Gerontological Nursing

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Gerontological Nursing
Revised by Dr. Maria Park
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Introduction

• The Aging population The world issue
• Prevalence and scope of the problem
• Impact of the Baby Boomers

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Impact of Aging Population Gerontological
Nursing Issue

• Health status of older adults
• Health Care Expenditure Use
• Health Care Setting
• Nursing home, Residential care, home care

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Barriers to health care

• Common myths of Aging
• Ageism
• Attitudes of caregiver and receiver
• Finance
• Transportation reliance on others
• Health care reform and it impacts on health care
  needs for older adults.

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Life Transition

• Role Changes
• Compound losses
• Widowhood
• Retirement
• Reduced income
• Loss of social prestige
• Social isolation

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The Aging Process

• Factors affecting Aging process
• Heredity
• Past and present illnesses
• Amount of life stress
• Lifestyle - exercise, nutrition, gen. fitness

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Theories of Aging

• Biological Theory
• Genetic programming/ Longevity
• Somatic DNA Damage theory
• Endocrine, immunological
• Normal Wear/Tear,
• Free Radical, Cross-link theories.
• Psychosocial

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Process of Aging

• Biophysiological Aging
• Psychosocial Aging
• Personality and socioenvioronmental
• Past coping mechanisms
• adjustment to stressful life event in later life
• Adaptation More difficult for the elderly
• Loss likely to occur close together with less
  time to adjust to each event.

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Process of aging Psychosocial

• Social support and interaction
• Sexuality and intimacy
• Role transitions and role reverse

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Legal/Ethical Issues in Gerontological Nursing

• Gerontological care issues
• Core ethical concepts in GR
• Patient-based principles Autonomy- right of the
  individual to hold views, make decisions, and
  take voluntary actions based on personal
  preferences and beliefs.
• Direct vs delegated autonomy
• Competent vs incapacitated autonomy

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Legal,Ethical cont.

• Other dimensions of Autonomy
• Substitute Judgment
• Beneficence and Nonmaleficence
• Paternalism Weak paternalism and strong
  paternalism.

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LegalEthical cont..

• Omnibus Budget Reconciliation Act
• Provision of service requirementsQuality of
  care
• Resident Rights
• Do not resuscitate orders
• Advanced Medical Directives
• Legal Tools living wills

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End of life decision diagram

• Person is competent
• Right to self-determination
• Not competent substitute decision
• Court appointed conservator if needed
• The living will speaks
• Durable power of attorney non-life support
  decisions
• Case law proof of their wishes

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Ethical decision making

• Encourage pts expressions of desires
• Identify significant others who impact are
  impacted.
• Review personal value system -know self.
• Form an ethics committee
• Consult clinical ethics consultation- mediate
  moral conflict.
• Read, discuss, share, evaluate decisions.

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Laws governing GN practice

• Legal risks facing Nurses
• Legal liability for Nurses
• Assault and Battery
• Negligence
• False Imprisonment
• Invasion of Privacy
• Defamation of Character
• Larceny

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Practice Setting / Competency requirement

• Nursing in the Acute Care Setting
• Specific competency and Expertise
• Critical Care and Trauma Care
• Special Care-related Issues
• Home Care and Hospice
• Community-based Services

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The Role of the GN

• Implementation of the plan of TX
• The Nurses Role
• OASIS an assessment toolcare
• The Role of the Nurses
• OASIS

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Standard used in Gerontological Nursing

• ANA Standard of Practice for GN
• Scope and major roles in GN
• GN practice setting
• Issues concerning GN

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ANA Standard of CLINICAL GN Care

• Standard 1 Assessment
• Standard 11 Diagnosis
• Standard 111 Outcome Identification
• Standard 1V Planning
• Standard V Implementation
• Standard V1 Evaluation

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Introduction to Mental Health and Illness among
Older Adults
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Depression

• Incidence Depression and Suicide
• Major depression and depressive symptoms affect
  eldery 20-40 in U.S.
• Incidence inc. among women and who are
  medically,emotionally ill or in long-term care.
• Age appropriate assessment and Dx.

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Barriers to Mental Health Care

• Attitudes Do not seek help as needed.
• Finance Limited income of elders.
• Transportation Elders rely on others
• Inadequate detection of MI Tx Seek
  GP, not psychiatrist somatic C/P results in
  misdiagnosis.

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Differential DiagnosisDepression

• Differentiating Physical from Mental Illness
• Differential DX between Depression and Dementia
• PSEUDODEMENTIA The phenomenon of depression
  appears to be demented.
• Drug Interaction and Side Effects Needs for
  drug inventory

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Assessment of Pt.with Depression

• Health Hx, Medical Illnesses,
• Medication inventory,
• Mental Status Assessment including Risk for
  suicide.
• Physical Assessment Energy level and level of
  independence - ADL
• Psychosocial Assessment Psychosocial stressors,
  and Coping ability
• Laboratory and other diagnostic tests EEG, ECG,
  Chem. Profile, CBC, B12 level, CAT, MRI,
  Serologic tests, Thyroid panel, urinalysis.

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Clues /Warning signs of Suicide

• Verbal Clues
• Behavioral Clues
• Situational Clues
• Recent move ( to a nursing home, relatives)
• Death of a spouse
• Diagnosis of terminal illness

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Geriatric Depression Scale(GDS)

• GDS best tool specifically designed to use for
  older adults.
• It consists of 30 questionnaire
• Direction Present questions VERBALLY. Circle
  answer given by pt. Do not show to pt.
• 21-30 severe depression
• 11-20 mild-mod . 0-10 considered normal
• . GDS scale available in reserve section.

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• GDS scale limitation Not applicable for
  severely demented pt.
• The GDS is not a substitute for a diagnostic
  interview.
• GDS is a screening tool for assessment of
  depression in older adults.

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Depression Secondary to Medical Illness

• How prevalent is depression in the medically ill
  patient?
• Up to 17 of adults
• ECA study 9.4-12.9 of medically ill patients
  experienced depression in comparison to 5.8-8.9
  in a matched control group of healthy individuals
  ( wells, et al. 1998).

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Under-diagnosis Under-treatment

• Depression in the medically ill patients are
  under-diagnosed and under-treated
• Only 34.9 of pts with major depressive disorder
  were identified and adequately treated by their
  primary care physicians( Coyne et al 1995)

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Depression secondary to Medical Illness

• Characteristics of
• Older age at onset
• More likely to respond to ECT
• More likely to show organic features in Mental
  Status Exam.
• Less likely to have SI or commit suicide (18
  vs45) Winokur, 90

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Common Medical Conditions Etiologically R/T
Depression

• CA
• endocrine disorders
• End stage renal disease and Hemodialysis
• Neurological disorders

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Common Medications Assocwith Depression

• Antihypertensives
• Benzodiazepines ( Anti-anxiety meds)
• Cancer- chemotherapeutic agents
• Contraceptives
• Corticosteroids
• Histamine 2 receptor antagonist
• Cimetadine(Tagamet)
• Ranitidine(Zantac)

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Psychoactive substances Assoc.with Depression

• Alcohol
• Amphetamine (withdrawal)
• Anabolic steroids
• Cocaine (withdrawal)
• Opiates

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Polypharmacy in the Tx of Older Adults

• Issues concerning polypharmacy in the elderly
• Prevalence
• Prevention strategies

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Nursing Care Plan

• Presenting problems and the risks
• Leading Dx for Older Adults with Depression, and
  suicidal tendency
• Outcome criteria
• Intervention plan

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TX of Depression in the Medically ill Pts

• Assessment of pt to identify mimicking problem
• Intervention strategies
• Psychopharmacologic management
• SSRIS, NSSRIs, TCAS

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Treatment of Depression Elders

• Somatic Tx. Consider pharmacodynamic changes in
  the Elderly Adverse drug reactions
  interactions
• Antidepressants Use with the lowest level of
  anticholinergic effect.
• Second gen. Antidepressants with low
  anticholinergic effects Zoloft and Paxel,
• Mood stablizer Divalproex NA ( Depakote)
• Benzodiazepines
• ECT

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SSRIs and NSSRIS

• Sertraline Zoloft
  Venlafaxine Effexor
• Paroxetine- Paxil
  Mirtazapine Remeron
• Escitalopram Lexapro
• Fluvoxamine Luvox
• Citalopram Celexa
• Remeron
  increases norepinephrine and serotonin through
  blockade of inhibitory receptors.
• Fluoxetine Prozac is not commonly
  prescribed to older adults because of long
  half-life.

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Psychosocial ApproachDepression

• Il N/T interaction develop trusting
  relationships.
• Overcome barriers (Ageism, attitudes)
• Improve pts self-esteem
• Help improve appearance
• Acknowledge any progress pt made.
• Encourage socialization - Dec. anhedonia.
• Focus on here-and now A graded system.
• Milieu management
• Reminiscence Therapy
• Cognitive Behavioral Therapy

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Normal Changes with Aging

• Cognitive function
• Personality and Self-Concept
• Stress and Coping

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Aging and Cognitive Changes

• Pathology begins
• _55__60_65__70__Onset symptoms________
• 
  Loss of ADLs
• _________________ 75 80 85 lt85
• _______/___________/_________/__90 lt90
  
  Normal Prodromal Symptomatic D
  eath

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Prevalence of Dementia Increase with Age
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Cognitive Mental Disorders Organic

• DementiaPermanent, chronic progressive form of
  CMD developed over an extended time.
• Incidence Prevalence Alzheimers disease is
  the most common form of dementia (50-70).
• Multi-infarct dementiaBy repeated strokes.
• Small caused by neurological disorders
  huntington, Parkinsons, and head injury.
• Alcoholism, drug overdose, malnutrition.
• Infectious diseases HIV

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Etiology

• Genetic
• Biological loss of neurons in the brain cerebral
  cortex and Hippocampus.
• Neurofibrillary tangles
• Amyloid plaques
• Environmental

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Diagnostic Test

• Spinal fluid analysis for b-amyloid measure
• Neuronal thread Protein (NTP) measurement.
• Postmortem autopsy.
• Differential DX
• Alzheimers D vs other organic dementia
• Alzheimers D vs Psuedodementia

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Cognitive Testing Mini-Mental State Exam(MMSE)

• Score 5/5 Orientation
• Score 3 Registration
• Score 5 Attention Calculation
• Score 3 Recall
• Score 9 Language
• Total score
• Assess level of consciousness
• Alert Drowsy Stupor-coma

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Cognitive Testing Clock Draw

• CLOX(Clock)
• Measure the executive control function(ECF)
• eg goal selection, motor planning, sequencing,
  selective attention.
• Directions Ask the pt to draw a clock
• Start by drawing a large circle
• Fill in all the numbers on a clock
• Set the hands to show the time 840

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Cognitive Testing Mini-Cog

• 3 item recall and clock drawing
• Directions
• Say 3 categorically unrelated words (like MMSE)
• Ask pt to repeat back to you and remember them
• Give the clock drawing test
• Ask the pt to tell you the 3 words again

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Cognitive testing Mini-cog

• Mini-cog
• Recall0 Recall1-2 Recall3
• Clock abnormal Clock normal
• Demented Non-demented

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Diagnostic Studies

• Blood Studies CBC, B12, Folate, TSH,
• Chem profile, homocysteine,
• Brain imaging
• MRI or CT

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Physical Exam

• Complete physical and neurological
• Essentially normal in AD
• Co-morbidities that may contribute to cognitive
  impairment.

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Diagnostic Criteria for Dementia

• Multiple Cognitive impairment manifested by
• 1). Memory loss(enable to learn new or recall).
• 2). One or more of the cognitive disturbances.
• -Aphasia, Agnosia Apraxia,, disturbance in
  executive functioning.
• Significant Impairment in social or occupational
  functioning due to deficit in criteria 1) and 2)
  above.
• Gradual onset progressive cognitive decline

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Dementia v.s. Delirium

• Chronic Acute
• Not easy to ident. early Obviously sick
• Irreversible Reversible
• Insidious Rapid onset
• Clear sensorium - Clouded sensorium (until
  progressed).

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Alzheimers D Clinical feature

• EARLY STAGE Mild Stage ( 2-4 years).
  Intermediate state between normal cognition and
  dementia.
• Symptoms mild -some IADLs maintained.
• Difficulty holding onto new information
• sign of short-term recent memory losses.
• Slower reactions ,slower learning
• labile affect and Poor concentration.
• Subtle personality behavioral changes
• Inc. risk for progressing to next phase.

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Alzheimers D

• MIDDLE/moderate STAGE( 2-8 years).
• Progressive need for help with ADLs Difficult
  to perform previously learned skills, Enable to
  retain new information. Loss of IADLs
• Behavioral and personality changes - agitation,
  aggression,
• Increasing long-term memory loss as well
• Confused, wonder off
• Ends with dependency for basic ADLs
• MMSE decrease from 19 to 12

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Alzheimers D

• LATE STAGE Severe stage (2-8 years)
• Nursing Home Care 24 hour nursing care
• Lives within the present only, still ambulatory.
• Incontinent. Follows only simple repetitive
  commands
• Disorientation - time and place - wandering off
• Behavior and personality change agitated,
  depressed,
• Unable to recognize family members, friends
• Remembers only distant past
• Difficult to perform most of ADLS
• MMSE lt 12

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Alzheimers D

• FINAL STAGE
• Memory loss all three
• Total loss of ADL
• Bedridden - Fetal position.
• Physical and mental deterioration

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Terms associated with speech/language findings in
AD

• Aphasia, Anomia, Alexia
• Agnosia, Agraphia
• Apraxia
• Dysphasia, Dysphagia, Dysphonia
• Dysarthria
• Confabulation

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Depression among AD

• Mild cognitive impairment accompanied by mild
  depression inc risk for AD (visser et al 2000).
• Depression is common in dementia at all stages
• (Lyketsos et al, 97).
• Symptoms may be subtle or unrecognized by pt and
  carer.
• Cornell Scale for Depression in Dementia

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Psychosis and Agitation

• Common in Alzheimers disease and other dementing
  illness
• Major source of caregiver distress
• Contribute to premature institutionalization
• Causes of distress to caregivers disturbing
  symptoms.
• Management of aggressive behavior in AD
• Risperidone, Olanzapine, and Quetiapine

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NURSING ASSESSMENT

• Assess current status of
• Extend of memory loss,Cognitive,affective/Mood,
  Behavioral ( aggression, agitation) problems.
• Risk factors injury, elope,
• Ability to perform IADLs, ADLs.
• Rest, exercise, recreation, socialization,
  communication difficulties.
• Events that trigger behavioral change( sundown
  syndrome? Wandering?)

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Nursing DX Intervention

• Risk for injury R/T
• Self-care Deficit R/T...
• Impaired Communication R/T
• Management of target symptoms

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AD Treatment Strategies

• Early detection
• Effective Tx
• Delay symptomatic onset
• Slow progression
• Palliative
• Affect the disease process to alter symptoms

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Disease slowing Tx AD

• Potential Drugs
• Nasal Al Vaccine Designed to attack brain
  B-Amyloid, and slow down mental decline. The
  result were not conclusive -stopped due
  significant SE.
• There is a host of new medications in various
  stages of development.

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Symptomatic Tx cognitive

• Acetylcholinesterase inhibitors
• Physostigmine
• Tacrine (Cognex)
• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Reminyl)Razadyne(new name)
• Memantine(Namenda)
• Vitamin E supplements

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Promotion of General Health

• Ensure adequate Medical Care
• Promote physical health nutrition, exercise
• Tx of Comorbid medical condition
• Care for iatrogenic events
• Monitor drugs taken for other medical disorders
  Need stringent control of unnecessary drugs taken
  - prescription/ OTC, herbal.

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Psychosocial Interventions

• Early stage Support group for person with AD
  and carer.
• An increase in knowledge
• Sharing of experiences and feelings
• Creation of individual support networks.

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Other Tx for Alzheimers D

• Anticonvulsant/Mood stabilizer -Divalproex (
  aggression management) Fall precaution.
• Antianxiety agents- Benzodiazepines
• Antipsychotic - Atypical.
• Sedatives
• Antidepressants
• Ergoloid Mesylate (Hydergine) - Slow down mental
  deterioration.

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Reference

• New videotapes in Nrsg Labn
• No.NV 132 - Preventing Client Abuse
• No.NV 133 - The Cognitively Impaired Geri
• No.NV 134 - The Cognitively Impaired Geri
• Also reference materials are available at
  Alzheimers Disease and rel. disorders
  Association. 1-800-621-0379
• 360 N. Michigan Ave.Chicago,IL60601

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Picks Disease

• Differential Dx
• Usually occurs after age 70
• Onset is slow, progress until death( duration 4y)
• Postmortem exam- Shrinkage of localized cortical
  areas and dec. number of neurons.

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Alcoholism in late life

• Introduction Incident, Myths
• Impact of alcohol on elders
• Decreased tolerance age-related physiological
  changes inc. likelihood of physical injuries.
• Interaction with prescription OCT drugs.

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Risk Group

• Older men when their wives die
• Older adults with freq. Hospitalization.
• Older adults with psychiatric illness
• Hx of ETOH use earlier in life.

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Diagnosis of Alcoholism

• Types of elderly alcoholics
• Early-onset Aging alcoholic
• Late-onset No previous Hx. Usually develop in
  response to stressor of aging.
• Future generation of elderly - more expose
• Referral Barriers - several pitfalls
• Brief Michigan Alcohol Screening Test

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ETOH Screening Tools

• Short Michigan Alcoholism Screening
  Test-Geriatric Version(S-MAST-G)
• Total 10 questionnaire
• Scoring 2 or more Yes responses indicative of
  alcohol problem.
• SMAST-C scale available upon request
• CAGE questionnaire.

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Treatment of elderly alcoholic

• Identify high risk elders in the community.
• Assess and recognize elderly pts with alcohol
  abuse.
• Be aware of their financial and transportation
  abilities.
• Be aware of recovery potential.
• Tx plans - emphasize social and interpersonal
  therapies that are appropriate

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10 Risk Factors Assoc.with the Abused Elder

• 1.Gender - Men - Victim of phy. Violence
• Women - neglected
• 2. Age -75 and older are more likely abused
• 3. Dependent elder/ caregiver burden.
• 4. Alcohol Abuse -
• 5.Hx of Violence -family violence may cont.
• 6. Isolated elder at higher risk for abuse.

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10 Risk Factors cont..

• 7. Physical/mental Impairment
• 8. Provocative Behavior.
• 9. Living with Family/relatives
• 10. Cognitive Impairments.

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10 Risk Factors assoc..withAbusive Caregivers
are

• 1.Alcohol or Drug Abuse. 2.Mental Illness.
• 3. Unemployment. 4.Hx of child abuse.
• 5. Excess stress. 6. Lack of Support.
• 7. Duration of Caregiving.
• 8. Dependence on the Elder.
• 9. Reluctance or Inexperience.
• 10. Hx of Violence outside the family.

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Victim Interview

• Provide privacy - ll is important
• Communicate mater- of - factly
• Non-threatening manner- general to specific
• Question the victim direct to the point if abuse
  is suspected.
• Reporting and Documentation of the finding
• Pay extreme caution when confronted with
  suspected batterers.

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Home Assessment forElder Abuse/Neglect

• Environmental Conditions
• Heating, lighting, furniture, cooking utensils
• Food in the refrigerator ( old? Locked?)
• Blocked stairways, doors.
• Victim lying in urine, feces, or food
• Unsanitary living cond. -pile of garbage.
• Medical Attention / Medication.

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Assessment of the Victim

• Physical appearance and behavior
• Physical condition Malnutrition? Bruises?
  Laceration?Scars? Burned marks?Fractures
  Hematomas? Sign of internal injuries?
• Emotional and Mental Level of anxiety,
• usual defense mech. Sign of depression (sense of
  hopelessness, low self-esteem), cognitive
  /sensory functions
• Assess risk for further abuse/neglect.

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Outcome Criteria The pt will

• Be free of physical /mental sign of abuse by
  (date)
• Be able to name two people who can be called for
  help by (date).

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Intervention for Abused Elderly

• Stress concern for physical safety.
• Stress that no one has the right to abuse another
  person.
• Provide information re Hotlines, Crisis
  units,Emergency numbers, if abused is capable of
  making decision.
• Explore the ways to make changes
• Involve community supports to help monitor and
  support the victim.

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Family Therapy

• Family members are the primary caretakers
• Abusers are usually the caretakers
• Family therapy can assist with
• elderly persons functional status
• function of the family system.
• Supportive services
• family therapy for maladaptive behavior