NURS 352 Final Exam Geriatrics

Presbyopia

Reduced elasticity of lens, Decreased pupil size

Opacification of lens and vitreous (gel like substance)

Decrease visual acuity

Decreased tear production

Dryness of eyes

Headaches

Related to muscle strains

Loss of photoreceptors cells in retina

Light perception decreases, Dark and light adaptation takes longer

Depth perception distorted

Balance issues, run into things, more falls

The effects of blindness increases after what age

65

What does medicare cover for eye care

Medicare A and B don't cover eye exams, Medicare C might if there is glaucoma

How can you promote vision in older adult

Use bright light, Avoid fluorescent light, Ultraviolet filter coating on lenses

Cataracts

Lens becomes opaque, Affects both eyes

-See halos around light, Diplopia (double vision)

-Glare from bright light is bothersome

-Red reflex is reduced (red glow in pupil when shining light into eye)

What is known to cause cataracts

Ultraviolet B light

Factors that contribute to cataract formation

-DM: Sorbitol accumulates on lens which makes it cloudy

-Smoking: Degradation of lens

-HTN: Impaired blood flow

-Kidney disease: Impaired blood flow

-Physical or chemical injury

-UV/Sunlight

Cataract surgery

Not based on age (anyone can have it), Simple procedure

Complications of cataract surgery

Eye infection, Loss of vitreous humor, Slipping of implant

Care for patient after eye surgery

Prevent squeezing eyelids, Use eye patch, Tell patient to contact provider if severe pain/pressure in eye/loss of vision

Glaucoma

Degenerative eye disease optic nerve is damaged from increased intraocular pressure, Irreversible

-Second leading cause of blindness

-May be asymptomatic in beginning

-Increases with age

Glaucoma risk factors

Size of lens, Iritis (inflammation of eyelids), Allergy, Endocrine imbalance (low estrogen), emotional stability (depression, anxiety), Family history

Acute (angle closure) Glaucoma

EMERGENCY, Rare unilateral seen with those who are farsighted with family history

-Symptoms: Acute pain, Headache, N/V, Loss of vision within 24 hours, Pupil unreactive and partially dilated

Chronic (open angle) Glaucoma

Chronic and progressive, Increase intraocular pressure from accumulation of aqueous humor, Aqueous humor (water like substance in eye) is not stagnant flows at very slow rate

-Symptoms: Tunnel vision, Halos around light, Blurred vision, Decreased peripheral vision, Difficulty adjusting to darkness

Chronic (open angle) Glaucoma risk factors

Frequent change in prescription, Anticholinergics (cause pupil dilation), Mydriasis = pupil dilation exacerbates glaucoma

Diagnosis of glaucoma

-Fundoscopic Exam shows cupping of optic disk and atrophy of optic nerve

-IOP > 22mmHg (normal is 10-21)

Management of acute angle closure glaucoma

Reduce intraocular pressure by meds (Beta blockers to reduce aqueous humor and Pilocarpine for pupillary constriction), surgery, laser

Macular degeneration

Systemic changes in circulation, accumulation of cellular waste products, tissue atrophy, growth of abnormal blood vessels in choroid layer beneath retina that leads to loss of central vision

Dry macular degeneration

Most common, Yellow deposits accumulate in retina

Wet macular degeneration

Abnormal, leaky blood vessels behind retina

Dry macular degeneration symptoms

Difficulty performing central vision, Decreased color vision, Wavy appearance of straight lines (Diagnose with Amsler grid test, Color vision test)

Risk factors for corneal ulcer

Febrile states, Irritation, Dietary deficiencies (Vitamin A), Lowered resistance (sick), CVA

Corneal ulcer symptoms

Bloodshot eyes, Increased tearing, Pain, Photophobia (light sensitivity)

Corneal ulcer treatments

Treat underlying cause, Corneal transplant, Cycloplegics (paralyzing agents for muscles in eye), Sedative, Antibiotics, Heat

Presbycusis

Age related hearing loss

When does smell perception decline

After age 60, Rapidly after age 80 due to cell loss (olfactory bulb and sensory cells)

When does taste perception decline

Gradual decline, Decrease in taste (taste bud atrophy, amylase decreased in saliva), Accelerated with dental problems meds and smoking

Polypharmacy

Use of multiple medications (OTC, Prescribed, Herbal supplement) concurrently

What are reasons people may be taking multiple medications unnecessarily

-Without indication (no diagnosis attached)

-Duplicate therapy

-Generic and brand at same time

-Prescribing cascade (one med gives side effects, give another to treat side effects of first)

-Excessive duration (may no longer need)

-Excessive dose

Beers criteria

Medication list for elderly (Meds to be avoided and used with caution)

Risk factors for polypharmacy

Multiple medical diagnoses, multiple providers, multiple sources for drugs, lack of patient knowledge

Primum Non Nocere

Do no harm

Latrogenesis

Harm from therapeutic regimen

Adverse drug reactions

Most common form of Iatrogenic illness

Negative outcomes of taking multiple medications

Adverse drug reactions or events, medication errors, non adherence to regimen, financial burden, decreased quality of life

Likelihood of adverse drug reactions based on the number of meds an elderly person is taking

6% risk with 2 meds

50% risk with 5 meds

100% risk with 8 meds or more

How do ADRs present in elderly

-May take prolonged time to become apparent (everything slows down)

-Vague symptoms

-May happen after long term drug use

-May be mistaken for geriatric syndromes

Ibuprofen side effects

Unintended event at normal dose, Nausea, Abdominal pain, Headache, Dizziness

Ibuprofen adverse effects

Intervention needed to prevent harm, GI bleed, MI, CHF, Renal damage/failure

Pharmacodynamics

What the drugs do to the body

Age related changes in taking medications

-Receptors in brain more sensitive to opioids, benzodiazepines, anticholinergics

-Heightened response to anticoagulants

-Decreased sensitivity to beta blockers

Metabolism

Drug passes through SI into network of veins and drain into portal vein which enters liver = High first pass

Metabolism in elderly

Decreased so greater non metabolized or free medication in plasma = becomes toxic, Oral doses need to be adjusted down

Elimination of medication in elderly

Decreased sweat and saliva, Decreased respiratory function, Decreased renal function

What is a good measure of renal function in elderly

Cockcroft-Gault calculation to measure creatinine clearance (Serum creatinine not good measure because decreased lean muscle mass leads to decreased creatinine production)

Half life

The time it takes for amount of drugs active substance in your body to reduce by half, Drugs half lives are much longer in elderly

S/S that are often misinterpreted as part of aging

-Fatigue

-Constipation, diarrhea, incontinence

-Confusion, changes to LOC

-Depression

-Weakness, tremors, dizziness

-Anxiety

-Decreased sexual desire/performance

Assessment of elderly on medications

Ability to self manage meds, Nutrition, Health beliefs of individual, Socioeconomic (ability to pay), Complete medication lists, Beers criteria review, Drug interaction checkers

Therapeutic effects

Response after treatment

Anticholinergic central effects

Agitation, confusion, disorientation, poor attention, hallucinations, psychoses

Anticholinergic peripheral effects

Constipation from decreased intestinal peristalsis, urinary retention, inhibition of sweating, decreased salivary and bronchial secretions, tachycardia, pupil dilation

What do medication effects depend on

Dose

Safe disposal of medications

Discourage pill sharing/hoarding, Check medicine cabinets once a year for expired meds, Sharps container or kitty litter

Gradual dose reduction

Tapering of a dose in a stepwise manner

Geriatric considerations for acetaminophen

-Increased risk of toxicity related to decreased hepatic function

-Use with caution during alcohol use

-Many meds contain and people may not realize

Maximum adult daily dose acetaminophen

3 gms/24 hours

What is increased INR a sign of

Acetaminophen interacting with warfarin

Elizabeth Kubler Ross Model Stage 1

Denial: Temporary defense, Replaced with heightened awareness of situations and individuals that will be left behind after death

Elizabeth Kubler Ross Model Stage 2

Anger: Recognizes denial can't continue, Difficult to care for due to misplaced feelings of rage, Resentment and jealousy

Elizabeth Kubler Ross Model Stage 3

Bargaining: Hope that individual can delay death, Negotiation for extended life made with higher power in exchange for reformed lifestyle

Elizabeth Kubler Ross Model Stage 4

Depression: Understand certainty of death, Disconnect himself from things of love, Not recommended to attempt to cheer individual up

Elizabeth Kubler Ross Model Stage 5

Acceptance: Peace and understanding, Want to be left alone, Feelings and physical pain nonexistent

Who did Dr. Kubler Ross originally design her model for

People dying of cancer (not the family members of people who have died)

Seven stage model stage 1

Shock and denial: Numbed disbelief, Deny reality, Shock provides emotional protection from being overwhelmed all at once

Seven stage model stage 2

Pain and guilt: Unbelievable pain, Guilty feelings or remorse

Seven stage model stage 3

Anger and bargaining: Frustration gives way to anger, Unwarranted blame -> Permanent damage to relationships may result, Bargain in vain

Seven stage model stage 4

Depression, Reflection, Loneliness: Long period of sad reflection, Encouragement from others not helpful, Realize true magnitude of loss

Seven stage model stage 5

Upward turn: Life becomes a little calmer and more organized

Seven stage model stage 6

Reconstruction and working through: Seek realistic solutions to problems posed by life without loved one, Start reconstructing themselves

Seven stage model stage 7

Acceptance and hope: Accept and deal with reality, Can never fully return to carefree self

What two things do you need to pronounce death

Absence of heartbeat respirations and BP, Pupils fixed