COA FINALS

Promoting Safety for Older Persons

Classification: General

  1. Module: NURS1504, Module 7

Learning Objectives

  • Identify factors contributing to falls in older persons

  • Discuss Best Practice Guidelines in falls prevention and management

  • Discuss tools for assessment of fall risk

  • Discuss different types of restraints

    • Physical restraints: such as side rails, wheelchairs, geriatric chairs, etc.

    • Chemical restraints: include sedatives, antipsychotics, etc.

  • Discuss Best Practice Guidelines regarding restraint use

  • Discuss Best Practices Guidelines regarding side rail use

  • Identify strategies for protecting the older person from injury and accidents

  • Describe types of elder abuse

  • Identify risk factors for abuse and neglect of older persons

  • Discuss expectations for reporting suspected abuse and strategies to prevent abuse

Falls

  • Falls are a common and often devastating problem for older people.

  • They cause substantial morbidity and mortality.

  • Falls can originate from slips, trips, or falls.

  • Leading cause of death by injury.

  • Most common cause of nonfatal injuries and hospital injuries for trauma.

Factors Contributing to Falls in Older Adults

  • Falls are multifactorial; therefore interventions must also be multifactorial.

  • Contributing factors include:

    • Advanced age

    • History of falls

    • Gait and balance problems

    • Poor vision

    • Postural hypotension

    • Chronic conditions

    • Fear of falling

    • Improper use of assistive devices

    • Environmental issues:

    • Stairs

    • Grab bars

    • Lighting

    • Lack of toileting

    • Obstacles or tripping hazards

    • Medications

    • Poor staffing

    • Restraint use

    • Side rails

Tools for Assessment of Fall Risk

  • Several specific fall risk assessment tools include:

    • RAI specific fall risk assessment tools

    • Hendrich II Fall Risk Model: multifactorial assessment

    • Morse Fall Scale

    • Berg Balance Scale

  • Assessment of fall risk should be conducted at a minimum on a yearly basis.

Best Practice Guidelines for Fall Prevention

  • Interventions include:

    • Exercise programs focused on strength and balance

    • Gait training

    • Medication review

    • Environmental modifications

    • Behavioral and educational programs

  • Emphasize that not just one approach is sufficient for fall prevention.

Restraints

  • Definition: "Physical, chemical, or environmental measures used to control the physical or behavioral activity of a person or a portion of his/her body" (CNO, 2018)

  • Types of restraints:

    • Physical restraints: Limit movement, include bed rails, lap belts, etc.

    • Chemical restraints: Medications affecting functioning, such as sedatives or antipsychotics.

    • Environmental restraints: Control a person’s mobility, can include seclusion or secure units.

  • Best practice for restraint use:

    • Use least-restraint approach, limiting duration and restrictiveness

    • Maintain dignity of the individual

    • Conduct frequent purposeful rounding

    • Address individuals by name

    • Require provider order for use

    • Implement monitoring and documentation

    • Obtain consent if not emergent

    • Employ restraint as a last resort only.

Alternatives to Restraint Use

  • Develop safety plans

  • Involve family and all staff

  • Establish a toileting plan

  • Manage pain

  • Implement distraction or diversion activities

  • Remove devices as soon as possible

  • Camouflage medical equipment/devices

  • Ensure call bell is within reach

  • Keep bed at the lowest level

  • Use bed, chair, or wearable sensor alarms

Elder Abuse

  • Definition: "Elder abuse is any intentional or reckless act or willful and negligent disregard occurring within a relationship of family, trust or dependency, directed at someone 65 years of age or older, that:**

    • Causes physical harm;

    • Causes emotional or psychological harm;

    • Involves the misappropriation or misuse of money or other personal possessions or real property;

    • Subjects an individual to non-consensual sexual contact or activity;

    • Fails to provide the necessities of life.

Signs of Elder Abuse

  • Indicators may include:

    • Fear, anxiety, depression, or passiveness when relating to family members, friends, or caregivers

    • Unexplained physical injuries

    • Signs of dehydration, poor nutrition, or inadequate hygiene

    • Improper use of medication, either over or underuse

    • Confusion surrounding new legal documents (e.g. new will)

    • Sudden drops in cash flow or financial holdings

    • Reluctance to discuss their situation

Risk Factors for Abuse and Neglect

  • Key risk factors include:

    • Social isolation

    • Lack of support

    • Female gender

    • Cognitive impairments (e.g, dementia)

    • Responsive behaviors

    • Living with someone who has mental illness

    • Dependency, especially in activities of daily living (ADLs) and instrumental activities of daily living (IADLs)

    • Recent health deterioration

    • Frequent conflicts with relatives

Reporting Obligations

  • Service providers and employees are responsible for ensuring client safety from abuse. They are required to:

    • Take reasonable steps to protect clients from abuse and to provide a reasonable level of safety

    • Act immediately to ensure safety when notified of abuse reports

    • Report to the appropriate authorities including:

    • Protection for Persons in Care Reporting Line

    • Police

    • Mental Health Patient Advocate

    • Professional regulatory body

Module 8: Common Chronic Conditions Affecting the Older Adult

Classification: General

Learning Objectives

  • Explain chronic illness trajectory

  • Describe holistic approaches to managing chronic conditions for older persons

  • Discuss pathophysiology, etiology, signs and symptoms, treatment of the following conditions:

    • Osteoporosis

    • Arthritis (osteoarthritis, polymyalgia rheumatica, rheumatoid arthritis, gout)

    • Benign prostatic hypertrophy

  • Discuss nursing care (assessments, management, patient teaching) for:

    • Osteoporosis

    • Arthritis

    • Benign prostatic hypertrophy

  • Discuss pathophysiology, assessment, management strategies for common visual and auditory changes with aging:

    • Glaucoma

    • Cataracts

    • Macular degeneration

    • Diabetic retinopathy

    • Hearing loss

    • Tinnitus

Acute vs Chronic Illness

  • Acute illness:

    • Definition: Sudden onset, requires immediate care, goal is to cure (e.g., stroke, myocardial infarction, infection, hip fracture)

  • Chronic illness:

    • Definition: Continues indefinitely, the goal is management, moves from stable to unstable to death (e.g., hypertension, arthritis)

Osteoporosis

Pathophysiology

  • Known as "Porous Bone" due to low bone mass.

Etiology

  • Results from loss of calcium (Ca2+Ca^{2+}) and bone mass.

Signs & Symptoms

  • Often termed "Silent" disease, may present with:

    • Pain

    • Kyphosis

    • Height loss

Management

  • Assessment Tools:

    • DEXA Scan

    • Calcium levels

  • Treatment includes:

    • Exercise

    • Dietary considerations

    • Patient teaching addressing lifestyle changes to prevent falls/injuries

Arthritis

Osteoarthritis

  • Definition: Degenerative disease characterized by

    • Cartilage loss

    • Inflammation of the synovium

    • Morning stiffness lasting less than 30 minutes

    • Heberden's nodes

Rheumatoid Arthritis

  • Definition: Autoimmune disease characterized by

    • Morning stiffness lasting more than 30 minutes

    • Asymmetrical or symmetrical joint degeneration

    • Extra-articular involvement

    • T-cells secrete cytokines (e.g., interferon-γ, interleukin-1) that recruit macrophages producing more cytokines (e.g., TNF-α, interleukin-6) leading to synovial cell proliferation.

Polymyalgia Rheumatica (PMR)

  • Characteristics:

    • Typically resolves in 1-2 years and responds well to small doses of corticosteroids

    • Symptoms include:

    • Stiffness lasting more than 1 hour

    • Acute onset of pain in the neck, shoulder, hip area

    • Low-grade fever, fatigue

    • Severe pain often worse at night and early morning

Module 9: Cognitive Impairment and Neurological Disorders in the Older Adult

Classification: General

Cognitive Decline

  • Distinction between gradual and rapid onset conditions:

    • Gradual onset: The decline is slow and steady, with memory impairment and cognitive decline, without consciousness alterations.

    • Rapid onset (e.g., delirium): Occurs over hours or days, symptoms fluctuate throughout the day, with disturbances in consciousness and attention, marked by memory deficits and perceptual disturbances, often accompanied by delusional thoughts, psychomotor behavior changes, and emotional fluctuations.

Communication Strategies for Dementia

  • Strategies for effective communication include:

    • Set a positive mood for interactions

    • Get the individual's attention consistently

    • Slow down communication pace

    • State messages clearly (5 words or less), breaking down activities into steps

    • Connect through memories or humor

    • Focus on "doing with" instead of "doing for"

    • Develop familiarity with the individual to enhance connection

Delirium Prevention

  • Preventative measure strategies for delirium include:

    • Treating pain effectively

    • Minimizing restraint use

    • Early removal of invasive equipment

    • Limiting psychoactive medications

    • Ensuring adequate nutrition and hydration

    • Utilizing sensory aids (glasses, hearing aids)

    • Maintaining appropriate light exposure throughout day/night cycles

    • Minimizing disturbances to sleep

Parkinson’s Disease

  • Classic Signs and Symptoms:

    • Bradykinesia (slowness of movement)

    • Tremor at rest

    • Cogwheel rigidity (muscle stiffness)

    • Postural instability

  • Complications in late-stage: can include pressure injuries, pneumonia, aspiration, and falls.

Alzheimer’s Disease Characteristics

  • Early Symptoms:

    • Difficulty remembering names and recent events

    • Trouble expressing oneself verbally

    • Problems with spatial cognition

    • Impaired reasoning and judgment

    • May exhibit apathy or depression

    • Language disturbances could emerge

  • Later Symptoms:

    • Impaired judgment and disorientation

    • Observable behavior changes

Module 10: Mental Health and Wellness in Later Life

Classification: General

Late Life Depression Assessment

  • Assessment may involve several components:

    • Use of depression screening instruments

    • Conducting interviews

    • Physical and functional assessments

    • Cogitative assessment

    • Blood work for potential medical causes

    • Review of medications for side effects or interactions

  • Interventions: Begin treatment as soon as possible following diagnosis which may include:

    • Pharmacotherapy

    • Electroconvulsive therapy

    • Psychotherapy

    • Psychosocial interventions

Suicide Risk Factors

  • Factors that increase suicide risk include:

    • Depressive disorders

    • Other mental illnesses

    • Feelings of hopelessness

    • Physical health complications coupled with depression

    • Experiencing significant pain or disability

    • Social isolation or loneliness

    • Family discord

    • Perception of being a burden to others

    • History as a residential school survivor

    • Access to lethal means

Assessment of Suicide Risk

  • Utilize direct and straightforward questions such as:

    • "Have you ever thought about killing yourself?"

    • "How often have you had these thoughts?"

    • "How would you kill yourself if you decided to do it?"

    • Reference Box 23.7 for suicide warning signs specific to older adults.

Late Life Anxiety

  • Risk Factors:

    • Being female

    • History of worry or rumination

    • Poor physical health or illness

    • Low socio-economic status

    • High-stress life events

    • Early childhood abuse

    • History of depression

    • Cognitive impairment

    • Family history of anxiety disorders

    • Substance misuse (alcohol or drugs)

  • Protective Factors:

    • Having social support from family members

    • Being married or cohabitating

    • Engaging in physical activity

Interventions for Anxiety

  • Treatment should be tailored based on symptoms and comorbidities, utilizing a therapeutic relationship as the foundation. Options may include:

    • Building family support systems

    • Engaging community resources

    • Forming support groups

    • Incorporating ethnic and cultural traditions into care

    • Non-pharmaceutical approaches:

    • Cognitive-behavioral therapy

    • Relaxation training

    • Mindfulness meditation

    • Pharmaceutical options:

    • Antidepressants

    • Short-acting benzodiazepines

    • Non-benzodiazepine anxiolytics

Signs of Substance Abuse in Older Persons

  • Substance abuse indicators may include:

    • Loss of coordination, resulting in falls

    • Slurred speech

    • Sleep disturbances

    • Neglect of personal care

    • Irritability, depression, or confusion

    • Gastric problems

    • Fabricating excuses for drinking

    • Relationship tensions

    • Decreased interest in previously enjoyed activities

    • Signs of alcohol withdrawal

Sexuality and Aging

  • Approximately half of older adults age 65-74 report being sexually active, with over a quarter of those aged 75-85 also active.

  • Older adults have the freedom to explore sexual relationships, though there is an increased risk of STIs, especially among recently widowed men.

  • Healthcare strategies should adapt to increase awareness and risk perception regarding safe sex practices among seniors.

Issues of Intimacy and Sexuality in Long-term Care (LTC)

  • Sexual needs in older adults should be accorded the same priority as other essential needs (e.g., nutrition, hydration). Issues may involve:

    • Ensuring privacy

    • Availability of partners

    • Reactions from healthcare staff and family members

Module 11: Safe Medication Use for Older Persons

Classification: General

Age-related Pharmacokinetic Changes

  • Pharmacokinetics: Refers to the movement of medication through the body from administration through absorption, distribution, metabolism, and finally excretion.

Polypharmacy

  • Defined as the use of multiple medications, including potentially inappropriate or unnecessary medications, which may result in

    • Increased risk for medication interactions

    • Adverse events

  • Considerations for medication compliance: Approach assessments without judgment.

Psychotropic Medications

  • Can be detrimental as they affect the ability to perform activities of daily living (ADLs)

  • Appropriate when combined with non-pharmacological approaches

  • Categories include:

    • Antidepressants

    • Anti-anxiety agents

    • Antipsychotics (neuroleptics)

    • Mood stabilizers

    • Sedative-hypnotics