Chapter 13: Management of Common Illnesses, Disease, and ...

Chapter 13: Management of Common Illnesses, Disease, and ...

Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: CV and Resp. Bonnie M. Wivell, MS, RN, CNS Statistics 27 million Americans age 65 or older have some form of CVD 32% of all deaths in 2008 were attributed to CVD (AHA, 2008)

Major diseases (AHA, 2005): Hypertension CHD MI Angina CHF Stroke Hypertension: Background

65 million Americans have HTN African American males have highest incidence In 2004, 63.6% of men and 73.9 % of women ages 6574 were diagnosed with HTN Of those age 75 or older, 69.5% of men and 83.8% of women had HTN Have a 1.8 times greater risk than whites of having a fatal stroke, and a 4.2 times greater chance of developing end stage renal disease (AHA, 2008)

Number one risk factor for stroke Significant cause of ESRD Goal: 120/80 or less consistently ideal BP determined with physician Hypertension: Risk Factors

Heredity Race (African American) Increased age Sedentary lifestyle Obesity Male gender High sodium intake Excessive alcohol intake Diabetes or renal disease Pregnancy Oral contraceptives or other meds Hypertension: Control

Limit alcohol intake to one drink per day Limit sodium intake Stop smoking Maintain a low fat diet that still contains adequate vitamins and minerals through adding leafy green vegetables and fruits Exercise Weight management Regular BP checks Take meds as directed Coronary Heart Disease (CHD): Background

Also called CAD or ischemic heart disease Atherosclerosis resulting in an impaired blood supply to the myocardium Older females after menopause are more than twice as likely to have CHD than those before menopause Over 82% of people who die with CHD are age 65 years and over (AHA, 2008) Myocardial infarction and angina are two results of CHD Angina: Background

Chest pain caused by lack of oxygen to heart muscle Higher incidence in females, Mexican American males and females, and African American females Stable managed with meds and lifestyle changes Unstable usually requires hospitalization Related to exercise or stress and is relieved with rest and NTG Symptoms in elderly: Dizziness Dyspnea

Confusion Chest pain Angina: Control Teaching patients and families: Weight management Stress management Limiting caffeine Smoking cessation Regular exercise Control of hypertension Medical management of any co-existing endocrine disorder (such as hyperthyroidism) Angina: Medications

Beta blockers and calcium channel blockers are often prescribed to decrease the oxygen demand on the heart Side effects Fatigue Drowsiness Dizziness Slow heart rate MI: Background

365,000 new and 300,000 recurrent heart attacks each year In the USA Risk increases with age Men more at risk until age 70 then risk equalizes Average age for a persons first MI of 65.8 for men and 70.4 for women (AHA, 2005) MI: Risk factors

Hypertension Race (especially African American males with HTN) High fat diet Sedentary lifestyle Diabetes Obesity High cholesterol Family history Cigarette smoking Excessive alcohol intake Stress MI: Warning signs

Chest pain appearing as tightness, fullness, or pressure Pain radiating to arms Unexplained numbness in arms, neck, or back Shortness of breath with or without activity Sweating Nausea Pallor Dizziness Unexplained jaw pain* Indigestion or epigastric discomfort, especially

when not relieved with antacids* *(of particular significance in the elderly) MI: Treatment Antithrombolytics if given early decreases morbidity and mortality Rest MONA (Morphine, Oxygen, NTG q 5 mins x 3, ASA chew, if not contraindicated) ECG Angiogram and/or Cardiac Cath

Angioplasty CABG Medications Beta blockers, ACE inhibitors, Antihypertensives MI: Patient Education

Exercise regularly Do not smoke Eat a balanced diet with plenty of fruits and vegetables; avoid foods high in saturated fats Maintain a healthy weight Manage stress appropriately Control existing diabetes by maintaining healthy blood sugars and taking medications as prescribed MI: Patient Education (contd)

Limit alcohol intake to 1 drink per day for women and 2 drinks per day (or less) for men Visit the doctor regularly After a heart attack, participate fully in a cardiac rehabilitation program Involve the entire family in heart-healthy lifestyle modifications Report any signs of chest pain immediately Be involved in and buy into the prescribed medication regimen Congestive Heart Failure (CHF): Background

Incidence varies by age, gender, and races AGE W Men W Women AA Men AA Women 65-74 15.2/1,0 00

8.2/1,00 0 16.9/1,0 00 14.2/1,00 0 75-84 31.7/1,0 00 19.8/1,0 00 25.5/1,0 00

25.5/1,00 0 Lifetime risk for persons is 1 in 5 >85 65.2/1,0 45.6/1,0 50.6/1,0 44.0/1,00 00 00 0 The risk in 00 older adults doubles for those with blood pressures over 160/90

75% of those with CHF also have HTN The major risk factors are diabetes and MI Often occurs within 6 years after an MI CHF: Signs and Symptoms Shortness of breath Edema Coughing or wheezing Fatigue Lack of appetite or nausea Confusion

Increased heart rate Older adults: decreased appetite, weight gain, insomnia CHF: Treatment Check O2 saturation - less than 90% requires intervention Daily weight at same time, clothes, scale Threshold wt. gain between 1 and 3 pounds Potential medications: ACE inhibitors, diuretics, vasodilators, beta

blockers, blood thinners, angiotensin II blockers, calcium channel blockers, potassium Digoxin rarely used any more CHF: Patient Education Teach lifestyle modifications as discussed for promoting a healthy heart Limit or eliminate alcohol use

Maintain a healthy weight Stop smoking (no tobacco use in any form) Limit sodium intake to 2 3 g per day Take medications as ordered do not skip doses Exercise to tolerance level Alternate rest and activity learn energy conservation techniques Stroke and TIAs: Background Cerebrovascular accident (CVA) Transient ischemic attack (TIA)

Interruption of blood supply to the brain that may result in devastating neurological damage, disability, or death Symptoms similar to stroke but go away with in minutes to 24 hours and leave no residual effects 780,000 new or recurrent strokes per year Third leading cause of death in US 10% of all strokes are preceded by a TIA CVA is the #1 diagnosis for hospital discharge to LTCF 2/3 happen to those over 65 years of age

Types of Stroke Ischemic (86%) Thrombotic: occurs when a blood clot forms in an artery that supplies the brain, causing tissue death (carotid artery stenosis); develops over time Embolotic: occurs suddenly when a blood clot (embolism) forms in one part of the body, travels through the bloodstream, and lodges in and obstructs a blood vessel in the brain Hemorrhagic Stroke and TIAs: Risk Factors

Controllable HTN #1 High Cholesterol Heart Disease Smoking (quit and risk equalizes after 5 years)

Obesity Stress DM Depression A Fib Uncontrollable Age Gender (males > females until menopause) Race (AA > White)

Heredity Stroke and TIAs: Warning Signs Sudden numbness or weakness of face, arm, or leg, especially on one side of the body Sudden confusion; trouble speaking or understanding Sudden blurred or decreased vision in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe, unexplainable headache -often described as the worst headache of my life (more common with hemorrhagic) 3 Easy Assessment Signs Facial droop Motor weakness Language difficulties Stroke: Treatment

H & P, esp. neuro exam Vital signs ECG, CXR, CBC, PT, PTT, Lytes, Glucose Diagnostic testing: CT scan and/or MRI Arteriography US of carotids Stroke: Acute Management Determine cause/type of stroke Hemorrhagic surgery to evacuate blood

Ischemic t-PA (tissue plasminogen activator): Gold standard Must be given within 3 hours after the onset of stroke symptoms Some patients will not be candidates May reduce or eliminate symptoms in over 40% of pts who receive it within time frame Stroke: Acute treatment Manage hypertension, hyperthermia, and hyperglycemia To prevent recurrence: Medications

ASA Ticlid Plavix Persantine Heparin Coumadin Lovenox Effects of Stroke

Effects and degree of recovery vary Hemiplegia Hemiparesis Visual /perceptual deficits Language deficits Emotional changes Swallowing dysfunction Bowel/bladder problems Stroke: Rehabilitation

Maximize function Prevent complications Promote QOL Encourage adaptation Enhance independence Emphasize abilities NOT disabilities Stroke: Mauk Model Phase/Concept Characteristics Agonizing Fear, shock, loss, questioning, denial Fantasizing Mirage of recovery, unreality Realizing

Reality, depression, anger, fatigue Blending Hope, learning, frustration, dealing w/changes Framing Answering why, reflection Owning Control, acceptance, determination, self-help Stroke: Patient Education

PREVENTION is KEY Know the warning signs of stroke Call 911 if experiencing warning signs TIA is a warning sign Manage high blood pressure Take medication as scheduled Visit the doctor regularly Peripheral Vascular Disease: Background Peripheral artery disease (PAD) is most common type of PVD

Affects 8 12 million Americans, 12 20% of those over the age of 65 PVD: Risk Factors/Symptoms Same as those for CHD Diabetes and smoking are the greatest risk factors (AHA, 2005) More at risk of MI or CVA Symptoms: Leg cramps with activity but alleviated at rest (intermittent claudication) None

PVD: Treatment Heart healthy lifestyle and modifications as those discussed previously with CAD Left untreated can lead to decreased quality of life Sometimes results in gangrene and amputation Respiratory

Pneumonia COPDs Chronic bronchitis Emphysema TB Lung cancer Pneumonia: Background

Leading cause of death among the elderly Those over age 65 have 5 10 times the risk of death from pneumonia than young adults Causes: bacterial, viral, aspiration More at risk if COPD, CHF, or immune-suppressing disease Pneumonia: Signs/Symptoms Viral (less severe) Fever, non-productive hacking cough,

muscle pain (chest), weakness, shortness of breath, anxiety, crackles in lungs Bacterial (sudden or gradual onset) Chills, chest pain, sweating, productive cough, or dyspnea Older adults may not present with these typical symptoms Confusion, disorientation, or delirium in the elderly Pneumonia: Treatment

CXR CBC Sputum culture to determine type and causal agent H&P Viral no tx; self-limiting Bacterial antibiotics Pneumonia: Treatment (contd) Hydration, rest Tylenol/ASA if not contraindicated

Monitor for worsening of symptoms Hospitalization often required in frail elderly Vaccines recommended Pneumonia once in life time Flu annually COPDs: Background Obstructed airflow Emphysema and chronic bronchitis

Fourth leading cause of death in the US 118,000 deaths in 2004 Nearly 24 million American adults have some type of impaired lung function Slightly more females than males are affected Female smokers have a 13 times greater chance of death from COPD than nonsmoking females COPDs: Risk Factors

Smoking 80-90% of COPD deaths Air pollution Second-hand smoke Heredity History of respiratory infections Industrial pollutants Environmental pollutants Excessive alcohol consumption Genetic component (alpha1-antitrypsin deficiency) Chronic Bronchitis

8.5 million Americans diagnosed as of 2005 Females 2x more likely than males Recurrent inflammation and mucus production produces blockage and eventual scarring that restricts airflow S/S: Increased mucus production, shortness of breath, wheezing, decreased breath sounds, and chronic productive cough Can lead to emphysema Emphysema

Alveoli are irreversibly destroyed; lungs lose elasticity, air comes trapped in alveolar sacs resulting in CO2 retention and impaired gas exchange Nearly 4 millions Americans have it Males more than females S/S: Shortness of breath, decreased exercise tolerance, and cough Diagnosed: PFTs and H&P COPDs: Treatment Control symptoms and minimize complications Lifestyle modifications

Stop smoking Respiratory therapy Medications Pulmonary rehabilitation Oxygen therapy required as disease progresses COPDs: Patient Education

Involve the family and plan for long term Lifestyle modifications reduce factors that contribute to symptoms Appropriate use of meds Alternating rest and activity (energy conservation) Stress management Relaxation Supplemental oxygen Work with respiratory therapist and physician on home maintenance program Tuberculosis:

Background Infection that can attack any part of body but targets lungs and is spread through air droplets Number of cases in US steadily decreasing over last 10 years Asian Americans, Pacific Islanders, African Americans, American Indians, Hispanics, Whites 8 times greater incidence in non-US born

Spread common in less developed countries related to immune suppression associated with AIDS Nursing home residents at risk TB testing prior to admission Tuberculosis: Signs and Symptoms Severe cough lasting more than 2 weeks Chest pain

Bloody sputum Weakness Fatigue Weight loss Chills, fever, night sweats (May not be present in elderly) Tuberculosis: Diagnosis & Treatment Skin test

CXR Sputum culture Infected with no symptoms = no tx Positive skin test = tx with isoniazid (INH) x 6 months for prevention Active TB = Combination drug regimen for many months, isolation, rest, adequate nutrition, hydration, breathing exercises Monitor LFTs due to drug therapy toxicity From another country? Language barrier? Lung cancer: Background

Second most common cancer Smoking is the number one cause 87% of lung cancers caused by smoking (ALA, 2005) Radon exposure Industrial Exposure Genetics Affects both men and women Lung Cancer: Signs and Symptoms

A cough that doesn't go away and may get worse Constant chest pain Coughing up blood Shortness of breath, or wheezing Loss weight and loss of appetite Frequent lung infections, such as bronchitis or pneumonia Hoarse voice Unexplained fever Lung Cancer: Treatment and Patient Education

Surgery, radiation, chemotherapy or combination Surgery generally indicated and most effective Prevention is best! Encourage smoking cessation Link with support groups Avoid second hand smoke and exposure to environmental toxins For those living with lung disease, employ all the strategies above for those with COPDs

Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: GI Gastrointestinal Disorders GI problems common among most frequent complaints in elderly Gastroesophageal reflux (GERD), peptic ulcer disease (PUD), diverticulitis, constipation, and several types of cancers discussed

here GERD Acid or other stomach contents back up into the esophagus Can be chronic disorder affecting QOL Associated factors: Decreased LES tone and increased pressure in stomach and abdomen Decreased peristalsis Delayed gastric emptying

Common cause: H. Pylori GERD: Symptoms Heartburn #1 Noncardiac chest pain Dysphagia Hoarseness Coughing Wheezing, respiratory problems, asthma Complications

Esophagitis Barretts esophagus Cancer GERD: Treatment Diagnosis: H&P, endoscopy with biospies Treatment Medications: Mild: Antacids & H2 blockers (Tagamet, Zantac, Pepcid AC, Axid) Proton pump inhibitors (PPIs) (Nexium, Prevacid)

Elderly have fewer complaints of heartburn but is more severe with more complications GERD: Patient Education Lifestyle modifications Smaller, more frequent meals Avoid food and drink within 3-4 hrs of lying down Elevate entire HOB Lose weight Avoid tight fitting clothes Take meds properly

Avoid: Caffeine Chocolate Nicotine Alcohol Peppermint Spicy and tomatobased foods

Acidic products Carbonated beverages Stress Peptic Ulcer Disease: Background Direct cost exceeds $2 billion/year Indirect cost exceeds $500K annually Incidence increases with age Occurs more often in Hispanics and African Americans Can be a complication of COPD

(increase in stress) so tx prophylactically Peptic Ulcer: Signs/Symptoms Causes: NSAIDS

H. Pylori infection Decrease protection of GI mucosa Early symptoms may not occur in elderly r/o cardiac etiology as may present as indigestion Epigastric pain esp. after meals Bowel changes Bloating Anorexia Peptic Ulcer: Risk factors & Diagnosis Risk factors: Smoking Drinking alcohol Caffeine

Stress Helicobacter pylori infection Diagnosis: H&P, barium swallow, endoscopy with biopsy Peptic Ulcer: Treatment & Patient Education Antibiotics Antacids and other medications to control

acid production Dietary changes Avoidance of risk factors Combination therapy if H. pylori present Teach Risk reduction Adhere to medication regimen Bleeding may result Diverticulitis: Background

Inflammation or infection of the pouches of the intestinal mucosa 65% of older adults will develop diverticulosis by age 85 Most common in elderly men Perforation of one or more pouches of intestinal mucosa Certain foods may irritate condition (seeds) Diverticulitis: Signs/Symptoms

Elderly may not present with typical symptoms LLQ pain Nausea Fever Constipation Diarrhea Mucus and/or blood in stool Diverticulitis: Risk factors & Diagnosis Risk Factors Obesity

Chronic constipation Hiatal hernia Family history Diagnosis H&P Barium enema Diveritulitis: Treatment Antibiotics Avoid irritating foods Extreme cases:

May require surgery to remove diseased bowel May result in bowel obstruction leading to colostomy Teach: dietary changes, adhere to medication regimen Cancers GI cancers account for > 25% of all cancer deaths in older adults

#2 cause of cancer next to lung disease Types: Esophagus Stomach Colorectal Pancreas Esophageal Cancer

Squamous cell type: most common in black males with a history of alcoholism and heavy smoking Adenocarcinoma: more often in white males, particularly resulting from Barretts esophagus Early detection is key Poor prognosis S/S: weight loss, difficulty swallowing In older adults, symptoms may not appear until advanced stage Avoid smoking and alcohol Tx: Chemotherapy, radiation, possible surgery Stomach Cancer

Common in older men age 65 74 Greater incidence among Hispanics, African Americans and Asians/Pacific Islanders than Whites Rates are high among Japanese men living in Japan (American Cancer Society, 2005) Men have twice the risk of women Good prognosis if caught early S/S: epigastric pain, anorexia, nausea, and difficulty swallowing Early signs may not be present in elderly Tx: Surgery, radiation, and chemotherapy (often combination)

Colorectal Cancer Most common yet treatable Most common is adenocarcinoma secondary to polyps Screenings recommended for early detection, esp. in high risk persons Hispanics and AA at higher risk

Good prognosis when detected early Risk factors: upper socioeconomic groups, high fat intake, alcohol, smoking, sedentary lifestyle, environmental toxins S/S: depend on location of lesion, rectal bleeding, anemia, fatigue, abd cramping, changes in bowel pattern DX: H&P, Hemoccult, barium enema, endoscopy Tx: Surgery, chemotherapy, radiation Pancreatic Cancer

Found more often in elderly (60-80 yo) and is leading cause of death for this age group 10 x greater risk in men > 75 yo Risk factors: smoking, family hx, DM Poor prognosis Difficult to detect due to lack of symptoms S/S: nausea, vomiting, anorexia, wt loss, depression, excessive belching Tx: Palliative, surgery, chemotherapy Constipation: Background

Most common bowel problem in elderly6 Causes: decreased peristalsis, decreased fluids from decreased thirst, decreased activity, lack of fiber in diet, side effect of meds, neurogenic bowel or other disease May lead to fecal impaction or bowel obstruction Treatment: depends on cause use all natural means first start with a clean bowel Factors to Consider in Bowel Management Uncontrollable Factors

Neurogenic bowel disorder Family history Environment Previous bowel disease Controllable Factors

Diet Fiber Fluids (1500-2000 mL per day) Timing Activity Positioning Medications Nursing strategies: Oral medications Bulk formers

Stool softeners Metamucil Colace Peristaltic stimulators Pericolace Senna Rectal Glycerin or bisacodyl suppository

Enemas Avoid if at all possible If must use, try a Fleets Should not be part of a regular bowel program for older adults can distend the bowel, make it lazy, cause dependence CVA, dementia, PD, MS, TBI, SCI may need comprehensive bowel program developed by rehab nurse Genitourinary problems

Bladder cancer Vaginitis Breast cancer Cervical cancer BPH Prostate cancer Erectile dysfunction Bladder Cancer: Background

Incidence increases with age Men 3x more likely than women Risk factors Chronic bladder irritation Cigarette smoking Classic symptom Painless hematuria Bladder Cancer: Diagnosis & Treatment

Dx: IVP, UA, Cystoscopy with biopsies Treatment: Burning through scope when superficial BCG washes If invasive into bladder muscle, then removal of bladder is indicated Chemotherapy and/or radiation Bladder Cancer: Patient Education Urostomy Several types Urine empties into a bag on the outside Stoma looks much like a colostomy Indiana pouch

Teach self-cathing Care of urostomy Appliances I & O Skin care Female Reproductive System Vaginitis

Cervical cancer Breast cancer Vaginitis Vaginal canal fragile due to atrophy Decreased lubrication Alkaline pH due to decreased estrogen Symptoms: itching, foul-smelling discharge

Tx: topical estrogen cream Pt. Education: Avoid douching, feminine deodorant sprays, powders, or perfumes Cotton undergarment Water-soluable lubricant during sex Cervical Cancer

Incidence peaks in women ages 50-60 Treated less aggressively with poorer outcome in elderly Pap smear annually until age 70 Risk factors: smoking, onset of sex prior to age 18, multiple sex partners Symptoms: post-menopausal bleeding; no pain Prognosis good if detected early Tx: Laser and/or cryo; surgery, chemotherapy, radiation Breast Cancer

Second leading cause of death in women Half of all breast cancers are diagnosed in women over age 65 Screening: Mammogram yearly until age 75 , SBE monthly, CBE annually Risk Factors: family hx, late menopause, 1st child after age 30, high fat diet, alcohol S/S: breast mass or lump, breast asymmetry, dimpling of skin, nipple discharge Dx: mammogram, US, MRI, biopsy Breast Cancer: Treatment

Surgery, radiation, chemotherapy or combination, depending upon stage Elective surgery done in some younger women with strong familial history Older women undergoing mastectomy may require more time for recoery PT to regain ROM Psychosocial and emotional support Male Reproductive System

BPH CA of prostate Erectile dysfunction (ED) or Impotence Benign Prostatic Hyperplasia (or hypertrophy) (BPH) Non-CA enlargement of prostate associated

Non-CA enlargement of prostate associated with age Affects 50% of men 51-60 and up to 90% of men over age 80 Can be precursor to CA, so must be monitored Symptoms: Decreased urinary stream, frequency, urgency, nocturia, incomplete emptying, dribbling, weak stream, incontinence Dx: UA, PVR, PSA, Urodynamic studies, US, Cystoscopy Tx: Meds and surgery Prostate Cancer

Second leading cause of cancer death in US males Incidence increases with age Over half men 70 and over show some histologic evidence, though only small percent die from disease S/S: urinary urgency, nocturia, painful ejaculation, blood in urine or semen, pain or stiffness in back or thighs Risk Factors: advanced age, high fat diet, family hx, AA higher risk, Asians lower risk

Dx: DRE, PSA, biopsy Tx: depends on stage, radical prostatectomy, radiation therapy, surveillance Erectile Dysfunction Defined as inability to achieve and sustain erection for intercourse Prevalent in approx. 70% of men age 70 Increases with age but not inevitable and is

treatable Causes: DM, HTN, MS, SCI, thyroid disorders, alcoholism, renal failure, hypogonadism, other diseases, medications, psychological factors Tx: Oral meds, vacuum pump, penile implant, penile injections Oral meds contraindicated in those with heart disease Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: Neurological Dementia: Background

4 million older adults have some form of dementia How is dementia different from depression and delirium? Slower onset Progressive, not variable Irreversible Different causes Lowest MMSE Other Types of Dementias

Vascular dementia results from multiple cerebral infarctions more rapid and more predictable than AD risk factors: HTN, hyperlipidemia, history of stroke, smoking Lewy body dementia presence of Lewy body substance in cerebral cortex many gerontologists consider this the same type of dementia as AD Other Types of Dementias

Creutzfeld-Jacob disease (Mad Cow) Rare brain disorder Rapid onset and progression Slow virus Familial tendency Destruction of neurons in cortex Symptoms more varied than AD Death with 1 year Other Types of Dementias Parkinsons disease Small percentage of those with dementia are this type Degeneration of neurons due to lack of neurotransmitter, Dopamine

Alzheimers Disease (AD) The most common type of dementia seen in older adults Advanced age is the single most significant risk factor Estimated 5.2 million Americans affected in 2008 5 million over age 65 Estimated to reach 7.7 million in 2030 Projected 11 16 million by 2050 Alzheimers Disease (AD)

May live from 3 20 years or more after diagnosis Seventy percent of people with AD live at home until the latest stages, being cared for mainly by family members (Alzheimers Association, 2005 Costs $61 billion annually Expected to exceed $163 billion/yr by 2050 Characterized by progressive memory loss Average life span of 8 years after dx

Alzheimers Disease (AD) Two types of abnormal lesions in the brains of individuals with Alzheimer's disease: Plaques Neurofibrillary tangles Definitive diagnosis is still through biopsy Dx: early dx is important to maximize function and QOL as long as possible

AD Stages Early Loss of STM (Safety concerns) Inability to perform math calculations and to think abstractly Middle

Bodily systems begin to decline Confused to date, time, and place Communication skills become impaired Personality and/or emotional changes Wandering Screaming Delusions/hallucinations Suspiciousness Depression Personal hygiene suffers AD Stages (contd)

Final Completely dependent upon others Severe decline in physical and functional health Loses communication skills Unable to control voluntary functions Death occurs from body systems shutting down and may be accompanied by infectious process AD: Warning Signs Ten warning signs of Alzheimers Disease

Memory loss Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgment Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative

AD: Treatment Medications (Aricept, Namenda) may help slow progress but does not change disease course Symptom management Behavior Safety Nutrition

Hygiene As dementia progresses, likely to be institutionalized Support for family/caregiver Support groups Respite Be aware of caregiver strain Parkinsons Disease (PD): Background

One of the most common neuro diseases Both men and women Generally 50 - 60 years of age at onset Originally called the shaking palsy Degenerative, chronic, and slowly progressing disease No known etiology though several causes are suspected Specific pathological marker is the Lewy body (under microscope round, dying neuron) No specific test to diagnose PD: Signs and symptoms

The four cardinal signs: Bradykinesia (slowness of movement) Rigidity Tremor Gait See page 422 in text Advanced PD may result in Parkinsons dementia PD vs. Parkinsonian symptoms

Drugs and toxins Alzheimers Vascular diseases NPH (normal pressure hydrocephalus) PD: Treatment

Levodopa synthetic dopamine amino acid that converts to dopamine when it crosses the blood-brain barrier Levodopa lessen most of the serious s/s Hallucinations Sinemet (levodopa/carbidopa) Most common combination Decreases side effect of nausea seen with levodopa PD: Treatment

Selegiline interferes with one of the enzymes that breaks down dopamine Dopamine receptor agonists Permax and Parlodel synthetic compounds that mimic dopamine not as powerful as levodopa Anticholinergics earliest used drugs Artane Cogentin PD: Treatment

New drugs being examined Wearing off effect requires higher dose Drug holiday to reset itself New research Fetal tissue/stem cell transplants Adult stem cells retinal cells PD: Treatment Surgery for symptom relief Deep brain stimulation Thalamotomy (used for tremor destroys group of cells in thalamus) Pallidotomy destroys group of cells in internal globus pallidus, major area where info leaves the basal ganglia

PD: Treatment Treat the symptoms Support Support groups, Parkinsons Foundation Preserve strength Also, care for the caregiver PD: Patient Education

Medication therapy (side effects, wearing off, drug holidays, role of diet in absorption) Safety promotion/fall prevention Disease progression Effects of disease on bowel and bladder, sleep, nutrition, attention, self-care, communication, sexuality, mobility PD: Patient Education

Swallowing problems Promoting sleep and relaxation Communication Role changes Caregiver stress/burden need for respite Community resources Dizziness: Background Affects about 30% of those over age 65

Most common complaint in those over 75 who are seen by office physicians Four major types of dizziness Vertigo Presyncope (light-headedness) Disequilibrium Ill-defined Dizziness: Vertigo False sense of motion or spinning caused by benign paroxysmal positional vertigo (BPPV) Other causes: Inflammation in inner ear Menieres syndrome

Vestibular migraine Acoustic neuroma Rapid changes in motion More serious: Stroke, brain hemorrhage, MS Dizziness: BPPV Most common cause of dizziness in older adults Increased incidence with age Brought on by normal calcium carbonate crystals breaking loose and falling into wrong

part of inner ear (otoconia or rocks in the ears) Underlying cause unknown Degeneration in vestibular system in the inner ear that occurs with normal aging Should be suspected if vertigo doesnt respond to meds, such as Antivert Dizziness: BPPV (contd) S/S: dizziness, presyncope, feelings of imbalance, and nausea Symptoms begin when person changes head position DX with Hallpikes maneuver: pt. is

laid down quickly from sitting position, with head turned to side and hung over the back of the exam table; will produce nystagmus Dizziness: BPPV (contd) Treatment Epley maneuver: patient is put into a series of specific positions and head turns to promote return of otoconia to their proper place in the ear Dizziness: Presyncope

Feels faint or light-headed Associated with drop in BP Can be caused by Meds Hypotension Hypovolemia Low blood sugar Lack of blood flow to brain Dizziness: Disequilibrium Loss of balance or the feeling of being unsteady when walking Causes Vestibular problems

Sensory disorders Joint or muscle problems Meds Dizziness: Ill-defined Catch all Inner ear disorders Anxiety disorders

Hyperventilation Cerebral ischemia Side effect of meds Parkinsonian symptoms Hypotension Low blood sugar Benign positional vertigo Dizziness: Menieres Vestibular Common in those over 50 Cause is unknown May be a viral or bacterial infection Signs and symptoms

rapid decrease in hearing a sense of pressure or fullness in one ear loud tinnitus (ringing in the ears) and then vertigo Dizziness: Treatment & Patient Education Early diagnosis Safety promotion Emotional reassurance that condition is generally temporary and treatable Dizziness is generally treatable by

addressing the cause Seizures: Background Present in about 7% of older adults Usually related to one of the common comorbidities found in older adults CVD accounts for nearly 40-50% of seizures in elderly Seizures are associated with stroke in 5 14% of survivors Seizures: Potential

Causes Stroke or other cerebrovascular disease Arteriosclerosis Alzheimers disease Brain tumor Head trauma Intracranial infection Drug abuse or withdrawal Withdrawal from antiepileptic drug

Seizures: Types Partial or focal (AKA localized) Generalized: grand mal or tonicclonic Status epilepticus Seizures: Characteristics in Elderly

Low frequency of seizure activity Easier to control High potential for injury A prolonged postictal period Better tolerance with newer antiepileptic drugs Seizures: Signs and Symptoms & Diagnosis S/S: Seizures

Changes in behavior, cognition, and level of consciousness Diagnosis: Careful description of the seizure event Thorough history and physical Complete blood work, chest x-ray, electrocardiogram (ECG), and electroencephalogram (EEG) Seizures: Treatment Treat causal factors AEDs newer medications may be

better tolerated with fewer side effects Tegretol Trileptal Topamax Safety Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: Musculoskeletal Osteoporosis: Background

Low bone density or porous bones 55% of adults age 50 or older Women (80%) > men (20%) Common yet preventable Leads to fractures, esp. of vertebral spine, hip, and wrists Osteoporosis: Risk factors

Inactivity Insufficient calcium or vitamin D intake Smoking Alcohol Lack of exposure to sunlight Hormonal imbalances Meds, such as steroids or anticonvulsants Osteoporosis: Risk Factors

Surgery related to reproductive organs Physical disorders affecting weightbearing Menopause Thin, fair-skinned, blonde, European or Asian woman Osteoporosis: Signs and Symptoms Fractures Pain Kyphosis Decreased bone density

Osteoporosis: Treatment Supplements biphosphonates (such as Fosamax) calcitonin (Miacalcin) What about ERT? estrogen/hormone replacement medications (such as Estratab or Premarin) Benefits Risks Arthritis

Affects 66 million Americans Number one chronic complaint and cause of disability in the US Over 100 types of arthritis 2 most common Osteoarthritis (OA) Rheumatoid arthritis (RA) Osteoarthritis (OA): Background

Degenerative joint disease (DJD) Characterized by chronic deterioration of the cartilage at the ends of the bones Cause unknown OA: Signs and Symptoms Herberdens nodes (bony enlargements at end joints of fingers)

Bouchards nodes (bony enlargements at middle joints of fingers) Pain/Aching Stiffness esp. in am Joint swelling and inflammation Limited range of motion Crepitus Limping Frequent fractures OA: Signs and Symptoms OA: Diagnosis & Treatment Dx: Lab tests, x-rays, MRI or CT scan Tx: aimed at symptom reduction Exercise

Coping with pain Pain meds (NSAIDS, COX-2, Tramadol) Rheumatoid arthritis (RA): Background Affects over 2 million Americans More common in women than men Characterized by remissions and exacerbations of inflammation within the joint Fingers, wrists, knees, and spine

Due to chronic inflammation that can cause severe joint deformities and loss of function over time Cause unknown but researchers believe it may be due to virus or hormonal factors Rheumatoid arthritis (RA) RA: Risk Factors Female Predisposing gene Exposure to an infection Advanced age

Smoking over a period of years RA: Signs and Symptoms Malaise/Fatigue Symmetrical patterns of joint inflammation Pain, stiffness, swelling Gelling (joints stiff after rest) Elevated sedimentation rate

Presence of serum rheumatoid factor Elevated WBC in synovial fluid of inflamed joint Erosion of bone (on radiograph) Pain more prevalent More debilitation than with OA RA: Treatment Meds

Anti-inflammatories Immune-suppressing Disease-modifying anti-rheumatic drugs (DMARDs) Used within 3 mons of diagnosis Modify disease process and prevent deformities and pain May not show results for several months Teach pt. to recognize signs of infection: chills, pain, fever RA: Goals of Care Independence within limitations Pain management

Education Exercise and mobility Individual PT/OT Independence with ADLs Joint Replacement: Background Used for Fracture Immobility Intractable pain Total hip arthroplasty

Arthritis or fracture from falling Total knee arthroplasty Advanced arthritis causing sever pain and decreased function Total Hip Replacement Total Hip Replacement: Patient Education

Surgical procedure Hip precautions Weight bearing status Maximum improvement over 1 2 years Signs and symptoms of wound infection Implications for travel Total Knee Replacement: Patient Education

Indications for replacement Bilateral versus unilateral General versus spinal anesthesia Rehabilitation process CPM (settings) Wound care Pain management Expected ROM Maximum function return may take 2 or more years Amputation: Background

Loss of limb, typically from disease, injury and/or associated surgery 135,000 new amputees annually in US Two thirds from circulatory problems, especially PVD related to diabetes Most involve the lower extremities AKA, BKA Advanced age and the incidence of diabetes in the elderly makes this a potential problem in the older age group HgbA1c level may be a significant predictor of foot amputation

Amputation: Patient Education Stump care preparing the stump to wear a prosthesis is one of the best ways to promote later independence Mobility elders will walk more slowly after amputation due to increased energy expenditure required Adaptation Coping Self-care

Managing phantom limb pain More common in trauma Massage and meds Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: Sensory Common Problems Most common visual problems among the elderly are: Cataracts Glaucoma

Age Related Macular Degeneration (ARMD) Diabetic retinopathy Cataracts: Background Common in older adults Etiology thought to be from oxidative damage to lens protein that occurs with aging Clouding of the lens50% of those

ages 65-75 have them Most common in those over 75 No ethic or gender variations Cataracts: Background Contributing factors: Advanced age, DM, HTN, poor nutrition, cigarette smoking, high alcohol intake, eye trauma, Exposure to UV B, strong family history Cataracts: Signs/Symptoms

No pain or discomfort Distorted vision/blurry Decreased night vision Photosensitivity Yellowing of lens Pupil changes color to cloudy white Cataracts: Treatment & Patient Education Tx: Surgery is the only cure; outpatient with few complications Removal of the lens and insertion of

intraocular lens implant (distorts vision less than special cataract glasses do) Pt. Ed: Avoid bright sunlight; wear wrap around sunglasses Avoid straining, lifting, bending Glaucoma: Background

Group of degenerative eye diseases in which optic nerve is damaged by High intraocular pressure (IOP) Blindness due to nerve atrophy Leading cause of visual impairment 10-20% of all blindness in the U.S. Increased incidence with age Blacks develop earlier than Whites Women more often than men Cause is unknown Acute Glaucoma Also called closed-angle or narrow-angle S/S:

Severe unilateral eye pain Blurred vision Seeing colored halos around lights Red eye Headache Nausea/Vomiting Symptoms may be associated with emotional stress Medical Emergency: Permanent vision

loss within 2 5 days if untreated Chronic Glaucoma Open angle or primary open-angle More common than acute Occurs gradually Peripheral vision slowly impaired S/S:

Tired eyes Headaches Misty vision Seeing halos around lights Worse symptoms in the morning Chronic Glaucoma: Diagnosis & Treatment Dx: Tonometer to measure IOP (normal is 10-21 mm Hg) Gonioscopy (direct exam)

Treatment: No cure Reduce the IOP Medications to decrease IOP (topical eyedrops) Surgery iridectomy Age-related Macular Degeneration (ARMD): Background

Most common cause of blindness for those over 60 Damage or breakdown of macula Loss of central vision Associated with aging process Can also result from injury, infection ARMD: Risk Factors High cholesterol Hypertension Diabetes

Smoking Overexposure to ultraviolet light Heredity ARMD: Two Types Dry (nonexudative) 90% are this type Better prognosis Slower progression Wet (exudative) 10% are this type More sudden onset More severe loss of vision

ARMD: Treatment No cure at present New research: Photodynamic therapy uses a special laser to seal leaking blood vessels in the eye Antioxidant vitamins (C, D, E, and Beta-carotene) and zinc also seemed to slow the progress of the disease Retinal cell transplantation or

regeneration Diabetic Retinopathy: Background Leading cause of blindness resulting from breakage of tiny vessels in the retina Generally affects both eyes No early outward warning signs Early diagnosis and treatment can prevent much of the blindness that occurs

4 stages Diabetic Retinopathy: Diagnosis & Treatment Pt. complains of seeing floating spots Dx: Visual acuity Dilated eye exam Tonometry Tx: Scatter laser treatment shrinks vessels Vitrectomy removal of vitreous gel containing blood

Diabetic Retinopathy: Patient Education PREVENTION is key Regular checkups for older adults with diabetes Visual loss can often be prevented Control hypertension Lower cholesterol Monitor blood sugars keep within suggested limits

Retinal Detachment: Background Result of trauma Symptoms may be gradual or sudden May look like spots moving across eye, blurred vision, light flashes, curtain drawing Keep person quiet Seek immediate medical attention May require surgery

Corneal Ulcer More common in elderly due to decreased tearing Inflammation of the cornea related to Stroke Fever

Irritation Dehydration Poor diet Difficult to treat may leave scars S/S: bloodshot eye, photophobia, c/o irritation Seek prompt assistance from physician Chronic Sinusitis: Background One of the top ten chronic complaints of the elderly

Irritants block drainage of the sinus cavities, leading to infection Acute = 1 day 3 weeks prior to reporting symptoms Chronic = 6 weeks to 3 months of symptoms Chronic Sinusitis: Signs/ Symptoms Severe cold Sneezing Cough that is

worse at night Diminished smell Hoarseness Colored nasal discharge Postnasal drip Headache Facial or upper teeth pain Fatigue Malaise

Fever Chronic Sinusitis: Diagnosis & Treatment Diagnosis: H & P, CT sinuses Treatment Antibiotics Decongestants Analgesic Nasal irrigation with NS Inhaled corticosteroid Increase fluids Avoid environmental pollutants Chapter 13: Management of

Common Illnesses, Disease, and Health Conditions: Integumentary Integumentary Skin cancer Herpes zoster (shingles) Skin Cancer Three major types Basal cell Squamous cell

Malignant melanoma (MM) The major risk factor for all types of skin cancer is sun exposure. Most skin cancers, when treated early, have a good prognosis Prevention is key Basal Cell Carcinoma Skin Cancer (Basal Cell)

Most common skin cancer Accounts for 65 - 85% of cases Found on the head or face, or other areas exposed to the sun When treated early, easily removed through surgery Not life threatening, though it is often recurring Skin Cancer Squamous Cell: More common in African American

Less serious than malignant melanoma Malignant Melanoma Accounts for only 3% of all skin cancers Responsible for the majority of deaths from skin cancer Tx: Surgery, chemotherapy, radiation therapy Malignant Melanoma Skin Cancer: Patient Education

The best treatment in the elderly is prevention All older persons, especially those with fair skin who are prone to sunburn, should wear sun block and protective clothing Annual physical examinations should include inspection of the skin for lesions Report any suspicious areas on the skin to the physician Check shape, color, and whether or not a lesion is raised, or bleeds Herpes Zoster (Shingles): Background

AKA: Shingles Same virus that causes chicken pox Latent varicella virus after initial exposure Reactivated due to immunosuppression Painful vesicles along the sensory nerves Herpes zoster occurs in both men and women equally No specific ethnic variations More common in the elderly Herpes Zoster: Risk

Factors Age over 55 years Stress Suppressed immune system For many older women particularly, emotional or psychological stress can trigger reactivations Herpes Zoster: Signs and Symptoms

Painful lesions that erupt on the sensory nerve path Usually beginning on the chest or face Unilateral Vesicles get pustular and crusty over several days Healing in 2 4 weeks Severe pain that usually subsides in 3-5 weeks but postherpetic neuralgia may last 6-12 months after the lesions disappear Herpes Zoster: Treatment

Anitviral medications Topical ointments Pain medications, particularly acetaminophen Post-herpetic neuralgia usually disappears with a year but may require additional medical interventions Herpes Zoster: Patient Education

Rest and comfort Explain that the virus will run its course, but the person is contagious while vesicles are weepy Persons should not have direct contact (even clothing) with pregnant women, people who have not had chickenpox, other elderly persons, or those with suppressed immune systems. Involve family to check on persons living alone Instruct medication use as ordered Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: Endocrine

Diabetes (DM): Background Body doesnt make enough insulin or cannot effectively use the little insulin that is produced Two types Type I (IDDM); Juvenile; little or no insulin production; insulin dependent Type 2 (NIDDM); Adult onset; insulin resistance; managed by diet, exercise, oral meds

Seventh leading cause of death among older adults Risk increases with age Early diagnosis is difficult in elderly because they dont present with typical classic symptoms DM: Risk factors Family history Obesity African Americans, Hispanics, Native Americans Asian Americans, Pacific

Islander Age over 45 Hypertension HDL less than 35 mg/dl History of large babies DM: Signs/symptoms Three Ps may not be present Polydypsia Polyuria Polyphagia Glucose intolerance may be an initial

sign in the elderly Screening should be done every three years over age 45 with FBS DM: Treatment Balance between exercise, diet, and medications Medications - may be oral hypoglycemics or insulin injection (needed in Type 1 and sometimes Type 2) Prevent complications - may be more frequent in elderly

CHD/MI Stroke Kidney failure Nerve damage (neuropathy) Visual problems DM: HgbA1c Role of HgbA1c if elevated, shows that blood sugar has been high over time more recent treatment is helping patients to maintain a normal level to decrease risk of complications DM: Patient Education

Proper nutrition Exercise Medications Signs and symptoms of hyper- and hypoglycemia Meaning of lab tests: FBS, blood glucose, HgbA1c Foot care Hypothyroidism: Background

Thyroid gland fails to secrete sufficient amount hormone Two classifications Subclinical TSH mildly elevated T4 normal Primary or overt

TSH elevated T4 decreased Hashimotos is most common cause Hypothyroidism: Signs/symptoms Classic may not be present in elderly

Fatigue and weakness Dry skin, brittle hair, alopecia, weight gain Cold sensitivity Puffy face, headache, insomnia Goiter, trouble breathing or swallowing Constipation Ataxia Depression Bradycardia Anorexia Hypothyroidism: Diagnosis

Thorough H & P Bradycardia and heart failure are often associated factors Labs: TSH, Thyroid panel, thyroid antibodies, lipid levels (associated symptom) Elderly can have bowel dysfunction and depression associated with hypothyroidism Hypothyroidism: Treatment

Thyroid replacement hormones (Thyroxine) Monitor effects of medication (can swing into hyperthyroidism) Teach patients to take meds daily for rest of life at same time each day Screening is not recommended for older adults Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: Delirium and Sundowners Syndrome Delirium: Background

Also called acute confusion Occurs in 22- 38% of older patients in the hospital Occurs in as many as 40% of longterm care residents Associated with increased length of stays in the hospital and higher mortality rates Delirium: Background

Altered level of consciousness Temporary Reversible Many treatable causes Need to distinguish delirium, depression, and dementia Delirium Treatment of delirium requires the diagnosis and treatment of the underlying physiological problem while using pharmacologic and nonpharmacologic interventions to maintain patient safety and return the patient to the pre-delirium state (Mauk, pg. 445). Delirium: Potential

causes Fluid and electrolyte imbalances Infection CHF Medications Pain Impaired cardiac or respiratory function

Emotional stress Unfamiliar surroundings Malnutrition Anemia Dehydration Alcoholism Hypoxia Delirium: Signs/Symptoms

Sudden onset Disorientation to time and place Altered attention Impaired memory Mood swings Poor judgment Altered LOC Decreased MMSE score (less than depression, but more than dementia) Delirium: Treatment

Detect promptly by good H & P MMSE, GDS and CAM are good assessment tools CBC, Lytes, LFTs, Renal function, Serum calcium and glucose, UA, CXR, EKG, O2 Sat Sundowner Syndrome

Nocturnal confusion Confusion as the sun goes down Disorientation, emotional upset, or confusion Increased with unfamiliar surrounding Often disturbed sleep patterns May result from excess sensory stimulation or deprivation Prevention/Management of Sundowners

Keep familiar objects in view Provide physical activity during the day Avoid napping during day Use a nightlight in room Provide human contact and touch for reassurance Meet basic needs for fluids, food, toileting Control noise and visitors in evening For all Older Adults with Cognitive Impairment

Maintain privacy and dignity Realize their value as a unique individual Maintain independence for as long as possible Minimize restraints find other answers to address wandering Continue human contact and environmental stimulation Repetition

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