what is failure to thrive?

• medical diagnosis 

• impaired physical function

• weight loss

• depression

• cognitive impairment

• dehydration

what makes a hostile physical environment?

• raised beds

• shiny floors

• restraints 

• lots of equipment