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Chapter 14: Management of Common Problems Bonnie M. Wivell, MS, RN, CNS Polypharmacy Demographics 34% of all prescription medications and 40% of all nonprescription medications are for elderly (American Society of Consultant Pharmacists, 2000) Those in nursing homes take an average of 6 – 8 medications per day; some take many more Polypharmacy (cont’d) Concurrent use of several drugs (ANA) Implications Risk Factors for polypharmacy Med errors Non-adherence Drug-drug interactions ADRs Increased hospitalizations Poor communication between physicians, number of co-morbidities, age-related change Beer’s list of potentially harmful drugs Interventions/Strategies Obtain a thorough history Start low and go slow Monitor lab values Consider nonpharmacologic approaches Streamline the medication regimen Provide information to patient/family Falls Demographics In 2001, more than 1.6 million seniors were treated in emergency departments for fall-related injuries and nearly 388,000 were hospitalized Implications Fractures Loss of independence Decreased quality of life Fear Death At least 50% of elderly persons who were ambulatory before fracturing a hip do not recover their pre-fracture level of mobility Falls (cont’d) Risk for falling Intrinsic: r/t changes associated with aging Extrinsic: r/t environmental hazards Drugs are a major contributing factor Fall assessment Initial Regular intervals Variety of assessment tools available Risk Factors for Falls Age Diagnosis Altered physical capabilities Altered mental state Altered bowel and bladder function Cognitive/sensory impairments Altered proprioception Day of hospitalization Medications Psychological factors, i.e. fear Interventions/Strategies for Care Evaluate gait and balance Up and Go Test Exercise Restraint use Avoid physical restraints Limit use of “chemical restraints” – effects number of certain medications that can be used in nursing homes Interventions (cont’d) Modify the environment: Minimize clutter Throw rugs Hand rails Flooring – wax, loose carpet, wires/cords Be sure phone can be reached from floor Raised toilet seat Grab bars Educate client and family Interventions (cont’d) Medication review Diuretics Narcotics Sedatives Hypnotics Tranquilizers Antidepressants Antihypertensives Laxatives History of drug/alcohol abuse Develop a Fall Prevention Plan Examine risk factors Anxiety Prevalence Most common mental health problem in older adults According to Surgeon General, 11.4% of adults over the age of 55 met criteria for anxiety disorders Phobic anxiety disorders most prevalent in older adults Non-specific anxiety rates up to 17% in older men and 21% in older women (U.S. Public Health Services, 2000). Implications/Relevance Manifests as Tachycardia/Palpitations GI disorders Insomnia Tachypnea Recurring and chronic can complicate illnesses Increases duration of disability Correlates with and predicts cognitive decline and impairment Elevates acute pain perception Warning Signs Generalized anxiety disorder (GAD): persistent, excessive worry with fluctuating severity of symptoms, restlessness, irritability, sleep disturbance, fatigue and impaired concentration Chronic condition Associated with depression Panic attacks: autonomic arousal that includes tachycardia, difficulty breathing, diaphoresis, light-headedness, trembling, and severe weakness Symptoms may be masked in elderly Risk Factors/Assessment Risk Factors Chronic medical condition Psychosocial stressors/negative life event Catastrophic events in early life Assessment ID risks Medications Medical conditions Pay attention to verbalization of thoughts and feelings Most prominent presenting symptom in depression Intervention/Strategies for Care Decrease environmental stimuli Stay with the patient Make no demands or ask the patient to make decisions Support current coping mechanisms (crying, talking) Avoid confrontation or argument Speak slowly and softly Reassure the patient that the problem can be solved Reorient the patient to reality Respect the patient’s personal space Deep Breathing Progressive Muscle Relaxation Cognitive Behavioral therapy Anxiolytics (benzos, SSRIs #1) Depression Most common mental health disorder in elderly but NOT a normal consequence of aging Depression rate is as high as 37% in older adults with co-morbid illnesses Medical conditions that increase risk of depression: Hypothyroidism, Arthritis, HTN, CVA, CHD, DM, PD, MS, CA Significant risk for suicide; older adults have the highest rates of suicide in the US Often undetected or inadequately treated Assessment Geriatric Depression Scale Cornell Scale for Depression in Dementia Medication history H&P Interventions/Strategies for Care Early recognition and tx can increase quantity and QOL Antidepressant medications (tricyclics, SSRIs #1) Psychosocial interventions Nursing interventions CBT uses recognition and relaxation strategies to change thoughts Alternative medicine Life review Socialization Exercise Community resources Urinary Incontinence (UI) Involuntary leakage of urine Is common problem but NOT a normal part of aging Requires evaluation Types of UI Stress Urge Mixed Overflow Functional Total Prevalence 30 - 50% in older women living in the community 9% – 28% in older men living in the community Incontinence may affect up to 43% of acute care patients Prevalence rates in institutions rise to 50% or higher Implications Depression/anxiety Decreased quality of life Relationships ADLs Decreased socialization Increased risk of hospitalization and/or admission to LTCF Increased risk of falls Increase risk of skin breakdown Stigma Fear of embarrassment Perception that UI is a normal part of aging Assessment Transient (acute) Established (chronic) Delirium, infection, meds, stool impaction Stress, urge, overflow, functional Evaluating bladder function History Bladder diary Physical DRE, pelvic exam PVR UA Cognitive status Environmental resources: location, accessibility of toilet Stress Incontinence Involuntary loss of small amounts of urine during activities that increase intra-abdominal pressure Causes: Lifting, coughing, sneezing, laughing Hypermobility of the bladder neck Urethral sphincter defects Weakness of pelvic floor muscles r/t pregnancy, multiparity, obesity, surgery, exercise, medications Treatment: biofeedback, Kegels Urge Incontinence Strong, abrupt desire to void and the inability to inhibit leakage in time to reach a toilet Moderate to large amounts of urine lost Causes: CNS disorders such as CVA, MS Local irritations such as infection or ingestion of bladder irritants like caffeine Treatment: Kegels Reflex Incontinence A variation of urge, results from uninhibited bladder contractions with no sensation of needing to void or urgency Large amount urine lost Causes: Spinal lesions transecting above T10-11 r/t birth defects, spine or nerve damage, developmental disability, senility, pelvic trauma Treatment: determine cause; may need intermittent cath, timed voiding Overflow Incontinence Over-distention of the bladder due to abnormal emptying Causes: Weak bladder Neurological conditions like DM, spinal cord injury below T10-11 Bladder outlet obstruction No warning prior to incontinent episode Small to moderate amount of urine lost Continual or intermittent Treatment: treat cause, intermittent cath, bladder scans for post-void residuals Functional Incontinence Problems with factors external to the lower urinary tract such as cognitive impairment, physical disabilities, and environmental barriers Related to inability to get to bathroom facilities due to functional reasons For example: obesity, clutter, immobility May be associated with urge incontinence (mixed incontinence) Treatment: modify environment; modify lifestyle Mixed Incontinence Existence of symptoms of urge and stress at the same time Interventions/Strategies for Care Behavioral Management: modify behavior or environment Scheduling regimens Relaxation exercises Pelvic muscle exercises Urge suppression techniques with or without Biofeedback, Vaginal cones, Electrical stim Hydration management Bowel regularity Prompted voiding Bladder training Interventions/Strategies for Care Pharmacological management Surgery Medications that alter detrusor muscle activity or bladder outlet resistance Increase bladder outlet resistance Remove bladder outlet obstruction Devices and products Depends, catheter supplies, urinals Sleep Disorders Sleep Changes Associated with Aging Decreased deep stage IV (restores the individual physically, and tissue healing occurs) Decreased REM sleep (deepest state of relaxation) Prevalence Chronic illness increases propensity 32% of adults reported a good night’s sleep only a few nights each month Types of Sleep Disturbances Insomnia Sleep apnea Restless leg syndrome Interventions/Strategies for Care Sleep hygiene Environmental restructuring Relaxation Aromatherapy Herbal therapy Medications Ambien Lunesta Sonata Pressure Ulcers Prevalence Acute care setting = 3-11% Long-term care facilities = 24% Community = 17% With a stage I ulcer, the older adult has a tenfold risk of developing further ulcers Implications Ischemia caused by unrelieved pressure Warning Signs/Risk Factors Thin or obese Poor nutrition/dehydration Immobility Assistive devices Patient on pain meds or sedatives Decreased mental status Increased age Impaired circulation/sensation Bony prominences/decreased muscle mass Incontinence Friction/shearing Assessment Braden Scale See pages 502-503 in text Score of 18 or less = high risk of pressure ulcer development in the older adult Determine baseline on admission and at regular intervals Determine stage Length, width, and depth need to be documented Photos Stages of Pressure Ulcers Stage I: non-blanchable redness, skin intact Stage II: partial thickness loss of the dermis, abrasion, blister, shallow crater Stage III: full-thickness loss of dermis, damage to subcutaneous tissue Stage IV: damage to muscle and bone, necrosis Ulcer Care Cleanse the wound with a noncytotoxic cleanser (saline) during each dressing change. If necrotic tissue or slough is present, consider the use of high-pressure irrigation. Debride necrotic tissue. Do not debride dry, black eschar on heels. Perform wound care using topical dressings determined by wound and availability. Choose dressings that provide a moist wound environment, keep the skin surrounding the ulcer dry, control exudates, and eliminate dead space. Ulcer Care (cont’d) Reassess the wound with each dressing change to determine whether treatment plan modifications are needed. Identify and manage wound infections. Clients with Stage III and IV ulcers that do not respond to conservative therapy may require surgical intervention. Pressure Ulcer Management Nutrition very important Tissue load management Protein Zinc Arginine Vit C, A, and B Positioning devices PUSH Tool Dysphagia Problems with swallowing that is an underrecognized, poorly diagnosed, and poorly managed health problem Negatively impacts quantity and QOL Prevalence 13-35% of elderly living in the community 25-30% of hospitalized patients Approximately 30%-40% of persons in nursing homes It is estimated that by 2010, 16.5 million persons will require care for dysphagia (U.S. Census Bureau, 2000). Warning Signs/Risk Factors Effects of Aging on Eating and Swallowing Impaired mastication - dentures Change in diet, change in appetite Diminished salivary secretions Decreased esophageal peristalsis Decreased production of digestive enzymes Assessment Stages of swallowing: Oral preparatory: chew and taste Oral or lingual: move food to back of throat Pharyngeal: involuntary, most critical, airway closure Esophageal: involuntary, movement down esophagus via peristalsis Assessment (cont’d) Cranial nerves involved in eating and swallowing: Trigeminal (V) - mandibular, maxillary Facial (VII) - taste, submandibular and sublingual salivary glands, facial expression Glossopharyngeal (IX) - taste, soft palate & uvula Vagus (X) - membrane of larynx and pharynx Spinal Accessory (XI) - sternocleidomastoid muscle Hypoglossal (XII) - intrinsic tongue Interventions/Strategies for Care Positioning - upright Establish arousal and attention Assist with head positioning Do not rush Use small amounts of food - 1/2 teaspoons Place food on unaffected side Push down tongue as remove food from spoon Interventions (cont’d) Assist with lip closure if needed Avoid use of straws (unless recommended by speech therapist) Provide frequent verbal cues Use thickener for liquids as recommended Stimulate the swallowing reflex Avoid milk and milk products Use adaptive equipment designed for that person Interventions (cont’d) Oral care Educate person and family Thermal stimulation - cold stimulates the swallow response Follow recommendations of speech therapist (may have multiple steps) Non-oral interventions G-tubes PEG tubes Percutaneous Endoscopic Gastrostomy tube Check abdominal girth for distension Check residual volumes Keep upright after feedings Monitor continually for aspiration Treat GERD Chapter 15: Nursing Management of Dementia Bonnie M. Wivell, MS, RN, CNS Dementia Progressive, degenerative brain dysfunction, including deterioration in memory, concentration, language skills, visuospatial skills, and reasoning Progressive forgetfulness, memory loss, and loss of other cognitive function Increased plaques and tangles in the brain (hallmark sign for Alzheimer’s) Interferes with a person’s daily functioning Not considered a normal part of aging Types of Dementia Alzheimer’s #1 Vascular Parkinson’s Lewy body Frontal lobe dementia Lose inhibition and executive functioning skills earlier than AD Normal pressure hydrocephalus Rare but partially reversible with surgery Acute onset of a triad of symptoms slowed cognitive processes, gait disturbances, UI Risk Factors for Dementia Age Family history Genetic factors Head trauma Vascular disease Infections Other modifiable factors Maintain ideal body weight Exercise Avoid smoking Control hyperlipidemia and hypertension Exercising the brain with lifelong cognitive activity may help lower the risk of dementia Causes of Dementia Drugs Environmental Metabolic Eyes/Ears – sensory deprivation Nutrition Trauma/Tumor Infections Alcohol abuse or intoxication Assessing for Dementia Mini-COG A reliable and valid instrument used to screen for cognitive impairment consisting of 3-item recall test and a clock-drawing test (CDT) It is evidence-based, easy to administer, and not too taxing for patient or provider Is a screening test, doesn’t provide diagnosis Administration of Mini-COG Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat the words. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distracter. Ask the patient to repeat the 3 previously presented word. CLOCK DRAWING TEST Scoring of Mini-COG Give 1 point for each recalled word after the CDT distracter. Score 1–3. A score of O indicates positive screen for dementia. A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia. A score of 1 or 2 with a normal CDT indicates negative screen for dementia. A score of 3 indicates negative screen for dementia. The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. Diagnosing Alzheimer’s Memory impairment alone doesn’t indicate AD Requires one of the following features Impaired executive function Aphasia – word finding difficulties Apraxia – cannot carry out motor skills Agnosia – cannot name familiar object Must rule out delirium, depression, other CNS disorders, medication side effects, and other medical conditions first! Diagnosing Alzheimer’s (cont’d) H&P Review of medications Laboratory testing Neuropsychological screening/testing Mini Mental Status Exam (MMSE) no longer available in public domain Mini-Cog St. Louis University Mental Status (SLUMS) exam Imaging Medicare will pay for PET scan to rule out dementia Medications for Dementia Medications slow progression but do not stop decline over time Cholinesterase Inhibitors (CEIs) N-methyl-D-aspartate (NMDA) Receptor Antagonist donepezil (Aricept) rivastigmine (Exelon) galantamine (Razadyne) memantine (Namenda) approved for moderate to late stage Anticholinergics can worsen cognitive function See page 540 in text Delirium Acute confusion Four basic features Acute onset or fluctuating course Inattention Disorganized thinking Altered level of consciousness Primary treatment is to eliminate the cause Delusion of theft and phantom intruder Another Fact About Dementia Study done in Japan: Delusion of theft and phantom intruder delusion are among the most frequent delusions in dementia and these delusions occur more frequently when pt. hospitalized Causes of Delirium Drugs Electrolytes Liver failure Infection Renal failure Impaction UTI or urinary retention Metastasis Potential Causes of Delirium Inadequate or inappropriate pain control Medications (including new or change in dose) Fecal impaction Infection/fever Injury/severe illness Electrolyte imbalance (glucose, Na+) Dehydration Change in surroundings Hypoxia Age Male gender Cognitive impairment (dementia) Hypotension Malnutrition Depression Alcoholism Restraints Multiple IVs, lines, tubes Assessing for Delirium Delirium is often unrecognized by clinicians Hence patients should be assessed frequently using a standardized tool to facilitate prompt identification and management of delirium and underlying etiology Confusion Assessment Method (CAM) Sensitivity of 94-100% Specificity of 89-95% CAM – The Short Version 1. Acute Onset Is there evidence of an acute change in mental status from baseline? 2. Inattention Does the patient have difficulty focusing attention; easily distractible; have difficulty keeping track of what is being said? Does this behavior fluctuate; come and go or increase and decrease in severity? 3. Disorganized thinking Is the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Altered level of consciousness Overall, how would you rate this patient’s level of consciousness? Alert = normal Vigilant = hyper-alert, overly sensitive to environmental stimuli, startled very easily Lethargic = drowsy, easily aroused Stupor = difficult to arouse Coma = unarousable Uncertain CAM Continued Should assess patient on admission and during each shift Engage pt. in conversation for about one minute. Ask: “What brought you to the hospital?” “How are you feeling now?” Delirium is identified only if there is evidence of features 1 and 2, and either 3 or 4 (or both) Depression Risk increases in older adults with chronic illnesses and/or dementia Often a missed diagnosis See Box 15 – 12 on page 541 of text for criteria of major depression Most common screening tool is the GDS The Cornell tool can be used to screen persons with dementia for depression Symptoms of dementia, delirium, and depression often overlap Nursing Interventions/Strategies Use general strategies (as appear in next slides) Address specific issues/behaviors Wandering Aggression Restlessness Agitation Physical comfort Pain Pain Clinical observations of facial expressions and vocalizations are accurate means for assessing the presence of pain, but not its intensity, in patients unable to communicate verbally because of advanced dementia. Pain Nonverbal Expressions Agitation/combativeness/resistance to care Increased confusion Decreased mobility Guarding/rubbing or holding particular body part Grimacing Restlessness Increase HR, Respirations Interventions for Pain Ask older adults with dementia about their pain as they can often respond to simple questions If pain is suspected, consider a time-limited trial of an appropriate type and dose of an analgesic Nonpharmacological Interventions Distraction Massage Heat/cold Gentle movement/repositioning Music therapy