Aging Final
Week One
Theories of Aging (Chapter 2)
Biological theories: aging differs
Stochastic theory: agign happens because of random things
Cross-linking theory: DNA mutates over time and impedes function
Free-radicals theory: againg is because of oxidative metabolism and free radicals
Lipofusion theory: similar to free radicals; oxidation of unsaturated lipids; accumulation interferes with diffusion adn transpirt
Wear and tear: use leads to breakdown
Evolutionary: mutations and natural selection
Biogerontology: bacteria, fungi, etc cause aging; aging and disease processes
Nonstochastic theory: aging is predetermined, not random
programmed/apoptosis: programmed cell death
Genetic theories: biological clock
Autoimmune reactions: decreased immune system function with age and it begins to attack itself
neuroendocrine /chemical: aging is bc of changes in the brain and hormones
Radiation: radiation causes mutations that promote aging
Nutrition: diet effects aging
Environmental: environmental factors effect health
Sociological
Disengagement theory: people draw back as they age
Activity theory: use it or lose it, stay active
Continuity theory: you age according to your personality
Subculture theory: old people are their own age group
Age stratification theory: it’s good for age groups to interact
Modernization: the value of old people decreases as they age bc they become outdated, resulting in social exclusion
Psychological theories
Developmental: Erik Eriksons idea of ego integrity vs despair; good psychological aging is because of good developmental task completion
Geotranscendence: seeing the world in a broader perspective
Nursing theories
Functional consequences theory: we can promote wellness by addressing them holistically, connecting mind, body, and spirit
Theory of thriving: everything that impacts people throughout life must be linked to create a holistic view of aging
Theory of Successful Aging: considers physical, mental, spiritual well-being, and self-appraisal
Functionalist theory: old people should disengage from previous roles and take on more age appropriate roles for their physical and mental decline
No single theory can adequately explain the aging process
Factors that contribute to a long and healthy life: diet, activity, play, laughter, faith, empowerment, stress management
Erickson’s theory of aging as it relates to older adults
The importance of cohort differences and aging, particularly in regard to the Baby Boomer cohort
Describe demographic, social, and economic trends in the aging population
People across the globe are aging and many live in low-mid income countries (most are)
Economically developing countries across the globe tend to be young
Older adults are asset-rich and money-poor
There will be many more older adults to care for soon which will be a huge nursing burden/responsibility
Definitions of Medicare, Medicaid and Social Security
Social Security
Act in 1935
Wages go into system and you get to withdraw them later
Provides a substantial amount of income for older adults
Many rely on it for more than half of income, but it doesnt bring in much money
Mainly for old people, also for those with disabilities
Medicare
For people 65 and up
You pay into it through life
Also for people with disabilities or chronic disease
Only for acute care
Entitlement program: because you paid and met the standard, you are entitled to it
Can pay into upper parts
2 week rehab would probably be the longest
Requires more RN contact
Part A: physician and hospital services, common
B: basically all other medical stuff, most buy into it, ‘ansullar services’
C: private insurance that supplements A and B, not as common
D is prescriptions, common
Federal program
Only lasts for up to 100 days after hospital discharge
Hard for old ppl who need long term care, help w ADLs, and more
Medicaid
Income based program for all ages
Very dependent on state laws
Primarily for family and kids, can be difficult if independent
Primary reimbursement source for nursing homes
Federal program?
Steps in when old people are poor to give long-term care
Its unusual for people to have long term care insurance
Most people who enter a nursing home stay for less than 14 days
Long term care is paid for out of pocket until there is no more money or assets, then medicaid
Assisted livings are paid for by the individual. Some states have a medicaid waiver program that may reimburse part
Long term home health is usually private pay
Liklihood of entering a care home increase with age, but most do not live in one
Federal government is the primary payer for older adult health services in the US
w/in the next 10 years, ¼ of older adults will identify as ethnic minorities
Common chronic conditions in the older adult population
Lifespan is 122 years max
Aging is very individual
Chronological age: years a person has lived since birth
Chronological age is not always reflective of functional ability
Functional age: physical, psychological, and social function
Perceived age: how people estimate a person’s age based on appearance
Age identity: how people feel or perceive their own age
Men live shorter bc wars, tough jobs, risky things
Women used to live longer and still tend to bc they arent in as physically tough stuff and less substance abuse
Most older adults dont live in nursing homes
Half of women over 65 are widowed bc men live shorter and women marry older men
Most men are married
Most older adults live with spouse or family members
2x more women than men live alone later in life
Potential for living alone increases with age
Older women are more at risk for poverty because their husband dies, so loss of income and his union, pension, and/or social security money
Acute: short and will be fixed
Chronic: treatable but incurable, increased risk as you age, increase healthcare system burden
Comborbidity: multiple chronic illnesses, risk increases a ton w age, likely to become functionally disabled, need more complex care
Most older adults have at least 1 chronic illness
10 leading chronic conditions
1. Hypertension
2. High cholesterol
3. Arthritis
4. Ischemic heart disease
5. Diabetes
6. Chronic kidney disease
7. Heart failure
8. Depression
9. Alzheimer’s and dementia
10. COPD
Leading causes of death for 65+ are related to those (I dont think we need to mem)
Diseases of the heart
Malignant neoplasms (cancer)
Chronic lower respiratory diseases
Cerebrovascular diseases
Alzheimer’s disease
Diabetes mellitus
Accidents
Flu and pneumonia
Nephritis, nephrotic syndrome, nephrosis
Parkinsons disease
Baby boomers
Next wave of older adults
Hippies in the 60s
Born 1946-1964, entering senior years between 2011-2030
Didnt have lots of kids
Better educated than before, higher income bc men and women worked, more casual dress code, more tech use, less leisure time, more likely to feel stressed at the end of the day, exercise more, lots of social changes
¼ adults will spend time in a nursing home, but less then 5% will live there
Most long-term residents spend their personal assets withing 1 year of admission
Population over 85 will double by 2040
Management of Common Medical Conditions Observed During Middle and Late Stage Dementia
The more advanced the stage of dementia, the greater the number of cormorbid conditions likely to be present
Worsening of comorbid conditions and diseases, such as pain, infection, incontinence, and eating dysfunctions can occur with dementia
Incontinence is often the primary cause of putting dementia people into institutional care
There is no clear criteria for early, middle, or late stage dementia
Dementia is a terminal, chronic disease
Progression rate varies by individual
Medication management
It can be difficult to manage medications, there is increased self error, liver and kidney changes make it hard to clear out meds or cause more side effects, and many comorbidities make managing meds hard
Sometimes the risk of taking a medication outweighs its benefits
Specific areas of concern are comorbidities, pain, infection, incontinence, eating dysfunction, and more
Comorbidities
High rate in dementia ppl
Multiple of them compromise health status
Most common are cardiovascular disease, diabetes, hypertension, parkinsons disease, and other neurological disorders
Pain
Nearly ⅔ have pain (common)
Can be difficult to treat pain bc they may not be able to express pain levels well
The changes to the brain that cause dementia can cause pain perception to increase or decrease. The pain is not from the dementia, but from the brain changes that cause dementia
Major challenge is to assess pain. Observe behavior changes, such as movements, interactions, appetite, facial expression, etc
There are ways to treat pain without medication, such as removing the stimulus, changing position, distractions, etc
Infections
Pneumonia frequently kills people with dementia
Age decreases inmmune system, transitions increase risk of infection, and sometimes there is malnourishment
Specifically for dementia, people become immobile and then their lungs dont work as well
Many times people in care facilities are required to have the pneumonia vaccine
Incontinence
Not a normal part of aging
Needs assessment and treatment to determine a cause, usually some disease
Catheters increase risk of infection and decrease human dignity
Can be addressed by scheduled toileting plans, bladder training, frequent clothes changing and skin care
Associate with higher levels of mortality
Bowel incontinence is a similar situation
People may not bring up these issues as early for fear of stigma or institutionalization
Eating dysfunction
The ability to eat, drink, and get the nutrition you need is altered by comorbidities, settings, and more
End stage dementia can cause weight loss
Older adults should eat in a chair, not bed, to reduce risk of aspiration, choking, and to get them moving. It is not normal to eat in bed. Better to eat in a dining room with others to also reduce risk of social isolation
Eventually, tube feed may be opted for bc it is unsafe to put food in the patient’s mouth or they are not eating
When someone has dementia, remember that some things could be a sensory impairment. Not being able to hear you may not be the dementia, they may just need hearing aids
The effects of agism on older adults and examples of everyday agism
Agism can have many negative effects on individuals and harm both physical and mental health
There are many different forms of agism
Types of care that make up the long-term care continuum: sites of care (nursing home, assisted living, home care, etc) and the differences between care sites on the continuum
Most nursing home residents are white women
There is no national system for long term care insurance
Most care of chronically ill older adults is in the home and by family and moves to an institution when the home is no longer sufficient
Nursing home
Need an RN there to do a full assessment on each patient and determine a POC for each
Need RN there 24 hours a day
Tend to be the most institutionalized
Regulated by government
Often have problems with providing good care
Assisted Living
Less regulated
Less skilled staff
Dont need as many staff
provide personal care for individuals with “chronic and stable” conditions. A licensed assisted living service provider is available to provide supportive services to those who reside in the facility. Most assisted living services are funded privately, but there are special state subsidy programs in place
Homemaker/companion services
provide non-medical assistance with housekeeping or companionship. Such services may be crucial for an older adult or disabled person to successfully maintain independent living. Services are funded privately or through Medicaid
Residential Care Home
provides personal care, meals, and recreation programs for individuals who need some supportive oversight. Residential care is funded privately or through supplemental state income sources
Hospice
palliative care services such as nursing, social services, personal care and pastoral care to the terminal, their families and significant others. Licensed hospice providers may care for patients in facility-based settings or at home. Medicare, Medicaid and commercial health insurance plans fund hospice care
Intermediate Care Facility
Nursing care and social and recreational services for individuals who need daily supervision. Intermediate care is funded through Medicaid or private pay sources
Continuing Care Retirement Community
provides the full continuum of services on one campus – from
independent living to skilled nursing care. Residents fund their participation in a CCRC privately through a combination of entrance payments and monthly fees
Skilled Nursing Facility
Need RN 8 hours a day there
Skilled nursing care, rehabilitation services, social services and recreational services for both short-term and long-term stays for individuals who require daily care. Skilled nursing care may be funded through Medicaid, Medicare, commercial insurance or private pay sources
Home health
offer supportive services and skilled nursing care in the home. Supportive services may include assistance with bathing, walking, and other activities of daily living; skilled nursing care may include services such as administration of medications, injections, and wound care. Physical and occupational therapy are also available to some home care clients. Home health care services are funded privately or through Medicaid, Medicare or commercial health insurance
Senior Housing
offers older adults smaller, more manageable living quarters and built-in opportunities for socializing. Programs may include services such as meals, transportation, and housekeeping. Senior housing may be funded privately, through rental payments or purchases or it may be subsidized through state or federal agencies.
PCA Services
hired privately to assist an older adult or disabled individual with activities of daily living so that they may continue to live in an independent living environment. There is also limited state funding for individuals who qualify
Adult Day Centers
community-based providers that offer daily care and social services. Participants are able to take advantage of day center services and return home in the evening. Day center may provide meals, recreation, transportation, bathing, medication administration, and nursing oversight. They are funded privately, through state subsidy programs, long-term care insurance and others
General understanding of the nature of nursing home care in the US
Can be institutionalized
Lots of fear around it
Need improvement
Still have neglect
The role of the AAA (Area Agencies on Aging)
help older adults and people with disabilities live with optimal health, well-being, independence and dignity in their homes and communities.
They assess, educate, serve, maximize funding, and develop programs to help older adults be sage within their communities and age in place
Want to make communities better for older adults
Physical changes that occur as part of the aging process
Metabolism decreases
Body uses less energy, dont need to eat as much, tend to gain weight, body slows down, less cells, less muscle mass, need to do more exercise for same results
More likely to get dehydrated
Less intracellular fluid, so less overall body fluid
Gray and thin hair
Thick hair in ears and nose
Ectropion of eyelids
Elongated ears
Darkening and wrinkling of skin around eyes
Facial hair growth in women
Deepening of hollows of axillae, ICS, and supraclavicular spaces
Narrower gait in women, wider in men
Decreased height
Diminished muscle mass and skinfold thickness
Resp sys
Decreased reflexes so coughs arent as effective
Rib cage is more brittle and cant expand as much
Less secretions so more infections
Less alveoli and less elastic too
All cumulative effects of lifestyle and SES
Cardiovascular
Increased risk of hypertension bc BP increases to compensate for increased peripheral resistance and decreased cardiac output
Vessels get stiff, so body cant respond appropriately, may get SOB and have circulation dysfunction
Decreased muscle mass so heart may be less effective (decreased cardiac output)
GI
Fewer cells
Fewer secretions
Decreased motility so increased constipation risk
Higher risk for malnutrition, constipation, and dehydration
Increased risk for adverse effects w meds bc the liver isnt as efficient at clearing stuff out
Increased risk of aspiration, indigestion, and constipation
Slower peristalsis
Less saliva
Reduced intestinal blood flow
Urinary
Incontinence is not a normal part of aging, but age does increase risk of development. Can be an adverse drug effect
Decreased kidney function, so cant clear fluids and meds as fast
Decreased bladder capacity
Weaker bladder muscles
Decreased size of renal mass
Decreased tubular function
Reproductive
Female
More alkaline vagina
Flattening of labia
Loss of vulvar subcutaneous fat and hair
Estrogen depeletion
Male
Possible reduction of sperm count
Prostate enlargement
Decreased orgasm and ejaculation intensity
Older adults remain sexual beings
Musculoskeletal system
Decreased muscle mass, strength, and movement
Increased risk of fractures
Nervous system
Decreased brain weight
Reduced blood flow to brain
Changes in sleep pattern
Slower response and reaction time
Decreased conduction velocity
Vision
Presbyopia- inability to focus on close objects clearly
Decreased in dim areas or at night
Decreased peripheral vision
Smaller pupil and less reactive to light
Depth perception distorted
Cataracts
Touch
Reduced sensation
Hearing
Presbycusis- progressive hearing loss
Distortion of high pitched sounds
More earwax
Less equilibrium
Chances to tympanic membrane
Taste and smell
Less for both
Tate dependent on smell
Less saliva, poor oral hygiene, meds and conditions can alter taste
Endocrine
Thyroid gland activity decreases
Decreases in certain hormones
Not as good insulin abilities
Cant metabolize sugar as well
Integumentary
Thin, gray hair
Brittle, fragile fingernails
Less elastic skin, more dry and fragile
Decreased subcut fat
Decline in immune response
More prone to infections
Immune
Less effective/efficient
High risk of infection
Thermoregulation
Lower body temp
Reduced ability to respond to hot/cold
Higher risk for heat stroke
Mind
Do not lose intelligence
Personality tends to remain consistent
May have slower mental processing
Age-related forgetfullness
Learning ability not changed
Easily distracted by irrelevant info/stimuli
Cant multitask
Aspects that are important to create age friendly spaces and communities
Things to consider for age friendly spaces are outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, and community support and health services
There should be adequate lighting, level and stable surfaces, safety features, easy things to grab, secure locks, etc
Methods for to prevent falls among older adults
Regular exercise to improve strength and balance
Ensure proper lighting in living spaces
Remove hazards such as loose rugs or clutter
Use assistive devices like grab bars and handrails
Regular vision check-ups
Medication review to minimize side effects
Adequate intake of vitamin D for bone health
Home modifications for safety, like non-slip mats in the bathroom
Risks older adults face during acute care hospitalizations
Care Transition Video by Dr. King
Increased risk for medical issues and several other things when transitioning between care places
Many risk factors with hospitalizations
HAI bc of old age, bacteria, medical procedures, and immobile
Loss of function and it can be very hard to get that function back. We should promote independence
Strong meds that their body may not be able to handle as well (body may have decreased function with age and they have a disease too, more side effects, harder to filter out meds)
Increased risk of delirium
Sleep disruptions → confusion → delirium
Disruption in normal routine
Make sure patients have assistive devices (glasses, hearing aids) to decrease risk
Unfamiliar environment = fall risk
Put fluids within reach to prevent dehydration
Begin discharge planning right away and promote independence
Diversity and caring for persons with dementia
Chapter 3
Aging populations are becoming more ethnically and racially diverse
Hispanics view states of health and illness as the actions of God
May use curanderos, sobadoras, espiritualistas, brujos, and senoras
Black Americans experience a lower standard of living, less access to healthcare, lots of hypertension; higher death rates from diseases like heart disease, stroke, cancer, asthma, influenza, pneumonia, diabetes, HIV, AIDS, and homicides; more obesity and smoking; recommend lifestyle changes and regular health screening
Asian Americans often use non-western/conventional medicinal approaches
Native Americans: traditional nursing assessment may be offensive and too probing; may be resistant to accepting services from agencies and professionals; higher rates of heart disease, cancer, stroke, cirrhosis, and chronic lower respiratory disease; low cancer survival rate\
Muslims may not take meds during fasting times; if dependent, turn to face Mecca in the west to northwest
Dont stereotype based on race, ethnicity, sexual orientation, or other factors
Diversity in Dementia Care
An attitude of cultural humility plus cultural competence is helpful when working with diverse older persons
There is little concrete evidence to assist providers with care for ethnoracially diverse groups
Ethnoracially- national heritage and ethnic identity are blended
Ethnogeriatric imperative is the idea that diversity in the population in general and elderly population is rapidly increasing
Rates of dementia differ by race and ethnicity
Risk factors of dementia include age, vascular system, and more
Minorities have an increased risk for certain conditions which also increases their risk for dementia
Much dementia care and what we know about it is for white people, it is not ethnically equal
Minorities seek help later on for a variety of reasons
Dementia is more prevalent in women because they live longer and the primary risk factor is age
Race- a person’s physical characteristics, such as bone structure, skin, hair, or eye color
Ethnicity- cultural factors, nationality, and ancestry
Indicence- measures how fast disease occurs and proportion of population developing new cases
Influenced by many things, such as medical and SES circumstances
Aka how many people are diagnosed w it in a certain time frame
Prevalence- measures proportion of population with disease
Aka how many people have it
Sex- biological status
Gender- attitudes, feelings, and behaviors culturally associated with biological sex
Gender identity- one’s sense of self as male, female, or trans
Sexual orientation- the sex of who ur attracted to
Things that influence rates of dementia: genetics, medical conditions, hypertension, cardiovascular diseases, diabetes
Hypertension and cardiovascular diseases are much more common in afri ameri pops. Higher risk of cardiovascular disease, stroke, high cholesterol, and hypertension
Ethnicity can influence dementia through onset, comorbidities, family history, APOE gene status, and cognitive changes over time
Lifestyle, health factors, and education level may have substantial influence on risk of dementia
Sex
More women have Alz and dementia bc women live longer, men have a high death rate from cardiovascular diseases, life experience, and genetic factors
Black/African American
Genetics increase risk
More diabetes increase risk
Social and cultural factors increase risk
More vascular dementia
Risk of Parkinson’s is lower
More missed diagnosis of Alz bc of diagnostic tools, underreporting, later stage diagnosis, and lack of rep in clinical trials leading to delays in treatment
Higher rates of medical conditions associated w dementia like hypertension, diabetes, and HIV
Care partners for those w/ dementia are less likely to be spouses
Higher rates of unhealthy behaviors in care partners than white counterparts
Hispanic/Latino
Fastest growing elderly pop
Longer life expectancies
Onset of dementia at a younger age
Dementia more related to preventable causes than in whites
SES factors increase risk
Many live below poverty line, dont seek medical care bc of financial/language barriers, and rely on family for assistance
Vascular and other medical risk factors increase risk
Obesity, type 2 diabetes, hypercholesterolemia, and hypertension increase risk
Need cultural sensitivity in diagnosis and treatment
Tailor care by address elder pt by last name, communicate indirectly through son or oldest child, limited or indirect eye contact, reserve close contact until familiarity is established, teach care partner adaptive coping skills
Asian American
Chinese
Many chinese americans and 1 in 10 are 65 or older
Many misconceptions about dementia
Memory problems are believed to be normal aging, therefore delayed diagnosis
Linguistic and cultural barriers make it hard to test and interpret results
Beliefs may interfere w/ willingness to seek diagnosis and treatment
Caring for elders is a social and moral responsibility
Filipino
Many risk factors
Vietnamese
Many are Buddhist or Christian/Catholic
Symptoms are believed to be a normal part of aging
Diagnosis brings shame to the entire family
Seen as a mental illness
Causes self-isolation of person and family
Use cultural norms when diagnosing and treating
Korean
Prevalence unknown
Is a cultural stigma and shame
Unaware of treatments and resources
Cultural barriers to care
Family is primary caregiving source
Japanese
Not lots of info, generally shamed
American Indian/Alaska Native
Prevalence and incidence differs by tribe
“Invisible” ethnically diverse group
No strong genetic risk
High diabetes rate
Dementia is seen as a spiritual or psychological problem
Caregiving within the family
Institutionalization at an earlier age bc lack of young people to provide care
Native Hawaiian/Other Pacific Islander
Often grouped with Asian Americans
SES factors include low income, high poverty rate, short life expectancy, high rates of obesity
Stay within family and church to manage dementia
LGBT
Lack of high quality health care access
Lack of disclosure results in incomplete assessments
Higher rates of depression, suicidal thoughts and attempts, substance use and abuse, and discrimination and stigma
May be denied health care
Increased risk for getting HIV/AIDS, esp trans
Rural
Lack of care facilities and transportation, high cost of care
Underreporting, underdiagnosis, and undertreatment
Intellectual Disabilities
Down syndrome = higher risk
Barriers to diagnosis and care management
Diversity and caring for persons at the end of life
Diversity in End-of-Life Care
Palliative care- a team-based approach to care for people with serious illness that is appropriate at any age/stage of illness. It can be provided along with curative treatment.
End-of-life care- focuses on palliative care for terminally ill individuals who may have only very limited time to live and have elected to no longer pursue curative treatment. It is often tied to hospice care, which is defined in the United States as encompassing the final six months of life.
Culture influences care preferences, attitudes toward health care, death, and dying, as well as advance care planning
Limited English proficiency, health literacy, and cultural differences can complicate communication between patients and healthcare providers
Families often want to be involved in their loved one’s care and pain management. For some marginalized groups, chosen friends may be preferred for support.
Psychologists and mental health providers with palliative care expertise can improve communication and provide emotional support for patients and families
The LGBTQ+ aging experience
LGBT aging sheet
More likley to be single and live alone, less likely to have children, more likely to face poverty, homelessness, and to have poor physical and mental health
Tend to rely on families of choice, facing unique obstacles in both giving and receiving care.
LGBT elders are less likely to reach out to senior centers and vital services, often delaying necessary medical care due to fear of discrimination.
Often dont receive appropriate care
Many experience victimization, such as threats, harassment, or physical assault. Many discriminated against in employment and/or housing
LGBT older people experience higher rates of poor physical health and mental distress compared to heterosexual older adults.
HIV disproportionately impacts the LGBT community
Vulnerable to social isolation, associated with poor physical health and the same impact as smoking 15 cigarettes a day
Many smoke, drink excessively, have had suicidal thoughts, and have attempted suicide
The role of the family caregiver
Taking Care of Those Caring for Persons Living With Dementia
Reasons to care about caregivers’ well-being include neglect, stress-related disease, fraility, and because it can prevent PLwD from going into a facility
Caregivers are more likely to report health as fair or poor
Caregivers have tons of sleep disturbances
As you get older, you are less likely to tolerate sleep deprivation as well
Caregivers may not be able to provide the proper level of care, resulting in unintentional neglect
Caregivers may end up dying first
Risks for caregivers include developing chronic health conditions and other things that result in declining health
Family caregivers are the primary source of care
We should look for indications of stress, raise the subject more than you would normally, acknowledge the stress of caregiving, be prepared to refer the caregiver for help
Help caregivers understand dementia, know what to expect, and what resources are available
Also talk about sleep, agitated behaviors of dementia people, eating issues, fears about abuse/anger, comfort level with medication management, social problems, psych problems, legal issues, feelings of competence and grief
Make sure caregivers dont neglect their own health
The person who normally did more household stuff and caring is less likely to label themself as the caregiver (often the wife in this position)
Dementia causes the longest goodbye
Encourage respite
Let the caregiver take a vacation and have someone else step in for that time so that the caregiver doesnt get burnt out
Caring for older adults with diseases/dementia is a marathon, not a sprint
Stress can result in a new disease
Existing disease may go unattended
Caregivers health must be maintained
Screening tools should be used
Respite is critical
Caregivers tend to not take care of themselves
General understanding of mild cognitive impairment and dementia: diagnosis, treatment, symptoms, necessary care
Mild Cognitive Impairment
Dementia
“A significant deterioration in 2 or more areas of cognitive function that is severe enough to interfere with a person’s ability to perform everyday activities”
Key indicator of dementia is it effects their function in everyday life and it is hard for them to be independent. They lose the ability to do ADLs and perform these tasks
not a specific disease; it's an umbrella term that encompasses a range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities.
Alzheimer's disease is the most common cause of dementia, accounting for 60-80% of cases.
Dementia is not a normal part of aging
Symptoms of dementia can vary but often include memory loss, difficulty communicating, inability to learn or remember new information, and difficulty planning and organizing.
Most forms sof dementia come on slowly and may be preceded by mild cognitive impairment that does not include functional losses
Dementia has 3 stages: early, middle, and late
Not all memory issues are indicative of Alz or other dementia
Dementia encompasses a range of neurodegenerative brain disorders; persons living with dementia (PLwD) have severe enough mental decline so as to interfere with daily life.
Chronic, persisten, progressive
Incidence is increasing because of the increase of old people
Delirium- sudden onset and curable when trigger is removed (UTI, anesthetia)
Early Onset Dementia- symptoms usually start age 30-65 (usually 50), also in adults with down syndrome.
Older adults often have comorbidities that complicate their care in may increase their risk of dementia
Types of Dementia:
Alzheimer's Disease:
Most common form of dementia
Caused by buildups of proteins that cause plaques and tangles that is somewhat predictive of Alz
Biomarkers are limited to research purposes only
Progressive neurodegeneration with increasing impairments
Symptoms typically begin with mild memory loss
Commonly mixed with vascular
Risk factors: age, cardiovascular and metabolic syndrome factors, head trauma, radiation from cancer treatments, family history (not predictive, but increased risk)
Vascular Dementia:
Caused by reduced/disruption of blood flow to the brain, often due to stroke or small vessel disease. “Hardening of the arteries”
Rates are decreasing
Risk factors: age, cardiovascular diseases, diabetes type stuff, brain damage, chronic kidney disease, stroke or heart attack, obesity, smoking, lack of exercise, lack of social support, poor diet
Symptoms: similar to Alz, cognitive, emotional, hallucinations, physical difficulties
Symptoms can vary widely, depending on the part of the brain affected
Similar lifespan to Alz- 3-5 years after symptoms begin
Lewy Body Dementia (LBD):
Characterized by abnormal protein deposits in the brain (Lewy body protein build ups)
Frequently under or misdiagnosed bc its tricky
Defining features include motor Parkinsonism and cognitive impairments
Symptoms can mimic psychosis just as much as it mimics Alz
Symptoms include visual hallucinations, fluctuating alertness, and problems with movement.
Risk factors: male, over age 60, genetic predisposition
Parkinson’s Disease Dementia- affects neurotransmitters and causes cognitive changes
Frontotemporal Dementia (FTD):
Group of disorders caused by progressive nerve cell loss in the brain's frontal lobes; protein accumulation in the frontal cortex
Often diagnosed in younger ages (less than 60)
Risk: increased with family history
Symptoms: changes in personality, behavior, and language; lack of impulse control, disinhibition, apathy, stereotypic behaviors,
Diagnosis and Treatment
Diagnosis of dementia requires impairment in 2+ core cognitive functions (memory, lang skills, visual perception, ability to focus/pay attention, ability to reason and solve problems
Often diagnosed by primary care provider, geriatrician, neuropsychologist, or neurologist
There's no single test for dementia. Diagnosis often involves medical history, physical examination, lab tests, and assessment of changes in thinking, day-to-day function, and behavior.
While there is no cure for most types of dementia, medications can temporarily improve symptoms or slow down their progression.
Non-drug approaches such as exercise, a healthy diet, and cognitive training can also be beneficial.
Communication Tips:
Speak clearly and calmly, maintaining eye contact.
Use simple words and short sentences.
Avoid quizzing or correcting the person.
Show empathy and understanding
Caregiver Support:
Caring for someone with dementia can be challenging and stressful.
Seek support from family, friends, and local resources.
Take breaks and make time for self-care.
Safety Precautions:
Ensure the home environment is safe and secure.
Reduce hazards such as clutter, loose rugs, and poor lighting.
Consider using alarms or locks on doors and windows to prevent wandering.
Planning for the Future:
It's essential to discuss legal, financial, and care planning early in the disease process.
Advance directives, power of attorney, and living wills can help ensure the person's wishes are carried out in the future.
The Alzheimer’s Association provides a range of resources, including support groups, educational programs, and a 24/7 Helpline.
Cognitive function- how a person becomes aware of, perceives, or comprehends ideas. While it does naturally decline, it does normally decline to the point of an inability to function unless there is a disease
Executive function- a set of mental or cognitive skills believed to be controlled by the frontal lobe, anterior cingulate, prefrontal cortex, basal ganglia, and thalamus
Organization: things like attention, managing time, planning and organizing, making a pot of coffee, etc
Regulation: emotions and behavior
Short-term/working memory- less than 1 minute, more likely to leave
Long-term/lifetime memory- includes sensual
Instrumental ADL- things like chores, cooking, using a phone, doing paperwork, etc. Requires intact executive function
Persons who have MCI (Mild Cognitive Impairment) have notable problems with memory or other core brain functions, but impairments are not sufficient to interfere with daily life
Not all MCI progresses to dementia
Depression can mimic MCI and lead to it
Many factors are considered in a differential diagnosis between natural aging, MCI, and dementia
Normal Aging
Key indicator is the ability to remain independent
body and brain gradually slow down, but intelligence remains stable
Changes in all 5 senses: visuoperceptual difficulties, auditory problems, speech and lang impairments, change in taste and smell
Some minimal changes to memory and perception are normal
Behavior and Psychological Symptoms
Can be the most disturbing
Avoid using restraints to manage
Can cause major personality and habit changes
Components of the role of the geriatric nurse
The Specialty of Gerontological Nursing
Core elements of gerontological nursing practice
Use evidence-based practice (base what we do on what research shows, continue to learn and grow)
Guided by standards for professional nursing practice (legal stuff too, know your scopes of practice, delegate appropriately)
Include competencies specific to gerontological nursing (its a specialty with certain certifications)
Be guided by nursing priniciples
RN roles
Healer: holistic approach; prevent, overcome, restore
Caregiver: actively participate; promote self-care
Educator: share knowledge, address problems
Advocate: unique to gerontological RN
Innovator: make changes
The Provider’s Role in Shared Decision-Making with Caregivers, Families, and PLwD
Client autonomy comes first
Identify the main question, identify what the PLwD wants, identify everyones goals (family and care team), and establish realistic expectations
Understand what the shared goal is
Advance care planning should end in the creating of an advance care directive
Decisions about medical care should result in a health care proxy
The 4 M’s of an age-friendly health system
Mentation- cognition, cognitive impairments, slowing it, delirium
Medication- polypharmacy
Mobility- lose quality of life when immobile, increased risk of falls and infection
Matters- making sure the older adult is making decisions regarding what matters to them the most
Other
Legal Aspects of Gerontological Nursing
Implied consent would be if you are actively dying
Durable POA has some limitations. They cant force their mom to take a medication that she is refusing
Consent- granting of permission to have an action taken or procedure performed
Durable power of attorney- allows competent individuals to appoint someone to make decision on their behalf in the event that they become incompetent
Duty- a relationship between individuals in which one is responsible or has been contracted to provide service for another
HIPAA- Health Insurance Portability and Accountability Act of 1996, assures confidentiality of health information and consumers access to their health records
Injury- physical or mental harm to another or violation of a person’s rights resulting from a negligent act
Malpractice- deviation from standard of care
Negligence- failure to conform to the standard of care
Standard of care- the norm for what a reasonable individual in a similar circumstance would do
A nurse must provide the patient with all of the information in a way that they can understand in order to make an informed decision
Assent- they may not fully agree, but they accet the treatment anyways
Guardian of property- this limited guardianship allows guardian to take care of financial matters but not make decisions regarding medical treatment
Guardian of person- decisions pertaining to consent or refusal for care and treatments can be made by persons granted this type of guardian ship
Plenary guardianship- all types of decisions pertaining to person and property can be made by guardians
Limited power of attorney- decisions are limited to certain matters and power of attorney becomes invalid if the individual becomes incompetent
Durable power of attorney- provides a mechanism for continuing or initiating power of attorney in the event the individual becomes incompetent
Need a physician order for restraints; they are rarely used and the last option
DNR is part of advanced directives
Capacity- the ability of someone to participate in their care decisions\
Make sure that all patients have advancd directives in place. It is a written document of who you want to make decisions and what decisions you want. DNR is part of this. It must be respected and followed. Need to make informed decisions for this. The care team should know these orders.
Ethics
Autonomy- individual freedom, preferences, and rights
Beneficence- do good for patients
Confidentiality- respect privacy
Ethics- a system of moral principles that guide behavior
Fidelity- to respect our words and duty to patients
Justice- to be fair and treat people equally
Nonmaleficence- to prevent harm to patients
Veracity- truthfulness
Utilitarianism- good acts are the ones where the most people will benefit and gain happiness
Egosim- its only good if it benefits yourself
Relativism- right and wrong are relative to the situation
Absolutism- specific truths that guide actions
Ethics and Capacity Issues
Have a high level of suspicion for elder abuse or neglect
Dont underestimate dementia peoples ability to express opinions about their care
Older people have the right to take informed risks
Providers have a role in determining a person’s decision-making capacity
Plan for the future asap so the PLwD can assist in decision making while still capable
Can be very difficult to get long term stuff paid for
Guardianship- enacted by a court when there is no family or there is family dysfunction, so there is no POA
Not common
Capacity is a functional assessment of understanding, appreciation, expressing a choice, and rationalization
4 primary ethical considerations:
Beneficence- does the benefit outweigh the risk
Nonmaleficence- first, do no harm
Respect for autonomy- pt gets to make their own decision
Privacy and confidentiality
Sexual functions or relations may change throughout life, but older adults remain sexual beings
Most common form of elder abuse is financial exploitation
majority of abusers are family members who are often the caregiver
People have a right to live in a way that is consistent with their culture, even if we dont feel it is the most appropriate (part of autonomy)
Sometimes people are unaware of what constitutes as abuse
Stick to your facts and what you see
Dont let your bias cloud your vision