May 6th Lecture #1

Management of the Older Adult Patient: Alzheimer's Dementia

  • Proportion of Americans 65+ has tripled in the past 100 years.
  • Life expectancy varies by gender and race.
  • Leading causes of death:
    • Heart diseases (heart failure, atrial fibrillation)
    • Cancers (malignant neoplasms)
    • COPD (chronic obstructive pulmonary disease)
    • Stroke
    • Alzheimer's disease

Preventive Health Care

  • Promote lifelong health behaviors.
  • Educate older adults on smoking cessation.

Cardiovascular Changes

  • Heart disease is the leading cause of death.

    • Myocardial hypertrophy occurs due to atherosclerosis.
    • Arteries get clogged, making it hard for blood to pass through.
    • Heart works harder, leading to heart failure and atrial fibrillation.
    • Decreased cardiac output.

  • Atherosclerosis:

    • Arteries narrow, reducing blood flow.
    • Results in decreased cardiac output.

  • Signs of decreased cardiac output:

    • Hypotension
    • Dizziness (due to poor perfusion to the brain)
    • Altered LOC (level of consciousness)
    • Heart failure develops as the heart tries to compensate.
    • Increased fibrosis, reducing stroke volume.
    • Calcium fat deposits can lead to hypertension.
    • Increased workload of the heart.
    • Orthostatic hypotension: Increased risk for falls.

Respiratory Changes

  • Diminished respiratory efficiency.
  • Reduced maximal inspiratory and expiratory force.
  • Smoking is a significant risk factor.

Integumentary Changes (Skin)

  • Subcutaneous fat diminishes, leading to less body heat conservation.
  • Hair pigmentation changes.
  • Balding may occur.
  • Wrinkling and sagging of the skin.

Reproductive System

  • Sexual activity declines.

  • Males:

    • Can produce viable sperm up to age 90.

  • Females:

    • Can only produce ova before menopause; after menopause, no more kids.

Genitourinary System

  • Slower restoration of acid-base balance in response to stress.
  • Decreased glomerular filtration rate (GFR).
  • Less efficiency in reabsorbing and concentrating urine.
  • Weakened sphincter muscle leading to stress incontinence (even with sneezing or coughing).
  • Weakened detrusor muscle; females may need a sling to prevent stress incontinence.

Gastrointestinal System

  • Decreased salivation and thirst sensation.

  • Nursing home patients may not drink enough; encourage small sips with a straw.

  • Dehydration can lead to UTIs (urinary tract infections).

  • In older adults, confusion may be the only sign of infection (UTI, pneumonia).

  • Doctor's orders for confusion: STAT UA with CNS as indicated and STAT chest X-ray.

  • Delayed esophageal gastric emptying and reduced gastric motility.

  • Small, hard stools due to not drinking enough fluid and reduced gastric motility; eat fiber.

  • Difficulty chewing and swallowing food (dysphagia); report to the doctor for speech therapy consult to prevent aspiration pneumonia.

Nutritional Health

  • Require fewer calories; encourage nutritious snacks.

Sleep

  • Sleep less (4-5 hours a day).
  • Poor sleep can lead to falls and daytime fatigue.
  • Waking up early (4 AM) in nursing homes may be due to worker schedules.

Retirement Planning

  • Considerations for future care needs.
  • Desire to stay at home versus nursing home placement.
  • Importance of family support and financial planning for private caregivers.

Musculoskeletal System

  • Loss of bone density (osteoporosis), especially in older females.
  • Risk for fractures.
  • Degeneration.
  • Loss of muscle strength and size.

Nervous System

  • Reduced cerebral circulation, prone to fainting and loss of balance.
  • Risk for falls.
  • Reduced speed in nerve conduction.
  • Homeostasis is difficult to maintain; fragile bones lead to fractures, which can start a decline.

Sensory Changes

  • Vision: Cataracts -> Ensure eyeglasses are accessible to prevent falls.
  • Hearing: Hearing aids -> Take care, as they are expensive.
  • Denture's: Without dentures, they cannot eat well. Be careful and have a system in place where they are not lost and have the patients name on them.

Psychosocial Aspects

  • Fear of aging; retirement stress and coping.
  • Normal aging changes impair physical function, activities, and appearance.
  • Death of significant others can lead to depression.

Coping and Living Arrangements

  • Living arrangements: Community, assisted living, or nursing home.
  • Encourage older adults to be as independent as possible.

Long-Term Care

  • Geriatrics and nursing management support cognitive function.
  • Some older adults have sharp minds well into their 90s.
  • Youngest dementia patient: 50 years old.
  • Reduce anxiety and agitation, especially in Alzheimer's patients.

Socialization and Nutrition

  • Socialization activities like bingo.
  • Adequate nutrition with scheduled nourishment.

Polypharmacy

  • Older adults take many medications (ibuprofen, acetaminophen, vitamins, Ginkgo Biloba).
  • Drugs can alter absorption and metabolism, with potential interactions.
  • Avoid Garlic, ginger, Ginkgo biloba when taking anticoagulants.

Problems with Older Adults

  • Depression: Most common affective disorder; increased risk for suicide.
    • Antidepressants are common, even for stroke patients.
  • Substance abuse: Overuse and misuse of drugs; alcohol.
    • Dangerous due to liver and renal effects.
      *Problem? Delirium: Acute confusion due to infection; can be cured once the cause is treated.

Dementia

  • Dementia is an umbrella term.

  • Alzheimer's is the most common type of dementia (~70%).

  • Types of Dementia:

    • Lewy body dementia
    • Vascular dementia: often from brain injury patients.
    • Alzheimer's: Neurofibrillary tangles and amyloid plaques in the brain.

  • Diagnosis of Alzheimer's:

    • No definitive diagnosis via CAT scan or MRI.
    • Only diagnosis method is autopsy.

  • Familial early onset: Genetic; rare.

  • Late-onset Alzheimer's: More common with age.

  • Stages of Alzheimer's

    • Stage One: Forgetfulness.
    • Stage Two: Denial and Confused.
    • Stage Three: Moderate-to-severe ambulatory dementia; more forgetful and confused.
    • Stage Four: End-stage.

  • Four A's of Alzheimer's

    • Amnesia: Loss of Ability to recognize familiar faces.
    • Forgetful.
    • Aphasia: Loss of memory caused by brain degeneration, mostly short-term memory.
    • Aproxia: Difficulty expressing themselves in spoken words.
Approaching Alzheimer's Patients

  • DO NOT FIGHT WITH THEM

  • DO NOT ARGUE WITH THEM

  • Avoid confrontation to prevent agitation. Persuade them instead of forcing them.

  • Ensure safety.

  • Personality Changes: Can be drastic.

  • Assistance with ADLs: Repetitive questions and stories.

  • Definitive diagnosis can only be made at autopsy:

    • Health history medical.
    • Family history,

  • Goals. Rule out what? Like rule out patient infection with UTI.
    EEG and MRI - There are not reliable definitive diagnosis measures but also genetic testing can be performed.

  • Main goal is to manage cognitive and behavioral symptoms with medication
    Medication: Will not get better with the medicine but rather delay progression or improve cognitive ability within 6-12 months.

    • Aricept/donesophil.
    • Exelon/rivastigmine.
    • Namenda/Momentin

  • Nursing diagnosis for Alzheimer patients:

    • Deceased memory.
Conservatorship?

  • If patients can not family members

  • Apply for conservatorship or request doctor.

  • Memory issue, potential for falls ( wandering).
    Inability to ambulate independently.
    ELDER ABUSE!

Manage memory, prevent injury and abuse.

  • Promote independence.
    • Cognitive function ( memory training).
    • promote physical safety.

** Geriatric triad symptoms**
** Cognitive changes, falls, INCONTINENCE.

Geriatric abuse!

  • Different firms include neglect. Which will allow to send that report to social worker and they may be reported.
    *Elder Abandonment!

Pulmonary: Artery, pulmonary vein , left atrium , mitral valve, left ventricle, Aortic valve, to the aorta out to circulation.

You need to know unoxygenated VS oxygenated blood.

Coronary Arteries: Supply the heart.

  • Need to know how to maintain hemodynamitics.

  • SA Nodes

    • Right Atrium.
      Superior venue Cava- Below
      SA Node- Natural Pace maker. *** 60-100 HR*

  • SA independently fires * No brain activity, commands need it.*
    Internodal Path away.
    AV NODE 40-60 HR! TO give ventricular FILLING!

  • Too fast is v tach!
    Bundle of HIS.
    Bundle branches ** Need to go at the same time* PERKJE FIBROID 20-40 HR SLOWER. NO FASTER.

Cardiac Action Potential

Depolarization contraction affects electrolytes!

  • The potassium - Inside the cell!
    Sodium/ with calcium OUTSIDE!
    CONTRACTION is potassium goes OUT, sodium goes IN
    Repolarization/Re- l axation They go back
    then sodium goes out.

Mechanical system?

Mechanical vs Electrical Activity!
**Need both to to have pulse pulse.
NO MECHANICAL AND ELECTRICAL A - PEA!
Cardiac cycle and how it relates cardiac output ( cardiac out put balancing between venoms input).

  • Cardiac output: amount heart pumps per minute.

Cardiac Output= Stroke volume HR.

SV= Pre load: degree of stretch of cardiac muscle fibers.
After Load is the resistance of that ejected.

Contractility ability. To electric.

Factors

  • Hyperlipidemia

  • TOO MUCH FLUID

  • HF.
    HTN - VasocoNstriction.
    WHAT IS
    EF
    Ejection Fraction?55 AND 75
    Amount of Blood in ejected from heart.
    Very common with HF due to drug uses. And leads to heart failure.