Transcript Chapter 14: Management of Common Problems

Chapter 14: Management of
Common Problems
Bonnie M. Wivell, MS, RN, CNS
Polypharmacy
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Demographics
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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)
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Concurrent use of several drugs (ANA)
Implications
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Risk Factors for polypharmacy
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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
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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
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Demographics
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In 2001, more than 1.6 million seniors were treated in
emergency departments for fall-related injuries and
nearly 388,000 were hospitalized
Implications
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Fractures
Loss of independence
Decreased quality of life
Fear
Death
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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)
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Risk for falling
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Intrinsic: r/t changes associated with aging
Extrinsic: r/t environmental hazards
Drugs are a major contributing factor
Fall assessment
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Initial
Regular intervals
Variety of assessment tools available
Risk Factors for Falls
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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
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Evaluate gait and balance
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Up and Go Test
Exercise
Restraint use
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Avoid physical restraints
Limit use of “chemical restraints” – effects
number of certain medications that can be
used in nursing homes
Interventions (cont’d)
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Modify the environment:
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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)
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Medication review
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Diuretics
Narcotics
Sedatives
Hypnotics
Tranquilizers
Antidepressants
Antihypertensives
Laxatives
History of drug/alcohol abuse
Develop a Fall Prevention Plan
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Examine risk factors
Anxiety
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Prevalence
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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
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Manifests as
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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
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Generalized anxiety disorder (GAD): persistent,
excessive worry with fluctuating severity of
symptoms, restlessness, irritability, sleep
disturbance, fatigue and impaired concentration
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Chronic condition
Associated with depression
Panic attacks: autonomic arousal that includes
tachycardia, difficulty breathing, diaphoresis,
light-headedness, trembling, and severe
weakness
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Symptoms may be masked in elderly
Risk Factors/Assessment
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Risk Factors
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Chronic medical condition
Psychosocial stressors/negative life event
Catastrophic events in early life
Assessment
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ID risks
Medications
Medical conditions
Pay attention to verbalization of thoughts and feelings
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Most prominent presenting symptom in depression
Intervention/Strategies for Care
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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
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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:
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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
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Geriatric Depression Scale
Cornell Scale for Depression in Dementia
Medication history
H&P
Interventions/Strategies for Care
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Early recognition and tx can increase quantity and
QOL
Antidepressant medications (tricyclics, SSRIs #1)
Psychosocial interventions
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Nursing interventions
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CBT uses recognition and relaxation strategies to
change thoughts
Alternative medicine
Life review
Socialization
Exercise
Community resources
Urinary Incontinence (UI)
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Involuntary leakage of urine
Is common problem but NOT a normal part of
aging
Requires evaluation
Types of UI
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Stress
Urge
Mixed
Overflow
Functional
Total
Prevalence
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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
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Depression/anxiety
Decreased quality of life
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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
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Transient (acute)
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Established (chronic)
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Delirium, infection, meds, stool impaction
Stress, urge, overflow, functional
Evaluating bladder function
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History
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Bladder diary
Physical
DRE, pelvic exam
PVR
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UA
Cognitive status
Environmental resources: location, accessibility of
toilet
Stress Incontinence
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Involuntary loss of small amounts of urine
during activities that increase intra-abdominal
pressure
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Causes:
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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
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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:
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CNS disorders such as CVA, MS
Local irritations such as infection or ingestion of
bladder irritants like caffeine
Treatment: Kegels
Reflex Incontinence
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A variation of urge, results from uninhibited
bladder contractions with no sensation of
needing to void or urgency
Large amount urine lost
Causes:
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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
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Over-distention of the bladder due to abnormal
emptying
Causes:
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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
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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
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Existence of symptoms of urge and stress
at the same time
Interventions/Strategies for Care
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Behavioral Management: modify behavior or
environment
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Scheduling regimens
Relaxation exercises
Pelvic muscle exercises
Urge suppression techniques with or without
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Biofeedback, Vaginal cones, Electrical stim
Hydration management
Bowel regularity
Prompted voiding
Bladder training
Interventions/Strategies for Care
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Pharmacological management
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Surgery
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Medications that alter detrusor muscle activity
or bladder outlet resistance
Increase bladder outlet resistance
Remove bladder outlet obstruction
Devices and products
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Depends, catheter supplies, urinals
Sleep Disorders
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Sleep Changes Associated with Aging
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Decreased deep stage IV (restores the individual
physically, and tissue healing occurs)
Decreased REM sleep (deepest state of relaxation)
Prevalence
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Chronic illness increases propensity
32% of adults reported a good night’s sleep only a
few nights each month
Types of Sleep Disturbances
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Insomnia
Sleep apnea
Restless leg syndrome
Interventions/Strategies for Care
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Sleep hygiene
Environmental restructuring
Relaxation
Aromatherapy
Herbal therapy
Medications
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Ambien
Lunesta
Sonata
Pressure Ulcers
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Prevalence
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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
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Ischemia caused by unrelieved pressure
Warning Signs/Risk Factors
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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
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Braden Scale
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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
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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
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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)
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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
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Nutrition very important
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Tissue load management
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Protein
Zinc
Arginine
Vit C, A, and B
Positioning devices
PUSH Tool
Dysphagia
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Problems with swallowing that is an underrecognized, poorly diagnosed, and poorly
managed health problem
Negatively impacts quantity and QOL
Prevalence
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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
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Impaired mastication - dentures
Change in diet, change in appetite
Diminished salivary secretions
Decreased esophageal peristalsis
Decreased production of digestive
enzymes
Assessment
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Stages of swallowing:
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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)
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Cranial nerves involved in eating and
swallowing:
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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
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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)
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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)
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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
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G-tubes
PEG tubes
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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
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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
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Alzheimer’s #1
Vascular
Parkinson’s
Lewy body
Frontal lobe dementia
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Lose inhibition and executive functioning skills earlier
than AD
Normal pressure hydrocephalus
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Rare but partially reversible with surgery
Acute onset of a triad of symptoms
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slowed cognitive processes, gait disturbances, UI
Risk Factors for Dementia
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Age
Family history
Genetic factors
Head trauma
Vascular disease
Infections
Other modifiable factors
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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
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Drugs
Environmental
Metabolic
Eyes/Ears – sensory deprivation
Nutrition
Trauma/Tumor
Infections
Alcohol abuse or intoxication
Assessing for Dementia
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Mini-COG
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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
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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
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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
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Memory impairment alone doesn’t indicate AD
Requires one of the following features
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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)
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H&P
Review of medications
Laboratory testing
Neuropsychological screening/testing
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Mini Mental Status Exam (MMSE) no longer available
in public domain
Mini-Cog
St. Louis University Mental Status (SLUMS) exam
Imaging
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Medicare will pay for PET scan to rule out dementia
Medications for Dementia
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Medications slow progression but do not stop
decline over time
Cholinesterase Inhibitors (CEIs)
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N-methyl-D-aspartate (NMDA) Receptor
Antagonist
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donepezil (Aricept)
rivastigmine (Exelon)
galantamine (Razadyne)
memantine (Namenda) approved for moderate to late
stage
Anticholinergics can worsen cognitive function
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See page 540 in text
Delirium
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Acute confusion
Four basic features
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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
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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
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Drugs
Electrolytes
Liver failure
Infection
Renal failure
Impaction
UTI or urinary retention
Metastasis
Potential Causes of Delirium
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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
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Hypoxia
Age
Male gender
Cognitive impairment
(dementia)
Hypotension
Malnutrition
Depression
Alcoholism
Restraints
Multiple IVs, lines, tubes
Assessing for Delirium
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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)
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Sensitivity of 94-100%
Specificity of 89-95%
CAM – The Short Version
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1. Acute Onset
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Is there evidence of an acute change in
mental status from baseline?
2. Inattention
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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?
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3. Disorganized thinking
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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
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Overall, how would you rate this patient’s level of
consciousness?
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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
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Should assess patient on admission and
during each shift
Engage pt. in conversation for about one
minute. Ask:
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“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
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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
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Use general strategies (as appear in next
slides)
Address specific issues/behaviors
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Wandering
Aggression
Restlessness
Agitation
Physical comfort
Pain
Pain
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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
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Nonverbal Expressions
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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



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Distraction
Massage
Heat/cold
Gentle movement/repositioning
Music therapy