Transcript 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
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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):
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Hypertension
CHD
MI
 Angina
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CHF
Stroke
Hypertension: Background
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65 million Americans have HTN
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African American males have highest incidence
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In 2004, 63.6% of men and 73.9 % of women ages 65–74 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
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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
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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
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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
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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:
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Dizziness
Dyspnea
Confusion
Chest pain
Angina: Control
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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)
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Angina: Medications
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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
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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 person’s first MI of 65.8 for
men and 70.4 for women (AHA, 2005)
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MI: Risk factors
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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
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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
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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
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Angioplasty
CABG
Medications
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Beta blockers, ACE inhibitors, Antihypertensives
MI: Patient Education
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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 (cont’d)
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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
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Incidence varies by age, gender, and races
AGE
W Men
W Women AA Men
AA Women
65-74
15.2/1,000
8.2/1,000
16.9/1,000
14.2/1,000
75-84
31.7/1,000
19.8/1,000
25.5/1,000
25.5/1,000
>85
65.2/1,000
45.6/1,000
50.6/1,000
44.0/1,000
Lifetime risk for persons is 1 in 5
The risk in 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
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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
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Check O2 saturation - less than 90% requires
intervention
Daily weight at same time, clothes, scale
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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
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CHF: Patient Education
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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
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Cerebrovascular accident (CVA)
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Transient ischemic attack (TIA)
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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
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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
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Hemorrhagic
Stroke and TIAs: Risk Factors
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Controllable
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HTN #1
High Cholesterol
Heart Disease
Smoking (quit and risk
equalizes after 5 years)
Obesity
Stress
DM
Depression
A Fib
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Uncontrollable
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Age
Gender (males > females
until menopause)
Race (AA > White)
Heredity
Stroke and TIAs: Warning Signs
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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
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Facial droop
Motor weakness
Language difficulties
Stroke: Treatment
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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
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Stroke: Acute Management
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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
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Stroke: Acute treatment
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Manage hypertension, hyperthermia, and hyperglycemia
To prevent recurrence: Medications
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ASA
Ticlid
Plavix
Persantine
Heparin
Coumadin
Lovenox
Effects of Stroke
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Effects and degree of recovery vary
Hemiplegia
Hemiparesis
Visual /perceptual deficits
Language deficits
Emotional changes
Swallowing dysfunction
Bowel/bladder problems
Stroke: Rehabilitation
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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
Answering why, reflection
Framing
Owning
Control, acceptance,
determination, self-help
Stroke: Patient Education
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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
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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
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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
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PVD: Treatment
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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
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Pneumonia
COPDs
Chronic bronchitis
 Emphysema
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TB
Lung cancer
Pneumonia: Background
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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 immunesuppressing disease
Pneumonia: Signs/Symptoms
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Viral (less severe)
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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
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Pneumonia: Treatment
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CXR
CBC
Sputum culture to determine type and causal
agent
H&P
Viral – no tx; self-limiting
Bacterial – antibiotics
Pneumonia: Treatment (cont’d)
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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
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COPDs: Background
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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
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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
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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
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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
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Control symptoms and minimize complications
Lifestyle modifications
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Stop smoking
Respiratory therapy
Medications
Pulmonary rehabilitation
Oxygen therapy required as disease progresses
COPDs: Patient Education
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Common cause: H. Pylori
GERD: Symptoms
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Heartburn #1
Noncardiac chest pain
Dysphagia
Hoarseness
Coughing
Wheezing, respiratory problems, asthma
Complications
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Esophagitis
Barrett’s esophagus
Cancer
GERD: Treatment
Diagnosis: H&P, endoscopy with biospies
 Treatment
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Medications:
Mild: Antacids & H2 blockers (Tagamet, Zantac, Pepcid
AC, Axid)
 Proton pump inhibitors (PPIs) (Nexium, Prevacid)
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Elderly have fewer complaints of heartburn but
is more severe with more complications
GERD: Patient Education
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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
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Avoid:
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Caffeine
Chocolate
Nicotine
Alcohol
Peppermint
Spicy and tomatobased foods
Acidic products
Carbonated
beverages
Stress
Peptic Ulcer Disease: Background
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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
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Causes:
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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
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Risk factors:
Smoking
 Drinking alcohol
 Caffeine
 Stress
 Helicobacter pylori infection
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Diagnosis: H&P, barium swallow, endoscopy with
biopsy
Peptic Ulcer: Treatment &
Patient Education
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Antibiotics
Antacids and other medications to control acid
production
Dietary changes
Avoidance of risk factors
Combination therapy if H. pylori present
Teach
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Risk reduction
Adhere to medication regimen
Bleeding may result
Diverticulitis: Background
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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
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Elderly may not present with typical symptoms
LLQ pain
Nausea
Fever
Constipation
Diarrhea
Mucus and/or blood in stool
Diverticulitis: Risk factors &
Diagnosis
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Risk Factors
Obesity
 Chronic constipation
 Hiatal hernia
 Family history
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Diagnosis
H&P
 Barium enema
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Diveritulitis: Treatment
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Antibiotics
Avoid irritating foods
Extreme cases:
May require surgery to remove diseased bowel
 May result in bowel obstruction leading to
colostomy
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Teach: dietary changes, adhere to medication
regimen
Cancers
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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
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Esophageal Cancer
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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 Barrett’s 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
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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
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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
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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
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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 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

Parkinson’s disease
Small percentage of those with dementia are this
type
 Degeneration of neurons due to lack of
neurotransmitter, Dopamine

Alzheimer’s 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

Alzheimer’s 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 (Alzheimer’s 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
Alzheimer’s 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 (cont’d)

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 Alzheimer’s 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
Parkinson’s 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 Parkinson’s
dementia
PD vs. Parkinsonian symptoms

Drugs and toxins

Alzheimer’s

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, Parkinson’s 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
 Meniere’s 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 doesn’t respond to
meds, such as Antivert
Dizziness: BPPV (cont’d)



S/S: dizziness, presyncope, feelings of
imbalance, and nausea
Symptoms begin when person changes head
position
DX with Hallpike’s 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 (cont’d)

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: Meniere’s





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
Alzheimer’s 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 tonic-clonic

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 weight-bearing
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









Herberden’s nodes (bony enlargements at end joints of
fingers)
Bouchard’s 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 Betacarotene) 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 doesn’t 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 don’t
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 P’s 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
Hashimoto’s 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 Sundowner’s
Syndrome
Delirium: Background




Also called acute confusion
Occurs in 22- 38% of older patients in the
hospital
Occurs in as many as 40% of long-term 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
Sundowner’s







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